MANUAL 
O F 
EYE SURGERY 
B Y 
A. J. HOWE, A. M., M. D. 
AUTHOR OF "A TREATISE ON FRACTURES AND DISLOCATIONS," AND PROFESSOR 
OF SURGERY IN THE ECLECTIC MEDICAL INSTITUTE. 
CINCINNATI: 
PRINTED BY WILSTACH, BALDWIN & CO. 
1874. ' Entered according to Act of Congress, in the year 1874 
BY JOHN M. SCUDDER, 
In the office of the Librarian of Congress, at Washington. PREFACE. 
In surveying the field occupied by ophthalmic writers I found 
the ground well covered with elaborate treatises ; but, in most in- 
stances, the subject of eye surgery has been treated by " specialists " 
for the benefit of " specialists," and the general practitioner was 
left without a work adapted particularly to his wants. 
Recognizing the merits of the several hand-books already in 
existence on this subject, but thinking that in one feature or an- 
other they fail to meet the requirements of the ordinary physician, 
I have endeavored to supply this apparent need. 
Such progress has of late been made in ophthalmic practice, that 
much which is said about the eye in the older surgical works, is 
now obsolete. Besides, the science of eye surgery has become too 
elaborate and extended to be embraced in a text-book devoted to 
general surgery. To this reason may be ascribed the failure to do 
justice to it in the somewhat comprehensive works of Gross and 
Erichsen. Although I have called this work a Manual, I have 
aimed at being thorough and systematic in the preparation and 
arrangement of what recent research has contributed to an emi- 
nently progressive branch of surgery. The physician of varied 
practice will find that degree of elucidation which will enable him 
to execute all the easier operations, and to comprehend what the 
expert oculist performs. Conciseness has been rigidly observed, 
yet no topic of importance has been sacrificed through a disposition 
to merely epitomize. Salient and practical points have been pre- 
sented in the fewest words possible, though not at the expense of 
perspicuity. VI 
Preface. 
The ophthalmoscope has thrown so much light upon obscure 
diseases of the eye, that the instrument is indispensable to the 
proper diagnosis of certain morbid conditions ; yet the beginner 
need not expect to gain much advantage from its use. It requires 
practice to become expert in making observations with any instru- 
ment of the kind. Only a trained observer understands the 
powers of the microscope or of the telescope. A novice could see 
about as much with one instrument as with the other, whether 
looking at near or distant objects. 
It has been considered excusable to omit a lengthy dissertation 
upon the general laws of optics, as well as upon the physiology of 
vision. These topics are fully discussed and well illustrated in 
works accessible to every student; and such subjects as the reflec- 
tion, refraction, and the diffusion of light, have no legitimate place 
in a work on the surgery of the eye. Though the eye is con- 
fessedly an optical instrument, its immediate connection with the 
brain renders it a living piece of mechanism, which is legitimately 
discussed by the physiologist. 
The nomenclature encountered in treatises devoted to diseases 
of the eye is truly formidable ; especially for those who have given 
little attention to the technicalities employed by writers upon oph- 
thalmology. Indeed, it would be proper to append a glossary, 
were it not that every reader of medicine is presumed to have a 
lexicon, to which he may refei' for the definition of rare and com- 
plicated terms. Although I have employed the scientific names 
for morbid phases, I have endeavored to make use of such syno- 
nyms, paraphrases, and explanations as were available while dis- 
cussing a subject notoriously technical. There are no common 
names for the majority of eye diseases, consequently it would be 
absurd to attempt to write upon ophthalmology, and affect to 
ignore technicalities. Besides, the learner obtains more informa- 
tion from a definition found in the dictionary than at first might 
be supposed. Owen, in the Preface to his " Skeleton and Teeth," 
says : " Without learning and understanding the technicalities of 
a science, that science can not be comprehended. The terms seem 
' hard ' only while the ideas which they represent are not under- 
stood. ***** To the intelligent reader of every class, Preface. 
VII 
who may be blessed with the healthy desire for the attainment of 
knowledge, let it be said : Be not discouraged with the^rray of 
' hard words ' which seem to bar your path in its acquisition. 
When such words are invented or adopted by the masters in science, 
be assured that your acquisition and retention of their meaning, 
will be the safest ' first steps ' in the science of your choice." 
The illustrations, which are thought to be sufficiently numerous, 
are mostly taken from Stellwag, though several are copied from 
other authors. Some are modifications, and only a few are origi- 
nal. Such a degree of perfection has been attained in the illustra- 
tion of ophthalmic diseases and operations upon the eye, that there 
is little need for new pictures. COMPARATIVE ANATOMY OF THE EYE. 
The organ of sight in animals of the most simple construc- 
tion consists of a primitive eye-spot, or is confined to the ex- 
pansion of a nerve on which the rays of light impinge, pro- 
ducing, as may be supposed, exceedingly vague sensations of 
vision. 
In the different grades of animal life a marked variation is 
observed in that part of the organism endowed with the 
function of seeing. But in all, from the lowest to the high- 
est, the essential feature of the visual apparatus is a sensitive 
nervous expansion on which light makes an impression. 
The sense of sight, so far as obtaining a notion of the out- 
lines, dimensions, and relative positions of external objects 
may be concerned, is allied to that of feeling. Many of the 
lower animals have no power of seeing, but depend upon the 
sense of touch for a knowledge of the things they come in 
contact with ; the blind fishes of Mammoth Cave have feelers 
of great length and sensitiveness, by means of which they 
discover food and obtain impressions of surrounding objects. 
Snails can both see and feel by means of long tentacles, which 
have eyes mounted on their ends. 
Many insects, like the fly and the bee, have what are called 
compound eyes, the visual mechanism not being composed of 
parts which enter into the construction of the simple eye of 
the higher animals, but is made up of a series of cones arranged 
somewhat like a piece of mosaic, a single cone with its hexa- 
gonal facette (segment of cornea) representing, in the act of 
seeing, only one portion of the figure, yet the entire lot, in 
combination, completing the image of anything seen. The 
number of these little eyes, or segments of an eye, is extra- 10 
Diseases of the Eye. 
ordinary, amounting to thousands in the dragon-fly, the 
butterfly, and a species of beetle. 
The higher animals have two eyes which are spherical in 
form and situated on each side of the skull in bony cavities 
called orbits. But some of the lower creatures have a multi- 
plicity of eyes. The star-fish has an eye at the extremity of 
each of its rays; and the spider possesses eight eyes in a 
group on the anterior aspect of its back. 
Several varieties of flat-fishes with asymmetrical bodies, 
have .singularly twisted heads, and both eyes on one side. 
The anableps has a cornea bisected by an opaque horizontal 
line, and an iris perforated by two pupils. In the eye of the 
tope and blue shark there is a nictitating membrane super- 
added to a well developed circular palpebral fold of the skin. 
A strong nictitator muscle rises from the temporal side of the 
orbit, and passing through a muscular and ligamentbus loop, 
descends obliquely to be inserted into the lower margin of the 
third lid. 
There is no lachrymal gland in fishes, the lubrication of 
the eye depending upon the liquid medium in which such 
animals perpetually move. The cornea of fishes is flat, and 
to make up for the small quantity of aqueous humor, the 
refractive power of the lens is maximised by its spherical 
form. The sclerotic is usually cartilaginous or bony. 
In some reptiles which possess eyelids, the lower is the 
nictitating one, the upper lid merely following the movements 
of the eye ball when it is turned down. The muscles ■which 
move the lower lid pass through pullies at each angle of the 
orbit. They arise from the lower and back part of the eye- 
ball. 
Serpents have a transparent layer of epidermic material 
which covers the eye ; and this, after becoming opaque, is 
shed in connection with that of the head and body at the 
exuviating period. In the chameleon each eye enjoys an 
independent motion. In all reptiles the optic nerve penetrates 
the sclerotic externally to the axis of vision. The turtle has 
a nictitating membrane situated vertically at the inner can- 
thus, and having a horizontal motion. The crocodile and 
alligator have powerful and complex eye-appendages, not less 
than thirteen muscles contributing to movements of the eye- 
ball and lids. Anatomy of the Eye. 
11 
The eyes of birds are remarkable for their great size, as 
compared with the brain and head, and possess extraordinary 
powers of adjustment-a quality which is necessary to keep 
objects distinctly in view during rapid flight. The anterior 
segment of the eye is more prominent than in other classes of 
animals, the cornea projecting forward in a marked degree. 
In the owl there is a great disproportion between the anterior 
and posterior divisions of the globe, the axis of the anterior 
portion being twice as great as that of the other. This gives 
room for an unusual quantity of aqueous humor, and for the 
lens to come forward, so that a greater convergence is given 
to the rays of light. The pupil is vertically oval, and seems, 
in its variability of movements, to be under the influence of 
the will. It is certainly very dilatable and active in its changes. 
The pupil of the parrot contracts and dilates independently 
of the quantity of light to which the eye is exposed. 
A peculiar feature in the eye of birds is a plicated vascular 
membrane blackened with pigmentum, and situated in the 
vitreous and in front of the retina. This is called the marsu- 
pium or pecten, and is analogous in structure to the choroid. 
The functions of the marsupium are not well understood, but 
the choroid character of the membrane indicates that it is an 
absorber of light. 
All birds have a third lid, or nictitating membrane, which 
sweeps over the eyeball horizontally, from the inner to the 
outer side of the globe. The lower lid is the one which closes 
the eye in sleep-a peculiarity marked in reptiles. 
In the scale of mammals there is but one blind creature, 
which is the Italian mole, the burrowing habits of the animal 
rendering vision useless. There is an orbital impression in 
the skull, and an 11 ocellus" or rudimentary eye, but the skin 
covered with hair passes over these without an eye-mark. 
American moles have a small eye, so do other rodent bor- 
rowers. 
The eyes of elephants, whales, and other large animals are 
small in comparison with the bulk of their bodies. The eye 
of the rhinoceros is but a trifle larger than that of man. A 
broad belt of tapetum of metallic brightness is found in the 
choroid of the ox. The larger animals have the power of 
rolling the eyeballs in every direction, so as to view objects on 
all sides without moving their ponderous heads. 12 
Diseases of the Eye. 
In man the eye is developed to the highest perfection; and 
in him it also performs a more exalted office than that of mere 
vision. It is a mirror in which are reflected his joys, his sor- 
rows, and his passions,-and has been graphically called " the 
window of the soul." 
ANATOMY OF THE HUMAN EYE. 
Works on human anatomy contain illustrations of the eye 
as well as. elaborate descriptions of the same, therefore it is 
unnecessary to repeat here what is in every medical reader's 
hands. The first and second diagrams represent quite dis- 
tinctly the motor apparatus of the eye, and the general fea- 
tures of the exterior ocular arrangements. 
Fig. 1. 
1, fragment of sphenoid bone; 2, the optic nerve ; 3, the globe of the eye; 4, the levator 
palpebrae muscle; 5, the superior oblique muscle ; 6, its cartilaginous pulley ; 7, its reflected 
tendon ; 8, the inferior oblique muscle, with piece of bone to show the origin of the muscle; 
9, the superior rectus muscle ; 10, the internal rectus ; 11, a part of the external rectus ; 12 
the external rectus, mostly cut away; 13, the inferior rectus; 14, the capsule of Tenon- 
"white of the eye." 
The eyelids, the conjunctiva, and the lachrymal apparatus 
will be described and illustrated when diseases of those parts 
are considered, a brief anatomical description introducing each 
topic. It is not deemed expedient to describe all the fascias 
and tissues of the orbital cavities, as some of them play unim- 
portant parts in the pathology of the eye. 
The eye is a dioptric apparatus, which by means of refrac- 
tive and accommodative media has the power of casting the 
images of objects upon the retina, a nerve-membrane that 
conducts these impressions through the optic nerves to the 
brain, where their recognition is enforced. 
The eye has been called an optical instrument of wonderful 
perfection; yet it has powers infinitely superior to any piece 
of art or mechanism. It has the property of adapting itself Anatomy of the Eye. 
13 
rapidly to long and short ranges of vision, and of changing 
its axis with admirable facility. A hawk soaring at a great 
height can adjust its eye so as to observe distant objects with 
precision. A small bird on the ground is watched with the 
greatest accuracy, and is not lost to view when the hawk 
stoops upon its prey. Though descending swiftly through the 
air the eye of the hawk changes its adjustment so rapidly that 
Fig. 2. 
A A, the parallel optic axes ; C C, the centres of motion of the globes ; B B, the axes of rota- 
tion of the oblique muscles; D D, the axes of rotation of the superior and inferior straight 
muscles; N N, the internal straight muscles ; O O, the superior oblique muscles, running 
through pulleys at DD; S, the superior straight muscle of the left eye; the muscle is 
removed from the right eye to show the optic nerve ; M M, the attachments of the inferior 
oblique muscles ; the view is from above, therefore the muscles can not be seen. 
the victim is kept clearly in view until the fatal plunge of 
beak or talons is made. Although the human eye is not pos- 
sessed of such remarkable accommodative powers as those of 
some animals, it will conform to different ranges of vision 
with great celerity. 
By what is already shown in the accompanying diagrams 
it may be seen that the eye is a complicated structure ; and 
that the kinds of derangements to which the several parts are 
liable, may be infinite. The shell, as it were, of the eyeball 
encloses the humors and delicate structures ; the muscles move 
the globe in its socket; the lids with their cilia shield and 14 
Diseases of the Eye. 
protect the parts within ; and the lachrymal apparatus affords 
lubricating moisture. 
By the action of the muscles the optic axes are held par- 
allel, and the two globes are moved consentaneously. To a 
certain extent the oblique muscles are the antagonists of the 
recti. The latter tend to draw the eye back into the socket, 
and the former pull the globe forward. A division of the 
Fia. 3. 
C, cornea; I, ins: A H, aqueous humor; L, lens; C S, circular sinus, or canal of 
Schlemm; Z, zone of Zinnius ; H, hyaloid membrane ; 0 M L, ciliary muscle and ligament; 
C P, canal of Petit; V H, vitreous humor; R, retina; C C, choroid coat; 8, sclerotica; 
N, optic nerve; M, muscle. 
recti muscles would enable the obliqui to make the eye pro- 
trude ; and to divide the obliqui would allow the recti to 
retract the eyeball deep in the socket. By the action of sets 
of these muscles the eyeballs may be moved to the right and 
left, and up and down ; besides, a rolling motion may be 
imparted to the eyes by the compound action of both sets of 
muscles. By looking to the right or left, one eye turns in, 
and the other out; and, although different muscles in the two 
eyes perform the action, the movements effected are harmo- 
nious. Anatomy of the Eye. 
15 
The eyeball is slightly less than an inch in diameter; and 
though spherical in appearance, is a little elongated in its 
antero-posterior diameter. The cornea, being the segment of 
a smaller sphere than the rest of the ocular shell, is more con- 
vex than any other portion. 
The dense scleral substance or the sclerotic, maintains the 
shape of the eyeball, affords firm attachments for the muscles, 
and protects the delicate structures within. The cornea occu- 
pies the front part of the eyeball, and is a transparent struc- 
ture-the window that lets the light pass into the globe. The 
iris is a disc, variegated in color, with a round hole in its 
centre-the pupil-and is situated between the cornea and the 
lens. The aqueous humor occupies the anterior and posterior 
chambers of the eye, the pupil forming a communication be- 
tween the two apartments. The lens, a double convex trans- 
parent body located behind the iris and between the aqueous 
and vitreous humors, is enclosed in a capsule, and made to 
change its shape and position by the action of the ciliary 
muscle. The vitreous humor is that glassy appearing mass 
behind the lens, which occupies the large space called the 
fundus of the eye. The retina is the sensitive membrane, 
spherical in shape, which is spread out in the fundus of the 
eyeball to receive visual impressions. It is a prolongation of 
the optic nerve. The choroid is a pigmentary and vascular 
membrane between the retina and the sclerotic. 
The conjunctiva is essentially a mucous membrane, though 
moistened by the lachrymal fluid. It affords a lining to the 
lids and a covering to the anterior portion of the eyeball. 
The part which forms the external layer of the cornea is 
transparent and exceedingly thin, and the part which extends 
from the borders of the cornea to the palpebral sinuses, hiding 
the attachments of the recti muscles-" the white of the eye" 
-adheres loosely to the parts beneath. In the free borders 
of the lids are the tarsal cartilages-two semicircular hoops- 
which give form and support to the softer tissues of the lids, 
and attachments to the palpebral muscles. In the sub- 
stance of the tarsal cartilages are embedded the Meibomian 
glands which have ducts opening near the inner margin of the 
edge of the lids. The cilia grow from the outer edge of the 
lids, having their follicles in the skin. 
The optic nerve pierces the sclerotica little internal to the 16 
Diseases of the Eye. 
antero-posterior axis of the eye, and expands into the retina 
after entering the eyeball. The point of entrance is called 
the optic disc, a circular spot which can be distinctly seen by 
the aid of the ophthalmoscope. The optic nerve is enveloped 
in a dense fibrous sheath (neurilemma), which springs from 
the dura mater and blends at last with the sclerotic. In fact, 
the nerve enters the eye in bundles, and the passage of the 
fasciculi through the sclerotic is by a series of perforations, 
constituting the lamina cribrosa. 
In the axis of vision the retina exhibits a deeply tinted 
yellow spot, called the macula lutea. This is a little to the 
outside of the optic disc, and is the most sensitive part of the 
retina. 
EXAMINATION OF THE EYE. 
Some tact and experience are required to examine the eye 
in a thorough and effective manner. A mote on the cornea 
or a distorted eyelash may escape an inexperienced observer, 
especially if the light be not good. It is essential, then, in 
examining the eyes for defects, to have the patient placed so 
that a clear, bright light shall fall upon the parts to be in- 
spected. A pocket lens is a useful instrument to be employed 
in the examination of points not distinctly visible to the 
unassisted vision. 
After the cilia and puncta have been scrutinized, the lids 
are to be opened so the conjunctiva, cornea, and iris, may be 
examined. The lower lid is easily depressed with the finger, 
but the upper needs to be everted in order to expose its under 
surface, as well as to exhibit the sclerotic, cornea, and iris. 
A probe laid upon the upper lid parallel with its free edge 
and gently pressed downwards, while the thumb and finger, 
grasping the cilia, exert an upward force, will readily evert 
the tarsus and expose the parts beneath. The lids may be 
held apart by using the thumb and finger to press in opposite 
directions. The manipulation should be conducted with due 
regard to the sensitive nature of the parts. Rough usage 
provokes opposition on the part of the patient, and an 
obscuring flow of tears. Examination of the Eye. 
17 
Children affected with photophobia will baffle all ordinary 
efforts to open the lids in a bright light, therefore it may be 
necessary sometimes to use an anaesthetic before an attempt 
is made to expose parts beneath the lids. It is surprising 
what involuntary force will be exerted to hold the lids closed 
when the eyes are morbidly intolerant of light. . And it would 
involve a risk to try to overcome the spasmodic action in a 
young patient not rendered insensible. The cilia and lids 
may be slippery with tears and purulent secretions, so that 
the fingers will not make a secure hold. Besides, if the lids 
be forced open while the patient is exerting great resistance, 
the rolling eye will turn the cornea upwards and inwards to 
an extent which hides the greater part of it. 
If only one eye be diseased, it is advisable to compare its 
condition with that of the other ; in fact, it is well to compare 
the conditions of the two eyes when both are diseased. The 
comparison extends to the condition of the lenses if they be 
visible, the size of the pupils, the £ints of the irides, the con- 
figuration of the cornefe, and the vascularity of the sclerotics 
and conjunctival membranes. Contrasts are often valuable 
in estimating morbid states. 
It is seemingly easy to determine which is the strabismic 
eye, and what the degree of squint; but so great is the diffi- 
culty that an instrument-called a strabismometer-has been 
devised for measuring the decree of deviation existing in any 
particular case. A plate of ivory or glass, graduated, and 
made to fit the lower lid, and having a central dot to corres- 
pond with a vertical line drawn through the pupil when the 
eye looks straightforward, constitutes the instrument. Now, 
if the eye is affected with convergent or divergent squint, the 
centre of the pupil will be one or more lines to the right or 
left of the central dot on the scale, and the extent of the 
deviation is thus measured. 
In the absence of a strabismometer, the same information 
can be obtained by directing the patient to look at an object 
some distance in front of him, and then making a mark on 
the lid corresponding to the centre of the pupil of the squint- 
ing eye ; then, if the patient close the sound eye, and with the 
other look at the distant object, the squinting eye will assume 
a straight position, when another mark must be made on the 18 
Diseases of the Eye. 
lid below the pupil; the distance between the first and second 
dots will denote the angle of squinting. 
The iris has to be examined to determine whether it dilates 
and contracts freely. If the pupil be too large and remain 
steadily in that condition, the cause must be investigated. 
Ordinarily if the eye be shaded for a minute or two with the 
hand, the pupil will enlarge rapidly, and when the light is let 
in it will as quickly contract. Belladonna, stramonium, and 
other agents, when applied to the lids or the integument in 
the vicinity of the eye, will cause the pupil to dilate; and the 
use of opium will influence it to contract. Choroido-retinitis, 
an inflammation in which the iris is usually involved, is com- 
monly attended with a dilated state of the pupil, especially 
when the eye is under the influence of bright light, and when 
the pupil would be contracted if the eye were sound. 
In synechia and other mechanical impediments to the move- 
ments of the iris, atropine is used to determine the mobility 
of the pupil. In cases of synechia the effect of atropine is 
usually to throw the pupillary border of the iris into serra- 
tions or irregular elevations and depressions. 
If the iris be dilated and inactive, the inference is that the 
deep structures of the eye, especially the retina, are diseased. 
In concussion of the brain the pupil is usually contracted ; 
and in compression it is dilated, though either condition may 
exist and the pupil remain at its normal size. 
An instrument-called a pupilometer-has been invented 
to measure the size of the pupil under different circumstances. 
It is not of much use; yet those who enjoy a great variety of 
implements will add it to their armamentaria. It consists of 
a horizontal bar, on which a scale of degrees is marked; 
attached to this are two vertical bars, the one fixed and the 
other moveable by means of a screw. In use the edge of the 
fixed vertical bar is brought into a line with the inner edge 
of the pupil, and the sliding one is gradually screwed up till 
its edge corresponds with the outer border of the pupil. The 
space between the two bars, corresponding to the diameter of 
the pupil, is measured by the graduated horizontal bar. 
Some persons naturally have small pupils, and others large 
ones. A wide pupil is considered a mark of beauty; and 
mydriatics are sometimes used by ladies about to appear where 
personal attractions are likely to excite flattering remarks, Examination of the Eye. 
19 
though the artificially dilated pupil lets in so much light that 
the condition is detrimental to vision. 
The lachrymal apparatus has to be examined with, care to 
ascertain its defects. The position and condition of the puncta 
are to be observed, and the permeability of the canaliculi 
tested by the use of small probes. Pressure upon the lach- 
rymal sac, causing its contents to pass along, or regurgitate 
through the canaliculi, is an easy method of ascertaining the 
nature of the fluids in the sac and the strictured state of the 
nasal duct. *feither an overflow of tears, or a lachrymal 
fistula indicates obstruction of the nasal duct. 
Distortion of the cilia, or malposition of the eyelashes, can 
not be fully seen without a critical examination of the tarsal 
borders in a strong light, and with the aid of a pocket lens. 
A look from directly in front of the patient is not so good as 
a side or oblique view. While the inspection is made the lids 
should be closed slowly in order to see whether a twisting hair 
is forced upon the cornea by the closing lids. A single " wild- 
hair" may create a troublesome conjunctivitis. Eczema of 
the tarsal borders, often indicated by thickening of the edges 
of the lids, and a scaly condition of the spaces between the 
lashes, should be considered ; and parasites should not be 
overlooked. 
Tension of the eyeball is to be estimated rather than mea- 
sured. A finger placed against one side of the eye, the lids 
being closed, holds the eyeball steady while the forefinger of 
the other hand exerts gentle pressure or palpation upon the 
opposite side of the globe. The resistance and elasticity 
offered by the eyeball indicate the degree of tension. A 
healthy eye can be easily indented, yet one which is glauco- 
matous offers a stony hardness. Mr. Bowman has gone so far 
as to designate nine degrees of hardness, and represents each 
by arbitrary signs, which are too uncertain and " doubtful " to 
be of much value. No two experimenters would be likely to 
agree in regard to a shade of variation so refined as nine 
degrees of tension might demand. 
Test types are now very commonly employed to demonstrate 
the acuteness of vision ; and are of great practical utility. 
Snellen's test types, which belong to an oculist's apparatus, 
consist of different sized letters on blocks-the sizes ranging 
from No. I. to XX. The smallest, or No. I., is seen by a 20 
Diseases of the Eye. 
normal eye at a distance of one foot and can not be distinctly 
made out beyond that distance. The next size, No. II., is 
seen at a distance of two feet at the same angle, and so on, a 
foot being allowed for each letter, up to No. XX. The differ- 
ent distances at which the several sizes of type can be dis- 
tinctly seen, indicate the degree of acuteness of vision in the 
persons making the tests. 
Jarger's tests are printed from common type, and are put 
into words; and these again into lines or sentences, the size 
of the type varying in the different lines or sentences, from 
the smallest that can be read at the closest range of accom- 
modation, to those large enough to be distinctly made out at 
a distance of twenty feet. 
It may be desirable to ascertain the extent of the visual 
field, in order to learn what part of the sentient surface of the 
retina retains its integrity. This may be done by seating the 
patient a foot from a blackboard, and making on its centre a 
small cross with chalk. At this mark the patient is to fix one 
eye, the other being closed. A line is now drawn with the 
chalk in several directions from the central point-to the right 
and left, and upwards and downwards, the patient stating, as 
the lines are drawn, when the extreme limit of vision is 
reached. Intermediate lines may then be drawn, all radiating 
from the centre. The outline thus established indicates the 
limit of the field of visual perception. After one eye is thus 
tested, it may be closed, and the other subjected to a similar 
test. If a retinal lesion prevents the patient from seeing the 
radiating lines with the same distinctness, the region of im- 
perfect perception should be marked in the diagram. 
THE OPHTHALMOSCOPE. 
Like most other discoveries, that of the ophthalmoscope 
was by the gradual development of an idea. Cumming 
demonstrated that, by a certain arrangement of light, the 
fundus of a healthy eye could be made visible. Although he 
never obtained a view of the optic nerve or vessels of the 
retina, his experiments prepared the way for a progressive The Ophthalmoscope. 
21 
discovery which was made by Helmholtz in 1851. The next 
year, Ruete brought out an ophthalmoscope quite in advance 
of the imperfect apparatus of his predecessor. Coccius, the 
following year, carried nearer perfection the work so auspi- 
ciously begun. The essential part of the instrument now in 
common use, consists of a concave mirror having a perfora- 
tion in the center. The mirror is mounted in a metal frame, 
to which a handle is fixed. 
Before examining a patient's eye ophthalmoscopically, the 
pupil should be dilated with atropine of a strength not to 
exceed a grain to an ounce of water; and then the observer 
takes a seat in front of the patient who is seated near a jet of 
Fig. 4. 
Method of using Liebrich's Ophthalmoscope. 
gas, or a table on which stands a lamp giving a brilliant flame. 
The light should be on a level with the patient's eye, and just 
far enough behind him to prevent any of the direct rays from 
falling on his cornea. The observer places the back of the 
mirror close to his own eye, so that he looks through the 
central aperture, and holds the instrument at such an angle 
that the reflected light from its concave and brilliant surface 
falls upon the patient's pupil. To do this requires consider- 
able practice, though it is not difficult to accomplish. The 
observer knows when he holds the instrument in the right 
position, and at a proper distance from the eye, by seeing the 
retina assume a brilliant reddish appearance. While holding 
the ophthalmoscope in this position with one hand, the other 
holds a convex eclass at such a distance in front of the cornea 22 
Diseases of the Eye. 
as to allow the retina to come within its focus. If the fundus 
of the eye be properly illuminated, and the convex glass cor- 
rectly placed, some of the retinal vessels can be distinctly 
seen. 
To bring the optic nerve into view, the patient must direct 
the eye a little towards the nose ; and by turning the eye in 
various directions every portion of the retina is successively 
brought under the view of the observer. 
If the ophthalmoscope of Liebreich be used, it may be 
employed much as is represented in the accompanying dia- 
gram. The mirror is held near the observer's eye, and about 
a foot from that of the patient. In what is called the direct 
method of using the ophthalmoscope, the object-glass is not 
employed, but the mirror is moved towards the patient's eye, 
and at different distances the optic nerve, macula lutea, the 
arteria centralis .retinae, with the veins, may be seen; and the 
image is erect. 
In the indirect process, as seen in the diagram, an object- 
glass is employed; and the rays of light reflected from the 
fundus of the eye strike the convex glass, and form an in- 
verted image. 
The appearances of the healthy eye as presented through 
the medium of an ophthalmoscope, have to be understood 
before morbid phases can be appreciated. In the sound eye 
the retina does not present a uniform color in all cases, but 
the tint varies from pale red, through shades of pale orange 
and yellow-orange, to buff. In vigorous persons the retina 
has a much redder appearance than in the feeble and anaemic. 
The tint of the retina is due in part to its own capillary net- 
work of vessels, and partly to the vascularity of the choroid 
which imparts a ruddy hue to the retina. 
Across the illuminated fundus of the eye will be noticed 
large vessels radiating from a central point towards the peri- 
phery. These are the large branches of the central artery 
and vein of the retina ; and by directing the patient to turn 
the eye a little towards the median plane, these vessels can be 
traced to their parent trunks in the middle of the optic 
papilla. The arteries have thicker coats than the veins, hence 
the color of the blood is not so distinctly seen as in the veins 
whose walls are thinner. The artery casts a faint shadow on 
each side of it. No pulsation is observed in the retinal vessels The Ophthalmoscope. 
23 
of a healthy eye; but heavy pressure on the eyeball with the 
finger will excite a decided pulsation both in the arteries and 
veins. 
The optic disc presents a variety of appearances in persons 
who enjoy good sight. As age advances it becomes smaller, 
and often deviates more or less from that circular outline 
which is presumed to be the normal standard. Contrasted 
with the reddish tint of the surrounding retina, the disc 
appears cream-colored, or tinged with a pinkish-gray peculiar 
to the brain. The extreme edge of the disc is of a more 
decided white than the central portion. The retinal artery 
close to the ring of the optic nerve, bends around the vein 
and starts off to its destination in nearly straight, or slightly 
wavy lines, branching as it advances, until it forms a plexus- 
ora serrata-at the front margin of the retitfa. Veins accom- 
pany the arterial twigs. 
The choroid can generally be seen through the retina, 
though with varying degrees of distinctness. The hexagonal 
pigment-cells of the choroid can often be discerned, yet they 
appear as if covered with a haze or mist. 
In young persons the vessels of the choroid can scarcely be 
made out; but in advanced life the retina does not conceal 
the choroidal vessels as much as might be supposed by persons 
unaccustomed to make ophthalmoscopic examinations. The 
vessels are larger than those of the retina, and are closely 
packed together, having between them narrow linear spaces, 
in which dark pigment is visible. In early life the choroidal 
vessels are bright red, but in old age the color is reduced to 
a brownish tint. 
Morbid appearances of the Betina, Optic Disc, and Choroid. 
No picture nor verbal description can convey an accurate idea 
of the morbid phases a diseased retina may present; and 
about the same may be said of the optic disc and the choroid. 
In many instances an abnormal appearance is observed, yet 
the patient may see clearly, therefore it would be a question 
whether the eye be diseased or not. 
Even the dusky halo which surrounds the optic disc in per- 
sons with impaired vision, is not constant, though it has been 
considered as a distinctive pathological sign. Headache, 
excitement,and mental depression may develop the halo, and 
a season of repose carry it off. It is well to understand oph- 24 
Diseases of the Eye. 
thalmoscopic appearances; it is better to comprehend their 
causes ; and the best to be able to remove them. 
At one time it was thought that the white patches seen in 
ths vicinity of the optic disc, especially if they were crescentic 
in form, were sclerotic. Now it is known that they are fatty 
deposits on the choroid, or fatty transformations of the retina. 
The change of color depends upon a loss of pigment-cells. 
The fatty deposits and transformations may have sprung from 
chronic inflammatory action, though there often is no outward 
sign of such action. Scrofulous and syphilitic taints work so 
insidiously that it is difficult to determine the modus operand! 
of the morbid processes. 
The extravasation of blood between the choroid and retina 
is followed by inflammation which calls out effusions oi 
lymph. As the inflammation subsides the absorptive forces 
come in and remove not only extravasated and effused mate- 
rial, but pigment-cells and nerve-substance, producing a white 
patch by laying bare the sclerotic, and leaving a black ring 
around it. Extravasations of blood in the tissues of the 
choroid and retina are exceedingly dangerous to vision, yet 
very good recoveries have been known to follow such acci- 
dents. Recent extravasations are easily detected with the 
ophthalmoscope, but it is difficult to comprehend the nature 
of the lesion when important changes have taken place at the 
site of the extravasation. 
Detachment of the retina from the choroid is a serious 
accident, and is recognized by a lobular gray mass which is 
in contrast with the reddish reflecting surface of that part of 
the retina which still retains its normal state. 
A detached segment of retina oscillates with each move- 
ment of the eye, and exhibits upon its surface a wavy state of 
the displaced vessels. 
A pearly white appearance of the optic disc, in contrast 
with a rose-tinted retina, and in combination with other 
unfavorable signs and symptoms, is not an appearance which 
is at all promising. "Cupping" or "indentation" of the 
optic disc is another sign of discouraging import, though in a 
less degree than some writers allow. In advanced life it may 
be a sign of atrophy and degeneration, and then the prog- 
nosis is, of course, unfavorable. 
In syphilitic iritis and retinitis a cloudy condition of the Remedies. 
25 
vitreous humor is sometimes observed; and shreds and fila- 
ments which appear black, though really whitish, float about 
in the vitreous body. The ophthalmoscope reveals these, and 
they are not the muscce volitantes the patient sees. 
REMEDIES. 
Although the morbid affections of the eye are numerous, 
the remedies employed for their relief are comparatively few. 
An observant visitor to a well attended eye clinic would be 
surprised at the number of patients treated with a half dozen 
medicinal agents; and not less would be the surprise when 
it was considered that the greater portion of the agents 
employed are for topical uses, and applied to the conjunctiva. 
Some ophthalmic*diseases are so emphatically systemic that 
constitutional remedies alone will be necessary. Defective 
vision from lactation or other debilitating causes, requires no 
local treatment; and some forms of rheumatic and syphilitic 
iritis demand more general than topical medication. Many 
kinds of ophthalmic disease require both local and constitu- 
tional management. It is always judicious to consider the 
importance of employing constitutional remedies when there 
is any indication for their use ; and a full habit or plethoric 
state is not always to be trusted as evidence of a constitu- 
tion free from contamination. It is better to err on the safe 
side, by administering constitutional remedies when they are 
not needed, than to neglect them when they are important. 
It would be foolish in most instances to prescribe internal 
treatment for the relief of an eye which was worried by a 
mote beneath the lid, though a febrile condition was pro- 
voked by the local irritation. The removal of the primary 
cause would generally be followed by immediate relief. 
However, an eye which has been suffering for days from a 
foreign body beneath the lid, might not be wholly relieved 
by the removal of the irritating substance :-the inflammation 
may have produced local changes and systemic derangements 
■which would require general treatment to overcome them. 
As has been intimated, local remedies constitute a large 26 
Diseases of the Eye. 
share of the agencies employed in the management of eye 
diseases. Collyria, medicated with astringents, stimulants, and 
sedatives, are frequently used, the strength being tempered to 
suit the conditions of the case. A caustic effect may be 
needed in some instances, especially to make a primary impres- 
sion ; and then the mildest applications must follow. It is 
sometimes necessary to cauterize granulations of the lids with 
nitric acid at full strength, the agent being applied with a 
pencil of wood.. Vessels traversing the cornea often have to 
be obliterated with nitric acid applied with the point of a 
stick near the margin of the corneal structure. Ointments are 
not fit to be used inside the eyelids, except in rare cases. 
Unguents may be applied to the edges of the lids in ophthal- 
mia tarsi, or to remove tetter from the follicles of the cilia. 
The mercurial ointments are all too irritating to be employed 
about the eye. Citrine ointment very much reduced with cod 
liver oil, has been highly commended in the treatment of 
eczematous lids, yet it is too irritating. Neutral glycerine 
with a small quantity of Fowler's solution-half a drachm of 
the latter to an ounce of the former-has done well when 
applied to the edges of eczematous lids. The same amount 
of Fowler's Solution to an ounce of " Cold Cream " is better. 
A neutral sulphate of atropia is the mydriatic in common 
use. A grain or two dissolved in an ounce of water, and 
applied beneath the lids every few minutes will soon dilate 
the pupil. Belladonna and stramonium rubbed upon the lids 
will affect dilatation of the pupil. Aconite applied to the lids 
and parts about the eye when the pupil is dilated in " amauro- 
sis," will induce contraction of the pupil or act as a myotic. 
Opium and its preparations ordinarily contract the pupil to 
pin-hole size. A myotic effect is also produced by the use of 
the calabar bean. The agent in the form of an alcoholic 
extract is employed locally to the lower conjunctival sac by 
means of a camel's hair brush. It should be greatly diluted 
with glycerine before use. Mixed with a solution of atropine 
the effect of each is neutralized. The extract of calabar bean, 
even largely diluted, is irritating, and should therefore not be 
used when not imperatively demanded. 
Nitrate of silver and the salts of lead are not fit to be 
employed upon the cornea and conjunctiva, as they sometimes 
produce stains, deposits, and unfortunate cicatrizations. Sul- Remedies. 
27 
phate of zinc and sulphate of copper, applied in substance or 
solution, are preferable to the salts and solutions of silver and 
lead. 
Tannic acid in powder and solution has been employed to 
arrest purulent secretions of the conjunctiva and to constringe 
granulations of the lids. Powdered tannin, either alone or 
mixed with calomel, has been blown upon the cornea and con- 
junctiva to arrest suppuration, but other well known means 
are preferable. An aqueous or fluid extract of pinus cana- 
densis is an excellent topical agent in the treatment of ulcers 
of the cornea, and diseases of the conjunctiva. The strength 
is to be gauged to the pathological conditions. 
The pith of sassafras has been used in the formation of 
collyria, but it is doubtful whether the agent possesses any 
special value. Alum curds, and poultices of various kinds 
have been employed in the treatment of ocular inflammations, 
and although they are comfortable when first applied, they 
are known to favor suppuration, chemosis, and destruction of 
the cornea. 
Local depletion by means of leeches and scarification is 
gradually going out of reputable use. The division of highly 
congested vessels in the conjunctiva gives transitory relief,but 
no permanent good is to be expected. 
The use of water in the form of douches and wet com- 
presses abstracts heat, therefore an agreeable sensation of 
coolness is effected by it when there is a high degree of 
inflammation in the lids and parts about the eye. Ice cold 
water provokes congestion of a part at first, and then by a 
contraction of the vessels and tissues produces pallor and a 
benumbed state of the parts chilled. Some sensitive patients 
can not endure the prolonged abstraction of heat without 
unpleasant effects. 
The hypodermic injection of morphia has been employed 
for the subjugation of intense circumorbital pains, but the 
dangers attending the hypodermic use of medicines are too 
imminent to be risked on trivial occasions. Hydrate of chloral 
is an anodyne of power when employed in large doses, yet its 
effects are variable and unreliable. Chloroform may be in- 
haled to arrest insufferable pain; and applied to the skin in 
the vicinity of the eyes, exerts a sedative influence. 
Internal or constitutional remedies are needed in the treat- 28 
Diseases of the Eye. 
ment of ophthalmic diseases, especially when scrofulous, rheu- 
matic, and syphilitic taints are known to exist in the patient. 
Iodoform is a powerful alterative, and may be used as such 
with marked effect. Iodides of potassium and ammonium, 
and other medicinal forms of iodine, may be administered 
with the expectation of their exerting an alterative effect. 
Sulphur is an agent which should not be neglected when it 
is desirable to overcome constipation of the bowels, and to 
produce an evacuation of pasty consistence. Cathartics, as 
such, are rarely required in the treatment of eye diseases. 
However, an efficient unloading of the bowels is sometimes 
salutary in its effects. The mercurials, which are generally 
laxatives, have been largely employed in the management of 
ophthalmic affections, but it is questionable whether any par- 
ticular advantage has been gained by their use. They are 
depletory and devitalizing in their action, and therefore unfit 
for general use. Some of the most eminent oculists continue 
to employ the mercurials, yet sparingly and with many pre- 
cautions. Once it was thought that iritis and retinitis could 
not be successfully treated without ptyalism; but now it is 
known that these diseases will succumb more satisfactorily 
without mercury in any form. Even in syphilitic iritis there 
is no necessity for a mercurial, better results being obtained by 
the use of iodides, sulphur, iron, mineral acids, salines, and 
bitter tonics. Stillingia, sarsaparilla, and other vegetable 
alteratives help to eliminate a scrofulous taint, but the effect 
is more decided when an iodide is combined with them. A 
syphilitic contamination is not eradicated by any single medi- 
cinal agent, but has to be expelled by a variety of remedial 
impressions made at different times. 
Arsenic in small doses is a vital stimulant, and may be pre- 
scribed advantageously in cases of enfeebled nutrition, and 
when a patient suffers from nervous rigors or intermittent 
shiverings. In strumous and tubercular complications the use 
of arsenic-one or two drops of Fowler's solution at a dose, 
and repeated three or four times every other day-is bene- 
ficial. 
Ophthalmic diseases are not unfrequently complicated with 
miasmatic difficulties, therefore quinine becomes indispensable 
as a remedial agent. 
It is not pretended that every remedy of value in the treat- Instruments. 
29 
ment of eye affections has been named. A few of the more 
prominent are introduced at present in a general manner, and 
others may be mentioned when special diseases are under 
consideration. 
INSTRUMENTS. 
No branch of surgery demands so great a variety of instru- 
ments as ophthalmic practice; and the ingenuity manifested 
in devising instruments is only matched by the skill displayed 
in their construction and elaboration. An oculist's ordinary 
operating case contains from twenty to a hundred different 
instruments, and an eminent specialist may possess a thousand 
separate instruments. Many instruments are so delicate that 
they ought not to be used but a few times. The edges or 
points become impaired by moderate usage, and they will not 
bear resharpening. Not a few oculists exhibit a preference 
for instruments of a particular workmanship, or for those of 
fancy forms and shapes, consequently an attempt to describe 
a hundredth part of all the instruments employed in ophthal- 
mic surgery, would occupy more space than can be afforded 
in a work of this character. 
The beginner in surgery can get along quite well with an 
operating case which contains instruments for the different 
cataract operations, for executing iridectomy in several ways, 
for overcoming strabismus, for removing pterygium, for treat- 
ing the lachrymal apparatus, and for correcting defects of the 
lids. Liebreich's ophthalmoscope, or one of some other 
pattern, is needed, several lenses of different magnifying 
powers, a variety of spring speculums for holding the lids 
apart, forceps of various kinds, including one with a plate 
and ring to be used in removing small tumors of the lids. 
Test types, spectacles, eye-bandages, shades, artificial eyes, 
and many other implements and appliances go to make up 
the oculist's armamentarium. 30 
Diseases of the Eye. 
THE LIDS AND THEIR DISEASES. 
The eyelids are two curtains which shield the deeper ocular 
structures, and have the power of winking. They have a 
delicate dermic covering without, and a conjunctival lining 
within. Their free margins bound the palpebral fissure, 
which terminates outwardly 
in an acute angle (external 
canthus), and inwardly in an 
obtuse angle (internal can- 
thus). The tarsal cartilages, 
which are crescentic in form, 
constitute firm attachments 
for the softer structures, and 
serve the purpose of semi- 
circular hoops at the mouth 
of a bag or net. On the der- 
mal edge of the free borders 
of the lids are rows of glossy 
and curved hairs, called lashes or cilia, which, besides being 
ornamental, serve to protect the conjunctival surfaces from 
motes and irritating substances. The lids have a broad, thin 
and pale muscular layer, the fibres sweeping semicircularly in 
each lid beneath the thin integument, and uniting in the 
palpebral ligapients at either canthus. This muscle is called 
the orbicularis palpebrarum, and is efficient in closing the lids. 
The upper lid has, besides, a long slender muscle (No. 4, in 
Fig. 1), which lifts the lid and holds the eye wide open. 
A fascia underlies the muscles of the lids and extends to 
the rim of the orbit. This is densest in the median line ter- 
minating at either canthus, and constitutes with the tendonous 
bands of the orbicularis muscle, the palpebral ligaments. The 
inner extremities of the tarsal cartilages are held in place by 
the internal palpebral ligament, and moved inwards or buried 
in the lachrymal fossa by bundles of muscular fibres denomi- 
nated Horner's muscle, indicated by II, in Fig. 6. 
The tarsal cartilages have a set of sinuous tubes opening 
upon their free margins. These are the outlets of the Meibo- 
mian glands which secrete sebaceous matter to lubricate the 
free borders of the lids. 
Fig. 5. 
The eyelids : aa, Meibomian glands; b, outer 
canthus; c,inner canthus; d, lachrymal *punc- 
jojUel.^1.; », orifice, of pitied eye. Diseases of the Lids. 
31 
The muscles of the lids are to some extent involuntary; 
and move with great rapidity when the eye is to be shielded 
from a sudden flash of light or a flying missile. 
The connective tissue of the lids is loose and liable to infil- 
tration, but it will not admit of fatty deposits. 
Erysipelas of the face is 
likely to extend to the lids, and 
result in abscesses. It is no 
uncommon occurrence for the 
lids to swell during erysipela- 
tous attacks, and keep closed 
for several days. The struc- 
tures, as has already been 
stated, are susceptible of infil- 
trations, therefore a suppura- 
tive condition is not always to 
be avoided when the inflamma- 
tion is active or acute. 
Abscess of the lids is to be 
treated with evaporative and 
anodyne lotions, if the avoid- 
ance of suppuration is desira- 
ble. But it is frequently im- 
possible to prevent suppuration, 
consequently in cases threatening that state, it is good prac- 
tice to employ warmth and moisture, and thus attempt to 
force the suppurative issue as rapidly as possible. 
As soon as it be ascertained that a mature abscess exists, 
the pus should be evacuated through an incision made par- 
allel to the course of the muscular fibres of the orbicularis 
palpebrarum. When the incision is made the thickness of 
the lid should be considered, that parts beneath may escape 
injury. 
The after treatment consists in keeping the walls of the 
abscess in contact by means of gentle pressure maintained 
with a compress and a flannel or elastic bandage. 
Injuries of the lids often result rapidly in a " black eye," the 
extravasated blood showing through the thin integument, pro- 
ducing a condition termed ecchymosis. Discoloration about 
the eyes so often follows pugilistic encounters, that a person 
Fig. 6. 
H indicates Horner's muscle. 32 
Diseases of the Eye. 
with a "black eye " demands immediate relief from the often 
disreputable marks. 
Leeches have been a popular remedy for ecchymosis about 
the eyes, yet it is now known that the creatures will not suck 
extravasated blood, but only that which is circulating in the 
vessels. In fact, leech-bites in loose tissues are followed by 
ecchymosis. 
A piece of raw beef is another popular remedy for the 
eradication of "black eye," but the cataplasm of flesh rarely 
gives satisfaction to the impatient sufferer. 
A contused eye which is black at first, soon passes through 
several hues, assuming at length a greenish tint, and finally a 
lemon color. 
It is well to apply to a recently bruised lid a dilute tincture 
of arnica, aconite, and other agents of that class. Such 
lotions prove sedative to irritated nerves, and seem to promote 
disintegration of the extravasated blood, and its removal by 
absorption. 
The best way to hide the discoloration is to cover the ecchy- 
mosed region with flesh colored adhesive strips. 
Incised and lacerated wounds of the lids are to be treated 
according to those principles in surgery which pertain to 
traumatic states in other regions of the body. Sutures are to 
be avoided when practicable, though they are sometimes 
essential to an efficient and judicious dressing. Linear cica- 
trices, when they take a direction parallel to the course of the 
orbicularis palpebrarum muscle, readily fall into a wrinkle, 
and thus escape observation. 
(Edema of the lids is not a distinct affection, but generally 
depends upon disease of the bones of the orbit, or of the 
nasal structures. The use of arsenic in poisonous doses will 
produce a puffy appearance of the lids ; and Bright's disease 
of the kidneys, as well as other complaints of an exhausting 
character, are accompanied with swelling of the lids. A 
removal of the cause of the oedema when it can be accom- 
plished, is the rational way to get rid of the swelling. 
Emphysema of the lids, like ecchymosis, is usually the 
result of a blow, but air from the nasal cavities gets into the 
loose tissues instead of blood. Necrosis of the thin bones in 
the vicinity of the orbit, establishing communications with 
the ethmoid cells or frontal sinus, is a common cause of Diseases of the Lids. 
33 
emphysema around the eyes. After fractures about the nose 
and orbits, and following ulcerative diseases of the bones 
alluded to, the patient can often make the lids puffy with air 
by " blowing the nose," or by closing the lips and nostrils, and 
distending the mouth and nose with air from the lungs. The 
emphysema is not a grave complication. Following fracture, 
it soon subsides; but if produced by ulcerative conditions, 
the cure will depend much upon the continuance of the cause. 
Warts occasionally develop upon the lids, and prove 
obstinate sources of annoyance. They are not essentially 
different in nature from excrescences of the kind on other 
parts of the body. If they grow upon the edges of the lids 
they can not well be attacked with caustics. Excision is an 
efficient method of destroying warts, whether located on the 
lids or other parts of the body. Evulsion with forceps may 
do, though if a " seed"-centre of evolution-be left behind, 
a reproduction of the excrescence may be expected. 
Congenital vascular tumors-ncevi materni, or " mothers' 
marks"-are not uncommon deformities of the lids. The 
vascular capillaries seem to be in an aneurismal state, enlarg- 
ing and discoloring the part affected. If the enlarged vessels 
be arterial in nature the tumor or excrescence will be pulsa- 
tile and of a light red hue, but if they be venous a livid tint 
prevails. These tumors usually remain stationary, or enlarge 
pari passu with the growth of the child, but they may 
develop rapidly and demand operative interference to check 
their growth. 
The treatment of these vascular excrescences does not 
differ from that applicable to the disease located in other 
parts of the body. " Monsel's Solution," a ferruginous 
preparation, is a valuable agent to constringe and eradicate 
nsevi. If apparently too strong, it may be reduced by adding 
an equal quantity of glycerine. Carbolic acid applied at 
full strength, with a stick or pencil, and renewed every day 
or two, will often obliterate the excessive vascularity of a 
naevus. Caustic and astringent darts have been employed to 
destroy these vascular developments. And strangulation by 
means of a ligature thrown around needles which have been 
made to transfix the tumor, has brought about satisfactory 
results. Excision in some instances, and transplantation 
may be required to overcome the defect. A vascular spot of 34 
Diseases of the Eye. 
restricted boundaries may be enclosed in a "ring forceps to 
isolate the parent vessels, then, after slitting the mass with a 
delicate knife, the incisions may be filled with tannic acid. 
If the forceps be left in place a few minutes no bleeding will 
occur. A small slough obliterates the original disease, and 
only a small cicatrix remains. 
Cysts in the integument of the lids, or below the brows near 
the nasal region, are not uncommon. Their contents may be 
sebaceous, oleaginous, or melicerous. An oily cyst, situated 
near the angular processes of the frontal bone, may contain 
hairs. This strange state of things is explained by supposing 
that one or more hair follicles have become inverted or so 
changed in their function that the capillary product is turned 
loose into the cavity of the sac. These cysts in or about the 
lids rarely produce discoloration, or inconvenience. But 
being conspicuous, their removal is desirable. Often they are 
not larger than a pea, yet; by irritation they may inflame, 
suppurate, and discharge, and thus disappear. Cysts just 
beneath the integument should be excised; and if the exci- 
sion embrace the entire sac there need be no fear of a return 
of the disease. Cysts the size of a pin's head need not be 
treated, as they are too insignificant to command attention. 
Cysts projecting on the inside of the 
lid, and producing conjunctival irrita- 
tion, may be destroyed by everting the 
lid, incising the sac to evacuate its con- 
tents, and cauterizing the cavity with 
carbolic acid or other escharotic intro- 
duced with a pencil of wood. No 
caustic need be used if the sac be 
entirely dissected out. 
Carcinoma and epithelioma near the 
palpebral border may be removed by 
excising a wedge-shaped piece of the lid, including the can- 
cerous or suspicious growth, and then uniting the edges of 
the wound with sutures. Epithelial cancer usually attacks 
the skin near the lachrymal sac, and extends towards the 
bridge of the nose as a shallow, pale ulcer. This form of the 
disease may commonly be removed, if it has not reached the 
deeper structures, by the use of the chloride of zinc paste. 
Fig. 7. 
Cystic tumor of the lower lid. Diseases of the Lids. 
35 
The graver forms of carcinoma involving the lids, rarely 
yield to treatment. 
Eczematous Pustules on the Borders of the Lids.-It 
is common to observe one or more pustules on the outer edges 
of the lids. The roots of the cilia and the minute glands 
around them seem to be involved in the affection. At first a 
nodule arises, which after showing signs of inflammatory 
action for a day or two, suppurates. The latter action loosens 
several lashes, and the pus escapes through the openings left 
by the displaced cilia. The pustules range in size, from a 
hemp-seed to a pea. 
The irritation accompanying the eczematous state is attended 
with reddening of the palpebral border and thickening of the 
edges of the lids. In young persons of a strumous diathesis 
eczema of the lids is a common way for the taint to manifest 
itself. The children in scrofulous families are frequently 
" pink-eyed," as the purplish red at the margins of the lids, 
is sometimes denominated. The eyelashes grow stiff, and 
become twisted and distorted ; and a scaly eruption seems to 
cling to the bases of the cilia. The contorted eyelashes 
reach the cornea, and establish chronic inflammation of the 
conjunctival membrane. In time the disturbance produced 
by " wild hairs " may obliterate the lachrymal puncta, forcing 
the tears to overflow, and constituting what has been termed 
lippitudo, or " blear-eye." , 
The herpetic affection is often attended with burning, itch- 
ing, and other annoying sensations. The difficulty in its 
worst form seems to be periodical, an active attack coming on 
from the reception of " a cold," or from an unrecognized 
cause, and after lasting a week or two, subsiding to an extent 
which promises substantial relief. 
Treatment.-It is well to puncture a mature pustule, using a 
cataract needle or a slender knife in the operation. In many 
cases this is all which may be required, especially if the dis- 
ease appear to be local in character. If the morbid action be 
persistent and paroxysmal, developing pustule after pustule, 
constitutional treatment is demanded. 
If the disease be decidedly herpetic in appearance, a medi- 
cated cerate may be useful to allay the topical irritation and 
to subdue the scaly condition at the roots of the cilia. Mer- 
curial ointments of various kinds have long been in good 36 
Diseases of the Eye. 
repute among oculists as the fittest to overcome eczematous 
states of the tarsal borders, but, as has been said elsewhere, 
the mercurial unguents do not often answer a satisfactory 
purpose in the treatment of tissues as delicate as those con- 
stituting the lids. The brown citrine ointment, reduced one- 
half with olive oil, is the least objectionable of the mercurial 
ointments; and this sometimes produces too much irritation. 
I prefer: 
Simple cerate, 5j. 
Iodide of ammonium, grs. iv. 
Pulv. sub. nit. bismuth, grs. x. M. 
Scent with an agreeable perfume. S. Use on the edges of the 
eyelids with a camel's hair brush or a delicate swab. 
The following is also a favorite pomade, which may be 
used upon pustular lids to advantage : 
R Ung. aqute rosse, 5j. 
Fowler's solution, f5ss. M. 
S. Apply to the palpebral borders morning and evening. 
Many other salves may do as well. Every practitioner has 
a recipe for an unguent which is held in high esteem. 
Obstinate eases of eczema tarsi can not be substantially cured 
without a prolonged course of " alterative" medication. And 
the ordinary syrups of stillingia and sarsaparilla are not very 
efficient remedies. The iodides of potassium and ammonium 
make more pronounced impressions; sulphur given in broken 
doses every few days, is an alterative worth mentioning; 
phosphorus, when administered in safe and reliable forms, is 
valuable; iron, dissolved in nitric acid, and administered in a 
dilute form, is a useful alterative; cod liver oil is known to 
be an efficient agent, but it is rarely offered in a palatable 
form; arsenic is a favorite on account of its efficacy in small 
doses. A common prescription of mine is the following: 
Peppermint water, f§iv. 
Iodide of ammonium, 5n. M. 
S. Teaspoonful four times a day. 
Iodoform, in grain doses, sugar coated, is an excellent alter- 
ative, and may be given as one of a series of remedies con- 
stituting a systemic course. No remedy should be continued 
more than a week without alternation with some other potent 
medicine. 
A mixture of sulphur and sulphate of magnesia, ■with a Diseases of the Lids. 
37 
stomachic, is sometimes more desirable than the common 
character of the agents might promise. I make extensive use 
of the following prescription : 
Pulv. crab orchard salts, Siij. 
Pulv. sulphur, 5j. 
Pulv. cubebs, 5ss. M. 
S. Quarter of a teaspoonful in half a wine-glass of water, 
four times a day, every other day-alternating with some of 
the other agents already mentioned. 
Phtheiriasis, " crab-lice," must not be overlooked in the 
consideration of eyelash affections. Although crab-lice have 
an affinity for the pudendal region, they will live about the 
cilia and supercilia. Inspection with a pocket lens will gener- 
ally discover the presence of the parasites. Cod liver oil pen- 
cilled upon the lashes and edges of the lids every day for a 
week, or until all the ova are hatched, will ensure a riddance 
of the pests. Any of the mercurial ointments will destroy 
the parasites. 
Hordeolum, or " sty," is a pustule or minute boil, which is 
not essentially different from those which arise in the course 
of an eczematous disease of the lids. A sty has its origin in 
one of the tarsal glands, and develops into a small abscess. 
Several days may be consumed in the evolution of the pustule. 
It begins to attract attention when the size of a pin's head, 
and becomes a painful nodule when the magnitude of a pea 
is attained. The inflammation is sometimes quite active, and 
extends to the conjunctiva and lachrymal apparatus. In fact, 
the entire eye may sympathize in the morbid action. 
A sty usually reaches maturity in a few days from its com- 
mencement, and then, after suppurating for a day or two, 
disappears quite rapidly. In rare instances, a hordeolum 
forms slowly, and continues for months in an inactive state. 
In fact, a sty may remain in a permanent form (chalazion), 
or as a non-inflammatory tumor. Hordeola are apt to recur, 
or return after a period of subsidence or repose. Indeed, any 
gland which has once been inflamed, is more likely to be sub- 
sequently attacked. If a Meibomian follicle once develops a 
sty, it is prone to repeat the morbid action. 
Treatment.-A sty is often too unimportant to demand 
treatment, yet in severe forms of the disease a compress of 38 
Diseases of the Eye. 
lint and an elastic bandage should be used, and a dilute tinc- 
ture of arnica or aconite may be employed to wet the dressing. 
Poultices are comfortable, but, if employed, they should be 
changed often to avoid ferments. As soon as the pustule 
" points " or shows that suppuration has taken place, it should 
be punctured or incised to allow an escape for the pus. Stys 
frequently evacuate their contents spontaneously, no surgical 
interference being necessary. 
If a chalazion resist the action of medicated cerates, the 
little tumor may be incised to provoke suppuration and reso- 
lution. If this course should fail, the indurated mass may be 
excised. 
Epicanthus is a defect arising from a redundancy of skin 
at the inner corner of each eye, or too much integument 
between the eyes. The redundant skin partly or wholly 
covers the caruncle, and gives to the face a Chinese expres- 
sion. Associated with this defect is apt to be a depressed con- 
dition of the nasal bones at the bridge, and other defects in 
the features of the face. Many young children have a redun- 
dancy of skin between the eyes, but a subsequent develop- 
ment of the bones of the nose and face distends the loose 
integument, and overcomes the infantile defect. 
If the redundancy continue till after puberty, it may be 
corrected by excising an eliptical piece of skin at the bridge 
of the nose, and closing the wound with silver sutures. The 
excision should be so performed that the line of union may 
be parallel to the course of the nose, and occupy the middle 
course. The cicatrix will thus be too slight to be observed. 
The operator is to judge how much integument is to be 
removed to overcome the defect. 
It is best to cut through the skin perpendicularly with a 
scalpel; and the incision should extend around the piece of 
integument to be removed. After the piece is dissected out, 
the integument on each side of the chasm should be loosened 
by means of a few undercuts with the knife. The separation 
from the subcutaneous tissues allows the flaps to slide freely, 
and obviates tension upon the sutures. The borders of the 
wound are then to be joined by three silver sutures, and sup- 
ported with strips of adhesive plaster. 
In five or six days the sutures can be removed, yet the 
adhesive strips may be continued a few days longer. If Diseases of the Lids. 
39 
enough integument has not been removed to remedy the 
defect, another eliptical piece of skin may be removed, and 
the wound treated as just indicated. 
Ptosis, or drooping of the upper lid, may exist in various 
degrees of deformity, and depend upon a variety of causes. 
Complete inability to raise the margin of the lid above the 
axis of vision is rare, but a moderate falling of one lid is 
common. The defect generally depends upon paralysis of the 
levator palpebree muscle, though it may come from defective 
nutrition in the muscle itself. Ptosis may occur from swell- 
ing of the upper palpebral fold, it being difficult to raise the 
thickened lid. Whatever be the cause, patients with this 
defect have feeble power to move the lid except by calling 
into action the occipito-frontalis ; and the forehead becomes 
furrowed by the forced efforts of that muscle. 
Attempts to remedy ptosis have generally failed. The 
hypodermic use of strychnia has been reported as proving 
serviceable, yet the relief, as under electro-galvanism, is only 
temporary. Surgeons have drawn down the occipito-frontalis 
through a subcutaneous incision, and endeavored to join the 
muscle to the under surface of the integument of the lid, but 
their success has not been such as to commend a repetition of 
the operation. A patient of mine, having an excessive degree 
of drooping in one lid, uses a strip of adhesive plaster to 
elevate the lid when he wishes to hide the deformity. 
Twitching of a few fibres of muscle in the lower lid, is a 
source of annoyance, and may exist for years without any 
known cause. Nervous and neuralgic states are thought to 
favor it, and these conditions may depend upon stomachic, 
intestinal, or other disorders. It has been observed that 
mental excitement, and the employment of certain muscles, 
as in the act of whistling, will temporarily arrest the twitch- 
ing. The orbicularis muscle may become spasmodic in parts 
or in individual bundles, causing a peculiar tremulousness, or 
rapid variation in winking (nictitation) which is exceedingly 
unpleasant. Pressure upon some of the ramifications of the 
trifacial may afford temporary relief; and, if the irregular 
movements depend upon habit, an interruption may prove the 
first step in the cure. 40 
Diseases of the Eye. 
Tonics and laxatives have exercised an influence which 
arrested the twitching in several cases coming under my 
observation. 
Ankyloblepharon.-Adhesion of the edges of the lids-a 
difficulty which bears the above technical term-arises from 
inflammatory action. The union commonly begins at the 
commissures or canthi, and sometimes extends until it has 
entirely obliterated the palpebral fissure. Occasionally a 
junction of the borders of the lids is complicated with a 
shortening or contraction of the tarsal cartilages, and then 
the defect is called blepharophimosis. 
Cicatrizations from burns, injuries, ulcerations, cauteriza- 
tions and ophthalmia tarsi, are the common causes of ankylo- 
blepharon. 
The defect is overcome by cutting the tarsal borders apart 
with scissors, or with a bistoury used along a grooved director. 
Frequently the union is not complete, but the edges of the 
lids are held near each other 
by adventitious bands; and 
these may be removed by sepa- 
rating their points of attach- 
ment with scissors. After sep- 
aration the lids are to be kept 
apart by means of adhesive 
strips which may be so applied 
as to pull in opposite directions. 
The adhesion when partial 
is commonly at the external 
canthus. If this be sufficiently 
annoying to warrant an oper- 
ation, it may be overcome by 
cutting through the outer can- 
thus with scissors, on a line 
with the palpebral fissure, the 
incision being to the extent of 
a half inch or so, and then pre- 
venting re-union by fastening 
with sutures a flap of conjunctiva into the wound thus made. 
A fold of conjunctiva is raised and so cut with scissors as to 
form a suitable flap to come between the tarsal cartilages. 
The incised edges of the conjunctival flap are held against the 
Fig. 8. 
Transplanting a flap of conjunctiva to 
the traumatic surfaces of a divided outer 
canthus, for the cure of partial ankylo- 
blepharon. Diseases of the Lids. 
41 
traumatic surfaces of the integument by means of three 
sutures, one at the extreme angle of the wound, and one for 
each lid near the original canthus. There is plenty of con- 
junctival membrane in the palpebral sinus to construct the 
flap. This operation is a species of canthoplasty which 
may be easily performed. 
Complete ankyloblepharon is rare, and difficult to cure. 
Though the palpebral fissure may be re-established, the dis- 
position to re-unite is very great, especially at the angles of 
the wound. 
Symblepiiaron, or adhesion of the lids to the globe, is pro- 
duced by suppurative inflammation of the conjunctiva in the 
palpebral sinuses, and cicatrizations following burns, ulcers, 
and the injudicious use of caustics. Trachoma-granular 
lids-is sometimes followed by adhesive connection between 
the lids and eyeball. The union is rarely complete, the lach- 
rymal secretion obviating a total blending of the structures 
resting in contact. Adventitious bands frequently connect 
the under surface of a lid to the cornea or scleral border. If 
the-adhesion extend to a considerable portion of the cornea, 
vision is irreparably lost. An adventitious band is frequently 
hour-glass in shape, slender or contracted in the middle and 
broad at each base. 
Treatment.-An eye that has recently been injured with quick- 
lime, strong acids or alkalies, or hot substances explosively 
hurled between the lids, should receive careful attention to 
prevent, if possible, symblepharon. The lid may be pulled 
away from the globe every few minutes; and the patient 
ought to be encouraged to roll the eye, motion serving to 
interfere with adhesive action. Granulating surfaces should 
be lightly touched with a sulphate of copper pencil. If the 
ulcerated surfaces be extensive the upper lid may be kept 
everted. It is not easy to keep the lower lid in a state of 
eversion without dividing the external commissure, a proce- 
dure which may be justifiable in bad cases. 
An adventitious band connecting the lid with the cornea 
may be clipped and turned away from the point of separa- 
tion. This allows the traumatic surfaces to heal separately. 
The entire band may then be snipped off without endanger- 
ing re-adhesion. If the neoplastic band be short and broad, 
there is danger of re-union unless the lid be kept everted. A 42 
Diseases of the Eye. 
band extending to the bottom of the palpebral sinus should 
be dissected out; and then the lid is to be kept in a state of 
eversion until the tendency to re-union has passed. To make 
sure of a good result the conjunctival fissure can be closed 
with sutures. 
When the removal of cicatricial tissue produces an exten- 
sive traumatic surface, a re-union can be prevented by the 
patient's wearing a leaden disc shaped somewhat like an arti- 
ficial eye. 
Distichiasis and Trichiasis.-By distichiasis is understood 
the existence of a double, row of lashes, though scattered hairs, 
and those which stand irregularly, bear the same name. It is 
rarely or never that an additional row of hairs exists, but 
straggling cilia coil inwards, and irritate the cornea, causing 
excessive vascularity and haziness of that body. A calloused 
and cicatrized border to the lid tends to spread and distort 
the cilia. 
By trichiasis is understood an inversion of the lashes, or a 
bending inwards of the cilia. In trichiasis, there is an irregu- 
larity in the size of the hairs, a large one may be associated 
with several small ones; and what had been a single follicle 
will send out three or four diminutive cilia, which will crinkle 
or spread in different directions. These " wild-hairs," as they 
are sometimes called, frequently give a great deal of trouble, 
eventuating in serious disorder of the cornea and loss of 
vision. 
Treatment.-Depilation is the old treatment for distichiasis 
and trichiasis. Cilia forceps, the blades of which are so 
ground and adjusted as not to cut the lash which is seized, 
are employed in the removal. The plucking process must be 
repeated every few days, as new hairs rapidly grow from the 
old follicles. Each offending hair should be firmly grasped 
near its base, and extracted with a slow steady pull. The 
fine hairs may escape detection unless the lid be scrutinized 
with a magnifier. After repeated depilation for weeks and 
months the hairs begin to grow more slowly and sparingly. 
At first it may be necessary to extract the distorted cilia every 
day or two, but at length intervals of weeks may elapse 
without the lashes receiving attention. 
Operative measures of different kinds have been devised to 
take the place of depilation which is tedious and uncertain. Diseases of the Lids. 
43 
Oue of the methods calls for a splitting of the lid, say the 
upper, while the patient is under the influence of an anaes- 
thetic. A horn spatula pushed into the palpebral sinus, serves 
to distend and support the lid while it is being split. An 
assistant is required to draw up the 
parts as they are loosened by the dis- 
section, and to steady the spatula. 
The operator must be careful to in- 
clude all .the cilia, embracing their 
bulbs, in the outside flap. If a hair 
follicle be left in the tarsal and under 
flap, a lash will be reproduced which 
may renew the trouble. The split in 
the lid should be a quarter of an inch 
deep, and not extend into the punc- 
tum lachrymalis. A second incision 
parallel with the first, yet in the in- 
tegument behind the cilia, and extend- 
ing a little beyond the boundaries of the first incision, isolates 
a belt of lid bearing the cilia, except at its extremities which 
are expected to furnish vascular supplies. A third incision is 
next made by beginning at one of the extremities of the 
second incision and after being carried in a semicircular 
sweep over the rotundity of the lid, terminates at the other 
extremity of the second incision. The crescentic piece of 
integument thus surrounded with incisions is to be dissected 
out, and the border of the cilia-bearing flap is to be stitched 
to the edge of the wound made by the third incision. In 
three or four days the sutures may be taken out and the heal- 
ing process left to itself. This operation will compel the cilia 
to take a higher range, and keep clear away from the parts 
within the palpebral fissure. 
Graefe has modified this operation by first making two 
vertical incisions through the skin and orbicularis muscle, and 
then splitting the lid as in the operation just described. The 
punctum should not be disturbed in the operation. After 
this flap is made, which contains the cilia, an oval piece of 
palpebral integument may be pinched up with the crutch- 
shaped forceps, and excised with scissors. The edges of this 
last wound are to be drawn together with sutures. This 
part of the operation elevates the flap bearmg the cilia, 
Fig. 9. 
This diagram represents a spat- 
uia beneath the upper nd, to act 
as a support to the loose tissues 
while the lid is being split and 
otherwise incised. 44 
Diseases of the Eye. 
carrying them away from sensitive parts within the palpebral 
fissure. This method of removing trichiasis is applicable to 
the upper lid. The disordered hair follicles may be dissected 
from the lower lid with- 
out having the result ob- 
servable as a defect., 
Stellwag remarks that 
" success is by no means 
assured either by one 
method or the other, 
although they may be 
carried out with the great- 
est precision and care." 
Fortunately, not all 
cases of trichiasis embrace 
the entire cilia, but the 
difficulty is restricted to 
a short space near the 
inner or outer canthus, or to a spot near the middle of the 
lid. For the removal of a few distorted cilia, confined to a 
space a third of an inch in length, the following process may 
be followed : A spatula is used to 
put the tarsal border on the stretch, 
then a lance, spear, or spade-shaped 
knife is employed to split the lid to 
the extent of the width of the blade, 
and the incision may be extended if 
necessary, xvith a small scalpel. The 
triangular flap thus raised is removed 
with scissors, and the edges of the 
wound closed with sutures. This 
procedure gets rid of the offending 
hairs and their foll-icles. 
If the trichiasis be confined to a 
narrow space on either lid near the outer canthus, the same 
lance-shaped knife may be used to under-cut the flap bearing 
the distorted hairs, an inverted A-shaped incision removes the 
flap, and sutures approximate the edges of the last incisions, 
overcoming the defect. 
As the inner extremities of the lids contain the puncta, the 
operation near the internal canthus, when required, must be 
Fig. 10. 
Crutch-shaped forceps grasping an oval mass of 
integument which is to be excised. 
Fig. 11. 
Lid split, and oval mass exci- 
sed ; the sutures will draw upward 
the strip of lid which contains the 
cilia. Diseases of the Lids. 
45 
conducted with reference to those points. Trichiasis does not 
so often affect the hairs near the inner canthus as it does the 
cilia near the outer commissure of the lids. 
It has been found that the removal of a triangular piece 
bearing distorted cilia, is followed by relapses, the hairs adja- 
cent to the wound being drawn inwards by the contracting 
cicatrix, therefore a sort of transplantation of the neighbor- 
ing part of the outer lips of the split lid should sometimes be 
combined with the excision. The incision dividing the lid 
into two layers, may be extended on either side to the distance 
of one or two lines beyond the 
base of the inverted cilia. Then, 
if the distorted lashes affect a spot 
near the middle of the lid, a tri- 
angular flap, with its apex want- 
ing and its base up on the lid, is 
to be marked out by an incision 
to the depth of the outer layer of 
the split lid, and dissected from 
its place. The two under-cut tips 
are to be united with a suture, 
and affixed above to the integu- 
ment which bounds the base of 
the triangle near the angles. 
Substantially the same operation may be performed near 
the outer canthus, even involving the commissure and parts 
of both lids, the shape of the pieces cut around and dissected 
out, being modified in accordance with the defect to be 
overcome. 
If a case occur in which transplantation is unsuccessful or 
is impracticable from cicatrizations, it may be best to entirely 
remove-after the lid has been split-the narrow strip bear- 
ing the distorted cilia. This creates a deformity, which, how- 
ever, is preferable to seriously impaired vision. 
Operations upon the lids require considerable skill in their 
performance ; and the degree of success depends much upon 
the plan of cure adopted. Only a few general rules of treat- 
ment can be laid down. The operator of moderate experi- 
ence must study'each case demanding surgical interference, 
and apply intelligently these broad principles, bearing in mind 
that two cases in surgery rarely accord in every particular. 
Fig. 12. 
This diagram represents the op- 
eration of splitting a lid. 46 
Diseases of the Eye. 
No inflexible direction for an operative procedure can be 
expected to reach a variety of palpebral defects and deformi- 
ties. In the event of doubt in regard to the propriety of 
applying a certain method of operating in a given case, time 
and thought should be 
devoted to a considera- 
tion of so important a 
subject. The most expe- 
rienced operators do not 
hastily engage in the ex- 
ecution of a means of 
cure until every import- 
ant point in particular 
cases has been deliber- 
ately weighed and deci- 
ded upon. Every plastic 
operation needs special 
consideration. 
Entropion'-The terms entropion and ectropion are respec- 
tively applied to the inversion and eversion of the margins of 
the lids. 
Entropion generally affects the lower lids of one or both 
eyes, the upper lids being nearly exempt from the disease. In 
the severer phases of the difficulty the border of the lid is 
completely inverted, the cartilage itself being rolled over, so 
that the cilia and the integument rub against the globe. 
Entropion is frequently produced in children by irritable 
forms of general ophthalmia, the orbicularis muscle being 
kept in a prolonged state of rigid contraction or spasm. In 
old subjects with wrinkled and relaxed skins, and irritable 
orbicularis muscles, entropion is not uncommon. 
The improper use of caustics in the treatment of trachoma, 
and the accidental introduction of lime, acids, and heated 
substances within the palpebral fissure, have been followed by 
entropion of either lid. 
Treatment.-Contractile collodion painted upon the integu- 
ment of the inverted lid, may be all the treatment needed in 
mild forms of the defect. But, in the more serious aspects 
of the disease, some kind of an operation is necessary to affect 
a cure. If the entropion depend upon contraction of the 
Fig. 13. 
This diagram represents the lid as having been 
split, and vertical incisions made. An oval piece 
is being excised from the loosened flap which is to 
undergo some degree of transplantation. Diseases of the Lids. 
47 
orbicularis, a division of the external commissure affords sub- 
stantial relief. The incision should not be made horizontally, 
as if to extend the palpebral fissure, but obliquely downwards, 
when the under lid is affected. A canthoplastic operation 
may be requisite to overcome entropion depending upon spasm 
or rigid contraction of the orbicularis. And, in addition, if 
the inversion be confined to the outer third of the lid, an 
eliptical piece of integument may be dissected from the lid 
just below the cilia and the wound united with delicate sutures. 
The peculiarities of some cases require compound operations. 
Another operative method of treating entropion is to seize a 
horizontal fold of integument with a crutch-shaped forceps, 
as represented in Fig. 10, and after transfixing the fold at its 
base with three ligatures, their ends are tied. In favorable 
cases, the inflammation is only sufficient to produce adhesion 
of the inner structures of the fold, which serves to contract 
the integument and evert the edge of the lid. 
Vertical tension is exercised by the raising of a fold and 
fixing it with ligatures, but horizontal 
tension may be more effectual in some 
cases of entropion. This may be 
obtained by dissecting a triangular 
fold from the lid, and joining the right 
and left edges, a and b, of the wound 
with sutures. The operation is per- 
formed by introducing a horn-spatula 
into the lower palpebral sinus, and 
then making an incision horizontally, 
just below the cilia, to the depth of 
the integument, and extending within 
two lines of each canthus. The tri- 
angle is completed by two other in- 
cisions beginning at the horizontal 
incision, a third of an inch apart, and 
converging at a point a half inch from 
the base line. The horizontal incision is left-to heal without 
sutures. 
Several other operations have been devised to cure entro- 
pion, but none seem to possess advantages over those just 
described. 
Ectropion.-The lower lid, wholly or in part, is liable to 
become morbidly everted; and the upper lid is not exempt 
Fig. 14. 
tegament?fromsther lower^ 
the Diseases of the Eye. 
48 
from the defect. There are several degrees of ectropion, the 
mildest being an appreciable everson which may not interfere 
with the functions of the eye; in a graver stage the palpe- 
bral conjunctiva is exposed to disturbing influences from 
without and may be quite unsightly; and in the worst forms 
the lid is totally everted. 
♦ The changed position of the free margins of the lids inter- 
feres with the free and proper escape of the lachrymal secre- 
tion. The tears collect in the lower palpebral sinus which is 
widened by the lid falling away from the globe, and give the 
eye a suffused appearance. The overflowing tears excoriate 
the cheek, and, as a consequence, there is a shrinking of the 
integument and an increase in the degree of ectropion. Motes 
falling upon the exposed conjunctival surfaces, produce irrita- 
tion, inflammation, hypertrophy, and induration of the lids, 
besides distortion of the lachrymal outlets. 
In isolated cases weakness and paralysis of the orbicularis 
muscle have been assigned as the cause of ectropion, espe- 
cially in old people who have suffered with conjunctival 
catarrh. It is then called senile ectropion. At first the lach- 
rymal punctum becomes everted, then the overflow of tears 
leads to shrinkage of the palpebral integument, and, finally, 
the lid becomes completely everted, the flesh-like conjunctiva 
swells, and appears roughened from trachomatous granulations. 
Shortening of the integument by contracting cicatrices 
following burns, wounds, and losses of substance, produces 
some of the worst degrees of ectropion. Traction upon the 
integument from large cicatrices on any part of the face, and 
even on the neck, may cause ectropion. 
Treatment. A properly adjusted compress resting upon the 
elongated and everted lid, and supported by a bandage, is 
often sufficient to cure ectropion. 
If the palpebral fissure be narrowed and shortened by 
paring the edges of the lids near to and including the com- 
missures, and uniting these freshened surfaces with sutures, 
the eversion may be relieved. Narrowing of the fissure often 
improves the patient's appearance by masking the actual or 
apparent prominence of the eyeball. 
" In ectropion of the lower lid, caused by elongation of the 
free border, with distention and relaxation of the cartilage, 
which can not be completely relieved, the lid must be rendered Diseases of the Lids. 
49 
tense m a horizontal direction, and at the same time lifted up, 
if we hope to have it fit the eyeball again. The simple 
narrowing of the palpebral fissure has almost always shown 
itself to be insufficient. 
" If it be accompanied by no very great shortening of the 
integument, and if the margin of the lid is in other respects 
normal, the excision of a triangular flap, from the outer por- 
tion of the lid, and closing the wound with sutures, is gener- 
ally sufficient. For this purpose the edges of the lids in the 
outer commissure are split with an irridectomy-knife, the 
splitting being continued, if necessary, with a scalpel. Then 
a triangular flap of integument is made by the converging 
incisions, which is dissected up from the tissue beneath. The 
edges of the wound are then 
united by suture, and a pro- 
tective bandage applied until 
adhesion has occured. In 
order to lessen the stretching, 
it is well, before closing the 
wound, to separate the inner 
edge from the tissue beneath 
for a little distance, particu- 
larly if the subcutaneous 
tissue be somewhat thick- 
ened from previous irrita- 
tions, and likely to resist the 
intended pressing out of the 
integument. It also seems 
advisable to somewhat dimin- 
ish the tension by keeping 
the adjacent parts drawn towards the cicatrix by strips of 
plaster. If we wish to secure a great elevation of the lid and 
of the commissure, the tarsoraphic operation deserves the 
preference. (Ammon, Graefe.) Before this operation is under- 
taken we should close the lids, bring the lower one into a 
normal position, then the border is put slightly on the stretch 
in a horizontal direction. We should then mark with ink, in 
a vertical line, the two points of both the edges of the lids, 
where both lid-margins fit each other, when they are in a 
normal position, and there is a slight amount of tension of 
the lower lid. Then, the lids being kept in the position 
Fig. 15. 
Ectropion of lower lid treated by dissect- 
ing up a triangular flap, and joining the edges 
of the wound to one another and to the ele- 
vated flap, sutures being employed. 50 
Diseases of the Eye. 
described, the integument over the outer commissure is lifted 
up in a horizontal fold, and as much of the integument of 
the lower lid very gradually fastened between the fingers as 
is necessary to bring the lid into its normal position, and to 
elevate the outer commissure to the level of the inner angle. 
W^hen the breadth of this horizontal fold of integument is 
also indicated by two lines parallel to the margin of the lid, 
we begin to extirpate the portion of the integument within 
the described boundaries. 
" While one assistant holds the head of the patient, and 
another restrains the bleeding, the operator (see Fig. 15,) 
pushes a small horn-spatula under the outer commissure, lifts 
it up from the globe, and splits it into two layers, first thrust- 
ing in a broad, lance-shaped knife immediately in front of the 
fascia tarso-orbitalis, and then enlarging the wound with a 
scalpel on both lids, up to the vertical boundary line. 
" When this intra-marginal splitting is done sufficiently, the 
lower and then the upper margin of the lid are freshened in 
a direction inward from the vertical 
boundary line for about one-half to 
three-quarters of a line, by a hori- 
zontal incision. The whole breadth 
of this incision falls behind the 
lashes. The lower margin of the 
lid is now cut through in the vertical 
boundary line, and down to the car- 
tilage, the wound elongated until the 
level of the horizontal line has been 
reached. The knife is then turned 
in an obtuse angle looking outward, 
carried on parallel to the margin of 
the lid, and beyond the commissure is turned upward in the 
shape of an arch. 
" The upper lid is treated in the same way. The horizontal 
incision is to be made at a greater or less distance from the 
edge of the lid, according as the outer commissure is to be 
more or less elevated; but it should always be so made that 
the two run together at an acute angle. The integument 
thus circumscribed is dissected up, and the wound closed by 
three or four sutures. The first suture is placed close to the 
Fig. 16. 
from 
next figure, draws the under lid 
unward and cures the ectropion. Diseases of the Lids. 
51 
vertical boundary line. When all are inserted, the curved 
incision is changed to a horizontal one. 
" In order to lessen the tension, strips of adhesive plaster, 
as well as the protective bandage, may be used. These are 
fastened on the cheeks and forehead, and draw up the integu- 
ment which is between them. 
" When there is a very great difference in the length of 
the edges of the lids, the result of 
the operation is endangered by the 
bulging forward of a large fold of 
the cartilage and the fascia under 
the suture. It is, therefore, advisa- 
ble, after the separation of the cir- 
cumscribed flap, to cut out a piece or 
gusset (Zwickd) next to the outer 
commissure, whose axis runs outward 
and somewhat downward, and whose 
base is about the same size as the 
difference in the length of the edges 
of the lids. The edges of the incision in the cartilage and 
the fascia should then be included in the suture." {Stellwag.') 
The excision of a V-shaped piece from the edge of the lid, 
with the purpose of shortening the palpebral border, rarely 
results in a satisfactory cure, because the outer commissure is 
not elevated by the operation. 
Attempts to relieve ectropion by the destruction of the pal- 
pebral fold with caustics, are often worse than useless. 
The worst cases of ectropion arise from the cicatrices of 
burns, and can only be remedied by a transplanting process 
called blepharoplasty. One illustration will explain the prin- 
ciple involved ; and then the ingenuity of the operator will 
determine how the varied deformities about.the lids are to be 
managed. The inodular mass, everting and distorting the lid, 
is circumscribed by two curved, oblique incisions; then the 
cicatritial structure is dissected out, drawing bands' in the 
adjacent integument under-cut, the lid stretched into its 
normal position, and the gaping wound closed by a flap (B) 
shaped like it, but somewhat longer and broader. The flap 
is taken from the temporal region, where the integument is 
free from inodular tissue, and one of its borders terminates in 
the incision employed to remove the cicatrix. After being 
Fig. 17. 
The completion of the opera- 
tion represented as commenced 
in the diagram immediately pre- 
ceding tms. Diseases of the Eye. 
52 
well dissected up, except at its base where vascular supplies 
are obtained, it is to be swung into the wound, and stitched 
in place. The flap should be large enough to fill the wound 
without the slightest stretching. The gap made by thetrans- 
Fig. 18. 
Blepharoplasty instituted to overcome ectropion of upper lid caused by cicatrization 
following a burn. 
planted flap is to be closed by sutures and adhesive strips. If 
any part remains uncovered it will All by granulation, leaving 
little or no deformity. 
STRABISMUS. 
Strabismus, or squinting, is a defect which generally arises 
from an unequal distribution of power in the motor apparatus 
of the eye; and is manifested by a preternatural turning in 
(convergent squint), or turning out (divergent squint), of the 
organ. The distortion destroys the parallelism of the eyes' 
axes, and thus impairs the personal appearance of the indi- 
vidual. Nor is appearance alone concerned in the defect; but 
the function of the eye so often suffers from the physical dis- 
tortion, that impaired vision results. A cure, then, involves 
an improvement in sight, as well as personal appearance. 
Every shade or degree of squinting exists, from the half 
burial of the cornea in the canthus, to the slightest appre- Strabismus. 
53 
ciable " cast in the eye?' The worst and most frequent forms 
of squinting are where the eye turns in, the outward variety 
being rare in occurrence and moderate in degree. An abnor- 
mal turning up or down of the organ, an uncommon distor- 
tion, constitutes a defect of the same nature. 
Squinting is generally confined to one eye, though it may 
affect both. Often the squint will apparently change from 
one eye to the other, and the faulty organ has to be discovered 
by covering one eye and then the other, and observing which 
is most under control and least liable to deviate from the 
straight position. As a general thing the eye which squints 
the worst can be determined by its habitual appearance, and 
by the direction it inclines when at rest. An examination 
often has a disquieting effect, causing the eyes to roll, and 
thus tending to defeat all attempts to discover the defective 
organ or the degree of defect. Upon trial it will be found 
that one eye can be turned out more than the other, when the 
opposite one is closed. By reversing the experiment two or 
three times a correct diagnosis can be established. If the 
vision of one eye is known to be weaker than that of the 
other, it may be inferred that the one suffering from impaired 
vision is the organ which is strabismic. 
The cause of strabismus may generally be referred to the 
nervous centres. The difficulty is not commonly congenital, 
but comes on most frequently about the period of dentition, 
a period well known to be fraught with danger from unequal 
distribution of nerve force. This is a period when intestinal 
derangements prevail, and convulsions spring from nervous 
irritation. Any disease which greatly impairs the general 
health, as hooping cough, measles, scarlatina, cerebro-spinal 
meningitis, and other disorders of early life, may so derange 
the nerve centres presiding over the ocular apparatus, that 
squinting results. 
Strabismus almost of necessity comes on when corneal 
specks, opacity of some part of the lens, or distorted pupil, 
will not allow the light to reach the retina without some 
twisting of the eyeball. The eye under such circumstances is 
obliged to accommodate its position so that rays of light 
shall not be obstructed in their passage through the cornea, 
pupil, and lens. 
Paralysis of the external rectus, sometimes producing diplo- 54 
Diseases of the Eye. 
pia or double vision, is occasionally the cause of strabismus ; 
and E. Meyer has suggested that the defect be overcome by 
holding the base of a prism against the temple on the affected 
side, so that in looking at it the rays of light shall be detracted 
to a spot internal to the macula lutea; then the external 
rectus, to correct the diplopia thus caused, would contract 
and slightly evert the eye, and being gently exercised in this 
way, day by day, would gain strength, and perhaps ultimately 
regain its former power. 
Tenotomy.-The operation of dividing the rectus tendon 
on the side the eye inclines to turn, is claimed for modern 
surgery, its history dating back only to 1839. An itinerant 
boaster by the name of Taylor published a pamphlet, styled 
" De vera causa strabismi," a century earlier, and heralded his 
discovery through many countries of Europe. The degree of 
success attending liis practice is not known, except that the 
people cried out " miracle." Why the inventions of the pre- 
tender were not heeded is not clear, but they were allowed to 
slumber a hundred years, before being rescued from oblivion, 
or the idea was re-discovered. 
As soon as the operation of tenotomy was put into active 
practice and pronounced legitimate, strabismus of all kinds 
was subjected to it, no attention being given to the nature of 
the difficulty or its cause. The consequence was, as might be 
expected, that the operation was attended with failures and 
fell temporarily into disrepute. " But, said Prof. Mutter, 
" notwithstanding all that has been said and done to discredit 
it, I have no hesitation in declaring, that when properly per- 
formed, and the case carefully selected, (for there are many 
altogether unfit for the operation), it richly deserves being 
ranked among the most useful modern improvements in our 
art." 
The instruments needed in an operation are a "retractor" 
for elevating the upper lid-(the under lid may be depressed 
with the little finger of the left hand while operating)- a 
pair of toothed forceps for raising the conjunctiva, a blunt 
hook for raising the rectus tendon, and a pair of curved 
scissors for dividing the loop of tendon which rests upon the 
blunt hook. The accompanying diagrams represent the entire 
operation. Strabismus. 
55 
In Fig. 19, forceps are seen holding the eyeball outwards, 
while a fold of conjunctiva on the inside of the eyeball is 
grasped with another pair of forceps and incised with scissors. 
Through the incision a blunt hook is carried and made to fish 
up the tendon of the rectus 
internus; and when the 
raised tendon appears in the 
wound it is divided with 
scissors, an act which com- 
pletes the operation. 
The pain attendant upon 
the operation is not severe, 
though an anaesthetic may 
be administered to children 
and nervous persons. The 
patient sits in a chair in a 
good light, and an assistant 
steadies the head, and uses 
the retractor to lift the upper 
lid. It is as well to raise a 
small fold of conjunctiva 
and cut out a piece as it is to make a slit in the membrane. 
One wound will heal as quickly as the other, and neither leaves 
a deformity. There is not much difficulty in finding the 
tendon and raising it on the blunt hook; the areolar tissue 
and fascias may offer some resistance to the passage of the 
hook. Care must be taken not to split the tendon with the 
hook, as only a part would then be raised and cut. The 
sclerotic is so dense that little danger need be feared of in- 
juring it. In a bad case, especially if the patient be an adult, 
a simple division of the contracted tendon is not enough to 
release the eye from the restraint under which it is bound, but 
the ocular fascia prevents the eye from assuming a position 
parallel with the other, therefore bundles of this fascia are to 
be sought with the blunt hook, and divided when found. A 
too free dissection should be avoided, lest the eye turn too far 
in the opposite direction, and present a bulging appearance.. 
The after-treatment is simple ; the patient should be kept 
from a strong light for a few days, and be made to use the 
defective eye by covering the other with a bandage. The 
divided ends of the tendon will unite to the sclerotic, and thus 
Fig. 19. 
A method of incising the conjunctiva to make 
way for the tfse of the blunt hook which is to 
fish up the tendon that needs dividing. 56 
Diseases of the Eye. 
force may be exerted upon the eyeball. The space between 
the divided ends will fill with new material, and so elongate 
the muscle. The wound in the conjunctiva generally heals 
kindly, and rarely needs any treatment. Sometimes a fleshy 
or granular excrescence appears 
in the wound; and if persist- 
ent may be excised with scis- 
sors. The extravasated blood 
which to the patient may seem 
alarming, will disappear in a 
few days. 
In cases of apparently 
double squint it is commonly 
best to operate upon one eye 
first, leaving the other to cor- 
rect itself as it sometimes will. 
If, in a few weeks, it be found 
that considerable squinting 
exists in the eye not operated 
upon, this eye may be subjected 
to the same treatment as the 
first. 
If the first operation do not 
satisfactorily overcome the de- 
formity, another may be performed after several weeks have 
elapsed ; even a third or fourth trial may be made. 
Divergent squint is seldom operated upon, for the defect 
generally occurs in elderly persons who are not sensitive about 
mere personal appearance. However, if the operation be 
demanded, the operative procedure is the same as that for the 
relief of convergent squint, except the external rectus is 
divided instead of the internal. 
When strabismus affects both eyes, though one more than 
the other, the operation upon both eyes is to be executed at 
the same time. In fact, cases will be found where the axes 
of the two eyes may not come parallel until corresponding 
muscles m the two eyes have been divided. 
Strabismic eyes are rarely rendered perfectly straight, or 
entirely free from appreciable defect, by an operation. How- 
ever, the remaining defect may not be noticeable, at least to 
the ordinary observer, therefore no dissatisfaction is expressed. 
Fig. 20. 
The upper lid lifted with a retractor, 
the tendon of internal rectus raised on the 
blunt hook, and the scissors ready to 
divide the tendon. The Lachrymal Apparatus. 
57 
THE LACHRYMAL APPARATUS. 
The lachrymal gland, constituting the secretory portion of 
the lachrymal apparatus, is situated in the upper and outer 
part of the orbit, in a digital depression formed for it in the 
orbital plate of the os frontis. The ducts of this gland, six 
to twelve in number, minute as hairs, open in a row along the 
under surface of the upper lid, near the outer third of the 
tarsal cartilage. After lubricating the conjunctival surfaces, 
the lachrymal fluid is directed to outlets near the inner can- 
thus. The commencements of the conduits are called puncta; 
one is in the upper, and the other is in the lower lid. Each 
punctual is the beginning of a small canal-canaliculus- 
that terminates in the lachrymal sac, which is an expansion 
of the lachrymal apparatus and lodged in a groove which 
is chiefly in the lachrymal bone. The sac is the commence- 
ment of a duct-ductus ad nasum-which conveys the waste 
tears to the inferior meatus of the nose. 
Diseases of the Lachrymal Apparatus.-The lachrymal 
gland is rarely the seat of disease.. Its situation beneath the 
projection of the frontal bone protects it from injury; and 
inflammatory diseases of the eye exert merely a sympathetic 
influence upon it. The gland is occasionally the centre of 
malignant deposits ; and it may suffer from ordinary hyper- 
trophy, constituting a tumor large enough to press the eye- 
ball downward. 
The lachrymal gland may be extirpated without much 
trouble. An incision three-quarters of an inch in length 
made through the skin and fascia near the orbital rim at the 
upper and outer part of the orbit, furnishes a wound large 
enough for the finger to explore the gland and make room 
for its removal. Toothed forceps may be used to lift the 
gland from its bed, when it may be excised with scissors. 
The vessels supplying the gland with blood are not large, 
and the pinching cut of the scissors prevents them from 
bleeding. In making the primary incision care must be exer- 
cised so as not to divide the supra-orbital vessels and nerves, 
and the levator palpebrse muscle. In other words, the inci- 
sion should be entirely outside these structures. As will be 58 
Diseases of the Eye. 
mentioned in another place, the lachrymal gland may be 
removed for the cure of fistula lachrymalis. 
The excretory ducts of the lachrymal gland may become 
obstructed, and enlarged from the accumulation of fluid. A 
cyst-like tumor-dacryops-seen in the upper lid, is produced 
by the obstruction. The swelling can be seen more distinctly 
when the lid is everted ; and it may then be punctured and 
allowed to discharge upon the conjunctival surface. If left 
to itself the fluid may find escape through the skin, and con- 
tinue to discharge externally, constituting dacryops fistulosus. 
Should the minute fistula prove troublesome, it may be cured 
by perforating the lid with a modern punch for making eye- 
lets, and then closing the external opening with fine sutures. 
The internal opening being left, the fluids from the duct will 
be turned inwards upon the conjunctiva, and thus a cure is 
effected. 
The puncta lachrymalia are liable to be affected by con- 
junctivitis, the inflammation extending to the edges of the 
lids and to the mouths of the canaliculi; they are exposed to 
external violence; and they participate in diseases extending 
upwards from the lachrymal conduits. The puncta are fre- 
quently distorted or obstructed by cicatritial contractions. If 
the puncta become impervious the tears must escape by over- 
flow. Under such circumstances the eyes appear suffused, 
and the cheeks are reddened by the trickling fluid. 
When the puncta are free and the canaliculi are contracted 
or strictured, the eyes may exhibit a watery state, but as 
some of the lachrymal fluid escapes by these conduits, the 
overflow of tears is not so marked and troublesome as when 
the puncta are obliterated. 
If the epiphora-lachrymal overflow-be exceedingly 
troublesome, and the puncta be incurably impervious, the 
lachrymal gland should be removed, to cut off the supply of 
tears. 
In many cases of obstructed puncta and constricted canali- 
culi, the difficulty may be remedied by slitting open the 
faulty conduits. This is done by carrying a delicate probe or 
lachrymal grooved director along the whole course of the 
lower canaliculus, and following it with a slender knife which 
completely lays open the canal. Before introducing the 
probe or director the canaliculus is to be straightened by pull- The Lachrymal Apparatus. 
59 
ing the lid outwards. After the incision has been made, a 
probe is to be passed along the track of the slit every day to 
prevent the lips of the wound from growing together. 
If the overflow depends upon a faulty position of the punc- 
tum, the slitting of the canaliculus remedies the defect by the 
fact that the point of escape for the tears is carried nearer the 
caruncle where the outlet is the more readily reached, over- 
flow being thus obviated. The canaliculus is converted into 
a gutter, which collects and bears along the tears. In cases of 
obstruction in the lachrymal sac or the nasal duct, the inci- 
sion affords easy access to the seat of stricture. 
It is no uncommon thing for the puncta to be turned in 
against the eyeball, where they are lost to view, and from their 
position can not gather the tears. In some cases the apertures 
are turned outwards, so they can no longer take up the tears. 
In either case a slitting up of the canaliculi will partially or 
wholly remove the difficulty. Operations for the cure of 
ectropion and entropion usually have in view, among- other 
objects, a restoration of the puncta to their proper positions. 
If the puncta be in their natural places, and the apertures 
appeal' open and unobstructed, yet tliQ tears fail to pass off as 
fast as they are supplied, some obstruction of the canaliculi 
may be suspected. The pervious condition of these canals is 
to be tested by pressing the finger on the lachrymal sac just 
below the tendo-oculi, when, if the canaliculi be open, tears 
can be made to regurgitate. Of course, the action of the 
finger prevents the contents of the lachrymal sac from 
escaping downwards through the ductus ad nasum. If the 
manoeuvre fail to discover the pervious condition of the 
canaliculi, a delicate probe must be made to explore the canals. 
As has already been suggested, the edge of the lid must be 
drawn outwards to straighten the tarsal border, hold it steady, 
and to take the abrupt angle out of the canaliculus. The 
probe should be manipulated carefully, as the lining of the 
canaliculus is extremely delicate. The butt of the probe may 
be weighty, but the part near the point should be slender and 
flexible. The point must not be too small, lest it catch in 
folds while being introduced. Several probes varying in size 
should be at command. 
In passing a probe into the lower canaliculus, the instru- 
ment should be directed almost vertically downwards for 60 
Diseases of the Eye. 
about half a line, and then turned inwards towards the nose, 
in which direction it will pass on, should no stricture exist, 
until its point strikes against the inner wall of the sac. 
Except to a practiced hand, it is often difficult to detect 
whether the point of the probe is arrested close to the junc- 
tion of the canaliculus with the external wall of the sac, or 
whether the instrument has reached the internal wall. In the 
former case any considerable pressure with the probe produces 
a dragging effect upon the tarsus; whereas contact of the 
probe with the inner wall of the sac not only conveys to the 
hand a peculiar feeling of firm resistance, but at once causes 
all movement of the tarsus to cease. As the lachrymal bone 
is very thin and fragile, much pressure upon it will not be 
endured without danger of perforation. 
If the canaliculi be found free from stricture, and the sac 
forms a distinct prominence below the inner canthus, it is 
pretty certain that the obstruction exists at the commence- 
ment of the nasal duct. To test this, the finger is to be 
pressed upon the swollen sac, when if the canal be closed, 
and the canaliculi be free, fluid will be made to escape from 
the puncta. But, if the canal be only narrowed, pressure 
downwards and a little backwards may overcome the stricture 
or obstruction and force the contents of the sac into the nose. 
Patients can be instructed in this manoeuvre, so that they can 
empty a distended sac at will, and thus save themselves much 
inconvenience. 
Undischarged tears in the lachrymal sac-and the presence 
of foreign particles, perhaps a stranded eyelash-tend to pro- 
voke inflammation in the lachrymo-nasal canal. In frequent 
instances of stricture of the ductus ad nasum, the irritation 
or inflammation may have begun in the lining of the nose, 
and extended to the lachrymal canal, but occasionally the 
difficulty commences in the sac. Arising from whatever 
cause, stricture of the nasal duct leads to trouble sooner or 
later. An inflammatory attack threatens a crisis. The sac 
becomes hard and painful, and a puffy condition of the lids 
follows. The redness appears erysipelatous, though it is not; 
and soon a condition of abscess affects the sac and surround- 
ing parts. If the inflammatory process be left to itself, the 
pus finds an outlet through the skin, when the tension being 
removed, the inflammation subsides and the opening remains, The Lachrymal Apparatus. 
61 
through which the tears escape upon the cheek, constituting 
fistula lachrymalis. 
To prevent an incipient abscess of the sac from maturing it 
is well to slit open the canaliculus on a probe or director 
carried along the lachrymal conduit as already described. 
The incision laying open the sac allows 
a free discharge of pent up fluids, and 
the inflammation soon subsides. It has 
been recommended that efforts be made 
to reduce the inflammatory action with 
poultices, cold applications and ano- 
dynes, yet valuable time is often wasted 
in futile attempts at relief through 
medication. 
Scarcely any form of local disease 
has given rise to a greater variety of 
local treatment than stricture of the 
nasal duct. If a fistula exist it may 
have contracted so that only a part of 
the lachrymal fluid finds escape, the 
remainder undulates in the lacus till the accumulation causes 
overflow. Although the symptoms of inflammation are not 
commonly prominent, the sac is tumefied, and when pressed 
upon with the finger will discharge muco-purulent matter 
through the puncta. The emptying of the sac in this way 
affords some relief, and patients resort to it very often. 
Surgical ingenuity has not succeeded in establishing a ready 
and certain means of cure for obstructions of the ductus ad 
nasum. Slitting of the lower canaliculus and dilating the 
nasal duct with probes, bougies, etc., have commanded atten- 
tion, yet the results are not always satisfactory. Dilatation of 
the stricture was at one time attempted, by the introduction 
of curved sounds into the nasal orifice of the duct. But these 
instruments were difficult to introduce ; they would not reach 
a stricture near the sac ; and their manipulation endangered 
the fragile bones constituting the walls of the canal. Tubes 
of silver, gold, and platinum, -were introduced into the sac 
and nasal canal, with the view of having them covered over 
by the healing processes ; but the lachrymal fluids deposited 
concretions upon the metals, converting the instruments into 
foreign bodies not to be endured. 
Fig. 21. 
Probing the ductus ad na- 
sum : the canaliculus has been 
previously slit. 62 
Diseases of the Eye. 
The style was in common use a few years ago. Its upper 
end was furnished with a nail-like head, to prevent the in- 
strument from descending too low, and its neck was curved 
or made angular, to allow the head to rest evenly upon the 
skin. The style is introduced in two ways-one, by slitting 
the canaliculus as far as the sac, 
and then introducing it into the 
nasal duct, strictures having been 
overcome with a " needle-knife '* 
or tenotome; the other, to first 
make an incision in the skin near 
the inner canthus and over the 
mouth of the ductus ad nasum, 
the knife transfixing the lachry- 
mal sac and dividing the strictures 
of the nasal duct. Into the per- 
foration made by the knife the 
style is made to go. 
The mouth of the bony canal leading from the orbit to the 
nose is just within the inner extremity of the lower orbital 
rim. The finger pressed upon the spot indicated readily finds 
where the knife is to enter. Not much force must be used 
with the perforator lest the thin bones of the part be broken. 
The style is to be taken out every day to be cleansed, then 
it is replaced. It is intended that the tears find their way 
along the sides of the style, and so empty into the nose. 
However, in most instances the style has not proved a success. 
Patients will often neglect to remove the instrument, leaving 
it in place till encrustations convert it into a source of irrita- 
tion. Or, if the style has been carefully manipulated, and the 
obstruction seemingly overcome, the strictured condition 
returns again as soon as the instrument is laid aside. 
Patients with stricture of the nasal duct are not always 
willing to persevere in the treatment until a satisfactory cure 
is accomplished. When probes are used as dilators they 
ought to be passed along the nasal canal every two or three 
days for a period of several months ; and even then the use 
of bougies should be renewed if new troubles arise. The 
condition of obstruction is like indurated stricture of the 
urethra, and must be treated with the same general principles 
in view. 
Fig. 22. 
Puncture made to overcome stric- 
ture of nasal duct, and to make a 
place for the insertion of a style. The Conjunctiva. 
63 
Obliteration of the sac has been advocated for the cure of 
lachrymal fistula, but the operation is less satisfactory than 
excision of the lachrymal gland. In the event of successful 
destruction of the sac, the tears find escape by overflow, 
creating an annoyance scarcely less than lachrymal fistula; 
but after removal of the gland there is no tear-waste to annoy, 
therefore the fistula will close without surgical interference. 
There is no uncomfortable dryness of the eye after the gland 
is excised. The conjunctiva furnishes some fluid and the 
Meibomian glands produce lubricating material for the tarsal 
borders. 
Calculi have been known to form in the lachrymal sac, and 
to afford extreme annoyance. Their presence is to be dis- 
covered by carrying a probe through a canaliculus; and they 
are to be removed by slitting up a canaliculus and the sac, 
when the concretions may be easily turned out of place. 
Polypus of the sac-a rare form of disease-may be removed 
by a similar process. 
Epiphora is constitutional in some families, especially in 
advanced life, the eyes constantly brimming with tears. The 
condition may result either from super-secretion of tears, or 
from incapacity on the part of the lachrymal conduits to carry 
away the fluids. Let the cause be what it may, the cure con- 
sists in removal of the lachrymal gland. Not much advan- 
tage could be expected from any kind of medication. 
THE CONJUNCTIVA. 
The membrane which lines the lids and covers the anterior 
portion of the eyeball, is called the conjunctiva. It is a 
mucous tissue, and is bathed with the lachrymal fluid. The 
outer layer of the cornea is the transparent portion of the con- 
junctiva; a crescentic fold or duplicature of conjunctiva at 
the inner canthus, called the plica semilunaris, rests on the 
tendo-oculi, and supports the caruncula lachrymalis; and the 
limbus conjunctivalis, so called, is the band of somewhat modi- 
fied conjunctiva which extends upon the border of the cornea, 
especially above and below, and is especially perceptible in 
aged persons. 64 
Diseases of the Eye. 
That part of the conjunctiva which lines the lids is called 
the palpebral portion. It begins at the free border of the 
eyelids, where, in a tarsal covering, there are eighteen or 
twenty small glands (Meibomian) which furnish a fluid to help 
lubricate the eye. After lining the lids the conjunctiva forms 
two folds, the superior and inferior, whose depths are called 
sulci; and then, as the scleral or ocular portion-the reflected 
conjunctiva-it covers the tendonous expansion of the muscles 
(Tenon's capsule), and being somewhat transparent exhibits 
the .lustrous capsule as "the white of the eye." Stillmore 
anteriorly the ocular conjunctiva is attached rather loosely to 
the sclerotic ; and its deep and superficial vessels here anasto- 
mose, forming a vascular zone around the cornea. Where the 
vascular ring is formed, the anastomosis extends to vessels 
which pierce the sclerotic and are continuous with those of 
the choroid and iris, hence the importance of noticing a 
prominent vascular zone in the diagnosis of diseases of the 
deeper structures of the eye. The corneal conjunctiva is 
devoid of vessels, except some vascular loops which may be 
traced into its border. 
Conjunctivitis.-A large proportion of all " eye cases " 
which occur in practice will be found to embrace some form 
of conjunctival inflammation, though many of these morbid 
processes may originate in other tissues of the eyeball. Con- 
junctivitis proper should be restricted to those inflammatory 
manifestations which originate in the conjunctiva, or extend 
only to the sclerotic. 
Conjunctivitis embraces the various forms of ophthalmia so 
elaborately described in systematic works on eye diseases. A 
light form of conjunctivitis is a simple ophthalmia; and 
severer forms of conjunctival inflammation may be catarrhal, 
purulent, gonorrhoeal, granular, scrofulous, and chronic. 
Simple conjunctivitis, or ophthalmia in its mildest form, is 
recognized by increased conjunctival vascularity, lachryma- 
tion, and an uneasy feeling in the eye. The uneasiness arises, 
in part at least, from the enlarged vessels, which, projecting 
above the membrane, produce a sensation as if foreign bodies 
(sand or dust) had lodged between the lids and the eyeball. 
And, in fact, irritating particles on the conjunctiva, may be 
the true cause of the inflammation. 
Slight injuries, as the switch of a twig, whip, or wisp, are The Conjunctiva. 
65 
often followed by conjunctivitis. The jagging of irregular 
eyelashes,or a single eyelash lodged in one of the puncta, may 
cause ophthalmic symptoms. 
A cinder or bit of steel lodging in the substance of the 
cornea excites violent conjunctivitis; and an insignificant 
mote lodged behind the upper lid will create a disagreeable 
sensation in the eye, and a high degree of inflammation. 
Riding in a cold wind, and the presence of irritating vapors 
and smoke, produce conjunctival congestion and mild oph- 
thalmia. 
Neuralgia and irritation of the ophthalmic ramifications of 
the fifth nerve, may be followed by conjunctivitis. 
Treatment.-It is culpably meddlesome to prescribe lotions 
for every shade of conjunctivitis, for the cause may be tem- 
porary, and its removal will be rapidly followed by a subsi- 
dence of the inflammation. However, the cause should be 
sought in every instance, and if found to be the presence of 
a foreign body, it should be removed. The manner of dis- 
covering and removing foreign bodies lodged in the substance 
of the cornea, will be found under the head of Keratitis. 
The removal of ill-growing eyelashes is also spoken of under 
the same heading, as well as that of Blepharitis. 
A mote lodged under the upper eyelid is to be sought by 
everting the lid. This requires considerable tact; and is 
accomplished as follows : a probe or pencil is laid horizontally 
across the lid, about a half inch from its free margin. The 
manipulator then grasps with his finger and thumb the eye- 
lashes growing from the middle of the tarsus, and draws the 
lid away from the globe, while at the same time he slightly 
depresses the probe or pencil, and tells the patient to look 
downward. By this manoeuvre the tarsal cartilage tilts over, 
and the conjunctival surface of the lid is exposed to view. 
The mote is almost invariably found near the middle of the 
lid not far from its tarsal margin. A patient, if instructed in 
the art, can often relieve himself by grasping the eyelashes 
of the upper lid with the thumb and finger of one hand and 
pulling the lid away from the eyeball, while a finger of the 
other hand pushes the lower lid upward and beneath the 
upper lid, and then letting the lids take care of themselves. 
The cilia of the lower lid serve as a brush to sweep the inner 
surface of the upper lid, and thus remove the foreign body. 66 
Diseases of the Eye. 
If a simple conjunctivitis depend upon irregular habits, or 
intense action as in reading and the examination of minute 
objects, common sense suggests the remedy. Ill-conditioned 
patients need some general directions in regard to those means 
which promote vigorous health. Tonic and alterative medi- 
cine may be needed in some instances. Depletion with leeches, 
low diet, mercury, and other depressing agencies once so 
popular, is to be scrupulously avoided. 
A collyrium which is mildly astringent may do some good. 
A decoction of table tea has been used with satisfaction, so 
has milk, and unmedicated liquids of a soothing character. 
A grain of sulphate of zinc or copper to an ounce of water, 
makes a harmless and often a useful wash. Some practi- 
tioners adhere to nitrate of silver and rose water, a grain of 
the salt to an ounce of fluid, yet this compound is no better 
than those mentioned. Another class of ophthalmic thera- 
peutists laud a lotion made of an infusion of hydrastis or 
other vegetable tonic, and denounce all others. 
A mild astringent wash, whether it be mineral or vegetable, 
is about all that is needed. An infusion of sassafras pith is 
mucilaginous, and is much used as a collyrium. Bathing the 
lids several times a day in warm or cold water, the tempera- 
ture being modified to suit the feelings of the patient, is 
generally useful. ' Glycerine, sweet oil or any unirritating 
unguent applied to the edges of the lids at night prevents 
agglutination. 
Catarrhal Conjunctivitis.-A vascular and puffy condi- 
tion of the conjunctiva, especially of the semi-lunar fold and 
caruncle, attended with inflammatory manifestations, is defined 
as catarrhal conjunctivitis. It may arise from exposure to 
draughts of cold air, or from various irritants affecting the 
eye. A burning, biting, and itching sensation accompanies 
an attack; and the secretion of considerable muco-purulent 
matter. The vascular congestion, as in simple ophthalmia, 
leads the patient to think that particles of sand or other 
minute foreign substances have lodged in the eye. In some 
instances the conjunctiva near the margin of the cornea swells, 
so that a state of chemosis exists. 
A peculiar characteristic of catarrhal conjunctivitis is the 
existence of numerous red blotches as if there was a free 
anastomosis of a number of $mall vessels. These vascular The Conjunctiva. 
67 
knots vary from the size of a pin's head to that of the 
caruncle. In some instances these blotches are true extrava- 
sations. 
Although the lids become agglutinated at night, and the 
secretions are considerably increased, the patient complains of 
a sensation of dryness in the eyes. 
Catarrhal conjunctivitis in its severer forms is attended with 
impairment of vision. Turbid mucus suspended in the tears 
and diffused over the cornea, may cause part of the visual 
defect. 
Eczematous and exanthematous eruptions are frequently 
accompanied or followed by catarrhal conjunctivitis, therefore, 
•writers upon the subject have designated the different forms 
of ophthalmia dependent upon an eruption by the specific 
exanthem producing the conjunctivitis. 
It is probable that some degree of transmissibility from one 
person to another, by contact of the secretion through the 
medium of a towel, exists in certain forms of ophthalmia, 
including the catarrhal. It is claimed that a certain variety 
of ophthalmia in one person, begets a different variety when 
communicated to another individual. 
Treatment.-The remedies recommended for simple ophthal- 
mia are often serviceable in the catarrhal form of the disease. 
The cause should be removed if possible, and everything 
made favorable for recovery. 
Collyria are generally used, though they often aggravate 
the difficulty. I have seen a wash made by adding a grain of 
the nitrate of silver to an ounce of water, effect so speedy a 
cure, when applied to the conjunctiva twice a day, that I was 
captivated with its action. However, the lotion is not always 
a remedy, and often an aggravating agent. So it is with 
solutions of zinc, copper, lead, alum, et id omne genus. And, 
what is puzzling, there are no reliable indications for lotions 
of an astringent character. A quick sweep across the con- 
junctiva of a sulphate of copper pencil once in three or four 
days, and the use of a solution of tannic acid-two grains to 
the ounce of water-several times a day, the wash coming 
between the applications of sulphate of copper, will often 
work well. 
When vascular blotches exist I have touched them once in 
two or three days with a pencil of wood, the smooth point of 68 
Diseases of the Eye. 
which had been dipped in nitric acid. The rounded point of 
a common match will do for the pencil; and after being 
dipped in the acid it should not appear wet, but the acid 
should have struck into the wood. This is an effective way 
to make a circumscribed impression upon fungous elevations 
and vascular excrescences. In what is called pustular oph- 
thalmia there is no better way to destroy the pustules or 
papules than to touch them with the nitric acid pencil. 
I have lately met with excellent results in the management 
of catarrhal and purulent ophthalmia by using as a lotion a 
dilute form of the fluid extract of Pinus canadensis. I com- 
monly put eight or ten drops of the extract into an ounce of 
water, and order it used three or four times a day. 
In the treatment of catarrhal ophthalmia, the general health 
of the patient is not to be neglected. A constipated state of 
the bowels is to be overcome with broken doses of sulphur, 
or such laxatives as are ordinarily favorites. An ansemic 
patient needs iron and stomachics ; the sufferer from miasm 
should have quinia; and the exhausted individual demands 
rest and restoratives. 
Inflamed eyes generally should be used as little as possible, 
and be shielded from strong light, and irritating vapors. 
Conjunctivitis complicated with sclerotitis, iritis and cho- 
roiditis, as it often is, should be managed with due regard to 
the complications. If the vascular scleral zone be apparent, 
astringent washes are contra-indicated, and a solution of the 
sulphate of atropine should be dropped into the eye; and the 
organ should be kept shaded. Neutral tint glasses may be 
worn by those who take exercise in the open air. 
Purulent Conjunctivitis.-A purulent disease of the eyes, 
historically known as Egyptian Ophthalmia, from the fact that 
armies invading Egypt have suffered from the scourge, begins 
as a violent conjunctivitis, and often terminates in the destruc- 
tion of vision in one or both eyes from disorganization of the 
cornea and iris. The affection is most common in hot and 
miasmatic countries, yet it is not unknown in high latitudes. 
Certain locations in the Mississippi Valley are subject to 
annual visitations of the disease; and many of our State in- 
stitutions for the blind contain scores of victims who have 
lost their sight from the effects of this terrible disease. The Conjunctiva. 
69 
The British hospitals of Chelsea and Kilmainham, accord- 
ing to Dr. Macgregor, contained at one time two thousand three 
hundred and seventeen soldiers who were totally blind from 
purulent ophthalmia. A faithful chronicler says; "Fifteen 
days after the ' Rodeur,' a slaveship, left the coast of Africa, 
purulent conjunctivitis broke out among the slaves; and at 
the end of the voyage, thirty-nine were totally blind, twelve 
lost each an eye, and fourteen had corneal opacities. Of the 
officers and crew, twenty-five in number, all were attacked; 
twelve persons, including the surgeon, lost their vision, five of 
the remainder lost one eye, four escaped with opacity of the 
cornea and adhesion of the iris, and the remnant ultimately 
recovered." 
The symptoms of the several forms of purulent ophthalmia 
resemble each other so closely in some stages of the disease, 
that a common purulent conjunctivitis can not be distinguished 
from one of gonorrhoeal origin ; and the pus from the eye of 
an infant suffering from what is called ophthalmia neonatorum, 
if applied to the eye of a healthy individual, young or old, 
may set up all the phenomena of purulent conjunctivitis. In 
fact, all forms of the disease are presumed to be contagious; 
and the symptoms closely resemble each other in the several 
varieties of purulent ophthalmia. 
Simple conjunctivitis is not so violent as the purulent type. 
In the contagious and vicious form of the disease the eyelids 
hurriedly become congested, then swollen, and soon after a 
profuse discharge escapes from the mucous surfaces. From 
the first there is increased lachrymation ; a few hours later the 
fluid poured forth is muco-purulent, and in a day or so from 
the onset of the attack a greenish pus is abundantly dis- 
charged. The local disorder, attended with pain and photo- 
phobia, is quickly followed by general fever. 
The patient soon becomes pale and depressed; and the lids, 
seemingly oedematous, take on a dull red appearance, incli- 
ning to purple. The dried secretion binds the tarsal borders 
of the lids together, and thus dams back the forming fluids, 
so that the palpebral sinuses become distended, imparting to 
the lids a still more swollen appearance. If the agglutinated 
lids be pulled apart, the pent-up secretion pours forth as from 
a recently incised abscess. 
When the lids are forced from one another the cornea is 70 
Diseases of the Eye. 
seen bathed in pus, and surrounded and overlapped by a wall 
of puffy conjunctiva. This condition is often destructive to 
the cornea. The puffed up and overlapping wall of con- 
junctiva, called chemosis, is thought to interfere with the cir- 
culation at the margin of the cornea. Beneath the edge of 
the overlapping conjunctiva an ulcer may form or softening 
set in, either of which endangers perforation of the aqueous 
chamber. 
A mild case stops short of ulceration, the inflammation 
subsiding before irreparable harm is done; but in severer 
cases a slough of the cornea takes place, or an ulcerative action 
which may result in thinning of the cornea and a consequent 
staphyloma. An ulcerative process beginning at the corneal 
margin, usually extends so as to excavate a crescentic groove ; 
and if any part of the corneal structure be perforated, a por- 
tion of iris prolapses, producing the appearance of a black 
speck or a dark colored nodule at the bottom of the ulcer. 
Protrusion of the iris causes distortion of the pupil; and the 
disorganization is attended with impaired vision, if not a 
total loss of sight in the affected eye. 
In a case of acute purulent conjunctivitis the swelling 
obscures the Meibomian glands ; and may so evert the puncta 
that they fail to conduct the tears into their natural channels, 
consequently a stream of the lachrymal fluid constantly over- 
flows at the inner angle of the eye, giving the patient consid- 
erable inconvenience and discomfort. 
Treatment.-If promptly called to a case of purulent oph- 
thalmia, the practitioner should consider the general condition 
of the patient. If a full habit and a robust constitution admit 
of evacuations, a brisk cathartic may be given with marked 
advantage. A free movement of the bowels is attended with 
diminished determination of blood to the head. This is not 
depletion, but an unloading which is desirable at the com- 
mencement of many forms of acute disease. 
After the bowels have been moved, anodynes, which are 
often useful to secure rest, exert a more favorable influence. 
Large doses of gelseminum, or chloral, relieve the patient of 
irritability, and thus, indirectly at least, contribute to a cure. 
Although poultices are often agreeable applications to inflamed 
eyes, they are thought to favor sloughing of the cornea, there- 
fore, should be prohibited. Cold compresses, often renewed, The Conjunctiva. 
71 
are very agreeable applications. It does little good to medi- 
cate the fluids which wet the compresses, unless a mydriatic 
be required. 
Patients affected with miasm should have quinine and 
mineral acids ; and the ill-fed and exhausted should be sup- 
plied with easily digested and nourishing food. Alcoholic 
stimulants are generally injurious, though a patient accus- 
tomed to such beverages might suffer from their sudden with- 
drawal. 
The local treatment of purulent ophthalmia is the most 
important part of the medication; and is to be modified 
somewhat by the condition of the cornea, and the stage of 
the disease. The photophobia is often so great that the 
patient will not allow the cornea to be exposed to light. The 
lids are slippery with secretions, therefore it is not easy to 
hold them apart, especially if the patient be a child. Rough 
handling might burst a softened or ulcerated cornea. Fre- 
quently it is best to subdue irritable patients with chloroform; 
and while the anaesthesia lasts the lids can be opened, the 
cornea examined, and the medicine thoroughly applied with- 
out inflicting pain. 
Those who expect to subdue an acute conjunctivitis with 
mild astringent washes, are sure to be disappointed. The 
ordinary solutions of mineral salts do very little good, and 
often harm. If such remedies be used the active caustic is 
the best. Nitric acid at full strength, applied with a spatula 
of wood to the highly inflamed and chemosed conjunctiva, 
makes a favorable and lasting impression. It may be applied 
every second or third day. I have lately had the best effects 
from the unreduced aqueous fluid extract of Pinus canaden- 
sis. A pencil or spatula of wood, wrapped with patent lint 
or soft muslin, is dipped in the extract and then applied to 
the palpebral sinuses. Each lid is slightly raised from the 
globe, and then the implement can be introduced into the 
sulcus and be made to sweep over the inflamed surfaces. 
Some of the extract comes in contact with the cornea, but 
that does no harm. A moderate degree of smarting is excited 
by the application, yet the distress thus produced is not lasting. 
An application once a day, or every second day, will generally 
prove so far curative in a week, that a dilute wash of the 
same agent is only needed to complete the cure. I have been 72 
Diseases of 'the Eye. 
surprised to observe the superiority of this application over 
the old collyria made of zinc, copper, nitrate of silver, lead, 
alum, tannin, and other well known agents. The discolora- 
tion caused by the escape of the extract upon the cheeks, is 
readily removed. The remedy arrests the profuse purulent 
secretion, subdues the congestion and chemosis, and generally 
preserves the integrity of the cornea. 
As yet there are no officinal forms for fluid extracts of Pinus 
canadensis. The alcoholic extract causes slight smarting, 
when applied to sensitive surfaces, therefore an aqueous fluid 
extract will do better, especially when it can be prevented 
from fermenting. It is not so thick and turbid as Kennedy's 
preparation, yet more efficient and less objectionable'. When 
ulcers of the cornea, staphyloma, or prolapse of the iris have 
occurred in the advanced stages of the disease, and the con- 
junctivitis has principally subsided, the complications must 
be managed according to rules laid down under treatment of 
the cornea and iris. It is always desirable to save as much of 
the cornea as possible ; and if an artificial pupil promise to 
improve vision, it is to be made at the proper time. I may 
mention in this place that eminent oculists recommend inci- 
sing a chemotic conjunctiva to relieve the congestion and the 
pressure upon the margin of the cornea. I have done this 
myself, but am not convinced that it did any good. 
In cases of suspected intraocular pressure the cornea may 
be punctured every day with a cataract needle to let out a few 
drops of the aqueous humor. I have known considerable 
relief to follow the paracentesis; and no subsequent defect of 
the cornea at the point of puncture. The difficulty is in cer- 
tainly knowing when paracentesis is necessary. Painting the 
lids with a strong solution of nitrate of silver-caustic in 
strength-is highly commended as a means of arresting 
violent conjunctivitis. While I do ndu condemn the measure 
as always useless, I believe it may occasionally do some harm. 
If the action on the integument be followed by cicatrization 
the lid would be distorted. Caustic applications to the con- 
junctiva have been followed by cicatrizations which warped 
the tarsal cartilages. 
Granular Conjunctivitis - Trachoma. - A common se- 
quence of conjunctivitis, especially the purulent variety, is the 
formation of vascular or papillary excrescences, called " granu- lations," on the conjunctiva. A hazy and vascular state of 
the cornea follows sooner or later. During the progress of 
purulent ophthalmia, the palpebral conjunctiva becomes 
spongy or villous; and, after the purulent discharge has sub- 
sided, this condition of the membrane does not lessen, but 
goes on increasing, until its surface resembles that of a granu- 
lating ulcer. In fact, there seems to be a disposition in the 
reparative action to overcome the conjunctival defect by blend- 
ing its palpebral and ocular surfaces-by establishing ankylo- 
blepharon. In the earlier stages the "granulations" may be 
simple enlargements of the follicles and papillae of the con- 
junctiva. " They are sometimes of the same color as the conjunc- 
tiva, and only slightly prominent, but again are greatly elevated 
from its surface, and from their shape and gelatinous translucency 
resemble the spawn of fish or frogs." (Stellwag). The firmness 
and solidity of the granulations vary in different subjects and 
in varying phases of the disease. When hard, and of con- 
siderable size, they cause irritability and provoke blinking of 
the lids. 
The Conjunctiva. 
73 
Fig. 23. 
Granular Lids. 
Ill some cases the trachomatous bodies are confined to the 
tarsal border of the conjunctiva; and the rest of the mem- 
brane exhibits only an evanescent vascular injection. Occa- 
sionally the palpebral sinus, on eversion of the lid, seems 
filled with a mass of granulations which protrude into a ridge, 
and encroach upon the cornea. The swelling and the granu- 
lar mass in such cases appear somewhat like ordinary che- 
mosis. The semilunar fold and the caruncle may become 74 
Diseases of the Eye. 
involved in the morbid action, and take on a granular appear- 
ance. 
In the earlier stages of ophthalmia granulosa, the lachrymal 
secretion is increased, and at length a turbid mucus comes in 
abundance, which mixes with the tears. During the stage of 
decline too little fluid is furnished to lubricate the roughened 
conjunctiva, and a sensation of dryness under the lids is 
experienced. 
In severe cases of long standing the levator palpebne muscle 
loses its tone and the upper lid drops or hangs down, and 
becomes sufficiently everted to expose some of its conjunctival 
granulations. 
Patients suffering from granular conjunctivitis are troubled 
with cloudy vision and irritable eyes. They can not endure 
smoke, dust, cold winds, and bright light. The impaired 
vision depends chiefly upon corneal complications, especially 
vascular keratitis. 
Granular conjunctivitis, like the purulent form of ophthal- 
mia, is unquestionably contagious; and is aggravated by 
miasm, squalor, poor food, lack of cleanliness, garments worn 
too long without change, and too many persons living in close 
apartments. Not unfrequently every member of a family will 
become affected, all being incapacitated for cooking, washing, 
or performing the pressing duties of the household. The 
general wretchedness cuts off the hope of improvement or a 
cure from ordinary remedial measures. 
Treatment. The first step in the successful management of 
trachoma is to improve the general condition of the patient. 
Clean clothes, nutritious food, and comfortable surroundings 
will accomplish much towards a cure; and without these the 
use of medicines will not be attended with rapid improve- 
ment. One or two clean handkerchiefs are needed every day, 
and a fresh towel. 
An every-other-day attack of fever is to be overcome with 
antiperiodics; constipated bowels are to be moved with 
sulphur ; an atonic stomach is to be persuaded to action with 
mineral acids and bitter tonics. It is unfortunate that patients, 
when they get a little better, neglect or abandon the means of 
cure. Many persons afflicted with trachoma, may get nearly 
well under judicious treatment, and then foolishly grow 
remiss, or refuse to do anything more. The consequence is 75 
The Conjunctiva. 
that a " relapse," as they call it, supervenes; they then change 
physicians, or openly declare that all medication is useless. 
The local treatment for trachoma, as practiced among the 
distinguished oculists of the day, is not varied. The sulphate 
of copper in a pencil or pointed crystal is in extensive use to 
touch granular lids; and many agents in reputable use are 
mot so good. I have seen notable cures brought about by the 
every-day use of this agent. The nitrate of silver, in solu- 
tions of varied strength, is a common remedy for topical 
application. It is generally applied to the everted lids with a 
camel's-hair pencil. At first, or occasionally, a strong solu- 
tion-from ten to thirty grains to an ounce of water-is 
employed. This is designed to produce a caustic effect ; and 
may be repeated every day for several days in succession. A 
weaker solution, from one to five grains to an ounce of fluid, 
is that in common use. When a solution of caustic strength 
is applied, the parts cauterized should be immediately brushed 
over with an alkaline solution to protect the cornea and to 
prevent the caustic effect being too lasting. 
Caustic applications, unless used with caution, will produce 
a permanent curving of the tarsus and a consequent ectropion. 
The ordinary astringent lotions of alum, tannin, and kindred 
agents, are powerless to subdue the severer cases, therefore 
the treatment must be conducted with much discretion. Even 
when a granular state of the lids has been overcome, vision 
may remain impaired in consequence of an opaque cornea 
kept up by the passage of large blood vessels which enter its 
borders and sometimes traverse its entire diameters. 
The plan of treatment in favor with me is about as follows: 
I cauterize the granular surfaces with nitric acid chemically 
pure and at full strength. To restrain the agent to surfaces 
intended to be cauterized, a spatula of soft wood is used. 
This is dipped in the acid, and then held in the air a few 
minutes to allow the caustic to sink into the wood. The 
spatula is not to be used until all wetness on the end of the 
stick dipped in the acid has disappeared. The upper lid is to 
be everted in the usual way, and the spatula laid upon the 
granular excrescences. The acid in the wood turns the granu- 
lations white, and imparts a keen burning sensation for a 
minute or two, then the painful impression passes off. The 
lower lid is to be turned down and treated in the same way, 76 
Diseases of the Eye. 
there being enough caustic power left in the wood to whiten 
the granulations there. If the lids of the other eye need 
cauterizing, they are to be treated like the first. 
The cauterization may be repeated on the third or fourth 
day; and on the intervening days the fluid extract of Pinus 
canadensis is to be applied to the granular surfaces. This 
agent may be employed with a delicate swab, which is made* 
by running a strip of soft muslin on a pencil of wood. The 
extract exerts an active influence, causing the granulations to 
disappear much faster than when treated to caustics alone. 
The vessels entering the cornea are to be obliterated after 
the conjunctival granulations have been subdued. This part 
of the treatment is to be accomplished by applying nitric 
acid to the edge of the cornea just over the largest vessels; 
and performed with great care so as not to injure other por- 
tions of the cornea. A splinter of wood whittled to the size 
and shape of a common probe, is dipped in the acid, and, 
when free from wetness, is pressed gently upon the vessel or 
the margin of cornea covering it. This is repeated every 
four or five days. If any cicatrix follow the cauterization, it 
is out of the range of the visual rays. As soon as the vessels 
are obliterated, the haziness of the cornea begins to disappear. 
Nervous and refractory patients may be subdued with chloro- 
form before the caustic is applied. Generally no anaesthetic 
is needed. After the granulations are overcome, and the 
corneal vessels obliterated, the following collyrium may be 
used: 
II Water, f§iv. 
Fid. ext. Pinus canadensis, gtts. xx. M. 
S. Use between the lids several times a day. 
During the severer forms of the disease and treatment, the 
patient may take an anodyne at night to induce sleep ; and 
cloths dipped in cold water may be applied to the eyes. 
Some cases that have been injudiciously treated with 
caustics and astringents, may exhibit a cicatrose state of parts 
of the conjunctiva, and a curvature of the tarsal cartilages. 
Such complications are unfortunate, as they can not be reme- 
died without operations upon the lids; and even then the 
results are not always satisfactory. 
I have occasionally met obstinate cases of vascular opacity 
of the cornea, none of the vessels being large, but countless The Conjunctiva. 
77 
in number. Such cases require a cauterization of almost a 
complete ring at the border of the cornea before the morbid 
vascular state will yield. During the treatment of granular 
ophthalmia, the iris and choroid may exhibit inflammatory 
action. However, little additional can be done except to 
screen the eyes from strong light, and apply Belladonna to 
the integument of the lids. Such inflammation generally 
subsides as the curative action in other parts progresses. 
Gonorrhceal Conjunctivitis.-It would be difficult in all 
cases to differentiate between a severe attack of purulent 
ophthalmia and gonorrhceal conjunctivitis. It has been 
asserted that gonorrhceal ophthalmia confines its attack to 
one eye; but such is not the case. It is plain that both eyes 
may be infected by the same towel or from the same source, 
whether it be a contaminated finger or wiping cloth. I 
recently saw a well-to-do farmer sixty years of age whose 
corneae had perished and the irides were laid bare by gonor- 
rcehal ophthalmia which attacked the eyes simultaneously. 
He was just recovering from gonorrhoea contracted a few 
weeks previously. He thought the virus was .transferred 
frem the penis to the eyes by rubbing the lids with the fingers 
after he had dressed the penis with a stall. Not many months 
ago I was called to a patient laboring under gonorrhoeal con- 
junctivitis in both eyes. His physician had applied a poultice 
to the inflamed parts the evening before, and when the appli- 
cation was removed in the morning the two corneae were rest- 
ing on the surface of the cataplasm. The patient declared 
that the poultice made his eyes comfortable soon after it was 
applied ; but undoubtedly the comfort came from the diminu- 
tion of intraocular pressure after the corneae sloughed. The 
poultice favored softening of the corneae. 
Gonorrhceal, like ordinary purulent ophthalmia, begins with 
redness of the conjunctiva, and a sensation of sand beneath 
the lids. In a few hours a muco-purulent discharge sets in, 
and the ocular conjunctiva becomes puffy from infiltration of 
serum. The swollen membrane overlaps the cornea at its 
margin, constituting chemosis, which is a marked symptom of 
gonorrhoeal contamination. The lids get red and swollen, 
and separate 'with difficulty. At this stage the cornea is to 
be carefully inspected if possible. The lids are so stiff, and 
the patient often so irritable that anaesthesia is necessary to 78 
Diseases of the Eye. 
obtain a view of the cornea. A wire speculum is a useful 
instrument to hold the lids apart after the patient is subdued 
with chloroform. A small spatula is needed to turn back the 
overlapping conjunctiva, and a swab of lint can be employed 
to wipe the border of the cornea, where the dreaded ulcer is 
most likely to be found. 
Treatment.-This doesnot differ essentially from that advised 
for ordinary purulent ophthalmia. If the patient be anaes- 
thetized to have the cornea exposed, that is the time to apply 
the caustic if one be used. A spatula of wood dipped in 
nitric acid, as described in another place, may be applied to 
the inflamed conjunctiva, and especially to chemosed parts. 
This makes a decided impression upon the puffy and spongy 
surfaces, which is highly beneficial. Cold compresses often 
renewed, are to be kept upon the lids ; and the next day the 
fluid extract of Pinus canadensis is to be applied beneath the 
lids, with a mop made by wrapping soft lint upon a spatula 
or pencil of wood. This agent tends to arrest the secretion 
of pus, and to preserve intact the imperiled cornea.. After 
the extract has been applied to the inflamed conjunctiva, the 
cold, wet cloths are to be kept in contact with the lids. The 
application of the extract should be repeated every day, until 
the violence of the symptoms is subdued. Afterwards, a very 
dilute form of the extract-four or five drops to the ounce of 
water-is to be used as a wash. 
If the cornea ulcerates or sloughs, as it may in some in- 
stances, the staphyloma, prolapse of the iris, and other com- 
plications are to be managed as directed in articles on those 
subjects. No special rules need be repeated here. 
The general condition of a patient affected with gonor- 
rhoeal ophthalmia, is to be managed with a view to sustain 
the vital powers. Depletion, as once practiced in many forms, 
is now strictly prohibited by the latest and best authorities. 
If any writer still adheres to leeches, antimony, el id omne 
genus, he will find few to follow his antiquated and ruinous 
notions. 
Purulent Conjunctivitis of Infants.-{Ophthalmia Neona- 
torum.}-It is not uncommon to meet with a mucous discharge 
from the eyes of infants. This may be simply a catarrhal 
condition which will pass off in a few days whether any treat- The Conjunctiva. 
79 
ment be employed or not, yet while the discharge is present, 
it creates apprehension of a more serious difficulty. 
Physicians and experienced nurses are aware that infants a 
few days old are sometimes attacked with a purulent con- 
junctivitis which often proves destructive to sight. The dis- 
ease is all the more to be dreaded because the patients are so 
small and difficult to treat. 
The most prominent symptoms of the disease are swelling 
of the lids, purulent discharges from the closed palpebral 
fissure,. irritability of the eye-structures, and fever about the 
head. If the lids can be opened, the conjunctiva will be 
found excessively red, puffy, and in a chemotic state about 
the cornea. 
The disease has been supposed to arise from contamination 
at the time of birth, the external genitalia of the mother 
being the seat of gonorrhoeal or infectious discharges. Such, 
of course, may be the cause of ophthalmia neonatorum,not 
a very frequent origin of the disease. It is well known that 
cases occur when the maternal contact was free from con- 
tagious qualities, and the early attentions to the infant were 
conducted with the most scrupulous regard to cleanliness and 
the avoidance of noxious influences. 
The danger attending an attack of purulent ophthalmia in 
infants, threatens the integrity of the cornea. Ulceration 
may be followed by staphyloma ; ulcers are succeeded by per- 
foration of the cornea, and prolapse of the iris; and the 
entire cornea may be lost in a slough. If any part of the 
cornea can be saved, it will serve a valuable purpose, though 
perfect vision be out of the question. 
Treatment.-There being no essential difference between 
ophthalmia neonatorum and the purulent conjunctivitis of 
adults there need not be much variation in the treatment, 
except that which is due to the delicate infantile organism. 
The child is to be well nourished, and kept in a cleanly con- 
dition. The eyes are to be made cool by wetting them often 
with cold water; and strong light should not be admitted to 
them. Astringent lotions do little if any good, especially 
should the disease be of a violent character, as it often is. 
But, as the destructive tendency of the disease is well 
known, active measures are to be instituted at once. The 
delay of a day may be fatal to vision. The fluid extract of 80 
Diseases of the Eye. 
Pinus canadensis, reduced one-half with water, is to be carried 
under the lids with a delicate swab. The lids are held closed 
with such firmness, that a camel's-hair brush can not be 
employed with effect. The stick used in the construction of 
the swab should come from wood not easily broken. The 
swabbing should be repeated every day, until the violence of 
the disease is spent. Then an every-other-day application 
will do, till, at length, no treatment is needed. 
The daily inspection of the cornea, insisted upon by some 
ophthalmologists, is unnecessary, and frequently harmful. 
What could the wise inspector do if he did see an ulcer? 
Would looking at it arrest its progress ? If it be urgent that 
the cornese be inspected occasionally, let the little sufferers be 
put under an anaesthetic, and then the inspection can be con- 
ducted with deliberation. 
As a topical application to the integument of the lids and 
regions about the eyes, I would recommend equal parts of the 
tinctures of aconite and belladonna, and this mixture reduced 
ten times with water. This wash relieves pain, keeps the 
pupils moderately dilated, and exercises a restraining influ'- 
ence upon the local fever. 
Complications arising from infantile ophthalmia are in due 
time to be managed according to rules laid down in the treat- 
ment of purulent conjunctivitis in general. 
Scrofulous and Strumous Conjunctivitis.-Several varie- 
ties of conjunctivitis exist which, from peculiarities, can not 
properly be arranged under the forms of ophthalmia already 
described. There may be some propriety in subdividing the 
scrofulous or strumous variety of conjunctivitis into a half 
dozen forms, but all would have phases in common. 
In what has been termed the phlyctenular form of con- 
junctivitis the cornea is the centre of action. A minute 
blister appears first, and this degenerates into an ulcer, which 
is attended with pain and excessive lachrymation. A vascular 
track extends from the ulcer to an inner or outer canthus, 
the vessels furrowing the layers of the cornea. Intolerance 
of light induces a spasmodic action of the orbicularis palpe- 
brarum muscle, so that the lids remain nearly closed, and are 
parted with difficulty, 
The local disorder produces general nervous irritability; 
and a train of constitutional symptoms arise which seem out The Conjunctiva. 
81 
of proportion to an ordinary ocular defect. In fact, the dis- 
ease is systemic in its nature, and the local disorder is only a 
phase of it. 
In some instances the disease is pustular in character, the 
pustules forming mostly upon the conjunctiva. In this form 
of ophthalmia the intolerance of light is not so great, and 
the constitutional shock or impression not so marked. Patients 
with vesicles, and even pustules, upon the conjunctiva may 
continue at ordinary vocations, and experience very little in- 
convenience, especially if the corneee remain in tact. The 
eyes feel as if particles of sand, or minute foreign bodies had 
lodged under the lids. Not uncommonly the pustules burst 
and discharge, and the little ulcers heal without any kind of 
treatment. 
Eruptive diseases, as scarlatina, measles, and variola, are 
sometimes attended or followed by exanthematous affections 
of the conjunctiva. Not unfrequently the ocular disturbance 
is so great that strong light can not be endured, and a real 
conjunctivitis is developed. However, as soon as the primary 
disease subsides, the photophobia and excessive conjunctival 
vascularity pass off. The general debility produced by 
measles is occasionally followed by conjunctivitis and ulcera- 
tion of the cornea; and scarlatina, from the severity of the 
disease, is still more liable to conjunctival complications of a 
serious nature. 
Erysipelas about the face may extend to the conjunctiva 
and exert a destructive influence upon the mucous structures, 
not exempting the lachrymal apparatus. Variola is especially 
damaging to the eye-structures, the corneae, from opacities 
and cicatrices, suffering most, though the borders of the lids 
and the conjunctival linings may be involved in the deformi- 
ties. 
Eczema, or herpetic affections of the tarsal margins of the 
lids, may impress morbidly the conjunctiva, and establish a 
form of ophthalmia difficult to cure. Eczematous lids are 
about sure to be attended with conjunctivitis. Chronic 
states of any of the varieties of ophthalmia just mentioned, 
generally exhibit the characteristic pinkish zone in the scle- 
rotic near the cornea. The inner angles of the eyes show 
prolonged irritation, which is due to a constant flow of tears, 
and to repeated wipings and rubbings of the parts. 82 
Diseases of the Eye. 
A scrofulous or strumous conjunctivitis may appear during 
childhood or adolescence, and then disappear from the reno- 
vating character of changes which take place at puberty. In 
connection with the eye-difficulty there may be scrofulous 
manifestations in other parts of the body. And these, too, 
may disappear at puberty, or soon after. 
Treatment.-From what has already been said in regard to 
the nature of the different forms of conjunctivitis just enu- 
merated, it will be seen that constitutional treatment must 
embrace an important part of the therapeutical management 
of the disease. What generally pass as "alterative" medi- 
cines should be exhibited, if not continuously for weeks, at 
least in broken periods for months. It is often no loss to 
allow a few days to intervene, during which no medicine is 
given. Sulphur is a valuable alterative, and may be given 
alone or in combination with sulphate of magnesia and 
cubebs. I generally employ the agent in combination with 
the laxative and stomachic just mentioned. Iodoform, in 
grain doses, and pill form, covered with sugar, is an excellent 
alterative, but does not often agree with the stomach. The 
iodides can be disguised in several vehicles, and be taken for 
a long while without deranging the stomach. Cod liver oil 
exerts alterative powers, but is disgusting to most patients. 
Arsenic is an efficient alterative and tonic; one or two drops 
of Fowler's solution may be given every three or four hours 
without producing the slightest poisonous effect. In strictly 
therapeutic doses, which are always small, arsenic is not a 
poison; and in scrofulous and tuberculous diseases it is in- 
valuable. 
The syrups of sarsaparilla and stillingia, compounded in 
the usual manner, are convenient vehicles in which to exhibit 
some of the iodides ; but they often offend the stomach, and 
thus do more harm than good. 
A patient with strumous conjunctivitis needs a nourishing 
diet; and digestion, as well as assimilation, should be pro- 
moted with such medicines as are known to assist the nutri- 
tive processes. There is a great difference in the character- 
istics of individuals ; one will improve under a certain course 
of medication and alimentation, and another would fail to be 
favorably impressed with the same regimen. To lay down 
rules dogmatically for all classes and conditions of mankind The Conjunctiva. 
83 
would be ridiculous. The physician must exercise a just dis- 
crimination in every case, and avoid a routine course. " To 
sustain the vital powers " does not necessarily mean that 
tonics must be administered exclusively. If iron be employed 
the doses should be small. There is a popular belief that 
feeble persons have too little iron in the blood, which is some- 
times correct, but the weak do not improve so fast under 
large doses of ferruginous preparations as they do when little 
is given. It is not often safe to follow the caprices of the 
unprofessional in the matter of medication. 
The topical treatment of strumous ophthalmia is to be 
varied according to local morbid conditions. An ulcer upon 
the cornea is to be managed according to rules laid down in 
another place under the head of Keratitis. Lead-lotions 
should not be used lest an insoluble deposit be left in the 
cicatrix. It is generally best to cauterize the borders of the 
ulcer every few days with nitric acid, using a pencil of wood 
as the bearer of the caustic, and to treat the inflamed con- 
junctiva with mildly astringent colly ria during the intervals. 
Vascular granules are to be treated as ordinary trachoma. 
Herpes upon the tarsal borders of the lids, with stiff and 
irregularly set cilia, may be subdued with a cerate employed 
to overcome tetter. 
The following prescription calls for an agreeable pomade : 
II Ung. aquse rosse, Sj. 
Fowler's solution, f5j. M. 
S. Use twice a day upon the edges of the lids. 
A purulent discharge may be arrested by the use of a wash 
made from the extract of Pinus canadensis. As the puru- 
lency subsides the collyrium may be weakened. 
Opacities of the cornea following ulceration, will generally 
become less and less dense, especially in the young. A 
prominent cicatrix moderate in size is carried to one side of 
the axis of vision by an accommodating squint, which is a 
useful strabismus, and not to receive treatment. 
Conjunctivitis arising from exanthematous affections gener- 
ally passes off in a few days or weeks, no treatment being 
demanded. Variola is the most likely to be followed by 
ulcers of the cornea and troublesome cicatrices. Erysipelas 
frequently leaves vascular excrescences on the conjunctiva, 84 
Diseases of the Eye. 
which obstinately resist means used to overcome them. 
Measles produce active conjunctivitis for a few days preceding 
and attending the exanthem, and this may degenerate into a 
chronic form which may prove quite intractable. Scarlatina 
has been accompanied with ophthalmia so violent in its nature 
that the cornese have sloughed in spite of well-directed efforts 
to save them. 
Chronic Conjunctivitis, as such, without being introduced by 
acute symptoms, is occasionally met. It begins in a hype- 
raemic condition of the edges of the lids, and a redness and 
fullness of the caruncle and semilunar fold. The lids feel 
stiff, and as if gritty particles were producing the trouble; 
luminous bodies, surrounded by a halo of prismatic colors, 
prove annoyances ; the eyes water when exposed to bright 
light or cold winds, and the eyelashes and angles of the lids 
become loaded with muco-purulent matter, especially during 
sleep. 
Ophthalmia of a chronic character, as that just described, 
needs constitutional and local treatment; and it often resists 
the most judicious measures directed for its cure. At least, 
it exhibits a disposition to return after being thoroughly 
routed. Persons affected with humors of the tetter family, 
may have the eyes recover as soon as an attack of asthma 
sets in, or pruritus of the perineal region comes oii. A 
patient of mine suffered for years with chronic ophthalmia, 
and then, while no treatment was employed, all at once the 
eyes recovered, and a persistent, irremediable pain became 
located near the lower end of the right lung, accompanied 
by cough. After this had continued for a year or two, salt 
rheum appeared on the hands, and the thoracic trouble sub- 
sided. At present the conjunctivitis has returned, and the 
other affections have disappeared. It is not easy to explain 
this seeming metastasis, yet changes in the form and location 
of morbid action are not very uncommon. 
Pterygium.-A vascular and fibrous growth, beginning at 
the semilunar fold, in a broad base, and extending towards 
the cornea, and even upon that body, the apex and general 
mass of the neoplastic structure resembling the head and tail 
of a comet, is called pterygium, from the corneal part appear- 
ing so much like the delicate outlines of an insect's wing. 
The growth outside the cornea is a reddish, fleshy-looking The Conjunctiva. 
85 
substance, having a conjunctival development, and is loosely 
connected with the sclerotic body. It is raised above the 
ordinary level of the conjunctiva ; and to the finger feels like 
a muscular mass. The disease, in some form, is rather com- 
mon, though the severer types which demand treatment are 
somewhat rare. 
Moderately developed vascular masses along the course of 
the inner recti muscles, the cornese not being invaded, are 
denominated false pterygia, and are objectionable only as 
deformities, the vision not being affected. 
A very large pterygium may extend clear across the cornea, 
and very seriously interfere with the transmission of light. 
In most cases which demand treatment the apex of the growth 
reaches to the centre of the cornea. Persons in middle life 
are most subject to the disease; and especially are they 
affected who expose their eyes to the irritating influences of 
dust and acid gases. Individuals suffering from " weak eyes" 
may at length have to endure the inconvenience of pterygium. 
The conjunctival hypertrophy, for such pterygium seems to 
be, is not absolutely confined to the inner canthus of the eye. 
Cases are occasionally met where the growth springs from the 
outer canthus, and from above and below. One eye alone 
may be affected, though from sympathy or identity of influ- 
ence both eyes become at length implicated. 
Treatment.-Excision of a portion of the vascular growth 
near the cornea is an effective method of destroying ptery- 
gium, so also is ligation of the neoplastic mass at the point 
where excision is advised. In several instances I have oblite- 
rated pterygium by attacking it with nitric acid. The end of 
a pencil of wood is dipped in the acid, then, when seemingly 
dry, it is applied to the vascular growth near the cornea, the 
cauterization extending clear across the the morbid mass. 
This agent, applied a few times at intervals of three or four 
days, constringes the vessels, and even obliterates them. 
Absorption then carries away the part which is upon the 
cornea, and the part between the cicatrized line and the inner 
canthus gradually disappears. 
Excision may be performed as follows, according to Arlt: 
11 While an assistant holds open the lids, the operator seizes 
the pterygium near the scleral border with a pair of reliable 
forceps, draws it away from the globe, and separates the cor- 86 
Diseases of the Eye. 
neal portion from the apex with a pair of scissors curved on 
the flat, or, what is to be preferred, enters a pointed bistoury 
or cataract-knife flat on the sclera, and cuts with a gentle 
course of the knife the corneal portion extending above the 
level of the sclerotica as evenly as possible from its substra- 
tum. Then the separated portion of the pterygium is drawn 
up, and the conjunctiva dissected up with the scissors toward 
Fig. 24. 
Method of removing a section of a pterygium with scissors. 
the palpebral fold, one or two lines distant from the corneal 
margin, keeping exactly to the edges of the pterygium, and 
close to the surface of the sclerotica. The two angles of the 
wound are then united by two converging incisions, which 
meet in front of the reflection, and thus enucleate the circum- 
scribed pterygium. The wound is now nearly of a rhomboidal 
shape." The excision includes a great part of the neoplastic 
structure, and in large pterygia makes a wound in the con- 
junctiva so large that its sides should be drawn together with 
one or more delicate sutures. After the operation the eye 
should be kept closed with a bandage until the wound is 
healed. The part of the pterygium left on the cornea soon 
disappears by absorptive action. 
Ligation maybe executed in the following manner : "Each 
end of a silk thread is passed through a delicate, curved 
needle. The lids being wide open, the pterygium is then 
seized with the forceps, and lifted up from the sclera. Then 
one needle is so thrust in at the base of the pterygium, the The Conjunctiva. 
87 
other at the margin of the cornea, that they enter at the 
upper border, hugging the scleral surface, and are then 
emerged at the lower border of the pterygium. The double 
thread now forms a noose above; by cutting off the two 
needles, the thread falls into three parts, an outer, middle, 
and inner. The inner thread is first tied, then the outer, and 
lastly the two ends of the middle one. In four days the 
ligated pterygium is seized by 
the forceps and removed, to- 
gether with the ligatures." 
Two ligatures carried be- 
neath the pterygium a third of 
an inch apart and then tied, 
are as efficient in destroying 
the neoplastic structure as the 
three described in the quota- 
tion and illustrated in the 
accompanying diagram. After 
the knots are tied the free ends 
may be clipped off. The eye 
is then kept bandaged for four 
or five days, to prevent motion 
of the lids, and the irritation 
light might cause. The seg- 
ment of pterygium between 
:he ligatures may then be removed with scissors, and the 
threads snipped and taken out. 
Either of the operations just described is often followed by 
i partial return of the disease; and in some instances the 
jorneal portion fails to be carried away. 
If pterygium can be cured with the caustic application, the 
'esult is more satisfactory than an operation. And if the patient 
leglects to have the caustic applications methodically followed 
ip, the cure may be imperfect. The caustic plan will 
;eldom fail when it is well executed. 
The use of ordinary astringent collyria often hastens the 
growth of a forming pterygium, therefore an inefficient prac- 
ice should be avoided. If the nitric acid employed be weak- 
med by exposure, the cauterization it produces is not severe 
mough to arrest the circulation in the pterygium. It is 
mportant, too, that the caustic be applied near the cornea, 
Fig. 25. 
Method of strangulating a pterygium 
with ligatures. 88 
Diseases of the Eye 
and in the same spot at each succeeding application. The 
pain inflicted is keen but momentary. The acid should be 
limited to the very end of th^ spatula of wood, as the lids 
close spasmodically as soon as the caustic is applied, and the 
tarsal borders would strike against the instrument and receive 
an escharotic impression, if the stick had acid upon it some 
distance from the end. 
The caustic constringes the vessels, and the cicatrization 
obliterates them. Absorption subsequently removes a great 
part of the pterygium. 
Pinguecula, and Fatty Tumors of the Conjunctiva.- 
Small tumors, the size of bird shot, near the cornea, between 
the sclerotica and the conjunctiva, not unfrequently develop 
after the middle period of life, and are as much a deformity 
as an inconvenience. Once they were supposed to consist 
chiefly of fat, hence were called pinguecula. It is now known 
that they are more fibrous than fatty. They rarely require 
surgical attention, though they may be easily excised. A 
slit through the conjunctiva allows of rapid enucleation. 
Fatty tumors beneath the conjunctival lining of the lower 
lid, the size and shape of a bean, and extending from the 
cornea to the outer canthus, are occasionally met in children. 
By dividing the conjunctiva and their proper fibrous envelop, 
the fatty masses are readily turned out of place, and the defect 
is removed. 
Cysticercus Tel^e Cellulose.-A tumor with vascular 
surroundings, the size of a pea, between the cornea and the 
inner canthus, has been known to contain a parasite of the 
cysticercus variety. A little watery bladder is seen at first, 
and this becomes enlarged by the irritation produced, more 
than by the growth of the parasite. The disease is cured by 
incising the tumor, as the cysticercus is then forced out by 
the contraction of the tissues. The escaping parasite may 
be too small to be observed unless the contents of the tumor 
be caught upon a piece of glass and viewed with a magnifier. 
The animal is a true tsenia, though in an earlier stage of 
development than those found in the intestinal track. 
Xerosis of the Conjunctiva-Xerophthalmia.-A dry- 
ness of the conjunctiva caused by cicatrices formed under the 
prolonged use of escharotics, or by chronic inflammation, has The Cornea. 
89 
received the name of xerosis or xerophthalmia. The secretion 
of the conjunctiva is very much decreased, and the secretory 
functions of the lachrymal apparatus seem to partake of the 
shrinkage. The cornea becomes turbid from the irritation 
produced by the movements of the roughened lids. The con- 
junctiva seems to have lost its normal elasticity, and degene- 
rated into cicatrose tissue. The Meibomian glands become 
partially or entirely obliterated, and the caruncle and semi- 
lunar folds shrink or disappear. The cilia drop out, and the 
borders of the lids appear rough and irritated. A few hot 
tears escape without moistening or lubricating the parched 
mucous surfaces. 
Treatment.-There is no substantial relief for xerosis. Fre- 
quent applications of " cold cream," or other nicely prepared 
unguents, may mitigate the stiff and dry sensations, but a 
cure need not be attempted. Pure and neutral glycerine may 
be employed to advantage to lubricate the lids, yet an inferior 
preparation is worse than useless. 
THE CORNEA. 
The cornea and sclerotic constitute a spherical shell which 
encloses the humors and delicate structures of the inner eye. 
The sclerotic forms five-sixths of the sphere, and the cornea 
the remaining one-sixth. The cornea represents the segment 
of a smaller sphere than that of the sclerotic, and constitutes 
the anterior, prominent, and transparent portion of the ocular 
capsule. In shape the cornea is slightly oval, the vertical 
diameter being less than the transverse, a variation which 
arises from the overlapping of the sclerotic along the superior 
and inferior margins. The cornea is^concavo-convex, and pro- 
jects forward from the sclerotic in the same manner that a 
watch-glass does from its case. During youth the cornea is 
more convex than in advanced life when it becomes flattened. 
The degree of convexity influences refraction-a flattened 
cornea makes vision long, and a prominently convex one short. 
The cornea consists of five layers, all of which are perfectly 
transparent. The central part is fibrous and tough, being 90 
Diseases of the Eye. 
identical with the sclerotic, with which it is continuous; in 
front of the central structure is the anterior elastic lamina, 
and this is overlaid by the conjunctival layer; behind the 
central body is the posterior elastic lamina, and this is lined 
by the delicate membrane of Descemet, against which the 
aqueous humor presses in front. 
The cornea ordinarily is a non-vascular structure, the 
capillary vessels terminating in loops at its circumferance. 
Branches of the ciliary nerves ramify in its entire substance. 
Arcus Senilis.-In many persons at the age of forty or fifty, 
an opaque whitish crescent may be observed skirting the 
margin of the cornea, especially above. In some old persons, 
the crescentic stripe is chalky white, and very striking in 
appearance. This white zone is produced by fatty degenera- 
tion ; and so far as the eye itself is concerned, the transform- 
ation may be considered as of very little importance. Whether 
"arcus senilis" indicates a tendency to general fatty degene- 
ration is a question. The opaque zone is at a little distance 
from the sclerotic, a narrow ring of partially clear 'cornea in- 
tervening. The entire thickness of the cornea is not involved 
in the fatty transformation, therefore a wound made in the 
opaque crescent for the extraction of cataract, will firmly 
unite, though not quite so readily. 
Conical Cornea.-Through some cause not well defined 
the cornea becomes changed from the segment of a sphere to 
a cone. The change in shape does not affect the transparency 
of the medium. Persons in good health, without peculiarities 
in habits or employments, are not exempt from the defect. 
The aspect of a patient with conical cornea is so peculiar, 
that when once seen, the affection is not likely afterwards to 
be overlooked. The eye, viewed in front, has a brilliant and 
sparkling appearance, as if a tear were hanging just in front 
of the pupil. When seen in profile, the conical shape of the 
cornea is at once recognized. No other tissue is complicated 
with the affection. The very apex of the cone appears hazy, 
but this is due to refraction, and not to friction of the lids. 
As the cornea grows conical the patient becomes short- 
sighted ; and at length, as the cone gets prominent, a remark- 
able refraction of the rays of light is produced. The flame 
of a candle appears surrounded with a halo, with a multitude The Cornea. 
91 
of diverging rays; and instead of a single flame several are 
seen, arranged in a circle. When the worst stage of conical 
cornea is reached, the patient can not read, even at the shortest 
focus. 
No efficient and satisfactory treatment has yet been devised 
for the cure of conical cornea. Paracentesis, pressure, dis- 
placement of the pupil, and other operations have been per- 
formed, but all without benefit. Astringent lotions are fre- 
quently worse than useless, actually inflicting harm. Internal 
remedies are ineffectual. 
Optical contrivances have been employed, but with indif- 
ferent results. A pin-hole aperture in a metallic plate, held 
close to the eye, will enable a patient to read at a focus of 
five or six inches. A slit three-quarters of an inch long and 
the thirtieth of an inch wide, in a plate fitted to a spectacle 
frame, enables the patient to enjoy a lateral range of vision 
without moving the head in the way which is necessary when 
objects are viewed through a small circular aperture. 
Keratitis (Corneitis).-When the cornea is inflamed, instead 
of being perfectly transparent, smooth, and brilliant, as it 
normally is, it loses those qualities, and becomes hazy, its sur- 
face appearing like glass bedimmed with the breath. The 
cloudiness generally proceeds from the margin of the cornea 
towards the centre. If the inflammation be acute, crescentic 
plexuses of vessels soon make their way from the edge of the 
cornea into its substance. These vessels are so fine, and so 
closely set together, that they appear like a vascular ring or 
zone at the margin of the cornea. Viewed with a good mag- 
nifier the loops of vessels constituting the plexuses may be 
identified. Branches spring from the vascular loops, and 
push towards the centre of the cornea, increasing the opacity 
as they proceed. A zone of pink vessels appears in the 
sclerotic bordering the cornea, as it does in iritis. Active 
keratitis can not long exist without complicating the con- 
junctiva and other structures in the inflammatory invasion. 
Dimness of vision attends keratitis, as well as intolerance 
of light, lachrymation, and more or less pain. The pupil con- 
tracts through sympathetic action of irritated nerves, and 
even the lids are disposed to contract spasmodically from the 
same cause. 
One eye is usually attacked at a time, and the other rarely 92 
Diseases of the Eye. 
escapes, though the first invaded may begin to recover before 
the second has reached the worst stage. The course of the 
disease is variable. An attack may last only a few days, or 
continue for months, becoming chronic. 
Children and young subjects are most liable to keratitis, the 
disease being rare after the nubile age. The feeble, the irri- 
table, the scrofulous and the anaemic, are most frequently 
victims to corneal inflammation. Keratitis is also a frequent 
accompaniment of herpes, conjunctivitis, and trachoma. 
Mechanical injuries of the cornea, including the irritating 
presence of foreign bodies, inverted cilia and chemical vapors, 
are sure to be followed by keratitis. 
The verminous diathesis is often attended with keratitis and 
corneal ulcers. Catamenial disorder, and derangements of 
the sexual functions may be enumerated as among the provo- 
catives of corneal inflammation. 
Keratitis in its simplest forms may not last but a few days, 
especially if the cause be removed ; yet it is not uncommon 
for attacks to become tedious, and disastrous to vision. A 
superficial cloudiness in a young subject readily disappears as 
soon as the inflammation subsides, but deeper opacities in 
older persons may always remain. 
Treatment.-When keratitis is evidently produced by con- 
stitutional disturbances, or systemic vices, nothing could seem 
more rational than to administer such remedies of an altera- 
tive nature as promise to effect a change for the better in the 
digestive, assimilative, and secernent organs. The iodides, 
sulphur, sarsaparilla, blue flag, iron, cod liver oil, and arsenic, 
sustain the best reputation for dispersing tetter, scrofula, 
tubercle, and kindred constitutional vices. The waters of 
certain springs, change of climate, diet, and exercise, are not 
to be forgotten nor neglected in the skillful management of 
chronic cases of keratitis. 
The local treatment of keratitis should be managed with 
discretion. The popular demand for washes and salves should 
be curbed and thwarted. A colored water lotion may serve 
to amuse and sustain confidence. A grain of morphia in an 
ounce of water, to which may sometimes be added a drop of 
aromatic sulphuric acid or compound tincture of lavender, 
constitutes a collyrium of some value in reducing irritability 
of the eye and diminishing photophobia. The Cornea. 
93 
Of course, the eye is to be very carefully examined to see if 
a foregn body beneath the upper lid or in the substance of 
the cornea, be doing the mischief. It would be unpardonable 
to overlook a foreign body which was keeping up the irrita- 
tion, and worse than waste time to prolong fruitless medica- 
tion. 
In chronic cases of keratitis where vessels, plainly visible, 
have channeled the entire meridian of the cornea, the local 
treatment must be especially directed to the arrest of the 
fortuitous circulation. This can be safely and effectually done 
in a few weeks by applying nitric acid to the principal trunks 
at the sclero-corneal junction every four or live days. The 
acid at full commercial strength can be applied with a pencil 
of soft wood, as follows: a splinter of wood whittled to a 
small yet blunt point, is dipped in the acid, and then with- 
drawn. In a minute or two the stick will appear dry, yet con- 
tain acid enough to cauterize, and is ready for use. The 
upper lid is now to be raised sufficiently to expose the cornea, 
and the pencil applied to the largest vessel as it enters the 
cornea. If several quite prominent vessels exist, the pencil 
may be applied to each. The largest vessel usually enters the 
cornea on the nasal side, but several large ones may come 
down from above. Quite small vessels may be let alone if 
the large ones are attacked. The object is to constringe the 
main vessels, or even to make an eschar of them at a point 
where they enter the cornea. The application causes sharp 
momentary pain, but no lasting disagreeable effect. The 
application should not be repeated oftener than every four or 
five days. During the intervals the patient may be amused 
with the use of a harmless lotion. If a small scar is left at 
the edge of the cornea it will do no harm as it is outside the 
field of vision. Acid which has been long kept in the light, 
and in a vial stopped with cork, is unfit for use. It is then 
an irritant and not a caustic. I know of no other efficient 
means of cutting off from the cornea a fortuitous circulation. 
I have divided and even excised the vessels at the border of 
the cornea, but the results were not generally satisfactory. 
No other active caustic, applied in any other way, is control- 
lable. By this method the action is confined to a point or cir- 
cumscribed spot. No other part is injured A strong solution 
of nitrate of silver, applied with a camel's-hair brush would 94 
Diseases of the Eye. 
spread, and do mischief. The point of a sulphate of copper 
crayon is not reliable. 
Keratitis is sometimes accompanied with trachoma, which 
is a complication needing special treatment, so far as the 
granulations are concerned. 
Herpes Corner.-Young persons of a scrofulous or herpetic 
diathesis are liable to have vesicles develop on the cornea. 
The vesicles are about the size of poppy seed, and may burst, 
and their cavities become minute ulcers. An attack of herpes 
cornese is usually ushered in with conjunctival congestion, 
photophobia and lachrymation, the tears seeming to scald. 
Pain is always an accompaniment and in some cases is exces- 
sive. The vesicular efflorescence and lachrymation impair 
vision. 
Herpes corn etc is aggravated, if not developed, by enfeebled 
digestion, lack of proper nourishment, despondency, and un- 
pleasant surroundings. The disease may run its course in a 
few days, or continue for weeks or even months. It may 
terminate in recovery, or leave the cornea more or less opaque. 
Before its career is ended, the conjunctiva and the deeper 
ocular structures may become involved in the morbid action. 
Treatment.-As herpes corneas seems to depend considerably 
upon a constitutional vice, its treatment would seem to call 
for proper systemic medication. The use of sulphur alone, or 
combined with sulphate of magnesia and cubebs, is a good 
remedy to employ. Fowler's solution of arsenic in one or 
two drop doses every four hours, has benefited debilitated 
cases, where digestion and assimilation were defective. The 
iodides of potassium and ammonium, when administered so 
as not to disturb the stomach, are valuable alteratives, and 
may be given in scrofulous cases. 
Local applications are to be prescribed with discretion. 
Ten drops of Fowler's solution to an ounce of glycerine, may 
be used as a lotion to destroy the herpetic virus. A very 
dilute chlorinated wash can be employed for the same pur- 
pose. Caustics and irritants are to be avoided ; also poultices 
and ferments. Warm applications are agreeable, but those 
which are cold are safest. Aconite and laudanum used about 
the eye tend to lull the pain, and to lessen the lachrymal 
secretion. The eyes should be shaded, but not heavily cov- The Cornea. 
95 
ered. A strip of flannel tied over the eyes forms an elastic 
protection. 
The course of the disease, whatever be the treatment, is apt 
to be attended with exacerbations and remissions, keeping the 
patient and friends in a state of vibration between hopes and 
fears. 
Suppurative Keratitis.- Inflammation 
of the cornea, instead of terminating in 
resolution, doing little harm, may, under 
certain conditions of the patient's system, 
run a very acute and rapid course, and ter- 
minate in abscess or ulceration. When 
suppuration takes place in the cornea, it is 
most frequently at the centre, or a little 
below that point, that the pus collects. Its 
presence is usually manifested by a yellow- 
ish patch in the midst of a general haziness. 
In very severe cases this yellow patch may 
rapidly spread, until the whole cornea 
assumes one uniform creamy tint, hiding 
every trace of the iris. At this stage of 
the disease the cornea softens, the iris pro- 
lapses through a rent, and vision is lost. 
If the abscess be in the deeper layers of 
the cornea, the pus gravitates downwards 
or bursts into the anterior chamber, and, 
sinking, forms onyx or hypopyon. 
Neuralgia of the branches of the fifth 
pair of nerves, and consequent paralysis, are often the cause 
of suppurative keratitis and ulceration of the cornea. I have 
observed a destructive keratitis to attend cerebro-spinal menin- 
gitis. Severe conjunctivitis, especially the gonorrhoeal variety, 
is attended with dangerous inflammation of the cornea, espe- 
cially when there is much chemosis. Some of the acute 
forms of keratitis, particularly those of gonorrhoeal or diph- 
theritic origin, are rapidly destructive, the cornea deliquescing 
in a few hours. In panophthalmitis following wounds of the 
eye and cataract operations, the cornea softens in a short 
time, and frequently bursts, allowing the iris to protrude. 
Treatment.-The walls of the cornea are too thin to permit 
a circumscribed abscess, but the pus gets infiltrated between 
Fig 26. 
Hypopyon, or pus in the 
anterior chamber d; ab- 
scess of cornea is repre- 
sented by e; and onyx by 
a; a layer of pus in an in- 
terlamellar space reaches 
from b to c. 96 
Diseases of the Eye. 
the layers; and is too much diffused to warrant puncture as do 
ordinary abscesses. If an incision were made to give exit to 
the pus, the pressure from within at that point might result 
in a staphylomatous state, or rupture of the remaining thin 
portion of the cornea. It is therefore best to let the abscess 
take care of itself. 
In most instances of acute suppurative keratitis not much 
can be done to avert serious consequences. Attention may be 
directed to sustain the general health The febrile excitement 
may be restrained with veratrum; and as soon as the inflam- 
mation shows signs of abating, quinine and mineral acids may 
be prescribed to advantage. If the cornea bursts, the aqueous 
humor escapes and the violence of the inflammatory storm 
subsides, though vision can not often be saved. 
In the chronic forms of suppurative keratitis, the results 
are not so disastrous. Neuralgia of the fifth nerve may be 
allayed by the application of aconite and chloroform to the 
integument about the eye. In many instances the ulceration 
is not fatal to vision. But if the cornea softens and yields to 
pressure from within the lids should be kept closed to furnish 
support to the weakened corneal structure. Any attempt to 
return a portion of iris which has prolapsed through a loss of 
substance in the cornea, is utterly futile; for it will escape 
again and again, so long as there exists an aperture to escape 
through. A portion of iris adhering to the cicatrix of a per- 
forated cornea and protruding beyond the level of the corneal 
tissue, may be snipped off with scissors, or lightly touched 
with caustic. 
Ulcers of the Cornea.-Ulceration of the cornea must 
obviously result in corneal ulcers. In purulent, scrofulous, 
and other severe types of conjunctivitis, there is danger of 
corneal ulceration ; and in the more simple forms of circum- 
scribed keratitis, ulcers of the cornea may be developed. 
A recent ulcer of the cornea, in which the destructive pro- 
cess is still going on, exhibits a sharply-cut, well defined edge, 
with little, if any, surrounding opacity; and the excavation 
itself, as regards transparency, offers but little contrast to the 
sound corneal tissue.. 
Ulcers of the cornea sometimes heal without filling up, so 
that the cicatrix presents a slight depression which the inex- 
perienced observer might take for an existing ulcer, and The Cornea. 
97 
damagingly attack with active treatment. While the healing 
process is going on, there is more or less opacity in and around 
the ulcer; and if the ulcer be large, vessels will be seen run- 
ning to it from the margin of the cornea. The cicatrix of a 
healed ulcer has its edges smoothly rounded off, and its area 
is slightly opaque. A magnifying glass reveals the true cica- 
tritial structure, and no pus can be seen within its borders. 
If the progress of an ulcer be not arrested, it may eventu- 
ally perforate the whole thickness of the cornea. The aqueous 
humor then escapes, the iris falls against the cornea, so that 
the anterior chamber becomes altogether obliterated ; a por- 
tion of iris-large or small, according to the 
size of the perforation-protrudes through 
the opening, towards which also the pupil is 
displaced. If the prolapsus iridis be very large, 
the whole area of the pupil may be annihi- 
lated. 
In rare cases the ulceration reaches only to 
the posterior elastic lamina of the cornea, 
which, in consequence of the pressure from 
behind, is thrust forwards as an almost trans- 
parent vesicle filling up the cavity of the 
ulcer. The term hernia, corneas has been ap- 
plied to this protrusion. Such a condition is 
unfavorable to vision. 
Ulcers of the cornea may heal without 
opacity, though generally they do not. Under 
favorable circumstances children escape 
opaque cicatrices, the excavations filling up with transparent 
corneal tissue, and disappearing without serious obstacles to 
vision. Large ulcers are apt to permit bulging where the 
corneal walls are thinnest, constituting staphyloma. In some 
instances the projection is so great that the lids can not be 
closed, and the tumor collects floating particles which prove 
a source of chronic irritation. The iris becoming involved in 
the inflammatory action, adheres to the posterior surface of 
the cornea (anterior synechia), and forms part of the staphy- 
loma. In rare cases the cornea being nearly lost by ulcera- 
tion, and the pupil having been occluded with organized 
lymph, the iris constitutes the chief part of the protrusion. 
Treatment.-Ulcers of the cornea being frequently the result 
Fig. 27. 
Results of suppura- 
tion of the cornea; a 
represents a segment of 
the cornea thinned to a 
" vesicle." 98 
Diseases of the Eye. 
of general debility, local treatment alone is not sufficient, but 
constitutional improvement is to be sought. A nutritious 
diet is not to be neglected; and digestion and assimilation are 
to be aided by the judicious use of iron, bitter tonics, mineral 
acids, sulphur, phosphorus, iodo- 
form, cod liver oil, pepsin, and 
other agents known to improve 
the general health. 
Locally lead lotions should not 
be used, as they are apt to leave 
permanent deposits in the ragged 
edges of the ulcers. Nitrate of 
silver solutions are open to the 
same objections. A lotion made 
of glycerine and rose water, equal 
parts, to each ounce of which is 
added a drop or two of nitric acid, commonly checks the 
ulcerative action, and favors the reparative process. A grain 
of chloride of zinc and a drop of muriatic acid put into an 
ounce of rose water or glycerine, or both combined in equal 
parts, make a suitable wash for corneal ulcers. A pencil of 
wood with its point dipped in 
nitric acid, and after no wet- 
ness is observable, touched 
to an excavating ulcer, 
arrests the disintegrating 
process, and imparts to it a 
healing disposition. 
The object of the treat- 
ment is to limit and suppress 
the suppuration, to favor reparation, and to prevent secondary 
accidents and the worst results. To effect these objects the 
local applications should be weak, or, occasionally, an efficient 
caustic. Quite astringent and irritating lotions should be 
avoided. 
Bulging of the cornea may be obviated to some extent by 
the use of a " protective or pressure bandage," or by holding 
the lids closed with adhesive strips. Compresses render the 
dressing hot and heavy. When perforation is threatened the 
iris should be kept out of the wound if possible. Should the 
ulcer be near the centre of the cornea, mydriatics may be used 
Ficl 28. 
Staphyloma. 
Fig. 29. 
uornea thinned by ulceration, and Iris ad- 
hered to it, constituting a form of anterior 
synechia. The Cornea. 
99 
to dilate the pupil; if the ulcer be near the periphery, pre- 
parations of calabar bean may be employed to contract the 
pupil. 
Corneal staphyloma is to be treated according to the extent 
of the distortion and pro- 
trusion. If the corneal 
curvature be slightly in- 
creased, the curves being 
deviated enough to afford 
different foci, and the irregu- 
lar focal lines and surfaces 
incline to each other in 
varied directions, the retina 
receives a number of figures 
of dispersion, instead of images of objects, and a state of 
astigmatism exists. This condition is to be corrected as far as 
possible with spherical glasses. 
A staphylomatous protrusion always occurs at the expense 
of the thickness of the cornea ; and the thinned walls are not 
unfrequently cicatrized and 
opaque. In some cases, 
where the protrusion has 
existed for some time, the 
summit of the staphyloma 
grows thick under prolonged 
irritation, but the thickening 
is a secondary condition. It 
has been recommended to 
puncture these staphyloma- 
tous protrusions, to permit the aqueous humor to escape, and 
thereby flatten the protrusion sufficiently to allow the lids to 
cover the tumor. But, it is found that the paracentesis affords 
only temporary relief, the aqueous fluid being reproduced and 
the protrusion re-established. It is better, therefore, to excise 
the staphylomatous mass. This operation of excision may be 
performed as follows: an upward incision is made with a 
Daviel's knife, much as the corneal wound was once made in 
the linear extraction of cataract; the flap is then seized with 
forceps and the downward cut made with a bistoury or 
Graefe's knife, care being exercised in terminating the inci- 
sions that lips remain to fall towards one another, to form a 
Fig. 30. 
Staphyloma, with thinning of the cornea. 
Fig. 31. 
Staphyloma, with protruded cornea thickened. 100 
Diseases of the Eye. 
linear cicatrix. The lens is then removed carefully, and the 
lids closed. A compress is to be placed on the eye and 
retained with a pressure-bandage to guard against evacuation 
of the vitreous, and hemorrhage. The operation should be 
performed while the patient is under chloroform. The part 
excised will show the iris upon its posterior surface; and the 
dislodged lens will appear fatty, or chalky. 
Another method of operating is to split the staphyloma 
Fig. 32. 
Ablation or excision of a staphyloma. 
through the middle, evacuate the aqueous, and bring the 
edges of the wound together, or allow them, in some instances, 
to overlap. This operation is recommended in thin-walled 
staphylomata, and especially those made up chiefly of iris. 
In such cases the overlapped walls add strength to the weak- 
ened structures. 
Mr. Critchett advises that an eliptical piece be excised from 
the staphylomatous cornea, and the edges of the wound be 
brought together with sutures, the protrusion being transfixed 
with needles before the excision is made. The needles are to 
be armed with silk threads which are to be drawn through 
and tied as soon as the excision is performed. The object of 
this operation is to evacuate the aqueous, and to retain the 
vitreous and lens. The advocate of the plan claims that the 
stump can always be secured of proper size to sustain an 
artificial eye. The Cornea. 
101 
Opacities of the Cornea.-Inflammatory changes in the 
corneal tissue frequently result in opaque spots, or in haziness 
or cloudiness of the entire cornea (partial or complete leu- 
coma.) The opacity may be confined to the superficial layer 
of the cornea, or extend to its deeper structures. The opaci- 
ties often appear like fleecy clouds resting upon the polished 
cornea. The popular term of " feather on the sight" is 
somewhat expressive. Frequently the opacity is so delicate 
that it appears like haze or smoke, and needs a careful ex- 
amination to be detected. An oblique light thrown through 
a convex lens helps to discover the more obscure of corneal 
opacities. The more prominent can be recognized at a glance. 
It is important to make a distinction between opacities 
which from their cicatritial nature are permanent, and a hazy 
condition of the cornea which, if promptly and skillfully 
treated, may be entirely removed. A cloudy condition of the 
cornea which has existed only a few days or weeks, and 
depends upon simple keratitis, with a vascular zone in the 
sclerotic, and some degree of irritability of the eye, may be 
cured very speedily; but if the general haziness has existed 
some months or years, with no sclerotic redness, or signs of 
inflammation in the eye, it is likely to be incurable. 
When the cicatrix in- 
volves the whole thickness 
of the cornea, and has 
attached to it a greater or 
less portion of iris, the 
nature of the opacity is 
marked by a black spot, and 
by the change of position 
in the iris and pupil. The anterior synechia in such a case is 
a serious complication, the optic apparatus being considerably 
distorted. 
Disturbance of vision is a constant accompaniment of all 
opacities which fall in the slightest degree over the pupil; 
but nebular spots near the border of the cornea do little or no 
harm. A nebula near the centre of the cornea causes the 
eye to roll sufficiently to throw the opacity out of the axis of 
vision, and strabismus is the result. A squint from such a 
Fig. 33. 
Cicatrix of cornea involving the iris. 102 
Diseases of the Eye. 
cause is permanent; at least, no attempt should be made to 
rectify it. 
Whether the corneal opacities exist as nebulce, albugo, or 
leucoma, for these several names have been given to designate 
differences in the density and character of the opacities, they 
have no power to change into transparent tissue, but some- 
times become diaphanous, especially in young subjects, and to 
interfere less and less with vision. 
Opacities of the cornea disturb vision in various ways. 
They compel the patient to bring objects quite near the eye, 
and cause a strain of accommodation which results in myopia. 
Besides, an eye which is impaired, whether from defects in the 
cornea or other structures, is neglected, and the functional 
inactivity leads to greater and greater feebleness in the retina. 
Treatment.-It has been stated that an opacity resulting 
from a cicatrix can not be changed into transparent tissue. 
But in young patients it is quite astonishing to witness the 
rapid interchange of material in leucoma resulting from kera- 
titis, and ulceration of the cornea. 
A solution of the iodide of ammonium-a grain of the salt 
to an ounce of water-may be applied to nebulae with some 
hope of benefit. Neither alkaline nor acid washes, as such, 
are known to effect more than neutral applications. It is cus- 
tomary for some oculists to apply dry calomel to corneal 
opacities, but no special impression is produced by the agent. 
If any preparation of mercury would accomplish any good 
purpose w'hen applied to the eye-as wash or unguent-the 
quantity employed would be so minute that no harm could 
arise from absorption. The idea that mercury is a solvent of 
adventitious deposits is not well established. Solutions of 
lead and nitrate of silver should not be applied lest insoluble 
deposits adhere to the irregularities of the cicatritial tissue. 
The application of finely powdered sulphate of soda directly 
to albugo or leucoma has been reported to produce wonderful 
results. M. de Luca claims that the agent has the power of 
removing corneal spots in an almost incredibly short space of 
time. A solution of chloride of sodium (common salt) has 
been advocated as an efficient agent in the removal of corneal 
opacities. 
The transferring of the pupil, by iridectomy, from a posi- 
tion behind a central opacity, to a point where the cornea is The Cornea. 
103 
transparent, is an operation entirely legitimate in cases favor- 
ing such an operative procedure. When vision in one eye is 
irrevocably lost, and an artificial pupil in the other promises 
anything, the operation should be performed. 
Injuries of the Cornea-Abrasion.-The epithelial layer 
of the cornea is often lacerated by the forcible contact of 
rough substances; and sometimes a little flap of epithelium 
is partially detached and doubled over. The injury may seem 
insignificant to the casual observer, but the patient experiences 
intense pain and is a proper subject for careful treatment. 
Abrasions and lacerations of the outer layer of corneal 
tissue should be examined with a magnifying glass, the patient 
being in a good light. The careless and inattentive often 
fail to detect the cause of the pain and irritation. As already 
stated, keratitis more or less severe is likely to follow corneal 
abrasions. 
The treatment consists in keeping the eye bandaged for a 
day or two, to prevent motion of the lids. A drop of olive 
oil applied to the abraded surface every few hours is com- 
mended. As soon as the epithelium is regenerated all irrita- 
tion ceases, and the uniform polish of the cornea is restored. 
Bad cases may be attended with suppuration, and be followed 
by an opaque cicatrix. 
Contusion of the Cornea is an injury not attended with 
abrasion, but is often produced by a whip, or stick, or missile. 
Ordinarily such injuries are merely painful, no lasting effect 
being observed. However, in the severer forms of contusion, 
suppuration and softening of the cornea occur, and serious in- 
flammation of the deep structures of the eye is to be feared. 
Young subjects recover without much trouble, unless it be 
temporary haziness of the cornea, but old persons are not so 
fortunate, the cornea after softening gives way, and allows 
the aqueous humor to escape. The globe, in such cases, 
shrinks, or a troublesome staphyloma forms. Contusion of 
the cornea, then, should be regarded as a serious accident, and 
managed accordingly. 
The treatment is not necessarily different from that indi- 
cated for corneal abrasion. The light should be shut out and 
the lids kept from moving by the use of a bandage and light 
compress. The tincture of aconite may be applied to the in- 104 
Diseases of the Eye. 
tegument about the eye; and a chloral anodyne may be pre- 
scribed for internal use to modify the pain, the shock, and the 
nervous excitement. 
Incised and Punctured Wounds.-A smart blow with a 
stick will sometimes inflict on the cornea a cut as clean as if 
made with a knife. Such wounds are more serious than those 
purely of an incised character, inasmuch as the shock is 
greater, and the inflammatory process more severe and longer 
continued, often ending in complete disorganization of ocular 
structures. 
Small, sharp bodies, such as fragments of glass or metal, 
when driven with great rapidity against the cornea, frequently 
produce so small a wound, that a physician unaccustomed to 
see such cases may easily underrate the size of the foreign 
body inflicting the injury; the elasticity of the cornea causes 
the wound to contract as soon as the foreign body has passed 
through. As soon as such an injury has occurred the iris 
should be carefully scrutinized, as well as the bottom of the 
anterior chamber, in order to detect the whereabouts of the 
penetrating missile; and if the cornea be still transparent, 
and the aqueous humor retained, the pupil should be dilated 
with atropine ; and the lens and deeper tissues explored with 
an ophthalmoscope. If any portion of the penetrating body 
protrude from the wound, it should at once be extracted with 
a delicate well-closing forceps, the lids being held apart with 
a spring speculum, and the globe steadied by nipping up a 
fold of conjunctiva covering the sclerotic. If the foreign 
body be lodged in the iris, the cornea should be incised with 
a lance shaped knife, and iridectomy performed, that part of 
the iris beino; removed which embraces the foreign substance. 
Should the foreign body be discovered in the lens, a cataract 
operation must be performed at once. 
The corneal wound may permit the iris to protrude ; and if 
not returned with a probe or small spatula, the prolapsed por- 
tion of iris will unite to the borders of the corneal wound. 
A protruded portion, of iris, which can not be returned, may 
be snipped off* with curved scissors. 
Penetrating wounds may transfix the cornea, and, as has 
been stated, reach the iris and lens. But more common and 
simple wounds are punctures of the cornea made by sharp The Cornea. 
105 
pieces of metal which lodge in the outer corneal layers. 
Grains of gun-powder, particles of sand, bits of steel, and 
cinders are most frequently projected with force into the sub- 
stance of the cornea. Machinists, metal-turners, mill-stone 
dressers, stokers, foundry and furnace-men often suffer from 
such accidents ; and the medical practitioner, while examining 
a wound of the cornea recently inflicted, often finds cicatrices 
and particles of foreign matter which have long been buried 
in the cornea and have ceased to be troublesome. 
A good degree of patience and skill is frequently required 
to remove or extract a foreign body from the cornea. If a 
slender bit of steel bury itself in the cornea too deeply to be 
reached with a delicate lever or forceps, attempts to reach it 
may result in forcing the foreign body within the anterior 
chamber, where it may become entangled among the fibres of 
the iris. If an elongated chip of metal strike the eye 
obliquely, it sometimes lodges in the cornea at about the 
middle of its thickness. Now, if the lodgement be recent, 
the missile can be seen, though affording no hold for forceps. 
Under such circumstances, the operator may with a cataract 
needle or slender knife slit up the outer corneal covering, 
when the foreign body may be dislodged with ease. 
Some patients can not hold the eye sufficiently steady to 
allow the operator to effect a removal of the offending body. 
Such persons should be put under the influence of chloro- 
form ; and then proper manipulations can be executed with- 
out trouble. I sometimes use the point of a slender bistoury 
to dislodge a piece of metal which is embedded in the corneal 
tissue. A cataract needle may be employed for the same 
purpose. The wound made by the penetration of the foreign 
body, and the moderate injury inflicted in the process of 
extraction, are generally obliterated in a few days by repara- 
tive action, though a small cicatrix may be lasting. The 
suffering eye should be kept bandaged for a day or two, and 
the other not subjected to active exertion. In severe cases 
where the cornea is transfixed the treatment should be 
managed with the greatest care and attention, until all danger 
from inflammation is passed. Severe pain is to be restrained 
with anodynes, and the eyes should be protected from light. 106 
Diseases of the Eye. 
DISEASES OF THE SCLEROTIC. 
The dense capsule which forms five-sixths of a sphere, and 
gives form to the eye and support to the soft structures with- 
in, and also affords attachment to muscles without, is, from 
its hardness, called sclera or sclerotic. The remaining sixth 
of the globe is a transparent structure-the cornea. The 
sclerotic is a fibrous tunic, very firm, opaque, and thicker 
behind than in front. Near the corneo-scleral junction where 
the tendons of the recti muscles are inserted, the sclerotic, 
though covered with conjunctiva, presents a glistening white 
band or zone behind the cornea, called the " white of the 
eye." The optic nerve pierces the sclerotic posteriorly, a 
little to the inner or nasal side. The sheath of the nerve is a 
prolongation of the dura mater, and the sclerotic seems to be 
an expansion of the neurilemma. 
The sclerotic, when inflamed, exhibits a zone of vascularity 
close around the margin of the cornea,. It is probable that 
sclerotitis never exists independently of inflammation of other 
structures. Keratitis must necessarily be complicated with 
sclerotitis. And the sclera is sympathetically affected in 
choroiditis. 
The sclerotic can not be observed as a whole when inflamed, 
but the zone covered with conjunctiva presents a peculiar 
pink tint, sometimes with a shade of violet; and pain, intole- 
rance of light, and lachrymation are pretty constant attend- 
ants of sclerotitis. In sclero-keratitis, and sclero-choroiditis, 
which are frequent combinations of morbid action, the symp- 
toms are more marked or observable. 
Rheumatic subjects are liable to a chronic form of sclero- 
titis, the inflammation being confined to the anterior zone, 
close to the cornea. This variety of scleral inflammation is 
apt to involve the cornea and the iris, and according to some 
ophthalmic writers, the ciliary body, making sclero-cyklitis. 
Treatment.-The general health should be kept good by a 
suitable diet, and the use of nux, cinchona, and other bitter 
tonics. The bowels are not to be scoured with cathartics, 
but moved easily with the aid of sulphur and sulphate of 
magnesia, an aromatic being added. In rheumatic and 
neuralgic states, macrotys, and the iodides of potassium and Diseases of the Sclerotic. 
107 
ammonium, are excellent remedial agents. The parts about the 
eye may be wetted every hour or two with chloroform. A pun- 
gent snuff, composed of bayberry, veratrum and sassafras, and 
used occasionally, exerts & beneficial effect. The eyes should 
not be exposed to brilliant lights, and may be shaded with 
tinted spectacles. 
If the sclerotitis be complicated with iritis, retinitis, and 
choroiditis, as it generally is, the remedies employed in those 
diseases, may be tried. By comparison it will be seen that 
there is a similarity in the treatment recommended for all of 
these difficulties. 
Injuries of the Sclerotic.-A simple wound of the scle- 
rotic, the parts within the globe remaining untouched, is not 
likely to terminate seriously, unless a foreign body of an 
irritating nature continue in the wound to provoke inflam- 
matory attacks. But if a bird-shot or piece of metal enter 
the globe, the injury to the choroid, retina, and vitreous 
body, is sure to be followed by inflammation which proves 
destructive to vision. 
A serious and singular injury to the sclerotic consists in its 
rupture near the sclero-corneal junction by the force of a 
counter-stroke. The punch of a cane or similar weapon 
against, say, the outer side of the eyeball, bursts the sclerotic 
on the opposite side, and the lens slips through the rupture 
and lodges beneath the conjunctiva, which, yielding, escapes 
laceration. Such a force may inflict additional injury to the 
eye, such as hernia of the iris and portions of the choroid and 
retina. The dislocated lens could be removed through an 
incision in the conjunctiva; but in the more complicated of 
injuries the surgeon is to be governed by circumstances. 
After the effused blood has been let out, the hernied iris or 
choroid might be snipped off with scissors, and the patient, 
with the eye closely shaded, kept at rest and free from in- 
fluences unfavorable to recuperation of the eye. The chances 
for useful vision, however, are exceedingly slender. 
Scleral or Sclero-Choroidal Staphyloma.- A thinning 
or yielding of the sclerotic at some point, and a consequent 
bulging of the scleral walls, constitute what is called staphy- 
loma. The choroid is intimately connected with the sclerotic, 108 
Diseases of the Eye. 
therefore the sclera, when it yields and bulges, usually takes 
the choroid along with it, constituting what is termed sclero- 
choroidal staphyloma. 
The staphylomatous condition tnay extend to the entire 
globe, ruining the dioptric apparatus by displacing and dis- 
torting every structure entering into the formation of the 
eyeball; but it oftener affects only a part of the scleral tunic. 
If the protrusion be far enough in front to be observed, it 
will appear as a bluish or 
slate-gray transparent nodule 
or tumor, projecting above 
the surrounding sclera. In 
some instances the protrud- 
ing mass is furrowed or 
divided into a series of ele- 
vations, giving it the appear- 
ance of a cluster of grapes. 
Ophthalmoscopic examin- 
ation of a staphylomatous 
eye usually shows inflamma- 
tory changes in the choroid 
and retina, cloudiness of the dioptric media, and fluidity of 
the vitreous. As a result of these changes, vision is entirely 
destroyed, or limited to a quantitative perception of light. 
If the scleral staphyloma be pretty well in front, and not 
extensive, the posterior portions of the retina may preserve 
their functions, vision being only slightly impaired. 
Scleral staphyloma may burst spontaneously, or as the 
result of a blow. As a consequence the contents of the globe 
are evacuated, and more or less hemorrhage occurs. At 
length the rent heals; and atrophy is the termination of 
morbid action. 
Treatment.-As soon as it be discovered that scleral staphy- 
loma exists, the intraocular pressure should be relieved by 
daily paracentesis of the cornea. It has been advised to per- 
form iridectomy, though the object of the operation is chiefly 
to evacuate the aqueous chamber, and thereby relieve the 
intraocular pressure. It is an established fact that iridectomy 
is followed by more lasting results than paracentesis. 
The progress of scleral staphyloma may be arrested in 
some instances by slitting the tumor. A large opening could 
Fig. 34. 
Sclero-choroidal staphyloma. The Iris. 
109 
not be made in the sclerotic without endangering a too free 
evacuation of the vitreous and intraocular hemorrhage, there- 
fore some caution should be exercised in the performance of 
the operation, and, afterwards, by employing a protective 
bandage to give support to the vessels within the globe. 
Sometimes the wound made by slitting the tumor heals 
rapidly, and the staphyloma appears again in its former 
shape. When such is the case, a repetition of the operation 
is necessary. 
In total sclero-choroidal staphyloma it has been recently 
recommended to bring about suppuration of the globe, and 
subsequent atrophy, by passing one or more threads through 
the sclera and vitreous in the ciliary region. The threads are 
to be left in place from one to three days, or until an active 
degree of inflammation has been provoked. There is danger 
of provoking too much inflammation ; and when such be a 
result, efforts must be made to subdue it. 
THE IRIS. 
The iris is a circular diaphragm which is placed between 
the cornea and the lens. It has a central aperture called the 
pupil, the diameters of which are regulated by muscular 
fibres in the substance of the iris. The pupil is an open com- 
munication between the anterior and posterior chambers, the 
aqueous humor flowing freely through the aperture. 
The peripheral border of the iris is attached to the ciliary 
muscle and processes ; and its pupillary edge rests posteriorly 
against the capsule of the lens. When the pupil is contracted 
the convexity of the lens bulges the pupillary margin for- 
wards ; and when it is dilated its borders do not touch the 
capsule of the lens. 
The pigment-uvea or tapetum-on the posterior surface of 
the iris, gives color to the eye. In the fair and light-brown 
races of mankind the pigment of the iris is bluish-gray; and 
in the dark skinned it is black. A particolored or variegated 
iris is very common as may be learned in attempts to find a 
match for the real eye from an assortment of artificial eyes. 110 
Diseases of the Eye. 
The vessels of the eye are abundant, producing the beau- 
tiful radiate appearance which is especially marked in light 
colored eyes. 
The nerves of the iris are chiefly branches of the trifacial 
(5th) and oculo-motorius (3d); a filament of the sympathetic 
is also sent to the iris ; and nerve-supplies come from other 
sources. 
Muscular fibres, generally running in a circular manner, 
contribute to the structure of the iris; and a bundle near the 
pupil constitutes a sphincter apparatus. Radiate muscular 
fibres, as dilators of the pupil, have been described, yet they 
are so delicate and pale that they may be merely connective 
tissue, elastic enough to widen the pupil when the circular 
fibres are benumbed or paralyzed. Congenital defects of the 
iris, as of other structures, are occasionally met; irideremia is 
the term given to denote a total absence of the iris. A child 
without irides shrinks from strong light, and exhibits much 
unsteadiness of the globes. When carefully examined in a 
favorable light, the whole space behind the cornea presents a 
uniform red or orange tint, and the edge of the lens is defined 
by a ring of golden light. 
Congenital coloboma is a malformation which results from 
an arrest of development, the two halves of the iris not meet- 
ing and blending. The pupillary aperture, under such cir- 
cumstances, presents an elongated form, the fissure extending 
down to the lower edge of the cornea. Coloboma iridis usu- 
ally coexists in both eyes, and the defect may be a little to 
one side of the median plane. 
In rare cases the pupil is placed near the margin of the 
cornea, instead of occupying a central position in the iris. 
Malposition of the lens may accompany this eccentric position 
of the pupil. 
In the Albino the iris exhibits the general want of pigment 
which characterizes the hair and skin. The layer of opaque 
pigment, termed uvea, is altogether wanting, and the structure 
of the iris presents a singular appearance, as if loosened by 
maceration. White fibres are intermixed with others of a 
lilac color, and through the whole attenuated iris the light 
reflected from the fundus of the eye transmits a reddish glow. 
Albinism is frequently attended with defective vision, and 
always with great intolerance of light. In some cases, how- The Iris. 
111 
ever, sight is very good, and extreme sensibility to light is the 
only cause of complaint. 
Iritis.-Tremulousness of the iris, and a deviation from 
the circular form of the pupil, are to be regarded with some 
suspicion, though neither of them is a positive pathognomonic 
sign. Diminished mobility of the pupil, a loss of the peculiar 
fibrous appearance of the iris, and a well-marked sclerotic 
zone, furnish additional evidence of iritis. Nodular excres- 
cences and granulations on the surface of the iris commonly 
indicate inflammatory action. Iritis is frequently complicated 
with inflammation of the cornea, sclerotic, choroid and retina, 
or is a part of panophthalmitis. Blue and gray irides, when 
inflamed, change to a dirty slate or yellowish green color; 
and black and brown irides, to an ochre or cinnamon red. 
Great sluggishness, or complete immobility of the pupil, is 
an essential feature of iritis, therefore if the pupil be mobile 
the iris is not seriously inflamed. In order to test the reaction 
of the iris, the patient should be placed in a moderately strong 
light, and the unaffected eye should be closed with a folded 
cloth, so that every ray may be excluded, for such is the sym- 
pathy between the organs, that when, in consequence of dis- 
ease in the nervous apparatus, an eye has become quite insen- 
sible to light, its pupil, otherwise motionless, will contract 
whenever light is admitted to the sound eye. The hand may 
be used to momentarily exclude the light from the eye under- 
going examination, the observer carefully watching any 
changes that may take place in the pupillary margin when 
light and shade are brought to bear upon the suspected organ. 
In doubtful cases a solution of atropine introduced between 
the lids would tend to settle the question. However, in the 
event of posterior synechia the pupil could not be dilated 
w'ith a mydriatic. 
Pain is not distinctive of iritis, nor is impairment of vision, 
for both may come from other morbid states. Purulent 
deposits upon the iris (hypopyon) give it the appearance of a 
gauze-like coating. The pus mixes with the aqueous, render- 
ing it turbid, and gives it the appearance of whey. 
The causes of iritis are numerous; among which are 
mechanical injuries (traumatic iritis). Clean cuts, as those 
made to establish artificial pupil, are rarely attended with 112 
Diseases of the Eye. 
severe inflammation, while the lodgment of a foreign body in 
the substance of the iris, as a piece of steel or percussion cap, 
is always followed by destructive inflammatory action. Some- 
times a splinter of steel or glass makes a wound in the corhea 
through which the iris protrudes; and uf not returned the 
hernied mass becomes fast there. However, the protruding 
part may be snipped off with scissors, or be made to shrink 
under the touches of nitrate of silver. A metallic chip may 
lodge in the iris, and for a time appear to be encysted by 
becoming enveloped in lymph, but it is only temporarily 
encased and hid from view, for in time it will create iritis, and 
in the end destroy vision. 
A forcible separation of the iris from the ciliary ligament 
is a serious accident which is often complicated with bleeding 
into the anterior chamber. Iritis follows, which has to be 
combatted with rest and endured with patience. In time the 
blood is absorbed, and a good degree of vision saved. A blow 
upon the eye may dislocate the lens and thus subject the iris 
to pressure. Iritis soon sets in, and lymph lodges in the 
pupil, blocking it up. In time the adjoining structures become 
inflamed, and vision is lost. To obviate such a result, the dis- 
located lens should be removed at once through an incision 
made in the cornea. 
Inflammation of the iris, attended with neuralgia through- 
out the first division of the fifth pair of nerves, extending 
even to the second and third divisions, is, whether properly 
or not, termed rheumatic iritis. A severe attack is accom- 
panied with lachrymation and intolerance of light. In its 
course it is attended with haziness of the cornea, and exuda- 
tion into the area of the pupil. During the progress of the 
disease, if the cornea be not hazy, the veins of the iris can be 
traced on various parts of its surface, as delicate red lines, 
diverging from the edge of the pupil to the periphery of the 
iris. 
A serious result of iritis is the exudation of lymph, which 
by organization unites the pupillary margin to the capsule of 
the lens (synechia posterior), the area of the pupil being 
encroached upon. In some instances iritis comes on slowly 
and almost imperceptibly, there being little pain, or outward 
sign of inflammation. Such an invasion may be termed The Iris. 
113 
chronic iritis, yet its results may eventually prove as disastrous 
to vision as the acute form of the disease. 
Treatment.-A patient just starting off with an attack of 
iritis, though not suffering severely, may turn prudence to a 
profitable account. Indoor rest with the eye shaded or 
bandaged, is necessary. Easy and reclining attitudes are to 
be commended. The diet should be nutritious, easily digested, 
and relishing, though neither hearty nor stimulating. The 
bowels should be kept open without cathartics. A two-grain 
pill of Chian turpentine may be administered every three 
hours every other day; on the alternate day a half-grain 
iodoform granule may be given every three hours. If there 
be considerable constitutional fever gelseminum or veratrum 
should be employed to reduce it or to hold it under restraint. 
During convalescence, iron, mineral acid, and quinine may be 
prescribed. The local treatment for iritis must be governed 
somewhat by circumstances. A dilute tincture of aconite 
may be applied to parts about the eye with advantage. It 
subdues circumorbital pains and checks nervous excitement. 
If a mydriatic effect be desired, and it often is when the 
pupil threatens closure, the tincture of belladonna may be 
combined with that of aconite. 
Cold applications are not well endured, and often prove 
injurious. Hot fomentations, though generally dangerous to 
apply to the eye, may be risked in iritis, and rarely do harm, 
while in many instances they act like a charm. Leeches and 
blisters seldom do good, and usually inflict needless injuries. 
Steaming the eye over hot water is very agreeable whenever 
neuralgia is present. Irritating the skin about the eyes with 
chloroform does some good. Pustulation with croton oil has 
been commended. In a few instances I have relieved the 
pain attendant upon iritis by puncturing the cornea, and thus 
relieving the pressure upon the iris by taking out a few drops 
of the aqueous humor. The operation is not attended with 
pain or risk of any kind. A cataract needle or a slender 
knife is a proper instrument to make the puncture with. If 
the puncture be made near the margin of the cornea, no defect 
comes from the slight cicatrix following the tiny wound. A 
repetition of the puncture may be made every three or four 
days, or oftener, until the tension and neuralgia subside. 
Paracentesis is the remedy for hypopyon. 114 
Diseases of the Eye. 
Syphilitic Iritis.-Constitutional syphilis, in its evolutions, 
frequently inflames the iris. It produces the most marked 
kind of iritis, and is characterized by a tendency to rapid and 
abundant exudation on the iris, especially about the edge of 
the pupil, in which situation yellow, reddish-yellow, or nearly 
red nodules sometimes attain to such a size as almost to close 
up the pupillary area. The cornea may remain clear during 
an attack of syphilitic iritis, or it may show dots or minute 
vesicles of a pale buff tint, which appear like a cloudy haze. 
A vascular zone in the sclerotic is observed just behind the 
corneal junction. The intolerance of light may not be as dis- 
tressing as in rheumatic iritis, though as a distinctive sign it 
would not be sufficiently reliable to determine whether a 
syphilitic taint was present or not. In fact, there are no 
morbid symptoms in the iris which demonstrate whether they 
be syphilitic or not. If a papular eruption exist upon the 
skin, or ulcers of a suspicious nature exist in the throat, or 
other marked signs of syphilitic contamination be present, a 
coexistant iritis may safely be diagnosed as of the syphilitic 
variety. 
Irides which have naturally a bluish tint, appear more or 
less green when invaded with syphilitic inflammation. This 
is caused by the presence of yellow albumen in the aqueous 
humor, the admixture of yellow and blue forming, of course, 
a green tint. 
Syphilitic iritis may attack both eyes at once, but it com- 
monly invades the right eye first, and the left sometime sub- 
sequently, or as a seemingly distinct invasion. In some in- 
stances a moderate degree of iritis in one eye might escape 
detection, unless it be determined by immobility or sluggish- 
ness of the pupil. In syphilitic iritis the danger is from 
closure of the pupil, which occurs by first having the pupillary 
margin unite with the capsule of the lens (synechia posterior), 
and then by the nodules of lymph extending over that part of 
the capsule covering the area of the pupil. Subsequent con- 
tractions draw together the pupillary aperture. 
Choroiditis and retinitis may attend iritis, the inflammation 
extending by anatomical continuity or functional sympathy. 
True panophthalmitis and disorganization of the eye have 
followed a syphilitic attack of iritis. The Iris. 
115 
Treatment.-Syphilitic iritis is not to be treated differently 
from ordinary iritis, except so far as the venereal taint is con- 
cerned. The local remedies are the same, as well as the diet. 
The eyes are to be shielded from light. Anti-syphilitic reme- 
dies are required to eliminate the venereal virus. What are 
anti-syphilitic remedies ? Is mercury one of them ? Very 
respectable authors allege that no agent is equal to mercury 
as a syphilitic expurgator; and others, just as experienced 
and respectable, declare that mercury is useless, or worse than 
useless. Dr. II. W. Williams, of Boston, an expert oculist, 
who has written " A Practical Guide to the Study of the Diseases 
of the Eye" says, " As regards the effect of mercury as a 
resolvent of effused lymph, I have seen so many cases where 
the pupil has become and remained obliterated by deposits, 
where mercury had been most lavishly, and, as it would be 
thought, judiciously administered; and, on the other hand,have 
so often seen the lymph absorbed, and the congestion of the 
iris resolved where only tonics had been given, that I can 
not coincide in a belief in the specific properties of this as 
surpassing those of any other remedy. A large proportion of 
the cases of both rheumatic and syphilitic iritis can be safely, 
quickly, and pleasantly relieved without it, and with a more 
rapid recovery of perfect health than where it is given. 
Many a case will perhaps be cited in the reader's mind, which 
seemed to go on more favorably, when, after a trial of other 
remedies, this was resorted to; but here the attack had 
already lasted a considerable time, and had probably reached 
its acme. As I have before stated, experience justifies us in 
believing, that from a certain point, varying in different cases, 
there is an evident tendency towards recovery, provided the 
deposit of adhesive lymph has not been so considerable as to 
fill the pupil and cement its edge to the surface of the lens. 
Given at this turning-point of the disease, when even an 
expectant treatment would have been followed by a favorable 
result, mercury has obtained credit which belonged to the 
vis medicatrix natures, or to other means employed conjointly 
with it." 
I might quote other authors who use language more 
emphatic against the use of mercury in the treatment of 
syphilis and iritis, but quotations which express opinions con- 
trary to partisan authority and a dogmatic adherence to 116 
Diseases of the Eye. 
ancient notions, especially when the champions of a belief 
in the resolvent powers of mercury feel that interest is at 
stake, will not be potent to convince. The alleged specific 
qualities of mercury as anti-syphilitic, and the resolvent 
powers of the mineral in iritis and other diseases, have been 
questioned, and the defendants of the agent seem disposed to 
maintain their position, right or wrong. I do not propose to 
waste words in an attempt to convince those who are deter- 
mined to continue in any given state of belief. Although I 
think that mercury is often prescribed when there is no 
rational indication for its use, yet, if I were to declare that 
the agent always worked mischief, and that no advantage 
could ever come from its employment, I might be classed as 
equally partisan with those who claim miraculously curative 
powers for the mineral. 
r: A person having iritis, who is suffering from venereal con- 
tamination of a constitutional character, should take a variety 
of remedial agents of an alterative nature with the view of 
hastening the elimination of the virus. Any particular 
remedy should not be given more than a week at a time 
before it is changed for some other. The iodide of ammonium 
is an efficient alterative and anti-syphilitic. From three to 
five grains of this may be given in water, syrup, or other 
vehicle, four times a day. Cod liver oil is not well tolerated 
by the stomach, but it is a remedy of some alterative and 
resolvent power, and therefore may be tried until it disturbs 
the appetite and digestion, when it should be withdrawn. 
Sulphur often produces desirable effects. Veratrum should 
be given, especially when there is any vascular and nervous 
excitement. Muriated tincture of iron in five-drop doses con- 
tributes to a favorable result. Sarsaparilla, stillingia, and 
other vegetable alteratives exert some beneficial influence 
upon such patients as have been severely mercurialized. The 
bitter tonics as a whole do good by improving the general 
health. If the patient can be made to eat and digest well it 
does not make much difference what particular remedy is 
employed; and any course of medication which disgusts the 
patient and thereby reduces his strength and spirits, should 
be radically changed. A generous diet of a tempting nature 
frequently accomplishes more than medicine. 
The local remedies for syphilitic iritis need not be different The Iris. 
117 
from those already named in connection with common iritis. 
In all forms and kinds of iritis, the use of atropine as a 
mydriatic is not to be forgotten nor neglected. 
Ophthalmologists are in the habit of devoting considerable 
space to the discussion of scrofulous, gonorrhoeal, and arthritic 
iritis, calling attention to distinctions, though without estab- 
lishing important differences. It would be unprofitable to 
draw attention to pathognomonic peculiarities, unless some 
advantage could be gained by a variation of treatment to suit 
the varieties of disease described. Iritis developed in a 
scrofulous patient does not necessarily require different treat- 
ment from that suggested for the common or syphilitic form 
of the disease. Iritis in a gonorrhoeal patient would not 
improve any faster by the administration of copaiba and tere- 
binthinate agents. Turpentine has a reputation for benefiting 
patients suffering from common iritis, therefore it might be 
useful in the management of a variety of the disease. Col- 
chicum, which would be given in gouty iritis, might exert a 
favorable influence upon iritis in general. What is called the 
arthritic ring in the sclerotic is not peculiar to the gouty form 
of iritis, but to a peculiar anatomical blending of the cornea 
and sclerotic. Iritis, common or specific, is often complicated 
with morbid states which eventuate in staphyloma of the 
cornea and sclerotic, distortion of the dioptric media, and 
destruction of visual power. In such cases the iris may be- 
come adhered to the cornea, or protrude into a sclerotic 
staphyloma. But in these varied complications the iritis alone 
should not attract attention. A combined or compound mor- 
bid action is to be recognized and overcome. 
IRIDECTOMY. 
The removal of a portion of the iris is executed for a 
variety of purposes : to open a new way for the rays to enter 
the eye when the pupil is closed ; to enlarge a contracted or 
displaced pupil; to establish an artificial pupil behind a trans- 
parent part of the cornea when the central portion is rendered 
useless by a dense corneal opacity ; to improve some forms of 
disease in corneal and scleral staphylomata ; to diminish intra- 
ocular pressure as a relief for glaucoma ; to enhance vision in 
lateral displacements and partial opacities of the lens and 118 
Diseases of the Ete. 
capsule; to assist in various cataract operations ; and to ex- 
pedite the removal of foreign bodies embedded or entangled 
in the iris. 
The instrume»ts required to perform iridectomy are a 
straight and curved lance-shaped knife, a slender iris hook, 
and delicate and slightly curved forceps and scissors. Toothed 
forceps, to answer as an ophthalmostat, are needed when the 
eye rolls upward, to seize the conjunctiva below the cornea 
and fix the globe. The loose conjunctiva of old subjectsis 
easily torn, therefore the teeth of the forceps should be long 
and sharp to reach the tendinous expansion of the muscles. 
Children and restless patients should be quieted by anaesthesia. 
One eye being closed with a protective bandage, an assistant 
holds the lids of the other eye open, and the patient occupies 
a recumbent position. The operation is divided into two quite 
different steps : the first embraces the corneal incision which 
Fig. 35. 
Incision being made in the cornea with a lance pointed instrument. 
is from two to two and a half lines long; the second consists 
in drawing out and excising the piece of iris to be removed. 
Stellwag says: " The incision in the cornea should always 
be made perpendicular to the meridian of the piece of iris to 
be cut out. Where the iridectomy aims at making a way for 
the rays of light, and where a somewhat central pupil may 
be made, the incision should fall a little outside of the middle 
of the corneal curvature. But where we are obliged to con- 
tent ourselves with more of an eccentric pupil, it is best to 
make one incision a quarter of a line from the border of the 
cornea, in order that the remaining peripheral portion of the The Iris. 
119 
iris may intercept the outermost peripheral rays. Where 
there is only a small space for the pupil on the corneal border, 
we should cut into the sclerotica about half a line from the 
margin of the cornea, and carry the knife in such a way that 
it enters the chamber exactly at the ciliary margin of the 
iris. The firm adherence to this rule is of the greatest 
importance in those cases in which the iridectomy is intended 
to influence in a remedial way the circulation and nutrition 
in the interior of the eye. If under such circumstances the 
incision is made within the corneal border, the operation is 
always fruitless. The knife should then be held obliquely 
when it is entered into the sclerotica. If, however, the inci- 
sion is made in the cornea, the instrument should penetrate 
almost vertically through it, and as soon as it has entered the 
aqueous chamber it should be immediately turned, and its 
point pushed as far between the iris and the membrane of 
Descemet as the required 
length of the incision 
may demand." The knife 
should be withdrawn 
gradually to avoid a gush 
of the aqueous and a 
sudden relaxation of the 
globe, which might en- 
danger intraocular hem- 
orrhage. 
" The second step in 
the operation always re- 
quires both hands of the 
operator. One hand uses 
the forceps, the other the 
scissors. The forceps should be held very lightly, and care- 
fully placed in the corneal wound, with the convexity toward 
the globe, and carefully pushed forward to very near the 
pupillary margin of the piece of iris to be cut out. Then 
they are to be opened, just wide enough for the breadth in- 
tended of the artificial pupil. As soon as this portion of the 
iris near the pupillary margin is fairly and certainly seized, 
it is separated by delicate and gradual traction from any 
existing adhesions, and slowly drawn out with forceps. 
During this, the scissors are placed with the convexity of 
Fig. 36. 
A piece of iris drawn through the corneal in- 
cision, is about to be excised with scissors. 120 
Diseases of the Eye. 
their blades flat upon the globe, and as soon as a sufficiently 
large portion of the iris appears to be drawn forward, it is 
quickly cut off close to the edge of the corneal wound." 
The dressing consists of a compress made of three layers 
of lint or jeweler's wadding, secured in place with a flannel 
bandage. The eye-bandage of Liebreich is a convenient 
holder of the compress. The part with the oval opening in 
it rests upon the back of the head, and the knitted belt 
Fig. 37. 
covers the eyes. The bandage may be worn for a number of 
days, or until the wound in the cornea has healed, and active 
inflammation has subsided. 
As a general thing a small artificial pupil is preferable to a 
large one; and especially if all the cornea in front of it be 
transparent. Should a corneal opacity be in the way of a 
direct transmission of light, a large aperture is often desirable. 
A clear cornea, to get rid of dazzling sensations, should 
have the artificial pupil made upward ; and central opacities 
call for excision of the interior and lower quadrant of the 
iris. If one operation does not accomplish all that can 
reasonably be expected, a second is in order, and with such 
modifications as the peculiarities of the case indicate. 
To remove a piece of the iris including a foreign body, 
requires considerable tact. The incision with the lance- 
shaped knife is to be made in the cornea near its margin, the 
place selected being near the foreign body. That part of the 
iris embracing the extraneous substance is to be carefully 
grasped with forceps and deftly dragged through the wound, 
when excision with scissors is practicable. Such operations 
are frequently attended with considerable hemorrhage into 
the anterior chamber, yet disastrous results rarely follow this 
complication. The blood is in time decomposed and absorbed. 
The foreign body may be inclosed in a capsule of exuded 
Eye-bandage. The Iris. 
121 
lymph, and remain undiscovered until the excised piece of 
iris is dissected. Sometimes, from intraocular pressure, the 
portion of iris enveloping the foreign body, will protrude 
through the wound in the cornea as soon as the incising 
knife is withdrawn. In such an event the prolapsed iris may 
be seized with forceps and excised. A delicate spatula 
readily returns any protruding portions of iris, and then the 
eye needs the after-treatment usually following iridectomy. 
The compress of lint may be changed every day, and the 
pressure of the retentive bandage regulated to suit conditions. 
If there be intraocular hemorrhage, a greater pressure is 
required than when this complication is absent. Children 
and intractable patients, who may push a bandage to one side, 
may have the lint compresses held in position with adhesive 
strips. 
In the execution of iridectomy the lance-shaped knife is to 
be so directed in its course that the part of the iris to be 
seized can be grasped with the forceps or hook without rub- 
bing the walls of the corneal wound, or rolling the thin and 
oblique edge outwards when the iris is being dragged through 
the wound. It will be perceived, upon considering the curves 
of the cornea, that if the blade of the knife enter the anterior 
chamber near the margin of the cornea, and be directed to- 
wards the ordinary place occupied by the pupil, the walls of 
the wound will be nearer perpendicular to the planes of the 
cornea, than a casual observer might suppose. 
Whether a hook or forceps be used to seize the iris, care 
must be exercised not to injure the capsule of the lens, or 
cataract may follow the accident. 
During the operation of dragging out the iris, it is perplex- 
ing to have this membrane tear. The lacerated wound will 
bleed, and the blood obscures the rest of the operation. 
In cases of posterior synechia it is difficult to avoid injury 
to the capsule ; and if the pupillary border is attached to the 
capsule, an intervening band of iris will remain between the 
real and artificial pupils. This may do no serious harm, yet 
it is generally best to break the bridge with a blunt hook, 
converting the two pupils into one. The remaining behind 
of the uveal layer of pigmentary matter-necessitated per- 
haps by posterior synechia-is a misfortune which may defeat 
the purposes of iridectomy, unless the obstruction can be 122 
Diseases of the Eye. 
seized and removed at the time, or at a subsequent operation. 
Should a restive state of the patient during the progress of 
the operation result in a detachment of the iris from the 
ciliary ligament, the loosened part should be excised, even if 
the artificial pupil be unduly and unseemingly large. 
Entire closure of the artificial pupil from inflammatory 
deposits, is possible ; and in the event of iter occurrence, a 
second operation may prove successful. 
Detachment of the retina from the choroid, opacity of the 
lens, escape of the vitreous, and other accidents have accom- 
panied and followed iridectomy, yet unfortunate results are 
uncommon. 
As a rule it is not desirable to operate for artificial pupil 
when the other eye is perfect; and an active state of iritis 
should be regarded as a valid reason for deferring an opera- 
tion. An iris thickened from chronic inflammation, or thinned 
from atrophy, is not a favorable one to attack. It may bleed 
too freely, or tear during attempts to bring it through the 
wound. 
Some operators prefer to bring the iris out of a corneal 
incision with a delicate hook invented by Mr. Tyrrell. The 
objections to the method are that the hook is likely to tear 
the iris, and to catch the walls of the wound while being 
removed. 
It is generally best to perform iridectomy without chloro- 
form, though in some instances anaesthesia is indispensable. 
A spring speculum and fixation forceps are needed to hold 
open the lids and prevent the globe from rolling. The opera- 
tion is not very painful, but the dread is great. 
A sedative may be needed from time to time after an opera- 
tion, especially at night, and the diet should be plain to avert 
a high grade of inflammatory fever. Mydriatics are to be 
employed during the process of reparation ; and the forehead 
and parts about the traumatic eye bathed often with a tincture 
of aconite root. The bowels are to be moved every day or 
two with mild cathartics. A state of repose is to be enjoined ; 
and a proper amount of sleep favored. Tinted glasses may 
be worn for awhile after the patient has begun to go out of 
doors. 
Corelysis.-When the pupillary margin of the iris has be- 
come adherent to the capsule of the lens, the separation of The Iris. 
123 
theadventitious attachments is sometimes practicable. Such 
an operation is called corelysis, and may be performed as 
follows: An incision is made in the cornea near its outer 
periphery with a lance-shaped knife; and through this wound 
a hook is carried, and made to break up the adhesions. The 
eye is prepared for the operation by the free use of mydri- 
atics; and atropine should be used for several days after the 
operation. Fixation of the globe and anaesthesia are neces- 
sary to execute the manoeuvre tute et jucunde. Great care is' 
to be exercised in the manipulation of the hook, or the cap- 
sule will be injured. The after-treatment is like that of iri- 
dectomy, except in regard to the more frequent use of mydri- 
atics. 
Iridodesis.-The transformation of the pupil into an 
elongated slit, by securing a fold of the iris in a corneal 
wound by means of a ligature, is called iridodesis; and, 
according to Stellwag, may be performed as follows : " A 
fine silk or linen thread is introduced through the limbus con- 
junctivalis of the proper portion of the corneal margin, by 
means of a delicate curved needle. Its ends are for the time 
laid upon the forehead and cheek. Then an incision exactly 
as in iridectomy is made in the cornea, close to the conjunc- 
tival ridge. The thread is then made into a loop, and Fischer's 
forceps are introduced through this into the chamber. The 
iris is seized near the pupillary margin, and a portion of it is 
drawn out of the wound. The loop is then tied, and the pro- 
lapsed portion is then fixed. Of course, the ends of the 
thread are then cut off. The operation is best performed 
with the patient under the influence of an anaesthetic. The 
globe should always be fixed. One assistant holds one of the 
lids open, and with the other hand draws one end of the 
thread, when it is required to be tied. The operator, while 
holding the forceps with one hand holds the other lid with 
the ring and middle fingers of the other hand, at the same 
time drawing the thread with the index-finger and thumb of 
this same hand engaged in holding the second lid. A second 
assistant fixes the globe. 
The after-treatment is like that of iridectomy. The loop 
generally falls off in about twrenty-four hours ; sometimes it 
remains, and should then be removed. The reaction is gener- 
ally very slight, and causes no danger." Diseases of the Eye. 
124 
Iridodesis is performed to bring some portion of the pupil 
behind a transparent portion of cornea, to improve vision, 
though at a sacrifice of personal appearance. The same may 
be said in regard to iridectomy, unless the coloboma be made 
upwards, so the upper lid may hide the deformity. 
THE LEHS. 
The crystalline lens is a double convex or disc-shaped body, 
about a third of an inch in its widest (transverse) diameter, 
and about a quarter of an inch in its antero-posterior diame- 
ter. Its anterior surface, which is the less convex, bulges into 
the pupil somewhat in front of the plane of the iris; and its 
posterior surface, which is the more convex, is embedded in a 
cup-like excavation of the vitreous humor. In early life the 
lens and its capsule are perfectly transparent; but at the age 
of thirty-five or forty, a period not unfrequently marked by 
a decline in the visual powers, it begins to take on a yellowish 
tinge which in old subjects attains an amber hue. 
The lens is composed of a series of concentric layers en- 
closed in each other like an onion, a nucleus constituting the 
centre. The capsule, though exceedingly attenuated, is suffi- 
ciently dense and elastic to exert a compressing force upon the 
enclosed mass. The anterior half of the capsule is thicker 
than the posterior, and offers considerable resistance to blunt 
instruments, yet a rent started by a sharp instrument may 
voluntarily extend to the zonula, and allow the lens to escape. 
This hyaline envelop transmits nourishment to the lens from 
the aqueous and vitreous humors, the enclosed organ having 
neither blood vessels nor nerves. 
The lens is held in place by the ciliary processes which 
form a peripheral clasp for its rounded border. These pro- 
cesses, sixty to eighty in number, and having pigment upon 
them, belong to the choroid, and serve to connect that mem- 
brane to the suspensory ligament of the lens. The ciliary 
ligament is a ring or band of fibrous material, whitish in 
color, which connects the peripheral border of the iris to the 
cornea, choroid and sclerotic, binding them all together, and 
giving attachment to the ciliary muscle which reaches from The Lens. 
125 
it to the ligament of the lens and ciliary processes. The 
ciliary muscle is of unstriped fibre, consequently is not under 
the influence of the will. By the action of the muscle the 
lens is drawn forwards, so that the eye is adjusted to the 
viewing of near objects. The elasticity of the ciliary pro- 
cesses will return the lens to its normal position. It is possi- 
ble that the lens is rendered more convex by the action of the 
ciliary fhuscle. If this be so, an increase in the accommoda- 
ting power is obtained. 
The function of the lens is to refract the rays of light which 
have passed through the pupil, converging them to an accu- 
rate focus at the surface of the retina. After the lens is 
removed in a cataract operation, a double'convex glass is used 
in front of the eye to compensate for the loss of the refract- 
ing body. 
CATARACT. 
•Cataract is a term used to denote a partial or complete 
opacity of the lens or its capsule. The opacity may depend 
upon faulty nutrition and atrophy, and upon inflammatory 
deposits among the layers of the lens. Not unfrequently 
fatty and earthy materials in the substance of the lens con- 
stitute the opacity. In some instances the cataractous changes 
proceed from the nucleus, though not so frequently as from 
the superficial layers of the lens. In rare instances a nuclear 
and cortical degeneration are observed at the same time. A 
cortical opacity has been termed soft, and a nuclear hard, 
though with not much regard for accuracy. A nuclear cata- 
ract is not always more dense than ordinary lens tissue, nor 
is cortical cataract necessarily soft. 
It is not uncommon for the outer layers of the lens to be- 
come opaque, and the capsule to participate in the changes, 
constituting capsulo-lenticular cataract. As a rule, however, 
the cataractous change is intracapsular, and affects only the 
lens-substance. 
Congenital cataracts are frequently milky not only in hue 
but consistence. Those which form later in life may contain 
cholesterin "which glistens through the opaque capsule with 
a peculiar mother-of-pearl or silvery-like lustre," though the 
chief part of the capsular contents may be fatty and chalky. 
Diagnosis.-The detection of cataract depends chiefly upon 126 
Diseases of the Eye. 
a careful examination of the lens. The experienced observer 
sees the whitened lens at a glance. He recognizes at once the 
normal lustre and transparency of the cornea, and the tints of 
the iris. Looking through the pupillary aperture he dis- 
covers the hazy or cloudy lens, which seems to be in the way 
of that lustrous blackness usually observable beyond the 
pupil, in the deep cavity of the eye. An oblique or side view 
while peering into the eye, is often necessary while making 
an examination, as a reflected light from the retina may for a 
moment resemble the opacity of cataract. 
Having made long journeys with the object of operating 
for the relief of cataract, and at my destination found nothing 
but a disorganized cornea, the physician calling me having 
made a mistake in the diagnosis, I hope I shall be excused 
for impressing what otherwise might seem an absurd point. 
If a physician can not distinguish between an opaque cornea 
and an opaque lens, he should not assume the responsibility of 
sending his patient to an oculist for an operation. If any 
practitioner entertains the preposterous notion that cataract 
is a " film " growing over the " sight " (cornea ?), let him at 
once post himself in regard to the great anatomical divisions 
of the eye. 
After the opacity has been examined casually, to determine 
that cataract exists, the pupil should be dilated in order to 
bring into view the greater part of the disordered lens. 
Shading the eye for a few minutes with the hand, will secure 
moderate dilatation of the pupil, but this is usually not suffi- 
cient. Two grains of the 'neutral sulphate of atropia to an 
ounce of distilled water constitute a good mydriatic. A few 
drops of the solution are to be let fall into the cup formed by 
drawing the lower lid away from the globe ; then the lids are 
to be kept closed for fifteen or twenty minutes. The patient, 
after the pupil is fully dilated, should be placed to a window 
admitting bright daylight-not sunlight-and care should be 
taken that reflections from other window's, mirrors, and 
polished surfaces do not interfere with the inspection. A con- 
cave glass of an inch focus may be used as a condenser, to 
concentrate light upon the patient's lens, while it is explored 
with the naked eye. By this method of examination faint 
streaks of opacity may be detected, and a cortical or nuclear 
condition of the cataractous body determined. The Lens. 
127 
With the aid of a pocket lens and oblique illumination the 
observer may recognize radiated striation, laminated opacity, 
cloudy or indistinct points, atrophy or decrease in the size of 
the crystalline, nuclear or cortical transformations, a tremu- 
lous iris, and other phenomena which go to make up the 
symptoms of cataract in its varied phases. If the iris at its 
pupillary margin be drawn backward and appear funnel- 
shaped, a shrunken cataract is logically presumed. 
A partially cataractous lens absorbs and diffuses the rays of 
light, rendering vision more or less indistinct. The distorted 
curvatures of the lens refract irregularly, and disperse light. 
There are degrees of blindness produced by cataract, the 
visual disturbance depending much upon the condition of the 
lens. Persons with unripe nuclear or laminated cataracts 
make out large objects at a moderate distance quite well, and 
read large type, especially with suitably adjusted spectacles. 
Although patients affected with forming cataracts need the 
objects viewed to be placed in a good light, they are least 
annoyed, or most comfortable, in twilight and cloudy days. 
When the eyes are shaded, in nuclear cataract, the pupil 
dilates and lets the light through the pelucid periphery of the 
lens, rendering vision quite tolerable. But when the opacity 
has extended to the border of the lens, the cataract is ripe or 
complete, and the retina is shut off from the images of ex- 
ternal objects. The wrinkling of the capsule in shrunken 
cataracts is a source of very decided visual disturbance. 
During the formation of cataract it is not uncommon for 
material changes to take place in the deeper structures of the 
eye, such as attend retinitis, choroiditis, etc., establishing a 
state of affairs which exist in amaurosis. It is therefore 
necessary before operating in any case to ascertain if possible 
the condition of the retina, especially in regard to its sensi- 
tiveness to light. The amblyopia of monocular cataracts 
developed during childhood may come from disuse; and 
gradually pass off after an operation. 
The sensitiveness of the visual nerves can not always be 
estimated by the movements of the pupil under the influence 
of light or mydriatics, for the pupillary margin of the iris 
may be fixed by posterior synechia. If amblyopia be com- 
plicated with cataract, the light of an ordinary lamp in a 
dark room can not be perceived at a distance of ten or fifteen 128 
Diseases of the Eye. 
feet, as it may be in most cases of uncomplicated cataract. 
The functional activity of the retina and optic nerve can be 
tested with colored lights exposed at different distances. The 
range of the visual field is to be ascertained by moving a 
light at different distances before the eye, and questioning the 
patient in regard to the grade of impressions produced. 
Congenital Cataract.-There are various degrees in con- 
genital cataract, the slightest form being a white central spot 
or dot on the anterior face of the lens, just within the capsule. 
This defect is so unimportant that, if the rest of the lens 
remain transparent, this cataractous dot should not be sub- 
jected to an operation. Sometimes the central dot projects 
forwards, like an obtuse white cone, and seems to intrude 
upon the pupillary aperture, appearing to be capsular while 
in reality it is a part of the lens. 
A common form of congenital cataract is where the nucleus 
is opaque, and around it is a transparent ring which admits 
the passage of more or less light, especially when the pupil is 
dilated. To an inexperienced observer this cataractous centre 
appears like a shrunken lens, and the dark surrounding to be 
the result of the contracting process. If not operated upon 
in childhood this ring-like peripheral border will at length 
become opaque. 
A rarer form of cataractous defect is where the nucleus is 
not wholly opaque, but faintly striated. This condition may 
pass unobserved, until the patient, when sent to school, is 
found unable to read in ordinary type. Occasionally the 
defective vision will depend upon a dotting of the lens with 
minute white specks. Congenital cataract is generally accom- 
panied by a rhythmical twitching and rolling of the eyeballs, 
(nystagmus), though defective sight from other causes than 
opacity of the lens may be attended with unsteady move- 
ments of the recti and obliqui muscles. 
Scrofulous and carcinomatous deposits in the deeper struc- 
tures of the eye have the semblance of cataract, though a 
careful examination will detect the real nature of the disease. 
In an eye affected with uncomplicated cataract the position of 
the iris is vertical, unless rendered funnel-shaped by posterior 
synechia; and the pupil is active. In the early stages of a 
scrofulous or encephaloid disease the opacity can be seen The Lens. 
129 
behind the lens, though in time the lens may become involved, 
when for a season the diagnosis will be in doubt. In advanced 
stages of the scrofulous or encephaloid disorder, the iris is 
distorted, the pupil fixed, and the anterior chamber encroached 
upon. Congenital cataract almost invariably affects both eyes, 
while encephaloid disease as invariably finds lodgment in one 
eye. Congenital cataract is often associated with defective 
and crumbling teeth, which would lead to the supposition 
that the origin of the ocular defect is more constitutional 
than local. 
A congenital cataract is commonly soft, even milky in con- 
sistence, hence it can not well be removed by the operation 
of " extraction," but is dissipated by incising the capsule with 
a needle, and trusting to absorption for the removal of the 
liquid lens. 
A child blind with congenital cataract exhibits wonderful 
powers of feeling or palpation. The sense of touch is 
developed and educated to compensate for that of sight. 
Traumatic Cataract.-A blow which ruptures the capsule, 
or a shock which disturbs the nutrition of the lens, is liable 
to be followed by cataract. A penetrating wound which 
reaches the capsule is about sure to induce opacity or destruc- 
tion of the lens. If the aqueous humor come in contact with 
the lens through a rent in the capsule, it is apt to dissolve 
that body, so it may partly or wholly disappear. It was a 
knowledge of this fact that suggested the operation for the 
cure of cataract by solution. However, a wound of the cap- 
sule and partial absorption of the lens rarely result favorably. 
Some part of the lens remains, and becomes opaque from 
fatty degeneration. The capsule is thickened and distorted, 
the iris adheres to the disorganized lens and capsule, and the 
pupillary aperture is blocked up. Occasionally there is a 
deceptive appearance in regard to the pupillary opening. A 
patch of black pigment fixed in the whitish membrane which 
blocks up the pupil may appear to be a real aperture, and 
deceive the casual or inexperienced observer who very natu- 
rally supposes that considerable light may pass through the 
apparent opening. A pencil of light concentrated on the 
deceptive spot will dissipate any false impressions in regard 
to its character. Diseases of the Eye. 
130 
The shapes and states the capsule may take after it has been 
accidentally wounded have contributed not a little to a proper 
management of this membrane in operations for the cure of 
cataract. The capsule when wounded purposely, should be 
incised or lacerated in lines radiating from its centre, so that 
retractions towards the periphery may clear the axis of vision. 
An opaque portion which may block up the pupil, is a serious 
obstacle to vision. 
Dislocation of the lens into the anterior chamber is an 
accident of a traumatic nature. The cut of a whip, a kick, 
sudden concussion, or any direct force applied to the eye, may 
dislocate the lens, and lodge it between the iris and the cornea. 
The iris then appears pressed back, and the pupil is immova- 
bly dilated. The lens, if transparent, appears more spherical 
than natural, and its margin presents a ring of golden light 
in contrast with a shadowy ring behind its free border. Pain 
and inflammation rapidly follow displacement of the lens, and 
loss of the eye can be averted only by prompt removal of the 
lens through a suitable opening made in the cornea. 
A very severe force may tear the lens from its attachments 
and drive it into the vitreous body. Then active inflamma- 
tion of the inner parts of the eye quickly occurs, and the 
functional power of the eye is lost by changes in the retina 
and choroid. 
Rupture of the sclera may allow the lens to escape from its 
normal position and lodge beneath the conjunctiva. It is 
needless to say that the lens may be easily removed from this 
novel position, though the original injury may result disas- 
trously to vision. 
Senile Cataract, or Cataract in Advanced Life.-Declin- 
ing years favor the formation of cataract. Before the fiftieth 
year the eye resists opacity, but after 'that time, if the sight 
fail, cataract is to be suspected. The disease usually begins 
at the circumference of the lens, in the form of opaque striae, 
which gradually advance along the anterior and posterior 
faces of the lens towards its axis. In rare instances the 
cataract commences in the nucleus, and slowly extends to the 
periphery, years being consumed in maturing the morbid 
changes. 
Cataract appears first in one eye, and after developing there The Lens. 
131 
to a certain extent, the morbid process begins in the other 
eye. The rise and progress of the disease are about as follows : 
first, opaque striae appear at the extreme edge of the lens; 
these striae gradually coalesce'into patches and spread them- 
selves over the entire lens, the posterior face being commonly 
invaded first. At this point of development the cataract may 
remain stationary for months and even years. Then what 
may be called a secondary metamorphosis takes place, and 
the w'hole body of the lens grows hazy, though the anterior 
surface may resist encroachment still longer. At length the 
entire lens becomes involved, and total blindness results. The 
stride disappear from disintegration of the superficial fibres, 
and deposits of earthy and fatty materials impart to the lens 
a yellowish white appearance. 
Occasionally a cataract forms without the opacity being 
white, say, of a dull brownish hue, and then the true nature 
of the difficulty is not so readily detected. An exceedingly 
rare form of lenticular opacity is that called "black cataract." 
The blackness is not always demonstrated until the lens is 
extracted, though it may be observed as a dark opacity while 
in the eye. There is no danger of confounding it with the 
blackness of the pupil in a healthy eye, in which all the 
humors are perfectly clear. 
Some cataracts are fluid from the beginning, or become so 
in the course of time. They usually present a bluish, milk- 
and-water hue, though a grayish, or pale yellow tint, like that 
of cream, has been observed. There is no propriety in calling 
them " Morgagnian cataracts," for there is no liquor morgagni 
in the human eye. Fluid cataracts are perhaps fuller than 
those which are hard, and therefore may press the iris slightly 
forward, but this sign can not be depended upon. The fluidity 
is often not suspected until an operation reveals the true con- 
dition. The alleged gravitation of the denser material to the 
bottom, and a floating of the lighter ones, can not be relied 
upon as signs of fluid cataract. 
Treatment of Cataract.-Thus far therapeutic measures have 
proved impotent in the treatment of cataract. The vagrant 
oculist, who has not the skill and courage to perform an opera- 
tion, occasionally imposes upon the credulous by employing 
atropia to dilate the pupil, thereby temporarily letting more 
light through the borders of a lens somewhat translucent at 132 
Diseases of the Eye. 
the periphery, and by using a scientific-looking galvanic bat- 
tery to divert attention from professional incapacity; but the 
accomplished eye surgeon never pretends by medical treat- 
ment to turn opaque lenses into clear ones. It is quite doubt- 
ful if any known agency will even stay the progress of a form- 
ing cataract. It is possible that preventive measures may 
avert cataract, for a time at least, in those predisposed to it. 
The abandonment of employments which require acute vision 
at short distances, such as, long-continued reading, writing, 
sewing, etc., and the wearing of broad-brimmed hats, eye- 
shades, etc., to keep off direct sun or artificial light, would 
certainly be rational. 
All cataracts are not fit to be operated upon. As long as 
one eye is serviceable, an operation upon the other is, as a 
general rule, unadvisable. An unforeseen or unexpected 
accident may result in the loss of sight in both eyes. How- 
ever, patients with monocular cataracts, after being informed 
of the dangers an operation portends to the sound eye, have 
demanded an operation to get rid of the cataractous deformity. 
Old adhesions between the pupillary margin and the ante- 
rior capsule, a bulging forward of the lens and iris against 
the cornea, an irregularly dilated and fixed pupil, disorgani- 
zation of the cornea, and total loss of power to perceive light, 
are among the more striking conditions which render it ques- 
tionable whether an operation promises relief, or a result likely 
to be satisfactory. A patient with no other ocular defect than 
an opaque lens, can not only perceive the shadow of a pass- 
ing hand, but with the back to a window can perceive the 
light reflected from a sheet of paper. 
If, then, a patient have some perceptive power (which 
ensures a sound retina), an iris maintaining its vertical plane, 
a pupil round and active, a brilliant cornea, and an unim- 
paired motory apparatus of the eye, the cataract is logically 
suitable for operative treatment. The freedom of the iris 
from concealed attachments to the capsule, can be tested with 
atropia. An eye which has passed through inflammatory 
attacks and is therefore unfit for operative interference, can 
be recognized by a variety of peculiarities not easily described. 
The propriety of operating in some cases is determined more 
by empirical impressions than by written rules. 
It is a question among ophthalmic surgeons, whether in The Lens. 
133 
binocular cataract both eyes should be operated upon at one 
sitting. If every condition is favorable there is no valid ob- 
jection to the double operation ; but in many cases there will 
exist some modifying circumstance which must exert its in- 
fluence. Not unfrequently considerable visual power still 
resides in one eye, therefore the degree of functional impair- 
ment must be considered. Although partial corneal opacities 
and pupillary attachments do not necessarily forbid a double 
operation, they constitute conditions which ought not to be 
overlooked. If one eye can probably be saved if operated 
upon alone, and a double operation would endanger both 
through sympathy or excess of inflammation, the single 
operation alone is indicated. 
Patients affected with gout, syphilis, habitual headaches, 
neuralgias, and severe nasal catarrhs, are uninviting subjects 
for cataract operations. 
The age of a patient is not a serious obstacle to operative 
interference. Infants may be operated upon for the relief of 
congenital cataracts, and the aged may endure an operation 
well. 
Patients with favorable surroundings may undergo an 
operation at any time of year, though extremes of heat and 
cold should be avoided. 
An operation having been decided upon, the choice of 
methods for each particular case is to be made. The proce- 
dure which promises to remove the cataract from the axis of 
vision with the greatest ease and least danger, is to be adopted. 
Fluid and pulpy cataracts, without hard centres, may be 
gotten rid of by solution (division or discission-needle operations.') 
The edges of the incised or lacerated capsdlewill retract, and 
let the aqueous humor in contact with the opaque lens. The 
iris is to be kept away from the capsule by the prolonged 
use of mydriatics. Congenital. cataracts are apt to be fluid, 
and are therefore fittest for a needle operation. In many 
instances the operation has to be repeated from time to time 
to bring the aqueous humor in contact with parts of the lens 
which are hard, or have been protected by uncut or untorn 
portions of the capsule. 
As the operation by discission is a very unsatisfactory one, 
it is now considered best to remove even fluid cataracts 
through a linear corneal wound, a delicate spoon being used 134 
Diseases of the Eye. 
to scoop out any fragments which may remain within the 
capsule. 
The dangers of a corneal wound consist in prolapse of the 
iris, and the loss of more or less of the vitreous in unruly 
patients. Anaesthesia subdues the patient during the opera- 
tion, yet the nausea and vomiting which frequently follow 
endanger secondary prolapse of the iris and vitreous. 
The ripe and firm cataracts of adults are to be removed by 
extraction through wounds made in the cornea or sclera, with 
or without iridectomy. As a variety of methods are in 
reputable use, it will require considerable space to describe 
them. 
Cataract Operations.-There are three general terms used 
to express the methods which have a history in operations 
for cataract, viz : depression, solution and extraction. 
The lodging of the opaque lens in the vitreous humor, 
below the axis of vision, is an obsolescent operation which 
bears the name of depression. When this operation was the 
only one known for the treatment of cataract it was consid- 
ered a triumph of surgi- 
cal skill. So instantane- 
ous the benefit conferred, 
and so trifling the pain 
inflicted, that it is not 
altogether strange the 
operation seemed to the 
inexperienced as a fine 
piece of jugglery. The 
operation was performed 
as follows : The needle 
was introduced through 
the sclera about a line 
from the border of the 
cornea, a little above or 
below the equator, and 
was carried between the iris and the lens until the point could 
be seen through the pupil, and then the flattened needle-point 
w'as made to push the lens backwards and downwards until it 
disappeared i-n the vitreous below the axis of vision. The 
best operators were careful not to force the lens upon the 
retina or ciliary processes. The position of the lens appears 
Fig. 38. 
One method of performing a "needle operation." The Lens. 
135 
very neat in the diagrams made to represent where it should 
rest, but there is no assurance or probability that the displaced 
lens would stay where it was thrust, even if fortunately placed. 
Certain it is that the displaced lens very frequently excited a 
destructive inflammation by pressure upon the retina, ciliary 
processes or iris. In some instances the depressed lens would 
rise to its original position and re-obstruct the passage of 
light to the retina. 
Reclination.-To avoid the difficulties following depression, 
an attempt was made to improve the operation by reclination, 
as it was called, the lens, instead of being forced directly 
downwards, was pressed downwards, backwards, and a little 
outwards, its anterior surface facing upwards. If the opaque 
lens proved too soft for couching, the needle-point would 
lacerate the capsule, thereby allowing the aqueous humor to 
effect solution. 
Other operators, finding that the elasticity of the healthy 
vitreous humor was an obstacle to the passage of the lens 
through it, suggested that the needle should first be passed to 
the spot where the lens was finally to be lodged, and that a 
bed should there be prepared for it by the disintegration and 
breaking-up of the cells of the vitreous humor; and to this 
bed (couch) the lens was finally to be conducted by the needle 
applied to its anterior surface. This was very ingenious in 
theory, but practically no superiority was gained over depres- 
sion or reclination. The patient may have been delighted 
because temporary sight was restored, but disappointment 
followed as soon as inflammation set in. 
Operation by Solution or Absorption.-In this operation, 
which is a modification of that by depression and reclination, 
it is proposed to break up the lens, and hope for its disappear- 
ance by solution, the aqueous humor exerting the dissolving 
influence. It was once supposed that the more completely 
the lens was broken up at first, the quicker and the more 
thoroughly would absorption go on ; therefore the term dis- 
cission was applied to the cutting-up operation. It is now 
known that the dissolving method is progressive, that is, it 
should be accomplished at several sittings. At first the cap- 
sule is to be lacerated, then after a few weeks have elapsed, 136 
Diseases of the Eye. 
the lens is to be punctured or incised, and finally undissolved 
parts of the lens are to be attacked. However, the process is 
so tedious and wearisome, the more rapid cure by extraction 
is to be preferred. The operation by " division " is best 
adapted to the soft or liquid cataracts of childhood ; and the 
needle better be carried through the cornea than the sclera, 
the point of entrance being 
selected away from the axis of 
vision. In cases of congenital 
cataract the operation may be 
performed upon a child before 
it has arrived at the age of 
teething. 
Different operators prefer 
different shaped needles. The 
escape of the aqueous is pre- 
vented by what is called a 
" stop-needle," the shaft being 
made conical to stop the corneal 
hole the point (a slender one, 
not lance-shaped) has made J 
but the wedging of the shaft 
is an obstacle to the free move- 
ments of the needle's point. Not much of the aqueous is 
lost, even if a lance-shaped point be used, the shaft being con- 
structed in such proportions to the size of the opening as to 
fill it without moving under restraint. Some operators prefer 
a needle with a curved point and a cutting edge, especially 
for dividing the posterior wall of the capsule after the lens 
has been absorbed. 
All cataract operations are best performed with the patient 
lying down, the head being slightly elevated, and the couch 
so arranged in regard to a window as to secure a strong light. 
An assistant steadies the head of the patient, and with his 
fingers holds apart the lids, unless they be fixed with a spring 
speculum. Timid and refractory patients are difficult to 
govern, therefore the operator may have to steady the eye 
with forceps which are made to nip a fold of the conjunctiva 
just beneath the cornea. Toothed forceps should be at hand, 
which can be made to fix upon the sclera in the event the con- 
junctiva prove thin and easily torn. Keratonyxis-operation 
Fig. 39. 
Needleoperationm.de throughch« cornea. The Lens. 
137 
through the cornea, is preferable to scleroticonyxis, or puncture 
through the sclera. In the former operation the point of the 
instrument is always kept in view ; and the scar left in the 
cornea is insignificant. The needle is made to enter the 
anterior chamber perpendicularly to the plane of the cornea, 
after the pupil has been well dilated wTith mydriatics, and 
then the point of the instrument is carried directly to the 
centre of the anterior wall of the capsule, when this mem- 
brane is to be lacerated in various directions, and the body of 
the lens pierced so as to cut the posterior capsular wall. 
Congenital cataracts permit of more discission than those of 
adults. The liquid cataracts of infants will frequently spurt 
their contents into the anterior chamber as soon as the cap- 
sule is slit with a needle, the contents of the lens being like 
wThey and granules of curd. The heavier portions gravitate 
to the bottom of the chambers, and would seemingly excite 
destructive inflammation, though such in fact is not usually 
the result. 
In an infant with congenital cataract, both eyes may be 
operated upon at once ; but in an adult, with one cataract 
more ripe than the other, the riper should be operated on at 
one time, and the other eye left for another occasion. The 
patient is thus left with one partially useful eye, while the 
process of solution in the other is going on. 
After an operation both eyes should be kept closed by 
means of a light bandage, or strips of plaster; and the patient 
managed in every respect so as to avert inflammation. In a 
week or two it can be seen what the operation and its sequences 
have effected. It is well to keep the pupil dilated for a few 
days following the operation ; and to administer a cathartic 
a day or two before the operation. It is not necessary to 
employ an anfesthetic, unless the patient be extremely refrac- 
tory. A child can be well wrapped in a shawl, and then 
held without much difficulty. Sometimes the parents pre- 
suming the pain is greater than it really is, demand that an 
anaesthetic' be administered. 
If the lens, when attacked with the needle, is found to be 
hard or of firm consistence, the capsule may be torn and the 
lens moderately incised, though in adults care should be ex- 
ercised not to set free any considerable pieces, lest they excite 
dangerous inflammation. It is well to extract a lens at once, 138 
Diseases of the Eye. 
after it is found to be hard. If a repeated needle operation 
be tried, there is no unvarying period that must intervene 
between repetitions. In children it may be best to wait 
months to ascertain what the absorptive processes may accom- 
plish. In an adult a few weeks may elapse between opera- 
tions. 
It is not unfrequent for nausea to follow a needle operation, 
especially if a detached portion of the lens rest against the 
iris; and attacks of neuralgia afflict patients predisposed 
to nervous disorders. The nausea may be combatted, when 
prolonged, by swallowing bits of ice, and the neuralgia may 
be subdued by the use of aconite and chloroform liniments 
around the eyes. 
Operation by Extraction-Flap Operation.-The solution 
and absorption of a cataract in adults constitute so slow and 
unsatisfactory a process, that the more rapid method by 
extraction was devised. This mode consists in removing the 
lens at once through an incision made in the cornea or sclera. 
There are several ways of executing extraction, which to be 
learned must be studied separately. I will describe first what 
is called the flap operation. This was an invention of Beer, 
and the knife devised for making the corneal section still 
bears his name. 
The introduction of better operative methods and means, 
was followed by as great improvements in therapeutic man- 
agement before and after the operation. Mr. Dixon, a dis- 
tinguished English ophthalmologist says, in referring to the 
course pursued by the older oculists : " The astounding plan 
of after-treatment which so long prevailed, and the remains 
of which still linger among us, makes us wonder, not that so 
many eyes were formerly lost after extraction, but that any 
were saved. Low diet, carried to the ver^e of starvation- 
profuse bleeding, both general and local-active purging and 
mercurialization, and long confinement to dark rooms-formed 
a course of discipline by which surgeons hoped to heal a 
wound inflicted on a structure devoid of blood vessels, and 
peculiarly liable, therefore, to slough or ulcerate whenever its 
vitality was lowered by any exhausting agencies. These 
surgeons saw the cornea die in persons worn out with scarlet 
fever, erysipelas, small pox or typhus; and yet, in the after- The Lens. 
139 
treatment of extraction, they seemed bent upon reducing the 
patient as near as possible to the same condition as those dis- 
eases would have done." 
Although the flap operation as once performed is almost 
wholly superceded by " linear " or " modified linear extrac- 
tion," there are cases in which it may still be performed with 
as much success as some of the later " approved " methods. 
The objections to it are that the thin edge of the flap will not 
heal as readily as the perpendicular walls of a " linear " cut; 
and that the hard cataracts of advanced life can not be readily 
delivered through the pupil and the corueal wound. Or, if 
the delivery be accomplished a spoon can not be easily used 
to scoop out the portions left behind. 
The flap operation was formerly made downward, but the 
objection being raised that the edge of the lower lid inter- 
fered with the wound, a change was instituted to a section 
upward. The operation is made as follows : after the pupil 
Fig. 40. 
Flap operation ; Beer's knife making a section of the cornea. 
has been dilated the operator, leaning over the recumbent 
patient, enters the triangular knife of Beer on the temporal 
side of the cornea, carries it across the anterior chamber and 
through the cornea on the nasal side, and then far enough in 
the same general course for the apex of the blade to complete 
the section. The flap thus made constitutes more than one- 
third of the cornea; and though the incison is made close to 
the corneo-scleral junction, both edges of the wound are 
wholly of corneal tissue. The point of the knife enters the 
anterior chamber perpendicularly to the plane of the arched 140 
Diseases of the Eye. 
cornea, so as not to split the layers of that structure, then as 
soon as the point of the instrument is seen, the knife is turned 
so as to pursue a course parallel to the plane of the iris. The 
counter-puncture is made on the same level with that of 
entrance. The knife has to pass through a chamber filled 
with fluid, and the escape of even a few drops would invite 
the elasticity of the eyeball to force the iris against the edge 
of the instrument, therefore the blade regularly increases in 
width and thickness from the point to the -widest cutting part. 
Such an instrument, if steadily carried in one direction, with- 
out rotation, completes the -wound at a single thrust, while its 
-wedge-like form prevents the premature escape of the aque- 
ous humor, and so lessens the danger of wounding the iris. 
An assistant raises the upper lid of the eye to be operated 
upon and the operator manages the lower while operating 
uponZhe left eye, the duties of managing the lids being 
reversed while operating upon the right eye. Forceps may 
be used to fix an unsteady eye, though little movement is left 
to the patient after the knife enters the cornea. As soon as 
the section is made great care must be exercised not to press 
out any portion of the vitreous body. After the flap is made, 
the patient should be allowed to close the lids for a minute to 
rest the organ and to prepare it for being steady while other 
parts of the operation go on ; then the operator lifts the 
upper lid and proceeds to lacerate the anterior capsule with a 
curved needle, a manoeuvre which should be accomplished 
without touching the iris. 
As near a crucial cut as practicable should be made in the 
capsule, each stroke of the needle point reaching across the 
area of the pupil. The laceration of the capsule requires a 
careful use of the needle; and when once executed the in- 
strument is to be withdrawn without entangling the iris, and 
the last act of the operation-the removal of the lens-per- 
formed. The lacerating needle (cystotome) is usually mounted 
in the same handle with Daviels's scoop or small spoon 
(curette), and with this placed upon the eye above the wound 
in the cornea, and the finger against the globe below, gentle 
pressure is made alternately by force imparted to the instru- 
ment and finger, which makes the lens turn on its transverse 
axis, the upper edge becoming tilted a little forwards, as it is 
inclined to do. As the lens revolves its upper edge engages The Lens. 
141 
in the pupil and readily glides into the wound, when, if the 
pressure on the globe be not moderated the delivery will be 
too rapid, endangering a gush of the vitreous. If the wound 
and pupil be large, and the lens small, the delivery will be 
easy and free; while if the wound be small, and the lens 
bulky and softened on its surface, a considerable quantity of 
lens matter will remain in the pupil and about the lips of the 
wound. 
The ready union of the corneal wound, upon which much 
of success depends, is favored by clearing away all soft lens 
matter which may adhere to the angles of the incision. 
The iris, which frequently protrudes, must be carefully 
returned with a small spatula. The emptying of the capsule 
being as complete as possible without thrusting in the spoon 
too often, an upward stroke of the scoop will adjust the 
corneal flap and bring the lips of the wound into apposition. 
The upper lid is then to be brought down by lifting it over 
the wound by the eye-lashes, so as to prevent the edge of the 
tarsus from catching against the projecting flap of cornea. 
The lids are then to be closed with strips of adhesive plaster 
or light compresses and a bandage. The loss of any of the 
vitreous humor is to be deplored, though the eye is not 
necessarily ruined. 
After the operation is completed there are several dangers 
to be apprehended. There may be hemorrhage, which occa- 
sionally sets in several hours after the operation. The danger 
is not from loss of blood, but from its presence among the 
humors, the effects of which are disastrous to vision. The 
corneal flap may slough, as another danger; the iris get into 
the wound as another; and destructive inflammation may 
follow a well executed operation. 
The wound in the cornea, under favorable circumstances, 
heals rapidly. Usually sufficient adhesion occurs in a few 
hours to retain the re-secreted aqueous, which soon restores 
the iris to its normal position. However, it requires several 
days for the healing process to make the union firm enough 
to withstand the intra-ocular pressure. During this time soft 
compresses of folded linen are held gently upon both eyes 
with a flannel or elastic bandage. It does no good to be 
peeping in to see what is going on. 
As soon as the operation is completed, including the dress- 142 
Diseases of the Eye. 
mg, it is well to administer to the patient a dose of chloral or 
morphia. This will allay the pain if it lias come on, or pre- 
vent it if not already set in. A repetition of the anodyne 
doses is to be governed by the pain. No more anodynes 
should be administered than the necessities of the case demand. 
It ought to have been mentioned that the bowels should be 
freely moved the day preceding the operation, and then a 
cathartic need not be employed for several days. The diet for 
a few days after the operation may be light yet nutritious 
and easily digested. If the appetite be poor it may be 
encouraged with acids and bitter tonics. Stimulants should 
be avoided unless the patient has been accustomed to them, 
where total abstinence would be worse than moderate indul- 
gence. 
The progress of the healing process is to be judged by the 
fluids escaping and by the appearance of the upper lid. If 
the discharge from the palpebral fissure be mostly tears and 
conjunctival mucus, and the upper lid be natural in hue and 
general appearance, the probabilities are that a satisfactory 
union is going on. 
An unfavorable sign after a season of restlessness is redness 
and swelling of the upper lid two or three days after the 
operation, attended with a puriform discharge from the palpe- 
bral sinuses. When the lid is raised, if the ocular conjunctiva 
be found injected and swelled (chemosis), the condition is not 
good. If the cornea is throughout yellow and opaque, and the 
wound is filled with bulging irides, vision is lost. . The flap 
sloughs in such cases, the eyeball shrinks, and sight is irrevo- 
cably gone. This unfortunate state of things is not always 
the fault of the operator. It may arise from defects peculiar 
to age, from cardiac troubles, and from fatty degeneration. 
If everything goes on favorably for four or five days after 
the operation, a successful result may reasonably be expected, 
though the eye should be kept in a bandage dressing for 
three or four days longer, and strong light is to be avoided 
for a week or more. During the period of convalescence 
gelseminum, hyosciamus, or kindred agents may be given at 
night, and bitter tonics in the daytime. 
A prolapse of the iris along the track of the corneal wound 
may not remain a permanent source of annoyance. A 
vesicular projection may be snipped off with scissors, when The Lens. 
143 
the cut surface blends with cicatricial corneal tissue, and is 
no longer troublesome. A delicate fistulous opening near a 
piece of prolapsed iris may drain away the aqueous fluid as 
fast as it is secreted, and become exhaustive in the end. 
Dr. J. R. Wolfe, Lecturer on Ophthalmic Surgery in the 
Aberdeen Medical School, has written a small work on " An 
Improved Method of Extraction of Cataract," in which the 
author claims an easy exit for the entire lens, without loss of 
the vitreous, by performing iridectomy several -weeks before 
the operation for extracting the lens is attempted. His object 
is to prepare in advance a large opening in the iris for the 
escape of the entire lens, without incurring a loss of the 
vitreous. After the iridectomy is executed, and the eye has 
fully recovered from the operation, a wound is made in the 
cornea with a knife much like Beer's, the section being essen 
tially that of the ordinary 11 flap operation." In traumatic 
cataract with dislocated lens, Wolfe performs iridectomy and 
extraction in one operation, the patient being under chloro- 
form ; but in all other cataracts he performs iridectomy, and, 
then, in about six weeks, extracts the lens through a corneal 
incision. He says : " I rather avoid doing both operations at 
the same time, because in some cases iridectomy can not be 
satisfactorily performed with a large opening-the corners of 
the section in the iris are apt to be invaginated in the corneal 
wound, thus giving rise to a larger pupil than the operator 
intended, which interferes subsequently with distinctness of 
vision-because the fresh wound of the iris may be irritated 
by the debris of the lens ; because the blood from the iris may 
conceal the lens from view, and so render its removal a sort 
of groping in the dark; and, finally, because when there is a 
glaucomatous tendency, or softening of the vitreous, the 
simultaneous performance of the two operations may cause 
internal haemorrhage or collapse of the eye. 
" As a rule, then, the eye.can more easily bear the opera- 
tion when thus divided into two periods, and the different 
stages of the operation can be performed with more regularity 
and precision. 
" In old people I perform iridectomy and the subsequent 
flap downwards, and find the optical effects perfectly satis- 
factory ; and in middle aged persons, where regard must be 
bad to appearances, I make them upwards. In either case I 144 
Diseases of the Eye. 
perform iridectomy exactly in the vertical meridian of the 
eye, so that the coloboma iridis shall correspond with the 
centre of the subsequent corneal section. The extraction is 
done as follows : 
" The patient being in a recumbent position upon a high 
couch, and the eyelids being held aside by an assistant, I stand 
behind the patient, operating with the right hand on the left 
eye and with the left hand on the right eye. 
Fig. 41. 
Wolfe's section of the cornea, iridectomy having been performed a few weeks previously. 
" 1. With the right hand I fix the globe with a pique de 
Pomaud, which I consider the most suitable instrument ; with 
the narrow Beer's knife in my right, I enter the external 
margin of the cornea close to its sclerotic junction, perpen- 
dicular to the surface, as if wishing to reach the iris, in order 
to prevent the knife running between the layers of the cornea, 
and also in a downward direction, after Graefe's example, in 
order to enlarge the internal opening. After the point is seen 
in the anterior chamber, I carry the handle backwards and 
pass to the counter-puncture, which is made directly opposite 
on the inner side. The points of puncture and counter- 
puncture are so made that the corneal flap extends to a line 
more than one-third of its circumference. The knife is then 
pushed on'in a plane parallel to the iris, until the corneal 
section is nearly completed, when its edge is inclined a little 
backward, so as to carry it under the conjunctiva, and it is 
then withdrawn, leaving a conjunctival bridge in the centre. 
" At this stage I take entire charge of the eye. My two The Lens. 
145 
fingers of the left hand serving the purpose of a speculum, I 
order the patient to look down, and introduce one blade of 
the probe-pointed scissors in the track of the knife, and, 
carrying it to the conjunctival flap, divide it. When opera- 
ting on the left eye I must here change my position, as the 
scissors can not conveniently be used with the left hand, and 
it is not advisable to divide the conjunctiva with the knife, as 
it is apt to peel off. 
" The capsule is then largely opened with the cystotome. 
To facilitate this process, gentle pressure with my fingers 
upon the ball is necessary to make the capsule tense. 
Fig. 42. 
Wolfe's section of the conjunctival flap with scissors. 
" After a few seconds' rest, I seize a fold of the upper eye- 
lid between my fingers, and the lower I depress with the other 
thumb, and, directing the patient to look down, I exercise 
pressure on the lower part, exactly in the vertical meridian 
facing the middle of the coloboma i ri dis, and with the other 
fingers through the eyelid I press upon the wound to make it 
gap, when the cataract advances through the corneal and 
conjunctival flap. 
"Due attention must be paid to this direction; pressure 
must be made at the point just indicated, otherwise the lens 
is pushed sidewise, and may rupture the hyaloid or damage 
the ciliary processes. This is, indeed, the most critical stage 
of the operation, for the surgeon must have his art literally 
at his fingers' ends. If inordinate pressure is used, the 
vitreous may come out, and the lens fall backwards. The 
pressure must be steady and graduated, and with due co- 146 
Diseases of the Eye. 
operation of both hands. If the cataract be found adherent 
(which can easily be diagnosed beforehand), I introduce the 
hook in the same manner as I introduce the cystotome, first 
in a horizontal direction ; with it I lacerate again the anterior 
capsule, to make sure that there is no impediment from that 
source; then I slip it flatly behind the lens, turn the point 
forwards, and draw the 
lens out. If cortical frag- 
ments remain behind, the 
ordinary friction and slid- 
ing manoeuvre, as adopted 
in Graefe's operation, is 
used to extrude them; 
should this fail a small 
curette is used." 
* * * * 
" The only objection 
that can fairly be made to 
this method-namely, that 
it makes two operations 
instead of one-may be 
met by the fact that 
Graefe's operation, in the hands of Prof. Arlt, has required 
subsequent operation in ten per cent. Of these secondary 
operations, according to Wecker, only fifty per cent, recover 
sight; if, therefore, two operations are to be performed, it is 
infinitely preferable that the secondary one should precede, 
and not follow, extraction. Besides which, it is frequently of 
essential importance to become acquainted with the habit of 
the patient's system, which we do during the previous iridec- 
tomy." 
Linear Extraction. - The operation of breaking-up soft 
cataracts, with a needle, and subsequently evacuating the 
pulpy mass through a small incision in the cornea, is called 
" linear extraction." The term is not well chosen, for it fails 
to accurately convey the intended meaning, namely, that the 
corneal wound is made in a straight line, in contradistinction 
to the crescentic wound made in ordinary extraction. " Recti- 
linear " would be the correct term, as implying that the wound 
is to be made straight. 
Fig. 43. 
The escape of the lens in Wolfe's operation. The Lens. 
147 
After the pupil is fully dilated with atropia, the cornea is 
to be incised to the extent of two or three lines with a lance- 
shaped knife. The incision is always to be made on the 
temporal side of the cornea, in the horizontal meridian or 
somewhat below it, about one line from the scleral border. 
The knife should be so placed that its cutting edge shall stand 
perpendicularly to the meridian of the point of entrance, and 
pass obliquely through the cornea, and towards the pupil. 
The depth of the wound should be sufficient to make a corneal 
section of two lines or more in length, the knife being lance- 
shaped the incision in the outer layer of the cornea will be 
longer than in the inner layer. The knife is slowly with- 
drawn, and the aqueous humor escapes. 
If the cataract be fluid or pulpy, and the capsule clear, a 
sickle-shaped needle is passed through the wound flat-wise, 
and the capsule is then divided with long strokes in various 
directions. Fluid cataracts will be evacuated, for the most 
part, during this manipulation ; and some portion of pulpy 
lens matter will escape. To complete the evacuation, the 
convex surface of Daviel's spoon is pressed against the outer 
lip of the corneal wound to make it gape. Then, by gentle 
pressure on the inner portion of the globe, the cataract is 
forced towards, and into, the gaping wound, and escapes. If 
any fragments of the lens remain behind, the lids may be 
closed for a few minutes to allow some aqueous fluid to collect, 
after which another attempt may be made to favor their 
escape. If pulpy lens matter still refuse to come out, the 
scoop may be introduced through the wound and be made to 
complete the evacuation, though the passing in and out of 
instruments through the small corneal wound is to be avoided 
as much as possible. 
Should the cataract prove to be hard, an iris-hook is to be 
introduced flat-wise through the wound, the capsule seized, 
and then dragged towards the point of exit. If the hook 
tears out, and the edge of the cataract can be grasped with 
forceps, the instrument is the best from its having more points 
for attachment. 
If a portion of iris prolapse and it can not be successfully 
returned by the aid of the spoon and shutting of the lids, the 
prolapsed portion should be seized with forceps, and with 
scissors cut off close to the cornea. 148 
Diseases of the Eye. 
After the operation is completed the lids should be closed 
with strips of adhesive plaster or a protective bandage. A 
solution of atropia used about the lids favors the return of 
a prolapsed iris. 
Modified Linear Extraction.-To remove firm cataracts 
and escape suppuration of the cornea, the late Professor Von 
Graefe, of Berlin, proposed to extract the lens through a 
scleral wound, after performing iridectomy. This method 
the distinguished operator called " Modified Linear Extrac- 
tion." 
A long slender knife is 
employed to make the sec- 
tion in the conjunctiva and 
sclerotic ; and the knife is 
entered quite close to the 
corneal border on the tem- 
poral side, the cut being 
made upwards. Although 
the incision is made in the 
scleral structure, the knife 
passes through the anterior 
chamber, i. e., in front of 
the iris, the patient being 
in a recumbent position, and 
the eyelids separated by a 
speculum or assistant. The operator stands at the side of the 
patient when operating on the left eye, and behind him when 
on the right. To prevent rolling of the globe the operator 
with his left hand seizes the conjunctiva with toothed forceps 
just below the cornea, and steadily draws downwards. If 
the conjunctiva be loose, thin, and easily torn as it often is in 
old people, the teeth of the forceps should be sharp and long 
enough to grasp the sclerotic. 
The operator enters the point of the knife a third or half 
a line from the cornea, and when carried straight through to 
complete the section, about one quarter of the circumference 
of the globe at that point is incised. But the knife is made 
to enter the anterior chamber as if to reach the centre of the 
pupil, and then it is turned horizontally, so as to be passed 
through the corresponding inner portion of the anterior 
Fig. 44. 
Graefe's knife making a scleral section before 
performing iridectomy and extracting the lens. The Lens. 
149 
scleral zone at the same height, and at an equal distance from 
the cornea as the point of entrance. After both conjunctival 
and scleral walls are transfixed with the knife, two or three 
sawing motions are imparted to the knife, by which the 
sclerotic is completely incised. A fold of conjunctiva which 
is distensible and loosely attached, is raised and should be cut 
by turning the edge of the knife forwards to the corneal 
attachment where it may be incised without danger of peeling 
the membrane from the sclerotic. The oblique entrance of 
the knife to the anterior chamber, is to enlarge the internal 
opening, and to avoid the small shelf or corner at the com- 
mencement of the wound, which is necessarily left 'when the 
knife is carried throughout in a horizontal direction, and 
which presents an obstacle to the passage of the lens. 
The conjunctival and scleral section having been completed, 
the iris is seized with a pair of forceps, pulled out, and with 
scissors cut off close to the incised sclerotic, so that no tags 
may remain in the wound. While the operator is performing 
this, the second step in the operation, the assistant takes 
charge of the fixation forceps. 
If a speculum has been used it may now be dispensed with, 
and the operator re-takes the fixation forceps, and with a 
sickle-shaped needle passed flat-wise through the wound as 
far as the lower part of the pupillary border, and then turned 
towards the lens, he incises the capsule in various directions. 
If the capsule be well incised, the lens often appears at the 
scleral opening, and but little assistance is required for its 
escape. If the lens do not move from its bed, the back of a 
scoop may be pressed gently upon the lower margin of the 
cornea, and then gradually slid upward, while no counter- 
pressure is applied to the upper part. When the cataract is 
advancing, the back of the spoon is pressed more strongly 
upward, until it has reached the centre of the cornea, thus 
chasing the cataract towards and through the wound. If the 
lens lodges in the lips of the wound, it may be removed with 
a hook or spoon. 
If the described manoeuvres do not dislodge the lens it may 
be seized with a hook or traction instruments and dragged 
out. The hook cuts through a normally consistent cataract; 
and in such an event the spoon should be used to remove the 
fragments. 150 
Diseases of the Eye. 
When cortical masses remain behind, as happens in the 
majority of cases, the lids may be allowed to close for a few 
minutes until some aqueous humor is collected, when the debris 
is driven towards the wound by circular friction through the 
closed eyelids ; then, after opening the lids, the fragments are 
removed by gentle sliding pressure, or, if this be inefficient, 
by means of a small spoon introduced into the anterior 
chamber. 
It should be esteemed important to clear out the cataractous 
lens as completely as possible; to draw out portions of cap- 
sule that obstruct the axis of vision; clean the wound prop- 
erly, 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, and the eye has been 
closed, it seems advisable to open the eye again, to see if 
everything appear in good condition. The re-opening of the 
lids assists to wash out small pieces of cataract and efl'used 
blood. 
The operation having been completed, the lids are to be 
closed with a soft, elastic bandage, and kept so for a couple 
of days. After that time the dressing may be removed twice 
daily, and a solution of atropia instilled between the lids. 
Chloroform should not be employedin the operation, except 
to very timid and unsteady patients, for the after-sickness is 
liable to force open the wound and to empty the eye of more 
or less of its contents. 
The principal danger in the operation is the loss of the 
vitreous. The accident may happen immediately after the 
section, by the incision being carried so far back that the 
zonula is left unsupported, and so may arch forward and 
burst; or by the point of the scissors touching the zonula in 
excising the iris; or by strong backward pressure of the 
needle or cystotome upon the hard cataract; or by too firm 
pressure in attempting to expel the lens; or by spasm of the 
orbicularis ; or, finally, by a pre-existing diseased condition 
of the zonula, caused by choroiditis with softening of the 
vitreous. If part of the vitreous escape before the cataract 
does, the hook or spoon should be instantly used to favor the 
exit of the lens. Should the vitreous escape with or after the 
cataract, it is best to close the lids at once, and apply a tight The Lens. 
151 
bandage for a couple of hours, so as, if possible, to prevent 
intraocular hemorrhage and detachment of the retina. 
Liebreich's Method of Extracting Cataract.-To escape 
the risks of Graefe's complicated plan of operating, Dr. 
Liebreich tried a new method, which is a modification of the 
flap operation, though the section is not entirely confined to 
the cornea. Prof. John King translated for the Eclectic 
Medical Journal (January, 1873), a pretty clear account of the 
operation, as described by Dr. Manche, in the Jour. d'Oph- 
thalmic for 1872, page 507. The article runs as follows : 
" Being convinced that the method of extraction adopted 
by Dr. Liebreich, since 1867, is the easiest of execution and 
the most certain in result, I have employed it in many cases, 
and I can say that I have obtained great benefits*from it. I 
desire to describe it in order to exhibit these advantages, and 
especially with the hope that many practitioners (particularly 
those who have not yet had sufficient experience in any other 
method) may be able to profit by it on the first occasion. 
"No one denies the superiority of the modified linear method 
of Graefe over the old method by flap, which, however, far 
from having fallen into oblivion, is still practiced upon a very 
great scale. The superiority is principally observed when the 
relatively small number of total suppurations of the cornese 
are taken into consideration. Now the slightest tendency to 
suppuration after Graefe's operation, even where the cornea 
is thin and soft, among very feeble old persons (very unfavor- 
able cases for extraction by the flap operation), is not due, as 
has been supposed, to the position of the incision made in the 
sclerotica, which is more disposed to cicatrization than the 
cornea, but rather, on the contrary, to the wound unavoidably 
made in the cornea. In fact, the wound made according to 
Graefe's method does not involve the sclerotica except at its 
superficial part, while its deeper part is found entirely located 
in the cornea alone. All the advantages of the modified 
linear method consist in the form of the incision, and the in- 
strument with which we operate. The linear form of the 
incision, as near as we can make it upon a spherical surface, is 
the sine qua non condition for the coaptation of the margins 
of the wound ; even if the cornea is very lax, the margins 
mechanically touch each other, and coaptation is perfect at 152 
Diseases of the Eye. 
the moment in which the aqueous humor commences to accu- 
mulate. Besides, with this form of wound which in order to 
open requires appropriate manoeuvres and pressures (which is 
not the ease in the flap operation in which the wound opens 
upon the slightest movement of the eye), the precautions on 
the part of the surgeon and the patient are not so necessary 
as when the old flap operation is performed. Moreover, the 
more regular a wound is made, the more promptly will its 
reunion be effected. Now, everybody knows the difference 
that exists between the two operations. On the one hand we 
possess the facility of making a linear incision with a knife, 
the very form of which favors a regular puncturing ; we may 
select the place for the counter-puncture, and often withdraw 
the instrument without the escape of any aqueous humor ; by 
the easy changing of its flat surface, we have moreover the 
advantage of making the incision larger or smaller, and more 
or less approximating the centre of the cornea; on the other 
hand we do not experience the same difficulties as with the 
Beer's knife, with which even the most skillful surgeon is 
never sure of making a flap as he desires. 
" Such are the real merits of Graefe's operation ; but the 
peripherical position of the wound renders the method difficult, 
painful, and dangerous. In fact: 
" 1st. It is impossible to take out the cataract without 
making a large iridectomy, or without cutting a peripherical 
portion of the iris, as this forms a hernia in the wound ; and 
besides, without iridectomy, the rotating movement of the 
lens, in the flap operation, by which that part of it nearest the 
wound is made to glide under the posterior surface of the iris 
in order to pass through the incision, can not occur. 
"2d. The large iridectomy which is necessarily made, up 
to the margins of the incision, obliges the operator to make 
this incision above, if he would correct the subsequent 
dazzlings (circles of diffusion) with the superior lid. 
" 3d. The upper section is much more difficult to perform, 
and renders necessary, during the several steps of the opera- 
tion, the employment of the dilator and the forceps for fixing 
the eyeball, which is painful, if not dangerous for the eye. 
" 4th. The position of this dilating speculum is frequently 
the cause of the prolapsus of the vitreous body, which is also 
facilitated by the peripherical section of the incision. The Lens. 
153 
" 5th. Prolapse of the vitreous body, and hemorrhage into 
the anterior chamber, are the chief obstacles to a careful 
removal of the debris of the cortical substance of the crystal- 
line, the presence of which may become a cause of iritis. In 
fact, the cortical substance, which it has sometimes been 
impossible to expel, swells up, irritates the iris, interferes 
with its movements, and provokes and keeps up the inflam- 
matory condition of this organ. 
" To obviate these disadvantages, Dr. Liebreich has modi- 
fied the process by removing the incision, nearly linear and 
made with Graefe's knife, more and more toward the centre 
of the cornea, in such a manner that this method preserves 
all the advantages of the method of the Berlin professor, 
while it avoids the greater part of its disadvantages. It is as 
follows: 
" The patient lies on his back, chloroformized or not, the 
pupil having been previously dilated with atropia. For the 
right eye the operator stands behind the head of the patient, 
and at his left side for the left. 
" There is no necessity for an assistant. The instruments 
needed are, a Graefe's knife (the smallest possible), a Daviel's 
curette, and a cystotome, all 
of which may be mounted on 
the same handles. Let us sup- 
pose the operation to be per- 
formed upon the right eye, 
(below and without iridec- 
tomy). The operator fixes the 
upper eyelid with the index 
finger of his left hand, at the 
same time slightly pressing the 
middle finger against the inner 
canthus of the eye. The knife 
held in the right hand, and 
directed horizontally with its 
back looking backwards, so that the flat part or plane of the 
blade makes with the horizontal meridian of the eyeball an 
angle of about 45°, is pushed into the sclerotica at a point 
about one millimetre externally to the margin of the cornea. 
Without changing the direction, the knife passes through the 
anterior chamber so as to make the counter-puncture on the 
Fig. 45. 
Liebreich's incision for the extraction of 
cataract. 154 
Diseases of the Eye. 
opposite side, the point of the instrument passingout at-about 
one millimetre beyond the internal margin of the cornea. 
The knife is now pushed forward, and when we withdraw it, 
we at the same time finish the incision, which is slightly 
curved, its central part being from one and a half to two 
millimetres from the inferior margin of the cornea, and almost 
wholly situated within this membrane. As soon as the 
incision is made, let the upper eyelid drop. 
" The second step of the operation, when iridectomy is not 
to be performed, which is not always possible, consists in 
lacerating the capsule in the manner usually pursued. In the 
third step, we slightly press with the Daviel's curette against 
the inferior margin of the cornea, and, with the index finger 
of the left hand, whi«h is rested upon the upper eyelid, we 
at the same time make gentle counter-pressure against the 
eyeball. Thus the lens executes a slight movement of rota- 
tion, its inferior margin 
is carried forward, presses 
(as in the fiap operation) 
against the posterior sur- 
face of the iris, pushes it 
forwards, glides behind 
it, is carried to the pupil- 
lary sphincter, clears it, 
and passes through the 
wound, which is made to 
gap by the pressure made 
with Daviel's curette. 
This manoeuvre is facili- 
tated by a gliding motion 
of the index finger of the 
left hand which acts upon 
the upper eyelid from above downward. Similar movements 
with the lids must be made to force out the debris of the 
cortical substance, after we have pushed them into the pupil- 
lary field by gentle frictions upon the closed eyelids. If the 
pupil does not manifest its regular appearance after this 
operation, but is drawn downwards, we may restore it to its 
normal position and form by a slight friction of the lower lid 
drawn outwardly, and if this does not answer, by the intro- 
duction of a hard rubber Daviel's curette. Immediately after 
Fig, 46. 
Delivery of the lens through a Liebreich in- 
cision. The Lens. 
155 
the operation, drop some atropia solution into the eye and 
close it with Liebreich's compressive bandage. 
" What are the real advantages of this method ? 
" 1st. The incision being nearer the centre of the cornea, 
one is not exposed to the disadvantages and dangers above 
mentioned, which are inseparable with Graefe's operation. 
" 2d. We may dispense with iridectomy, which is an immense 
advantage ; or, if we perform it, we only make it very small. 
" 3d. Since the operation may be performed without iridec- 
tomy, the incision may be made downwards, which renders 
the operation much more easy and much less dangerous, for 
the drawing of the globe downwards, its fixation with the 
forceps, and the use of the elevator in the latter step of the 
operation of Graefe, are too frequently the cause of the pro- 
lapsus of the vitreous body, which hinders cleaning the eye 
or the expulsion of the cortical substance. 
" 4th. The operation being more easy, may be made by 
practitioners who operate only occasionally ; and those, like- 
wise, who can not attend special clinics or receive counsel 
from experienced operators, will find in this method all the 
resources of a good and easy operation, and will not be con- 
demned to the method of depression or of reclination which, 
under the appearance of great simplicity, present the greatest 
dangers. 
" 5th. This process is preferable to the flap operation, 
because we have not to fear suppuration from the want of 
nutrition of the flap, and still more from the difficult coapta- 
tion and the irregularity of the incision; besides, even in the 
most unfavorable cases, the operator not being very skillful, 
owing to the simplicity of Liebreich's process and to the con- 
venience of the instruments, extraction may be finished in 
the most satisfactory manner. 
" 6th. Finally, it is preferable to the method of Graefe, 
because the dangers are evidently less; and as to the final 
result, it yields in nothing to the best result obtained by the 
flap operation. 
" This operation is applicable to all cataracts in general, 
with the exception of lamellar cataracts, those of childhood, 
and liquid or deprived of nucleus. Only we must be careful 
to make an incision (downward or upward, with or without 
iridectomy) proportioned to the size of the nucleus; that is to 156 
Diseases of the Eye. 
say, when the nucleus is large and hard, the cortical substance 
tough, and the cornea small, the puncture and the counter- 
puncture must be made a little nearer to the horizontal 
diameter of the cornea, that the incision may consequently 
be more curved, and which is effected by inclining the plane 
of the knife blade at an angle greater than 45° from the 
horizontal plane of the eyeball. When iridectomy is per- 
formed, although small, it must be proportioned to the volume 
of the nucleus, besides which the previous state of irritation 
of the eye must be taken into consideration. 
" At St. Thomas Hospital, Dr. Liebreich performed ex- 
traction, making the incision downward and without iridec- 
tomy, so that his process is reduced to the greatest simplicity, 
not requiring the aid of an assistant, elevator, fixation, or 
anaesthetics; two instruments sufficed. Besides, the method 
has the advantage of being, on the one hand, the least danger- 
ous mode of extraction, and on the other of giving the best 
results. After the eye operated on is cured, it differs from 
the normal eye only by the absence of the lens and the pres- 
ence of a hardly visible cicatrix of the cornea." 
The removal of cataract is attended with unsatisfactory 
results in a larger proportion of cases than is generally sup- 
posed. The best operators have their " bad cases," though 
they have learned to avoid touching what promises little. 
The inexperienced are apt to conclude, without duly consid- 
ering the subject, that cataract is a curable disease in all in- 
stances. They never stop to think that a disorganized eye 
will not see though a cataractous lens be successfully removed 
from it; that an opaque cornea will not transmit light; that 
an inflamed iris indicates pretty decidedly that the retina and 
choroid are not all right; and that a cataract operation is 
often unsuccessful when every indication is favorable. Sunken 
eyes, stiff lids, thickened conjunctive, vascular cornee, and 
other complications of greater or less importance, constitute 
conditions which will impart a serious lesson to those who are 
reckless enough to attack every case of cataract they chance 
to meet. Results are impressively disastrous when all the 
conditions are propitious. Vitreous Humor. 
157 
DISEASES OF THE VITREOUS HUMOR AND HYA- 
LOID MEMBRANE. 
The vitreous humor, of the consistence of thin jelly, and 
of glassy brilliance, is a translucent mass of albuminous fluid, 
and contained within a delicate, transparent membrane-the 
hyaloid-which adheres quite firmly to the retina. 
In old age the vitreous often exhibits a milky cloudiness 
which arises from a diffusion of fatty particles and a delicate 
precipitate of, perhaps, a saline substance. In syphilitic 
changes of the retina, the vitreous loses its perfect transpa- 
rency, and becomes turbid; and in severe cases, flakes of 
lymph are seen freely moving about in it, appearing like 
tangled blackish threads. 
After inflammation of the hyaloid, flakes, filaments, and 
corpuscles are seen floating about in the vitreous, and chang- 
ing positions so rapidly that they can not be observed with 
accuracy. 
Cysticerci have been observed in the aqueous humor and 
the vitreous. They are described as real entozoa, which 
generally are attached to the choroid, retina, or iris, but in 
some cases become detached and float freely in the translucent 
fluids. Although light-colored or nearly white, they are 
sufficiently opaque to intercept the rays of light, and, there- 
fore, appear black. 
Hyalitis may be caused by an injury, or result from disease 
of the retina. It is usually confined to parts about the optic 
nerve-entrance and the ciliary processes. As it can not be 
determined when the hyaloid membrane and vitreous are 
inflamed, unless there be a perceptible product, when the 
vitreous is clouded with a fine molecular detritus, it is assumed 
that an inflammatory process has been going on. True pus 
is developed in some forms of hyalitis, and its debris becomes 
diffused through the vitreous. 
Extravasations of blood from the retinal vessels produce a 
darkening of the visual field, and inflammation of the hyaloid 
and vitreous. The blood at length decomposes, and its debris 
by sinking, disappears from the visual field, or appears when 
disturbed by movements of the eye. 158 
Diseases of the Eye. 
Synchesis is an abnormal fluidity of the vitreous. It some- 
times conies on without inflammation or other disturbing 
cause or visible sign except it be by waviness of the iris and 
lens. When flakes are seen floating in the dissolved vitreous, 
and disappear by sinking when the eye is at rest, it may be 
presumed that the synchesis is accompanied with inflammatory 
action. Synchesis renders a cataract operation exceedingly 
dangerous. 
As hyalitis and inflammation of the vitreous rarely occur 
without choroido-retinitis, or inflammation of other eye-struc- 
tures, no separate treatment need be laid down for their man- 
agement. 
Cysticercus of the vitreous is to be removed by an opera- 
tion. Graefe, after performing iridectomy and extracting the 
lens through a corneal incision, carried a pair of forceps into 
the centre of the vitreous, and, after seizing the parasite, 
dragged it from the eye. 
THE OPTIC NERVE. 
On account of the origin of the optic nerve in the brain an 
important portion of the visual apparatus can not be ex- 
amined ; and, consequently, a large share of visual defects, in 
common with many cerebral diseases, must forever remain 
subject to the uncertainties of theory and speculation. 
No part of the optic nerve can be seen except its distal 
termination in the fundus of the eye. Its entrance has been 
denominated the " optic papilla," from the fact that early 
ophthalmoscopic observers thought they saw a slight promi- 
nence where the nerve enters the eye. Ophthalmoscopically 
the entrance of the nerve is all there is of it, therefore in 
speaking of healthy and morbid appearances it is better not 
to employ a distinct term for the spot where the nerve-trunk 
ends and the retina begins, but to call it optic nerve. In a 
healthy eye the nerve presents a plane surface, no prominence 
or papilla existing. 
In examining the interior of the eye, no structure com- 
mands greater attention than the optic nerve. There is a The Optic Nerve. 
159 
variety in its appearance in healthy subjects; and in disease 
a wide range of appearances is presented. Contrasted with 
the reddish tint of the surrounding retina, the nerve appears 
cream-colored, or it sometimes presents that faint tinge of 
pinkish-gray peculiar to the cineritious portion of the cere- 
bral convolutions. The extreme edge of the disc is of a more 
decided white than the central portion. At the centre of the 
nerve-porus opticus-the main trunks of the retinal vessels- 
arteries and veins-may be seen, and their pulsations ob- 
served, or may be artificially produced by pressure upon the 
eyeball. Commonly each vessel issues as a single trunk, 
which then divides into branches, but sometimes the division 
into two or three trunks takes place before the vessels quit 
the substance of the nerve in which they are embedded. 
Sometimes the variation in color observed in the disc 
depends much upon the size and form of the vessels, which 
may pass in straight or slightly wavy lines, or curve and twist 
Fig. 47. 
" Excavation of the optic disc." 
on the surface of the nerve. In dark-haired individuals, with 
strongly pigmented choroids, the color of the disc is mostly 
much brighter than in blondes. 
In patients affected with general dimness of sight (ambly- 
opia), it is not uncommon to find a dusky halo surrounding 
the optic nerve, which shades off- and is altogether lost at 
some distance from the disc, the peripheral portion of the 
retina presenting a natural appearance. Greater variations 
are compatible with good sight, therefore not much import- 
ance can be placed upon the dusky zone as evidence of serious 
structural change. 
As age advances the tissue of the nerve appears to become 
denser, and to occupy a smaller space than in early life. Its 160 
Diseases of the Eye. 
color, in some instances, becomes darker, or approaches to 
gray, while its outline deviates from the circular form, though 
these changes may coexist with a fair amount of vision. 
Sometimes the optic nerve attracts attention by way of 
contrast with redness of the retina, the optic disc appearing 
as white as ivory. Atrophy of the optic nerve occasionally is 
attended with this whiteness by contrast with a reddened 
retina; the combination therefore is not a favorable symptom. 
" Excavation of the optic nerve" has of late been esteemed 
of considerable importance in the diagnosis of certain eye 
diseases. It being met in cases of greatly impaired vision, 
and in combination with " intraocular pressure," is considered 
pathognomonic of " glaucoma." I have observed pitting of 
the optic disc without finding " stony hardness" of the eye- 
ball, or evidence of inflammatory action in any of the deep 
structures of the eye. However, impaired vision existed, and 
a state which called for an ophthalmoscopic examination. 
THE RETINA. 
The retina is the expanded optic nerve within the eyeball. 
It is a layer of brain-like matter, pinkish-gray in color, and 
extends from the optic disc to the ora serrata. It is spread 
out smoothly between the choroid and the vitreous. An in- 
experienced ophthalmoscopic observer might overlook the 
retina, which appears in the fundus like a delicate bluish or 
pinkish-white mist or veil, and recognize only the retinal 
vessels which are quite prominent. The tint of the retina 
varies from grayish-red, through shades of orange-red to 
yellow or buff. The tint of the retina in a full-blooded 
person is redder and brighter than it is in the feeble and 
anaemic. 
The vessels radiate from the central trunks in the optic disc 
to the periphery of the retina. The veins are thinnest and 
therefore the blood is plainest seen through their walls. By 
pressing upon the globe pulsation can be seen, both in arteries 
and veins. 
The macula lutca is observed to be free of vessels; and by 
a peculiar reflection which the fovea centralis causes, it has the 
appearance of a bright spot of oval or semilunar form. 
Retinitis.-When the retina is inflamed a gelatinous lymph 
is exuded upon the surfaces of the retina, especially upon its The Optic Nerve. 
161 
outer side, uniting the retina to the choroid. The exuded 
lymph is seen in extensive patches, with ragged borders. The 
exudation causes a cloudy opacity, which dims the visual 
powers. 
Among the more striking appearances revealed by the 
ophthalmoscope are irregular deposits of black pigment on 
the illuminated field of the retina. These pigmentous deposits 
present endless varieties as to quantity and mode of arrange- 
ment. In one case two or three minute isolated dots may 
alone be visible ; in another case the pigment may assume 
the form of fine threads, ramifying over a considerable portion 
of the retinal surface; while, in a third case, the pigment 
may be aggregated in large black masses, the intervening 
portions of retina presenting a normal appearance. 
Extravasations of blood, from rupture of the retinal vessels, 
constitute a serious accident. The effused blood overspreads 
the tissue of the retina, and the entire field of vision may 
become a perfect blank. All this may occur suddenly, and 
without forewarning, like apoplexy, there being no congestion 
or cerebral disturbance. A slight hemorrhage may be less 
serious, the patient complaining of a variable state of vision, 
objects being seen in some positions or directions. There 
may be glimmerings, glitterings and tremblings in connection 
with dimness of vision. 
The origin of retinitis is not always ascertainable. Excite- 
ment, feeble nutrition, injuries, and syphilitic taints may be 
enumerated as constituting the most common causes. Cere- 
bro-meningeal diseases are frequently followed by retinitis. 
When other structures are involved in the inflammatory 
action, as the choroid and iris, the state of the pupil may in- 
dicate the nature of the disease, especially if circumorbital 
pains and defective vision are complained of. In times past 
such difficulties wTere put down as " glaucoma" or " amauro- 
sis," and the patient was mercurialized, but the use of the 
ophthalmoscope has enabled us to determine exactly what 
structures are diseased, and the extent of the disorder. 
Persons having Bright's disease of the kidneys are subject 
to what is called nephritic retinitis, a difficulty which is 
characterized by exudative deposits of fat and lymph in the 
meshes of the retina. As the disease upon which the retinitis 162 
Diseases of the Eye. 
depends is incurable, the retinal complication commands less 
attention than it otherwise would. 
Detachment of the Retina.-Chronic effusion of a watery 
fluid between the retina and choroid may take place in the 
most gradual and insidious manner, so as to manifest itself 
only by impairment of vision, there being no pain or outward 
signs of inflammation. When the retina has become detached 
to a considerable extent, a corresponding portion of the field 
of vision becomes a total blank so far as the perception of 
objects is concerned ; while that portion of the retina which 
remains in apposition with the choroid may still distinguish 
even small objects, though in an imperfect and partial manner. 
Subretinal effusion usually begins near the optic disc, and 
gradually descends to the bottom of the fundus-perhaps 
through gravitation. There are no external signs by which 
we can ascertain the existence of effusion beneath the retina. 
The ophthalmoscope alone enables us to detect it. 
When a large portion of the retina has been separated, it 
presents the appearance of a lobular mass, of an opaque gray- 
ish color, contrasting in a remarkable manner with the red- 
dish reflecting surface of that part of the retina which still 
retains its natural position. Myopic eyes are said to be pre- 
disposed to the accident. 
In some instances, after the pupil is dilated, the detached 
portion of retina can be distinctly seen with the naked eye. 
With ophthalmoscopic aid the detached retina appears like a 
relaxed folded surface which is elevated above the surround- 
ing parts, and trembles with every movement of the eye. 
The results of subretinal effusion are far from satisfactory. 
In some instances the difficulty gradually subsides, but in 
most cases the detachment progresses steadily until all hope 
of restoration vanishes. Frequently the loss of one eye does 
not end the evil, the other becoming similarly affected sooner 
or later. 
Atrophy of the Optic Nerve and Retina.-Several of 
the morbid changes already observed, are followed by wasting 
of the true nerve-elements. Atrophy may occur without any 
known cause, unless it be from advancing age. The power 
of sight gradually fades away, until eventually mere percep The Optic Nerve. 
163 
tion of light alone remains. The ophthalmoscope reveals a 
perfectly clear condition of the dioptric media, and at the 
same time affords such a complete view of the choroidal 
vessels, that the observer could almost fancy the retina to be 
altogether absent. The optic nerve is small and shrunken, 
irregular in its outline, and of a dark gray or drab color; and 
the vessels emero-ing from it form delicate, hair-like, red lines, 
barely traceable across the area of the illuminated choroid. 
Treatment of Retinitis.-From what has been said of the 
varied morbid states of the retina, all of which were once 
grouped under the head of "amaurosis," and treated as one 
difficulty, it will be understood how foolish the attempt to lay 
down a course of treatment applicable to all of them. If 
there was a simple retinitis to manage, a rational plan of 
treatment might be devised for its cure or relief; but when 
the inflammatory action is complicated with atrophy of the 
nerve, detachment of the retina from subretinal effusion, ex- 
travasation of blood from the retinal vessels, and many other 
dissimilar conditions, and all accompanied with impairment of 
vision, what rational plan of treatment can be adopted which 
will affect any two of these morbid changes ? In a group of 
patients making about the same complaints in regard to defects 
of sight, and, before the invention of the ophthalmoscope, all 
would be subjected to the same course of treatment, one suf- 
ferer is now discovered to have a portion of the retina over- 
spread with blood ; in another the axis of vision will be found 
covered with a patch of pigment; while in a third, the retina 
and choroid will be partially separated by an effusion 1 An 
English oculist very pertinently inquires if such patients are 
to be treated alike ? 
" Do they, in fact, possess anything in common ? And yet 
they would all have been formerly classed together as ' amau- 
rotic,' and probably have undergone salivation accordingly. 
" If the ophthalmoscope had done nothing else than limit 
the wholesale administration of mercury in eye-diseases, it 
would have conferred an immense boon upon mankind." 
Not much can be done of a positive character towards 
overcoming morbid conditions of the retina, and restoring 
impaired vision which depends upon such conditions. If the 
retinitis be connected with iritis, choroiditis, and intraocular 
pressure, the operation of iridectomy may afford indirect 164 
Diseases of the Eye. 
relief. But in uncomplicated retinitis, except that of sub- 
retinal effusion, the treatment is that of rest. Strong light is 
to be avoided, and, of course, reading prohibited. In the 
worst cases a comfortable bandage is to be worn over the 
eyes; and after some improvement has been gained, smoke- 
colored glasses may be worn. Much attention is to be devoted 
to a proper regulation of the bodily health. Wretched 
digestion and its debilitating concomitants, aggravate the 
disease. Nux, veratrum, and arsenic are agents which usu- 
ally produce a favorable effect if administered judiciously. 
Scrofulous, eczematous, and syphilitic taints should be dis- 
covered when they exist, and attacked with the iodides and 
other alteratives. The patient should be encouraged to culti- 
vate a cheerful disposition, and should enjoy pleasant sur- 
roundings. It is next to impossible to cure a fretful and 
desponding sufferer. If the patient have any vices or depres- 
sing habits, an effort should be made to correct them. 
The operation of puncturing the vesicle in detachment of 
the retina has been successfully performed in a few instances. 
After the pupil is dilated a double-edged needle is carried 
through the sclerotic four or five lines behind the edge of the 
cornea, and on through the vitreous to the swelling produced 
by the subretinal effusion, when the vesicle is to be punctured 
and torn, care being exercised not to wound the choroid and 
the retinal vessels. The operation is legitimate, but should 
be performed by an expert lest more harm than good be done. 
THE CHOROID. 
The choroid is a vascular and pigmentary tunic which lies 
between the sclerotic and the retina. It is pierced posteriorly 
for the passage of the optic nerve. In front it is bounded by 
the ciliary muscle and ligament ; and the ciliary processes are 
its appendages. The pigmentary layer is on its inner or 
retinal surface; its outer surface is loosely connected with 
the sclerotic. 
Choroiditis.-A structure so highly vascular as the choroid 
must necessarily suffer from inflammatory attacks ; but its The Choroid. 
165 
intimate relations with other structures necessitate a complex 
morbid action. An uncomplicated choroiditis could not exist, 
therefore it is not strange that ophthalmic writers, who had 
not the ophthalmoscope to assist in the demonstration of cer- 
tain morbid conditions, yet did understand the anatomical 
relations of the choroid to the retina, iris, etc., should say so 
much about "choroido-retinitis," " irido-choroiditis," and 
other compound difficulties. 
When examined ophthalmoscopically the choroid is yellow- 
ish-red, with a shade of brown. This appearance comes from 
a mingling of the red tint of the blood with the brown or 
black of the pigment. 
The external layer of the choroid consists chiefly of veins, 
which are disposed in curves, and on that account are called 
venae vorticosce. Pigment cells, stellate in shape, are lodged 
between these. The middle layer is made up of an exceed- 
ingly delicate vascular plexus, which is called the tunica 
Ruyschiana. The internal layer resembles a tessellated pave- 
ment, whose appearance depends upon the arrangement of 
the pigment cells, which are hexagonal in shape. The venous 
branches of the vasa vorticosse carry off the greatest part of 
the blood of the inner structures of the eye. These veins 
pierce the sclerotic and pass obliquely to its outside. The 
condition of the sclerotic, then, whether it be firm or yielding, 
has considerable influence upon the haemostatic state of the 
choroid and iris. A constriction of these efferent vessels 
must result in " congestion " which necessitates intraocular 
pressure and " excavation of the optic nerve"-both promi- 
nent signs of choroiditis. 
A state of partial blindness is a result of inflammatory 
action in the choroid and the structures in intimate relation 
withit. This " impairment of vision" receives the name of 
" amblyopia," and when the visual obscurity is more profound 
and the morbid action is more intense, "glaucoma" is the 
term used to designate the complicated defect. 
Glaucoma.-Defective vision depending upon inflammation 
of the sclerotic, choroid, retina, iris, etc., and morbid changes 
in the vitreous, lens, and cornea, or upon more or less of these 
structures, especially upon irido-and choroido-retinitis, has so 
long borne the name of glaucoma, that it is difficult to get 166 
Diseases of the Eye. 
rid of the term. Inflammation of the choroid and retina is 
attended with a sea-green reflection from the ocular fundus, 
hence the literal signification of glaucoma. But it will be 
observed that a term which only signifies a hue or tint is 
exceedingly inappropriate to designate the complex conditions 
usually ascribed to glaucomatous states of the eye. 
Amaurosis.-This is another term in common use to indi- 
cate blindness depending upon morbid changes in the deeper 
structures of the eye, whether arising from inflammation, 
atrophy, or cerebral disturbances affecting parts which pre- 
side over vision. The witty reply of the old oculist, when 
asked what amaurosis meant, was once significant. It was as 
follows: " amaurosis is a condition of the eye in which the 
patient sees little or nothing, and the observer-less." Since 
the invention of the ophthalmoscope a variety of morbid 
changes can be seen in glaucomatous and amaurotic eyes; 
and a new phraseology is employed to designate the real state 
of the parts diseased. If all understand that amaurosis 
means inflammation of the sclerotic, choroid, retina, etc., the 
term may be continued without much confusion ; but a state 
of impaired vision depends upon defects of the optic nerve 
and other conditions not inflammatory in character, therefore 
no single word can be employed which may convey a definite 
idea in regard to the pathological condition of an " amau- 
rotic " eye. 
Muse.® Volitantes often attend choroiditis. They appear 
in flecks and spots which float about in the field of vision. 
These spots change their position whenever the eyes are sud- 
denly moved. Beaded filaments greatly annoy the patient, 
making him believe they are the forerunners of amaurosis or 
other serious ocular defects. 
A peculiarity of the muscce is that they float around in 
various directions, and, then, as the eye becomes steady, 
appear to settle down as if sinking in a fluid. It is difficult 
to determine the physical character of these floating spots, if 
they have any. A congested state of the choroidal vessels 
may be their origin. A person occasionally troubled with 
muscce, will find them more numerous and variagated after 
alcoholic or other excitement; and especially after the eyes 
have been irritated with strong light. I know a healthy man The Choroid. 
167 
in middle life, who complained of floating spots in the field 
of vision for several years, and then all at once missed the 
annoyance. During the invasion I examined his eyes several 
times with the ophthalmoscope, and never could detect any 
morbid changes in the choroid or retina. If a person 
anxiously direct his attention to the dancing spectres, he will 
acquire the habit of multiplying them. 
Being common attendants of some serious diseases of the 
eye, muscae are regarded by those unacquainted with their 
comparatively harmless character, as evidence of approaching 
amaurosis or glaucoma. But assurance may be given to those 
who have no other sign of visual defect, that these spectres 
are not incompatible with excellent and enduring sight. The 
best way to get rid of the annoyance is to neglect giving it 
attention. 
A class of persons engaged in pursuits which require pro- 
longed looking at minute objects-such as lace-workers, 
engravers, and jewelers-from over-taxing the eyes, at length 
lose the power to see distinctly small objects at even close 
range. For awhile the defect may be momentarily removed 
by closing the eyes, the temporary rest lending freshness to 
the sight. However, the recuperation is not lasting. In time 
the field of vision becomes permanently misty, compelling an 
abandonment of every occupation which exhausts the visual 
power. 
Age alone is sufficient to impair vision. Persons who have 
never abused their visual powers by protracted examinations 
of minute objects, begin to lose the ability to thread a fine 
needle at the age of forty; and need the aid of spectacles to 
enable them to read small type at the age of fifty. The 
visual defect does not arise from changes inflammation pro- 
duces, but from an inability to adjust the eyes for near objects; 
and convex glasses, of thirty inch focus, are required to com- 
pensate for the loss of adjusting power. 
The ophthalmoscope reveals the changes produced by 
choroiditis, such as extravasations of blood, effusions of lymph, 
deposits of pigment, etc., yet the appearance of the choroid 
varies so much in different individuals, that caution should 
be exercised in drawing conclusions based wholly upon oph- 
thalmoscopic appearances. The choroid tints vary in persons 
of contrasting complexions; and the vascularity of the 168 
Diseases of the Eye. 
choroid is far from uniform. Excavation of the optic nerve 
in an eye the sight of which is seriously impaired, is a promi- 
nent sign of choroiditis, or choroido-retinitis. Add to cup- 
ping of the optic nerve, a thrombosis in the choroid vessels, 
and irregular deposits of lymphoid and pigmentary substances 
in the choroidal stroma, and the evidence of choroiditis be- 
comes reliable. The ophthalmic division of the fifth nerve 
lias ramifying branches in and about the eye, which are apt 
to become painful-when the deep structures of the eyeball 
are inflamed, therefore circumorbital pain not unfrequently 
attends choroiditis. 
Patients who have no external signs of eye-disease, and are 
first led to suspect something wrong in the visual apparatus 
by a slowly advancing dimness of vision, appear surprised 
when informed that extensive changes of a serious nature 
have taken place in the choroid, retina, and iris. 
The treatment for choroiditis is not essentially different from 
that recommended in retinitis. Aconite is to be used freely 
about the eye; strong light is to be cut off; the general 
health supported or improved by regulating the diet and 
administering iron, sulphur, phosphorus, the iodides, and 
bitter tonics. 
The operative treatment for choroiditis, including the com- 
plex disorders usually ranged under the head of glaucoma, 
consists in the performance of iridectomy. The removal of a 
portion of the iris has the effect of a genuine neurotomy, and 
is analogous to the removal of a part of the portio dura for 
the relief of tic douloureux. The operation necessitates the 
evacuation of the aqueous humor, and thus temporarily 
relieves the intraocular pressure. 
Since the introduction of iridectomy for the cure of glau- 
coma, the most brilliant results have been obtained ; but, as 
might reasonably be expected, some failures have attended 
the operation. Not unfrequently harm has been done by 
performing the operation in unsuitable cases. Iridectomy as 
a means of cure is of greatest service in acute and sub-acute 
forms of choroiditis, and before the eye has become in any 
way disorganized by the progress of the disease. Whenever 
ciliary pain is present the operation is useful, both in restoring 
vision and in the abatement of suffering. In purely chronic, 
or non-inflammatory cases, where blindness steals on gradu- Ocular Tumors. 
169 
ally without pain or other acute symptoms, the operation of 
iridectomy is absolutely useless, whatever the degree of intra- 
ocular pressure may be. 
OCULAR TUMORS. 
Attention has already been called to tumors of the lids, 
such as hordeolum, comedones, and miliary nodules; some of 
which are mere phlegmons that pass away and return 
again, like pustules or small abscesses. About the eyebrows 
cystic tumors of a sebaceous nature, with gelatinous, oleagi- 
nous, and honey-like contents, some of them containing hair, 
develop and continue as annoyances and deformities. The 
caruncle is liable to granulate, and form fleshy or warty out- 
growths. 
Mucous polypi develop in the nasal and frontal cavities, 
and by their size encroach upon the orbital cavity, protruding 
the eye. Cysts and fungous growths of the antrum, in their 
development press upward, and thus cause the eye to bulge 
(exophthalmos), producing that peculiarity of expression 
called " frog-face." 
Myxomata, vitreous or jelly-like tumors, benign in character, 
fix themselves on the internal tissues of the eyeball, and 
develop to an extent which is destructive to vision. 
Glioma is a medullary fungus, or outgrowth of the retina. 
As soon as the tumor attains any considerable size, its dis- 
organizing effects are fatal to vision. The growth of a glioma 
is often luxuriant, and imitates the rapid development of 
true carcinoma. When it breaks through the lens and cornea, 
and appears a true fungus externally to the eyeball, its nature 
is still obscure, simulating cancer in many phases. 
Sarcoma, so called, is occasionally an affection of the eye- 
ball, and proves destructive and intractable. It is malignant 
in its tendencies, though this character may not be apparent 
at first. When its seat is in the dense tissues, its growth is 
slow and seemingly innocuous ; but when the soft structures 
get involved, the proliferating power of the disease becomes 
manifest. Sarcoma may spring from any of the ocular tunics, 
but generally it begins in the choroid. 170 
Diseases of the Eye. 
Carcinoma of the eyeball, and orbital cavity, commencing 
in any of the structures, has no unvarying phase, but shows 
every variety of form it does when developed in other regions 
of the body. It would be unprofitable to attempt to describe 
the ever changing features, especially as the result of the 
disease is commonly fatal. Excision of the eyeball may stay 
the destructive processes for awhile, but a renewal of the 
malignant tendency may be expected. 
Epithelioma of the lids and superficial structures is often 
curable, at least to the extent of removal and subsequent 
cicatrization. However, if the disease attack the lachrymal 
passages, the hope of cure is greatly diminished. 
Benign tumors of the orbital structures, not involving the 
eyeball, can generally be removed with safety, and if thor- 
oughly extirpated, no fear of return need be entertained. 
In the removal of tumors about the orbit great care should 
be exercised that as little deformity and loss of function fol- 
low as possible. The operator is to guard against injuring 
the levator palpebrae muscle lest ptosis follow; a cicatrix may 
establish trichiasis; and an injury to the lachrymal sac may 
result in fistula. 
Little can be done with intraocular tumors; they have been 
known to go away without being plied with remedial measures, 
yet such is not to be expected. Gliomata can be seen dis- 
tinctly with the aid of the ophthalmoscope, yet seeing them 
and their removal are quite different affairs. Tumors of the 
retina and choroid in the beginning often produce amaurotic 
and glaucomatous symptoms, and the real condition is only 
determined by ophthalmoscopic examinations. When intra- 
ocular tumors are syphilitic deposits, active treatment may 
bring about retrogression. 
Intraocular tumors which protrude through the cornea or 
sclerotic often demand enucleation of the eyeball. Excising 
the protruding mass does very little good, as it is soon repro- 
duced. Removal of the Eyeball. 
171 
REMOVAL OF THE EYEBALL. 
The entire removal of the eyeball leaves no " stump " on 
which an artificial eye can rest and move, therefore partial 
extirpation is to be preferred when the conditions will permit. 
Complete extirpation is occasionally necessitated by the 
presence in the eye of foreign bodies, injuries and staphy- 
lomas of a disorganizing nature, malignant diseases, some 
intraocular tumors and insufferable neuralgia. 
The danger from enucleation of the eyeball is not trifling, 
yet not so threatening as to forbid an operation under pressing 
demands. In fact, the eyeball has been extirpated for cosmetic 
Fig. 48. 
Amputation of the eyeball. 
purposes, when disorganization of the globe was repulsive, 
and an artificial eye could probably be worn with ease and 
good effect. 
The operation is executed while the patient is under anaes- 
thetics ; a spring speculum may do to hold the lids apart, yet 
retractors in the hands of assistants are better. If the eye be 
so enlarged that it will not come out through the tarsal fissure, 
the space is to be increased by dividing the outer commissure, 
the incision extending to the bony margin of the orbit. A 
fold of conjunctiva is seized over the insertion ot the external 
rectus, and a free incision is made in this membrane with 172 
Diseases of the Eye. 
scissors. Through this wound in the conjunctiva the rectus 
muscle is grasped with strong toothed forceps, and held 
steadily while a circular incision is made in the conjunctiva 
with curved scissors. Then the external rectus is divided a 
little distance back, and the near end is seized with reliable 
forceps, and the eyeball pulled forwards and rolled inwards, 
while a pair of scissors is used to divide fascias and the upper 
rectus and superior oblique muscles; after these are divided 
the lower rectus and inferior oblique may be served in the 
same way. The scissors are next carried back along the 
sclerotic to the optic nerve, and that is then divided. The 
globe now starts forward, and a few snips of the scissors 
divide the internal rectus, vessels, bands of areolar tissue, and 
whatever prevents the removal of the eyeball. The operation 
is thus completed, and the hemorrhage will prove to be in- 
considerable. If the bleeding be troublesome the finger may 
be carried into the orbital cavity and pressure applied to the 
divided vessels. In a few minutes the hemorrhage will gener- 
ally cease. If the bleeding still be persistent the cavity may 
be packed with lint and the tampon held in place with a 
bandage. The lint should be removed the second day, as it 
provokes unnecessary suppuration and inflammation. If a 
tampon be not used, a compress is placed against the lids, and 
retained with a bandage. The wound is to be redressed every 
day, and kept clean. The drainage affords moisture enough, 
therefore water and medicated fluids are not called for. The 
injury inflicted requires a week or two to heal. In the course 
of a year or less, an artificial eye can be worn, which supports 
the shrunken lids, and hides and disguises the defect and 
deformity. 
ARTIFICIAL EYES. 
An artificial eye is made of enamel, and in shape is the 
segment of a sphere. It is used after abscission or amputa- 
tion of the eyeball, generally after the cornea, iris and lens 
are removed. Its object is to lessen the unpleasant appear- 
ance produced by the absence of a part or the whole of the 
globe. The shell, when in place, restores the normal fullness Artificial Eyes. 
173 
to the lids, and prevents the eyelashes of the inverted lids 
from jagging the conjunctiva and delicate parts •within the 
socket. It re-establishes the power of winking, and renders 
possible the normal conduction of .the lachrymal secretion. 
Before an artificial eye is inserted the lids and the stump of 
the eye must be examined to ascertain if everything be in a 
favorable state for the insertion. The wound which destroyed 
the eye may have been followed by the adhesion of the tarsal 
borders of the lids to the stump of the eyeball. The union is 
commonly not extensive, but in bands or bridges of neoplastic 
tissue. These false connections must be severed before the 
artificial shell can be introduced. This is generally done with 
scissors ; and the presence of the shell between the traumatic 
surfaces obviates re-union. 
Fig. 49. 
Artificial eyes. 
To select an eye which is of proper size and form to rest 
easily beneath the lids, and in size of pupil and shade of iris 
to closely match the sound eye, is a difficulty little appre- 
ciated by the inexperienced in such matters. It requires a 
large stock to select from, and then a perfect or even tolera- 
able match is rarely attained. An artificial eye costs from 
five to ten dollars, therefore few oculists can afford to keep a 
large assortment. 
The size of the shell must conform to that of the stump. 
If a considerable portion of the eyeball has been excised, the 
artificial eye must be of extensive dimensions; and if the 
globe is merely atrophied or shrunken, there is only room for 174 
Diseases of the Eye. 
the smallest pattern of a shell. When the eyeball is entirely 
gone the artificial substitute should represent at least a hemi- 
sphere. 
The shell is hollow posteriorly, yet rests upon the stump 
and receives considerable motion from the muscles which have 
not lost all of their action. Should the shell be too large the 
pressure of the lids restricts the motions of the stump; and 
should the artificial eye be too small, the stump moves with- 
out imparting motion to the shell. 
An artificial eye should be moistened with saliva and intro- 
duced while the patient's face is held over a bed or cushion, so 
that if it falls it will not hit a hard substance and break. In in- 
troducing the shell, the upper lid must be raised, and while the 
patient looks downwards, the upper edge of the artificial eye 
is pushed beneath the lid, which is then allowed to descend; 
and the lower lid being in turn depressed, the inferior edge 
of the shell is pushed into the lower palpebral sinus, and the 
insertion is complete. At first the artificial eye may feel un- 
comfortable, and can not be worn but a few hours at a time, 
but a few days or weeks experience do away with the dis- 
comfort. 
It requires tact to remove an artificial eye, especially if the 
shell stick fast in its bed. The lower lid is to be turned down 
or everted, and the thumb-nail or a thin spatula of wood 
forced beneath the lower edge of the shell, to act as a lever 
to pry the artificial eye from its place. The shell is then 
pressed downwards by the upper lid, and it falls into the 
hand, or upon a cushion ready to receive it. 
An artificial eye should be removed and properly cleaned 
before going to bed ; and re-introduced in the morning. The 
shell should be wiped with clean lint, and occasionally dipped 
in whisky or cologne, to cut the animal substances which 
adhere to it. If dropped from the socket into cold water the 
sudden change of temperature may check the enamel or 
break the shell. Artificial eyes are exceedingly fragile, there- 
fore great care must be exercised in handling them. A good 
shell, if not broken, will last for years. The enamel at length 
loses its polish and lustre, and a new eye is then desirable. Injuries of the Orbit. 
175 
INJURIES AND DISEASES OF THE ORBIT. 
Violence inflicted upon the os frontis, malar, or superior 
maxillary bone, may start a fracture which will extend to the 
thin plates constituting the orbital walls. Complicated with 
the fracture may be laceration of the periosteum and the soft 
tissues between the eyeball and its socket. If the fracture 
reach the frontal or maxillary sinus, or the ethmoid cells, 
emphysema is likely to occur. Extravasation of blood into 
the loose tissues produces swelling and discoloration. The 
inflammation following such injuries is apt to be severe. The 
cicatrization may establish permanent deformities in the 
ocular apparatus. The orbitar plates are occasionally broken 
by what is known as contre-coup; the force being received on 
the vertex or posterior region of the skull, does not produce 
a fracture at the point hit, but extending to the opposite pole 
of the cranium, causes a fracture there. If the orbitar plate 
of the frontal bone be thus broken, the effusion of blood will 
be observed in the upper lid ; if the floor of the orbit be 
broken, ecchymosis of the under lid will occur. The extrava- 
sation of blood may be the only symptom of orbital fracture. 
Bullets and other missiles may enter the orbit by going 
through the soft tissues in front, or by penetrating the bones 
constituting the orbital walls. The entrance inflicts dangerous 
wounds, and the continuance of the foreign body in the orbit 
may result disastrously to vision. 
Penetrating wounds of the orbit may prove unimportant, 
yet from the beginning they are to be regarded as serious, if 
not dangerous. The instrument may pass through the orbit 
without doing much damage to the ocular apparatus, yet in- 
flict a fatal injury to the brain or structures within the skull. 
Penetrating injuries of the orbit have been considered trivial 
at first, yet have resulted fatally in a few days. 
Gun-shot and punctured wounds of the orbit should be 
probed or explored to ascertain if any foreign body is to be 
extracted, unless it be positively known that nothing is left 
which can do mischief. Pistol bullets and bird shot have 
remained in the orbit for years without doing serious harm, 
yet they form exceptional eases. Generally such wounds can 
be enlarged with safety, care being taken to avoid important 176 
Diseases of the Eye. 
structures, and the foreign bodies sought and extracted. It 
is to be borne in mind that a bullet or shot may glance after 
entering the socket, and lodge in a position quite inexplicable, 
except on the ground that the missile took a circuitous route. 
It is not advisable to inflict severe injuries to extract what 
may not prove dangerous if let alone. Splinters of wood 
will induce suppuration, therefore they should be removed at 
once if possible. The sclerotic is so thick and dense that 
none but sharp instruments are apt to penetrate its walls. 
Inflammation of the tissues between the eyeball and the 
socket, periostitis, and necrosis, are among the difficulties 
which may affect the orbit and the structures it encloses. 
Tumors develop in the orbit, and hypertrophy of structures 
behind the eye may produce exophthalmos. 
Inflammation of the orbital tissues is to be managed on the 
same principles as inflammation in other parts of the body. 
Cold applications, poultices, fomentations, and anodynes, con- 
stitute the local agencies to be employed. 
Periostitis is to be subdued chiefly by the internal use of 
iodide of potash. The pain may call for anodynes. If the 
affection depend upon a syphilitic taint, the treatment should 
be modified accordingly, though iodide of potash in large 
doses would then be one of the best agents which can be 
employed. 
Necrosis can not be forced into subjection, but the disease 
will have pretty much its own way. To be sure the dead 
bone can sometimes be removed by a simple operation, yet 
there is no security against the dying process continuing. 
The suppuration will establish fistulous tracts for the escape 
of pus, and these can be used for the injection of carbolic 
acid or other agents presumed to exert a restraining influence 
upon the progress of the disease. 
Tumors whether cystic or fibroid in nature, can generally 
be removed with celerity and safety. If their development 
is from a point deep in the orbital cavity, the eyeball is pro- 
truded by their increasing size, and their removal is not un- 
attended with danger. 
When the diagnosis of orbital tumors is obscure the ex- 
ploring needle may be employed to help decide upon the 
nature of the disease. The contents of a hydatid cyst may Injuries of the Orbit. 
177 
be discharged through the puncture an exploring needle has 
made, yet the cyst will refill. 
Scirrhous tumors of the orbit are not essentially different 
from kindred growths in other regions ; nor is the treatment 
to be conducted upon a plan peculiar to the location of the 
disease. Extirpation of the malignant growth may be allow- 
able in some instances, yet surgical interference is generally 
of little avail, the disease reappearing to bring discredit upon 
operative measures in general. 
Epithelioma is a less malignant and destructive form of 
cancer; and may sometimes be removed without recurrence, 
especially when the system is plied with renovating agencies, 
Basedow's Disease.-Enlargement and pulsation of the 
orbital vessels, with hypertrophy of the thyroid gland, and 
functional or organic disease of the heart, constitute a group 
of disorders occasionally associated in one patient. This 
complication of pathological conditions has gotten the name 
of "Basedow's or Grave's Disease." The most prominent 
feature of this morbid action is exophthalmos or bulging of 
the eyeballs. Females are more subject to the disease than 
males ; and suffer most just after the menstrual function is 
established. The nervous system at this age is impressible 
and excitable, and the palpitation is a result. The veins about 
the neck are enlarged, and sometimes pulsate. The goitre is 
not necessarily large, nor need the eyes protrude enormously. 
The palpitation sometimes comes on in paroxysms, and may 
depend upon derangement of the menstrual periods. 
There is no specific cure for this complication of morbid 
conditions, yet certain remedies exert a favorable influence, 
especially veratrum. This should be administered steadily in 
as large doses as the patient will bear without vomiting being 
excited. The medicinal agent will lessen the palpitations and 
pulsations and otherwise exert favorable influences. Iodides, 
bromides, and ferruginous preparations have been given with- 
out appreciable effects. Cases frequently recover, though the 
course of convalescence is tedious. 178 
Diseases of the Eye. 
VISION AFFECTED BY INTRACRANIAL DISORDERS. 
Vision is occasionally impaired, disturbed, or destroyed by 
disorders which are cerebral or intracranial. Tumors of the 
brain may affect vision by pressure upon the optic nerves or 
the cerebral substance giving origin to those nerves. Apo- 
plectic clots, and abscesses of the brain may affect vision in 
the same way that cerebral tumors do. Meningitis, especially 
the cerebro-spinal variety, is a frequent cause of partial or 
complete blindness. The disease is attended with meningeal 
effusions, and followed by the organization of exuded lymph, 
either of which may press upon the optic nerves directly or 
remotely, and disturb vision. Severe cases of cerebro-spinal 
meningitis have been followed by incurable blindness and 
deafness. Pressure upon the motor nerves of the eye destroys 
the parallelism of the two eyes ; and pressure upon the fifth 
pair leads to ulceration of the cornea and other defects of the 
ocular apparatus. Abnormal deposits, whether from neuritis, 
periostitis, or meningitis, which interfere with the conduction 
of nerve-force along the nerve-tracts, impair vision, and 
develop squinting. 
Cerebro-spinal paralysis may not be of the same severity 
on both sides, and thus destroy harmony of action in the two 
eyes. Paralytics rarely escape some degree of visual distor- 
tion. Inflammation of the brain, especially in children when 
a convulsive tendency is present, by its products compressing 
intracranial nerves, is often attended with distortion of the 
eyes, and complicated visual defects. The disturbance may 
not be continuous, but vary with the intensity of convulsive 
action. 
Tuberculosis and syphilis are among the common causes of 
ocular defects, especially when morbid deposits are located in 
the vicinity of the optic nerves. Complicated with the visual 
disturbances there may exist aphasia and other functional 
defects having a cerebral origin. Gummy masses in the brain, 
generally developed in syphilitic subjects, are frequent causes 
of impaired vision in obscure cases where no other morbid 
influence can be traced or reasonably suspected. Gummatous 
deposits along the course of the motor nerves have been 
known to produce squinting, ptosis, and bulging of the eyes. Intracranial Disorders. 
179 
Thrombosis and hemorrhagic extravasation, neither of which 
need be syphilitic in origin, may induce ocular distortion by 
compressing the motor nerve trunks. Exostoses have, by 
exerting compression, disturbed the visual functions, producing 
diplopia, amblyopia, and paralysis of the motory apparatus. 
The treatment of visual defects depending upon intracranial 
diseases is not generally very satisfactory ; something may be 
accomplished by the discreet employment of constitutional 
remedies, when the disturbing element is systemic. But what 
can be done towards the removal of exostoses, or brain 
tumors ? It is probable that a robust state of health is most 
favorable to the removal by absorption of abnormal deposits, 
therefore attention to the general functions of the body 
would be rational. A hemorrhagic extravasation may be 
removed by absorption, or so diminished that the disturbance 
caused by it^may cease. Syphilitic deposits may be removed 
by the action of large doses of iodide of potassium. In some 
cases where the venereal taint is known to exist, and gum- 
mata in the cranial cavity are suspected, from thirty to sixty 
grains of iodide of potassium may be taken three times a day 
for a week or more ; and good and not bad effects be counted 
upon. After a season of rest, the medicine should be pre- 
scribed again, syphilis being a disease which, though routed 
for awhile, is inclined to renew its attacks. The bromides 
and hypophosphites are in good repute as agents to act upon 
nerve-centres, yet they may not always exert a beneficial in- 
fluence. Galvanism has been known to favorably impress in 
obscure cerebral difficulties, yet the indications for its use are 
not well-defined. The agent rarely does harm. Necrosis, 
periostitis, and exostoses of the cranial bones can not be 
overcome at once, therefore eye affections depending upon 
either of these morbid processes are likely to be chronic. 
Necrosis of the sphenoid has produced incurable blindness, 
the disease extending from the cells to the body of the bone, 
upon which is the optic chiasm. 
Intracranial diseases being obscure, and beyond the reach 
of topical applications, their management can not be under- 
taken with confidence. Phosphorus has been administered 
with beneficial effects in softening of the brain, though the 
visual disturbances depending upon the disease, have not 
always been corrected by the use of the medicinal agent. 180 
Diseases of the Eye. 
MYOPIA. 
» 
The ability of the eye to adjust its dioptric apparatus, so as 
to see objects distinctly at different distances, is called the 
power of accommodation or adaptation. If the'refractive media 
be defective or the adaptive power be abridged, the range of 
vision is restricted. If a person can see objects only when 
they are near, while distant ones appear dim and confused, 
the defect is that of " short-sightedness "-myopia exists. 
The sight, under such circumstances, may be clear, but it is 
limited to short range-to close views ; and is only dim when 
applied to objects at a distance, or beyond its range. 
There is a popular notion that excessive convexity of the 
cornea is the cause of " short-sight," yet such is not generally 
nor necessarily the case. A fish is short-sighted, though its 
cornea is flat; a bird of prey is far-seeing, yet its cornea is 
exceedingly convex. The cause of myopia, then, must be 
sought in other parts of the dioptric mechanism. It may not 
always be the same in different short-sighted people, yet the 
changes of curvature in the cystalline lens, brought about by 
the action of the ciliary muscle and the elasticity of the lens, 
have much to do with " adaptation." 
The defect may be hereditary, though acquired by using 
the sight at short range by ancestors. It is rare among savage 
or uncivilized nations, and among persons engaged in out- 
door employments ; while it is common among those devoted 
to in-door pursuits. Literary people who engage in reading 
and writing for hours together during a considerable portion 
of life, lose the power to see distant objects elearly. The 
same may be said of artisans and of those who are engaged 
in minute and delicate manipulations. A child is rarely 
myopic, but the defect comes on a little before puberty, and 
increases till about the age of twenty-five, when the focus 
settles into what is to continue for the rest of life. It is a 
popular folly to suppose that as the cornea flattens in advanced 
age, longer range of vision is attained. 
In myopic eyes the rays of light which ought to come to a 
focus upon the retina, converge to a point in front of it. 
This defect arises from an elongation of the globe in its 
antero-posterior axis, or from the lens being too convex, a Myopia. 
181 
state due to the ciliary muscle, as it is the active agent in 
altering the curvature of the lens. 
Haziness of the cornea and lens induces the patient to hold 
objects near the eye for careful examination, and this exercise 
tends to develop myopia. When short-sight exists the cornea 
and lens should be critically examined, as opacity of these 
media may be the true cause of the myopic manifestations. 
Snellen's test types, to be found at the end of this volume, 
are useful in detecting the acuteness of vision in a given case. 
The following rules, from Dr. Snellen, have been formulated : 
" I. The smallest angle, at which objects of known size 
and form can be distinguished, determines the degree of the 
relative acuteness of vision. 
" II. To determine the smallest visual angle, we measure 
O 7 
the utmost distance at which objects of definite size can be 
recognized. 
" III. A visual angle and corresponding distance being 
taken as the unit of measure, the proportion between such 
distance and that at which the object is actually seen, expresses 
the acuteness of vision. 
u IV. We take as a unit of comparison the recognition of 
letters seen at an angle of five minutes. 
" V. The numbers placed above each type express in 
Parisian feet the distance at which the letters are seen at our 
standard angle of five minutes. 
" VI. The utmost distance at which the types are recog- 
nized (d), divided by the distance at which they appear at an 
angle of five minutes (D), gives the formula for the acuteness 
of vision (v.) 
d 
v=- 
D 
Thus if d and D be found equal, No. XII, of the test types 
being recognized at a distance of 12 ft. v=±%-1; in other 
words, there is normal acuteness of vision. If, on the other 
hand, d be less than D, and if No. XII. be only visible within 
6 ft. or VI. within 2ft. or No. XXX. at 20 ft., 
but d may sometimes be greater than D, and No. XII. be visi- 
ble at a greater distance than 12 ft. ; in this case the acute- 
ness of vision is greater than the normal average. 182 
Diseases of the Eye. 
" VII. The normal acuteness of vision decreases with age. 
" VIII. The value of v should be found equal in testing 
with the different types, each in its corresponding distance. 
If such be not the case, and v appear to diminish considerably 
within or beyond a certain distance, it may be inferred that 
the refraction is at fault, or that the eye is not adjusted for 
such distance." 
The optical remedy for short-sight consists in the use ot 
concave glasses of a focus suited to the individual case. If 
glasses can not be found which enable the patient to define 
distant objects with accuracy, the defect is not wholly myopic, 
but springs from faults of another nature. 
lu selecting glasses for the young, an excess of concavity 
should be avoided; and an increase of concavity admitted 
only when it becomes absolutely necessary. Young persons 
who are slightly myopic may require a low concave power 
only when reading music, or examining objects which can not 
be brought near the eye. When they have reached the age 
at which the eye settles into its permanent focus, they may, 
according to circumstances, either permanently adopt specta- 
cles, or occasionally use an eye-glass. The latter should 
always be made with a glass for each eye. The practice of 
using a single glass is prejudicial to the eye which is unem- 
ployed. 
American opticians follow the French and German methods 
of numbering glasses whether concave or convex. Thus, 
"No. 1 " means glasses which are most convex, or least con- 
cave ; "No. 2 " is more so, each successive number indicating 
an increase in the convexity or concavity; and every number 
expresses the focal distance of an inch. "No. 20," for in-* 
stance, would imply that the focus of the glass was twenty 
inches, whether convex or concave, and the convexity of 
"No. 30," for instance, exactly fits the concavity of "No. 
30," and so on from the beginning to the end of the series. Presbyopia. 
183 
PRESBYOPIA-HYPERMETROPIA. 
When refraction and accommodation render small and near 
objects indistinct, while distant ones are seen clearly, the 
defect is called presbyopia or hypermetropia, and is also 
designated as " long-sightedness." The difficulty is not 
necessarily the result of age, although eyes affected with pres- 
byopia seem to be flattened in their antero-posterior diameter, 
as they are in advanced life. It is occasionally met in young 
persons-even in children-and it is also a frequent result 
of exhaustion in the nervous and muscular powers of the eye 
in consequence of over use. A disproportion in the diameters 
of the eye is the prevailing cause of myopia and hyperme- 
tropia. In the former defect the rays of light, entering at 
the pupil, come to a focus in front of the retina, and in the 
latter they come to a focus behind it. Long-sight may be 
due to insufficient convexity of the lens-from'want of power 
to move it in that slight degree necessary for due adjustment 
-as well as from the antero-posterior diameter of the globe 
being too small. 
Young persons having presbyopic eyes are apt to fall into 
the habit of viewing small or near objects with one eye- 
binocular vision being impracticable-and thus acquire a 
peculiar squint, the strabismus being convergent. The squint 
is temporary at first, but in time it becomes permanent. If the 
use of convex glasses does not overcome the strabismus, it is 
best to divide the internal rectus which has by prolonged 
exertion acquired preponderating power over its antagonist. 
Persons who in early life have had remarkably acute sight 
for distant objects, commonly find, as they approach the age 
of fifty, that reading becomes more and more difficult. The 
book is placed farther off, and at last is held at arm's length. 
The effort is attended with a sense of strain in the eyes, which 
can not be prolonged without pain. Glasses of low convex 
power-say of twenty-four inches focus-at once remedy the 
defect, reading being resumed with ease and comfort. 
In examining hypermetropic eyes it is well to use Snellen's 
types; the imperfection of vision when thus tested, will be 
found at the extremes of visual range, i. e., at the near and 
far points. The larger types at the longest distances will 184 
Diseases of the Eye. 
probably be seen with greater distinctness than the smaller 
ones held close to the eyes. A presbyopic patient, when ex- 
amining near or distant objects, strains the ciliary muscles 
and the internal recti to gain the advantage which the con- 
vergence of the optic axes affords in increasing the power of 
accommodation. 
In testing hypermetropic eyes it is often advantageous to 
ascertain whether the defect is due to the flattening of the 
eyeball or to impaired accommodation. If a patient can at a 
distance of twenty feet, read No. 20 of Snellen's test types, 
with a No. 20 convex lens, and, upon paralyzing the ciliary 
muscle with atropine it requires a greater convexity in the 
glasses, say No. 10, to read with equal distinctness, the differ- 
ence between these lenses expresses the amount of accommo- 
dation employed before the atropine was used. 
In the common forms of hypermetropia convex spectacles 
remove all difficulty in reading. In order to ascertain the 
number of the glasses to be selected that the defect of vision 
may be corrected, the patient should be asked to read No. 20 
of Snellen's test types at a distance of twenty feet. He may 
now try to read the types with No. 30 convex glasses, and 
then with No. 20, ascertaining experimentally the lowest 
power (highest numbers) of glasses with which the types can 
be clearly read without effort, the higher powers are objec- 
tionable inasmuch as they tend to increase the defect. The 
glasses should be worn only while reading or writing, or 
while necessary to examine minute objects. If aid be required 
for viewing distant objects, a less convex form of glass should 
be used in observing them. 
Presbyopia, which, as has been intimated, is a defect in the 
accommodating powers of the eye-a fault which may lie in 
the ciliary muscle or the form and consistence of the lens-is 
apt to increase with age, therefore as the patient grows older 
the focal power of his spectacles must be increased. No. 36 
may be strong enough at the age of twenty, but No. 20 may 
be needed at the age of sixty. It is common for hyperme- 
tropes to look over their glasses when suddenly called to view 
distant objects. 
Hypermetropia, strictly speaking, or as now defined, is a 
defect of vision depending on a want of refractive power in 
the dioptric media, as the curves of the cornea and lens, and Acritochromacy. 
185 
the antero-posterior diameter of the eyeball, therefore changes 
for the worse, as age advances, are not so common as in pres- 
byopia where the defect depends upon impaired muscular 
action. As the two states generally exist in common, there 
is little advantage gained by attempts to draw fine lines of 
distinction between presbyopia and hypermetropia. Both 
defects are remedied by convex glasses; and the proper focal 
power of the spectacles can be obtained experimentally. To 
be sure, the use of atropine, by paralyzing the ciliary muscle, 
will determine what proportion of the defect is accommoda- 
tive, or depending on muscular action, and, by inference, 
what is refractive, or depending upon the dioptric media. 
ACRITOCIIROMACY, OR INABILITY TO DISCRIMI- 
NATE BETWEEN COLORS. 
Certain individuals are unable to discriminate between 
colors, or to apppreciate different colors. The defect may be 
called acritochromacy, though a half dozen other technical 
terms, highly compounded, have been invented to express the 
visual abnormity. The peculiarity has been called Dalton- 
ism, after the celebrated chemist, who could not recognize 
several distinct tints, and published, in 1798, some speculations 
upon the subject. Dalton could appreciate blue, and supposed 
that a blue tint of the vitreous humor was the cause of the 
personal peculiarity. In accordance with an expressed wish, 
his eyes were examined after death, but as might have been 
expected, if the cause had been understood as it now is, 
nothing unusual was discovered. The cause of " color-blind- 
ness " resides not in the eye, but in that portion of the brain 
to which the impressions of light are conveyed. The defect 
in most instances appears to resolve itself into inability to 
perceive red. Yellow and blue are generally appreciated. 
The compound tints which are doubtful in their impressions 
are those into which red enters to a greater or less extent. 
Many persons fail to distinguish clearly between blue and 
green, and to quickly make out the difference between other 
allied colors. Among those individuals who are unwilling to 
admit they suffer any degree of defect in the appreciation of 186 
Diseases of the Eye. 
colors, there exists a variety of opinion in regard to tints and 
shades of color, which is very interesting. 
Sometimes acritochromacy is temporary and depends upon 
some bodily ailment. Persons suffering from jaundice claim 
that everything bears a yellow hue. Disease of the brain has 
been attended with a faulty perception of colors. Lead- 
poisoning produces violet vision ; and certain medicines in 
large doses temporarily derange the powers which appreciate 
colors. 
HEMERALOPIA AND NYCTALOPIA. 
Intense light, direct or reflected, produces a dazzling effect 
upon the eye which is followed by inability to see distincily 
except in broad daylight. The derangement in the visual 
powers is called hemeralopia which means, in its literal signi- 
fication, " day-sight." Persons who have taken sea voyages 
in the tropics suffer most from the affection. Sailors attribute 
the difficulty to sleeping on deck with the eyes exposed to 
the moonbeams. The real cause is to be attributed to ex- 
haustion of the nervous power of the retina from over-excita- 
tion produced by the sun's rays, so that the weaker stimulus 
of twilight and moonlight will not make an appreciable im- 
pression. "Snow blindness" is a defect of a similar nature, 
the eye having been subjected too long to an intense reflected 
light. Hemeralopia is occasionally met in temperate regions, 
the cause being analogous to that which produces the defect 
in the tropical belt. Defective nutrition may contribute to 
the visual derangement. 
Nyctalopia literally signifies " night-sight," and implies 
that vision is more distinct at night than during the day-the 
converse of hemeralopia.. Persons who have a super-sensi- 
tiveness of the retina, being dazzled by intense sunlight, can 
see better in the evening than during the day, hence they are 
called nyctalopes, though they are not truly such, as are bats 
and owls. Nyctalopia is a morbid condition produced by in- 
flammation of the retina, and may be regarded as a phase of 
"amaurosis." An irritable form of corneal inflammation. Asthenopia. 
187 
attended with photophobia, may compel a sufferer to peep out 
only at night or when the light is dim, and thus the defect 
may seem to be a species of nyctalopia. However, a careful 
examination of the eyes will soon determine whether the 
" night-seeing" is a peculiarity-an idiosyncracy-or the 
result of inflammatory action. 
ASTHENOPIA. 
Inability to prolong an adjustment of the dioptric apparatus 
for short distances, faulty refraction, and lack of power to 
continue the use of the eye without confusion of sight, con- 
stitute ocular defects which have been grouped under the 
term " asthenopia." 
When a person endeavors with two eyes to follow an 
object-say a coin-which is brought nearer and nearer from 
a distance where its outline can be distinctly made out, to a 
point close to the face, the eyes will be observed to converge 
by the action of the internal recti muscles, so that the rays 
of light proceeding from the coin fall upon precisely corre- 
sponding spots on both retinae. But, if the internal recti be 
weak or not under control, the external recti prove too power- 
ful for their antagonists, and the eyes will lose their normal 
steadiness, and soon become everted, one more than the other, 
so that the pictures of the object viewed fall unsteadily upon 
dissimilar points of the retinae, and imperfect vision results. 
This is called motor asthenopia from the fact that the muscular 
apparatus is at fault. 
Patients who are normally myopic may suffer occasionally 
with asthenopia. They use the eyes while examining minute 
objects in a state of constrained convergence, until the in- 
ternal recti are tired, and then the external recti exert a pre- 
dominance of force, turning the eyes outward. Rest must 
then be taken to allow the internal recti to regain their 
accustomed vigor. If an attempt be made to continue the 
use of the eyes after the muscles are exhausted, the objects 
viewed will become confused, and pain sets in from futile 
efforts to see, and from congestion of the choroid. 
In motor asthenopia the patient is often troubled with 188 
Diseases of the Eye. 
double images. This annoyance comes from the fact that the 
rays from the object viewed do not fall upon spots correspond- 
ing in the two retinae. Myopes are frequently harrassed with 
double vision, especially while reading, the letters running 
together, and blending in inextricable confusion. Patients 
who persist in reading after the double images appear are 
obliged to shut one eye, or fix the weak one with the finger. 
However, make-shift advantages gained by such expedients 
are not lasting, and often terminate in serious injury to vision. 
Motor asthenopia can generally be demonstrated by asking 
the patient to look steadily at a small object which is moved 
gradually towards the face. When the object is approaching 
within a few inches of the nose, one eye-the weaker-begins 
to oscillate, and finally inclines outward, making vision in- 
distinct. 
The existence and the amount of asthenopia may be tested 
by the use of a prism, whose refractive angle is up or down. 
If a black spot a quarter of an inch in diameter be made on 
a sheet of paper, and a perpendicular line be drawn through 
the spot, and then a person who is emmetropic (normal- 
sighted) be directed to look steadily at the figure while a 
prism is held before the eyes, two spots will appear, one 
directly above the other. But if asthenopia exist in either 
eye, one of the spots will appear to the right or left of the 
perpendicular line. This deviation proves the existence of 
asthenopia; yet the degree of deviation is to be demonstrated 
by the use of a second prism in front of and across the first, when 
the angle of the prism required to restore the spot to its position 
on the perpendicular line will indicate the amount of the diplo- 
pia. By testing one eye, then the other, it may be determined 
whether both eyes are affected alike, and the degree of differ- 
ence, if any exist. 
Motor asthenopia is remedied by the use of properly 
selected spectacles ; and sometimes cured by dividing the 
external rectus muscle. Concave glasses remedy the defect 
by permitting the patient to see distinctly without bringing 
the object viewed too near the eyes. Prismatic glasses have 
been constructed with the view of bending the rays of light 
upon corresponding points of the retinae. 
If tenotomy of the external rectus is deemed necessary to 
correct the evils of motor asthenopia, great care should be Astigmatism.* 
189 
exercised in the performance of the operation lest by the 
entire division of the muscle the defect be converted into a 
convergent strabismus. Partial division of the muscle will 
commonly render the antagonism equal; and it is safer to cut 
too little than too much, as a second operation is always 
practicable. 
Accommodative asthenopia is similar to the motor variety, 
the difference consisting chiefly in the part which is defective. 
In the accommodative variety the ciliary muscle is deficient 
in energy. Patients suffering from this form of asthenopia, 
may see well at long and short distances, but are unable to 
read a great length of time without the letters becoming con- 
fused and running into each other. The ciliary muscles get 
tired and through fatigue refuse to adjust the lenses until 
they have a few minutes rest. 
Accommodative asthenopia is frequently associated with 
hypermetropia, therefore convex glasses may assist in reme- 
dying the defect. Something valuable may be gained by 
improving the conditions under which the eyes are used. 
The patient should have an abundance of light, and be placed 
so as to receive it to the best advantage. Reading should 
not be allowed in bed, or when the bodily powers are ex- 
hausted. Objects viewed should not be too high nor too low, 
but everything favorable to easy vision should be sought. 
In some instances the patient loses confidence in his ability 
to use the eyes, and needs to be encouraged to employ them 
for a few minutes at a time, daily increasing the period of use. 
ASTIGMATISM. 
The cornea does not always have the same curves from its 
centre to its border-there is asymmetry in its meridians. 
This irregularity of corneal surface does not refract the rays 
of light coming from different directions to a focus, conse- 
quently a very imperfect image is formed on the retina. The 
difficulty is called astigmatism, and is pretty common. The 
lack of symmetry in the different meridians of the cornea 
may be that of myopia at one point and hypermetropia at 190 
Diseases of the Eye. 
another. An astigmatic person viewing a Greek cross sees 
distinctly the upright part and imperfectly the horizontal 
portion, or vice versa. 
Astigmatism may be an hereditary affection, and then both 
eyes are symmetrically defective ; or it may arise from dis- 
ease which warps the normal curvatures of the cornea, and 
be confined to one eye. In advanced life one or both eyes 
may become astigmatic without the patient being aware of 
Fig. 00. 
The radiating lines form a series of crosses with equal arms, to test eyes suspected of 
astigmatism. 
any visual defect. The Boston Advertiser, in a recent issue, 
contains the abstract of a lecture delivered by Dr. B. Joy 
Jeffries on "Defects of Vision Affecting Artists," which 
embraces some points illustrative of the defect under consider- 
ation. 
" Astigmatism is the name given to a physical defect of 
the eye in which the cornea is at fault. Its curve is not the 
same in all its meridians, so that there is no perfect focus on 
the retina. The result is that a cross of equal arms may look 
quite uneven, the horizontal arms appearing longer or shorter 
than the vertical. Letters, especially certain type, may be Astigmatism. 
191 
much blurred, greatly reducing the apparent power of vision. 
Ordinary spectacle glasses do not, of course, relieve this, and 
many persons may go through life without finding out that 
the deformity, for so it is, may be counteracted by appropriate 
cylindrical glasses, the selection of which requires the care 
and the attention of the specialist." 
About a year ago, Dr. Liebreich, ophthalmic surgeon of 
St. Thomas' Hospital, London, delivered a lecture at the 
Royal Institution, in which he spoke of having examined 
several painters who suffered from this form of trouble, and 
explained how it affected their pictures. The special trouble 
it produced in a portrait painter was that he drew his faces 
too long. This was shown by the magic lantern being made 
astigmatic, and then properly corrected by the appropriate 
cylindrical glass to correct the astigmatism. 
According to Donders there is ordinarily a marked difter- 
ence between the refractive power exerted by the horizontal 
and the vertical meridians of the eye. The fact is demon- 
strated by placing a series of vertical and horizontal lines or 
bars at a distance of fifteen or twenty feet from the observer, 
and asking him to look at them steadily. The perpendicular 
stripes can be distinctly seen, while the horizontal ones will 
appear indistinct even at a diminished distance. And the 
converse of this .holds good if the lines be brought near to 
the face. The perpendicular bars then become confused, and 
the horizontal well defined. This lack of correspondence in 
the refractive power of the vertical and the horizontal 
meridians of the healthy eye produces no appreciable incon- 
venience ; but if the defect be exaggerated a little, consider- 
able impairment of sight is the result. 
Persons who have occasion to view large objects only, do 
not complain even if a high grade of astigmatism exists ; but 
as soon as they engage in reading, writing, and the execution 
of fine work, slight degrees are very annoying and demand 
correction with proper glasses. When the focal distance 
varies in the two eyes, patients learn to evade the difficulty 
by placing their glasses obliquely across the nose. Astig- 
matics who do not wear glasses, learn to remedy the defect 
by holding the head so as to modify the refractive power. 
There is often chromatic aberration in high grades of 
astigmatism. The image of dispersion appears surrounded 192 
Diseases of the Eye. 
by circles of various hues ; and the colors can be modified by 
the use of positive and negative glasses. 
The ophthalmoscope may be employed to detect astigma- 
tism, yet much experience with the use of the instrument is 
needed to apply the various tests in the investigation. Elon- 
gation of the optic disc, and an indistinct exhibition of the 
retinal vessels running in one direction, are among the phases 
which indicate astigmatism. 
The presence and degree of astigmatism maybe determined 
by the use of blackened metal plates which have slits cut in 
them. If a patient will press one of these plates close to the 
eye, and steadily rotate it, he will discover the direction the 
slit takes when vision is the sharpest, and another direction 
perpendicular to this, in which the indistinctness reaches a 
maximum. These two directions of the slit give the position 
of the two meridians where refraction is greatest and least. 
When astigmatism depends upon ulcers and cicatrices of 
the cornea, or upon a defective lens, the anomalies of refrac- 
tion constitute what Bonders termed irregular astigmatism. 
This variety of astigmatic defect is not remedied by the use 
of spherical glasses, nor with other means. 
As has been already indicated, regular astigmatism is to be 
corrected by the use of cylindrical glasses-or such as have 
one or both surfaces ground with a concave or convex cylin- 
drical curvature. It requires great care and much experience 
in the adjustment of spectacles, to supply an astigmatic 
patient with proper glasses, and to give the best instructions 
for their use. The glasses when properly selected, or fitted 
for the peculiarities of the case, should be worn close to the 
eyes, and parallel to the plane of the pupil. Even after the 
errors of refraction are corrected, the vision of the patient 
may be seriously imperfect. 
NYSTAGMUS. 
Instability of the ocular muscles is not uncommon. The 
difficulty-called nystagmus-is associated or combined with 
strabismus. One eye is usually more unsteady than the other, 
and the patient is unable to fix the visual line on one point. 
An attempt to fix the eyes on any object results in aggravated Nystagmus. 
193 
oscillation. The motor muscles do not steadily antagonize 
each other, but act in rapid alternation, and quite rhythmi- 
cally in pairs or groups. The sight in one or both eyes is apt 
to be defective in patients thus disturbed in their ocular 
muscles. 
The cause of nystagmus is unquestionably in the nerves 
imparting motion to the eyeball, or in that part of the brain 
from which these nerves have their origin. It has been 
declared that the primary defect is in the nerves of vision, 
and that the oscillations were a sequence-the eyes rapidly 
moving to catch a better view of objects. The fact that per- 
sons having congenital cataract are affected with rolling eyes, 
seems to favor the idea that the movements in nystagmus 
come from imperfect vision. 
Twitching of the orbicularis muscle, or parts of it, is occa- 
sionally associated with unstable ocular muscles. However, 
the lid complication is not a necessity. 
A peculiarity of nystagmus is that the eyes become quiet 
when turned laterally, in a horizontal or oblique direction, 
and are made to look upon a point at considerable distance. 
When the recti muscles are most affected the motion of the 
eyes is oscillatory; if the obliqui chiefly partake of the 
agitation, the movement is rotatory; and should both sets of 
muscles be involved, a mixed, nystagmus exists. The agitation 
is increased by excitement, by straining the eyes to view near 
and minute objects, and by taxing the eyes when the illumi- 
nation is scanty. When the eyes are brought into a condition 
of comparative steadiness, and then turned upon an object at 
a greater or less distance, especially to a point at one side or 
the other of the one steadily gazed upon, the agitation is 
provoked. The lateral motion necessary to follow the lines 
in reading, will throw the eyes into a state of tremulousness; 
and patients learn to turn the head, and not the eyes, or carry 
the book from side to side to avoid nystagmus, and to secure 
quiet vision. A book held at right angles to what it usually 
is, will enable some patients to read with greater facility, par- 
ticularly if the recti muscles be at fault. 
A paroxysm of nystagmus may be provoked by gazing at 
objects in motion, as the panorama of a crowded street; and 
considerable time is required in a quiet room to allay the 
fit of agitation. 194 
Diseases of the Eye. 
Opacities of the corneae, partial cataract, and congenital 
defects in the dioptric media, are causes of nystagmus; and 
when any one of these produces the tremulous movements, 
there is little hope of a cure unless the cause can be removed. 
Perhaps the corneal opacity will diminish, or the lens will 
improve, giving the oscillating eye an opportunity to become 
steady. 
When strabismus is a complication, the division of one or 
more muscles may prove remedial. A partial severance of 
the internal recti has been attended with beneficial effects. A 
division of all the ocular muscles would render the eye steady, 
yet the operation is followed by a lack of mobility which is 
disagreeable. If the eyes tend to convergent squint, the in- 
ternal recti may be divided first; and afterwards the external 
recti; and, finally, the obliqui. 
Something may be accomplished by covering one eye with 
a compress, and using the other solely for a few weeks at a 
time. Then, to escape the dangers arising from inactivity, 
the bandage may be changed to the eye which has been in 
use, and the other will then enjoy the wonted stimulus of 
light. The wearing of a spectacle frame which has delicate 
springs to press gently upon the eyeballs, will enable some 
patients to overcome the oscillation. 
Persons having nystagmus should select an occupation 
which does not require steady vision. There are many trades 
which are carried on by the use of the hands or the sense of 
touch, vision not being necessary to the manual execution. 
Electricity has been employed with the hope of curing 
nystagmus, but very little benefit has arisen from this or other 
agencies. The tremulous condition having existed from 
youth, a habit is established which, like stammering and 
other habits, is exceedingly difficult to overcome. SNELLEN'S TEST TYPES. 
When the United States ceased to be a part of the British empire, 
and assumed the character of an independent nation, they became 
subject to that system of rules which reason, morality and custom 
had established among the civilized nations of Europe, as their publ:c 
law. During the war of the American R volution, Congress claimed 
cognisance of all matters arising upon the law of nations, and they 
professed obedience to that law, "according to the general usages of 
Europe." By this law wo are to undei stand th't code of public in- 
struction, which defines the rights and prescribes the duties of nations, 
in their intercourse with each other. The faithful observance of thia 
law is essential to national character, and to the happiness of mankind. 
According to the observation of Montesquieu, it Is founded on the 
2 
principle, that different nations ought to do each other as much good in peace, and as little harm 
in war, as possible, without injury to their true interests. But as the precepts of this code are 
not defined in every case with perfect precision, and as nations have no common civil tribunal 
to resort to for the interpretation and execution of this law, it is often very difficult to ascertain 
to the satisfaction of the parties concerned, its precise injunctions and extent; and a still greater 
difficulty is the want ot adequate pacific means to secure obedience to its dictates. 
3 
There has been a difference of opinion among writers concerning the foun- 
dation of the law of nations. It has been considered by some as a mere 
system of positive institutions, founded upon consent and usage; while others 
have insisted that it was essentially the same as the law of nature, applied to 
the conduct of nations, in the character of moral persons, susceptible of obli- 
gations and laws. We are not to adobt sither of these theories as exclusively 
3i 
true. The most useful and practical part of the law of nations is, 
no doubt, instituted or positive law, founded on usage, consent 
or agreement. But it would be improper to separate this law en- 
tirely from natural jurisprudence, and not to consider it as deriv- 
ing much of its force and dignity from the same principles of right 
reason, the same views of the nature and constitution of man, and 196 
Test Types. 
4J 
the same sanction of Divine revelation, as those from 
which the science of morality is deduced. There is a 
natural and a positive law of nations. By the former, 
every state, in its relations with other states, is bound 
to conduct itself with justice, good faith and benevo- 
lence; and this application of the law of nature has 
6i 
been called by Vattel the 
necessary law of nations, 
because nations are bound 
by the law of nature to 
observe it, and it is termed 
by others the internal law 
12 
of nations, as it 
is binding upon 
them as a matter 
of conscience. Test Types. 
197 
20 
The rights, 
duties, and 
responsibil- 
ities which 
arise from 
natural law 198 
Test Types. 
30 
No man 
can dis- 
obey the 
laws of 
nature. INDEX 
Accommodation, powers of, in the eye 12, 180 
Acritochromacy 185 
Albino no 
Albugo ' 102 
Amaurosis 166 
Amblyopia 165 
Amputation of the eye 171 
Anatomy of the human eye 12 
Anatomy of the eyes of animals 9 
Ankyloblepharon 40 
Appearances, morbid, of retina 14 
Appearances of optic disc and choroid 23 
Aqueous humor 14 
Arcus senilis 90 
Arsenic 28 
Artificial eyes 172 
Asthenopia 187 
Astigmatism 99, 189 
Atropia 18, 26 
Atrophy of optic nerve and retina.,. 162 
Axes, optic 14 
Bandage for the eyes, Liebreich's.. 120 
Basedow's disease 177 
Beer's cataract knife 139 
" Black eye " 35 
" Blear eye " 31 
Blepharophimosis 40 
Blepharoplasty 51 
Blind fishes .... 9 
Blind mole 11 
Calabar bean 26 
Cancer of the lids 34 
Canal of Petit 14 
Canal of Schlemm 14 
Canaliculus 57 
Canthoplastic operation 47 200 
INDEX. 
Canthus, internal and external 30, 45 
Carcinoma 34, 169 
Cartilages, tarsal 15 
Cataract 125 
Cataract, congenital 128 
Cataract, traumatic 129 
Cataract, senile 130 
Cataract operations 134 
Cataract operations, Graefe's 148 
Cataract operations, Liebreich's 151 
Chalazion 37 
Chambers of the eye 15 
Chemosis 66, 70, 77 
Choroid 14, 23, 164 
Choroiditis 164 
Cilia 15, 30 
Cilia forceps 42 
Ciliary muscle and ligament 14 
Ciliary processes 124 
Collyria 26, 67 
Coloboma 110 
Color blindness . 185 
Conjunctiva. 15, 63 
Conjunctiva, xerosis of 88 
Conjunctivitis 64 
Conjunctivitis, catarrhal 66 
Conjunctivitis, purulent 68 
Conjunctivitis, Egyptian 68 
Conjunctivitis, granular 72 
Conjunctivitis, purulent, of infants 78 
Conjunctivitis, gonorrhoeal 77 
Conjunctivitis, eczematous 81 
Conjunctivitis, chronic 84 
Conjunctivitis, scrofulous or strumous 80 
Cornea .5 14, 89 
Cornea, conical ' 90 
Cornea, ulceration of 96 
Cornea, opacities of. 101 
Cornea, injuries of 103 
Cornea, foreign bodies in... 105 
Corneitis (keratitis) 91 
Corelysis 122 
Crab lice 37 
Crystalline lens 124 
Curette 140 
Cystic tumors of the lids 34 
Cysticercus . 88, 157 
Detachment of the retina 24, 162 
Depression of cataract 134 
Distichiasis 42 
Ductus ad nasum 57 INDEX. 
201 
Ecchymosis of the lids 31 
Ectropion 46 
Eczema of the lids 35 
Eczema tarsi 36 
Eczematous conjunctivitis 81 
Eczematous lids 26 
Emphysema of the lids 34 
Entropion.,. 46 
Epicanthus 38 
Epiphora 58 
Epithelioma of the lids 34 
Eversion of the lids 46 
Examination of the eye 16 
Excavation of the optic nerve 160 
Exophthalmos 177 
Extraction of cataract 138 
Extraction of cataract, linear 146 
Extraction of cataract, modified linear 148 
Eye, comparative anatomy of. 9 
Eye, rudimentary 11 
Eye, an optical instrument 12 
Eye, its powers of accommodation 13, 180 
Eye, of hawks 13 
Eye, muscles of the 13 
Eye, examination of the 16 
Eye, amputation of the 171 
Eye, artificial 172 
Eye-bandage 120 
Eyelashes 30 
Eyelids 30 
Fistula lachrymalis 61 
Focal distances 182 
Glaucoma 165 
Glioma 169 
Glasses, selection of. 182 
Gonorrhceal ophthalmia 77 
Graefe's cataract operation 148 
Graefe's cataract knife 148 
Granular lids 72 
Grave's disease a 177 
Helmholtz, his discovery of the ophthalmoscope 21 
Hemeralopia 186 
Herpes of the lids 35 
Herpes of cornea 94 
Hordeolum 37 
Horner's muscle , 31 
Human eye, anatomy of. 31 
Humors of the eye 15 
Hypopion 95, 111 
Hyaloid membrane - 14, 124, 157 
Hyalitis 157 202 
INDEX. 
Hypermetropia 183 
Instruments, ocular 29 
Iodides 28, 36 
Iodoform 36 
Inversion of the lids „ 46 
Iris 109 
Iris, prolapse of 
Iritis Ill 
Iritis, rheumatic 
Iritis, chronic , 113 
Iritis, syphilitic 24, 114 
Irideremia HO 
Iridodisis 123 
Iridectomy 117 
Iris-hook 
Keratitis 91 
Keratitis, suppurative 95 
Keratonyxis 36 
Knife, Beer's cataract 
Knife, Graefe's cataract 
Lachrymal apparatus 57 
Lachrymal gland 57 
Lachrymal sac 57 
Lachrymal fistula 61 
Laminaria cribrosa 16 
Lens, crystalline 14, 124 
Lids of the eye 30 
Liebreich's ophthalmoscope 21 
Liebreich's eye-bandage . 120 
Liebreich's cataract operation «... 151 
Linear extraction (cataract) ,...146 
Linear extraction, modified 148 
Leucoma 101 
Limbus conjunctivalis., 64 
Long sight 183 
Macula lutea.. ...16, 160 
Marsupium H 
Meibomian glands 15 30 
Mercurials, use of 28 115 
Musca? volitantes , 25, 166 
Mydriatics 18 
Myopia 180 
Myotics, calabar bean 26 
Myotics, opium 26 
Naevi materni 33 
Nebula 101 
Necrosis of the orbits 32 
Needle operation (cataract) 136 
Nictitating membrane 10 
Nictitation 39 
Nyctalopia ..186 203 
INDEX. 
Nystagmus 128, 192 
Ocular tumors 169 
Ointments 26 
Onyx 95 
Opacity of the cornea 101 
Ophthalmostat 118 
Operations, cataract 139 
Operations, cataract, Graefe's 148 
Operations, cataract, Liebreich's 151 
Opium, a myotic 26 
Ophthalmia 64 
Ophthalmia, purulent 68 
Ophthalmia, neonatorum 69, 71, 78 
Ophthalmia, granulosa 74 
Ophthalmia, gonorrhoeal 77 
Ophthalmia, scrofulous or strumous 80 
Ophthalmia, chronic . 84 
Optic nerve 14, 158 
Optic nerve, atrophy of 162 
Optic axes, 14 
Optic papilla 158 
Optic disc 16, 23, 24, 159 
Ophthalmoscope 20 
Ora serrata 160 
Orbit, injuries of. 175 
Papilla, optic 158 
Photophobia 17 
Phtheiriasis (crab lice) 37 
Pinus Canadensis 68, 76 
Pinguecula 88 
Pigment 109 
Plica semilunaris 63 
Plastic operations upon the lids 46 
Poultices 70 
Porus opticus 159 
Presbyopia .183 
Puncta lachrymalia 30, 57 
Ptosis 39 
Pterygium 84 
Pupil of the eye 15, 109 
Pupilometer 18 
Pustules of the lids 35 
Pectination (cataract) 135 
Remedies for eye diseases 25 
Retina 14, 160 
Retina, atrophy of. 162 
Retina, detachment of. 24, 162 
Retina, morbid appearances of 23 
Retinitis . 160 
Sclerotic (tunic) 14, 106 
Sclerotic, injuries of 107 204 
INDEX. 
Sclerotitis 106 
Scl eroticon yxi s 137 
Scrofulous ophthalmia 80 
Sinuses, palpebral 16 
Sinuses, circular 14 
Short sight 180 
Snellen's formulae 181 
Snellen's test types 195 
Solution of cataract ; 135 
Squinting 52 
Staphyloma 70, 98 
Staphyloma, ablation of 100 
Staphyloma, scleral 107 
Sty 37 
Style, lachrymal 62 
Strabismus. „ 52 
Strabismometer 17 
Stricture of the lachrymal ducts 60 
Sulphur 16 
Synechia 97, 112 
Symblepharon 41 
Syphilitic iritis 
Tapetum n, 109 
Tarsal cartilages 15 
Tarsoraphic operation 49 
Tenon's capsule 64 
Tenotomy 54 
Test types, Snellen's 19, 195 
Test types, Jaeger's 20 
Trachoma 72 
Trichiosis • „ 42 
Tumors, cystic, of the lids 34 
Tumors, fatty, of conjunctiva 88 
Tumors, ocular 
Tumors, intracranial 
Twitching of the lids 39 
Ulceration of the cornea 96 
Uvea 109 
Vense vorticosse 
Visual field 20 
Vision disturbed by intracranial disorders 178 
Vitreous humor 14 157 
Warts upon the lids 33 
'Wild hairs7 35 42 
Wolfe on cataract 743 
Xerophthalmia go 
Xerosis gg 
Zone of Zinnius 14