OPHTHALMIC SURGERY AND TREATMENT: WITH ADVICE ON THE USE AND ABUSE OF SPECTACLES. BY JOHN PHILLIPS, OPTICIAN AND OCULIST. X "* 'O CO CHICAGO: WESTERN NEWS COMPANY, W. B. KEEN & CO. 1869. Entered according to Act of Congress, in the year 1869, by John Phillips, in the Clerk's office of the United States District Court of the Northern District of Illinois. CHICAGO; ROBERT FERGUS' SONS, PRINTERS. PREFACE. So great an amount of talent and industry has of late years been devoted to the investigation of Diseases of the Eye, that a new volume on the subject appears to require a few words of introduction. Notwithstanding all the assistance the student may derive from systematic treatises and pictorial instructions, close per- sonal examination of a large number of patients can alone enable him to recognize those delicate changes which the tissue of the eye presents under various morbid conditions. Specially to direct his attention to these changes, and to explain the best methods of observing them for himself, is the primary object of the following pages. I have, therefore, chiefly dwelt on the description of outward phenomena; for, inasmuch as the peculiar susceptibility of a patient must cause endless modifications of his subjective symp- toms, a full consideration of these would have expanded my volume, from its present moderate dimensions, into a System of Ophthalmic Pathology. I have endeavored to describe accurately and simply the ap- pearance of the various tissues of the eye, both in health and in disease; and, after 30 years' practice as practical optician and oculist, and recorded in essays, periodicals, etc., in this country and Great Britain, by far exceed in practical impor- tance those made in any other branch of medical science. vi PREFACE. I shall consider this book to have attained its object if to the student it renders ophthalmology intelligible and useful, and if to the practitioner it affords a faithful record of the present state of this branch of medical science. The matter contained in this book being, however, in great part derived from the labors of others, and adapted by myself to the requirements of men in general practice, it is necessary to mention here the books which should be read by those who wish for more ample information on the subjects treated, and to state the nature of the more important innovations in oph- thalmology. Among periodicals, should be consulted—" The American and London Ophthalmic Hospital Reports, and Journal of Ophthal- mic Medicine and Surgery;" and "The Ophthalmic Review, a Quarterly Journal of Ophthmalmic Surgery and Science." Among continued publications must be mentioned—A peri- odical published by Professor Donders, of Utrecht. No ophthalmological work, however, more deserves the atten- tion of the medical men in general practice, or that of the ocu- list, than the one translated by W. D. Moore, M.D., Dublin, etc., W. Mackenzie, M.D., C. Bader, C. Stellwag, M.D., J. Dixon, J. Z. Laurence, and H. W. Williams, M.D. The ophthalmoscope, in its simplified form, has come into general use, and has proved indispensable to the oculist, as well as to the medical man in general practice. It not onlv enables us to view the retina, optic disk, etc., in health and disease but often also affords the earliest means of recognizing the presence of general morbid changes, such as albuminuria, syph- ilis, cerebral tumors, etc. A knowledge of the mode of using the ophthalmoscope may be acquired within a few hours, and richly repays the philosopher as well as the physician. Among the numerous works upon the changes of the retina choroid, etc., which have appeared since the invention of this instrument, must be mentioned "A Practical Treatise on the PREFACE. Vll Use of the Ophthalmoscope, etc., by J. W. Hulke, F.R.C.S.," and the "Atlas of Ophthalmoscopic Drawings, with Text, by Dr. LiEBREica, of Paris." I have not entered into any criticism in the course of the work as regards the medical, surgical, or optical treatment of affections of the eye. To Dr. Fowler I must also pay my tribute of thanks and admiration; and no less to my friend Dr. Lord, of Springfield, Illinois, who has greatly assisted me by many suggestions, dur- ing keeping the Infirmary for four years in Springfield; and also to Dr. J. B. Walker, Dr. Ralls Smith, and Dr. Under- wood, of Chicago, who have greatly assisted me in many im- portant suggestions, during keeping the Infirmary twelve years in Chicago. Also to Dr. David Prince, Jacksonville, 111. I am under obligations to others, whom I name not in detail, that I may escape the charge of parading the catalogue of my kind friends. To all and each I tender my warm and respect- ful thanks. I shall in this place, however, take the opportunity of mak- ing a few remarks upon the more important changes which ophthalmology has undergone in reference to diagnosis and treatment. A service of great importance has been rendered to ophthal- mology by Mr. Jonathan Hutchinson's researches in infan- tile syphilis. These have shown a very frequent form of •corneitis, hitherto described as strumous, to be one of the nu- merous symptoms of inherited syphilis. The treatment of affections of the lachrymal passages has been rendered much more simple and successful by Mr. Bowman's operation of slitting open the lachrymal puncta and canaliculi, and by his adopting a series of large probes and other instru- ments in the treatment of obstructions and strictures of these passages. The operations, as Well as the necessary instru- ments, have come into general use. viii PREFACE. The Operation for Strabismus.—The two methods of operating most frequently adopted are that termed the subconjunctival method, and that by which an incision is made into the con- junctiva over the tendon, the latter drawn out of the wound and divided close to the sclerotic, and the conjunctival incision united again by a suture. The latter mode of operating, known as V. Gr^efe's method, is generally practised on the Continent, and has found advocates in this country. Mr. Critchett was the first to operate by the subconjunctival method at the Eye Infirmary, Moorfields, where this mode of operating is main- tained by most of the surgeons. More practice is required to operate by the subconjunctival method, and I have found that beginners obtain better results, and succeed with greater facili- ty, by the other mode of operating, though I prefer the sub- conjunctival method. The treatment of strabismus (convergent as well as divergent) by the application of atropia, together with the use of proper spectacles, has of late been adopted in many cases with great success, since Prof. Donders has shown the connection between strabismus and its cause, viz., the anom- aly in shape of the eyeball. Operations for the Removal of Cataract.—Instead of the usuai mode of removing soft cataract by absorption, many surgeons adopt the operation of linear extraction, or remove the cataract by suction (an operation which was first extensively practised by Mr. Pridgin Teale, Jitn., of Leeds), as a quicker method of restoring vision. Both methods, if the cataract is fluid or very soft, may with safety be employed by any one. If the cataract is glutinous, much experience and manual dexterity are required, to avoid the complications arising from attempts at rapid removal. The innovations introduced for the removal of hard cataract refer chiefly to the application of chloroform, to the operation of iridectomy, and to the extraction of the cataract by artificial means, and through a smaller or differently shaped section. As regards the question of chloroform, many differences of opinion exist, and I shall confine myself to stating that, for the PREFACE. ix last four years, I have been in the habit of giving chloroform to every patient with cataract, whatever his general health or age may have been, if from his manner, or from his behavior while examining the eye, or from existing increased tension of the eye, I had any doubt as to the complete passiveness of the pa- tient, or of his eyes, during the operation. Only in one case out of nearly 200 did hemorrhage occur into the vitreous cham- ber after the operation, during vomiting; and, in this case, I had doubts whether the bandage applied had not been dis- turbed.—[Bader. As regards the performance of iridectomy, the result of the experience of those who operate by extraction, without giving chloroform, is, that the risks of losing vitreous humor are more numerous; and that it is preferable not to perform iridectomy, but to wait, and to remove the prolapse of the iris by iridectomy whenever it shows itself after the operation. For removal of cataract with the scoop, iridectomy is indispensable. Though vision is less acute, even if the iridectomy "is made upwards," than- when the pupil is circular, yet it is, as a rule, sufficiently good to admit of the usual occupation of the patient. A com- parison of the results obtained, when removing cataract by sim- ple extraction, with those when removing it "under chloro- form" with the scoop, or by other artificial means, combining with the operation an iridectomy, shows, according to statistics published by others, that a smaller number of patients obtain useful vision by the operation of simple extraction. This statement, I believe, holds good only if the operator has obtained equal dexterity in both modes of operating. More practice and a more thorough knowledge of the physical prop- erties of the parts within the eye are required for the success of the scoop operation. The complications which may present themselves, during certain stages of the operation, are more numerous. The Opefdtion of Iridectomy.—This operation was introduced into practice in 1856, by Professor Gr^eFe, of Berlin. Its in- fluence upon the morbidly-increased tension of the eyeball led PREFACE. him to adopt it in glaucoma. The operation has become gen- erally established. Its modus operandi is not yet understood, but it has proved the remedy by which the largest number of patients suffering from glaucoma are relieved. The operation of division of the ciliary muscle was first prac- tised by Mr. Hancock, and performed by him, and others, for glaucoma, as Well as for other morbid changes not accompanied by, or not caused by, undue tension of the eyeball. The Operation for Iridesis, or Iridodesis, introduced by Mr. Critchett, is preferred by some to the old operation for artifi- cial pupil. The Operation of Excision of the Eyelid, in its present sim- plified form, was first brought into practice at the Eye Infirm- ary, Moorfields, by Mr. Critchett. The Acuteness of Vision, and the State of Refraction and Accommodation of the Eye, are, as a rule, ascertained by test types, i.e., by a series of different definite sizes. The most perfect of the kind are those published by Dr. Snellen (Dr. H. Snellen. "Test Types for the Determination of the Acute- ness of Vision. New Edition. Printed by P. W. Van de Weyer, Utrecht, Holland. 1866"). Though, in the course of this book, it is shown how to make use of common letters, when ascertaining the acuteness of vision, etc., it is very desirable that those who are engaged in the study of ophthalmology should procure Dr. Snellen's test types. In most Continental works the decimal system is employed for the expression of linear measure. In this system the unit is called a metre, and expresses the ten-millionth part of the meridian arc passing through Paris, and extending from the north pole to the equator. A metre is equal to 39.3707904 English inches. Hence, we have a decimetre, equal to 3.93708; a centimetre, equal to .0393708. By those who wish to convert metrical into the preface. XI present English lineal measure, the following mode may be adopted:—Let it be required to express fifteen millimetres (=15mm) in English inches. Since one millimetre =.0393708 English inches, 15 millimetres =15X.0393708 English inches, =.590563, or =j5^ or T60, or |- inch, nearly. To convert English inches into French millimetres:—Since one metre =39.37079 inches, therefore one inch =-3^.3^7? metre =.02539954 metre =25.39954 millimetres =25.4 milli- metres nearly. Ex.—How many millimetres are equivalent to 3| inches? 3f inches =3£X25.39954=95.24827 millimetres. If we assume 1 inch =25.4 millimetres, then Sf inches =3f X 25.4, or 95.25 millimetres. The sign ' is used for foot, " for inch, and '" for line (or J% of an inch). Thus, distances of 5', 5", 5'", signify distances of five feet, five inches, and five lines. The same sign (') as for the notation of foot, and the sign " for the notation of inch, is used in other books, the former for angular minutes, and the latter for angular seconds. It is therefore better (and it is mostly practised in the different subjects) to write the denom- inational word after the number—-thus, instead of 5', 5", 5"', we write five feet, five inches, five lines. In the course of each subject, those abbreviations are given which are generally accepted by modern ophthalmologists. To save trouble to the reader, however, the words which are rep- resented by those abbreviations have been printed in full. It was thought necessary to give those abbreviations, since in many essays, etc., on ophthalmological subjects, they are made use of without explanation. I conclude with the expression of my sincere thanks to those whose valuable advice and assistance have been so freely ren- dered me in the preparation of the following work for publica- tion. My thanks are especially due to my friends. JOHN PHILLIPS. January, 1869. INTRODUCTION. Every one who examines or attempts to treat of the interest- ing subject of vision, finds himself compelled to exclaim in terms of highest admiration of the superior beauty and contriv- ance of its inimitable organs, the eyes. Whether we take into consideration the brilliancy of structure so remarkable in that organ, the complication and rapidity of its movements, or its exquisite sensibility, we are equally astonished and delighted. We have said that it is the most beautiful of all organs of the senses; it is, likewise, the most important and, therefore, the most valued. All the othjer organs are necessary to the well-being of the individual, but there is none so essential as that of vision. It is, evidently, the great inlet to the higher road of knowledge. It is capable of imparting to the mind information relative to objects so vast that the other senses cannot grasp them, and of bodies so minute as to elude the most delicate and refined tact. It recognizes objects, whether placed in the immeasurable wilds of space, or at a distance of a hair's breadth. Possessing such power, we perceive that it is with justice that the eye has been termed the "window of the soul." Its importance is further apparent, when we consider what a lengthened, tedious, and unintelligible account we receive in words, which, if directed to the eye, either actually or by rep- 1 9 INTRODUCTION. resentation, would be comprehended in all its bearings. Thus, we shall often obtain more information concerning objects at a single glance, occupying but an instant of time, than by a whole hour's description addressed to the mind through the ear. To man}T mysterious things must a blind man give credit, if he will believe the relation of those who can see. It requires no argument to prove that the loss of so impor- tant a function as that of vision is one of the greatest misfor- tunes that can befall us. It would appear still more incredible to such beings as we have supposed, if they were informed of the discoveries that may be made by this little organ, in things far beyond the reach of any other sense. That, by means of it, we can find our way on the pathless ocean, traverse the earth, determine its size and figure, measure planetary orbs, and make discoveries in the fixed stars. Would it not appear still more strange to these beings, if they should be further informed that, by means of this organ, we can perceive the temper, dispositions, affections, and passions of our fellow- creatures, even when they most desire to conceal them; that, by this organ, we can often perceive what is straight and crooked in the mind, as well as the body; that it participates in every mental emotion, the softest, as well as the most vio- lent; that it exhibits these emotions with force, and infuses into the soul of the spectator the fire and agitation of that mind in which they originate. It is not, therefore, without reason, that the faculty of seeing is looked upon as a more noble one than the other senses, as having something in it superior to sensation, as the language of intelligence, the evidence of reason, so-called; not feeling smelling, tasting; nay, we express the manner of the divine knowledge of seeing, as that kind of knowledge which is most perfect in ourselves. ADVICE ON THE EYE AND ITS DISEASES. IMPERFECT SIGHT. There is no branch of science of which it is more important that a general knowledge should be diffused, than that branch which treats of the various imperfections of sight, and the remedies for them. To relieve an organ which is the source of the most refined pleasure, is certainly a desirable object. To determine whether spectacles will be advantageous or detrimental, and what kind will best suit their sight; and so instruct those who already use glasses that they may discover whether those they have chosen are adapted to the imperfection of their sight, or are such as will increase their complaint and weaken their eyes, are subjects worthy the consideration of every individual, and constitute the principal business of this work. To this end, we shall, in the first place, explain what we mean by imperfection of sight. We here understand by imperfection of sight, an absolute or relative debility of it, without any opacity, either in the cornea or other internal part of the eye, and without disease of the retina or the optic nerve. The sight is relatively imperfect when we cannot see an object distinctly in a common light, and at the usual distance 4 ADVICE OX SHORT-SIGHTEDNESS. at which it is observed by an eye in the perfect state. In this sense, both the long and the short-sighted are said to have imperfect sight. The short-sighted see distant objects con- fusedly, those that are near at hand distinctly; their sight is, therefore, defective with respect to distant objects. On the other hand, the long-sighted see distant objects distinctly, and near objects confusedly. An imperfect sight is caused by a confusion in the image formed upon the retina. This happens when all the rays that proceed from any one point of an object are not united again in one, but fall upon different points of the retina; or whenever several pencils of light, from different points of an object, terminate upon one point of the image. This species of confusion takes place both in long and short- sighted eyes. An imperfect sight differs from an amaurosis or gutta serena; for in the latter, the sight is entirely lost, and the pupil becomes immovable; though if one eye remain sound, the pupil of the blind eye will move with the pupil of the sound one; but if the sound one be shut, the pupil of the blind eye will be destitute of its motion. SHORT-SIGHTEDNESS. Short-sightedness is that state of vision in which a person can see objects perfectly, only when they are at a very short distance from the eyes; nine inches, or less, being the greatest distance at which objects can be plainly seen. It is owing either to too great refractive power of the refractive media of the eye, or to the distance of the retina behind the crystalline being too great; so that in either case, rays of light come to a focus before arriving at the retina, cross, and are in a state of dissipation, when they do impinge on the nervous membrane, and therefore form indistinct and confused images. By bring- ing the object near the eyes, it is distinctly seen, because the rays from it, which enter the eyes, being now more divergent than when it was at a distance, are not so soon brought to a ADVICE ON SHORT-SIGHTEDNESS. 5 focus; in other words, the different points of the object, as foci of incident rays, and the focus to which these rays are brought in the interior of the eye by the refractive media, to conjugate focus, and accordingly, when the foci of incident rays are brought nearer the refractive media, the foci of refracted rays recede from them. Too great a refractive power of the media of the eye may be owing either to too great a convexity of their curvatures— the curvatures of the cornea and crystalline—or too great refractive density, or both conjointly. The situation of the retina at too great a distance behind the crystalline body may be owing either to a preternatural elon- gation of the eyeball, or to the lens being nearer the cornea than usual. In short-sightedness, the power of adjusting the eye to differ- ent distances is still retained, but within certain limits, thus: the nearest distance may be from two to four inches, the fur- thest from six to twelve inches. The peculiarities of short-sighted persons are: 1st. They see small objects more distinctly than other people, because, from their nearness, the objects are viewed under a longer visual angle. 2d. They see them also with a weaker light, because the object being near, a greater quantity of rays from them arrive at the eye. Hence, they can read small print with a weak light. 3d. But they can also eee more distinctly, and somewhat further off, by a strong light than by a weaker one, because the pupil is contracted by the strong light, and all but the more direct rays of light thereby excluded. On the same principle, they see at some distance distinctly through a pin-hole in a card; and when they try to view distant objects, they half close their eyelids. The rays of light in these cases have their divergence at the same time somewhat increased by diffraction. 4th. They sometimes see objects beyond the limit of their distinct vision, double, and sometimes multiplied. Subjects of Short-sightedness.—■This defect of vision seldom 6 ADVICE ON SHORT-SIGHTEDNESS. occurs in so great a degree before puberty as to be troublesome; when in a great degree in children, it may be a symptom of a central cataract. After puberty, when the eyes come to be used in earnest, short-sightedness is usually first discovered to exist, and it may go on gradually increasing, especially if a person use his eyes much in reading, and on minute objects; as the greater fre- quency of short-sightedness among the educated classes and those whose occupation with minute objects will show. Myopia sometimes occurs in old persons, whose vision was previously good for ordinary distances. To persons whose occupation is with minute objects, short- sightedness, unless in a very great degree, is rather an advan- tage, as they are enabled to observe all the details of their work very accurately; and in the ordinary exercise of vision, the use of concave glasses is a ready and simple help. When a tendency to short-sightedness manifests itself m young persons, and especially if the future occupation of the person is to be of a kind requiring good vision for distant ob- jects, much exertion of the eyes on minute work should be avoided, and the eyes exercised on large and distant objects. Concave glasses help the vision of short-sighted persons for distant objects, simply by increasing the divergence of the rays of light before they enter the eye, so that they may be less speedily brought to a focus than they would otherwise • have been, in consequence of the increased refractive power of the media of the eye; or, supposing the refractive power of the media of the eye not increased, but the distance of the retina behind the lens increased, that they may be brought to a focus at a greater distance behind the lens than it would otherwise have been, in order to correspond with the greater distance o-f the retina behind the lens. Concave glasses are made of dif- ferent degrees of concavity; the shallower being those adapted for the slighter degrees of short-sightedness, the more concave for the greater degrees. When very short-sighted, a person requires the use of con- eave glasses, not only to be enabled to see distant objects, but ADVICE ON SHORT-SIGHTEDNESS. 7 also for reading with, in order to avoid the necessity for stop- ping. Less short-sighted people use glasses only to see distant objects. The focal length of the concave glass which a person will require to see objects at more than two or three hundred yards distance, should be equal to the distance at which he can see to read distinctly an ordinary type with the naked eye six inches, for example. The focal length of a concave glass which a very short- sighted person will require to read at a convenient distance is determined thus: suppose he can see to read with the naked eye* at the distance of six inches, and desires to be able to read at the distance of twelve, the one distance is to be multiplied by the other, and the product, seventy-two, divided by the dif- ference between the two distances, viz., six. The quotient, twelve, is the number of inches the focal length of the glass required should be. The following are the circumstances which should guide him to his choice: The glasses should be the lowest power which will enable him to distinguish objects as he wishes, quite readily and clearly, and at the same time comfortably. If they should make ob- jects appear small and very bright, and if in using them the person should feel his eyes strained or fatigued, or if he becomes dizzy, and if, after putting them aside, the vision is obscure, they are not fit for his purpose, as they are too con- cave. Having once fitted himself, a person should not too hastily change his glasses, although they may appear not to enable him to see quite so clearly as when he first used them. A glass to each eye should always be used; vision is by this means clearer, and its exercise less fatiguing to the eyes, than when a glass to one eye only is used. The use of a glass to one eye only is, in fact, very detrimental, especially to the opposite eye. Appearance presented by the Eyes of Myopic Persons.—In many cases, there is nothing peculiar to be observed; but fre- quently the eyes are prominent and firm, the cornea very con- 8 ADVICE ON SHORT-SIGHTEDNESS. vex, the anterior chamber deep, the pupil dilated, the crystal- line lens more convex, and the "pigmentum nigrum" more diluted and of a higher color. TREATMENT. There is a peculiar condition of sight liable to be mistaken for myopia, but which I am inclined, with Dr. Walker, to refer to a congenital weakness of the retina. Such persons cannot see distant objects as well as other people; but they can distin- guish tolerably large distant objects better than small ones, and the effort required to make out small type is frequently productive of fatigue in the eyes. As they habitually approach objects nearer the eyes than natural, they pass for near-sighted people. But these are the points of difference: a true myope, having found his points of distinct vision, can read or write for any length of time, without fatigue, and can see clearly, even in a feeble light. This vision of distant objects, too, is mate- rially assisted by the use of concave glasses. The amblyope (as the other may be called, from the dulness of his sight,) always requires a strong light, and that only for a short time. Concave glasses, instead of assisting, rather con- fuse his vision, and diminish objects. Convex glasses of a low power, on the other hand, rather assist him. In such cases, slightly magnifying glasses may, by increasing the dimensions of small objects, diminish the fatigue of the eyes; but they should not be granted without due caution. I have known instances of children having been punished for supposed stupidity, they not learning to read as quickly as others, but slowly and with many mistakes, blundering over their spelling. This really depends, in some cases, on imper- fect sight, and the child, with every desire to do his best, is unable to distinguish the letters quickly. In these cases, en- couragement, rather than punishment, is needed; the child should have large type, plenty of light, and not be kept at his lessons too long at one time; his general health should be strengthened, and the eyes and head freely bathed in cold water two or three times a day, and twenty drops of muriated ADVICE ON SHORT-SIGHTEDNESS. 9 tincture of iron twice a day. The question often arises, as to whether young boys should be sent to public schools. I am quite of the opinion that those laboring under defective vision should not. For, being physically unable to compete with other boys, they are placed in a false position; whilst it is quite im- possible that they can receive from the masters that patience and attention necessary for their advancement. Thus, they are kept back in every respect, are laughed at by schoolfellows, and the unfair character of dunces allotted to them. That a power of adjusting the focus of the eye to different distances exists in the healthy eye, is proved as follows: Let a person place a couple of thin objects fifteen or twenty yards asunder, in a line with one eye (the other being shut), and let the nearest object be a yard from the eye; on fixing the eye on the nearest object, he will perceive the distant one to be indistinct, and on looking at the distant object, the near one will become indistinct; and on each change of the object of the vision he will become conscious of an alteration in the adjustment of the anterior of the eye. If, then, a person employs himself for long periods together, and that for successive days, in reading, microscopical observa- tions, or other pursuits requiring close application, he becomes, not strictly near-sighted in the general acceptation of the term, for he does not hold objects much nearer the eyes than usual, but he finds that he discerns distant objects less and less dis- tinctly. In fact, he finds that the eyes being exercised so much in adjusting the focus for near objects, lose the power of adjustment to the focus for distant objects. The prevalence of concave spectacles among the Americans, who are great readers, is proverbial; and many must have noticed the same prevalence at our universities. Mr. Ware found, out of 127 students in one college in Oxford, 32 who used either a hand-glass or spectacles. Indeed, I believe that few persons of studious and sedentary habits entirely escape the consequence of their labors. The public are little aware of the extent to which the studious, and those who live by the exercise of their intellect, suffer from imperfection of sight. 10 ADVICE ON SHORT-SIGHTEDNESS. Many instances have fallen under my notice, of poor students and writers whose poverty compelled them to pursue their lit- erary avocations in the gloom of dusky apartments, or by the aid of a dim candle, and who have become myopic and ambly- opic in consequence. And scarcely less numerous, are those who, though pursuing their labors under more favorable circum- stances, are equally visited with this affliction. It would ap- pear that even the study of ophthalmic science may cause the same penalties to be paid; for M. Desmarres informs us, that one of his pupils became very myopic by exerting his eye too much in the diagnosis of diseases of the eye; a sad result of most rare industry! The progress of this infliction is generally by insensible de- grees, and it often happens that the person in whom it is com- mencing is warned of it more by bis own feeling than by the remarks of others, who notice that, when studying or regarding objects, he holds his face nearer than itkwas his wont. After a time, however, he is sensible that he cannot distinguish dis- tant objects as quickly as formerly; that the eye does not seize them at once, and when seen they are indistinct; and when the affection has made still more progress, they cannot be seen at all. If, in the very earliest stage, a low convex glass be held to the eye, vision is rather assisted; but when the abnormal condition is established, convex glasses cease to render aid, and concaves are required. If this affliction is induced in an adult, whose eyes have been previously strong, it may be overcome without much difficulty, if taken in time; but when the subjects of it are feeble, stru- mous youths, in whom the intellectual powers are more vigorous than the bodily, and who have, perhaps, suffered in infancy from constitutional weakness of the eyes, the case is much more unmanageable, and the prospects of cure much less favorable. The popular idea that the eyes of near-sighted persons are rendered fitter for seeing as they advance in years, is not borne out by experience. The subject has been investigated by Dr. Walker, whose astute mind is well qualified for such inquiries, says: "It has been very generally, if not universally, asserted ADVICE ON SHORT-SIGHTEDNESS. 11 by systematic writers on vision, that the short-sighted are ren- dered by age fitter for seeing distant objects than they were in their youth; but this opinion appears to me unfounded in fact, and to rest altogether upon a false analogy. If those who pos- sess ordinary vision when young, become, from flatness of the cornea, or other changes in the mere structure of the eye, long- sighted as they approach old age, it follows that the short- sighted must, from similar changes, become better fitted to see distant objects. It is generally supposed that the short-sighted become less so as they advance in years, and the natural shrinking and decay in the humors of the eye lessen its convexity, and thus adapt it better for viewing distant objects; but among the great number of short-sighted people that I have accommodated with glasses, I have never found the reverse of this theory to be true, and the eyes of myopes never required glasses less con- cave, but, generally, more concave, as they grow older, to enable them to see at the same distance. I have lost no opportunity of inquiring of myopic persons whether their sight had improved, and I cannot call to mind a single instance in which the reply was decidedly in the affirma- tive. One case, especially, occurs to me: A lady, 82 years of age, who is a patient of Dr. Walker's, told me that, as long as she could remember, she had used No. 8 myopic glasses, and that, with them, she could read the smallest type and thread a needle with the greatest facility; but, most decidedly, her sight had not changed, as to focus, within her recollection. I exam- ined her eyes and glasses very carefully, and satisfied myself of the power of the latter. One of the most frequent questions of patrons at my office is, "Do you think, sir, that spectacles will be of use to me?" It matters little whether the sight be impaired by overwork, by congestion, by debility, or by opacities of the cornea; the same idea is current in the minds of the poor. They often try them, and if they do not find assistance from ordinary spectacles, they take to colored glasses, green or blue, as an improvement on the former. I need scarcely say, unless really called for, spec- 12 ADVICE ON SHORT-SIGHTEDNESS. tacles do more harm than good; and, for reasons hereafter to be given, such colored glasses are inadmissible; not only are they injurious and exciting complimentary colors, but they are apt- to render an eye over-susceptible to light, and if there be retinal congestion, it cannot fail to be aggravated by the addi- tional effort to see objects but dimly illuminated; therefore, in cases where the sight is impaired, but where no intolerance of light exists, the habitual use of colored glasses is highly objectionable. I have noticed that young persons, about the age of puberty, after severely trying their eyes upon minute objects, as in paint- ing, embroidering, and the like, suddenly become short-sighted. They and their friends are alarmed at their being no longer able to see objects on the opposite side of the street, which a few days before they were able to distinguish with ease. The effort necessary for seeing small objects is attended with pain, and, instead of fifteen or twenty inches, at which the patient used to read, the book must be brought as near to the eyes as six or eight inches. Sudden myopia is most apt to occur in boys sent to learn such trades as watchmaking or engraving, or in young ladies at school occupied with music, painting, em- broidering, and other pursuits requiring continued and keen employment of sight. In these cases, the intense application has temporarily paralyzed, as it were, the adjustment to dis- tant objects, and the proper course to pursue is, to give the eyes rest for a few days, when they will recover their natural condition. Frequent bathing of the eyes with cold water will relieve any congestion of the vessels. I have also found great relief by applying concentrated tincture of capsicum, by rub- bing it for a few minutes, daily, over the forehead and temples with a sponge; but care should be taken not to allow it to enter the eye. The circumstance of eyes differing in their focal length is a common occurrence, and needs but a few words on the proper course to be pursued. There is a very general impression that one eye is stronger than the other, the right being supposed to be the strongest, partly, perhaps, from its being preferred for ADVICE ON SHORT-SIGHTEDNESS. 13 looking at objects when one eye only is required, as in taking aim in shooting, using a microscope or telescope, etc. Conven- ience has much to do with this, the right arm and the right eye corresponding in action; when, however, there is really a dif- ference in the vision of the eyes, it may be found how far this depends on the focal length, by placing an open book at the ordinary reading distance. We also occasionally find that one eye will be myopic and the other presbyopic, a condition of vision embarrassing both to the patient and to the surgeon, but the nature of which may easily be ascertained by a careful trial with glasses, and look- ing at the page with the eyes alternately, the one not used being closed. Supposing, then, that the type appears distinct to the right eye but confused to the left, the book should be slowly drawn nearer, and if the focus of the left eye is shorter than that of its fellow, the type will become distinct at a cer- tain distance; one or more inches less than the ordinary dis- tance. To make the point more certain, the vision of the left eye can be made equal with the other, by holding before it a slightly concave glass if the difference be trifling, or a higher power if the inequality be great. It is important to all persons, but especially to the young, and to those whose position in life requires much exercise of the eyes, that they should have the benefit of both, and that all the labor should not be thrown on one, as necessarily hap- pens in the condition of vision under consideration, a condition sometimes produced by the carelessness of inferior opticians or the hawkers of cheap spectacles, who sell lenses of different focal lengths in frames intended for persons whose eyes are equal; or who supply those eyes in which there is an inequality in the foci with duplicate glasses, rendering, in each case, one eye useless. In early life, the vision of the eyes may often be brought into harmony by blindfolding the perfect eye and patiently practis- ing the other at the utmost distance, increasing that distance by small but steady degrees, avoiding rapid or vacillating changes. If this does not suffice, practise, with lenses hereaf- 14 ADVICE ON SHORT-SIGHTEDNESS. ter to be described, will be proper: but if circumstances pre- vent the exercise being satisfactorily carried out, it will be necessary to have a spectacle frame made with a lens for the imperfect eye, just sufficiently strong to equalize the vision. The circle before the perfect eye should be blank, but, in order to counteract the weight of the lens (which would throw the frame out of its proper position), the empty side of the frame should be made heavier than the other. Near-sighted persons are very apt to stoop while engaged in study. To avoid a practice so injurious to the figure and health, they should use a high desk when reading or writing; and if glasses are indispensable, such only should be used as just suf- fice to enable the parties to pursue their occupations at the ordinary reading distance, that of fourteen inches. Small type, sketchings, microscopical pursuits, and objects requiring close inspection, should be avoided; the individual should over- come his natural tendency to a cramped hand, and write boldly and freely; and be the pursuit what it may, in which he is engaged, the greatest possible distance should be maintained between his eyes and the object. In all cases of myopia, and especially in early life, or when the affection is just commencing, it is highly important that any tendency to an over-supply to the eyes .should be counter- acted by a proper amount of bodily exercise, and every oppor- tunity should be embraced for exercising the eyes on distant objects. Near-sight is comparatively rare in persons engaged in agricultural pursuits, and. is almost, if not quite, unknown among those uncivilized nations whose eyes are constantly practised in nomadic warfare or the chase. Near-sight may be acquired in early youth, by the habit common to infants, of approaching their eyes very close to any object on which their attention may happen to be engaged. Observe a group of children learning to write or draw, almost all with their faces sideways and their tongues in one corner of their mouths, nearly touching with their cheeks the paper or slate on which they are laboriously accomplishing their task. Many infants have been rendered short-sighted, and many have ADVICE ON SHORT-SIGHTEDNESS. 15 acquired squints, from constantly playing with toys; for, as the visual axis converges when objects are held near the eyes, fre- quent repetition of this may end in strabismus. And I may here remark, that strict attention should be paid to the position of an infant's sleeping cot, and to the attitude in which it is placed in its nurse's arms. The eyes of the infant ever seek the light, and many an unsightly cast has been entailed on a child by its being always placed with one and the same side to a candle or a window. The light in the nursery should not be too much on one side of the cradle, nor should a candle or lamp, in the evening, be so placed that the eyes of the child are dis- torted when looking at it. There is sound judgment in print- ing children's books in good, bold type, in encouraging them to observe distant objects, and in inviting them to describe what they see in landscapes. Near-sighted children are often fond of books, and love to pore over some favorite story, in a quiet corner, for hours to- gether. They should be watched, and compelled to hold their heads ten or twelve inches from the page, and the same in the schoolroom. Such children are obliged, during music lessons, to lean forward in a very unseemly manner, to distinguish the notes. To obviate this, a sliding bookstand should be attached to the piano, and should be drawn forward when the child is practising. As, however, some musical instruments will not admit of such an arrangement, spectacles of a low power may be used at that time, and at that time only; and the lesson should not exceed half an hour, without a pause of a few min- utes for the eyes to rest. Insufficiency of light in rooms where children receive instruc- tion, or where they are taught mechanical work, is a cause of near-sight, and, occasionally, even more serious mischief. Care should, therefore, be taken that school and working rooms should be properly and sufficiently lighted. 16 ADVICE ON FAR-SIGHTEDNESS. FARSIGHTEDNESS. To detail those circumstances which are, in general, marks of advancing age, and always of partial infirmity, must be ever unpleasant, and would be equally unnecessary, if it were not for the means of lessening the inconvenience attendant on those stages of life. By long-sightedness, remote objects are seen distinctly, near ones confusedly, and, in proportion, as this increases, the nearer the objects, the more indistinct they become, till at length it is found almost impossible to read com- mon-sized print without assistance. An imperfect image is formed upon the retina, because the rays of light which come from the several points of an object, at an ordinary distance, are not sufficiently refracted, and, therefore, do not meet on the retina, but beyond it. Various are the causes which may occasion this defect: If the convexity of the cornea be lessened, or if either side of the crystalline becomes flatter, this effect will be produced; if the retina be not sufficiently removed from the cornea or crystalline, or if the retina be too near the cornea or crystalline, it will give rise to the same defect, as will also a less refractive power in the pellucid parts of the eye. In like manner, too great proximity of the objects will prevent the rays from uniting till they are beyond the retina. But if all these causes occur together, the effect is greater. This defect is, h&wever, in general, attributed to a shrinking of the humors of the eye, which causes the cornea and crystalline lens to lose their original convexity, and become flatter. The same cause will bring the retina too near the cornea. Another change which the eye undergoes in age, is the impairment of its power of adjustment. As we advance in life, not only does the refractive power of the eye diminish, but we lose the power of accommodating the organ to near objects. The eye, in its state of perfect indolent vision, is adapted only to distant objects, and it cannot see near objects dis- tinctly but by an effort. This effort, long persevered in, be- ADVICE ON FAR-SIGHTEDNESS. 17 comes painful, whereas, the regarding of distant objects can be continued without any feeling of fatigue. The power to make the peculiar effort in question, is partially or totally lost by the presbyopic eye; a fact analogous to the diminished activity which takes place in all the functions of the body as life advances. The symptoms of presbyopia, then, are: Difficulty in dis- cerning close objects; so that a person who, in early life, could read ordinary print, with ease, at twelve or fourteen inches, is now obliged to hold a book two feet, or even further, from his eyes; and the act of threading a needle, or nibbing a pen, be- comes fatiguing to the eyes, if not almost impossible, excepting when assisted by an increase of light. Employing them at fine work for any considerable length of time, induces headache and uneasiness about the brows and forehead. These symp- toms may be accounted for thus: In consequence of the object being removed to a greater distance, the visual angle, the quan- tity of light, and the picture on the retina become smaller; so small, indeed, as to render it difficult for the retina, with its impaired sensibility, duly to appreciate it without effort and a considerable increase of light. The diminished size of the pupils, which attends declining years, increases the necessity for more light. With this state of vision the person can see objects distinctly only when they are at a very considerable distance from the eyes; in reading, for example, he holds the book at arm's length. Far-sightedness being in almost all respects the converse of short-sightedness, the best way of discussing it here will be to reverse the account given of short-sightedness, and which will therefore stand thus: Far-sightedness is owing either to diminished refractive power of the refractive media of the eyes, or to the distance of the retina behind the crystalline body being too short; so that in either case the rays of light tend to come to a focus at a point behind the retina, on which, therefore, they impinge in circles of dissipation, and form indistinct and confused images. 2 18 ADVICE ON FAR-SIGHTEDNESS. By removing the object from the eyes, it comes to be dis- tinctly seen, because the rays from it which enter the eye, be- ing now less divergent than when it was near, are more quickly brought to a focus; in other words, the different points of the object as foci of incident rays, and the foci to which these rays are brought in the interior of the eye by the refractive media, are conjugate foci; and accordingly, when the foci of incident rays are removed from the refractive media, the foci of refract- ed rays come nearer them. Diminished refractive power of the media of the eye may be owing to diminution of the convexity of their curvatures, flat- tening of the cornea and crystalline. As to refractive density, there is probably an increase rather than a diminution of it, but this appears to be more than overbalanced by the diminution of curvature. The situation of the retina too near the crystalline may be owing either to a preternatural shortening of the axis of the eyeball, or a receding of the lens from the cornea. In far-sightedness, the power of adjusting the eye to different distances is much weakened. In this respect far-sightedness differs from short-sightedness, in which the power of adjust- ment is still retained. In far-sightedness, it may be said that the habitual adjustment of the eye is for distant objects, and that in trying to read, for example, the power of adjustment is exerted to the utmost; hence the fatigue and confusion of vision which soon ensue. Appearances presented by the Eyes of Far-sighted People.—In many cases, there is nothing peculiar to be observed; but fre- quently the eyes are sunk, the cornea flat, and of small dia- meter, and the pupil contracted. Peculiarities of Vision of Far-sighted People. — 1. They see small objects indistinctly at every distance, because when near they are out of focus, and when removed from the eye some- what they are seen at a small visual angle and with little light. By increasing the light, they see better. Hence, they do not see so well by candle-light as before, and when attempting to read by candle-light, they place, perhaps, the candle between I ADVICE ON FAR-SIGHTEDNESS. 19 them and the book held at arm's length. 2. They see large and distant objects very distinctly. 3. In most presbyopic persons, Dr. N. Arnott has ascertained that double vision in the eyes singly exists in a slight degree. Subjects of Far-sightedness.—Far-sightedness seldom occurs except in persons who have passed middle age, and in them it is so common, that it is to be viewed as a natural change in the state of the eye. As it occurs in young persons, it will be spoken of under the head of Asthenopy. Prevention and Treatment.—Though instances have occurred of persons who have been long presbyopic, recovering their for- mer vision, and thereby being enabled to lay aside the use of their spectacles, recovery from presbyopy is not to be calculated on; but this is of small moment, as vision can be so perfectly assisted by means of spectacles. Something, however, may be done in the way of preserving the sight by avoiding over-exer- tion of the eyes in reading and other minute work, especially by artificial light, at the time of life when far-sightedness, with diminution of adjusting power, usually comes on. Convex glasses help the vision of far-sighted people for near objects, by diminishing the divergence of the rays of light be- fore they enter the eye, so that they may be more speedily brought to foci than they would otherwise have been, in conse- quence of the diminished refractive power of the eye; or, sup- posing the refractive power of the eye not diminished, but the distance of the retina behind the lens diminished, that they may be brought to foci at a less distance behind the lens, than they would otherwise have been, in order to correspond with the diminished distance of the retina behind the lens. Convex glasses are made of different degrees of convexity: the least convex being those adapted for the slighter degrees of far-sightedness, the more convex for the greater degrees. To see distant objects, far-sighted persons do not, in general, require convex glasses. It is most commonly to enable them to read and do minute work that far-sighted people use spectacles. If it is only at a very great distance that a person can see distinctly, the focal length of the convex glasses which he will 20 ADVICE ON FAR-SIGHTEDNESS. require to enable him to read will be equal to the distance at which he wishes to see to read. If he is not so very far-sighted, but can see small objects dis- tinctly at twenty inches distance, for example, the focal length of the convex glasses which he will require to enable him to read at twelve inches distance, is determined by multiplying the two distances together, and dividing the product, 240, by the difference between them, viz.: 8. The quotient, 30, is the focal length in inches of the glasses required. The following are the circumstances which should guide him in his choice:—The glasses should be of the lowest power which will enable him to see objects distinctly as he wishes, and at the same time comfortably. Glasses which make the objects ap- pear larger than natural, and strain and fatigue the eyes and cause headache, are not adapted to his case—they are too con- vex. It is usually found that glasses the next degree more convex are required for work by artificial light. The alteration in the eye on which the far-sightedness de- pends, generally goes on to increase with age; hence it is neces- sary, after a time, a few years, to change the glasses first chosen for others more convex. In regard to this exchange it is to be observed, that it ought not to be too hastily had recourse to, nor, on the other hand, too long delayed. The same feeling of necessity which first prompted to the use of glasses, will indi- cate the necessity of change. It is a not uncommon notion that glasses of certain focal lengths are adapted to certain ages, but this is erroneous. Still, though the choice of glasses cannot be determined by the mere age of the person, there is a certain average relation be- tween the age and the focal length of the convex glass required, which is expressed in the following table: Age in years---------40, 45, 50r 55, 60, 65, 70, 75, 80, 85, 90 100 Focal length in inches,__36, 30, 24, 20, 16, 14, 12, 10. 9' 8 7 Q Reading Glass.—This is a double-convex lens, broad enough to permit both eyes to see through it. It is used for the pur- pose of magnifying the object; whereas, convex spectacles are used merely to render objects distinct at a given distance, with- out magnifying them as above mentioned. ADVICE ON FAR-SIGHTEDNESS. 21 The color and consistence of crystalline humor alters with age: it is thicker, cloudy, and less transparent as we advance in years; which is one reason, among others, why many elderly people do not reap all the benefits from spectacles which we might naturally expect. There is, usually, little in the appearance of the eyes to account for the changes. This, indeed, may be expected; for although the cornea, in the majority of cases, is, perhaps, some- what diminished in convexity, yet it is not perceptible. The inefficiency of the eyes probably depends less on the altered form of the cornea, than upon that of any other media of the organ, especially of the crystalline lens. The eyes of an old person are commonly sunken in their sockets; but this is de- pendent upon the general absorption of the adipose tissue of the orbits, as well as of the body generally, which is one of the phenomena of age. It is the diminution of the aqueous con- tents of the globe, in combination with peculiar changes in the lens, which becomes denser and less convex, of diminished transparency, and more or less of an amber hue, which influ- ences the refractive powers. As age creeps on, the "pigmen- tum nigrum" (to which the blackness of the pupil is due) dimin- ishes in quantity, giving to the pupil a greenish or grayish hue, which, to an inexperienced eye, might be mistaken for incipient cataract or glaucoma. The cornea becomes less transparent, a white circle, called "arcus senilis," forms around its margin, the colors of the "iris" fade, and the nervous power of the eye becomes less energetic. The period of life when presbyopia displays itself, is the same as that at which hard cataract commences; and I have seen many cases where the imperfections of vision caused by the decay of the lens has been confounded with presbyopia. These facts make it clear that a protuberant eye is not so well constituted for vision as one that is sunk in the head; nei- ther extreme is, indeed, desirable, yet, undoubtedly, of the two, that which is deep set is preferable, as affording the clearest sight, and being least liable to injuries from external accidents and of light. 22 ADVICE ON FAR-SIGHTEDNESS. TREATMENT. The sun of our animal existence has been wisely ordained to travel at so slow a rate that its progress is almost impercepti- ble, and so ardently do we love to bask in its rays, that when Time whispers to us that he has passed the meridian, we vainly endeavor to persuade ourselves that he may have mistaken the point of his culmination. I have already said that the failure of the sight is one of the earliest symptoms of declining years, but there is a strong dis- inclination to admit this failure; at any rate, we are not will- ing to proclaim it by adopting glasses. Their use, however, should not be deferred; for, although it is a common notion that spectacles are injurious to the eyes (and no doubt they are so, if those of an improper description be employed), yet, when the powers of the eye begin to fail, so that we can neither read nor write for any length of time without great discomfort, it is reasonable to conclude that refraining from their use is more injurious than their adoption. 2d. We, therefore, who prize the most valuable gift of nature, should be less anxious as to what others may think of our age, than for the preservation of so valuable a possession. 3d. The term "preservers," applied, as it is, to the lowest description of convex glasses, alone tends to convey the idea that if such glasses are used in time, they prevent any further changes in the eye. This is erroneous; and it is to be regret- ted, that the lowest magnifying power should have received that appellation, for all glasses are preservers, if well adapted to the eye; whereas, by applying that term to those particular glasses alone, thousands are induced to use them before they really require them,, which is productive of injurious conse- quences, inasmuch as, by assisting the eye before it requires help, it encourages it to be indolent in its action. As a gen- eral rule, spectacles always act beneficially when they afford just so much assistance to the eye in its attempt at adjustment as enables it without fatigue to form a distinct picture upon the retina, rather than beyond it. ADVICE ON FAR-SIGHTEDNESS. 23 Some refrain from the use of glasses who really require their aid, from the belief that if they once begin to use them they will never be able to leave them off. In the great majority of cases, this is perfectly true; but, even then, it is better to sub- mit with a good grace to an affliction which can seldom be averted, and to have recourse to those simple means which at once set the eye at ease and enable its possessor to enjoy many hours of comfort and rational employment, which would other- wise be lost. Daily experience teaches us that the decay of vision is has- tened by many causes, which are frequently overlooked. Al- though it is about the age of 40 that the sight begins to fail, yet we find some persons who attain extreme old age Avithout needing glasses at all. Other persons, on the contrary, require glasses at the age of 30; and though much depends on constitu- tion, much also depends upon the person's habits. One of the worst habits, is that of overworking the eyes by candlelight. Repose from labor, so necessary for the restora- tion of tone and vigor to the several organs of the body, is too sparingly granted to the eyes. Some, from a desire to distin- guish themselves; others, urged by necessity, encroach upon the hours of rest, and overtax the sight without mercy by lamp or gas work. To the poor, but working classes, medical treat- ment, when the eyes are thus oppressed, affords only temporary relief; the return to similar habits, however necessary, invaria- bly brings back the same disease, and, by its repeated attacks, vision is sooner or later destroyed. Let us hope that the ad- vancing spirit of the age will arrest so crying an evil. The following remarks are addressed to the former class; to those who from motives of ambition, or from love of study, neglect those ordinary precautions, without which the eyes will inevitably suffer: Let it be remembered that day-work is preferable to night- work; that while the light of a candle or lamp is trying even to the strong eye, the moderate light of the sun is strengthening to it. Those whom circumstances compel to study in the even- ing, should select that kind of work which is least distressing 24 ADVICE ON FAK-SIGHTEDNESS. to the eyes. They should especially avoid indistinct writing or small print; the diamond edition, in which the print is ex- tremely small and very injurious to the eves. Persons who write much, especially in the evening, should use blue wove paper in preference to that of the yellowish- white description, to which the term "cream laid" is applied. There is a paper of a deeper blue than ordinary, which is very agreeable to irritable eyes, for writing by artificial light. Jet-black ink is far better than blue or fancy shades of pur- ple, brown, etc. Pale ink is altogether bad, and the fair sex, especially, would do well to bear in mind that they would show the most kindly consideration for their correspondents and ben- efit their own sight, by using good black ink, and, I may add, writing legibly. Red ruled lines, when in any number on a page, are objec- tionable. It is wise to change the position occasionally, during hard study; to write, sometimes standing, and other times sitting; and to break the labor, now and then, by walking about. The simple plan of raising the eyes from the sheet or page and fix- ing them for a few seconds on the cornice at the other side of the room, so that the adjustment of vision may be altered, can- not be too strongly recommended. Persons with feeble sight or irritable eyes should not sleep with their couches facing the window, nor should their writing- tables be in that position. There is another thing to be espe- cially avoided by such parties, namely: reading whilst travel- ing in a railroad carriage. The peculiar vibration imparts an unsteadiness to the page which is most trying to the eyes, and more than one person, to my knowledge, has suffered from this thirst for knowledge, during daily journeys to and from the town. Reading by firelight, or simply gazing at the fire when sit- ting alone, or in a contemplative mood, is highly injurious to feeble eyes, and should be avoided by all. It is not advisable to read by twilight; too little light is as pernicious as too much ADVICE ON FAR-SIGHTEDNESS. 25 light. Yet, many persons, evening after evening, try their eyes in this way, rather than burn a candle or lamp. It is injurious to the eyes to be long exposed to th6 reflection of a strong light, whether artificial or natural, such as the reflected sunshine from the page of a book; too brilliant a light produces undue excitement of the eyes. Travelers in African deserts find it necessary to protect these organs from the sun's rays by a piece of crape. The inhabitants of some Eastern countries, for the same purpose, anoint the edges of the lid and the eyelashes with a black pigment, composed of oxide of antimony and oil, which has the effect of subduing the light, and, at the same time, improving the personal appearance. The inhabitants of the Arctic regions ingeniously protect their eyes from the light reflected from the snow, by wearing in front of the eyes a long and thin piece of wood, perforated by two long horizontal slits, one corresponding to each eye. By means of this simple contrivance, just such a quantity of light is permitted to enter the pupil as will suffice for vision. To preserve weak eyes as much as possible from a strong light, neutral tint spectacles are preferable. Many physicians recommend wire goggles, which absorb the heat and overheat the eye, and I have seen many eyes injured by using them. In reading or writing, just that amount and quantity of light, whether natural or artificial, should be allowed, which, while it thoroughly illuminates the objects, feels grateful and pleasant to the eyes. This desideratum can never be obtained without due regard to the position of the light. The light cast upon a book, whilst the candle or lamp is in front, is by no means pleasant, and the glare of the flame is very trying to weak eyes. It will be found that if the candle or lamp be placed a little above and back of the reader and slightly to one side, the most pleasant and least injurious effect is produced; for the light when reflected to the eyes is least distressing, and, at the same time, the eyes are perfectly protected from the heat and glare of the flame. The habit, common with far-sighted persons, of drawing the candle to them, and holding the book they are reading close to 26 ADVICE ON FAR-SIGHTEDNESS. it, has reference to the need which then exists for strong light. Eyes, when far-sighted, require more light than younger eyes; and judgment is required to secure this without overdoing it and stimulating the organs too much. It would be well, if in public buildings more attention was paid to the position of the lights. It is very distressing to sit in a gallery, immediately in front of a gas-burner or lamp, for an hour or more; the eyes frequently do not recover from the irritation thus excited for several days. Not only might the evil be easily removed, by employing lights of greater power, properly subdued and placed near the ceiling, but there would be a great advantage gained from the increased purity of the air. Sudden transition from gloom to strong light should be avoided. The dazzling effect produced when we come suddenly from darkness to light, arises from the pupils having been widely dilated to admit the greatest number of luminous rays whilst in the gloom; as the pupil of the eye requires time to contract, sudden transition from comparative darkness to a bright light compels the eye to admit far more rays than is agreeable, or it is calculated to bear without injury; tempo- rary dazzling and a sensation of pain is excited in consequence. So weak and susceptible do the eyes become, if kept for a long time in darkness, that the ordinary light of day is distressing to them. I have frequently been consulted by patients labor- ing under this morbid sensibility, sometimes, from having been kept for a long time in a darkened room: at other times, from having injudiciously covered up the eyes with a bandage or shade, in hope of subduing an inflammation. The working classes are fond of binding up their eyes or those of their chil- dren, if attacked with any disorder, whether attended with in- creased sensibility to light or not. It is difficult to convince them of the necessity of taking the bandage off, and, by de- grees, to accustom the eyes to the stimulus of the light. The following are the circumstances which should guide them in their choice of glasses: The glasses should be of the lowest power which will enable them to see objects as distinctly as they may wish, and, at the same time, comfortably; glasses ADVICE ON FAR-SIGHTEDNESS. 27 which make objects appear larger than natural, and strain and fatigue the eyes and cause headache, are not adapted to their case. There are two convex glasses used, the double convex being preferred. The lowest power in ordinary use in England has a focus of 48 inches; but in France, very much lower pow- ers are used. M. Sichel commences with a 72-inch, and in some cases with a 96-inch. Mr. Andrew Ross, however, whose experience as an optician is well known, has informed me that, in the course of his business, he has met with but one person who could perceive any sensible difference between those two powers, as far as assistance to sight was concerned. It is quite possible that, in the early stage of far-sightedness, a 72-inch glass may be sufficient, and if found to be so, it should be by all means preferred to a higher number; but, practically speaking, a 48-inch is that most usually required, because persons in this country seldom seek assistance until the far-sightedness has advanced beyond the aid of a 72-inch glass. It cannot be too strongly urged upon any one about to use spectacles for the first time, that that power which will enable them to read without much exertion by candlelight, is the only one suitable for them. It is only by candlelight that glasses should be used at first; and as soon as they find that they stand in need of glasses by day, as well as by gaslight, and that the glasses which they use no longer afford them sufficient assist- ance by gaslight, it will be proper to use the next power for the evening, but for the evening only, and to allow themselves the use of the others only during the day. The greatest caution, as to increasing the power, should be observed, for persons who change their glasses unnecessarily, increasing the power each time, are exhausting the resources of art, instead of economizing them as much as possible. Optical aid can only be extended to a certain point, and the steps to that point should be as slow and as numerous as possible. By exercising prudent precautions, persons may attain great age, and yet never require the aid of glasses beyond a very moder- ate power; others, on the contrary, who, from ignorance, fre- 28 ADVICE ON FAR-SIGHTEDNESS. quently increase the power of their glasses, may run through the whole assortment, and leave themselves only the most in- convenient resources to fall back upon, viz.: the very highest powers. The eye should not be permitted to dwell on glaring objects, more particularly on first awakening in the morning; the sun, of course, should not be permitted to shine in the room at that time, and only a moderate quantity of light should be admitted. It is plainly to be seen that, for the same reason, the furniture of the room should be neither altogether of a red nor a white color; indeed, those whose eyes are weak would find considera- ble advantage in having green for the furniture of their bed- chambers. Nature confirms the propriety of the advice given in this rule, for the light of day comes on by slow degrees, and green is the universal color she presents to our eyes. There is nothing which preserves the sight longer than always using, both in reading and writing, that moderate de- gree of light which is best suited to the eye; too little strains them, too great a quantity dazzles and confounds them; the eyes are less injured by the want of light than by an excess of it; too little light never does them any harm, unless they are strained by efforts to see objects to which the degree of light is inadequate, but too great a quantity has, by its own power, destroyed the sight. Thus, many have brought on themselves a cataract, by frequently looking at the sun or a fire; others have lost their sight by being brought too suddenly from extreme darkness into the blaze of the sun. ADVICE ON SPECTACLES. 29 ADVICE ON SPECTACLES. The discovery of optical instruments may be esteemed among the most noble, as well as among the most useful gifts which the Supreme Artist has bestowed on man. For all-admirable as the eye came out of the hands of Him who made it, yet He has permitted this organ to be more assisted by human contriv- ance; and that not only for the uses and comforts of common life, but for the advancement of natural science, whether by giving form and proportion to the minute bodies that wTere imperceptible to the unassisted sight, or by contracted space, and as by magic art, bringing to view grander objects of the universe, which were rendered invisible by their immense dis- tance from us. Noble as these inventions are, the discovery of spectacles may still claim the superiority, as being of more universal ben- efit and more extensive use. They restore and preserve to us one of the most noble and valuable of our senses; they enable the mechanic to continue his labor, and earn a subsistence by the work of his hands, till the extreme of old age; by their aid the scholar peruses his studies and recreates his mind with intellectual pleasures, and thus pass away days and years with delight and satisfaction, which might have been devoured by melancholy or wasted in idleness. As spectacles are designed to remedy the defects of sight, it is natural to wish that the materials of which they are formed should be as perfect as the eye itself; but vain is the wTish, for the materials we use, like everything human, are imperfect. Yet, we may deem ourselves happy, to have in glasses a sub- stance so analogous to the humors of the eye, a substance which gives new eyes, eyes to decrepit age, and enlarges the views of philosophy. The two principal defects are small threads or veins in the glass, and minute specks. The threads are most prejudicial to the purpose of vision, because they refract the rays of light irregularly, and thus distort the object and fatigue the eyes; whereas, the specks only lessen the quantity of light, 30 ADVICE ON SPECTACLES. and that in a very small degree. We are now able to decide upon a very important question, and say how far spectacles may be said to preserve the sight. It is plain they can only be recommended as such to those whose eyes are beginning to fail, and it would be as absurd to advise the use of spectacles to those who feel none of the forecoming inconvenience, as it would for a man in health to use crutches to save his legs. But those who feel these inconveniences should immediately take to spectacles, which, by enabling them to see objects nearer, and by facilitating the union of rays of light on the retina, will support and preserve the sight. From whatever causes this decay arises, an attentive consid- eration of the following rules will enable any one to judge for himself when his sight may be assisted or preserved by the use of spectacles: First. When we are obliged to remove small objects to a considerable distance from the eye, in order to see them distinctly. Second. If we find it necessary to have more light than for- merly, as, for instance, to place the candle between the eyes and the object. Third. If, on looking at and attentively considering a near object, it becomes confused, and appears to have a kind of mist before it. Fourth. When the letters of a look run into one another, and hence appear double or treble. Fifth. If the eyes are so fatigued by a little exercise that we are obliged to shut them from time to time, and relieve them by looking at different objects. When all of these circumstances concur, or any of them sep- arately take place, it will be necessary to seek assistance from glasses, which will now ease the eyes, and, in some degree, check their tendency to grow flatter; whereas, if they be not assisted in time, the flatness will be considerably increased, and the eyes weakened by the efforts they are compelled to exert. Blindness, or at least weakness of sight, is often brought on by these unexpected causes. Those who have wenk eyes should ADVICE ON SPECTACLES. 31 therefore, be particularly attentive to such circumstances, since prevention is easy, but the cure may be difficult and sometimes impracticable. Whatever care, however, be taken, and though every precau- tion be attended with scrupulous exactness, yet, as we advance in years, the powers of our frame decay, an effect which is, generally, first perceived in the organs of vision. Age is, however, by no means an absolute criterion, by which we can decide upon the sight, nor will it prove the necessity of wearing spectacles. For, on the other hand, there are many whose sight is possessed, in all its vigor, to an advanced old age; while on the other, it may be impaired in youth by a variety of causes, or be vitiated by internal maladies. Nor is the defect either the same in different persons at the same age, or in the same person at different ages. In some the failure is natural, in others it is acquired. Though in the choice of spectacles every one must finally determine for himself which are the glasses through which he obtains the most distinct vision, yet some confidence should be placed in the judgment of the optician of whom they are pur- chased, and some attention paid to his directions. By trying many spectacles the eye is fatigued, as the pupil varies in size with every different glass, and the eye endeavors to accommodate itself to every change that is produced; hence, the purchaser often fixes upon a pair of spectacles not the best adapted to his sight, but those which seemed to relieve him most while his eyes were in a forced and unnatural state, and, consequently, when he gets home they are returned to their natural state, and he finds the glasses which he has chosen fa- tiguing and injurious to his sight. The most general, and per- haps the best, rule that can be given to those who are in want of assistance from glasses, in order to so choose their spectacles that they may suit the state of their eyes, is to prefer those which show objects nearest their natural state, neither en- larged nor diminished, the glasses being nearer the eye, and which give a blackness and distinctness to the letters of a book, neither straining the eye nor causing any unnatural exertion of 32 ADVICE ON SPECTACLES. the pupil. For no spectacles can be said to be properly accom- modated to the eyes, which do not procure them ease and rest. If they fatigue the eyes, we may safely conclude, either that we have no occasion for them, or that they are ill-jnade or not adapted to our sight. It is a certain and very important fact, that long-sightedness may be acquired, for countrymen, sailors, and those'who are habituated to look at remote objects are generally long-sighted, want spectacles soonest, and use the deepest magnifiers; on the other hand, the far greater part of the short-sighted are to be found amongst students and those artists who are daily conver- sant with small and near objects, every man becoming expert in that kind of vision which is most useful to him in his particu- lar profession and manner of life. Thus, the miniature painter and engraver see very near objects better than a sailor, but the sailor sees distant objects better than they do; the eyes, in both cases, endeavoring to preserve that configuration to which they are most accustomed. In the eyes, as well as other parts of the body, the muscles, by constant exercise, are enabled to move with ease and power, but are enfeebled by misuse. The elastic parts, also, if they are kept too long stretched, lose part of their elasticity; while, on the other hand, if they be not duly exercised, they grow stiff and are not easily stretched. From the consideration of these facts, we may learn, in a great measure, how to preserve our eyes. By habituating them occasionally to near as well as distant objects, we may main- tain them longer in their perfect state and be able to postpone the use of spectacles for many years, but we may also infer from the same premises that there is great danger when the eyes have become long-sighted of deferring too long the use of spectacles, or using those which magnify too much, as we may by either method so flatten the eye as to lose entirely the ben- efits of naked vision. It may not be improper, in this place to remark that the long-sighted eye is much more liable to be injured by too great a degree of light than those which are short-sighted. Though it is in the general course of nature ADVICE ON. SPECTACLE FRAMES. 33 that this defect should augment with age, yet there are not wanting instances of those who have recovered their sight at an advanced period, and have been able to lay aside their glasses and read and write with pleasure without any artificial assistance. Among many causes which may produce this disease, the most probable is, that it generally arises from a decay of the fat in the bottom of the eye. The pressure in this part ceasing, the eye expands into somewhat of an oval form, and the retina is removed to a due focal length from the crystalline lens. Increasing years have a tendency to bring on this defect, and earlier among those who have made less use of their eyes in their youth; but whatever care be taken of the sight, the decay of nature cannot be prevented. The humors of the eye 'Will gradually waste and decay, the refractive coats will be- come flatter, and the other parts of the eye more rigid and less pliable; thus, the latitude of distinct vision will become con- tracted. It is also highly probable that the retina and optic nerve lose a portion of their sensibility. ADVICE ON SPECTACLE FRAMES. There is one point of considerable importance, which is often disregarded, viz.: the fitting of the spectacle frame so that the centre of each glass shall be exactly opposite the pupil of the corresponding eye. A moment's reflection will show how im- portant this is. There are scarcely two persons of precisely the same width between the eyes, and yet, in the majority of cases, this fact is entirely lost sight of in the selection of spec- tacles. A person finds that when, at an optician's, he looks through a lens of a certain power, it suits him exactly; he sees delightfully with it, and forthwith orders spectacles of that power. He tries them on as soon as he receives them, antici- pating with eagerness the comfort they will afford him, instead of which, he finds that he can hardly see at all, or, if he does, 3 34 ADVICE ON SPECTACLE FRAMES. his eyes soon feel fatigued. The glasses are right; the error is in the frame. Unless the width between the eyes is such that the centre of each glass is exactly in front of the eye which it is to assist, the rays which pass through the lens will not all enter the pupil, and the spectacles will be comparatively value- less. Care should be taken, then, in every case, to have the bridge made of such a curve and such a width that the position of the lenses, as regards the eyes, should be perfect, both hori- zontally and vertically. In ordinary myopic spectacles, the average height of the bridge above the axis of the lenses is from one-eighth to three- sixteenths of an inch. Where the arch of the nose is depressed, the bridge is made one-eighth below the centre. The^ three most remarkable spectacles a,re represented in the following figures. The first (Fig. 1.), is that commonly used for presby- opic glasses. The second (Fig. 2.), brings the glasses near the eyes. The third (Fig. 3.), is sometimes preferred, as being generally useful: (Fig- 1.) (Fig. 3.) I have mentioned the curve, as well as the width, for by it the height of the glass is adjusted. Short-sighted persons require the glasses to be nearer the eyes than do far-sighted, ADVICE ON. SPECTACLE FRAMES. 35 and this is to be regulated by a peculiar curvature of the bridge, a curvature in two planes, rising vertically and projecting out at the same time, as represented in (Fig. 2.) It may be as well to notice here that whenever the frames are well fixed, the two eyes appear to the individual to be looking through the glasses only. The material best adapted for spectacle frames is blue steel, which combines the advantages of lightness, elasticity, dura- bility, and neatness of appearance. The brilliancy of gold and silver frames is objectionable, as tending to dazzle the eyes, and from this the blue steel frame is free. Some persons pre- fer tortoise-shell frames, but these have a heavy appearance, and are very liable to be broken. If, however, fancy incline toward them, care should be taken that the front is all black, because if it is framed of variegated shell, the dazzling will be even greater than that from silver or gold. The front of the frame should be made to project sufficiently beyond the glasses to protect them from friction in drawing them in and out of the cases, or from being scratched when laid flat down. Many persons are very careless as to this, leaving their spectacles lying about, allowing them to become dim with moisture and dirt, and wiping them with the first thing that comes to hand—their coat-tails or pocket-handkerchief; but if they wish to keep their glasses in a good state, they should be sedulous to clean them with wash-leather which has been freed from the yellow ochre used to color it, for this offers less risk of scratching the glasses than does silk or any other material. One cause of the prevalence of small spectacles is to be found in the supposed interest of some opticians to prevent the use of any other kind. The reasons they allege for so doing would really be laughable, were not the injury thereby done rather too serious to be treated as a joke. Some of these gentlemen object to the large spectacles because, forsooth, they would "cut into too much shell!" others wish to know "what is to become of their old stock;" and others, again, assert that far more small spectacles are sold than ever would be were large ones worn. The shopman of one of them always recommends the 36 ADVICE ON SPECTACLE FRAMES. small ones, but the master himself wears the large oval ones, because he finds them much more serviceable, and can see bet- ter with them. Whether the opticians are right or wrong as to their own interests in this matter, I will not undertake to say, but certainly none of these reasons are likely to have much weight with the party chiefly concerned. The public portrait painter, and others who require to com- pare objects at different distances quickly and frequently, often use semicircular lenses, straight at the top, so that by raising the eyes they can see over them. This, howTever, causes grim- aces and fatiguing elevation of the brows. These spectacles are represented in (Fig. 4.) (Fig. 4.) There is one obstacle more dangerous than all—that is, the divided glass. The lenses for divided glasses are cut in halves, and a portion of each mounted in a large circular frame; in this description of spectacles, the two segments of lenses are united as firmly as possible in the medium line, the most con- vex or reading lens is below, the least convex above, so that by simply dropping the eyes or raising them, the person can see near or distant objects. These spectacles are objectionable, because the medium line where they are attached together is exactly in front of the pupil of each eye. In reading the rays are on the retina, and the distant glass is on the other side of the retina, and the rays of the reading glass form before they reach the retina, which causes confusion, fatigue, and headache. The divided glass is represented by (Fig. 5.) (Fig. 5.) ADVICE ON DOUBLE GLASSES. 37 There is another sort of spectacle frame that I object to: that is the octagon shape, which is very small, and the eye collects a pencil of rays from each corner, which creates con- fusion and dazzling of objects. This is represented by (Fig. 6.) (Fig. 6.) I recommend the large oval steel spectacles, which give the eye rest and ease, and with which a person can read longer and with less fatigue. Blue steel acts as an absorbent to the eye. I have made it my study, for forty years, to ascertain what is good for and what is an injury to the eyes. ADVICE ON DOUBLE GLASSES. We have represented the four-glass spectacles, opaque or colored glass sides being attached to the lens-holder of the spectacle, thus enabling one to exclude all side rays, as well as those directly in front of the eye. They were formerly made with convex or concave glasses fitted in the front of the frame, and by simply shutting down the colored plane glass sides, a tinted lens was at once formed. I highly recommend them for far and near glasses, mounted in light steel frames, four-glass spectacles to obtain a double-focus spectacle; thus: in the front frame is placed the lens which best suits for distance, and in the side frame a lens of such a power as, when combined with, the front lens, would suit for reading, etc. By this method, when spectacles for distant vision are desired, it only becomes necessary to remove the side glasses from the front ones. When properly suited, the rays of light are brought to a point upon the retina, and by letting the side glasses down, they also are brought to a point for reading. They do not cause confusion, headache, or dazzling. 38 ADVICE ON DUST SPECTACLES, G0(iOLES. DUST SPECTACLES, GOGGLES. Wire-work in spectacle frames was at one time used as such, and called by this name. These dust spectacles have the dis- advantage of keeping the eye behind them continually envel- oped in the vapor of its own moisture, which cannot fully escape. Thus, the irritated condition is rather increased than diminished. The principal reason for their disuse lies, how- ever, in the impairment of distinct vision, which compels the patient to strain his eyes severely in order to see surrounding objects distinctly. By the wire-work considerable objective light is kept away from the eye, and the frame of the, dust spectacles places the translucent gauze in an unfavorable angle to the outer world, thus limiting the visual field; moreover, the manifold diffraction which the transmitted light undergoes on the wire-gauze comes into consideration. Besides, when these spectacles are worn in aa atmosphere loaded with dust, the meshes of the gauze become filled, and then their defects are increased. Ordinary glass spectacles of circular shape, about an inch in diameter, are to be preferred to the dust goggles above described. Of course they protect the eye less; but where the dust is so abundant that sufficient protection is not afforded by the ordinary glass spectacles, or where a small amount of dust upon the eye proves injurious, the surgeon does well to prohibit the patient from being thus exposed. EYE PROTECTORS. I now proceed to speak of those contrivances by which assist- ance may be rendered to eyes where the vision is impaired from accident, operation, or imperfection in form or direction. For perfect vision, it is essential that the rays of light pass through the centre of the crystalline lens, as then only is a true and ADVICE ON EYE PROTECTORS. 39 correct image depicted on the retina; this cannot take place if the pupil be displaced, and just in proportion as it is removed from its natural position towards the periphery of the iris is the refraction imperfect, and, consequently, the vision confused. This almost always follows, in a greater or less degree, the operation for artificial pupil; for the very object of the opera- tion is to give sight by making a new opening in the iris, in cases where the natural pupil has been closed or destroyed; and the instances are few in which this can be placed exactly in the centre. Again, as the proceeding in question consists in dividing or cutting away a portion of the iris, the new pupil is devoid of that beautiful arrangement of fibres by which con- traction or expansion is provided for; it is, therefore, motion- less under all conditions of light. The following are the results of many experiments made by me, for the relief of such cases: If the aperture be central, but too large, it resembles mydri- asis, or permanent dilation of the pupil, and may be thus obvi- ated: A thin plate of Japanned black steel, slightly concave on the inner side, should be fitted into a spectacle frame; in the centre there should be a small hole, the actual size of which must be determined by experiment in each case, in order that its dimensions may be precisely those which afford the best vision. This, worn before the eye, imitates a pupil in a state of contraction, and, by limiting the light entering the eye, ma- terially assists vision. It may, however, be more convenient to have a slit instead of a simple aperture, to admit of extended lateral vision. (Fig. 9.) represents both forms. THE VARIETY OF LENSES. In order that the action of spectacles may be clearly under- stood, I will, before entering upon the subject, explain the effects of the different kinds of lenses upon the rays of light. There are six varieties of common lenses: 40 ADVICE ON SPECTACLE LENSES. ■ODflM' 1. The double-convex lens is bounded by two convex spher- ical surfaces, each of whose centres is in the axis of the lens only on the sides opposite to their surfaces. 2. The plano-convex lens has one side convex, the other plane. 3. The meniscus has one surface convex, the other concave, and the surfaces meet if continued. 4. The double-concave is formed by two concave spherical surfaces, whose centres are on the same side of the lens as their surfaces. 5. The plano-concave has one surface plane, the other concave. 6. Concavo-convex has one surface concave, the opposite convex, but these do not meet if continued. ADVICE ON SPECTACLE LENSES. When a convex lens is properly worked, it should exactly represent two segments of the sphere, or of two different spheres, with their plane surfaces in opposition, and placed in the same axis. Then only does it give a clear and distinct image of the object submitted to its action. If the working of the lens be not accurate, every variation from the true curvature will inter- fere with refraction and the perfect definition of the image, points of much importance in lenses used to assist vision. The same remarks apply to concave lenses. In China, rock crystal is used throughout the empire for lenses. They are ground with the powder of corundum, and when mounted, form most original spectacles, being circular THE MANUFACTURE OF LENSES. 41 and of immense size, and retained in position by silken cords with weights attached, which are slung over the ears. / THE MANUFACTURE OF LENSES. I shall, in the first place, describe the mode in which specta- cles are made; after that, proceed to their application. The glass principally employed for spectacles and optical lenses is plate glass of the purest quality; it requires the nicest adjustment as to the proportion of its ingredients—silicate of 6oda, and lime; the presence of too much alkali attracts humid- ity from the atmosphere, causing the glass to become dull, or, in the language of the opticians, to "sweat." The French plate glass is, in point of color, superior to the British, but has the disadvantages of softness, fraxility, and a tendency to become dull; therefore, although it is preferred by some opticians, the glass known as "British Plate" is, on the whole, the best. The mode of making spectacle glasses and lenses generally, is as follows: A piece of glass, of a thickness proportionate to the convex- ity or concavity of the intended lens, is cut into small squares with the diamond; after these small squares have had their corners snapped off they are fixed with cement to a metal tool, the concavity or convexity of which corresponds to the curve which they are intended to receive. They are then worked by hand or machinery o» the smoothing tool, which latter must be perfectly true, of a radius in accordance with the focal lengths of the intended lenses. They are worked with a peculiar kind of eccentric motion, which is found to give equal friction to all parts of the surface. After the lenses have been thus gradu- ally rounded into shape, and smoothed by emery powder of different degrees of fineness, prepared for this purpose, they are subsequently polished with oxide of tin, commonly called putty, which is laid on a polisher made of felt and cement, and formed to the curve of the smoothing tool. When one side of 42 ADVICE ON COLORED GLASSES. the lens is completed, the other side is subjected to a like pro- cess; and when both sides are perfectly polished, all that is required is to cut and grind the edge to fit the spectacle frames. There is a common prejudice in favor of pebbles, and they certainly possess two advantageous qualities: extreme hardness, rendering it difficult to scratch or break them; and clearness, never becoming dull from moisture. They have, however, the disadvantage of being expensive, partly on account of the addi- tional labor in making them, partly from the number of imper- fect ones found in their manufacture, whereby the price of good spectacles is enhanced. The earliest mention of artificial aid to sight occurs in the writings of Roger Bacon, who speaks of an "instrument useful to old men, and to those who have weak eyes, for they may see the smallest letters sufficiently magnified." Mons. Spoon, in his "Recherches Curieuses," fixes the date of the invention of spectacles between A.D. 1280 and 1311. This seems to be satisfactorily made out, for a number of ref- erences to them is made in the writings of persons in the early part of the fourteenth century. ADVICE ON COLORED GLASSES. From time immemorial, the Chinese have used, for checking the glare of the sun, a substance called cha-she, or tea-stone, from the resemblance of its transparent hue to a weak infusion of black tea; it is probably smoky quartz or silex, allied to the cairngorm of Scotland. In selecting this color, they have shown wisdom; for although glasses of all tinges of blue and green are to be found in the shops of opticians, the hue is called neutral tint, similar to that used by the Chinese. It does the least injury to the eyes, and for the following reasons: When the eye, after having been strongly impressed with any particular species of colored light, is directed to a sheet of white paper, it will not be capable of determining for some time ADVICE ON COLORED GLASSES. 43 that the paper is white, neither will it attribute to the paper the color with which the eye was impressed, but a different color, which is called its accidental or complimentary color. The following is a table of the colors, and of those which are complimentary to them: Color. Complimentary Color. Red, . . . Bluish-green. Orange, Yellow, Green, Blue, Indigo, Violet, Black, White, Blue. Indigo. Violet-reddish. Orange-red. Orange-yellow. Yellow-green. White. Black. Thus, when the eye has been for some time looking through a blue glass, the retina becomes less sensible to light; conse- quently, the moment the blue glass ceases to be used, the ret- ina being less sensible to the blue rays which form part of the white light flowing from the paper, the paper will appear of that color which arises from the combination of all the rays of the white light which it reflects, with the exception of the blue, that is, it will appear orange-red; in like manner, green will excite the violet-red spectrum. As colored glasses are almost always made use of to screen the eyes in cases where there is undue sensibility of the retina, anything which unnecessarily blunts the sensitiveness of that membrane (such as a particular color), though temporarily, should be avoided. It is on this account that the neutral tint glasses are to be preferred. Being, as the name implies, of no definite color, they screen the eyes from all colors alike, and produce in the sunshine the effects of a cloudy day, which is exceedingly grateful to weak and irritable eyes. There are two descriptions of neutral tints: a bluish-gray and a brownish-gray, and the several shades of each. I give the preference to the brownish-gray. The chief risk in select- 44 ADVICE ON COLORED GLASSES. ing glasses of this description is that of choosing too dark a shade. Neutral tinted glasses are divisible into two distinct classes of cases: those in which the retina is irritable and will not bear the excitement of light, and those cases of incipient cataract in which they assist vision simply by modifying the light and causing dilatation of the pupil. In the first class of patients, the use of too dark a shade of glass is injurious by rendering the eyes still more susceptible to light; producing, in fact, the same effect as shutting up the patient in a darkened room. The shade selected should be that which is grateful to the eye, but never darker than necessary; and if dark glasses have been in use, it will be proper to discon- tinue them, and to gradually accustom the eyes to the stimulus of ordinary light, by reducing the tint in successive changes. It is advisable that persons habitually using tinted glasses should close the eyes once or twice, for a second, on taking them off, thus rendering the contrast between the shade and the light less marked. It must be borne in mind, with reference to the darker shades of neutral tint, that they are liable to heat the eyes; a black substance absorbs all the calorific as well as the luminous rays, and, therefore, sooner becomes warm and rises to a higher temperature than substances of other colors. The nearer, then, the neutral glass approaches to black, the more it will heat the eye. I may refer, en passant, to an experiment of my own, demon- strating the relative heating properties of black and white. I covered two patches of snow with cloths, the one black, the other white. The snow beneath the black cloth very soon melted, whilst little or no effect was produced on that beneath the white. This is a fact of practical value, for the tunics of a sensitive or morbidly irritable eye soon feel the discomfort arising from this property of dark glass, which literally, as well as figuratively, feels hot to the eye it covers. It occasionally happens that myopic persons require the aid of neutral-tinted glasses. There are two ways of supplying the ADVICE ON CYLINDRICAL LENSES. 45 want: either by grinding the lens of the tinted glass itself, or by cementing an ordinary plano-concave lens on a tinted plane glass. The last mode is much used by Messrs. Carpenter and Westley, who inform me that the low numbers, up to about No. 6, may be cemented with the utmost nicety; but that when a higher number is required, it is preferable to have a tinted side-piece let down when required, as the inequality of the refractions, if cemented, would interfere with the perfection of the spectacles. The desire to conceal from the world any imperfection which wound? our self-love, is inherent in the human heart, and leads to all sorts of artifices on the part of those who, by natural conformation, advancing years, or other causes, suffer from an imperfection in their vision. CYLINDRICAL LENSES. Conceive a lens ground with two cylindrical surfaces of equal radius, one concave* and the other convex, with their axes crossed at right angles. Call such a lens an astigmatic lens; let the reciprocal of a focal length in one of the principal planes be called its power; and a line parallel to the axis of the convex surfaces, its astigmatic axis. Then, if two thin astigmatic lenses be combined, with their axes inclined at any angle, they will be equivalent to a third astigmatic lens, deter- mined by the following construction:' • From any point draw two straight lines, representing in magnitude the powers of the respective lens, and inclined to a fixed line drawn arbitrarily in a direction perpendicular to the axis of vision at angles equal to twice the inclinations of their astigmatic axes, and complete the parallelogram. Then the two lenses will be equivalent to a single astigmatic lens, represented by the diagonal of the parallelogram, in the same way in which the single lenses are represented by the sides. 40 ADVICE ON CYLINDRICAL LENSES. A piano-cylindrical or sphero-cylindrical lens is equivalent to a common lens, the power of which is equal to the semi sum of the reciprocals of the focal lengths in the two principal planes, combined with an astigmatic lens, the power of which is equal to their semi difference. If two piano-cylindrical lenses of equal radius, one concave and the other convex, be fixed, one in the lid and the other in the body of a small round wooden box, with a hole in the top and bottom, so as to be as nearly as possible in contrast, the lenses will neutralize each other when the axes of the surfaces are parallel; and by merely turning the lid around, an astigmatic lens may be formed, of a form varying continuously from zero to twice the astigmatic power of either lens. When a person who has the defect in question has turned the lid till the power suits his eye, an ex- tremely simple numerable calculation, the data of which are furnished by the chord, of double the angle through which the lid has been turned, enables him to calculate the curvature of the cylindrical surface of a lens for a pair of spectacles which will correct the defect in his eye. A curious case is related in the Annales de Oculistique, of an anomaly of vision, probably the conseofuences of a defect in the form of the cornea, such as that under consideration: Mrs. Holstrid, of Chicago, was presbyopic for horizontal, and myopic for ventricular. This she remedied by wearing spectacles, the glasses of which were cylindric bi-convexes, with rectangular, horizontal, and similar axes. These glasses obvi- ated the presbyopic relative to the horizontal lines, and they were confined with sphero bi-concave lenses to get rid of the myopia for vertical lines. Each of the glasses were made mov- able, for the facility of cleaning. The following means are recommended, to ascertain if an eye has the defect now described: The person should attentively contemplate, for some time and with attention, a cross -f three or four lines in size, made of fine wire, and fixed in a frame; if affected, he will see the horizontal lines differ in thickness and blackness of tint from the vertical. In astigmatic eyes, vision is distributed in such a manner ADVICE ON CYLINDRICAL LENSES. 47 that the patient finds it difficult to describe his symptoms, but on testing his sight, it is evident that it had not the normal acuteness, and that it is improved in a slight degree only by ordinary concave or convex lenses. On desiring him to look at test-lines of equal length and breadth placed parallel to each other, some of them in a vertical and some in a horizontal posi- tion, he finds that he sees one set of the lines more clearly than the other. A square appears elongated to a parallelogram, and, at the same time, less sharply defined in the direction of its length. A small round hole in a screen, behind which is a bright light, seems oval or even linear. If large letters are looked at at twenty feet distance, some of the lines will be clearly seen, while those at right angles with the first will appear blurred, or of double contours. On looking through a spectacle with a small aperture or narrow slit, held in a proper direction, the confusion disappears. (Fig. 9.) represents the spectacles: (Fig- 9.) This forms, perhaps, the readiest method to ascertain the direction of astigmatism. Its degree is ascertained by placing convex or concave glasses before the slit till we find with what number vision is clearest. Great care is required in setting cylindrical glasses; as even a slight want of correspondence between the meridian of devia- tion and the proper relative position of the glass almost annuls its effect. The glass is to be turned before the eye till the vision becomes clearest, and at this point should be marked by the optician, so that it may be set in the frame in precisely the same position. The frame should be well fitted to the wearer, as even a very slight obliquity or tilting of the glasses lessens their beneficial effect. For this reason, spectacles are, usually, to be preferred to eye-glasses, as they keep more steadily their proper position. The cylindrical glasses are required for all 48 ADVICE ON PERISCOPIC GLASSES. purposes; both near and distant objects seeming blurred and distorted without their aid. PERISCOPIC GLASSES. There are th*.ee varieties of lenses in common use for spec- tacles : the double-concave for short-sighted persons; the double- convex for long or aged sight; and a third description, invented and patented by Dr. Woolaston, to which he applied the term periscopic, so called from the facility they were supposed to afford for looking around at various objects without turning the head, and so giving a wide field for vision. They were also intended to obviate the defects in common lenses, in which no object appears distinct through them, except such as are seen through the centre. Dr. Woolaston conceived that by making each side concave towards the eye, each portion of its surface might be nearly at its right angles to the axis of vision, and would thus render lateral objects distinct without impairing the distinctness of those seen through the centre. This effect, for far-sighted persons, he accomplished by means of the meniscus, with the concave surface next the eye; and for short-sighted persons, he adopted the concavo-convex. There can be no doubt that the advantage of a wide field is gained, in proportion as the second surface of the lens ap- proaches to the form of the curvature of the cornea; but this is scarcely necessary, as we generally turn the head to look at an object, instead of glancing at it obliquely. Periscopic glasses would be applicable, but they do not ren- der vision so distinct as ordinary lenses, and they increase (although in a very slight degree) the aberration both of color and figure; therefore, the double-concave or convex lenses are to be preferred to the periscopic, ADVICE ON CATARACT GLASSES. 49 CATARACT GLASSES. The object aimed at in operation for cataract is, either to abstract the opaque crystalline lens from the eye, to cause its absorption, or to displace it, so as to give a free passage to light. As the image formed on the retina depends upon the refraction produced by means of the crystalline lens, and on its power of self-adjustment to objects at different distances, the consequences of its loss, usually, are indistinctness of vision, and loss of power of accommodation to distance. If, prior to the formation of cataract, the eye was perfect (not merely as to its power to define objects at a given distance, but as to the power of adjustment to distance also), there is, after the opera- tion, an incapability of discerning near objects, as the eye no longer has the power to accommodate itself to the necessary focus. To remedy these inconveniences, double-convex glasses are employed; and it is necessary to have two pairs, of differ- ent focal lengths: one for looking at distant objects, the other for reading and writing. The following are the numbers of my test-glasses: For reading, Nos. 2, 2£, 2J, 3; for distant ob. jects, Nos. 3^, 4, 4|, 5. Opticians, however, have a greater variety, to suit exceptional cases.* Where only one eye has been operated on, or where the operation has failed in one, it is convenient to have a frame with a double bridge, as in (Fig. 3.), so that it can be worn with either side up; one circle may be fitted with a reading lens, the other with a lens for distant vision; and by simply turning the frame either way, it will be placed before the useful eye. * The lenses used by divers, if made of crown glass and equi-convex, must have the curvatures of both surfaces equal to that of the cornea; for, in order that the refraction of such a lens may be equal to that of the cornea which it is intended to supply, the focal length of the lens in water must be equal to that of the cornea in air. It must be borne in mind that when the eye is immersed in water, the first and most considerable of its refraction is lost, for the refractive power of the aqueous humor is very nearly that of water, and so, the coriKa being bounded by surfaces which are nearly parallel, the rays will pass from water into the aqueous humor without undergoing refrac- tion. Thus, a powerful convex lens is required to afford distinct vision. 4 50 ADVICE ON CATARACT GLASSES. If the sight of one eye be so imperfect that it interferes with the vision of the other, a dark neutral-tinted glass or a thin opaque plate may be advantageously fitted in the circle intended for that eye. There is considerable variety in the amount of assistance required, but glasses of four and a-half inches focus ordinarily serve for viewing distant objects, and two and a-half inches focus for reading or writing. In the selection of glasses, those of the longest focus that will answer the purpose are to be preferred. The glasses recommended by my lamented friends, Mr. Tyrrell and Mr. Dalrymple, were of three-quarters of an inch diameter, and mounted in a broad tortoise-shell rim, to diminish the weight of the spectacles and limit the quantity of light admitted into the eye. A cataract glass, when placed in front of the eyes, gives perfect vision of objects at the distance at which they could be distinctly seen before the change in the lens commenced. If the focus be too long, the patient will find it necessary, after a time, to remove the glasses two or three inches from the eyes, in order to see distinctly, and in such a case, glasses of a shorter focus must be procured. If the focus be too short, the patient will mistake the distance of objects from him, as they will appear nearer than they really are, and the hand, in the effort to grasp them will fall short of them. For some time after operation for cataract, the patient (especially if young) should endeavor to do as much as possible without glasses; for although the adjusting power inherent in the eye is destroyed by the operation, nature will, if compelled, make great efforts to provide a substitute. Glasses, then, should not, under any circumstances, be permitted for a considerable time after the operation, nor, indeed, so long as vision continues to improve without them. If they be used too early, and the glasses are too powerful, the eyes may become enfeebled and require more and more assistance, so that, after a time, no lenses will be found of sufficient power. If the individual will wait until the eye has completely recov- ered, and will habituate the organ as much as possible to its altered state, he will then be in a condition to select glasses of ADVICE ON READING GLASSES. 51 a proper strength, and these, if used sparingly, will probably serve him all his life. READING GLASSES. Thus it is, that some persons prefer to use an eye-glass, in lieu of spectacles. Reading-glasses and hand-glasses are adapted for occasional use, as the elastic mounting enables them to be opened and brought into position at once; but they are objec- tionable, from not being firmly fixed in front of the eyes. The motion of the head not being in accordance with that of the hand which holds the glasses, has the effect of trying the eyes exceedingly, in their constant and ineffectual endeavor to adjust themselves to the position of the glasses, inducing con- siderable fatigue of the eyes, and rendering necessary an ear- lier resort to glasses of a higher power than would have been required had proper spectacles been adapted from the com- mencement. The eye-glasses which are fixed by a spring to the nose, have the disadvantage of the centres of the glasses never being in front of the pupils, and though serviceable for prompt and occasional use, are objectionable for reading, writ- ing, or any continued occupation. But a single eye-glass is more injurious still, and many young men who, from shortness of sight, have thought proper to use a quizzing-glass (as it is frequently termed), have had reason to repent it to the end of their lives. I am acquainted with a gentleman, the sight of whose right eye has been seriously im- paired from his having in early life constantly used one of these eye-glasses; and numerous other instances have come to my knowledge. The consequences to perfect vision are serious, for as one eye is made to do more work than the other, an alteration in their relative strength takes place; the result is, that, sooner or later, when a person resorts to spectacles, he finds that the lens which suits one eye will not at all suffice for the other. Watchmakers and other artists who work with a magnifier, are very subject to this imperfection of vision, and 52 ADVICE ON GLASSES FOR AMAUROSIS. generally find that they can see better with one eye than the other. If, instead of always applying the magnifying-glass to one eye, they were to use the other eye in turn, a habit which might be easily acquired in early life, though with difficulty after- wards, they would preserve the power of their eyes more equally, and the perfection of vision longer; for, by using the eyes al- ternately, rest and an opportunity of recovering from the fatigue produced by the exertion of looking through the magnifier would be afforded to each. In like manner, those who indulge in microscopical or astro- nomical pursuits, should learn to use either eye indifferently, instead of always trusting to one; although we almost instinct- ively apply the right eye to a telescope or microscope. Many medical men have informed me that from constantly looking through microscopes, etc., with their right eyes, the focus of that eye has been rendered so much longer than that of the left eye, that while the left eye is suited by a glass perfectly plane, the right requires a lens of 30 inches focal length. GLASSES FOR AMAUROSIS. The first person who appears to have systematically used magnifying glasses as a means of restoring sight to amaurotic eyes, was a German charlatan, named Schlesinger, who visited Brussels in 1838, professing to cure weak sight, strabismus, cataract, amaurosis, etc., with glasses of his own invention. This attracted the attention of Dr. Cunier, who, after some pains, discovered the means employed by this man, which were neither more nor less than practising the eyes daily with plano- convex glasses, beginning with very high powers and reducing them, first, by quarters of an inch, then, by halves, and last, by one and two inches, till the lowest powers were reached. Dr. Cunier put this in practice, with happy effect. The fol- lowing is a description of the treatment, as applied to a partic- ular case: Madame la Baronne de R., 40 years of age, per- ADVICE ON GLASSES FOR AMAUROSIS. 53 ceived that the sight of her left eye failed, without particular cause, and after eight years, during which treatment was un- successfully employed, she could with difficulty discern the large letters forming the heading of newspapers; neither could she distinguish the features nor the form of a person one or two feet distant. On examination, the pupils were seen to be moderately contracted, but on covering the right eye, that of the left dilated widely, and did not react under the strongest light. The greenish-grey tinge often seen in long-standing amaurosis was visible deep in the eye. After a variety of unsuccessful treatment, Dr. Cunier determined to try what could be done with glasses. With No. 3 plano-convex, Mad- ame R. recognized, though with difficulty, letters of the largest type. After some minutes' exercise, there was confusion of sight, the eye watered, and a sort of veil, thickening more and more, grey, then black, shrouded the letters; frontal pain also came on, and it was necessary to discontinue the exercise; but, on the application of cold water to the forehead and eyes, these symptoms soon disappeared. On the second day, the reading was with No. 3^; and was practised seven times, from eight to ten minutes each time, before fatigue came on. The interval of an hour took place between each exercise. The letters were easily recognized that evening at the distance of three inches. The following is a summary of the exercises: No. 3, one day, 5 exercises of from 2 to 4 minutes. » 3-i, " 7 " "8 to 10 " " 4,"'half day, 3 " " 10 to 15 « 41, « 5 " " 10 to 15 " " f>l\ one day, 6 " " 10 to 16 " 6," 2 days, 13 " " 10 to 15 " 6|, one day, 6 " " 10 to 15 « 7 « 6 " " 10 to 15 " « 8, " 7 " " 10 to 15 " The exercise was continued on the evening of the 10th day during 22 minutes. Madame de R. saw the hour by the clock at 75 centimetres, and recognized persons at double that dis- tance. The glasses, when used, were: 54 ADVICE ON GLASSES FOR AMAUROSIS. 11th day of treatment,----------------No. 11 12th " " ---------------- " 12 13th " " ---------------- " 14 14th " " ---------------- " 16 15th " " ---------------- " 18 16th " " ---------------- " 22 17th " " ---------------- " 24 Each of the exercises requiring from 20 to 40 minutes. Small text was read on the seventeenth day without difficulty. Mad- ame R. did not cease to use No. 24 until the expiration of two months, during which time aloetic medicines were taken. Ul- timately, the sight of the left eye became as good as that of the right for reading, at from 12 to 14 inches, and for seeing large objects at from 10 to 14 metres. M. Froaim tiller has already reported favorably of the use of graduated glasses, and states that, by their aid, he has- cured many eases of amblyopia and mydriasis. He thus explains their action: The retina is irritated by the employment of glasses, and especially by the increase of light thrown »pon it, and by the direct excitement of its function. This irritation communicated to the brain and reflected from it thro-up-h the oculo-motor nerve, neutralizes the action of the sympathetic nerve, which (he imagines) determines the dilatation of the pupil, and so the disorder is- overcome. This explanation will, it is feared, not be satisfactory to physiologists in general, but there can be no doubt, whatever may be the modus operandi, that in many cases of amblyopia, either from disuse of the eye, or from deficient energy in the retina, the careful and judicious. employment of glasses is attended with excellent effect. The plan which seems last, is to commence with such power as ena- bles the person to see large type; to rouse, but not fatigue, the retina by repeated exercises, short in duration at first, but gradually increased in length; and to reduce the power of the glasses by very short steps, so that each glass, in succession^ may establish and improve upon the effect produced by the former. Simple though the plan is, it requires caution, should not be adopted without consideration, and the practice should ADVICE ON ASTHENOPIA. 55 be carried on under the superintendence of a competent author- ity. In the first instance, the largest type may be required, but its size should be diminished in proportion as the dormant sensibility of the retina is aroused. The exercises should be performed in a good light; and after each, the eye should be bathed with cold wafer, if practicable, by means of an eye- fountain. In cases of strabismus, where the sight is imperfect from dis- use, the practice with the glasses may be concurrent with that recommended to strengthen and equalize the muscles; and in cases of amaurotic insensibility, treatment calculated to remove any functional derangement which may tend to keep up the disorder of the sight, ought to be carefully employed. ASTHENOPIA. There is a condition of the organs of vision, in which they are unable to sustain continued exercise upon near objects, although the patient, on first viewing such objects, generally sees them distinctly and clearly. But after a time, varying in different subjects from a few minutes to an hour, a sensation of constraint affects the eyes of some, whilst others complain of a feeling of tension or of weight, with heat, running of water, and double vision, accompanied with a feeling of fatigue in the eyes and headache, confusion and obscurity having spread over the objects which had been previously clear and distinct. These persons can employ their sight for any length of time in viewing distant objects, and present no external appearance of disease of the eye. This affection of the eye is called "asthen- opia," or weak-sightedness, and is often mistaken by both phy- sicians and patients for "amaurosis," and treated accordingly; but there is no necessary connection between the two diseases, nor does the one lead to the other. Asthenopia generally affects the two eyes pretty equally. If 56 ADVICE ON ASTHENOPIA. only one eye is affected, and the other good, the disease is apt to pass undetected. Asthenopia rarely commences in those who have reached the middle period of life, but almost exclu- sively takes its origin in childhood or youth. The habit of body of asthenopic patients is generally delicate, for we rarely, if ever, meet with the disease in robust or plethoric subjects. Females are as frequently the subjects of this disease as males. There are certain diseases of the eye, with which asthenopia is very apt to be confounded, such as photobia, or dread of light; myopia, or short-sightedness; presbyopia, or long-sightedness; night or day blindness; amblyopia; and incomplete amaurosis. On the other hand, it is by no means uncommon to find as- thenopia complicated, either with some other disease of the eye or with some general disorder of the nervous or of the circulat- ing system. Asthenopia is often attended by considerable depression of the powers of the mind as well as those of the body, and the disease becomes seriously aggravated by the mental apprehension • of the patient. In order to allay these gloomy forebodings, a careful and thorough examination should be made, so as to become satisfied whether there is any disease complicated with the asthenopia that is likely to destroy or seriously impair the vision. If there is not, assure the patient, in the most confident way possible, that he need not have any apprehensions about being blind; that, in fact, he could not become blind from the asthenopia if he were to try. A patient thus relieved of the terrible apprehension of becoming blind almost invariably improves. The cause or causes of asthenopia are somewhat wrapped in obscurity. In many cases, it appears to be an idiopathic dis- ease, resulting entirely from over-exertion of the sight; work- ing by artificial light, as in night-work of all kinds, and espe- cially in night-study; want of sleep is sometimes the chief agent in producing the disease; prolonged investigations with the microscope, is sometimes the cause of asthenopia; undue exercise of the sight, while a person is convalescing from some general and acute disease; what may be called the fashionable and hothouse education of modern times, is a fruitful source of ADVICE ON ASTHENOPIA. 57 this disease; the ophthalmia of childhood or of youth may give rise to it, particularly scrofulous inflammation of the eyes; in- juries of the eye, and, still more readily, injuries of the branches of the fifth nerve around the orbit, are apt to give rise to as- thenopia; asthenopia is often traceable to affections of the brain; the teething of children, any malignant disease of the body, excessive venery, masturbation, spermatorrhoea, congen- ital imperfection in the organs of vision, a bent position of the body during work, constipation, dyspepsia, agitation, grief, sudden fright, and the use of narcotics, such as alcohol, opium, or tobacco, which tend to blind all our sensitive and motive powers; in fact, debilitating influences of every kind, are apt to aggravate, if not to induce, asthenopia. Different definitions are given of this disease: McKenzie calls it "incapability of sustaining the eye in adjustment of near objects;" Lawrence says, "an affection of the retina from excessive employment, commonly called weakness of sight;" and Stellwag defines it, "first, the inability to keep the dioptric system or the visual lines, for a long period, directed to near objects; and, secondly, in close pathological relation to this condition, hyperesthesia, or exalted sensibility of the retina and ciliary nerves." This definition of Stellwag's is, undoubt- edly, the best of the three; but it does not fully define the dis- ease called asthenopia, for there are cases of refractive errors and muscular disturbances not properly of the ciliary muscle, as well as cases in which neuralgic symptoms predominate, which cannot be included in this definition. Success in the treatment of this disease depends, to a very great extent, upon its cause; if it has originated from disease of the brain, from injury to a branch of the fifth nerve, or from one of the ophthalmias, the prognosis would be somewhat unfa- vorable. If the disease is connected with plethora or local congestion, the prognosis is better; but, if the patient is much debilitated or of a scrofulous constitution, it is very unfavora- ble. In some cases, it is our duty to declare the disease incur- able, and give a reason for this opinion. There are, however, a great many cases of asthenopia which are amenable to treat- 58 ADVICE ON ASTHENOPIA. ment, and this treatment will depend, to a great extent, upon the cause of the disease and the constitutional strength or in- firmity of the patient. As a general principle, the patient must endeavor to desist from everything which has a tendency to weaken the nervous system or exhaust the organs of vision. Luxury and indolence should be avoided, and, instead, should be substituted early rising, a hard bed, plain and wholesome food, abstinence from the use of alcohol and tobacco and other bad practices, with plenty of exercise in the open air of the country. The application of medicines, either locally or gen- erally, must depend entirely upon the judgment of the physi- cian," who will be guided by the nature of the case, its cause and present symptoms, and by the constitution and present condition of the patient. Certain cases of asthenopia can be cured by the use of con- vex glasses, a strong proof that the seat of the disease must be, in part, the apparatus of accommodation, for the employment of such glasses relieves the eye almost as completely as it does that of presbyopia. When the patient has procured his glasses, which he should never do without the advice of a good oculist or optician, let him use them in the way and manner prescribed for him by his adviser, and he will find a marked improvement in a short time, which will inspire him with hope and zeal for further and permanent benefit. I, myself, during a practice of 40 years as an oculist and optician, have cured hundreds of cases by the aid of convex glasses, conjoined with medical treatment, such as stimulating embrocations, etc., etc., etc. MUSCLE VOLITANTES. Muscse volitantes appear to the patient who has made no par- ticular examination of them, under the form of blackish motes, or of a thin film, like the wing of a fly, or of semi-transparent grey threads, like spider's web; but if viewed attentively against the clear sky, a white wall, or the like, they are recognized to ADVICE ON MUSCiE VOLITANTES. 59 be made up of appearances such as the ,„.; following: ^©^'o 1st. A convoluted string of beads, ■;*, or a convoluted transparent tube, con- ,'/X, ® ©I-v.-, taining in its interior a row of beads \ " , n smaller than its diameter, except here '•'*-'''j'-, •-. r% '// and there where one larger than the ....."~\ y' rest is seen occupying its whole diam- x f . eter, the end of the string or tube V\/ .' /' sometimes presenting a dark, knobbed //- ' ,' • extremity as if formed by an aggrega- / , L..... ' tion of the beads composing the string, /| or contained within the tube. \t 2d. Insulated beads, some of which, (Fig. 10.) and these the more frequent, have a well-defined outline; others, and these rarer, have an indistinct outline; and, 3d. A parcel of flexuous, round, watery-looking or spun- glass-like filaments, with dark contours, often divided inferiorly into truncated branches. These different appearances may be seen altogether, the beaded appearance on one side of the parcel of watery-looking filaments, and interspersed, here and there, the insulated beads, one or two of the well-defined of which often appearing as if attached to the outside of the beaded tubes; or some one of the appearances may be seen principally or exclusively. Accord- ing as the distance of the object against which the muscse vol- itantes are viewed is greater or less, they appear larger and fainter, or smaller and more distinct. Vision is not affected by floating muscae. Between the several portions of the muscse and by the side of them, the eye still sees everything with per- fect distinctness. Even the portions of the retina, over which the shadows which cause the appearance of the muscse fall, are found by the patient, when the corpuscles ascend out of the field of vision, to be perfectly sensible. Muscat volitantes are often detected suddenly, and thus sup- posed to have just occurred. They are most observed when 60 ADVICE ON MUSC.E VOLITANTES. the patient looks at the clear sky, a thin cloud, snow on the ground, a white wall, or the like. They are not much, if at all, noticed under the opposite circumstances of a dull night, and looking at a dark object. They are not much seen when near objects are looked at. They are rarely seen in the axis of vision, but generally seen to one or the other side, or above or below. The patient thus seeing them only by a side glance, finds it difficult to fix them in order to study their appearance. They move as the eyes move, upwards or downwards, or from side to side; but besides this motion, which, as dependent on that of the eye, is merely apparent, the muscae have a real mo- tion of their own, and still more extensive than their apparent motion. Thus, if from looking before him in a horizontal di- rection, the patient suddenly raises his eyes and fixes them on some object above the horizon, he observes that the muscae fly upwards, considerably above that degree of elevation, and even beyond the field of view, and then come sailing down before him, till they disappear below. Besides the motion of ascent and descent, the muscse volitantes under consideration present lateral movements, although less marked, as well as changes in the relative positions of their several parts. Nature of Floating Muscat.—Hitherto, a very common opin- ion as to the nature of floating rnuscse has been, that they are subjective sensations, depending on some intrinsic change of state of the optic nervous apparatus, thus confounding them with mixed muscas; but that they are truly objective sensa- tions, occasioned by the presence of particles in the interior of the eye, but extrinsic, and in front of the retina, throwing their diffracted shadows on the retina, admits of mathematical dem- onstration. But, without entering minutely into the matter, the matter may be easily demonstrated thus: Hold between a convex lens and the white surface on which the image of the light falls, some small object, as a pin. When this is near the lens, its shadow is not seen on the white ground, but when it is brought nearer and nearer the white surface, its shadow appears more and more distinctly. The particles, moreover, appear to be of normal occurrence ADVICE ON MUSCiE VOLITANTES. 61 in the eye, for the appearance of floating muscse maj, in gen- eral, be seen by any person by simply looking through a small aperture in a card at the clear sky, or through the eye-glass of a compound microscope at the flame of a candle two or three feet distant, or simply bringing the eyelids towards each other, and looking at a lighted candle. Nature of the Particles, the Presence of which Occasions Floating Muscat.—This has not yet been with certainty deter- mined. In the vitreous humor (as also in the aqueous) there is contained a great number of corpuscles, most of them resem- bling lymph-corpuscles, though smaller, being between ^Xj^ and -gfa-Q of an inch in diameter; but it appears from the cal- culations of Brewster, Mackenzie, and Ueute, that the size of the particles, the presence of which occasions floating muscae, is much greater than this. Muscae volitantes are often seen by persons without any particular notice of them being taken, as they are distinct, present themselves occasionally only, and are therefore not troublesome. Their appearance in cataract is owing to the opaque lens acting much in the same way as the perforated card. They are seen most distinctly, and are, therefore, most trou- blesome, when there exists an irritable state of the retina, with weakened irradiation. Such a state of the retina may therefore be viewed as the general condition on which floating muscse, considered as a disease, depend. Dilution of the im- ages of external objects favors, distinctness, on the contrary, prevents the perception of muscse. Hence, when the person is short or far-sighted, they appear far less evident to him when he uses the glasses fitted to render his vision distinct. This appears to be' owing to the stronger impression of the external objects making up for the weakened irradiation, so that the weak impression of the objects of the muscse is more readily effaced. The pupil of an eye affected with muscae volitantes is generally contracted, even when the eye is myopic. From what has been said, it will be seen that the occurrence of float- ing muscce is of itself no indication that either cataract or amaurosis is taking place. If, however, there be along with 02 ADVICE ON MUSC.E VOLITANTKS. the appearance of muscse a failure of vision, and if that failure be not attributable to myopia or presbyopia, which may be ascertained by a concave or convex glass not improving the vision, then cataract or amaurotic amblyopia may possibly exist. In uncomplicated cases, the muscse may indeed increase in numbers, but very slowly, and never to such extent as to inter- fere with the distinctness of vision in any very troublesome de- gree. But sometimes the muscge remain stationary, or even become less. A question which the patient is very likely to put to us is, whether the floating motes or threads which he sees are not liable to increase, and that to such a degree as at length to deprive him of sight. That they increase is true, although only very slowly, and never to such an extent as ma- terially to interfere with vision. Even when the whole field of vision presents entohyaloid spectra, the patient is still able to read, although, as he continues to do so, the muscse sometimes gather together, so as to render portions of the page before him temporarily obscure. Very often they remain stationary for ten or twenty years, or increase by almost insensible degrees; and although alarming at first, the patient gets habituated to them, and troubles himself no more about them. I believe the increase of myodesopsia arises more from the eye becoming in a greater degree susceptible to the impressions of the bodies which cause the disease, than from any increase of the bodies themselves. This increasing susceptibility arises from over-use of the eyes, and from searching for and examining the muscse too much. Many authorities might be quoted, to prove that entohyaloid muscos increase only with extreme slowness, and sometimes become even less perceptible. "I know many people who have complained to me of such things fifteen or twenty years ago, and who are still in the same state." "These kinds of phantoms, which increase very slowly dur- ing the first five or six years, continue during the whole remain- der of life without any kind of ineonvenience. * * * t know a great number of persons who have seen them thirty ADVICE ON MUSCiE VOLITANTES. 63 forty years, and more, without their number or their figure having undergone the slightest change." "It is certainly for from twenty to thirty years that I have seen these same appearances," says Prevost, at the age of 50; and at the age of 79, he adds: "Since, up to a very advanced age, I have enjoyed very good sight, I may support, by my case, the opinion of the oculists who reckon these appearances of small importance." "They are quite innocent in their nature, and exist in per- sons whose powers of vision are most acute. I have been subject to them from childhood." Treatment of Entohyaloid Musece.—Entohyaloid or floating muscsc are not much under control, and are very seldom re- moved by medical applications. If of old standing, and not increasing, it is needless to interfere. When of recent origin, and the exciting cause evident, they are sometimes cured. The treatment most likely to be useful is as follows: 1st. The patient must be put on his guard against the excit- ing causes, and carefully avoid them; such as too much strain- ing of the sight, excess of every sort, night-watching, and the use of alcohol in any form or quantity. "The only means which often does good in this disease," says Dr. J. B. Walker, of this city, "is rest of the eyes, and refraining from every employment which strains the sight. I know patients who have got completely free from rnuscaa volitantes which they had seen for several years, by long-continued rest, which, however, again appeared, as soon as they wrought for some days, so as to strain their sight." 2d. If the stomach is weak and the bowels costive, a course of laxatives, followed by tonics, should be prescribed. To strengthen the constitution, and especially the nervous system, should by every likely means be attempted. This indication will best be answered by cinchona, steel, and the cold bath. 3d. A torpid state of the liver requires small doses of the blue pill, either by itself or combined with purgatives. I have known a gentle course of mercury successful in curing the dis- ease, probably by its sorbefacient powers. Iodide of potassium 64 ADVICE ON MUSCLE VOLITANTES. I have also found completely successful in removing muscae vol- itantes of recent standing. 4th. Where the symptoms of determination of blood to the head are well marked, venesection or arteriotomy, leeches to the head, or cupping and counter-irritation are indicated. Of twelve cases treated by Dr. Schlagintweit, eight, we are told, were cured by solvent and derivative medicines, and by bleed- ing at the foot. 5th. When muscae appear to depend on disease of the heart, leeches are recommended, by Mr. Wardrop, to be applied over this organ till its impulse is diminished. The fulfilment of this indication may be promoted by small doses of antimony and the use of laxatives. If the patient complains of cold feet, the warm pediluvium is to be used at bedtime; and it may be re- marked that this simple remedy is of great importance, where the disease is connected with a difficulty of obtaining sleep. An irritable state of the heart, remaining after its impulse is subdued, Mr. Wardrop endeavors to remove by the exhibition of sulphate of iron. 6th. Antispasmodics appear to have been chiefly confided in by Ware in the treatment of muscas; such as, two or three times a day, a small dose of the volatile tincture of valerian, mixed with an equal quantity of tincture of castor, and joined occasionally with the camphor mixture, or with the infusion of cascarilla. 7th. Exercise in the open air, and a change of residence, and such occupations and amusements as are likely to withdraw the mind from any source of anxiety and distress, are found to be beneficial. A course of mineral waters has sometimes been successful, probably more from the change of scene, hilarity of mind, exercise of body, and regularity of habits, by which such a course is accompanied, than from the effects of the waters themselves. 8th. If the eyes feel hot, heavy, or uncomfortable, they should be bathed with either some cold or warm application according as the patient feels one or the other more agreeable! Cold water, or a cold lotion, consisting of water with a small ADVICE ON CONICAL CORNEA. Q5 proportion of spiritus aetheris nitrosi, will answer in the one case; tepid water, or a tepid infusion of any aromatic herb, in the other. Sponging the forehead, temples, and outside of the eyelids, morning and evening, with a camphorated tincture of rosemary, eau de Cologne, or the like, is also recommended. CONICAL CORNEA. The convexity of the cornea varies in different individuals; it sometimes projects so much, in the form of a cone, as not only to diminish but to quite destroy vision. The point of the cone is generally in the centre of the cornea, but it is sometimes situated on the side of it. Authors formerly considered the disease as a thickening of the cornea, but pathological anatomy has shown that it? is a thinning of the (Fig. 11.) cornea in that particular part which forms the cone, and that this part yields to the pressure of the aqueous humor. This state of the eye is rarely, if ever, ac- companied by inflammation. The patient at first becomes short-sighted, which causes him to partially close his eyes when engaged in examining objects. As the disease advances, he sees objects multiplied, or will not see them at all unless held laterally to the eye. If at the commencement of the disease, the surgeon looks straight into the eye, he sees no change in the shape of the cornea; but if he examines the eye in profile, the cone will be observable, shining like a diamond. At first the cone is per- fectly transparent, but, after the disease has continued for a long time, it becomes opaque. The disease sometimes begins in one eye, and after a time appears in the other. Cause.—The cause of this disease is very obscure; it has been met with in every stage of life, but is said to be more fre- quent in women than in men. Dr. Ammon met with congenital cases of it. 5 66 ADVICE ON ADAPTATION OF AN EYE. Treatment—The only treatment that has been found to pro- duce any benefit, is giving the eyes rest, prescribing tonics, and attending to the generul health; benefit will also be derived from the application of stimulating liniments around the orbit. Evacuating the aqueous humor, and using pressure upon the cornea, have been practised, but with very little benefit. Mr. W. W. Cooper was more successful than others in this treat- ment, by means of an apparatus which he invented for keeping up long-continued pressure upon the eye without producing irritation, at least it produced less irritation than any previous means which have been tried; it was not, however, so success- ful as to encourage its use. The apparatus was an air-cushion acted upon by a spring, after the manner of a truss. ADAPTATION OF AN ARTIFICIAL EYE. When an eye has been partially or wholly exercised, or has atrophied considerably, the appearance of the patient may often be greatly improved by the adaptation of an artificial eye to the stump. The artificial eye has also the advantage of assist- ing the natural play of the lids, and thus preventing inversion of the lashes and its attendant evils. Artificial eyes, vulgarly called "eye-limpets," are constructed of glass or enamel. The anterior surface is convex, with a representation of the iris and pupil upon it; the posterior is concave, to adapt itself to the form of the stump. The artifi- cial eye should be thin and light, and it should be so made as to allow of its introduction without causing pain to the patient, and should admit of the perfect movements of the eyelids over its anterior surface. If fraena exist between the lid and the stump, the artificial eye may be correspondingly notched. The mode of inserting and removing the eye is exceedingly simple. All manipulations should be conducted over a soft cushion, in order that the eye may not be broken in the event of its falling; and before introducing it, it should be dipped in EXTRACTS FROM LONDON LANCET. 67 tepid water. To insert it, the upper lid must be drawn upwards with the thumb of the left hand, whilst the upper border of the eye is slid by the thumb and forefinger of the right hand under the lid into the upper palpebral sinus. The lower lid is now depressed, and the eye, with a little manipulation, glides into its socket. In removing the eye, the lower lid is depressed, and the patient's thumb-nail, or a small hook inserted under the eye, which is tilted out of the lower palpebral sinus, and is then easily drawn from behind the upper lid. After removal, which should be done every night, the' eye should be dipped in tepid water, cleaned, and carefully wiped. If inflammation of the conjunctiva ensues from the pressure of the artificial eye, its use for a time should be discontinued, and the socket be syringed with cold water or alum lotion. If the insides of the eyelids "become the seat of polypoid growths, they should be snipped off with scissors. EXTRACTS. [Lecture on the Physiology of the Nervous System, delivered in 1836, in the College of France, by Magendie.—Lancet, April Mth, 1837. Page 186.] "The integrity of both the optic and fifth nerves, then, is indispensably necessary for the exercise of vision, which is lost whenever either of these nerves is separately destroyed." [Lancet, May 20th, 1837. Page 299.] "Nervous pains of long duration and the greatest intensity have been quickly removed by topical applications to the tem- poral region." [Lancet. Page 280.] "Amaurosis cannot be considered as a simple affection of the optic nerve; at least, in the actual state of the science, it is generally impossible to say that the fifth nerve has no connec- tion with the loss of sight, and in many cases the connection is evident. Hence, a rule, which I invariably follow, of address- ing my remedies in the first instance to some of the branches 68 OPHTHALMIA. of the portal nerve; and I have frequently had the satisfaction of observing some of these cases of incomplete amaurosis im- prove sensibly under the influence of therapeutic agents applied to the fifth pair. I would go even further, and say, whenever you have a case of incipient amaurosis, commence by acting on this nerve, for it is at once the most expeditious and efficient method. I cannot, however, quit this point without assuring you that no physician is capable of treating diseases of the eye, unless fully in possession of the facts that I have first had the honor of explaining to you. These facts are daily becoming more numerous and more convincing, and already a considera- ble number of our young practitioners, who devote themselves wholly to the study of diseases of the eye, are fully aware of the immense influence of the fifth pair of nerves over the exer- cise of vision." [Lancet. Page 289.] "To resume, then, what I have said concerning the sense of vision and our several experiments, allow me once more to impress you with the idea that sight can never be exercised in a complete and perfect manner without a certain influence of the fifth pair of nerves. Destroy that influence and you de- stroy vision. This is all we know of the matter, for up to the present moment we have been unable to determine how far this influence extends, or in what manner it is communicated." OPHTHALMIA. By the term ophthalmia is meant inflammation of any part of the eye, but more particularly when the conjunctiva is the part affected. There is no term more likely to set the student or young practitioner astray than that of ophthalmia, being applied to every inflammation of the eye, without any distinc- tion as to the part inflamed. I shall endeavor, in as simple a manner as possible, to show what are the diseases to which the term is apphcable, avoiding all such divisions and subdivisions TREATMENT. 69 as do not lead to any practical result, and carefully adhering to those that do. And here I think it well to remark, that although any one particular part of the eye may become the seat of inflammation, and that of a particular kind, yet, when speaking of inflammation of a part, it is not meant that the in- flammation is confined to that part, but that it originated there; for inflammation cannot continue any great length of time in any part of the eye without spreading to other parts, not at first affected. The phenomena of inflammation, in part, are heat, redness, pain, and swelling. As a general rule, these signs are to be found in inflammation of the eye, but other symptoms are to be found accompanying them, according to the texture inflamed; and in some instances some of these symptoms will not be seen, while in other cases none of them will be observable; hence, the great necessity of describing the inflammation of each part separately. Inflammation of the eye may be either acute or idiopathic; and these may be modified by a peculiarity of con- stitution. Another distinction which is to be particularly at- tended to in inflammation of the eye, is its division into chronic and acute; for the means which would subdue the former would have no good effect on the latter. The practitioner must never lose sight of the important difference between inflammation and its consequences; he must also bear in mind that inflammation may be, from the very beginning, of a chronic form, and never partake of the acute, unless such a state is produced by the erroneous interference of those who do not understand the exact phases of the malady. General Causes of Inflammation of the Eye.—Among the general causes of inflammation of the eye are injuries of every kind, both mechanical and chemical. Either very warm or very cold air will act. as an exeiting cause. Beers was of the opin- ion that the quantity of electricity in the atmosphere had much to do in affecting the eye. Among the indirect causes, he enumerates immoderate bodily exercise, violent emotions of the mind, injudicious clothing, and high living. He also considered contagion a more frequent direct cause than infection. It is 70 OPHTHALMIA. strange that light, which is indispensable to the functions of the eye, should be a cause of inflammation; nevertheless, such is the ease, both as respects its quantity and its quality, but more particularly the latter. All strong artificial lights, or reflected light from red or polished surfaces, are well known to act as an exciting cause of ophthalmia, but it is in a greater or less degree, according to the irritability of the eye. Dr. Walker, of this city, considered the direction of the rays of light to make a great difference, conceiving that the eye was less capable of bearing them with impunity the more they re- ceded from the perpeadicular line, and struck the orgaa sloping or horizontally.. When we consider the position of the eye- brows and eyelashes, acting, as they do, as a shade to prevent horizontal rays from striking the eye, it musfc be acknowledged that there is some reason in this theory of Dr. Walker's. But he further observes, that every statement concerning light should be only received in a relative sense, for the degree of light which would answer very well fos the eye of an African, would destroy the eyes of Europeans; and the same light which is borne without inconvenience by the eye of an adult, would! excite in the eye of a new-born infant ophthalmia* neonatorum. Why light should produce inflammation m any of the coats of the eye, or how it produces it, I have n>ever found; explained by any author. Nor do I wonder at it, when- I consider the views. taken on. the physiology of the eye. We?e the retiaa only the seat of inflammation,, it would admit of an explanation^ but; when we find that the conjunctiva is the part that is generally attacked, we are at a loss to explain how it oceors. I consider ' that it can be explained in. one way only, which, is, by granting; that the ophthalmic brana-h of the fifth pair of nerves is sensi- ble to the stimulus of lig&t, and that under particular circum- stances,, light of a peculiar kind,, acting oa this nerve,, producer a morbid irritabilty of it,, and thus acts as an exciting cause of inflammation. [See the Physiology of the Opkthakaic; Branch; of the Fifth Pair of Nerves.] There are many other indirect causes of inflammation of the- eye,, such as.the free use of ardent spirits,, ex&ntkematous fevers TREATMENT. 71 suppression of the natural discharges, etc. All these causes will be more particularly considered when treating of the pecul- iar kind of inflammation which they produce. To give any general treatment for inflammation of the eye, I have only to state that it is the same, varying according to circumstances, as that which has been mentioned by every writer on surgery, for inflammation in any part of the body, such as bleeding, purging, nauseants, diuretics, opiates, diaphoretics, mercury, rest, low diet, etc. CATARRHAL OPHTHALMIA. Catarrhal Ophthalmia, or Mild Inflammation of the Conjunc- tiva.—This disease is purely specific, and differs in every re- spect from all other forms of inflammation of the conjunctiva. It is distinguished from purulent ophthalmia by the compara- tive mildness of its symptoms; the discharge being much less copious, the pain not so severe, and although the vascularity may be very great, yet it never runs into perfect chemosis, or induces sloughing of the cornea. Symptoms.—The first symptom is an itching of the eyes, fol- lowed, in a short time, by an unpleasant sensation, as though an eyelash or mote had got between the eyelid and the eyeball; which sensation is caused by the rubbing of the eyelid over the enlarged vessels of the conjunctiva. With this vascularity of the conjunctiva there is a copious flow of tears, and both symp- toms are much increased by the patient rubbing the eye with his hand. The second morning after these symptoms, the eye- lids will be found adhering together, from the increased mu- cous secretion of the conjunctiva, and the secretion from the meibomian follicles collecting on the edges of the lids, and becoming dry and encrusted from exposure to the air. If, at this stage of the disease, the eye be examined, the pal- pebral conjunctiva will be found to have an uniform deep-red 72 CATARRHAL OPHTHALMIA. appearance, and the sclerotic conjunctiva will be seen to be an equal vascular network, but the vessels not crowded together so as to produce a general redness, as in severe ophthalmia. Chemosis spots may sometimes occur in the vascular network, but true chemosis never exists, for when what might be called chemosis does exist, it is no longer the disease here treated of, but severe inflammation of the conjunctiva. At the commencement of the disease, the secretion from the conjunctiva is transparent but it soon becomes opaque, thick, and puriform, and during the daytime is not so visible, being removed, as fast as it is formed, by the great flow of tears; but if the patient remain quiet, with his lids closed for a short time, then, on depressing the lower lid, flakes of matter will be seen floating in the tears. As the disease advances, all these symptoms increase in severity. Exacerbations generally take place in the evening, which, however, are generally followed, and the patient relieved, by a good night's rest. During the prevalence of the above symptoms, vision is not much impaired, but there is an occasional haziness of sight, caused by the tena- cious fibres of purulent matter adhering to the cornea. If the patient be a healthy subject, and the case goes on well, on about the third day the sensation of a foreign body in the eye, and the great flow of tears becomes less frequent, the vascularity not so intense; but the discharge is more freely secreted. Subsequently, all the symptoms gradually diminish and finally disappear, leaving the parts something more vascu- lar than before the attack; but this vascularity disappears in a couple of weeks, leaving the eye perfectly well. Unfortunately, the cases met with in every-day practice are not such as has been just described, as the inflammation is generally modified either by a scrofulous constitution, improper treatment, neglect, deficient food or clothing, and, what is general, a want of cleanliness. Treatment.— It is, then, only necessary, in the severer cases, to keep the patient in his room. In mild cases, and where the conjunctivitis is subsiding, the patient is much more comfort- able in the open fresh air, and he recovers quicker than in a TREATMENT. 73 confined room. But he must be warned to avoid wind and dust, and not to visit places which are overheated, or in which the air is impure or smoky. He is especially to be warned against pursuing any occupation over a fire, and to avoid bright light or great contrasts of light, straining the eyes by reading, writing, or sewing, especially by lamp or gaslight; all of which may cause hyperaemia and congestion. Cold compresses, in this stage, should only be used at long intervals, and with the greatest care. They are to be used for cleansing the eyes, and for the removal of the frequent burning, itching sensations, etc. Cloths dipped in cool, fresh water answer this purpose excel- lently well, while pressure, or rubbing the lids, although pleas- ant to the patient at the moment, increases the irritation very markedly, and are, therefore, to be carefully avoided. In the use of astringents, we should remember that they always irritate more or less, and that their therapeutic value depends on this effect. Astringents can, then, only be indi- cated only where an irritation is desirable of itself, or for the purpose of overcoming a relaxation of tissue and of the vessels. In cases in which neither the irritation nor relaxed condition are very prominent, where it is, therefore, doubtful whether the anti-irritative or astringent treatment be proper, it is ad- visable to keep on for a few days with the antiphlogistic treat- ment, or to try the ground with the experimental use of a mild astringent; and in case the latter is not borne, to again take up the antiphlogistic method, and wait till the relaxation is more distinct and the astringents are indicated. Penciling the conjunctiva with a solution of nitrate of silver, five grains to the ounce, does by far the most service. Wherever the relaxa- tion of the tissue is quite prominent in catarrhal conjunctivitis, and the symptoms of irritation do not contraindicate, the treat- ment should be begun and continued with this remedy, until the relaxation and morbid secretion of the conjunctiva are removed. If, under such a treatment, the morbid condition is subdued, except as to some hyperaemia of the conjunctiva, or if the catarrh from the beginning has been but slight, and the relaxation of tissue little noticeable, or if the patient be not in 74 CATARRHAL OPHTHALMIA. a position to consult the physician daily and allow the pencil- ings to be made, the astringent collyria should be advised. In old, chronic catarrhal conjunctivitis, and, in general, where the relaxation of the conjunctiva and its vessels has reached a very high grade, especially in the habitual catarrhal inflammation of old persons, the treatment above indicated will not be sufficient to attain the desired result. Then, the daily application of a smooth crystal of sulphate of copper to the tarsal portion and the palpebral folds will do very well. But if the patient cannot visit the physician every day, we may sub- stitute an ointment of five grains of sulphate of copper to two drachms of simple cerate, which the patient causes to be intro- duced, or places, in the conjunctival sac with a camel's-hair brush. If, however, the very much relaxed and loosened con- junctiva is superficially rough, velvet-like, or even granular, it is better to first pencil the conjunctiva daily, for some time, with a solution of ten grains of nitrate of silver to the ounce of water, continuing this until the conjunctiva becomes smoother, when the sulphate of copper, in the form of a crystal or an ointment, may be continued until the end of the treatment. In order to prevent the formation of crusts and its evil re- sults, the edges of the lids may be cleansed with a piece of soft linen. At night, the lids should be smeared with fresh fat, with glycerine, cream, simple cerate, or the like. It is best to apply the ointment with a brush upon the edges of the lids, and it must be got between the lashes. The application is made when the lids are closed, and the patient should not open them for some time after. The parts should be covered by a thin layer of fat. If, in spite of all these precautions, or on account of insufficient treatment, thick, hard crusts are formed on the edges of the lids, which adhere closely to the ciliae and epider- mis, these should be first completely softened by soaking them in warm water with a sponge or a piece of soft linen; otherwise, their removal will cause excoriations. Lukewarm milk mav be used instead of water. TREATMENT. 75 PURULENT OPHTHALMIA. This disease has received various names, according to the nature of its secretion (ophthalmo-blennorrhoea; conjunctivitis paro-mucosa; suppurative ophthalmia); its contagiousness (oph- thalmia contagiosa, M'Kenzie); or from the persons who are chiefly liable to it (Egyptian ophthalmia; ophthalmia lellica; military ophthalmia.)* From what I have just said respecting catarrhal ophthalmia, the reader will readily perceive how impossible it is to make any definite practical distinction between it and purulent oph- thalmia, inasmuch as a severe case of the former and a mild case of the latter offer precisely the same phenomena. The difference between the two diseases appears to be one simply of degree, unless we consider contagiousness to be a distinctive mark of the purulent affection. If seen, then, at the first on- set, a case of purulent ophthalmia resembles one of ordinary catarrhal inflammation, but proceeds so rapidly that twenty-four hours are sometimes sufficient to furnish the peculiar signs of the more serious disease—the swollen lids, chemosis, and hazi- ness of the cornea. It is the last-named structure that should chiefly engage the surgeon's anxiety, for, unlike the common catarrhal ophthalmia, which limits itself to the comparatively unimportant conjunctiva, the purulent form rapidly endangers sight, by involving the cornea in its ravages. In a well-marked case of purulent ophthalmia, the patient is usually pallid, and both physically and morally depressed. The eyelashes are loaded with yellow discharge; the lids are swollen and dusky red, and so infiltrated that the patient can- not separate them sufficiently to expose the cornea. This ina- bility naturally suggests to him the notion that he is literally * The literature of purulent ophthalmia is most extensive. From its preva- lence in armies, and other large bodies of men, it has specially attracted the notice of military surgeons; it has formed the subject of several prize essays; and the most celebrated ophthalmic surgeons of Europe have, at various times, published reports on its ravages among the troops of England, France, Prussia, Austria, Russia, and Belgium. 70 PURULENT OPHTHALMIA. blind; and it is sometimes important, as a means of raising his spirits, for the surgeon at once to expose the cornea, and con- vince him that sight is still retained. The conjunctiva is every- where reddened, infiltrated, and elevated above the level of the cornea, producing the appearance termed chemosis, but usually looking more solid and less watery than in common catarrhal ophthalmia. If this chemosis has proceeded to its fullest ex- tent, it overlaps and completely hides the margin of the cornea, and it may even protrude a little between the lids. The cor- nea being overspread with thickened secretion, often appears at first sight to be really opaque or hazy; and the surgeon must take pains carefully to wipe away this secretion before pro- nouncing a positive opinion as to the state of the cornea beneath it. But even then, he can only speak very guardedly, for the ulceration, which in this disease is so destructive, frequently begins at the extreme edge of the cornea, the very part hidden, as I have said, by the overlapping of the chemosis; and it may thus escape detection until it has perforated the entire thick- ness of the cornea, and caused prolapsus of the iris. In very severe cases of purulent ophthalmia, this ulceration rapidly advances in the form of a crescentic groove, becoming deeper and wider, until it has isolated the central part of the cornea, which, by that time, has assumed a hazy or even opaque appearance. Then, this central portion likewise yields to ul- ceration at one or more points, becomes softened, sloughy, and infiltrated with pus; it gives way, the iris bulges through the large opening thus formed, and, eventually, becoming coated with fibrous exudation, assumes the prominent appearance known as staphyloma. The ulceration may stop short of ac- tual perforation, after destroying a large portion of the ante- rior surface of the cornea, and in such cases the cicatrices formed by the healing of the ulcers remain, ever afterwards, white and opaque; while the rest of the cornea, in consequence of inflammatory deposit and infiltration of pus, never regains its healthy transparency, but, at best, becomes sufficiently translucent to allow a dim view of the iris, not, however, afford- ing the patient any useful sight. TREATMENT. Those attending the practice of our eye infirmaries must be familiar with the aspect of patients whose corneae have under- gone some of the changes I have been describing. Soldiers who have suffered froui severe purulent ophthalmia, in India or some of the British colonies, exhibit the most distressing rav- ages of this disease. Another result of the inflammation of purulent ophthalmia is slough of the cornea. The chemosis having increased, so as to overlap not only the extreme margin, but the greater part of the anterior surface of the cornea, the latter loses its transpar- ency, becoming at first milky, then yellowish, and quite dull on the surface, and, finally, flabby and perfectly opaque, like a piece of wetted wash-leather. At this stage, the chemosis di- minishes, the profuse purulent discharge ceases, and is suc- ceeded by a flow of tears, rendered slightly turbid by a small quantity of mucus, and the patient and those about him are often pleased at the apparent improvement, and flatter them- selves with hopes of a speedy recovery, at the very moment when the surgeon knows but too well that sight is lost forever. Still, as long as any portion of either cornea retains its vitality, the case must not be abandoned in despair; for if only a small portion, less even than one-quarter of one cornea, can be saved from destruction, and its transparency retained, useful sight may eventually be gained by the operation of making an artifi- cial pupil. It was to obviate, if possible, this sloughing of the cornea, that Tyrrell devised, and so warmly advocated, the plan of making radiating incisions through the chemosed con- junctiva. He believed that the swelling of this membrane caused such tension and pressure on the vessels supplying the cornea as arrested the flow of blood, and so induced death of the part. But the operation was based on an anatomical mis- take, namely: that the cornea is wholly nourished by vessels prolonged into it from the conjunctiva. Mr. T. W. Jones, in a letter published in the Medical Gazette, exposed the fallacy of this theory; and subsequent experience has, I think, decided that these radiating incisions by no means ensure the happy 78 PURULENT OPHTHALMIA. result the inventor of the plan so confidently anticipated. I have frequently tried them, but could never satisfy myself of their contributing towards the cure of the disease. Two precisely opposite modes of treatment have been adopted in purulent ophthalmia—the depletory and the stimulating. The first was carried to its fullest extent in the various armies of Europe during the late war, and has since been advocated by eminent authorities in civil practice. The opinions of the profession on the subject of inflammation and blood-letting have undergone such a total change, that I need hardly caution the reader against attempting to cure acute purulent, or gonor- rhoeal ophthalmia, on the principle so strongly urged, only 24 years ago, by one of our most distinguished writers on eye dis- eases, who, in reviewing a case of gonorrhoeal ophthalmia, which had been seen at a very early period of the complaint, and treated by large bleedings, both local and general, records his opinion, as follows: "From the unfortunate termination of this case, * * * * I jnferj not thafc antiphlo. gistic treatment is incapable of arresting this inflammation, but that it had not been carried to a sufficient extent; and if I had to treat some of these cases again, I should certainly bleed more freely." "As much blood should be taken from the arm as will flow from the vein, and the evacuation should be re- peated as soon as the state of the circulation will allow us to get more." This practice is enforced by the following quotation from Bacot's Treatise on Syphilis: "There are cases which defy all the usual etiquette of regular and ceremonious visits. If we wish to save our patient from the destruction of his vision we must scarcely depart from his bedside until the inflammatory symptoms are controlled. The lancet must be hardly ever out of our reach, for if ever there was a disease in which blood may be taken away without limitation, it is this." Mr. Wardop's statement is still more startling: "The only case (of gonorrhoeal ophthalmia) he had seen, in which the eye was saved, was that of a young woman, in which venesection was repeated as often as blood could be got from the arm She TREATMENT. 79 had lost 170 ounces in a few days, and looked as if every drop of blood had been drawn from her body; the skin having nearly the hue of a wax candle." Can wc wonder that thousands of persons with that tendency to rush into extremities, which is one of the infirmities of our nature, should seek refuge from such treatment under the milder discipline of Homoeopathy? If the treatment of puru- lent ophthalmia by excessive depletion be judged by its results —:the only sure test—we shall, I think, be forced to confess that there was ample cause for trying some less violent means of cure. It has been suggested that the more temperate habits of the mass of the people at the present day, as compared with what existed fifty years ago, may exert a considerable influence over the inflammatory manifestations of certain diseases, and that those surgeons who describe purulent ophthalmia as they saw it at the commencement of the present century, had really some- times to contend with a greater fulness and force of circulation in their patients than we are in the habit of witnessing, espe- cially among the overworked and crowded population of our larger towns. Certain it is, that, as far as my own experience in traveling through large cities enables me to form an opinion as to the general condition of patients suffering under purulent ophthalmia, I should say that they are uniformly more or less depressed, with a pulse more feeble than natural, and in a state which in every way contraindicates general bleeding, and calls for the administration of tonics. There is usually a coated tongue, with loss of appetite, and a brisk purgative is needed at the very outset of the treatment. Afterwards, either bark and ammonia, or quinine, should be given, and hyoscyamus if the patient be restless. Pure air—to many the best of all tonics—must, if possible, be obtained; and all unnecessary con- finement to bed, or to one room, avoided. Meat may be al- lowed once a day, and a moderate quantity of beer or wine; but on this head no arbitrary rule can be laid down. The sur- geon's judgment must guide him as to the cases in which he ought to forbid stimulants, use them in moderation, or even to insist upon an extra quantity being taken. 80 PURULENT OPHTHALMIA. Treatment.—The surgeon should never forget that the puru- lent process is a very changeable one; that the severity of the inflammation, and the quality and quantity of the secretion, often change very much in a short time, and thus alter the indications. What is indicated in the morning may be contra- indicated at noon, and be urgently required again in the even- ing. It is seen from this, that it is not sufficient to see the pa- tient once or twice a day, to prescribe for half a day in advance, and then leave the carrying out of the orders to unin- telligent attendants; he who treats his patients in this way will have bad results. It is imperatively necessary to see the pa- tient often, to attentively weigh all the indications, and to use the remedies with the greatest care. Those about the patient should be warned from any unnecessary contact with him, or with anything that he uses. The attendants should see to it that, after each assistance they render the patient, they wash the hands with soap and water, and especially avoid any con- tact with their own eyes. The linen of the patient, and espe- cially the bed linen, the handkerchiefs, towels, etc., are only to be used again after boiling with soap and water. 1st. Cleaning the Eyts.—The first point in the local treat- ment is to clean away, completely and frequently, in the course of the day and night, the puriform discharge. This is to be done with a small piece of soft, clean sponge, while the patient lies on his back. The fluid which I recommend is a tepid solu- tion of 1 grain of corrosive sublimate, with 6 grains of sal ammoniac, in 8 ounces of water, to which are occasionally ad- ded 1 drachm of vinum opii. This not only cleans the eye, but acts as a gentle astringent. It is still more efficient to inject the same collyrium into the sinuses of the conjunctiva with a small syringe, the fluid being sent over the whole surface of the diseased membrane with considerable force; and especially into the fold between the eyeball and the upper lid. The sur- geon must be careful in inserting the syringe between the eye- lids not to press upon the cornea. 2d. Astringents—Escharotics.—With regard to other astrin- gents, my experience leads me decidedly to condemn su^ar of TREATMENT. 81 lead, in whatever form; nor can I speak favorably of sulphate or acetate of zinc. Some highly recommend a solution of alum, while others trust to solid sulphate of copper, rubbed over the internal surface of the eyelid?. I consider a solution of nitras argenti as the best remedy for constringing the inflamed ves- sels, allaying the painful feeling of sand in the eye, and lessen- ing the discharge. I have tried this solution in various degrees of strength, and consider 5 to 10 grains to the ounce of simple distilled water, as recommended by Dr. Ridgway, to be, in general, the most suitable. The solution may be applied every five or six hours, or as soon as the raw, painful feeling in the eye is renewed. It is to be taken up with a pretty largo cam- el's-hair pencil, with which first the inside of the upper eyelid is to be well brushed, and then that of the lower, not omitting any of the folds formed by the chemosed conjunctiva. We generally find a very marked improvement in the course of 24 hours under the use of this application. Circumstances may lead the practitioner to vary the strength from 2 to 10 grains. It may be well to begin with it weak, and see how it agrees. If weak, it may be used oftener. Should it disappoint our expectations, and the purulent discharge run on unabated, re- course may be had to a salve containing from 10 to 15 grains of the nitrate of silver in an ounce of axunge, or the inside of the lids may be touched rapidly with the lunar caustic pencil. Some practitioners trust almost entirely to this last means, to the exclusion even of depletion of any kind. They apply it once or twice a day chiefly or only to the inside of the lower eyelid. I conceive that if only caustic is employed, without depletion, the eye is very likely to be lost. Depletion enables us to use astringents and escharotics with more effect and less danger. Red precipitate salve, of the strength of 10 or 15 grs. to the ounce of axunge, has been found useful as an application to the conjunctiva, and may be substituted for the preparation of lunar caustic. These two local applications, the nitrate of silver solution and the corrosive sublimate wash, cannot be managed by the patient himself, and can rarely be trusted to a nurse; they 6 82 PURULENT OPHTHALMIA. should be applied by the practitioner. If crusts have formed on the lids and lashes, they should be softened by applications of cold water before they are removed; tepid water should not be used until the cold applications have been abandoned. When there are excoriations, castor oil and glycerine, equal parts, applied to the eye every evening, is found to be an excellent remedy. Opiate Fomentations and Friction.—Considerable relief to the pain of the eye is sometimes obtained from allowing the steam of hot water with laudanum to rise into the eyes from a teacup: or from fomenting the eyes with a decoction of poppy- heads. Rubbing the head with warm laudanum, when the cir- cum-orbital pain threatens to commence, is also highly useful. Dilation of the Pupil.—Although it is rarely the case that adhesions of the iris form in any of the puro-mucous ophthal- mias, unless to the cornea in case of penetrating ulcers; still, in case adhesions should occur, it is proper to paint the eye- brow and eyelids with the extract of belladonna, so as to dilate the pupil. This ought always to be done when ulcer of the cornea occurs. Solid Caustic to Ulcers of the Cornea.—In cases of ulcers of the cornea, much advantage is derived from the use of the lunar caustic pencil, sharpened to a point, and applied for an instant to the spot. The good effects of this application are often very striking, where a small portion of the iris pro- trudes through an ulcer. Yet this is a practice not altogether exempt from danger; for if a myocephalon is touched with caustic, the aqueous humor is apt to be discharged; the cornea, consequently, becoming flattened, may not again become plump, and hence vision will be permanently impaired. Vinum Opii.—When the purulent discharge is gone, or nearly so, the vinum opii, pure or diluted, proves an excellent appli- cation to the relaxed conjunctiva. It is sometimes advanta- geously combined, in this stage of the disease, with a solution of the lapis divinus. In hospitals, care should be taken that there are not many persons put together in one ward. The rooms should be kept TREATMENT. 83 as clean as possible, well ventilated, not overheated, and pro- tected from bright and irregular light by curtains and lamp- shades. The patient himself should be kept as quiet as possible. PURULENT OPHTHALMIA IN INFANTS. We must ever bear in mind that in this Ophthalmia, just as in the Purulent Ophthalmia of adults, it is upon the degree to which the cornea is involved that the whole importance of the disease depends; and his chief attention, when an infant is first examined, should be fixed on the clearness or opacity of that structure, and not on the more obvious appearances of redness, swelling, and purulent discharge which the eyelids present. Various theories of the origin of this ophthalmia have been sug- gested,—some regarding it as a mere catarrhal affection; some as due to actual contact with leucorrhoeal discharge of the mother in parturition; while others attribute it to irritating substances applied soon after birth, or to other causes. It seems probable that the marked difference of symptoms ob- served in infants suffering from this disease is due to the excit- ing cause not being in all instances the same; and that, as in adults, we meet with purulent discharge from the conjunctiva in simple catarrhal, in the "purulent," specially so called, and in the most severe, or gonorrhoeal, ophthalmia, just so do the milder cases of the disease now under consideration arise from exposure to draughts of cold air, and sudden changes of temperature; while contact with leucorrhoeal or gonorrhoeal matter may give origin to those severe cases, in which rapidly destructive ulceration of the cornea dooms the unhappy child to life-long blindness. In a case of ophthalmia neonatorum, the surgeon is so deeply interested in forming an accurate diagnosis, both to satisfy the parents and to preserve his own reputation, that he should spare no.pains to ascertain the precise condition of the cornea. For this purpose, having properly secured the child's head, he should endeavor 84 PURULENT OPHTHALMIA IN INFANTS. carefully to separate the lids without everting them. This is often extremely difficult, especially when the palpebral open- ing is small, and the lids offer but a very small surface to the point of the finger. With a bit of moistened lint the creamy matter, which oozes out as soon as the lids are drawn apart, is to be wiped away, and the surface of the cornea thoroughly examined. Occasionally it will happen, especially if a strong astringent lotion has been dropped into the eye, without any regular cleansing with the syringe or otherwise, that some of the secretion becomes coagulated, and is found overlying the cornea, like a piece of wetted wash-leather, resembling very closely the appearance of a sloughy cornea. I have sometimes had to remove with forceps such a layer of solidified secretion (which, on hasty inspection, might have been mistaken for a slough), and have found the cornea itself sound and clear. The conjunctiva of the lids is always red and villous. The secretion varies much, both as to quantity and color. It has a deep yellow tinge, if the child be jaundiced. The lids are red and swollen during the acute stage of the severe form of inflam- mation; but they commonly become flabby, and lose their red- ness, when softening and ulceration of the cornea have fully set in. The disease, as may readily be supposed, attacks both eyes, although an interval of a day or two, or even morer may elapse before the second eye suffers. But if the attack be a severe one, all local means prove un- availing, unless the child be well nourished: the health of the mother, therefore, and her ability effectually to suckle the child, are most important points for the surgeon's consideration. For the real danger of the disease consists, not in the profuse dis- charge, which so much alarms the uninformed, but in the liabil- ity of the cornea to undergo extensive ulceration. This morbid process it is which destroys those eyes which are said to have been lost by purulent ophthalmia. The cornea, in such cases, first becomes dull and hazy, then opaque towards the centre, with softening of its tissue; and, finally, an ulcer forms, which soon perforates the whole thickness of the cornea; the iris pro- lapses; perhaps, if the ulcer be very large, even the lens and TREATMENT. 85 part of the vitreous humor escape; and the eye ultimately shrivels to a mere nodule. It depends upon the severity of the disease, but even more, I believe, upon the general vital power of the child, whether purulent ophthalmia prove merely a troublesome complaint, or a calamity which impairs or even wholly destroys sight. During that early part of life at which the disease shows itself,—commonly three or four days, almost always within the first week, after birth.—the interchange of material in the system is so active, and there is such a power of forming new tissues, that, if this power be only sustained by suitable treatment, it is quite astonishing to see how rap- idly a large ulcer of the cornea will heal up, and with how slight an amount of opacity. When- this favorable change sets in, the peripheral portion of the cornea acquires a faint pink tint, from the vessels carrying blood to repair the breath. Treatment.—1st. As it is of the utmost importance to remove the purulent discharge from time to time, in the course of the day, I may be excused for explaining minutely how the eyes are to be cleansed. Unless the discharge is removed with regularity and care, other means will fail in curing the disease. The surgeon lays a towel over his knees, on which to receive the head of the child, which the nurse, sitting before him, lays across her lap. Every person bringing a child with ophthalmia neonatorum to an eye infirmary, should be supplied with a separate bit of sponge for cleaning the eyes, lest, by using the same sponge for different children, we may reinfect the eyes when they are beginning to get better. The fluid which I commonly use for washing the eyes is a tepid solution of 1 grain of corrosive sublimate, with 6 of sal ammoniac, in from 8 to 12 ounces of water. The lids are opened gently, and, with the bit of sponge, the purulent discharge which gushes out is removed. The lower lid, and then the upper, are next everted, and wiped clean with the sponge. The upper lid has a tendency to remain everted, especially if the child cries. This is overcome by pushing the swollen conjunctiva into its place, and bringing down the edge of the lid- All this ought to be repeated three or four times, 86 PURULENT OPHTHALMIA IN INFANTS*. or oftener, in the 24 hours, by the nurse, or by the surgeon. Washing out the discharge with a syringe is more effectual; but the surgeon only should attempt this, and if he does so, should guard against the fluid injected spirting, along with the dis- charge, into his own eyes. The impetus, however, with which a fluid is sent to the cornea by a syringe is not altogether free from danger, but is apt to bring on or to increase ulceration. The use of the sponge is sufficient and safe. 2d. The corrosive sublimate eollyrium, used in cleaning the eyes, tends gently to repress the discharge. Alone, however* it is not sufficient for that purpose, and we have recourse, there- fore, to astringent applications of more power. The solution of nitras argenti is what I have found most useful. The strength of the solution should vary, according to the state of conjunctiva and the duration of the disease, fron 2 to 10 grains to the ounce of distilled water. In recent cases, where there is little thickening of the conjunctiva, a weak solution is to be used; when the disease has gone on for a week or more, and the membrane has already become hypertrophied, a stronger solution will be required. With a large camel's-hair pencil, the solution is to be applied to the whole surface of the inflamed conjunctiva, immediately after it has been cleaned as above described. This application ought to be repeated every six or eight hours. Not only the local, but even the constitutional good effects of removing and restraining the purulent discharge are very remarkable. The first night after the use of eollyrium and drops, we generally find that the infant has been much quieter than it had been when the disease was neglected. In two or three days the eyes begin to open-, and in ten or twelve the acute symptoms are overcome. 3d. To prevent the eyelids, from adhering together, yellow- oxide of mercury,, mixed up well with glycerine ointment, or cas- tor oil and glycerine equal parts, is found to be an excellent remedy; melted on the end of the finger, it is to be applied along the edges, whenever the child goes to sleep. 4th. The above remedies are perfectly sufficient to remove this disease, if had recourse to within two or three days after TREATMENT. 87 the first symptoms have shown themselves. I have seen two applications of the nitris argenti solution, viz.: on the third or fourth day after birth, on the first and second days of the disease showing itself, remove the complaint completely, although thick white matter was flowing from the conjunctiva. In cases attended by a discharge less distinctly puriform, the use of yellow oxide of mercury ointment at bedtime has sometimes been suffi- cient. In cases, again, which have been neglected for perhaps 8 or 10 days, it is necessary to take away blood from the exter- nal surface of the upper eyelid by the application of a leech, or from the inflamed conjunctiva by scarification. The former may b#e tried in the first instance; and unless followed by marked abatement of the redness and swelling on the inside of the lids, the conjunctiva may next day be divided with a lancet. The taking away of blood in either of these ways is productive of much benefit, and ought by no means to be omitted, if there be much swelling of the lids, any tendency to chemosis, or haziness of the cornea. A more profuse loss of blood than can be obtained by the methods here recommended, I do not con- sider necessary. It may be proper, however, to leech or to scarify repeatedly. 5th. Should the conjunctiva threaten to assume the sarcom- atous or granular state, scarification should be used, after which, if there is no ulceration of the cornea present, the inside of the lids may be rubbed with a smooth bit of sulphas cupri. For the same purpose, a salve containing from 2 to 6 grains of nitrate of silver in 1 ounce of axunge may be applied to the palpebral conjunctiva; or the membrane, being wiped dry, may be rapidly touched with the lunar-caustic pencil. The latter application generally produces considerable pain and swelling of the lids, which subside under the use of cold wet compresses. The medicated stick, 1 part nitrate of silver and 2 parts nitrate of potash, is also a valuable application in granular conjunctiva. 6th. None of these strong applications are to be used, if the cornea is affected with ulceration. In this case, the solution of nitrate of silver should be omitted, and the eye brought under the influence of belladonna, by painting the lids with the moist- 88 PURULENT OPHTHALMIA IN INFANTS. ened extract. We may further the same object by infusing 1 drachm of the extract of belladonna, or dissolving 2 grains of the sulphate of atropia, in every 8 ounces of the corrosive sublimate eollyrium. It is not for the mere dilation of the pupil that the belladonna or atropia is to be used, but to obtain the influence of this anodyne over the ulcerated cornea. Much experience has convinced me of its efficacy, in inducing a heal- ing action in the cornea when affected with ulceration. Many eyes, which seemed, from the extent and depth of the ulcer present, to be doomed to destruction, have to all appearance been saved by its careful employment. Even in cases of per- forated cornea, I have seen the ulcer begin to fill up, and ulti- mately heal, without any adhesion of the iris, under the influ- ence of belladonna. 7th. A remedy of considerable service in this disease is the application of blisters behind the ears. A bit of candle-wick, covered with cantharides plaster, and laid into the angle be- tween the head and the external ear, is a convenient mode of breaking the skin; and by continuing this application either constantly, or several hours daily, a continued discharge will be procured. As soon as there is a discharge of matter from the blistered parts we perceive an amendment in the state of the eyes. If, however, the ears are allowed to get well, we often observe a renewal of the inflammation, and a more copious flow of matter; but the symptoms again subside if the blisters are reapplied. 8th. A dose of castor oil occasionally will be found useful. 9th. Small doses of calomel are highly beneficial; from half a grain to a grain daily will be sufficient. Besides acting favor- ably on the conjunctiva, this remedy is likely to counteract the tendency to capular cataract. 10th. In threatened disorganization of the cornea, Mr. Jones, of London, strongly recommended the extract of cin- chona. The sulphate of quinia answers better, and is more easily administered. From half a grain to a grain may be given thrice a day. 11th. The relaxed conjunctiva, after the purulent discharge TREATMENT. 89 has entirely subsided, may be advantageously touched, once a day, with vinum opii. I have sometimes treated cases with the vinum opii throughout, but I consider this remedy as more applicable for the chronic stage of the complaint than for the acute. It serves to clear the cornea from the opacities so apt to be produced by this disease. 12th. The child should be nourished by the breast alone: giving it food often seems to keep up the disease. The mother's or nurse's diet should be carefully regulated. During the acute stage of the ophthalmia, she should take little or no animal food, and should take neither wine, spirits, nor ale. After the acute stage is over, should the conjunctiva continue relaxed, tincture of iron may be given to the nurse with advantage to the child. In several instances, I have known ophthalmia neonatorum attack one child after another of the same parents. Such cases I suspect to be generally leucorrhoeal. SCROFULOUS OPHTHALMIA. Strumous Ophthalmia. —<- Phlyctenular Ophthalmia. Perhaps there is hardly an eye disease less correctly named than the well-known irritable form commonly called "Scrofu- lous Ophthalmia;" for, although it is very frequently met with in patients who afford decided evidence of a scrofulous consti- tution, it undoubtedly affects others who have never shown any such tendency; and, again, the cornea is the tissue in which the disease especially manifests itself, not the conjunctiva, which the conventional meaning of the word "ophthalmia" would imply to be primarily affected. We must, however, re- tain the old term until ah unexceptionable substitute has been suggested, only taking care not to confound the disease with mere conjunctival inflammation, or to suppose that medicines of specific action against scrofula (if any such there be) can afford a substitute for that general dietetic and other treatment which has for its aim the strengthening and soothing of an en- feebled and irritable system. 90 SCROFULOUS OPHTHALMIA. Scrofulous ophthalmia is chiefly met with in patients above two years of age, and below puberty. The most prominent svmptom is extreme intolerance of light (photophobia), and the lids are often so forcibly closed, by involuntary spasm, that it requires all the surgeon's tact to obtain a thorough examination of the eyeball. Frequently, the evidences of local inflamma- tion in the hitter are trifling, as compared with the distress evinced by the patient. We find on the cornea a small cloudy speck, an ulcer, or a slightly elevated whitish point, like a minute pustule; or there may be several such morbid appear- ances. But whatever form the inflammatory deposit or the ulcer may assume, we invariably trace an opaque pinkish streak, formed by a lash of fine vessels, extending to it from the edge of the cornea. Should the cornea be more deeply affected, it becomes hazy throughout, and traversed by vessels in various directions; or softening, and deposit of pus, may occur within its substance. The sclerotic exhibits more or less of the pink zone, in proportion as the corneal inflammation is more or less considerable. The conjunctival injection is chiefly seen in the enlargement of the veins running in the course of the recti muscles. The secretion of tears is very abundant, and they gush out every time the lids are drawn asunder. Violent sneezing often attends the admission of light to the eyes, espe- cially in those truly scrofulous patients whose nasal membranes are in a constant state of unhealthy irritability, with an over- secretion of mucus. Swelling of the lips and alae nasi, fissures about the nostrils and behind the ears, various forms of impe- tigo and eczema, and enlargement of the cervical glands, are all accompaniments of inflammation of the cornea in scrofulous subjects. There is no disease of the eye so tedious, so liable to relapse, and in all respects so trying to the surgeon's patience, as that now under consideration; and in a work like the present, I can but indicate the chief heads of treatment. I generally commence the treatment with an emetic, either of ipecacuanha or tartar emetic, and uniformly with good effects. Four grains of the latter being dissolved in six ounces TREATMENT. 91 of water, a tablespoonful is given every five minutes till free vomiting is produced. In cases where there is considerable quickness of pulse and heat of skin, I frequently put the pa- tient on a course of nauseants, or of emeto-cathartics. For instance, to an adult, a mixture may be given of from one to four grains of tartar emetic, with one to two ounces of sulphate of magnesia, dissolved in a pound of water. Of this solution, two or three tablespoonfuls may be taken every half-hour till vomiting is excited; after which, the dose is to be repeated at intervals of three, four, or six hours, as circumstances may require. This is the method to be followed in acute cases. In chronic cases, the nauseant may be exhibited at longer intervals. It may then be conveniently exhibited in pills; each pill containing from one-quarter to one-half a grain or more of the tartar emetic. To children, the same solution of tartar emetic and salts may be given, or a solution of tartar emetic by itself, or powders of the same rubbed up with a little sugar. From one-twelfth to one-sixth of a grain may be given, accord- ing to the age of the child, thrice a day. When there is much febrile excitement, this plan will often prove effectual, while purgatives or tonics would produce little or no good. Purgatives.—In children laboring under phlyctenular oph- thalmia there is commonly a full and hard abdomen, and a load- ed state of the stomach and bowels. Even in feeble and ema- ciated children, it will usually be found that, by the exhibition of purgatives, a large quantity of murbid feculent matter will be discharged. In such cases the administration of purgatives is followed by marked benefit; and without these, other medi- cines avail but little. In recent cases, a purge of calomel, with jalap, rhubarb, or scammony, will often be sufficient to remove the attack of ophthalmia altogether. Such a purgative is to be repeated at intervals of two, three, or more days, ac- cording to the urgency of the symptoms. It not only empties the bowels, but reduces very powerfully the impetus of the blood in the affected part, increases the action of the absorb- ents, and restores to a healthy state the sections of the diges- tive organs. It proves in short, alterative as well as depletive; 92 SCROFULOUS OPHTHALMIA. and its use as such may be persisted in, in many cases, for a length of time, with very decided benefit. \ have found a powder, containing from the sixth to the third of a grain of tarter emetic, with from five to ten grains of rhubarb given each night, to be of much service. The purgative plan is more useful than any other in those cases in which an impetiginous eruption over the body accompanies the affection of the eyes. Care, however, must be taken not to push its debilitating action too far. Sulphate of Quinia and other Tonics.—In scrofulous ophthal- mia it is of great importance to remove the debilitated state of the patient; for unless this is done, the eye will not recover. We attempt to increase the strength of the patient, chiefly, by improving his powers of digestion. This is often accomplished by the remedies mentioned under the last head; and especially by the use of rhubarb, which both keeps the bowels regular and improves the action of the stomach. There are several other remedies, belonging more decidedly to the class of tonics, which prove strikingly beneficial in the treatment of phlyctenular ophthalmia. After a trial of many internal medicines in this disease, I have found none so useful as the sulphate of quinia. It exer- cises a remarkable power over the constitutional disorder which attends this ophthalmia, and thereby over the local complaint. The dose which I employ is, generally, a grain thrice a day; in very young children, half a grain; and in adolescents or adults, two grains. It may be given rubbed up in a little sug- ar; but it appears to act best when administered in solution. For this purpose, I use the acidum sulphuricum aromaticum, to which I add a sufficient quantity of syrup and water. In most instances, the effects are very remarkable. Although I have met with a few cases which appeared to resist its beneficial in- fluence, in most of the little patients to whom I have adminis- tered sulphate of quinia, it has acted as a charm; abating, commonly in a few days, the excessive intolerance of light and profuse epiphora, promoting the absorption of phlyctenulae and hastening the cicatrization of ulcers of the cornea. As soon as TREATMENT. 93 the stomach has been cleared by an emetic, and the bowels put to rights by repeated doses of calomel with rhubarb, or some other purgative, the use of this medicine may be begun, unless the pulse is very quick and the skin hot, when small doses of tartar emetic will be preferable; or where an impetiginous eruption is observed on the surface of the body, in which case a course of purgatives ought to be adopted. As internal remedies, Dr. J. B. Walker, of this city, places in the very first rank, a solution of iodide of lime with protox- ide of iron. Dose: from half a teaspoonful to a teaspoonful twice or thrice a day. We may set down the cold plunge or shower bath as a very efficient tonic in scrofulous ophthalmia; but it is not to be em- ployed till after the acute symptoms have subsided. It proves one of the very best means for preventing relapses. The employment of tonics, both medicinal and dietetical, must be continued long after all the inflammatory symptoms have disappeared, in order, if possible, to communicate to the consti- tution that degree of vigor, which may enable it to resist any tendency to relapse, which may still linger in the eyes, and which, were this precaution not adopted, might, on exposure to the slightest exciting cause, lead to a new and severe attack. We may class change of air among the tonic remedies for this disease, or rather among the preventives which are to be em- ployed after the first attack is subdued. A dry, warm, inland situation is preferable to the sea-cost. The glare from the sea is very apt to aggravate slight attacks, and give rise to relapses. Antacids.—There is reason to believe that phlyctenular oph- thalmia frequently depends on acid generated in the stomach, whence proceeding into the bowels, it mixes with the bile, and produces green stools and general irritation. The teeth, in such cases, are apt to become carious. Under these circum- stances, relief may often be obtained by using antacids such as magnesia, its carbonate, or a mixture of rhubarb and bi- carbonate of soda, in small dpses frequently repeated. Car- bonate of ammonia, with tincture of gentian, as recommended by Dr. Charles Armstrong, in common cases of scrofula, may also be employed, with good effect. 94 SCROFULOUS OPHTHALMIA. Mercury.—Calomel is very often administrated in phlyctenu- lar ophthalmia; more frequently, however, as a purgative than as an alterative. That this medicine is often injurious to chil- dren does not admit of doubt. That their constitutions are shattered by an indiscriminate use of calomel, and that in this way they are rendered more susceptible of suffering from the exciting causes of scrofula, is a truth which is too much over- looked. Given as an alterative ophthalmia, I have frequently known mercury prove injurious, because mistimed, that is to say, it was administered before the irritation attending the acute stage of the disease was moderated by depletion. After local blood-letting, and the use of evacuants, we sometimes find de- cided advantage from the exhibition of blue pill, or even of calomel with opium. In some cases this combination may be pushed with advantage, till the mouth is affected. Prognosis.—As there is no disease of the eye more liable to a relapse than this, or one that more depends upon the careful attention of the friends of the child, great caution must be ob- served in giving a prognosis. The practitioner must by no means make light of the complaint, and lead the friends of the child to believe that the case will soon get well, for there are many uncontrollable causes to prevent it, and if his prognosis does not turn out to be correct, he is sure to be blamed; therefore, he should plainly tell the friends all the dangerous consequences which may result from the disease, that there is no security against a relapse, and that the cure may be tedious under the most favorable circumstances. Treatment.—As a general rule, perhaps there is not one dis- ease of the eye less under control of the practitioner than strumous ophthalmia, nor is there one which is subjected to more various modes of treatment, all appearing equally suc- cessful at one time, and unsuccessful at another; indeed, like inflammation of other parts modified by scrofula, it will at some period successfully oppose the very directed treatment. The surgeon must always bear in ininc! that this disease is dependent upon a constitutional cause, the removal of which must claim his chief attention, while he does not neglect the local treatment. • TREATMENT. 95 Believing, as I do, that the nutritive powers of the diseased eye are diminished, I cannot recommend blood-letting in any, nor any other debilitating remedies. However, there are those who recommend the application of leeches. Mr. Mackenzie says: "When the inflammatory action runs higher than ordinary, or when it is suddenly or violently aug- mented by the formation of ulcers on the cornea, it is proper to moderate the impetus of the blood by the application of leeches to the eyelids or temple." I do not think the surgeon can com- mence the treatment better than by giving the following advice to the friends of his little patient, viz.: If the child is living in an impure atmosphere, let it, if possible, be removed to a pure one; let him be well clad particularly with flannel next the skin, and let him have good, nutritious food. Pay particular attention to cleanliness, and keep the child in a large, well-lighted, and moderately warm room, and let him be brought out into the pure air when the weather is fine. He should be encouraged to play with his companions, and not allowed to keep his head buried in his nurse's lap, or on her shoulder; even when in bed he should be made to lay upon his back, having his head raised by means of pillows. If the practitioner can get the friends of the child to attend the above directions, he will have accom- plished the most important part of the treatment. Diaphoretics.—Keeping up a healthy action of the skin is of much importance. This may be promoted by the wearing of flannel next the skin, and by the use of tepid bath every night, or every second night. The warm bath often greatly relieves the intolerancf of light. It proves soothing and refreshing, and ought to be frequently employed. A tepid salt-water bath is highly useful. The tepid pediluvium every night, for weeks or months together, proves very serviceable; also warm fomen- tations of the belly, as in infantile remittent fever. Dover's powder at bedtime sometimes proves useful, by exciting a healthy action of the skin, as well as soothing irritation and procuring sleep. In cases where the perspiration is immoder- ate, this medicine is not less remarkable for its good effects than where the surface of the body is dry and husky. Tartar 96 SCROFULOUS OPHTHALMIA. emetic operates also with good effect on the skin, and sympa- thetically on the conjunctiva. Local Treatment.—Finding that veratria was recommended by Dr. Turnbull for the cure of neuralgia, gout, rheumatism, and some forms of paralysis, I was induced to try it in various cases of disease of the eye, where I could trace the affection to any disordered state of the ophthalmic branch of the fifth pair of nerves; and I have found it productive of the very best ef- fects. Its immediate effects, in strumous ophthalmia, are to remove the morbid irritability of the extreme filaments of the fifth, and thus to get rid of the painful sensibility to light, pro- fuse lachrymation, and blepharospasmus; and this is doing much towards accomplishing the object in view. I believe it even does more than this; for, by giving the nerve its healthy action, it restores the nutritive properties necessary for a healthy eye. The manner in which I use this remedy is by brushing the eyelids, eyebrows, and temples with a J-grain so- lution of it, till a slight burning sensation is produced in the parts. I repeat the application three times a week, until the pain, blepharospasmus, and intolerance of light are removed. Great caution is necessary, in its application, not to let any of it get on the conjunctiva, for such an accident will produce great pain, and do no good. If the use of it is found to pro- duce twitching of the muscles of the face, it should be at once desisted from. Tincture of iodine painted behind the ears, and on the temples, and the eyelids, very carefully, so that none of the liquid runs into the eyes, is sometimes even more efficacious than blisters in subduing the intolerance of light. In most cases it may be repeated twice a week. ' Fomentations.—When the symptoms are in any degree se- vere or of long continuance, warm soothing applications will be found more useful than cold ones. By means of a piece of sponge or flannel, the eyes may be fomented, several times in the course of the day, with a decoction of chamomile flowers, poppy-heads, or digitalis leaves, or with a watery infusion of opium, heated to about 100° Fahr. Much relief is experienced from exposing the eyes to the steam of warm water, or the TREATMENT. 97 vapor of laudanum or camphor, raised by means of a cupful of hot water. Belladonna and hyoscyamus, in vapor or in fomen- tation, are of great service in relieving the intolerance of light. A solution of 1 grain of corrosive sublimate and 6 grains of sal ammoniac, in 6 ounces of water, with 1 drachm of vinum belladonna, or from 1 to 2 grains of sulphate of atropia, is the eollyrium which I have found the most useful; a tablespoonful being mixed with an equal quantity of hot water. It is to be used three times a day; and after the eyelids are carefully bathed with it externally, for the space of five minutes, a little of it ought to be allowed to flow upon the eye. Scarification of the inside of the eyelids, especially in chronic cases, where the palpebral conjunctiva is much loaded with red vessels, will be found one of the most valuable means of cure. In cases of vascular speck, division of the fasciculus of vessels running over the sclerotica to the albugo, can scarcely be dispensed with; no other remedy having the same power in checking this very annoying and dangerous symptom. Counter-Irritation.—In scrofulous subjects, we frequently find that the occurrence of disease in one part relieves another part which was previously suffering. Imitating this natural conversion of disease, when we find other means to fail, we em- ploy blistering in scrofulous ophthalmia, and generally with great benefit. The intolerance of light is often suddenly re- moved by this remedy; the child being enabled, in a few hours after the blister rises, to open its eyes, although it had not done so for months before. The temples, behind the ears, the crown and back of the head, and the nape of the neck, are the situa- tions generally chosen for the application of blisters. The last is the most painful, but not the least ineffectual. In general, the discharge ought to be kept up, by the use of some stimu- lating dressing; or, if this is not done, a quick succession of blisters ought to be employed. Friction on the nape of the neck with tartar-emetic ointment is sometimes had recourse to in this disease, for the purpose of bringing out a crop of pus- tules. This is a practice much more painful than blistering: the pustular eruption sometimes spreads over the body, and 7 98 SCROFULOUS OPHTHALMIA. causes considerable constitutional disturbance; the pustules, if of considerable size, leave indelible pits, and, from mismanage- ment of the remedy, large portions of the skin are sometimes made to slough; so that, on the whole, blistering is pref- erable. Stimulants applied to the inflamed surface of the eye, in this disease, are decidedly useful. Indeed, it is scarcely possible to effect a cure without them. The impetiginous state of the con- junctiva, or, in other words, of the skin covering the eye, in this ophthalmia, not merely bears stimulants, but, like most other chronic cutaneous diseases, is benefited by their applica- tion, if they be well chosen, carefully used, and properly timed. They often act as the best local sedatives, if applied after the acute inflammatory excitement is subdued by the general reme- dies already enumerated. Employed before this is effected, they will scarcely fail to prove hurtful. In this respect, the treatment of phlyctenular ophthalmia is directly contrary to that of the puro-mucous inflammations of the conjunctiva; for in them we employ stimulants from the very first, but in the phlyctenular we must wait till the symptoms of irritation are somewhat abated. Various stimulants have been used in scrofulous ophthalmia; but the nitras argenti solution and yellow oxide of mercury, 4 to 5 grains, mixed up well with 1 ounce of glycerine, are the most deserving of confidence. Next to them I would place the vinum opii. Whichever be selected, its application must be continued with regularity once a day, or once every two days, the child being laid in a horizontal position, the head fixed be- tween the knees, and the lid opened so as fully to expose the diseased membrane. The solution of 4 grains of the nitras argenti in 1 ounce of distilled water is the stimulant which I generally employ. It evidently possesses very considerable power in abating the vascularity of the conjunctiva, hastening the absorption of phlyctenulae, promoting the cicatrization of ulcers, and clearing specks of the cornea. The relief which it affords to the intolerance of light is not the least of its good effects. We not unfrequently observe that TREATMENT. 99 a single application of this remedy will effect so much relief that, by next day, the patient is able in a moderate light to keep the eyes half open, without uneasiness, although previous- ly he could not bear the least accession of light. In producing this effect, it probably operates by inducing the healing of mi- nute ulcerations, and the contraction of enlarged bloodvessels, both of which give rise to the sensation of sand in the eye, to spasm of the lids, and equiphara. Whenever ulceration is present on the cornea, recourse should be had to the solution of nitras argenti. A stronger so- lution than that of 4 grains to the ounce may be employed, and with a small camel's-hair pencil applied directly to the sur- face of the ulcer, without permitting the solution to spread over the rest of the eye. Solid Caustic.—When an ulcer threatens to penetrate deep into the substance of the cornea, or when it has already perfo- rated into the anterior chamber, it is proper to touch the ulcer; or, if there is prolapsus of the iris, the myocephalon, every second or third day, with a pencil of lunar caustic, filed to a sharp point. Mydriatics.—Even when a portion of iris is involved in such an ulcer, the dilating power of the belladonna may be sufficient to free it, and thus to preserve the pupil entire. In cases of perforating ulcer near the edge of the cornea, we can have re- course to the use of belladonna with less confidence; for while the dilation cannot, in this case, be carried so far as to remove the iris from the vicinity of the ulcer, it is doubtful whether the state into which the iris is thrown is not apt to favor, rather than prevent, prolapsus. Belladonna is of great service in sub- duing the intolerance of light; indeed, it may be regarded as a specific for this distressing symptom. A good mode of ap- plying it is to expose the eyes to a teaspoonful of its vinous solution, raised into vapor,'by being added to a teacupful of boiling water. An ointment containing extract of belladonna, rubbed around the eye, is serviceable; as is also the eolly- rium of murias hydrargyria with vinum belladonna, already noticed. Similar benefit is to be derived from the salts of atro- 100 PUSTULAR OPHTHALMIA. pia, and from other mydriatics, besides belladonna; such as hyoscyamus and stramonium. Relapses.—No disease is so apt to recur as ophthalmia. It is therefore necessary for children who once suffered from it, to be submitted, from time to time, to the inspection of their medical attendant, who must endeavor promptly to subdue every symp- tom of a reattack, and to conduct his patients safely through that period of life which is most exposed to the disease. In this way much mischief will easily be prevented, which, should the disease be neglected, may require years to remove, or prove altogether beyond remedy. PUSTULAR OPHTHALMIA. Although pustular ophthalmia may be found in persons in whom no strumous affection can be traced, yet it can hardly be considered anything more than a variety of the disease; how- ever, the subjects of it, generally speaking, are those who pass the age of strumous ophthalmia, viz.:—persons from 12 to 25 or 30 years old. It is not so dangerous a disease as strumous ophthalmia, nei- ther is there the same intolerance of light; blepharospasmus is of very rare occurrence; and it is found to yield more readily to well-directed treatment. Although the pustules vary in situation, yet they are always on the sclerotic, never on the cornea, but generally close and in- ferior to it. They also vary in size and number; are very little elevated, of a yellowish cast, although, when they burst, they dis- charge a fluid that is more of a watery than purulent character* The ulcer left by the bursting of a pustule generally forms a groove between the cornea and sclerotic; and although it does not spread, it will sometimes penetrate into the interior cham- ber of the eye, which may be followed by prolapsus of the iris. Treatment.—The best treatment is that recommended for strumous ophthalmia. Unless an ulcer is formed, I have rarely found it necessary to use a stronger stimulant than from 5 to TREATMENT. 101 10 grains of nitrate of silver, twice a day; if it gives much pain, I generally drop on the conjunctiva 1 or 2 drops of 1 grain of morphine, to 1 ounce of rose-water; at bedtime I order yellow oxide of mercury 4 to 5 grains mixed up well with 1 ounce of glycerine ointment. ERYSIPELATOUS OPHTHALMIA. It frequently occurs that erysipelatous inflammation of the head and face extends to the conjunctiva, but idiopathic ery- sipelatous conjunctivitis is a disease very seldom met with; it does sometimes, however, take plaee, and may be produced by any of the causes which excite simple inflammation of the conjunctiva. Why injury, cold, etc, will produce simple conjunctivitis in one person, and the erysipelatous in another, is not more easily explained, than that from the same causes simple inflammation will be produced in the integuments of one, and erysipelatous in another person. All that can be said in explanation is, that there is some pre- disposing cause existing in some persons, that is not in others, when, if they only receive the slightest injury, erysipelatous in- flammation is sure to follow. Symptoms.—The symptoms of this disease are, an increased vascularity of the conjunctiva, but the color is of a much paler red than in any other form of inflammation. This vascularity is soon followed by watery infusion into the sub-conjunctival cellu- lar tissue, causing the conjunctiva to become so elevated as to overlap the edge of the cornea, and even, sometimes, to pro- trude between the lids; this swelling resembles chemosis in every respect, except in not being so vascular. The pain is generally very slight, and of a prickly nature. Intolerance of light and lachryination are seldom complained of, except when the dis- ease is very severe, and even then these symptoms are not very bad. The secretions from the conjunctiva and meibomian glands 102 RHEUMATIC OPHTHALMIA. become increased, and altered in character, so that the lids are glued together when the patient awakes in the morning. If the case be mild, the conjunctiva, instead of swelling in the manner just described, merely forms yellowish vesicles around the edge of the cornea. When the disease goes on favorably the symptoms subside, the secretions of the eye gradually as- sume their natural appearance, the swelling abates, but for a long time the conjunctiva does not assume its natural color. The local treatment must be particularly attended to. As a general rule, the 10 grain solution of nitrate of silver will be a sufficiently strong stimulant, but when the inflamma- tion is very severe, from 15 to 20 grain solution may be ap- plied. The patient should bathe his eyes two or three times a day with the soothing lotion, or the 8 grain solution of alum, and smear the edges of the lids, at night, with some yellow oxide of mercury ointment, from 4 to 5 grains to the ounce of water. When the conjunctiva is greatly swollen, benefit is derived from opening it either with a lancet or cataract knife. Some authors recommend depletion, but it is a treatment I should never think of adopting. RHEUMATIC OPHTHALMIA. It has been already stated that there are three ophthalmias frequently produced in adults from atmospheric influences, viz.: the catarrhal, the rheumatic, and the catarrho-rheumatic. Diagnosis.—The following particulars will serve sufficiently to distinguish rheumatic from catarrhal ophthalmia:— 1st. Seat of the Disease.—The catarrhal ophthalmia is an affec- tion of the conjunctiva; the rheumatic has its seat in the albu- ginea and sclerotica, and frequently extends, in some degree, to the iris, and even to the retina. 2d. Redness.—The redness in the catarrhal ophthalmia is reticular, and the turgid vessels are evidently conjunctival; in the rheumatic, the chief redness is radiated or zonular, and TREATMENT. 103 seated under the conjunctiva, or in the deep-seated conjunctival, or sclerotic, net-work. We never see spots of blood extrava- sated under the conjunctiva in rheumatic ophthalmia; whereas, this is a frequent occurrence in catarrhus oculi. 3d. Nature of Inflammation.—The catarrhal ophthalmia is an inflammation of a mucous membrane, and is a blennorrhoeal or profluvial disease, attended with an increased and morbid se- cretion of mucus; the rheumatic attacks the fibrous membrane of the organ of vision, and is unattended by any morbid secre- tion from the surface of the eye. 4th. Pain.—The pain in the catarrhal ophthalmia arises on the surface of the conjunctiva, is compared to the sensation of roughness, or the feeling which might be excited by sand or broken glass under the eyelids, does not extend to the head, and is felt most in the morning, or when the eyes begin to be moved ; the pain of the eyes in the rheumatic ophthalmia is pulsative and deep-seated; the chief pain, however, is not so much in the eyeball, as round the orbit, under the eyebrow, and in the tem- ple, cheek, and side of the nose, and is severely aggravated from sunset till sunrise. When I am asked, "What is meant by rheumatic ophthal- mia?" I should answer to the following effect:— 1. By rheumatic ophthalmia, I mean simply inflammation of the fibrous membrane of the eye (the sclerotic), and of the adjacent parts of similar structure, excited by exposure to cold. 2. I do not regard this ophthalmia as an fnflammation, dif- fering in kind from common inflammation, in consequence of the existence of what has been called the rheumatic habit, or diathesis. The train of symptoms seems to depend, not on the constitution of the person, but on the structure and functions of the part affected. 3. Rheumatic subjects are by no means exempt from this ophthalmia; yet it frequently occurs in individuals who have never suffered from rheumatism in any other part of the body. We seldom see both eyes affected with rheumatic ophthalmia at once. When both are attacked, the one is always much more severely inflamed than the other. 104 RHEUMATIC OPHTHALMIA. m Dimness of vision uniformly attends this ophthalmia, de- pending on an accompanying haziness of the cornea and pupil, attended by a slight contraction of the latter, and sluggishness in the movements of the iris. If only one eye is affected, which, at least for some time, is generally the case, the pupil of that eye is seen at once to be less than that of the sound eye. The iris becomes slightly discolored: it becomes greenish, for instance, if naturally blue; and the attending iritis may pro- ceed even to effusion of coagulable lymph within the pupil. It must be understood, however, that a severe degree of iritis rare- ly attends rheumatic ophthalmia. The access of light does not, in general, prove very distressing to the patient. The affected eye feels dry and hot in the early period of the disease; but after a time, especially when the symptoms are somewhat abated by blood-letting, there is considerable epiphora. The pain which attends rheumatic ophthalmia at its com- mencement is of a stinging kind. The patient never fails, in the history he gives of his ease, to insist on the nocturnal pain, and with his finger to point out its supra-ocular or circumorbi- tal seat. It affects much more the forehead, temple, and side of the nose, than the eyeball. It is reasonable to conclude that, in this disease, the periosteum, in and around the orbit and the fascia of the temporal muscle, structures similar in na- ture to the sclerotica may also be affected with rheumatism. The chief seat of the pain, however, appears to be one or more of the six branches of the fifth nerve, which, radiating from the orbit, are distributed to the face; and we may fairly suppose a considerable portion of the pain to arise from the sympathy which these nerves have with those distributed to the interior of the eyeball, and which lie embedded on the inside of the sclerotica. Constitutional Symptoms.—A considerable degree of symp- tomatic fever attends this disease, increasing along with the nocturnal paroxysms of pain. The pulse becomes frequent, and sometimes strong, full, and hard. The tongue is white and TREATMENT. 105 furred, and the mouth ill-tasted; there is more or less nausea, and the skin is hot and dry. The digestive organs are de- ranged, the appetite impaired, the bowels generally confined, and the excretions morbid. Exciting Causes.—Rheumatic ophthalmia may be distinctly traced, in most instances, to exposure of the eye to a continued stream of cold air, while the head and face are in a state of per- spiration. The patient, in the history which he gives of his case, com- monly mentions some particular exposure of this sort, soon after which the redness and rheumatic pain commence: for ex- ample, sleeping with the head exposed to the air entering by a chink in the wall, or by a broken pane of glass; travelling dur- ing the night in a carriage, with one side of the head close to a broken window; suddenly issuing from a crowded room into the cold air of the street; exposure to the current of air which flows from the stage into the body of a theatre; keeping wet cloths on the head when overheated; and the like. I have not observed that this disease is much more apt to occur at one season of the year than another. It is certainly more prevalent when the wind is cold and north-easterly. It is much more apt to attack persons of middle age than either the young or old. Indeed, I have never seen it in children, nor in those far advanced in life. Probably the same exciting causes which, in persons of middle life and robust constitution, are apt to produce rheumatic ophthalmia, would in a child excite catar- rhal or scrofulous ophthalmia, and in an old person the catarrho- rheumatic or arthritic. Rheumatic ophthalmia is very apt to reattack an individual who has previously suffered from it. Prognosis.—If the disease is taken in time, the prognosis is favorable. Allowed to proceed in its course, the pupil may close, or the anterior crystalline capsule be left opaque. Treatment—Calomel and Opium.—I have never failed to find this combination highly useful in checking the circum- orbital pain, and dissipating the other symptoms. A pill, con- taining 4 grains of calomel with 1 grain of opium, is to be ad- ministered every evening, till the gums be affected, when the 106 RHEUMATIC OPHTHALMIA. calomel may be omitted, and 10 grains of Dover's powder sub- stituted for the opium. In some cases smaller but more fre- quent doses of calomel and opium may be proper, such as 2 grains of calomel with half a grain,of opium thrice a day. Mr. Jones states that mercury, given in this disease so as to produce ptyalism, aggravates more than mitigates the symptoms. This does not correspond with what I have observed. I do not, in- deed, push the mercury to make the mouth sore, but I have not witnessed any bad effects from the gums becoming affected. Opiate Frictions.—The patient experiences great relief from carefully rubbing the forehead and temple with a piece of sponge for five minutes, with the concentrated tincture of cap- sicum, and mind and do not let it get into the eyes; if it gets into the eyes, it gives much pain, and does no good; or with warm laudanum, or extract of belladonna infused in laudanum. This ought to be done about an hour before the nocturnal par- oxysm is expected, which it will greatly assuage, and sometimes entirely prevent. In chronic cases, equal parts of laudanum and tincture of cantharides form a useful liniment. Where there is morbid pain, I order half a dozen or a dozen leeches, to the forehead or temple. Blisters behind the ear, and to the temple, will be found useful. Belladonna.—During the whole course of rheumatic oph- thalmia, the pupil of the affected eye ought to be kept under the influence of belladonna, either by painting the moistened extract upon the eyebrow and eyelids morning and evening, but especially at bedtime, or by infusing 1 drachm of the extract in each ounce of the laudanum which is used for rubbing the head. Purgatives.—A smart dose of laxative medicine ought to be administered at the commencement of treatment. Afterwards, a laxative clyster every morning, or a small dose of Epsom salts may be employed, to obviate the constipating effects of the opium. More powerful purgatives are now improper, as they would carry off the calomel and opium, and thereby prevent their good effects. Sudorifics.— The warm pediluvium at bedtime, with diluent TREATMENT. 107 drinks towards evening, operating along with the opium, will, in general, excite a sufficient degree of diaphoresis. Mr. War- drop recommends antimonial powder, and Beer employed guaiac, for exciting the skin in this disease. Tonics.—Small doses of sulphate of quinia, or of the min- eral acids, will be found advantageous in the chronic stage of the disease, and during convalescence. In old mistreated cases, Fowler's solution sometimes gives great relief, in doses of from 8 to 12 drops thrice a day. Applications to the eye itself have but little power over this disease. Those which are so useful in other ophthalmia, are often hurtful in the rheumatic. The lunar-caustic solution, for instance, which may be regarded as a specific in catarrhal oph- thalmia, is in the present disease decidedly injurious. WJien all the febrile and painful symptoms, however, are gone, and a little more than lingering redness, with weakness of the eye, remains, 2 grains of morphine to 1 ounce of rose-water, or 1 drachm of laudanum to 1 ounce of rose-water, will be found beneficial, dropped upon the eye twice or thrice, or the pure vinum opii, ss. These ingredients to.be moulded into sticks, and used for "touching" the conjunctiva when granular. Granulations are generally treated with caustics. Those commonly used, are the sulphate of copper ("blue stone"); a mixture of the latter with alum, etc. ("green stone," or lapis divinus); the nitrate of silver; the crystallized nitrate of silver (1 part), saltpetre (2 parts), melted into sticks, and, for protec- tion, covered with gauze and collodion; and the powdered ace- tate of lead (used in chronic granular ophthalmia). The latter, when sprinkled upon the conjunctiva, remains between the granulations, causes the surface of the conjunctiva to become more uniform, and contributes towards the shrinking of the granulations. The guttae cupri sulphatis (grs. xj. ad aquae 5j-)> are ^"re" quently prescribed; also the lotio plumbi acetatis (grs. x. ad aquae 3j). The unguentum cupri sulphatis, made with glycer- ine, may be found of use. Mr. Lawrence recommends the liquor aluminus compositus, which, at first, is to be used in a diluted state. Each fluid ounce of this preparation contains about 8 grains of alum, and as many of sulphate of zinc. The method of applying this and similar astringents in the fluid form, is to pencil them on the diseased membrane with a camel's-hair brush. M. Chassignac used a crayon of borax, or sulphate of zinc. The borax he employs in its native state, only cut into the form of a cylinder. As it is but little soluble, he leaves it in contact with the conjunctiva for a few moments, and it has the effect of slightly whitening^ the surface without producing any scar. Sulphate of zinc he employs also in the form of a crayon, but mixed with variable proportions of powdered gum Arabic. TREATMENT. 119 A paste being made of the two substances, it is rolled into the shape of a crayon, to be applied in the same way as the borax. M. Buys introduced the neutral acetate or sugar of lead, in the state of an impalpable powder, applying it over the diseased sur- face with a miniature pencil, allowing it to dissolve in the tears. The immediate effect is to cause strong contraction of the dis- eased tissue; the granular prominences shrink; and the mem- brane appears smooth and uniform. After replacing the eye- lid, the salt assumes a white, shining appearance, and it is often a very long time before it becomes detached. It is to be ap- plied at intervals of five or six days, till the cure is accom- plished. It is stated that in this mode of treating granular con- junctiva, no insoluble precipitation is met with, even in cases where ulcers exist on the cornea, which is scarcely credible. [An astringent wash of sulphate of zinc and common table- salt, in rose-water, of the strength of 10 or 12 grains of each salt to the ounce, will be found to be an excellent application in the management of granular conjunctiva, in connection with its treatment by escharotics.—H.] Escharotics.—The escharotics most frequently used, have been nitrate of silver and sulphate of copper. A day or two after leeching or scarification, the lids being everted and dried from the gleety mucus with which they may be covered, the lunar caustic pencil is to be brought into a single rapid contact with the granular prominences. Before allowing the lids to be replaced, a little warm water is to be squirted over the surface which has been touched' with the caustic, and after which a little castor oil is found very serviceable, as it relaxes the cor- nea. It is advantageous, after a time, to change the lunar caustic for the sulphate of copper, which may be more liberally applied to the diseased surface; and a smooth wedge of it pushed up occasionally behind the everted tarsus into the upper sinus of the conjunctiva. A very convenient method of applying the sulphate of copper, and which will sometimes prove to be the only one available, as in cases of chronic ophthalmia attended with great tension of the orbicularis, softening of the tarsal cartilage, or disease of the 120 GRANULATED OPHTHALMIA. ciliary follicles, precluding the possibility of eversion of the lid, is that recommended by Mr. Wilde. It consists in, first of all, slightly lifting the lid (the upper lid) off the globe, by drawing the integument upwards against the brow, in the usual manner, and then the piece of blue stone may be inserted underneath the lid, towards the internal side, as far up as possible, and held a lit- tle out from the eye, so that it does not touch the surface of the ball. It i3 then to be drawn downwards and outwards towards the external angle. This way of using the sulphate of copper we have often found very convenient. Caution should always be observed in drawing it from the one canthus to the other, so as not to allow the surface of the copper opposite to that which is in contact with the lid to touch the cornea, for, should it do so, an abrasion of its epithelial covering would be produced, and more or less opacity of its substance ensue. This can readily be avoided by drawing the crayon towards you, so as to make the lid stretch itself over it as you pass it downwards and outwards to the external angle. The crayon of blue stone requires some care in its prepara- tion. A large and perfect crystal of the^salt sfiould be selected. This is to be filed and rubbed down to about the size and form, as Mr. Wilde describes it, of the spade of cards, and of about the eighth of an inch in thickness at its shank, which is to be securely fastened in a quill or porte crayon. The whole of the crayon, thus prepared, should be kept always smooth and even, by frequently rubbing the surfaces and edges on a wet cloth. This, we believe, to be the proper condition in which sulphate of copper should be applied for granular disease of the lids. M. Desmarres uses quite a rough, crude crystal of the salt, and thinks that advantage is to be derived from the additional irritation produced by its application in such a condition. But we feel satisfied, after having carefully watched its effects in M. Desmarres' own hands, at his clinique, and after having given it a full trial at Wills' Hospital, that such is not the re- sult of its application in this manner. On the contrary, we feel assured that, in the majority of cases at least, the irritation will only impede the salutary effect of the escharotics, and, not TREATMENT. 121 unfrequcntly, serve to keep up the diseased action in the part. Alternately, every two or three days, local depletion, and one or other of the escharotics, is to be employed; while warm fomentations, as the bichloride of mercury eollyrium, are to be used thrice daily, and the yellow oxide of mercury ointment, or glycerine and castor-oil, equal parts, applied to the edges of the eyelids at bedtime. Besides lunar caustic and sulphate of cop- per, in the solid state, the application of these substances, and of other escharotics and stimulants, to the granular surface, in solution or in ointment, is useful; and especially yellow oxide of mercury, or a weak solution of sulphate of copper and morpine. These assist in charing the cornea, as well as repressing the sarcomatous state of the conjunctiva. A proper remedy, which I have known do good, is castor oil. Under this head may be mentioned the plan of pencilling the external surface of the lids, every second day, with Dr. J. B. Walker's crayon.* Sorbtfacients.—Much advantage is obtained, in many cases * Dr. Walker has, for many years, made use of a crayon, composed of pure Bulphate of copper and morphine. The lid being thoroughly everted, the dis- charge and moisture is to be removed, and the crayon applied every night, or every second night, according to indications. He also uses, in the same man- ner, a crayon of borax, and another of sulphate of cadmium. These remedies, as well as all other medicines and appliances required in ophthalmic practice, and recommended by the author of this work, may be obtained at the North-western Medical Agency, 82 Madison Street, Chicago. Dr. Walker insists on the importance of improving the patient's general health, by the administration of iron and quinine, singly or in combination, and regulating his diet. R. Solution Iodide of Lime, with Protoxide of Iron, Tilden's, oz. viij. A teaspoonful to be taken three times a day. J. B. W. Ferri et quiniaa citras, dr. iss; ainmon. carb., dr. ij; tinct. aurantii, oz. ij; aquas destillat., oz. ij. Mix. A teaspoonful to be taken at 10 and 4 o'clock daily, in a little water. J. B. W. He also recommends the Turkish bath. Dr. Dixon, of London, speaks of the liquor potassge as exerting almost a Bpecific influence on palpebral granulations. The fluid is dabbed over the everted lids, so as to be thoroughly brought into contact with the whole sur- face, and it appears to act by saponifying and dissolving away the hypertro- phied tissue. It may be applied at intervals of a few days, mild collyria being used in the interval. 122 CORNEITIS. of granular conjunctiva, by putting the patient on the external use of iodide of potassium. Rubbing the external surface of the lids, for some minutes night and morning, with mercurial ointment, or with yellow oxide of mercury ointment, is found useful, in reducing the hypertrophy of the diseased tissue. Excision.—When granular conjunctiva has proceeded to a great degree of exuberance, and continued for perhaps many months, notwithstanding a careful trial of other plans of treat- ment, recourse may be had to a more speedy method of remo- val, namely, by the knife. The eyelid to be operated on is to be everted as completely as possible, and the hypertrophial pa- pillae, at least the most prominent of them, shaved off by means of a small and very sharp lancet-sharped knife, or dissected away with the scissors. In performing the operation, it is necessary to beware of re- moving more than the mere granular layer. If more than this is taken away, hard and irregular cicatrices are left on the in- ternal ^surface of the lids, the effects of which on the cornea may be scarcely, if at all, less prejudicial than those of the morbid structure which has been removed. CORNEITIS (KERATITIS; INFLAMMATION OF THE CORNEA). Syphilitic Corneitis {Scrofulous, Strumous Corneitis; Strumous Ophthalmia; Aquo-capsulitis; Corneitis punctata). This form of corneitis rarely occurs in infants, or in very young children, or in persons advanced in age; but most fre- quently between the ages of 9 and 15; and in girls oftener than boys. It appears, as a rule, in connection with syphilitic changes in other parts, and is the result of inherited syphilis. On inquiry, we often find that the mother of the patient had miscarriages or stillborn children previous to the birth of the one suffering from corneitis; also, that the patient has suffered from other symptoms of syphilis during infancy: as prolonged TREATMENT. 123 snuffles, a sore mouth, ulcers round the anus, various skin erup- tions, etc. Hydrocephalus, of different degrees, discharge from the ears, and deafness, are common complications. The physiognomy of these patients is very characteristic, and, when once recognized, cannot readily be overlooked. Its pecul- iarities are: a generally old, pale-looking face, a squarish fore- head, with the bridge of the nose frequently wide and depressed, which, in most cases, is the result of anomalous development of these parts; in a few, the effect of loss of bone from caries. Cicatrices of former fissures in the skin round the lips, especially about the angles of the mouth, are met with, and there is a pe- culiarity in the shape, size, color, and number of the permanent incisor teeth, especially of the upper central ones. These teeth are small, narrow, squared, sometimes of a yellowish color, and, as a rule, more or less deeply notched in a vertical direction. The corneitis generally appears in both eyes, though seldom simultaneously; a few days or weeks (rarely more than a year) pass, before the fellow-eye is attacked. The left eye frequently suffers first. Recurrent attacks, though rare, have been observed in both eyes, sometimes repeatedly. The corneitis may take a chronic cause, and continue for several years; the cornea may become completely opaque or crimson red, yet again recover its trans- parency after a few weeks. Patients generally seek advice on account of the impairment of sight. Vision for a time may be reduced to mere perception of light, from the corneal changes alone. It frequently remains permanently impaired, through changes in the other tunics. The degree of impairment varies during the different stages of the inflammation. The patient, if able to read, holds the type very close. Vision may remain permanently impaired from one or several of the following causes: Opacities in the cornea, alterations of its curvature, opacities in the crystalline lens, changes following choroido- retinitis, inflammation of the optic nerve, or cerebral changes, as hydrocephalus, etc. The ocular changes, though varying in degree, occur as a rule in both eyes, but are often more severe in the left; vision may remain useful during the prime of life, 124 CORNEITIS. but fail prematurely. Patients are often much distressed by the different (dazzling) of light, caused by its transmission through semi-transparent portions of the cornea. A profuse flow of tears, intolerance of light, slight swelling or spasmodic closure of the lids, are sometimes present, but may be entirely absent, or may appear or disappear during different stages of the cor- neitis. They are usually caused by changes on the surface of the cornea, e.g., vesicular or nodular elevations. As a rule, there is no pain, or hardly any complained of, in the eye, while there is sclerotic or conjunctival redness. Some- times, however, very severe pain occurs during the process of cicatrization, if the ciliary region has been implicated, or if choroiditis round the optic disc has accompanied the corneitis. The vascularity of the ocular conjunctiva is, in many cases, but slightly increased, while a more or less broad, pink zone in the sclerotic, along the margin of the cornea, is usually present. Course.—The cornea at first loses its transparency more or less, especially in the centre and lower half. Frequently, small, ill-defined, gray, yellowish or brownish, and opaque dots, in groups or singly, appear in its lamellated structure; more fre- quently at or near the posterior elastic lamina, about the mid- dle or lower part. This appearance, if combined with slight iritis, is described by some as "Aquo-capsulitis." It may be absent, or the patient may present himself after it has passed away. The surface of the cornea often appears dull or slightly uneven, as if pricked with a pin in numerous places. In rare cases, small flaccid vesicles or pustules appear upon it, usually along its upper margin. These are situated imme- diately beneath the anterior elastic lamina. Within a few weeks the entire cornea may have lost its transparency, assum- ing a ground-glass color, some portions (the most depending) being more densely opaque, or appearing pink or crimson. The red color is most intense at the surface and periphery of the cornea, and is caused by bloodvessels passing from the sub- stance of the sclerotic between the lamellae of the cornea. These vessels are placed close together, and run somewhat parallel. TREATMENT. 125 In severe attacks, or in patients of feeble health, lymph is abundantly developed in the cornea and iris, the former assum- ing a yellow and opaque color. Swelling of the iris and cor- nea, and their adhesion to each other, are followed by dense and permanent opacities, occupying, most frequently, the lower half of the cornea. The cornea rarely regains its transparency throughout; changes in its curvature and faint opacities remain for life, particularly if the ciliary processes have been much implicated. Though the cornea be the part most conspicuously altered, we find, as a rule, the other tunics simultaneously inflamed. The surface of the iris, after the corneitis has subsided, presents, in most cases, a characteristic and permanent steel-gray hue. Posterior synechiae or irregularities of the pupil often become visible after instillation of atropia. With the ophthalmoscope, we frequently discover changes in the transparency of the lens; its nucleus becomes prematurely large, yellowish, and strongly light-reflecting. Dotted opacities occur on its surface, beneath the capsule. Changes in the vitreous chamber, with or without opaque shreds floating and gravitating in it; chronic suppura- tion of the choroid and vitreous substance, with subsequent softening and shrinking of the eye, and consequent loss of sight, are not infrequent occurrences. These lesions have been observed in both eyes of the same patient. [See, also, Syphilitic Changes in the Deeper Parts of the Eye.] Treatment.—In the treatment of this disease, much depends upon the state of the constitution; if the patient be of a full, strong, healthy habit, bleeding, with other antiphlogistic means, will be found serviceable, particularly if the acute stage be very severe. However, such cases are of rare occurrence; indeed, generally speaking, such are the subjects in which corneitis is found, that much more harm than good would be experienced from bleeding. As long as active inflammation (deep-seated or superficial) is going on, the treatment is directed against the syphilitic dia- thesis. Frictions with mercurial ointment are employed. Un- 126 CORNEITIS. guent. hvdrarg. nitratis mitius, "the size of a small pea," is ordered to be rubbed over the eyebrows at bedtime, and the internal use of iodide of potassium with sarsaparilla are pre- scribed. Some patients, however, are so weak, that good nour- ishment is the only thing that could be ordered for some time. In such cases, the formation of pus or lymph is particularly abundant. Locally, we use atropia, a few drops to be applied to the conjunctiva of the lower lid with a camel's-hair brush, from three to six times daily, as long as the tunics are unduly vascular; and three times weekly for one or two months after all vascularity has subsided. Slight purulent or catarrhal ophthalmia seems to hasten the course of the corneitis considerably, and the applications of warm fomentations over the closed lids, every quarter of an hour during the day, and a linseed-meal poultice at night, should be tried in all cases, as long as the cornea appears vascular. These local means also favor the rapid development of blood- vessels in the cornea, in which the lymph tends to change into pus, and thus prevents perforation, etc. Some advise, for the same purpose, the local application of the oleum terebinthinae. Slight pressure, by means of lint and cotton-wool tied over the closed lids, materially assists in the preservation of the nat- ural curvature of the cornea, and of the shape of the eyeball; and should be kept up until all undue vascularity has subsided. Opacities of the cornea occur frequently, after all inflamma- tion has ceased, in spite of appropriate treatment. The patients, or parents, must be informed of the often very slow course of the disease, which may extend over months; and of the frequently permanent impairment of vision, with opaci- ties of the cornea, etc., which often ensue. STRUMOUS CORNEITIS. (VASCULAR CORNEITIS: STRUMOUS OR SCROFULOUS OPHTHALMIA.) This form of corneitis has been observed at all ages, but most commonly in scrofulous children, and in females shortly before, or about the age of, puberty. TREATMENT. 127 Injuries of different kinds, foreign bodies upon the cornea, inverted eyelashes, also pustular ophthalmia, may, in weakly persons, give rise to it. Vascular corneitis accompanies the different forms of suppuration of the cornea (in which cases its appearance is a favorable symptom); it is also present during the healing of ulcerations. The absence of nodulous infiltra'- tions distinguishes it from pustular corneitis. .The patient suffers from "pain in the inflamed eye;" this, sometimes, is severe, and extends over the corresponding side of the head and face. The lids are generally red along the margins, slightly swollen, and spasmodically closed, and there is abundant flow of tears, with more or less intolerance of light. These symptoms, coupled with the presence of one or several small, ill-defined opacities in the cornea, are characteristic, provided there be no changes in the conjunctiva, as granula- tions, which may give rise to similar symptoms. Opaque and slightly vascular (inflamed) spots appear, in many cases, at the onset of the attack, at or near the centre of the cornea; in some, these spots seem to advance from the margin towards the centre. They are superficial; they rarely extend into the deeper parts. In weak persons, the entire thickness of the cornea may be implicated. The inflamed portions, which ap- pear gray, grayish-white, or yellowish and opaque, shade off into the transparent cornea, or merge into the sclerotic. The vascularity of the sclerotic and conjunctiva is most marked next the inflamed part; a varying number of vessels pass to- wards or into the opacity. Ulceration or suppuration of the inflamed portion, with per- foration and hypopion, or iritis, may occur if the patient be weak, or the corneitis wrongly treated. The cessation of intol- erance of light and of the flow of tears are sure signs of im- provement. The bloodvessels and the redness and swelling of the lids then gradually disappear; the opacities fade away, and the cornea becomes again transparent. Semi-transparent opac- ities disappear in from three to nine months, but dense white or gray opacities may remain for life. A peculiar form of vascular corneitis, accompanied by pain, 128 CORNEITIS. intolerance of light, and lachrymation, is sometimes observed, most particularly in young females. Its symptoms are: a dense vascular web, resembling pannus, and generally appearing first like the latter along the upper margin of the cornea, but dis- tinguished from it by the absence of "granulations in the conjunctiva.*' This form is probably of syphilitic origin. It readily subsides after a blister to the temples, small doses of bichloride of mercury being at the same time prescribed. I place in the very first rank, iodide of lime with protoxide of iron. Dose: For children, half a teaspoonful three times a day; for adults, a teaspoonful twice or three times a day. Treatment.—The intolerance of light and the spasmodic clos- ure of the eyelids are the unX troublesome symptoms of stru- mous corneitis. The former is caused by uneven and opaque portions of the cornea; the latter is a reflex action, but may lead to a spasmodic condition of the orbicularis muscles, which persists after the changes in the cornea have subsided. Blisters behind the ears, and tincture of iodine upon the temples, hardly ever fail to remove the intolerance of light. Excision of a small portion of the supraorbital nerve, or divi- sion of the nerve, where it passes around the margin of the orbit, has been recommended by some. In adults, if there be much pain or "redness," a few leeches to the temple may be tried. The pain and intolerance of light may also be relieved by frequently fomenting the eyelids with lint dipped into warm water, and by the application of olive oil containing some chlo- roform or morphia to the skin around the eyes. In all cases, we order a few drops of atropia to be applied to the conjunc- tiva once daily, and the eyelids to be bathed occasionally with warm poppy-head lotion. The inflamed eye, or the one which is more inflamed if both are affected, is kept bound up until all redness has subsided. If there is any purulent discharge, with or without an ecze- matous condition of the skin at or near the margins of the eye- lids, or if the latter stick together after sleep, the patient is ordered to bathe the eczematous parts twice daily with alum TREATMENT. 129 and mur. ammon. (equal parts) lotion, and, after having dried them well, to rub in some yellow oxide of mercury ointment. The ointment should be washed off with warm water, and alum mur. ammon. used before applying fresh ointment. This, if repeated morning and night, succeeds in removing the eczema in from three to ten days, as a rule, and thus get rid of a great source of irritation. In making use of medical treatment, we must be guided by the state of the patient's general health. Plain diet and clean- liness are essential. Children or adults, with a swollen or eczematous condition of the nostrils, are much benefited by the internal use of arsenic combined with steel. The fact that blisters rerfove, within the shortest time, the troublesome symp- toms of most cases of vascular corneitis, provided the cause (granulations, cicatrices, etc.) be not seated in the conjunctiva of the lids, must not be lost sight of when considering the effects of internal remedies. If ulceration or suppuration of the cornea complicate the case, we must be guarded in our prognosis; and the patient or the parents should be informed that a "speck" will remain on the eye for a long time, perhaps for life. PUSTULAR CORNEITIS. {Phlyctenular, Strumous Corneitis; Herpes Cornea; Pustular or Strumous Ophthalmia.) Pustular corneitis, like the foregoing form, occurs most fre- quently in young persons and children. Extreme intolerance of light, continuing sometimes for months, slight redness, swell- ing and spasmodic closure of the eyelids, an abundant flow of tears, and frequent eczema of the surrounding skin, often with comparatively but slight changes in the cornea, are the usual symptoms. As the pathognomonic sign, we observe one or several round- ish, small, somewhat projecting, opaque nodules in the super- ficial layers of the cornea, standing alone or in groups, or in a 9 130 PUSTULAR CORNEITIS. row at or near the margin of the cornea. One nodule, or a small group of nodules, may appear at the apex of a bundle of bloodvessels, which latter diverge over the cornea, forming a vascular triangle, and ultimately lose themselves in the adjoin- ing conjunctiva. The nodules often appear in the conjunctiva first (pustular ophthalmia), or are preceded by attacks of oph- thalmia with sclerotic vascularity and intolerance of light. Nodules, pustules, patches of vascular corneitis, small ulcera- tions and opacities may be found together. In rare cases, the entire surface of the cornea and conjunc- tiva is covered with vascular cicatrices, intermingled with pus- tules and nodules in different stages of development. At an early stage we may find the corneal epithelium rafsed at the apex of the nodule, causing a resemblance to a pustule. The nodule, or a part of it, may either undergo suppuration, some- times in a few hours, or change into an ulcer, which, by its extension, may lead to perforation of the cornea. The changes of nodules are preceded and accompanied by the above-mentioned symptoms, by inflammation of the sur- rounding cornea, and by a varying amount of vascularity of the sclerotic and conjunctiva. The duration of these cases varies much. Some patients recover in a Aveek, others only after months. The number of successive nodules, the time required for repair of the lesions of the cornea, the complications with higher degrees of cornei- tis, and, in a few cases, with iritis, are some of the causes of its prolonged duration. The cessation of intolerance of light is always a sign of a favorable turn of the disease. The corneitis may return for several years at about the same season, or at any time when the general health is impaired. Whether the affected portion of the cornea ultimately be- comes transparent, or remains more or less opaque, depends on the size, changes, and number of the nodules. One, or several, dull or chalky-white and opaque spots, shading off into the sur- rounding cornea, sometimes of the peculiar triangle shape men- tioned above, may permanently remain. Causes.—Pustular corneitis is most common in what are TREATMENT. 131 termed strumous persons. It frequently occurs after scarla- tina, measles, and variola. It is most obstinate in persons suffering from acne rosacea, and from herpes of the mucous membrane of the nose. It is attributed by some to deranged function of the fifth nerve. Treatment.—The general medical treatment varies, according to the state of health. In children, particularly, we order plain, regular diet, with some Avine, and a warm bath every day. If the lips and nostrils are SAvollen and red, with crusts around the nasal orifices, Tilden places in the very first rank a solution of iodide of lime with protoxide of iron. Dose: in children, half a teaspoonful three times a day, and to adults, a teaspoonful two or three times a day. Mr. Bader recommends arsenic and steel. If the sclerotic is implicated (much swollen and vascular), the bichloride of mer- cury is prescribed. In adults, the dose is one-sixteenth of a grain in half an ounce of water, tAvice daily. In young children, the exhibition of hydrarg. c. creta will be found of use at the commencement. The general medical treatment is continued for tAVO or three weeks after all intolerance of light has subsided. Local Treatment.—Adults should wear London-smoked spec- tadles, Avhile at the same time the more inflamed eye is kept bound up. In children, both eyes, if severely inflamed, must be kept closed for one or two weeks. Touching the vesicle at the apex of the nodule Avith the solid nitrate of silver may arrest the inflammation at once; but we rarely see the case at this early stage. If the vascularity, pain, and sensation of heat are great, one or two leeches should, in groAvn persons, be applied at bedtime to the corresponding temple. In all cases Ave prescribe atropia, to be applied once daily, with a camel's-hair brush, to the conjunctiva of the lower lid of the inflamed eye. The intolerance of light, if the lids cannot be kept bound up, is relieved by the application of the tincture of iodine, twice a week, to the skin of the lids. If the vascu- larity of the conjunctiva or cornea is considerable, but the intolerance of light and the flow of tears moderate or absent, 132 PANNUS. calomel powder, applied twice daily to the cornea, until all vas- cularity has disappeared, has been found of use. Lotio alumi- nis is ordered, to wash the margins of the eyelids carefully, morning and night, if they are at all gummed up. The lotion is discontinued as soon as this has subsided. If the discharge is only watery, we order the lids to be kept clean with warm water, or with lotio papaveris. The skin of the lids, if excoriated, should be Avashed twice daily with warm water or warm lotio aluminis, well dried, and then some yellow oxide of mercury ointment should be rubbed upon the excoriated portion. The eyes should not be used for near work as long as there is increased vascularity, with intolerance of light; and the patient must be informed of the liability to fresh attacks. PANNUS. (VASCULAR CORNEA.) Pannus is a term applied to a vascular condition of the sur- face of the cornea. Pannus appears, as a rule, first along the upper margin of the cornea, where bloodvessels encroach upon its surface from the surrounding conjunctiva and subconjunctival tissue. Pannus often accompanies morbid changes of the con- junctiva of the eyelids, especially granular ophthalmia. Attacks of corneitis, of ulceration, suppuration, softening, etc., of the cornea, may appear as complications of the pannus. The term xerophthalmos is applied to the species of pannus in which a dry, gray, and opaque cuticle, continuous with the conjunctiva, covers the surface of the cornea. Treatment—For treatment of pannus with granulations in the conjunctiva, see Granular Ophthalmia. Pannus caused by contraction or distortion of the tarsi, with contraction of the palpebral aperture, often disappears after enlargement of that aperture by operation. Pannus caused by cicatrices in the tarsus is much relieved by the excision of a portion of tarsus which includes the cicatrix. If the cause of pannus is removed, and the latter slight, occupying, for exam- TREATMENT. 133 pie, only the upper third of the cornea, no further remedies need be applied; but if it is considerable, so as to hide the pupil from view, and if there is no pain or increased heat, or undue watering of the eyes, benefit is derived from the applica- tion of a solution of nitrate of silver (grs. x., ad aqua §j.), with a camel's-hair brush, to the surface of the pannus every other day; and by touching any granulations, which may be present in the pannus, with a crayon of sulphate of copper and mor- phine. The operation of syndectomy is recommended by some, and by others the treatment of inoculation. CORNEITIS WITH SUPPURATION. {Abscess in the Cornea; Suppuration of the Cornea.) A yellow-white, or yellow and opaque, discoloration of the cornea, Avhen it appears in the course of corneitis, or of ulcer of the cornea, generally, indicates the presence of pus. The pus may accumulate between the lamellae of the cornea, layers of pus alternating with lamellae, and thus no pus may escape, when the suppurating cornea is punctured. The lamellae frequently, however, becomes destroyed, and an abscess, with irregular lamellated walls, is found. The weight of the pus, the pressure of the aqueous humor, and the distance of the pus from the surface of the cornea, modify the shape and size of the abscess. The abscess rarely remains stationary for longer than a Aveek, but perforation into the anterior chamber may occur, giving rise to hypopion, to iritis, etc.; or perforation outwards may be followed by ulceration, by escape of aqueous humor, Avith ante- rior synechire, or lastly, by opaque or staphylomatous cicatrices. The extent and situation of the opacity, which mostly follows, depends upon Avhether the suppuration has been confined to the centre or to the margin, or whether the entire cornea has been affected. Onyx signifies an accumulation of pus between the lamellae of the cornea, the pus having gravitated in the inflamed por- 134 CORNEITIS WITH SUPPURATION. tion, so as to assume a yellow and opaque crescentic figure, near the margin of the cornea. The onyx may remain station- ary for several Aveeks, and not seldom occurs in connection with hypopion, i.e., Avith an accumulation of pus, of shreds of corneal tissue, etc., at the most depending part of the anterior chamber. Hypopion frequently accompanies those large, flat ulcers which follow an injury, such as an abrasion of the surface of the cor- nea, in debilitated subjects. The pus and fibrin are supposed to reach the anterior cham- ber by transudation from the cornea. They may finally become absorbed, or escape by perforation of the cornea. Onyx or hypopion may be complicated with an abscess in the iris. The pus, whether in the iris or in the anterior chamber, changes its position during certain movements of the eye. The inflamed and suppurating parts of the cornea may become rapidly de- stroyed; the cornea being changed into a gray, semi-transpar- ent, pulpy, or flaccid, pale-yelloAv substance, which is sometimes thrown off by the pressure of the aqueous humor. Extensive suppuration may, however, subside, and leave the cornea trans- parent, or nearly so, if the pus is thick, and the intervening lamellae of the cornea not destroyed. Practically, we may distinguish— {a.) Cases in Avhich the suppuration comes on rapidly, in from one to three days, with great increase of vascularity and pain, Avith some chemosis, intolerance of light, and laclu \ mation. This form often follows operations or injuries, especially blows from stones, from branches of trees, etc., accompanied by abrasion of the cornea. It may also appear in the course of pustular corneitis and purulent ophthalmia. {b.) Cases in which the suppuration appears slowly, and has been preceded by protracted corneitis, as in weak, ill-fed per- sons, suffering from syphilis. (to three weeks, until all irritation and SAvelling from the operation have subsided. The canaliculus is permeable, and the point of the probe is in the lachrymal sac, if the skin over the sac and the palpe- bral margin remain motionless (the canaliculus being well stretched) while the point of the probe is.repeatedly pushed towards the inner bony wall of the sac. Any resistance encountered by the probe, Avhile passing along the canaliculus, causes the skin beneath the internal palpebral ligament to appear Avrinkled. The free margin of the lid, though held on the stretch, also becomes pushed tOAvards the lachrymal sac, when the probe is pressed against the resisting portion of the canaliculus (stricture, etc.) It is important to recognize this movement of the lid, and to estimate its extent- Its existence is a certain sign that the probe has not entered the lachrymal sac. If a fine probe passes, thicker ones will gradually be admitted. We discontinue probing when number six can be passed; and teach the patient to pass the probe, or do it again themselves, !f the epiphora reappears. With stricture in the canaliculus, others may exist in the nasal duct. If an injection does not pass through the nasal duct, but the probe enters the sac, we pass it on into the nasal duct. If we do not succeed the first time in doing so, it is well to be satified with keeping open the punctum and canaliculus, and to wait two or three weeks before trying again to pass the probe. If the epiphora becomes less, or ceases, as often occurs in stricture after the canaliculus has freely laid open, no probe should be passed into the nasal duct. The nasal duct is most easily probed throngh the lower canaliculus; and we hardly ever fail in passing the probe, if we carry it in the direction which the duct occupies in health. On finding a stricture, which is generally situated at or near the duct orifice of the sac, we use that probe which passes with some difficulty into the stricture. When once number six passes TREATMENT. 199 readily, we discontinue probing. We only reintroduce the probe, if, through contraction of the stricture, the epiphora be- comes troublesome. Some patients learn to pass the probe themselves. No probe should be passed unless we have a defi- nite curative object in vieAV. DESTRUCTION OF THE LACHRYMAL SAC. The cavity of the sac is freely laid open by an incision through the integuments, about three-quarters of an inch in length, commencing just above the internal palpebral ligament, passing outwards and downwards, and running parallel with the nearest portion of the margin of the orbit. If the sac is dis- tended, the incision is carried over its most prominent part. If there is a fistula, it must be slit, and the sac laid open. All discharge is wiped aAvay, and the inner surface of the sac touched with the solid nitrate of silver, or with the actual cau- tery. The scab formed by the solid nitrate of silver is re- moved after 48 hours Avith forceps; this must be done thor- oughly and carefully, otherwise tedious suppuration follows. Continuous gentle pressure, until the wound has healed, is made upon the sac by means of lint or Avadding, and a bandage. This is taken off twice daily, and the parts are cleansed with warm water. Erysipelas or severe inflammation has, in a few cases, occurred after this mode of cauterization. In 11 cases of cauterization with the actual cautery, of which notes were kept, no erysipelas or severe inflammation fol- lowed. Irons of a particular shape are used for counter-irritation. The eyeball must be protected by a spatula placed between it and the sac, and the latter must be freely exposed, so as to en- able the operator to touch it thoroughly. To avoid bleeding, the white-hot iron only should be used. The pain is slight. Cold fomentations are applied until the incision is closed. The patient need not remain in bed for more than 24 hours. Complete destruction (obliteration) of the lachrymal sac has 200 INSERTION OF A STYLE. been found beneficial in cases of fistula, in Avhich we have not succeeded in restoring the natural passage for the tears; in cases of extensive disease of the bones round the sac, or of ul- cerations within it; of fistulous openings from the lachrymal passages into the nose, and of closure of the nasal duct from cicatrices. The operation should be preceded by closure of the puncta and canaliculi by cauterization. The tears, if this preliminary step is not taken, find their Avay towards the sac; and mucous discharge from a newly-formed cavity or fistlua, etc., may again appear. INSERTION OF A STYLE. The above method of treating by dilation has found much favor both at home and abroad, and possesses great advantages over the old style, which we now only employ after every other plan of treatment has failed. The treatment of lachrymal stricture by the modern method is as superior to that by the style, as the periodical dilation of a urethral stricture would be to that of the life-long retention of an instrument in the ure- thra. On the introduction of the method, it shared the com- mon fate of all novelties: it Avas either rejected in toto by those who either could not, or, what is Avorse, Avould not recognize its advantages; or, on the other hand, its value was, we believe, overrated by those who adopted it. We have ourselves pur- sued it from its first appearance; in many instances we have found it easy and efficient; in others it has proved difficult and unsatisfactory in its application. In such cases, the lachrymal sac may be destroyed by caustic or the actual cautery—a pro- cedure Avhich, however apparently illogical in theory, has proved successful in practice. OBLITERATION OF THE LACHRYMAL SAC is performed in the following manner:—The sac is opened by a free incision, and thoroughly cleansed. After the bleeding has ceased, the lips of the wound are held apart by Manfredi's TREATMENT. 201 speculum, which is provided with a plate to protect the cheek from caustic. The surgeon then freely cauterizes the interior of the sac Avith a piece of lint steeped in some deliquescent caustic, such as butter of antimony or perchloride of iron, taking care to touch every part of the wall, and especially the lachry- mal orifices. The after-treatment consists in iced-Avater appli- cations for some hours after the operation, till all acute pain has subsided, Avhen they may be replaced by warm poultices. In a few days the slough separates and leaves a granulating surface, Avhich may be dressed Avith dry lint. A leaden probe must now be introduced through the canaliculus (which should be slit up prior to cauterization) into the nasal duct, and must be there retained until the cicatrization of the Avound is com- plete. By this means the tears will be encouraged to flow in their normal channel, and the external opening will rapidly heal. After repeated inflammation of the sac, or after in- effectual attempts have been made to cure the disease by the above methods, the style may be tried. An incision is made Avith a narrow, straight bis- toury just below the tendo oculi, which, on drawing the eyelids Fig. 24. outAvards, may be felt as a rounded cord, passing inwards from the inner canthus. The bistoury is then passed doAvn- Avards and outwards into the lachrymal sac, and serves as the guide for introduc- ing the style into the sac, after which the bistoury is withdrawn, and the style left in the sac. A silver style (Fig. 25), about IJ inch long, with its neck at an obtuse angle to the shaft, and surmounted by a rounded head, is to be passed into the nasal duct. The style should previ- ously be put through a piece of adhesive Fig. 25 represents the ope- J f • v. ration of a style. plaster, to prevent it sinking into the sac. 202 PTERYGIUM. Every morning it must be removed and cleansed, and immedi- ately replaced into the nasal duct. CLOSURE OF THE LACHRYMAL CANALICULI. Take a silver probe, dip it into pure nitric acid for tAvo or three seconds, and then Avarm it slightly over the flame of a spirit-lamp. This causes a coating of nitrate of silver to form over the warm part of the probe. Introduce the latter into the canaliculus, and withdraw it after a minute. An adhesive in- flammation, causing closure of the canaliculus, is expected to folloAV. PTERYGIUM. The term pterygium is applied to a someAvhat triangular- shaped, tolerably well-defined substance, which, movable with the conjunctiva, projects slightly from its surface. It gener- ally occupies the ocular conjunctiva between the cornea and semilunar fold of each eye. As many as four pterygia have been observed in each eye, their apices encroaching upon the cornea (in a direction parallel with the recti muscles), and meet- ing about its centre. In rare cases, the triangular shape may be lost in consequence of changes in the cornea. The apex of the triangle is situated at the margin of the cornea, or upon it. In the latter case it appears opaque, and embedded in the cornea. The base is situated in the ocular conjunctiva, and generally loses itself in the fornix. The pterygium, microscopically, consists of hypertrophied connective tissue, and of bloodvessels. Its vessels diverge from the apex tOAvards the base, and then anastomose with those of the recti muscles. If nearly transparent, like the conjunctiva, it is termed pterygium tenue; if gray, opaque, and vascular, pterygium grassum. Ulcerations and pustular ophthalmia, followed by hypertro- TREATMENT. 203 phy of the conjunctiva, are mentioned as causes. But the usual cause is not yet discovered. Pterygium occurs frequently among sailors, and in young persons living in a hot climate. It causes no pain, but, if very dense in texture, may interfere with some of the movements of the eyeball. It is not generally noticed until it encroaches upon the cor- nea and gives rise to impairment of vision. Treatment.—The patient, if he object to an operation, may be told that, unless the pterygium interfere with "sight," it need not be removed, but that a cure may be effected without an operation, and that the recovery of vision will be slower the longer the removal is postponed. The frequent recurrence of the pterygium after removal has given rise to various methods of treatment. The transplanta- tion of the apex is the mode generally adopted for fresh cases, as Avell as for those previously operated upon. Operation.—The best method is probably the following:— While an assistant holds open the lids, the operator seizes the pterygium near the scleral border with a pair of reliable for- ceps, draws it aAvay from the globe, and separates the corneal portion from the apex with a pair of scissors curved on the flat (Fig. 26); or, what is to be preferred, enters a pointed bistoury or cataract-knife flat on the sclera, be- tween this and the neck of the ptery- gium, its cutting edge being directed toAvards the cornea, and cuts with a gentle course of the knife the corneal portion, extending above the level of Fi8- 26- the sclerotica, as evenly as possible from its substratum. Then the separated portion of the pterygium is draAvn up, and the conjunctiva dissected up Avith the scissors towards the palpebral fold, one to two lines distant from the corneal margin, keeping exactly to the edges of the pterygium, and close to the surface of the sclerotica. 204 PTERYGIUM. The twro angles of the wound are then united by tAvo converg- ing incisions, which meet in front of the reflection, and thus enucleate the circumscribed pterygium. The wound is now nearly of a rhomboidal shape. It is not necessary, but rather hurtful, to extend the incision into the reflection; still, we should, as far as possible, include all hypertrophying tissue. In large pterygiums, the wound will then naturally be also very extensive, and it is, in such cases, necessary to unite the gaping edges by some extremely fine suture, after having dissected the affected portion of the ocular conjunctiva to a sufficient extent from its base, in order to enable the edges of the avouik! to be drawn together without too great stretching. Besides, in order to attain the desired result, Ave do not need to move completely the rhomboidal portion, or the entire pterygium. It is suffi- cient to simply throw back the ncAv growth which has been dis- sected up, and to close the triangular wound by a suture. The pterygium soon shrinks aAvay, and in a short time is un- noticed. After the operation, rest of the eye is to be secured by the application of a binocular protective bandage, in order that union of the edges be not interfered Avith. This bandage should be Avorn, according to necessity, from three to four days, Avhen the sutures are to be removed. In the mean time, a proper antiphlogistic regimen is to be carried on. If, with the secretion of pus, granulations subsequently form, pencillings of the parts with tincture of opium, having first cut off the prominent fleshy growth, is the best treatment. Cold- water dressings are required. In consideration of all this, it is scarcely possible to be a very earnest advocate of an operation in pterygium. In small ones, where it accomplishes the result, indications are predom- inantly of a cosmetic nature. With the most of those affected with pterygium, these indi- cations do not weigh very heavily. In a large pterygium Ave can do much less, and the danger is considerably increased. It is well, then, in these cases, to avoid an operation; and, in case the vision is considerably affected by covering over of the pupil, we may improve it by iridectomy. TREATMENT. 205 THE EXTERNAL MUSCLES OF THE EYEBALL. ANATOMICAL AND GENERAL REMARKS. The external muscles of the eyeball receive their blood from branches of the ophthalmic artery. The blood is carried off by veins Avhich lead, some into the facial, others into the oph- thalmic vein. The nutrition of the muscles increases with ex- ercise, and rapidly adapts itself to changes in this respect. The motor nerves supplying the muscles are the third, fourth, and sixth. These have been traced within the skull as far back as the pons varolii and the medulla oblongata. The nerves pass through the sphenoidal fissure into the orbit; and as they do so, they are nearer together than elsewhere. The third nerve supplies the levator palpebrae, the internal rectus, the superior and inferior recti, and the inferior oblique (and iris), and, according to some anatomists, also the external rectus. The fourth nerve supplies the superior oblique. The sixth nerve supplies the external rectus. The tendons of the muscles penetrate the sclerotic, and break up in its middle layers. The internal rectus muscle is firmly at- tached to the periosteum, near the inner margin of the optic foramen, and loosely to the subconjunctival fascia and tissue. It is inserted into the sclerotic about 2J"' from the margin of the cornea. It is the strongest and largest of the recti mus- cles, its Avidth being about 4"'. Function.—It draws the cornea horizontally inwards towards the inner canthus, without altering the inclination of its vertical meridian. The inferior rectus muscle arises from the periosteum near the lower margin of the optic foramen, and is inserted into the scle- rotic about 3'" from the lower margin of the cornea. The mid- dle of its sclerotic insertion lies about \'" to the inner side of the vertical meridian of the cornea. I unction.—If acting alone, it draws the cornea doAvnwards, and slightly inwards, inclining its vertical meridian outwards. Its action is opposed- by the "superior oblique," which draws 206 THE EXTERNAL MUSCLES OF THE EYEBALL. the cornea doAvnwards and outwards, inclining its vertical me- ridian inwards. Both muscles acting together draw the c'orne'a straight (vertically) downwards. The superior rectus muscle arises from the periosteum near the upper margin of the optic foramen, and passes forwards and slightly outAvards over the sclerotic, into which it is inserted at about 3'" from the upper margin of the cornea. The line of insertion is not parallel with the margin of the cornea, but somewhat slanting, so that the inner margin of the tendon is about V" nearer the margin of the cornea than the outer. Function.—When acting alone this muscle moves the cornea upAvards and slightly inwards, inclining its vertical meridian in- wards. In this it is counteracted by the "inferior oblique," Avhich turns the cornea slightly upwards and outAvards. The combined action of both muscles causes the cornea to be draAvn straight (vertically) upwards, the vertical meridian of the cornea remaining vertical. The inferior oblique muscle arises from the periosteum within the orbit near the orbital edge of the superior maxillary bone, close to the outside of the lachrymal sac. It passes backwards and outAvards along the floor of the orbit, beneath the inferior rectus, to which it is loosely attached, and then following the curvature of the sclerotic, it becomes inserted into the latter exactly over the yellow spot, and opposite to the insertion of the "superior oblique." Its line of insertion, however, does not run parallel with that of the superior oblique. A needle thrust through the middle of its line of insertion and through the tunics into the eye passes through the centre of the yellow spot. The branch of the third nerve which supplies the muscle also sends a branch (the motor root) to the ciliary ganglion. Function.—This muscle rolls the cornea upwards and out- wards, and inclines its vertical meridian outwards. The superior oblique muscle ("the trochlears") arises from the periosteum, near the inner margin of the optic foramen. It passes forwards towards the inner and upper margin of the orbit. Close to the latter, still within the orbit, is attached a TREATMENT. 207 fibro-cartilaginous ring ("the trochlea"), through Avhich a tendi- nous portion of the muscle glides. Thence the muscle takes a direction outwards and backwards, passes beneath the upper rectus, then becomes broader (about 2'" wide), and is inserted into the sclerotic about 3//r above the yellow spot. The near- est point of the optic nerve where it joins the sclerotic is about 4'" from the nearest point of the insertion of this muscle. It is supplied by the fourth nerve, and, according to some, re- ceives also a branch of the third. Function.—When acting alone, this muscle rotates the cornea outwards and dowmvards, and inclines its vertical meridian in- wards. If both oblique muscles (the superior and inferior) act forcibly together, they draw the cornea towards the outer can- thus. They assist the recti muscles, and rotate the eyeball round an imaginary axis, the anterior pole of which is external to the anterior pole, and the posterior internal to the posterior pole of the eyeball. The external rectus muscle is a long, narrow muscle, which arises from the periosteum at the outer margin of the optic fora- men, and is inserted into the sclerotic about 3|'" from the outer margin of the cornea. It is supplied by the sixth nerve. Function.—This muscle draws the cornea straight (horizon- tally) outwards, and does not alter the inclination of its vertical meridian. Having shortly stated the function of each muscle, it remains to show:— (1.) What muscles come into play during the combined move- ments of both eyeballs. (2.) The means by Avhich the amount of contraction of the muscles during binocular vision may be ascertained. (3.) The method of demonstrating the changes of position which especially the cornea and retina undergo during move- ments of one eye, or of both. Some of the terms made use of in describing these move- ments refer to the position of the eyes in relation to the head. Looking up, or moving both eyes upAvards, signifies that the visual lines are raised, the cornea approaching the upper mar- 208 THE EXTERNAL MUSCLES OF THE EYEBALL. gin of the orbits. Fixing an object equidistant from both eyes, or converging the eyes tOAvards an object, implies a convergence of both visual lines towards the median line, etc., etc. The object of most movements of the eye is to direct the visual line to the point Avhich Ave wish to see accurately. In order to cause the images of objects to fall on the most sensitive parts of the retina, the eyeballs have to excite cer- tain movements, which are preceded by a Avish to turn the eyes in the necessary direction. If we Avish, e.g., to turn the eyes tOAvards our right side, we have to imagine an object situated in that direction, and then to look tOAvards it. When we Avish to converge the eyes, Ave look tOAvards an object which we imag- ine situated about the median line of the body. A continuous innervation of the muscles of both eyes is re- quired to maintain the direction of both visual lines to one point of an object. A person who uses one eye only for vision, may direct the visual line of the other eye properly for certain positions. The eye, the vision of which is impaired, deviates if the object is brought into a position in which an amount of mus- cular power is required for distinct vision, e.g., when the object is held near the eye. Each visual line, together with the different parts of the eye- ball, moves round an imaginary fixed point, termed the centre of motion, which point lies Avithin the eye. The angle which the visual line of one eye forms that of the other, when the muscles of both eyes are at rest, is termed the muscular meroropter. The visual lines are then inclined to- wards each other, and if prolonged, would meet at a point situated at about 6' from the eyes. The angle formed by the visual lines when meeting at a point is termed the angle of convergence. The nearer such point is to the eyes the greater is the angle, i.e., the inclination of the visual lines towards each other. Dur- ing reading the angle is about eleven degrees (11°). The axis of the cornea, if prolonged to the opposite point of the eyeball, is termed the axis of the eyeball, or the "visual axis." It does not coincide with the visual line. As stated TREATMENT. 209 under Strabismus, an eye may apparently squint inwards or outwards, and yet the visual lines may be directed properly. The visual line passes through the cornea near the inner (nasal) side of the axis of the cornea. This axis crosses the visual line at the nodal point (the crossing point of the rays of the eye), under an angle varying in the normal eye from 3° to 7.° An imaginary plane laid through the visual lines and the point to which they are directed is termed the visual plane. The movements of both eyeballs may be subdivided into— (1.) Associated movements. In these the visual lines remain parallel. (2.) Accommodative movements. In these the visual lines are more or less inclined towards each other. Some distinguish between a primary position of the eyes in which the visual lines are parallel and 45° below the horizontal, and secondary positions in which the eyes are rotated round a vertical or a horizontal axis, or obliquely upwards or down- wards. Several muscles are at work in every movement to prevent, as some suppose, the individual muscles from becoming fatigued too soon. More muscular power is required when looking up- wards or downwards than when looking outwards or inwards. The least fatiguing movement is the one in which both eyes are directed inwards and doAvnwards; the most fatiguing is the one in which they are directed outAvards and downwards. When looking at objects, muscular power is consumed in overcoming the resistance offered by the muscles themselves. The action of the contracting muscle is opposed by the elasticity of its an- tagonist; and further resistance is offered by the structural elements of the contracting muscle itself. Oblique or diagonal movements require the action of three muscles (of two recti and one oblique). The vertical meridian of the cornea remains parallel with that of the other during oblique movements upwards, but is in- clined towards the side towards Avhich Ave look. For example, when looking outwards upwards and tOAvards the left, the ver- tical meridian of the cornea of the left eye is inclined outwards, 14 210 THE EXTERNAL MUSCLES OF THE EYEBALL. i.e., towards the left, while that of the cornea of the right eye, remaining parallel with it, is inclined inwards, i.e., also towards the left. The vertical meridian also remains parallel, but inclined in a direction opposite to the one in which we look during oblique movements downwards. For example, when looking down- wards outwards and to the left, the vertical meridians remain parallel, and we are inclined towards the right, i.e., that of the left cornea is inclined inwards towards the meridian line, and that of the right cornea outwards and away from the meridian line. The oblique movements upwards and inwards is carried out by the superior and internal recti and the inferior oblique. The cornea is drawn upwards and inwards, and rotated inwards. Its vertical meridian is inclined inwards. The superior rectus, contracting somewhat more than the others, is'regulated in its action by the superior oblique, which during this movement of- fers most resistance. The movement downwards and inwards is carried out by the inferior and internal recti and the superior oblique. The cornea is drawn downwards and inwards, and rotated outAvards. Its vertical meridian is inclined outwards. The rectus inferior, which exercises most power, is limited in its action by the su- perior oblique. The movement upwards and outwards is carried out by the superior and external recti and the inferior oblique. The cor- nea is drawn upwards and outwards, and rotated inwards. Its vertical meridian is inclined outwards. The inferior oblique not only counteracts the tendency of the superior rectus to in- cline the vertical meridian inwards, but even also inclines it outwards. The movement downwards and outwards is carried out by the inferior and external recti and the superior oblique. The cornea is drawn downwards and outAvards, and rotated inwards. Its vertical meridian is inclined inwards. Vertical Movements.—In these the eyeball is rotated round a horizontal axis, the vertical meridian of the cornea remaining vertical. TREATMENT. 211 The movement vertically upwards is carried out by the su- perior rectus and the inferior oblique. The eyeball is slightly rotated inwards. The resistance opposed to this movement by the internal and external rectus is greater than when looking downwards. The movement vertically downwards is carried out by the in- ferior rectus and the superior oblique. The eyeball is slightly rotated outwards. During horizontal movements of the eyeball, rotation occurs round a vertical axis. Round this the axis of the cornea, sup- posing it to stand perpendicularly upon the centre of the ver- tical axis, can be turned inwards towards the median line, so as to describe an angle of from 42° to 51°, and can be turned out- wards, so as to describe an angle of 44° to 49°. The vertical meridian of the cornea remains vertical during the movements. ACCOMMODATIVE MOVEMENTS. The most frequent accommodative movement is convergence of both visual lines during reading, "near work," etc. The convergence is least fatiguing, and the reflex action of vision upon the recti muscles strongest, Avhen the visual lines are at the same time directed someAvhat downwards. The power of convergence increases when looking downwards; it decreases when looking upwards. The power which the internal recti possess to turn both eyes inwards ("to converge the visual lines") varies in eyes other- wise healthy. Some are able to converge with ease to a point situated V or 2" from both eyes, while others can only con- verge to a point situated 4" or 5" from the eyes. (See Insufficiency of the Internal Recti Muscles.) Great con- vergence, if too long continued, produces muscular asthenopia. The power of convergence and divergence, in other words, the strength of the internal and external recti muscles when responding to the act of binocular vision, can be measured with prismatic glasses. (See Insufficiency.) Method of demonstrating the Changes of Position which the Cornea, Retina, etc., undergo during Movements of the Eyeballs. THE EXTERNAL MUSCLES OF THE EYEBALL. It has been repeatedly stated above, that the vertical merid- ian of the cornea of one eye remains parallel Avith that of the fellow-eye, especially during oblique movements of both eyes. The same is the case with the vertical meridian of the retina. The movements and positions of the vertical meridian are ascertained in the folloAving manner:— A piece of red tape is stretched out vertically and level with the eyes upon a bright-gray background, the latter being di- vided into squares by horizontal and vertical lines crossing each other. Standing at such a distance from the red tape as to avoid all perceptible convergence of the eyes, we look steadily at the tape for a few seconds. Looking then at some other part of the gray background, we perceive on it a green image of the tape, which after a short time fades away. When we have at once succeeded in producing this image, we find, however much we look horizontally or vertically, the image of the tape remains vertical in relation to the lines drawn on the gray background. Should this not be the case, then the position of the tape must be altered until its image remains vertical during these move- ments. The changes of position of the horizontal meridians are as- certained by producing a horizontal image of the tape. On ex- ecuting other than horizontal or vertical movements, we find that the image of the tape forms an angle with the lines on the background. This angle, which varies according to the degrees of obliquity of the movements, can be measured. We can thus ascertain the extent of change of position of the horizontal or vertical meridian of the retina and cornea during oblique move- ments. DEVELOPMENT. About the end of the third month the muscles can be recog- nized as fine thread-like filaments. They are well marked about the fifth month, but appear inserted further behind the cornea, so that at that period the anterior two-thirds of the eye- ball are in front of their insertion. At the apex of the orbit they are connected with one-another by a reddish substance. TREATMENT. 213 CONGENITAL ANOMALIES. Absence of one, of several, or of all of the "recti muscles." Presence of all the muscles, the eyeball being missing. Ab- normal adhesions of the muscles among themselves, e.g., of the oblique to the recti muscles. Adhesion of the superior oblique to the trochlea. Abnormal length, or shortness, or thickness of the muscle. NYSTAGMUS. ("TREMBLING OF THE EYEBALL.") Nystagmus signifies a peculiarly involuntary movement of both eyes, Avhich is the result of quick contraction of antago- nistic pairs of muscles, or of entire groups of muscles. Nyetagmus may be continuous, or appear only during excite- ment, or when the eyes are brought into certain positions. It may disappear, or nearly so, during reading, and generally in- creases when the muscles are exerted by looking in rapid suc- cession at different objects. The movements may be jerking, or oscillating in the direction of the recti muscles; or it may be rotatory round the axis of the oblique muscles; or a combi- nation of both. The ordinary movements of the eyes are not interfered with. Causes.—Nystagmus generally becomes developed during in- fancy. It has been observed to folloAv purulent ophthalmia. It»is a common combination of atrophy of the choroid (follow- ing choroiditis disseminata, with or without opacities in the cornea), or of congenital cataract, or of both. Vision.—The continuous movement of the eyeballs rarely gives rise to dimness, or uncertainty of vision. Cases have been observed in which distant objects appeared to move, and a few in which this has been the case with near objects also. Some patients, while reading, counteract the nystagmus by movements of the head; the eye appears more steady. As soon, hoAvever, as the head remains quiet, e.g., when looking at distant objects, the nystagmus increases again. In most cases, vision is impaired in consequence of the changes, of which the nystagmus is a complication. 214 STRABISMUS. Treatment.—Several cases have been benefited by altering the insertion of the recti muscles by operation. LUSCITAS. This term, by some, is applied to an oblique position of one or of both eyes, the mobility being lost entirely, or in part. Luscitas has been observed to accompany changes of shape of the eyeball; and also as a complication of orbital tumors, and of spasmodic and paralytic affections of the muscles. Rare anomalies of the action of the muscles are:— (1.) Clonic spasm accompanying general (especially cerebral) diseases. (2.) Tonic spasm, as part of a general spasmodic state in eclampsia, epilepsy, and after injury. The muscles are firmly contracted, the eyeball and the eyelids fixed, and the former drawn backwards into the orbit. STRABISMUS. {"Squint") Strabismus is the inability to direct both eyes ("both visual lines") simultaneously to the same point of an object. One visual line is directed to the object which the patient wishes to see directly, while the other deviates either too much inwards towards the inner canthus, producing strabismus con- vergens; or outwards towards the outer canthus, causing stra- bismus divergens. These are the most frequent forms of strabismus. Apparent strabismus may exist without real strabismus— i.e., the axes of the cornea may diverge or converge too much, and yet the visual lines of both eyes may be directed properly. This apparent strabismus is, as a rule, but slight, and is the result of the too great or too small angle which the visual line makes with the axis of the cornea. This angle in the normal eye amounts to about 5°. We have apparent divergent stra- bismus, if it is greater than 5°, as it is often the case in hyper- metropia; apparent convergent strabismus, if it is less than 5°, as it is frequently observed in myopia. TREATMENT. 215 The degree of strabismus may be measured in the following manner: The patient is directed to look at an object held at 20" from the eyes. A mark (a) is made on the margin of the lower lid of the squinting eye, in a line with the centre of its pupil. The non-squinting eye is then covered ("excluded," but not closed), and the patient is directed to look with the other (squinting) eye at the object. A second mark {b) is traced on the same lower lid, in a line Avith the pupil. The distance of a from b indicates the degree of the strabismus. If that distance amounts to 2r//, 3//;, or 5'", we speak of a strabismus of 2'", 3'", or 5'". MOVEMENTS OF THE SQUINTING EYE AND OF THE FELLOW-EYE. The deviation of the visual line of the squinting eye, the visual line of the other eye being directed to the point of an object, is termed the primary deviation. The deviation of the visual line of the non-squinting eye, when covered (excluded) while the squinting eye is directed to the object, is termed the secondary deviation. The secondary deviation, being an associated movement, be- comes less if the mobility of the squinting eye diminishes. In this case, the patient often assists the eye by movements of the head. The properly-directed eye, while looking at an object which approaches it, converges; Avhile the squinting eye, if the object is brought very close, may remain fixed, or squint more, or de- viate slowly or suddenly in a direction opposite to "the squint." The patient may for a considerable time continue to direct the squinting eye properly, when the other eye is excluded. In some cases this power is soon weakened, or even lost. Vision becomes more and more impaired. Abnormal changes of struc- ture (fibrous degeneration) occur in the unduly-contracted mus- cle and in its antagonist, leading to permanently impaired mo- bility. It is stated that if this fibrous degeneration has set in, the eye can still be directed to objects, but its movements under such circumstances are uncertain. The strabismus is termed concomitant if the squinting eye ac- 216 STRAB1SAIUS CONVERGENS. companies the movements of the other one, except those of extreme inversion and eversion. In concomitant strabismus, the primary deviation is equal to the secondary; Avhile in stra- bismus following paralysis, the secondary deviation exceeds the primary. STRABISMUS CONVERGENS. {Convergent or Internal Strabismus.) Causes.—(1.)—The anomaly of refraction termed Hyperme- tropia is the most frequent cause. We very rarely err if, when meeting with convergent strabismus, we look upon it as one of the symptoms of hypermetropia. About 95 out of 100 cases can be traced to this cause. The origin of strabismus in hypermetropic persons is thus explained: To read or to look at near objects for a prolonged time requires a certain power of accommodation to keep up the necessary curvature of the crystal-line lens, and a proportion- ate amount of power of the external muscles of the eyeball to maintain the requisite convergence. Accommodation and con- vergence go hand in hand. Strong accommodation is neces- sary, accompanied by strong convergence. Hypermetropic eyes, to be able to see distinctly, use more power of accommo- dation than emmetropic eyes, and simultaneously converge more. While reading type held at a distance of 12", healthy eyes are directed to a point 12" distant; but hypermetropic eyes, to read at the same distance, have to accommodate and converge strongly; and though the eyes are directed to a point which lies 12" distant, there is a great tendency to converge for a nearer point, as may be seen if one eye is excluded, but not closed, while the other looks at the object. The excluded eye, as a rule, at once converges too much. If vision of both eyes is accurate, then the tendency to use both {to maintain binoc- ular vision) is so strong, that both remain properly directed, and no strabismus arises. Though even then we may find one of the eyes squinting for a few moments, just Avhen commencing to read, and again when "the eyes grow tired." TREATMENT. 217 The occurrence of strabismus is facilitated by diminution of the acuteness of vision of one eye. The second eye, if only one is used, follows the tendency to too great convergence, while the other is directed to the object. Diminished acuteness of vision of one eye may be the result of a high degree of hyper- metropia, or of alternations in the refracting media—e.g., opa- cities of the cornea, etc., etc. Looking at objects placed laterally, or reading with the book held to one side, so that only one eye is used, allows the other eye to follow the tendency to too great convergence. The con- vergence of hypermetropic eyes is facilitated by the globular shape of the eyeball admitting of greater mobility, and particu- larly by the large angle which the visual line makes Avith the axis of the cornea. The greater this angle, the more readily does the eye follow the tendency to strabismus. (2.) Myopia.—The explanation, how myopia can give rise to convergent strabismus, is given under Myopia. (3.) Inflammation of the internal rectus muscle, occurring together with inflammation of the subconjunctival tissue. (4.) Paralysis of the external rectus muscle, the convergent strabismus appearing as a latter complication. (5.) Disease of the brain, e.g., hydrocephalus, tumors in the orbit, displacing the eyeball, or impeding its movements. GENERAL REMARKS. The strabismus which is connected with hypermetropia ap- pears as soon as the patient uses his eyes much for near work, e.g., when learning to read. The strabismus at first is periodi- cal, only appearing whenever the impulse to convergence is in- creased. Periodical convergent strabismus may continue for years, or it may become permanent soon after its appearance. Patients suffering from it, as a rule, are moderately hyperme- tropic. In such, the acuteness of vision is much improved by excessive efforts at accommodation and convergence. The im- pulse to convergence is therefore greater than in higher degrees of hypermetropia, in which even great efforts at accommodation do not improve the images on the retina much, and thus do not induce great efforts at convergence. 218 STRABISMUS CONVERGENT. The strabismus having become permanent, is termed simple, if only one eye habitually deviates, which is usually the case. It is at the same time concomitant, if the squinting eye is prop- erly directed, while the other, when excluded, squints in its turn. The mobility outwards of both eyes is somewhat diminished, Avhile the poAver of convergence is increased, and both internal recti are somewhat shortened. If the strabismus is alternating, i.e., if sometimes one, some- times the other eye squints, other causes besides hypermetropia must be looked for. Alternations of the contracted muscle may, if existing for many years, lead to loss of contractility through what is termed fibrous degeneration. The internal rectus muscle at the same time undergoes atrophy. Treatment.—Without an operation. Many cases of periodic, and even of permanent, strabismus occurring in hypermetropics, have been cured by the use of spectacles with convex lens for near work, as well as for walking, and by the application of atropia to the non-squinting eye, so as to thoroughly paralyze its accommodation. The operation for strabismus should be performed, if the treatment with atropia and spectacles has not succeeded within two or three months. If, for some reason, the operation has to be postponed, e.g., in a child under the age of five years, we make the patient ex- ercise each eye separately, especially the squinting one, by keeping the other eye closed for several hours every day. The acuteness of vision of the squinting eye is less likely to become deteriorated before the time for operation. Some recommend the use of spectacles with plane glasses: the glass corresponding to the better eye is tinted blue, so that objects appear of a pale-blue tint, and the impressions on the retina become Aveak- ened. Treatment by Operation.—The immediate object of the opera- tion is to alter the insertion of the tendon of the internal rectus muscle, and to retain the full length of the muscle. The ten- don should be divided close to the sclerotic. After division, it TREATMENT. 219 recedes from its original insertion, and undergoes a new adhe- sion to the sclerotic. It has been stated that it may be made to recede as much as 3'". The muscle, before reaching the sclerotic, passes through the subconjunctival fascia and connective tissue. To these it is attached, as well as to the sclerotic. It recedes too much if it is completely separated from these attachments, as if divided between them. The determination of the degree to Avhich these attachments should be separated (to obtain the desired position of the eyes) constitutes the difficulty of the operation. In se- vere cases, not only the internal rectus, but also the nearest part of the superior and inferior recti muscles, and the sub- conjunctival tissue intervening betAveen them, may have to be divided. The effect of the operation, besides immediately altering the position of the eyes, should be to weaken the contraction of the muscle. The squinting eye only need be operated upon, if the other, when excluded, does not deviate inwards while the squinting eye is directed to the object. Both eyes should be operated upon if both squint; or if, the habitually squinting eye being directed to an object, the other eye, when excluded, deviates inwards. In this case we divide the tendon, and more or less of the subconjunctival fascia ad- joining it in the habitually squinting eye, while in the fellow- eye Ave only divide the tendon close to the sclerotic. No operation should be proposed if the strabismus is con- nected with the causes given above under 2, 4, and 5, unless these causes have for a considerable time ceased to act. VISION BEFORE THE OPERATION. The accuracy of vision of most squinting eyes is defective previously to their squinting. Patients often remark that they see better when they "squint" with one, or, while reading, hold the book towards the side of the non-squinting eye. A secondary diminution of vision always ensues if the stra- bismus continues for a long time. On the other hand, the weaker vision becomes, the less power does it exercise over the muscles of the eye. 220 STRABISMUS CONVERGENS. The field of vision becomes more limited. The functions of the inner half of the retina of the squinting eye persist longer, and assist the vision of the fellow-eye. The rest of the retina becomes more amblyopic. With increase of the deterioration of vision, the eye gradually loses the power of looking steadily at an object. If this occurs, but little improvement of vision is observed after the operation. The reason Avhy diplopia is so rarely complained of, seems to be, that the strabismus often commences during childhood, when no attention is paid to the diplopia. Besides, the images of objects formed on the retina of the squinting eye are indistinct, and lie at the same distance from the yellow spot; while the attention is occupied by objects directly looked at. VISION AFTER THE OPERATION. One object of the operation is to restore a proper direction of the visual lines for all points of the field of vision, and thus to obtain, as far as possible, binocular and single vision. Binocular vision is obtained in about half the number of pa- tients operated upon for convergent strabismus. The results are more favorable, the earlier the operation is performed. Much is already gained if binocular vision is obtained even for a limited range of the field. An increase of acuteness of vision from mere recognition of large letters before the operation, to ability to read ordinary type immediately after it, is often ob- served. This is perhaps-connected with a change which occurs in the ciliary muscle after division of the tendon of the internal rectus muscle. Diploplia often appears immediately after the operation, but, as a rule, disappears spontaneously. It is more troublesome if the double image is slanting, or stands above, or behind the true one. If, after from six to eight weeks, it still persists, prisms may be tried. (See Diplopia.) Among a very large number of cases operated upon, in which the position and movements of the eyes, and the acuteness of vision, and accom- modation appeared normal, few cases have occurred in which a slight diplopia could in no way be removed by prisms. TREATMENT. 221 MOBILITY OF THE EYE AFTER THE OPERATION. The separation of the muscle from its original insertion causes it to recede to an extent at from V" to 3'", and thus a diminu- tion of the mobility of the eye towards the side operated upon is effected. This mobility having been too great towards the squinting side, a slight receding of the insertion is still com- patible with normal, or nearly normal, mobility. All movements are restored to the normal state in a small number of cases only. The result may be considered as satis- factory if both eyes are properly directed to an object placed at a distance of ten feet, and if they continue so while ap- proaching the object to within 4 inches from the eyes; also if, on excluding one eye, there is no deviation of the excluded eye. Parallelism of the visual lines for extreme convergence and di- vergence is rarely restored. If, in from six to eight days after the operation, all other points of treatment having been ob- served, the eyes can only be brought to converge to a point sit- uated 8 inches from the eyes, and not nearer, divergent strabis- mus must be counteracted by subconjunctival division of both external recti. Operation.—Before I give the opinion of others, I shall state in as few words as possible the operation given by myself. I shall describe the operation as performed upon the rectus internus, for convergent strabismus; all the other operations, when required, being executed in a similar manner. The surgeon should be provided with a spring speculum, toothed forceps, a pair of blunt-pointed forceps, a round stra- bismus hook, a small, soft piece of sponge, and a bowl of water. The sitting position is the best for the patient, during the operation of strabismus, for it alloAvs the Wood to escape read- ily from the little wound, instead of lodging in it, and obscure the parts to be divided. With unsteady patients, it is a useful pre- caution to secure the arms by means of a broad belt and buckle passed round the back of a chair. Patients or adults very sel- dom require chloroform in this little operation, as there is very little pain attending it; the speculum gives more pain than the operation. 9-70 STRABISMUS CONVERGENS. The first thing I do is to place the patient in a chair; I sit myself in another. I let his knees come betAveen mine, and get as close to him as I can. I place the strabismus box of instru- ments on his knee; the assistant stands behind the patient, re- ceives his head and holds it steadily, after Avhich I separate the lids with a spring speculum. I take the toothed forceps in my left hand, between my first finger and thumb. I place my little finger on the frontal bone or forehead, to steady my hand. I tell the patient to turn his eyes outwards. I then seize a small fold of the conjunctiva and subconjunc- tival fascia; this is to be raised with the forceps half Avay be- tween the cornea and the inner canthus, and divided with the scissors in an oblique direction, and a little below the equator of the eyeball, that the incision may be over the edge of the muscle. The blunt hook is then taken in his right hand, and then passed under the muscle, draAvn out towards the external wound; then it is passed over to his left hand, and then he (as is shown in Fig. 27) takes in his right hand the probe-pointed scissors and divides the muscle. Should the breadth of the muscle or the smallness of the opening prevent the point of the blunt hook from being brought out at the wound, the conjunctiva may be seized [;: y^with the forceps and slid back /.over the point, so as to allow of the division of the muscle without enlarging the conjunc- tival wound; or this may be divided to a further extent at the same time with the mus- cle. Should the eyes not ap- pear parallel on testing them, the blunt hook should be again passed in, to explore if any fibres remain uncut. Fig. 27. TREATMENT. 223 When the deviation is slight, an operation on one eye is gen- erally sufficient; but where convergence is very marked in both eyes, it is frequently necessary to perform a double operation before perfectly harmonious action is recovered. Both eyes are to be operated on, by all means, at the same sitting. No after- treatment is generally required, in either form of operation, except a little cold water with which to bathe the eyes two or three times a day. Should a fungus make its appearance in the wound, when the conjunctiva has been divided, it may be snipped off with scis- Bors at a single stroke, or will fall off after some time, if left to itself. Time for Operating.—Any and all seasons may be selected for the operation, which is of so slight importance, as regards any after effects to be dreaded, that very few precautions are necessary. After the operation, I highly recommend goggles, with small apertures, for a week or two, particularly when only one eye is operated upon. CHARLES BARDAO'S OPERATION. Children and restless patients should be operated upon under chloroform. The patient lies on the back, the head being slightly raised and Avell steadied. The eyelids are kept open with the wire speculum. The eyeball is fixed by means of forceps. This is done by placing a pair of closed forceps perpendicularly upon it, near the inner margin of the cornea; then, while pressing gently upon the eye, the forceps are made to glide down to the spot where Ave propose to make the incision. There the forceps are allowed to open, and some of the conjunctiva and subcon- junctival tissue is seized. Close to this, i.e., at the lower edge of the incision of the internal rectus muscle, a small opening, about \ inch in length, is made into the conjunctiva and sub- conjunctival fascia, with the blunt-pointed strabismus scissors, so as clearly to expose the sclerotic. The strabismus hook is now passed through the incision along the sclerotic, and placed between the eyeball and the incision of the muscle. If introduced properly, when we try to draw it 224 STRABISMUS CONVERGENS. forwards towards the cornea it becomes arrested at the point where the tendon is inserted into the sclerotic; while, if it has merely been introduced beneath the conjunctiva, it can be drawn up to the margin of the cornea, beneath that membrane. The hook being placed between the tendon and the eyeball, the scis- sors are introduced through the incision, and the subconjuncti- val tissue is divided in front of the insertion of the muscle. The tendon is next divided close to the sclerotic, one blade of the scissors passing along the hook, and the other in front of the tendon. The gliding forwards of the hook beneath the con- junctiva up to the margin of the cornea is a sign that the ten- don, or the part impeding the advance of the hook, has been divided. The hook should be repeatedly introduced,, to ascer- tain whether the insertion of the tendon has been completely divided. Whether, and to Avhat extent, the subconjunctival fascia adjoining the muscle may have to be divided, is a matter of experience, determined by the degree of strabismus. The eye Avhich squints most is operated upon first. Much blood occasionally is effused beneath the conjunctiva. An opening should be made at the most bulging part, to allow it to escape. From four to six weeks may elapse before it has all disappeared. Cold applications to the closed lids a few hours after the op- eration will be found grateful. No further treatment is required. The patient may go about the folloAving day, and use the eyes, except for near work, reading, etc., which, hoAvever, may be al- lowed a Aveek after the operation. Among the accidents Avhich may occur during the operation must be mentioned the wounding of the sclerotic, one of the blades of the scissors being thrust into the vitreous chamber. This grave accident is guarded against by the blades being blunt-pointed, and manipulated in such a manner as to cut along the surface of the sclerotic. If, after all undue vascularity and suffusion have subsided, the strabismus reappears, in spite of the operation having been performed properly, spectacles to remove the hypermetropia should be worn for reading and other near work. TREATMENT. 225 A second operation may have to be performed if the strabis- mus returns, and the impossibility of removing it by other means has been established. Sometimes it suffices, at the sec- ond operation, to divide the internal rectus muscle of the eye the vision of which is the most acute. The range of move- ments being less, too great inversion of the fellow-eye is pre- vented. Should slight divergent strabismus folloAv, and the division of the external rectus be determined upon, the operation should be performed subconjunctivally on both eyes, and as soon as the divergence becomes evident; but not until all effused blood from the primary operation has disappeared. Before operating a second time, we ascertain whether, with spectacles which neutralize the hypermetropia for all distances, reading Avith both eyes is possible, the book being held at 6" or 8" from the eyes: if so, no operation is necessary, and the di- vergence must be attributed to the large angle which the visual line makes with the axis of the cornea. Many, especially Continental surgeons, divide the conjunc- tiva over the insertion of the muscle, instead of at its lower margin. They pass a small strabismus hook between the ten- don and the eyeball, bring the insertion of the tendon into virw, and then divide it close to the sclerotic. The wound in the conjunctiva is closed by a suture which runs from the angle of the wound next the caruncle to the one next the cornea. Thus the caruncle, which by this mode of operating is apt to sink back more than by the subconjunctival method, can be raised. Again, by enclosing more or less conjunctiva within the suture, the muscle can be drawn forwards Avhile tying the suture, and, as is asserted, the point of its new insertion can be regulated. Those who adopt the mode of operating have laid down rules as to the cases in which it is necessary only to divide the mus- cle, and those in Avhich the suture must be inserted. About two-thirds of a line of conjunctiva enclosed by the suture on either side of the incision suffice to raise the caruncle without altering the position of the divided tendon. The ten- don may be carried back to its original insertion, if much con- junctiva is enclosed in the suture. 15 226 STRABISMUS DIVERGENS. The position and mobility of the eyes are tested immediately or a few hours after the operation; and the suture is loosened, or tigntened, as may be required to regulate any faulty posi- tion, etc. In strabismus of \\'" to 2'", no suture need be ap- plied. In children, the divided muscle recedes more, and a strabismus of 2"' to 3"' requires no suture. In grown persons with strabismus of 2'" to 2J'", the insertion of the tendon must be exposed freely, some of the adjoining subconjunctival tissue be divided, and a suture applied. In strabismus of 5'", both eyes have to be operated upon: in the squinting eye, a strabis- mus of 2|"', and in the fellow-eye one of \\'" is corrected. A suture is inserted in each eye. STRABISMUS DIVERGENS. ^External or Divergent Strabismus.") Causes.—(1.) Anomalies of the functions of the muscles, wheth- er congenital, or following disease or operations {e.g., for con- vergent strabismus). Such anomalies are spasm, insufficiency, and paralysis. The insufficiency may be the result of faulty shape of the eye- ball; or of congenital weakness of the internal, or of undue power of the external recti muscles; or of the operation for convergent strabismus, causing too great receding of the internal rectus. (2.) Myopia.—In every case of divergent strabismus, we should ascertain whether myopia is present. It is the most fre- quent cause of divergent strabismus. The latter at first is but slight, and may remain stationary. If it increases, it does so slowly. The increase of the myopia, i.e., the enlargement of the eye- ball, gives rise to difficulty of convergence. The images of ob- jects which are placed at equal distances from both eyes are less perfect on the retina of the more myopic eye. Vision of one eye being less perfect, the impulse given by binocular vision to TREATMENT. 227 maintain the convergence of the eyes is weakened, antk the di- vergence of the weaker eye facilitated. The eyeball Avhich resists the converging power most, soonest -induces fatigue of that'power; and the eye diverges the quicker the more convergence is required, as in reading, or other near work. The attempts of the "converging" muscles to maintain binocular vision lead to fatigue, and the eye rests itself by di- verging. The divergence is facilitated by the smaller angle which the visual line forms with the axis of the cornea. (3.) Impairment of Vision.—An eye the vision of Avhich is impaired to such an extent that it no longer assists the felloAV- eye in near work, reading, etc., may become divergent whatever be the state of its refraction. The anomaly of refraction may be the cause of the impairment of sight, and thus indirectly the cause also of the divergence. It has been observed that all other parts being normal, no di- vergence has occurred through the retina of one eye being am- aurotic in the region of the yellow spot, if the peripheral parts of the retina have remained sensitive. Amaurosis, Avhatever be its cause, if confined to one eye, is generally followed by divergent strabismus. This not unfre- quently occurs in both eyes, if both are amaurotic. The inter- nal recti are no longer excited to contraction, and their power gradually decreases. Divergent strabismus, including slight cases, is as frequent as convergent strabismus. In 90 per cent, of cases it is a compli- cation of myopia. It is generally confined to one eye. The most extreme forms occur after long-continued paralysis of the internal rectus muscle, and after operation for convergent stra- bismus. GRADATIONS OF DIVERGENT STRABISMUS. (1.) Alternating Relative Divergent Strabismus.—After main- taining both eyes properly directed for some time, one eye di- verges through its internal rectus becoming fatigued. After rest, the convergence can again be maintained. (2.) Relative Divergent Strabismus.—The poAver of conver- 228 STRABISMUS DIVERGENS. gence, Svhen looking at near objects, remains insufficient, while it continues undisturbed when looking at more distant objects. The relation betAveen convergence and binocular vision is only disturbed for certain distances. When looking at distant ob- jects, this may be combined with convergent strabismus as the result of impaired functions of the external recti muscles. In high degrees of myopia, in which objects must be held very near to be seen distinctly, the convergence of the eyes is often imperfect, and relative divergent strabismus is the rule. (3.) Absolute Divergent Strabismus.—At no distance can both eyes be brought to converge to the same point. The divergence exists for all distances, though it may diminish Avhen one eye looks at near objects. Neither binocular vision, nor attempts towards it, longer exist. The diverging eye may be blind, or at least not participate in binocular vision. Comparatively few myopic eyes with relative diverging strabismus become absolutely diverging. Paralysis of the internal rectus muscle—unsuccessful operation for internal strabismus—and especially amaurosis—furnish a large number of cases of absolute divergent strabismus. Treatment.—If the diverging eye is blind, or can only per- ceive large objects, no benefit is derived from treatment by op- tical means. It may, to improve the patient's appearance, become desirable to make the diverging eye assume a position similar to that of the normal fellow-eye when looking at objects from 5 to 15 feet distant. This position, in slight cases, is ob- tained by dividing the conjunctiva, subconjunctival tissue, and the tendon of the external rectus muscle of the diverging eye. If this does not produce the desired effect, we divide the con- junctiva and subconjunctival tissue as far as the nearest margin of the superior and inferior recti muscles, and likewise, but sub- conjunctivally, the tendons of these two muscles. Should this not succeed in restoring the required position, then the tendon of the internal rectus has to be divided also, and the end of the tendon, which remains attached to the muscle, has to be stitched to the conjunctiva and subconjunctival tissue near the cornea. To secure the new attachment of the tendon, a large portion of TREATMENT. 229 the conjunctiva and of the subconjunctival tissue must be en- closed in the suture; and care must be taken, while tying the suture, that it does^not give. The eyes, after these operations, must be kept closed until all "redness" has disappeared. Lint dipped into cold water is applied frequently to the closed eyelids of both eyes for two days after the operation. It is better not to administer chloroform while our operations remain confined to the external, superior, and inferior muscles. If the position obtained is not satisfactory, then chloroform is given, and we proceed to the division, etc., of the internal rectus muscle. If with the diverging eye the patient can recognize large let- ters, or even read small type, the operations described above can also be recommended, provided the eyes are not myopic. If the diverging eye is myopic, some advantage as regards position when looking at distant objects is derived from the di- vision of the tendon of the external rectus muscle. Some advise, if one myopic eye is used for reading, and the diverging fellow-eye for distant objects, not to operate, but to allow the patient to continue using the eyes in this manner. SUBCONJUNCTIVAL OPERATION FOR STRABISMUS. For the subconjunctival operation, the instruments necessary are a small hook or forceps to raise a fold of the conjunctiva, a lance-shaped knife curved on its flat surface, and a probe- pointed knife like those used for tenotomy, but having a pecu- liar bend of its shaft near the handle. It is Avell to cover the other eye, that the affected eye may move more freely, and may be directed forwards at the moment of commencing the operation. A fold of the conjunctiva over the lower edge of the internal rectus is raised Avith the forceps, and the lance-shaped knife is passed through this membrane and the fascia beneath it, and carried into the sheath of the muscle, so as to pass behind it. Its convex surface is to be 230 SUBCONJUNCTIVAL OPERATION FOR STRABISMUS. directed towards the globe, that the risk of puncturing the scle- rotic may be avoided. The probe-pointed knife is then to be passed through the wound and behind the ^uscle, which is to be divided by turning the edge of the knife forward, and giving it a slight sawing motion, the patient being directed to turn the eye outwards as much as possible; or, if necessary, the globe being turned in this direction by seizing it with the forceps, so as to render the fibres tense and facilitate their section. The advantages of this method are, that the danger of falling back of the caruncle to hide itself at the inner canthus, or of the formation of granulations in the wound of the conjunctiva, are avoided. Its disadvantages are, the considerable ecchymosis Avhich results from the effusion of blood between the conjunctiva and sclerotic, the greater difficulty of determining whether all fibres of the muscle have been completely severed, and the dan- ger of penetrating the globe Avith the instrument used for mak- ing the puncture; a danger which has not always been avoided, even by skilful operators. PARALYSIS AND PARESIS. Causes.—Paralysis and paresis may be the result of morbid changes:—(1.) Implicating the nerves of the muscles; (2.) Oc- curring in the muscles themselves; or (3.) Affecting both simul- taneously. The causes may be classed according to the seat of the lesion Avhich gives rise to the paralysis. Intercranial and Cerebral Causes.—In these, the paralysis is often complicated with impairment of memory or of speech, with paralysis of other nerves, with anaesthesia, etc. Paralysis progresses rapidly in plastic effusions at the base of the brain. Several muscles in both eyes, or several in succes- sion, become paralyzed. Ptosis is frequently, lagophthalmos only exceptionally, pres- ent. Paralysis of the third, fourth, fifth, and sixth nerves, with TREATMENT. 231 hemorrhage into the retina, has been observed, in the course of aneurism, if the arteria cerebrar is posterior. The third nerve, where it emerges from the brain, is sur- rounded by numerous arteries. Its paralysis is rarely compli- cated with hemiplegia. Orbital Cases.—Periostitis—abscess—tumors (neuroma, exos- tosis, etc.)—effusion of blood. (The passage of the nerves through narrow fissures, the nu- merous bloodvessels near the nerves, and the attachment of the muscles near each other, favor the occurrence of paralysis, if morbid changes become developed in the orbit, or at its inlets.) —Inflammation of the subconjunctival fascia (of Tenon's cap- sule), (accompanied by pain round the orbit, and when moving the eye). Injuries.—The operation for strabismus, folloAved by diver- gence of the eye in the direction of the antagonist. (Both mus- cles may undergo secondary changes, the divided muscle becom- ing atrophic, and its antagonist "fibrous.") Destruction of the muscle by suppuration. Distension of the muscles by protrusion of the eye. Atrophy of the muscles (congenital, or through some of the above changes). Syphilis, in one-half of the cases, is found to be the primary cause. Mobility of the Affected Eye.—We distinguish betAveen im- paired (paresis) or completely arrested mobility (paralysis) of the eyeball in one, in several, or in all directions. Those ac- quainted with the functions of the muscles in health will have little difficulty in determining which muscle or muscles are af- fected, when the patient is unable to make the eye assume any desired position. Paresis of one, or of several muscles, readily becomes appar- ent during accommodation for near objects, during reading, etc., in Avhich case all muscles are required to act. A morbid devia- tion soon arises in the direction of the antagonist of the paretic muscle. Symptoms of fatigue appear in paresis in the impaired muscle 232 PARALYSIS AND PARESIS. first, if, while the patient holds the head steady, and only moves the eyes, we make him look at an object held in succession in different parts of the field of vision. The fatigue becomes the more evident the longer such experiments are continued; in other words, the more the affected muscle is taxed. The eye, in Avell-marked cases, can only folloAv the object up to a certain point, when the movements become jerking or uncertain. The eye finally deviates in the opposite direction. When we "exclude" the normal eye, and Avatch its move- ments behind the hand, we find that, Avhile the paretic eye looks steadily at an object, the simultaneous movement ("the devia- tion") of the excluded normal eye is greater than that of the paretic eye. The same effort of the will acting upon the mus- cles of both eyes, the one with the weaker ("paretic") muscle responds to it by a lesser movement. The paretic muscle, to direct the eye to an object, requires a stronger impulse of the will (a strong innervation). The same impulse, acting upon the healthy muscles of the fellow-eye, gives rise to too great devia- tion of the healthy eye. The deviation of the impaired eye is termed primary, that of the normal eye secondary. In the de- gree of the two deviations we possess a means of measuring the paresis. For example, if the left external rectus muscle is pa- retic, we exclude the right eye, and cause the left to look at an object held towards the left side. We then find that, to make the left external rectus muscle carry out the necessary contrac- tion, an innervation (an effort of the will) is required which is much stronger than the one which would be required for the same contraction in health. The effect is, that the same im- pulse being given to the muscles of the normal fellow-eye to carry out the necessary associated movement inwards, this move- ment becomes too great, and the eyes squint inwards. Another illustration of difference of contraction of tAvo muscles under the same effort of the will, is afforded by paresis of the supe- rior rectus, while the levator palpebrae of the same eye remains intact. When looking upwards, the upper lid of the affected eye appears raised more than that of the fellow-eye, in conse- quence of the paretic upper rectus muscle not being able to re- TREATMENT. 233 spond to the impulse of the will to the same extent as the "levator palpebrae." Strabismus may develop itself as the result of changes in the paralyzed muscle, and contraction of its antagonist. Paresis or paralysis of one eye may induce strabismus of the felloAv-eye, if the vision of the affected eye be the more perfect. The ef- forts to direct the visual line of the affected eye to the object give rise to too great associated contraction of the muscles of the fellow-eye, and finally to strabismus. Paralysis may lead to strabismus through the non-paralyzed muscle altering the position of the eye so as to remove troublesome diplopia, i.e., to cause the double image to fall on a more eccentric part of the retina. All trace of paralysis having disappeared, concomitant stra- bismus may remain. In this case, the usual operation for stra- bismus is performed. Vision.—The anomalies of vision usually observed are:— Diplopia, impaired judgment as regards the position of objects, and amblyopia, if the paralyzed eye has not been used for a considerable time. In fresh cases of paralysis, as long as no attempt is made to call into action the paralyzed muscle, no diplopia is observed. In some cases of long standing, Avith morbid convergence or di- vergence, secondary contraction of the antagonist of the para- lyzed muscle often occurs, which may give rise to the diplopia extending over a large portion of the field of vision. This secondary contraction appears to occur sooner, if, previous to paralysis, vision has been impaired, or if there is great differ- ence of refraction of the eye. Some patients avoid the diplopia by keeping the lids of the affected eye closed; or they assist the paralyzed muscle by moving the head, eg., by turning it towards the right side, if the riedtt eye cannot look in that direction. Holding the head in peculiar positions assists the affected eye in avoiding those movements Avhich Avould require a contraction of the impaired muscle. The symptom diplopia is sufficient to enable us to determine which muscle is paralyzed, and to what degree: 234 PARALYSIS AND PARESIS. In order to find, in slight cases, which eye is affected, Ave di- rect the patient, Avhile he looks at an object, to close the eyes alternately Avhen the image of the object belonging to the af- fected eye is described as moving. In slight diplopia, the images partly cover each other, or the objects appear sur- rounded Avith a halo. To facilitate the distinction of the im- ages, we make the patient look through a slip of red glass placed before the normal eye. This causes one image to appear col- ored red, and less brilliant. The double image is the less strik- ing the further it lies from the yelloAV spot. The double image is seen at a spot opposite to the one which it occupies in the retina: e.g., if the eye deviates upwards, the image is formed on the upper part of the retina above the yel- low spot, and is seen by the patient below the image seen by the normal eye. Diplopia from paralysis of the oblique muscle persists for a long time, and can, by the aid of the tinted glass, easily be made perceptible to the patient. The judgment as regards the position of objects is impaired. The patient, on closing the normal eye, and using the affected eye only, misses an object when attempting to touch it quickly, if the object be held in the part of the field of vision which would require the help of the paretic or paralyzed muscle to direct the visual line. The power of localizing objects in the field of vision depends chiefly upon the sensation of contraction of the muscles of the eye. The insufficiently innervated muscle requires a much stronger impulse of the will to effect a certain movement than would be required in health to effect the same amount of movement; and the patient, misled by the strength of the impulse, overestimates the contraction effected by the im- paired muscle, believes the object to be more towards the side of the impaired muscle, and aims too much towards the side. This symptom disappears after the impairment has existed for some time. The judgment as regards the position of the field of vision, and of the objects in it, becomes altered grad- ually. The difference between the imaginary and the real position TREATMENT. 235 of an object gives rise to the sensation of dizziness; and the patient, with the normal eye closed, when quickly walking tOAvards a fixed object, turns tOAvards the side of the paralyzed muscle. The dizziness is greater if the diplopia is but slight. GENERAL REMARKS, ESPECIALLY ON PARALYSIS OF THE THIRD NERVE. Paralysis of all the muscles of the eye is generally a compli- cation of cerebral or spinal disease. The paralyzed eyeball is slightly protruding, and immovable. The visual line is directed straight, or slightly outwards and doAvnwards. The iris and the ciliary muscle are paralyzed. The upper lid is drooping. The muscles most frequently paralyzed are those supplied by the third and sixth nerves. Paralysis of the third nerve frequently extends over all its branches. The paralysis may affect only part of a muscle, or one or several muscles in each eye. If complete, it is com- bined with ptosis, which is still more considerable if the orbicu- laris muscle is also paralyzed. The eye diverges slightly. It cannot be directed inwards (paralysis of the internal rectus); it cannot be directed upwards (paralysis of the superior rectus and of the inferior oblique, which latter is less frequently im- plicated). When attempting to look doAvn, the superior oblique alone acts, rotating the eye slightly inwards, the inferior rectus being paralyzed. The pupil, as a rule, is dilated, and further dilatable by atropia. The ciliary muscle is generally impaired, and often paralyzed. Secondary contraction of the external rectus soon follows, causing "divergent strabismus." Vision with both eyes is at first much disturbed. The affected eye diverges when steadily looking at an object placed in the median line, the normal eye being closed. Great dizziness is complained of. In paralysis of the third nerve, the double images, when look- ing straight fonvard, are crossed; the false image stands some- what loAver, with its upper end inclined towards the normal eye. The inclination increases when looking upwards, and becomes greatest on looking upwards and outAvards. The difference in the lateral distances of the images increases with increasing de- 236 PARALYSIS AND PARESIS. viation of the object towards the side of the normal eye. The difference in height increases Avhen raising an object above the horizontal line; and decreases on lowering the object below that line, or AAThen looking outwards and downwards. The action of the superior oblique may cause this difference to disappear. Objects, during attempts at accommodation, appear smaller, and nearer the affected eye. Prognosis and Treatment.—The prognosis of paralysis or of paresis is more favorable, if syphilis or rheumatism is the cause, —if the cause lies A\Tithin the orbit,—if the paralysis is fresh,— or if there is only paresis;—or if the double images stand side by side, Avithout any difference in their height. The prognosis is bad if long duration has led to atrophy of the nerves or mus- cles, Avith or Avithout contraction of the antagonist. The general medical treatment depends upon the cause. Locally, we have to attend to the conveniences Avhich arise— from the diplopia,—from the impairment of vision,—and from the impairment of mobility and its consequences, e.g., secondary strabismus, insufficiency, etc. The diplopia is generally troublesome if vision of both eyes is acute, and the double images stand close to each other. If there is paralysis, the inconvenience arising from diplopia is avoided by keeping the affected eye closed, or by Avearing spectacles with a tinted glass for the paralytic eye. In paralysis of the superior oblique (the inclined retinal im- ages being above, and internal to the yellow spot), the diplopia may be removed by placing in front of the eye a prism with the refracting angle upwards and slightly iinvards. If the inclina- tion of the retinal image is too great, it may suffice to remove by prisms the lateral distances of the double images. If there is a difference in the lateral distances and in the heights of the images, the image of the affected eye standing lower, we remove the difference in height by placing a prism with the refracting angle upAvards before the affected eye. A second prism with the refracting angle inwards is placed before the normal eye, if the difference of the lateral distances is not removed by spontaneous contraction. This prism induces a TREATMENT. Or>r7 convergence of that eye and an associated movement outAvards of the felloAv-eye, thus uniting the still laterally displaced images. The treatment of diplopia from paresis is adopted, if the de- viation, and with it the distance of the double images from each other, is so great that no discomfort is felt, or if the affected eye-muscle has regained some contractility. If there is paresis, the affected eye should be used frequently alone, so as to practise the paretic muscle, while the normal eye is kept closed. Prisms may be tried to bring the double images near each other, and thus to excite contraction of the paretic muscle to unite the images. The prism suits if it enables the eyes to see single without there being a sensation of straining. The prism at first should be used for objects situated not nearer than 10 feet from the eyes. Less contraction of the muscles is required at that distance, and also at greater distances. The prism, if too weak or too strong, may cause contraction of the antagonist of the paretic muscle. If the prism is too Aveak, the distance of the double image from the yellow spot remains too great to be overcome by contraction of the paretic muscle; and, instead of contraction of the paretic muscle, contraction of its antagonist ensues to remove the diplopia. If no tendency exists to unite the images, or if this tendency is very slight, or if stronger prisms than of 14° are required to bring the images near each other, then prisms must be given which completely unite the images; the refracting angle being directed imvards in paresis of the external rectus, and out- Avards in paresis of the internal rectus. If these remedies do not remove the diplopia, the paresis or paralysis having existed for two months or more, Avithout any contraction of the antagonist having followed, then an opera- tion may be recommended, the result of which is better if the contractility of the affected muscle is good. Tenotomy of the antagonist of the affected muscle should be performed, and have the effect of producing single vision for near Avork. If this result is not produced, and diplopia continues luring reading, then, in addition to the first operation, tenotomy oi the 238 PARALYSIS AND PARESIS. paretic muscle should be performed, and its tendon should be attached nearer the cornea. The object of these operations is to assist the contraction of the affected muscle, by advancing its insertion, to Aveaken its antagonist by carrying its insertion further backAvanls, and to remove the diplopia as much as possible, especially for reading, etc. Cases have occurred in which the double images, though close to each other, could not be made to unite. This Avas attributed in some to cerebral changes, in others to an anomaly of accom- modation. In paralysis Avhich has existed for a considerable time (for two months and longer), satisfactory results have been obtained from the use of electricity. PARALYSIS OF THE INTERNAL RECTUS MUSCLE (BRANCH OF THE THIRD NERVE). Symptoms.—Movements.—The inward movement of the af- fected eye is impossible, as far as the internal rectus is con- cerned. A slight inward and dowmvard movement is effected by the combined action of the superior and inferior recti mus- cles. The eye diverges sooner Avhen looking upAvards than Avhen looking doAvmvards. In paresis, the associated movement of the external rectus of the normal eye, when excluded, is too great. The patient, to avoid the diplopia, turns the head tOAvards the side of the nor- mal eye. Vision.—Diplopia appears Avhen looking towards the side of the paralyzed muscle. The line, dividing the field of vision in which diplopia is observed, is not vertical, but oblique, running from Avithout and above, inwards and doAvinvards. The double images are crossed, level, and parallel Avith each other. Their lateral distances increase the more the object looked at is placed towards the side of the unaffected eye. The double image, in- stead of remaining parallel with that of the fellow-eye when looking obliquely upAvards or downwards, remains vertical, while the image of the unaffected eye is inclined outwards. The height of the images differs through the vertical meridian of TREATMENT. 239 the affected eye, being inclined outwards, although the height of the cornea appears unaltered. The image is formed on a part of the retina external to and above the yelloAv spot, and there- fore is seen internal to and below that of the fellow-eye. A prism held before the affected eye with the refracting angle di- rected outwards unites the images. PARALYSIS OF THE INFERIOR RECTUS MUSCLE (BRANCH OF THE THIRD NERVE). Symptoms.—Movements.—The eye cannot be directed down- wards, and Avhen attempting to do so, it turns outwards and up- wards. Even when looking at objects placed horizontally, the eye already deviates slightly outAvards. The paralysis makes itself most felt when attempting to look dowmvards and out- wards. In paresis, Avhen excluding the normal eye and directing the paretic eye doAvnwards and inAvards, a greater associated move- ment of the excluded eye dowiiAvards and outAvards is ob- served. Vision.—Diplopia appears when looking doAvmvards. The double images are crossed. The one of the affected eye stands deeper, lies on the side of the normal eye, and is inclined towards the median line (tOAvards the image of the normal eye); thus the upper extremities of both images stand nearer each other. The obliquity of the images and their height increases the more the image is moved inwards and doAvnwards. The image is formed on the retina above the yellow spot, and is therefore seen beloAv that of the normal eye. The refracting angle of a prism, to unite the double images, has to be held up- wards, and slightly outwards. The patient, Avhen attempting to touch an object, passes beneath it. PARALYSIS OF THE SUPERIOR RECTUS MUSCLE (BRANCH OF THE THIRD NERVE). Symptoms.—Movements.—The affected eye, when trying to look upwards, deviates slightly outwards and doAvnwards, through the action of the inferior oblique being no longer opposed by that of the superior rectus. In paresis, when raising the visual line above a certain height, 240 PARALYSIS AND PARESIS. an unnatural rising of the lid is observed—i.e., more of the sclerotic is exposed on the normal than on the paretic side. The associated movements of the excluded healthy eye upwards and outwards are too great Avhen the paretic superior rectus muscle acts. Vision.—The patient, when striking at an object, aims too high. Diplopia appears on looking upwards. The images of objects fall on a part of the retina which lies outwards and dowmvards from the yelloAV spot. The double images are crossed, ami do not stand parallel. The inferior oblique being unopposed, the vertical meridian is inclined outwards, and the crossed double images diverge above. This obliquity increases during diver- gence. The height of the image increases Avhen the eye di- verges, and decreases during convergence. PARALYSIS OF THE INFERIOR OBLIQUE MUSCLE (BRANCH OF THE THIRD NERVE). Paralysis very seldom affects this muscle alone. The affected eye, Avhen attempting to look upAvards, deviates downwards and inwards. Vision.—Diplopia only appears when the object is raised above the horizontal median line; it is homonymous, the double image at the same time standing higher, and being inclined in- wards. The position of the double image is most striking when the object looked at is moved in a direction opposite to that of the affected eye; while its inclination increases when the object is moved outAvards, tOAvards the side of the affected eye. PARALYSIS OF THE SUPERIOR OBLIQUE MUSCLE (FOURTH NERVE). Symptoms.—Movements.—The affected eye, when looking at an object placed in the horizontal median line, deviates slightly inwards and upwards. The deviation increases when the object is moved outwards. The eye deviates outwards if the object is held above the horizontal median line. The affected eye moves downwards and outwards when the fellow-eye is excluded, while the latter makes a stronger associated movement downwards and inwards. Secondary contraction of the inferior oblique TREATMENT. 241 ensues if the paralysis persist for a long time; and the cornea of the affected eye comes to stand higher during all move- ments. Vision.—At first objects seem to move, and one eye has to be kept closed when reading. This is soon followed by well- marked diplopia, which especially appears when looking down- wards. In fresh cases the diplopia is confined to the half of the field of vision which is situated below the horizontal plane, while in cases of long standing it extends over the entire field. The double image is homonymous (lies on the side of the affect- ed eye), if the object, the image of which is formed on the retina inwards from and above the yellow spot, is held below the hori- zontal median line. If the object is held above that line, the double image is crossed (divergent strabismus), stands deeper, and is inclined outwards. Diplopia, with strabismus, when looking downwards, is the chief symptom of this form of paralysis. The difference in height, inclination, and distance of the im- ages increase when the object is moved downwards in the median line. Moving it in the lower half of the field of vision towards the side of the normal eye causes a decrease of the lateral dis- tances and of the inclination, and an increase in the height. The double image appears above the normal one if the object is held far down in the lower half of the field, though the cornea of the affected eye stands higher. Moving the object in the lower half of the field of vision towards the affected eye causes a rapid decrease in the height of the images and in their lateral distances, while their inclination increases. Through excessive increase of the vertical meridian, one image appears to lie nearly above the other. The patient, when attempting to touch an object quickly, misses it, and strikes too low, and towards the side of the affected eye. The double image appears to lie nearer than that of the other eye. Some describe it as appearing bent, or its upper part fur- ther distant than the lower one. In fresh cases, the head is held forwards to cause the double image to be seen in the upper half of the field of vision. 16 242 PARALYSIS AND PARESIS. PARALYSIS OF THE EXTERNAL RECTUS MUSCLE (THE SIXTH NERVE). Symptoms.—Movements.—The affected eye cannot be directed horizontally outwards. The attempt to do so gives rise to an irregular jerking movement, caused by the alternating action of the superior and inferior oblique, the former draAving the eye downwards and outAvards, the latter upwards and outwards. An abnormal convergence appears Avhen looking upwards, though less than when looking doAvnwards or straight forwards. The convergence is the greater the more an object is held tOAvards the side of the paralyzed muscle. Vision.—Diplopia appears Avhen, Avithout moving the head, the patient looks at an object placed in that half of the field of vision which lies next the paralyzed muscle. The double images are not crossed, but stand parallel to each other, and side by side. Their distance from each other is the greater, the more the object is moved in a horizontal direction towards the side of the paralyzed muscle. When looking out- wards and upwards, the double image stands higher, and is in- clined inwards. It stands deeper, and is inclined outwards when looking outwards and dowmvards. The patient, to avoid the troublesome diplopia, turns his head towards the opposite side, and holds objects towards the side of the paralyzed muscle. When quickly striking at an object held into the half of the field of vision next the paralyzed muscle, he misses it, by strik- ing too much towards the side of the affected muscle. CATARACT. GENERAL REMARKS. In the following remarks, concerning some of the more im- portant operations practised on the eye, I have endeavored to confine myself to such a general description as may render the principles upon which they are founded intelligible to the stu- dent, rather than to give him minute directions for every ma- nipulation which their accurate performance demands. TREATMENT. 243 There are so many points of detail to be borne in mind dur- ing the extraction of a cataract, or the formation of an artifi- cial pupil, that almost every case becomes a study in itself. The most labored written instructions will never suffice to form a skilful practitioner, nor confer that presence of mind, and readiness to take advantage of circumstances as they arise, which, although required in every branch of Operative Sur- gery, are yet preeminently necessary in that connected with the eye. There are three principal methods of removing an opaque lens from the axis of vision:— 1. By thrusting it in such a manner from its natural position that, although left in the eye, it may not prevent the rays of light passing uninterruptedly through the pupil to the retina. This, the earliest of all Cataract Operations, is termed Depression, or Couching, the lens being pressed down into the vitreous hu- mor. 2. By removing the lens bodily out of the eye, through a wound made for that purpose in the cornea: Extraction. 3. By taking advantage of the peculiar facility with which Nature, under certain conditions, dissolves and absorbs the en- tire substance of the lens; the Operation for Solution, or Ab- sorption : termed also, from the modes of performing it, Division and Discussion. Fig" 28. Fig. 29. This is a disease of the eye which may be recognized by the loss of the clear black lustre of the pupil or sight of the eye, as may be seen by the above engraving. Fig. 27 represents a partial or incomplete cataract. Fig. 28 shows a complete and perfect cataract. It is a disease which ordinarily arises very 244 CATARACT. slowly, and without any previous inflammation of the eye (unless it has been produced by accident). In its early stages it is likely to escape observation, unless closely and carefully exam- ined; but after it has become fully formed, may be readily seen at a distance. It is a disease Avhich completely destroys sight when it is fully formed, and its first symptoms are, a mistiness or fog before the sight, and a difficulty of recognizing persons or objects as usual. This continues to increase more or less rapidly, according to the nature of the case and the constitu- tion of the patient, and may not become complete for months, or even for a year or two. This is an important disease, and requires skilful hands to manage. It is seldom cured without an operation, though much relief may be given to the patient, during the formation of the disease, by local treatment. I have frequently, in such cases, enabled a patient to read large print, by an application to the eye, which has taken effect in ten minutes, though before the treatment they Avere unable to guide themselves. This improve- ment will continue for four or five days, and by repeating it, the effect may be continued during nearly the whole process of the formation of the cataract, and without experiencing the least pain whatever by the treatment. There is no medical treatment that will remove this disease after it has once com- menced, or any other application to the eye that will stay its progress. Nothing short of a surgical operation, by skilful hands, will remove it, and undue proper management may be disposed of in a few days, with very little pain. The loss of transparency (color) of the lens is accompanied by alterations in the cohesion and consistence of its fibres. These lose the gelatinous consistence, and become more or less fluid. The fluid is supposed to escape gradually through the capsule into the aqueous chamber, and to become absorbed. The size of the cataract, which at one time may have consider- ably exceeded that of a healthy lens (bulging the iris forward), becomes less. The cataract may shrink to such an extent as to give rise to tremulous iris, through the latter losing its support. The semi-transparent nucleus, after spontaneous ab- sorption of the opaque matter, may become visible again. TREATMENT. 245 The nucleus of cataract in old persons is generally large, flat, and slightly convex; Avhile in middle-aged persons it is smaller, and more convex. Two bi-convex nuclei have been found in the same cataract. The yellowish transparent, the brownish-gray, and the amber- colored nuclei are the most frequent. The elimination of what is termed myeline is less marked among the fibres of the nucleus. EXAMINATION FOR CATARACT. The presence of cataract and its kind are best recognized by artificial light (uby local lateral illumination"). The patient (the pupil being dilated with atropia) is placed in a dark room, and the light of a lamp is concentrated in suc- cession upon different parts of the lens, by means of a bi-convex lens of about 2-inch focus. The faintest alterations in transparency can be recognized. The details of the opacities may be examined with a second lens. Opacities which, thus viewed, appear in their natural color, e.g., gray and opaque, appear, when looked at with the ophthal- moscope, as black spots, streaks, etc. The presence of cataract having been ascertained, we deter- mine, as far as possible, its consistence (see Consistence of Cataract), and then the condition of the retina, choroid, etc. Opacities in the vitreous chamber, blood-spots in the retina, anomalies in the color, curvature, etc., of the optic disk, can in many cases be recognized through less opaque portions of the cataract. After this, we test the retina for its sensibility for light. Complications Avith amblyopia are thus recognized. Ex- perience must teach us the amount of light thrown through the cataract that can still be perceived by the healthy retina. At- tention should particularly be paid to the sensibility of the most depending parts of the retina, these being more frequently impaired, especially in traumatic cataract, and in contact Avith myopia. As regards complications arising from changes external to the eyeball, it may be remarked, that extraction of cataract has been successfully performed in patients with granulations, tinea, 246 CATARACT. trichiasis, everted tear-puncta, or purulent discharge from the lachrymal sac. Numerous enlarged vessels emerging from the sclerotic, near the cornea, ahvays indicate some anomaly in the circulation of the choroid, and frequently glaucomatous changes. If cataract be coupled with increased tension, iridectomy should be per- formed some Aveeks previous to the removal of the cataract. Opacities in the cornea may require iridectomy to carry the pupil behind transparent cornea. A shallow anterior chamber is observed when a large "swollen " cataract displaces the iris forward. A deep anterior chamber may be a sign of a small, shrunken lens, or of inflammatory changes of the cornea, such as occur in inherited syphilis. A tremulous iris is not necessarily a sign of fluid in the vit- reous chamber. Fluidity of the vitreous within the area of the retina, that within the area of the ciliary processes being nor- mal, or the floating of a small, hard nucleus in a loose lens cap- sule, may cause it. Shrinking of the cataract, together Avith increase of aqueous humor, may cause the tremulousness. In cases with tremulous iris scoop, extraction with iridectomy (under chloroform) should be performed. The pupil in every case should be dilated by atropia, previous to performing any operation. An iridectomy is performed if the pupil does not become dilated by atropia, or if the pupil is irregular from synechiae. We must not neglect to ascertain the shape of the eyeball. Small or hypermetropic eyes frequently present glaucomatous complications. Myopic and large eyes often contain fluid in the vitreous chamber, and present retinal and choroidal complica- tions. Great protrusion of one eye, or of both, may exist with- out any morbid changes of the tunics. Causes.—(1.) Injuries (perforation of the tunics, or mere concussion of the eyeball) may at any age produce catar ct of the injured eye. (2.) Altered nutrition occurring in the course of morbid changes of surrounding tunics., especially after choroida-iritis TREATMENT. 247 (so-called Secondary Cataract). The opacities caused by iritia are generally circumscribed (gray-white dots or streaks), and situated immediately beneath the anterior capsule. Serous effusion behind the iris and glaucoma give rise to diffused opacity, and to increased density of the lens. Posterior polar cataract frequently occurs in myopic persons. Anterior polar cataract in children Avho have had purulent oph- thalmia with corneitis. A peculiar form of cataract (the green and black one ) arises from deposit among the lens fibres of hsematin and other col- oring matters. Cataract (the consistence of which varies according to age) is often observed in both eyes of persons who suffer from dia- betes mellitus, or who have taken secole cornutum for a prolonged period, and not unfrequently in females during suckling. In the latter case it generally remains confined to one eye. Congenital cataract most frequently occurs in children suf- fering from inherited syphilis. Cataract in old persons (senile cataract) is attributed to im- paired nutrition of the fibres of the lens, and to anomalies in the permeability of its capsule. CONSISTENCE OF CATARACT. The treatment of cataract would vary but little if its con- sistence were the same in all the cases. If every cataract were fluid, we should uniformly remove it by suction. If all cataracts were hard, we should have to deal with them by the more hazard- ous operation for extraction. The consistence of the healthy lens varies according to age. Up to the age of thirty-five it is glutinous. About that time a difference becomes apparent between the central and the more superficial portions. The former become more yellowish, and are termed the nucleus. Large, hard nuclei have, however, been extracted from the eyes of persons aged from twenty to thirty (after iritis). In rare cases the change from glutinous consistence to hardness extends throughout the lens. The hard nucleus is rarely opaque, but generally yellowish and trans- lucent. A complete absence of nucleus is in old persons ex- 248 CATARACT. tremely rare. The nucleus is generally surrounded by opaque lens matter. The latter varies in consistence, and is not un- frequently fluid, or so soft that the nucleus sinks into it. If the nucleus floats, it gives rise to tremulous iris, and dur- ing movements of the eye rolls about in the opaque fluid. The sinking of the nucleus is always a sign of softening of the sur- rounding lens matter. It can frequently be recognized by ex- amination Avith the ophthalmoscope, the pupil being avcII dilated, when the reflection peculiar to the nucleus is perceived, not in the centre, but near to, or at the lower margin of, the cataract. The sinking of the nucleus is thus far favorable—that, together with the soft matter, it can be removed through a smaller in- cision. We distinguish four varieties of consistence, and as many forms of cataract:—the fluid, the soft, the glutinous, and the hard cataract. The fluid cataract is white or gray, or yelloAvish-white and uniformly opaque, and, as a rule, without gray and opaque streaks or dots. An abundance of particles of lime settling at the lower half of the capsule may, however, give rise to a dif- ference of color, this part appearing more intensely white and opaque. The movements of the eye cause the chalky fluid to mix with the rest, and for a time to impart to the cataract a uniform white color. The change into fluid commences at the surface nearest the capsule, and rarely extends over the entire lens. Often a brownish hard, small, well-defined nucleus floats in the fluid. A rare form of fluid cataract is a change of the lens into a yelloAvish, nearly transparent, oily liquid. All fluid may be- come absorbed, and merely particles of lime remain attached to the thickened capsule. The fluid readily escapes if the capsule is punctured. Third cataract is frequently congenital, and has been observed at all ages. The Soft Cataract.—We must distinguish between the kind of cataract Avhich, when incising the capsule, in great part es- capes spontaneously (it is generally termed soft cataract), and TREATMENT. 249 the kind which is described as gelatinous cataract The soften- ing, as a rule, commences at or near the capsule. In rare in- stances it occurs first in the centre, which then appears bluish- Avhite and opaque, shading off into more translucent opacities dispersed through the superficial layers of the lens. Examination with the ophthalmoscope shows that in soft cat- aract the marginal parts appear more opaque than in the cen- tre, if the nucleus is transparent; Avhile the opacity is densest in the middle, if the nucleus is also opaque. The cortical substance may be considered soft— (1.) If the opacity reaches up to the capsule ("to the margin of the pupil"). (2.) If the cataract has a Avhite and opaque color, its surface being dotted over with ill-defined (diffuse), irregular-shaped opacities; or Avith broad, ill-defined, and opaque streaks. (3.) If in the eye with cataract (supposing only one eye is affected) the iris is pushed forwards, and the pupil slightly dilated and not very movable. Cataract in persons below thirty-five, presenting the above signs, is, as a rule, soft throughout. The older the patient,.the more must Ave expect to find a hard nucleus, of varying size, surrounded by soft cortical substance. The gelatinous or glutinous cataract has the consistence of the crystalline lens in health. No lens matter, or only a little, es- capes after incising the capsule. It is difficult to recognize this kind of consistence, if no opaque streaks are visible. The nar- rower these streaks are, the more glutinous is the cataract. It is glutinous—(1.) If the layers of the lens nearest the capsule are transparent or semi-opaque, so that Ave can to a certain depth look into the cataract. (2.) If narrow and opaque streaks alternate Avith transparent lens substance. The cataract following choroido-iritis in young persons is often gelatinous; so also is the one described as lamellar cat- aract. The hard or senile cataract derives its name from the hard consistence of the "nucleus," Avhile the portions of lens near- est the capsule are, as a rule, more or less soft. The cataract frequently commences in the portion of the lens near the nu- 250 CATARACT. cleus, Avhile the latter remains broAvnish-yellow, and semi-trans- parent. The nucleus often becomes smaller, Avhile the super- ficial (fluid or soft) and opaque lens matter becomes absorbed. The term lamellar cataract has lately been introduced, to des- ignate a lens in Avhich opaque layers of lens fibres alternate with transparent ones; e.g., the nucleus and the lens fibres im- mediately beneath the capsule may be transparent, while the intermediate parts of the lens are opaque or semi-opaque. The opacity, in this case, is more intense near the margin of the lens. On examination with the ophthalmoscope, we observe a red- dish reflection from behind the cataract, when looking through its middle (the light returning through the transparent centre of the lens), which would not be the case if that part of the lens Avere opaque. The appearance of diffused opaque streaks and dots immedi- ately beneath the capsule indicates an increase of the cataract. The opaque layer often shrinks, causing the lens to become smaller. Other parts, in their turn, become opaque, so that, at the age of thirty, we may find the lens opaque throughout, while at the age of twenty-five it had the appearance of lamellar cataract. Another form of lamellar cataract is the one in which the anterior or the posterior half, or lateral portions of the lens, appear opaque and shrink, while the rest remains transparent. Lamellar cataract, when stationary, should be removed, if the patient can only read large type. An artificial pupil should be made if, the pupil being dilated by atropia, ordinary type can easily be read. At the same time, the patient must be told of the probable "increase" of the cataract. The Striated or Streaked Cataract.—Gray or white and opaque striae, or streaks, appear first at the margin of the lens, beneath its capsule. Here they are broadest, and extend over both sur- faces of the lens, and frequently first over the posterior. In the latter case, we find in a more advanced stage an opacity with radiating striae, which, seen through the transparent bulk of the lens, appears concave and deep-seated. Sooner or later, the striae extend over both surfaces of the lens. The opacity TREATMENT. 251 may extend over the entire surface Avhich lies next the hyaloid fossa, before any striae appear on the anterior surface. Narrow gray and opaque, or moderately broad, but white and opaque, striae are made up of opaque lens fibres of nearly normal con- sistence and cohesion, surrounded by healthy lens fibres. Striae of similar size, but of a grayish opalescent color, are softer, and less coherent. If the striae are broad, and the interven- ing lens substance is opalescent, with the iris pushed forwards and but slowly moving over it, we suppose the cataract soft throughout. The "Black Cataract."—This rare form (the entire lens having a black or deep-brown color) has been found in eyes in Avhich hemorrhage has occurred in the vitreous chamber. Each lens fibre, Avhen the cataract is examined minutely, appears trans- parent, but has a yellowish-brown tint. The brown substance chemically resembles the coloring matter of blood. Different from this form is the senile cataract Avith a reddish- brown, or amber-colored, or black nucleus, which occurs fre- quently. The "green" cataract has been observed betAveen the ages of forty and eighty in persons with strongly-pigmented irides. The lens, though nearly transparent, has a dark pea-green color while within the eye, and a light yelloAvish-broAvn one when removed from it. The optic disk, viewed through the lens, ap- pears hazy. The removal of this kind of lens is accompanied by improvement of vision. The absence of glaucomatous symp- toms distinguishes this kind from the greenish lens of many glaucomatous eyes. The chalky cataract has a characteristic dead-white, or yellow- white and opaque color. The following are the usual forms:— (1.) Aflat, irregularly-shrunken, someAvhat disk-shaped, stony, hard cataract. (2.) A cataract consisting of a shell of chalk, enclosing opaque lens matter, bloodvessels, and cholesterine crystals. In rave cases the nucleus becomes changed into chalk. (3.) A lens changed into a chalky fluid, the heavier particles 252 CATARACT. gravitating towards the most depending portions of the capsule. Chalk in the form of minute white granules, or in groups of granules, or spiculse, is fund deposited on the surface of many transparent or opaque lenses. The lens capsule of the fluid variety is much thickened; in the other varieties it is ex- tremely thin. Minute and chemical examination of the cat- aract shoAvs that it consists of carbonate and phosphate of lime, of cholesterine crystals, and of fat. This kind of cataract is, as a rule, complicated with atrophic changes of the choroid, retina, etc. It has, in rare cases, been observed Avith a healthy retina, but with fluid in the vitreous chamber. Spicules or shells of true bone Avith bloodvessels have, though rarely, been found within the capsule of the lens. Cataract in diabetic persons is soft in young, and combined with a hard muscle in old, diabetics. Choroidal or retinal com- binations are comparatively rare, while paretic or paralytic af- fections of the ciliary muscle are frequent. The cataract generally has an opalescent surface, and is swollen, pushing the iris fonvards. In young persons it may be removed by suction; provided it be, or have been, rendered quite soft. Persons in the last stage of diabetes, Avho have had both eyes operated on simultaneously, have recovered good vision. Cat- aract without complication, i.e., Avithout morbid changes in other tunics, is termed primary ; such may be the traumatic, the idiopathic, and the congenital cataract. Secondary cataract exists if morbid changes of the "vitreous," "choroid," etc., can be traced as the cause. VISION. Most of the complaints of persons suffering from cataract can be traced to the cataract interfering with the course of the rays of light through the crystalline lens: some to changes in the refraction and accommodation; others to amblyopia or am- aurosis. Black spots floating before the eye—dimness, or a mist Avhich is not removed by spectacles—.intolerance of light, obliging the TREATMENT. 253 patient to shade the eyes or to turn the back to the light, to be able to see small objects better—are complaints often heard from persons suffering from incipient cataract. Numerous small, ill-defined opacities cause much dazzling or diffusion of light, which is relieved by the use of spectacles with tinted glasses. A dark disk-shaped figure, Avith its centre someAvhat clearer, and surrounded by a more transparent portion, has been de- scribed by some patients suffering from lamellar cataract. In such, vision has been improved by the use of atropia. In senile cataract with semi-transparent nucleus vision may improve gradually through spontaneous absorption of the opaque superficial "lens matter." It may improve suddenly through spontaneous displacement of the cataract from behind the area of the pupil. Flashes of light of various colors, fiery circles, "falling stars," if observed in daylight, may be caused by the light, on entering the eye, impinging upon peculiarly placed particles of cataract. Morbid changes in the nervous apparatus of the eye, especially if these symptoms are observed in the dark, are, however, the usual cause. They frequently occur in myopic eyes, and are then of less consequence. Careful examination of the sensibility of the retina for light and ophthalmoscopic examination must decide how far these symptoms should influence our treatment. Pain in the ciliary region and over the "eyebroAvs," or a sensation of "grit" in the eye, are frequently complained of by hypermetropics with commencing cataract. Vision after Removed of Cataract.—Spectacles are required to give the patient the best possible degree of vision, whether one eye has been operated upon or both. Refer to page 49. TREATMENT FOR CATARACT—GENERAL REMARKS. We inquire into the state of the general health of our patient, and treat medically any morbid changes we may discover. Syphilis, affections of the kidneys, atheromatous changes in the arteries, etc., verv much influence the final success of operations for cataract. Thin, quiet persons with soft skin are the most favorable 254 CATARACT. for extraction. Suppuration is frequently observed to follow in those Avith very Avhite hair and rigid arteries ("Avith a hard, large pulse"). Persons suffering from syphilis, gout, delirium tremens, asth- ma (emphysema), bodily deformities, have been successfully operated upon by extraction. Extraction with iridectomy (with the smallest possible incision) should be adopted in persons with cough, or with infirmities which prevent their remaining in bed for a few hours in succession. In different quarters a local medical treatment has been rec- ommended for the dispersion or for the arrest of the cat- aract. As far as I could learn, the remedies used for the pur- pose have contained iodide of potassium. The following is a copy of a prescription used by some Continental oculists for dis- persion of cataract:— B/. Potassii Iodide, 5vj.; Tincture Conii et Misturae Oleosae Balsamicae, aa, §iij. From 12 to 15 drops to be rubbed over the eyebrow four times daily. I have accurate notes of two patients, one a lawyer, who used the remedy for the last three years, and followed his occupation, which he could not do when I saw him for the first time; and the other a lady who is much engaged in reading, near work, etc. In both cases the opacities have become whiter and smaller. The Age of the Cataract—Cataracts from thirty to sixty years old have been removed with good result. Vision has improved much after removal. The Age of the Patient—Persons aged ninety and ninety-four have been operated on successfully by extraction on both eyes simultaneously. The habits of aged people are hardly disturbed by the operation of extraction with iridectomy and with a small corneal incision. The Season for Extraction of Cataract.—Cold or rainy weather is less favorable, since it prevents patients from taking out- door exercise after the operation. Hot weather (especially hot nights) prevents many patients from sleeping, and suppuration seems to appear more readily. Spring and autumn are the most favorable times; though otherwise healthy persons may with perfect safety, be operated on at any time of the year. TREATMENT. 255 REMOVAL OF CATARACT FROM ONE EYE ONLY, THE FELLOW-EYE POSSESSING USEFUL VISION. The advantages of removing the cataract are, that the field of vision becomes larger, the judgment of distances and shapes of objects more perfect, and the patient can more readily guard against accidents. Diplopia rarely folloAvs, or soon disappears. Strabismus does not necessarily occur, and may as easily do so if the cataract is not removed. The cataract, age and circumstances permitting, should be removed by absorption, or by a small corneal section, with iri- dectomy. Vision of the eye operated upon should occasionally be practised separately, with an appropriate convex lens. Removal of cataract from an eye which has not perception of light has often been performed with success—(1.) For reasons of personal appearance, e.g., if there is chalky cataract. (2.) For sympathetic irritation of the fellow-eye caused by, or at- tributable to, a dislocated chalky or other cataract. (3.) In blind eyes, the tension of which is too great, and not the result of intraocular tumor. Both eyes have frequently been operated upon simultaneously by extraction, with good result. Cases, however, have occurred in which both eyes have been lost. It is a safer plan to oper- ate on the second eye a week after the first. In selecting the mode of operating, we must be guided by the accidents, etc., which may have happened during the first operation. OPERATIONS FOR THE REMOVAL OF CATARACT. Removal of Cataract by "Extraction."—The object of the operation is to remove—"extract"—the cataract through a larcre incision in the cornea, or in the sclerotic close to, and in front of, the insertion of the iris. Many surgeons combine an iridectomy with every operation for hard cataract; others confine iridectomy—(1.) To eyes with posterior synechiae; (2.) To cases in which suppuration of the flap of the cornea is likely to happen; (3.) To traumatic cata- ract in old persons; (4.) To cataract with a very large, hard nucleus; (5.) To cataract in Avhich the superficial part of the lens is of normal consistence; and (6.) To dislocated lens. 256 CATARACT. OPERATION. The patient is put to bed, lying on the back, and facing the light, with the head slightly raised, and the hands AYatched by an assistant. The surgeon sits or stands behind, and, e.g., when operating upon the right eye, places the tip of the forefinger of the left hand upon the middle of the outer edge of the margin of the upper lid, and gently raises the lid above the margin of the cornea by causing it to glide along the curvature of the eyeball. Slight pressure is then made upon the eyeball Avith the tip of the forefinger, and Avith that of the middle finger upon the side of the eyeball near the inner margin of the cornea. This much control is obtained over the movements of the eye. An assist- ant draws down the lower lid, and presses it against the malar bone, Avithout touching or dragging the eyeball. Some surgeons keep the eyelids open Avith a light stop-specu- lum, and fix the eye with the forceps. If the stop-speculum is used, it should be carefully removed after the incision is com- pleted. Others raise the upper lid as just stated, while an assistant fixes the eye with the forceps at the insertion of the inferior rectus, draAvs it down, and at the same time depresses the lid. Fig. 30 represents extraction of the superior section of the cornea. TREATMENT. 257 The forceps are removed shortly before completing the corneal incision. Having secured the greatest possible control over the eyelids and eyeball, the cataract-knife is taken into the right hand. The thumb is placed on one and the fore and middle fingers on the other side of the handle, near the spot where it joins the blade. The little finger of the same hand rests upon the pa- tient's face. The point of the knife is thrust through the cor- nea at its junction with the sclerotic, and a little above the point Avhere its horizontal meridian touches the sclerotic. • The knife is steadily pushed across the anterior chamber, the blade remaining as much as possible parallel with the iris. The point of the knife is again thrust through the cornea, about opposite the spot where it entered. The cutting-edge of the knife, while making the incision, is directed towards the upper margin of the cornea, and the in- cision is completed by a to-and-fro movement of the blade, with- out allowing the point to return into the aqueous chamber. The line of incision, if well made, should be parallel Avith the margin of the sclerotic. A crescentic flap should be formed, which comprises nearly the upper half of the cornea. The size of the corneal flap depends upon the size of the hard nucleus, which we should ascertain as nearly as possible. The flap should always be sufficiently large to allow the nucleus of the cataract to escape with the greatest ease. The incision must be completed very slowly, and at a moment when there is no straining on the part of the patient, and no pressure whatever exercised upon the eyeball. The incision being completed, the lids are released and gently closed. After a minute's rest, we proceed to the laceration of the anterior capsule. An assistant draws down the lower lid while the operator carefully raises the upper lid. The patient is di- rected to look doAvnwards ("towards his hands"). The opera- tor with the right hand introduces the pricker through the wound in the cornea (raising the latter as little as possible, and without touching the iris), to opposite the middle of the pupil. 17 258 CATARACT. He then directs the point of the pricker towards the cataract, and, without displacing the cataract or pressing hard upon it, pierces the capsule and makes several incisions into it, so as to lacerate an area Avhich is about equal in size to a moderately dilated pupil. No resistance is felt in incising the capsule, un- less it be thickened. In rare cases, the thickening is so consid- erable that the pricker cannot pierce it; in which case, a sharp hook must be used to withdraAV as much of the capsule as will follow. Sometimes cataract and capsule can thus be removed together. (The removal of the capsule, or cataract and cap- sule, with the sharp hook, should always be attempted.) The capsule having been opened, we again "drop" the lid for a few seconds, and then proceed to the removal of the cataract. Experience is required as regards the necessary amount of pressure upon the eyeball to cause the cataract to escape. To do this, we place the flat part of the scoop upon the lower lid, near its margin, while the patient looks downwards. We then press with the scoop gently upon the sclerotic, the top of the forefinger of the left hand, which keeps the upper lid raised, being placed upon the eyeball. Careful alternating pressure is now made upon the eyeball in these two parts. This should cause the cataract slowly to advance into, and through the pupil, and through the incision in the cornea. As soon as the greatest diameter of the cataract lies in the section, we cease pressing. The margin of the lid, or a finger, or the scoop, is used to re- move the cataract from the section. After the nucleus has es- caped and been removed, we close the lids gently, and allow the patient to rest a minute. By placing the tip of one finger upon the closed upper lid, and gently rubbing the lid against the cornea, we cause the soft part of the cataract, accumulated behind the iris, to advance into the area of the pupil. We then raise the lid, and carefully remove the soft parts of the cataract with the scoop. Some of the soft cataract may be left, if the iris shows much tendency to bulge; the pupil, however, must be afterwards kept well dilated by atropia. The lids of both eyes are then closed carefully with narrow strips of sticking- plaster, and two pieces of lint, dipped in cold water, are tied lightly over the closed side of each eye. TREATMENT. 259 Accidents during the Operation.—(1.) The aqueous humor may escape too soon. This happens if the knife is not well made, or if it is steadily pushed on while making the section, or during a sudden movement of the eye. In these cases we withdraw the knife, and complete the section with strong, blunt-pointed, strabismus scissors. Corneal incisions, thus made, heal readily. If we do not wish to withdraw the knife, and the iris places itself over the edge of the knife, we gently press with the fore- finger (Avhich assists in raising the upper lid) upon the cornea. The pressure is kept up until the section is almost completed. If the iris cannot be pushed back, we cut through it, or with- draw the knife, and finish the section with scissors. If the iris has been much bruised, we exercise the bruised portion. (2.) If the margin of the pupil, or some other portion of the iris, has been wounded, bleeding occasionally occurs into the aqueous chamber. This is of little consequence, unless the iris has been bruised, Avhen the bruised part should be exercised, to avoid iritis. (3.) If a second pupil has been formed, by some marginal portion of iris having been cut away, the intervening bridge of iris must be divided with scissors before opening the capsule. We thus avoid the cataract becoming entangled in the new pupil. (4.) The iris, having completed the corneal section, may "bulge," i.e., may project slightly, and push the margins of the corneal incision asunder. This, if posterior synechiae exist, may be caused by aqueous humor accumulated behind the iris. An iridectomy should be performed. If the apparently healthy iris "bulges," there being neither straining nor pressure upon the eye from without, we must be prepared for a troublesome course. The bulging is the result of undue tension of the eye, and escape of vitreous, etc., threatens. The patient must be particularly careful, during the further steps of the operation, not to strain; and all pressure upon the eye should be avoided. If in these cases we perform iridectomy of the bulging portion of the iris, the greatest delicacy is required lest vitreous be lost. 260 CATARACT. The Cataract may not Escape—{1.) From the corneal in. cision being too small. The incision may be too slanting, or generally too small, so that even much pressure does not cause the cataract to escape. The incision must be enlarged (with strong, blunt-pointed scissors) if the cataract does not escape readily. (2.) From the pupil not dilating, if, previous to the operation, the pupil resists atropia, iridectomy should be performed before opening the capsule. This accident rarely happens—it is ob- served in highly presbyopic persons, and in persons suffering from cerebral changes, e.g., from the effects of apoplexy. Both pupils are generally contracted, and resist the action of atropia. (3.) From being adherent to the capsule,—as has been ob- served in cataract with dead-white superficial spots, and in traumatic cataract. Removal of the capsule with the sharp hook becomes necessary. " Vitreous" Substance may Escape.—(1.) Before the cataract is removed, sometimes even before the capsule has been lacerated. This may occur if the section is carried too near the ciliary processes, if the patient strains much; or after the capsule is opened, if too much pressure is made upon the eye. The vit- reous in these cases bursts through the suspensory ligament, and the cataract sinks back behind the iris. To prevent this, the scoop should be rapidly carried through the pupil, behind the iris and cataract. The latter must be removed, however much "vitreous" may be lost. Loss of vision, through glau- comatous changes or suppuration of the eyeball, follows if the cataract be allowed to remain in the vitreous chamber. (2.) "Vitreous" may escape with the cataract, or immediately after its removal, through straining of the patient, or through too sudden completion of the section. The lids should at once he closed, and a sponge, dipped into cold water, placed upon them. After a few moments the lids are raised carefully, to see whether the corneal flap is doubled down. If so, we pass the curette gently beneath the slightly raised upper lid, and along the curvature of the cornea, so as to bring the flap into a more natural position; having succeeded TREATMENT. 261 in this, we at once close the lids, and apply a bandage with wet lint. The cataract escapes enclosed in its capsule, if too great pressure is made upon the eye, or if the patient strains much. This is of no consequence if no "vitreous" is lost. The un- favorable consequences, if vitreous is lost, may be—partial dis- placement of retina,—hemorrhage between choroid and sclerotic, more particularly in the region of the ciliary processes, followed by more or less shrinking of the eyeball, or more or less severe inflammation. "Vitreous" may escape though there be no straining, and no fault committed by the operator. (1.) This, if the "vitreous" has the natural consistence, or is too firm, is a sign of the eye being glaucomatous. Due re- gard to the tension may assist us in avoiding this grave accident. It occurs more particularly in persons with very large and hard arteries, and in persons with very white hair. The iris bulges, and the cataract escapes as soon as the corneal incision is finished, or immediately after the capsule is opened; "vit- reous" follows immediately, or a few seconds later. The patient at the same time complains of severe pain in the eyeball, which is caused by sudden displacement of the ciliary nerves. Blood oozes out through the corneal wound as soon as all the vitreous has escaped. On making a section of the eye, we find the retina and choroid separated from the sclerotic (except at the optic disk, and near the ciliary muscle) by coagulated and fluid blood. The accident has repeatedly occurred in both eyes. Vision is lost; and the eye, if not removed at once, remains often painful for weeks, until it gradually shrinks. (2.) If the "vitreous" is fluid and the tunics collapse, little need be feared. It is only when the curvature of the tunics remains unaltered that intraocular hemorrhage need be expect- ed. The tunics of both eyes may collapse completely, and be thrown into folds, without their relative position being dis- turbed. All fluid occupying the vitreous chamber may escape; and twelve hours later, we may find the natural curvature of the tunics restored, through fluid again filling the vitreous 202 CATARACT. chamber. Good vision is generally obtained. In these cases, after the cataract is removed, some wet lint, dipped into tepid Avater, should be tied over the closed lids, so as to exercise very slight pressure, Avhile the patient, for from 24 to 48 hours, is kept in bed. (3.) The area of the pupil remains gray and opaque, though soft portions of cataract having been left after removal of the nucleus. The more glutinous the soft parts of the cataract is, the less readily does it escape. If it does not come away easily by using the syringe or the scoop, no further attempts at re- moval should be made. We must be prepared for iritis, or for a more protracted recovery. Particles of the nucleus, if soft and left behind, may become absorbed without further disturb- ance; if hard, they often cause iritis (within 24 to 60 hours), which reaches its height from the fourth to the seventh day after the operation. We must prepare for this if, from the irregular shape of the hard nucleus, we infer such particles to have remained behind. TREATMENT AFTER THE OPERATION, SUPPOSING NQ ACCIDENT TO) HAVE OCCURRED. The patient should occupy a well-ventilated room, which is still sufficiently light to allow of our seeing the color of the skin of the eyeball, and applying the wet lint securely. The patient is placed in the position which is most comfort- able, and is told to avoid undue muscular effort, and all un- necessary movement. The uppermost piece of wet lint is- changed every quarter of an hour until bedtime. The patient should be prevented, for the first five days, from touching the eyes during sleep, by having the bed-co-vering stitched to the pillow, allowing sufficient room to. turn round, but not to bring the hands up to the face. Should this be found inconvenient, the patient must be watched for four or five nights. The wet lint placed on the lids is secured with a band- age during sleep- Restless persons may require a narcotic. The patient has to remain in bed for from 36 to 48 hours. The next five days he may remain up a few hours in the middle of the day, having TREATMENT. 263 the lids bound up with wet lint. The application of wet lint is repeated frequently during one hour after breakfast, and during several hours before going to sleep. No food requiring mastication is allowed during the first twenty-four hours. Broth, beef-tea, wine, eggs, vegetables may be given; and solid animal food (finely-minced meat) on the second day. Spirits or beer may be allowed to those who are in the habit of having them. The outward appearance of the lids, the quality of the dis- charge, and the presence of pain, are the guides which we have as to the necessity of examining the eye. The eye is doing well if the color of the lids (especially of the upper lid) is not changed, or their margins only slightly red- dened; and if there is only slight watery or mucous discharge, and no pain. In this case, we inspect the eye on the eighth day after the operation. The incision frequently has healed on the second or third day. We may find—(1.) slight or no redness of the conjunctiva; the incision healed, and the line of incision smooth, or very slightly uneven; the anterior chamber good, and the pupil clear and central, or slightly displaced towards the section. (2.) Or we may find all as just mentioned, except no anterior chamber, the iris resting against the cornea. In this case a bandage is applied over the closed eyelids until the section has healed completely and the anterior chamber has become restored. In rare cases, four or six weeks may elapse before the union is complete. (3.) We may find some sclerotic redness, the pupil occupied by opaque matter, and all other parts healthy; in which case a bandage over the closed lids and atropia are made use of, the latter being applied every third hour during the day until the pupil appears clear, or nearly so. The eye operated upon may be used as soon as all sclerotic redness and intolerance of light have ceased. A shade must be worn, or the eye kept closed and not exposed to bright light, as long as there is the slightest intolerance of light. Atropia is applied to the eye not operated on, once daily- 264 CATARACT. Twenty-four hours after the operation it may be allowed to re- main open with a shade over it. It must again be closed if keeping it open gives rise to uneasiness. This favorable progress of the eye operated upon is, by no means, the rule. Generally a pricking sensation or pain is complained of for a few hours after the operation, especially when moving the eyeball. The pain ceases, or is temporarily relieved, by escape of tears. Lint dipped in cold Avater must, in this case, be applied more frequently to the closed lids, even until late at night. The fre- quent application of wet lint„ if pleasant to the patient, is con- tinued on the folloAving days. Swelling and redness of the lids, and pain in the eye or "over the eyebroAv," are certain signs of undue inflammation. We must, wherever they appear, carefully (and Avithout exposing the eye operated upon to more than is necessary) inspect the cornea and iris. We may find—(1.) prolapse of the iris. This is readily rec- ognized by a change in the curvature of the cornea. The margins of the incision are not in apposition Avith each other, but are pushed asunder by a dark substance (the iris next the section) which projects more or less. The pupil is drawn up, and often disappears behind the margin of the cornea. It much depends upon the general health of the patient, and upon the condition of the eye previous to the operation, whether the prolapse (being a great source of irritation) gives rise to inflammation, and if so, to what kind. If left alone, the pro- lapse generally disappears spontaneously, accompanied by great pain and prolonged irritation. It should, however, as soon as its presence is ascertained, be either treated by— (a.) Puncturing and then touching with the solid nitrate of silver. This is useful if aqueous humor or swollen particles of cataract are in contact with the bulging iris. Touching with caustic has been followed by severe inflammation, if the pro- lapse has been caused by protrusion of "vitreous." Pressure upon the closed lids, by means of a bandage and wet lint, must be kept up for several Aveeks. The operation of puncturing TREATMENT. 265 and touching with caustic may have to be repeated if the pro- lapse has not subsided after one application. Only- {b.) Snipping off the prolapse with scissors. This, if followed by loss of vitreous or by fistula, may lead to shrinking of the eye. A satisfactory result has in many cases been obtained (especially Avhere the pupil has been much displaced towards the section), by first (under chloroform) "making an artificial pupil" downwards, supposing the prolapse to be upwards, and then by removing the prolapse with forceps and scissors. In doing this, care must be taken to leave a narrow rim of iris along the base of the prolapse, to secure ready union. After the operation both eyes are kept bound up with wet lint; the lint has to be changed frequently until the anterior chamber is restored. (2.) We may find the incision healed, its margin hazy, the aqueous humor slightly turbid, the pupil someAvhat irregular and occupied by opaque matter, the tension of the eye normal or slightly increased, and perception of light normal. Locally, we treat as in iritis, i.e , order four or six leeches to be applied to the corresponding temple, if the pain is at all considerable, and atropia to be used every second hour during the day. Lint dipped into cold or warm Avater (according to the feelings of the patient) is applied frequently to the closed lids of both eyes. Suppuration of the incision may set in even as late as two or three weeks after the operation. It may occur Avhile union is going on, or after it is completed. (3.) Suppuration may extend from the incision. The cornea becomes gray, or yelloAvish, and opaque. This is accompanied by increased swelling and redness of the lids; by chemosis, es- pecially round the incision, Avith more or less muco-purulent dis- charge; by pain in the eye and over the corresponding side of the head, etc. The suppurative inflammation subsides in about eight weeks, if ic remains confined to the cornea, and cornea and iris. The cornea remains opaque and adherent to the iris; part of it may recoxr its transparency- If the cornea sloughs a cicatrix folloAvs, which sometimes becomes staphylomatous. 266 CATARACT. The patient retains perception of light. The suppuration some- times extends to the " vitreous," choroid, and retina. The suppuration may commence in the ciliary processes and in the adjoining vitreous, and thence extend. A yellow re- flection from behind the pupil indicates the presence of pus. Suppuration of the iris and cornea soon folloAV. In rare cases a form of cornea-iritis appears, which resembles the one in persons Avho suffer from inherited syphilis, and should be treated as such. In old or badly-nourished patients suppuration of the cornea may appear without any, Avith little swelling of the lids, and with severe purulent discbarge from the conjunctiva. In such, when examining the eye on the second or third day after the operation, Ave find chemosis, and the cornea changed into a yellow opaque substance. The eye gradually shrinks. By the frequent application of lint (dipped into warm water) to the closed eyelids, and by generous diet, Ave may succeed in confining the suppuration to the cornea, and in retaining good perception of light. REMOVAL OF CATARACT BY THE SCOOP. ("By Traction")—Scoop Extraction.—The object of this mode of operating is to remove the cataract Avith the aid of a scoop, through a smaller incision in the cornea than is made for common extraction. The removal of the cataract is preceded by iridectomy. The advantages are:—(1.) That we can give chloroform with greater safety, as regards the eye. (2.) That we avoid the complications arising from prolapse of the iris, and derive the advantages of an iridectomy as regards the tension of the eye. (3.) That the cataract can be removed more completely. The disadvantages of an irregular pupil, if the iridectomy be not made upwards, can partly be counteracted by properly- arranged spectacles: the iridectomy, if made upwards, creates but little inconvenience. Operation.—The patient, being under the influence of chloro- form, is placed as for the extraction of cataract. The eyelids are kept open Avith a light stop-speculum, and the eyeball is TREATMENT. 267 fixed with the forceps opposite to the point Avhere we propose commencing the incision. The incision should have a length of from three to five lines, according to the size of the nucleus of the cataract. It should always be large enough to alloAv of easy removal of the cataract. It should commence in the sclerotic, at the margin of the cornea; its extremities should lie in front of the iris, in the sclerotic adjoining the cornea. Those who are in the habit of performing eye operations make the incisions along the upper margin of the cornea; it is, however, easier to make it along the outer margin. The straight, or the bent lancet-shaped knife (largest size), the point entering at the extreme margin of the anterior chamber, is steadily pushed on into the anterior cham- ber (the point being directed very slightly forwards), until the incision has the desired length. Should the point have reached the opposite cornea before this is attained, then the incision is enlarged while withdraAving the knife, or afterwards with strong, blunt-pointed scissors. Care should be taken not to wound the iris or the capsule of the lens. Iridectomy is then performed. The portion of iris exercised should be sufficiently large to prevent our bruising the remain- der during further manipulations. Blood in the chamber should, as far as possible, be removed before proceeding to the lacera- tion of the capsule and to the removal of the cataract. During the removal of the cataract the patient should be thoroughly under the influence of chloroform. The aqueous humor having escaped and the iridectomy having been performed, the operator fixes the eye himself, and, with the sharp hook or the pricker, proceeds to the opening of the cap- sule. The sharp hook (or the pricker) is passed through the incision over the surface of the capsule to the spot where Ave wish to make the first opening. It is best to lacerate the capsule, first, along the margin of the lens Avhich lies farthest from the in- cision. There the point is thrust through the capsule. After- wards the other portions of the capsule are freely lacerated. To do this, Avithout wounding other parts, Ave must be familiar 268 CATARACT. with the shape and size of the lens. While opening the cap- sule Ave must neither bruise the iris nor displace the cataract. The part of the capsule next the incision is opened last. We sometimes succeed in withdraAving the capsule with the sharp hook. While opening the capsule attention should be paid to the consistence of the cataract, and to the size of the nucleus. The spontaneous escape of soft, opaque matter should be encouraged by gentle pressure upon the eyeball. The nucleus can often be removed by passing the sharp hook behind, and into it, and then withdraAving it. The sharp hook must be withdrawn if Ave do not readily succeed in removing the nucleus of the cataract, and the scoop must be made use of. If the pricker is used for lacerating the capsule, Ave Avithdraw it, after having freely opened the capsule, and, if necessary, loosened the nucleus. Knowing the size, shape, and position of the nucleus of the cataract, our next object is to pass the scoop between the cap- sule and the nucleus. Having succeeded in passing the scoop through the Avound in the cornea, and, through the pupil, into the cataract and behind the nucleus, we gently press the scoop and nucleus forwards into the area of the pupil, and then sloAvly Avithdraw both from the eye. During these manipulations all pressure upon the iris and cornea should be avoided. The entire nucleus having been Avithdrawn, we remove the speculum, close the lids, and gently rub the upper lid over the cornea, so as to cause softer portions of cataract, which may have been left behind the iris, to advance into the area of the pupil. If any are visible, we remove them with the scoop or syringe, as in extraction of soft cataract. Portions of the nucleus are sometimes broken off, if the incision has been made too small, or too much force has been used while withdrawing the nucleus. This must be ascertained by examining the nucleus which has been removed. All particles of the nucleus should be removed with the scoop. Accidents during the Operation.—(1.) If the incision is too small to allow the scoop, or the scoop and nucleus, to pass, the TREATMENT. 269 scoop must be withdraAvn and the incision enlarged with the knife, or Avith scissors, after Avhich the scoop is reinforced, and the nucleus removed. (2.) The scoop, instead of passing behind the nucleus, may push the entire cataract towards the opposite side. Insufficient opening of the capsule (especially if thickened), or a glutinous (normal) consistence of the superficial portion of the lens, or insufficient loosening of the nucleus, may cause this. The scoop should be withdrawn, the capsule opened freely, and the nucleus freed Avith the sharp hook or pricker. (3.) Portions of the nucleus may be broken off, and left be- hind, especially if force has been used while withdrawing the nucleus. We should endeavor as much as possible to remove these portions with a small scoop, and, if unsuccessful, take the necessary steps to prevent the occurrence of inflammation; apply leeches, though there may be no inflammation as yet, etc., etc. (4.) Vitreous may escape before the capsule has been opened. This may happen if the incision is made too far behind the margin of the cornea, or it may occur immediately after iridec- tomy (if the patient is straining), or while attempting to intro- duce the scoop behind the nucleus. Some operators rapidly introduce a large scoop into the vitreous chamber, behind the cataract, and Avithdraw the cataract with, or without the capsule. Others remove the speculum, close to the lids, and leave the cataract until the incision has healed, and the parts have re- turned to their natural positions. The latter proceeding is preferable if the vitreous escapes before the capsule has been opened. If it escapes during the after removal of the nucleus, no attempts should be made to remove particles of cataract that may be lodged behind the iris. These particles which are visible should be left, if soft; if hard, they should be remo\red with the scoop, syringe, or forceps. The escape of vitreous is frequently followed by more or less inflammation; and sometimes by suppuration of the eyeball. From six to eight leeches should be applied to the temple of the eye operated upon, the evening after the operation. Pieces of 270 CATARACT. lint, dipped into Avarm Avater, are applied frequently to the closed lids of both eyes,.and atropia is made use of, as in severe iritis. Depression of Cataract.—Reelination, Couching.—The object of the operation is to displace the lens into the vitreous chamber aAvay from the area of the pupil. In half the number of cases operated on in this manner the result has been favorable. While, where the cataract has been removed from the eye, out of 100 eyes, certainly, 85 have obtained useful vision, while only three per cent have lost vision completely. Vision often begins to fail in from three months to three to four years after the operation, if it is not lost at once by in- flammation. Causes of failure of the operation are:— (1.) The cataract rising again, having only in part become absorbed, or not at all. (2.) Inflammation round the non-depressed portions. (3.) The displaced cataract acting as a foreign body (this is the most common cause of failure), and giving rise to glaucoma, or to exudation upon the ciliary processes, with displacement of the adjoining retina. Operation.—The patient and the operator are placed as for (Fig. 31.) TREATMENT. 271 extraction; the pupil being dilated by atropia, the eyelids are kept open by the wire-speculum, and the eyeball is "fixed" with the forceps. A "couching needle" is thrust through the sclerotic near the loAver and outer margin of the cornea, as is shown in Fig. 31. It is pushed on behind the iris until its point appears in the area of the pupil. The broad surface of the needle is then placed upon the cataract, a little above its ante- rior pole. By steady pressure backwards and downwards the cataract is displaced into the vitreous chamber. It should not come in contact with the retina or with the ciliary processes. It should rest in the vitreous chamber, with its anterior surface directed upwards. As much as possible of the capsule should be depressed with the cataract. Some, at first, break up the vitreous to "prepare a bed for the cataract." Soft portions of cataract, Avhich may have remained behind the pupil, are left undisturbed. It suffices to have depressed the hard nucleus. Accidents.—The needle, if it becomes entangled in the nucle- us of the cataract, has to be Avithdrawn and reintroduced in a better direction. The consistence of the vitreous substance may impede the displacement of the cataract. In this case, we continue pressing in the proper direction until the cataract has disappeared from behind the pupil. If the cataract has been displaced into the anterior chamber, and Ave do not succeed readily in pushing it back through the pupil, it must be moved through an incision in the cornea. The cataract has to be extracted if it should rise again. An iridectomy with extraction of the displaced cataract from the vitreous chamber is the last resource if glau- comatous changes appear. Removal of Cataract by Absorption {Solution, Discussion, Keratonixis).—This mode of treatment takes advantage of the power which the "eye" possesses to abstract the cataract Avhen brought in immediate contact with aqueous humor. The operation is indicated—(1.) In persons below the age of fifteen. (2.) In soft cataract, especially with broad opaque striae, if the pupil responds well to atropia. 272 CATARACT. (3.) In persons of all ages, if the nucleus of the lens is not too hard, only one eye is affected, and slowness of recovery of no consequence. Linear or scoop extraction may have to folloAv the operation if it is desirable to hasten the removal of the cataract; or if, through iritis, the capsule has become thickened, or the pupil closed. The operation should be combined Avith iridectomy—(1.) If much of the lens is transparent, or if the cataract has the con- sistence of the healthy lens. In both cases much SAvelling of the lens must be expected. (2.) If the centre of the lens is hard. (3.) If the pupil is small, and but little influenced by atropia. (4.) If glaucomatous symptoms appear. The Operation.—Restless patients are placed under chloro- form. In all cases the eyelids are kept open by the Avire-spec- ulum, and the eyeball is fixed by forceps. A "cataract needle" is thrust through the cornea (about one- eighth of an inch from it's mar- gin), as is shown in Fig. 32, into the anterior chamber, and pushed on until its point has passed a little beyond the mid- dle of the previously dilated pupil. The point of the needle is at that point thrust through the capsule. No resistance, or hardly any, is felt when doing this. A well-dilated pupil is a favorable symptom, since com- (Fig- 32.) plications are less likely to arise from the contact of particles of cataract with the iris. The manipulations with the needle can be carried out with much greater precision when using lateral illumination. The object of these manipulations is to make several incisions into the cataract. The incisions should converge towards, and pass TREATMENT. 273 into, the first puncture of the capsule. By these incisions the capsule is freely opened round the anterior pole of the lens. After having made the first incision, we withdraw the point of the needle from the cataract, carry it over the surface of the capsule to a point situated more eccentrically; thrust it again through the capsule, and carry this incision into the first one. In this way, from four to six incisions are made to converge into the first one. The entire anterior surface of the capsule and of the cataract may be broken up at once if the iridectomy has been performed before the needle operation. Large incisions should also be made if iritis has preceded the cataract, since the capsule is often thickened, or has lost its elasticity. The more the capsule is lacerated the better is the cataract exposed to the contact of the aqueous humor, and the more complete is its absorption. Capsular obstructions are also less likely to occur. Free laceration of capsule, however, is accompanied by considerable swelling of the cataract. Con- tact of the cataract with the iris and ciliary processes is, in many cases, the cause of unfavorable complications. It is therefore safer, by the first needle operation, only to break up the capsule and lens at and near the anterior pole, and not tot carry the incisions too deep. In children, the entire lens is often broken up at oncpj,- ancfc with impunity, though, in these also, it is safer to procfeeA-'as1 indicated above. In older persons, even, small p&r&eieg of cataract, when coming in contact with the iris or cilitttfy prq-J cesses, may give rise to severe inflammation. ' flR mmn.<*\: <;/i The incisions into the capsule, as a rulejifoec#&e"('e&largted spontaneously through swelling of the ca^arac^i^ACfe^'dkys after the operation we find gray and opa^@'flodculi:J|)^^je8tSn^ from the wound in the capsule. The centre? '(ttufclMs)1^ thi* lens, or some segment of it, occasibnafllyo fMls%to!&e^'tfcrior chamber. Hard nuclei swell oufc. bilt? 3 littley and-fbe&)ffie>*&s sorbed very slowly: if theyi-gtre Hsfc k& iWtis •J&e^atoUdtt'-'ifoS removed by extraction. jimoIoJui Ur. liinu qrr fuuiod jqX ..-.qu The time necessary fon^^rpbion^atiestfVom four weeks to 18 274 CATARACT. nine months. The softer the cataract, the remainder of the eye being sound, the quicker is the absorption. The more glutinous or transparent the lens the more swelling may be expected when it becomes opaque. Accidents during the Operation and after Treatment.—(1.) The aqueous humor may escape before the needle has reached the cataract; in which case the pupil becomes contracted. This happens if the needle is not well made, or if the patient suddenly moves the eye, so as to cause the needle to escape from the aqueous chamber. In this case we break up the sur- face of the cataract, which lies in the area of the contracted pupil; being careful neither to stretch nor to scrape the iris. (2.) Puncture of the iris with the needle is of no consequence. (3.) The capsule of the cataract may be so tough that we are unable to tear it readily with the needle. In this case an in- cision should be made through the cornea, and the capsule ex- tracted with the sharp hook. (4.) Breaking through the hyaloid fossa with the needle. This allows the vitreous to advance into the pupil. The latter suddenly becomes clear. This accident is followed by more or less inflammation, and requires the treatment which would be adopted for severe iritis. The absorption may be arrested—(1.) Through the wound in the capsule being too small, or becoming closed by transparent, newly-formed substance. Absorption is progressing as long as opaque flocculi can be perceived in the pupil. A second needle operation becomes necessary only when the area of the pupil has assumed an uniformly smooth and opaque appearance. (2.) Through iritis. This is by far the most common cause. Iridectomy with extraction through a small opening in the cornea should be performed after the iritis has completely sub- sided under treatment. During absorption, only slightly increased vascularity, with some watering, and intolerance of light, should appear. The pupil should be well dilated by atropia; and the eye operated upon kept bound up until all intolerance of light has ceased. Suppurative iritis or choroiditis, or even ophthalmitis, may TREATMENT. 275 occur. Slight iritis, leading to posterior synechiae, is quite the rule, however carefully the after-treatment may have been con- ducted. The usual cause of inflammation, especially of iritis, must be sought in the irritation produced by portions of cataract coming in contact with the iris or ciliary processes. The tendency to inflammation varies much. In one case, suppuration of the iris may follow after one carefully-performed needle operation; in another case, as many as twenty needle operations, each followed by some iritis, may result in useful vision. The patient, after the operation, is kept in bed for 36 hours; and lint, moistened with cold water, is applied frequently to the closed eyelids, especially in the evening. Atropia is applied to both eyes three times daily. The eye operated upon is kept closed; and a shade is worn over both eyes until all intolerance of light has ceased. One needle operation may suffice to induce complete absorp- tion of the cataract. By some, as many as twenty have been deemed necessary on one eye. Iritis may set in a few days after the operation, or six, or eight weeks later, or as long as larger portions of the cataract are left for absorption. We, therefore, should keep sight of our patient, and, at once, adopt the treatment of iritis if severe pain is complained of over the eyebrow and in the temple of the eye operated upon, with watering and intolerance of light. Most of the complications arising from iritis are avoided by a timely iridectomy and by the frequent use of atropia. Spectacles may be given for near work as soon as the area behind the pupil has become clear, and all intolerance of light hiis ceased. Frequently no spectacles need be worn for going about. REMOVAL OF CATARACT BY LINEAR EXTRACTION. rlhe operation is indicated— In cataract with a hard nucleus, i.e., as a rule m cataract occurring in persons beloAV forty. The object of the operation is to remove the soft cataract,— whether rendered soft by nature or by art,—through a small 276 CATARACT. incision in the cornea. Many perform iridectomy immediately, or several weeks preA'ious to the linear extraction. Operation.—The patient, if quiet, need not take chloroform. A lancet-shaped knife is thrust through the cornea (at about j1^ in. from its outer and upper margin) into the anterior cham- ber, and an incision about \ in. in Avidth is made. While slow- ly withdrawing the knife the aqueous humor, and generally some of the cataract, escapes through the incision, if the cap- sule of the lens has also been incised while making the corneal incision. Gentle pressure upon the eyeball, with the forceps, which fixes it, or friction of the closed eyelids against the eye, assists in removing the rest of the cataract. Portions which do not readily escape by these means should be removed by suction. Particles of chalk mixed up with lens matter, when left in the anterior chamber, may set up iritis. They should be re- moved with the scoop, forceps, or syringe. If the capsule has not been opened previous to, nor while making the incision into the cornea, this should be done with the pricker as in extraction, or better, with the sharp hook after completing the incision. The capsule should, if possible, be withdrawn with the iris forceps, or with the sharp hook. This may be done either before or after the removal of the opaque lens matter, care being taken not to encourage the escape of vitreous substance. Accidents during the Operation.—(1.) The consistence of the cataract may have been mistaken, and none, or only a small quantity, may have escaped by the means indicated above. In this case, no force must be used to remove the cataract, but iridectomy, upwards, should be performed. The eye must be watched carefully, and treated as after extraction, the rest of the cataract being left to become absorbed, or to be removed a week or fortnight later, after it has become more fluid. (2.) Prolapse of the iris, or anterior synechiae. This accident and its complications are avoided by iridectomy. The protrud- ing iris is removed with forceps and scissors, if friction of the eye with the eyelid does not cause it to recede. The same pro- TREATMENT. 277 ceeding is adopted if the prolapse occurs some time after the operation, and if it does not subside on the application of Cal- abar. Most accidents arising from the iris are avoided by iridectomy performed at the time of, or previous to, the extraction. (3.) Spontaneous bleeding from the iris. The blood, if it does not escape readily by the use of the scoop or syringe, must be left to be absorbed. (4.) The vitreous substance may advance into or through the pupil (the occurrence of this accident is characterized by the area of the pupil suddenly becoming "black"); or the "vit- reous" may even escape through the incision. It always dis- places particles of cataract behind the iris. Attempts to re- move small particles are useless. The termination of these cases is more favorable if iridectomy has been combined with the extraction. Severe pain in the eye and corresponding side of the fore- head, and even attacks of vomiting, often follow. Iritis fre- quently appears about the third or fourth day after the accident. Sometimes it is followed by suppuration of the iris and cornea, or by ophthalmitis. In rare cases the pupil (with its margin pushed back) remains irregularly dilated, but clear. The margin of the pupil proba- bly becomes adherent to the vitreous substance. This state, with a good anterior chamber, with slight intolerance of light, and with some increase of tension, continues in some cases for six or eight months. In the majority of cases, the vitreous substance after from 12 to 24 hours (during which the pain continues more or less) recedes behind the pupil. The patient must remain in bed; and ice, or application of cold water, must be used very frequently to the closed eyelids of both eyes, to- gether with atropia every second hour, during the day, until the pain has subsided. 278 MODIFIED LINEAR EXTRACTION. MODIFIED LINEAR EXTRACTION. The indications for this operation are the same as those for flap extraction. But it has also certain special indications: 1. For the removal of cataracts whose cortical portion is quite adherent, and whose capsules are of normal consistency. 2. Where general or local conditions render suppuration at the cornea imminent. 3. Where the' condition of the patient renders a less strict regimen advisable, or, more particularly, a shortening of the time of confinement to bed. The operation is much like flap extraction, and, like this, is done with several pauses, for the patient to rest and recover himself. The instruments required are a narrow, pointed knife (Graefe), iris forceps, and a fine Louis' scissors; a delicate sickle-shaped needle, with rounded, blunt back; a sharp and a blunt hook; a thin and very flat spoon (Bowman's), or better, a scoop with projecting anterior edge (Critchett), a toothed forceps and a spring speculum. The sickle-shaped needle and the hook should have mailable necks, so that we may alter the curvature; for if the neck of the instrument is straight and stiff, and the eye is deeply set, the in- strument cannot be readily introduced flat into the wound and moved in various directions in the plane of the iris. For the same reason, the spoon is more convenient, if its concavity is at an angle to the neck. Snowden's spring speculum, which has long been in use, does not answer well here, because the part uniting the two arms interferes with the introduction of the different instruments. Hence this part has been much elongated, so that, when in use, it rests on the temporal region (Graefe). But the elongation of the arms causes a loss of power in the spring; hence the instru- ment must be made heavier, or furnished with an adjusting screw, which is somewhat objectionable. It would seem best, therefore, to have a small Snowden's TREATMENT. 279 speculum, with an anterior curve, so made that the part uniting the arms should lie on the side of the nose, Avhen the instrument is placed in the conjunctival sac. In modified linear extrac- tion, the upper part of the anterior scleral zone is usu- ally opened. In order to make the requisite linear section at this place with one, or a few strokes of the knife, the upper eyelid should be held well back by the operator or assistant; and, to prevent the rolling of the globe, this is seized with toothed forceps, placed exactly under the lowest point of the corneal margin, downward, and held in this position. (Fig. 33.) The incision should vary in length according to the supposed size of the nucleus; but four, to four and a-half lines, may be considered as the medium length. For this purpose the knife should be entered about one-third to half a line from the anterior margin of the cornea, and two- thirds of a line to a line below a tangent to the highest point of the cornea, in the outer part of the anterior scleral zone. The knife is to be held with the cutting-edge inward and up- ward, and its point directed towards the middle point of the an- terior chamber. It is entered obliquely in this position, so that it appears in the anterior chamber, close to the origin of the iris; it is advanced about three lines, and then turned horizon- tally, so as to be passed through the corresponding inner portion of the anterior scleral zone, at the same height, and at an equal distance from the cornea as the point of entrance. When this has been done, the instrument should be passed on horizontally, with its back downwards, and anteriorly (Fig. 33.); and if the point comes near the nose it should be drawn back till its edge 280 MODIFIED LINEAR EXTRACTION. has severed the attachment of the upper section of the iris, as far as the margin of Descemet's membrane, and rests against the inner wall of the sclera. Now the knife should be turned so that its back shall be tOAvards the ideal centre of the corneal curvature, so that the capsule of the globe may be divided by long strokes almost perpendicularly to its surface. Then the knife lies between the sclera and conjunctiva, and the latter ap- pears raised in a broad fold. As the conjunctiva is very dis- tensible and gives way, the cutting-edge should be turned for- ward, and the membrane divided by a saAving motion. The wound in the latter thus forms an anterior convex arc, whose summit reaches nearly to the limbus conjunctivalis. The second step of the operation, the excision of the portion of iris presenting at the wound, is facilitated by the use of the spring speculum. In order to manipulate readily, it is neces- sary to lay the conjunctival flap back on the cornea. The piece of iris is then seized with the forceps, pulled out and cut off close to the scleral wound, so that no tags may remain in the wound. The speculum may now be dispensed with, and had better be removed. The opening of the capsule requires a sickle-shaped needle, whose neck is suitably curved. This is passed flat through the Avound to the lower part of the pupillary border. Its edge is then turned towards the capsule, which is to be di- vided by several incisions, crossing each other as far as the up- per margin of the lens. It is also well, if possible, to pass the needle around the margin of the lens, so as to make the cap- sular opening large. If the capsule has been sufficiently divided, the lens often ap- pears at the scleral opening, and but little assistance is required for its escape. For this purpose, it is well to draw on the fix- ation forceps a little, so as to render tense the lower part of the capsule of the globe, and, at the same time, with the back of the spoon, to make pressure on the posterior lip of the scleral wound. If this does not accomplish the object, we should try the sliding manoeuvre, i.e., while the finger fixing the upper lid makes slight pressure on the upper part of the eyeball, the back of the spoon TREATMENT. 281 is gently pressed against the lower border of the cornea, and towards its centre. In most cases, this manipulation brings the lens into the scleral wound, and so far through it, that it may be seized with the hook or spoon, and drawn out. We may especially count on this, when the cortical layers are wholly disintegrated, and the nucleus is loose in the capsule. But if the cataract does not come out, Ave should use the so-called traction instruments, as they are certainly less dangerous than continued pressure on the globe, which, moreover, does not attain the desired end. If we have to deal Avith a large sclerosed nucleus, we should use a blunt hook, which, like the sickle-shaped needle with a bent neck, should be passed flat through the wound, and the posterior cortical layers of the cataract, to a point beyond the equator of the nucleus; then the point should be turned fonvard, the lens seized and drawn out. This usually succeeds readily, even if the upper margin of the capsule has not been sufficiently divided, for the latter is easily everted by the escaping cataract. In cataracts Avith normally consistent nucleus, hoAvever, the hook readily cuts through, breaks up the lens, and leaves the frag- ments behind, as they readily avoid it. In such cases,'as well as where a normally consistent cortex must be separated, a suit- able spoon should be substituted for the hook. Any of the soft, broken lens mass that still remains in the capsule may, as in flap extraction, be pressed towards the open- ing by stroking the cornea with the back of a spoon. If the remaining portions are not completely evacuated, there is nothing left but to pass a spoon into the wound and scoop them out. Just as in flap extraction, we should make it a rule to clear out the cataractous lens as completely as possible; to draw out portions of capsule that have become stiff from deposits; clean the wound properly, and remove any pieces of iris that may be caught in it; and, finally, to replace the conjunctival flap in its natural position. When all this has been done, it seems advis- able to open the eyes again in a minute or so, and let out aque- ous that has collected; for this not unfrequently washes out with it some small pieces of cataract and effused blood. 282 CAPSULAR OBSTRUCTIONS. The after-treatment and dressing are to be regulated as in flap extraction. But in modified linear extraction, after the first couple of days, the patient requires less restriction, and may be allowed more freedom, as the detachment of the flap is here less to be feared. After the second day, instillations of solution of atropine should be made with proper care, once or twice daily, so as to diminish, as much as possible, the irritating influence of any retained portions of cataract. CAPSULAR OBSTRUCTIONS. {"Capsular Opacities" "Opaque Capsule;") False Membrane; Opacities behind the Pupil. We distinguish the following capsular obstructions:— (1.) Those which precede the removal of cataract; and (2.) Those which follow the operation. Changes accompanied by inflammation near the surfaces of the capsule give rise to opaque spots upon those surfaces; e.g., if, during purulent ophthalmia, the lens and its capsule come into contact with the swollen suppurating cornea (whether per- foration occurs or not), opaque dots upon the surface of the capsule may follow. The anterior polar or pyramidal cataract, situated on the outer surface of the anterior capsule, and projecting through the pupil, is of this origin. Ulceration of the cornea, wounds of the capsule, iritis, eyelids, etc., may give rise to opaque spots, which, as dissection shows, are due to an alteration in shape and transparency of the intro-capsular cells. These, instead of de- veloping into lens fibres, grow out into differently-shaped cells. Particles of chalk and spicules of bone have been found in such opaque spots. On the outer surface of the anterior capsule, and in its sub- stance, have been found globules of a yellowish, translucent, finely-granular substance in appearance, and, chemically, re- sembling that of the capsule itself. Opaque, warty, globular "excrescences," and deposits of lime TREATMENT. 283 • in grains, globules, etc., if considerable, appear to the naked eye as radiating or irregular white, or gray and opaque, streaks or dots. Posterior synechiae, corneal opacities, and other signs of past inflammation, often occur simultaneously. Spots of brown or black pigment, or vascular or non-vascular opacities, derived from the iris (Avith or without synechiae), are common complications of capsular opacities. The opacities just described may be present with or without any other alteration in transparency of the lens; or may re- main after the lens, or part of it, has been removed. The opacities observed after the removal of cataract are chief- ly caused by "opaque lens matter," which has not been removed; or has not become absorbed; or being transparent at the time of operation, has subsequently become opaque. If the anterior capsule is freely opened, and the entire lens re- moved, and no inflammation follows, no opacities occur behind the pupil. The anterior capsule retracts towards the suspensory ligament, and the transparent posterior capsule is slightly bulged forwards. This favorable result, unless the anterior capsule be entirely removed, is hardly ever obtained, however good vision be. We mostly find, on dilating the pupil, an opaque white rim of varying width near the tips of the ciliary processes. This rim consists of debris of cataract, enclosed within the cap- sule. It need not be disturbed as long as the area of the pupil is clear, and the transparency and smoothness of the posterior capsule are not altered. Opaque deposits upon the surface of the capsule occur when- ever inflammation (iritis, eyclitis, etc.), however slight, follow the operation for cataract. They retard or prevent the absorp- tion of opaque lens matter, render the capsule stiff, and are the means of adhesion between it and the adjoining iris. Minute examination of sections of "opaque capsule," the re- sult of one or of several of the above causes, shows that in all instances the capsule can be traced as a transparent line across the opaque substance. When using the term "opaque capsule" in these, avc do not mean an opacity of the capsule itself, but a deposit of opaque lens matter, of chalk-granules, of connective tissue, etc., upon the surfaces of the transparent capsule. 284 CAPSULAR OBSTRUCTIONS. . Treatment.—The removal of capsular obstructions, especially if performed roughly, is not Avithout danger. Eyes with useful vision have been lost in consequence of glaucomatous changes, or suppuration, or intraocular hemorrhage, or displaced retina, or severe iritis, with closure of pupil. Among the accidents which may give rise to these unfavorable results are—separation (by the instrument used for the opera- tion) of the suspensory ligament and of the adjoining retina from the choroid;—laceration of the ciliary processes, and hemorrhage into the vitreous chamber; laceration of the vitreous substance, causing the latter to advance through the pupil into the anterior chamber. The latter accident is sometimes com- plicated with hemorrhage between the choroid and sclerotic, and glaucomatous symptoms ensue. We should leave the capsular obstruction undisturbed aa long as the capsule and the opacities attached to it do not pre- vent vision, i.e., as long as the patient can read ordinary type. The removal of such obstructions, whether opaque or transparent, while the eye is irritable, intolerant of light, or inflamed, ia often followed by iritis, or by hemorrhage, and by fresh opaque deposit. The removal of capsular obstructions, which follow depression of cataract, most frequently give rise to severe inflammation. Those who perform depression advise, unless vision be ma- terially impaired, not to interfere with the obstructions. It is safest to perform the operation of removing capsular ob- structions when the eye is entirely free from all undue vascu- larity, and when it is of normal tension, and possesses good per- ception of light in all parts of the retina. The only obstructions requiring removal are those which lie in the area of the pupil; and only as much need be removed aa is equal to the size of a pupil of medium dilation. The Operation.—The pupil having been dilated as much aa possible by atropia, and the patient placed as for extraction of cataract, chloroform is given if the patient is at all inclined to be restless. The lids are kept open with a stop-speculum, and the eyeball is well' steadied by the operator before attacking the TREATMENT. 285 capsule. An assistant, standing at the side of the patient with a convex lens of from three to four inches focal distance, con- centrates the light of a lamp upon the portion of capsule we propose removing. A careful examination of the capsule, of its relation to the parts surrounding it, and of the portions we wish to remove, should immediately precede the operation. All steps which may give rise to bleeding should be avoided; or if unavoidable, should only be taken after removal of the obstruc- tion. Softish eyes, and those in which, after long-continued choroido-iritis, the parts within the eye have lost their elasticity, are most inclined to bleed. The blood, which becomes accumu- lated in the anterior chamber, in these cases proceeds from ves- sels of the conjunctiva, or of the iris or capsule; and bleeding is often avoided by making the incision through a transparent part of the cornea. The vitreous substance is least disturbed, while removing capsular obstructions, by moving the instrument, needle, etc., as much as possible in a plane with the portion of capsule which we wish to withdraw. Folds of transparent capsule should be torn through with one or two needles. Suppose such folds to have a vertical direction, and we propose dividing them with a cutting-needle; Ave pass the needle through the cornea near to the upper margin, carry the point up to and through the folds near the inner margin of the pupil, and thence horizontally across the folds, dividing them with the cutting part of the needle as far as the outer margin of the pupil. We then, having obtained a transverse clear slit in the folded capsule, withdraw the needle, if possible without passing any aqueous humor. Opaque filaments, stretched across behind the area of the pupil, may, in the same way, be divided with one or two needles. The divided portions are expected at once, or after some weeks, to shrink away from behind the area of the pupil. When using two needles, some practice is required to keep the attention fixed on both. Suppose we have not succeeded with one needle in dividing an opaque filament, Avhich, e.g., extends horizontally across the area of the pupil, we then, without with- drawing the first, introduce a second needle. The first needle, 286 CAPSULAR OBSTRUCTIONS. having been thrust through the cornea near its upper margin, and the point having been carried a little beyond the opaque filament and in front of it, the second needle is thrust through the cornea near its lowrer margin, and the point is carried be- hind and a little beyond the filament. The points of the two needles are then rotated round each other, so as to cause the elastic filament to become tAvisted once or twice round the stems of the needles. By draAving the points in opposite directions the filament is torn through. Opaque capsular obstructions which are too large to be cut through Avith one or two needles, are removed with the sharp hook. To do this, an incision is made through the cornea near its margin, and opposite to the spot where the capsule appears thinnest, or its attachments to the surrounding parts are least thickened, by previous inflammation. The sharp hook is then introduced (in the same manner as a blunt iris hook) up to and through the part of the opaque capsule which lies farthest from the incision in the cornea. The capsule is gently torn away from its attachment, and either drawn out through the incision, or, if too firmly attached near the incision, it is draAvn out, as much as possible, and cut off; the rest is pushed back "into the eye. The opaque capsule need not be removed from the eye if a clear pupil, about the size of a natural one, has been obtained by merely tearing the capsule aAvay from its insertion opposite the incision; and if, at the time of operation, it shows no ten- dency to return to its former place. If the attachments of the capsule are so firm that considerable force is necessary to tear them with the hook, or if, while attempting to do so, the sclerotic next the hook is drawn in, Ave take a small, sharp, lancet-shaped knife, and thrust it through the cornea and capsule into the vitreous chamber between the hook and the part of the sclerotic thus drawn in. Then, having cut through the firmly-attached part of the capsule, we quickly withdraAv the knife, and having with the other hand held the hook inserted into the capsule, withdraAv the latter. The pupil, though much of the capsule and iris may have TREATMENT. 287 been removed, may become closed by blood and fibrine; or may become contracted again, though no hemorrhage has occurred. This happens often in eyes which have suffered from severe choroido-iritis, and in those in which an inflammation, following operation, has not completely subsided. Good vision has been obtained in such cases by counteracting the tendency to con- traction by a T-shaped incision through all the parts which sep- arate the anterior (aqueous) from the vitreous chamber. To ef- fect this, we thrust a lancet-shaped knife through the cornea close to its margin, and through the adjoining iris and capsule into the vitreous chamber, then withdraw the knife quickly, and introduce a pair of strong iris scissors through the incision in the cornea. In the anterior chamber we open the scissors, and pass one blade through the incision in the iris and capsule into the vitreous chamber, the other in front of the iris; we next push on both blades until the one in the anterior chamber has nearly reached the opposite margin of the cornea, and then cut through all the parts which lie between the blades. Most of the above operations are attended with loss, or at least with displacement or disturbance, of some of the vitreous substance. To avoid inflammation and complications arising from sickness, we apply atropia to the eye not operated on, tie wet lint over the closed lids of both eyes, and keep both eyes at rest and the eye operated upon closed, until all intolerance of light and other signs of irritation have ceased. CONGENITAL CATARACT AND CATARACT IN CHILDREN. Causes and General Remarks.—In a few instances congenital cataract has been observed in one eye only. Its most frequent cause appears to be inherited syphilis (with or without traces of iritis). Peculiarities in the shape of the head; in the color, etc., of the incisor teeth, Avhich may be of the notched syphilitic kind, or may present nodular, uneven surfaces, so-called 'rocky teeth,' are observed in most cases. As many as six cases of congenital cataract have occurred in one family. A frequent cause of cataract in children is purulent oph- 288 CONGENITAL CATARACT. thalmia.' An opaque, white, nodular deposit, at or near the an- terior pole, with the lens otherwise transparent, and opacity of the entire lens, if there has been much suppuration of cornea, are the two forms usually observed after purulent ophthalmia. As complications must be mentioned—posterior synechia (following intra-uterine iritis); persistence of portions of the pupillary membrane; atropic changes in choroid and retina; displacement of the retina (particularly if the cataract has ap- peared rapidly) is large, of the uniform gray and opaque kind, with chalky deposits on its surface, or if it appears as Avhat is termed posterior polar cataract; opacities of the cornea (follow- ing intra-uterine corneitis, or purulent ophthalmia); nystag- mus (Avhich generally appears soon after birth), if there be cata- ract in both eyes; coloboma, arrest of the development of the entire eyeball; absence of the iris; conical cornea; myopia. The latter is a frequent complication. Symptoms and Course.—The cataract, if Avell marked, is readily noticed by the parents soon after birth. When slight it is often overlooked. Patients may pass through life without its having been noticed, until it may have become complicated with senile cataract. Nystagmus, smallness of the eyeballs, or some peculiarity in the movements of the eyes Avhen objects are grasped, may attract the attention. If the cataract has been overlooked at first, it generally becomes noticed when the child begins to read; objects are held close to the eyes, or in a peculiar position. The characteristic symptoms are opacities, varying in kind and extent, in and upon different parts of the crystalline lens and its capsule. The lens should be examined with artificial light, the pupil being dilated with atropia. Numerous varieties arise from the varying forms and positions of the opacities. The most frequent are:— (1.) A minute dot of chalky whiteness, situated in the middle of the clear pupil. The dot may have a conical shape project- ing into the anterior chamber; or it may occupy the entire area of the pupil, the rest of the lens being transparent or slightly opaque; small white dots may be found round the central one. TREATMENT. 289 A similar white, opaque, and circular dot is occasionally met with at the posterior pole of the lens. (2.) Irregularly-shaped or circular faint gray and opaque or buff-colored spots, of different sizes, which are sometimes ex- tremely minute, very numerous, and sprinkled over the anterior surface of the lens (this form is often overlooked). (3.) A ring-shaped, faint gray opacity at the posterior pole of the lens, with opaque striae radiating from it. (4.) An irregularly-shaped, small, opaque, and white sub- stance occupying the place of the lens. (5.) A uniformly gray and opaque lens, or a semi-opaque nucleus, with a transparent cortical substance. The lens is generally smaller, and not unfrequently irregular in shape: the distance of its margin from the ciliary processes varies. Transparent portions of lens may intervene between opaque ones (so-called lamellar cataract). The cataract, espe- cially if of long standing, may be fluid (a thin layer of chalky white and opaque fluid enclosed within a tough capsule). Even in children (especially if iritis has preceded) a hard nucleus may be found. The opaque white dots which are often seen in the area of the pupil are attached to that portion of the surface of the capsule which lies next the lens. They project through the pupil into the anterior chamber, and when touched with the needle often break off. In infants they generally appear gray- and opaque. They gradually become whiter. Treatment.—Any treatment tending to improve vision, or operations for the removal of cataract, should be adopted as early «as possible. The sooner an operation is performed the quicker is the recovery, and the better the result as regards vision, movements of the eyeballs, etc. Cases of congenital cataract without perception of light, unless for reasons of per- sonal appearance, should not be operated upon. The removal of cataract from one eye, the fellow-eye being sound, does not interfere with the functions of the sound eye. If there be per- ception of light, however slight, and even if the shape of the 19 290 CATARACT IN CHILDREN. eyeball be below par, the cataract should be removed. Improved vision and nutrition of the eye operated upon will result. Patients with an opacity confined to a circumscribed portion, e.g., the anterior pole of the lens, can with advantage, for years, make use of atropia. An iridectomy, without removing the cataract, may be recommended if the margin of the lens be transparent (which may be ascertained with the ophthalmoscope), the opacity well-defined, and no increase of impaired vision com- plained of. By this treatment the accommodation of the eye is preserved, and the use of spectacles rendered unnecessary for years. If neither the use of atropia nor an artificial pupil procures useful vision, we remove the cataract, either by absorption, which is the slower and safer mode, or by linear extraction, or by suc- tion. Children bear these operations well. The greater part of the cataract may, after opening its capsule, come to be in the anterior chamber; and may become absorbed without set- ting up much irritation, while the same accident in a grown-up person may lead to ophthalmitis. Cases in which the bulk of the lens is transparent, and only the surface or some of the layers of the lens opaque, are more troublesome; more irritation accompanies absorption. When removing the irregular white and opaque substance, which in some cases occupies the place of the lens, we must be very care- ful not to use any force. If the substance should not readily follow traction with the forceps or sharp hook, it must either be left, or must be separated from adhesion, especially on the side next the vitreous chamber, by passing a small, lancet-shaped knife behind it. DISLOCATION OF THE CRYSTALLINE LENS. {"Ectopia of the Lens.") (1.) Dislocation of the Lens into the Anterior Chamber.—The presence of the transparent lens into the anterior aqueous cham- ber betrays itself by a yellowish, shining, circular line (the mar- TREATMENT. 291 gin of the lens), which, on looking sideways into the chamber, may be seen near the margin of the cornea. A similar appear- ance, though not so well-marked, has, in one case, been caused by "vitreous" filling the chamber. The iris is pushed back- wards; the pupil sluggish, or fixed, and somewhat dilated. The optic disk, viewed with the ophthalmoscope through the dislocated lens, appears unusually small. The lens in this situation may remain transparent for years (in one case twenty years). It appears larger in its anteropos- terior, and smaller in its lateral diameter; it gradually becomes yellowish. Attacks of iritis frequently follow, and the lens be- comes adherent to the anterior surface of the iris. The posterior surface then loses its transparency, thus hiding the iris, the pupil, etc. After having undergone adhesion, the lens becomes smal- ler, and shrinks towards its adherent portion; while the pupil and the remainder of the iris become visible and tremulous. The dislocated lens may also become adherent to the posterior surface of the cornea, and cause ulceration and perforation, which proceed from within outwards. The lens may become opaque and be absorbed, or it may change into a small, chalky- white, hard substance. The latter sometimes rolls about freely, and passes from the anterior through the pupil into the posterior chamber. This substance may become adherent somewhere. Attacks of iritis, when once they appear, often recur. The lens may be dislocated so as to stand sideways in the pupil, part of it projecting into the anterior chamber, where the peculiar golden reflection from its margin may be seen. (2.) Dislocation of the Lens into Vitreous Chamber.—A clear, sluggish pupil, and a deep anterior chamber with tremulous iris, together with the history of the case, may lead us to sus- pect this dislocation. The lens is generally visible to the unaided eye, and always when sought for with the ophthalmoscope. The observer should look with the ophthalmoscope as much as possible behind the lower posterior surface of the iris, while the patient directs the eye downwards. The dislocated lens, which may be transparent, or grayish and opalescent, or chalky-white, is readily perceived '292 DISLOCATION OF THE CRYSTALLINE LENS. as a disk-shaped substance which floats behind the iris in the vitreous chamber. The entire lens is seldom visible; the well- defined opalescent margin farthest distant from the iris generally comes into view. Sometimes the suspensory ligament is elongated, or only a portion of it is ruptured, and the lens is seen swinging to and fro behind the pupil. Cases have occurred in which the patient has had the power of displacing the lens through the pupil into the anterior chamber, and back again behind the iris. The lens may be displaced directly backwards, together with the suspensory ligament, the latter having for some distance been stripped of the ciliary processes; or the lens, enclosed in its capsule, may have become detached from the hyaloid fossa, and fallen into the posterior chamber. In a case of this kind extraction of the lens has been performed with good result. (3.) Lateral or Oblique Dislocation of the Lens.—The lens, in some cases, is found displaced towards the ciliary processes; in others, one margin is tilted forwards towards the iris, while the opposite margin recedes towards the vitreous chamber. Part of the iris is pushed forwards; part of it recedes, as may be seen from the unequal depth of different portions of the anterior chamber. The iris is not always tremulous. Dislocation in- wards and upwards is the most frequent form. The lateral dis- placement may be so considerable that only one-third of the pupillary area is occupied by the lens; and when looking at the optic disk with the ophthalmoscope two optic disks are visible, one indistinctly, the other distinctly. When examining the everted image, we have to change the distance of the convex lens from the patient's eye, according to whether we view the optic disk through the patient's lens, or through the part of the pupil- lary area free from it. If the dislocated lens leaves part of the pupil free, images of different degrees of distinctness are formed upon the retina, and diplopia or polyopia is complained of in the affected eye. Much light is reflected, and interferes with the distinctness of vision. Symptoms of astigmatism arise. A convex lens im- proves vision when held opposite the part of the pupil from which the crystalline lens is displaced. TREATMENT. 293 The oblique position of the lens (one margin receding to- wards the vitreous chamber) can be recognized by the reflex images from its surface not standing opposite each other when the eye is directed straight forwards. The oblique position may be considerable without much lateral displacement. Vision, in dislocation of the lens into the anterior chamber, is improved by concave lenses. Convex lenses should be tried when the crystalline lens has in part or entirely disappeared from the pupillary area. Patients with the lens swinging to and fro behind the pupil complain of objects moving, of an appear- ance as if flowing water were obscuring the object looked at, etc. When once the absence of the lens from a part of or from the entire pupillary area, and the nature of the dislocation, have been ascertained, we must, in our further examination, be guid- ed by the general rules in use in anomalies of refraction, accom- modation, etc. Every dislocation of the lens is complicated with more or less rupture of its suspensory ligament, and, consequently, with a less, or a great, impairment of the faculty of having the curvature of its surfaces changed during accommodation. (4.) Dislocation of the Lens beneath the Conjunctiva.—The lens, if it has escaped through a rent in the tunics (which rent is generally found close to the upper margin of the cornea), may have done so completely; or its nucleus may have remain- ed while the cortical substance has escaped; or the entire lens and capsule may have become lodged beneath the conjunctiva- The conjunctiva may appear vascular, or may remain trans- parent; in the latter case, the displaced lens can be seen as a transparent or opaque, disk-shaped, little tumor, sometimes hid- ing the rent in the coats of the eyeball. The iris is not always tremulous; frequently a portion of it is drawn into the rent, the pupil being distorted or displaced towards it. For two or three months the lens may remain beneath the conjunctiva, and give no trouble"; or it may become opaque and absorbed, leaving the capsule sprinkled with particles of chalk. Causes.—Most of the above forms of dislocation may be pro- duced by injury (frequently by a blow upon the lower part of 294 DISLOCATION OF THE CRYSTALLINE LENS. the eyeball). Looseness or rupture of the suspensory ligament, or changes in the consistence of the "vitreous," favor disloca- tion by injury. Dislocation occurs often spontaneously in both eyes; and sometimes in several generations, or in several mem- bers of one family. It is often congenital. Most frequently it becomes troublesome after middle age. A fluid condition of the "vitreous," shrinking of the lens itself, a looseness of the sus- pensory ligament, a general enlargement of the eyeball, may give rise to, without any other changes being visible in the tunics of the eyeball. Myopia is not an unfrequent complication. The shape of a dislocated lens is often altered; it is inden- tated or flattened in some part of its margin. Complications.—Among the complications arising from injury, the most frequent are:—rupture of the tunics of the eyeball,— laceration of the iris,—hemorrhage into the interior of the eye- ball,—escape of vitreous,—displacement of the retina. The complications to which the displaced lens gives rise are iritis, choroiditis, and glaucoma. The lens sometimes undergoes adhesion to the iris, hyaloid membrane, etc., during an attack of inflammation, after which all further disturbance may cease. Attacks of inflammation are often accompanied by great pain. Sudden attacks of pain may occur (the lens being displaced into the vitreous chamber) during certain positions of the patient, e.g., during the recumbent posi- tion. Glaucomatous symptoms frequently appear, whether the dis- located lens be fixed or moved about, whether the eye suffer from inflammatory attacks or not. Sympathetic affections of the fellow-eye are not unfrequent. Treatment—the Lens being Dislocated into the Anterior Cham- ber.—We need not interfere if the lens is transparent, if the eye is free from irritation, if the fellow-eye does not sympathize, and if vision is such as to allow the patient to follow his occupa- tion. The lens should be extracted if opaque or chalky, and if the patient is anxious to have it removed, though the eye be blind. The lens ought to be removed (by absorption, by linear extrac- TREATMENT. 295 tion, or by suction) if it is opaque and the retina sensitive. If iritis or glaucomatous symptoms should arise, iridectomy is per- formed as well as extraction. These operations, in some cases, have been followed by slow displacement of the retina (in otherwise large myopic eyes), in others by shrinking of the eyeball, in a few by ophthalmitis. If the lens is dislocated into the vitreous chamber it does not become absorbed, though it be lacerated. In some cases it has been extracted successfully with the scoop through an incision in the cornea. In a few instances the operation has been followed by shrinking of the eye. The lens should, if possible, be removed by absorption, com- bined with iridectomy, if it is displaced laterally or obliquely, and if iritis, or sympathetic irritation, or glaucomatous symp- ^ toms arise, or if vision is too much impaired. If there be no such complication, and vision is sufficiently good for the occupa- tion of the patient, nothing need be done. If myopia exist, concave lenses may be of use. If the greater part of the pupil- lary area is free from the lens, convex lenses may be tried. If the lateral dislocation is but slight, an iridectomy on the side towards which the lens is displaced can be recommended; and spectacles are thus rendered unnecessary. Treatment.—Simple traumatic cataract in persons below middle age may be left for absorption; or may be removed by linear extraction, the pupil being kept well dilated by atropia. In persons above the middle age we remove the cataract by ex- traction. At all ages, if there is much iritis, or the iris is pres- sed forwards upon the cornea, or the tension of the eyeball too great, iridectomy is performed, and the cataract, according to its consistence and the age of the patient, removed either by suction or by extraction. The same treatment is adopted if considerable time has elapsed since the injury, and part of the cataract has become absorbed, but absorption from some cause been arrested. 296 THE AQUEOUS HUMOR AND THE AQUEOUS CHAMBERS. THE AQUEOUS HUMOR AND THE AQUEOUS CHAMBERS, AND THE VITREOUS SUBSTANCE AND THE VITREOUS CHAMBER. The aqueous humor ("the aqueous") chemically consists of transparent fluid, with trace of salt (chloride of sodium) in solu- tion. Mixed with it we may find albumen {e.g., in cases of iritis); fibrine and blood-corpuscles (from spontaneous rupture of bloodvessels, or from injury); or merely the coloring matter of blood; sugar (in diabetes); bile; or pus (in inflammation of the surrounding tunics). Hypopyon signifies an accumulation of pus in the aqueous chamber. The pus may come from an abscess of the cornea perforating into the chamber, or from transudation of plastic 4 material from an inflamed cornea, iris, etc. In the purulent fluid we find mucus, pus-cells, granular and fat molecules. An unusual quantity of aqueous humor, or its complete ab- sence, or the presence of blood or pus occupying its place, has been observed at birth. The anterior chamber in most persons of advanced age be- comes smaller, from decrease of the quantity of aqueous humor. The bloodvessels of the iris, and especially those of the ciliary processes, are supposed to be the chief source of the aqueous humor. This view is supported by the facts that little aqueous humor is found when most of the vessels of the ciliary processes and of the iris have become obliterated by inflammation, and that, if the pupil appears completely closed and the tissue of the iris tolerably healthy, aqueous fluid is found in the ante- rior chamber. In total posterior synechia we may find the iris bulged for- wards by accumulation of fluid behind it, or between its uvreal and contractile portions. An increase in the quantity of aqueous humor is observed after a successful iridectomy, performed for diminution of in- creased tension of the eyeball. Escape of aqueous humor, especially if it occurs suddenly, TREATMENT. 297 causes contraction of the pupil, with sudden enlargement of the bloodvessels of the choroid and retina. A prolonged escape through a fistula in the cornea may lead to gradual shrinking of the eye. Twelve hours is supposed to be the time necessary for the secretion of the usual quantity of aqueous humor of a healthy eye. After operations on the iris we often find the anterior chamber filled with aqueous humor half an hour after all has escaped. Changes in color of the aqueous humor disguise the real color of the iris, e.g., a blue iris appears greenish or yellowish when viewed through even a slight mixture of hacmatine with aqueous fluid ("yellowish aqueous humor"). Blood in the aqueous hunrar becomes quickly absorbed (in from twelve to thirty-six hours) if the eye is healthy; while, if under the influence of inflammatory changes, months may pass before all blood has disappeared. The effused blood itself some- times sets up irritation. Artificial pressure should be applied to hasten the absorption of blood in a diseased eye; while blood effused into the chambers of a healthy eye may be left to itself. Pus generally disappears rapidly from the anterior chamber. The heavier particles of pus, blood, etc., settle at the most de- pendent part, and appear along the lower margin of the cornea as a Avell-defined, crescentic, yellow or dark-red substance. Movements of the head or eye cause this substance to change its position; or, when stirred up, to mix Avith the fluid in the aqueous chambers. Particles of cataract, of lymph, of blood, etc., frequently leave spots of pigment, or of earthy salts, upon the walls of the chamber. A cysticercus, moving about in the aqueous humor, has been removed by paracentesis. Cilia and particles of glass have remained free in the an- terior chamber for ten years without causing irritation. A case is reported in which vision was lost by bleeding be- tween the choroid and retina; after a leech-bite in the lower half of the cornea. The chambers were filled with blood. 298 VITREOUS SUBSTANCE AND VITREOUS CHAMBER. The boundaries of the anterior aqueous chamber are: in front, the epithelial covering of the posterior elastic lamina of the cornea; laterally, those portions of that lamina which pass on to the iris; behind, the epithelial covering of the anterior sur- face of the iris, and the capsule of the crystalline lens as far aa it occupies the area of the pupil. The remainder of the anterior capsule of the lens, together with the anterior surface of the suspensory ligament (part of the canal of Petit), form the posterior boundary of the posterior aqueous chamber; the tips of the ciliary processes, the lateral boundary; and the transparent membrane covering the uvea, the anterior. The pupil is the opening of communication be- tween the anterior and posterior aqueous chambers. The aqueous humor probably passes between the margin of the pupil and the surface of the capsule of the crystalline lens, from one chamber into the other. The size of the chamber is determined by the position of the crystalline lens, of the iris, and of the posterior surface of the cornea. In a deep anterior chamber (where the distance of the iris from the cornea is unusually great) the margin of the pupil and the insertion of the iris may be in the same plane; while in a shallow anterior chamber the pupil lies much in advance of the insertion of the iris. Adhesions of the pupillary margin may cause an accumulation of aqueous fluid behind the iris, or between its uveal and con- tractile portion; and by bulging these may give rise to a shal- low anterior chamber, with retraction of the margin of the pupil. A small puncture of the bulging portion causes the fluid to pass into the anterior chamber, and the bulged portion of iris to assume a more normal position. On the other hand {e.g., after extraction of cataract), the margin of the pupil may become ad- herent to a portion of the capsule of the crystalline lens, and appear pushed back towards the vitreous chamber, thus increas- ing the depth of the anterior chamber. Changes in the depth of the anterior chamber are observed in chronic glaucoma, presby- opia (diminished depth), inflammatory changes of the choroid and iris during foetal life or in infancy (increased depth). TREATMENT. 299 THE VITREOUS SUBSTANCE AND THE VITREOUS CHAMBER. ANATOMICAL AND GENERAL REMARKS. The vitreous substance (vitreous humor, vitreous body, "vit- reous ") occupies the vitreous chamber. The " vitreous " slightly exceeds, in consistence and cohesion, that of the white of a hen's egg. It is transparent, and some of its elements possess great elasticity. Placed on blotting-paper, the watery portion becomes absorbed, and a delicate tissue, consisting of nucleated fibres, remains. Replaced in water, this tissue swells out again, and resumes almost its former appearance. Continued pressure, whether from external or from intra- ocular causes, tumors, etc., rapidly cause the fluid part to dis- appear. Traces of albumen are found in the healthy vitreous. The vitreous microscopically consists of transparent fluid and of numerous transparent fibres enclosing cells. These cells and fibres are more numerous at and near the surface of the hyaloid membrane, especially where this membrane passes over the cil- iary processes. Upon the inner surface of the hyaloid membrane is found a single continuous layer of large cells. Each cell has one large transparent nucleus. These cells are smaller on the portion of the hyaloid membrane which joins the suspensory lig- ament of the lens. i The "vitreous" is separated from the surrounding tunics by the hyaloid membrane. The outer surface of the latter is slight- ly adherent to the retina, and more firmly to the part of the optic disk from which the retinal vessels emerge, and to the sus- pensory ligament. The suspensory ligament of the lens ("the zonula zinnii" or "the pars ciliaris retinae," see also Crystalline Lens—Anatomi- cal Remarks) is a transparent membrane. Some describe it as a continuation of the retina. It is intimately connected with the retina, covers the ciliary processes, and is placed between these and the hyaloid membrane. An amorphous portion passes over the posterior surface of the 300 OPACITIES IN THE VITREOUS CHAMBER. iris, and merges into its elastic lamina; while the fibrous portion, which lies next the hyaloid membrane, leaves the ciliary processes, near their optics, to join the anterior part of the capsule of the lens. For the method of examining the vitreous, see Opacities in the Vitreous Chamber. Senile Changes.—The transparent cells of the vitreous sub- stance appear less numerous as age advances; Avhile the "opaci- ties," especially those close behind the lens, increase in extent. The central portions of the "vitreous" become more fluid; while the hyaloid membrane becomes thickened, and more so in some parts. The transparency of the "vitreous" becomes altered. The vitreous assumes a more or less yellowish tint. OPACITIES IN THE VITREOUS CHAMBER AND MUSCE VOLI- TANTES MOTES. The nutrition of the vitreous substance is intimately con- nected with that of the retina and choroid, and we hardly ever fail to discover morbid changes in the vitreous if the adjoining tunics are in a state of inflammation. These changes result in what are generally termed opacities, the loss of transparency being the most striking symptom of morbid alterations of the vitreous substance. The nucleated fibres and membranes of the healthy vitreous substance become visible under peculiar circumstances, and rep- resent what are termed muscae or motes. Suppuration, and other, especially syphilitic, forms of inflam- mation, and absorption of the fluid part of the vitreous substance, give rise to opacities. Opacities, as a rule, appear round tumors and foreign bodies, wherever in the vitreous chamber these may be seated. The opacities are most numerous immediately round the tumors, etc. Opacities are usual complications of inflammation of the cho- roid, especially of the ciliary processes. They appear as yellow- ish and opaque floating membranes, etc., if the choroiditis be of a suppurative character; gray and opaque if it be more of the TREATMENT. 301 plastic kind. They are readily seen by the observer, but not by the patient, to whom they produce the sensation of a mist in- tervening between the eye and objects. Hemorrhage into the vitreous chamber, foreign bodies in it, entozoa, tumors, distension of the vitreous chamber during staph- ylomatous changes, and the different forms of retinitis, are other causes of opacities. Vision is impaired according to the den- sity, size, and situation of the opacities. Those near the retina throw a shadow, and more or less inter- cept the light. Such, as regards shape, are accurately described by the patient if the retina is sensitive. Opacities close behind the lens and in the middle part of the vitreous chamber give rise to general "mistiness" of vision, and to absorption of some, and to diffusion of much, of the light which passes through the vitreous chamber. During reading the opacities may intervene between the retina and the letters looked at. The patients, by rapid movement, of the eyes, cause the opacities to move away from opposite the parts of retina used in reading. The repetition of this move- ment finally becomes a habit frequently met with in persons suf- fering from opacities. The mobility of the opacities is the greater the nearer they are to the middle of the vitreous chamber; the density and num- ber are the greater the nearer they are to the hyaloid membrane. Opacities of great mobility are less dangerous to nutrition of the eye, and to the functions of the retina, than those of a more fixed character. The latter, while shrinking, may lead to displacement of the retina, or to alteration in shape, or even to shrinking of the eye- ball. The movable ones, though they rarely disappear completely, often become less perceptible under treatment. Treatment of Opacities.—See treatment of hemorrhage into the vitreous chamber; of suppuration of the vitreous substance; of choroiditis. The different forms of choroiditis are frequently complicated by inflammatory changes in the vitreous substance of a similar character to those in the choroid. 302 CYSTICERCUS IN THE DEEPER PARTS OF THE EYE. An injury of the vitreous substance may be followed by sup- puration (see Pus in the Vitreous Chamber and Ophthalmitis), or by an escape of blood into the vitreous chamber (see Hemorrhage into the Vitreous Chamber). It is generally complicated with in- jury of adjoining tunics (see Traumatic Cataract and Injuries of the Tunics). Incisions into the vitreous substance, such as are made when operating upon displaced retina,—Avhen tearing up opacities in the vitreous chamber,—when remoA'ing portions of that substance protruding from wounds,—or by accidental Avounds, are rarely followed by formation of pus, or by inflammation, provided they are made with clean instruments, and do not give rise to suppu- ration of adjoining parts. Prolapse of " Vitreous" and Loss of " Vitreous."—Much vit- reous may be lost without finally impairing vision. (See Extrac- tion of Cataract) CYSTICERCUS (C. TELjE CELLULOSE) IN THE DEEPER PARTS OF THE EYE. The cysticercus has been observed in all parts of the eye. The ages of the patients have varied between 20 and 60. The greatest number were from 20 to 30 years of age. Some of frhese had suffered from worms in childhood (oxyuris and ascar- ides), others from taenia (lata?), for some time previous to the eye having become affected. In several cases no worms can be traced. The cysticercus has been found in the vitreous chamber, and in, upon, and beneath the retina. Vision may be lost within a fortnight after the appearance of the entozoon. For a varying period this may be preceded by impairment of vision confined to certain parts of the retina, so that, e.g., objects can be perceived better in some directions than in others; or a mist, which gradually becomes thicker, may ap- pear to intervene between the affected eye and objects. Flashes of light, fiery circles, etc., were complained of by some of the patients in whom the entozoa were visible beneath TREATMENT. 303 the retina. In several cases the appearance of the entozoon was preceded (for years) by severe headache. The cysticercus, when in the vitreous chamber, appears as a bluish-gray vesicle, occupying some part of the chamber. It has a limited undulating movement of its own (contraction and dilation), which is independent of the movements of the eye. This vesicle (by a circular indentation in some part of it) is separated into a large portion (the body) and a smaller one (the head), which latter, when protruding, brings into view the long, thin neck. In older cases one or several vesicles are visible near the cysti- cercus. In one case the hooklets (one being in the middle and two at the sides) could be distinguished. Fine peculiarly continuous, grayish-opaque membranes ("opa- cities") are found round the cysticercus soon after its appearance in the vitreous chamber. These increase during its growth. Only in a few cases have these opacities been missing. In such cases the entozoa were seen changing their places in the vitreous chambers. Iridectomy, followed by extraction of the entozoon, should be tried in all cases in which the entozoon is distinctly visible and only surrounded by semi-transparent opacities, especially as long as some vision is likely to be saved. The incision for its re- moval is made through the equatorial part of the sclerotic, if all vision is lost. The cysticercus, when appearing in the retina (in and beneath which it has primarily been observed), always gives rise to dis- placement of that membrane. It may thus be easily overlooked. When it is situated beneath the displaced retina, we find, on careful examination with the ophthalmoscope, that in addition to the floating displaced retina with its bloodvessels, a sharply- defined line is visible beneath some part of the retina. On trac- ing the continuation of this line it can be recognized as the out- line of a vesicle (the body of the cysticercus being about four times as large as the optic disk). The choroid near the entozoon assumes a gray or yelloAvish-opaque color. Sometimes the undulating movements of the entozoon can be 304 HEMORRHAGE INTO THE VITREOUS CHAMBER. recognized; these are independent of the movements of the dis- placed retina. A Avhite dot on one part of the vesicle represents the head. The latter, with the neck, seemed in one case to move to and fro in a kind of tube formed by membranous "opacities." The cysticercus generally perforates the retina. In several cases a greenish or yellow and opaque line in the retina (at some distance from the entozoon) has seemed to have been the spot through which it has passed into the vitreous chamber. In one case a kind of capsule had formed round the cysticer- cus, after which it remained stationary, not giving rise to fur- ther inflammatory symptoms. Choroido-iritis, yelloAvish aqueous humor Avith sluggish pupil, discolored iris, and a yellow metallic reflection from behind the pupil, have occurred as frequent complications. Within from six months to two years shrinking of the eyeball follows. Entozoa have not yet been observed in both eyes of the same person. HEMORRHAGE (EFFUSION OF BLOOD) INTO THE VITREOUS CHAMBER. Blood, when penetrating into the vitreous substance, breaks up the latter and remains almost fixed in its position, until sec- ondary changes and the movements of the eye lead to its be- coming more mobile. The opacities, as observed with the ophthalmoscope after hemorrhage, are partly caused by blood, partly by displacement of the elements of the vitreous substance, and by subsequent chemical changes of the latter and of the blood. Hemorrhage in the equatorial region of the vitreous chamber, or close behind the lens, gives rise to the complaint of objects appearing surrounded by a mist, and to impairment of the functions of the retina adjoining the effused blood. Rarely is the hemorrhage so considerable as to occupy a large portion of the vitreous chamber, and to reduce vision to per- ception of light. It is in such cases that it is mostly observed in both eyes either simultaneously or in succession. TREATMENT. 305 Large clots of blood soon become freely movable in the vit- reous chamber. They settle during sleep at the most depend- ing portion of the chamber, and the patient, on getting up, finds that vision is much clearer. Movements of the eye disturb the clots, which is often accompanied by a sensation of aching. When ascertaining the state of vision, especially in hemor- rhage following injury, we must remember that displacement of portions of retina may likewise have occurred. Though the lower portion of the retina is the part which suffers most frequently, any other part may become displaced by injury. It is probable that the retina is either detached, or has otherwise been injured, if we find the sensibility to light of any portion, especially the lower parts of th'e retina, destroyed or much diminished. Treatment.—Among remedies which have been found of use in the removal of blood from the vitreous chamber, can be rec- ommended the local use of atropia (continued for months), and the operation of iridectomy (whether there be increase of ten- sion or not). In hemorrhage into the hyaloid fossa, the re- moval of the lens, and the laceration of that fossa, have been practised with success. In several cases of extensive hemor- rhage, reducing vision to perception of light, a large iridectomy. has been followed by complete recovery of sight. THE IRIS AND THE CHOROID. THE IRIS. ANATOMICAL AND GENERAL REMARKS. The more important parts which enter into the structure of the iris are the contractile fibres, the elastic fibres, the pigment the elastic laminae, the epithelium, the bloodvessels, and the nerves. The contractile fibres are pale, very thin, undulating and nuc- leated; the nuclei are round, or oval. Mingled with these fibres are found others resembling very fine hairs, and contain- ing numerous round nuclei. 19 306 THE IRIS AND THE CHOROID. The contractile fibres have a circular arrangement near the margin of the pupil, and are termed the sphincter of the pupil. At some distance from this, nearer the insertion of the iris, a smaller circle of fibres is observed. The fibres which radiate from those of the sphincter are termed the dilator of the pupil; they are not well marked. The extreme margin of the pupil is thin. The Elastic Fibres.—These have their origin in that portion of the posterior elastic lamina of the cornea which faces the aqueous chamber. The fibres form part of the anterior surface of the iris, and are the chief means of its attachment behind the cornea. The pigment cells are found among the contractile fibres, and contain yellow, brown, or blue pigment granules. The pos- terior surface of the iris is occupied by "the uvea," which con- sists of one layer of so-called epithelial cells. Each cell en- closes a number of brown granules, similar to those in the hex- agonal cells of the choroid. The Bloodvessels.—The two anteriae ciliares longae, and some of the arteries of the choroid, supply the ciliary muscle and the iris. These vessels possess a well-marked muscular layer, and near the insertion of the iris, as well as close to the margin of the pupil, have a somewhat circular arrangement (circulas arterialis minor). In other parts of the iris their course is also somewhat similar to the arrangement of the con- tractile fibres. The veins pass from the iris backwards, between the ciliary processes, and anastomose with the numerous veins which oc- cupy the part of the ciliary processes near the ora serrata. In their course they receive veins from the ciliary processes, and some from the ciliary muscle. They also anastomose with those of the circular sinus. The nerves follow the vessels in their course. They are de- rived from the third, from the ophthalmic, or 1st division of the fifth (which is the sensitive nerve of the iris), and from the sixth and sympathetic nerves. (See Ciliary Muscle.) Some suppose that the filaments of the third nerve, which act during accom- TREATMENT. 307 modation, come from a different part of the brain to those which induce reflex movements of the iris. The "sphincter" of the pupil is not solely supplied by nerve-filaments from the third, nor the "dilator" by filaments from the sympathetic nerve. There merely exists a difference in quality, i.e., one kind of nerve-filaments is more numerous in the one set of contractile fibres than in the other. The action of these two nervous supplies is regarded as an- tagonistic : for instance, if the influence of the third nerve is suspended, then the sympathetic produces a greater effect. The Elastic Laminae and Epithelium.—Upon the anterior surface of the iris there is one layer of round, flat, epithelial cells, separated from the iris by a very thin, transparent mem- brane (elastic lamina); a similar, though somewhat thicker, membrane intervenes between the iris and uvea. The following terms are made use of in the description of morbid and other changes of the iris: The Anterior and the Posterior Surface of the Iris.—The for- mer faces the anterior, the latter the posterior aqueous chamber. The somewhat circular elevation upon the anterior surface near the margin of the pupil is caused by a circle of arteries, which, when light is thrown obliquely upon the iris, produces a shadow that is hardly perceptible in myopic persons. Part of the posterior surface, from the uveal margin of the pupil to near its insertion, glides upon the capsule of the crystal- line lens during the alterations in curvature of the latter. Insertion of the Iris.—The iris has its insertion about x inch behind the outer margin of the cornea. The attachment of the anterior surface is effected by elastic fibres, that of the posterior surface by uvea and a transparent membrane, which intervenes between uvea and iris, and also be- tween iris and ciliary muscle. This membrane, together with the tendon of the above muscle, is attached to the walls of the circular sinus at the point where the fibrous and the elastic por- tions of the walls of the sinus meet. Margin of the Pupil.—We shall have occasion to speak of the uvea (posterior) -margin (the one which glides upon the cap- 308 THE IRIS AND THE CHOROID. sule of the lens), and of the anterior margin (the one which faces the cornea). The Pupil.—Most of the natural and morbid changes of the eye reflect themselves in the state of the pupil. The alterations of its size, shape, and color assist us in our diagnosis, not only of changes in the iris, but of numerous ocular and cerebral anomalies. Light thrown upon the healthy retina causes con- traction of the pupil by reflex action of the optic nerve in the brain (in the corpora quadrigemina, which are considered as re- flex centres), upon the third nerve. Examination.—The choroid, when examined with the ophthal- moscope in the healthy living eye, presents many peculiarities. It differs in appearance as regards color in "dark" and "fair" persons. From the color of the iris we can foretell that of the choroid. The contrast between the brilliant red color of the choroid in the eye with blue iris, and the almost neutral tint of the one with black iris, is very striking. The color of the choroid is one of the most striking features of the interior of the living eye. The brilliancy of the gen- erally red color depends upon the quantity and degree of tint- ing of the pigment, and upon the blood circulating in the cho- roid. The greater the quantity of light which is reflected from the inner surface of the sclerotic, and which returns through the choroid, retina, etc., to the observer's eye, the better can the details of the choroid be recognized. The sclerotic is to the choroid what the silvering is to the glass of a mirror. The more pigment there is in the choroid, the less light passes through it; and the less can the details of the interior of the eye be recognized with the ophthalmoscope. Any opaque substance (clots of blood, etc.) intervening be- tween choroid and sclerotic prevents our seeing that part of the sclerotic and choroid. To be able to examine the choroid thoroughly, the pupil should be well dilated. The whole of the choroid, from the optic disk to near the ora serrata, can be seen with the ophthalmoscope, and, in albinos also, the tips of the ciliary processes. Par- TREATMENT. 309 ticular attention should be paid—(1.) To " the choroidal aper- ture," i.e., to the choroid where it surrounds the optic disk. (2.) To the region of the yellow spot, which is readily seen by directing the patient to look at the sight-hole of the ophthalmo- scope. (3.) To the equatorial region, which becomes visible on looking slantingly into the eye. The details of the structure of the choroid which can be recog- nized by direct ophthalmoscopic examination are, groups of hex- agonal cells, groups of stellate pigment cells; the veins (venae vorticosae), and the ciliary arteries. The hexagonal cells {i.e., their pigment granules) appear more transparent when the light traverses them obliquely; and more so in some eyes, or in some parts of the same eye. The granules of many cells have a deeper brownish tint. Groups of such cells, when standing side by side with cells con- taining less tinted granules, cause the inner surface of the cho- roid to appear sprinkled with groups of minute brown spots. The recognition of the situation of the hexagonal cells is an important means of localizing morbid changes in other parts of the choroid and retina. Morbid changes, occurring in these tunics, hardly ever fail to be accompanied by alterations in the hexagonal cells. The groups of stellate pigment cells, which occupy the spaces between the veins of the choroid, appear as small, defined patches, varying in color from light to dark brown. The pecu- liar honeycomb appearance of a strongly-pigmented anaemic choroid is produced by the pigment patches which surround the nearly empty veins. An abundance of these strongly-tinted stellate pigment cells, when intervening between the veins and the hexagonal cells, gives the choroid a more uniform brown- red color. i Coloboma of the Choroid.—The existence of the coloboma is diagnosed with the ophthalmoscope. Coloboma of the choroid is always accompanied by anomalies of the retina, with corre- sponding impairment of vision, and by an abnormal shape of the eyeball. The sclerotic, instead of assuming the natural curvature and 310 THE IRIS AND THE CHOROID. thickness, remains thin and bulged (staphylomatous) in some of the parts formerly occupied by the foetal fissure. The oval, elongated shape of the myopic eye is thought to depend upon this condition, though it must be remarked that coloboma has also occurred in highly hypermetropic eyes. The most striking change observed with the ophthalmoscope is a brilliant white figure about the region of the optic disk, extending, however, in extreme cases, forwards to the ciliary processes, or even to a coloboma in the iris. This figure presents a variety of shapes. Sometimes we find it close to the optic disk, and resembling a brilliant gray or bluish-white atrophic optic disk. The pink color and the reti- nal bloodvessels assist in recognizing the optic disk itself. The white figure is the result of incomplete closure of the sheath of the optic nerve where it joins the sclerotic, and of the tunics immediately adjoining it. A nearly transparent membrane (? the retina) may sometimes be seen extending from the margin of the optic disk over the white figure. Irideremia, or Absence of the entire Iris.—Varieties of iride- remia are:—(1.) Absence of all the parts of the iris except the uvea; and (2.) Absence of the circular fibres, or of the radical fibres, of the iris. Irideremia, as a rule, occurs in both eyes, and! is frequently complicated with peculiar opacities of the cornea, together with "cataract;" sometimes with atrophic changes of the optic disk, and absence of the retinal bloodvessels. With the ophthalmoscope we readily see the margin of the crystalline lens, and the space intervening between it and the ciliary processes. Vision.—Patients have been known to pass through life, and to attend to their work, without applying to the oculist. They sometimes seek assistance when presbyopia sets in. Stenopaeic spectacles, and those with convex lens, have been found of ser- vice. Persistence of the Pupillary Membrane.—Portions of this membrane are frequently met with upon the anterior surface op TREATMENT. 311 the circular fibres of the iris, near the pupil. They generally encroach upon the area of the pupil, as grayish-white and opaque filaments. If adherent to the capsule of the crystalline lens, they are found relaxed during contraction, and stretched during dilation, by the pupil. In one case, the entire pupil was found masked by the perforated pupillary membrane. In an- other case, the entire iris and pupil were partially obscured; through holes in the membrane, the pupil could be seen to con- tract and dilate normally. Displacement of the Pupil.—Occurs most frequently upwards. Displacement of the pupil behind the margin of the crystalline lens has been observed. An irregularly-shaped (frequently oval) pupil is sometimes the sequel of intra-uterine iritis. Too small a pupil with tremulous iris, and too large an one, have occurred. Several Pupils.—Cases are recorded of two or three pupils occurring in the same iris, either near the natural pupil, or more towards the insertion of the iris, all becoming dilated by bella- donna. An explanation of this anomaly may be found in the fact that the iris at first is attached to the choroid, not in a continuous line, but by numerous isolated fibrillae. Anomalies in Color.—The iris of one eye may have a brown, and that of the fellow-eye a bright yellow, or a blue color. It is not uncommon to find one-half of the iris to have a blue, the other a brown color. The circular fibres of the iris frequently differ in color from the radiating fibres. In a brown iris the margin of the pupil is lighter, and in a blue one darker, than the other parts. White opaque, frequently concentric, lines occur on the sur- face of the iris, near its periphery. Pigmentations, generally of a rust color, are met with upon the iris midway between the pupil and the insertion of iris. 312 INJURIES OF THE IRIS AND THE CHOROID. INJURIES OF THE IRIS AND THE CHOROID. Incisions, dividing the radiating fibres of the iris transverse- ly, if made in a direction parallel with the fibres, can, even with the ophthalmoscope, only be recognized with difficulty. Separation of the iris from its insertion, however small, be- trays itself by irregularity of the pupil. The separated portion never becomes adherent again. Rupture of the sphincter and of the margin of the pupil have given rise to traumatic coloboma. Hyperaemia follows these injuries, but rarely iritis. Rest of the injured eye and of the sound eye, if inconvenience is felt from using it, and the local treatment for iritis are re- quired, and continued until all undue vascularity has disap- peared. Prolapse of the iris, when it occurs through a wound in the cornea or sclerotic, should, if covered by conjunctiva and not bulging, be left alone; but, if bulging, it should be punctured with a needle, and the collapsed protruding portion should be seized with the forceps, and removed with scissors. Care must be taken not to cut off the protruding iris too close to the eyeball, but to leave a little along the margin of the wound, or else a fistula may remain. Rest of the eye and closure of the lids by a bandage are re- quired, until all undue vascularity has subsided. A large prolapse of the iris may be changed into a flat cica- trix by puncturing it in numerous places every second or third day. Foreign bodies in the iris, whether visible or merely suspect- ed to be there, require the immediate performance of iridectomy to remove the injured or suspected portion of iris. (See, also, Traumatic Cataract.) Concussion of the iris by blows, etc., may cause— (1.) Mydriasis. In every case we should ascertain with the ophthalmoscope the state of the deeper parts of the eye. By making the patient look through a small opening, we deter- TREATMENT. 313 mine Avhether the impairment of vision is due to the mydriasis only. If vision (tested by these means) is found normal, no imme- diate fear need be entertained. The eye is kept at rest, and Calabar is applied locally, if, after a few weeks, the pupil has not resumed its natural size and mobility. (2.) Partial or complete disappearance of the iris. This has been observed after blows on the eye, causing partial or entire dislocation of the vitreous substance and of the crystalline lens, these being simultaneously rotated within the area of the retina. The iris, or part of it, becomes drawn backAvards, and is kept out of sight through vitreous substance pressing it against the ciliary processes. In an eye with apparent absence of the iris (which had been blind for years), a chalky lens was seen rolling about in the hy- aloid fossa, whilst the iris, after excision, was found pressed upon the ciliary processes by aqueous humor. Rupture of the sclerotic is often accompanied by displace- ment of the portion of iris adjoining the seat of injury. The kind of injury of the choroid, which have come under observation, have been perforating wound; concussion of the choroid; foreign bodies (pieces of metal, glass, etc.) lodged in or near the choroid; and injuries of adjoining tunics, secondari- ly implicating the choroid. The regions of the choroid most frequently injured are the ciliary region, and the one above and below the yellow spot. The morbid changes following injury of the choroid vary ac- cording to the general health of the patient, the nature of the injury, the parts injured, the state of the eye previous to the injury, and the treatment adopted. The same kind of injury may be followed by suppurative choroiditis in a weak^person, which in a strong one gives rise to a less destructive form of inflammation. A foreign substance lodged in the choroid gives rise to a graver injury than an incised wound, or a concussion of the choroid. 314 INJURIES OF THE IRIS AND THE CHOROID. Injuries about the region of the yellow spot are more seri- ous, in consequence of their frequently implicating parts of the retina which are essential for direct vision; and injuries about the ciliary region, in consequence of their giving rise to sympa- thetic changes. An injury of the choroid of an eye, Avhich previous to the injury was neither "glaucomatous" nor otherwise morbidly al- tered, is less grave in its consequences than one occurring to an unsound eye. The morbid changes most frequently observed in the choroid after injury are—Hemorrhage (see Hemorrhage into Choroid); Suppuration (see Ophthalmitis and Choroiditis); Plastic Choro- iditis (see Choroiditis); Glaucoma. Rents in the Choroid.—Owing to some peculiarity in the structure of the choroid, we find the margins of the rent wide apart if the rent runs transversely; i.e., if it has a direction parallel with the margin, e.g., of the cornea. Rents of the choroid have been observed after concussion of the eyeball by blows, without any of the other tunics appearing ruptured. Viewed with the ophthalmoscope, the rent appears as a white, or brilliant white, irregularly-shaped surface. Its long axis runs somewhat parallel with the margin of the cor- nea. It is skirted by pigment spots, and retinal bloodvessels may be seen passing across its area. The treatment of injuries of the choroid is, in a great meas- ure, included in that of the morbid changes which follow the injury. Foreign bodies lodged in or near the choroid have repeatedly been removed successfully. The injured eye, and the fellow-eye, if sympathetic irritation appears, should, in all cases, be kept at absolute rest until all signs of irritation or of inflammation have disappeared. TUMORS OF THE IRIS. Tumors advancing from the deeper parts of the eye, in their course often implicate the iris. (See Orbit, Tumors in the, etc.) The following are instances of tumors originating in the iris:— TREATMENT. 315 A globular tumor, with a dirty-yellow, flocculent surface, and consisting of myeloid corpuscles and connective tissue. In one case the tumors increased in size, and finally became compli- cated with hypopyon, corneitis, and perforation of the cornea. Some time later this was followed by shrinking of the eye. A whitish tumor (diameter Ty), with a shining surface, pro- jecting from the anterior surface of the iris near the margin of the pupil, was removed. It proved to be covered with epithe- lium, and to contain a white chalky substance, and a few short hairs. Sebaceous tumors have been known to cause circumscribed suppuration of the iris and the cornea. A small pigmented tumor of the color of the uvea, near the margin of the pupil, has been observed. It accompanied the movements of the iris. Cysts (situated near the margin of the pupil) enlarge very slowly at first; they become painful as they increase, and re- semble the bulging of a circumscribed portion of iris, as is some- times seen after severe iritis with synechiae. The cyst or cysts may at last come in contact with the cornea; and sometimes occupy the entire anterior chamber, and hide the pupil. They are generally situated between the uvea and the fibrous part of the iris. When punctured fluid escapes, the cysts collapse and the iris resumes its natural appearance. They fill again, and do not always disappear after repeated puncturing. A cysticercus appearing in the shape of a small black nodule, and attached to the anterior surface of the thickened and vas- cular iris, has been removed successfully. For tumors of the choroid, see Orbit—Tumors of the Orbit and Eyeball. PARALYSIS. The iris, if completely paralyzed, is tremulous (iridodonesis); and the pupil of the medium size, and fixed. Mydriasis signifies an abnormal dilation; myosis, an abnor- mal contraction of the pupil. 316 INJURIES OF THE IRIS AND THE CHOROID. Mydriasis, or abnormal dilation of the pupil, may rise from— (1.) Paralysis of those branches of the third nerve Avhich sup- ply the iris. This condition by some is termed the paralytic, to distinguish it from the spasmodic form of mydriasis. The pupil is not dilated to its utmost. It remains fixed when exposed to bright light and during accommodation. It often contracts somewhat when the external rectus muscle (supplied by the sixth nerve) acts. (2.) Irritation of the sympathetic nerve. This gives rise to greater dilation of the pupil than the preceding. The cause of mydriasis may be—glaucoma,—injuries,—mor- bid changes of the brain, as hydrocephalus, meningitis, or hem- morrhage at the base of the brain,—poising by gas, by bella- donna, hyoscyamus, niger veratrum album, aethusa cynapium, strych-nia, cicuta virosa, digitalis purpurea, hydrocyanic acid. Mydriasis, if confined to one eye, is generally caused by changes in the eye itself, or by circumstances acting locally upon the eye. The pupil is either fixed or sluggish, and often irregularly dilated; while the felloAv-pupil appears unusually contracted. Mydriasis is generally combined with paralysis of the ciliary muscle, and often Avith paralysis of other muscles supplied by the third nerve. It has been observed to be the forerunner of mental derangement. Treatment.—The local application of Calabar should be tried in all cases of non-glaucomatous origin, and should be continued as long as improvement of vision is observed. The "mydriatic" eye, if it resists Calabar or interferes with the use of the other eye, must be kept closed. Vision is often but little disturbed if the mydriasis is confined to one eye. Patients complain of the light being too dazzling, and of inability to distinguish near or small objects. In the selection of spectacles for reading, we must be guided by the existing state of refraction and accommodation. Mydriasis, as a symptom of increased tension, comes under the treatment of glaucoma. We should direct our attention also to the cerebral changes that may exist or threaten. TREATMENT. 317 Myosis, or Abnormal Contraction of the Pupil.—Myosis gen- erally exists in both eyes. It may be of the spasmodic or of the paralytic kind. When of the former variety, the pupils re- spond to the agents which produce dilation. As causes have been observed:—(1.) Hyperaesthesia of the retina, brought on by continued work at small objects. (2.) Paralysis or paresis of the branches of the sympathetic nerve, Avhich go to the iris (with or without irritation of the third nerve); from morbid changes about the medulla oblongata (as precursor of spinal amaurosis); or from pressure upon the sympathetic nerve in the neck (by large tonsils, or by aneurism of the subclavian artery). (3.) Spinal or cerebral disease. (4.) Long-continued and close work. (5.) Contraction of the pupil, following division of the fifth nerve, is probably a reflex action of the irritated cerebral por- tions of the third nerve. Treatment.—Solutions of atropia, of varying strength, may be tried (to dilate the pupil to a moderate extent), if the dimi- nution of the field of vision and the desire for light are great. In some cases of cataract with myosis, the latter resisting atropia, iridectomy has had to be performed previous to extrac- tion, in order to enable the cataract to pass in front of the iris. ANOMALIES AND ACCOMMODATION. The anomalies of accommodation which arise from abnormal changes of the crystalline lens are described,under Presbyopia, under Dislocation of the Lens, and under Aphakia. We shall treat here of those which arise from disturbed action of the ciliary muscle itself, and distinguish—(1.) Paralysis or paresis. (2.) Weakness. (3.) Spasm. PARALYSIS OF THE CILIARY MUSCLE. Causes and General Remarks.—We must, if both eyes are affected, look for a central cause (cerebral disease, syphilis, tumors). The immediate cause is paralysis of the nerve-fibres which supply the ciliary muscle. In a large number of cases, we find 318 INJURIES OF THE IRIS AND THE CHOROID. simultaneous paralysis of other fibres of the third nerve, pro- ducing ptosis, and paralysis of the external muscles of the eye. The iris and ciliary muscle are very rarely found unaffected when other parts supplied by branches of the third nerve are paralyzed; and again, paralysis of all the branches of the third nerve is uncommon; while paralysis of the ciliary muscle (of the accommodation) and of the iris alone is not unfrequent. In the latter case only the short root of the ciliary ganglion is par- alyzed. This paralysis has been observed at all ages, but more fre- quently in young and in middle-aged persons. In all cases we should examine the functions of other nerves (of the fourth, sixth, and also of the fifth nerve). Symptoms.—(1.) Loss of contractility of the sphincter of the pupil. The pupil is immovable, of medium dilation, and accom- modative and reflex movements are absent. The pupil may re- main slightly movable (paretic) while the accommodation is par- alyzed; or, on the contrary, the latter may be found tolerably good while the pupil remains fixed. (2.) Loss of contractility of the ciliary muscle. Vision at distance is generally normal, unless there is some anomaly of refraction. Vision for near work, reading, etc., is more or less disturbed if only one eye is affected; it is impossible if both eyes are implicated. Myopic persons, who wear spectacles, are as much inconven- ienced as emmetropics; while, if no spectacles are worn, and the myopia is such that the farthest point of distinct vision lies about at the distance at which the book, etc., is held, little dis- turbance is felt. Patients sometimes complain of objects ap- pearing too small, and, if the recti muscles are implicated, of their appearing to move. Patients also mistake the position of objects. Treatment—The constitutional changes which may give rise to the paralysis are syphilis, rheumatism, general weakness fol- lowing severe illness, etc.; these require appropriate medical treatment. The local treatment, if only one eye is affected, consists in TREATMENT. 319 the application of Calabar until the accommodation is restored. Calabar should also be tried if both eyes are affected, though it is of little use if the cause of the paralysis be cerebral. Spectacles with convex lenses are necessary for Avork. The lenses should be of the focal distance at which the patient wishes to see distinctly when at work, e.g., spectacles with lenses (each lens having a focal distance of 16") are required if work has to be performed at that distance. The local treatment of paralysis of other branches of the third nerve has to be combined with this. PARESIS OF THE CILIARY MUSCLE—PARESIS OF ACCOMMODATION. Causes.—Paresis is frequently observed after acute disease. A cause which of late has attracted much attention is diphthe- ria. The paresis appears suddenly after the specific lesions of diphtheria have nearly, or quite, subsided. Accommodation and speech are often the only functions impaired. Other causes of paresis are those enumerated under paralysis. Myopic persons, who do not wear spectacles, may experience no inconvenience if the myopia is such that the farthest point of distinct vision lies at about the distance at which reading, work, etc., is performed. Paresis of accommodation may be mistaken for asthenopia. Paresis appears rapidly within a few days or weeks; as- thenopia has often existed for years before the patient seeks advice. In paresis prolonged vision of distant objects causes no inconvenience. Near objects cannot be recognized, or only with difficulty; fatigue appearing almost immediately after the attempt has been made to see them distinctly. In asthenopia, on the contrary, fatigue appears after pro- longed vision of distinct, as well as of near objects. Objects can be recognized distinctly for some time, though vision be painful. Treatment.—The treatment is similar to the one adopted for paralysis. Besides the local application of Calabar, Ave may try secale cornutum, to be given in ten grain doses (with carbonate of magnesia, or with iron) four times daily for a few weeks. 320 IRITIS (INFLAMMATION OF THE IRIS). SPASM OF THE CILIARY MUSCLE—(PAINFUL VISION). The characteristic symptom of spasm of the ciliary muscle is pain felt in the eyes, e.g., during "near work" ("during ten- sion of the ciliary muscle"), or after application of a strong solution of Calabar. The pain continues during tension of the muscle; it subsides after repeated application of atropia. The pain may be so severe that all work has to be discontinued: it often appears suddenly, and is accompanied by myosis. Causes of painful contraction of the ciliary muscle are:— (1.) Insufficiency of the internal recti muscles, with hyperme- tropia. (2.) Frequent efforts at accommodation for the nearest point of distinct vision, as occur in amblyopic and in astigmatic per- sons. (3.) Moderate degrees of hypermetropia, inducing persistant efforts to overcome the hypermetropia. (4.) Myopia, partly from undue tension of the accommodation during prolonged work, partly from hyperaemia Avithin the eye, extending to the ciliary muscle. Treatment.—Near work, reading, etc., may have to be dis- continued for months if the treatment of the cause {i.e., the an- omely of refraction or the insufficiency of the recti muscles) does not, within a few weeks, remove the pain and make prolonged work easy. Spectacles must then be laid aside; and the ciliary muscle must be thoroughly paralyzed by atropia, and kept in that condition. Spectacles, with tinted convex lenses, may be given to hypermetropic persons for going about. Plain tinted glasses are ordered for the same purpose in all other cases. IRITIS (INFAMMATION OF THE IRIS). GENERAL REMARKS. Different forms of iritis have received special names, some of which are derived from the cause (such as syphilitic, traumatic, etc., iritis); others from the course (as acute, chronic, recurrent, etc., iritis); others from the "inflammation" (as suppurative, serous, plastic, etc., iritis)! TREATMENT. 321 In each special form of iritis Ave meet with symptoms which occur in every case of iritis, and with symptoms Avhich charac- terize the special form. The symptoms of simple iritis are always mixed in varying degrees with those of the special forms; so also those which are characteristic of a special form of iritis may pass away, and the case run on as one of simple iritis. This should be borne in mind when treating iritis. A trial should be given in all cases to a combination of the local treatment of simple iritis with any general medical treatment that may be thought fit. The symptoms characteristic of the special forms are:—for syphilitic iritis, the separate nodules of lymph—for sympathetic iritis, the unusual enlargement of the vessels of the iris;—for serous iritis, the enlargement of the pupil, combined with in- creased tension and increased quantity of aqueous humor. An embolic or metastatic iritis has been described as occur- ring during, or soon after, an attack of measles, scarlatina, variola, typhoid or rheumatic fever; or during pregnancy, or whilst nursing, etc. The iritis in these cases is, as a rule, partly plastic, partly suppurative in character, and accompanied by inflammation of other parts of the eye. Syphilitic iritis, when occurring in very debilitated persons, may be accompanied by hypopyon, or by an abscess in the iris. The injuries Avhich frequently cause iritis of the simple or of the suppurative form are operations for the removal of cataract, and wounds or concussions of the cornea. Iritis often appears as a complication of morbid changes in other parts of the eyeball, e.g., during an attack of glaucoma, with tumors or entozoa within the eye; during choroiditis, during corneitis, etc. SIMPLE IRITIS. Iritis is probably always preceded by hyperaemia of the iris, with slight redness of the sclerotic adjoining the margin of the cornea, by impaired mobility, and by some discoloration of the iris. A similar hyperaemia of the iris is also observed during morbid changes in the ciliary processes, choroid, retina, cornea, and even the conjunctiva. 21 322 IRITIS (inflammation of THE iris). The presence of hyperaemia should put us on our guard, not only because it readily increases to iritis, but also because it often indicates a grave disturbance of other important textures of the eye. The symptoms which are common to all forms, and Avhich are characteristic of iritis, are:— (1.) A varying amount of "plastic" material in, upon, and round the iris. (2.) Impairment, or complete loss of mobility of the iris gen- erally, with adhesion (synechiae) of the uvea to the capsule of the lens. (3.) Irregularity in the shape of the pupil. (4.) Alteration in the color of the iris. (5.) More or less sclerotic vascularity along the margin of the cornea. The appearance of "plastic material" or of "inflam- matory products" is attended with anomalies in the nutrition and texture of the iris. The iris, near the margin of the pupil, appears most altered. The plastic material, seen with the naked eye, generally appears as a grayish, semi-opaque sub- stance, which is diffused throughout the iris, or appears as spots of varying size. It gives rise to adhesions of the iris to adjoin- ing parts. The chemical properties of the aqueous humor are altered. The latter often becomes turbid from the presence of mucus and pus-corpuscles. Hypopyon may appear simultaneously. Dif- fused opacities, or minute spots, may occur (especially at the lower half of the posterior surface of the cornea); which are partly the results of effusion, partly of alterations in the epithe- lium. The dotted opacities are characteristic of syphilis (both in- herited and secondary). The term aquo-capsulitis, hydro-meningitis, were formerly used to designate the form of iritis which is accompanied by the appearance of opaque spots upon the posterior surface of the cornea. The quantity of plastic material may be so small that the irregularities of the pupil, which appear on the application of TREATMENT. 323 atropia, are the sole signs of iritis; it may be so great that the SAvollen iris comes in contact with the cornea. The plastic material impedes the movements of the iris; and its subsequent changes more or less destroy the texture of the iris. The margin of the pupil, though no adhesions may exist, loses its mobility, and often its regular shape. Synechia?, or Adhesions of the Iris to other Parts.—We dis- tinguish anterior and posterior synechiae. Anterior synechiae, i.e., adhesions of the iris to the cornea, or to textures occupying its place. Synechiae, if occurring without perforation of the cornea, are often observed near the insertion of the iris; and are the result of the prolonged contact of the swollen and inflamed iris with the cornea. Swelling of the inflamed cornea facilitates these synechiae. Posterior synechiae, or adhesions of the iris to the parts situ- ated behind the uveal surface. They are by far the most fre- quent. To examine them thoroughly atropia should be applied, and lateral illumination used. Circular posterior synechiae exists if the margin of the entire pupil is adherent to the capsule of the crystalline lens; the area of the pupil may be free from effusion, or nearly so. Total posterior synechiae exists if the entire posterior surface of the iris is adherent to the capsule of the crystalline lens. Synicesis of the pupil means closure of the pupil by a more or less opaque substance, Avhich is continuous with the iris. This is a frequent result of iritis. Changes in color of the iris are observed throughout the course of iritis, and are one of its earliest symptoms. A blue iris appears greenish, and a brown one of a rust color. Large masses of lymph, or pus, or suppuration of the plastic material, give the iris a yellow appearance. The "sclerotic redness" ("sclerotic zone," "ciliary redness") appears alon^ the margin of the cornea. It varies from a hardly perceptible pink zone to a large crimson belt, surround- ing the cornea; in severe cases it is coupled with much con- junctival vascularity, and sometimes with chemosis. The decrease of the sclerotic zone generally coincides with that of the iritis. 324 iritis (inflammation of the iris). Other symptoms, which vary in degree, or which may be com- pletely missing, are:—loss of appetite, sleeplessness, pain, intol- erance of light, "watering of the eye," with swelling and red- ness of the eyelids. The pain is sometimes very severe, either in the eye, or fore- head, or both; it may only be felt on touching the ciliary region, or may be intermittent or continuous. Leeches and atropia hardly ever fail to remove it. The variations which occur in the course of iritis depend upon— (1.) The quantity of plastic material (the greater the quantity the more extensive the synechiae, and the greater the structural changes of the iris). (2.) The health of the patient. In those whose constitutions are much shaken, we may expect suppuration and subsequent atrophy of the iris. (3.) The period at which we undertake the treatment. (4.) And, lastly, upon the complications which arise from changes in other parts of the eye. Simple iritis in an otherwise healthy person, and when of moderate degree, subsides in about four weeks» The sclerotic vascularity and the plastic material gradually disappear, the aqueous fluid and cornea become clear, and the color of the iris and the mobility of the pupil (on discontinuing the use of atropia) more natural. Pigment spots upon the capsule of the lens, if not in contact with adhesions of iris, often disappear. The changes in the structure of the iris depend upon the in- tensity, kind, and duration of the iritis; and also upon the number of attacks. Opaque patches and streaks upon the sur- face of the iris, together with changes in color, alterations in mobility (from slight loss of contractility of some parts, to com- plete immobility with iridodonesis), may occur. The iris may lose all elasticity, and become nearly transparent. Complications.—Iritis is a frequent complication of morbid changes in the cornea. Deep ulcers, abscesses, or purulent corneitis, with or without hypopyon, are, as a rule, accompanied by iritis, and sometimes by suppuration of the iris. TREATMENT. 325 The local application of atropia, and, still better, iridectomy, frequently arrest the corneal changes. Changes Behind the Iris.—Cyclitis is often present with iritis. Its presence may be assumed in every case of chronic iritis, if the tension of the eye becomes increased, and still more, if sub- sequently it sinks below par, and is accompanied by opacities in the vitreous chamber, close behind the lens. Simultaneous inflammation of the choroid, of the same kind as that of the iris* is equally common. With the ophthalmo- scope we can often detect these changes during the height of iritis. Treatment of Simple Iritis.—In every case, and at any stage of iritis, Ave should prescribe the local application of belladonna, or of atropia, to produce dilation of the pupil. {a.) To prevent, as much as possible, irregularities of the pupil and synechiae. (b.) To secure rest by preventing contraction of iris and cil- iary muscle. (c.) To alter the tension of the eye, and the circulation in the choroid. In slight iritis, the atropia should be applied from three to ten times daily; and if there is severe pain, every five minutes for some hours in the evening. These frequent applications are continued for from three to five days, or until pain and vascu- larity have become less. The application, twice daily, is continued for from two to three weeks after all vascularity has subsided; by so doing, a relapse or a fresh attack is less likely to occur. The pupil, in rare cases, remains dilated for weeks, or acts but sluggishly long after the application of atropia has been continued; to remove this condition, we apply Calabar. (See Calabar and Atropia.) Leeches (from two to six) are applied at bedtime to the skin of the corresponding temple, if the pain is severe, and not soon relieved by atropia. Afterwards bleeding should be en- couraged for one or two hours, according to the general state of health. The eyelids must be kept closed for twenty-four hours after the application of the leeches. 326 iritis (inflammation of the iris). Tepid water should be used to bathe the eyelids morning and night, or as often as may be agreeable. Lotio alum am., mur. ammon., equal parts, is ordered, if there is purulent discharge. The eyes may be used for work if no pain is caused by it, or if there is no intolerance of light. Spectacles with blue-tinted glasses, or a shade, should be worn, if there is intolerance of light. (See, also, Treatment of Syphilitic Iritis.) Vision.—Impairment of vision is often the sole symptom for which advice is sought. Unfortunately, several attacks of iritis may occur in the same eye, and permanently disturb the rela- tions between the iris and crystalline lens, without sensibly im- pairing vision. Neglect on the part of the patient, in such a case, prevents recovery without synechiae. The impairment varies in degree. Only a slight "mist" may appear to inter- vene between the object and the eye, the patient being still able to attend to ordinary work. In severe cases there may be mere perception of light. Vision, if atropia is employed in time, becomes "worse" by the pupil becoming dilated; and this symptom, though favor- able, may frighten the patient, and induce him to forego the use of the atropia. We should warn the patient against this, and explain the object and effect of the remedy used. The causes of impaired vision, if the iritis has completely subsided, must be sought— (1.) In the disturbed transparency of the cornea or pupil, or capsule of the crystalline lens. (2.) In changes of the iris or ciliary muscle. (3.) In complications arising from either the crystalline lens, vitreous substance, choroid, or retina. (4.) And lastly, sometimes in orbital or cerebral disturb- ances. If only one eye has been affected, we should use those medi- cal, surgical, or optical means, which render this eye, as regards vision, as useful as possible. Thus, after the cessation of iritis, we may have occasion to treat corneal opacities, posterior sy- nechiae, closed pupil, cataract with closed pupil, impaired accom- TREATMENT. 327 modation with undue hardness of an otherwise transparent crys- talline lens, cyclitis, etc. (1.) Adhesions of the iris to the crystalline lens (posterior synechiae) impede the movements of the iris and crystalline lens, and interfere with accommodation. They give rise to as- tigmatism, and occasionally to troublesome polyopia. Loss or great impairment of mobility of the iris is sxd to produce hemeralopia (from the inability of the pupil to dilate at dusk), and occasionally sympathetic irritation of the healthy fellow-eye. (2.) In children, several rents (spontaneous artificial pupils) have been observed in the iris. These may be the results of adhesions opposing the growth and movements of the iris. (3.) Pigment and opaque spots upon the capsule of the lens intercept or diffuse the light, and may give rise to intolerance of light, or to "muscae." If occluding the pupil, they may re- duce vision to mere perception of light. The amount of light which can still be perceived (together Avith the power of indicat. ing the direction from which the light is thrown upon the iris) may be the sole means of ascertaining the degree of sensibility of the different parts of the retina, (4.) We often find, especially in total posterior synechiae, portions or the Avhole of the anterior surface (fibrous part) of the iris, or, more rarely, the entire lens, pushed forwards, " or bulged." The pupil appears drawn back while the bulging portions of iris sometimes touch the cornea; behind these fluid is accumulated. This condition must not be mistaken for dis- placement of the iris and crystalline lens towards the cornea, as is sometimes observed in cyclitis. The "bulging" of the iris may be followed by glaucomatous changes—viz.: increased tension of the eye; anaesthesia of the cornea; paralysis, at first of the peripheral parts of the retina, finally followed by loss of vision and cupping of the optic disk, etc. At a still later period atrophic changes appear, with de- crease of tension, chalky cataract, and atrophy of the tunics, etc. A few synechiae interfere but little with vision; the applica- tion of atropia, continued for several months, causes them some- 328 IRITIS (inflammation of the iris). times to become torn through. The synechiae can, if desirable, be removed by corelysis. If many synechiae exist and interfere with vision, or, if they are the results of recurrent iritis, iridectomy with corelysis should be performed. Synechiae, with occlusion of the pupil, with or Avithout bulg- ing of the iris, often require the combination of iridectomy with removal of the crystalline lens, unless we succeed in re- moving the uvea from the capsule of the lens. In all cases we must be prepared to find uveal pigment adherent to the cap- sule, and always examine for it by lateral illumination. The non-removal of the uvea, together with the fibrous part of the iris, is a frequent cause of failure of iridectomy, or of the op- eration for artificial pupil. By a thoroughly-performed iridec- tomy communication is established betAveen the aqueous cham- bers; and a favorable change frequently occurs in the nutrition of the choroid, retina, and vitreous substance. No benefit is derived from any operation if the eye is soft, and vision so impaired that, e.g., a strong flame of gas-light held close to the eye is barely perceived, or only in certain di- rections. The operation of iridectomy may, however, be rec- ommended, if the flame can be perceived at from six to ten feet from the eye, and if, at the same time, the peripheral parts of the retina are sensitive. SYPHILITIC IRITIS AND SYPHILITIC CHANGES OF THE STRUCTURE BEHIND THE IRIS. SYPHILITIC IRITIS. This form of iritis is frequently confined to circumscribed portions of the iris. The pupil is contracted, generally irregu- lar, and acts sluggishly. The inflamed portions of iris appear swollen, reddish, and soon become covered with the characteris- tic yellowish, or reddish, or brown nodules termed "lymph- nodules." These, when examined quite fresh, consist of closely- packed connective tissue corpuscles (?), enlarged capillaries, new vessels, and deep brown or black pigment granules. TREATMENT. 329 The lymph-nodules may fill the area of the pupil, and in se- vere cases obscure the greater part of the iris; they may touch the cornea or sclerotic, and give rise to infiltration and perfora- tion of the tunics. They may undergo suppuration, and de- stroy the entire iris. They disappear gradually; their place becomes occupied by gray opaque tissue, which in its turn may become "absorbed." This form of iritis is most common betAveen the ages of twenty and forty, but it not unfrequently occurs in infants betAveen the ages of two months and one year. In these, as well as in adults, we rarely fail to discover other syphilitic symptoms. Beyond this peculiar stage the iritis does not present any feature characteristic of syphilis, although the existence of pos- terior synechiae, together with contracted and irregular pupil, should always make us treat it as such. The usual absence of redness of the eyelids, and the slight sclerotic vascularity, often cause iritis to be overlooked by the patient Avhen confined to one eye. (See Simple Iritis.) Syphilitic iritis, especially if the first attack has been a se- vere one, often recurs, and sometimes with remarkable perio- dicity, though it is rare during any of the subsequent attacks to meet Avith the characteristic "lymph-nodules." Treatment—Mercury.—A small quantity (about the size of a large pea) of the unguent, hydrarg. nitrat. mitius is rubbed into the skin of the forehead at bedtime, until all undue vascularity of the eye has disappeared. The use of the ointment is discon- tinued if the gums should become affected. For infants Ave prescribe one grain of the hydrarg. c. creta, to be given daily for from five to ten days. Bromide of potassium is an excellent remedy, in doses from 5 to 10 grains 3 or 4 times daily, for an adult. B^. Potassa Bromide,------------------- 5iv- Syr. Aurantii,-----------------------Siv. Mix. A teaspoonful four times a day. Some recommend from one-sixth to one-third of a grain of morphia, at bedtime, after the bowels have acted. Turpentine (in five-grain doses three or four times daily) has 330 SYPHILITIC IRITIS, ETC. been found of use in weak persons suffering from frequent at- tacks of iritis, and in chronic iritis of so-called rheumatic char- acter, with much sclerotic and subconjunctival vascularity. The local treatment is that of simple iritis. Iridectomy.—No benefit is derived from this operation in sim- ple, nor in syphilitic iritis, nor in cornea-iritis, as long as fresh plastic material or lymph makes its appearance; the new pupil becomes closed again with plastic exudation. Some describe a gonorrhoeal iritis, the peculiarities of which are stated to be, excessive pain, intolerance of light with pro- fuse flow of tears and disky sclerotic redness, the iritis being preceded by gonorrhoea, with effusion into the joints. Mercury and atropia were found of no use. SYPHILITIC CHANGES IN THE STRUCTURES BEHIND THE IRIS. If a person shows symptoms of syphilis, e.g., of the skin, or in the cornea, or iris of one eye, and complains of impairment of vision of the externally healthy fellow-eye, we often discover syphilitic changes in the deeper structures of the other eye. These changes are in most cases characteristic of syphilis. It is usual in inherited as well as in secondary syphilitic inflammation of the deeper structures, to find several of these structures inflamed simultaneously. The name by which the inflammation is described is derived from the structure which appears most altered. Thus, we speak of syphilitic choroidi- tis, choroido-iritis, retinitis, etc., though the vitreous, or lens, or sclerotic, etc., may participate in the same inflammatory changes. From this point of view we meet in order of frequency with— (1.) Choroiditis (of which the choroiditis disseminata is one form). (2.) Inflammation of the optic disk and of the choroid and' retina immediately adjoining. (3.) Inflammation of the vitreous substance. As rarer changes, observed in patients suffering from syphi- lis, should be mentioned—(a.) Rather sudden decrease in the size of one eyeball, with signs of choroiditis, and with a marked TREATMENT. 331 decrease in the number of the retinal vessels, {b.) Rapid in- crease in the size of one or of both eyeballs, (c.) Ciliary staphyloma, with glaucoma, {d.) Circumscribed cyclitis. (e.) Anaemia of the outer half of the optic disk of both eyes after sudden impairment of vision. Five of the eyeballs belonged to patients suffering from sec- ondary syphilis, and four to persons with inherited syphilis. Three of the former eyeballs presented the changes obser^d in ophthalmitis (in two these changes appeared spontaneously, and in one during chancre of the sclerotic and eyelids). In one eyeball (after repeated attacks of iritis) an attack of choroiditis occurred. This was followed by circumscribed staph- yloma of the tunics in front, and beneath the insertion of the superior rectus muscle, with severe pain and loss of vision by glaucoma. In another eye (which was blind, slightly shrunken, and soft, and which was exercised on account of great pain) blood was found in the vitreous chamber, with extensive atro- phy of numerous portions of the choroid and retina, as observed after choroiditis "disseminata." Of the four eyeballs belonging to patients suffering from in- herited syphilis, one was removed during an attack of choroido- iritis. The cornea in three was found opaque, and the iris adher- ent to it (total anterior synechiae). The synechiae probably was the result of prolonged contact between the swollen and inflamed iris and cornea. SYPHILITIC INFLAMMATION OF THE VITREOUS SUBSTANCE. 'I his inflammation has been observed in one eye alone, as well as in both eyes simultaneously; it can only be recognized with the ophthalmoscope. The optic disk, retina, and choroid ap- pear uniformly hazy throughout. During the height of the inflammation we find (either on di- rect ophthalmoscopic examination, or by means of focal light) very minute, numerous, white and opaque dots throughout the vitreous chamber. These dots appear slightly movable during movements of the eyeball. They disappear under proper treat- ment, and are attributed to a temporary loss of transparency of portions of the vitreous substance. 332 SYPHILITIC IRITIS, ETC. Patients complain of a mist (coming over the sight rather suddenly), which increases rapidly in density; in order to rec- ognize-objects, they are obliged to look for some time. Some- times the mist becomes "too thick" even to recognize objects. The sensibility of the retina is impaired throughout, but pro- portionately from its centre tOAvards its periphery. The treatment locally consists in the application of atropia (as in iritis); and generally in the use of mercury, of Avhich the bichloride, in doses of ^ or of Jg of a grain, has been found most effectual. The treatment is continued until a good view can be obtained of the optic disk. Besides the peculiar opacities observed during the inflamma- tion just described, we often meet with opaque threads in the vitreous during, and after, choroiditis, or retinitis. The threads are readily seen with the ophthalmoscope, and also by the pa- tient, if they are close to a sensitive part of the retina. Those which occur in large numbers close behind the crystalline lens are particularly conspicuous, in consequence of their admitting but a small quantity of light into the eye. SYPHILITIC INFLAMMATION OF THE OPTIC DISK AND OF THE ADJOINING CHOROID AND RETINA. The centre of the optic disk (at the height of the inflamma- tion) appears pink, the remainder swollen, gray, opaque, and ill-defined. The contours of the optic disk shade off into those of the inflamed choroid and retina, which, in their turn, gradu- ally pass into the healthy retina and choroid. Choroiditis dis- seminata often occurs simultaneously. The retinal bloodvessels appear much less numerous; they are thin in the pink central part of the optic disk, and more or less indistinct in the swollen, gray, opaque portions; the veins in the retina are unequally dilated. In some cases we find extreme anaemia of the optic disk and retina, and one or two thin bloodvessels passing through the swollen optic disk into the retina. Opaque flocculi in the vitreous adjoining the inflamed parts occur in most cases. The inflammation at this stage may be mistaken for that TREATMENT. 333 observed during albuminuria, or for that which accompanies tumors at the base of the brain. This last kind of inflammation is characterized by the turgid state of the retinal veins in the disk as Avell as in the retina, and by the swelling being confined to the optic disk. Inflammation of the optic disk during albu- minuria is accompanied by brilliant yellowish patches, which appear in the infiltration round the optic disk and in the region of the yelloAV spot, together with bloodvessels. Simultaneously with the farther changes in the optic disk, we find the vitreous, retina, and choroid becoming more transpar- ent; portions of the retina may retain a semi-opaque color for years. Signs of atrophy gradually appear in the choroid, near the optic disk, in the form of pigment spots and transparent patches. This, in young persons, is often accompanied by thinning of the sclerotic, bulging of the tunics, and elongation of the eye- ball. The inflammation frequently occurs in both eyes, some- times with iritis in one or both. Vision.—At the commencement of the inflammation, patients occasionally complain of intolerance of light, with pain when using the eyes; of fiery stars, etc. (from hyperaemia of the optic nerve); or of a "mist" before the eyes, or of "small" black spots; or of a black web floating before the eyes, obscuring sight in certain directions (caused by opacities in the vitreous close to the retina). These symptoms may disappear rapidly; or may be followed by occasional sudden loss of sight; or by inability to distinguish small or distant objects. The slightest pressure upon the eyeball is sometimes followed by complete loss of vision for several minutes. The prognosis, as regards vision, depends much upon the stage of the inflammation at which we undertake the treatment of the case. It is more favorable if lymph and other morbid products have not yet undergone secondary changes, nor in- duced atrophy. No improvement of vision has been obtained in those cases in which the optic disk has been anaemic (bluish-white), with atrophic patches in the choroid. 334 SEROUS IRITIS. SEROUS IRITIS. This form of iritis generally occurs in young or middle-aged persons. It appears suddenly, Avith more or less irregular dila- tion of the pupil, and with increased tension of the eyeball. The iris at the height of inflammation is highly hyperaemic and discolored, with little or no plastic exudation. The anterior chamber appears enlarged by increased quantity of more or less turbid aqueous humor. If there is opacity of the cornea, it is either diffused, or assumes the form of minute opaque dots, many of which disappear after escape of the aque- ous humor. The ciliary region is unduly vascular, and the ten- sion of the eyeball above par. The intolerance of light and the Aoav of tears (of the "non- inflamed eye") also are often great. Severe pain is complained of in the inflamed eye, and over the corresponding side of the head. The iritis subsides gradually within about two months; and, OAving to morbid changes in the deeper tunics, is often followed by softening and shrinking of the eyeball, with complete loss of vision. The probable cause of this form of inflammation is the sud- den appearance of some foreign substance, such as clots of blood, an entozoon, etc, in the ciliary region, or in some other part of the interior of the eyeball. Treatment.—Great relief folloAvs the application of from four to six leeches to the skin of the temple next the "inflamed eye," with frequent application of atropia or of lotio belladonnae to the inflamed eye; or to both eyes, if no amelioration is obtained within 36 hours. No leeches should be ordered if the pain is slight. No benefit has been deriA'ed from general medical treatment, nor from iridectomy, during the height of iritis. The prognosis is unfavorable, on account of the deep-seated changes which often lead to shrinking of the eye. TREATMENT. 335 SYMPATHETIC IRITIS AND OTHER SYMPATHETIC CHANGES. A series of morbid changes are termed sympathetic, on ac- count of their occasionally appearing in one eye, subsequent to traumatic or spontaneous inflammation of the fellow-eye. The following, in order of frequency, seem to be the usual causes of such changes:— {a.) Injury to one eye, implicating the ciliary muscle and the ciliary processes; or the presence of a foreign body lodged in the eye, and more particularly in the ciliary region. The in- jured eye may be inflamed, suppurating, glaucomatous, staphy- lomatous, or even shrinking, Avhen the sympathetic change ap- pears in the fellow-eye. [b.) Dislocation of the crystalline lens {e.g., depression). (c.) Choroiditis, followed by chalky deposit among the ciliary processes. These sympathetic changes arc tabulated under the following heads, viz.: sympathetic irritation, sympathetic inflammation, and sympathetic amblyopia or amaurosis. One or several of these may appear in the non-injured eye simultaneously with the changes in the injured eye, or at the height of its inflammation, or even long after all apparent mor- bid action has ceased. Sympathetic Irritation.—The symptoms are, pain in the cil- iary region, often only felt when touching that part; also pain in the forehead of the corresponding side, Avhich is rarely con- tinuous, but ahvays appears when looking steadily at an object. There is increased flow of tears, and undue vascularity of the conjunctiva, especially in the ciliary region. Vision, as to acuteness, is normal, but there is more or less asthenopia. Removal of the injured eye, as a rule, arrests the sympa- thetic irritation of the felloAV-eye immediately, or within a few days. The patient, as long as the injured eye or the cause of the sympathetic irritation has not been removed, must thoroughly rest the eyes; out of doors wear a shade, and spectacles with tinted glasses, and use atropia tAvice daily to both eyes. 336 SEROUS IRITIS. Sympathetic Inflammation.—The inflammation, in most cases, commences with Avhat is termed sympathetic iritis, and in many it goes on the chronic ophthalmitis. SYMPATHETIC IRITIS. Sympathetic iritis is a peculiar, and fortunately rare, form of iritis. It has been observed after concussion of the eyeball, and after some foreign substance has become lodged in one eye. It appears first in the injured eye, and soon after affects the sound one; or the injured eye may have become destroyed at the time when the iritis sets in the fellow-eye. The iritis commences without pain, with moderate intolerance of light, and slight undue vascularity of the sclerotic It thus escapes notice on the part of the patient; and if confined to one eye, may, together with the deep-seated changes, have al- ready caused shrinking of the eyeball before it attracts atten- tion. At first there is slightly increased tension of the eyeball; this is gradually followed by normal decrease of tension. The aqueous humor is somewhat turbid, the pupil fixed and contract- ed, or of medium size, with often total posterior syncchire. The iris is swollen, discolored, and crowded Avith large vari- cose bloodvessels; sometimes in such numbers that its texture seems changed into a close network of enlarged vessels. There is slight sclerotic redness, and some enlargement of the ciliary veins. It must be borne in mind that in most cases the choroid and vitreous substance become similai'ly affected. (See Sympathetic Ophthalmitis.) When examining the uninjured eye with the ophthalmoscope, before any iritis is perceptible and while vision is still acute, we find the optic disk pink; some diminution in the width of the retinal arteries, along Avith enlargement and varicosity of the retinal veins. We may still be able to view the retina, etc., after iritis has set in; Ave then find (if the iritis has existed from four to six weeks) the optic disk pink, ill-defined, the reti- nal vessels few and thin, and only traceable a short distance TREATMENT. •.'0 7 ■)■) I into the retina. The latter, together with the choroid, has a uniform hazy, dirty-red color. Vision gradually becomes misty, and is in many cases lost in both eyes. The eyeballs become reduced to small, soft "stumps." Treatment.—Medical treatment has hitherto been found use- less. The removal of the injured eye should be urged at once, if vision is destroyed, or if symptoms of sympathetic inflamma- tion appear in the other eye, though vision of the injured eye may not be quite lost. Excision of the injured eye should like- wise be recommended if the symptoms of sympathetic irritation do not subside on proper treatment; such as the application of warm fomentations,—the frequent application of atropia,—the wearing, when out of doors, of spectacles with tinted glasses,— and confinement in a darkened room when at home, as long as there is the slightest intolerance of light,—with complete rest of the eyes for months after all vascularity has disappeared. In three patients under Dr. Walker's care within two years, in which the varicose state of the vessels of the iris existed already in both eyes, useful vision and normal tension were re- stored to both eyeballs, by performing iridectomy, with removal of some of the ciliary processes adjoining the excised iris; and by subsequently removing the crystalline lens, which previously had been rendered opaque. This treatment was adopted upon the supposition that the crystalline lens acted as a foreign body; and with the wish to interrupt the circle of infiltrated ciliary processes. The excision of the injured eye, though there be no sign of disturbance in the sound one at the time of the operation, un- fortunately does not exclude the subsequent occurrence of the sympathetic inflammation. Sympathetic Ophthalmitis.—If, as happens frequently, the changes observed in sympathetic iritis occur simultaneously in the choroid, and in the parts adjoining it, then the inflammation is termed sympathetic ophthalmitis. This differs from common suppurative ophthalmitis by the . 9-2 338 SEROUS IRITIS. chemosis, the swelling of the eyelids, and the pain being but slight, and by there being no abscess Avithin the eye. In sympathetic ophthalmitis Ave find the tunics, especially the choroid, retina, and the vitreous substance, -saturated with a nearly transparent, highly coagulable substance, termed by some fibrinous infiltration. At first there is slight swelling of the parts in Avhich the substance appears; this is followed, in the majority of cases, by more or less shrinking of the eyeball. A section of an eyeball thus inflamed very much presents, at one stage, an appearance as if all the parts Avithin the sclerotic were occupied by semi-opaque cancerous growth. The infiltra- tion is so uniform that the boundary between sclerotic, choroid, retina, and vitreous cannot be traced, or only with difficulty. The semi-transparent "infiltration" gradually changes into opaque tissue. A section made of such an irregularly-shrunken eyeball shows the parts within the sclerotic changed into a mass of bluish-white, and opaque, dense, fibrous tissue. Shrunken eyeballs, when resulting from concussion, or foreign bodies lodged within the eye, are apt to become inflamed or painful, especially in persons advanced in life; while eyeballs lost by sympathetic ophthalmitis remain quiet. The treatment of this form of ophthalmitis is the same as that of sympathetic iritis. Sympathetic Amaurosis, or Amblyopia.—The exterior of the affected eye generally presents no morbid changes, except im- paired mobility of the pupil; whereas, examination with the ophthalmoscope shows more or less anaemia of the retina and optic disk, with varying degrees of atrophy. These changes, in some cases, may be the result of chronic choroiditis. The anaemia often appears first in the part of the optic disk nearest the yellow spot, and thence extends. Vision may remain "good" for months, or even years after the injury to the fellow- eye, before it begins to fail "gradually". Only in a few cases has some benefit been derived from the alternate use of strychnia and bichloride of mercury. TREATMENT. 339 CYCLITIS, OR INFLAMMATION OF THE CILIARY REGION OF THE CHOROID. There are probably as many forms of cyclitis as of iritis. Dissections of eyes, exercised from the living, and observation on the fellow-eyes, to those exercised (which have suffered from a minor degree of the same form of inflammation), have assisted in establishing the existence of a simple or plastic cyclitis, and a syphilitic cyclitis. Plastic Cyclitis.—Plastic cyclitis frequently occurs after in- juries (foreign bodies lodged in the eye, dislocation, swelling, etc., of the crystalline lens, depression of cataract). The cyclitis is the usual complication, and often the cause of se- vere iritis or choroido-iritis; it is the cause of the chronicity of their course. Cyclitis often causes permanent impairment or loss of vision. The choroid in the ciliary region is destroyed, or is impeded in its functions by more or less thick and extensive, gray and opaque, fibrous substance, which intervenes between it and the crystalline lens and vitreous chamber. The nutrition of the vitreous substance and of other structures suffers. The eyeball becomes softer, the cornea opaque and smaller, the pupil closed. The tunics of the ciliary region gradually shrink, though the retina may continue sensitive for a long time. The retina frequently becomes drawn away from the choroid during contraction of the altered vitreous substance. When using the term "fibrous substance" for the opaque tex- ture found after cyclitis adhering to the inner surface of the ciliary processes and to the hyaloid fossa, it must be understood that this substance consists of "organized" portions of a plastic "effusion" mixed up with the structure of the ciliary processes, vitreous substance, etc. Symptoms.— Pain, when touching that part of the sclerotic which corresponds to the "inflamed" portion of the ciliary pro- cesses, etc., is the most constant symptom of this form of cyclitis. The pain may be extreme and continuous in the eye; and in the head there may be none. It is attributed to displacement of and pressure upon the ciliary nerves. More or less severe sclerotic and subconjunctival vascularity 340 SEROUS IRITIS. along the margin of the cornea, with enlargement and tortuositv of the veins of the iris, choroid, and retina. This having existed for some days, hypopyon may appear and disappear repeatedly. At the same time yellowish and opaque shreds become visible behind the crystalline lens in the vitreous chamber. These and the hypopyon, if there is no corneitis or iritis, are characteristic of cyclitis. The hypopyon may be present, or cause cornea-iritis; whilst the "vitreous opacities" are always found. The opacities may disappear in from four to six Aveeks; while gray and opaque, fibrous and chalky spots make their appearance among and upon the ciliary processes and the hyaloid fossa, together with the changes which follow inflammation of the tunics. Whether, subsequent to cyclitis, the eye shrinks or remains softer; or, having been so, resumes its normal tension, depends— (1.) Upon the severity of the cyclitis. The more of the ciliary region of the choroid is destroyed, or the thicker the fibrous substance is upon and among the ciliary processes and in the hyaloid fossa, the less favorable is the result. (2.) Upon the state of health. The same degree of cyclitis Avhich in a poor, ill-fed person leads to shrinking of the eye, may in a strong patient end in recovery of useful vision. (3.) Upon the cause. Foreign substances in the eye—a piece of metal, a dislocated lens—may become a continuous source of irritation, and of re- peated attacks of cyclitis. Vision.—On account of frequent complications with cornea- iritis or choroido-iritis, it is difficult to determine the share which cyclitis takes in the impairment of vision. The opacities in the vitreous chamber give rise to the complaint of a "mist" inter- vening between the eyes and the object looked at. The usual cause of loss of vision is displacement, or atrophy of the retina, or both. Treatment—The treatment of cyclitis is the same as that of simple iritis. Leeches (from four to eight) are applied at bed- time if the pain is great. Applications of iced water should be tried at first, and continued as long as cold is pleasant. TREATMENT. 341 The fclloAv-cye must be kept at rest, and under the influence of atropia, if any sympathetic irritation exists. Excision of the inflamed eye is performed if a "foreign body," e.g., a dislocated crystalline lens, is within the eye (attempts to extract it having failed), or if the shrinking blind eye is very painful. Syphilitic Cyclitis.—This form of cyclitis is a sign of severe syphilitic inflammation: it is not unfrequent, and often occurs in both eyes. Lymph sometimes not only appears among the ciliary pro- cesses, but also in the sclerotic along the margin of the cornea, cornea-iritis, and choroido-iritis, occur simultaneously. The cyclitis is observed in inherited as well as in secondary syphilis; in both, though especially in the former, it gives rise to staphyloma of the sclerotic, to thinning of the structures of the ciliary region, and to the peculiar sugar-loaf shape of the eyeball, with or Avithout staphyloma. Its effects upon the nutrition of the tunics are similar to those of simple cyclitis, though better recoveries are observed in the syphilitic form. Cases of shrinking of the eye with loss of vision, unfortunately, often occur. (For treatment, see Syphilitic Iritis and Staphyloma.) HYPEREMIA OF THE CHOROID. Hyperaemia of the choroid gives rise to a sensation of fulness in the eye, and to slight lachrymation and intolerance of light, Avith pain in the eye. When comparing the hyperaemic choroid with that of the healthy eye, e.g., in myopic persons (who are frequently subject to it), we observe an increase of "redness," with unusual fulness and a tortuous course of the retinal veins over and near the hyperaemic portion. INFLAMMATION OF THE CHOROID. CHOROIDITIS. The o-eneral remarks Avhich were made upon iritis apply equally to choroiditis. Certain symptoms are common to all forms of choroiditis; these are:—loss of transparency of the choroid and atrophic changes. 342 CHOROIDITIS. Others are peculiar to different forms; from these special names are derived. Lymph-nodules are observed in the syphilitic; large gray, or yellow and opaque patches, in the plastic—a "turbid" red color of the choroid, and increased tension and dilation of the pupil in the serous forms of choroiditis. Choroiditis can, to insure accuracy of diagnosis, only be rec- ognized with the ophthalmoscope. External and objective symp- toms may be absent altogether. Pain, intolerance of light, im- pairment of vision, fulness of the veins emerging from the scle- rotic in the ciliary region, sclerotic redness, a sluggish pupil, etc., are symptoms frequently observed, but not characteristic of any of the forms of choroiditis. Ophthalmoscopic observations show that, as regards duration, choroiditis differs little from similar forms of iritis, unless im- plication of other tunics be a source of prolonged disturbance. The state of vision varies according to the seat, extent, and severity of the inflammation, and according to its effect upon the retina or optic disk. Small inflamed spots, implicating the retina at the yellow spot, give rise to complaints of disturbed vision; whilst large portions of choroid, near peripheral parts of the retina, though the retina be perhaps more extensively affected, may run through all stages of inflammation, and neither disturb vision nor give rise to other complaints. Solitary portions of choroid, when impairing the functions of corresponding parts of the retina, give rise to loss or impairment of the functions of these parts. These may be paralyzed, com- pletely destroyed, or merely reduced to perception of light. A gradual transition from less sensitive to normal parts of retina is the rule in circumscribed choroiditis. The prognosis, as regards recovery of inflamed parts of the choroid, is more favorable if no atrophic patches are perceptible. As regards vision, it is less favorable if the inflammation is at or near the region of the yellow spot, and if the retina over the inflamed part is quite paralyzed. The "exudation," seen with the ophthalmoscope, appears TREATMENT. 343 (/enerally of a gray, or yellowish, rarely of a broAvn and opaque color; it assumes the shape of roundish spots, or of large patches surrounded by vascular ("red") choroid. Only one large por- tion of choroid, or one or numerous small isolated spots, and in severe cases the entire choroid, may be occupied by "infiltra- tion." Among the changes which are peculiar to choroiditis, and which are observed with the ophthalmoscope, we must distin- guish those which are produced by the "exudation," those which are the result of hyperaemia or of atrophy of the choroid, and those which are situated in the retina, or optic disk, or vitreous chamber. Round the choroidal aperture, and in the region of the yellow spot, the infiltration frequently appears in the shape of roundish spots and patches. These gradually disappear; and the changes of atrophy, etc., are observed in and round the portion of cho- roid which they occupy. Minute examination has shown, that in the portion of choroid occupied by the infiltration, the bloodvessels are obliterated, partly by exudation, and partly by changes in the contents of the vessels themselves. The transparency of the retina, over and near the focus of inflammation, is impaired in most cases. The grayish, hazy retina merges gradually into transparent por- tions. The vessels may be lost sight of in the hazy portions of retina, or may appear varicose and enlarged. Blood-spots occasionally appear from rupture of small vessels. CHOROIDITIS AT OR NEAR THE OPTIC DISK. The inflamed portions of choroid are readily recognized by the outlines of the optic disk appearing ill-defined. The optic disk may become as red as the choroid; and often can hardly be rec- ognized but for the enlarged retinal veins meeting in it. The disk, in other cases, appears anaemic in the middle, and very congested next the choroid; or part or the whole of the disk may be occupied by "exudation." The appearance of the disk varies according to the stage of the inflammation. Destruction of the optic nerve-fibres by choroiditis at the choroidal aperture (in one or both eyes) is not an uncommon occurrence. 344 ATROPHY OF THE CHOROID. Opacities in the vitreous chamber, near the seat of choroiditis, are usually present; and are often the only symptoms noticed by the patient, Avho, if these opacities are close to a sensitive portion of retina, complains of black spots, clouds, etc., float- ing before the eyes. Iris, and hyperaemia of the iris, are frequent complications. (See Syphilitic Choroiditis and Inflammation of the Optic Disk.) Treatment.—The treatment of the different forms is the same as that of corresponding forms of iritis. If mercury is given Avith a vieAv of producing salivation within a few days, it is best to employ frications Avith mercurial ointment (from one to three drachms to be rubbed into the armpits, twice daily). No treatment seems of use Avhen atrophic spots have become visible in the choroid. ATROPHY OF THE CHOROID. The atrophic portions of choroid, vieAved with the ophthal- moscope, are conspicuous by their contrast with the parts adjoin- ing them. Transparent portions represent the highest degree of atrophy. In these the pigment and blood have disappeared, and only a thin, transparent membrane is left. These portions, in the liv- ing, appear as brilliant A\hite patches, spots, etc.; the white color being caused by the sclerotic, Avhich subtends the trans- parent and atrophic choroid, and from which the light is re- flected. These transparent portions, as a rule, are surrounded by pigment spots. These and the transparent spots are found side by side. Atrophic portions of choroid often skirt the optic disk, in the form of crescents in the myopic eye; they are observed as small, well-defined, brilliant white and brown or black spots in other portions of choroid, after various forms of choroiditis, etc. Pigment spots caused by groups of stellate pigment cells can- not be mistaken for those due to alteration of the hexagonal cells and of their granules; since the shape of the former, in different parts of the choroid, is sufficiently characteristic. Alterations in color of groups of stellate pigment cells (from a TREATMENT. 345 light to a dark-brown, and vice versa), or a diminution of tint (from light-broAvn to pale-yelloAV, or to complete transparency), are observed in prolonged anaemia of the choroid, and especially in atrophy and in staphyloma. In health, Ave find that the darker the iris, the deeper is the tint of the choroid. Every inflammation is accompanied by pigment changes. The pigment granules of the hexagonal cells, over and near the seat of inflammation, become too transparent or too much tinted. They decrease in number, or are destroyed, or they become dis- placed and accumulated round the foci of inflammation. Hence the groups of circles, or spots of deep-brown and black pigment which skirt transparent atrophic parts of choroid, or which are scattered over more or less anaemic portions. Pigment spots are the results of changes in the hexagonal cells, or in the stellate pigment cells; and may assist in local- izing morbid changes of the retina or choroid. The choroid, which undergoes atrophy, may appear light-red before it becomes transparent. If there is staphyloma at the same time, we find at its margin the large choroidal vessels unusually broad and farther apart from each other; and also the vessels of the retina deviating from their normal course. The choroid, retina, and sclerotic are adherent to each other at the transparent atrophic spots, and frequently also at the pigment spots. DISPLACEMENT OF THE CHOROID. Displacement of the choroid has been observed in the course of cancer and other tumors, and also after effusion of trans- parent fluid or of blood betAveen the choroid and sclerotic. The displacement has been observed in young persons suf- fering from irregularities incident to menstruation; frequently in glaucomatous eyes, but rarely after injury. The equatorial region of the eye is the usual seat of the dis- placement; though, in several cases, it has occurred at the yellow spot. Viewed Avith the ophthalmoscope, the displaced portion ap- pears as a dark-brown, sharply-defined, roundish patch, with 346 ATROPIA AND CALABAR. semi-transparent retina over it, and surrounded by the natural color of choroid and retina. In those cases in Avhich large por- tions had become detached, no light reached the sclerotic, and all appeared dark behind the clear crystalline lens. The eye should not be lighted up Avith the ophthalmoscope. In some cases this condition was marked by displacement of the retina. Sudden impairment of vision, to correspond to the displaced portion of choroid, was observed in some cases. Decrease of tension Avith gradual shrinking of the eye occur- red in some cases; Avhereas in others the blood became absorbed; and this was followed by circumscribed atrophy of the choroid, with loss of vision from atrophy of the retina. ATROPIA AND CALABAR. Among medical agents which are employed to act upon the iris Ave distinguish mydriatics, or remedies Avhich cause dilation of the pupil and paralysis of the poAver of accommodation; and myotics, which increase that poAver, i.e., the contraction of the ciliary muscle, and Avhich cause contraction of the pupil. Of mydriatics the preparations of atropia belladonna (solanea) are in general use. As myotics are used the preparations obtained from physistigma venenosum (leguminosae). The Sulphate of Atropia.—Wherever the term atropia is used the solution of sulphate of atropia {\ of a grain of the sulphate of atropia to Sj. of distilled Avater) is to be understood. Atropia or "atropine" is supposed to act as an excitant of the ganglion cells and the fibres of the sympathetic nen'e. A solution of the sulphate of atropia, brought into contact with the conjunctiva, passes through the cornea, mixes Avith the aqueous humor, and produces dilation of the pupil. Such aqueous humor, applied to another person's conjunctiva or cornea, again produces dilation of the pupil. Profuse "Avatering of the eye," morbid changes of the cornea, and great increase in tension of the eyeball, may prevent the atropia from reaching the iris. TREATMENT. 347 The pupil of a healthy eye becomes dilated to its maximum {i.e., its sphincter is paralyzed and its dilator strongly con- tracted) in from fifteen to thirty minutes after applying to the conjunctiva a solution of the sulphate of atropia (atropiae sulpha- tis, gr. \; aquae distillatae, 5j.). Soon after this the ciliary muscle, and Avith it the poAver of accommodation, becomes par- alyzed. Within about three hours after application its effects can, Avith the ophthalmoscope, be perceived in the retina and choroid; in these it causes dilation of the bloodvessels. It also affects the action of the external muscles of the eye. Its effect continues for several days after one application. By para- lyzing the ciliary muscle, it is supposed to contribute towards diminution of the tension of the eyeball. The stimulus of light, efforts of accommodation, etc., some- times act injuriously when the bloodvessels of the interior of the eye are dilated with atropia. Atropia reaches the throat by passing through the lachrymal passages; and, if frequently applied, may, especially in chil- dren, cause symptoms of poising. Such symptoms are increased rapidity of the pulse, e.g., 110 pulsations instead of 70, with dryness of the throat and restlessness, folloAved by sleep Avith much dreaming. Graver symptoms are general excitement, with hallucinations ("strange figures and objects seeming to move about on the bed") and inability to swallow. In cases of iritis of one eye only, and in cases of spasm of the ciliary mus- cle, symptoms of poising may appear before any local effect upon the iris or accommodation is produced. Our attention should be directed to the above symptoms if prolonged appli- cation of atropia is required. The best antidote, if the graver symptoms present themselves, is the subcutaneous injection of the acetate of morphia, which produces its effects in from ten to twenty minutes after injec- tion. The sulphate of atropia is prescribed in the form of—(1.) Drops of varying strength (guttae atropiae). Two kinds are in general use:—(a.) R. Atropiae Sulphatis, gr. \; ad Aquae Dis- tillate, 5j. Misce (to be used in inflammatory changes, corneitis, 348 ATROPIA AND CALABAR. iritis, etc.). {b.) B/. Atropiae Sulphatis, gr. ij.; Aquae Dis- tillatae, 5j. Misce (to be used to bring on rapid paralysis of the poAver of accommodation). The effect of the atropia is best secured by giving directions "to take a camel's-hair brush or the fan of a quill, to dip it into the lotion, then gently to draw the loAver lid aAvay from the eye, and to touch the inner surface lightly with the brush. The mere touching of the conjunctiva Avith the brush suffices. The sulphate of atropia should be pure, and contain no resin- ous substances: it should cause no irritation. One part of the sulphate of atropia to tAvo thousand parts of distilled water is sufficient to dilate the pupil. If, for ophthalmoscopic purposes, Ave wish to dilate without impairing the accommodation too much, Ave may use a lotion made of one part of atropia to one hundred and twenty parts of water. If the drops are used frequently or for a considerable time (in some patients even after one application), increased redness of the conjunctiva with chemosis and muco-purulent discharge, with swelling of the eyelids, and sometimes erysipelas on that side of the face, may appear. This form of inflammation caused by atropia is termed atropinism. The atropia must, in such cases, be discontinued for a few days, and some astringent lotion (of acetate of lead, or alum) be used. In such cases, instead of using the drops, we apply the atropia gelatine. (2.) Unguentum Atropiae.—B/. Atropiae Sulphatis, gr. j.; Unguenti Spermaceti, gij. Misce. (3.) Endermatic application of atropia. A blister is raised over the spot beneath Avhich lies the nerve which we Avish to act upon by atropia. The skin of the blister being removed, from J.2 to \ of a grain of the poAvdered sulphate of atropia is sprinkled over the raw surface. (4.) Subcutaneous injection of atropia. An injection of g'ff of a grain of the sulphate of atropia pro- duces acceleration of the pulse. As much as T»2 of a grain has been injected at one time. (5.) Atropia gelatine. TREATMENT. 349 The pu-cos of atropia gelatine supplied by Messrs. Allen & Ilanbury, of Plough Court, Lombard Street, E. C, London, are divided into little squares. Each square contains (accord- ing to an examination made by Mr. Daniel Ilanbury) somewhat more than y^go °f a grain of the sulphate of atropia. When brought into contact with the conjunctiva the atropia gelatine becomes rapidly dissolved; it does not, like atropia paper, act as a foreign body. Physotigma Venenosum.—The fruit of this plant is\a bean, termed the Calabar bean. (Wherever the term "Calabar " is used a preparation of the Calabar bean is to be understood.) The alcoholic extract of the bean, known as the extract of "Calabar bean," and the Calabar gelatine are the preparations generally used. Calabar, when brought into contact with the conjunctiva, causes lachrymation, and, in about five minutes later, contrac- tion of the pupil, followed by contraction of the ciliary muscle. This contraction reaches its height in half an hour, and con- tinues for about twelve hours, without, however, producing com- plete immobility of the pupil. Calabar counteracts the effect of atropia, and also acts if there is paralysis of the pupil. The contraction of the pupil and ciliary muscle, thus produced, generally causes pain, which may be very severe, and continued for hours. The pain in- creases if the eye is used, i.e., if efforts at accommodation are made. Slight efforts at accommodation produce much more contraction of the ciliary muscle if a Aveak solution of the Cal- abar has been applied, than if the same efforts are made under ordinary circumstances. Patients, if directed to apply the Calabar themselves, should use small squares of Calabar gelatine (as prepared by Allen & Hanbury), Avhich contain a known quantity of the active prin- ciple of the bean. An examination of Calabar gelatine (made by Mr. Daniel Hanbury) shoAvs that "500 of the little squares weigh 9.75 grains, say in round numbers 10 grains. This alloAvs for one square a weight of .02 grain, or ^ of a grain. Then, as the 350 GLAUCOMA. gelatine contains one-sixth of its weight of extract of Calabar bean, a little square, Avhich Aveighs .02 grain, Avill contain of it (the extract) .0033 grain (=-s-J-Ij of a grain)." A square of the Calabar gelatine placed on the conjunctiva of the loAver lid readily dissolves. Its local effect ceases in from twelve to tAventy-four hours. Atropia applied to one eye and "Calabar" to the other produce their specific effects; and do not interfere with each other's action. Calabar taken internally depresses the functions of the spinal cord, and thus prevents the transmission of nervous impulses through the cord, to and from the iris. Calabar is by some looked upon as a respiratory poison, caus- ing asphyxia; by others as interfering with the contraction of the heart, and producing syncope. GLAUCOMA. Formerly the term glaucoma was applied to the last stage of the disease only, viz.: that in which the pupil had become fixed, irregular, and dilated, its area greenish, the ciliary vessels en- larged, the eyeball of strong hardness, and vision lost, etc. With our improved means of diagnosis we can discover the signs of glaucoma in persons with apparently perfect sight. The term glaucoma is at present applied to a series of morbid changes of the eyeball; the most prominent of which, and, ap- parently, the one which causes nearly all the others, is an in- crease in the tension of the eyeball. This increase of tension, or, in other words, the abnormal re- sistance of the tunics of the eyeball to the touch, is attributed to an increased amount of, and to changes in the contents of the vitreous chamber, which give rise to disturbances in the cir- culation, nutrition, and functions of the textures of the eyeball. No satisfactory explanation can as yet be given of the primary cause of the increased tension; whereas most of the subsequent changes in the textures of the dyeball are readily explained by TREATMENT. 351 reference to it. These changes, in the majority of cases, are accelerated by attacks of inflammation; Avhich either appear suddenly with remissions, or asXmronic inflammation Avith slight exacerbations. These attacks of inflammation themselves are symptoms of disturbed tension. Their occurrence, succession, and rapidity seem to depend, in a great measure, upon the power which the eye possesses of adapting its nutrition and circulation to the disturbance occa- sioned by the increased tension. Glaucoma, Avhen appearing without attacks of inflammation, is termed simple glaucoma. The increase of tension, and the changes resulting from it, appear gradually, and proceed without any external inflammation. If attacks of inflammation accom- pany the glaucomatous state of the eye, it is termed chronic cr acute inflammation. Chronic glaucoma, or, rather, glaucoma Avith slight attacks of inflammation, is the most frequent form. The attacks of inflam- mation occur at first at long intervals, are slight, and not well marked. In acute glaucoma, or, rather, glaucoma Avith acute inflam- mation, the latter is severe in character and sudden on its onset. Simple or chronic glaucoma may appear in one eye, and acute glaucoma in the other. An acute attack of inflammation may occur in an eye with chronic glaucoma; and vice versa, e.g., an eye suffering from acute glaucoma may, after the attack has subsided, assume the aspect of chronic glaucoma. The gradual and often hardly perceptible progress of the glaucomatous changes, with only slight attacks of inflammation, and Avith little or no pain, finally produce the same Avell-marked glaucom- atous aspect of the eye, as an acute attack of inflammation does in a short time. To be able to recognize glaucoma in its different forms and stages, we must be familiar Avith the normal tension of the eye- ball (see Tension of the Eyeball), and with the glaucomatous symptoms peculiar to the different textures of the eye. Glaucomatous symptoms, i.e., such as are occasioned by an increase of tension in the eyeball, have been mentioned when 352 GLAUCOMA. speaking of other morbid changes of the eyeball (as cataract, corneitis, iritis, and myopia). Here again avc find that a thor- ough acquaintance Avith the alterations of the tension of the eye- ball, as well as the recognition of symptoms and changes de- pending upon it, are of the greatest service in the treatment of these morbid changes. The progress of glaucoma, in the majority of cases, is accom- panied at one period by attacks of inflammation. These attacks attract the patient's attention, particularly on account of their generally being accompanied by impairment of vision, and pain. They vary as regards severity, frequency, and rapidity of ap- pearance. If severe and sudden, they are termed acute. An attack may pass off, and some time intervene between it and a fresh one. The interval betAveen the attacks becomes, as a rule, shorter in the later stages of glaucoma. Often a severe attack follows several slight and rapidly succeeding ones. An acute attack, however, often appears without other symp- toms having attracted the patient's attention. Cases have oc- curred in which vision has been lost suddenly, a few days pre- vious to the appearance of the acute inflammation. Acute inflammation has been observed in glaucomatous eyes which had been blind for years, and in eyes the sight of which had been lost by cerebral amaurosis. A patient suffering from an attack of glaucoma Avith acute in- flammation generally states, that he was seized with sudden severe pain in the eye (frequently while in bed, or after having passed some sleepless nights, or after having been subject to ex- citement). He describes the pain as extending over the cor- responding side of the head, and more especially over the fore- head and temple; and says, that on closing the other eye he has found that Avith the painful eye he cannot see, or, at best, but very imperfectly. Should the patient be seen the same day, or one or two days after the attack, we generally find the eyelids slightly reddened and sAvollen along their margins; the conjunctiva somewhat chemotic, with its bloodvessels, and those of the sclerotic, numer- TREATMENT. 353 ous and enlarged; profuse Aoav of tears, and often much intoler- ance of light; and the aqueous humor turbid. The pupil is more or less dilated, often immovable and irreg- ular; vision much impaired, sometimes reduced to bare percep- tion of light; the pain is severe in the eyeball and over the forehead and temple; the tension of the eyeball is increased. The changes observed with the ophthalmoscope are stated be- Ioav, together with other glaucomatous changes of the textures of the eye. The acute inflammation, after a few days or weeks, passes off spontaneously, although gradually, unless it be treated properly. The functions and structures of the eye remain more or less altered. Similar acute attacks may appear repeatedly; but more frequently the eye assumes the character of "chronic glaucoma." The symptom Avhich most distresses the patient, when suffer- ing from glaucoma with slight attacks of inflammation ("chronic glaucoma "), is the temporary " dimness " of ATision. On inquiry, we generally find that these "attacks of dimness" coincide Avith those of slight inflammation. The symptoms of the latter are —more or less pain in and round the eyeball, Avith increase of the already abnormal tension; undue vascularity of the con- junctiva and of the sclerotic along the margin of the cornea; slight turbidity of the aqueous humor; and sluggishness of the movements of the iris. The course of simple glaucoma is still less striking than that of chronic glaucoma. Attacks of inflammation, acute or chronic, may appear during any part of the course, sometimes only after vision is destroyed. To recognize glaucoma in its simple form, we must be familiar with the use of the ophthalmoscope, and with the mode of ascer- taining the tension of the eye. Simple glaucoma is often mistaken for cerebral amaurosis. Vision becomes impaired gradually, the power of accommo- dation lost, and the pupil sluggish, and more or less dilated. The increase of tension, and mode of impairment of vision, the alteration of the optic disk and of the retina, when seen with the 23 354 GLAUCOMA. ophthalmoscope, are in themselves sufficiently characteristic to prevent our mistaking this or any other form of glaucoma. The glaucomatous symptoms, as exhibited by the various structures of the eye, require a more detailed description. The increase of tension of the eyeball is, as far as is knoAvn, the earliest perceptible symptom of glaucoma; it may precede most of the others for some years. The tension, though remaining above par, varies in degree at different periods; and likewise varies in its effects upon the dif- ferent structures. A retina, for instance, may have become com- pletely paralyzed by pressure, while the sensibility of the cornea and the shape of the pupil, etc., are but little altered. The tension increases suddenly during an acute attack of in- flammation. The hardness of the glaucomatous eyeball reaches its height soon after vision is lost, and continues for a long period. As one of the later and rarer changes in the blind glaucom- atous eye, must be mentioned a fluid condition of the vitreous substance, with dislocation of the chalky crystalline lens, and a decrease of tension to T—2. The tension of the glaucomatous eye, after removal from the orbit, sinks below par in some in- stances; in others it remains unaltered. In many cases the tension is reduced to the normal degree soon after iridectomy, and, at a later period, it may sink below par. In another series of cases the tension remains a little above par after iridectomy; whereas in glaucoma, complicated with attacks of profuse hemorrhage into the vitreous chamber, it often is not altered at all, or only at a late period. The same has been observed when, in young persons suffering from glaucoma, the iris has been much pushed forwards, previous to the operation. If a well-performed iridectomy does not reduce the tension, a second operation should be tried: this sometimes succeeds in controlling the tension. The Eyeball becomes more Globular in Shape.—Alterations in curvature of the cornea, staphylomatous portions behind and at the side of the insertion of the recti muscles, and in the equa- TREATMENT. 355 torial region, and beneath the insertion of the oblique muscles, often occur in later stages of the disease. Staphylomata decrease much, and sometimes disappear of suc- cessful iridectomy. The conjunctiva in simple, and in chronic glaucoma is remark- able for its rotten condition. Together with the subconjunctival tissue it becomes atrophic, and readily tears, when seized, so as often to be quite useless for fixing, or rotating the eye during operation. It becomes chemotic and vascular in "acute glaucoma." The sclerotic, in acute glaucoma, appears slightly reddened. The ciliary vessels, which emerge from the interior of the eye through the sclerotic, especially in front of the insertion of the recti muscles, are large, tortuous, and numerous in most cases of chronic glaucoma, although they often become smaller, or disappear entirely in the later stages, or after successful treat- ment. The cornea gradually becomes anaesthetic. The anaesthesia, at first, may be confined to certain parts; but it disappears if the tension is relieved in time. In the later stages the shape of the cornea often suffers; some parts (the more paralyzed ones) becoming staphylomatous. Softening of the cornea, and chiefly of its central portion, ad- vancing from the surface inwards, has been observed. The cornea may become more or less opaque. Sometimes a crescentic ulcer or diffused purulent infiltration occurs; which may be followed by perforation, intraocular hemorrhage, and shrinking of the eye. The latter result may also follow when the suppuration spreads from the cornea into the eye. The Aqueous Humor and its Chambers.—The anterior cham- ber appears smaller through the iris and crystalline lens ap- proaching the cornea—in some instances to such a degree as to touch the cornea in certain places. The quantity of the aque- ous humor is diminished. These changes in the aqueous cham- bers may be missing in any form of glaucoma; they have also been observed in young glaucomatous persons. 356 GLAUCOMA. The diminution in the size of the aqueous chamber occurs slowly in chronic and often quickly in acute glaucoma. It is a favorable symptom if the size of the chamber increases after iridectomy. Attacks of inflammation cause the aqueous humor to appear turbid; this turbidity may disappear after a few minutes, or it may appear and disappear several times in the course of the day. Spontaneous hemorrhage from the vessels of the iris in the aqueous humor is a frequent occurrence. The iris gradually loses its mobility, partly through pressure upon the ciliary nerves, partly through atrophic changes. The iris hardly ever returns to the normal condition, though an iridectomy may otherwise have been successful. It has been observed, that if only part of the cornea has lost its sensibility, the corresponding portion of iris has alone been paralyzed. In acute glaucoma the mobility of the iris may become ar- rested at once, whereas in simple and chronic glaucoma this occurs slowly. The color of the iris appears altered, according to the stage of the glaucoma—the dilation of the bloodvessels—the compli- cation with iritis—and the state of the aqueous humor. Enlarged bloodvessels are often seen with the naked eye in / the iris, especially in simple glaucoma. The iris, at last, be- comes atrophic, and assumes a slate color; and its rotten con- dition renders removal by iridectomy very difficult. The pupil is, in many cases, at first unusually contracted. Its movements gradually become sluggish, and generally some- what irregular. In the latter stages of glaucoma, unless pre- vented by adhesions, it becomes widely dilated and motionless. Cases of simple glaucoma often occur in which the pupil, though immovable, retains a medium size. In the choroid we observe—(1.) Hemorrhage (? from impeded return of blood). (2.) Anaemic spots. (3.) Atrophy, extending (as in the retina) from the ora serrata backwards. (4.) Staphy- lomatous changes in the atrophic parts. The hemorrhage frequently occurs in the equatorial region, TREATMENT. 357 and in the region of the yellow spot- The blood is accumulated in the outer layers of the choroid, and between the latter and the sclerotic These blood-spots, when viewed with the ophthalmoscope, appear as black or brown, roundish, ill-defined patches, sur- rounded by the neutral red reflection from the choroid; not unfrequently they are situated close to atrophic portions. Only after operations (iridectomy, extraction of cataract, etc.) has the hemorrhage been so great as to separate the choroid nearly completely from the sclerotic The anaemic spots, as seen with the ophthalmoscope, appear roundish, white, well-defined, and in groups. They are mostly in the region of the yellow spot, and near the optic disk. The staphylomatous atrophic portions of choroid (and other tunics) are usually found in front of the equator, between it and the ora serrata, and, by preference, behind the insertion of the muscles. Viewed with the ophthalmoscope, they have a pale- red color; which is the more marked, the greater the atrophy of the choroid. This form of atrophy differs from other forms, on account of the frequent absence of pigmented patches round the atrophic portions. Microscopic examination of the choroid, in chronic glaucoma, shows the large veins and the capillaries gorged with blood, and much dilated. The stellate pigment appears normal round the optic disk, as well as in most other parts of the posterior half of the choroid. From the equatorial region to the ora serrata, it is thin and atrophic in some, and completely missing in other places. The hexagonal cells, round the optic disk, appear normal, or nearly so, as regards size, shape, and pigmentation. They are more altered nearer the ora serrata. Upon the atrophic parts of the choroid they are missing; near these parts they appear rugged in some, and round, and unusually large, in other places. Some are filled Avith pigment granules, whilst others contain but few, or are entirely empty; many of the granules themselves appear abnormally large. Colloid globes or globules, disarranging the regularity of the cells, are found in a few cases only. 358 GLAUCOMA. The changes in the bloodvessels and in the pigmentation are, in all cases, most conspicuous from the equatorial region to the ora serrata. The texture of the choroid is rotten. The crystalline lens, in the later stages of glaucoma, assumes, as a rule, a greenish tint; Avhich, hoAvever, is not characteristic of glaucoma. Light, reflected from the hyaloid fossa, returns through the crystalline lens, and mixes with the slightly bluish-gray light; which is reflected from the anterior surface of the capsule, and from the portions of the lens adjoining it. The greenish tint disappears frem many eyes successfully operated upon; it be- comes less marked after removal of the aqueous humor. The lens, when removed from a glaucomatous eye, appears of a pale- orange color (from imbibition of haematin). The position and the consistence of the crystalline lens be- come altered; its capsule, like the other textures, becomes rot- ten and readily ruptured, spontaneously, or during iridectomy. The cataract, which follows, or which may appear spontaneously, has a peculiar uniform gray, or greenish-gray, and opaque color; which sometimes is preceded by large, silvery striae. The cat- aract at first is very large (swollen); gradually, chalky patches appear, with loosening of the attachments of the cataract, and sometimes with dislocation into the vitreous chamber. The vitreous substance, in cases of acute glaucoma, when ex- amined soon after the attack, is found transparent, and of nor- mal consistence, with clots of blood suspended in it. In chronic glaucoma it possesses unusual firmness; it is trans- parent, with a more or less yelloAvish tint. Clots of blood are comparatively rare in the vitreous chamber; if present, they are more numerous along the ora serrata, and near the hyaloid fossa. In a staphylomatous eye, and in one in which the choroid had been separated from the sclerotic by spontaneous hemor- rhage, the vitreous was more viscid in consistence; it was nearly fluid where it touched the displaced or staphylomatous portions of the tunics. Part of the vitreous may be missing (having become absorbed ?); TREATMENT. 359 and the entire hyaloid membrane may be separated by yellowish fluid from the membrane limitans of the retina. Impaired transparency of the retina and choroid renders rec- ognition of the state of the vitreous difficult. Mode of Impairment of Vision.—In simple glaucoma the impairment is so gradual that the sight of one eye may be lost without the patient being aware of it. Some patients state that vision has been lost gradually, both for distant and near objects ; and this has been accompanied at times by rainbow colors round luminous objects. Symptoms of glaucoma may exist for twelve or sixteen years before vision becomes sensibly impaired. In "chronic glaucoma" we usually hear the patient complain of "attacks of dimness,"—of a "mist" round the flame of a candle,—and, in most cases, on injury of "rainbow color." Many observing patients state, that when looking straight for- ward, they no longer perceive objects held sideways. The "attacks of dimness" are observed by most patients; and are supposed to coincide with temporary increased pressure upon the optic nerve (optic disk) and retina. The retina and optic nerve may thus be paralyzed, without the optic disk appearing cupped. Fatigue, excitement, and stooping are the usual causes of these attacks; which may appear at different times of the day, but generally do so towards evening. Vision becomes "dim," not only when reading, but also when looking at distant objects; a mist appears to intervene between the eye and the object looked at. "Normal light" may permanently be destroyed, within a few minutes, by acute glaucoma. Though reduced to perception of light, it may return to what appears to the patient a normal condition. In most cases, however, vision remains impaired. The perception of "colors" of a "rainbow" round luminous objects (termed "irization," whether all the colors of the prism are present or not), is one of the most constant symptoms of glaucoma. The colors generally assume the shape of a rainbow, in which 360 GLAUCOMA. the margin most distant from the flame appears red, and the one nearest the flame green, or bluish-green. Irization, though generally not in the form of a rainbow, is observed by persons suffering from granular ophthalmia, and by many healthy eyes, if the pupil is much dilated. Irization has been knoAvn to exist for ten or fifteen years previous to vision becoming impaired. In some cases of glau- coma it does not occur at all, in others only at certain stages; and disappears if the pupil is contracted beyond a certain size. "Fiery stars," "flashes," intolerance of light, etc, are only occasionally observed. In presbyopic persons, who use spectacles, Ave may suspect the presence of glaucoma, if their spectacles are repeatedly changed in the course of a few months. The statement of the patient as regards vision should be fol- lowed by an examination of the functions of the retina; and when ascertaining these, Ave should pay particular attention to the condition of the peripheral portions of the retina. For a patient may be able to read small type (held opposite to the region of the yellow spot), and yet may have lost the use of the surrounding retina. The peripheral portions of the retina are found impaired in all forms of glaucoma, and are often destroyed before vision for reading is much affected. In simple glaucoma increased tension may exist for a long time before any diminution in the function of the peripheral parts of the retina is observed. The impairment, at the com- mencement, is only discovered Avhen the examination is made in dull light. The peripheral parts of the retina, which lie to the outer side of the yellow spot, are generally first impaired. Cases often occur in which the movements of the examiner's hand (the patient's eye being directed straight fonvard) are per- ceived opposite the outer parts of the retina; whereas opposite the inner, upper, and lower portions, not only can the move- ments be recognized, but also the number of fingers held up. The peripheral portions of the retina above and below the yellow spot become impaired next, those inwards and slightly TREATMENT. 361 upwards last. The movements of the hand, placed outwards and below the eye {i.e., opposite the inner and the upper parts of the retina), are often recognized while the rest of the retina is completely paralyzed. It is very rare to find those peri- pheral parts of the retina, which are to the inner side of the yellow spot, impaired first; as is often the case in amblyopia from cerebral changes. The upper half of the retina may, how- ever, be paralyzed, Avhile the yellow spot and the lower half remain sensitive for a considerable time. The latter form of impairment of vision, by some, is termed hemiopia; while the other forms are described as contractions of the field of vision. The contraction is slit-shaped if the still sensitive portion of retina has a somewhat oval figure, with the long axis of the oval placed horizontally. As regards the efficacy of iridectomy, with reference to vision in glaucoma, it has been found that, as a rule, no favorable result is obtained if, previous to the operation, the paralysis of the retina has extended from the ora serrata to near the yellow spot; more especially if the latter has been situated close to one of the margins of the paralyzed part, and if, at the same time, the optic disk has been much cupped. The results have been better if the yellow spot has been at an equal distance from the surrounding paralyzed or impaired portions of retina, or if much of the impairment of vision could be explained by the turbid condition of the contents of the aqueous and vitreous chambers. A good result has been ob- tained by the operation if, in the intervals between the attacks, vision has been but little impaired. The less the optic disk is altered, and the less the peripheral parts of the retina are im- paired, the better is the prognosis. General Remarks.—Glaucoma occurs most frequently be- tAveen the a^es of 50 and 60, but it has been observed between those of 7 and 40. In a case, aged 7, simple glaucoma of both eves, and in another, aged 10, acute glaucoma of both eyes, occurred. Glaucoma, like senile cataract, ahvays appear in both eyes, but rarely Avith equal severity, or simultaneously. 362 GLAUCOMA. In one case 19 years elapsed before the second eye became glaucomatous. Glaucoma is more frequent in females; and appears, by preference, soon after cessation of menstruation. In some families it seems hereditary; and undue hardness of the eye in other members of the same family is often observed. Glaucomatous persons frequently suffer from "severe bilious attacks with sickness," from so-called rheumatism in the head, from sleeplessness, and from great prostration and dizziness. Simple glaucoma occurs, seemingly by preference, in persons with a large, full, and hard radial pulse. Attacks of erysipelas often precede chronic glaucoma. Atheromatous changes in the cerebral and in the ophthalmic arteries have repeatedly been observed after death, in glaucom- atous persons. In myopic persons, when suffering from glaucoma, the in- crease of tension and the attacks of inflammation are less marked. The analysis of a series of cases, in which the ages varied from 14 to 50 (five being below 30), shows that the de- gree of myopia may vary from \ to J. The tension of the eyeball was found nearly normal in two, and but slightly in- creased in the other cases. Only in one case was there exten- sive atrophy of the choroid. In all the optic disk was deeply cupped. In all both eyes were affected, but in different de- grees. Those not operated upon, lost vision; whereas those who were early operated upon, did well. In all cases the pig- mentation of the choroid became very conspicuous round the optic disk, while previous to iridectomy in most a crescent had been the only sign of choroidal atrophy. Hypermetropia is observed in a large majority of the cases. Glaucomatous changes, i.e., undue increase of tension, with its Consequences, are of frequent occurrence after operations. They have been observed after operations for cataract (particu- larly after depression), and also after spontaneous dislocation of the lens, after injuries (traumatic cataract), adhesions of the iris to the cornea or to a cicatrix, and after an intraocular tumor. Careful attention should be paid in such cases to the tension TREATMENT. 363 of the eyeball, the state of vision, and the sensibility of the peripheral parts of the retina, so that the necessary steps may be taken in time to remove the abnormal tension. Treatment.—Numerous surgical and medical means have been made use of in the treatment of glaucoma. Local or general bleeding, mercury, opium, etc., may seem to have checked "the disease;" or several attacks of inflammation may have passed off spontaneously, and left vision but little impaired; but it has been found that, if glaucoma be left to itself, or be treated medically only, or by inefficient surgical means, or at too late a period, vision sooner or later is destroyed. Tapping of the aqueous chamber, and frequent instillation of a strong solution of atropia, afford temporary relief. When once the tension has increased to a certain extent, atropia seems no longer to pass into the eye. Most oculists have adopted the operation of iridectomy as a remedy which, in numerous cases, has the effect of diminishing the abnormal tension of the eyeball. Every medical man Bhould learn to perform this operation. In cases of acute glaucoma, where it is of the greatest service, and where imme- diate surgical aid is required, the difficulties of its performance are but few, for the textures of the eyeball are little altered, provided vision has been useful before the attack. The operation is more difficult if the textures are rotten, as in simple and chronic glaucoma with much impairment of vision. The removal of a portion of iris is in itself a most harmless step, and never followed by serious consequences. No excuse exists for not performing the operation in acute glaucoma, es- pecially if vision has not been good before the attack. Persons who suffer from glaucoma, and whose sight is but little impaired, must be acquainted with the usual course of "the disease," and with its more serious symptoms. Patients should avoid those things which cause irritation of the eyes, such as much reading, "near work," mental excitement, sleepless nights, etc. We should urge the operation of iridectomy if we find the peripheral parts of the retina already impaired, or if attacks of dimness, with increased tension, appear at short intervals. 364 GLAUCOMA. Patients who have lost one eye by glaucoma are"more readily induced to have the operation performed. The longer the operation is postponed, the less favorable is the result. Secondary changes (mostly of an atrophic character) in the structures of the eye, brought on by long-continued pressure, are not remedied by iridectomy. Accidents which may arise during the operation, such as hemorrhage into the retina, Avounding of the crystalline lens, loss of vitreous, etc, diminish much the chances of success. As the result of careful examination of the retina, before and from six to eighteen months after iridectomy, properly per- formed, the following conclusions have been arrived at:— (1.) That the operation may be recommended as long as there is perception of light; and, in acute glaucoma, even if perception of light has been lost for a week after the attack. (2.) That the usual causes of failure are—advanced structural changes of the optic nerve of the retina; fresh increase of ten- sion; hemorrhage, especially in the region of the yellow spot, or into the optic disk; and accidents during or immediately after the operation, as intraocular hemorrhage, etc. (3.) That in the majority of cases, the amount of vision is preserved which the patient had before the operation, and that for months vision continues to improve. (4.) That the result is the less favorable the more the paraly- sis of the retina has approached the yellow spot, especially if it has done so more from above and below; or if the sensibility of the region of the yellow spot is so much diminished that the patient, when looking at an object, turns the eye to one side ("eccentric fixation"). (5.) That if we find the aqueous humor turbid, the transpar- ency of the vitreous substance impaired, and the entire retina sensitive, a better result is obtained by iridectomy than if these are clear, with a similar amount of impairment of vision. (6.) Thft in acute glaucoma the pain ceases almost immedi- ately. (From four to six leeches should be applied at bedtime to the corresponding temple, if the pain returns* soon after the TREATMENT. 365 operation.) The external "inflammation" and the turbid state of the media, as a rule, disappear tfter from ten to fifteen days. (7.) That the less the eyes are used for near work, the more satisfactory and lasting is the result of iridectomy. For the changes which the various structures undergo after the operation, see above—cornea, iris, optic nerve, etc., etc., in glaucoma. The pain attributed to pressure upon the ciliary nerves is felt in the eye and over the corresponding side of the forehead and temple, sometimes extending into the nose and the teeth. It may be so severe as to deprive the patient of sleep and appetite for days. It is so rare in simple, intermittent in chronic, and sudden as well as sharp in acute, glaucoma. In the latter the eye in the ciliary region is tender to the touch. Pain may appear with equal severity in blind glaucomatous eyes. It has been arrested for a time, by injecting from % to J of a grain of morphia, beneath the skin of the temple. It generally ceases at once after iridectomy. Blind glaucomatous eyes, if painful, should be excised. THE OPERATION FOR ARTIFICIAL PUPIL AND THE OPERATION FOR IRIDECTOMY. The object of the operation for artificial pupil is to establish a new pupil. , The operation differs from "iridectomy" in the Smaller quan- tity of iris removed, and in its object being merely to improve vision; Avhilst that of iridectomy is to influence the tension and nutrition of the eye. The operation for artificial pupil may be performed on one or both eyes, provided there be sufficient perception of light, no iritis, and no increase of tension. The operation for artificial pupil is indicated— (1.) In dense opacity of the cornea, Avith or without syne- chiae. 366 OPERATION FOR ARTIFICIAL PUPIL. (2.) In closed pupil, with or without synechiae. (3.) In lateral displacement of the crystalline lets, where its margin interferes with the functions of the natural pupil. (4.) In stationary opacities of the crystalline lens, or of its capsule. (5.) In obstinate myosis. The operation of iridectomy is performed on one or both eyes— (1.) In suppuration of the cornea, especially if at a future period, on account of opacity, an artificial pupil might be re- quired, or if otherwise paracentesis might have been performed. (2.) In some forms of chronic iritis, choroiditis, or ophthal- mitis. (3.) For the removal of foreign bodies from the interior of the eye. (4.) To relieve the irritation caused by swollen particles of the crystalline lens. (5.) Preliminary to extraction of cataract, especially if sy- nechiae exist; or after extraction, if the iris has been much bruised. (6.) In various forms of staphyloma. (7.) In hemorrhage into the vitreous chamber. (8.) In glaucoma. ARTIFICIAL PUPIL. As regards the advisability of the operation for artificial pupil, if the fellow-eye is sound, it must be remarked that an enlargement of the field of vision is frequently the sole advan- tage obtained. The artificial pupil should be made as small, central, and well-defined as possible, and behind the most transparent por- tion of the cornea, and that which is least altered in curvature. A careful examination by lateral illumination of the curvature and transparency of the cornea, of the appearance of the nat- ural pupil, and of the state of vision, must precede the opera- tion. During the operation we act on the supposition of the crys- talline lens being transparent. If we find it opaque, we en- large the incision in the cornea, remove more iris, and extract TREATMENT. 367 the opaque lens with the scoop, hook, or syringe, or break it up with the needle, and allow it to become absorbed. If it has been removed and the pupil has become closed aftenvards, we proceed as stated beloAV. On the day preceding the operation atropia is applied to the conjunctiva of the eye we wish to operate upon. Chloroform must be administered in most cases, unless the patient be very quiet, and no complications are expected during the operation. The Operation.—The patient is placed upon a bed, with the head slightly raised. The operator, standing behind, intro- duces the stop-speculum, to keep open the eyelids to the desired extent, and fixes the eyeball with the forceps, if possible, tak- ing hold opposite the point where he proposes making an inci- sion. The incision is made Avith a cataract-knife, or with one of the straight or bent lancet-shaped knives, by passing the in- strument slowly through the cornea or sclerotic into the ante- rior chamber, holding the blade as nearly as possible parallel with the anterior surface of the iris. The width of the incision depends upon the kind of operation we Avish to adopt. A very small incision suffices if we propose using the iris- hook or the canula forceps. A larger incision is necessary for the use of the iris forceps. Having obtained an incision of the proper width, we slowly withdraw the knife, Avhen from the escape of aqueous humor, and from the advance of the iris towards the cornea, we infer that the incision leads into the anterior chamber. We now proceed to the formation of the artificial pupil. METHODS OF "MAKING" AN ARTIFICIAL PUPIL. (1.) By Corepolinanoixis, that is, by reopening the natural pupil, by removing any opaque membrane from its area, that may have remained there, e.g., after iritis. Excellent results have been obtained by this operation, which, if the crystalline lens is not wounded, and the opaque mem- brane is but loosely attached to its capsule, admits of restoring, as regards position, the original pupil. The opening into the 368 OPERATION FOR ARTIFICIAL PUPIL. anterior chamber is made with the smallest lancet-shaped knife through the sclerotic near the cornea. The point of the knife, if the entire margin of the pupil is adherent, is thrust through the iris, behind that portion of its margin which lies farthest from the incision in the sclerotic. Having thus made an opening to alloAv of the iris-hook being. carried behind the iris, the knife is quickly withdrawn, so as to lose but little aqueous humor. The hook is then introduced, and its short, bent portion carried through the artificially- made, or through an already existing, opening behind the mar- gin of the pupil. The short portion of the hook, being turned towards the crystalline lens, is made to glide behind the opaque membrane, which, on Avithdrawing the hook gently, may be seen following in its wake. The membrane, which is generally elas- tic, need not be drawn out of the anterior chamber, but may be detached from the greater part of the margin, and from the area of the pupil, and left to itself. We should select another mode of operating if, after one or two attempts, Ave do not suc- ceed in passing the hook behind the membrane. (2.) By Corelysis, i.e., by separating adhesions of the iris from the anterior surface of the capsule of the crystalline lens. The pupil must be thoroughly under the influence of atropia. The incision is made in a part through Avhich the largest number of synechiae can be reached. The instrument, after having made the opening large enough to admit a spatula or iris-hook, should be withdrawn quickly, to avoid losing aqueous humor; for the less is lost, the more effectual are the move- ments of a hook or spatula. To detach the adhesions, we pass a blunt iris-hook or a spat- ula close to an adhesion behind a not adherent part of the margin of the pupil; or, if the entire margin be adherent, be- hind a portion which previously has been separated from the capsule of the crystalline lens, as is done in corepolinanoixis. The instrument is then carried on behind the iris, until it is supposed to ha\e passed beyond the adhesion or adhesions. By a to-and-fro movement Avith the hook or spatula behind, and as parallel as possible with the iris (so as not to wound the TREATMENT. 369 capsule of the lens), and thence through the pupil into the an- terior chamber, Ave detach some or all of the adhesions from the capsule. A more or less circular, active, and clear pupil is fre- quently obtained. (3.) By iridectomeenkleysis, in other words, by cutting off part of the iris, leaving part entangled in the corneal incision. (4.) By iridoialysis, i.e., by tearing away the iris from its inser- tion. A sharp hook (or an iris forceps) is introduced through an incision in the cornea up to the insertion of the iris*; a portion of which is seized and torn away from its insertion. The entire iris can in this way be readily removed. A pupil is thus formed close to the margin of the cornea. The incision through the cornea, or through the opaque sub- stance occupying its place, should be made at a spot through „ Avhich the instrument, used for removal of the iris, can easily reach the insertion of the iris. This mode of operating has been found of use in cases in which only a narroAV rim of cornea has remained transparent; and in cases in which it has been desirable to diminish the ten- sion* of the eyeball, without removing any iris. (5.) By making an incision through a portion of the iris, with- out removing any. This method has been employed in cases in which a great part of the iris, along with the pupil, has been adherent to the cornea, or to a cicatrix, which has occupied its place; the crystalline lens being absent, or opaque. The incision is made by thrusting the small, or middle- sized, lancet-shaped knife through the cornea or cicatrix, near the part of the iris Ave wish to divide, and then into and through the iris. The stretched fibres of the iris are expected to recede from the line of insertion. This operation is also employed in cases in which, after absorption or removal of the crystalline lens, the iris has become adherent to parts (capsule, hyaloid, fossa, etc.), Avhich are themselves thickened and opaque. In such cases an artificial pupil, when made in any other way, frequently becomes closed again; whereas extraction with the 24 370 OPERATION FOR ARTIFICIAL PUPIL. hook or forceps, of the opaque parts, may be followed by de- structive inflammation. In these cases a middle-sized lancet-shaped knife is thrust through the cornea, near its margin, and through the adjacent iris into the vitreous chamber. The knife is withdrawn quickly, so as to lose as little fluid from the vitreous chamber as possible, and a pair of iris scissors is introduced, closed, through the in- cision hi the cornea. Arrived in the anterior chamber, the blades of the scissors are opened—one to pass through the in- cision behind the iris, and behind the parts adherent to it, into the vitreous chamber; and the other to glide along the surface of the iris, across the anterior chamber. The blades are then closed, and the largest possible incision made, through the parts betAveen the blades. Useful vision has been obtained by this mode, where other methods had failed. (6.) By iridodesis, or iridesis, i.e., tying with silk a portion of the iris, after having drawn it through an incision in the cor- nea, as is shown in Figure 34. The operation has been performed in cases in which the natural pupil has been entirely or in part preserved: An incision, just large enough to ad- mit a very small iris hook or canula for- ceps, is made thro' the margin of the cornea into the an- terior chamber (too '8- 340 large an incision may allow the loop of silk, together with the included iris, to slip into the anterior chamber). A small loop, made of a piece of very fine black silk, is laid upon the eyeball, round the incision, in such a manner that each 51 TREATMENT. 371 end of the loop can readily be grasped with ciliary forceps by an assistant. The small iris-hook (Avhich is more manageable than the can- ula forceps, and less likely to bruise the iris) is passed through the loop and incision in the anterior chamber, and the iris which we wish to tie is draAvn out through the incision, and through the loop. The assistant, in readiness with the ciliary forceps, draws the loop tight, as soon as the operator, having withdrawn the desired quantity of iris, directs him to do so. By this means, the withdrawn portion of iris is fixed outside the eye. The assistant, Avhen tightening the loop, should closely follow the curvature of the sclerotic, and not draw its ends away from the eyeball. One end of the silk thread is cut short; the other is left about a quarter of an inch long, to allow of withdrawing the loop, which, if it has not fallen off after the eighth day, should be removed. The advantage of this mode of operating is, that the "arti- ficial" pupil retains its contractility. The disadvantages are, that a small staphyloma of the conjunctiva, with escape of aque- ous humor beneath that membrane, often remains, and also that troublesome iritis occasionally follows. Iridenkleisis.—Strangulating an artificially excited prolapsus, in a long and narrow opening, is then an advantageous substi- tute for the complicated iri- dodesis. For the purpose of performing this, Ave proceed exactly as in iridectomy; but the incision is made three- quarters of a line from the corneal border, on the scle- rotic, and the lancet-shaped knife is entered very ob- liquely, and only so far that the inner opening of the wound has a length of not more than a line. Then (Fig. 35.) the iris is pulled out of the 372 OPERATION FOR ARTIFICIAL PUPIL. opening, as may be required, with the forceps {vide Fig. 35), but the prolapse is simply felt. The after-treatment is the same as in iridectomy. The prolapsed portion falls off after some days. In case it remains longer, and becomes finally trouble- some, it may be simply removed. No reason follows, as a rule. (7.) By coremorphosis—that is, by exercising a small portion of iris. This is the usual and the easiest mode of "making an arti- ficial pupil". An incision, sufficiently large to admit of the free passage of the iris-hook which we propose to use, is made with a cataract or lancet-shaped knife, through the sclerotic, close to the margin of the cornea. The iris-hook is introduced through the incision, and carried along the posterior surface of the cornea, until its short bent part, somewhat turned towards the cornea, has passed beyond the margin of the pupil or the part of the iris we intend to withdraw. Then, by slightly rotating the handles of the hook, we cause the short bent part to turn towards the pupil, without, however, pressing it in that direction. We now slowly withdraw the hook, which should cause the short bent part to glide behind the margin of the pupil. Whilst withdrawing the hook, and with it some of the iris, we again rotate the handle, so as to cause the short bent part, together with the iris held by it, to turn towards the cornea. This turn we give the hook, before its short bent part has reached the margin of the incision, and thus prevent the hook from be- coming arrested at that margin. An assistant cuts off the iris, which has been withdrawn, with a pair of iris scissors; close to the hook, if a small, close to the eyeball, if a large, pupil is re- quired. By drawing out the iris more or less we can, in a great meas- ure, regulate the size of the artificial pupil. It is preferable, if the margin of the pupil is adherent through- out (as previously ascertained by instillation of atropia), to use, instead of the hook, the iris forceps. The incision, in this case, must be larger, to admit of easy manipulation of the iris forceps. TREATMENT. 373 IRIDECTOMY. Instruments.—A thin, stop-speculum (to keep the eyelids open without stretching the conjunctiva too much, and without causing pressure upon the eyeball). A pair of forceps to fix the eyeball (for this purpose, forceps with sharp points, to enter the sclerotic, are required, if the conjunctiva is so rotten that it tears when grasped). Straight and angular lancet-shaped knives, of different sizes. A pair of iris forceps, a pair of blunt-pointed iris scissors, and a turette. The Operation.—The patient, placed in a recumbent position, with the head slightly raised, is brought thoroughly under the influence of chloroform, so as to avoid all straining. The oper- ator, standing behind the patient, introduces the stop-speculum, to keep the eyelids open to the desired extent. With the forceps ("to fix the eyeball") he seizes the con- junctiva and subconjunctival tissue (or, with the sharp-pointed forceps, the sclerotic, if the conjunctiva should tear) close to the margin of the cornea, and, as nearly as possible, opposite the spot where the point of the knife has to enter. Previous to commencing the incision the eyeball should be rotated in various directions, so as to insure its being well secured. The point of the knife is then thrust slowly through the sclerotic into the anterior chamber, just m front of the insertion of the iris; care being taken to keep the point, while in the anterior chamber, directed towards the cornea, so as to avoid wounding the crys- talline lens. The knife, having entered the anterior chamber, is carefully pushed on until the incision has the desired size. The width of the cutting-blade of the lancet-shaped knife should be such that the desired size of the incision is obtained whilst the knife is advancing into the anterior chamber. The incision, if not wide enough, must be enlarged while withdrawing the knife. The knife, after completing the incision, is gently withdrawn; its point being kept inclined towards one or the other side of the anterior chamber, away from the area of the pupil, so as to 374 OPERATION FOR IRIDECTOMY. avoid wounding the lens, and to prevent too rapid escape of the aqueous humor. If, previous to making the incision, there is little or no aque- ous humor, so that the iris nearly touches the cornea; especially if, at the same time, the pupil is much dilated, and, consequently, the lens more likely to be injured, then the incision is made with the smallest lancet-shaped knife; and some iris is drawn out with the iris-hook, and cut off. After a feAV days a larger quantity of aqueous humor has accumulated, Avhen a larger iridectomy may be performed. Instead of adopting this proceeding, we may enlarge the small incision with scissors (Avhich is more difficult), and per- form iridectomy at once. Some, to obviate a cystoid cicatrix, commence the incision at the extreme margin of the cornea; thrusting the blade, perpen- dicularly, through the cornea, and, on reaching the anterior chamber, pass it on in the usual direction. Better vision and better outward appearance of the eye is obtained by making the incision near the upper margin of the cornea. The subsequent steps of the operation are, however, rendered easier by making it near the outer margin. The operator, after completing the incision, either confides the forceps to the assistant, who seizes and steadies the eyeball, or he does it himself, while the assistant is intrusted with the manipulation of the iris scissors. The next step is the removal of a portion of the iris. The iris, if protruding from the wound, is seized with the iris forceps, close to one of the angles of the incision, and cut off as directed beloAv. If the iris is not protruding, the curved iris forceps are closed, and introduced through the centre of the incision, and pushed oiiAvards in front of the iris, and carried up to and not beyond the margin of the pupil; where they are allowed to open to the extent of the incision. The iris, by pressure of the parts behind, is pushed between the branches of the forceps; it is seized by closing the forceps, with- out pushing them back towards the iris. The latter is then slowly drawn out through the incision, and, with the scissors, TREATMENT. 375 cut through, on the side of the forceps, close to one angle of the incision; care being taken to divide the iris from the margin of the pupil to its insertion. Having divided the iris at this point, we draw the portion grasped by the forceps towards the other angle of the incision; we thus tear it away from its insertion, and again divide it with scissors at the other angle. Before making this second cut, care should be taken to draw the iris towards the angle where it was divided first. Adhesions of the iris to the incision are thus avoided. In this manner we remove the entire width of the iris, or nearly as much as corresponds to the length of the incision in the sclerotic. The more widely the forceps are opened, the more of iris can be seized and excised. Some are satisfied with the less difficult proceeding of cutting off, at once, the portion of iris which has been withdrawn with the forceps. No iris should be left entangled in the incision. A flexible spatula or a scoop may be passed through the incision, at its angles; and any iris that may have remained there may be pushed back into the anterior chamber; care being taken not to wound the crystalline lens, nor its suspensory ligament. The speculum is then sloAvly removed; and some lint, dipped in cold water, is tied over the closed eyelids, so as to exercise slight pressure, while the patient is recovering from the effects of chloroform. Accidents during the Operation of "Iridectomy," or that for "Artificial Pupil."— Experience is required as regards the distance from the mar- gin of the cornea at Avhich the incision should be made through the sclerotic. By piercing the sclerotic too far from that margin, we may be led behind the iris, and Avound the lens or some of the ciliary processes; or, with the point of the knife, tear the iris from its insertion. The former accident has been folloAved by cataract, or by loss 376 OPERATION FOR IRIDECTOMY. of "vitreous;" the latter by profuse hemorrhage into the cham- ber and beneath the conjunctiva. Bleeding into the Anterior Chamber.—(1.) Through Avounding the ciliary processes, or detaching the iris from its insertion. This accident may happen if the knife, entering through the sclerotic, is introduced too far from the margin of the cor- nea, or is not properly directed. The bleeding may be so profuse as to oblige us to discontinue the operation. Severe traumatic iritis may follow. The point of the curette should be kept in the wound; and slight pressure made upon the eye, to encourage the escape of blood. If this does not succeed in removing the blood, it is better to postpone the other steps of the operation until all blood has become ab- sorbed. (2.) Through blood running into the anterior chamber, from cut vessels of the conjunctiva. This often occurs in eyes in which the tension is below par, or in Avhich, from the protracted, extensive inflammation of the choroid and iris, with normal ten- sion, and generally with total posterior synechiae, the textures have lost their elasticity. To recognize such eyes, experience is required. It is generally useless to attempt to remove the blood. Slight pressure, by means of wet lint tied over the closed eyelids, causes it to become more rapidly absorbed. The incision should be made in such cases through the cornea; and the operation conducted in a manner to avoid, as far as possible, all sources of bleeding. (3.) Through spontaneous bleeding from the iris. This occurs more frequently if there is chronic iritis, or if the bloodvessels of the iris, after protracted iritis, have lost their elasticity. We sometimes succeed in removing the blood (if fluid) by suction, or by pressing upon the cornea with the finger or curette, or (if clotted) by drawing out the clot with the iris forceps. Clots of blood, if left, sometimes set up new iritis, and, occasionally, closure of the artificial pupil. Pressure upon the closed lids, by means of wet lint, should be made until all blood has disappeared. TREATMENT. 377 The aqueous humor may escape before the incision is completed, i.e., before it has the desired width. The knife should be withdraAvn, and the incision completed with blunt-pointed (strabismus) scissors; taking care to carry the point of that blade of the scissors, which is introduced into the anterior chamber, close along the insertion of the iris. An incision may thus be enlarged to any extent. Some difficulty may be experienced in the introduction of the iris-hook or of the iris forceps. If the incision has been made through the sclerotic, very slight pressure with the instrument, upon the sclerotic, next the margin of the incision which is farthest from the cornea, will cause the incision to gape, and thus generally allow the instrument to pass. Occasionally some conjunctiva may have to be excised, or the incision may have to be enlarged, or even a second incision may have to be made through or near the cornea. We may not succeed with the iris-hook in drawing out the iris, through the texture of the iris being so rotten that the hook passes through it, as it would through wet blotting-paper. In this case we enlarge the incision and remove the iris with the forceps. The same proceeding is adopted if the margin of the pupil is adherent throughout; causing the short part of the hook to glide from the area of the pupil over its margin, instead of be- hind it. Difficulties in the removal of iris with the iris forceps may arise through the texture of the iris being so altered by inflam- mation that* it has become stiff, and often glazed over with trans- parent exudation, or adherent throughout to the capsule of the lens, so that it cannot be grasped by the forceps. In this case a lancet-shaped knife is thrust, close to the incision in the sclerotic or cornea, through and behind the iris into the crystalline lens. A square-shaped piece of iris and lens capsule is grasped with the iris forceps (one of the branches being passed through the incision behind the iris into the lens, the other in front of the iris), and torn away; or a piece of the iris and capsule are cut out with iris scissors. This step is followed by the removal of 378 OPERATION FOR IRIDECTOMY. the crystalline lens. A similar proceeding is adopted if the iris, on account of its being too rotten, can only be removed in small particles; while the uvea remains adherent to the capsule of the lens. Adhesions of the uvea to the capsule of the lens is the rule if extensiA'e iritis has preceded the operation. The exercised portions of iris should therefore be placed in Avater, and ex- amined for the presence of the uvea; and, if no bleeding has ensued at the time of the operation, lateral illumination should be used; by Avhich means, in every case, the presence of uvea in the area of the artificial pupil can be discovered. The uvea, during lateral illumination, may be scraped away with a spatula from the capsule of the lens. The treatment generally adopted, however, is to remove the capsule of the lens, with the uvea attached to it, and the lens itself. Causes of Failure, or of Incomplete Success of the Operation for Artificial Pupil.—(1.) Opacities, and alterations in curva- tures of the cornea (Avhich may only become conspicuous after the operation); (2.) Pigment on the capsule of the crystalline lens; (3.) Cataract; (4.) Alterations in the shape of the eye- ball; and (5.) Morbid changes of the choroid and of the other tunics. 1, 2, 3, can, as a rule, be discovered by lateral illumination; 4 and 5 by the use of the ophthalmoscope. (6.) Hemorrhage into the anterior chamber. In this case considerable time must be allowed to pass before attempting a second operation. All inclination of the eye to "redden up," and all discoloration of the aqueous humor, should have disap- peared before operating again. During the steps of a second operation, all things should be carefully avoided which had given rise to bleeding before, e.g., an incision through the scle- rotic, straining during the operation, wounding of certain por- tions of iris, etc. A combination of several of the causes of failure of the oper- ation is frequent; and often renders the treatment after the operation difficult. (See the Treatment of Opacity of the Cor- nea, Cataract, etc.) TREATMENT. 379 Iritis attributable to the operation itself, is a rare occurrence; probably owing to the fact of the piece of iritis, seized Avith hook or forceps, being removed, and to the iris tissue, which is generally altered in structure, being less perceptible of inflam- mation. (7.) A so-called cystoid cicatrix, i.e., an incision which has become incompletely closed by loose opaque tissue, alloAving the aqueous humor to escape beneath the conjunctiva: this gives the latter an cedematous appearance. In extreme cases the aqueous humor may extend beneath the conjunctiva, all round the cornea; Avhereas in slight cases there may be more bulging of the intervening tissue, between the margins of the inci- sion. The cystoid cicatrix frequently occurs after the oper- ation of iridesis, and after iridectomy, if the incision has been made through the sclerotic, and if some of the iris has remained entangled in the incision, or if increased tension has caused ex- pansion of the tissue filling the incision. Generally no harm results, but suppurative iritis has been known to follow. The local application of atropia, gentle pressure, by means of a bandage applied over the closed eyelids, or puncturing the bulging cicatrix with a broad needle, has been recommended. The bulging of the conjunctiva, if troublesome, or disfiguring the appearance of the eye, may readily be removed; and the cystoid cicatrix closed, by passing a silk thread through the sclerotic, across the point through which the aqueous humor seems to escape. The thread is tied lightly, the ends are cut short, and the lids kept closed until the thread has come away spontaneously. The inflammation, caused by the presence of the thread, suffices to close the opening Avhich leads into the aqueous chamber. Closure or contraction of the artificial pupil is observed—(1.) In eyes with total posterior synechiae; (2.) In eyeballs which are more or less shrunken, and the tension of which is below par. Vision after the Operation for Artificial Pupil—We may obtain binocular vision (the most favorable result) by most of the various modes of operating; if the retina is sound in the 380 ANOMALIES OF VISION. region of the yellow spot, and the artificial pupil not too near the margin of the cornea. Strabismus may follow from non-use of the eye operated upon. Sometimes diplopia occurs; which disappears either spontane- ously, through both eyes acting together, or through the less distinct retinal image of the eye operated upon being no longer observed. ANOMALIES OF VISION. An object, e.g., a luminous point, appears single if both visual lines are directed to the point. The point appears double if Ave look at an object placed in a straight line beyond it, while the object in its turn appears double, if we look again at the point. Scotoma in the Region of the Yellow Spot {Central Scotoma, Central Interruption of the Field of Vision, Impairment of Direct Vision).—Scotoma in the region of the yellow spot may appear after looking into strong light, or after working too much at the microscope. It may appear in both eyes, if both are used in succession. In the eye thus used a yellowish mist is noticed. This mist is followed by a deep-broA\n one, if the work which caused it be continued. Objects placed opposite the region of the yellow spot can no longer be perceived. Hours may elapse before the mist has cleared away, and vision has be- come normal again. The boundary of the impaired portion of retina is ill-defined, while the function of the more peripheral parts may continue undisturbed. With the ophthalmoscope, we observe an increased grayish haze, surrounding the reddish centre of the yellow spot. From this kind of scotoma, which may occur whenever cause is given, we distinguish the one which appears more gradually, without any apparent cause, often in both eyes, and which re- mains. On ophthalmoscopic examination, in the latter case, we may find choroido-retinitis and loss of transparency, followed by local pigmentation and atrophy. TREATMENT. 381 Peripheral parts of the retina sometimes acquire, in such cases, a degree of acuteness which is not possessed by equally eccentric parts of the healthy retina. Another form of central scotoma is that caused by cerebral or extraocular changes. In these changes the ophthalmoscopic examination is often negative, and the boundaries of the im- paired portion of retina are very irregular. The arrest of the function of a certain number of optic nerve-fibres, e.g., from cerebral changes, gives rise to impairment of the functions of those parts of the retina to which such fibres belong. A sco- toma is observed opposite the impaired part of the retina, while the rest of the retina remains normal. The functions of the more eccentric parts of the retina are likeAvise annihilated, if the elements of the retina and the entire layer of optic nerve- fibres are destroyed. The folloAving mode of ascertaining the extent of small central scotoma (the felloAv-eye being healthy) has been proposed:— The patient is directed to look at a white spot on black, dull paper. To healthy eyes, the white spot, viewed through a blue- tinted glass, held before one, and through a yellow-tinted glass, held before the fellow-eye, appears of a dirty-green color. If the region of the yellow spot, e.g., of the left eye, is impaired (the healthy right eye looking through the yellow, and the left through the blue-tinted glass, at a piece of white chalk, held at the side of the white spot), then the spot and the piece of chalk appear yellow. The chalk appears of a dirty-green color (on moving it along the black paper, away from the white spot, both eyes being fixed on the latter), the moment a point is reached where both retinae participate in the act of vision. The shape of the impaired portion of retina can be found by ascer- taining a certain number of such points. An amblyopic or amaurotic portion, i.e., a scotoma, adjoining the optic disk, and, most frequently, the portion next the yellow spot "Enlargement of the blind spot" Small blind or impaired portions of the retina, adjoining the optic disk, are generally not noticed by the patient. Large ones, if encroaching upon the region of the yellow spot, betray 382 ANOMALIES OF VISION. themselves by portions of an object, situated externally to the point directly looked at, appearing indistinct or missing. The impaired portion is rarely irregular; generally it is transversely oval. Atrophic changes, commencing at the choroido-retinal aperture, and following inflammation or simple distention, as in extreme myopia, are the usual cause. These changes, when recent and appearing rapidly, for a time impair ("dazzle") the vision of the fellow-eye. To make the impaired portions of retina more strikingly per- ceptible, we cause the patient to look, with the affected eye, through a small opening, at a strongly illuminated white surface: the impaired portions appear as dark spots. Amblyopia or amaurosis of other parts of the retina ; eccentric scotomata ; eccentric interruptions of the field of vision. If eccentric portions of the retina are not destroyed, but only impaired, we find the patients complain of differently-shaped gray, black, or colored spots. These either obscure portions of an object, or cause them to appear indistinct, misty, or distorted, or too small, or too large. Small impaired spots are often over- looked, especially if confined to one eye, and are least perceived if the other eye is closed. They are generally the result of choroido-retinitis. Amaurosis, progressing from the periphery {margin) of the retina towards the yellow spot; contraction or limitation of the field of vision. The impairment of vision—(1.) May be confined to one-half of the retina ("hemiopic limitation"). (2.) May advance, to an equal extent, from all points of the periphery of the retina, towards the yellow spot ("concentric limitation"), as frequently occurs in both eyes of the same patient. A zone of amblyopic retina generally joins the amau- rotic one. (3.) May advance more rapidly from one side ("irregular limitation"). Of this latter, different varieties occur, e.g., the amblyopia or amaurosis may progress more rapidly from the outer margin of the retina, as in cupping of the optic disk; or more rapidly from TREATMENT. 383 above and below, as in anaemia and atrophy of the optic disk; or irregularly, from all sides, as in the different forms of cho- roido-retinitis. The "amaurotic" portions of the retina may join healthy portions; but more frequently they are contiguous with "ambly- opic", ones. Cerebral changes, affecting vision, lead simultaneously to eccentric limitation and to impairment of direct vision, but not to morbid changes in the retina. If, from impeded innervation, or from non-use, direct vision is much impaired, while the eccentric parts of the retina remain sensitive throughout, the prognosis is better than if direct vision is good, but the eccentric parts are much or irregularly impaired. Amaurosis, from overuse of the eyes, through fine work, micro- scopic or telescopic work, or from sudden exposure to strong light {lightning). The region of the yellow spot is the part usually impaired. With the ophthalmoscope, we may find choroido-retinitis. Exposure to strong light has even given rise to ophthalmitis of the exposed eye. In other cases no changes are discoverable within the eye, with the ophthalmoscope. Anomalies of vision, which are caused by extra-ocular, and especially by cerebral causes, often present no marked objective symptoms beyond the impairment of vision. The eye, the vision of which is disturbed, may appear quite healthy, or there may be but slight alteration in color of the optic disk. To decide upon the prognosis and treatment of such cases, it becomes necessary to examine other functions of the body. The following are symptoms which frequently precede or accompany the cerebral lesions, which give rise to impairment or loss of vision:— Headache.—Headache, in itself, is no guide as to the cause and seat of the lesion, which may have given rise to impaired vision. It may precede the impairment of vision for years, and is attributed to morbid changes in the dura mater. Anaemia and atrophy of the optic disks of both eyes, are the changes which are finally observed with the ophthalmoscope. 384 ANOMALIES OF VISION. Vomiting.—We should ascertain what kind of vomiting there has been; whether of bile (the age of the patients attacked by this kind of vomiting varies, as a rule, between 18 and 30),— or of blood (the age of the patients varies between 40 and 50). We should also inquire whether there has been obvious cause for it, or whether it has appeared after meals, or at any other time. The vomiting may be a reflex action, which ceases as the ocular changes progress; or it may be connected with morbid changes about the medulla oblongata, or at the roots of the eighth nerve. Vomiting and headache with amblyopia or amaurosis are, as a rule, signs of cerebral disease. Inflammation of the optic disk of both eyes is the morbid change which is frequently found in ophthalmoscopic inflammation. Giddiness is often complained of, long before lesions of vision occur, by persons suffering from heart disease, with intermittent pulse, or from rigid arteries, or from derangement of the cir- culation, in consequence of cerebral changes. Convulsions {"epileptic fits") of otherwise healthy, or of par- alyzed parts. Neither the character nor the frequency of the fits is a guide as regards the nature of the lesion, which may have given rise to defective vision. If confined to one side, we may suspect the cause of impaired vision to lie near, or at the corpus striatum. The fit is sometimes preceded by complete blindness; the latter is attributed to temporary anaemia of the retina, from spasm of the coats of its bloodvessels. Hemiplegia is a frequent forerunner or companion of disturb- ance of vision. If the two appear simultaneously, they are at- tributed to apoplexy near or in the corpus striatum, or thalamus opticus. If the hemiplegia precedes the amaurosis for a long time, then we may attribute the latter to secondary cerebral lesions; or if it occurs suddenly, to fresh apoplexy. In amau- rosis with hemiplegia of the right side, and with loss of speech, both hemispheres have repeatedly been found diseased. Amaurosis, when occurring on the same side as the hemiplegia, is attributed to embolism. Amaurosis from inflammation of the TREATMENT. 385 optic disk of both eyes, without anomalies of locomotion, is gen- erally complicated with, or caused by, lesion of the cerebellum or of the hemispheres. Eleven patients suffering from this anomaly, all of the middle age, have come under observation within the last four years. They complained, at first, of great general weakness (including that of the genital organs), of a sensation of "pins and needles" in the lower extremities, and of numbness, accompanied by a painful feeling of constriction of the chest. Then folloAved cramps in the feet and trembling of the hands, especially when attempting to seize objects. Two months after the first symptom of "ataxy" had appeared, vision became impaired, a mist "ap- pearing before the eyes, and gradually getting thicker." The blood-supply to the retina and choroid remained normal, but the optic disks rapidly became anaemic, and remained so even in the cases in which the acuteness of vision rose from T\ to \. The treatment of these cases by nitrate of silver has been at- tended with favorable results. The nitrate of silver is supposed to have restored the normal relation betAveen the optic nerve- fibres and the nerve-cells, in the corpora quadrigemina. In the cases in Avhich there was no perception of light, no effect was produced, while in the patients who could still read large letters, the acuteness of vision rapidly (within from four to ten days) increased. After six weeks all signs of ataxy had disappeared. The nitrate of silver is given twice daily, in doses of a quarter of a grain, gradually increased to one grain. Causes of amblyopia and of amaurosis.—(1.) Ocular (in the retina, choroid, or optic nerve). (2.) Extra-ocular {orbital). (3.) Cerebral or spinal. Cerebral changes, accompanied by great disturbance of the circulation Avithin the head (as observed during rapidly-groAving- cerebral tumors, and during meningitis), are often complicated with hyperemia of both the retinae, with rupture of retinal blood- vessels, swelling of the optic disks, etc. Anaemia and atrophy of the optic nerves are usual changes observed during certain chronic cerebral changes. Such cerebral changes may be far 25 386 ANOMALIES OF VISION. away from the optic nerve-fibres, and yet, through pressure, etc., impair their functions. There may be extensive disease of the hemispheres, with perfect vision. Morbid changes of the right hemispheres are more often complicated by amaurosis. Changes confined to one side of the brain may cause hemiopia, but never complete amaurosis. Amaurosis or Amblyopia (a) from Intra-cranial and Cerebral Tumors.—The usual seat of such tumors is the basis cranii, especially the sella turcica and the neighborhood of the cere- bellum. Loss of vision is produced either by pressure, impeding the functions of the optic nerves or the circulation, or by complica- tion with inflammation of the optic nerves, with meningitis, etc. The most frequent changes observed Avith the ophthalmoscope in the course of cerebral tumors are—hyperaemia,—oedema,— inflammation of the optic disks and retina,—anaemia, or anaemia with atrophy of the optic disks. Slight protrusion of the eye- ball, with fulness of the veins about the eyelids, is an occasional complication of tumors at the sella turcica, or at other parts of the basis cranii. Amaurosis {b) from Morbid Changes at the Base of the Brain. —The most frequent change observed is meningitis (tubercular, pyaemic, typhoid). In some cases the impairment of vision appears at the time of meningitis; in many, long after the men- ingitis has passed. Both optic nerves, or one, or only part of one, may be affected. Amaurosis of both eyes, in these cases, is generally complicated with paralysis of other cerebral nerves. Amaurosis {c) following Apoplexy, or Softening, or Tubercu- losis, or Abscess of the Brain.—The lesion of vision is often com- plicated with paralysis of separate spinal nerves, or of other spinal nerves, with hemiplegia or paraplegia. Apoplexy is a frequent cause. It may appear simultaneously in the eye and brain. Monolateral hemorrhage into the thalamus opticus causes hemiopia. To produce blindness, hemorrhage must occur on both sides. Hemorrhage into the chiasma may cause blindness. When occurring at other parts of the basis cranii, it generally affects the third nerve also. TREATMENT. 387 Simulation of Amaurosis or of Amblyopia (1) of both Eyes. —This has been observed in insane persons, and in others, with a vieAv of obtaining a certificate of blindness. Simulation may be suspected, if both pupils are active, and if it is stated that light cannot be perceived. We may be unable to express an opinion if the person only denies the power of recognizing objects Simulation of Amaurosis or of Amblyopia (2) of one Eye {generally of the Right).—If the pupil of the supposed blind eye (provided it be not under the influence of a mydriatic, and the fellow-eye be thoroughly excluded from light) does not contract when suddenly exposed to strong light, but does so when both eyes are open, we can pronounce the first eye to be blind. We should, if any doubt remains, after having carefully examined the "supposed" blind eye, place a strong prism, e.g., one of 12°, with the refracting angle doAvmvards, before the good eye. The patient is directed to look at the flame of a candle, Avhen the simulation at once becomes apparent, if he states that he sees two flames (attributing them to the suction of the prism on the sound eye). Amaurosis with Disease of the Spinal Cord.—Tenderness, on pressure in the region of the first cervical vertebra, with impair- ment of vision, has been observed to precede the amaurosis. The ophthalmoscopic symptoms, in advanced cases, are anaemia and atrophy of the optic disks and retinae. The atrophy of the optic disks is, in some cases, the first of a series of symptoms arising from spinal changes. Much benefit has been derived, in some cases, from repeated blisters applied to the cervical region. The post mortem examination of some cases has shown atrophy of the trunks of the optic nerves, and morbid changes, e.g., atrophy in the thalami optici. As causes have been observed injuries, inflammation, atrophy. Reflex amaurosis (/) from "irritation," originating in one of the sensitive nerves, or from "irritation" of other parts of the nervous system. Cases belonging to this group occur, not frequently without any apparent changes in the eye (the optic disks, among other 388 ANOMALIES OF VISION. parts, appearing healthy), or in the functions of the cerebrum or cerebellum. The amblyopia or amaurosis is attributed to alterations in the tubercula quadrigemina; Avhich alterations are supposed to be the result of "irritation" elsewhere, e.g., of injuries to the spinal cord, or irritation of the frontal nerve, of neuralgia of the face, of gastralgia, of irritation, caused by Avorms. The disturbance of vision following such irritation, the in- crease or decrease of vision keeping step with the irritation, and improvement of vision, on cessation of the supposed cause, justify the assumption of a reflex amaurosis. Amaurosis or Amblyopia {h) from General or Constitutional Causes.—(1.) Appearing among other symptoms of albuminuria. (2.) During syphilis. (3.) During diabetes mellitus. (4.) Through embolism. The morbid changes comprised under (1), (2), (3), and (4), when localizing themselves in the eyes, assume certain character- istic forms, e.g., that of effusion of lymph, in syphilis, that of peculiar infiltrations with rupture of bloodvessels, in albuminuria, etc., etc. If, on the appearance of amaurosis or amblyopia, we find the eyes intact, and, after examination of other organs, dis- cover albuminuria, syphilis, etc., we adopt the same general treatment, which would have been carried out if the eyes had been attacked. Amaurosis {k) appeariny during Irregularities of Menstrua- tion, during Pregnancy, Parturition, or Lactation.—Sudden amaurosis, appearing about the time when menstruation has been expected, has been observed, in two cases, to subside again, after the reappearance of that function. Vision returned gradually, in both cases, and has remained normal. Cases of recurring amblyopia or amaurosis, commencing at some period of pregnancy, and subsiding after parturition, have repeatedly been recorded. A frequent cause of amblyopia or amaurosis, after sudden arrest of menstruation, is the occurrence, at that period, of intra- ocular or of cerebral hemorrhage; which has been preceded, in several cases, by severe pain in the head, with unconsciousness. TREATMENT. 389 The morbid changes, which give rise to lesion of vision during the above changes in the body, in many respects resemble those observed during albuminuria, and may be divided into three groups:—(1.) Cases in which the chief symptom is hemorrhage within the eye, Avith oedema of the parts adjoining the seat of hemorrhage; (2.) Cases in Avhich infiltration (inflammation) appears with the subsequent changes of texture (generally at and near the optic disk); and (3.) Cases in which no lesion is discoverable within the eye. Amaurosis {I) from Anaemia {Ischaemia).—(1.) Anaemia from general causes, e.g., from diabetes, diarrhoea, spermatorrhoea? loss of blood. Vision, in these cases, is lost; in some gradually, in others suddenly. Much good may be done, if the impairment is not considerable, by improving the general health; while if the ophthalmoscopic signs of atrophy of the optic nerve and retina have appeared (and the sooner the Avorse), little hope remains, though the general health may have been restored. Vomiting of blood has been accompanied or followed by sud- den loss of vision of one eye, or of both. If one eye only is affected, the other generally becomes impaired in from one to six months later. Vision, in such cases, if lost suddenly, often remains lost, though the general quantity of blood may have been restored. The anaemia and atrophy of the retina and of the optic disk appear at a later period. There may have been amaurosis for some time, Avhile, with the ophthalmoscope, we find only slight anamiia, or no changes at all. The loss of vision is not explained by the quantity of blood lost, nor by anaemia of the brain, since other cerebral functions return as the quantity of blood increases. The amaurosis sometimes appears while the patient is recover- ino- from the loss of blood. In some cases the loss of blood has been so slight that the amaurosis could not be attributed to it. Several of the patients suffered from ulceration, with slough- incr of the mucous membrane of the stomach. Their ages varied from between 40 and 50. (2.) Amaurosis or amblyopia from anaemia from local causes. Gradual compression of the artery of the retina is followed 390 ANOMALIES OF VISION. by impairment of the functions of the retina, in the region of the yelloAV spot. Sudden obstruction causes sudden amaurosis. The less arterial blood enters the retina, the more is vision im- paired. Amaurosis {m) produced by Tobacco, or Lead, or Quinine, or Alcohol.—These substances often produce spasm, or paresis, or paralysis of the ciliary muscle; and Ave must guard ourselves against mistaking for amblyopia or amaurosis the disturbances of vision due to these conditions. By Tobacco.—The patients generally are of middle age, thin, of pale-yelloAv complexions, and rarely complain of pain in or about the eyes. They generally state, that the impairment of vision has progressed slowly. Vision may, hoAvever, within six months, be reduced to mere perception of light. The impair- ment of vision (if the disease is progressing) reaches this degree in from six to eighteen months. Both eyes are affected, though in varying degree. One eye may become blind without the patient being aware of it. Night blindness and decrease of acuteness of vision, for distance, are often the earliest objective symptoms. Photopsia frequently appears, and sometimes after all vision is lost. With the ophthalmoscope, we observe, at first, hyperaemia of the optic disk, with anaemia of the retina. Anaemia and atrophy of the optic disk and retina finally follow. The greater the dim- inution in the number of arteries in the retina, the greater is the impairment of vision. Post mortem examinations have shown traces of basilar meningitis, which has affected the optic nerves, and also the third and facial nerves. By Lead.—Impairment of vision from medicinal application of lead has been observed in two cases, and from Avorking with lead in several cases. In the former, protracted headache Avas followed by sudden loss of vision in the right, and, tAventy-four hours later, in the left eye. This was complicated with paralysis of the ciliary muscle and iris, and with some increase of temper- ature. In one case vision returned after the use of mercury (to salivation), followed by that of iodide of potassium. In one of the latter cases no morbid changes, except extreme anaemia, were discovered on post mortem examination. TREATMENT. 391 By Quinine.—Deafness and noises in the ears are usual com- plications. With the ophthalmoscope, we find a tortuous con- dition, or, at least, an overfulness of the veins of the retina, in the otherwise healthy eye. Much benefit has been derived from repeated bleeding. By Alcohol.—In one case in which vision was reduced to mere perception of light, during prolonged abuse of alcohol, the optic disks appeared healthy. Vision, after drinking was dis- continued, and leeches had been applied to the temples, returned rapidly, so as to allow the patient to folloAV his employment. Amblyopia of one Eye {n) from Non-use, after Prolonged Exclusion.—This form of amblyopia reaches a high degree, only, if it be congenital, or of very long standing. It may remain un- discovered for years. Cases have occurred in which the functions of the retina of one eye have seemed to interfere with those of the fellow-eye. In these cases, direct vision of one eye gradually becomes im- paired. The development of higher degrees of amblyopia seemed to be prevented, in some of these cases, by the pupil becoming closed, or cataract developed. Paralysis or paresis of the iris, and of the accommodation, opacities of the cornea, and espe- cially strabismus of one eye, are usual complications. INJURIES OF THE RETINA AND OF THE OPTIC DISK. The retina readily undergoes suppuration, together with other tunics, during ophthalmitis, after injury. During operations on the deeper parts of the eye, the retina may be wounded; or it may become lacerated by foreign bodies passing through it,. without the ensuing inflammation extending beyond the seat of injury. (See Retinitis, Ophthalmitis, and Injuries of other Tunics, and of the Vitreous Substance.) Concussions by blows, etc., may be followed by displacement of the retina, or by rupture of its bloodvessels, or by glaucoma, or by ophthalmitis, or by a combination of these. 392 AMBLYOPIA OR AMAUROSIS. The changes of the retina, as seen with the ophthalmoscope, have appeared, in many cases of concussion, confined to the bloodvessels. These, especially the veins, have appeared more numerous and unequally dilated: and more so if the injury has given rise to hemorrhage into the vitreous chamber. In the majority of cases the arteries and veins have been found abnor- mally thin, and have remained so for months; Avhile those of the felloAv-eye have appeared more numerous, and, on the slightest pressure, have shown pulsation. The optic disk, as a rule, appears unduly vascular, and some- times as red as the choroid. This is occasionally folloAved by anaemia, Avith some atrophy, if inflammatory changes have appeared in or near the optic nerve. Rupture of the choroid, near the optic disk, leaving a bluish- white cicatrix, is an occasional complication. Traumatic choroido-retinitis round the optic disk, Avith or with- out inflammation of the latter, has, in several instances, led to complete loss of vision, Avithout externally altering the appear- ance of the injured eye. AMBLYOPIA OR AMAUROSIS, WITH APPARENTLY HEALTHY OPTIC DISK. Cases of sudden loss, or of rapid impairment of vision, if ex- amined Avith the ophthalmoscope soon after the impairment or loss of vision has occurred, often present no perceptible changes as regards the optic disk. As causes of such loss of vision have been observed—cerebral apoplexy;—echinococcus in one of the hemispheres;—hemor- rhage from the stomach or uterus;—general impairment of nutri- tion;—neuralgia in the face or eye;—periostitis of the facial bones;—inflammation accompanying "carious" teeth. If confined to one eye, anaemia of the retina may be observed in the affected eye. In some cases it is difficult, even for an experienced observer, to decide whether an optic disk is normal TREATMENT. 393 as regards color, or unduly hyperaemic, or slightly anaemic, etc. An intimate acquaintance with the different shades of color ob- served in health, at different ages, and in eyes of different color, must assist us in the diagnosis. The prognosis is uncertain, as long as the optic disk retains its natural pink color. Such cases have been described as cases of reflex amblyopia, or of reflex amaurosis, if no morbid changes have been visible in the retina and in the optic disk. The treatment, in great measure, depends upon the nature of the symptoms. The division of a nerve, which may be the source of spasm or of neuralgia, the removal of a carious tooth, complete exclusion from light for some weeks, general medical treatment adapted to the patient's constitution, etc., have, in many cases, rapidly succeeded in restoring or improving vision. HYPEREMIA OF THE RETINA. The examination of numerous healthy eyes, the comparison of the tAvo eyes (if this condition is confined to one eye), and the general appearance of the patient, are, in slight cases, the guide as to the existence of hyperaemia of the retina. An in- crease in the number both of arteries and of veins, Avith an un- usual brilliancy of the retina and hyperaemia of the optic disk, is observed in hypermetropics, with asthenopia, and in myopics, Avith signs of irritation. Hyperaemia of the retina often appears during severe inflammation of other parts of the eye, and occa- sionally, in cases of protrusion of the eye, from extra-ocular causes. Overfulness of the veins of the retina—venous hyperaemia— is observed in persons suffering from syphilis or albuminuria. It also precedes inflammation of the optic disk, and appears whenever the return of blood from the retina is impeded, through pressure upon the optic disk, or upon the optic nerve, inside or outside the eye. The arteries generally appear thin and fewer in number, while 394 RETINITIS. the veins are large, tortuous, numerous, and most conspicuous in and near the optic disk. Venous hyperaemia also precedes and accompanies inflamma- tion of the retina. RETINITIS (INFLAMMATION OF THE RETINA. ' DYCTITIS). Retinitis is very rarely idiopathic. As a rule, it appears as one of the symptoms of other morbid changes, such as albumi- nuria, syphilis, cerebral tumors, etc. Retinitis appears very frequently in both eyes simultaneously, though it may vary in degree: it most frequently occurs in the part of the retina which adjoins the optic disk, and in the por- tion which occupies the region of the yellow spot. Peculiarities as regards color and shape or situation of the inflamed portion have given rise to the distinction of various forms of retinitis. These forms, if duly developed, are suffi- ciently characteristic to alloAv of recognizing the general morbid change, of which the retinitis is a symptom. FORMS OF RETINITIS. To facilitate reference, we will number the different forms. (1.) Retinitis, extending from the optic disk over a varying area of the retina. The retina, together with the entire optic disk, or with a part of it, appears hazy, gray, or gray-white and opaque. A similar change may simultaneously be found in the region of the yellow spot. The arteries appear thin and fewer in number. The veins are tortuous, gorged (pale-red in the leucaemic form, dark- red in the form which complicates cerebral tumors). (See In- flammation of the Optic Disk.) (2.) Retinitis apoplectica. An unusually large number of blood-spots (many of which lie close to gorged tortuous bloodvessels) appear in the turbid retina, especially at and near the optic disk (3.) Retinitis, with yellow or buff or crust-colored spots, or patches. TREATMENT. 395 This form of retinitis appears, by preference, in the region of the yellow spot, and round the optic disk, and is generally ac- companied by marked decrease of blood-supply to the retina. (4.) Retinitis pigmentosa. (5.) Retinitis, with one or several large, gray, and opaque patches. This form of retinitis occurs more frequently at some distance from the optic disk, or near the ora serrata. Small blood-spots, Avith increase in the number of arteries and of veins (which are particularly conspicuous in the optic disk), are observed in the retina; the retina adjoining the inflamed portion is oedematous. The vessels, in the further course of the disease, gradually resume their natural calibre, though overfulness of the veins often continues long after the retina has resumed its transpar- ency. The blood-spots and the opaque patches disappear, the retina gradually becomes transparent, and the choroid becomes visible. Some atrophy of the retina, with slight anaemia of the optic disk, generally remains. (6.) Suppuration of the retina. The retina rapidly (in from 12 to 36 hours) becomes yellow- ish-Avhite, opaque, and swollen, especially round the optic disk and in the region of the yelloAv spot; where its thickness may be three or four times that of the retina in health. This swell- ing and the loss of transparency are caused by the pressure of pus-cells, exudation corpuscles, etc. The pus-cells and the ex- udation corpuscles are supposed to originate in the nuclei of the fibres of the frameAvork of the retina. The outer surface of the suppurating retina, in many instances, has a uniform red color, from the extreme capillary vascularity developed in it. Causes and General Remarks.—1. Retinitis (5) has been observed after sudden exposure of the retina to bright light, and after undue prolonged exertion. The retinitis, in these cases, is often confined to the injured eye, and more often to the region of the yelloAv spot. 2. Retinitis (5) and (6) occur after injuries and operations. (See Ophthalmitis.) 396 RETINITIS. 3. Retinitis (5) and (6) often appear after general illness, such as scarlatina, measles, small-pox, etc., or during pregnancy, suckling, etc. 4. Embolism, albuminuria, diabetes, diseases of the heart and arteries, frequently give rise to retinitis (1), (2), or (3). 5. Syphilis gives rise to retinitis (1) or (3). 6. Intra-ocular causes of retinitis are choroiditis, inflammation of the optic disk, cyclitis, rupture of bloodvessels ("retinitis apoplectica"), tumors, and entozoa. These causes generally lead to retinitis (5) or (6). Retinitis, with much loss of transparency of the retina, is often folloAved by atrophy. The retinitis may remain stationary, or may decrease (according to the habits, occupation, etc., of the patient); or it may progress rapidly to a certain point, and then become chronic. The longer the duration, the less favorable is the prognosis. Retinitis is frequently accompanied by choroiditis. Symptoms common to all or to several of the above forms of retinitis:— 1. Loss of transparency, varying from slight haziness to a uniform gray and opaque color. In the opaque portion Ave find blood-spots, or yellow and opaque spots (as in albuminuria), or rusty-colored, or yellowish-Avhite, nodules (as in syphilis). The lesions of transparency are most conspicuous in the region of the yellow spot and round the optic disk; and, together Avith anomalies in the circulation, are char- acteristic of retinitis. 2. Alterations in the appearance of the bloodvessels. In most forms of retinitis we find an apparent decrease in the number and size of the arteries, and a gorged, tortuous condition of the veins. Portions of these latter are entirely, or more or less, hidden in the opaque retina. Groups of enlarged capillaries, appearing to the naked eye as blood-spots, are particularly frequent in the retinitis (5) and (6) covering the outer (choroidal) surface of the retina. Blood- spots, the result of rupture of bloodvessels, occur in most forms, but more particularly in (1) and (2). 3. Photophobia, photopsia, chromopsia, with headache, pain TREATMENT. 397 in the eye, and with lachrymation, may appear in the beginning or in the further course of the disease, or may be entirely miss- ing; or only one, or several of these symptoms, may be present. 4. The exterior of the eye (the eyelids, conjunctiva, cornea, etc.) presents nothing characteristic of retinitis. In suppuration of the retina, we generally observe those changes which appear during ophthalmitis, or chemosis, swelling of the eyelids, pro- trusion of the eye from oedema, or inflammation of the parts within the orbit, etc. 5. Vision. No impairment of vision may be observed by the patient if the inflammation occupies only peripheral parts of the retina, or if it is confined to one eye only, or if the occupation of the patient does not require acute sight. We often find entire loss of transparency of the retina, with very slight impairment of vision, probably because the changes are, in that stage, confined chiefly to the connective tissue of the retina. In slight degrees, or at the outset (when the inflammation occupies the region of the yellow spot or of the optic disk), objects appear to tremble, or glitter, or seen distorted, or sur- rounded by a gray-Avhite, or broAvnish, or yellowish, or red, mist. Much light is required for vision, and objects have to be held closer. In higher degrees, interruption or limitation of the field of vision is observed. Vision may become reduced to bare percep- tion of light rather suddenly, and then decrease or improve gradually. The impaired portions of retina are generally ill-defined. They are described as black or gray patches, by the patient, when looking at a sheet of Avhite paper, held close to the affected eye. The prognosis, as regards recovery of vision, is less favorable if there is interruption or limitation of the sensibility of the retina, than if the entire retina is more uniformly impaired. The longer the duration of the retinitis, the worse the prognosis. Dark spots in the field of vision may clear up in some parts more than in others, or may disappear entirely. 398 RETINITIS. Treatment.—For the treatment of the forms of retinitis (1), (2), (3), and {A), see articles on the several subjects. Treatment of form (5). Both eyes must be kept thoroughly at rest, until all hyper- aemia has disappeared from the retina and optic disk. This is effected— 1st. By keeping the lids of both eyes closed during the day, if there is intolerance of light: we simply prohibit the use of the eyes for near work, if there is no intolerance. 2d. By ordering atropia to be applied, twice daily, and tinted spectacles to be used, if the atropia should give rise to intoler- ance of light. 3d. By avoiding everything that might derange the circula- tion in the retina, such as travelling in a carriage, stooping, occupations causing excitement, etc. 4th. By bathing the closed eyelids Avith cold or warm water, according to the liking of the patient, and as often and as long as it is pleasant. One or tAvo leeches to the temple, on the side of the affected eye, applied at bedtime, relieve pain, if it be accompanied by such hyperaemia of the inflamed part. The retina and optic disk should occasionally be examined with the ophthalmoscope. A glance will suffice to ascertain their condition. When once the retina has become transparent, and the choroid again visible, little further improvement of vision can be expected. The general hygienic and medical treatment must be directed according to the cause of the retinitis, and the health of the patient. Mercury has been found of use in retinitis, occurring during pregnancy. Tonic treatment is adopted when the retinitis has appeared during or after small-pox, measles, and similar weak- ening diseases. This form of retinitis, in weak persons, often goes on into suppuration. (See, also, The Treatment of Choroi- ditis.) TREATMENT. 399 ATROPHY OF THE RETINA. The cause of the atrophy, in a great measure, determines the kind; and, again, the different kinds point to different causes. With the ophthalmoscope, and on a minute examination, we can distinguish four different forms:— No. 1. No morbid changes are perceptible in the choroid, nor in the transparent retina, beyond an extreme anaemia of both tunics, or of the retina only. Anaemia of the choroid (the groups of the stellate pigment cells being visible throughout the choroid) may be mistaken for atrophy of that tunic, by those Avho are not familiar with the color and shape of these groups in health. The retinal arteries and veins are thinner the farther they are from the optic disk. They are tortuous and unequally di- lated, the optic is anaemic, or anaemic and atrophic. It has a waxy-Avbite and opaque color. No. 2. This form is described as one of the sequels of inflam- mation of the optic disk. It is the conjoined result of an im- peded blood-supply to the retina, and of impaired nutrition, through arrest of the function of the optic nerve. (See Inflam- mation of the Optic Disk.) No. 3. Atrophy following retinitis or choroido-retinitis. The optic disk may be anaemic or atrophic, or highly hyperaemic Its margin, according to the changes in the choroid and retina, is either Avell-dilated, or its color merges into that of the tunics. Causes and General Remarks.—Atrophy of the entire retina, or of portions of it, the result of old age, is very rarely ob- served to such an extent as to be regarded as morbid. In the few cases which have occurred, the appearances were those de- scribed as "retinitis pigmentosa." The following changes lead to atrophy of the retina:— 1. Any of the lesions Avhich, for a long time, prevent retinal impressions from reaching the brain, such as diseases of the brain or of the optic nerves. The atrophic changes described as for No. 1, in these cases, appear late, and progress very slowly. 400 ATROPHY OF THE RETINA. A certain amount of atrophy may disappear again, if the extra- ocular lesion subsides. 2. All changes which mechanically cause anaemia of the retina, such as embolism, inflammation of the optic disk, cupping of the optic disk, increase of tension. 3. A large series of intra-ocular changes, Avhich may be sepa- rated into—(a.) Those which commence in the choroid, leading to atrophy of that tunic, and, secondarily, to atrophy of the retina; or Avhich, during choroiditis, invade the retina, destroying it from its outer surface (form No. 3); and {b.) Those which com- mence in the retina, subsequently to retinitis (form No. 3), or which are caused by pressure of the contents of the vitreous chamber upon the retina, destroying the latter from its inner surface (form No. 2). RETINITIS DURING ALBUMINURIA. Retinitis may appear Avhenever albumen is present in the urine: it is most frequently observed in patients suffering from Bright's disease. Retinitis, in these cases, has been considered a forerunner of albuminuria. On careful examination, however, it will be found that alterations in the kidneys have existed long before, though the symptoms may have been so slight, or pro- gressing so sloAvly, that the retinitis has become the first promi- nent symptom of the kidney-disease. When meeting with this form of retinitis, we must be prepared to see other ursemic symptoms make their appearance, though they need not necessarily follow. " Granular kidneys," with dilation of the cavities of the heart, and with hypertrophy of the left ventricle, have been found, not in all, mit in most cases in which post mortem examination could be obtained. The opacity and swelling of the retina, and the tortuosity and enlargement of its veins, disappear gradually. The outline of the optic disk becomes visible again, together with the vessels in it. We may find the yellow spots, which appear in the later TREATMENT. 401 stage of the retinitis, alone, or mixed Avith blood-spots, while the rest of the retina has regained its transparency. Peculiar changes, by some described as "sclerosis," have been found in the coats of the bloodvessels, especially in those of the small arteries, and of the capillaries of the retina and of the choroid. These; vessels have appeared unusually tortuous and flattened in many places, with their walls thickened by a homo- geneous, strongly light-reflecting "amyloid," not quite trans- parent, substance. In some cases the thickening of the Avails has caused occlusion of the lumen of the vessels. This may have been the cause of the small aneurismata, which have been found in many parts of the capillaries. The retina and choroid, adjoining the thickened vessels, in some cases, appeared hypertrophied. The yellow or buff-colored spots, Avhen situated in the retina itself, were found amongst its ganglion cells, but more frequently in the granule layers. The spots were most numerous round the yelloAv spot. The thickness of the retina, as could best be' seen in sections, Avas considerably increased. Treatment.—The general medical treatment is that of albumi- nuria. Much benefit is derived from large doses of strychnine, combined Avith steel; and, in stout nervous persons, from a com- bination of Mixt. Ferri Co. and Decoct. Aloes Co., aa, §j., to be taken at bedtime. No advantage has yet been gained from surgical treatment, such as iridectomy, etc. Rather abundant local depletion {e.g., by applying from six to eight leeches to the corresponding temple) is found of great use in the commencement of retinitis, but is injurious Avhen once the yelloAv patches have appeared. If these spots and patches are numerous in the retina, or if blood has been effused into the vitreous chamber, atropia should be applied, twice daily; and the eyelids should be kept closed by a bandage, if one eye is affected, or a shade should be worn, if both eyes are attacked. The local treatment is discontinued as soon as the yellow patches have disappeared. Displacement of the retina, follow- ing extensive hemorrhage, or destruction of the retina, through 26 402 DISPLACEMENT OF THE RETINA. atrophy, etc., is the frequent cause of permanently impaired vision. The prognosis, as regards recovery of vision, is good, if there are but few spots of the retina affected. An improvement may be expected as long as yellow or blood-spots are visible. DISPLACEMENT OF THE RETINA. Displacement of the retina, if it commences Avithout pain or outward inflammation, may escape notice for some time, until the patient accidentally discovers the sight is failing. Some patients state, that when the eye began to fail, they suddenly found they could only see the halves of objects, or that a black, well-defined cloud (sometimes appearing, at first, red, then yel- low) obscured some, and generally the upper parts of objects. Objects, at the outset of the displacement, often appear crooked, bent, or multiplied, or as if surrounded by red haze. The changes, in many cases, especially if folloAving an injury of the tunics of the ciliary region, may be preceded, for years, by muscae, or by some "dimness." In some cases the muscae ap- pear suddenly, and the displacement shortly folloAvs. Severe throbbing pain in the eye and temple, fiery circles, stars suddenly appearing and disappearing, may precede the displacement, for weeks. Some patients state, that after bodily exertion, a flash of light passing across the eye has been followed by sudden impairment of vision. Owing to changes in the retina adjoining the displaced portion, the impairment of vision is often more considerable than might be expected from the extent of the displacement, especially in fresh cases. The transition from the blind to the normal parts of the retina is gradual, if the displacement is small; it is sudden, if large portions of retina are displaced. The greater part of the retina may be displaced, and the patient may still be able to read small type, if the region of the yellow spot has remained intact; or all perception of objects may be abolished, if the retina round the optic disk has been TREATMENT. displaced, though there still be a large eccentric portion in its proper position. The upper or the loAver parts, only, of an object are perceived, if the upper or loAver half of the retina is alone displaced. In a feAV cases of complete displacement of the retina, the poAver of perceiving light has been retained. Secondary changes often destroy the sensibility of portions of retina which are not displaced. Vision may become much improved after the changes in the retina next to the displaced portion, and those in the vitreous chamber, have subsided. The fluid between retina and choroid often becomes less, or alters its position; and the sensitive parts of the retina are thus excluded from vision. It not unfrequently happens that the displacement is complicated with effusion of blood into the vitreous chamber, or Avith cataract; in such cases the retina may not be accessible to ophthalmoscopic examination. Cataract generally appears tAvo or three years after displace- ment of a considerable portion (generally the lower half) of the retina: it is particularly necessary, in such cases, to recognize the presence of displacement, by testing the sensibility of the retina. For this purpose, the patient is placed in a dark room. The healthy eye kept closed, the flame of a candle is moved be- fore the suspected eye, or reflected upon it with the ophthalmo- scope. The flame can be perceived only by sensitive portions of the retina. Suppose the lower half of the retina to be dis- placed, we shall find that if the flame be held opposite to it (that is, above the level of the pupil), the patient cannot perceive the flame, and if requested to indicate with his hand the position of the flame, he cannot do so. In cases of cataract, this is con- clusive. In effusion of blood into the vitreous chamber, a doubt remains as long as the blood is accumulated at the most depend- ing part, thus preventing the light from reaching the retina. Treatment.__Spontaneous "absorption" of the fluid between retina and choroid (in part, or in toto) has frequently been ob- served. This occurs sometimes with unusual rapidity. The retina comes again in contact with the choroid, but does not resume its functions. If the displacement is limited, and the displaced retina transparent, or nearly so, and the patient is 404 DISPLACEMENT OF THE RETINA. otherwise in good health, from six to tAvelve leeches should be applied to the temple of the affected side, at bedtime; after which both eyes must be kept closed for two or three days, and the patient must remain in bed. The improvement, in some cases, is very great after repeated leeching. Patients with bare perception of shadows have been able, after the second leeching, to read large letters. In some, hoAvever, effusion of blood has occurred, between the choroid and retina, after the leeching; in others no improvement has folloAved. No treatment restores even perception of light, if the entire retina is displaced. The local application of atropia, though it may not affect im- provement of vision, seems to retard further displacement. Atropia should be used sufficiently frequently to keep the ciliary muscle of the affected eye at rest. No treatment seems of use— (1.) If the entire retina is displaced, or if the displaced retina has lost its transparency, or if there exists atrophy of the rest of the retina and of the optic disk. (2.) If the displacement has occurred in the course of ophthal- mitis, or if suppuration of the retina, or if suppuration of the vitreous substance, within the area of the retina, has set in. (3.) If the displacement is a complication of intra-ocular tumors. In the two latter cases excision of the eyeball may have to be performed. Myopic persons are the only subjects in whom the displace- ment has hitherto been observed in both eyes. It is in myopia that photopsia and hemorrhage into the vitreous chamber most frequently precede the displacement. A diffused red color, appearing suddenly in the interior of a myopic eye (vieAved with the ophthalmoscope), so that- no distinct view can be ob- tained of the optic disk and of the tunics, has been observed as a symptom of commencing displacement ("of loosening") of the retina. The displaced retina occasionally becomes ruptured spontane- ously, and the fluid between it and the choroid escapes into the TREATMENT. 405 vitreous chamber, while the retina resumes its position upon the choroid. This has led to the operation of perforating the dis- placed retina. No serious accidents have followed, in the cases hitherto operated upon. The earlier the operation is performed, the greater is the im- provement of vision that may be obtained. This, sometimes, is almost immediate, or appears a few days later. Signs of the success of the operation are:—disappearing or diminution of the displacement; turbidity of the previously transparent vitreous substance; improved sensibility of the pe- ripheral parts of the retina. Immediately before performing the operation, Ave should ascertain the degree of impairment of vision, and the extent and position of the displacement. Operation.—The patient is seated as for ophthalmoscopic ex- amination ; the eyelids are kept open by the wire-speculum; and the eyeball is fixed by an assistant. The operator uses the ophthalmoscope Avith the left hand; and having, by "direct" examination, obtained a vieAV of the prominent portion of the displaced retina, thrusts a cataract-needle, of sufficient length, through the tunics into the vitreous chamber, at the spot which seems most suitable. The operator Avatches, with the ophthal- moscope, the passage of the needle across the vitreous chamber, and through the displaced retina into the space between it and the choroid. Having thrust the needle through the displaced retina, he gives the ophthalmoscope to an assistant, who, with it, throws light upon the eyeball. The operator then passes through the tunics a second needle, about the third of an inch from the first one, carrying it, as nearly as possible, to the spot where the first one has passed through the displaced retina. After bavins brought the second needle in'contact with the first, the operator thrusts the former on, still, a little farther (about to the same extent as the first needle). The points of the two needles are now supposed to be in the space between the choroid and displaced retina, their stems crossing each other The object of the next manoeuvre is to tear a hole in the dis- placed retina. This is accomplished by approaching the bandies of the needles towards each other (without withdrawing them, 406 PROTRUSION OF THE EYEBALL. or pushing them further into the eye, and Avithout making the movements so extensive as to cause the points to touch the por- tion of the retina not displaced). Having manipulated with the needles in such a manner as to make the existence of a rent in the displaced retina probable, one needle is AvithdraAvn, and the ophthalmoscope is again used, to ascertain, if possible, the effect of the operation. If the previously transparent vitreous substance is noAv turbid, or a rent is visible in the retina, or if flocculi of retina are seen projecting from the displaced portion, the second needle is also withdrawn. The manipulation with the tAvo needles should be repeated, if no alteration has occurred in the appearance of the displaced retina. The patient is put in bed, and the eyelids of both eyes are kept closed for a few days. Experience, as re- gards the kind of cases in which the operation should be recom- mended, and the final results, is too limited to enable us to establish any rules. The prognosis of displaced retina is, under all circumstances, very gloomy, and justifies our recommending an operative treat- ment, which, in several of the cases in Avhich it has been adopted, has had favorable results. An eye, with displacement of a small portion of the retina, between the yelloAv spot and the optic disk, and with divergent strabismus, Avas operated upon for the strabismus. A few weeks after the operation, the vessels in the displaced portion of the retina resumed their natural course, and vision became much improved. PROTRUSION OF THE EYEBALL. (Exophthalmos=protrusion of one or both eyes through— generally acute—inflammation within the orbit, or of the orbit and eyeball. Hydrophthalmos=protrusion of one or both eyes through distention of the tunics of the eyeball, especially by fluid, and without real change of place of the enlarged eye. Ophthalmoptosis=protrusion through paralysis or paresis of the muscles. Luxation of the eye=sudden protrusion through TREATMENT. 407 injury. Evulsion of the eye=sudden protrusion by injury; the eyeball being more or less torn away from its appendages.) Protrusion of the eye, if it interferes Avith the functions of the retina or optic disk, gives rise to impairment or loss of vision. Anomalies in the functions of the fifth nerve (pain, anaesthesia), or paresis or paralysis from changes in the third, fourth, or sixth nerve, may arise, with or without derangement of the cir- culation and nutrition of the eye. If adjoining cavities are implicated, an additional series of symptoms appear, which may be due to tumors in these cavities. Rapidity f Appearance.—Protrusion occurs suddenly during and after hemorrhage behind the eyeball, and in some cases of aneurism. In a few cases of aneurism, it has appeared gradu- ally, but has increased rapidly. It has occurred within a few days after simultaneous paralysis of the third, fourth, and sixth nerves. Slight pressure upon the eyeball made it disappear. A rapid succession of the signs of tumors in the orbit, Avith outward inflammation, may lead us to suspect the presence of an abscess, especially if fluctuation is felt somewhere between the eyeball and the margin of the orbit. Of tumors Avhich are accompanied by gradual protrusion, the bony tumors are the sloAvest, the cancerous ones the most rapid, in their progress. Mobility of the eyeball, and increase and direction of the pro- trusion. Increase of the protrusion indicates an increase of the morbid changes behind the eye, or their extension tOAvards it. If situ- ated in front of the equator of the eyeball, they may spread between it and the walls of the orbit, push forwards the con- junctiva and the lids, impair the movements of the eyeball, and yet hardly displace it; Avhile, if situated behind the equator, protrusion always appears. The eveball becomes displaced outwards and doAvnAvards, or outAvards and upAvards, through changes in the frontal sinuses. Through enlargement of the lachrymal gland, it may be dis- placed inwards and downwards. The direction of the displace- 408 PROTRUSION OF THE EYEBALL. ment of the eyeball varies, if caused by changes at the apex of the orbit, according to Avhich Avail of that cavity is most impli- cated; if, e.g., it be pushed doAvnwards and fonvards, we suspect the apex of the orbit and its upper Avail to be most at fault. The amount of protrusion is not proportionate to the size of the tumor, etc, which may cause it. A tumor may fill out the adjoining cavities, and encroach but little upon the orbit. The protrusion, Avhen caused by disturbances in the circulation, in- creases on stooping, or increases and decreases spontaneously, or may be arrested, or otherwise influenced by compressing the carotid artery of the corresponding side. The protrusion may be increased by the action of the orbicularis muscle—the ex- panded fibres of which, Avhen closing the lids, may press upon the protruding tissue, between the margin of the orbit and the eyeball, and, through this, upon the eyeball, behind its equator. The more the eye is pushed forAvards the more its mobility is decreased. Its movements may be impaired in one or two directions, particularly if the cause of protrusion is confined to one side of the orbit, as in tumors, caries, etc. They may be impeded in all directions equally—as, for instance, in struma, and in hypertrophy of the orbital tissue. A mobility in all directions, however impeded, shows that the eyeball is not ad- herent to the walls of the orbit. The movements may remain impeded in all directions, or may be destroyed; or the eyeball may become fixed in a certain position after the protrusion has subsided. Changes of the Protruded Eye and of its Appendages.—The lids readily become floccid, if expanded over a large or pro- truding eyeball, and by accident,, or during manipulation, the margin of either lid may slip back over the eye. A bent probe, passed beneath the displaced lid, readily succeeds in lifting it forAvards. (Edema, drooping and redness of the lids, and oedema, chemosis, and enlargement of the vessels of the conjunctiva, occur in rapid or considerable protrusion. Vascularity of the conjunctiva, in one particular part, may be a guide as to the situation of the cause. As soon as the protrusion is so consider- able that the cornea is no longer protected, the destruction of TREATMENT. 409 the eye may be expected. Anaesthesia of the cornea frequently occurs even in moderate degrees of protrusion. The cornea and the conjunctiva of young people may remain exposed to the air, etc., without injury, for a longer time than those of the aged. The state of nutrition and health of the cornea, previous to the protrusion, materially influence its power of resistance to exposure. Cases of struma and of cancer have occurred in which poAver the "protruding cornea sup urated or sloughed. In a case of hemorrhage behind the eyeball, in a young man, the cornea slouched within 36 hours after the commencement of the extreme protrusion. The cornea having become per- forated, the contents of the eye may escape, and the eyeball shrink; or the suppuration may extend, and ophthalmitis ensue. In some cases extreme protrusion may exist, for weeks, during an inflammation of the deeper parts of the orbit, and yet, the protrusion subsiding, the eye may resume its functions, or, though apparently intact, may remain amblyopic or amaurotic In other cases, ophthalmitis may appear even during moderate protrusion. Vision.—Double vision is complained of when protrusion of an othcrAvise healthy eye occurs rapidly; especially is associated with lateral displacement. In every case, Ave should inquire for double vision, and also ask Avhether it came on suddenly, whether it has existed for a long time, and whether it is present in all directions, or in what direction of the eye it is most per- ceived. For instance, Ave suspect morbid changes at the roof of the orbit, if, on looking upwards, the patient observes double vision, with differences in the height and parallelism of objects. In slowly-progressing protrusion, double vision remains unob- served, or vision may have become too much impaired to make it perceptible. An eve may protrude so much as to render it difficult for the lids to close over it, and yet, for months, the patient may be able to read well, and have otherwise Avhat he terms good sight. In other cases of but slight protrusion, sight may be lost. In a case of aneurism of one ophthalmic artery, vision was lost Ions after the recovery from protrusion. 410 PROTRUSION OF THE EYEBALL. Patients complaining of "a black veil coming over the sight," or of "only seeing half an object," frequently suffer from dis- placement of part of the retina; an accident which accompanies most intra-ocular, and some of the extra-ocular tumors. Visions of bright colors, flashes of light, falling of stars, are frequently complained of in congestion of, or pressure upon, a healthy optic nerve; for instance, in the course of melanotic tumors of the orbit. Pain and Cerebral Symptoms.—Absence of pain is a favorable symptom. Pain felt when pressing upon the eyeball, or on the tumors, generally indicates periostitis. Pain in the head, at the back of the eyeball, coming on suddenly, has been ob- served in aneurisms, and in periostitis, at the apex of the orbit. Headache occurs frequently in protrusion from periostitis (es- pecially if of syphilitic origin), or from impediments to the cir- culation of blood in the larger vessels. Inflammation, originating in the tissue of the orbit, may ex- tend into the brain, and cause meningitis, etc. Convulsions, epileptic fits, hemiplegia, impairment of the mental faculties, and paralysis of the first, second, and third nerves, have occurred when suppuration has extended from the orbit to the base of the brain. Brain symptoms, during inflammation in the orbit, and without paralysis of the first, second, or third nerves, indi- cate the probability of the presence of pus, betAveen the dura mater and the bones, near the roof of the orbit, or in the an- terior lobe of the brain. Loss of appetite, vomiting, increase of heat, increased frequency of pulse, shivering, sleeplessness, delirium, may occur after operations for protrusion, and indi- cate disturbance at the base of the brain. In a case recently operated on, in Dr. Walker's Infirmary (for enlargement of the right frontal sinus), with protrusion, hemiplegia and delirium appeared on the second day, and subsided a week after the operation, the patient recovering completely. Causes of Protrusion in General.—Protrusion of both eyes is frequently observed in persons suffering from palpitations of the heart, with enlargement of the thyroid gland (struma). Accumu- lation of blood in the vessel of the orbit is the probable cause. TREATMENT. 411 It has been observed in feeble, stout persons, generally females, from an undue accumulation of fat in the orbits (as found after death), with Aveakness of the muscles of the eyeball. Protrusion durimg acute inflammation of both eyeballs, or of the tissue of both orbits, is very rare; so also is cancer in both eyeballs or orbits simultaneously. More frequently we observe protrusion of both eyes, as a complication of hydropbthalmia. Protrusion of one eye, from inflammation Avithin the orbit, has occurred during scarlatina, measles, variola, puerperal fever, and similar diseases, and most frequently during recovery. Also after injuries, during erysipelas, phlebitis, glanders, and tuberculosis, from inflammation of the lachrymal gland, from abscesses formed in adjoining cavities; for instance, in the cranium, or the frontal sinuses, and perforating a Avail of the orbit. Acute inflammation of the soft parts of the orbit, or of its bones, or of the eyeball, constitute, as a rule, the immediate causes of the protrusion. Every ophthalmitis, especially if it occur quickly, as may happen after extraction of cataract, causes in itself protrusion, by implicating the soft parts of the orbit. Considerable protrusion, without external inflammation, may be caused by tumors, for instance—bony neAv groAvths, cysts, or aneurisms; by paralysis of the third, fourth, or sixth nerATes; by hemorrhage behind the eyeball, occurring spontaneously, or after an illness; by accumulation of serum between the eyeball and Tenon's capsule (in a case of this kind, it increased on stoop- ing, and then occasioned pain; the eye was subsequently ex- cised)*, by enlargement of the nasal cavities, of the frontal sinuses, or of the antrum. General Remarks on Treatment.—Great similarity often exists between the external symptoms of protrusion from dif- ferent causes; and, in many instances, the line of treatment remains uncertain until we have reached the cause—tumors, etc—with the knife. This is particularly the case if inflam- mation of the soft parts of the orbit, or of the eyelid, complicate deep-seated tumors. In every case of protrusion, we compare the thickness, position, etc., of the margins of the two orbits, and, if possible, pass the finger into the fornix of the conjunctiva, 412 PROTRUSION OF THE EYEBALL. betAveen the walls of the orbit and the eyeball, to ascertain the elasticity, consistence, fluctuation, etc., of a deep-seated cause of protrusion. By directing the patient to turn the eye in various directions, to bring into view the curvature of the sclerotic, we ascertain the shape of the eyeball, and how much of the protrusion is due to enlargement of the eye, and also whether the sclerotic is ad- herent to whatever may cause the protrusion, and Avhether the functions of the recti or oblique muscles are impaired. Other means of diagnosis are, auscultation of the margin of the orbit, ophthalmoscopic examination, and a careful scrutiny of the cavities adjoining the orbit. The operation of removal of a tumor is indicated, if the tumor increases in spite of medical treatment; if the eyeball or the brain is in danger; if a permanent disfigurement is eminent, especially if the eye can be saved. Cases of removal of large tumors from the orbit, in which vision has been preserved, are numerous. Whether the eye be lost or not, Ave adopt that mode of operating which, with com- plete removal, gives the best result as regards personal appear- ance. The operation is the more difficult the longer it is post- poned, if the tumor groAvs rapidly. . Tumors Avhich groAv sloAvly and Avithout pain, which are Avell-defined, where the eyelids are not implicated, and where the patient's health is good, are, as a rule, of a non-malignant character. The size, situation, and especially the nature of the tumor, Avhether cancer or not, in- fluence our prognosis. If the nature of the tumor is not known, and its complete removal necessary, then, for Avant of space, we may be obliged to remove the eyeball. The removal of bony tumors may take hours. Cases of this kind have occurred in which the attempt at removal had to be discontinued, on account of the difficulties met with during the operation. Before pro- ceeding to the removal, an exploring trocar may be passed into the tumor, along the wall of the orbit which gives the easiest access to it, unless there be symptoms of aneurism. For the removal of bony tumors, we require the instruments used in other parts of the body for similar purposes, or gouges, TREATMENT. 413 chisels, etc., of different sizes. It may be necessary to keep the patient under the influence of chloroform for an hour or more. If Ave determine upon the removal of the eyeball, this part of the operation should be done first; the tumor may thus be rendered more accessible. The incision through the skin and the soft parts is carried over the most prominent part of the tumor, and parallel with the margin of the orbit. A large tumor may require a second incision, meeting the first at right angles. The surface of the tumor, once freely exposed, if of bony nature, is seized with the forceps, and sometimes may be broken off from its attachment. With the saw, gouges, chisels, etc., we may have to work round its base to detach it. Diseased bone, near the tumor, should be removed. Bruising of the eyeball must be avoided as carefully as possible. A soft tumor or a cyst must be freely exposed, in order to reach the base or pedicle. After the operation, we facilitate free escape of pus, etc., and adhere to the general rules for the treatment of inflammation of the orbit. No secondary operations for the correction of changes in the position of the eyelids or eyeball, etc., need be performed until the effects of the first operation (swelling, redness, tenderness, discharge, etc) have completely subsided. For further particulars, see the treatment of the special causes of protrusion. TUMORS OF THE ORBIT, OR OF THE EYE- BALL, OR OF BOTH. Tumors may cause protrusion of the eyeball, whether they be situated within the eye, or in the orbit, or in the cavities ad- joining the latter (the frontal sinuses, the antrum, and the nasal cavities). They may appear simultaneously in several of these localities; or they may secondarily cause inflammation, etc., of the soft parts Avithin the orbit. Cancer.—The groAvth, as in other parts of the body, consists 414 TUMORS OF THE ORBIT OR THE EYEBALL. .^t/pz-^'j^^^fw^ sistence and somewhat the color of of a variable quantity of connective tissue, bloodvessels, or inter- stices filled with blood, brown or black pigment in varying pro- portion, and cancer-cells. Portions of the growth may be of a ^. a^^ brown color ("mixed melanotic and .jJ^_U%Xo;t^ medullary cancer "), or have the con- ^'X^v^^^^^illl brain substance ("pure medullary cancer"), Avhile other portions are of fibrous hardness. Sudden transi- tions of color or consistence may (Fig. 36.) appear in some parts, gradual tran- sition in others. In the melanotic form, the cells and fibres are loaded Avith brownish or black pigment granules, and with amorphous black matter. The cancer-cells of cancerous growth, in the orbit or eyeball, differ, in most respects, from those found elseAvhere. The medullary and melanotic forms of cancer have been primarily in all parts of the orbit and eyeball, e.g., upon the cornea, upon the outer surface of the sclerotic, near the optic nerve,—attached to the inner surface of the sclerotic, and pass- in cr through the choroid and retina into the vitreous chamber, —and in the ciliary muscle. In the retina the medullary, and in the choroid the melanotic, forms seem to occur primarily most frequently. (Cancer may appear simultaneously in different parts of the orbit and eyeball. It may cause inflammation of the adjoining tissues, or it may extend into them by infiltration, and thus fre- quently appear as a "tumor". It seems especially prone to ex- tend along the course of the veins; it may fill the eyeball (scle- rotic), destroying all its contents, long before appearing else- where; it may show itself upon the outer surface of the sclerotic, soon after its appearance within the eye. Increased vascularity of the conjunctiva, displacement of the iris, paralysis of the pupil, swelling, with loss of transparency of the lens, enlargement of the ciliary veins, and swelling of the sclerotic, with bulging of the latter, may precede the extension of cancer from the interior of the eye; while, in other cases, TREATMENT. 415 hardly any irritation occurs, during extensive development of cancerous tissue, within and around the eyeball. Destruction of the iris, suppuration or sloughing of the cornea, with protrusion of cancer, occur but rarely; this may, however, happen from Avhatever part of the anterior of the eye the cancer may have originated. Cancer in the choroid is most frequently of the melanotic kind, and originates in the part of the choroid occupied by the large veins (vasa vorticosa). Its favorable seat is the region of the yellow spot. It may appear as a defined tumor, or in the form of diffuse infiltration, or as both. Traces of the elastic lamina, generally covered Avith colloid globules, swollen, round- ish (changed hexagonal) cells, Avith enlarged nuclei, and with only a few or no pigment granules, may be found on the surface of the new groAvtb; while its base rests among the stellate pig- ment cells of the choroid. The secondary changes, usually found in the other tunics of the eye, are: destruction of the vitreous substance (by pressure), and partial or total displacement of the retina. Every cancer which springs from the sclerotic or choroid, and projects into the vitreous chamber, Avithin the area of the retina, causes changes in the position of the latter. Thus the retina may become adherent to the tumor, or its curvature may undergo alteration, in consequence of its being pushed into the vitreous chamber; or it may be completely detached from the choroid by an accumulation of fluid. This fluid, which is highly albu- minous, may be clear or mixed Avith blood, cancer-cells, or pus; its effusion is supposed by some to be caused by pressure of the tumor upon the veins of the choroid. A very small tumor may be accompanied by displacement of the entire retina by fluid; Avhile a large tumor may merely de- tach that part which passes over its surface. The same applies to the vitreous substance, Avhich does not disappear in proportion to the size of the tumor, nor to the rapidity of its growth. A small tumor, together Avith fluid effused betAveen the choroid and retina, may cause all "the vitreous" to disappear; while some "vitreous" may remain by the side of a tumor which occupies the greater part of the interior of the eyeball. 41 TUMORS OF THE ORBIT OR THE EYEBALL. Displacement of the retina may precede, for some time, and frequently marks, the appearance of a tumor in the choroid. Complete displacement of the retina, Avith increase of tension, indicates the probable existence of a tumor within the eyeball. In such cases, a part of the retina is in apposition with the lens, and is thence reflected tOAvards its insertion along the ora ser- rata. This indicates great pressure upon the outer surface of the retina by the fluid between it and the choroid. Other secondary changes are: destruction of the retina, cata- ract, iritis, sloughing of the cornea, etc, etc Such changes may not appear until years after the loss of A'ision. In one case eight years elapsed. In the case of a patient, aged 50, "five years ago, a black cloud was observed rising from the lower part of the eye, and obscuring the upper halves of objects;" displacement of the retina was thus indicated: sight was entirely lost in three months after the first appearance of the cloud. The eye was not othenvise troublesome, until five months ago, when it began to shrink (instead of becoming perforated, as is usual in cancer) and to become painful. It was excised. The interior was found occupied by a hard, black (melanotic) mass, firmly adherent to the sclerotic, and consisting of a dense net- work of fibrous tissue, loaded Avith broAvn pigment granules and amorphous black pigment. Traces of choroid, and a "chalky" crystalline lens, were found; but neither vitreous nor retina. Such a course of melanotic groAvth in the choroid is very un- usual. Cancer in the Retina and Optic Nerve.—In one case the growth appeared primarily in the retina, in the shape of grayish-white and opaque nodules; some of which were ill-defined, and seemed to originate in the layers of the retina adjoining the optic nerve- fibres. The outer surface of retina was not adherent to the choroid. In several cases cancer has been observed primarily in the optic nerve, and, by preference, at the sclerotic aperture, and at the optic foramen. The medullary form, with a moderate amount of connective tissue, is the most frequent. It may give rise to great protrusion, without involving the organ itself; or TREATMENT. 417 it may encroach considerably upon the brain, without sensibly disturbing the cerebral functions. Vision.—The accounts given by patients suffering from intra- ocular tumors, as to loss or impairment of vision, vary. Many find, accidentally, that "the sight of the eye is lost," or are led to examine the state of vision, by some peculiarity in the appearance of the eye. Some state, that "the eye has been blind for years, and has only lately commenced to be trouble- some." Muscae and flashes of light are rarely observed. A mist intervening betAveen objects and the eye, and gradually becoming thicker, is often complained of. Some, at first, notice that objects can be perceived, only, when held in certain posi- tions. The perception of a black cloud, which seems to rise "from the loAver part of the eye," and obscure the upper halves of objects, is very common; the cloud rises higher and higher, and finally destroys sight. This symptom must be referred to displacement of the retina, preceding or accompanying the growth of a tumor. Diagnosis and Cause.—If the lens is transparent, we may after, with the ophthalmoscope, obtain a view of the tumor. In a patient, aged 26, a tumor (medullary cancer), projecting from the upper equatorial region of the tunics of the eye into the vitreous chamber, presented the following appearances:—close behind the lens was seen a rounded, well-defined substance, about the size of a large pea, and of a waxy-Avhite color. It had no independent movement. Its summit stood about opposite the posterior pole of the lens, and both sides and summit were overrun by bloodvessels belonging to the retina. Some, coming from the optic disk, could be traced round the sides of the tumor; Avhile others, disappearing behind it, reappeared on the summit. Gray and opaque flocculi Avere observed floating in the vitreous chamber, near the tumor. From the transparency of the retina and choroid, immediately round the base, it was inferred that these tunics were in their normal positions, at that part. Displaced portions of retina, if opaque, mark a tumor of the choroid or sclerotic. In this case, an increase of tension of the 27 418 TUMORS OF THE ORBIT OR THE EYEBALL. eye, attacks of ophthalmia, Avith pain, paralysis, and dilation of the pupil, Avith displacement of the lens forwards, make the presence of intra-ocular tumors very probable. We must not neglect to ascertain the mobility of the eye and the curvature of the sclerotic. The diagnosis is more difficult if the lens is opaque, and vision impaired or lost. The mode in which vision has been lost, the general health of the patient, the family history, and such points as are taken into consideration in cases of tumors elscAvhere, have to be inquired into. If there is no pain and no perception of light, Ave may be obliged to wait before expressing an opinion. Melanotic cancer, Avhen appearing upon the outer surface of the sclerotic, may be mistaken for staphyloma of the sclerotic, unless the ophthalmoscope be used, Avhen the semi-transparency of the staphyloma will decide the question. Cancer, as a rule, increases much more sloAvly AA'hen confined to the interior of the eyeball. Ten years or more may elapse, in grown persons, from the first symptoms of cancer in the eye to its becoming fatal. Ill-health, more than anything else, seems to favor its increase. Pain is rarely absent throughout its course; paroxysms may occur at any time. Attacks of "ophthalmia," as a rule, occur after vision is lost; they have a glaucomatous character, being accompanied by increase of tension. After a certain stage is reached, the neighboring glands may become infiltrated. Patients may die from the effects of fever, from general ema- ciation, from loss of blood or pus, or from the effects of cancer in other organs. Treatment.—Respecting the advisability of excision of the eyeball, or of removal of a cancerous growth from the orbit, opinions vary. Some think that if the general health is sup- ported and no operation performed, the patient lives longer than if operated upon. The experience of those who advocate an operation is, that melanotic cancer returns sooner than any other form, and that cancer originating in the retina or optic nerve, though the orbit be not implicated, is likely to return sooner than when springing from other parts of the eye or orbit. TREATMENT. 419 An operation is thought not advisable (a) if the total removal of the cancer be impossible (the eyeball immovable and adherent to the orbit); {b) if the glands near it be swollen (this swelling being referable to the cancer); {c) if the cancer have existed for a considerable time, and have lately been increasing rapidly. The increase of pain and tension has, in some cases, been temporarily arrested by iridectomy. Complications of cataract with cancer are not uncommon. We must be guided in the diagnosis by careful examination of the sensibility of the different parts of the retina, of the tension of the eye, and by the state of health preceding the appearance of cataract. The presence of cancer renders the removal of the cataract useless. Excision of the eyeball, or tumor, if decided upon, should be performed as soon as possible. If the patient's general health is good, especially if he is young, and if the cancer is confined to the interior of the eye, there is the greatest probability that the return of the cancer will be tardy. STRUMOUS DEPOSIT. Choroiditis Hyperplastic a.—A yellowish and opaque, some- times brilliant metallic reflection from behind the pupil, most frequently observed in children, is, by many, considered as characteristic of cancer. Displaced retina alone, however, with or Avithout chalky changes in the vitreous substance, lymph close behind the lens, and particularly the so-called strumous deposit, are often found to be the cause of this appearance. Whatever may be the substance which gives rise to the yellow reflection, both in cancer and in strumous deposit, we observe the bloodvessels. These vessels differ in size and arrangement from retinal bloodvessels, which latter, if the retina is displaced bv fluid, accompany the movements of the floating fields of the displaced retina. The diagnosis betAveen strumous deposit and cancerous growth remains uncertain, as long as the former is on the increase. Both develop spontaneously, and may occur at any age. In this countrv, the strumous deposit is observed more often in fair than in dark-complexioned children. 420 TUMORS OF THE ORBIT OR THE EYEBALL. The yellow substance behind the pupil, if covered by retina, appears smooth, but its surface assumes a flocculent, vascular aspect Avhen the retina is destroyed. It may, if much pigment be present, have an almost black color, the gray or yelloAv and opaque portions only shining through in places. While growing, it consists, microscopically, of elongated fusi- form, or round nucleated cells, with intercellular substance traversed by bloodvessels. The cells rapidly increase in number, and are frequently mixed Avith pus-cells. When shrinking, an amorphous, smeary substance, Avith a few nuclei and cells, fat, cholesterine, pigment granules, and varying proportions of con- nective tissue, are found. As this deposit increases, it destroys the vitreous substance, and pushes the lens forwards. The iris becomes paralyzed, and the pupil extremely dilated. In many cases the lens becomes opaque, and the iris and ciliary processes infiltrated. Portions of sclerotic, adjoining the parts within the eye which are undergoing changes, may become vascular, swollen, bulging, and infiltrated. Suppuration of the cornea, or profuse purulent discharge from the interior of the eye, may take place. The occurrence of pain seems chiefly to depend upon an in- crease of the tension of the eye. There may be no pain, if the "strumous deposit" increase slowly. Strumous deposit may be spontaneously arrested at any stage. Such arrest most frequently takes place after the vitreous sub- stance is destroyed. It establishes the difference of the disease from cancerous growth. The progress of strumous deposit is slower in grown persons than in children. It may appear in both eyes. Its arrest most frequently shoAvs itself by gradual shrinking of the eyeball, with increase of tension. The eye becomes flaccid, and finally reduced to a small irregular mass. With the naked eye, no vessels containing blood could be seen in the tumor, which was easily broken away from its attach- ments. The fibres of the optic nerve disappeared in it. Its interior was softening. It consisted of cells of the size of pus- cells and larger, filled with granular matter; among these were TREATMENT. 421 pus-cells, and numerous capillary vessels, sprinkled with fat- globules and traces of connective tissue. The outer and inner surfaces of the swollen and infiltrated choroid were thickly sprinkled Avith plexuses of capillaries, re- sembling blood-spots. Cells, similar to those in the tumor, Avere found in sundry infiltrated portions of the choroid and sclerotic, and in the little tumors along the sheath of the optic nerve. Treatment.—The removal of the eye is indicated in those cases only in which the pain or suppuration threaten to exhaust the patient. General tonic treatment, and local frictions, with mercurial ointment, are adopted with benefit. In several cases of undoubted syphilitic character, arrest and decrease of the deposit have been effected by anti-syphilitic treatment. In some cases vision has been restored. Pneumonia and meningitis are the usual causes of death. BONY, FIBROUS, SARCOMATOUS, AND FATTY TUMORS. Exostosis, of Avhich the ivory exostosis is the most frequent, enchondromato, fibro-calcareous tumors, and fibrous tumors, with spicula of bone, have been met with. Bony tumors most fre- quently originate from the inner wall of the orbit, and thus may be mistaken for enlargement of the ethmoidal cells or frontal sinuses. Fibrous and sarcomatous tumors spring from the periosteum of the orbit, by one or several pedicles. Fatty tumors are some- times congenital. Of the fibro-calcareous species, a specimen is in Dr. Walker's Eye Infirmary. It sprang from the inner and upper wail of the orbit, near the margin, and consisted of fibrous tissue, contain- ing large irregular spaces filled with blood, and lacunae, Avhich were occupied by calcareous matter. It grew from the peri- osteum, inwards, i.e., neAV material was deposited from the peri- osteum, and the latter displaced outAvards. CYSTS. Cvsts most frequently occur at some part of the inner wall of the orbit. They may become as large as bens' eggs. Some are multilocular, with strong fibrous walls, and are barely attached to the orbit. They contain reddish serum, with 422 TUMORS OF THE ORBIT OR THE EYEBALL. cholesterine, or dark-brownish fluid (decomposed blood), or flakes of a grayish and opaque, cheesy-looking, substance (sebaceous cysts). The latter originate, as a rule, in the skin of the eye- lids. Hydatids (the cysticercus and echinococcus) and hemorrhage into the orbit are the most frequent causes of cysts in this region. A bursa is occasionally found in front of, or behind, the in- sertion of the levator palpebrae muscle. This may become dis- tended, and form a cyst, called a hygroma, which may give rise to protrusion of the eye. Cysts may occur in the course of morbid changes of the lachrymal gland. A case of polypus, commencing in the nose, perforating tta orbit, and thence passing into the brain, has been observed. Death was caused by meningitis. Treatment.—If, by an exploratory puncture, or by any symp- toms, we have ascertained the existence of a cyst or cystic tumor, we should, as the shortest, and, in the end, least hazardous treatment, attempt its complete removal. In one case, in Avhich a seton was introduced through the upper lid, and through the cyst, the eye resumed its normal position at the end of ten months. Ten years afterwards, the protrusion reappeared, and was arrested by another seton. Excision of the front wall of the cyst has been followed by hemorrhage into its interior, and by increased protrusion of the eyeball. Rest, leeches, and cold fomentations have been required to check the protrusion. In one case in which part of the wall of the cyst had been removed, a second portion had to be excised a year later. De- lirium and much suppuration folloAved. Recovery took place three months after the second operation. Some advise the ap- plication of a paste, made with chloride of zinc, spread upon leather, to those parts of the cyst or morbid deposit not removed by the operation. PULSATING TUMORS OF THE ORBIT. The causes of pulsating tumors of the orbit usually met with TREATMENT. 423 have been—(1.) True or diffused aneurism of the ophthalmic, or some other artery within the orbit; (2.) Impediments to the return of the blood from the ophthalmic vein. Of these, the true aneurism of the ophthalmic artery is the least frequent. The tumor, as a rule, appears during middle or advanced age; rarely spontaneously, or from bodily exertion, but frequently sooner or later after an injury. The pulsation, the protrusion of the eyeball, and other symptoms, in the larger number of cases, appear suddenly. The patient complains of a beating or throbbing in the eye, or over the eyebroAv, which increases on stooping. The pulsation is communicated to the eyeball, and a loud blowing murmur, or a bruit synchronous, Avith the systole of the heart, is heard, by placing the ear upon the (upper) margin of the orbit. In two cases of injury, all the symptoms of aneurism behind the eyeball were present, and yet none was found, in either case, after death. The symptoms were caused, in the one case, by partial compression of the internal carotid artery against the sphenoid, in consequence of swelling of the bone about the cav- ernous sinus. The cavernous, transverse, circular, and petrosal sinuses were inflamed and filled with pus. In the other case, the ophthalmic vein, at its junction with the cavernous sinus, was found to be closed by fibrin and pus. In these cases, the momentary increase of the quantity of blood in the orbit, during the pulsation of the ophthalmic artery, and the resistance offered by the walls of the orbit, together with the impeded return of blood through the veins, seem to explain the impulse imparted to the eyeball. Treatment.—Ligature of the common carotid artery, of the side corresponding to the pulsating tumor, proved successful in eleven out of tAventy-one cases in Avhich it was performed. Two cases Avere cured by digital pressure upon the common carotid. This mode of treatment should be fairly tried, in every case, before proceeding to any operation. In several of the unsuc- cessful cases the pulsating tumors remained stationary. In one, the tumor returned after a feAv Aveeks; and in one, several small aneurisms appeared after the large one had ceased to pulsate. 424 NJEVUS. NJEVUS "ERECTILE TUMOR." Naevus has been observed at different depths in the orbit; most frequently in the neighborhood of the eyelids. In one case, the tumor Avas found, on dissection, to be enclosed in a "capsule" of connective tissue, which might have been removed by operation. A naevus, when forming a tumor in the orbit, is soft to the touch, and increases in size and tension during crying or strain- ing. It is rarely met Avith in groAvn people. Varicose veins, situated near the margin of the orbit, and increasing in size on stooping, have sometimes assumed the ap- pearance of tumors. Treatment.—Several cases of naevus have been treated suc- cessfully by injection. Instances of sudden death after this operation have, however, occurred within the last three years. The pure tincture of perchloride of iron Avas used. The children died immediately after the injection. Ligature of the naevus succeeded perfectly, in one case, and arrested the further increase of the naevus, in another case. The least dangerous, but slowest treatment, consists in drawing silk threads, saturated with tincture of perchloride of iron, through the naevus. Care should be taken that the threads are thick, and that they close the opening made by the needle. The num- ber used must depend upon the size of the naevus. The object is to set up adhesive inflammation in different parts of the growth. The threads may be removed at the end of a week, or as soon as slight suppuration has set in around them. Other threads may have to be inserted, if the naevus has not disappeared, after all inflammation, caused by the first set, has ceased. SPONTANEOUS HEMORRHAGE INTO THE ORBIT. This form of hemorrhage generally comes on suddenly, e.g., after illness, or after great fatigue in weakly persons, or after an injury, without any brain symptoms, Avith or Avithout paralysis TREATMENT. 425 of all the muscles of the eye. It causes protrusion of the eye, without signs of aneurism. The protrusion remains stationary if the blood become encysted; if not, a fortnight ora month will suffice for recovery. The general treatment must depend upon the patient's health. In persons Avith a tendency to hemorrhage, a recurrence of the protrusion may happen. Locally, several leeches, or a small blister to the temple, or frictions, with mild mercurial ointment, and gentle pressure upon the closed eyelids, with a bandage, may be tried. Protrusion caused by hemorrhage behind the eye, during operations in or near the orbit, requires the immediate closure of the eyelids by a tightly-applied bandage, if necessary, Avith Avire sutures, until the protrusion is subsiding. EiXOPHTHALMIC GOITRE. protrusion of the eyeball, with palpitation of the heart, and enlargement of the thyroid gland (exophthalmic goitre). The nature of this form of protrusion, and the changes in the heart, arteries, thyroid gland, etc, Avith which it is associated, are not well understood. In some cases, the thyroid gland is not enlarged; in others, the heart appears healthy; in feAV, only one eye is found protruding. In most cases, no organic disease of the heart is found at the commencement of the protrusion. As primary causes may be enumerated—atheromatous changes in the coats of the arteries, followed by hypertrophy of the heart; impediments to the return of blood, and subsequent enlargement of the thyroid gland: and as secondary causes of the protrusion __distention of the veins of the orbit, Avith an oedematous con- dition of the tissue within the orbit. On post mortem examination of a case Avhich occurred lately, neither hypertrophy of the orbital tissue, nor increase of fat, nor enlargement of'the lachrymal gland, was found. The thy- 426 exophthalmic goitre. roid gland was enlarged, the left ventricle of the heart, hyper- trophied, and atheromatous changes Avere observed in the arteries. The youngest patient affected with this form of protrusion was ten years old. The patients, as a rule, suffer either from chlorosis, or from morbid action of the heart, or from both. In females, the enlargement of the thyroid gland is more marked than in males. The course of the disease is very chronic; it seems to be more acute in males. The first symptom generally observed is an abnormal action of the heart; the pulse is increased in frequency from 80 to 150, and the impulse of the heart is strong, and ac- companied by palpitations. A bruit is heard Avith the systole, in some cases. A sensation of tightness and of difficulty in breathing frequently folloAvs. The enlargement of the thyroid gland, and the protrusion of one or more, generally of both eyes, occur later. The protrusion is preceded by insufficient relaxa- tion of the levator palpebra muscle. The protrusion has been observed in about 16 per cent, of the cases. In 6 per cent, the sight of both eyes was lost. The degree of protrusion varies. One or both eyes may be protruded straight forwards, and their movements equally im- paired, in all directions. One eye, generally the right, may be more displaced than the other. The displacement may be so considerable as to give rise to difficulty in closing the lids, or to more or less complete exposure of the cornea. In the latter case, yellow, opaque, dry scales become accumulated upon the opaque and continually exposed portion. Ophthalmitis may occur even Avhile the corneae are still pro- tected The chemosis and varicose condition of the conjunctival bloodvessels vary in degree. Treatment.—In Aveak or old persons the hope of recovery is slight. The greater the frequency of the pulse, the worse the prognosis. Rest, milk diet, the local application of ice, bathing the eyes with iced Avater, and such general treatment as the constitutional symptoms of the case may suggest, should be prescribed, if the pulse is above 100. Preparations of iron are of great service, and may be con- TREATMENT. 427 tinued for months or years, if the pulse is only from 80 to 100. In one case, the administration of secale cornutum in ten-grain doses, four times daily, for two months, was attended by com- plete recovery. Locally, frictions with iodine ointment, into the skin, over the thyroid glan/1, may be ordered, if the latter is enlarged. This treatment is expected to diminish the fulness of the orbit, and thereby the protrusion of the eye. In cases of impaired mobility of the eyelids, the palpebral aperture has been narroAved by operation. By this means the cornea becomes more protected, increased pressure is exercised by the lids upon the eyeball, and the protrusion is rendered less conspicuous. The operation must be performed over both sides, and symmetrically, in order to enable the patient to close the lids readily. If the surface of the cornea, from continued exposure, has become opaque, or covered Avith scales, the temporary complete closure of the lids is indicated, until, under general treatment, the protrusion has diminished, so as to admit of the lids readily protecting the cornea. Much benefit is derived from the application of a bandage, causing slight pressure upon the closed lids during sleep. PROTRUSION, THROUGH ENLARGEMENT OF THE FRONTAL SINUSES. The upper and inner portions of each orbit, anteriorly, form part of the floor of the corresponding frontal sinuses. Large sinuses are generally accompanied by great prominence of the superciliary eminences. The sinuses are lined by mucous mem- brane, Avhich is continuous Avith that of the nasal cavities. Their abnormal distention by mucus, etc., may be suspected, 1st, if Ave find the eyeball displaced outAvards and slightly dowmvards, with a greater prominence of the anterior Avail of the sinuses {i.e., of the superciliary eminence); or, 2d, if we find a diffuse enlargement of the inner and upper portion of the orbit, ante- 428 PROTRUSION. riorly, compared with that of the healthy side; such enlarge- ment may be accompanied by a more or less prominent swelling beloAV the broAV, of varying consistence (elastic or firm) and shape (smooth or uneven), Avith defined or undefined base. The skin may be unchanged and movable, or red and adherent to the SAvelling. There may be one or several fistulous openings. The swelling generally extends backAvards, along the roof and inner wall of the orbit. There is hardly ever any pain. Tumors attached to this part of the orbit, or circumscribed inflammation of the bone and periosteum, may be mistaken for enlargement of the sinuses. In periostitis, the great pain, es- pecially at night, or when the part is touched, together with the relief afforded by medical treatment, may assist in the diagnosis of the case. Most commonly, the sinuses are enlarged by accumulation of thick, transparent, or partly opaque, mucus, or by muco-pus, rarely by pus; this may be fetid and mixed Avith blood. The mucus or muco-pus is of the same kind as that Avhich is secreted during catarrh by the mucous membrane of the nose. In rare instances, solid bony tumors, exostoses, and polypi, attached to the walls of the sinuses, or encroaching from adjoining cavities, have been found. Injuries (blows on the face), causing obstruction of the pas- sages betAveen the sinuses and the nasal cavities, are the usual cause. Such has been found to be the case in eight out of nine instances. The enlargement may exist for a few weeks only, and then become perceptible, or it may continue for from four to six years Avithout causing much inconvenience. The patient's attention is generally attracted when the enlargement displaces the eyeball, impedes its movements, and, as sometimes happens, causes diplopia, or some other derangement of vision. Treatment.—Little benefit is derived from medical treatment. It should, however, be tried. In a case in which some insect had become lodged in one of the sinuses, and had caused irrita- tion of the mucous membrane, the smoking of cigars, impreg- nated with arsenic, was found beneficial. A careful inquiry into the cause, the course, and the extent of the SAvelling and the TREATMENT. 429 inconvenience arising from it, determines the line of treatment. Surgical interference is required, if the SAvelling increases rapidly, and impairment of vision becomes marked, or cerebral symptoms appear. If removal of the enlargement is decided upon, an incision is made below the supra-orbital ridge over the most prominent part, avoiding the supra-orbital vessels, etc. The incision must vary in length according to the size of the swelling; and should be at once carried through the soft parts down to the bone,—the blade of the knife being held parallel to the wall of the orbit, along which we wish to reach the SAvell- ing; we thus avoid wounding the eyeball. The most prominent part of the SAvelling, only, is exposed, and the point of the knife is thrust into it. If we find a solid tumor, we expose its entire surface freely, and remove it with the forceps, chisel, or gouge, either by breaking it off from its attachment, or by working round its base, and removing it as well as Ave can. The thin- ness of the Avails of the orbit must be borne in mind. If avc find enlargement of the frontal sinuses by mucus, etc., an aperture, cut into the most prominent part, will enable us to expose and clear out the contents of the cavity with the finger or sponge, and to ascertain the relation of the enlarged sinus to the brain, to the eye, etc. In the cavity Ave may find rough portions of bone (from fracture or disease) or the expanded, smooth, mucous membrane only. After having removed the mucus, one finger is introduced into the corresponding nasal cavity, up to the nearest part of the enlarged sinus; a bistoury is then passed through the open- ing made in the expanded bony Avails of the sinuses to the spot corresponding to that touched by the finger introduced into the nose, and an incision is made through this part of the wall of the sinus down upon the finger, so as to establish a large opening of communication betAveen the nose and the sinus. A "seton" (a strong cord of tAvisted silver wire, or a stout silk thread) is car- ried through this opening, and the end projecting from the nasal cavity is tied to the one Avhich projects from the incision in the skin. The loop thus formed is moved by the patient, several times daily, with the view of establishing a permanent opening • 430 PROTRUSION. betAveen the sinus and the nasal cavity. The patient has to keep in bed as long as there is headache, or much redness and SAvelling round the incision. The position of his head must be such as to facilitate the escape of matter. Cold-Avatcr dress- ing is applied over the wound. The patient should be shown how to press upon the SAvelling over the "eye," so as to cause the discharge to escape readily through the external wound, and, if possible, also through the opening made into the nose, and hoAv to move the seton to and fro, or to introduce some blunt instrument into the nose, and into the opening w7hich leads from it into the sinus. Four weeks after the operation, the seton may be removed. In some cases, it has been left in for several months. This operation for removing enlargement of the frontal sinuses has succeeded in all cases. In one instance, the silver Avire gave rise to much irritation and to cerebral symptoms; and Avas there- fore Avithdrawn. HoAvever, the daily introduction (by the pa- tient) of a smooth piece of ivory (the handle of a cataract-knife) through the nasal cavity into the opening, finally succeeded in restoring the normal dimensions of the sinus and its communica- tion with the nose. In this case, the distention of (right) frontal sinus Avas very great, extending towards the brain, and as far back as the apex of the orbit. It caused displacement of the entire orbit, outAvards and downwards, with protrusion of the eyeball. The eye ultimately resumed its natural position, and the orbit also nearly returned into its normal place. In one case in which, from the commencement, there had been mucous discharge from the enlarged sinus into the nose, as well as a fistulous opening in the skin, the latter closed spontaneously in about two years. Portions of the wall of the expanded sinus may become ab- sorbed; or a communication may be established between the right and left sinus; or one or several fistulous openings, lead- ing into the orbit, may exist. This discharge of mucus, through the incision, or through a fistula in the skin, may continue; or the incision may close, and the distention reappear, and require reopening, if the above treatment have not been adopted. TREATMENT. 431 After the operation, a deep cicatrix remains below the eye- brow, with light ptosis. ACUTE INFLAMMATION WITHIN THE ORBIT. Acute inflammation within the orbit often commences with more or less fever and pain in the head. If it increases rapidly, it is accompanied by much SAvelling and redness of the eyelids and conjunctiva. The conjunctiva is ceclematous (serous che- mosis), if the inflammation is slight, or deep-seated, or circum- scribed; it is infiltrated with more solid matter (fibrin, pus), if the inflammation is severe, e.g., if accompanied by suppuration of the eyeball. The swelling may be so great that the con- junctiva, protruding from the palpebral aperture, may become dry and covered Avith crusts; there is rarely much purulent dis- charge from its surface. The eyeball, in every inflammation Avithin the orbit, is dis- placed. Its movements are rendered painful and difficult, or are entirely prevented. A slight protrusion of the eye may appear considerable, from the great SAvelling of the lids. (See Ophthalmitis.) At the commencement of the inflammation, the cornea often appears brilliant, the pupil contracted, the retinal veins large and tortuous, the retina cedematous, especially round the optic disk, Avhich thus seems ill-defined, shading off into the adjoining fundus. The interior of the eye may, hoAvever, appear healthy; or morbid changes elseAvhere may prevent us from obtaining a vieAV of the retina, etc. Vision may be slightly impaired or completely lost. The degree of impairment is frequently disproportionate to the visible intra-ocular changes. Flashes of light, fiery circles, etc., seen in the dark, are complained of in hyperaemia of the optic nerve. The inflammation rarely remains confined to the tissues be- tAveen the eyeball and the bony Avails of the orbit. The most frequent primary cause of this disease is some mor- bid changes in the bony walls; but whether they are actually 432 ACUTE INFLAMMATION WITHIN THE ORBIT. implicated cannot be decided, so long as no access to the seat of inflammation, nor any opening for the escape of pus, exists. Inflammation, if situated at the apex of the orbit, is dangerous, and its course is very protracted, however circumscribed it may be. If, at the commencement, the inflammatory action is not too severe, or if it is soon arrested, no abscess may folloAV. A second- ary attack, with protrusion, may occur after the first has subsided. Patients may die from meningitis or phlebitis, before an abscess has formed, or after perforation into the cranial cavity has taken place. This sometimes occurs suddenly after protracted suppuration, about the apex of the orbit. The more rapidly the inflammation increases, the greater is the danger to the eye, as well as to the life of the patient. An acute inflammation generally has passed its height in from ten to fourteen days, while the morbid changes which may have occurred in the eye, in the bones of the orbit, or in other struc- tures, may continue for years. The inflammation is rarely chronic, unless it'accompanies bone disease. Setting aside the changes in the functions and nutrition of the eye, we find that the inflammation either sub- sides gradually and disappears, or an abscess forms. Besides the abscess, following inflammation of the bones of the orbit {e.g., after injuries, fever, or erysipelas), we meet with rare instances of abscesses perforating the Avails from without {e.g., abscesses in the frontal sinuses, or in the anterior lobe of the brain) and breaking through into the orbit. In cases of abscess in which death has occurred, a sero-purulent infiltration of the tissues of the orbit, with pus in the ophthalmic veins and the cavernous sinuses, has been found. There may be very little swelling and redness of the parts round the eyeball, previous to the appearance of pus. The abscess may perforate into cavities adjoining the orbit, or it may point beneath the conjunctiva, or somewhere on the surface of the lids, but rarely at more places than one. An abscess behind the suspensory ligament of the lids generally perforates the con- junctiva; but the pus escapes through the skin of the lid, when TREATMENT. 433 the abscess is formed in front of this ligament. After the escape of pus, the eyeball often recedes, and the redness and swelling of the lids, conjunctiva, and tissue within the orbit, disappear, if the cause of the abscess has been removed. In rare cases, though the lids and the eye return to their normal condition, an abundant discharge of pus continues for several months. In a case of abscess within the cranium, in which the patient recovered, portions of brain came away occasionally with the pus. Other cases, in which the abscesses appeared simultaneously within the cranium, and in the orbit, proved fatal. In a case of glanders, purulent infiltration, and sloughing of the tissue betAveen the eyeball and the walls of the orbit, occurred, together with one abscess in the choroid, and another in the brain. The abscesses Avere surrounded by yellowish-gray and opaque infil- tration. When pus escapes from an opening leading in the orbit, or from an incision made in the course of treatment, a careful ex- amination must be made for diseased bone. A probe may have to be introduced into the orbit, at different times, before rough or necrosed bone can be discovered. Caries of the orbit, if frequently superficial, but sometimes is seated far back at the apex. Pain is, as a rule, felt when pres- sure is made on the bone, near to diseased portions. If the latter be at or near the margin of the orbit, the diffused swelling of the bone, and periosteum, and the pain, are generally well marked. The granulations round the opening from which dis- charge escapes appear flabby and bluish-red, and the pus is dirty, yellow, and frequently offensive, as long as the morbid changes are progressing. The nature of the pus and of the granulations changes, as the caries or other disease subsides; the granulations become less numerous, and of better color; the pus becomes less abundant; and the sinuses and fistulous open- ings close. The openings may close before all the necrosed or carious portions are gone; in which case, fresh attacks of inflam- mation will ensue. A patient has been attending at Dr. Walker's Infirmary during the last seven years, on account of a minute 28 434 ACUTE INFLAMMATION AVITHIN THE ORBIT. fistulous opening, situated near the outer canthus. Whenever this closes, protrusion of the eye and ophthalmia appear, and continue, until, by pressure upon the temporal fossa, some pus is forced out through the opening. The portions of bone which, from time to time, come away, are generally very small. The bone, during inflammation, loses its hardness; its earthy salts become absorbed; and the connective tissue predominates. Years may elapse before the disease comes to an end. The cicatrices, following loss of bone, are deeper than those after any other form of inflammation of the orbit; and, accord- ing to their situation, impair the functions of the neighboring parts. If near the margin of the orbit, they may, through con- traction, cause ectropion, with or without destruction of the sur- rounding skin of the lids by inflammation. The lachrymal gland may be destroyed. Treatment.—In every case of inflammation of the orbit Ave adopt some general treatment, e.g., the anti-syphilitic treatment, if syphilis, or the suspicion of syphilis, exists; general anti- phlogistic treatment (salines, bleeding from the arm, etc.), if injury is assigned as the cause. If, from the history of the case, we infer the existence of a tumor, we treat according to the probable nature of the tumor. Cerebral disturbances and impairment or loss of vision are the chief complications to be avoided, whatever treatment we may adopt. Rest in bed must be enforced, in all cases, as long as the inflammation is acute. We inform the patient of the danger to which the "sight" and the eyeball are exposed by the inflammation; and of the irreparable loss of "sight" which must ensue, if signs of sup- puration in the vitreous are present. A very protracted course must be expected, if we find dis- eased bone. The degree of intensity of the inflammation, the changes in its products, and their relation to the functions of the eyeball, indicate variations in the line of treatment. Some believe the changes of inflammatory products into pus can be avoided by giving large doses of chlorate of potash; some recommend mer- TREATMENT. 435 cury, as having the power of altering the character of the inflam- mation; others adhere to simple tonic treatment. If we suspect the presence of pus, whether the inflammation be acute or chronic, an incision should be made. We thus avoid fistulous openings, and obtain better cicatrices. The in- cision should be made early, and without waiting until the pus "points." It must be made large, if, on introducing the finger, we find the periosteum pushed away from the bone by pus. If the pain is very severe, or the cornea in danger (its surface dull, misty), the protrusion being caused by changes outside the eye- ball, a narrow, long bistoury is thrust, at once, into the in- flamed and swollen part, between the Avail of the orbit and the eyeball, where the latter is pushed farthest aAvay from the for- mer; or the bistoury may have to be passed, in succession, close along the upper and lower Avails of the orbit, if the eye is protruding straight forwards. A thorough acquaintance with the depth of the orbit and direction of its Avails, and with the course of the optic nerve, must guide us as to the depth to Avhich the bistoury can safely be introduced, and the direction it should take. The bleeding relieves the patient, even if no pus escape. The incision is kept open by passing a probe into it daily, or by introducing some lint, until the inflammation has someAvbat subsided. After completing the incision, Ave should at once ' ascertain whether there is any diseased bone, and what is its situation and extent; bearing in mind, during the examination, the thinness of the upper wall of the orbit, and the neighbor- hood of the brain. The lids are kept closed by strapping, if the cornea is in danger. Sometimes it becomes necessary to produce, temporarily, ad- hesion of the margins of the eyelids, in order to prevent ectro- pion, etc, arising from contraction of the tissue round fistulous openings. If the inflammation of the skin and the pain are moderate, and the protrusion slight, we prescribe rest, frequent bathing, with lint dipped in cold or iced water (as long as the sensation of cold is pleasant to the patient), and an appropriate general medical treatment, always trying the iodide of potassium with 436 ACUTE INFLAMMATION WITHIN THE ORBIT. sarsaparilla. If no increase of heat is felt, we apply gentle pressure, by keeping pieces of lint, dipped in Avarm Avater, or in warm poppy-head lotion, tied over the closed eyelids; we also order the unguent, hydrarg. nitrat. nitrus (a quantity the size of a pea) to be rubbed into the skin of the temple, morning and night. If the inflammation is severe, especially if the fever is great, and brain symptoms are present, frequent application of lint, dipped in iced water, must be used, and changed as often as the lint becomes warm. In grown persons, the effect of from six to ten leeches, applied to the temple, may be tried, if no erysipelas exist. If the tension of the eyeball is increased, or if hypopion, from purulent infiltration of the cornea, appears in the protruded eye, iridectomy, or repeated tapping of the anterior chamber, may be tried. Pus in the vitreous chamber, if there be much pain, must be let out by making an incision through the tunics of the eye, between the ocular insertions of the outer and inferior recti muscles. If, after the incision has healed, and the inflammation sub- sided, the protrusion of the eye continues {e.g., from thickening of the soft parts of the orbit), a bandage, causing slight pressure upon the closed eyelids, must be worn for some time. In protrusion, from ophthalmitis, if there is much pain or prolonged sympathetic irritation of the felloAV-eye, excision of the eye is the shortest and safest treatment; frequent fomenta- tions, with warm water, or warm poppy-head lotion, will suffice, in the absence of sympathy or pain. Necrosed bone generally comes away in small particles. It is extremely rare to find large pieces loose. Injections of warm water through the fistulous openings, to facilitate the escape of the portions of dead bone, reopening of fistulse that may have healed, if an attack of inflammation within the orbit, with pro- trusion, occurs after their closure, and appropriate general treat- ment, are the measures that can be recommended. Years may pass before such cases are well. Syphilitic nodes, if recent, are tender to the touch; sometimes TREATMENT. 437 they are accompanied by much periostitis. This occurs fre- quently along the margins of the orbit. Periostitis accompanies most inflammation of the soft and bony parts of the orbit; its symptoms, if deep-seated, are those Of inflammation of the soft parts within the orbit. It may as- sume an acute or a chronic character. It is readily recognized by the pain felt spontaneously, or Avhen the inflamed portion is pressed upon. There is often also inflammation of the adjoin- ing skin, if the periostitis occurs along or near the margin of the orbit. It may lead to suppuration, and abscesses, following it, have been mistaken for cancer. Periostitis complicating disease of the antrum, and extending to the orbit. In the cases observed, paralysis of the third nerve, with che- mosis and protrusion of the eyeball, preceded the loss of vision, which occurred rather suddenly, i.e., within a feAV hours from the commencement of the attack. No brain symptoms appeared. The periostitis probably caused rapid obstruction of the aper- tures leading into the orbit. Anaemia of the optic disk, Avith good blood-supply to the retina (shoAving the cause of amaurosis to be situated behind the spot at which the vessels pass into the optic nerve), Avere the alterations observed Avith the ophthalmos- cope. From the permanent loss of vision and the subsequent atrophy of the optic disk, it may be inferred that the optic nerve- fibres Avere destroyed in their passage through the optic foram- ina. The general treatment should be the same as is adopted in periostitis in other parts of the body. It must be carried on actively, on account of the dangers which threaten the eyeball and its appendages, as well as on account of the possible cere- bral disturbances. Inflammation of Tenon's Capsule.—This affection accompanies every acute ophthalmitis, and occasionally also occurs in cases in Avhich a laro-e portion of the sclerotic has been exposed during the operation for strabismus. Slight impairment of the mobiltty of the somewhat protruded eyeball, and swelling and redness of the subconjunctival tissue and sclerotic, are observed. 438 INJURIES OF THE ORBIT. It resembles, if near the cornea, what is described as rheumatic ophthalmia. Treatment.—Fomentations, Avith lint dipped in warm Avater, or in warm poppy-head lotion, Avith appropriate constitutional remedies, constitute the treatment, if the disease appears spon- taneously. If it occurs after an injury, the antiphlogistic regi- men, ice, cold applications, etc., come into use. INJURIES. If we suspect the orbit to have been injured, we must bear in mind that inflammation of the bones, impairment of vision, and other morbid changes caused by injury, may only become per- ceptible weeks or months after the accident has happened. A foreign body may remain in the orbit for years, before giving rise to disturbance. A cicatrix, e.g., in the upper lid, may guide us as to the spot at which it entered. If a recent wound exists, we should search at once for any foreign substance that may have passed into the orbit, and not Avait for suppura- tion. We examine, if possible, the instrument with which the injury was inflicted, and inquire whether the patients suspect any portion to have remained in the wound. The throbbing in the orbit, displacement of the eyeball, pain round the orbit-, indicate the probable presence of a foreign body. Otherwise, we treat as in cases of simple inflammation of the soft parts of \he orbit. A not unfrequent result of severe blows on the face is, closure of the communication between the nasal cavities and the frontal sinuses, and the gradual enlargement of the latter. Concussion of the bones of the skull has, in a few instances, been followed by inflammatory changes, which have given rise to slight pro- trusion of the eyeball, and to well-marked signs of aneurism within the orbit. "Emphyseme of the orbit," Avith protrusion of the eyeball, from fractures of the inner wall of the orbit, readily subsides, if slight continued pressure is applied to the closed eyelids. Hemorrhage, beneath the conjunctiva, or into the orbit, has been observed after fractures of the upper wall of the orbit. r TREATMENT. 439 Amaurosis and amblyopia have been known to result from injury to the supra-orbital nerve, as well as from implication of this nerve in cicatrices, tumors, etc. Excision of a cicatrix, or of a portion of the nerve, where implicated, has been followed by recovery in some, by improvement in other, cases. With the ophthalmoscope, the optic disk has been found anaemic, in some instances, and in others, healthy in appearance, together with the rest of the eye. THE EYELIDS. ANATOMICAL AND GENERAL REMARKS. The skin of the eyelids is thin and elastic, and the subcutane- ous connective tissue loose, and free from fat. The skin is freely movable over the tarsal cartilages, and is thinnest where it be- comes continuous with the conjunctiva. The loose and elastic tis- sue, which connects it with the orbicularis muscle, encloses hair- follicles, and numerous sudoriparous glands. This latter are small, and have tortuous ducts, each of which opens into the sheath of a hair, near its root. The looseness of the subcutaneous tissue explains the ready accumulation of blood or serum beneath the skin; as, for example, after the application of leeches to the lids. The eyebroAvs {supercilia) are parallel Avith the upper margins of the orbits. They are very movable downwards and inAvards {e.g., Avhen froAvning), but hardly at all outwards and upwards. This peculiarity should be borne in mind Avhen the surgeon is about to open an abscess or to remove a tumor; inasmuch as, if the incision be carried along the eyebrow, the resulting cicatrix will be hidden. The eyelashes {cilia) project in two or three rows from the outer ed»e of the margin of each. They are farther apart at their points of emergence from the lids than at the extremities. They vary in length, color, and number. Those of the upper lid are thicker and larger. From 100 to 150 are in the upper, from 50 to 80 in the loAver, lid. They grow during a certain time. After having reached their full size, they become thin- 440 THE EYELIDS. ner again, and at last fall out; the follicles becoming atrophied. An eyelash is supposed to have arrived at the term of its exist- ence in about five months; after Avhich time its place is occupied by a neAv one. Every hair-follicle has numerous hair-bulbs; and the young hairs push out the full-grown ones. Frequently a young lash may be seen projecting by the side of an old one; in Avhich case, the latter can readily be draAvn out. After hav- ing nearly reached its full size, the lash groAvs very sloAvly. During the first month of its groAvth, it reaches a length of J in., while, at the end of the fifth month, it has only increased to the length of somewhat less than ^ in. altogether. The lashes of the loAver lid grow less rapidly than those of the upper one. The hair-bulbs, with the follicles, are situated, some among, others beneath, the fibres of the orbicularis muscle; many are firmly adherent to the outer surface of the tarsus. A horizontal incision through the lid, about ^ in. from its outer edge, would pass through the largest number. Besides the proper eyelashes, there are numerous fine hairs, projecting from the skin, near them; these also have sebaceous glands. The sebaceous glands of the lower lid are shorter than those of the upper ones; their ducts open into the sheath of the hair, just before it reaches the edge of the eyelid. From two to five ^s of an inch in length, 3 J7 in. in breadth) go to each hair-fol- licle. The cells, in these glands, resemble those of the sheaths of the eyelashes. They undergo a change into fat molecules. The Meibomian glands are readily brought into view Avhen either of the lids is everted. They appear as yellowish, nearly parallel lines, imbedded in the tarsus, shining through the con- junctiva, and passing toAvards the inner edge of the lid. About 40 glands are in the upper, about 30 in the lower, lid. Their ducts are straight. Their orifices open upon the rounded-off inner margin of the free border of the lid, previous to Avhich, two or three sometimes unite into one. On transverse section, they are found to be surrounded by muscular fibres. In health, a greasy matter issues from the orifices. This consists chiefly of cells; the contents of which rapidly become changed into TREATMENT. 441 what resembles fat-globules, which escape from the cells, and constitute "the secretion of the glands." This "secretion" spreads over the moving surfaces of the eyelids and eyeball, and mixes with the secretion of the conjunctiva. Mixed with air, it gives rise to a white scum, at the outer and inner canthi. The tarsus of each eyelid consists of dense, fibrous tissue, with only a few cartilaginous cells. It is covered externally by the orbicularis muscle and the skin, and internally by the conjunctiva. It gives the eyelid firmness, and maintains the shape of the palpebral aperture. But for the tarsus, the levator palpebrae muscle Avould, when contracting, cause this aperture to become triangular; and it Avould appear round during the action of the orbicularis muscle. The convex or attached margin of the tarsus merges into a fibrous structure, termed the suspensory ligament of the lid, Avhich is inserted along the margin of the orbit. This is sufficiently strong to allow of the entire body being lifted from the ground by it. The tendon of the levator palpebrae muscle loses itself in it. Behind this fibrous structure we find the fat of the orbit. The Muscles.—The levator palpebrae muscle raises the upper lid, the orbicularis muscle closes the lid. The latter is not a complete sphincter, but is interrupted ("inserted") at the inner palpebral ligament. The different portions of the orbicularis do not contract si- multaneously when closing the lids. The portion belonging to the lower lid is the stronger; it raises and slightly moves this lid inAvards, toAvards the inner canthus, even Avhen the upper lid is fixed. The orbicularis muscle extends beyond the margin of the orbit, where it is flat and thin. The portion Avhich passes over and among the roots of the eyelashes is thicker than the remainder, and has been named the ciliary muscle (m. ciliaris). The relation of its fibres to the surrounding parts is not well understood. The functions of the gland, the direction and groAvth of the eyelashes, and the position of the margins of the lids, may be affected by morbid changes of the muscle. The Nerves.—The seventh (facial) nerve supplies the orbicu- laris muscle; the third nerve, the levator palpebra; and the fifth nerve furnishes the sensitive branches. 442 THE EYELIDS. The Vessels.—The ophthalmic artery sends branches to the eyelids; the largest of which passes along the roots of the eye- lashes, betAveen the orbicularis muscle and the tarsus. The veins of the upper lid, like those of the eyeball, carry their blood into the ophthalmic vein. The Outer and Innc Canthus, i.e., the Outer and Inner Angles of the Palpebral Aperture.—-A fibrous structure passes from the temporal fascia, at the outer angle, and from the peri- osteum of the frontal and maxillary bones, at the inner angle of the orbit, over to the nearest portions of each tarsus. Before reaching the tarsi, this structure splits in tAvo portions; one of which goes to the upper, the other to the loAver, tarsus. The angle thus formed is termed the outer or the inner canthus, as the case may be; and the fibrous structure, the outer or the in- ner palpebral ligament. Into the lower margin of the inner palpebral ligament, numerous muscular fibres, coming from the outer anterior surface of the lachrymal sac, are inserted; it is likeAvise the point of insertion of some of the fibres of the orbicu- laris muscle; and, by some, it is described as the tendon of this muscle. It is readily made conspicuous by placing a finger on the skin, near the outer canthus, and draAving the latter out- wards—a manipulation frequently resorted to during operations upon the lachrymal canaliculi. The Margin of the Eyelids.—We distinguish an outer edge of the margin (the one from which the eyelids project), and an inner edge (which is rounded off, and rests against the eyeball), and a space between the two. The inner edges of the upper and lower lids do not touch each other when the lids are closed. This gives rise to a triangular space between the eyeball and the line along which the closed eyelids touch each other. By momentary closure of the lids, i.e., by the act of winking, particles of dust, epithelium, etc., are wiped aAvay from the sur- face of the cornea; and the secretion of the conjunctiva and lachrymal gland are spread over it, and the tears directed to- wards the lachrymal passages. This act also exercises some influence upon the circulation of the blood in the choroid and retina. Eyes which become fatigued soon, wink more frequently than others. TREATMENT. 443 DEVELOPMENT. About the sixth week of foetal life, we observe, as the first traces of the eyelids, two narrow folds of skin, projecting from the face, on either side of the nose. These gradually grow for- wards and towards each other. About the end of the third month, they have the shape of the eyelids; but they are open, and apparently too small to close completely over the eyeballs. At the beginning of the fourth month, the margins of the upper and lower lids touch each other, and become glued to- gether ; the palpebral aperture thus becoming temporarily closed. This closure persists during the fifth and sixth months. During this period, some clear fluid becomes accumulated between the eyelids and the eyeball. Neither eyelashes nor eyebrows are perceptible before the closure of the palpebral aperture. These, the Meibomian glands and the tarsus, can be recognized about the end of the fourth month. The hair-bulbs of the eyelashes appear a little sooner than the Meibomian glands. The separation of the margins of the lids occurs first at the orifices of the Meibomian glands; which temporarily give the free inner edges of the lids a somewhat serrated appearance. CONGENITAL ANOMALIES. Of the Eyebrows.—Anomalies as to quantity, color, and posi- tion. Tavo eyebroAATs, one above the other (in which case, re- peated application of the tincture of iodine, and shaving off of one, has been found useful). Of the Eyelashes.—Trichiasis, and distichiasis, and difference in color. Of the Eyelids.—Absence of the eyelids, or congenital la- gophthalmos; impaired groAvth, preventing the complete closure of the lids. Coloboma of the upper and lower lids of one eye (Avith harelip), and a too narrow palpebral aperture. (Sym- blepharon or anchyloblepharon), or union of the margins of the upper and loAver lids with each other. Complete or incomplete ptosis from paralvsis, or from anomalies in the size of the lids, 444 THE EYELIDS. or from defective development of the levator muscle. A third eyelid, in the shape of a fold of skin, advancing from behind the inner canthus, over the eyeball. Pigment spots, nawia, fibrous tumors, with or Avithout hair and Avarts. Epicanthus is another congenital anomaly, consisting of a crescentic fold of skin, Avhich overlaps, more or less, the inner canthus of each palpebral aperture. Personal gratification may require its removal. This is done by pinching up and removing a vertical fold of skin from the bridge of the nose, in a line with, and at an equal distance from, the inner canthi. The incision should be accurately united with sutures, and the epicanthus, if a sufficient quantity of skin has been removed, should have completely disappeared at the time of operation. TUMORS. Cysts in the skin are often observed, especially in elderly people. They appear as little, roundish, watery-looking tumors, single or in groups, along the outer edge of the lid. Some may be as large as hemp-seed. The milium is a small, yellowish-Avhite, and opaque tumor (nodule), of the consistence of cartilage, projecting among the eyelashes, from the margin of the tarsus. Several milia are generally present simultaneously. On minute examination, we find that the milium consists of concentric layers of cells. Treatment—Cysts and milia have been successfully removed, to improve the personal appearance, or on account of their irri- tating the cornea. So also have warts. The molluscum glandiforme or albuminous tumor is Avhiter than the milium. Its surface is shining and slightly nodular. It projects from the skin, which is someAvhat vascular, if the molluscum is large. It may reach the size of a large pea. When squeezed, milky fluid escapes through a small opening on the surface. It occurs frequently in children, accompanied by similar tumors in the skin of the lips, nose, etc.; and is supposed to be caused by some animalcule having become lodged in a sebaceous follicle. Treatment.—With the cataract-knife, the tumor is divided TREATMENT. 445 into lateral halves, and then nipped well Avith a pair of forceps, or, better still, between the thumb-nails. The halves of the whitish, nodular, solid substance are thus squeezed out. The empty bag of loose skin is left. The tumor "returns," if it has not been squeezed out thoroughly. All such tumors about the face or lids should be removed at one sitting. The molluscum can always be removed in this manner; not so the milium. The tarsal tumor (encysted tarsal tumor, cyst in the tarsus, chalazion). One or several such tumors may occur in the same eyelid. They are the result of morbid changes of the glands within the tarsus, and are often preceded by inflammation (styes). The tumor is usually situated near the inner surface of the tarsus. Sometimes it perforates the conjunctiva, and a few granulations surround the opening. When the tumor projects from the outer surface of the tarsus, its position can be readily recognized by everting the eyelid. A darkish, gray-red spot, covered with, abnormally vascular conjunctiva, indicates its sit- uation. Treatment.—Derangement of the functions of the eyelid, or of the cornea, or other reasons, may require the remoA'al of the tumor by operation. If several tumors are present, all should be removed at the same time. The patient, seated in a chair, rests his head against the chest of the operator, who stands behind. The hands and eyelids of the patient must be secured. The tumor is removed through the conjunctiva. The eyelid is everted, and, with a narrow-pointed knife, an incision is made through the abnormally vascular conjunctiva, and the gray-red, thinned portion of the tarsus. The knife may have to pass through the entire thickness of the tarsus, if the cyst is near the outer surface. The texture of the tarsus being very dense, some force has often to be used to carry the instrument through it into the tumor. The incision, made parallel with the margin of the lid, should be equal in length to the greatest diameter of the tumor, as felt through the skin. A cross incision is sometimes necessary, if 446 THE EYELIDS. the tumor is large. Generally some serum, pus, or gray, gelat- inous substance escapes at once. A small scoop is then carried along the surface of the tumor, Avith a view to separate the bulk of it from the surrounding tarsus. If this does not succeed, the scoop should be turned rapidly about, to break away the gelatinous contents from the walls of the cavity. This must be continued until all seems to have escaped. Blood frequently fills the cavity, and the tumor often appears even larger than before the operation. If all the contents have not been re- moved, Ave may, at some future time, be compelled to use the scoop a second, or even a third, time. This does not occur, if the operation is performed thoroughly at first. Cold-water dressing is applied to the lids, for a feAv days. If, after ten weeks, the tumor or the hardness has not com- pletely disappeared, a second operation may be required. The Sebaceous Tumor.—This tumor is generally observed in children. It is congenital, and almost always situated beneath the skin, near the outer and upper margin of the orbit. It some- times reaches the size of a small Avalnut, and, if large, is, in part, adherent to the skin. The skin usually maintains its natu- ral color: sometimes it is vascular, where the tumor is adherent; in rare cases, a small opening leads into the tumor, which, on pressure, gives vent to some sebaceous matter, of an unpleasant smell. The matter is enclosed within a capsule of varying thick- ness, together with hairs, of the shape, and often of the color, of those of the eyebrows. These may be found attached to the sac, or curled up and mixed with the sebaceous matter. Old tumors of this kind consist of yelloAv, oily substance, en- closed in sacs of fibrous tissue, which are often extremely thin. The tumor is the less movable the more extensive its adhesion to the periosteum of the orbit. Treatment.—The tumor, if thoroughly removed by operation, does not return. It rarely suffices to puncture it, and cauterize the interior. Chloroform should be administered, the operation being a tedious one, and accompanied with troublesome bleeding. Two assistants are required. While one assistant holds the head of the patient, and another is ready with a sponge to restrain TREATMENT. 447 the abundant hemorrhage, a small horn-spatula, or the index- finger of the operator is pushed under the lid, Avhich is tightly stretched by the aid of the thumb, and made to project as far as possible. Then an incision is made parallel with the edge of the lid, on the summit of the tumor, throughout its entire length. This incision should pass be- yond the base of the tumor, at both extremities. The surface of the tumor is then exposed by dissecting up the integument and the muscle, and a cataract-knife is en- tered at the base, and pass- ed through its Avhole length. The tumor is thus almost separated from the carti- lage. It is then seized with the forceps and completely removed by the scissors. A good view of the tumor must be maintained by keeping open the large skin incision, and sponging away the blood. After having separated the adhesions of the tumor, to the skin and other soft parts, we cut through its attachment to the periosteum, which may be broad or have the form of a ped- icle. The white sebaceous matter escapes, if the tumor has been opened during the operation: this renders the complete removal difficult. Portions of the walls, left behind, should be touched with nitrate of silver. , Incisions through the suspensory ligament and removal of portions of the fat of the orbit may readily be avoided by dis- secting close to the walls of the tumor. The wound being deep and lacerated, some suppuration gen- erally follows; lint, dipped into cold water, is applied, as fre- quently as is pleasant to the patient. We may, to hasten union, insert one or two sutures, near the corners of the incision. The 448 THE EYELIDS. wound heals in from two to three weeks; the cicatrix is scarcely perceptible, and no other disfigurement follows. Naevus, about the eyelids, occurs frequently. One or several may be found in the same eyelid; or may extend from the eye- lid into the orbit. The appearance and symptoms are similar to those elsewThere. If not operated upon, the naevus increases to a certain size, and then remains stationary, or becomes smaller. Treatment.—Ligature and injection of the tincture of per- chloride of iron have been followed by sloughing of the eyelid. The safest and quickest method is to completely remove the naevus by operation, if its size and situation permit. The parts may be rendered insensible by the ether spray. Another effectual method of treatment consists in the destruc- tion of the naevus, by means of the galvanic current. Next to this can be recommended the insertion of stout silk threads, previously moistened Avith tincture of perchloride of iron. Due regard must be paid to the portion of the eyelid we operate upon, in order to avoid disfigurement, displacement, etc. Lupus has been observed in various stages in the eyelids, either extending from the face, or commencing in the lids (gen- erally along their margins). By extension to the eye, or to the orbit, it has caused death, in several instances. It generally appears in young people of othenvise good health; it spreads over large surfaces (different stages of the lupus being present simultaneously); it leaves peculiar star-shaped cicatrices; it is painless; and it is curable. In these respects it differs from epithelial cancer. Syphilitic ulcers are, as a rule, primary, and commence with thickening along the margins of the lids. Syphilitic infiltrations, from the slowness of their course, their hardness, and, if ulcerating, from the dirty appearance of the ulcer, can hardly be mistaken for acne. The local application of mercury is found of great use. Cancer of the Eyelids.—The medullary and melanotic forms are rarely primary. Nodules of both forms, springing from the margins of the lids, have been removed by excision. Both forms frequently extend on to the lids, from the eyeball or orbit. TREATMENT. 449 Epithelial cancer appears under the form of small, roundish, hard nodules, or so-called alveolar cancer. The nodules, situated in the skin of the lid, or over the lachry- mal sac, at a later period, become covered with yellow crusts, and overrun by enlarged veins. Beneath the crusts, we find ulcerating surfaces, with irregular outlines and everted margins, secreting but little pus, etc. The alveolar cancer appears either as a defined tumor, or as an ill-defined infiltration. The latter form is less common; and occupies the skin, or commences beneath it, and is painful when touched. The dark-red, nearly flat surface of the cancerous infiltration, after some weeks, becomes ulcerated. Crusts ap- pear, with an offensive purulent discharge. The edges of the ulcer are swollen, roundish, and nodular. Epithelial cancer has been mistaken for lupus. It may exist for years. In the alveolar form, the neighboring glands are much sooner affected. Cases have occurred in which the eye- ball has been destroyed by numerous attacks of inflammation. Treatment—The cancer, if small, confined to the skin, and occurring in a strong patient, may be removed by operation. The loss of substance is covered by skin, transplanted from healthy neighboring parts. The cancer reappears more speedily, if the operation be per- formed after the glands have become implicated. The cancer may be also successfully treated by the application of a paste made of starch and chloride of zinc. The paste must be freshly made for each application. The paste is spread over the surface and margins of the ulcer,. and over a narrow strip of the adjoining healthy skin. The layer of paste should be sufficiently thick to hide these parts from view; and care should be taken not to touch the eyeball. The paste temporarily destroys the growth; and a cicatrix forms. The application is repeated whenever any part of the margin of the ulcer shows an inclination to extend itself, or wheu fresh nodes appear. The general health of the patient should be well supported. Palpebral ephidrosis is the term applied to an unusually large 29 450 PARALYSIS OF THE ORBICULARIS MUSCLE. secretion of perspiration by the skin of the eyelids. In the cases observed, it has been confined to the upper lids. On wip- ing away the confluent drops, others soon appear. Slight oph- thalmia and eczema are the consequences. Phthiriasis signifies the presence of crab-lice among the eye- brows and eyelashes. The pear-shaped egg of the crab-louse (phthirius) is attached to the hair, close to the skin, by means of a transparent cement. A lid, found at the broad end of the shell of the egg, falls off, on completion of the intra-oval life of the insect. The lice and their eggs, when present in large numbers, give rise to an ap- pearance as if the eyelashes were covered Avith yellowish, gray, and brown crusts, as observed in tinea. These crusts, on close inspection, present a marked leaded form, and, when pressed between the nails, burst suddenly. Treatment.—The daily application of the unguent, hydrargyri nitratis mitius, or of a solution of the hydrarg bichloridi (gr. j. ad aquae Sj.), by means of a camel's-hair brush, to the "crusts," on the eyebrows and eyelashes, suffices to destroy the lice, within a few days. PARALYSIS OF THE ORBICULARIS MUSCLE (SEVENTH NERVE). The paralyzed eyelids are wide open, and cannot be closed at will; and the margin of the lower lid sinks away from the eye- ball. A thorough, voluntary relaxation of the levator palpebrae muscle, however, nearly suffices to "close" the upper lid. The lid remains immovable, if the levator is likewise paralyzed. In rare cases, though the power of moving the lids volun- tarily may be lost, reflex movements (during sneezing, exposure of the eye to strong light, etc) may still occur. The continued exposure of the eyeballs gives rise to epiphora, irritation, in- flammation of the cornea, etc. TREATMENT. 451 PARESIS OF THE ORBICULARIS MUSCLE. The more prominent symptom of paresis is epiphora, accom- panying inability to close the lids forcibly, or to throw the skin of the lids into folds. The causes of paresis and paralysis are:—inter-cranial changes {e.g., congestion of the brain, apoplexy, etc.), Avhich generally affect both orbicularis muscles; morbid changes of the structure of the orbicularis muscle itself, or of the parotid, or of the seventh (facial) nerve. The paralysis may be confined to those branches of the nerve which go to the orbicularis muscle. The treatment belongs essentially to the domains of general medicine and surgery. The irritation caused by the epiphora, and by exposure of the eyeball to the air, etc, is best overcome by keeping the eyelids continually closed. Neuralgia in the frontal branches of the fifth nerve ("pain over the eyebroAvs," "in the forehead") appears, in rare cases, independently of the eye. In such cases, especially if periodical, three to five grain doses of quinine will be found of use. Still better are subcutaneous injections of a solution of the acetate of morphia. Similar injections, beneath the skin of the temple, are of tem- porary use, also, in those forms of inflammation of the eye which are accompanied by severe pain. The effect is produced in a quarter or half a minute after injection. A quantity, of from x\ to 1 of a grain, generally \ or \ of a grain, of the acetate of morphia, in solution, is injected at one time. In irritable people, even small doses cause sickness or vomit- ing, with shortness and quickness of breath. We should not neglect, in cases of neuralgia, to examine the refraction of the eye, particularly if pain is felt during reading. Properly selected spectacles have often removed long-con- tinued neuralgia. 452 SPASM OF THE MUSCLES OF THE EYELIDS. SPASM OF THE MUSCLES OF THE EYELIDS. SPASMODIC CONTRACTION OF THE LEVATOR PALPEBRAE MUSCLE. This form of spasm occurs very rarely. The eyelids, during the spasm, are wide open. The upper lid resists attempts to close it Avith the finger. This affection has been observed during morbid changes of the urinary organs, and after injuries. SPASM OF THE ORBICULARIS MUSCLE (BLEPHAROSPASMUS)— SPASMODIC CLOSURE OF THE EYELIDS. Blepharospasm is frequently observed. Morbid changes in the seventh (facial) nerve, or cerebral changes, may give rise to it. Sometimes it appears combined with neurosis of the facial nerve and spasm of the ciliary muscle. Most frequently it is the result of morbid changes of the' surface of the cornea acting upon the sensitive nerves (first division of the fifth), and of these, in their turn, reacting upon the seventh. The spasm may continue after the primary cause (irritation of the fifth nerve) has subsided; or it may have given rise to entropion, which, in itself, keeps up the irritable condition of the cornea and the spasm. Treatment.—The spasmodic closure of the red, swollen, and tense lids, occasionally occurring in the course of purulent oph- thalmia, subsides, on the cessation of the ophthalmia, unless kept up by morbid changes in the cornea. The spasm, when accompanying inflammation of the tunics of the eye (especially syphilitic and pustular corneitis, ulcers, ab- scesses, and abrasion of the cornea), sometimes continues after all inflammatory changes have passed; and is attributed to un- due irritability of the orbicularis muscle itself. The spasm readily subsides after the insertion of a seton into the skin of the corresponding temple, or after division of the supra-orbital nerve; by which means, the muscle is rendered temporarily insensible. The forms of spasm, in which the eye appears otherwise healthy, are often accompanied by neuralgia. In such cases, spasmodic contraction {e.g., of the face) may lead to spasm of TREATMENT. 453 the orbicularis; and, vice versa, spasm, commencing in the or- bicularis, may spread to other muscles. In one case, epileptic fits Avere finally induced, which ceased after division of the supra-orbital nerve. In such cases, we must ascertain whether the spasm is arrested by digital pressure upon the sensitive, or upon the motor, nerves of the orbicularis, or upon both kinds of nerves, or upon their branches. The nerves which deserve our special attention are: the supra- orbital, the infra-orbital, the subcutaneous malae the lower max- illary, and the auriculo-temporal. Sometimes we find diseased bone or periostitis to be the cause; and, by medical treatment, succeed in removing the spasm. Generally, however, we are compelled "to perform neurotomy," i.e., to divide the nerve branches, and the arteries next to them; which, when pressed upon, cause the spasm to cease. For these operations, chloroform should be given. The in- strument for dividing the nerve and artery is thrust through the soft parts down to the periosteum, close to the spot where we propose dividing the nerve. It is then carried along the peri- osteum, to, and a little beyond, the nerve; and the latter, to- gether with the artery and periosteum, are cut through. Press- ure, by means of a pad of lint, is applied, to arrest hemorrhage. Hyperaestliesia of the retina occasionally gives rise to spasm, or to frequent winking. The hyperaestliesia may be accompanied by an unusual sensibility of the cornea and conjunctiva. Attention must be paid, in these cases, to the tension and re- fraction of the eye (anomalies of which are a common cause of hyperaesthcsia). Trembling or spontaneous twitching ("the live-blood"), es- pecially of the lower lid, which may increase to spasmodic clos- ure of the lids, is observed in many hypermetropic persons. It is probably a symptom of undue contraction of the ciliary muscle. It often ceases after the instillation of atropia, or after treatment of the hypermetropia. A blister in front of the ear (over the seventh nerve), or the endemic application of atropia (gradually increased from T'2 to \ of a grain of atropia), has also been found of use. 454 INFLAMMATION OF THE EYELID. The spasmodically closed lids exercise continued pressure upon the eyeballs, and may thus cause protracted impairment of sight. This complication, or changes in the cornea, may require the speedy removal of the spasm, by division of the supra-orbital nerve. For the treatment of entropion, with spasm of the orbicularis muscle, see Entropion. INFLAMMATION OF THE EYELID. The term anchylops is applied, by some, to circumscribed in- flammation about the eyelid, at the inner canthus; and the term aegilaps, to perforation of an abscess at the inner canthus. In- flammation of one or several of the glands of the eyelashes is described under Acne Ciliaris; inflammation of the bulb and follicles of the eyelashes, under Tinea; and acute inflammation of the Meibomian glands, under Stye. The causes of inflammation, commencing in the eyelids, are: injuries (burns, blows, stings from insects, etc.), severe illness (scarlatina, measles, pyaemia, etc.). More frequently, however, the inflammation folloAvs or accompanies severe inflammation of adjoining parts, as purulent ophthalmia, ophthalmitis, erysipelas, inflammation of the gland adjoining the eyelids, etc. The swelling of the "inflamed" lid or lids is generally con- siderable, and often prevents their being opened. It is caused by the rapid increase of nuclei and cells, of the various structures of the lid, and by these structures becoming infiltrated with serum and blood. No case is recorded in which abscess has folloAved inflamma- tion, accompanying purulent ophthalmia or ophthalmitis. Ab- scess "by metastasis" often forms, if the inflammation appears after severe illness. The skin becomes dense and painful to the touch, until pus has escaped. The pus occasionally perforates the conjunctiva, or it under- mines the skin, and escapes through several openings. Abscess occurs more frequently about the eyebrows, the upper lid, and near the inner canthus. In the latter place, it may be mistaken for abscess of the lachrymal sac. TREATMENT. 455 The inflammation generally passes off without permanently disturbing the appearance and functions of the lid. If occur- ring repeatedly in the same lid, it gives rise to hypertrophy. Disturbances of the functions of the lachrymal passages, cicatrices, irritating the cornea or disfiguring the lid. Ectro- pion, entropion, or symblepharon, may follow the inflammation. Slouching of part, or of the whole, of one or both of the eyelids, has been observed in inflammation, following erysipelas, and after severe illness. Treatment.—At the commencement of the inflammation, when caused by injury, we order the frequent application of pieces of lint, dipped in cold or iced water, to be continued as long as the sensation of cold is pleasant. Applications of lint, dipped into cold water, should be tried, also, in inflammation from other causes; but must be discontinued if the cold is unpleasant, and a simple poultice, during sleep, and the frequent use of lint, dipped into warm water, or into warm lotio papaveris, may be substituted. If an abscess is found, an incision is made, at once, parallel with the margin of the inflamed lid, and sufficiently large to allow of free escape of pus. Sometimes a small, spontaneous opening has to be enlarged, or several openings have to be united into one, or a counter-opening may have to be made into the skin, after spontaneous perforation of the abscess, through the conjunctiva. The lids, after the pus has escaped, are kept closed by the application of lint, dipped into warm water, and by a bandage, which should exercise gentle pressure. The lint has to be changed frequently. Bathing the eyelids with lotio aluminis, for five minutes, several times during the day, will be found of use if there is purulent or mucous discharge from the conjunc- tiva. The state of the eyeball may require examination; in which case the swelling sometimes necessitates the use of the wire- spec'ulum. This operation is painful, and requires the adminis- tration of chloroform. In inflammation of the eyelids, as a complication of changes of the eyeball, we must inform the patient, or parents, of the 456 PTOSIS. dangers which threaten "the sight," otherwise the loss of sight might be attributed to our treatment. A small abscess occasionally occurs in the follicles, near the inner edge of the margin of the eyelid. A vascular, somewhat swollen patch, close to the inner edge of the tarsus, beneath the conjunctiva, with a yelloAv spot in its centre, indicates the posi- tion of the abscess. If it touches the cornea, it gives rise to disturbances of vision, and may require puncturing. Care must be taken to adapt the general medical treatment to the cause of the inflammation. For the treatment of inflam- mation accompanying morbid changes of the glandular structures of the eyelids, see Acne, Tinea, Stye. Anomalies in the position of the lids, and in the function of the lachrymal apparatus, following inflammation, are more suc- cessfully treated, if the inflammation is first alloAved to pass off completely, unless it be kept up secondarily by these changes themselves. PTOSIS. Ptosis, or drooping of the upper eyelid, with inability of vol- untarily raising it, may be caused by paralysis or paresis of the branch of the third nerve which supplies the levator palpebrae muscle, before it reaches that muscle, or by alterations of nu- trition of the muscle itself, or of the entire eyelid. In the first case, it is generally complicated with paralysis of the ciliary muscle, of the sphincter of the pupil, and of one or several of the recti muscles. On raising the drooping lid, we find divergent strabismus, and the pupil somewhat enlarged and fixed. In complete ptosis, the upper lid hangs motionless, and the outer canthus appears loAver than that of the felloAV-eye. A slight impairment of the power of raising the upper lid is termed paresis of the levator palpebrae muscle. The skin of the forehead, in such cases, is thrown into folds, when an effort is made to raise the lid, while the skin of the lid hardly changes its appearance. TREATMENT. 457 Treatment—Ptosis may be the result—(1.) Of severe or re- peated inflammation, leading to hypertrophy and increase in weight of the upper lid. (2.) Of protracted intolerance of light, with spasmodic clos- ure of the eyelids, producing hypertrophy of the orbicularis muscle, and thus destroying the antagonism between the orbicu- laris and the levator palpebrae muscle. (3.) Of increase of weight of the lids, in aged persons, from superabundance of skin, with weakness of the levator palpebrae muscle. In all cases, the action of the levator palpebrae muscle is often further impeded by narrowing of the palpebral aperture. After all inflammation has ceased (1), and the intolerance of light has subsided (2), we can, by the removal of some skin, and the orbicularis muscle, along the margin of the anterior surface of the tarsus, improve the condition of the patient; who, for personal reasons, or to improve the sight, may be desirous to undergo the operation. To determine how much of the skin to remove, we pinch up a fold, along and parallel with the margin of the lid, so as to raise that margin above the upper edge of the pupil, Avhile the eye is directed straight forwards. When the fold of skin is raised, the patient must be able to close the lids readily, Avithout effort. The fold is removed Avith scissors. Then, a strip of the orbicularis muscle, varying in width from one-fifth to one-quar- ter of an inch, is dissected aAvay from the tarsus; particular care beinc taken to remove the thick portion attached to the edce of the tarsus. One suture is applied midway betAveen the outer and inner canthus, and is carried through the outer edge of the margin of the eyelid (tarsus), and through the nearest portion of skin. The Avound heals Avithin a few days. Cold- water dressing may be applied. The suture often comes aAvay spontaneously. Acute alterations of nutrition during oedema or inflammation of the eyelids e.g, in the course of purulent ophthalmia, ery- sipelas, ophthalmitis, etc., cause the swollen and often immova- ble upper lid to overlap the lower one, the patient having but 458 PTOSIS. slight or no poAver of raising it. In such cases, no treatment need be adopted, so long as the cause (the purulent ophthalmia, etc.) has not subsided. Ptosis from paralysis of the third nCrve, the result of tumors, of syphilitic or rheumatic changes, or of abscesses in other parts, or occurring during congestion or hemorrhage into the brain, as a rule, appears rapidly. The treatment must be di- rected against the morbid changes Avhich may have caused the paralysis. Some patients have derived benefit from raising the eyelid during the day by means of a metal suture, or strapping. The operation of raising the lid by removal of some of its skin and muscular structure is not advisable. An operation, the object of Avhich is to raise the orbicularis muscle and tarsus beneath the skin of the eyelid, and thus to diminish the width of the drooping lid by a cicatrix formed be- tween the displaced portions of the orbicularis muscle and tarsus and the skin, has in a few cases proved successful. An incision is first made parallel with, and about an eighth of an inch from, the outer edge of the margin of the eyelid, through the skin doAvn upon the orbicularis muscle. The skin is then dissected away from the orbicularis to the extent of the tarsus, and a little beyond its upper margin. A loop of silk is next passed round some of the bundles of the orbicularis muscle, near the margin of the eyelid, at an equal distance from the outer and inner canthus. The silk is carried upAvards, beneath the skin and out at the eyebrow, and fixed there. One or two more silk threads may be inserted in the same way along the margin of the lid. The effect is to raise the tarsus and orbicularis muscle behind the skin, Avhich is thrown into fold and overlaps the margin of the lid. Cold-Avater dressing is applied frequently, and the patient should be kept in bed about a Aveek. The SAvelling, etc., of the lid has been considerable in several cases. The silk threads are removed about the eighth day, by Avhich time the displaced muscle and tarsus are supposed to have become adherent to the skin. TREATMENT. 459 THE STYE. The stye is a small, red, roundish, smooth, hard, and elastic SAvelling, situated "in the eyelid," with the skin movable over it, and with the SAvollen red margin of the lid rounded off, if the stye is near it. It is caused by morbid changes of one or several of the Meibomian glands, accompanied by more or less acute inflammation. On everting the eyelid, a grayish or yel- lowish ill-defined spot, surrounded by vascular, and sometimes granular, or SAvollen conjunctiva, may be seen. This indicates the portion of the stye which lies nearest the conjunctiva. Small styes may escape notice. Several may appear simulta- neously. They are the more conspicuous the more the skin and tarsus are implicated in the inflammation. The swelling of the lid or lids may be so considerable as to prevent their being opened. The lid, at the commencement, "itches," or feels "stiff"; it then becomes painful. Some patients at first complain of headache, and feverishness. In a few days the matter points; at last some pus escapes, generally near the margin of the lid, through the conjunctiva, or through the skin, together Avith a peculiar grayish, gelatinous-looking substance, consisting of ill-developed connective tissue. In rare instances, the pus es- capes into one of the lachrymal canaliculi. The lid, after this, either soon resumes its natural appearance, or "a granulation," or some gray and opaque substance, may be seen for a consid- erable time projecting from the opening of the perforation, especially if situated in the conjunctiva. In some cases no perforation is observed. In others, the stye, sometimes Avith- out preceding acute inflammation, after escape of pus, takes on a chronic course, and appears as a little hard tumor in the substance of the tarsus. It is then termed a chalazion. In chalazion Ave generally find ill-developed connective tis- sue mixed with a fatty or chalky-looking substance. If the chalazion, hoAvever, is old, a broAvnish turbid, or a clear oily, fluid is found. The skin and conjunctiva over it are unduly vascular. 460 THE STYE. Styes occur in persons of delicate health, and in those troubled with acne; and sometimes after or during the different forms of purulent ophthalmia. They frequently reappear periodically in the same eyelid during several years. Treatment—At the outset of the acute inflammation, Ave order the lid to be washed frequently during the day with lotio papaveris mixed Avith hot water in equal proportions, and a hot linseed-meal poultice to be applied over the closed eyelids during sleep. A small incision parallel with the margin of the eyelid, through the part Avhere the pus points, hastens the course, and relieves the patient sooner, but it need not be insisted upon if an operation should be objected to. Appropriate general med- ical treatment, and bathing the inflamed lid with lotio papave- ris, suffice after the escape of pus. All redness and swelling should have disappeared in from two to four weeks after the commencement, unless a chalazion follows, which for its removal requires an operation. Acne Ciliaris.—Acne cilia vis signifies inflammation of one or several of the glands of the eyelashes. The gland or glands become expanded, their secretion is morbidly altered, the nutri- tion is disturbed, and the surrounding tissue becomes inflamed. This affection varies in degree, and occurs more frequently in the upper than in the lower lid, probably on account of the glands being larger and more numerous in the former than in the latter. Externally, if the inflammation is severe, we find the entire lid red and cedematous, and the skin over the swell- ing tense and painful. If the inflammation becomes developed rapidly, suppuration of the contents of the gland may folloAV, with perforation of the skin at or near the edge of the lid. The patient may be feverish at the commencement of the in- flammation. If the inflammation is slight, we find a circumscribed round- ish, defined red swelling at or near the outer edge of the lid, with a few dry, yelloAv, and opaque crusts adhering to it and to the eyelashes. The margins of the lids sometimes undergo changes similar to those observed after tinea. TREATMENT. 461 Acne, though observed at any age, and usually in the spring of the year, appears most frequently about puberty, and in per- sons Avbo have acne nodes in other parts. The course is gen- erally chronic, in consequence of the glands being affected in succession. Treatment.—A small vertical incision is made into the in- flamed skin, if the pain is great, to let out blood or pus. A linseed-meal poultice is placed upon the closed lids during sleep, until all redness has disappeared. In other respects Ave adopt the local treatment of tinea. Pustular ophthalmia and corneitis, Avhich often exist simulta- neously Avith acne, require separate treatment. We also adopt the general medical treatment which is usual for the removal of acne in the skin. TINEA. {Tinea Ciliaris; Blepharitis Ciliaris, or Marginalis; Tinea Palpebralis; Follicular Blepharitis; Psorophthalmia.) Patients suffering from tinea generally present themselves with yellow, dry, and opaque crusts adhering to the eyelashes. Parts or the whole of one or both eyelids, also, are slightly red and swollen along the margin. The crusts consist, chiefly, of dried pus. We find, after their removal, the surface of the margin of the lid raw or fis- sured, easily bleeding, and scattered over with small ulcera- tions (the result of pustules). The entire margin may be thus changed into an ulcerating surface. Its inner edge sometimes appears uneven, from granulations springing up, during the course of time. Considerable swelling of the lid, with pain and intolerance of light, may occur in the commencement of the inflammation, especially if complicated with pustular, catar- rhal, or granular ophthalmia, as is often the case. The course of the disease is chronic, and may be protracted through life. It frequently recurs at certain periods of the year, e.g., every spring. When the disease is at an end, the crusts fall off, and the 402 TTNfeA. corresponding margin of the lid appears thickened (so-called tylosis, or pachy-blepharosis). The tissue surrounding the roots of the hair-follicles becomes hypertrophied, and the nutrition of the eyelashes impaired, unless tinea is properly treated. The margins of the lids appear rounded off, and the skin and conjunctiva, in extreme cases, are blended into one smooth, red, shining cicatrix, Avithout eyelashes or Meibomian gland orifices. A feAV badly-nourished pale eyelashes may be seen, which, by thickening of the margin of the lid, or by cicatrices following the ulcerations, are displaced, inverted, etc. The conjunctiva is more or less everted. Ectropion, through de- struction of skin and contraction of cicatrices, may follow. This extreme stage of tinea is termed lippituclo. Displace- ment or closure of the lachrymal puncta and canaliculi, with epiphora, continuous Avinking, and irritability of the eye, are frequent sequelae. Among constitutional causes must be mentioned variola, mea- sles, scarlatina, and, especially, syphilis; among local causes, the different forms of purulent ophthalmia. Tinea occurs most frequently in children and in young persons. Treatnh- -An anti-syphilitic or a tonic treatment is adapt- ed, accordinv- to the general aspect of the patient. Much ben- efit is der; jd from the "liquor FoAvleri," especially if the upper lid d alae nasi are swollen at the same time. To adults, we gi : gutt. x. of the liquor, Avith mist, ferri co., to be taken tX^p daily. For a child six Aveeks old, we order vini ferri o-'J ii'!1101* Fowled gutt. iij.; one teaspoonful to be taken twice daily Exerclx in the open air, and general cleanliness, must be enforced Loci . we have to prevent the accumulation of crusts. These ar most easily removed by patiently touching them Avith a sponge • pped in warm Avater, or, better still, by using the eye- douche Avith wurin Avater, until they are softened, and can be wiped oil The inflamed margin of the lid is then dried, and TREATMENT. 463 the places from which the crusts have been removed are painted over with a camel's-hair brush dipped in lotio plumbi acetatis. This is repeated three times daily. At bedtime, after using the lotion, some unguentum hydrargyri nitratis mitius, made with glycerine, is applied with the camel's-hair brush, or with the finger, along the inflamed margin of the lid. If, after the removal of the crusts, we find many ulcerations or fissures, Ave either make puncture into the skin, along the edge of the lid, so as to abstract some blood, or touch the ul- cerations with the solid nitrate of silver, or apply a solution of the latter (half a drachm of nitrate of silver to one ounce of distilled Avater) with a camel's-hair brush. This application has to be repeated every second day, as long as crusts are found. Some recommend calomel powder, to be sprinkled upon the skin along the edge of the lid, instead of applying mer- curial ointment. If tinea have existed for a long time, or the margin of the lid has become much thickened, lint, steeped in a strong solu- tion of nitrate of silver (3j. ad aquae Sj.), has been recommended to be tied over the closed lids. The lint should be changed twice daily. In lippitudo, we slit open the displaced tear-puncta and canaliculi, if epiphora exists. The patients, as a rule, are very nervous, and render this little, but essential, operation somewhat difficult.—[Bader. ENTROPION. Entropion, or an Inversion of the Eyelashes,—Is a not infre- quent result of injuries of the conjunctiva of the lids, from burns or scalds from lime, mortar, strong acids, or any other escharotic which may have caused destruction of a portion of that membrane. As cicatrization proceeds, a contraction of the surrounding tissue goes on, to help close up the gap occasioned by the es- charotic, and the margin of the lid, with its lashes, often be- 464 ENTROPION comes inverted and drawn toAvards the globe. This folding in of the lashes is a source not only of great discomfort to the patient, but of danger to the eye. The continued brushing of the lashes against the cornea, in every movement of the eye, is apt to induce a troublesome form of corneitis with ulceration, and will invariably, in a short time, render the cornea nebulous and vascular. Treatment.—If few eyelashes are displaced, they should be drawn out gently Avith the cilia forceps (without breaking them off). Frequent repetitions of this may produce atrophy of the hair-papillae. Some recommend the removal of the hair-papil- lae by operation. The growth of fresh eyelashes may be prevented for months, by applying some sulph. hydrate of calcium to that portion of the margin of the eyelid Avhich surrounds the orifices of the eyelashes. The calcium, after five minutes, is Avashed away with a sponge. During the application, a spatula is placed between the lid and the eyeball, to protect the'latter. The papillae of the eyelashes may be destroyed with pure liquor potassae. To do this, a needle, moistened with the liquor, is thrust along the eyelashes, in the direction of, and a little beyond, the papillae. Slight inflammation follows. The eyelashes, after a feAv days, are drawn out with the forceps. There are many operations recommended for the cure of entropion; but when it is dependent on cicatrization following a loss of substance of the conjunctiva of the lids, there is only one Avay of efficiently dealing with it, and that is, by dissect- ing out the entire toav of lashes. Any other mode of treating this deformity will be only temporary, and, after a while, the lids will again become inverted. As soon as it is noticed that the margin of the eyelid is folded inAvards, and the lashes are in contact Avith the ej-e, an operation for their removal should be performed, as delay will only give time for the cor- nea to become injuriously affected by them. Operation for the Removal of the Eyelashes.—This consists in first splitting the tarsal cartilage, and then excising the thin wedge of it, in which the bulbs of the lashes are imbedded. TREATMENT. 465 The lid being drawn tense by one hand of the operator, with the other he makes a long incision Avith a cataract-knife along the inner, or ocular, edge of the lashes, and of a sufficient depth for the point of the knife to pass beyond the roots of them. The lid is now to be relaxed, and a second incision is to be made just behind, but parallel to, the row of lashes on the outer surface of the lid, so as to cut through the integuments and the margins of the cartilage just beyond their roots; the depth of the two incisions will thus meet, and the whole row of lashes will be excised. The cut surface of the cartilage should now be carefully scanned over, so that if any of the bulbs of the lashes have es- caped excision, they may be removed; should any be left, neAv lashes will sprout again from them, and the object of the opera- tion will not be completely fulfilled, as a single eyelash brush- ing against the cornea may cause a great amount of suffering, and produce considerable irritation. The bulbs of the lashes may be recognized by their appearing as fine black dots. Lastly, the skin should be gently pressed over the cut edge of the cartilage, and a compress of wet lint be applied to the eye Avith a bandage. No sutures should be used. By this operation the lid is not shortened, for the edge of the cartilage is simply split, and the thin wedge of it removed in which the lashes are implicated. 466 ENTROPION. To facilitate the performance of this operation, either Snel- len's eyelid forceps (Fig. 38), or the horn spatula (Fig. 39), may, when practicable, be used. If Snellen's forceps are se- lected, the lower blade should be gently insinuated beneath the upper eyelid as far as it will pass, and then, Avith a few turns of the screw, a metallic clamp is made to compress firmly the circumference of the lid, Avith the exception of its tarsal border, which is left free for the operator. The advantages which this instrument offers are:—1st. That the operation, which is usually accompanied by sharp hemor- rhage, is rendered by it an almost bloodless one; and, 2d. That, as all bleeding is arrested whilst the clamp is applied, an efficient exploration can be easily made for the bulbs, or any lashes Avhich may have been inadvertently left. The great disadvantage of this instrument is, that the ex- treme lashes, both at the inner and outer part of the lid, are often concealed by the rim of metal which is screwed upon them, and that they are thus apt to evade the notice of the operator. This may be avoided by first confining the operation to the parts within the clamp, and by then completing it after the instrument has been shifted first to one and then to the other extremity of the eyelid. Snellen's forceps are made right and left handed, according to the lid for which they have to be used. These are only applicable to operations on the upper eyelid. When the horn spatula (Fig. 39) is used, it should be held by an assistant after one of its extremities has been passed be- neath the eyelid. It will serve to support and extend the eye- lid during the operation. There are, however, many cases of traumatic entropion where it is impossible, on account of a partial union of the lids to the globe, to use either Snellen's forceps or the horn spatula. In such cases, the plan recommended of making the lid tense by drawing upon it with one of the fingers must be adopted.— [Lawson. Entropion, if the tarsus is not thickened or distorted by cica- trices, can be remedied by establishing one or several cicatrices in the integuments of the inverted lid. TREATMENT. 467 As close as possible to the outer edge of the margin of the inverted lid, a needle, armed with strong waxed thread, is thrust through the skin and other soft parts. It is carried along the outer surface of the tarsus, and brought out again, about ^ in. from the point where it entered. The distance of these two points from each other, and, Avith it, the quantity of skin, muscle, etc, enclosed by the thread, must be regulated by the decree of entropion. By pinching up a fold of skin, parallel to the margin of the lid, previously to inserting the needle, Ave can, in a measure, ascer- tain how much of the skin, etc., need be en- closed. The thread is tied firmly, so as to strangulate the skin, muscle, etc., and is left to come away by suppura- tion. This requires from six to ten days. The linear cicatrix, which re- mains, is expected to keep the lid in proper position. Several of the cicatrices may be re- quired, if the entropion be considerable. The threads have to be removed, if erysipelas appears. Entropion, Treated by Removal of a Fold of Skin, etc.—The relaxed skin of the inverted lid is seized close to the margins by the fino-er or forceps, and raised in a horizontal fold, so that the inner edge of the margin of the lid is slightly drawn away from the eyeball. If sufficient skin has been pinched up, the patient, when forcibly closing the lids, will not be able to pro- duce entropion. The fold of skin is then removed by scissors; a narroAV strip of the entire thickness of the exposed portion of the orbicularis muscle, about \ in. wide, likeAvise taken away, close to the margin of the hd. Two or three sutures are applied to convert the wound sur- face into a linear incision. Immediately after the operation, the margin of the lid should be very slightly everted. Water dressing is applied for a few days. 468 ENTROPION. Entropion of the lower eyelid, at or near the outer canthus, caused by enlargement and flaccidity of the eyelid, is removed by displacing the margin of the lid, so as to render it less flaccid. An incision, about £ in. long, and commencing at the outer canthus, is made through the skin and other soft parts horizon- tally outAvards, doAvn to the external palpebral ligament and ad- joining periosteum. Two other incisions, likeAvise extending to the periosteum, the one from the beginning, the other from the end, of the horizontal incision, are carried downwards, and made to meet at an angle, on a level with the lowest point of the lower margin of the orbit. The soft parts, enclosed by these incisions, are dissected aAvay, and the margins of the two downward incisions are united by sutures. The operation should have the effect of stretching the margin of the lower lid over the eyeball, and keeping it in proper position. (Fig. 41.) 1. Method of securing the cords which control the levator. 2, 2. Cords holding the levator. 3, 3. Stitches securing proper position of external integument. 4. Ciliary border. 5. Lachrymal punctum. 6. Border of tarsus, projecting below the ciliary margin. TREATMENT. 469 Dr. Joseph S. Hildreth, of Chicago, has devised an opera- tion, somewhat similar to that of Jaesch, only that there is no strip of integument removed from the upper lid, and there is, consequently, no isthmus of integument including the ciliary matrices to be in danger of sloughing. The skin, orbicularis muscle, and ciliary margin, are dissected up from the cartilage, and the skin, with the underlying orbicularis, are maintained in a folded condition, by a suture at either end of the lid, as represented in 3, 3, Fig. 41. Then a thread is passed from the mucous side over one border of the levator palpebrae, and, without penetrating the skin, it passes out again through the mucous membrane; another similar thread is passed through and over the other border, in the same way. The threads 2, 2, are then brought down upon the cheek, and retained by the plaster, 1. This is in order to hold down the cartilage, until the integument and orbicularis form a new attachment, high enough up, so that the eyelashes will not again project from the cartilaginous margin over upon the globe. Saunders proposed to take out a portion of the inferior bor- der of the cartilage; and others have cut off cartilage, eye- lashes, and all, as if in despair of affording relief by any con- servative method. The recognition of the contraction of the conjunctiva, and the shortening of the palpebral fissure, has led to the attempt to create a new external canthus, by establishing a fistula by means of a silver wire, and afterwards cutting out between the canthus and the fistula. And again: the canthus has been elongated by incision, and the conjunctiva has been drawn out and stitched fast, as in Dieffenbach's operation for elongating the fissure of the mouth (the 2d variety of the 4th method). This last expedient fails, because the supply of mucous mem- brane is already too small for its legitimate purposes, without affording any material for elongating the palpebral fissure. The indication is, to lengthen the palpebral fissure, to diminish the closeness with Avhich the upper lid glides upon the eye, and to enable the operation of Des Marres to evert the eyelid. It is to fulfil this indication, that a new operation is proposed, 470 ENTROPION. which, instead of attempting to supply the deficiency out of mucous membrane, supplies it out of skin, by the implantation of integument behind the outer portion of the upper lid; the first variety of the fourth method. Operation.—From a point in a line drawn horizontally through the external canthus, and about ,'g of an inch from the canthus, carry an incision dowmvards and iiiAvards from one- third to one-half the length of the lower eyelid, and parallel Avith its ciliary margin. Make another incision, beginning at a point \ of an inch further out in the same horizontal line, cutting downwards and inwards, and meeting the other incision at its lower extremity. If the incisions are made by a narrow-pointed bistoury pierc- ing the skin and cutting it out, it is best, in making the second incision, not to bring the point of the bistoury out exactly at the lower end of the first incision, lest the skin should slide over the edge of the knife and make the flap too short. The integument between the incisions, doAvn to the orbicularis, is then dissected up as a triangular flap, beginning at the apex below. The flap is then turned up, and its apex is transfixed with a needle attached to a silver wire, having, also, a needle attached to the other end. This affords a convenient means of holding up the flap. Care should be taken here, as in all cases where it is expected to escape suppuration, to avoid contusion of the flap by the pinch of forceps. It is better not to use for- ceps at all in this operation, but to lift the point of the flap with a tenaculum, and as soon as sufficient integument is raised, to transfix the flap Avith the needle, which affords an adequate handle to it. rihen, under the base of the elevated flap, an incision is car- ried in the horizontal line already indicated, through the can- thus, deep through the fibres of the orbicularis, doAvn to the bone, and outwards to the upper end of the outer vertical inci- sion. The mucous membrane is then freely incised behind the outer portion of the upper lid, so as to permit the easy eleva- tion and eversion of the lid. The flap is then doubled upon itself, and drawn under and behind the outer portion of the TREATMENT. 471 upper lid, being drawn into its new position by the wire suture previously introduced through the flap. To this end, the points of the needles are introduced, about \ of an inch apart, behind the outer portion of the upper lid, and brought out through the integument beneath the broAV. Care should be taken to intro- duce the points of the needles in the dissected space, where an open space has been created in the mucous membrane. The object of this caution is to secure the contact of the areolar tissue of the flap, with the corresponding tissue behind the lid, in order to make union possible. The inverted integument thus comes to occupy the position, and to perform the function, of mucous membrane. The wire is twisted over a compress for the protection of the skin from ulceration, and it is left in five days or longer. For the easy extraction of the silver wire, it is convenient to have put a thread into the loop, before drawing it in. This should be tied down upon the wire, in order that it cannot, by any possibility, become displaced, instead of leaving it loose, as shown in the cut. After cutting the free ends of the loop com- ing out below the brow, a gentle pull upon the thread which hangs out at the canthus, readily extracts the loop in the direc- tion contrary to that in which it had been introduced. The tAvo lines bounding the space from which the flap had been taken, are made to meet by a little undercutting of the margins, and retained by interrupted sutures. The nearness to the margin of the lower lid, to be observed in making the first incision, depends upon the amount of eversion to be secured to the lower lid. If there is no inversion of the lower lid, the flap should be taken from a space more distant, and vice versa. The accompanying illustrations, Figs. 42, 43, will render the account more intelligible. Fig. 42 represents the external commissure, contracted by inflammation. The space from which the flap has been dis- sected is seen below the outer part of the lower lid, and the flap itself is turned up, with the wire passing through it. A dotted horizontal line shows the place in which the deep inci- sion is made, to extend the external canthus. 472 ENTROPION. (Fig. 42.) A new operation for entropium, by inverting a portion of the integument of the face behind the upper lid. The flap is seen dissected up. In the cases of entropium which require this operation, it will generally be necessary to perform that of Celsus, or Des Marres' modification (the first expedient mentioned in the pre- ceding enumeration), in order more perfectly to effect the ever- sion of the ciliary margin. In cases in which chronic inflammation and long-continued granulation have produced a marked diminution of the oculo- TREATMENT. 473 palpebral fold, the plan of inversion of integument may be applied to both lids. A strip of integument may first be taken from the upper lid, immediately above the eyelashes, after the method of Des Marres, and leaving it attached at its outer extremity, it can be attached behind or within the lower lid; and after the complete healing from this operation, a strip of integument may be taken from beneath the lower lid, in the same Avay, and implanted behind the upper lid. We thus com- bine the most efficient means of everting the ciliary margins, with a mode of supplying redundant skin to take the place of deficient mucous membrane. The only deformity which is left by this operation is a somewhat unnatural fulness above the external commissure, which, if desired, can be remedied by a subsequent operation, removing a portion of the integument which had constituted the base of the flap. It has been suggested, that modifications of this operation may be made for symblepharon, in order to supply, to some extent, the deficiency of the mucous membrane, by implanting the delicate skin of the lids. This is very extensible, so that though a flap, at the time of its implantation, may seem very small, yet it is capable, after its adhesion in its new location, of great enlargment. To remove any deformity which may arise from the increased thickness, when the flap turns in at either the inner or the outer canthus, the pedicle through which the vascular supply was first maintained may be cut away, after the circulation has been established through the adhesions in the new relations.* Dr. I. Hays, of Philadelphia, f has secured some success in adhesion of the lids to the globe, by dividing the adhesions, and introducing a metallic plate between the lid and the globe, hav- incr it so shaped as to correspond with the curvature of the eye, or&like the rim of an artificial eye. This is worn until the cicatrization is complete. The writer, following this example, introduced a gold plate, *A description of this operation was published in the American Journal of the Medical Sciences, for October, 1866. f American Journal Med. Sciences, January, 1861, page, 116. 474 ECTROPION. with partial success, but there was so much difficulty in keep- ing it in position, that he determined, if he should have another case, to have a Avire soldered near each end of the border, the loAver border for the lower lid, and the upper border for the upper, to arm these with needles, and having introduced these deep and brought them out through the integument, to fasten the ends as represented in Fig. 43. It must be practicable, by this means, to hold the plates in position any length of time. The wearing of the plate may be combined with the insertion of a piece of skin, to increase the extent of the internal lining of the lids.—[Prince. ECTROPION. EVERSION or turning out of the eyelid. Ectropion varies in degree, from slight sinking away of the inner edge of the lid, from the eyeball, to complete eversion of the entire lid, and of the adjoining fornix of the conjunctiva. The conjunctiva, exposed to the air, etc., appears unduly vascular, in recent cases. It gradually becomes hypertrophied and granular. Accumulation of tears, in the sulcus, betAveen the lid and the eyeball, and epiphora, are frequent complications. The cornea, if continually exposed, becomes vascular. Opaci- ties, infiltration, and ulcers, etc., appear. This occurs sooner in old and weak patients. Ectropion of the swrollen eyelids is observed during purulent and other forms of ophthalmia, especially in children. Its occurrence is favored by the spasmodic action of the orbicularis muscle, or by attempts to inspect the cornea. Causes.—Cicatrices, from injuries, burns, ulcers, etc, in or near the lids. Shortening or destruction of the skin, or of the skin and suspensory ligament of the eyelids, or of the tarsus. Atrophy of the orbicularis muscle, from undue extension, caused by protrusion of the eyeball, or by inflammation of the eyelids. Paresis or paralysis of the orbicularis muscle, as fre- quently seen in old persons. Acute inflammation of the conjunctiva, with much chemosis, TREATMENT. 475 especially if the tarsus has become softened. Long-continued overflow of tears and mucus, causing eczema and contraction of the skin. Treatment.—During the healing of injuries, burns, or in the course of bone disease, to prevent ectropion, as far as possible, it may become necessary to keep the lids closed, sometimes for tAvo or three months. This is done by the application of strap- ping; or in cases requiring a prolonged treatment, by producing (temporary) adhesion of the margins of the eyelids. In slight cases of ectropion, and in those which arise from expansion or relaxation of the tarsus, or from paresis or pa- ralysis of the orbicularis muscle, the palpebral aperture is nar- rowed by operation. In extreme cases, we may have to perform the same operation at the inner canthus; also, taking care not to disturb the tear-puncta. Ectropion, arising during acute inflammation of the conjunc- tiva, often subsides spontaneously. During the inflammation, the lids can be maintained in position by the application of metal sutures, pieces of strapping, or a bandage. In considering what are the best means of restoring to its normal condition an eyelid which is deformed by ectropion, it is necessary to determine accurately the relative changes which have been produced by it, in the different parts of the lid. 1st. The eyelid is more or less elevated. 2d. As a consequence of this, the punctum lachrymale is displaced: it is drawn away from its proper relationship with the globe, so that it ceased to act as a conduit for the tears. 3d. The tarsal edge of the lid is more or less elongated, according to the extent of the eversion. 4th. In many cases, the exposed conjunctiva is hypertrophied and thickened. 1st. In a mild case of ectropion, these defects will be only slightly marked, and, possibly, one or other of them may be ab- sent; but, where there is a great eversion of the lid, they will probably be all present and distinctly seen. In treating of these defects, I will take them in the order in which it would be wise to proceed in an operation for their relief. 2d. If the exposed conjunctiva is much thickened and hyper- 476 ECTROPION. V trophied, the prominent excrescent-looking portion should be excised. This is most easily done by seizing, with a pair of fine- toothed forceps, the piece of conjunctiva which is to be removed, and cutting it off Avith a pair of small scissors, curved on the flat. The contraction Avhich accompanies the cicatrization of the conjunctiva draAvs the edge of the eyelid inAvards, and helps, very materially, to restore it to its natural position. 3d. When the tarsal edge of the lid is elongated, it must be shortened, before the lid can be restored to its proper position. This lengthening of the tarsal margin is due to the constant pull which has been exerted upon it, during the contraction and cicatrization of the wound, which has caused the ectropion. To remedy this defect, a V-shaped piece of the edge of the lid, as in Fig. 44, may be excised with a fine scalpel. The lips of the wound are then to be brought together with fine pins and twisted sutures; taking care that one of the needles is inserted close to the tarsal edge, as in Fig. 45, so that an accurate apposition of the corresponding surfaces is secured. A portion of the tarsal cartilage may thus be removed from any part of its length; but, in most cases, it is advisable to make the excision from the extreme end, close to the outer canthus, taking away, at the same time, sufficient from the edge of its fellow-lid to form a raw surface, with Avhich it may be united. The edges of the wound are brought more easily and accurately together than when the part excised is near the centre of the lid; and the scar which is left is much less noticeable. (Fig. 44.) (Fig. 45.) TREATMENT. 477 In shortening the lid, it is always necessary to take away a piece of sufficient size, so as to reduce the palpebral aperture to a little below its normal dimensions. . 4th. To relieve the eversion of the eyelid, many operations have been suggested and practised. When the ectropion de- pends, as it generally does, in traumatic cases, upon a cicatrix, either of the skin, in the neighborhood of the orbit, or of the lid itself, the first endeavor should be to free the eyelid from the influence of the scar which binds it down. This can be often readily accomplished: the great difficulty is to prevent a re- union of the parts, and a return of the deformity. Where there is Complete or Partial Ectropion, dependent on a Cicatrix, at a Short Distance from the Lid.—For convenience of description, I will deal with a case in Avhich the lower lid is the one affected: the same plan of treatment, modified according to circumstances, will be applicable to ectropion of the upper lid. If the ectropion is partial, and due to a small cicatrix, which is only adherent to a very limited area of the cellular tissue beneath it, while, around the scar, the skin will glide easily over the subjacent tissues, it will be sufficient, first, to free the deep adhesions of the cicatrix by subcutaneous division. A tenotomy-knife is to be introduced beneath the integument, at a short distance from the scar; and, by a few semicircular sweeps, the union between it and the cellular tissue will be parted. If this is satisfactorily accomplished, the skin will now glide with freedom over the parts to which it was before adherent. The tarsal edge of the lid should now be shortened, in the man- ner already described; and, if the exposed conjunctiva is much thickened, a portion of it also should be excised. By these means, the lid will be restored to its normal position, and, as the scar will be lifted from its original site, the chance of its re- uniting to the parts from which it has been severed will be di- minished. In the daily dressing of the wounds, the lid should be well supported with a pad of lint, to prevent the cicatrix being again drawn down to its former position. If the Ectropion is severe, and the Cicatrix, which has caused it, is dense and firmly attached to the subjacent cellular tissue, a 478 ECTROPION. different proceeding must be adopted. One very excellent mode of treatment is, by including, in a V-shaped incision, the cicatrix, which is to be separated, by a feAv strokes of the scalpel, from all its adhesions to the underlying parts, as is Avell shown in Fig. 46. (Fig. 46.) (Fig. 47.) The triangular-shaped piece of skin, in Avhich is the cicatrix, is then to be pushed upwards, whilst the loAver edges of the V wound are united by tAvo pins and twisted sutures, in the situa- tion marked by the dotted lines in the Avood-cut so as to con- vert the V, when the parts are brought together, into a Y- The everted lid will thus be raised; but, in order to keep it in posi- tion, its tarsal edge should be shortened at the outer canthus, removing, at the same time, a small piece of the margin of the upper lid, to which the lower one should be united by pins and twisted sutures. If the conjunctiva is much thickened, a portion of it may be excised, before shortening the lid. Fig. 47 shows the appearance the eye will present after the operation is completed. The following operation was the one recommended and per- formed by Dieffenbach for the relief of ectropion of the lower lid, which had been caused by a cicatrix, at a short distance beneath it:—He first dissected out the cicatrix by including it in a triangular incision (Fig. 48), the base of which corresponded with the tarsal margin of the lid. Having removed this tri- angular flap of skin, he then extended the cut c c to c a, c a, to TREATMENT. 479 (Fig. 48.) (Fig. 49.) allow of the ready approximation of sides bb ; Avhich, having been first raised from the subjacent parts by a feAv strokes of the scalpel, he brought together and united by sutures, as in Fig. 48, the two lateral incisions, c a, c a; he then fastened, by sutures, to the integument, beneath the lower lid, in the line c c. Fig. 49 represents the appearance after the operation Avas completed. —[Lawson. Formation, by Operation, of an Entire Eyelid, or of Part of an Eyelid.—We first ascertain Avhether any part of the eyelid remains. Though the skin and muscular tissue may have been destroyed, Ave often find that the tarsus, or part of it, Avith some altered conjunctiva, has been preserved. In such cases, we free the distorted or everted tarsus from adhesions, place it in a natural position, and unite it by sutures with the opposite eye- lid. The union is maintained until the tarsus is covered with cuticle, and all tendency to contraction has disappeared. Cases of supposed complete destruction of the upper lid, in which large and deep cicatrices, over the forehead and temple, rendered the success of transplantation of skin very doubtful, have thus recovered, Avith preservation of sight and useful upper lid. In transplanting skin from adjoining parts on to the replaced tarsus or in forming an entire eyelid out of transplanted skin, the following rules should be observed :— (1.) For a lower lid, the skin should be taken from near the ear- for an upper lid, from the forehead and temple; and, in either case from a part as near as possible to the spot where it is wanted. 480 ECTROPION. (2.) The portion of skin to be transplanted should be as sound as can be obtained. (3.) The flap of skin should be considerably larger, in all its dimensions, than the surface Ave Avish to cover. The shape of the desired eyelid should be traced on paper, cut out, and placed upon the part from which Ave propose to take the flap. We then mark upon the skin an outline similar to that of the paper, the lines running parallel Avith the margins of the paper, but de- scribing a space which, as regards size, is, at least, as large again as the paper. The skin flap, in fat persons, should be still larger. (4.) The base or bridge Avhich connects the flap with the sur- rounding skin should be broad. The flap, however, should have sufficient mobility to alloAv of its being sufficiently displaced, without being too much stretched. The flap is secured in its new position by sutures, and the after-treatment conducted upon general surgical principles. Warmth should be applied, if the flap has been taken from anae- mic cicatrized skin; cold, if the swelling and redness are con- siderable, and the sensation of cold is pleasant. SYMBLEPHARON. Symblepharon signifies adhesion of the conjunctiva of the eye- lid to that of the eyeball. We distinguish— (1.) Anterior symblepharon, i.e., adhesions of the conjunctiva of the lids to different parts of the surface of the eyeball, by means of vascular or non-vascular bands. The entire conjunctiva of the lower lid may be found adherent to the eyeball. The conjunctiva of the upper lid is rarely adherent throughout. Extensive adhesions of this kind have been separated success- fully, by means of scissors and a grooved director. If the en- tire conjunctiva, of one or both eyelids, is adherent to the eye- ball, a stout lead wire should first be thrust through the adhesion, in the direction and situation of the fornix of the conjunctiva. TREATMENT. 481 This is left until the walls of the channel, thus formed among the adhesions, have become cicatrized. It is then withdrawn, and the rest of the adhesions are divided by means of scissors. The lids are kept everted by a suture or bandage until the wounded surface has become cicatrized. It may become neces- sary to split the outer canthus, in order to produce and main- tain a more complete temporary eversion of the lids. Bands, extending from the margins of the lids to the eyeball, are dissected from the latter; and a needle, armed with silk, is passed through those portions which Avere attached to the eye. The needle is carried through the lid from within outwards, close to the margin of the orbit, and the silk is fixed upon the skin. The band is thus drawn in the same direction, and its smooth surface is caused to lie next the eye. In this manner, reunion is prevented. If this mode of treatment cannot be adopted, the band is di- vided, close to the eyeball. After cicatrization of the Avound, the edges of Avhich must be prevented from reuniting, the band is removed from the lid, unless it has shrivelled away spontane- ously. If the cornea is implicated, an opacity may remain; though opacities, occupying half of the surface of the cornea, may gradually disappear, after removal of the adhesions. Syncanthus signifies a symblepharon at the inner canthus, com- plicated with destruction of the caruncle and of the semilunar fold. (2 ) Posterior symblepharon, i.e., shortening of the conjunctiva, caused by shrinking of the fornix alone, or by adhesions between the fornix and the adjoining palpebral and ocular conjunctiva, is of no consequence, if slight. If extensive, it impairs the mobility of the eyeball, gives rise to entropion, etc. It is, at present, considered incurable. Anchyloblepharon signifies adhesion of the margins of the lids- to each other, by means of membranous bands, extending from the edges of 'one eyelid to those of the other. This generally occurs at or near the outer, rarely at the inner, canthus. The adhesion may be divided, and the wounded surface, after bleed- ing has ceased, painted over with collodion. 31 482 SYMBLEPHARON. Anchylosymblepharon signifies adhesion of the margins of the eyelids to each other, and to the ocular conjunctiva. Blepharophymosis signifies narrowing of the palpebral aperture. The outer palpebral ligament and the other parts which con- tribute to the formation of the outer canthus appear thickened, and often inflamed. The causes are:—shrinking of the con- junctiva, after injuries, after loss of the eyeball, after protracted tinea, and especially after protracted granular ophthalmia, with pannus. Blepharophymosis gives rise to entropion, eczema, and epiph- ora, and to more or less blepharospasmus. Operation for Blepharophymosis {Enlargement of the Contracted Aperture of the Eyelids). The eyelids are kept open by a strong wire-speculum, and the outer canthus is thus put on the stretch. With scissors, or with a scalpel, a horizontal incision, about half an inch in length, is carried through the outer canthus, outer palpebral ligament, and orbicularis muscle, doAvn to the outer angle of the orbit. The edges of the incision are then drawn widely asunder, and the conjunctiva is united, by sutures, to the nearest portions of skin. Some of the conjunctiva is thus interposed between the fibres of the orbicularis muscle, and slight ectropion is produced. Tarsarophy.— Union, by operation, of any portion of the mar- gin of the tarsus of the upper to that of the lower lid. The tough texture of the tarsus, the great pain felt on wound- ing it, and the profuse bleeding which always occurs, render it advisable to administer chloroform. With a sharp cataract-knife, or, better, with a lancet-shaped knife, we remove, from the upper and lower lids, those portions of the inner edges of the tarsi which lie opposite to each other. None of the eyelashes need be removed. The wounded parts, when the lids are closed, should be opposite each other. The lids are united by passing a suture beneath the wounded sur- faces; the needle being carried close to the margin of the wound through the conjunctiva, tarsus, and skin. The lids of both eyes are kept closed and at rest for thirty- six hours, when the sutures may be removed. TREATMENT. 483 The inner and outer canthus, and any portions of the margins of the lids, may be thus united. WOUNDS. The cut edges of a Avound, however large, if fresh, or not yet granulating, should be carefully united by sutures. Care should be taken to prevent the tear-puncta from becoming closed or displaced, if the wound should happen to be near them. If the wound is already granulating, strips of sticking-plaster should be applied, so as to secure a natural position of the lid, while the wound is healing. Any displacement of the lid is to be remedied afterwards. Ecchymosis, or suffusion of the lid with blood, whether the result of a blow, of leech-bite, or of an operation, should be treated by the application of a poultice, made of the scraped root of black bryony (Bryonia nigra), mixed with equal portions of linseed meal, or bread-crumbs. The poultice, spread between pieces of linen, is placed upon the closed lids, and left on as long as the patient can bear it. Several poultices may have to be applied in succession. Ecchymosis of the lids, following ex- cision of the eyeball, causing extreme swelling and dislocation of the lids, disappears completely, after applying such poultices for from one to three days. An "almost unbearable stinging sensation" accompanies the disappearance of the suffusion. Some recommend fomentations with hot Avater, instead of the poultice. Emphysema of the lids results from fracture of the bony wall of the nasal cavity, with laceration of the lining membrane. The air passes beneath the skin of the lids, when the nose is blown. When this is done, the lids become suddenly swollen, without changing color. On percussion, a clear sound is heard, and, on touching with the finger, a crackling of air is felt, as when squeezing an emphysematous lung. Lint, with cotton- wool, is applied over the closed lids, so as to cause slight pressure, and the parts are kept at rest for some days. 484 EYE-BANDAGES. EYE BANDAGES. LiebreicKs Eye Bandage.—After all operations on the eye, but especially after an extraction of cataract, the comfort of the patient is increased, and the prospect of success improved, by an easy, well-adjusted bandage. The one now in use at the Royal London Ophthalmic Hospital fully accomplishes its pur- pose; it was introduced by Dr. Liebreich, about three years ago, when on a visit to the hospital. Fig. 50. is a close representation of it; the only difference between the original bandage and that in the drawing is a slight modification in the way in which the tapes are fastened to the (Fig. 50.) knitted band. The bandage consists of a knitted cotton band, A, from 11 to W\ inches in length and 2J inches in width, at either end of which are attached tapes, to keep it in position on the head. The tape should be 1 inch in width. One tape, B, 12 to 12J inches in length, passes across the top of the head from ear to ear; whilst the second tape, C, 10J to 11 inches in length, goes across the occiput from the ear to the other, and terminates in a free end, D, by which it is tied to the tape, E, and fastened on the head. The patient having been told to gently close the lids of both eyes, a small, single square of linen is laid over the one which has been operated on; upon this is placed a little cotton-wool, and over the whole, and across both eyes, the bandage, which-is to be tied on the side of the head, opposite to the eye which has undergone the operation. The advantages which this bandage INSERTION of a seton into THE TEMPLE. 485 has over the many different methods which are practised for keeping the eyes closed after operations are:— It is easily applied, and fits accurately, without slipping; it can be unfastened quickly, and the eye examined without dis- turbing the patient, or without requiring him to sit up, if he is lying down. It is also very easy to the patient, and it does not exclude the use of moist applications to the eye, as they can be applied through .the bandage. I have lately had the bandage made with linen, instead of a knitted band; and, in some respects, I prefer it, as it is not so hot to the eyes; and, if water-dressing or lotions have to be used, they can be more conveniently applied through the linen than the knitted cotton. When moist dressings are required, the cotton-wool should be omitted, and, in its place, a double fold of linen should be laid upon the closed lids, over which the bandage is to be fastened. INSERTION OF A SETON INTO THE TEMPLE. The patient is seated, with his head well steadied against the surgeon's chest, who stands behind him. The surgeon, to avoid wounding the temporal artery, first ascertains its pulsation be- neath the skin. He then pinches up a fold of skin, between the outer margin of the orbit and the artery, and thrusts the seton- needle, armed with stout silk thread, through the entire thick- ness of the skin, on the side of the fold next the ear, pushes it on in a vertical direction beneath the skin, along the base of the fold, and brings it out about an inch and a half higher up. The silk thread (seton) thus lies close in front of, and somewhat par- allel with, the temporal artery. The needle is removed, and the silk securely tied into a loose loop, to allow of its being moved to and fro. The hair being placed over it, hides it from view. Bleeding beneath the skin sometimes occurs, causing consider- able swelling, if the temporal artery has been wounded. The seton should be removed at once, to arrest undue loss of blood, if the escape of blood is profuse and of arterial character, or if it does not discontinue within half an hour. Another seton may 486 LEECHES. at once be placed into a part of the skin beneath which the hemorrhage has not extended. The patient or nurse must be shoAvn hoAV to move the seton to and fro: this should be done once daily. The seton gives rise to inflammation of the surrounding skin, and purulent discharge, which latter should be carefully cleansed away with warm water, twice daily. The discharge may cease before the seton has had the desired effect, if the tract through which the silk passes becomes cuticu- lar. Insertion of a seton into another part of the skin, or applica- tion of some irritating ointment to the first one, should be tried. Large granulations, or much swelling of the skin, need not alarm us. The seton may be removed after the intolerance of light and corneitis have subsided. A new one must be intro- duced (through the original tract, if possible), if the first should fall out accidentally. The openings in the skin, after removal of the seton, gradually approach each other, and frequently co- alesce, leaving a hardly perceptible cicatrix. The seton is of the greatest use in opacities, pustules, and ulcers of the cornea, when accompanied by spasmodic closure of the eyelids, increased vascularity, lachrymation, and intolerance of light, where granulations of the conjunctiva are not present simultaneously. It may be inserted at any age, and is, in hospital practice7 almost the sole remedy adopted for the rapid removal of the disturbances accompanying the just-mentioned corneal changes. LEECHES. If ordered for the purpose of acting upon the eye, are applied to the skin of the corresponding temple. Instillation of atropia increases their effect. The eyes should be kept closed during the bleeding, and for some hours after it has ceased. Evening is the best time for the application of leeches. TURNBULL'S PRACTICE. 487 The bloodvessels of the choroid (vieAved with the ophthalmos- cope, during the application of leeches) at first become con- tracted, then dilated, then contracted again, within their usual diameter, and finally dilated again to their normal calibre. TURNBULL'S PRACTICE. My first experiment was undertaken in 1837, with the diluted acid, by dipping a sponge into it, and rubbing it upon the fore- head for the space of a feAv minutes, Avhich gave the skin a very red appearance; but the patient experienced not the least sense of heat, and the pupil was slightly dilated. I continued to use this, with very beneficial effects, in incipient cataract, opacities of the cornea, inflammation, amaurosis, iritis, etc. Of late, in- stead of the diluted acid, I have applied the vapor of the con- centrated acid to the eye with much more decided effect, and without the slightest danger. The plan I generally adopt is, to put into an ounce phial a drachm of the acid, and hold it in close contact Avith the eye, the eyelid being open for the space of about half a minute, or until such time as the patient feels a little Avarmth, or the person holding the phial sees the pupil greatly dilated, and the vessels of the eye injected with blood, which is the invariable effect of the application of the acid. The patient is not sensible of pain, from this peculiar state being in- duced; which appears to me to result from the poAverfully seda- tive influence of the acid; thereby showing, that two opposite p0wer3_t0 wit, the stimulating and the sedative—are exerted at the same time; and thereby the uneasiness, arising generally from a stimulant alone, is prevented. Its great power in re- moving these diseases chiefly arises from the two powers being so blended, and thus enabling the eye to bear a sufficient stimu- lating action, without injury. The person who holds the acid to the eye should be careful not to allow the patient to smell it The Medical Gazette and the Lancet gave insertion to the following statement of mine, of date October 20, 1842:— «^JE_In October, 1841, I gave an account of the action of 488 TURNBULL'S PRACTICE. the vapor of hydrocyanic acid upon diseases of the eye. Since that period I have been engaged in investigating the action of various other bodies on the same organ, and under the same form. One reason why I did not rest satisfied with the effects pro- duced by the hydrocyanic acid, Avas, that its action, like that of all other medicines, decreased in poAver by continued application; thereby rendering it necessary to have occasional recourse to other medicines, in order to insure a more speedy recovery. An- other reason Avas, the reluctance of many individuals to submit the eye to the action of so potent a medicine. The first medicines to which I shall refer, and which I have employed Avith some success, are: the chlorocyanic acid, and sulphuretted chyazic acid. The plan I pursue is that of putting a drachm of one of the medicines into a bottle (containing a small piece of sponge) of about two-ounce size, having a mouth precisely fitted to the eye, and AA'ith a ground-glass stopper. The action of these medicines is very different from that of the hydrocyanic acid, in as far as they both stimulate the eye, and produce much greater warmth and irritation, with less dila- tion of the pupil. Few, hoAvever, can bear the chlorocyanic acid to be applied longer to the eye than half a minute; though, in a minute after its application, all irritation is removed, and the eye feels perfectly at ease. The next medicine which I have employed in the form of vapor, was the chloruret of iodine. This medicine produces very little warmth or uneasiness to the eye, if continued for the space of two minutes or upwards, but a sensation of irritation, accompanied with a flow of tears, takes place on its removal. It contracts the pupil, and in no case have I seen it dilate it. Its vapor rises very readily, and does not leave the yelloAv, dis- agreeable coloring on the skin, produced by the vapor of iodine, when uncombined; which is a great draAvback in the use of iodine in diseases of the eye. The last medicine which I have employed is the bisulphuret of carbon, which is so volatile that the application of it to the eye, when the bottle is held in a warm hand for a few seconds, TURNBULL'S PRACTICE. 489 is as much as can be borne, in consequence of the intense prick- ling heat and flow of tears which it occasions. Owing to this fact, I generally use it by causing the patient to shut the eye- lid during its application, which can then be continued for a minute or tAvo, with the same beneficial effect upon the eye, with- out inconvenience to the patient. It generally contracts the pupil, and very seldom dilates it. I used to employ iodine by putting it into the same bottles, and immersing it in hot water, and, in its state of vapor, apply- ing it to the eye: but I find it answers much better when dis- solved in the bisulphuret of carbon. It may not be out of place here to state, that I have employed, with great success, the bisulphuret of carbon, to enlarged indurated lymphatic glands. In the first instance, I rubbed equal quantities of the bisulphuret of carbon and alcohol upon the parts affected, but without any effect upon the glands. But as its effects were so great Avhen its vapor was confined to the eye, I was led to apply it in the form of vapor, and by means of glass bottles similar to those I have described. By these means I excluded the action of the medicine from the external air, and thereby prevented its speedy evaporation. When it had been applied about one minute, the patient felt the part very cold, but, immediately after, a gradual heat, accompanied with great prickling; the heat increasing the longer the medicine was kept in contact with the part, until it could be no longer endured. On removing the glass, the part was red to an extent two or three times greater than the part enclosed. In a few days, the change in the size of the glands was very great; and, by its daily repetition, a complete and speedy removal of the disease was effected. I also find that its action upon diseased glands is more decided, if the surface of the skin is well mois- tened with water, previous to the application of the bottle to the part. The water, in fact, not only prevents the escape of the vapor between the glass and the skin, but assists the imbibition of the carbon- a point of the highest importance, inasmuch as all its action on the part depends upon the exclusion of the atmosphere 490 TURNBULL'S PRACTICE. from the vapor. I may here observe, that these applications occasion no injury whatever to the skin. I have also found the bisulphuret of carbon and the chlorocy- anic acid valuable medicines in the removal of deafness, depend- ing upon a Avant of nervous energy and deficiency of Avax. The mode of its application is substantially the same as that Avhich I employ in diseases of the eye, Avith this difference only, that the bottle is formed with a small neck and stopper, adapted to the size of the orifice of the ear, and held close to the organ, until a considerable degree of warmth is produced. The action of those medicines, which contain so large a share of carbon, arises from the carbon, in thexapor, permeating the cuticle, and coming in contact with the oxygen in the vessels, which is conveyed through every part of the frame, by inspira- tion and otherwise; and thereby forming carbonic acid gas, which evolves heat in the ratio of the quantity consumed by the oxygen. But, in drawing my remarks to a close, at this time, I cannot refrain from saying less in regard to the utility Avhich is likely to arise from this medicine, when properly applied, than that, in such a similar case as I have stated, I would not for a moment hesitate again in giving it, and the extract of belladonna, a fair trial, so convinced am I now, after applying it pretty freely, by itself, in different affections of the same organ (in all of Avhich more or less improvement of vision was manifested), of its po- tency to remove many of those formidable diseases of the eye, more especially that of the cornea, which are so often the oppro- brium of our art. HoAvever, before I have done, it is but justice to ascribe this noble discovery to Dr. Turnbull, whose indefati- gable research has not failed to find out others, no less wonderful in their effects, as they are useful to mankind; and, for such, he cannot but claim to himself the best thanks of the profession at large. ON THE ACTION OF ESSENTIAL OILS, ETC. In October, 1835, a paper of mine appeared in the London Medical and Surgical Journal, stating the beneficial action of a concentrated tincture of capsicum for diseases of the eye, by TURNBULL'S PRACTICE. 491 rubbing it, for a few minutes daily, over the forehead and temples with a sponge. Soon after this, I was induced to try Avhat effect essential oils, possessing poAverful stimulating properties, might possess in removing amaurosis and diseases generally of the eye. The for- mulae Avhich I use are— EMBRO. CARYOPH. CO. ty. 01. Caryoph., \ *. 01. Lavand., / aa'----------------- dlV' 01. Cinnamom.,-------------------- 5ss. Sp. Vin. Rect.,--------------------- Siij. M. Ft. Embro. EMBRO. PIMENT. CO. ty. 01. Piment., \ - 01. Rosmar.. / aa'----------------- ^SS' 01. Cinnamom.,--------------------5ss. Sp. Vin. R.,----------------------- Shj- M. Ft. Embro. Finding great utility to arise from the use of the cloves and pimento, it appeared by no means undesirable or hopeless to administer them internally for the same complaints. In order to shield the pungency of these oils, I united them with calcined magnesia, which, by its very strong affinity with these essential oils, forms a body nearly solid; and thereby removes all pun- gency, warmth, and even smell; for, in this state, it requires to be held in the mouth for a considerable time before it produces any warmth or pungency. They are thus rendered easily taken, in sufficient quantity, without heat or uneasiness. Some children are the subjects of many diseases of the eye, producing blindness, from opacities, etc. I ordered the same to be made into a powder, in which form it can be easily taken in any vehicle, without exciting disagreeable warmth. The for- mulae are— PIL. CARYOPH. C. B/. 01. Caryoph., | ______________3j. Magnes. Cal., J 01. Cinnamom.,-----------------gtt. vj. M. Ft. Pil. xxiv. 492 TURNBULL'S PRACTICE. PIL. PIMENT. CO. B/. 01. Piment., \__ Magnes. Cal., /aa' -------------- OJ' 01. Cinnamom.,------------------ gtt. vj. M. Ft. Pil. xxiv. The dose of these pills is one or two, thrice a day. Expedition is required in the making of these pills; othenvise, it becomes a solid mass, and unable to be formed into pills. I have found an alcoholic extract of clovers and pimento, made into pills, AA'ith magnesia, equally efficacious. PULV. CARYOPH. C. R, 01. Caryoph, 1 - Magnes. Calc, / aa'------------- 5J' 01. Cinnamom.,----------------- 5j. M. Ft. Pulv. PULV. PIMENT. CO. B/. 01. Piment., ) . Magnes. Calc,/ aa'----------------- 5J' 01. Cinnamom.,---------------------- 5j- M. Ft. Pulv. The dose of these powders is from four to eight grains, thrice a day. In the making of these powders, the oil and the magnesia ought to be well mixed, and alloAved to remain for half an hour; then reduce the mass to fine powder, and keep it in glass bottles with stoppers. These medicines, by their local application, increase their circulation, and give a greater supply of blood to the deficient organs; and thereby produce natural tone and power. They are equally useful in removing chronic diseases, where thicken- ing and opacity have taken place, by rousing into activity the absorbent and nervous influence by their stimulating power. Among many others possessing the same poAver, is a concen- trated tincture of pepper, nigrum, ginger, etc. The internal administration has been found much more ser- viceable in chronic diseases of the eye, such as opacities, etc., than in amaurosis. The manner of using the embrocations is, by rubbing the TURNBULL'S PRACTICE. 493 forehead and temples with a sponge saturated with the liquid. This plan alone, kept up daily, is beneficial; but the efficacy is more than doubled, if another sponge, with warm or cold water, is rubbed upon the forehead, for a minute afterwards. By this, the energy of the medicines in inducing a free circulation is greatly augmented, and greater warmth is rapidly developed. The rationale, in my opinion, is, that the large quantity of carbon in some of the essential oils, and its solubility in alcohol, permits it, by the friction, to pass through the cuticle and unite with the oxygen. As the oils are very insoluble in water, and as the alcohol has a strong affinity for the water, the carbon is more readily disengaged, and forms a union with the oxygen, in the vessels; and thereby produces heat and great activity of circulation. I have no doubt that is the reason why many bodies are so pungent, when put into the mouth. It will be seen, in the following extract from Tyrrell on the Eye, "functional amaurosis arises from a deficient supply of red blood." He says:— "In these cases there always exists, I believe, a want of gen- eral power and vigor of circulation, at first; but, in some in- stances of long-continued affection of this kind, the local circula- tion never regains its proper force and fulness, and the supply of blood is inadequate to support the functions of the part, although the general system recovers its natural tone and power." I think this statement very correct, and, therefore, the em- brocations producing so much additional circulation, point out, at once, the essential oils, along with the water, as its proper remedy. I here quote Magendie, who corroborates the plan which I adopt—viz., the medicines being most useful when ap- plied to the forehead and temples, in amaurosis. 494 THE OPHTHALMOSCOPE. (Fig. 51.) EXAMINATION WITH THE OPHTHALMOSCOPE. (=0.S.) The instruments necessary for the examination are: an oph- thalmoscope and a spherical lens. The ophthalmoscope consists—{a.) Of a slightly concave, circu- lar mirror, of a focal length of from 12 to 15 inches. The mirror should have a diameter of about 2 inches, and be mounted in a light frame of tortoise-shell, horn, or gutta-percha, Avith a broad rim, to admit of its being held securely, {b.) A circular portion (a.) Among the great variety of ophthalmoscopes must be mentioned: the Binocular Ophthalmoscope, the Anto-Ophthalmoscope, for examination of one's own eyes, the Ophthalmoscope with micrometer, etc., fixed on a stand, and the Ophthalmoscope for viewing the image reflected from the interior of the eye in a second reflecting surface. Any good light-reflecting surface may be used as an ophthalmoscope, as long as the observer is placed in a position to receive the light returning through the pupil of the examined eye into his own. The ophthalmoscope de- scribe 1 above answers all practical purposes. (b.) More light is gained by not having a hole bored through the glass, to THE OPHTHALMOSCOPE. 495 (diameter about one-sixth of an inch) of silvering is removed from the centre of the mirror. Thus a sight-hole is obtained. (c.) To this corresponds an opening of equal size in the frame. The spherical convex lens should have a focal distance of from 2 to 3 inches. It should be mounted in the same material as the ophthalmoscope, Avith a broad rim, so that when laid flat upon a table, it rests upon the rim, and does not become scratched. Position of Observer and of Patient.—{d.) Both are seated in a dark room, facing each other. The eyes of the observer should be level with, or an inch or two above, those of the patient. (g.) A gas-light is placed at the side and someAvhat behind the patient's head and level Avith his eyes, so that no light, but that which is reflected by the ophthalmoscope, fails upon the eyes. Mode of Examination of the different Parts of the Eye.— Every ophthalmoscopic examination should be preceded by the examination with lateral illumination. All alterations in the appearance of the deeper parts of the eye, arising from anom- alies in front of the vitreous chamber (in the cornea, lens, etc.), can, with the greatest accuracy, be recognized, if the ophthal- moscopic examination is preceded by that with lateral illumina- tion. This is followed by examination of the vitreous chamber. For the direct ophthalmoscopic examination (or for the ex- establish the sight-hole; and the direct ophthalmoscopic examination is much facilitated. (c ) Attached to the back of the frame of the ophthalmoscope, used at the hye Infirmary is a contrivance which may be used as a handle, thus facilitating manipulations with the ophthalmoscope; but which is principally intended for receiving any spherical or other lens we may wish to place there for more mi- nute ophthalmoscopic examination. Id ) Both may stand, or one or both be seated, or the patient he down, or the observer stand behind the patient, and view the image of the optic disk, etc received upon a piece of glass, mirror, etc., which u held in front of the patient's eye, and receives the raysof light which return from the interior of thfJ The gas-light, by placing round it a pale-blue glass, becomes whiter and less troublesome to the observer. Any light, the flame of a candle, etc., may be used Amaurotic persons are best examined by sun-light The ophthalmoscopic examination may be carried on in a light room, as long as sufficient light is thrown through the pupil of the eye under examination, to distinguish the details of its optic disk, etc. 496 THE OPHTHALMOSCOPE. animation of the erect image), we require the ophthalmoscope only. By this method, we obtain a correct vieAv of the color and relative position, and also a much enlarged vieAv of the parts examined. For the indirect ophthalmoscopic examination (or "the ex- amination of the inverted or aerial image"), avc make use of the ophthalmoscope and of the spherical convex lens. We can over- look more parts at one glance, but Ave see them inverted; e.g., what appears as the upper margin of the optic disk is, in reality, the loAver one, etc. Examination of "the Inverted Image," or Indirect Ophthal- moscopic Examination.—Suppose we Avish to examine a healthy right eye, with blue iris, the pupil being dilated by atropia (/), and the observer, patient, and the gas-light, being placed as di- rected above: we take the ophthalmoscope in the right hand, grasping its margin with the thumb and forefinger, as is shoAvn in Fig. 51, and turn the reflecting surface towards the patient. We "throw" the light upon the right eye, and approach the eye with the ophthalmoscope, until the circular surface of light on the patient's face has nearly the size of that of the ophthalmos- cope. We must take care continually to keep the circular sur- face of light on the patient's eye, while raising the ophthalmos- cope to our own right eye. When looking through the sight- hole, we perceive the patient's pupil to appear brilliant reel in- stead of black. If it appears black, we either do not throw the light upon the pupil, or we do not look through the sight-hole of the ophthal- moscope. Supposing we have obtained the red reflection from the pupil, we at once look for the optic disk, which is most quickly found (the ophthalmoscope being held by the thumb and forefinger) by holding up the little finger of the same hand, and directing the patient to look at the tip of it. The centre of the yellow (/.) A solution of a quarter of a grain of sulphate of atropia to half an ounce of distilled water is used. The optic disk and the tunics, where immediately adjoining it, can, with very few exceptions, be examined without the use of atropia. THE OPHTHALMOSCOPE. 497 spot of the patient's right eye is thus directed to the tip of that finger, and the optic disk comes to stand opposite the pupil. A change in the color of the reflection from the pupil, from red to whitish-red or brilliant white, indicates that the optic disk is in view. The observer should persist in his endeavors, until he has obtained the brilliant whitish reflection. In persons with dark irides, the difference in the reflection from the pupil is still more striking, on account of the contrast of color between the optic disk and the tunics. Having obtained the reflection peculiar to the optic disk, we place the convex lens (holding it between the forefinger and thumb of the left hand) before the eye under examination. The diffused image of the flame, which is "thrown into the eye" by the ophthalmoscope, serves to illuminate those parts of the in- terior of the eye which lie within the area of the flame. The rays of light reflected, e.g., from the optic disk thus illuminated, have to pass through the lens held in front of the patient's eye, and an everted, defined image of the optic disk, etc., is formed in front of this lens, i.e., between it and the observer. In this case, we do not directly examine the optic disk, but only its inverted aerial image; hence the term examination of the inverted image by the indirect method, or indirect ophthal- moscopic examination. The little finger of the hand which holds the lens is placed on the patient's cheek, to steady the lens, while the middle or ring-finger is kept disengaged, to be placed, if necessary, upon the margin of the upper lid, so as to raise it, or gently to press upon the eyeball, to produce and watch the pulsation of the retinal artery in the optic disk. The spherical convex "lens is held at from one to two inches from, and somewhat obliquely in front of, the patient's eye. If the lens is held vertically, the image of the ophthalmoscope, which appears upon each surface of the lens, at its centre,»*iter- feres with the view of the part beyond. If the lens is held ob- liquely, the two images recede from each other. By approach- ing the lens to, or removing it from, the eye under examination, 32 498 THE OPHTHALMOSCOPE. we soon succeed in obtaining a distinct view of the well-defined (aerial) image of the optic disk, etc. This image can be enlarged by our placing behind the sight- hole of the ophthalmoscope a convex lens of greater focal dis- tance (one of from 10 to 20 inches focal distance). After having seen the optic disk, we proceed to the examina- tion, of the region of the yellow spot (see Retina, Examination of the), and then to that of the more peripheral parts of the tunics, by directing the patient to turn the eye in different di- rections, while the ophthalmoscope'and convex lens remain un- altered in position. Examination of the "Erect Image," or by the Direct Method, or Direct Ophthalmoscopic Examination.—The gas-light is placed more at the side, and level with the left eye, supposing again that we examine the right eye. We direct the patient to "look straight out," and sitting, or better, standing, in front, we look for the place occupied by the optic disk. The optic disk occupies a portion of the interior of the eye, situated internal to, and a little below, the yellow spot. As soon as we perceive the reflection peculiar to the optic disk (and not before), we should slowly approach the eye from a distance of from 12 to 15 inches, taking care continually to throw the light through the pupil, and not to lose Sight of the reflection peculiar to the optic disk. On approaching very near the eye, only a small (the central) portion of the ophthalmoscope remains available; and some practice is required so as continu- ally to illuminate the interior of the eye. As long, however, as we do not lose sight of the reflection peculiar to the disk, we may be sure that we are handling the ophthalmoscope properly. From the degree of distinctness with which we see the optic disk, and the bloodvessels in it, while approaching the eye, we can form a general idea of the refraction {of the shape) of the eye. If the optic disk appears the more distinct the nearer we approach the eye, we pronounce the eye to be too short (hypermetropic); if the optic disk appears the more indistinct the nearer we go, we infer the eye to be too long (myopic); if we only see the optic disk distinctly, after having approached the eye to within about THE OPHTHALMOSCOPE. 499 three-quarters of an inch, we consider the eye to be normal in shape (emmetropic), or but very slightly myopic, or hyperme- tropic. This method of ascertaining the refraction, though not equal, as regards accuracy, to the one obtained by examination with spherical, etc., lenses, is the quickest means of furnishing the key to the state of refraction in moderate and in higher degrees of ametropia, and should be well practised. The observer's eye, for this and the indirect ophthalmoscopic examination, if not emmetropic, should be made so, by placing that spherical lens, which corrects the faulty refraction, behind the sight-hole of the ophthalmoscope. The optic disks of emmetropic and of hypermetropic eyes can readily be examined directly. The optic disk of the myopic eye requires the concave lens, which corrects the myopia, to be placed behind the sight-hole of the ophthalmoscope. On approaching with the ophthalmoscope to within about an inch from the patient's eye, we distinctly see the entire optic disk, or part of it, its vessels, and part of the adjoining tunics. The patient's cornea and crystalline lens act, in this case, as a strong magnifying lens. The optic disk often appears so much enlarged, that, though the pupil be dilated to its utmost, we cannot overlook the entire disk at once; but, to do so, have to look into the eye from different directions. The direct mode of examination, besides assisting us in de- termining the shape and refraction of the eye, admits of our see- ing the details of the optic disk, and of the tunics near it, better, more quickly, and more easily than any other method. Having seen the optic disk, we inspect the tunics, by looking in different directions through the pupil.—[Badee. 500 OINTMENTS. OINTMENTS. Ointments of one part of the yellow amorphous oxide of mer- cury to eight parts of lard, as they have recently been recom- mended (Pagenstecher), act too severely, and require subsequent cleansing of the conjunctival sac. The amorphous yellow oxide has one unpleasant property, and that is, it readily decomposes when exposed to light; therefore, it should be carefully protected and frequently renewed. The ointment should be thoroughly rubbed up, so that one part does not act more powerfully than the other. Recently, instead of the lard, a mixture of one part of starch with five parts of glycerine has been used. By soak- ing the former in glycerine, heated up to 70° R. (about 190° F.), the mixture attains the consistency of lard. It does not become rancid like lard, however, which then does harm and decomposes the preparation. Most of the agents used in eye- salves are readily soluble in glycerine. Besides, the glycerine itself deliquesces in the tears, and the medicaments enveloped in it are more easily disturbed throughout the whole conjunctival sac, and thus are more certainly taken up, than when applied m the ointments made with lard, which the moist conjunctiva, at it were, throws off. Therefore, glycerine ointments, contain- ing the same amounfc of the active substance, have almost double the effect of the others. The glycerine used should be chemi- cally pure, perfectly colorless, and as clear as water.—[Graefe. 501 TERMS OF CLASSIFICATION OF MEDICINES. Narcotics are substances which diminish the actions and powers of the system, without occasioning any sensible evacua- tion. They have the effect of producing sleep. Antispasmodics are medicines which have the power of allay- ing irritations and spasms. Tonics are those articles which increase the tone of the ani- mal fibre, by which strength is given to the system. Astringents are articles which have the power of binding or contracting the fibres of the body. Emetics are medicines which excite vomiting, independent of any effect arising from the mere quantity of matter introduced into the stomach. Purgatives, or Cathartics, are medicines which increase the peristaltic motion of the intestines, and thereby produce a pre- ternatural discharge. Emmenagogues are those medicines which are capable of promoting the menstrual discharge. Diuretics are those medicines which increase the urinary dis- charge. Diaphoretics are those medicines which increase the natural exhalation by the skin, or promote moderate perspiration. Sudorifics are those medicines which produce copious exhala- tions or sweating. Expectorants are those medicines which increase the discharge of mucus from the lungs. Sialogogues are those medicines which excite a preternatural flow of saliva. Errhines are those medicines which increase the secretion from the nose and head, and excite sneezing. 502 TERMS OF CLASSIFICATION OF MEDICINE. Epispastics, or Blisters, are those substances which, when applied to the surface of the body, produce a serous or puri- form discharge, by exciting a previous state of inflammation. Rubefacients are substances which, when applied to the skin, stimulate, redden, or inflame it. Refrigerants, medicines which allay the heat of the body or of the blood. Antacids, remedies which obviate acidity in the stomach. Lithontriptics, medicines Avhich are supposed to have the power of dissolving urinary concretions in the bladder. Escharotics, or Caustics, substances which corrode or dissolve the animal solids. Anthelmintics, medicines which have the effect of expelling worms from the intestines. Demulcents, medicines which obviate and prevent the action of stimulating and acrid substances, by involving them in a mild and vascid matter, which prevents their action on the body. Diluents, those medicines which increase the fluidity of the blood. Emollients, substances which soothe and relax the living fibre. Alteratives. This term is applied to substances which are found to promote a change in the system favorable to recovery from disease, but not with certainty referable to any other class. Counter-irritants, agents applied to the surface, which excite an eruption or an inflammation, and thus divest the humors from the internal to the external parts. INDEX. Abscess, 180; of the lachrymal sac, 180; opening of the abscess, 136; fistula, 182. Abscission of the eyeball, 167; oper- ation, 167; shrinking of the eyeball after insertion of a seton, 169. Abrasion of the cornea, 140; symp- toms, 140; prognosis, 140; treat- ment, 141. Accommodative movements, 211; de- velopment, 212. Acute inflammation within the orbit, 431; diseased bone, 433; treatment, 434; syphilitic nodes, 436; perios- teum, 437; general treatment, 437. Acne ciliaris, 460. Adaption of artificial eyes, 66; mode of inserting, 66. Advice on double glasses, 3*7; specta- cle lenses, 40; spectacle-frames, 33; ordinary myopic spectacles, 34; ma- terial best adapted for spectacles, 35; front of frames, 35; small spec- tacles, 35; semicircular spectacles, 36; divided glasses, 36; octagon- shaped spectacles, 37; oval specta- cles, 36; colored glasses, 42; tinted glasses, 44; blue and green glasses, 43; too dark shades, 44; reference to dark shades, 44. Albuminuria during retinitis, 400; treatment, 401; local treatment, 401. Amaurosis, glasses for, 52. Amblyopia, amaurosis or, 392; prog- nosis, 393; treatment, 393; amau- rosis cured by glasses, 52; amblyo pia or amaurosis of other parts of the retina, 382; amaurosis progress- ing periphery margin of the retina towards the yellow spot, 3S2; am- blyopia or amaurosis from overuse of the eyes, 383; headache, 383; vomiting, 384; convulsions, 384; treatment, 385; causes, 385; amau- rosis from intra-cranial or cerebral tumors, 386; amaurosis from mor- bid changes, 386; following apo- plexy, 386; simulation of amblyopia or amaurosis of both eyes, 387; simulation of amblyopia or amau- rosis of one eye, ii87; amaurosis with disease of the spinal cord, 387; reflex amaurosis, 387; amaurosis from constitutional causes, 388; appearing during irregularities, 388; from anaemia, 3S9; from local causes, 389; produced by tobacco, lead, quinine, alcohol, 390; amblyopia or amaurosis with apparently heal- thy optic disk, 392. Anaesthesia, 138; morbid changes, 139; treatment, 139. Anomalies of vision, 380; region of the yellow spot, 380; ophthalmos- copic examination, 380; mode of ascertaining the extent, 381; en- largement of blind spot, 381; ac- commodation, 317; paralysis of cil- iary muscle, 317; symptoms, 318; treatment, 318; spasm of the ciliary muscle, 318; painful vision, 320; paresis of accommodation, 319; treatment, 319. 504 INDEX. Aqueous humor. and aqueous cham- ber—Vitreous substance and vitre- ous chamber, 296. Aqueous humor, 296; chemical prop- erties, 296; changes in color, 207; blood in the aqueous chamber, 297; cysticercus, 297; boundaries of the anterior chamber, 298; deep, 298; shallow, 298. Asthenopia, 55; general effects, 55; causes, 56; success in treatment, 57; certain causes, 58. Astigmatic eyelids, 46; cylindrical glasses, 47. Astringent remedies, 80. Atropia of the choroid, 344. Atropia and Calabar, 346; Calabar bean, 349; subcutaneous injection, 348. Atropia of the retina, 399; causes, 399 ; different forms, 400. Blennorrhoea, 183, Blepharophymosis, 482. Blepharitis, 461. Blepharospasmus, 452. Calabar and atropia, 346. Cancer of the eyelids, 448. Cancer in the choroid, 415; displace- ment of the retina, 416; cancer in the retina and optic nerve, 416; vision, 417; diagnosis and course, 417; treatment, 418; advisability and operation, 419; strumous de- posit, 419; diagnosis, 419; treat- ment, 421; bony, fibrous, sarcoma- tous, and fatty tumors, 421; cysts, 421; treatment, 422; pulsating tu- mors of the orbit, 422; treatment, 423; epithelial, 177; melanotic, 177. Cataract, 242; general remarks, 242; loss of transparency, 244; examin- ation, 245; opacities in the vitreous chamber, 245; tremulous iris, 246; shape of the eyeball, 246; causes, 246; consistence, 24.7, fluid, 248; soft, 248; examination with the ophthalmoscope, 249; gelatinous, 249; hard or senile, 249; lamellar, 250; striated or streaked, 250; black, 251; green, 251; chalky, 251; diabetic persons in, 252; pri- mary, 252; secondary, 252; vision, 252; vision after removal, 253; general remarks on treatment, 253; age of the cataract, 254; age of the patient, 254; reasons for extrac- tion, 254; removal of from one eye only, the fellow-eye possessing use- ful vision, 255; removal of from an eye which has no perception of light, 255; both eyes have frequent- ly been operated upon, 255; opera- tion, 255 ; experience, 258; may not escape, 260; vitreous substance may escape, 260; accidents during the operation, 259; treatment of the operation, supposing no accident to have occurred, 262; after-treat- ment, 264; removal by the scoop, 266; operation, 266; iridectomy, 267; accidents during the opera- tion, 268; depression, 27(>; reclina- tion, 270; couching, 270; opera- tion, 270; accidents, 271; removal by absorption, 27i; solution, 271; discission, 271; keratonixis, 271; operation, 272; removal of by lin- ear extraction, 275; accidents dur- ing the operation, 276; operation, 276; accidents during the operation and after treatment, 274. Cataract in children, 287; causes and general remarks, 287; complica- tions, 288; symptoms and causes, 288; numerous varieties, 288; treat- ment, 289. Cataract-glasses, 49. Catarrhal ophthalmia, 71. Cat»ut probes, 191. Capsular obstructions, 282; opacities, INDEX. 505 282; different kinds, 282; minute examination, 283; treatment, 284; operation, 284; opaque capsular obstructions, 286. Congenital anomalies, 443; eyebrows, 443; eyelashes, 443; abscess of the eyelids, 443; coloboma of the up- per or lower lid, 443. Choroid and iris, 305; anatomical and general remarks, 305; examination, 308; coloboma of the choroid, 309; vision, 310; displacement of the pu- pil, 311; injuries of the iris and the choroid, 312; foreign bodies in the iris, 312; rupture of the sclerotic, 313; hyperaemia of the choroid, 341; cyclitics, or inflammation of the ciliary region of the choroid, 339; symptoms, 339; treatment, 340; atrophy of the choroid, 344; displacement of the choroid, 345. Choroiditis at or near the optic disk, 343; treatment, 344; inflammation of the choroid—choroiditis, 341; ophthalmoscopic observations, 342. Ciliary muscle, paralysis of the, 317; paresis, 319; spasm, 320; treat- ment, 320. Coloboma of the choroid, 309. Color of the crystalline lens, 21. Congenital anomalies, 443. Congenital cataract, 287. Conical cornea, 65; commencement, 65; treatment, 66. Conjunctiva, 173; anatomical and general remarks, 173; examination, 174; development, 175; congenital anomalies, 175: tumors, 175; nae- vus, 176; cysticercus, 176; pemphi- gus, 177; epithes cancer, 177; me- lanotic cancer, 177; dislocation of the lens beneath the conjunctiva, 293. Corneitis, keratitis, inflammation of the cornea, 122; syphilitic cornei- tis, 122; physiognomy of patients, 123; vision, 123; causes, 124; treat- ment, 125; strumous corneitis, 126; scrofulous ophthalmia, 126; vascu- lar corneitis, 126; treatment, 128; pustular corneitis, 129; phlyctenu- lar, 129; causes, 130; treatment, 131; local treatment, 131; cornei- tis, with suppuration, 133; abscess of the cornea, 133; causes, 134; treatment, 135; opening of the ab- scess, 136. Cylindrical lenses, 46; sphero-cylin- drical lens, 46; piano-cylindrical lens, 46. Cysticercus in the deeper parts of the eye, 302; iridectomy, followed by an extraction, 303. Destruction of the lachrymal sac, 199. Dislocation of the crystalline lens, 290; ectropia of the lens, 290. Dislocation of the lens into the an- terior chamber, 290; into the vit- reous, 291; lateral or oblique dislo- cation of the crystalline lens, 292; vision, 293; dislocation of the lens, beneath the conjunctiva, 293; causes, 293; complication, 294; treatment, 294; operation for some cases, 295; treatment, 295. Displacement of the choroid, 345; viewed with the ophthalmoscope, 345. Distention of the lachrymal sac, 183. Dropping of the upper lid, 456. Dropsy of the eyeball, 137. Dyctitis, 394. Ectropion, 474; causes, 474; treat- ment, 475; if exposed conjunctiva thickened and hypertrophied, 475; tarsal edge is elongated, 476; de- pendent on a cicatrix, 477; of lower (Dieffenbach's operation), 473; for- mation by operation of an entire eyelid, or part of an eyelid, 479. 506 INDEX. Egyptian ophthalmia, 75. Entropion, 463; inversion of the eye- lashes, 463; treatment, 464; opera- tion, 464; Snellen's forceps, 466; entropion, treated by removal of a fold of skin, 467; Hildreth's opera- tion, 470; Prince's operation, 472. Epileptic fits, 384. Epiphora, watering of the eye, 185; foreign bodies, 186; treatment, 186; Excision, enucleation, of the eyeball, 169; operation, 171; after the op- eration, 172. Examination of the conjunctiva, 174. Examination with the ophthalmos- cope, 494. Exophthalmic goitre, 425; treatment, 426. Extracts from the London Lancet, 67. Eye bandages, 484. Eyebrows, 439. Eyelashes, 439. Eyelids, 439; anatomical and general remarks, 439; Meibomian glands, 440; outer and inner canthus, 442; margin, 442; development, 443. Eye protectors, 38. Far-sightedness, 16; advance in life, 16; symptoms of presbyopia, 17; power of accommodation, 17; appearances presented by the eye, 18 ; peculiari- ties of vision, 18; subjects of far- sightedness, 19; prevention and treatment, 19; how convex glasses are made, 19 ; age in years, 20; fo- cal length in inches, 20; alteration in the eyes, 20; the color of the crystalline lens, 21; the period of life when presbyopia displays itself, 21; description of convex glasses, 22; overwork of the eyes, 23; day- work preferable to night, 23; per- sons with feeble sight, 24; reading by fireside, 24; inhabitants of the Arctic, 25; transition from gloom to strong light, 26 ; choice of glasses, 26; changing glasses, 27; dwelling on large objects, 28; discovery of optical «instruments, 29; of specta- cles, 29; when spectacles should be worn, 30; choice of spectacles, 31; trying many spectacles, 31; impor- tant facts, 32 ; consideration of the fact, 32; increasing years, 33. Glands, Meibomian, 440. Glaucoma, 350; simple, 351; chronic, 351; acute, 351; attacks, 352; symptoms, 353; increase of tension, 354; conjunctiva, 355; sclerotic, 355; ciliary vessels, 355; cornea, 355; aqueous humor, 355; iris, 356; pupil, 356; choroid, 356; micro- scopical examination, 357; lens, 358; vitreous, 358; retina, 359; general remarks, 361; treatment, 363. Granulated lids, 114. Granulations, 113. Green stone, 118. Hemorrhage, effusion of blood into the vitreous chamber, 304; treat- ment, 305; spontaneous into the or- bit, 424. Hyperaemia of the choroid, choroiditis, 341; of the retina, 393; examina- tion of healthy eyes, 393. Imperfect sight, 3; imperfection of sight, 3. Inflammation of the eyelids, 454. Injuries of the retina and optic disk, 391; changes of the retina, as seen with the ophthalmoscope, 392. Injuries, 190-438. Injuries of the iris and the choroid, 313. Insertion of a seton into the temple, 485. Insertion of a stye, 200; obliteration of the lachrymal sac, 200. INDEX. 507 Iridectomy, 373; instruments, 373; operation, 373; accidents, 375; bleeding into the anterior chamber, 376; pressure upon the closed lids, 376; causes, 378; vision after the operation, 379. Iris and the choroid, 305; the iris, 305; anatomical and general re- marks, 305; contractile fibres, 305; elastic, 306; bloodvessels, 306; in- sertion of the iris, 307; displace- ment of the pupil, 311; anomalies of colors, 311. Iritis, inflammation of the iris, 320; general remarks, 320; simple iritis, 321; chemical properties, 322; change in color of the iris, 323; complications, 324 ; changes behind the iris, 325; treatment, 325; im- paired vision, 326; syphilitic iri- tis, 328; changes, 328; strictures behind the iris, 328 ; treatment, 329; gonorrhoeal iritis, 330; syphilitic changes in the structures behind the iris, 330; inflammation of the vit- reous substance, 331; optic disk, and of the adjoining choroid and retina, 332; vision, 333; serous iritis, 334; treatment, 334; sympathetic iritis, and sympathetic changes, 335; ir- ritation, 335; iritis, 336; treatment, 337; sympathetic ophthalmitis, 337; amblyopia or amaurosis, 338; cy- clitis, or inflammation of the cili- ary region of the choroid, 339: plastic cyclitis, 339; treatment, 340. Keratitis, 122. Lachrymal gland, 193; operation for fistula, 193; the operation for slit- ting open the lachrymal punctum and canaliculi, 195; knife used, 196; removal of the gland, 192; canalic- uli, 195; cyst in the gland, 179; ob- struction of the ducts of the gland, 179; fistula of the gland, 179. Lachrymal caruncle, 180; sac, 180; inflammation of, 180; abscess, 180; treatment, 181, 182; fistula of the caruncle, 182-188; treatment, 1S9; distention of the sac, 183; enlarge- ment, 183; tumor, 183; discharge, 183; treatment, 184; passing the probe, 190; experience, 190; injec- tion of fluid, 192. Lachrymal organs, 177; anatomical and general remarks, 177. Lachrymal passages, probing the, 196; stricture or closure of the, 187; in- struments Used in the treatment of the, 191; injection of fluid into the, 194. Lachrymal sac, destruction, 199. Leeches, 486. Lens, variety, 39-48; cylindrical, 45; manufacture of, 41. Leucoma, filling ulceration, 147. Linear extraction, modified, 278; in- struments required, 278; after-treat- ment, 282. Medicines, terms of classification of, 501. Meibomian gland, 440. Muscae volitantes, 58; different ap- pearances, 59; nature of floating muscae, 60; nature of particles, the presence of which occasions floating muscae, 61; distinctly seen, 61; how they increase in number, 62; treat- ment, 63; when it appears, 64. Muscle, external muscles of the eye- ball, 205; anatomical and general remarks, 205; internal rectus, 205; inferior rectus, 205; superior rectus, 206; inferior oblique, 206; superior oblique, 206; external rectus, 207; accommodative movements, 211; insufficiency of the internal rectus, 211; development, 212; congenital anomalies, 213. Myopia, 6; treatment, 8. Myopic persons, 362. 508 INDEX. Naevus "erectile tumor", 424; treat- ment, 424. Near-sighted children, 15. Nebulae, 146 Nystagmus, 213; causes, 213; treat- ment, 214. Ointments, 500. Opacities of the cornea, 146; causes, 146; leucoma, following ulceration, 147; chalky or bony substances, 147; disturbance of vision, 148; large fields of vision, 148; treat- ment by medical agents, 149; symp- toms of irritation, 150; remedies in general use, 151; treatment by op- tical means, 152; vision for distant objects, 152; treatment by surgical means, 153; opacities of the cornea, from lead, 154; treatment, 154. Operation for artificial pupil, and the operation for iridectomy, 365; arti- ficial pupil, 366; operation, 367; method of making, 367; incision through the cornea, 369. Ophthalmia, 68; gonorrhoeal ophthal- mia, 107; treatment, 108; ophthal- mia from eruptive fevers, 109; treatment, 109; chronic ophthalmia, 109; blisters, 110; ophthalmia va- riolosa, 111; commencement, 112; treatment, 112; granulated oph- thalmia, 113; granular lid, 114; part which suffers first, 114; cloud- iness of vision, 115; prognosis, 116; towels, lint, and sponge, 116; treat- ment, 116; discharge during acute attacks, 117; astringent, 117; green stone, 118; crayon of sulphate of zinc, 118; escharotics, 119; mode of applying sulphate of copper, 119; crayon of blue stone, 120; iodide of lime and protoxide of iron, 121; liquor potassae, 121; excision, 122; rheumatic ophthalmia, 102; rheu- matic subjects, 103; dimness of vi- sion, 104; constitutional symptoms, 104; prognosis and treatment, 105; opiate frictions, 106; purgatives, 106; catarrhal ophthalmia,' 71; treatment, 72; purulent ophthal- mia, 75; severe cases, 76; Mr. War- dop's statement, 78, treatment, 80; local applications, 81; opiate fo- mentations and friction, 82; solid caustics, 82; purulent ophthalmia in infants, 83; life-long blindness, 83; conjunctiva of the lids, 84; if attacks be severe, 84; treatment, 85; corrosive sublimate eollyrium, 86; preventing the eyelids from ad- hering together, 86; first symp- toms, 87; a remedy of considerable Bervice, 88; disorganization of the cornea, 88; scrofulous ophthalmia, 89; treatment, 90; purgatives, 91; tonics, 92; internal remedies, 93; antacids, 93; mercury, 94; progno- sis, 94; treatment, as a general rule, 94; diaphoretics, 95; local treat- ment, 96; fomentation, 96; counter- irritation, 97; solid caustics, 99; pustular ophthalmia, 100; treat- ment, 101; erysipelas ophthalmia, 101; symptoms, 101. Ophthalmoscope, examination with the, 496; examination of inverted image, 497; indirect ophthalmo- scopic examination, 497; examina- tion of the erect image, 498; direct ophthalmoscopic examination, 498; how to ascertain the shape and with it the refraction of the eye, 499. Pannus vascular cornea, 132' treat- ment, 132. Paralysis and paresis, 230; causes, 230; injuries, 231; mobility of the affected eyes, 231; vision, 233; di- plopia, 233; general remarks of the third nerve, 235; treatment, 236,, 237; paralysis of the internal rec- INDEX. 509 tus muscle, 238; paralysis of the inferior rectus muscle, 239; paraly- sis of the superior oblique, 239; pa- ralysis of the inferior oblique, 240; paralysis of the superior oblique muscle, 240; paralysis of the exter- nal rectus muscle, 242; paralysis, 315; treatment, 316. Paralysis of the orbicularis muscle, 7th nerve, 450. Paresis of the orbicularis muscle, 451; neuralgia, 451, Protrusion through enlargement of the frontal sinuses, 427; treatment, 428. Protrusion of the eyeWl, 406; rapid- ity of appearance, 407; mobility of the eyeball, 407; changes, 408 ; vi- sion, 409; pain and cerebral symp- toms, 410; causes, 410; general remarks and treatment, 411; opera- tion, 412. , Pterygium, 202; treatment, 203; op- eration, 203; after the operation, 204. Ptosis, 456; treatment, 457. Reading glasses, 51; motion of the head, 51; single eye-glasses, 51; mi- croscopical pursuits, 52. Retinitis during albuminuria, 400; pe- culiar changes, 401; treatment, 401; local treatment, 401; inflammation of the retina, 394; forms of retini- tis, 394; retinitis with large gray and opaque patches, 395; cause and general remarks', 395; loss of transparency, 396; vision, 397; prognosis, 397; treatment, 398; atrophy of the retina, 399; causes and general remarks, 399; displace- ment of the retina, 402; vision, 403; treatment, 403; operation, 405. Sclerotic, 159; anatomical and general remarks, 159; thickness of the scle- rotic, 160; development, 161; con- genital anomalies, 161; tumors, 162; inflammation, 162; treatment, 162; rheumatic inflammation of the sclerotic, 163; treatment, 163; in- flammation of Tenon's capsule, 163; treatment, 164; ulceration of the sclerotic, 164. Scotoma in the region of the yellow spot, 380. Scrofulous ophthalmia, 89. Sebaceous tumors, 446. Second-sight, 33. Short-sight, 4; the power of adjust- ing the eye, 5; subjects of short- sightedness, 5; the focal length of concave glasses, 7; appearances presented by the eyes of myopic persons, 7; treatment, 8; accommo- dation of the eye, 9; the prognosis of this affliction, 10; advancing years, 11; the difference in focal length, 12; one eye myopic and the other presbyopic, 13; vision of the eye in early life, 13; cases of my- opia, 14; near-sighted children, 15; insufficiency of sight, 15. Spontaneous hemorrhage in the orbit, 424; general treatment, 425. Staphyloma of the sclerotic, 164; ex- citing causes, 164; size, shape, and color, 165; ciliary staphyloma, 165; causes, 166; treatment, 167. Staphyloma, 155; staphylomatous opaque tissue, 156; iris undergoing adhesion, 157; recurrent attacks, 158; treatment, 158; staphyloma of long standing, 158. Strabismus, 214; apparent, 214; real, 214; degree, 215; movements of the eye, 215; strabismus conver- ges, 216; convergent internal, 216; causes, 216; general remarks, 217; periodical, 217; permanent, 218; simple, 218; alternating, 218; 510 INDEX. treatment without an operation, 218; treatment by operation, 218; vision before the operation, 219; vision after the operation, 220; mo- bility of the eye after the operation, 221; operation, 221; time for ope- ration, 223; Charles Bardao's ope- ration, 223; divergent strabismus folloAvs, 225; divergent strabismus, 226; external, 226; causes, 226; gradation, 227; treatment, 228; op- eration for divergent strabismus, 229. Spasm of the muscles of the eyelids, 452; spasmodic contraction of the levator palpebrae muscle, 452; spasm of the orbicularis muscle, 452; treat- ment, 452; trembling, or spontane- ous twitching, 453. Stye, 459; treatment, 460; acne cil- iaris, 460; insertion of a stye, 200. Symblepharon, 480; mode of treat- ment, 481; operation, 482. Syndectomy, 137; operation, 137 af ter the operation, 138. Terms of Classification of medicines, 501. Test types, 511-516. Tinea, 461; tinea ciliaris, 461; treat- ment, 462. Tumors, 444; treatment, 444, 445; of the orbit, or of the eyeball, or of both, 413; cance», 413; medullary, 414; cancer of the choroid, 415; displacement of the retina, 416; cancer in the retina, 416; vision, 417; diagnosis and course, 417; treatment, 418; advisability of an operation, 419; strumous deposit, 419; diagnosis, 419; treatment, 421; bony, fibrous, sarcomatous, and fatty tumors, 421; cysts, 421; treatment, 422; pulsating tumors of the orbit, 422; treatment, 423; sebaceous tumors, 446; treatment, 446; treatment, 448; epithelial can- cer, 449; cancer of the eyelid, 448; treatment, 449; tumors of the iris, 314; cysts situated near the margin of the pupil, 315. Turnbull's practice, 487. Ulcers of the cornea, 142; superficial ulcer, 142; deep ulcer, 142; trans- parent ulcer, 143; treatment, 143. Vitreous chamber, 299; anatomical and general remarks, 299; senile changes, 300; opacities of the vit- reous chamber and muscae volitan- tes motis, 300; hemorrhage, 301; treatment, 301. Vitreous substance, 299. Wounds, 483. Wire goggles, 38. Yellow-spot region, 380. TEST TYPES. No. 1—Diamond. Though, in the choice of spectacles, every one must finally determine for himself which are the glasses through Which he obtains the most distinct vision; yet, some confidence should be placed in the judgment of the artist of whom they are purchased, and some attention paid to his directions. By trying many spectacles, the eye in fa' tigued, as the pupil varies in sire with every different glass; and the eye endeavors to accommodate itself to every change that is produced. Hence, the purchaser often fixes upon a pair of spectacles, not the best adapted to his sight, but those which seem to relieve him most, while his eyes are in a forced and unnatural state; and, conse- quently, when he gets home, and they are returned to their natural state, he finds what he had chosen fatiguing and Injurious to his sight* No. 2—Pearl. Increasing years have a natural tendency to bring on the defect, and earlier among those who have made the least use of their eyes in their youth; but, whatever care be taken of the Bight, the decays of nature cannot be prevented: the humors of the eye will gradually waste and decay; the refractive coats will become natter; and the other parts of the eye more rigid, and less pliable: thus, the latitude of distinct vision will become contracted: it is also highly probable that the retina and optic nerve lose a portion of their sensibility. Though it is in the general course of nature that this defect Should augment with age, yet there are not Wanting instances of those who have recovered their sight at an advanced period; and have been able to lay aside their glasses, and read and write with pleasure, with- out any artificial assistance. Among many causes which may produce this effect, the most probable is, that it generally rises from a decay of the fat in the bottom of the orbit; the pressure in this part ceasing, the eye expands into somewhat of an oval form; and the retina is removed to a due focal dis- tance from the crystalline. No. 3—Nonpareil. Though it is in the general course of nature that this defect should augment with age, yet there are not wanting instances of those who have recovered their sight at an ad- vanced period; and have been able to lay aside their glasses, and read and write with pleasure, without any artificial assistance. Among many causes which may produce this effect the most probable is, that it gener- ally arises from a decay of the fat in the bottom of the orbit; the pressure in this part ceasing, the eye expands into somewhat of an oval form; and the retina is removed to a due focal distance from the crystalline. No. 4—Minion. We are now able to decide upon a very important question, and say how far spectacles may be said to be preservers of the sight. It is plain they can only be recommended, as such, to those whose eyes are beginning to fail; and it would be as absurd to advise the use of spectacles to those who feel none of the foregoing inconveniences, as it would be for a man in health to use crutches, to save his legs. But those who feel those inconveniences, should immediately take to spectacles; which by enabling them to see objects nearer, and by facili- tating the union of the rays of light on the retina, will support and preserve the sight. 512 TEST TYPES. No. 5—Long Primer. Many are the advantages that are derived from our having two eyes—some that are known, others that are unknown; for the corres- pondence of the double parts of the human frame, and their relation to the two great faculties of the human mind, has not been sufficiently attended to by anatomists. By having two eye-^, the sight is rendered stronger, and the vision more perfect; for, as each eye looks upon the same object, a more forcible impression is made, and a livelier concep- tion formed by the mind. No. 6—Small Pica. Some refrain from the use of glasses who really require their aid, from the belief that if they once begin to. use them, they will never be able to leave them off. In the great majority of cases this is perfectly true; but, even then, it is better to submit with a good grace to an affliction which can seldom be averted, and to have recourse to those simple means which at once set the eye at ease, and enable its possessor to enjoy many hours of comfort and rational employment, which would otherwise be lost. No. 7—Pica. The color and consistence of this humor alter with age; it becomes thicker, cloudy, and less transparent, as we advance in years; which is one reason, among others, why many elderly people do not reap all that benefit from spectacles which they might naturally expect. No. 8—English. By a medium, in the language of op- ticians, is meant any transparent sub- stance, solid or fluid, through which light passes. No. 11. By a medium, in the language of opticians, is meant any trans- parent substance, solid or fluid, through which light passes. No. 12. Whatever is seen or be- held by the eye, is by opti- cians called an object. No. 13. Whatever is seen or ' beheld by the eye, is by opticians called an ob- ject. No. 14. One medium is said to be more No. 15. Dense than another when \ CO HH (A 0 "Hi 5 ■Hi © HO «JS w XQXOOCXXQO-O DQDQDC OXC-CX DX Surgeon General's Office JUaA5£1!A£I>,$£ Xs,<„............................... l '{V /,r./<'xX •r . /■' ,X!XX .•sfXYX:, X uv ;■■/■;"•''■■'■" .;^ ■*■.'$ i I ? X xx !•• V