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DISEASES OF THE EYE

GOULD AND PYLE

Blanthes of
^H The chor

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Fhe Nohmal Fundus in the rHVEBTBD Im^cr.— lifter Jaex'r.]
ring only on the r^bt lide.

?aUIZ-COMPENDS? No.. 8

A COMPEND

OF THE

DISEASES OF THE EYE

AND

REFRACTION

INCLUDING TREATMENT AND SURGERY

GEORGE M. GOULD, A. M., M. D.

FORMERLY OPHTHALMOLOGIST TO THE PHILADELPHIA HOSPITAL^ ETC.

AND

WALTER L. PYLE, A. M., M. D.,

ASSISTANT SURGEON TO WILLS BYE HOSPITAL, PHILADELPHIA, ETC.

Second £Ntion, IRcviBC^ and Enlarged

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I

PREFACE TO THE SECOND EDITION.

Encouraged by the sale of a large edition of this compend within
two years, the authors have corrected, revised, and enlarged the text as
much as compatible with the necessarily limited space, until now the
volume far exceeds the ordinary size and scope of a compend.
Through the liberality of the publishers the whole book has been re-
set in larger type, and several new illustrations, including five colored
plates, have been added. The section on Local Ocular Therapeutics
has been increased to include all the recent mydriatics, miotics, local'
anesthetics, ocular antiseptics, etc. Additional emphasis has been

given to points of practical value.

GEORGE M. GOULD,

WALTER L. PYLE.
Philadelphia, June, j8gg.

PREFACE TO THE FIRST EDITION.

The object of this compend is to describe simply and concisely the
most important subjects in Ophthalmology, giving the novice all the
necessary preparation for an intelligent comprehension of the more
exhaustive literature of this branch of Medicine. For the benefit of •
the general physician, to whom some elementary knowledge of
Ophthalmology is imperative, especial attention has been given to
the principles and practice of refraction ; to muscular anomalies ; to
the diagnosis and differentiation of the common ocular diseases ; and
to local ocular therapeutics.

A table of abbreviations, a glossary, and a complete index are
appended. Dr. James Thorington has kindly written the section
on Retinoscopy.

Philadelphia, June, iSgy.

GEORGE M. GOULD,
WALTER L. PYLE.

OOrkc\>^

TABLE OF CONTENTS.

PART I.

EXAMINATION AND REFRACTION OF THE EYE, . 13

General Description of the Eye, 13

Elementary Optics, 18

Optical Consideration of the Eye, 27

Examination of the Eye, 33

Inspection, 35

Tension 38

Ophthalmoscopy, 39

Retinoscopy, 49

Test-cards, 58

'lest-Ienses, 62

Prescribing and Testing Glasses, 65

Spectacles and Eye-glasses, 70

Mydriatics and Cycloplegics, 72

Ametropia, 74

Hyperopia, 74

Myopia, 78

Astigmatism, 84

Presbyopia, 93

Anisometropia, . 95

Asthenopia, 98

Amblyopia and Amaurosis, 100

Amblyopia ex anopsia, 100

Hemeralopia, 100

Nyctalopia, loi

Toxic Amblyopia, loi

Traumatic Amblyopia, loi

Hysteric Simulation and Malingering, . 102

Color Blindness, 103

The Field of Vision, . . 106

Hemianopsia, 109

Ocular Muscles, iii

Anatomy, Ill

Functional Anomalies, 1 12

Strabismus, 126

Paralysis, 128

Nystagmus, 131

Operations, I36

TABLE OF CONTENTS.

PART II.

Page

DISEASES OF THE EYE, 139

Diseases of the Eyelid, 139

Anatomy, 139

Diseases of the Skin of the Lids, 139

Diseases of the Edge of the Lids, 142

Blepharitis, 142

Hordeolum, 143

Chalazion, '. . 143

Malposition of the Lids and Lid-edges, 144

Congenital Anomalies, 152

New Growths 153

Diseases of the Lacrimal Apparatus, 153

Anatomy and Physiology, ^ ^53

Diseases of the Lacrimal Gland, 155

Diseases of the Lacrimal Passages, 155

Diseases of the Conjunctiva, 160

Anatomy, 160

Simple Conjunctivitis, 164

Purulent Conjunctivitis, 167

Follicular Conjunctivitis, *. . 1 73

Trachoma, 1 74

Phlyctenular Conjunctivitis, , 177

Pinguecula, 178

Pterygium, 178

Injuries of the Conjunctiva, 179

New Growths, 181

Diseases of the Cornea, 181

Anatomy, < 1 81

Pannus, 183

Interstitial Keratitis, 184

Phlyctenular Keratitis, 185

Suppurative Keratitis 187

Corneal Opacities, 190

Staphyloma, 192

Conic Cornea, 192

Tumors, . 193

Injuries, 193

Operations, 195

Diseases of the Sclera, 196

Anatomy, 196

Scleritis or Episcleritis, 1 96

Staphyloma, 197

Wounds, 198

Diseases of the Iris and Ciliary Body, 199

Anatomy, 199

Inflammations of the Iris, 201

Plastic Iritis, 201

TABLE OF CONTENTS. XI

Page

Serous Iritis, 203

Suppurative Iritis, 204

Malignant Tumors, 205

Injuries, 206

Congenital Anomalies, 206

Pupillary Anomalies, 207

Mydriasis, 207

Miosis, 207

Ai^U Robertson Pupil, 208

Hippus, 208

Operations, 208

.Iridectomy, 208

» Iridotomy, 210

Iridocystectomy, 211

Iridodesis, 211

Cyclitis, 211

Paralysis of the Ciliary Muscle, 212

Spasm of the Ciliary Muscle, 212

Diseases of the Choroid, 212

Anatomy, 212

Choroiditis, 213

Exudative, 213

Suppurative, 215

Myopic, 215

Sarcoma, 216

Rupture, 217

Detachment, 217

Coloboma, . . .' 218

Diseases of the Retina, 218

Anatomy, 218

Hyperemia, ' 219

Retinal Hemorrhage, 220

Retinitis, 221

Albuminuric, 221

Diabetic, 223

Leukemic, 223

Retinitis Pigmentosa, 223

Thrombosis and Embolism of the Retinal Vessels, . . . 225

Detachment of the Retina, 225

Glioma, 227

Injuries, 228

Opaque Nerve-fibers, 228

Diseases of the Optic Nerve, 229

Anatomy, 229

Optic Neuritis, 230

Optic Atrophy, 234

Diseases of the Lens, 235

Anatomy, 235

Cataract, 236

Causes, 2^6

Xll TABLE OF CONTENTS.

Pack
Cataract :

Varieties and Nomenclature, 237

Symptoms and Diagnosis, 237

Objective Examination, 237

Treatment, 241

Operations for Cataract, 242

Discission, 243

Extraction 244

Secondary Cataract, 247

Injuries to the Lens, 248

Congenital Anomalies, 249

Diseases of the Vitreous, , . . . 249

Anatomy and Physiology, ^9

Hyalitis, 249

Muscae Volitantes, 250

Persistent Hyaloid Artery, 250

Glaucoma, 251

Causes, 251

Pathologic Changes, 251

Symptoms, 252

Diagnosis, 253

Varieties, 254

Prognosis, 255

Treatment, 255

Diseases of the Orbit, 256

Anatomy, 257

Periostitis, 257

Orbital Cellulitis, 258

Injuries, 258

Tumors, 259

Exophthalmic Goiter, 259

Enophthalmos, 259

Injuries to the Eyeball, 260

Wounds, 260

Foreign Bodies, 261

Parasites 262

Sympathetic Ophthalmia, 262

Operations on the Entire Eyeball, 264

Evisceration, 264

Total Combined Keratectomy, 265

Enucleation, 265

Artificial Eye, 266

Exenteration of the Orbital Contents, 267

LOCAL OCULAR THERAPEUTICS 268

ABBREVIATIONS 280

GLOSSARY, 281

INDEX, 289

A COMPEND

OF THE

DISEASES OF THE EYE

AND

REFRACTION.

PART 1.

EXAMINATION AND REFRACTION OF THE

EYE.

GENERAL DESCRIPTION OF THE EYE.

The eye is the organ of vision. Impressions of light are received
in the peripheral organ, the eyeball ; are transmitted by the optic
nerve and optic tract to the base of the brain, and thence to the cortex,
and become known to us as images, through the visual centers in the
occipital lobe.

The eyeball is contained in a bony cavity called the orbit, which is
conic in shape, with its apex posterior. The eyeball resembles in
shape a sphere, which has on its anterior surface the segment of a
smaller sphere. The average diameters of the human eyeball are :
24 mm. anteroposteriorly, 23 mm. transversely, and 23 mm. verti-
cally. The eyeball is held in place by its muscles and membranes,
and is supported in the orbit in a cushion of fat. It is surrounded by
a thin membranous sac, called the capsule of Tenon or tunica vagin-
alis oculi. The axes of the two eyeballs are parallel with each other ^

GENERAL DESCRIPTION OF THE EYE. I5

white the axes of the orbit are divergent. The optic nerve enters the
posterior portion of the eyeball through an opening called ihe poms
opticus, slightly to the nasal side-

The eyeball consists of three tunici or outer coats, and three refrac-
tive media called humors.

The tunica are { r) the scUra and cornea ; {2) the choroid, iris, ciliary
muscle, and ciliary processes : (3) the r^/twa, "Vac sclera q^ sclerotic
coal is a tough, fibrous covering, forming the chief protection of the
eyeball. The choroid is the vascular coat, and is chiefly concerned
in the nutrition of the eye; it and the retina are pigmented, and
absorb all the superfluous rays that might, by reflection, confuse the
retinal image. By its contractile and expansile powers, the iris
regulates the quantity of hght admitted into the pupil; ordinarily
it is Bufficienlly pigmented to prevent the passage of light through
its substance. The retina is the inner and most delicate layer, and
contains the nervous elements. It is the percipient tunic of the eye.

The Humors. — The several humors are the aqueous, the crystalline
(lens), and the vitreous. The cornea and the humors are transparent.
All that portion of the interior of the eyeball lying behind the lens
and ciliary processes is called the vitreous chamber, and contains the
vitreous humor, a transparent, jelly-like substance. The crystalhne
lens lies in front of the vitreous chamber. The rernaining anterior
portion of the cavity of the eye is called the aqueous chamber. The
aqueous chamber is subdivided into two portions, the anterior cham-
ber and the posterior chamber, which are in free communication
through the pupil, and both contain the aqueous A«»ior, a slighdy
sahne, transparent fluid. The anterior chamber is an angular space,
covered in front by the posterior surface of the cornea, at its angle by
ihe tigamenlum pectinatum iridis, and behind by the anterior surface
of the iris, tii& posterior chamber m a small cavity, bounded in front
by the posterior surface of the iris, and behind by the ciliary pro-
cesses, the suspensory ligament of the lens, and the anterior capsuli
of the lens.

The nervous supply of the eyeball and its appendages is through
sensory branches from the first and second divisions of the fifth pair
of nerves, and motor branches from the third, fourth, sixth, and
seventh pairs of cranial nerves, and sympathetic filaments from the
carotid and cervical plexuses.
^^Tbe vascular supply of the eye is through ophthalmic branttit^

.XAurNATION /

the internal carotid, and indirectly by anastomoses between its
terminal branches and similai branches of the external carotid. The

f, ss

of Ihe lelina. /. E

the posteiioi shorl ciliary arteiy to the optic nerve, i. Anastomosis of
d vessels with those of Ihe optic nerve, m. Choriocapiliaris, », Epi-

verse seciion). o. Blood-vessels of the itis._, f. Ciliary process, j.

vessels of the globe proper are the long, the short, and thi
ciliary arteries, and the central artery of the retina. Figure 2

GENERAL DESCRIPTION OP THE EVE. I7

schematic representaiion of the vascular supply of the eye. The
venous blood is returned from the eye through the superior and
inferior ophthalmic veins, which empty into the cavernous sinus and
also freely anastomose with the facial veins.

Tbc lymph-ayBtem of the eye consists of numerous small lymph-
canals, which empty into three chief lymph-spaces : the perichoroid
space, the cavity between the choroid and the sclerotic ; the cavity of
the ciipiule ,'/ Tenon,hityieeTi\iic eyeball and capsule ; andlhe x-a^na/
space, between the optic nerve and sheath. It is probable that the
lymphatic spaces in the cornea communicate with the great lymph-
space of the anterior chamber by means of SchUmm' s canal -ixtA the
spaces 0/ Fontana. It is supposed that a stream of lymph flows from
the ciliary body, diffusing through the vitreous, and from [he canal of
Petit to the posterior chamber ; thence downward and forward
through the anterior chamber, from whence it escapes at the angle,
through the membrane of Descemet and the pectinate ligament, to
the canal of Schlemm, Tributary streams of lymph flow into both
the anterior and posterior chambers from the surrounding surfaces.
It is possible that all the lymph-spaces communicate with the ante-
rior chamber, except those of the retina, which discharge through
the/>or«j opticus into the vaginal space.

The muscles of the eyeball are six : the superior, inferior, internal
and external recti, and the superior and inferior oblique.

The appendages of the eyeball are the eyebrows, the eyelids, the
capsule of Tenon, the conjunctiva, the lacrymal apparatus, the mus-
cles, the aponeuroses, and the vessels and nerves.

The anatomy and physiology of the individual components of the
eyeball and appendages will be set forth under the separate headings.

Dissection of the Eye.— It is somewhat difficult to obtain human
eyes, and for practical dissection fresh bullocks' eyes ia which the
corneie are still clear may be used, while for practising operations
pigs' eyes are to be preferred. If the eyes can not be used during
the day on which they arc obtained, they may be preserved in i : looo
solution of formaldehyd. For dissection the eye should be held
firmly In the left hand, and the sclera incised at the equator of the
globe by repeated cuts until the black choroid is seen, and systematic
examination of the different parts of the interior of the eye should
be carefully made, following the plans laid down by the best anato-
Cross-sections of frozen eyes are very valuable to sWiA-^ v'wt

riB EXAMINATION AND KEFKACTION OF TUB EVE. ^H

relative position of the tllfferent parts, whicti is disturbed in ordinarylH
di,.ec.i... ■

For practising operations several masks are on the market, and V
that consisting of a pliantom face with an orbital clip for holding the
eye in a proper position is to be preferred. Operations on the ocular
muscles should be studied on the human cadaver, or on the rabbit,
^^ cat, or dog,

^H ELEMENTARY OPTICS. ^M

Raya of light diverge from a luminous point in a straight line in
every direction and in every plane. At six meters the divergence
of the rays is so slight that for practical purposes we may consider
rays from a point at such a distance as parallel.

Light travels through space at a speed of about i!J6.6B o^ mil es a.
second, but in the air or other transparent mettium of a known density
the rate of speed diminishes, generally with the density of the media
traversed.

The Action of Opaque Substances on Rays of Light. — When a J
ray of light meets an opaque body it is either absorbed or reflected.* ]

Reflection. — The condition first requiring our attention is reflection I
from highly polished plane, concave, or convex surfaces, or, gener- J
ally speaking, mirrors. Rays of light from a luminous point striking j
the mirror are called incident rays; rays leaving the mirro
called reflecled rays.

Resection by a plane Gurface gives an erect image, and the ;
of reliection is equal to the angle of incidence. The reHected a
incident rays are both in a plane perpendicular to the raflectii^
surface. The image is formed at a distance behind the reflectin*
surface equal to the distance of the luminous point in front of it, aBi
is called a virtual image, in contradistinction to a real image which 1
formed directly by the reflected rays, and not by their prolor
If a plane mirror he rotated on any axis in its own plane, the
image moves in an opposite direction to the mirror.

ELEMENTARY OPTICS.

Reflection by a concave surface may be considered as reflection
from a number of plane surfaces inclined toward one another.
Parallel rays falling on a concave surface are reflected as convergent
rays which meet at a point on the axis of the surface inside the cen-
ter of concavity, called iS\^ principal focus (Fig. 3, F\ The distance

*^$^

-V'

Fig. 3.

of the principal focus from the mirror is called ^^ focal length of the
mirror.

The formation of the image varies with the distance of the light
from the mirror. If the light be placed at the principal focus, F, the
reflected rays leave the mirror parallel with each other and the axis

Fig. 4.

of the mirror. If the light be placed at the center of concavity, C,
the reflected rays return along the same line. If at a point beyond
the center, A^ the reflected rays focus between the center and the
principal focus, a ; and, vice versa, if the luminous point be situated
between the principal focus and the center of concavity, the t^€iR.^\35A.

' REFRACTION OF THE EVE.

rays fncus at a poinl beyolid the center ; and [he nearer the point is
( the distance at which the reflected rays
focus. The points A and ii are mutually convertible; j. a, cither
may be taken as the point of emanation of the rays, or. conversely,
as ihe point of collection, and hence are called conjugaU foci. If
the light be placed neater the mirror than the principal focus, the
reflected rays will diverge and never meet ; if, however, the divergent
rays are continued backward, they will unite at a point, H, behind
the mirror (Fig. 4), called the virtual focia, and an observer situated
in the path of reflected rays will receive them as if they came from
this point. Hence, concave mirrors produce a small inverted real
image of an object beyond the center of concavity, no image of an
object at the focus, and an erect and a larger virtual image of an
object inside the focus. If a concave mirror be rotated, the real
inverted aerial image of the object will move in the same direcdon as
the rotation of the mirror.

Reflection by a cooves surface produces a negative image at a point
back of the surface called the principal focus, as parallel rays falling
on a cnnvex surface diverge and never meet. Whatever the position
of the object before a convex mirror, the image is always virtual,
erect, and smaller than the object.

The Action of Transparent Substances on Light. — A ray of light
traversing a homogeneous substance like ether passes through undis-
turbed and in straight lines, and, as already stated, when it is inter-
cepted by an opaque substance it is reflected or absorbed ; but if it
meets with a transparent medium it is only partially reflected and
absorbed, the greater portion traversing the media, and during its
passage it is deflected toward the perpendicular to the plane dividing
the medium from which it comes from the medium which it enters.
This bending of the ray is called refraction; the medium trav-
ersed is called the refracting medium. In considering the transmis-
sion of light through a transparent surface, the infinitesimal amount
reflected and absorbed is disregarded, and only that refracted is con-
Refraction by a Plane Surface.— Rays of light perpendicular to the
surface separating the two media are not refracted, but continue in a
straight line. In figure 5 the ray C O, perpendicular lo the surface
A M,K not refracted, but continues its coutm in the straight lins

ELEMENTAKV OPTICS.

As a. ray passes from a rare into a denser medium it is refracted
toward the perpendicular. In figure S. if the incident ray £ O passes
from air into water, then, instead of proceeding in a direct line to ^, it
is bent toward the perpendicular C C, and takes the direction O W.
Were the refractive media glass,- — ^a denser substance, — the refraction
would be still greater and the ray would take the direction O G.
Were the medium still denser, — as, for instance, diamond, — the ray
l_would take the course indicated by O D. Upon emergence from the

T to the rare medium again the ray pursues its original course
d a line parallel, but not identical, with its initial direction.
The sine {t e^oi E O C, the angle of incidence, bears a
ratio to the sines {iv w'.gg'. d d') of the angles of refraction, tf ' O C
G C. D O C': and this ratio is called the index of refraction,
Taking air as a standard, its index of refraction is called
the refraciive indices of the other substances are based on this stand-
ard. According to Krause, the refractive index of water is 1.3342; of
the cornea, 1.3507; of the aqueous, 1,3420; of the vitreous, 1.3485;
■ of the crystalline lens, 1.4541. The index of refraction of otd\T.a.vi

*1NAT10N AND

i EYE.

spectacle glass is 1.53. The diamond has the highest refractive |
power of any transparent substance, its index of refraction bcingfron
2.4. to 3.5-f . The refractive power of a substance is not always i:
proportion to its density.

Refraction by Prisms. — If the two sides of a refracting medium ar
it parallel, as in a prism, the refracted rays do not emerge ii

1 parallel t(
ofthe prism, bolh :

is called the principa
of deviation, and is at

The Btrength of a pi
angie, the prism-diopt

The prism-diopter 1,
n of prisms

the incident course, but are bent toward the base
t the incident and emergent surfaces. In figure 6,
the ray D M falling on the prism
A B C&x the point M, instead of pur-
suing the direction of M N,\s bent
toward the base of the prism B C and
assumes the direction M N. It is
again deflected toward the base at A'
and takes the direction N E, and an
observer placed at E would receive
the ray as if it came from A'. B A C
IT apical angle. K H D\% called the ii«^/I#
It one-half the size of the principal angle.
m is expressed in three ways : the refracting
, and the centrad.

s suggested with the idea of conforming the
the dioptric system of numbering lenses. A
prism -diopter is that prism which has the power to deflect rays of light
passing through it and to a distance of one meter beyond, exactly
one centimeter. This deflection is measured on the tangent. In
this system Ihe higher prisms are not simple multiples of the lower
ones, — as, for instance. 20 prisms of two prism. diopters each equal a
prism of 42 prism -diopters, and not 40 as would be the natural infer-

The centrad is based on the sajne principle, but the amount of de-
flection is measured on the arc at a meter distance instead of on the
tangent. This method has been recommended by the American
Ophthalmological Society. In the ordinary low number prisms the
difference in Ihe numeration is so slight as to cause no inconveni-
ence.

Refraction by a Spheric Surface. — Parallel rays passing through a
spheric surface separating media of dilTetent densities are refracted
sothatlhey meet at a point on the principal axis, called \\\e principal

ELEMENTARY OPTICS.

Table Showing the Equivalence of Centrads in Prism-diopters
AND IN Degrees of the Refracting Angle (Index of

Refraction 1.54).

Centrads.

Prism-diopters. ■

Refracting Angle.

I°.oo

2.0001

2°. 12

3.0013

3°. 18

4.0028

4°. 23

5.0045

5°.28

6.0063

6°. 32

7.0115

7°.35

8.0172

8°.38

9.0244

9°.39

10.

10.033

100.39

If.

11.044

ii°.37

12.

12.057

1 2°. 34

13.

13.074

I3°.29

14.

14.092

14°. 23

15.

15.II4

150. 16

16.

16.138

i6°.o8

17.

17.164

i6°.98

18.

18.196

I7°.85

19.

19.230

i8°.68

20.

20. 270

i9°.45

25.

2555

23°.43

30.

30.934

26°. 8i

35.

36.50

29^.72

40.

42.28

32°. 18

45.

48.30

34°. 20

50.

54.514

35°- 94

60.

68.43

38°.3i

70.

84.22

39°.73

80.

102.96

40**. 29

90.

126.01

40°. 49

focus. Divergent rays proceeding from a point at a distance from
the lens greater than its principal focus meet at a point on the prin-
cipal axis beyond the principal focus. Divergent rays proceeding
from a point nearer its surface than its principal focus will still diverge,
and hence never meet; but if continued backward they would meet
at the negative conjugate focus of the initial point of divet^e^xc^*

EXAM

? THE EYE.

Refraction by lenses. — A lens is a. transparent refracting medium,
isiially of glass or crystal, which is bounded by two curved surfaces
>r a curved surface and a plane surface.
Lenses may be considered as a juxtaposition of prisms with different
refracting angles (Fig, 7), Convex lenses
are equivalent to prisms with their bases
placed together, A ; and concave lenses, to
prisms with their apexes placed together, fl.
Therefore, rays of light always being de-
flected toward the base of a. prism will be
rendered eonvergent by cowvex Itttsts, in
which the prismatic bases are central : and
will be rendered divergent by concave lemts,
in which the prismatic bases are peripheral,
'' Spheric lenses are used in ophthalmology

in six different forms (Kig. 8):

1. HanocoHvex, the segment of one sphere, having a plane surface
an one side and a convex surface on the reverse side.

2. Biconvex, segments of two spheres having two convex surfaces

3. Concavoconvex. or converging meniscus.

4. Biconcave, having two concave surfaces.

;. Planoconcave, having on one side a plar
reverse side a concave surface.
6. Canvexoconcave, or diverginf; meniscus.

■S 3 *"d 6, having opposite sides at different surfaces, are
called pcriscopii: or meniscus liHses, and are used to avoid spheric
aberration and to gain a greater field of clear vision.

The principal axis of a lens is a line passing through the optic
center, at tight angles to Ihe surfaces of the lens. Rays passing
through this axis are not refracted. Rays passing through the oplic
center of a lens, but not passing through the principal axis, are
slightly deviated, although in practical optics they may be considered
as straight lines. The/ocal length of a lens is the distance from the
lens to the point at which parallel rays, refracted by the lens, focus.

A cylindric lens is a lens with a plane surface in one axis, and a
convex or a concave surface in the axis at right angles to it. ' This
form of lens is really a segment of a cyUnder. Examination of any
cylinder — as, for instance, a bottle — will show there is curvature
only in one direction, from side to side, and not in the axis. As the
axis of a cylinder has a plane surface, the rays are only refracted at
right angles to the axis, and the strength of the cylinder depends on
the curvature possessed by the surface at right angles to the axis.
The axes of the cylinders in a test case are usually shown by grinding
and making partially opaque portions of each side of the lens in the
direction of the axis.

// must be remembered that a cylinder refracts rays of light only in
the meridian at right angles to its axis, while a spheric lens refracts
rays of light in evety meridian.

Classification and Numbering of Lcnaes. — Lenses are numbered
according to their focal distance, and the strength of the lens varies
inversely as its focal distance. Formerly lenses were numbered
according to the inch system, the unit of which was a lens whose
focal distance equaled one inch, — a very strong lens. This system
necessitated the use of large numbers or fractions ; and, moreover,
the denomination inch had different significations in different coun-
tries, the French inch, for example, vJrying from the English inch.
The metric or dioptric system of numbering lenses is now in use, and
the unit is a lens having a focal distance of one meter, and is called
a lens of one diopter strength — a comparatively weak lens ; a two-
diopter lens is one having half the focal length of the one-diopter
lens, or J^ of a meter. Decimals, of course, are used instead of
fractions ; a lens of a focal length of four meters is called an 0.35-
diopter lens.

26 EXAMIKATIOH AND REFRACTION OF THE EVE.

Convex lenses form real images, and are called positive or plus
lenses, and are designated by the sign +.

Concave lenses produce only virtual images, and are called negative
or minus lenses, and arc designated by the sigo — .

To convert a prescription written in the old system of numbering
lenses into the modern metric system of diopters, we may roughly
consider the meter as equivalent to 40 inches. A 10-inch lens would
be equivalent to a lens having a focal length of J^ of a meter, or four
diopters. The following table from Landolt gives the equivalents in
both the old and new systems.

11.

111.

IV.

VI.

VII.

VIII.

otthe

Foc=:

Foe si

of the

Focal

c"ri

Lens,

II EtiKlish

Distflnce

Eq«lva-

11 I^nKlish

^jTi:'e''i?,5

Sysum.

inches.

mEtBrs.

DiUplcrs.

System.

"*•""■

Inches.

System.

67.9

.724

n.sS

D2S

4000

■ 57 ..18

166.M

S6.6

0.69s

78.74

B3J6

^5-3

0.S7

55.63

39.fi

D.OT

86i

1.16

71 S

1.39

^.33

17.79

2,.6

i!.4a

>3.83

Ij'*

S-5

400

19.69
17.48

J087

lis

3S8

a. 79

333

3.«'

ia6

1
'4,

Is?

5.35
5.96

S.6J

6.4)

4-6J

'>*'

3.S
33

11.9

',64

1.46

■

'lU

«[

OPTICAL CONSIDERATION OF T

B of Lenses used to Correct Refractive Errors:

1. The simple sphere may be either convex or concave, and is used
to correct the uncomplicated forms of refractive errors.

2. The simple cylinder is limited in refractive power to the direction
of its curvature, and is used in cases of simple astigmatism, in which
there is an error of refraction in only one meridian of the eye.

3. Tlie spkerocylinder is a combination of a sphere with a cylin-
der, and is used in cases of compound or mixed astigmatism in which
there is a different refractive error in the two principal meridians of

4. The cross-cyliitdcr is a form of lens made up of two cylinders
with their axes at right angles to each other. It is seldom prescribed,
but is occasionally used in making tests.

OPTICAL CONSIDERATION OF THE EYE.

^'■Optically considered, the eyeball is a refracting ir
to produce small and inverted objects upon the retina at the macular
region. The impression received on the layer of rods and cones is
conveyed to the visual centers in the brain, and the sense of sight
results. Although the retinal images of external objects are inverted,
the objects are seen in their proper positions, because all external
sensations are referred outward along the lines of impact. The eye-
ball only receives the rays of light ; the act of vision is performed in
the higher centers.

The refracting surfaces of the eyeball are the cornea, the anterior
and posterior surfaces of the lens. The refracting media are the aque-
ous, the substance of the lens, and the vitreous.

The Cardinal Points. — Although it is possible geometrically to
follow rays of light through the ocular media, this procedure is very
difficult, and separate calculation is necessitated for each distance for
the determination of the size of the image. By assuming certain
ideal or cardinal points, to which such a complicated system of
refracting media may be reduced, and learning their relative position
and properties, we may determine, either by calculation or geometric
constniction. the path of the refracted ray and the position and size
of the retinal image.
» Gauss has demonstrated that every dioptricsystem may be replaced

by a single system composed of six cardinal points and six pla
perpendicular to Ihe common axis at these points.

The cardinal points of the eyeball are the Iwo principal points,
two nodal points, and the two principal foci. These points are
simated on the optic axis, (Fig. 9.) The planes are the tvio pri*
p<i! planes, the two focal planes, and the hvo nodal plants.

The principsl pointB may be defined as two points situated <

optic axis, or the line connecting the centers of curvature

various refracting surfaces of a compound dioptric system, and

lated that the final emergent ray bears the same relation to the;

^^^ (or posterior) principal point that Ihe initial or incident ray

^^■^ bear to ihe first (or anterior) principal point, after having undergo
I refraction through a single refracting surface of determinate curva

In the eyeball, these two points are so closely situated that they
be considered as one point, B, about two mm. behind the corne:
The nodal points may be defined as two points on the optic an
a dioptric system, and so related that every incident ray which i
reeled toward the jfrj/noi/a/ ^a/ji/ is represented after refraction

ka ray emanating from the second nodal point, and having a direct
parallel to that of the incident ray, The nodal points of theeyel
are ao close together that they maybe considered as one point, whf
nearly corresponds lo the optic center. They are situated near
posterior pole of the lens, about seven mm. behind the cornea {N),
L

of the eyeball is located at jV in ihe vitreous,
9 8 mm. in front of the retina.

The first principal focus is a point on ihe axis at which rays parallel
in the vitreous meet, F. It is situated about 13.7 mm. in front of the

The second principal focuB is that point on Ihe axis at which par-
allel rays meet after being refracted by the dioptric system of the eye ;
that is, on the rods and cones of the macular region. A. It is usually
about 22.8 mm. behind the cornea, in the emmetropic eye.

The following are quoted as the mean dimensions of careful oph-

^^^Thi

idiua of curvature of cornea 7.S29

.adius of curvature of anterior surface of lens, Ihe ciliiiry

muscle beinj; relaxed, 10,

Jladius of curvature of posterior surface of lens 6.

■istuice from summit of cornea to anterior pole of lens, . 3.6
Thickness of crystalline lens, 3.6

Taking the above dimensions, with Helmholtz's later index for the
crystalline lens (1.4371). calculation gives for the schematic eye the
following distances ;

Summit of cornea to first principal point, I'TSJ^

Summit of cornea to second principal point 3.1101

Summit of cornea to iirat nodal point 6.96S5

)f cornea to second nodal point, 7-3154

between the principal planes equal Ihe distance

between the nodal paints, 0.3569

Ttrst nodal point in front of posterior pole of lens, . . . . 0.2315

Second nodal point behind posterior pole of lens, ... o. 1 254
Anterior focal distance (measured from the lirst principal

P'"ie). 154983

Poiterior focal distance (measured from second ]>rinci[ial

P''"*). 20.7136

Anterior focus in front of summit of cornen, I3-745I

Posterior focus behind summit of cornea, 22.8327

Posterior nodal point to posterior focus, 15.4983

The size of the retinal image may be calculated from the siie of
the object and its distance from the nodal point. Multiply the svi.e.(i(

^^^umi
^^HHstE

the object by the distance of the nodai point from the retina (apjv
mately 15 mm.); divide the product by the distance of the objw
from the nodal point, and the quotient will be the size of the r
image. All measurements must be reduced to millimeters, st
the result will be in millimeters. Suppose the eye nearly e
tropic, and the size of the object five mm., and its distance from thq
nodal point — /. e., its distance from the cornea, /t/UJ seven
approximate distance of the nodal point from the con
mm. Then, 5 X 15 = 75 I 75 -»- '«» = -075 mm., the siic of thi
retinal image.

I The first requiBite of perfect vision is that all rays proceeding frotfl
La distant object and entering the eye at rest must pass through tl
rrefractive media and be united exactly on the retina. An eye u

which the refracting surfaces (namely^
the anterior surface of the cornea a
the anterior and posterior surfaces of thd
lens) and the intraocular media (namelyJ
the aqueous, crystalline, and ■>
humors) fulfil this condition is 1
and is called einmelrapk , and in such &
eye distinct, reduced, inverted i
are formed on the retina. Any fault il
the liioplric sys/eni of the eye c
blurring of the image by the formatiol
of circles of dispersion or diffusion.
,e power accurately to unite all rays pa»
from an object on the retina is called an amitropu eye, and the c(
dition is called ametropia. The three principal forms of ametropia ai
hyperopia, myopia, and astigmatism.

Hyperopia is a condition in which the eyeball Is too short or tl
refracting media too weak, and the rays of light focus behind t
retina. In the schematic diagram (Fig. 10), E represents the postdi
rior receptive surface of the emmetropic eye. and the rays of ligl
are focused at a, a point exactly on the retina. In H, the hyperopt
eye, the rays are focused behind the retina, and a blurred image ^
formed in front of the focus at iTj.

Myopia is a condition in which the eyeball is loo long
refracting media too powerful, and the retina is behind the C

An eye which h

^(M, Fi

Fig. to). In such condition a blurred image is formed a
behind ihe focus.

Aatigmatism is a condilion in which the retina may be eithi
:oiit of or behind the focus, or both, but by dilTerenl amount
ridians of the eye.

ACCOMMODATION.

As has already been said, rays corning from a distant object—that
is, beyond six meters — may be considered, for practical purposes, as
parallel, and the normal eye at rest gives them such convergence that
they are brought to an exact focus on the layer of rods and cones of
the retina. Rays from any given point of a nearer object approach
the eye with a divergence so considerable that they can not be focused
on the retina by the simple refractive properties of the dioptric system
of a normal eye. However, to obviate this difficulty the eye has the
faculty of increasing its refractive power in order lo give increased
convergence to the rays coming from a near object, and this change
in the eye is called accommodation.

The Mechanism of Accommodation. — Optically considered, the
extra divergence might be neulraliied in two ways ; by displacement
of the retina backward, or by a shortening of the focal distance of
the dioptric apparatus of the eye. Investigations have proved that
accommodation is effected through Ihe dioptric apparatus, the in-
creased refractive power being due to a change of the curvature of
the refractive surfaces of the tens. It is commonly believed that this
is effected in the following manner : The ciliary muscle contracts,
thus relaxing the suspensory ligament of the lens, allowing the inher-
ent elasticity of the lens to act and push forward the anterior surface,
which, bybecoming moreconvex, increases its refractive power. The
posterior surface of the lens scarcely alters in shape. This view is
not accepted by Tscherning, who maintains that the ciliary muscle in
contracting increases the tension of the suspensory ligament, and
thus induces bulging of the lens anteriorly outward, and hardly at all
toward the periphery. However, all theorists believe that ciliary
contraction is the important factor in accommodadon, although they
differ as to how it acts. Associated with the act of accommodation
is a simultaneous contraction of the pupil. The elastic power of the
I a peculiar watch-spring arrangement of its fibers.

OF THE B

1 of Ihe eye ;

Figure 1 1 represents the

accommodation.

The Far and Near Pointa.^When the ciliary muscle is entire
I relaxed and the eye is completely at rest, distant objects are receivl

at an accurate focus on the retina, and the eye is said to be adapt)
for its far point, or puncium temotum. When, however, the cilia:
muscle has contracted to its fullest extent, the tens becomes convi
to its greatest degree, and the nearest point from which rays ma
diverge and yet focus on Ihe retina is called the near point, or punctt
pronimum. This is found by directing the patient to look at soi

ffine print of a definite measurement, and bringing it slowly do!
and closer to the eye until It becomes blurred and illegible, a'
noting the distance from the eye of the point where Ihe print is si
distinct. The print may be brought up close to the eye, and a
slowly away until it is first legible ; the distance of this point
Ihe eye gives an equally accurate result.

The distance between the far and near points is called the
or amplitude of accommodation. This range is dependeht on t]
elasticity of the lens and lessens with advancing age, until aba
seventy or seventy- five years, when it becomes nil and the eye
incapable of adjusting itself for objects nearer than infinity.
range of accommodation is usually expressed in diopters, and
represented by that convex lens which, placed closely in front of I
eye, would take the place of the increased convexity of the lens
giving rays from a near point a direction as if they came from inl
ity. The table on page 94 gives the range of accommodative poi
^^H^ which an emmetropic eye at ditTerenl ages is found to possess.

EXAMINATION OF THE EYE. 33

hyperopia the range of accommodation is diminished to an
extent expressed by the number of a lens which will enable the eye
to see distant objects without accommodation.

The Association between Accommodatioti and Convergence. —
Convergence is the power of directing the visual axes of two eyes to a
near point, and is effected chiefly by the action of the internal recti. The
nearer an object, the more convergence is necessary, and usually for
every increase of the convergence there is a certain increase in ac-
commodation, the internal recti and ciliary muscles acting in unison.
Although accommodation and convergence are usually harmonious
in action, they may take place separately and independently. If we
paralyne the accommodation with a mydriatic, convergence is not
interfered with, and also in advancing life, when greater
of the ciliary muscles is necessary to produce the requisite chi
the convexity of the lens, the amount of convergence rema
same. It must be remembered that the relations between
dation and convergence are necessarily very different in ametropia,
and this important point will be discussed later.

The diminution of the power of accommodation by age to such an
extent as to interfere with the use of the eyes for ordinary near work
is called presbyopia.

EXAMINATION OF THE EYE.
student is advised to follow some systematic method in the
a patient consulting him for ocular trouble. No one
plan can be arbitrarily dictated; different data will be required by
different persons, and the authors suggest the following comprehensive
plan, which may be modified at pleasure;

I, Record the Name, Address, Sex, Age, and by whom re-

II. The History, including the date of the present trouble, pre-
vious attacks of ocular disease, family predisposition, and
any useful collateral data.
HI. The Subjective Symptoms :

I. Inquire as to pain, including the location, kind, dura-

34 EXAMINATION AND REFRACTION OF THE EYE.

The Subjective Symptoms (continued) :

2. Smarting, itching, or other uncomfortable sensations

about the eyes.

3. Increased lacrimation, its character and possible

cause.

4. Possible reflex troubles : Headache, indigestion, neu-

rasthenia, etc. Inquire as to the character of the
headache; whether frontal, temporal, occipital,
" sick,** neuralgic, etc. ; whether worse in the morn-
ing or evening.

5. Alterations in vision :

Record the visual acuity for distance and near. In-
quire whether the diminished vision is constant,
and whether the onset was gradual or sudden, and
how long since it began. Color-sense and light-
sense and the fleld of vision may be tested. Sco-
toma scintillans, muscse volitantes, or dark spots
before the eyes, etc., may be noted.

IV. Objective Symptoms :

1. Inspect the lids, cilia, lacrimal apparatus, conjunctiva,

cornea, iris and pupil, and anterior chamber.

2. Measure the intraocular tension.

3. Test for muscular anomaly by the cover-test.

V. Ophthalmoscopic Examination :

1. Examine the media for transparency.

2. Examine the disc for shape, size, color, cupping, blood-

vessels, etc., and refraction.

3. The peripheral eye-ground.

4. The macular region.

VI. Objective Examination of Refraction :

1. By the ophthalmoscope.

2. The retinoscope.

3. The ophthalmometer.

VII. Subjective Examination of Refraction :
I. By the test-lenses.

VIU. Test for Muscular Insufficiency and Squint.

[

EXAMINATION C

SIMPLE INSPECTION.
; whether Ihe eyelids are swollen, hypertrophied, or faulty in

shape, position, o

of the eyeball. In
does not exist: This symptom w

Is. Normally, the lids follow the
ophthalmic goiter this harmony
i first noticed by von Graefe, and

e been shown by Cowers a:
: central cerebral lesions.
I their form, she. and positi
:onditioiis may arise from m

has been named after him. It has si
others that this sign is present in so:

The cilia should be inspected, J
carefully noted, as many unpleasac
placed cilia.

The position of the lacrimal puncta should be noted, and whether
or not they are patulous. In the normal state the lacrimal sac is
empty, while if it is distended with mucus or pus, pressure with the
finger will usually cause escape of the contents, either from the nose
orfrom the puncta. Further examination is effected by lacrimalprobes.

The conjunctiva is normally so translucent as to allow the bluish-
white sclera to show through ; it contains only a few minute blood-ves-
sels. In age there may be a deposition of fat in the subconjunctival
tissue, giving a yellowish tinge to the membrane, and its translu-
cency is additionally affected by an increase in the siie and number
of blood-vessels. In inflammatory conditions of the conjunctiva it
should be thoroughly examined for the presence of a foreign body or
an inverted cilium. The surface of the bulbar conjunctiva is first
inspected, and then the lower sulcus, which is easily brought into view
by simple tension downward with one finger. Eversion of the upper
lid is readily effected without the use of a probe or other instrument
by telling the patient to look down, selling the edge of the lid and
cilia with the thumb and forefinger of the right hand, and drawing
the lid first forward and downward away from the globe, and then
upward over the point ofShe thumb or forefinger of the left hand,
which is held stationary on the lid and acts as a fulcrum.

Conjunctival injection is recognized by its brick-red color ; by the
great irregularity, tortuosity, and intimate anastomosis of the blood-
vessels ; by the mobility of the vessels on the sclerotic ; by the fact
that pressure applied through the hd to the globe produces a distinctly
anemic spot ; by the injection being more intense on the lids and ii
the culdesac, and diminishing toward the cornea; by the accompany-
ing mucous or mucopurulent si

1 36

REFRACTION OF THE EYE.

Ciliary injection is distinguished by its pink appea.rance; by t1
vessels running in a straight parallel course, radiating from the!
cornea; by the immobility of the vessels when the conjiii
moved; by the fact that gentle pressure on the margin of the lowerfl
lids produces an anemic spot, which gradually becomes pink when |
the pressure is removed ; by the congestion being most intense nearest I
the cornea, and fading away toward the equator of the globe,

!Thc cornea is perfectly transparent and glistening in health, aii4;J
^ums diminished erect images of all objects held before it. Tbcl
f

shape of the image is diagnostic of the curvature of the cornea. The
iris and the pupil are readily seen througli the cornea. A foreign
body, abrasion, opacity, ulcer, scar, or vascular formation is usually
readily detected by simple inspection in a bright light, or with the
ophthalmoscope and a high convex lens ; but it is always best to use
what is called focal or oblique illuminatioa. {Fig. 12.) This method
is effected by placing the patient in the line of the source of illumina-
tion, to the right side if the left eye is to be examined, and focusing
the rays of light obliquely on the cornea with a convex lens held
the hand of the surgeon nearest the light. The illuminated point

t EXAMINATION OF THE EVE. 37

wed either directly or through a magnifying lens held at the focal
distance from the patient's eye. Diffuse keratitis, corneal abscess,
leukoma, and other similar corneal alTections. as well as lenticular
opacities, should be examined by oblique examination.

The exact extent of the corneal abrasion of an ulcer may be ascer-
tained by the apphcalion of a drop of a solution of fltioreacin in the
lower culdesac and rubbed over the eyeball, A few drops of boric
acid solution are then instilled to wash away the superfluous stain,
and the denuded area is stained a bright yellowish-green color. If
the epithelium is changed and roughened but not denuded, as in
keratitis and glaucoma, then the defective spot does not stain.

The aqueous humor Is so transparent in health as to be invisible,
but may be rendered turbid by inflammatory and hemorrhagic de-
posits, or may contain pus which gravitates to the bottom of the ante-
rior chamber, forming a condition known as hypopyon.

The iris is ordinarily bright and presents a pohshed surface. The
pigmentation and fibrillation are distinctly visible, and the pupil is
perfectly round, and surrounded by a ring of dark pigment. The
size of the pupil in its usual state varies with each individual, A
general average is four mm. The pupils should be nearly equal in
size and should at all times respond to light. The patient should be
placed before a window or light, the surgeon standing before him,
and one eye permanently obstructed either with a hand or bandage;
then one hand should be placed over the exposed eye and quickly
withdrawn. Under the shadow the pupil dilates, and when the hand
is removed it quickly contracts. This is a direct refiex by means of
the optic nerve. To study the consensual reflex, the patient Is placed
in a room near a point of iight and the rays focused gradually on the
corneaof the proximal eye, the eye farthest removed from the light
still being in the shade. In health a simultaneous and sympathetic
contraction of the shaded pupil is also seen. The pupil normally
contracts in the act of convergence, and the patient should be di-
rected to look at some distant object and then at an object near the
lip of the nose, and the variations in the size of the pupil noticed.
There arc certain conditions, such as locomotor ataxia, in which the
eye contracts as usual in accommodation, but has lost its contractility
to light. This condition is commonly known as the Argyll Robertson
pupil and is a significant diagnostic sign. If the eyes do not react at
n light and accommodation, there is probably disease Q£hQV"ats^iK. :

^3° EXAMINATION A

nerves. Permanent dilatation (mydriasis) and contraction (miosis) 1
will be spoken of under Diseases of the Iris. Furiher inspection of I
the iris should determine whether it is steady or tremulous, :
whether it is in its normal vertical position, or is convex and dis- !
placed forward toward the cornea, or concave, depressed toward the j
vitreous, thus forming a shallow or deep anterior
stead of being circular the pupil may be oval, with its greatest 1
diameter horizontal, as is often seen in glaucoma. Adhesions of
the iris to the anterior capsule of the lens or to the posterior surface |
of the cornea, called synechia, also distort the pupil. Focal illumi-
nation and examination with a high convex lens with the opblbal-
H,inoscape render iritic adhesions more conspicuous.

MEASUREMENT OF THE TENSION OF THE EYEBALL.

The surgeon stands in front of Ihe patient, who is directed to look |
downward. All but the index fingers of the surgeon's hands res
the eyebrow of the patient, and the tips of the index fingers through !
the closed lid, alternately and slightly, indent the eyeball. The edu-
cated sense of pressure {laclus erudilus) measures the elasticity and I
resistance. It is well to immediately compare one eye with the other,
as there is often quite a noticeable difference between the two. As a J
standard, the student has the tension of his own eye as a guide, from 1
which any abnormal tension can be estimated. In glaucoma the
eyeball is often hard, and the normal sense of elasticity is wanting.
In certain extensive destructions of the choroid and liquefaction I
of the vitreous the eyeball is soft and mushy. The eyes of the \
young are generally softer than those of the old. The degree of J
tension is expressed by the capital letter T., preceded by a plus
sign (+) if there is increase ; or preceded by a minus sign ( — )ifthere I
is decrease. The amount of deviation from normal is expressed by |
numerals; thus, +T. i expresses distinct hardening; + T. 3, decided |
hardening; and + T. 3, extreme hardening, resisting all efTorts I(
produce dimpling.

The ophthalmotonometer is an instrument devised to me:
sion mechanically, thus avoiding the discrepancy in the results of I
several physicians testing the same eye ; but these instruments havB']
often been constructed on principles theoretically wrong, and are pi
tic ally useless.

^B^ Theory.— It is

THE OPHTHALMOSCOPE.

► Theory. ^It is self-evident that rays reflected from the fundus of
the eye emerge from the eye in the same direction as that in which
they enter it, the refractive media of the eye having the same action
on light whether passing in or out. However, as ordinarily seen, the
pupil !5 black. There is no light reflected from the patient's eye into
ours, because our own eyes are not a source of light. Now. if the
observer's eye is artificially made the source of light, and if he looks
in the same direction as that in which the luminous rays enter the
observed eye. as, for instance, through the sight-hole of a mirror,
illumination renders the interior of the eye visible. This is the funda-
mental principle of the ophthalmoscope, and it was first explained
and made practical by Helmholtz, in 1851.

Upright Image. Direct Method. — ^The dioptric system of the eye
acts as a convex lens of a focal distance of about zo mm.

If the retina lies within the focal distance/^ (Fig. 13, H), the eye is
hyperopic, and rays leaving the fundus are divergent at the cornea,
and the image of the fundus a' b' is ■virtual, upright, and magnified.
To see this image the observer must accommodate for its location, or
use a convex lens.

If the posterior focal pointyiies exactly on the retina (Fig. 13, E),
the eye is emmetropic, all rays emerge from the cornea parallel, and
no image is formed. If the observer is also emmetropic, the rays
passing parallel from the observed eye into his own eye form an
image on his retina.

If the retina lies behind the posterior focal point _/'(Fig. 13, M), all
rays emerge from the cornea converging to the far point of the eye
under examination. The observer can only receive on his own retina
the image of the other's eyeground, when the (virtual) far point
coincides with a', the actual far point of the myopic eye under ex-

To be able, therefore, to examine the upright image of any eye the
observer must be able to adjust his own refractive condition to that
of the eye under examination. In the ophthalmoscope this is done
by means of lenses. If the eye under examination is myopic, an
emmetropic observer needs a concave lens in order to make him
proportionally hyperopic; a myopic observer needs for the same

40 EXAMINATION AND RtFRACTiUN OK THE EVE.

purpose a concave lens increased in strength by the amount of his
own myopia; a hyperopic observer must increase his own hyperopia
by such a concave lens, or decrease it by such a convex lens
make his (tjegntive) far point coincide with the far point of the eye
under examination, lo speaking of the theory of the ophthalmo-
scope, we consider that the observer does not use his accommodation,

In ordinary practice such is not the case except in nien past middle
age who have long practised suspension of accommodation. As &
rule the observer employs some accommndative effort which aids him
in examining hyperopic eyes, but which compels him to resort to
optical aid 10 see distinctly the funduses of emmetropic and myo^nc

a. falsi

of the exact refraction of it

The magnification of the image in the direct method is greatest ir
the myopic eye and least in the hyperopic eye.

Inverted Image. Indirect Method, — In this method the eye is
made artificially myopic by a convex lens ; however, in high myopia

S&e observer is beyond the image a' h' (Fig. 13, M), and if he u:
his accommodation for the location of the image, he will be able
see it without the aid of a lens. In low degrees of myopia the image
is so small as to be of little practical use. Figure 14, illustrates the
i iormalion of the inverted image in all three refractive conditiov.=, t.^

43 EXAMINATJON AND REFRACTION O? THE EYE. I

the eye. The rays from the hyperopic eye H. divergent when they<
strike the convex lens 5 S. are united the greatest distance from the
eye, and hence form the largest image. The rays from the myopic
eye ^If. already convergent when they strike Ihe convex lens S S,
unite at the shortest focus, and therefore the smallest image is the
result. The rays from the emmetropic eye E are parallel when they
strike the convex lens 5 S, and the result is an image midway in size
between the two others.

By the interposition of the convex lens in the inverted method, the
ophthalmoscopic field is much larger than in the examination of the
upright image, although the magnification of the fundus is less. The
size of the ophthalmoscopic field increases with Increasing myopii
and diminishes with increasing hyperopia.

Description. — The simplest form of ophthalmoscope is a
a hole in the center, which is held close to the patient's eye in such a
manner as to reflect light from a luminous point near by into it, illu-
minating theinferior of the eye and revealing the details of ihe fundus.
The ophthalmoscopes in use to-day are of more intricate mechanism,
and render the examination much easier and more satisfactory. The
mirror most used in this country is small, concave, oblong or round
in shape, with a central aperture of from two to four mm. in diameter,
and so arranged that it can be tilted or rotated from side to side, thus
saving the trouble of inclining the whole instrument to reflect the
light properly. By means of various ingenious appliances a series of
lenses are incorporated with the instrument in such a manner that,.
by turning a wheel with the finger, the convex or concavi
strength desired can be brought before the sight-hole in the mirrot;
By arranging the lenses so that they can be combined, the range ma]

nded from a fraction of a diopter to a lens of as high power
is ever required. The large mirrors are more useful in the indi:
method, in retinoscopy, and for illuminating a large surface of
eye. In the direct method a very small mirror is as good or be
than a large one. A small sight-hole gives a more distinct imagt
and does not necessitate so much accommodation or optical aid ~
examining slightly amelropic eyes. The large sight-hole is better \
the accurate estimation of refraction. As the direct method is
generally employed, and refraction is not ordinarily estimated by
thalmoscopy, and retinoscopy is usually performed with a \
plane retinoscopic mirror, for all practical purposes it is belter
3 small mirror mih a small sight-hole.

Ihere i

OPHTHALMOSCOPY. 4.3

/here are many forms of ophthalmoscopes, for all of which some
advantage has been claimed. The model of Loring is cheap and
answers all practical purposes, but it is awkward to use and necessi-
tates removal from the eye and a combination of lenses to secure the
higher powers. To avoid these and other disadvantages the instru-
ment described below (Fig. 15) was designed and has proven most
satisfactory to the author. It consists of two superimposed lens discs,
,. and 37 mm. in diameter respectively, each containing 14

Each disi

has independent tt
tto the observer's e;

apertures for lenses,
inner disc— that is, the o
high-power lenses, both
milled and it is rotated directly by the finger, i
ment. The outer disc — that is, the one nearest :
the low-power lenses, both convex and conca
ircumference, and it is rotated by

Its circumference i:
in the Loring inslru

EXAMINATION AND REFRACTION OP THE EVE.

1 diameter. The two discs arc inclosed in a metal
Vith 3. detachable handle. The lenses are six mm. in diam
They are slopped hy a spring which clicks as i
lens is wheeled into place.

The purposes in view were to obtain :

1. Neatness, compactness, and durability.

2. Avoidance of direct rotation of the disc
taining the low-power lenses by the finger close
the patient's nose and cheek, as in the Lorinj

3. Continuous 1
crease of both convex and concave lenses up t
74. D. without removal from the first position before

4. Avoidance of combinations of lenses,
}. Continuous registration and single registeiioi

n the c

6. A small, round, rotary mirror, small aperture;,
with absolute exclusion of direct or reflected light
in the space between the observer's eye and llie>
sight-hole of the mirror.

7. Simplicity and cheapness.

The dimensions of the instrument are iji
wide by 2j^ in. long. There is no serviceab]
instrument of smaller size made. It can
carried in the vest-pocket. The exact
shape are shown in the accompanying illustra6i
(Fig. 15). There are no points of special wear a.i
tear or of line adjustment to get out of order, Thi'
case and all the framework are made of
If a more elaborate and expensive
i-n's desired, that designed by Morton is very satisf&e*
lory. Still more complete and elaborate is that.
instrument shown in figure 16. As in the Moitoa
ipe, the Rekoss disc is dispensed with and the lenseii
in revolving, endless chains, after the idea of Couper^
o series — those most used at one end, and the highW
h plus and minus, ni the other. The arrangement
so that a surgeon with high ametropia, except in

OPHTHALMOSCOPY. 45

il'ill seldom be compelled to tra.nsfer the mirror so as
to use the high-power lenses. The transfer, however, requires but an
instant. There are sixty lenses, all the lower powers proceeding from
zero by 0.5 D. intervals ; the highest minus lenses being 40 D., the
highest plus, 30 D. The instrument requires no handle itself when
used, being grasped by the hand. The mirror is turned at any angle,
so that examination of an eye is easy, whatever the position of the
patient or the liijht. The size of the sight-hole, by an ingenious
device, can at pleasure be made large or small.

In addition to the ordinary instruments, binocular and astigmatic
ophthalmoscopes are among the many devised.

USE OF THE OPHTHALMOSCOPE.

Direct Method (Fig. 1 7). — The patient is placed in front of the source

of illumination, and to the side of the eye to be estamined, the light

behind him so that it shines on his temple, just touching the tips of
the outer lashes. He is then told to look straight ahead to an object
on a level with his eyes across the room. To examine the patient's
right eye the surgeon sits or stands, and holds his ophthalmoscope in
his light hand before his own right eye. To examine the patient's left
eye he places himself to the left of the patient and holds (he oph-
IJttalinoscope in his left hand before his own left e^e, Ttito^'

46 EXAMINATION AND REFRACTION OF THE

moscope is brought close to the eye under examination, the mirror
of the ophthalmoscope having been inclined and the instrument held
in such position that the light from the source of illumination will be
reflected directly into the patient's pupil ; then, if the media are clear
a red glare called the fundus leflex is seen through the hole in t
mirror. If the examiner wears glasses, he need not remove them;
fact, if he is astigmatic, he had better accustom himself to workh
with his correcting lenses on.

GxaminatioD of the Media. — ^The reaction and form of the pupil 1
first noticed. If a foreign body or opacity is present in IhepupQla
area, it appears as a d jrk spot on a red background. A slight corm
opacity appears only as a mere shadow. It must be remembei
that spots on the cornea and lens always maintain their same re
live position and are immovable, while opacities in the vitrei
are usually freely movable and can be diagnosed by their chaii
of position as the patient turns the eye quickly in various directio
and then looks straight forward. To locate corneal or lenticu!
opacities, in addition to focal illumination, we take advantage of t
phenomenon of parallactic displacement, which is governed by t
rule that opacities lying in froHt of the pupil move in ike same dm
tigrt as ike patient's eye, tuhile opacities behind the pupil move
the opposite direction to tke patient's eye, a.-nA the extent of this appi
ent movement enables us to approximately determine the distance
the opacity either in front or behind the pupillary plane. After ha
ing observed any anomaly of the pupil or media at a distance of
13 to 16 inches, a strong convex lens (10 D. to 16 D., according 10
location) is then wheeled before the sight-hole of the ophthalmosco
which allows the observer to approach closer to the patient's eye, 9
greatly magnifies the conditions present.

ExaminatioD of the Fundus. — If the media are clear, the surgi
approaches close to the patient's eye and at once the details of
eye-ground become visible. (See Fronti-ipiece.) The refracti
media of the eye magnify the details of the fundus about fouiU
times, and by this fortunate circumstance the minute details of 1
eye-ground are plainly visible. Probably the first distinct object 1
be a retinal vessel which can be easily traced to the most promini
part of the fundus, the optic disc. At this point a bright whitish
pinkish reflex is seen, standing out in sharp distinction to the surrotu
ing red fundus. By adjusting the proper lens before the sight'hol«

ir the outlines of the disc may be brought sharply into view.
The average size of the normal disc as seen by the direct method is
nearly that of a twenly-five-cenl. piece or a shilling, while to the naked
eye it measures only 1.5 mm. Emerging from the disc is seen the
central retinal artery and vein, dividing into inferior and superior
branches. The veins may readily be distinguished from the arteries
by Iheir darker color and their size, about one-fourth larger. Pulsa-
tion of the veins is observed under normal circumstances, while
pulsation of the arteries indicates a pathologic eondition^ — either rise
of intraocular tension or decrease of blood -pressure. Reflexes con-
sisting of bright Unes in the middle of the blood-vessels are seen.
Frequently a depression may be seen in the disc called the physio-
logic cupping, caused by the branching of the internal fibers of the
optic nerve at a lower level than the more external ones. This is
white with a surrounding zone of pink. Pathologic cupping includes
the whole of the disc, and is characteristic of glaucoma. The form,
the siie, the color, and olher appearances of the disc must be further
studied. At the external border of the disc is often seen a black,
circular pigment-ring, bounding the opening in the choroid through
which the optic nerve enters. To the outer side of this is the ivhife
scleral ring, ■vWvA'vi not always distinctly circular. A white conus,
or even a crescent, may be seen at the edge of the disc if there is
choroidal atrophy. In high myopia this condition is noticeable. If
there is distinct sign of cupping, the extent may be approximately
estimated by the refractive conditions of two points lying at different
elevations. The difference in diopters in the lenses required to
distinctly focus the two points multiplied by .35 mm. will give us the
difference in depth. It is usual to select one point at the bottom of
the cup and the other near the surface.

The parallax teat is based on the fact that in the indirect method,
while the whole fundus seems to move along with the lateral move-
ments of the convex lens, the floor of the excavation apparently
moves in ihe same direction, but at a slower rale. This parallax is
more marked the deeper the excavalion.

The general aspect of the eye-ground is then studied, and any
abnormalities in the retina, choroid, or sclera should be noted. If
there is absence or deficiency of pigment between the relina and
choroid, the larger choroidal vessels are seen through it, and ihe eye-
ground is streaked with well-defined interspaces. At an^ ^cwvov. (A

EXAMINATION AND REFRACTION OF THE EVE.

the fundus in which both the retina and choroid are tacking, the
while, glistening sclera is seen shining through. To examine ihe
macular region the patient is told to look into the light coming from
mirror, or, better, beyond it in the same direction, which move-
it of the eye generallj' brings ihc macula into view. This appears
as a dark spot isolated in the fundus, with a small, bright spot in the
center, called the/ovea centralis. There are usually no vessels lo be
seen in this vicinity. The macular region should always be studie
carerully, as any lesion or hemorrhage in this location has a

Iportant bearing on the vision of the patient.
Refraction by the ophthalmoscope is usually a
direct method. Refraction of the macular region is
the intense dazzling produced by light makes it almost impossible,!
disc is usually the objective point selected. The observer 6rst c
reels his own ametropia, and as much as possible relaxes bis accei
modation. It is this inability to regulate the relaxation of a
I hat makes this test unreliable in simple e
the lower degrees of astigmatism it is comparatively »
1 the mostskilful hands. The ri

t for the objective method of refrac
ig relaxed the accommodation and corrected his
surgeon moves before the eye the lens which gives hin
lines of the disc, and subtracts his own correcting lens from I

OPHTHALMOSCOPY. 49

of astigmatism the disc is usually oval, its long diam-
eter corresponding to the axis of astigmatism. Two vessels at right
angles to each other in the principal meridians are refracted sepa-
rately, and the results noted. Glasses should not be prescribed from
the ophthalmoscopic refraction atone.

Indirect Method (Fig. iS). — The indirect method is less valuable
than the preceding. The image is inverted and less magnified (ihree
or four diameters), but we are able to see a larger part of the fundus
at one glance, and we are not compelled to approach so near the
patient's face. It also enables the surgeon to intensify his illumina-
tion incasesof very small pupil or of cloudy media. In this country the
indirect method is being less and less used. Themethodofprocedure
is usually the same as in the direct method, except that the surgeon
keeps his eye a foot or more away from the patient's face and holds
in front of the patient's eye a strong convex lens. However, the
surgeon need use but one eye and may stand directly in front of the
patient. The lens is usually held at such a distance from the eye
that the iris just disappears from view; a plus spheric 4 D. lens may
be held before the opening in the mirror to enlarge the image and to
replace the observer's strain of accommodation. By directing the
light from the mirror through the lens into the eye, an inverted aerial
image is farmed in front of the lens, and it is this image that the
surgeon sees. In high degrees of myopia it is easy to examine the
inverted aerial image without a convex lens.

The salisfaclory use of the ophthalmoscope, both in examining the
fundus and approximately estimating the kind and degree of ame-
tropia, can only be obtained after considerable practice. A normal
fundus in both a light'Complexioned and dark-complexioned person
should be repeatedly studied, as abnormal conditions are not recog-
nized until one is thoroughly familiar with the normal healthy fundus.

^B RETINOSCOFY.

^^P Br JAM£S Thorcmiton, M.D.

Definition. — The method of estimating the refraction of an eye by
reflecting into it rays of light from a plane or concave mirror, and
observing the movement which the retinal illumination makes by
rotating the mirror. To avoid confusion, the description of t«i'

1 o-

REFRACTION OF 1

oscopy that follows will apply to the plane mirror, which is

ferred lo the concave mirror, as it is decidedly more salisfaclory ft

general use and convenience.

The principle of retinoscopy is the finding of the point of reversi
or myopic far point. Should the eye under examination be emm
tropic or hyperopic, it must be given an artificial far point,

Synonyma. — Many names have been given to this method <
refraction, viz.: Shadow-tesl, skiascopy, fundus-reflex test, pupillo!
copy, etc.; but retinoscopy seems the most appropriate, as it is t
retina in its relative position to the dioptric media which we study.
the present time the term skiascopy is suggestive of jr-ray skiagraphy

Advantages, — Of all the objective methods of refraction, red
□scopy in the hands of the expert is the most exact, but, like i
objective methods, its results should, when possible, be confirme
with the trial-lenses.

Retinoscopy offers the following advantages :

I. The character of the refraction is quickly diagnosed.

z. The refraction is estimated without the verbal assistance of th
patient.

3. No expensive apparatus is necessarily required.

4. Little time is taken to estimate the refraction. .
;. It is of inestimable value in the young, in the feeble-minded, th

illiterate, in cases of amblyopia, nystagmus, and aphakia ; and n
such cases the retinoscopic correction may be ordered.

Preparation. — To learn retinoscopy the beginner is urgeoil
advised to study the form, direction, and rale of movement of th
retinal illumination from one of the many schematic eyes i;
market before attempting the human eye. The beginner should als
be thoroughly acquainted with the laws of refraction, and especiall
understand conjugate foci, for it is the recognition of the point c
focus of the convergent rays of light from the eye under exam
nation that gives the true solution of the test.

Before proceeding to the examination of an eye, the begini
understand several important details, namely ;

The reiinoscDpc, or mirror, is of varying form and size. The Oi
recommended is the small plane mirror, two cm. in diameter, on
four cm. metal disc, with a two mm. sight-hole at the center of tl
ir, made by removing the silvering and net by cutting a ha
gh the glass. (Fig, 19.)

RETINOSCOPV.

Tho light should be steady, clear, and white, and secured li

movable bracket. For general use the Argand burner is best. As
only a small portion of the flame is used, it is necessary to cover n

mtha

ir cover-chimne}', is made of thin asbestos and of

It easily over the [jiass chimney of the Argand burner,

:d, generally one cm. in diameter, should be opposite

part of the flame.

The screen

The opening

to the bright

An asbestos cover-chimney is used

in preference to metal, as it intercepts

most of the heat.

The room for retinoscopy must be
darkened, and the darker the better;
all sources of light except the one in
use must be excluded. This must be
insisted upon, as darkness offers the
best contrast to the test.

Position of the Light and Mirror. —
The rays of light coming out of the
opening in the light-screen should be
five or six inches' in front and to the
left of the observer, so that the rays
may pass in front of the left eye and
fall upon the mirror held before the
right eye, thus leaving the observer's
left eye in comparative darkness; or
this may be reversed if the observer
is left-handed. The observer should
keep both eyes wide open.

In order to see the movements dis-
tinctly, the observer should wear his Fic. 19.— Rhtinoscope,
correcting glasses, but need not make
any note of his accommodation as in using the ophthalmoscope.

The patient must have his accommodation thoroughly relaxed with
a reliable cycloplegic, and be comfortably seated in front of the
observer, preferably at one meter distance, with his vision steadily
fixed on the observer's forehead just above the
better, the patient may concentrate his vision on the edge of the metal
disc of the mirror, but never directly into the uvUiot, ■».% ■*•-■' ™""\;

I $Z EXAMINATION AND REFRACTION OF THE B

soon irritate and compel him to dose his eye. In cases of sqniiif
is particularly necessary to cover one eye while its fellow is bein
refracted.

Distance of Surgeon from Patient. — Each observer may chooB
his own distance, and must be eoverned accordingly. There
fixed rule of distance, and it will be well for ihe observer to try
different distances and then choose for himself. The (
distance offers two advantages ; it is convenient for the observer it
reaching forward to place neutralizing lenses in front of the eye, ;
in the ultimate result it is easy to calculate i D. for this distance.

Reflection from ihe Mirror. — The rays of light coming from thi
round opening in the screen to the plane mirror are reflected diver*
gently, as if they came from the opening in the screen situated jui
far back in the mirror as they originally started from in front.
nearer the light and mirror are brought together, the brighter will III
the reflected rays.

How to Use the Mirror.^lt should be held firmly in the ri^
hand before the right eye, so that the sight-hole is opposite tt
observer's pupil. The movements imparted to the mirror should t
very limited, though they may be quick or slow ; but never, at an
time, should the mirror be tilted more than two or three mm., olhe
wise the light will be lost from the patient's eye.

With the patient, light, mirror, and observer in position as jti
described, and as near In line as possible, the observer may find ill
patient's eye by reflecting the light on to his left hand held betwe^
the mirror and the patient's eye, and, when this is done, to drop I:
hand and have the light pass into the patient's eye.

Retinal Illumination. — This is the portion of the retina that rcceiv
the rays of light from the mirror after they have passed through ti
media of the eye. The size and form of this illumination is conirolle
in great part by the refractive power of the media.

The Shadow. — This is the nonilluminaled portion of the retina sui
rounding the illumination. When the mirror is tilted and the illumi
nation is passed to one side, darkness precedes and follows it ; it i
this combination of illumination and nonillumination (shadow) tbi
gives the "shadow-test" its name. The contrast between illii
mination and shadow is most marked when the illumination |
bright est.

Where to Look and What to Look For.— Through a foiur, five, i

RETCNOSCOPY. 53

t the apex of the cornea, whLch corresponds to the
position and si^e of Ihe pupil when Ihe effects of the cycloplegic pass
away, the observer studies the character of the retinal illumination
for ([) form, (2) size, (3) direction, and (4) rate of movement.

Point of Reversal. — This is the myopic far point, the artificial focus
of the emergent rays, the point at which the emergent rays cease lo
converge and commence to diverge, the point conjugate to Ihe
retina, or the point where the erect image ends and the inverted
image begins.

To Find Ihe Point of Reversal. — In observing the retinal illumina-
tion, one of the most important things to study is ^ha direction m
which it moves, or whether it moves at oil. For example; having
determined at one meter distance, with a + 2.00 D. lens before the
patient's eye, that the retinal illumination moves in the same direction
in which the mirror is lilted, and then substituting a + 3.35 D., and
the illumination appears to move in the opposite direction ; the
observer will know at once that the difference in the strength of these
lenses, + 2.12 D., would bring the emergent rays to a focus on his
retina and that no movement of the retinal illumination could be
made out, and this point, when found, is the point of reversal or arti-
ficial far point.

The Principle of Retinoscopy. — The point of reversal or focus of
emergent rays Is always negative in hyperopic and emmetropic eyes.
In myopic eyes, however, the emergent rays always focus at some
point inside of infinity, and Ihe observer may, therefore, if he is so
disposed, by moving his lightand mirror closer lo orfarther from the
patient's eye, as the case maybe, find a point where Ihe retinal
illumination ceases to move. If ibis should be at two meters, the
patient would have a myopia of 0.50 D, ; if at four meters, a myopia
of 0.3S D.; if at one meter, a myopia of i.oo D., etc.

It is well for the beginner to remember thai when using the plane
mirror the illumination on the patient's face always moves in the
same direction in which the mirror is tilted, but not necessarily so in
the pupillary area, where it might move opposite. It is in the pupil-
lary area ihat the retinal illumination is spoken of as moving with or
against (opposite to) the movement of the mirror, and the diagnosis
is made accordingly.

The direction, rate, and form of the retinal illumination are the
three essentials to be noted in all retinoscopic work, and should
therefore receive individual consideiaiiott.

EXAMINATION J

JD REFRACTION OF

Ato

e with plar

—The movement of Ihe retinal illumination going with
t of the mirror signifies emmetropia, hyperopia, and
myopia when the myopia is less than 1 .00 D.

The retinal illumination moving opposite to the movement of (he
mirror always signifies myopia of more than i .00 D.

Rate. — This is under the control and is influenced in great part by
Ihe rate of movement of the mirror itself ; yet after a little practice the
observer will recognize the fact that there is a certain slowness in the
apparent rale of movement of the illumination when the refractive 1
error is a high one and requires a strong lens for its neutralization ;
whereas, when the retinal illumination appears to move fast, the

refractive error is but slight and requires a wez

Form. — While a large round illumination may signify either hyper-
opia or myopia, yel astigmatism may be in combination. When the
retinal illumination is a band of light extending across the pupil it
iignifies astigmatism. The presence of astigmatism is known by
he straight edge of the illumination; or, in its place, a crescent edge
would mean 3 spheric correction. (Fig. 20.) When the illumina-
ion appears to move faster in one meridian than Ihe meridian at
'i^'hl angles to it. astigmatism will be in the meridia

DIAGNOSIS BY RETINOSCOPY,
Immetropia, — The rays of light from an emmetropic eye (woceed I
■allel, and by reflecting the rays of light into such an eye from a
le meter the observer sees a small bright retinal illu-

RETINOSCOPV. 5S

m, which moves rapidly in the same meridian through
which the light is passed. By placing a + i.oo D. lens in front of
such an eye all apparent movement in ihe pupillary area ce;
showing that the + i.oo D. has bent the emergent rays and brought
tliem to a focus on the observer's retina. This -(- i.oo D. has made
this emmetropic eye myopic just one D., so that in taking the patient
thus refracted from the dark room to test his vision at six meters, this
one D, of artificial myopia must be removed, thus proving the
emmetropic condition.

H3T>eropia.— In hyperopia the same conditions hold true a
emmetropia. For example, having placed a + 3.00 D. in front of the
eye and found that the previously slow movement with the mirroi
ceased, and substituting a + 3.25 D. makes it move opposite, it will
be known at once that the + 3.00 D.was the correcting glass for
meter ; or, in other words, that the original divergent rays proceeding
from the eye were bent by the -|- 3.00 D. and brought to a focus o
the observer's retina. Two D. of this + 3 00 D. would have made
Ihe eye emmetropic, but the additional + 1.00 D. made the
myopic just that amount, and taking the patient from the dark n
this I.oo D. of artificial myopia must be taken from the dark-n
result, which would leave + 2.00 D. as the amount of the hyperopia.

Myopia. — The rays of hght from a myopic eye always proceed c(
vergently, and to the observer seated at one meter distance Iheretinal
n appears to move opposite to the direction in which the
s moved '/the myopia exceed? one D,, and lo move ivilh the
of the mirror if the myopia is less than one diopter. Ai
eye that is myopic just one D. has its emergent rays focusing at oni
meter, and the observer with his eye at this point does not recognin
any apparent movement in the pupillary area.

For example, an eye thai is myopic 4.00 D. has its emergent rays
focusing at ten inches, and the observer at one meter has the apparent
movement of the retinal illumination moving opposite to the m
ment of the mirror. If a — 3.00 D. be placed in front of this eye,
the emergent rays then focus at one meter, at which point the observ
does not appreciate any movement of the retinal Illumination. Itwill
thus be seen that the eye which is myopic more than I.oo D. rel
one D. of its myopia when tested at one meter, and this i.oo D. must
be supplied in taking the patient from the dark room lo test his dis-

56 EXAMINATION AND REFRACTION OF THE EVI

If the observer will remember to always use a plus lens whei^
relinal illQminalion moves with the movement of the mirror, and a
minus lens when it moves opposite, and allow for the one D. of
myopia when -working at one Mfler,h^ will have the following rule (o
Ruide him, namely ; To add a minus i.oo D. to the dark-room result 1
in every instance ; i. e. :

— _ Dark roomo.ooD. + 0.25 D. + 0.50 D. + 0,75 D. + 1.00 D.
■L add —i.oo —1.00 —1.00 —1.00 —1.00

■ Result —1.00 —0.7s —0.50 —0.85 —0.00

I" Regular Astigmatism. — The presence of this condition when look-
ing in the eye before any neutraUzing lens has been placed in posi-
tion, can be determined when a band of light is seen extending across
the pupil, or when it is possible to note a difference in the rate of
movement of the retinal illuminations of any two meridians at right
angles to each other. If the spheric error is high and the cylinder a
low one, then it will not always be possible (o recognize the charac-
lerislic band of light (astigmatism) until the approximate neutralit-
ing sphere has been added.

Tfii axis subiended by the band of light after the requisite sphere '
has corrected the tneridian of least ametropia, is the axis for ti
cylinder in the prescription to be given.

The better way to neutralize cases of astigmatism is to use sphet
lenses in preference to cylinders, for by so doing the difficulty of '
placing cyhnders on the exact axis is avoided; for example,
following formula, + S. 2.00 + C. 1,00 axis 90°, it will be found that
a + 3.00 sph«re in the dark room will correct the 90° meridian and
partly correct the 180° meridian. And that a + 4,00 apher
rect the 180° and overcorrect the 90° meridian, making a difference
in Ihe strength of the two spheres employed of 1,00 D., which is
Ihc amount of the cylinder required. After thus obtaining the result,
the observer may, if so disposed, confirm it by placing the spher
cylinder combination.

Aionomeier. — To find the exact axis subtended by the band of
light while studying the retinal illumination when the meridian of
least ametropia has been corrected, the writer has suggested a small
instrument called an axonometer. (Fig. ii.) It consists of a black I
metal disc with a milled edge, 1 ;i mm, in thickness, of Ihc diameter I
of the ordinary trial-lens, and mounted in a cellof the trial-si

RETINOSCOPV. S7

^^cen^Tround opening i3 mm. in diameter — the diameter of the
average cornea at ils base. Two heavy wbite lines, one on each side,
pass from the circumference across the central opening, bisecting the
disc. The aitonometer is turned in the triaMrameuntil Iheiwo heavy
while lines coincide with the band of light, and the degree mark on
ihe trial-frame to which the white line points is the axis for the

Irregular Astigroalifim. — This condition is either in the cornea or

lens, generally in the former, making it difficult in any instance to

study the refraction, as the reflex is more or less obscured by areas of

^^^^kness, so chat to study the condition the observer may have to

change his working distance toward or from the eye. The kineto-
scopic picture obtained by moving the mirror so as to make the light
describe a circle around the pupillary edge of the iris is quite diag-
nostic of the corneal condition. Whatever result is obtained, the
observer must take care to refract in the area of the cornea that will
correspond lo the small pupil when the efTects of the cycloplegic pass
away. It is best in these cases to retain the correction found as a
guide in a postcycloplegic manifest refraction.

Irregular Lenticular Astigmatisin. — This is often more uniform than
the corneal variety, and is characterized by faint stria; in the lens
pointing in toward the center from the periphery. WKerv i^s-^ Sa\«t

K Position.

^ th

EXAMINATION AND KEFKACTION OF 1

these stride are fine, and only seen when the point of reversal
proached. If the stria; are prominent, they are often seen by
ophthalmoscope even before the use of the cycloplegi

Scissors Movement. — Cases in which this movement is seen are'
not unusual, and are recogtiized by the presence of two parallel bands
of light with a dark interspace; the axes of these bands are generally
horizontal or inclined a few degrees therefrom. By tilling the mirror
in the vertical meridian these bands are seen to approach each other,
like the opening and closing of the scissors blades, and hence the
name. In neutralizing a case of this kind the observer must look
carefully between the bands for the central illumination, and
great extent ignore the bands.

Conic Cornea. — In this condition the observer is impressed at
with the bright, round, central illumination that moves opposite ti

t of Ihe mirror, the peripheral movement being with ll

\ perchance the margin be myopic also, but of li

degree. The best way to refract a case of this kind is to foUoi

suggestion given for refracting cases of irregular astigmatism.

c Aberration, — There are two forms of this condition, positji
and negative. In the positive form [he peripheral (at the edge of'
is) refraction is stronger than the central, and in the negative tl
peripheral is weaker than the central ; that is to say, in the positil
form, when Ihe neutralizing lens has reduced the retinal illi
ind increased its rate of inovemenl, and the point o
for the center of the pupil is close to one meter, the peripheral illui
n grows broader and has a tendency to, and often will, crowd
upon Ihe center, giving the idea of overcorrection, the refraction

tthe periphery moving opposite. The observer must be on his gui
for this condition. The negative form is just the opposite of the
live, and has the central illumination neutralized and the periphi
still moving with the movement of the mirror. This is the conditii
seen in coni
;

are'-"

N
^

TEST-CARDS.

It has been discovered thai the smallest retinal image which can fa

perceived at ihe macula corresponds to a visual angle of

visual angle is the angle included between two lines drawn from ti

I opposite edges of the object through the nodal point. Following d

TEST-CARDS.

in such a manner that
proper distance it subtends an

principle, test-types have been
every letter is so made that wher
angle of 5'.

To tind the exact size of letters at different distances which sub-
tend an angle of 5', we multiply the distance expressed in millimeiers
by the tangent of the angle of ;' (.001454), and 'he result will be the
correct size of the letters, both vertically and horizontally, expressed
in millimeters.

Snellen's letlera are constructed in such
a manner that each part ts separated
from the other parts by an interval equal
lo not less than the arc subtending i' at
the nodal point. The ordinary cards in
use give a series of letters which should
be seen by the emmetropic eye at dis-
tances varying from 3 to 4J meters. The
distance in feet is usually also noted
opposite each line of letters. Physiolog-
ically, the ordinary construction of black
letters on a while background is wrong.
While surfaces reflect all the larger part
of the light thrown upon Ihem, positively
stimulating a relatively targe portion of
the retina, leaving, as it were, small por-
tions of n on -stimulated parts, correspond-
ing to the black letters to be distinguished.
The positively stimulated portions should
be the letters, and the enormously larger
part should be black and unstimulated,
saving much ocular labor and weariness.
In testing the eyes under a mydriatic,
and in amblyopic, strained, and aslhen-
opic eyes, we h.ive found that test-cards with black background a

white letters (Fig. 22) are

Ii is well to have two

patient learning the letlere

The mode of procedu

: satisfactory than the ordinary lesl-

s follow:

cries of letters,
of a single card,
determining the acuity of

lid doubt from the

The patient is placed with hh bac k to v'ac'n^Vw

60 F.XAMINATION AND REFRACTION OF THE EYE.

front oFthe test-cards, which must be hung at a distance offii
meters and be well illuminated by artificial light from a reflector, about
two feel away and to the side. In using the cards with the dark back-
ground, f/ie card must be inclined at suck an angle that the patient
sees no disagreeable reflection from its surface. We then cover the
eye not under examination, and ask the patient to read the lowest
line possible. If seated at six meters' distance he read the line marked
six meters, his visual acuity is expiessed by the fraction | ; if he read
the line marked four meters, he has remarkable acuteness of vision.
and we express it by the fraction \; if he is amblyopic or ametropic
he will not be able lo read the six-meter letters, and may possibly read
onlylhe line marked 15 meters, when his visual acuity is expressed
by the fraction ^. Some surgeons prefer to use feet instead of meters
in their estimations, and seat their patients at about 20 feet from
the card, and express Ihe visual acuity by using 20 for the numer-
ator and the foot-number of the card seen as the denominator.
It sometimes happens that the patient is not able to read anyletteroo
the card at six meters' distance ; in such a case we have him gradi^
ally approach Ihe card, or bring the card toward him, until the
letter is distinguished. This distance is noted and serves as
numerator in the fraction of visual acuity.

With illiterates it is best to use a regular illiterate card, consisting
of lines shaped like the plain capital letter £. The patient is asked
to tell which way the prongs of the E point, upward, downward, to
the right, or to the left. More difScult are the Burchardt dots for
counting. These cards are constructed on the Snellen principle.
For foreigners special cards have been constructed, The German
and Hebrew letters are often of value in hospital work,

Near Tjtjb. — The test-cards usually employed lo estimate the ac-
commodation are after the model of Jaeger, and are merely printer's
types of various sizes. These cards have the advantage of closely
resembling ihe work ordinarily done by the eye in reading, but have
the disadvantage that they are not arranged on any scientific plan.
It is possibly better to use cards in which each word is composed of
several letters constructed in strict conformity with the Snellen basis
of letter formation. Figure 23 represents a card of this description.
On account of the impracticability of ever printing books and papers
with white letters on black background, the ordinary appearance of
reading mailer should be imitated in Ihe near card, and it is in II14

TEST-CARDS.

ml)' that we advise the white

: card for distance

In most cards there is a purposive succession of confusion-letlers,
such as C O D. H M N. E L F, etc, which are of value in recognizing
astigmatism. The mode of procedure with the near type is to find
the farthest and nearest point at which the smallest recognizable
type is legible. In pres-
byopes it is necessary lo

strength varying with the
age of the patient. Each
eye should be examined
separately.

The light'Sense may be
approximately estimated
by the degree of illumin-
ation necessary to make
the lelters on the test-card
legible. In the same

measure the difference in
acuity of vision under dif-
ferent degrees of illumin-
ation. Fore
menls of the light

called a pbotometer. One
of the best instruments of
this class is that designed
by Dr. Henry, of Leices-
ter, England. The in-
strument consists of an
oblong box, open at the

anterior end, through which the patient looks ; lo the edge of
this opening a hood is affixed, which is drawn over the patient's
head during the examination, in order lo exclude any external light
from the candle. Al the posterior end is an aperture, opposite
which are nine discs of 15-ounce standard opal glass, so arranged
ihat one by one they can be swung back. Beh\i\4 VtvM., ovi ».V

EXAMINATION AND REFRACTION C

^ of a meter distant from the box, is a standard candle in a spring
holder, keeping the flame at a constanl level ; behind this is a shade
to prevent flickering. The jiholometer rests on a stand. The patient
is kept in the dark for five minutes in order that his retina may be-
come adapted to the dark. The eye not under examination is closed
with a light bandage. The patient looks into the instrument, and the
opal discs are removed, one by one, uniil the palient detects any
light. If he detects any light from the candle-flame through five of
the opaque discs, his minimum light-sense ( L. M.) is noted as 6ve. etc.
If the eye does not readily perceive the difference in illumination be-
tween two discs, the light-sense is also abnormal, the ligbt difTeience
(L. D.) being too high. L. M. is greatest in early and middle life,
and gradually diminishes toward old age. Diseases primarily involr-
ing the nervous elements of the optic nerve show defective L. D.,
while diseases primarily involving the choroid and retina
defective L. M. In chronic simple glai
while it is only slightly affected in simple ;

Adaptation of the n
perception of images v

This

intact while the adapta
Ji^ndness.

a L. M. is much reduced,
rophy of the oplic nerve.
s the power of gradual adjustment for the
when there is a. change from bright to dull

ronfused with light-sense, which maybe
may be defective, as in cases of night*

TEST- LENSES,

should contain a set of -f- spheric lenses a:
; from 0.12 D. to 2d D. ; a set of -|- cylindenrB
12 to at least 6 D., and a set of prisms fromfl
:o degrees ; several plain colored glasses,T

The case of lest-iense:
— spheric lenses in pair;
and — cylinders from o.
0.5 degrees to at least
opaque glasses, blanks, stenopaic discs, etc., and a trial-frame.

Trial-frames for test-lenses are of several varieties. The moat'
common form (Fig. 24) consists of an arrangement whereby the nose-
piece maybe rapidly adjusted by means of a screw, so as to make the
frame conform to any height or depth of the bridge of Ihe patient's
nose. A vertical and horizontal adjustment by a rack-and-pinion
movement on the nose-piece enables us to quickly and perfectly
adjust the frame to any peculiarity of the patient's face. A millimet-
scale with a pointer moved by a double rack-and-pinion device

-es the distance between the pupils at a glance. The lens-holder

^^^TOisls

Sisls of two hollow grooves, with a slot in each eye-piece lo permit
rotation of cylindric lenses wilh handles. On the ouUide of each eye-
piece are hooks for adjusting an additional lens or a blinder. The
markings on the eye-pieces begin at zero at the nasal side, and run to
the temporal side to 180°. The axis at which the cylinder Is inclined
is found by comparing the axis marked on the test-cylinder with the
coinciding number on the trial-frame. However, as the trial-frame
is not often perfectly adjusted, it is well for the surgeon to learn to
estimate the angle, particularly in the vertical and horizontal merid-

1, wilh his eye. In placing strong lenses in the trial-frame it is
well to have the convex surface of convex lenses turned away from
the eye, and the concave surfaces of concave lenses turned toward
the eye. In all cases the lenses should be placed as near the eye as
possible.

Practical Procedure with the Test-lenses. — Having been assured
that all the accommodation is suspended, we seat the patient to the
left of the table containing the test-lenses, and
wilh the right eye, covering the left wil

64 EXAMINATION AND REFRACTION OF THE CYB.

meial disc. We then ask the patient to read down the card an
at five or six meters' distance, until he conies to the letters that are
indistinct; we then commence the application of the lei
perience will give us a good idea what lens to start with, by notinf
Ihe amount of interference with vision after mydt
patient is able to recognize only the largest letters on the card, he
either amblyopic, myopic, or highly hyperopic, and is quite likely 11
every case astigmatic. If the patient is amblyopic from intraocular
disease or other cause, the application of a pin-hole peiforaled disc
will not increase his vision, and it is not likely that glasses will im-
prove his sight. If the trouble is only refractive, he will at once
notice an improvement of vision through the small perforation. If
he is astigmatic, he will select the stenopaic disc (a blank disc with a
small open slit, described under Astigmatism) at an angle corre-
sponding to the axis of his astigmatism, and the two meridians may;
be refracted separately by spheric lenses alone.

It is perhaps well to assume the simplest examination of a Qioderatt^'
degree of ametropia.

First using a low power -|- spheric lens (o.zj), we inquire if die
confused letters are improved by it ; :f the patient answers yes, we
try a corresponding strength astigmatic lens starting at axis 90°, aod
inquire if the vision is still belter ; we then rotate the cylinder in the
frame, Ending the axis at which the lettersare best seen. If the patient
prefers the cylinder to the spheric lens, we put on the cyUnder at the
aiis preferred, and determine the line read with this correction. A
low power + spheric lens (0.35) is held in front of the eye which is
already corrected by a cylinder, and we inquire if the vision is itn-
ptoved, and also whether a correspondingly low + cylinder still
further Improves the vision ; If the spheric lens is preferred to the
cylinder, it is put in the trial-frame, back of the cylinder first applied,
and the same mode of procedure further pursued, testing with a low
spheric lens and then a low cylinder until the vision can no longer
be improved. The result is then noted and the examination of the
other eye commenced in the same manner.

If. however, neither a + spheric nor a + cylinder lens improves
the vision, a — spheric and a — cylinder arc used in the preceding
manner. It sometimes happens that a -J- cylinder is accepted, but
fuiihcr improvement can not be obtained by an advance in the
strength of a cylinder. 01 by the addition of a -f- spheric lens ; U

jlar^

PRESCRIBIl

g^TESTING GLASSES. 67

such case we immediately q ^

placed at an axis at right a 5 -S^hould be fully explained in

der was preferred. OccasiJ r^ fi ^

with both eyes corrected « 2 .«>« ^glasses are for constant

determine a doubtful axis l I "5 <? S. ^ "* convenient to

an opaque disc. 3 " s S "^ .nee, 798;^ means

An exact knowledge of tl . ;§ I ^ ^ ^ ^" ''*"''' '° ""**

lenses can only be obtained ^ S ] § i § I ^

pointswillbegiveninthedi ^ f §- rJ S- ^f t^t*^^^ *^

&-^S^S'^ S ^4inless

U S \the

Other Methods of Detern; So o

cussion the many other ing< vo ^ ^

numerous text-books on opl ^ \

only necessary to describe t \

tive method with test-cards i

of importance — namely, xt _

ophthalmoscope, and the eSnmation of corneal astigmatism by the

ophthalmometer.

PRESCRIBING AND TESTING GLASSES.

Mode of Prescribing Lenses. — The right eye is designated by
R., R. E., or O. D. (pculus dexter)^ and the left eye by L., L, E.,
or O. S. {pculus sinister). Both eyes are generally designated by
B. E. or O^. The convex spheric lenses are designated + S. or Sph.,
and the minus convene spheric lenses — S. or Sph. A convex cylin-
dric glass is designated -\- C. or -f- Cyl., and a concave cylindric
glass, — C. or — Cyl. The combination sign 3 ^^^ ^^ diopter (D.)
are superfluous, as they are understood. Ax. indicates axis. The
degree mark is not necessary in ordering cylinders. To illustrate the
various forms of prescriptions, examples of each are given.

Simple Hyperopia :
R., + S. 1,25

Simple Myopia :
Z., — S. 1. 25

Simple Hyperopic Astigmatism :
R.y -\- C, 1.50 ax. go
5

64 EXAMINATION AND REPRACTION OF THE EYE.

metal disc. We then ask thm :

at five or six meters' distaj-^Q

indistinct; we then c<y * ,.

Ml . ^ic Astigmatism :

penence will give ur . ^

the amount of. ^^^ + ^' ''^5 ^^^ 90

patient is abla«yoP»c Astigmatism :

either amb^^^*. I,00 — C, 1,2^ ax, i8o

every cjf^stigmatism :

^^^!?<?^., + S, l,oo — C, 1,50 ax. 180

Wll''

y Z., — S, 1. 00 + C 7.75 ax, go

In ordering a plane glass in cases in which one eye is blind or em-
metropic, we use the term piano,

R,, + S. I,2J
Z., Piano

Bifocal glasses are indicated by the peculiar double form of pre-
scription, and the word bifocal. A complete bifocal prescription,
which may be taken as a model form of prescription, is as follows :

Adam Smith, ffi,. D.,

5000 Chestnut St., Philadelphia.

Jaymary /, i8gy.
Mr, John Smith,

Bristol, Pa,

R
L

?., + 5. 1,00 + C, 1.25 ax, Qo\ ^

r I c- *- ^ r ^ r For distance,

.., + S. o.ys + C. 0.25 ax. go j

R., + S. ^.00 and Cyl, \

L.,-^ S: 2 75 and Cyl.)^'^ "'''''■

Bifocals in i^-k, gold, rimless spectacles,

Adam Smith, M, D.

PRESCRIBING AND TESriNG GLASSES. O7

-Opaque glasses, tinted glasses, etc., should be fully explained
English on the prescription.

Every prescription should state whether the glass
use, or for near or distant use only. Trade terms
indicate the style of glasses ordered — as, for instance, 798^^ means
14-k. gold, ritnless spectacles. However, it is possibly better to write
the full directions out.

Finding the Center of Lenses, — Expert opticians will endeavor to
make the geometric and optic centers of lenses coincide, unless
decentration Is desired to obtain prismatic effect. To tind the
optic center of a lens, we look at two lines, several inches long, 3t
right angles to each other, in the shape of a + sign, through the lens
held a few inches above. We rotate the lens until both the vertical
and horizontal lines appear continuous when viewed through the lens,
and when viewed beyond the lens. Then the point on the lens just
opposite to the center where the two lines cross is the opiic center of
the lens, and should be marked in ink. It is necessary to know the
optic center of a lens, to see if it corresponds to the center of the
pupil when the glasses are in position on the face, and properly to
apply a neutralizing cylinder.

Neutralization of Lenses, — The lens is held a few inches in front of
the eye, and some object, such as the vertical and horizontal lines of
a window-frame or the test-letters, is viewed through it. The lens is
then moved to the right, and if it is convex, the object will move to
the left ; if it is concave, the object will move with the lens lo the
right. Having determined what sort of a spheric lens we have under
examination, we proceed to neutralize it by holding successively a

ment of the object is perceived through the lens ; therefore, to find
the strength of a spheric lens it is only necessary to combine it with
successive lenses of the opposite sign until one is found which neutral-
izes the apparent movement of objects seen through the lens under
examination. The more rapid the apparent movement, the higher
the power of the lens required to neutraUze.

Cylindric lenses only show movement in the direction opposite to
their axes ; the movement is against in convex cylinders, and with in
concave cylinders. To find the axis, an object presenting a straight
line, such as the vertical line of the window-sash or the edge of a
frame, is viewed through the lens. As the lens is toWici, AiomV ■&«

1 REFRACTION OF THE E

visual axis, the portion of the vertical line se
appear to be oblique, as compared with tliat
the lens. (Fig. 25.) This oblique displ;
tion contrary to the rotary motion given
same direction as the rotary motion given
lain the position of the axis of a cylinder

through the lens will
;n above and below
akes place in a direc-
ivex lens, and in the
lens. To ascer'
slowly rotated until the
n through it appears continuous above and below. {Fig, 26 )
If motion from side to side produces apparent motion of the object,
this line is the axis of the cylinder, and if no motion results, the line
is at right angles to thg axis of the cylinder. The axis being deter-
mined, the cylinder is neutralized by successive cylinders of opposite
curvature applied in Che same axis.

Spherocyiindric lenses are neutralized the same way as two cylin
ders with their axes perpendicular to each other. Having neutralized
me meridian, we note the result, and neutralize the
a the other meridian.
The pbacomeier is an instrument designed to ascertain quickly the
strength of a lens under examination. It is operated by pressing
ibe surface of a spheric lens squarely against three steel pins, the
central one of which is movable. When the central one is depressed
until all three points touch the glass, the curvature of the lens is indi-
cated on a dial.

Mode of Prescribing Prisms. — When it is found necessary to pre-
scribe prisms, we may distribute the full prbmatic strength between

PRESCRLBrNG AND TESTING GLASSES.

o eyes, or order it all in one eye ; as, for instance, if we desire
lo order five degrees base out or five degrees base in, we can put the
prism in either lens or we may distribute it 2% degrees base out — or
base in, as the case may be — in each eye ; or two degrees base out or
base in in one eye and three degrees base out or base in in the other
eye. In testing for hyperphoria we always record which eye has
been tested — as, for instance, our record reads five degrees base
up, left. If we desire to prescribe this prism entire, we insert it ii
the left lens; if, however, we desire lo divide it, we order 2^ degrees
base up in the left lens, and 2yi degrees base down in the right lens.
If we had ordered 2)^ degrees base up in both lenses, one pt
would have simply neutralized the other, and we would have had
correction of the vertical deviation, only a uniform downward dis-

B. D. is a symbol for base down ; B. U., for base up ; B. 1., for base
in ; B. O,, for base out ; R. stands for right, and L. for left.
The following is a form of prescription for a simple prism :

prism B. 0.
ic following is the usual mode of combining a prism wii

R., -\- S. i.oo + C. 0.25 ax. go

L., -\- S. 1.00 -\- C. 0.3S ax. 90

With prism 3° S. D., L. {i.e., base down, left);

« 2° B. 0., R. ami L. {i. e., ^ base out in each eye).

Decentering spheric lenses produces a prismatic effect identical
wilh the lens of the same strenglh combined with a prism. (Figs. 2?
and 38.) The stronger the lens, the less decentering it require;
produce prismaiic effect, and in cases in which it is desired to order
a strong lens with a weak prism, decentering is of great value.

Rule. — ^To find the exact amount of decentering lo produce a
prismatic effect, we divide the number of cenlrads required by the
strength of the lens in diopters. The quotient is the necessary de-
centration expressed in centimeters. For example, to produce a
prismaiic effect of two centrads by means of a spheric lens of four
I -diopters, it is necessary lo decenter ihe lens 2 -;- 4, or .5 cm.

LpTO EXAMl.NAflON AND REFHACTION OF THE EVE. ■

NeulraliiBtion of Prisma. — The apex of a prism may be determined
by looking through it at fine lines crossed at right angles, or at the
border of a card. Holding the prism so that its edge just touches one
hne at the point of intersection, we rotate the prism until the other
line appears continuous through the prism and beyond it. The point J
of intersection in such case marks the true apex of the prism. The 1

The IKitlc center O. in fiiiiire 17 caini
removed loward the ba»e of the 1

Strength of the prism is then ascertained by the prism with its apex I
pointing in the opposite direction that will neutralize the pris
effect of displacement when looking at a distant object, such a
side of a picture-frame or a door jamb.

r SPECTACLES AND EYEGLASSES.

The fittingof spectacles and eye-glasses is a most necessary adjunct
to the art of ophthalmology. Spectacles should always have stout
temple-pieces, to maintain their shape and stay in proper position by
their weight. To prevent jarring while walking or running, the aide-
pieces should fit closely to the face and temples ; in fact, it is S
times preferable that they should exert sufficient pressure to slightly '1
groove the skin. By this means a definite and fixed support is given.
Fourteen -karat gold is to be preferred, and stout steel should be the I
second preference. Although silver does notriisl. it can not be made J
of sufficient rigidity. Delicate wires, either of gold or stee!, should I
not be accepted, .is they can only maintain their position by uncom- ]
fortable pressure behind the ears and on the nose.

Spectacles are preferable to eye-glasses whenever there is astigma- 1
tism.otwhen the nose is not properly shaped for the ready adjustment |

^M SPECTACLES AND EVE GLASSES.

of eye-glasses. Hooka are to be preferred to straight temple-pieces
when the glasses are to be worn' constantly. Reading-glas

lonvenient with straight side-pieces, particularly in
it of the abundance of hair about the temples.
e lenses should be slightly inclined at acomprami'e
angle between the straight position and the inclination preferred for a
reading-glass. Of course, the occupation of the patient must be taken
into consideration in adjusting the glass.

In high defects the glasses should be fitted closely to the eyes and,
if necessary, the lashes should be trimmed from time to time.

Glasses should be worn constantly in high defects, in astigmatism,
and in all cases in which there are asthenopic or reflex symptoms.

Bifocal glasses are particularly valuable for a presbyope, or a high
myope who is compelled to use a different glass for reading and for
distance. The improved form, with a reduced curved segment
cemented on the distance glass, is far more satisfactory than the old
straight Franklin bifocals. The lower segment should be about 2
cm. wide, and the upper edge more curved than the lower. If the
occupation of the patient subjects him to high degrees of heat or
steam, the lower segment should be inserted into a groove in the
boilom of the distance glass instead of being cemented on. Although
it takes the patients some little time to become accustomed to bifocal
glasses, they ultimately give far greater satisfaction and are more
convenient than two different pairs of glasses.

Before discharging the patient, the adjustment of the glasses should
be carefully examined and the correctness of the lenses verified by
neutralization. The good effects of many a careful diagnosis of re-
fraction are ruined by maladjusted and decentered glasses.

Tinted glasses of any kind should never be ordered for constant
use, but only temporarily prescribed in inflammatory conditions,
during mydriasis, for use at the seashore, etc. The habit of wearing
tinted glasses once formed is difficult to overcome. Photophobia is
usually due to uncorrected or improperly corrected ametropia. It
is a well-known fact that tinted glasses are most used in countries
in which the importance of eye-strain in comparatively low defects
is unrecognized. When tinted glasses are oidered, it should be
specified that London smoke piano lenses are wanted. Coquilles
generally have some spheric or cjlindric effect on an irregular

f'3 EXAMINATION AND REFRACTION OP THE EVE. ^^^^^H

MYDRIATICS AND CYCLOPLEGICS. ^M

Definition. — A mydriatic is an agent which produces dilatation a^^

.flhe

ssing ,

rtbfl

oyed
lor at^l

^K4sti

agent which produc
cjclople^c is a
ciliary muscle oflhceye. In ophthalmology these two terms s
usually considered interchangeable, as the ordinary drugs possessing
the power of producing mydriasis, also produce in a more or less d ^
gree cycloplegia

The mydriatics which have been used in the examination of tl
eye are atropin, belladonna, homatropin, cocain, hyoscyamin,*
duboisin, dalurin, scopolamin, muscarin, mydrin, euphthalmin, and
ephedrin. Alropin and homatropin are the drugs usually employed
in refraction, and are the ones to be recommended, as they tuve
been extensively used and their action and dangers are far betb
understood than those of the newer substances.

Physiologic Action. — Atropin and homatropin produce mydriaa
by paralysing the sphincter of the pupil and stimulating the dilator a
the same time. Cocain affects the dilator of the pupil chiefly, stimulat-
ing it. Alropin paralyzes the ciliary muscle completely, and leaves
the eye adjusted only for the far point. Homatropin paralyzes it lesc
completely, but sufficiently for the purposes of refraction, when a^
nislered in (he manner indicated. Cocain has a very sligh|
paralytic action on the ciliary muscle. As usually administered, tl
of atropin lasts from ten days to two weeks ; of homalropia,
one to two days ; of cocain, only a few hours.
Indications in Refraction. — /n all first refractions of the ejff <'/U
under forty-five or fifty years of age, in "whom there is no .
'pition of glaucoma. No absolute diagnosis of the finer grades
'Astigmatism can be made without a mydriatic in a person p
■the power of a

igers. — These drugs may precipitate an attack of glaucoma fa
the eye of a person past middle life, or in whom there is already I)
tendency to increased intraocular tension,

It has been said that if a mydriatic ordinarily applied for purpose
of diagnosis produces glaucomatous symptoms, the patient would
likely have been the subject of insidious glaucoma later in life anji
way, and that (he early diagnosis by the mydriatic facilitates t

Mydriatics may also cause general toxic symptoms in susceptible
patients. The general symptoms are tickling and dryness in the
throat, vomiting, diarrhea, redness of the face, and quick and irreg-
ular pulse ; even fatal cases have been recorded. If there is any
history of idiosyncrasy, the patient should always be instructed to
press the finger against the lacrimal sac for ten minutes after using
the drops. This danger may also be averted by using minute or
divided drops of the solution. Congestion of the conjunctiva is often
a temporary result of the instillation of a mydriatic. The systemic
effects of a mydriatic may be combated with a full dose of paregoric.
Administration. — The most effective of this class of drugs, and that
mostfrequentlyused, is the sulphate of atropin. A solution of one grain
to two drams is ordinarily prescribed ; one drop of this strength solu-
tion is placed in each eye three times daily for two days prior to the
examination. An additional drop is generally applied at the office of
the oculist before beginning the examination. For the reason of its
prompt action and the short duration of its effect, the hydrobromate
of homatropin offers a very efficient and necessary substitute for
atropin in office practice. It is, however, a much more expensive
drug than the sulphate of alropin. The best solution is a mixture of
two-thirds hydrobromate of homatropin, ten grains to the ounce, and
one-third hydrochlorate of cocain, ten grains to the ounce. A drop
of the mixed solution is instilled in each eye every ten minutes for an
hoiu- preceding examination. If it is necessary to have repeated
examinations of the eye or to have prolonged mydriasis, atropin should
be invariably used. Cocain is useful to dil.ite the pupil to facilitate
ophthalmoscopic or retinoscopic examination, but is valueless as a
cycloplegic. The four per cent, solution is generally used. Sufficient
dilatation is usually obtained in from fifteen to thirty minutes.

Hyoscyamin, duboisin, daturin, and scopolamln are sometimes
used, but investigation has not yet definitely established reason why
they should be preferred to the older drugs. These and the rarer
mydriatics are further described in the section on Local Ocular
Therapeutics.

EXAMINATION AND REFRACTION OP THE EYE,

AMETROPIA.
HYPEROPIA.*
Synonym 8 . — H y perme tropia, far-sightedness.

^^^H, Definition. ^A condition of the refraction of ihe eye in which, yrht

^^^Fihe accommodation is at rest, the focus of parallel rays of light tra.i^

1^^^ mitted through the eye is heyond the ri

Causca. — Hyperopia may be due to a lessening of the convexin
of the refracting surfaces of the eye(/iypeiofi!a of curi'ature), cha.ng|
in the index of refraction of the dioptric media, of absence of tl
crystalline lens (aphakia). It is, however, most commonly due to a
shortening of the anteroposterior axis of ihe eyeball (axial hyperopia).
Hyperopia may be looked upon as arrested development. Animals
are, as a rule, highly hyperopic ; and savages are, as a rule, more or
less so. Children are usually hypevopic, and become emmetropic or
even myopic while growing to maturity. Properly speaking, hyper-
opia is a failure of the modern eye to properly adapt itself for its uses
in modern civilization. Hyperopia is often hereditary.

The rcBuItB of hyperopia on the ciliary muscle are quite noticeable.

I Excessive contraction produces abnormal development, particularW

I of the circular fibers, which become greatly in en
ifibers. The continuous contraction may lead to ti
m very difficult to overcome, and renders refraclior
i|nydriasis most unreliable.
Axial Shortening in Hyperopia :

2.S24

1.50

15.91 391

17.92 4.00

•Alihoogliii

n or>lli

lUl

. praciii

JBilBI

h-.l

uklafini

ilh.

;I^Bplerfor

™..»«JI

UkhHiIhI nil)

■stismiit

■ defect! «LI1 1j=

lUlf.

HYPEKOPIA. 75

idvmnUges. — Parallel rays of tight do not focus on the retina,
but form circles of diffusion and hence a blurred image. Divergent
rays impinging on the cornea form still larger circles of diffusion on
the retina. The only rays that can focus exactly on the retina and
give a distinct image are those rendered convergent to a certain
degree by convex lenses. The eye contains a mechanism for over-
coming its hyperopic defect. In order to render the rays more con-
vergent, the anterior surface of the lens is made more convex by the
IS contraction of the ciliary muscle. In this way hyperopia,
:erlain point, varyingwith each individual, is involuntarily cor-
However, we can readily realiie the result of a constant
n the ciliary muscle. Nervous energy is consumed and the
equilibrium is disturbed, with the result not only of annoy-
ing local symptoms of pain, fatigue, and congestion, but more remote
reflexes, such as headaches, gastrointestinal disturbances, and many
general neurotic disorders. As the correcting effort of the ciliary
muscle is involuntary, the resultant annoying symptoms of eye-strain
can only be relieved by atrophy or paralysis of the muscle, or cor-
rection of the defect which necessitates the ciliary contraction.

Varieties.' — Manifest, which is measured by the strongest spheric
lens which, without mydriasis, gives the greatest acuity of vision.
Latent hyperopia is that part of the total error which can only be
revealed by mydriasis, as It is at all limes masked by the accom-
modation. The younger and more vigorous the subject, the greater
the amount of latent hyperopia. It is on account of the ever-present
latent hyperopia in the eyes of persons younger than fifty years, that
it is necessary to paralyze the ciliary muscle in order to measure
the full degree of hyperopia. The old classification oi facullati-ve,
relative, and absolute hyperopia is too vague to be used.

Symptoms, — The objective symptoms are inconsiderable. TTie
leading subjective symptoms are caused by the strain upon the
accommodation, and may be grouped under the heading " accommo-
dative asthenopia," The patient will complain of inability to perform
continuous near work: the letters and words are indistinct and seem
to run together. Headaches and pains about the eyes are present.
There is increased lacriraation and tendency lo chronic congefition
of the conjunctiva. The local reflex symptoms may range from a
slight p.ilpebral conjunctivitis to inlfuse blepharitis and even granular
lids. There may be such intense photophobia as lo ci ^

F76 EXAMINATION AND REFRACTION OF THE EVE. ^H

of retinal disease. The remote systemic reflexes, such as headacl^^|
nausea, indigestion, general neurotic disturbances, etc., are l^^|
numerous to be discussed here. JH

^^^ The distant vision is usually sood, as the ciliarv muscle is caoable '

^
»
^

■opic W
lomfoo^J

The distant vision is usually good, as the ciliary muscle is capablr '
of overcoming a moderate defect. Hyperopia of a high degree, or
complicated with astigmatism, markedly diminishes real aculeness.

There is an intimate connection between convergent strabismus
and hyperopia. It is likely that the associated movements of accom-
modation and convergence are controlled by the same ceriter, or by
contiguous centers, acting automatically from long association. The
increased strain on the accommodation causes extra innervation to
convergence, which may result in permanent squint inward. Or,
again, persistent stimulation of the adductors may weaken them and
thus produce divergent squint. Very often if a child is hyperopic W
some extent, and unequally in the two eyes, to avoid the discomfool
of a blurred or double image one eye is turned in and becom
amblyopic, It has been estimated that over three-fourths of [he c
of convergent strabismus are caused by hyperopia. We, therefore,
see how very necessary it is to examine carefully the refraction of an
eye beginning to converge in a child.

Hyperopia increases with age, on account of the lessening of the
refractive power of the lens caused by a change in its substance. At
the age of eighty this lessened refractive power is quite apparent.

Diagnosis can be made with certainty only by the use of a mydri-
atic, although failure of accommodation and recession of the near
point incommensurate with age give strong reason to suspect hyper-
opia. The most important point in the diagnosis is the acceptance
of a convex lens, and we usually estimate the full degree of hyperopia
by the convex lens which gives the eye under complete mydriasis the
best vision with the test-cards at six meters.

In the higher degrees of hyperopia the patient must choose be-
tween a small, more or less distinct, and a larger blurred image. As
n rule, his choice is the latter evil, and to this end he will hold his
book or instrument very close to his eye, simulating the action of s
myope. In addition, the high hyperope complains of inability to sec
distinct objects, which makes another point of confusion with myopia.
In casual examination of hyperopia with ciliary spasm, a weak con-
cave plass may be accepted with relief. However, all confusion wilh
myopia may be avoided by thorough mydriasis.

(be test-lenses, hyperopia is diagnosed and the degree esti-
mated by the ophthalmoscope and the retinoscope in the manner
described in the sections relating to these instruments.

The treatment of hyperopia consists in prescribing correcting
lenses. Having estimated the degree of defect, several points must
be taken into consideration in prescribing glasses. It is taken for
granted that the patient has been thoroughly under a mydriatic dur-
ing the preliminary tests. When he comes back to our office for a
prescription, it very often happens that we find at the postmydriatic
examination that a hyperope of a slight degree will not accept any
of his correction, either for reading or for distance. In such c^se, if
anisometropia is not present and if the patient has complained of no
asthenopic symptom and is apparently vigorous, we do not prescribe
a glass, but tell him of his defect, and warn him of the ultimate
results of eye-strain, and urge him to come back at the first sign of
trouble. It more often happens that a certain proportion, or even a
full correction, is accepted for reading, but all correction is rejected
for distance; in such case, if there is no prominent asthenopic reflex,
we only prescribe a reading glass.

Prescription of glasses in hyperopia is a most important subject.
No definite and dogmatic conclusions or rules are applicable in every
case. We must study each case separately and be influenced by the
degree of defect, the muscle-balance, the age of the paiient, the con-
stitutional condition, the asthenopic symptoms, and the occupation
or habits of the patient.

It is very often necessary in young people wiih strong accommoda-
tion to make considerable deduction from the full correction in order
to obtain sufficient distant vision. Young and vigorous adults who
have never worn glasses will not accept their full correction. In such
cases we must be governed by our judgment. As a general rule, we
try to prescribe the highest convex lenses which allow sufficient dis-
tant vision; these are usually readily accepted for near work. If
the patient is engaged in continual near work and complains of
marked asthenopic symptoms, we order, for near vision, a large share
of the full correction, and consider it advisable to blur slightly the
distant vision. We must explain to the paiient that such glasses
will not be satisfactory at first, but that the eye will gradually become

Emed to them, and that the glasses were not ordered to improve
lant vision, and may diminish it at first, but iVvaX \Vc \-i<>\\\'>. ^^^

~,^^,^

isideration is to effect easy near vision, and to avoid e;re-strun ai
.s distressing consequences.

In cases of very Vijgh defect with enormous accommodative power
weak lenses are at tirst ordered, and these are strengthened at
:I intervals until the full correcdon is approximated. It is surpris-
ing to note the rapidity with which the eye will accommodate itself to
what was at first an unacceptable correction.

The muscle -balance must always be tested before ordering glasses.
In cases of orthophoria or exophoria we must reduce the correction
in hyperopia to force the intemi into action. The ideal hyperopic
muscle- balance in most office patients is about two degrees of eso-
phoria with the Maddox rod, or orthophoria with the Stevens phoroin-
eter. Cases of higher esophoria need a strong correction.

In presbyopia and in other cases in which a mydriatic has not been
used we endeavor to order the full strength of the manifest refraction.

A final point is the influence of avocation. We readily see thai the
musician and artist, to obtain the best acuity and accommodation at
theitworking distances, will require a different correction from ihal of
the copyist and engraver.

MYOPIA.

Synonyms. — Near-sightedness, short-sightedness, brachymetropU.

Definition. — A condition of the eye in which parallel rays of light
are brought to a focus in an eye at rest in front of the retina. It is
most often dependent on the lengthening of the axial diameter of the
eye, and such cases are called irue or sfa/ii^ myopia. A /a/se or
functional myopia is produced by spasm of the ciliary muscle, conic
cornea, swelUng of the lens in incipient cataract, etc. In such cases
the sclera is of usual thickness and the axis of the eyeball is not
lengthened ; the change is in the refractive media.

Axial Len^^thening in Myopia :

Myopia in D. Length of Myopic Eye. Jncieaie in Lcngtt,.

□ a2.S24 0.00

1 83,14 0.32

a 23.48 o,t>6

3 33-83 i-or

4 a4->9 '-37

5 »4S6 1,74
10 26.62 J. So
15 29.10 6.j8

20 33.IJ q.H

rarely congenital, and, when si
lid to be the pecuha
in certain people.

Devitalization and weakened resistance of the ocular tissues are
predisposing causes. Scrofulous children are ready victims to
myopia. The early necessity for increased convergence and accom-
modation by the precocious application of hyperopic eyes of child-
hood to continuous near work produces a hyperemia of the
ocular tissues, which if of low resisting power are stretched,
the eye gradually becoming lengthened, and, as a result, myopic.
Myopia is often se»n in persons of intellectual pursuits requiring
excessive near work, such as students, artists, engravers, etc. How-
ever, in the congenital and hereditary types, the patients may be of
the most ignorant classes of mere manual laborers. In such cases a
low-grade choroiditis is an important etiologic factor. Myopia
rarely results from an increased refractive power of the lens in the
early stages of cataract in old persons, and to this fact maybe possibly
attributed the cases of so-called " second sight," in which aged per-
sons find themselves able to read again without their convex lenses.
However, their distance vision becomes markedly decreased.

The entire eyeball is not necessarily involved in myopia — as. for
instance, myopia results from the condition known as conic cornea,
the relation between the retina and other media being normal.

An occasional and a curious cause of myopia is a marked decrease
in weight of an extremely stout emmetrope or a low degree hyperope.
In a like manner we have noticed considerable decrease of myopia
in persons who suddenly and markedly increase in weight.

Disadvantages and Dangers. — The axial diameter being too long,
the parallel rays of light falling on the eye focus in front of the retina,
and hence only a blurred image of external objects is received on
the rods and cones. In moderate hyperopia a similar defect is over-
come by the accommodation, but the myopic eye possesses no
mechanism adapted to the correction of the refractive error. There
is no way of diminishing the refractive power of the dioptric system,
and hence distant objects are always blurred. There is false estima-
tion of size and distance, and altogether the myope is at a decided
disadvantage in sports or occupations. However, the myope is still
able to see near objects distinctly, and unfortunately therein lie^U
I danger. Deprived of many out-door pleasutea, "

) REFKACTION OF THE

:upation and amusement within his own limited circle o
By holding his book or implements close to his eye, he is able ti
distinctly ; but in so doing he strains his power of convergence t
:ly, producing ocular congestion and compression of the eil
ball ; and by bending over he affords a favorable position for the
tcniion of the ocular veins. The coats of the eyeball, already i
weakened resistance and put upon the stretch, are further pulled a
damaged. The eyeball becomes more and more lengthened, and d
myopia increases. With the stretching of the ocular
tion of the eye is seriously disturbed, and, as a result, the chorQ
becomes diseased, and this causes associate retinal changes, defec
vision, even with proper glasses, resulting. The nutrition of ti
vitreous and lens is also seriously damaged. The consequences 3
this dcnutrition in the highly myopic eye are serious, and such eyj|
are liable to cataract, vitreous opacities, and retinal detachmenL
The danger is, of course, greatest in youth.

Contrary to the popular impiession, the myopic eye should be con-
sidered as a " sick eye." However, if proper glasses are prescribe
and constantly worn and excessive near work interdicted, a moder
degree of ntyopia unaccompanUd by posterior staphyloma i
liable to progress, but will remain more or less stationary throng
•dull life. This again offers another argument for the early coir
tion of myopia.

Another danger of excessive convergence In a myopic child!
divergent iquint. The strain in excessive convergence, necessiliU
by the diminished distance for near work, and extra eHbrt t
the elongated eyeballs, may be so great that the effort to ci
both eyes is finally relinquished, and one eye diverges.

A 6nal danger of myopia is the liability to accidents on account 9
the inability to see distant objects clearly.

ProgrcMivc or malignant myopia is the serious type in which d
ocuUi coats continue to stretch and tiecome devitalised until t1
ultimately give way. The bulging occurs at the weakest portion m
the posterior pole, to the temporal side of the disc, and c
what is known as postcHoi Biaphyloma. The destruction of D
choroid is accompanied by many conditions which are readily recog-
niied through clear media with the ophthalmoscope. The myopic
(C Fig. 19) is caused by the absence of the jHgment of
stretched choroid and retina, usually al the nasal margin of the

disc, allowing the sclerotic to show through as a white

white spots indicative of chronic choroiditis may be

throughout the fundus. Hemorrhages and

produce retinal detachment. In e«reme c;

fluid and the eyeball soft. Vitreous opacity and lux:

may result. With such serious sequels we readily s

mate result of unchecked malignant myopia maybe disorganization

of the whole eye and total blindness; and in all cases of high

myopia, whether progressive or stationary, there are pathologic

changes of such import as la produce more or less amblyopia.

becomes

in of the lens
that the ulti-

Symptoms — The object ve symptoms in the lower grades of
myopia arc of 1 Itle importance In the h gh degrees tl e eyeballs
may be promment and when stronj,ly converged ire seen to be
elongated In s ch cises the p p Is are Hrge and nactive. The
myopic crescent and the choro dal cond t on help the d at,nosis.

The most noticeable subjective symptom is the interference with
vision. In moderate myopia distant obj'ects can not be seen dis-
tinctly. Myopic children complain that they can not see the clock
across the room or distinguish writing on the *> ""t bcTmmsV,

although they are able to read at close range V "— ^ i

I 82 EXAMINATION AND REFRACTION OF THE

exiretnE cases of myopia or in the progressive tj'pe the far point ]■
close to the eye as to render the eye virtually useless for distant
vision. ScDtomata, limitation of the visual Held, vitreous opacities,
photophobia, photopsia, muses, and ocular pains are additii
symptoms of the higher degree of myopia.

As a rule, the symptoms of accommodative asthenopia and tl
remote reflex irritations from eye-strain are not complained of
myopia, as the cilinry muscle is passive rather than active. Its radial
I fibers are better developed and are greatly in excess of the circular
fibers, the opposite of the condition in hyperopia. However, because
of the strain on the convergence, evidences of muscular aslhenopii
such as headache, we:iriness and seust of heat in the eye, and chroi
conjunctivitis may follow.

Diagnosis rests upon the diminished acuteness of distant visioi
the ophthalmoscopic examination (refraction and fund us -changes]
the retinoscopic examination, and the acceptance of and
provement by a concave lens. Conic cornea is easily differenliati
from myopia by the pecuhar protruding appearance of the
depth of the anterior chamber, and the characteristic retinoscopic
reflex. Hyperopia with ciliary spasm simulating myopia is readilf
differenliaied under mydriasis.

Treatment- — Prophylactic measures consist in the careful examina-
tion of children's eyes, particularly about the time they are to start to
school, and in securing the best hygienic conditions for them during
their school hours. Good ventilation, pro perlv' constructed desks.and
suflicient and rightl/ directed light are requisites for the maintenance
of normal vision. There should be a north light coming in over the
left shoulder, and notfathng directly on the desks. The walls and
ceilings should be painted in light colors. There should be
of window space for every five feet of floor space, and small type
should be distinctly read in the most remote corner of the school-
on a cloudy day. Books should be printed in large, broad-faced
and on dull-faced paper. The desks should be sloping and
arranged as lo avoid all stooping positions. In young myopes exi
sive near work must be interdicted. Such children should be
lo forego studying, reading, and other in-door amusements, and must
be encouraged to go out into the open air and take plenty of health-
ful exercise, meanwhile rigorously wearing their correcting gla-
^ In myopia the book, writing, etc., should be placed

ial ■■
use

iieqH

I type
-rooi^l

lealth-

MYOPIA. 83

at least 13 inches from the eye, artificial or insufficient light should be
avoided, and the eyes should be given frequent imermissions of rest.

In the progressive type of myopia, and in the extremely high
degrees, nea.r work must be virtually excluded from the daily occupa-
tion. In such cases the treatment depends upon rest, abstinence
from near work, constitutional and hygienic measures, the relief of
any increased ocular tension by the administration of eaerin, or
iridectomy, attention to the associate choroiditis and other pathologic
changes, and the constant use of correcting lenses.

Prescription of GUsges. — Ordinarily, it is desirable to prescribe
spectacles that will give fair distant vision and. at the same time,
enable the patient to read easily at the proper working distance.
However, in cases of persons doing much near work, a pair of weak
lenses may be ordered for reading, etc., and stronger glasses for out-
door use, theaters, receptions, etc.

In myopia of three diopters or over the far point is inside of the
ordinary reading distance, and there is necessarily extra conver-
gence; but unfortunatfly there is no necessity for accommodation;
the adductors are deprived of this stimulus, and exophoria results.
In order to cause the requisite accommodative stimulus to the adduc-
tors, constant use of Ihe full correction of myopia has been urged.
The theory of this is plausible, but Ihe strain on the undeveloped
accommodation is too severe and serious asthenopia results. We
unfortunately find that most myopes complaining of unsatisfactory
glasses are wearing not only their full correction, but are, in a major-
ity of cases, overcor reeled. A myope will naturally select a strong
lens, and we should be cautious in the trial with the test-lenses, and
accept as the proper refraction the weakest lens which gives normal
vision, and which does not diminish the size of the letters, and, as
the patients so often say, makes them seem belter but farther away.

In prescribing glasses for constant use, some deduction from the
full correction should be made in cases of children and young adults,
in order that compromise lenses may be continually used which give
fair distant vision, but which necessitate only a moderate accommoda-
tive effort in reading. It must always be remembered that overcor-
recied myopia may produce as distressing symptoms as uncorrected
hyperopia.

At the presbyopic age bifocal lenses should be constantly woirb.
and the full distance-correction ordered in ttic y^^W ?«%'wimA.

^Hs4

^^^P high myc

^^^ glasses ar

S4 EXAMINATION AND REFRACTION OF 1

Ihe high degrees of myopia (above six lo eight diopters) the

lolerated. In the unfortunate
high myopia (12 lo 30 diopters), with extensive choroidal chang<
glasses are often of little service in making a useful working eye,
are so bulky and heavy as to be uncomfortable.

Removal of the Lens for Hig'h Myopia. — -It is a well-kni
that the removal of the crystalline lens makes an emmeiropii
hyperopia by about 12 or 13 diopters. In the knowledge of this fa
it has been suggested that removal of the lens would be an advisal
procedure in cases of extremely high myopia — for instance, of from ij
to 20 diopters. Although this operation has been performed quite a
number of times recetitly, the actual practical results are not definitely
settled ; there is great danger of retinal detachment, and, moreover. It
is too radical a treatment to be advised to the beginner in ophthi
mology. An ideal Indication for this operation would be lenliculi
myopia.

i>thal^

ASTIGMATISM.
I Definition. — An error of refraction usually due lo some irregul
' of the curvature of the refracting surfaces of the eye. The earnest
most often the faulty structure, but lenticular astigmatism is not vtt-
common ; in fact, it is said that all eyes possess some irregular astig-
matism in the lens, and for this reason a point of light at a great dis-
tance is not seen as a point, but as a star. However, it must be re-
membered that light coming from the heavens travels through medltt
of different refractive powers. In simple myopia or hyperopia, whilfl
the refraction is faulty, the corneal meridians are all of equal curvM
ttire. In astigmatism the curvature of the meridians is different; OOC
I principal meridian may be of proper curvature while the other
[ markedly defective. It must be remeuibered that astigmatism does
not depend upon the length of the globe, but upon the curvatures of
the cornea and lens.

Varieties. — Regular astigmatism is present when the two princi|
meridians— I.e., those of greatest and least curvature — are si
angles to each other.

Irregular asCigmalism is a condition in which the unequal cui
lures of the cornea bear no definite relation to each other, Thi
> principal meridians, and dilTerent parts of the same meridii
may have different refractive powers. This form of astigmatism

ler is

idi^H

usually due to cicatrices of the cornea following injuries, surgical
operations, or destructive inflammations. If the cornea is clear and
apparently regular, we are safe in attributing irregular astigmatism
to a diiTerence in the refractive power of the different sectors of the
lens, or to its oblique position.

Causes of Regular Astigmatism. — As previously staled, the chief
factor in the production of regular astigmatism is imperfect curvat
of the cornea. Regular astigmatism may be congenital or hereiiitary.
Congenital malformation of the cornea may be a part of a general
anatomic defect in the bones of the face and skull.

The causes of acquired regular astigmatism are not exactiy under
stood, but as almost every person is slightly astigmatic, we must sa;
that among civilized nations regular curvature of the corneal surface
Is the exception rather than the rule. However, the excessive use of
the eyes in modern life is attended by so much muscular and accom-
modative effort that we may readily believe that both tension and tor-
sion on the coats of the eyeball by the muscles are prime factors in
the meridional change in corneal curvature. Pressure of the lids,
particularly in ametropia and when they are hypertrophied and '
even afler some marked conjunctival inflammation, is often suggested
as a cause. Finally, after operations on the cornea or sclera, the
subsequent changes during cicatriiaiion may produce a high degree
of astigmatism.

Explanation of ihe Several Varieties of Regular Asligmalism
Ordinary refraction through a perfect dioptric system causes rays of
light from a point to be focused as a point. When, however, there is
meridional difference of curvature, the point of light appears as a
group of lines. If the surface bounding one meridian is more curved
than thai bounding the other meridians, the rays of light impinging
on this surface will be focused sooner than those striking Ihe less
curved meridian.

If a cone of light passing through a regularly convex spheric su
face corresponding to the normal cornea be divided perpendicul;
to its axis, either at a point in front of its focus or after the rays hav
crossed and are divergent behind the focus, a circle is formed. I
however, the parallel rays passing through a convex spheric surface
are refracted more in the vertical than in the horizontal meridians,
the resulting cone will be more or less ovoid, and form a circle only
a the rays of the vertical meridian, diverging after focusing, c^

86 E

the converging rays of the horizontal meridian, not yet focused, (
the intersecting plane. (Fig. 30, line 4.)

In figure 30, V V are rays impinging on the vertical meridian, :
H H arc rays striking the horizonlal meridian ; V V are brought to jl
focus at the line V 2, while H H are not focused until they reach tl
line H 6. If we suppose the intersecting lines i to 7, dividing t

rays, to represent the retina in, different forms of ametropia,
of forming a circle, the resultant cones will be similar to the geometi
figures represented in figure 31. Instead of distinct im^es, the resi
is circles of difTusion and blurred outlines.

The several possible com bin at i

onsin the differences

i of refraction

of the principal meridians give 1

ise to the five variet

ies of regular

astigmatism.

Simple hyperopic astigmatism i

s the form in which

one meridian

■

^H op

is emmetropic and the other hyperopic. If we presume li
the retina, it is obvious that far rays passing through the vertie*!
meridian V V it is emmetropic, while the rays through the horiiontal
meridian focus behind the retina,—;, r., they would cause a hypei^
opic refraction, — and a horizontal straight line is formed. ]

a j

^ simple myopic astigmatism is a. form in which one meridian is en
metropic and the other myopic. If the relitia be supposed at line
the horizontal rays focus directly upon it, while the vertical rays focus
in front of it; ;'.■•., they would produce a myopic refraction. The
image is a larger and longer vertical straight line.

Compound h}^eropic astigmatiam is a form in which both merid-
ians are hyperopic, but one more so than the other. If the retin;
at line I. both sets of rays have their focus behind, and an oblate
oval is formed.

Compound myopic astigmatism is a form in which both meridians
are myopic, though unequal in degree. If the retina be at line 7,
both sets of rays focus behind it, and the resultant image is a large
prolate ellipse.

Mixed astigmatism is a variety in which one meridian is hyperopic
and the other myopic. If the retina be at lines 3, 4, or 5 (Fig. 30),
the vertical rays will focus in front and the horizontal rays will focus
behind, and the images 3, 4. or ; in figure 31 are formed.

Aatigmalism with (be rule is a term given to cases of hyperopic
astigmatism with the axis in or near [he vertical meridian, and 10
cases of myopic astigmatism with the axis in or near the horizontal
meridian.

Astigmatism against the rule is the reverse of foregoing condition.

Symmetric astigmatism is the usual form in which the axes of the
two eyes added together make exactly 180 — as, for instance, R. axis
30, L. axis 150; or, R. axis 180. L. axis 180 (in this case one of the
axes in the left is taken as o).

Unsymmetric astigmBtism is the troublesome form in which tbc
two axes collectively do not make 180 — as, for instance, R. axis i
L. axis 40 ; or, L. axis iSo, R. axis 140. This form is a prolific ca
of asthenopic symptoms.

Disadvantages. — An astigmatic eye sees a point as a line ; hence
images are distorted and marked visual disturbance results. I;
believed that there is an involuntary efl^ort on the part of the ciliary
muscle and even the external muscles to remedy the astigmatic defect.
By constant unequal contraction the ciliary muscle partly compen-
sates for moderate inequalities in the curvatures of the cornea. Such
continuous and unequal accommodative effort must result in e
strain, and consurne much of the normal nervous energy, eventually
ing reflex manifestations of disturbance of the nervous e<jf\V4s-

EXAMINATION i

Hum. Therefore, an astigmatic person may be able to improve
vision only at the expense of his heaUh. Uncorrected astigmatis
particularly in delicate and nervous women, results
forms of reflex asthenopic symptoms.

Symptoms.— Nearly every person consulting us for refraction
more or less astigmatic, and in the majority of cases part of ibe
astigmatism is masked by the accommodative effort of the ciliary
muscle. Under this natural correction the visual acuity is more or
disturbed, and in the moderate degrees of astigmatism the
reflex symptoms are the most prominent sii;ns. The patient com-
plains of headache, nausea, anorexia, indigestion, inability to per-
work, etc. In reading, the letters often fade
and seem to run together. There is significant confusion of sucb
letters. Commonly there will be noticed an inclination of the head
to one side, the patient say-
ing that he can see better
with his head in that posi-
tion. In very high degrees
of astigmatism the pupil may
be ova], and the asymmetry
of the cornea may be de-
tected by simple inspection.
From the preceding re-
marks as to the involuntary
correcting action of the cili-
ary muscle, the use of a mydriatic in determining the full degree a
correct axis of the astigmatism is seen to be necessary.

Tests for astigmatism are very numerous; there are a dozen c
more valuable methods of qualitative and quantitative diagnosis tn
ligmatism. The astigmatic cards and dials, the slenopaic dtsi

keratoscope furnish us easy methods for simple diagnosis, whilfffl
the ophthalmoscope, ophthalmometer, retinoscope, and tesc-teoses ai
rvaluable methods for the more exact determination of the kind a.

igree of astigmatism. Besides these tests we have the perforate
'chimney disc, the cobalt glass, etc.

The diagnosis of astigmatism by the ophthalmoscope, by the n
oECope, and by the lesi-lenses has been described in the section^

ing with these special instruments, and in the following lines «

shall attempt to describe only instruments especially designed for ll

itection of astigmatism.

^^^Btigmatic cards and charts are of several varieties. Snellen's
cards consist of a series of equally colored dark lines arranged like
the spokes of a wheel, wiih the an^le of inclination of each hne
marked opposite to it. (Fig. 32.) Seated at six meters and looking
at this card, an astigmatic person sees clearest the lines correspond-
ing to the axis of his astigmatism, and sees poorest the lines at right
angles to this axis. Another form is the arrangement of lines similar
to a clock-dial ; the numbers of the clock are used to indicate the
chief meridians, as these are so well known by the patient and can
be easily indicated by him to the physician.

Fray's astigmatic tetters (Fig. 33) are formed of equally black lines
inclined at different angles. The letter seen the blackest is the one
formed of lines at an angle corresponding to

the axis of the patient's astigmatism. Many ^? ^^^ '^^
other forms of cards and charts have been jS ^^ ^S^
suggested.

The stenopaic disc consists of a round ||iilip aiif W«fc
disc of metal or hard rubber containing in ,,||J,|| 'l,Jl ^^

one of its diameters a fine linear slit-like

opening. It is mounted in a test-lens cell J^sj jjiwij; mm

for use in the trial-frame. One eye is ex- ^g^^jj ^^^, ^^^^yj

eluded from vision with an opaque disc, and

the disc is placed before the other. The ^^ ''^^ ^'^'
patient is directed to look at the test-letters ^5^^ »3^ ^
or astigmatic chart. The stenopaic disc is . _

then rotated in the trial-frame until it reaches matic LtirtKB.

the position in which the letters are seen

most clearly, or in which the lines on the chart are of nearest equal
distinctness. The angle marked on the trial-frame corresponding to
the inclination of the slit indicates the least defective meridian, and
also the axis of the necessary correcting cylinder, as such a cylinder
would correct only the defect of the meridian at riglit angles to its
axis (the most defective meridian). The convex or concave glass
that gives the best vision is put down as the refraction of the first
meridian. The slit is turned exactly 90°, and the second meridian is
similarly refracted. If both meridians are hyperopic or myopic, the
refraction of the first meridian represents the spheric defect, and the
difference is the cylindric defect at the axis of the first meridian. If
preferred in the vertical, meridian (axis 90°), and the

^di.

t 9°

EXAMINATION AND RKFRACTION t

1 D., and the refraction of ^
I- 2.O0 D., the defect would ti

refraclion of this meridian is -f

hori^ontal meridian (axis [So") i

expressed thus : + S. i.oo + ^. i

If the refraction of the first meridian is myopic, say, — i D., a

the refraction of the 180 meridian, hyperopia, say, -+- 2 D., the defid^
[■ could be expressed either — S. 1 .00 + C. 3.00 ax. 90, or + S. 3,4
' — C. 3.00 ax. 180. The first would be the belter formula

the meridian of least defect is generally taken for the spher

The stenopaic disc furnishes a simple means of refracting 3
matic eyes, but it is not always accurate. It is of greatest valued
cases of mixed astigmatism. It has the advantage of not requiri
cylindric lenses in refraction.

A ready means of delecting astigmatism is the applic
low power cylinder before the eye, which if preferred in any speciaT
axis gives a strong reason to suspect astigmatism in that axis or at
right angles to it. Indeed, after the acquirement of considerable
expertness no device except the test-lenses and the test-letters aj^^
required for the accurate diagnosis of astigmatism, with paralyttfl
accommodation, swinging the cylinder 10° or zo° readily locates ttH
precise axis even in low degrees of defect. ^H

A keratOHcope is an instrument for examining the cornea and test-
ing the symmetry of its meridians of curvature. Several forms have
been devised, such as the Wecker-Massclon, which is a black board
18 cm. square, bordered by a white stripe about 15 mm. broa<t.,
Through a hole in the center, the image of the white frame i;
rcftecled on the cornea. By turning the board on its handle ti
while frame will take a position from which a rectangular image J|
reflected. When this position is found, we have the direction of (■
principal meridians in an astigmatic cornea. If the mirror is held||
any other direction, a rhomboid image of the r
degree of astigmatism is found by comparing the size and sbap£ ■
the image with a series of rectangles printed on an accompaiiy)|
card, showing the appearance of the corneal image in astigm
conditions from o to 10 13.

Placido'a diac is a white disc about ten inches in diameter, t
the surface of which are painted concentric black rings one 11
apart. The observer looks through a hole in the center of thi« d
and notes the appearance of the image of the rings that is refiedi

ASTIGMATISM. 9 1

upon the patient's cornea. The image is elliptic or distorted, accord-
ing as the astigmatism is regular or irregular. In emmetropia the rings
appear circular.

A ready method of keratoscopy is to place the patient in front of 3
window having several panes of glass in it, and observing the appear-
ance of the image of the sash on the patient's cornea. The lines are
curved or irregular if astigmatism is present.

The ophthalmometer (Fig. 34) is an instrument used for the deter-
mination of the kind and amount of corneal astigmatism. It is less
exact than the retinoscope, and, moreover, it is very expensive. That
of Javal and SchiSti consists of a telescope attached lo a graduated
arc, upon which are two objects called mires, the left one being
fixed, white the right is movable. These mires are white enamel,
one quadrilateral in shape and the other the same size, except that on
one side it is cut out into five steps. The observer looks through the
tube, which contains a combination of convex lenses and a birefracl-
ing prism, and sees four magnified images in a line on the cornea
under examination. He first finds the meridian of least refraction
by moving the semicircular arm to the position in which the two cen-
tral images are farthest apart. The mires are then moved together
until the two central images on the observed cornea, touch and their
central black lines coincide, the lowest step of one image with the
side of the other. The arm is now turned at right angles to this
meridian, and we notice the overlapping of the two central images ;
for each step overlapping there is a difference of one diopter between
the meridians. In higher degrees of astigmatism we add five diopters
to the number of steps protruded on the other side. At five diopters
of astigmatism the steps exactly cover the plain quadrangular mire.

The meridian of least curvature corresponds to the axis of astigma-
tism. The findingsof the ophthalmometer are not exact. No account
is taken of the lenticular astigmatism, and even though the cornea is
al fault, no rules for adapting the ophthalmometric results can be for-
mulated. Speaking broadly, the total astigmatism is approximately
equal to the amount indicated by the ophthalmometer, expressed as
myopic astigmatism, combined with an inverse myopic astigmatism
of 0.75 D. ; or, in other words, when there is no corneal astigmatism
by the ophthalmometer, the test-lens will likely show about 0.73 D.
of inverse astigmatism (Bull).

Treatment of regular astigmatism consists in using the ~

PHEsnvopiA. 93

recting glasses. The full astigmatic correctian should be ordered,
and in the compound or mixed forms, combined with the spheric cor-
rection. If the degree of defect is high, or if there are symptoms of
accommodative asthenopia, the glasses should be worn constantly.
Sometimes in cases of simple hyperopic astigmatism of high degreei
it is necessary to order — S. 0.25 or 0.50 in addition to the cylinder, lo
enable the patient to see at a distance. This is particularly the case
with first glasses. We should generally urge the patient to wear
spectacles, as eye-glasses are continually getting out of shape, and
we can never be sure that the glass is applied to the eye at the proper
axis. In very sensitive eyes the slightest tilting of the axis of the
cylinder is provocative of the most disagreeable asthenopic symp-
toms, and often a proper glass wrongly adjusted will aggravate the

Treatment for irregular lenticular astigmatism is worthless. 'For
irregTilar corneal astigmatism, generally due to a corneal cicatrix,
stenopaic glasses — i.e., discs having small openings in the middle lo
prevent the rays of light from being received on any but an extremely
limited corneal area, the curvature of which may be regular — have
been used. However, the field of vision is so limited in these cases
that the glasses are of little value. By patiently applying the test-
lenses to an irregularly astigmatic eye, we can sometimes find a
cylindric combination which at a particular axis seems to improve
the vision.

PRESBYOPIA.

lynonym. — Old-age sight.
Definition. — A condition of the eye in which the power of accom-
modation (s either partially or wholly lost by age. Properly speaking,
presbyopia implies diminution of the accommodative power in adults
past middle life, to such an extent as to interfere with near vision.
Presbyopia usually occurs between forty and fifty years of age. As
a hyperopic eye is obliged to exert a portion of its power of accom-
modation to overcome its refractive error, it necessarily has less ac-
commodative powerin reserve, and consequently becomes presbyopic
sooner than an emmetropic or myopic eye. An uncorrected myope
may never exhibit the signs ol presbyopia, as he can read at his far^
It. but if he wears a distant correction , he wvU \\ave vtve -.Mtvc v,i!«

^^H 94 EXAUtKATlON AND REPKACTIDN OF THE EYE. ^^^^^H

ft for a reading glass about the presbyopic age as ihe emme^ape3^|

hyperope. ^H

Cauje.— The direct cause of presbyopia is the diminishing elastici^H
of the lens simultaneously with the solidification and sclerosing con^^*
ditions which take place elsewhere in the body with advancing age.
As a consequence of the changes in the lens-struciure, it gradually

I loses its power to become convex, and hence to refract diverging rays

I from a near point so that they will meet directly on the retina and
give a clear image. This diminution in the refractive power of the
lens is physiologic, and when it has advanced to such a point that
rays at the average reading distance — about thirteen inches — are t
longer refracted exactly on the retina, presbyopia is said 10 hal
commenced.
Nolwiihsianding the fact that each patient should be studied im
vidually, and no arbitrary rules can be constructed by which we O
estimate the relative range of accommodation to age, forconveniei)
I it is desirable to have the following tables in the mind in refracdj

presbyopes ;

6;. or over + JJo D.

Symptoms. — The chief symptom of recession of the near p
^ beyond the ordinary working distance is dimness of visio:

Drk, the palient particularly complaining of inability to read, t
or sew, without holding the work at an uncomfortably increased dis-
tance. The ordinary symptoms of accommodative asthenopia are
very often present, and it is quite likely that ihe headaches, dys-
pepsia, and neurotic conditions in women about forty-five years gfl

ANISOMETROPIA, 9S

age, so often attributed to the menopause, are really directly due t<

eye-strain. The gradual progress of presbyopia, logether with the
attempt of nature to remedy the defect by narrowing the pupil, s
what delays Ihe marked symptoms, and unfortimately most pres-
byopes unconsciously undergo considerable eye-strain before seeking

Diagnosis rests on ihe age of the person, the history of faihng
near-vision, the recession of the near point as tested with Jaeger
types, and the acceptance of a convex lens at close range, A dis-
proportionate loss of accommodation with the age is indicative of
ciliary palsy or insufficiency.

Treatment. — In every case it is necessary to detect and correc
ful! amount of hyperopia, myopia, or astigmatism that may e
and for this purpose, in strong, vigorous persons under fifty, the
administralion of a mydriatic is necessary. Following the ordinary
method of prescribing lenses for distance in the kind and degree of
ametropia detected, we correct the presbyopia by adding U
distant correction a convex spheric lens that gives the best visit
an ordinary working distance. If allowed to choose the glass and
distance, the presbjope will usually select a strong glass at a dose
reading point, and thus lead the examiner into error. Always try
the test-lenses with the reading card at least thirteen inches from the
eye. Again, it must be constantly borne in mind that the patient's
occupation is an important factor to be considered in prescribing
presbyopic glasses. The engraver will need a stronger glass than
the seamstress, and, conversely, persons working at a comparatively
long distance, such as musicians, artists, ministers in the pulpit, etc,
will need a weaker glass in the pursuit of their occupations than they
will in ordinary reading.

ANISOMETROPIA.

Definiiion. — A term used to indicate marked inequality in
refraction of the two eyes. Minor differences are the rule ii
ordin.ary refraction, but these are not practically considered.

Varieties. — Anisometropia may be produced by almost any combi-
nation of refractive disturbances. The eyes may be myopic, hyper
opic, or astigmatic, in different degrees, or there may be emmelropia.,
myopia, hyperopia, or astigmatism in one e^c andarv CpWav^ij fi^ffi«t«s&

to t^l

: still

dian

It he
r »«■

96 EXAMINATION AND REFRACTION OF THE !

defect in the other. The condition may be classed according 6
manner in which the visual act is performed. Following this claa
fication, we have the following three varieties :

1. Cases in which there is synchronous fixation and,
sense of the word, binocular vision; for, even though the retinal
images are not of equal distinctness and size, binocular vision is still
possible. In surh cases it seems likely that satisfactory near- visiolL
may be obtained by unequal accommodation for each eye.

2. Cases in which there is alteration of fixation in vision — as, I
instance, the eye with the weaker refractive power may be used ti
distant objects, while the other, with the greater refractive power, ii
used for near objects. In this condition the patient 1
factory vision and so extensive a range of accommodation that he
is often not aware of any defect. Alternating vision can easily b
discovered by successively covering each eye and testing for n
and distant objects. In this class there is usually correct po»tioil1
the eyes.

3. Cases in which only one eye takes part in vision, the active e
being usually the one with the least refractive error ; tl
being excluded from vision, deviates, and there is a noticeable squint.
Even in this condition the patient is very often unconscious of the faO
that one eye has lost its visual acuity, and usually discovers 1
by accident. Few of the laity are conscious of the fact that a
ing eye is usually more or less amblyopic, and that the refraclt^
error is directly the cause of the squint, and indirectly the caused
the amblyopia. With this knowledge we see how important a
examination is in cases in which there is a tendency for one
deviate in either direction.

Treatment .^It is in this condition that all the judgment and p
tience of an oculist is called forth. Many arbitrary rules have I
advanced, but none have been found that are satisfactory,
individual case presents new phases, and must be treated separattj
and with the greatest introspection and caution. The two oppos
factors in the treatment of anisometropia are the ambition of the W
list to prescribe such correction as will give synchronous binoculSI
vision and equal acuity, and the rebellion of the established visual
system to such a marked innovation.

hardly be doubted that many eyes amblyopic from disuse
could be saved by care and patience. It should be the ultimate 0|

ANISOMETROPIA. 97

ject of every oculist skilled in the finer refraction to do all in his
power to establish equal acuity and harmonious action in every in-
stance of anisometropia, and to strive, even under the most unfavor-
able circumstances, to bring an amblyopic eye into function. As
would naturally be supposed, ihe best results are obtained in children
and young adults; but even in older persons there is a strong response
on the part of nature to measures of restoration, faithfully pursued.

To better enable the beginner to obtain an idea of the mode of
procedure in this condition, we will consider a hypothetic case of a
child who comes to us with a convergent squint in the left eye. We
immediately suspect anisometropia, and on examination we find a
slight refractive error in the right eye, but a high degree of compound
hyperopic astigmatism in the left. It may be that the left eye is am-
blyopic to such an extent that vision is reduced to counting fingers at
a few feet, and refraction can not be satisfactorily estimated with the
lest-lenses, and we resort to some objective method, preferably the
retinoscope. We prescribe the proper correction for the right eye
and slightly under-correct the left eye. We then instruct that these
glasses be worn constantly; and for a short period each day, begin-
ning with a few minutes and gradually increasing, we direct that a
blinder be worn over the good eye, thus necessitating the use of the
amblyopic eye. It is astonishing how quickly vision is restored in a
young and healthy child. We must impress upon the mother or
guardian of the child the importance of the blinder- exercise and of
prompt appearance at the oculist's office at stated intervals for re-

If the patient be an adult, and particularly if of nervous tempera-
ment, the case is sure to be a tedious one. With advancing age there
is less response to recuperative measures, the long- established visual
habit is abruptly broken, and all sorts of distressing symptoms inter-
vene. In such cases, rather than resort to any arbitrary rules, Irre-
spective of variety, we must explain to the patient the overwhelming
advantages of binocular vision and the dangers of amblyopia in one
eye. The active eye is under extra strain, and is hence more liable
to disease ; and in such case obscuration of vision , as by cataract in
that eye, means almost total blindness ; whereas if the amblyopic eye
is restored, not only are the dangers to the one eye lessened, but
there is still left a more or less active eye on which to depend in case
of accident or disease. We then instruct the patietv*. \ci ^^st ■Otwi

REFRACTION OF THE EYE.

greatest persistence in the blinder- exercise, and to constantly wear
his correction, and we only suspend our restorative treatment after a
long and faithful trial. Ignoring the refraction of an undiseased
amblyopic eye is unpartionable in a scientific oculist.

ASTHENOPIA.

Definition. — Weakness or speedy fatigue of the ocular muscles j
visual powers.

Causes. — Errors of refraction, excessive use of the eyes, muscnl
insufficiency, and constitutional denutritive processes, such i

Varieties, — f. Accornmodative asthenopia, generally due to hyp«
opic astigmatism or to simple hyperopia producing strain of tbeciliai

2. Muscular Bsthcnopia, due to weakness, incoordination (hetet
phoria), or strain of the external ocular muscles. Myopia, by n
sitating extra convergence and straining of the internal recti

3- Retinal, or nervous, asthenopia is a rare variety caused by retiiH
hyperesthesia, anesthesia, or other abnormafily, or by general t
vous affections. In overworked schoolchildren it is manifested by
complaint of haziness and dimness of the letters, occasional diplopia,
photophobia, lacrimation, and local ocular pain. In neurasthenic
and hysleric adults all these symptoms are aggravated, and such
patients constitute very troublesome cases.

Symptoms. — Symptoms of asthenopia are of such diversity and
differ so in degree that a thorough discussion of the effects of eyfci
strain would necessitate a volume in itself.

As a causative factor In the production of headache, eye-strain i
by far the most important. Anorexia, dyspepsia, constipation, heaH
burn, nausea, repeated attacks of vomiting, etc., represent s
ihe gastric reflexes. Amenorrhea and dysmenorrhea are mi
anomalies sometimes caused by eye-strain. Insomnia, nightm
chorea, nocturnal enuresis, and even epilepsy, have often owed thdi
existence and perpetuation to uncorrected eye-strain in some form.
The multiformity of the effects of eye-strain can only be properly
reatited when we understand how vita! the function of v
every act, emotion, and thought. The visual centers .

thd^

perly
is to

closest conaectioD with the other brain-centers, a.nd the slightest dis-
tmbance of the visual mechanism produces sympathetic irritation in
the entire motor, sensory, and psychic systems. Happily, the mani-
fold effects of eye-strain, so long ignored, are being appreciated and
recognized more and more every day. Besides the reflex symptoms,
which are often remote and only brought out by careful questioning
(the usualcomplaint in asthenopia is discomfort in near-work), the pa-
tient complains of inability to read or sew for any length of time; the
print runs together, there is heaviness of the lids, and often excessive
lacrimation. Local congestion soon produces conjunctivitis or blepha-
ritis, and it is our duty to examine the refraction in all cases of chronic
conjunctival and palpebral inflammations instead of carelessly dis-
missing the patient with a time-worn formula for an ointment or a
wash. So long as uncorrected ametropia exists there will be recur-
ring attacks of inflammalion.

A peculiar rule in asthenopia is that the amount of local or consti-
tutional reflex is in direct proportion to the debility or neurotic tend-
ency of the patient. Strong, vigorous men may, by accommodative
and muscular effort, overcome ametropia to such a degree as to
tirely mask the condition, and such patients may pass all their lives
without experiencing a single uncomfortable reflex; on the other
hand, a nervous school-girl or a neurasthenic woman may suffer
severest headaches or be the victirn of anorexia, nausea, dyspepsia,
etc., from the slightest astigmatic error. There is also someti
noticed an interchange ability of reflexcB, When the vision c
tinues normal in spite of the ametropia, reflexes ate present; if the
vision suffers, reflexes are less conspicuous. Intense local symp-
toms are also usually unattended by severe reflex symptoms, and

Diagnosis rests on a careful examination of the refractive condition
of (he eye and of the muscular power and muscle-equilibrium. In
all cases in which there is presumed to be retention of accommoda-
tive power, a mydriatic must be used.

Treatment. — In the accommodative form, rest of the eyes, absti-
nence from excessive near-work, and constant use of correcting iense
are necessary, Constilutional and hygienic treatment must be urged.
If there is any muscular anomaly, it must be corrected by gymnastic
exercise with prisms, constant wearing of prisms, or in extreme cases
tenotomy and advancement. For nervous asthenopia., w.ca.x-~«tn\.

I lOO EXAMINATION AND REFRACTION OF

must be reduced to a minimum, and out-door exercise, good f04
the administration of tonics, massage, or electrotherapy, a

j AMBLYOPIA AND AMAUROSIS.

Definition. — Amaurosis is a term which, from its vagueness, i
happily becoming obsolete, signifying partial or total loss
When partial, the term amb!yopia\^ now used; when complete, bliHd\
ntss. The word is still sometimes used to express blindnt
the cause is unknown or doubtful. Properly speaking, amb/yopM
means subnormal aculeness of vision, due neither to dioptric abnoi
malism nor to visible organic lesion.

Amblyopia exanopsia is a term applied to partial or total blinijlF
oess in an eye from disuse. It is of common oc
tropia and in strabismus. The individual with a squinting eye i
rally has double vision ; in order lo obtain monocular vision he i
either turn the axis of the squinting eye or learn to mentally s'
press the image of that eye. If for anatomic reasons rotation is
impossible, or if there is such difference of refraction that images of
different distinctness and size are observed, the mental suppression
_ of the image is the only alternative, and progressive amblyopia n
iBUltS.

Treatment is successful directly in proportion to the youth of ti
patient. It consists in restorative measures, such a
Tractive error and subsequent exercise of the weak eye.
strabismus, tenotomy or advancement is necessary. The treau
ment of anisometropia has already been reviewed.

Night-blindness (hemeralopia) may in itself constitute a disease dai
to over-stimulation or lack of proper nourishment, or it may be |
symptom of retinitis pigmentosa or similar degenerative disease of th^
retina, alone or with disease of the choroid. It is sometime
among people the subject of extreme denutrition from ciin
social influences, such as the lower classes of the Russians ; and tha
disease is, in fact, almost endemic in some parts of Russia afler thfl
religious fast during Lent.

Treatment consists In rest from bright light by protective glaaseii
improvement of the general health, and the administration of tonicM
''tod-liver oil, etc.

AMBLYOPIA A

Other farms of retinal injury from prolonged exposure
glares, such as the sun's rays upon the sea, upon vast expanses of
snow, and continual gazing at a bright light, such as an electric light,
are the causes of temporary amhlj-opia and amaurosis. Snow-blind-
ness, moon-blindness, electric -light- blindness, sun- blindness, are the
significant terms applied in such cases. The tteatment consists of
rest under favorable hygienic circumstances.

Nyctalopia etymological I y means night-blindness, but the general
usage making the term mean night-vision is so strongly intrenched
that it is useless and confusing to reinstate the old significance. The
condition in which one sees better at night, relatively speaking, than
by day, is due lo some lesion in the macular region rendering it blind;
at night the pupil dilates more than in the day-time, and hence vision
with the extramacular or peripheral portions of the retina is corre-
spondingly better. Nyctalopia is a symptom of macular disease and
not a disease in itself. All night-prowling animals have widely,
dilated pupils, and in addition to this they have in the retina a spe-
cial organ call(?d the iapeium iucidum, the function of which is Co
reflect to a focus in front of ihem the relatively few rays of light that
enter the widely dilated pupil and thus enable Ihem the better to see
their way. Hence the luminous appearance of the eyes of such
animals in the dark.

Tonic amblyopia may be due to such conditions as provoke super-
saturation of the blood with toxic ingredients — as, for instance, in dis-
ease of the kidney we may have accompanying the resultant uremic
poisoning, amblyopia, or even total blindness of both eyes, appearing
somelimes suddenly and sometimes after a day or two of gradually
failing vision. The disturbance in such a case is supposed to be cor-
tical. If the patient survives the attack of uremia, the blindness may
disappear completely in a few days. Diabetic amblyopia is distin-
guished by its association with the ordinary symptoms of diabetes.

Amblyopia from malarial fever and quinin has been reported, and
in rare cases complete blindness has intervened, Quinin itself has
produced bilateral amblyopia, and conversely has cured malarial
amblyopia. Other poisonous substances, such as tobacco, alcohol,
lead, etc., by causing either macular disease or retrobulbar optic neu-
ritis, produce subnormal acuity of the central field. These will be
discussed under Diseases of the Retina and Optic Nerve.

iBumatic amblyopia follows blows upon the skull, on the face.

directly on ilie eye, or on so remote a portion as the spinal cord.
Rigid miosis may follow such injuries. The visual disturbance is
caused directly either by hemorrhage into, or pressure upon, some
portion of the visual apparatus, either in the orbit or in the brain,
reflexly, as after spinal injury.

Hysteric Simulation and Malingering. — Hysteric amblyopia is :
uncommon, but very many cases so diagnosed are properly i
sequence of asthenopia. Malingering by the declaration of ainblyi
pia or blindness may be found in insurance examinations and
military life, and often to procure damages after alleged inji
Many ingenious devices have been adopted to expose the simulant
all depending upon the fact that in ordinary visual perception thei
is no account taken of the exact participation of the two eyes.
hold a book before the patient's eye and interpose a pencil in front
of the eye supposed to be active, tbe reading will be slightly inter-
rupted if the left eye is amblyopic ; if, however, the amblyopia
feigned and not real, the left eye will escape the pencil and the read-
ing will be uninterrupted. Another way is to interpose a highly
vex lens in front of the eye supposed to be well, and if test-type
removed beyond the focal distance of the lens and is still legibli
know that the other eye participates in vision. The production ol
double images by the interposition of prisms also proves binocular!
vision. Still another method depends upon colored letters placed,
upon a dark background which can not be seen through glasses
complementary colors. A person looking at green-blue letters on
dark ground through a red glass over the sound eye, and a white
green glass over the alleged blind eye, will be unable to see t
letters if the allegation is true.

Amblyopia from Enloptic Phenomena. — Muscce volitantea :
curious dots or rings of all shapes which float before the eye, and
some conditions, such as high myopia, are so numerous that they cai»i
not be ignored, and cause considerable disturbance of vision. The
origin of musc^ is not exactly understood, but they are probably
the remnants of some ocular debris. It has been suggested thai
they are intraocular manifestations of general waste-
ntulation (uric acid diathesis), and that they are reheved by appro^J
priale diet, exercise, and medication. Subjective exam'
muses is of interest, and they can be studied by lying on the bad
uid looking at a bright cloud in the sky. By what is called

ably
that

>pro^^

lactjH
iulaf^l

103

balloltemem, turning the eye downward and arresting the n
very sharply and suddenly, one may get a positive rebound of niuscK
from the bottom of the chamber up to the hne of visual perception.
Wicropsia is a condition in which images of objects seem too small,
and is supposed to be due to a dispersion of the retinal end-organs,
so that fewer receive the image, Megalopsia is live opposite of this
condition. ^~^~^

Metamorphopsja is an apparent distortion or change of the form of
objects, supposed to be produced by changes in the relative position
of the retinal end-organs.

Little can be done for the relief of emoptic phenomena. Proper
correction of the refraction and muscular anomaly, together with
hygienic precautions and the use of eliminatives, as sodium phos-
phate and the iodids, will sometimes diminish muscEe.

COLOR-BLINDNESS.

-perception. — A beam of light passed through a small open-
ing, or if passed through a prism, will separate inlo an arrangement
of colors on a. screen. This arrangement is called the spectrum.
The explanation of the spectrum is that the beam of while light is
made of a number of rays having different wave-lengths or rates of
vibration. Rays under four hundred billion vibrations a second
are not perceived by the human retina as light, and are called heat
rays. The range of the perceptible spectrum is from red light, about
four hundred million millions vibrations a second ; to violet, haying
over seven hundred and fifty milhon millions a second. Between
red and violet are found orange, yellow, green, and blue rays. Rays
having a higher tale of vibration than violet can not be appreciated
by the human eye, and are only recognized by their chemic and
physical effects. Therefore, the usual definition of color-sense is the
power of the eye to distinguish different wave-lengths. Different ex-
planations are given of color-perception. We know that the irrita-
tion on the rods and cones of the different wave-lengths is carried
back through the optic chiasm to the visual center in the occipital
lobe in the brain ; but in exactly what manner we become conscious
of color-impression, and in what way it can be altered, we are not
definitely certain. The majority of observers in this field seem to for-
get that the retina is a substance of considerable thickness and not a.

^104- EXAMmATlON AND REFRACTION OF THE EYE.

hypolhetlc plane, and also the participation of the visual center
the brain in color-consciousness and color-blindness-. At the present
time there are two important theories, both of which have been found!
faulty, but which have become so identified with this subject that w
briefly note them. According to the Young-Helroholtz Iheoiy, iheV
retina possesses three sets of color-perceiving elements, —
red, green, and blue or violet. According to Bering's theory, thel
color-sense and the light-sense depend upon chemic changes in
retina, or in the substance called the visua] purple of the retina.
suggests that there ate three different visual substances, — the whitfr
black, red-green, and blue-yellow, — and that sensations of light and^
color are due to the using up and restoration of these substances.

Varieties of Color-Blindness. — Total and partial ; congenital and
acquired.

Total color-blindness, in which the solar spectrum appears grayish, |
is very rare. ■

Partial color-blindness is quite common. Statisticians tell us thad
the proportion is 1:25 among males, and i : 400 among females. J
I There may be blindness to blue, yellow, red, or green. However, the
I colors that most often fail to make proper impressions are red and its
complementary color, green. These colors do not appear as abso-
lutely black, but they can not be distinguished from one another and J
from certain shades of gray and brown. In extreme cases there b
total blindness for red and green, and even the brightest shade o
red can not be distinguished from green. Unfortunately, the color
most often at fault have been selected by railroad companies a
navigators as iheir signal colors ; hence, we see how important it i
for the employees of transportation companies to have the colof
sense absolutely perfect.

Congeoital color-blindness is the most common form. Ii
hereditary, and sometimes skips several generations. The dbcovei
of color-blindness was Dalton. a distinguished professor of chemistiji
who himself was color-blind, afact which he ascertained byaccidenl

Acquired color-blindness may be the result of disease or accident
Defective color-sense often appears after disease of the optic nerv
and is a particular symptom in optic neuritis and atrophy due to e:
cessive use of tobacco and alcohol. However, central color-blind^
ness may be seen in all forms of toxic amblyopia. A peculia
to be noted in tobacco-amblyopia is the fact that Ihc p.iticnt may b

able to distinguish colors close to the eye, but when they are farther
removed, he is cotor-blind, particularly for green and red, This
makes it quite important to lest for color-blindness at the normal
signal distance in addition to the skein-test at close range. Color-
blindness is sometimes the result of traumatism; occasionally, afler
blows upon the head, color-blindness is noticed in one-half the field
of vision only, the other half being normal in its color- perception.

Cbromatopsia is a condition in which all objects became tinged
with certain colors. It is common after cataract extraction. Large
doses of santonin have the pecuhar property of rendering the whole
field of vision yellow.

Diagnosis. — In the ordinary Holmgren test, the person is given a
test-skein of wool of a light-colored pink, and told to se/eci {and not
Dame) from a mass of similar skeins those which most nearly resem-
ble the skein to be matched. If he is color-blind he will confuse the
grays, the greens, the pinks, the browns, and the reds. As a con-
firmative test, he is then given a light pure green skein to match in
the same way.

Dr. William Thomson has devised a convenient apparatus for
testing for color-blindness, which has been widely adopted by rail-
road examiners. It consists of a stick lo which numerous bundles
of yarn are attached, a light green being used as the test-skein. The
method of using the Thomson stick is described by its author as fol-
lows : Using the light green test-skein, the patient under examination
is asked to match it in color from the yarns on the stick, which are
arranged in alternate green and confusion colors, and which are
numbered from one to twenty. The selection of ten tints is re-
quired, and the examiner notes the number of the tints chosen.
The odd numbers are green and the even ones the confusion colors.
If the patient has a good color-sense, his record will exhibit none
but odd numbers ; if he is color-blind, the mingling of even numbers
betrays the defect. To distinguish between green-blindness and red-
blindness, the rose-teU is used, and the color-blind patient will select,
indifferently, either the blues intermingled with the rose, or, perhaps,
the blue-greens or grays. Finally, the red test is tised as a control.

There are other color-tests, but these two are sufficient for practical
purposes. The tield for vision for different colors is tested in the
same manner as the field for while, using a colored object instead
of a white one.

io6

EXAMINATION AND REFRA1.T1UN OF T

In the peripheral field of vision there is a
ranging from white thus: Yellow, blue, red, and green. In contri
distinction to this, we find the central \\^\<:i-a for red the most disIinG^
and violet least distinct. Hence the use of red for signals.

The tests for distant color-vision should be made with color
lamps or lanterns, under normal conditions, either oq the track orq
the depot.

Treatment for the congenital form is useless. The treatment
acquired color-blindness is directed to the cause. In the li
abstinence from tobacco and alcohol is necessary.

THE FIELD OF VISION.

The field of vision of an eye is that portion of space before tl
eye from which, when at rest, it can receive impressions of lighL
Ordinarily speaking, the field of vision is considered the space before
the eye in which small objects can be seen while the visual :
6Ked in one position. The binocular field is the space in which^
objects can be seen with both eyes open without moving the hea^
Tlte field of fixation designates that portion of the field of vision 1
which objects may be directly looked at.

Modes of Testing the Field of Vision, — The simplest method I
to face the patient, covering [he eye not under examination,
closing your own eye opposite the patient's covered one — as,
instance, in testing the patient's left eye, close his right eye and yo*
left eye. Then teil the patient to look directly at your open eye, :
while standing accurately in front of him, you meet his gaie ;
holding your finger off to the side beyond the field of vision
gradually bring it in and note the point at which the patient firs
the finger. This test can be tried in every direction, and If the s
geon's field of vision is normal, by comparison he can readily e
mate any alteration in the patient's field. Due allowance n
made for extra prominence of the brow or nose. This test will do fo^
simple diagnosis, but it is somewhat unscientific, and does n
out the finer points which it is so often necessary to detect.

The perimeter is an instrument for exact measurement of the fielj
of vision. It consists of a graduated arc, which turns at it
upon a pivot. At the inner side of the arc, and directly opposite ll
pivot, is a small, white disc, upon which the patient's gaze must \

^sEadil

Eadily fixed. The most improved form of perimeter (Fig. 35) is
self- registering, and marks on a special card the exact limitation of
the field at every angle to which the graduated arc is turned. The
patient is seated in front of the perimeter, with the chin on a rest,
which brings the eye to be tested into the middle line directly oppo-

site the point of fixation. The other eye is covered. During tlie
whole examination the patient must gaze directly at the white spot in
the center of Ihe perimeter. A movable disc containing a small
while surface is gradually brought in toward the center until it is
seen by the patient as while. This is repealed at every a

esults recorded upon a special perimetric chart. The fields fi

loS

1 REFRACTION (

color are obtained in the same manner, using instead of a w)
object a limed one, corresponding to the color to be tested for.
order to detect scotoniata, the disc should be moved all the way
center, and any point within the field at which the color
appears should be noted. If the patient is amblyopic
instead of the ordinary disc, a lighted candle may be moved along
irc of the perimeter, and another light put at ibe point of fii
The perimeter may also be used to enamine the angle
I deviation in strabismus.

le normal field of vision (Fig. 36) is naturally contracted at
nasal side to about 65° on account of the projection of Ihe bridge

nose. It contains a physiologic " blind spot "to the
side of the fixation point, between 10 and lo, as shown by the stn:
circle in the diagram, The fields for blue and yellow are somewhat
smaller than that for white, the field for red still more contracted, and
green is the innermost field. However, the size of field for any color
varies considerably for different persons, and for the same person'
different degrees of illumination.

Atleraltons in the field of vision may be concentric or regular
tractions in all directions, or diaimctly uneven and irregular

]

THE FIELD OF VISION. lOg

tions, according to the amount of fundus-invalvement. Scotomata
are patches in the field of vision in which there is blindness to the
object under observation. A positive scotoma appears as a dark .
spot before the patient's vision ; a negative scotoma is generally only
delected by examination with a perimeter, and appears as an appre-
ciable interval in which there is blindness. It is usually due to some
loss of perceptive power, which, when Eocated at the macula, or in
the central fibers of the optic nerve, causes the well-known ceotral
scotoma, which is particularly noticeable for red, and which is an
important sign in many toxic amblyopias. The physiologic scotoma,
or blind spot, represents a point at which the optic nerve enters the
eye. The changes in the field of vision are of diagnostic importance
in many pathologic conditions of the fundus, and the perimeter is
an efficient aid not only In diagnosis, but in showing the exact rt
of treatment.

The disadvantages of limitation of the field of vision may be readily
understood when we look through a long tube. Peripheral objec
are not seen, and unless the patient continually moves the head from
side to side and rotates the eyeballs, he will stumble over neighboring
objects. It sometimes happens that the central vision may rema
good that the smallest print can be read while the peripheral v
is absolutely destroyed. In central scotoma the patient must look
above, below, or to one side of the object, for, if he fixes directly o
it, the object is not visible.

Hemianopsia is a term used to indicate obliteration of half the
visual field in both eyes. It may be complete, but is usually incom
plele. There is generally a bending out of the hemianopsic lire 3
the point of fixation, giving us re;
plied by fibers from both optic li
retina is supplied by the tract on
supplies the right halves of the ti

When the obliterated half
speak of homonymous bemianop!
indicative of di
have crossed,

that the fovea is
whereas the remainder of the
ie — that is, the right optic tract
tinK, and the left the reversi
le same side in both eyes, ^
{Fig. 37.) Such a condition is
pressure behind the chiasm, before the fibers
ided hemianopsia there is some lesion of the

right optic tract or its connection with the cerebral cortex, and the
reverse of this in right-sided hemianopsia. In heteronymous (
crossed hemianopsia — that Is in both temporal or both nasal halves
■3- there is probably a lesion at some part of the chiasm. -hVivAi, S:

I
I

eludes the decussating fibers of both tracts. Vertical bemianop!
due to partial lesion in front of the decussation.

In homonyrnous hemianopsia we have additional aid in locatil
a tumor or lesion by the pupillary reflex to light. The pupilh
centers are near the corpora quadrigemina; if we carefully direct
rays of light upon the blind side of a retina in a case of homonymous
hemianopsia, and yet get pupillary reaction, we know that the pupil-
lary centers and all the region in front in the path of pupillary reaC'

1 are intact, hence the lesion is back of the corpora quadrigemina;

Lversely, if pupillary reaction is destroyed, we have reason to
believe that the lesion is somewhere between the corpora qu,
gemina and the chiasm. This test is known as V/emicke's eign.

— INCOMPEBTE H□M(I^(VKC

> Hemianopsia. Rbsultinc from UniLATRBAL

Causes. — Hemianopsia is usually due to hemorrhage, embolus.

The clinical significance of hemianopsia depends on the amount
and form of the obliterated field and the associate symptoms, such as
hemiplegia, hemianesthesia, aphasia, etc.

Transient hemianopsia is a sign of some cortical disturbance, and 1$
probably the result of spasm of the superficial cerebral arteries. Ii
is oflen associated with unilateral headache, vertigo, apham.
amnesia, and other symptoms referable to a cerebral origin. In a
number of the patients there is a family history of epileptirorm
■eizurei.

^^™Anato my. — T h

THE OCULAR MUSCLES.

■Anatomy. — The eye is moved by the following six muscles ; ihe
superior, inferior, external and internal recti, and the superior and
inferior obliques. (Fig. 38.)

The superior rectus rises from the upper margin of the optic fora-
men and from the ftbrous sheath of the optic nerve, and is inserted
by a tendinous expansion into the sclera, about 7.7 mm. from the
margin of the cornea.

The inferior rectus rises from the lower margin of the optic fora-
ivith the internal rectus, and from the fibrous

Front.— (H/7;t Mniil.)

sheaih of the optic nerve, and is inserted into the inferior portion of
the sclera, about 6.5 mm. from the margin of the cornea.

The internal rectus is the thickest and shortest of the straight
muscles, and arises from the common tendon a
the optic nerve, and is inserted into the inner
about 5.5 mm. from the cornea! margin.

The enternal rectus, the longest of the straight muscles, arises by
two distinct heads, one from the location of the common tendon of
the inferior and internal rectus, and the other frowv \\it ■w^i'ije.t \niwe.-a

FII2 EXAUtNATlOS AND REPRACTION OF THE EVE. ^^^^^^|

of the optic foramen with the superior rectus. It is inserted into tbff^|
outer surface of the sclera 6.g mm. from ihe margin of the cornea. H
Passing between ils heads are the nasal, third, and sixih nerves, ^

The superior oblique arises from the upper margin of the optic
foramen, and from the fibrous sheath of the optic nerve, and passes
forward to the pulley beneath the internal angular process of ihe
frontal bone ; its tendon is then reflected beneath the superior rectus
muscie to the outer and posterior surface of that part of the sclera
near the entrance of the optic nerve. At the point at which it passes
through the pulley the tendon is inclosed in a synovial membrane.

The inferior oblique is a thin, narrow muscle, arising from ihc
inner margin of the superior maxilla, immediately exterior to the lac-
rimal groove. It passes beneath the inferior rectus to be inserted
the external and posterior portion of the sclera, about 5.5 mm. from,
the entrance of the optic nerve.

Nervous Supply. — The third nerve (oculomotor) suppli
muscles of the eye, except the external rectus and the superior
lique. The fourth nerve (trochlear) supplies the superior oblique
and the sixth nerve (abducens) supplies the external rectus.

Function. — The eye is turned out by the abductor muscles — the
external rectus and the two oblique ; it is turned in by the adductor
muscles — the internal rectus and the inferior and supetior recti. The
superior rectus and the inferior oblique turn the eye upward, and are
called the elevators ; the inferior rectus and the superior oblique turn
the eye downward, and are called the depressors. The upper part of
the eye is rotated inward by the superior oblique and the superior
; the lower part of the eye is rotated inward by the inferior

t oblique and the inferior rectus. There is harmonious impulse and^J
concerted action of the muscular apparatus of the two eyes, ^H

FUNCTIONAL ANOMALIES. H

Muscular Balance. — When the visual axes of the two eyes exacdf <^|
meet at the object to which they are directed, the eyes are said to be
balanced or in equilibrium. This muscular balance is maintained
by the constant and equally distributed innervation of the ocular
muscles, and is directly dependent upou vhc relative anatomic f'W'^J
mation and physiologic strength o( the to\isc\cs. Nti-j ftira^.m'Oiwtti^^H

FUNCTIONAL ANOMALIES. II3

ces muscular imbalance. However, muscular
imply inability to perform perfect binocular fixa-
tion, for in some cases the visual axes are rightly directed by in-
creased innervation, and it is this necessary extra expenditure of
nervous energy that causes the aslhenopic symptoms so frequent in
minor disturbances of muscular equilibrium.

Perfect binocular vision requires that the visual axes should exactly
meet on the point of fixation and that the retinal impression of both
eyes should be simultaneously conducted to the brain and be fused
as one image in the visual centers. When there is any deviation
from these normal requisites, diplopia, or double vision, results.

In studying the classification of the functional anomalies of the
ocular muscles, it must be remembered that both eyes are involved,
and the nomenclature used qualifies the fault, but does not locate it —
for instance, right hyperphoria Indicates thai either the right superior
rectus is too strong for the right inferior rectus, or the left superior
rectus is too weak for the left inferior rectus — that is, one eye tends to
turn upward, or the other downward.

Arbitrary classification of the functional anomalies can not be
made; the differences are of degree rather than variety, and the divid-
ing line is somewhat indistinct. Cases of muscular imb.alance in
which the equilibrium is maintained by increased innervation of any
of the muscles, or in which the deviation of the vjsua! axes is only
transient or slight, may be classed under the head of insufficiency.
Cases in which there is decided deviation, which can not be over-
come by increased innervation, may be classed under the head of
BtrsbiBinus. In the ordinary acceptation of the two words we may
consider insufficiency as latent or nearly corrected squint, and stra-
bismus as manifest or uncorrected insufficiency.

Adduction is the power of rotating the eyes inward — that is, of
overcoming the diplopia produced by prisms, bases out.

Abduction is the power of rotating the eyes outward — that is,
of overcoming the diplopia produced by prisms, bases in,

Sursu induction is the power of rotating the eyes in the horizontal
meridian — that is, of overcoming the diplopia produced by prisms,
bases up (infraduction) or bases down (supraduction),

Stevens, of New York, has suggested a descriptive nomenclKtAue
(or the fiinctional anomalies of ocular muscles "«\iicti\va3. ^lewvawwcv-
sally accepted in this country. For norma\\lv and \'^e SiSfttwi

11+ EXAMINATION ANU REFRACTION OF THE EVE.

of disturbance of muscular equilibrium, or latent squint. 1
gests the use of the following terms :

Orthophoria, perfect binocular equilibrium.

HeUropkoria, imperfect binocular equilibrium.

The varieties of heterophoria are :

Hyperphoria, a. tendency of one eye to deviate upward.

Esophoria, a tendency of the eyes to deviate inward,

Exophoria, a tendency to deviate outward.

Hypertsophoria, a tendency of one eye to deviate upward and i
ward, or of its fellow to deviate downward and inward.

Hyperexophoria, a tendency of one eye to deviate upward a
outward, or of its fellow to deviate downward and outward.

For cases in which there is absolute turning or deviation of tl
visual axis instead of only a tendency, and hence inability to
perfect binocular fixation, the following terms are suggested :

Orlhotropia, perfect binocular fixation.

Heterotropia, a decided deviation from parallelism (squint).

Of the different varieties of helerotropla we have :

Esotropia, a deviation Inward (convergent squint).

Exolropia, a deviation outward (divergent squint).

Hypertropia, a deviation of one eye upward or the other dow

Hyperesotropict and hyperexolropia are combinations of the abov

TESTS FOR FUNCTIONAL ANOMALIES.

General Remarks, — A prism deflects rays toward its base ; bene
by placing a prism before an eye the rays entering the eye will be
bent as to cause them to leave the visual axis, and, unless there
muscular compensation, in such a case diplopia, or double vision,
the resuh. A high-degree prism base down before an eye will
bend the rays that they will reach the retina at a point below that
upon which they would have impinged had they not been inter-
rupted. By the mental habit of judging the position of an object,
the deflected rays are referred to a point above the optic
same way, rays impinging on the nasal side of the retin
impression of an object on the temporal side, and vice ■
forms of diplopia may be illustrated by figures 39 and 40

In figure 39 the right eye is turned in, and instead of perceiving-j

Ject,

t FUNCTION A I- ANOMALIES.

single object, 0#, diplopia tesulls, and the patient sees one image,
which he refers to ob, and another, which is referred to F. ob. The
image of the right eye is to the right of that of the left eye, and the
case is designated bomonymous diplopia. In figure 40 the right eye
is turned out, and the apparent position of the object ob is at F. ob.
The images have crossed ia their relative positions ; that of liie right

Bb. Obj.

eye is seen to the left of that of the left eye. and the case is called
crossed diplopia.

The amount of muscular insufRciency is measured by the strength
of the prism, which, placed before the eye at rest, will deflect the
imperfectly directed rays of light in such a manner that there will be
perfect binocular fixation.

The strength of the ocular muscles is measured by the prism wtvich.
they can overcome, and, by increased innctvalivoii n\&. ^.tvioTViWiivti!-

Iltl6

.ECKACriON OF T

tain perfect binocular fixation. The muscular strength varies with
each individual, but [here is a normal relation between the strength
of certain muscles. The adductors can normall}' overcome prisms J
from 10° to 30°, and the abductors can overcome prisma of from 6"J

It must be remembered that in cases of stable muscular equilibriut

by rlgbleyar4

there may be still decided insufficiency and disproportion ;
mal relative strength of the adductors and abductors.

Tests for the strength of ocular muscles are based upon their ability I
to overcome prisms while both eyes are fixed on a small light about ]
six meters' distance. In these tests we aim to measure the associated 1
powers of the muscles concerned in abduction, adduction, and sur- J
samduclhn rather than the slrengtb o( V\ie KnAvjidvial muscles whichS
may never Aai-e individual action. To \es^ adivittv^tv. "4«; ^

TESTS FOR FUNCTIONAL ANOMALIES.

are placed bases out; to measure abduction, bases in

the elevators (supraduction), bases down ; to measure the depressors

(infraduction), bases up.

It is the measurement of the strength of the abductors and ad-
ductors that is of most practical importance in ordinary practice, and
in all cases in which there is reason to suspect any muscular insuffi-
ciency in the causation of asthenopic symptoms not only should the
tests for muscular equilibrium be applied, but also the power of ad-
duction and abduction should be measured.

Cases of apparent orthophoria sometimes show great insufficiency
of the lateral muscles of the eye. The performance of reading and
other near-wQ k w'th a weakene I
power of addu on g es se o h
roost annoying symp oms

The ordinary p edu e n e n
adduction and abdu on to e

the patient abou
a small flame.

nd I

, yfo

hisv

n thefl

To n

5 ed

-lAuhy.)

abduction, prisn ba es n i

before the eye un pe m

plopia is produ ed The h ^1

that can be ove ome s he

menl of the abdu on In

adduction, prisms, bases out

until increased convergence is no

longer able to maintain the image of the light single. The highest

prism that can be overcome is the measurement of adduction.

A more convenient mode of testing adduction and abduction is by
the so-called '' prism-batiery " suggested by the senior author.

Rotary variable prisms are constructed in such a way that two
prisms of equal strength shall be equally rotated in opposite direc-
tions. During the rotation certain components of the two prisms
neutralize each other, while the remaining components act together
and give the variable effect. Risley's rotary prism (Fig. 41) is an
adaptation of the Cri5l6s prism. Two 15° prisms are mounted in a
milled-edge containing-ceil, having the same diameter as empIa-jtA
in the ordinary test-lenses, and wil\ iheTctorc yeaSAl ^V vtv "Cw^ coto.-
mon trial-frames. The superimposed pvis,ms Mt c'iMf.^i \-'^ tovj**

I 118 EXAMINATION AND REFRACTION OF THE EYE.

over each other by means of a milled-edge screw projecting from the
front. The strenglh of the resulting prisms is indicated by a grad-
uated scale engraved on the front plate of the containing cell. To
produce more delicate results in the lower prismatic powers, Jackson
has employed three prisms, one stationary of 15° and two rotary
prisms of 75^° each.

Phoromeler. — The ocular muscle teats may be simplified and made
more exact by the use of instruments called phorometers, by
which ihe degree of insufficiency existing in a muscle can be easily
found. Stevens, of New York, has devised an excellent ir
of this description, consisting of two revolving 4° prisms si

arrajiged -

that diplopia is produced and any heterophorii
me.isured simultaneously.

Various opiomeiers have been devised, including trial-frame, pho-
rometer, revolving Maddox rod, and revolving rotary prism. With
these instruments the powers of adduction, abduction, and sursum-
duction, as well as hetcrophoria, may be measured. The best of ■
these instruments is that represented in figure 42. ■

By careful stimulation at progressively increasing distances, ihol
full amount of the adducting power, called the convergence- stimulus 1
adduction, may be measured. The patient fixes first on an object
brought within six inches of the eyes and then slowly carried away
toward the flame, transferring the vision on the flame just as the
object reaches it.

;st," although unreliable
s enables ihe physician to
For rough diagnosis the
with his eyes at about the
at which he is told to look

TESTS FOR FUNCTIONAL

"Tests for Heterophoria.— The "cover

and not available in law degre

detect the tendency toward deviatio

patient is placed in front of the physii

level of the bridge of the physician's r

steadily. A card is placed over one of the eyes and a

ward withdrawn; if there is a tendency to deviate outward, a slight

movement inward is noticed immediately after the withdrawal of

the card. In the same manner a tendency inward will be detected

by quick movemenioutward after the withdrawal of the card. Both

eyes can be tested in this manner.

In cases of insufficiency, so slight an obstacle as a colored glass
placed before one eye may produce immediate diplopia — for ir
in a case of unstable muscular equi*
librium, we place a red or a blue glass
before the left eye ; the patient may
immediately declare he sees two
images of the light at six meters'
distance, the colored one being to
the left of the white image, showing
that we have homonymous diplopia,
and consequently a tendency toward
inward deviation. If the colored
light were seen to the right of the
white one, we would have crossed
diplopia, and hence a tendency p^, _ _maddox Rod

toward outward deviation. There

might also be a tendency toward upward or downward deviation in
addition to the lateral forms. The tendency toward deviation pro-
duced by the interposition of a simple colored glass is soon overcome,
and for this reason the test is unreliable. Another disadvantage lies
in the fact that the lateral and horiionlal defects can not be meas-
ured separately and distinctly.

The Maddox rod consists of a glass rod or series of rods which,
acting as a strong cylinder, distort the natural image of a small flame
at six meters into a streak of light. It is usually mounted in a metal
disc to fit in the trial-frame. (Fig. 43.) When a Maddox rod is placed
before one eye, the difference between the images seen before the two
eyes is so marked that, unless there is perfect muscular ei\uiUbtv\iwv,

^pO EXAMINATION AND REFRACTFON OF THE EYE.

binocular fixation is impossible. In order to make the diffi
more marked and readily to call the patienl's attention to the streal^
the Maddox rod is ordinarily colored red, or a white rod may be
used : or a plane colored glass may be placed before the other ejt.
In testing with the Maddox rod ihe patient, as before, is seated sir
meters in front of a small flame, which should be placed in the darkest'
portion of ihe room and beyond confusion with any other lights.
The rod must be placed in the trial-frame, exactly before the pupil,
or no streak will be seen. To begin the test, the eye containing the
rod is first covered and the point of light noticed ; the other eye i
then covered and the rod, adj usted until the streak is seen ; then b
eyes are uncovered, and if the adjustment is correct, both streak a
flame will be seen simultaneously.

To test for a tendency toward lateral deviation the rod is placed
horizontally before the left eye ; being refracted through a cylinder^
the image is seen running at right angles to the axis of the rod, which,'
in this instance, being horiiontal, the streak will appear verticaL
there is orthophoria, the streak will run immediately through the light;
if there is exophoria, the streak will be to the right of the light.
there is esophoria, the streak will be to the left of the light ; the de^
gree of defect is measured by the prism, base out or base in, whic^
will bring the streak immediately through the light. The rotary
prism or individual prisms mounted in cells may be used for tiM
measurement.

To test for hyperphoria the rod is placed vertically before Ihe lef^
eye, and if the streak, which now runs horizontally, is above o
the light, a prism, base up or base down, as the case may require, tha
brings the streak immediately through the light is a measurement o'
the hyperphoria. In recording results it must be mentioned which'
eye Ihe prism is placed before ; as, for instance, base down left
base up right. It is well to establish imiformity in using this
and we invariably place the MaddoK rod and the correcting pi
before the left eye.

We have found that the segment of a high-power glass cylinder
just large enough lo fit in the test-lens cell will give as good a streak
as the Maddox rod.

The Maddox rod is usually perfectly salisfactor>', but if for uij
reason the streak is not plainly seen, or we believe that the patient si
^Jfoluniarily attempting to overcome his heterophoria. we must n

r OF FUNCTIONAL ANOMALIES. 121

to the use of prisms in tesiinj; for the helerophorla. Procedure in
this case tlepends upon the production of diplopia by prisms of such
strength that ihey can not be overcome by increased action of the
ocular muscles. To lest the lateral muscles an artificial hyperphoria
is produced by placing a prism of about eight degrees base up or base
down before one eye, and a red glass before the other. If there is
perfect muscular eqvulibrium, the two images will be seen, one imme-
diately above the other. However, should there be exophoria, there
will be crossed diplopia, and the left image will be seen on the right-
hand side. The degree of eKophoria is measured by the prism, base
in, which, placed before the left eye, brings one image directly above
the other. If there is esophoria, homonymous diplopia is present,
and the left image will be seen to the left of the right image. The
degree of esophoria is measured by the prism, base out, which,
placed before the left eye, will bring the two images in the same
vertical plane.

To test hyperphoria, a. prism of about ten degrees, base in, is placed
before one eye and a red glass is placed before the other eye. If
there is perfect equilibrium, the two images will be seen by the patient
exactly on the same horizontal level. If the red glass is before the
left eye and the red image is seen lower than the while one, there is
left hyperphoria, and conversely. The degree of hyperphoria is
measured by the prism, base up or base down, which, placed before
the left eye, will bring the two images on an exact level. The pho-
rometer is the most convenient means of measuring deviations made
manifest by the production of diplopia.

TREATMENT OF TUNCTIONAL ANOMALIES.
As anomalies of refraction are the chief causes of heterophoria in
almost every case, the refraction should be examined under a mydri-
atic, and ametropia corrected. We must also bear in mind the mus-
cular condition when prescribing. If the patient is hyperopic, we
must order a weak correction in exophorla, reduce the correction
slightly in orthophoria, and only use a strong correction in esophoria.
(See treatment of hyperopia.) In many cases such procedure alone
will sufficiently modify the defect, or even perfectly restore the mus-
cular balance, and relieve such reflex symptoms as headache, nausea,
indigestion, vomiting, and various other nervous pheii

I
I

said that hyperopia and hyperopic astigmatism are the error;
associated with esophoria, and that exophoria is frequently associaU
with myopia and myopic astigmatism. This is theoretically c

It it is not always confirmed in practice.

Another cause of heterophoria is distinctly weakened general i
tality, and we expect no decided results until the systemic conditit
is improved. In young pr vigorous persons we may expect to
crease the mu5cular power and innervation sufficiently by norx
exercise of the eyes with the correcting lenses. If, however, I
patient is extremely debilitated or weak, the only relief that can 1
given is by the use of correcting prisms. However, in such cases
partial correction should at first be applied, which, if satisfactor
should be worn for a. wh'ile and, if possible, afterward carefully r
duced in strength, or, if unsatisfactory, should be gradually increas
until comfort is obtained. Tenotomy should be a last resort.

Treatment of Insufficiency of the Adduction. — In healthy indivii
iials, even past middle life, we expect the best results in cases of i(

ifficiency in adduction (a common defect), by systematic exerci!

ith prisms, bases out. To prescribe a prism for permanent i

perform tenotomy in such cases without a prolonged trial of gyn
nastic exercise with prisms is assuredly unwarrantable and bad priU
tree.

Patients suffering from insufficiency of the interni are chiefly p

ns whose habits and occupations cause excessive use of the eye
The intense headaches and gastric neuroses accompanying this d
feet call for a special mode of treatment. To prescribe prisms is oil
affording a crutch and encouraging the insufficiency, Permanei
cure can hardly be effected by such treatment. The principle
tenotomy in exophoria is to weaken a strong or normal muscle 1
such 3 degree that it will be equally insufficient with its defectiv
'. Such treatment as this can hardly increase the adductii
power, the deficiency of which is at the root of all the uncomfortab
symptoms. Advancement of the interni docs not secure inci
innervation. In view of these facts, the only rational treatment
that of a tonic nature, effected by the best hygienic and constitution!
treatment, and careful and graded gymnastic exercise of the deficie
muscles.

It is a noteworthy fact that the prescription of healthful, opco-4
will of itself be sufficient to cause the muscular defect I

I Oisappeai

TREATMENT OF FUNCTIONAL ANOMALIES. ISJ

^sappear and the aslhenopic symptoms to subside, and it is also a
fact that the general health will improve very often under the ocular
gymnastics, which, by remedying the muscular defect, removes the
exciting cause of the systemic troubles.

The skepticism as to the value of ocular gymnastics in cases of
insufficiency of adduction is largely due 1o the fact that the treat-
ment has not been carried out rationally and systematically, and we
especially call the student's attention to the proper modus operandi.
For minor cases the '■ thumb exercise " is of value. This consists of
exercising the convergence by drawing a thumb gradually toward the
bridge of the nose, meanwhile trying to maintain a single image of
the finger. The thumb should be withdrawn immediately when dip-
lopia results. This exercise should be repeated a doien limes at
each exercise, and the exercises should be used several limes daily.

The more Important method is that by graduated exercise in over-
coming BuccesBively higher prisms, bases out. The following is the
usual mode of treatment: The amount of exophoria is noted, the
abduction and adduction is then measured, followed by the measure-
ment of the convergence-stimulus adduction. , This is obtained by
coaxing the patient to overcome as strong a pair of prisms, with the
bases out, as possible in the following manner : A pair of prisms
just a little stronger than the normal power of adduction are placed
in the trial-frames ; these will, of course, cause diplopia for the dis-
tance, but not, as a rule, at the near point. The patient is then
requested to fix his gaze on a mark made on a card (a cross or a dot
seven or eight mm. in size), which is held at the reading distance or
nearer.. The card is then gradually withdrawn to a small gas-jet,
the size of a candle-flame, about six meters from the patient's chair,
the patient endeavoring and being encouraged to maintain a single
image all the time. When this point is reached, the patient can
transfer his gatt and fuse the double image of the flame instead of
the mark on the card. This manosuver is then repeated with stronger
pairs of prisms until the limit of adduction is reached. It will gen-
erally be found that a pair of 10° or 15° prisms is as much as can be
overcome at first, but if the exophoria is not too great, it is seldom
(hat. after a few trials, a patient can not fuse the image of a candle-
flame at 2D feet with this handicap.

The examiner should then prescribe a pair of pdsKW.bi.'iK'i wA,
suiting the strength to the indications, givmj aW^VvVj \t^s ■Ckmv 'ia's.

OF THE EYE.

It of adduc

shows the
The patie

: the I
-e 44

lack- I

Is of great importance to have I
in a well-adjusted frame. Figure
ordinary interchangeable prism-frame^
: is instructed to place himself 20 fee
from a flame, and endeavor to fuse the doubW
image ; if, a5 is usual, it is impossible for him
fuse at this distance, he must approach the Aam^
until he gets the single image, then walk back-
ward, keeping his gaze steadily fised on the flame,
until he reaches his starting-point. This is much
more difficult for the patient than having some one
withdraw the marked card from the near point to
the flame ; so that whenever feasible it is prefer-
able to call in the assistance of a second person,
particularly in the earlier days of this treatment. J
This assistant, unfortunately, is not always avait^
able. If the image is still single, the patient i
to hold it steadily so for about a quarter of a
ule, then to raise Ihe glasses and gaie at the flam
with naked eyes for the same length of lime, anj
repeat this ten or twenty times three times a (
The patients are instructed to continue this c
cise for a week. During the first few days con
plaint may be made that the exercise is dilGca
and tires the eyes, but before the week is over it
becomes easy. At the next visit the strength of the
prisms is increased and Ihe exercise continued at
home, and at each succeeding visit an addition—
of about five degrees may be prescribed until ll
patient can, without the slightest trouble,
come a pair of 35° or 30° prisms. Patients C
sometimes be educated to overcome a combined
prism -strength of over 100°. In such c
ability of convergence is remarkable,
rangement may be effected with an optician t
lend prisms and make the necessary changes fil
a very moderate charge, and the patient i
saved the expense of buying a whole outfit a
it would be useless to him after a few weeks

)MALIES. 1:25

a moderate degrees of exophoria, or in cases in which there is no
exophoria, but a lack of power of convergence, the symptoms disap-
pear after the second week ; but this is no indication lo slop treat-
ment, for unless the adduction is farced up lo 50°, or 40° at least, the
trouble is likely lo return ; if the patient can overcome a pair of
25° prisms, the cure is probably permanent. The higher the degree
of insufficiency, the more necessary does it become to force up the
power of convergence.

Insufficiency of adduction is not necessarily accompanied by exo-
phoria ; it is not usual, but still quite possible, to find a lack of con-
verging power in cases of esophoria.

Occasionally a case of divergent strabismus may be cured by prism
exercise ; but a partial tenotomy of the external recti, one or both,
may accelerate ihe cure and save much valuable time. It is a safe
rule lo follow, never lo over-correcl by a tenotomy, and to follow up
the operation immediately with prism exercise, — " not to wait for the
tenotomized muscle to unite in its new position and later on contract,
but stimulate the internals to fight and push their advantage lo vic-
tory while their opponents are nursing their wounds." (Bennett.)
Much, however, can be done without operation, and many a nervous
woman will go through months of treatment rather than submit to the
slightest cutting procedure.

!t often happens that in cases of mixed muscular defect, by correct-
ing the ametropia and properly exercising the adduction with prisms,
not only is the adducling insufficiency remedied, but general mus-
cubr bal.mce is restored and all the asthenopic symptoms relieved.

Hyperphoria is often thus relieved. If it persists despite this treat-
ment, it must be treated by correcting prisms, base up or base down,
ground in the ametropic correction, or by tenotomy. It is not un-
common to find that hyperphoria increases when it is corrected by
prisms. Tenotomies are often unsuccessful, as the hyperphoria may
return after a few months. The defect is likely innervational, and

Happily esophoria is rare, and seldom causes distressing symp-
toms. It should be treated by prescribing a strong ametropic correc-
tion, the use of correcting prisms, or by tenotomy and advancement.
Prism exercise is of little use, as there is no stimulus In man to cause
bilateral divergence. Sometimes prolonged mydriasis is helpful by
suspending accommodation and, hence, convergence.

riz6 EXAMINATION AND KEFRACTION OF THE EYE. ^H

STRABISMUS. ^|

Sjmonyma, — ^Hclerotropia, or manifest squint. ^^M

Varieties.^The difference between strabismus and insufficiency!!^^
onlj' one of degree. In strabismus the muscular insufficiency is un-
corrected, the squint is manifest, and diplopia is produced. How-
ever, strabismus may be only periodic, as when ihe patient is fatigued
or the systemic condition weak ; or it may be present only when the
patient looks at distant objects or accommodates for near-work.

Concomitant strabismus is a variety in which there is equal move-
ment of the eyes, but the eye still deviates on account of some defect
in one of the ocular muscles.

Paral)^ic strabismus is due to paralysis of an ocular muscle, and
n the eyes are turned toward the paralyzed muscle, one eye a

deficient in movement. This form will be fully discussed in the leO^H

tion on ocular paralysis. ^^M

I Spastic squint is a term applied by some authors to cases ^^H

^^H which deviation is caused by spasmodic contraction of one muscli^^|

^^B It is very rarely, if ever, present, and must result from some peculil^^|

^^H central irritation. ^H

^^r Alternating strabismus is fixation with either eye, the other ey^^l

I deviating. Part of the time one eye squints and part of the time ihe

other eye is at fault. It occurs when the vision is nearly equal in the

two eyes, or when one eye is used for near-work and the other for

distance. ^H

Monolateral or constant strabismus is the name given to tbcM^^H

cases ill which the squint is always in the same eye. ^^M

Internal strabismus, or convergent squint, is deviation inward ^^|

one or both eyes, and is usually due to the increased convergence <|^^|

an ametropic eye. The converging eye is usually highly hypetopi^^f

Homonymous diplopia is produced. ^^H

External strabismus, or divergent squint, is a deviation Qutward
of the visual axis of one or both eyes, and in most cases is due to
insufficiency of adduction rather than to overaction of the abducton
in an ametropic eye. The diverging eye is usually highly myofnc _
Crossed diplopia is prnduced. J

Disadvantages.— When there is uncorrected deviation of on« tyti .H

I diplopia results. To overcome this anomaly of vision, one eye >C^|

^^^ thrown out of use and the image suppressed, and if this amblyopi^^H

li ~ J

127

intreated for any length of time it gradually increases until the
affected eye may become practically blind. Before the eye is turned
out of use and the amblyopia exanopsia developed becomes dis-
commoding, aslhenopic symptoms are caused by the struggle for
perfect binocular fixation. In long-continued convergent squint
the temporal half of the retina being continually unstimulated, loses
its sensibility ; in such cases there is sometimes a quite accur
simulation of hemianopsia. This condition we have named squint
bemianopsia. The cosmetic disadvantage of squint needs no discus-
Diagnosis. — Ordinarily, strabismus is apparent on simple inspec-
tion. However, we can not depend on the symmetric situation of the
cornea, as it sometimes happens that the visual axis is to one side of
the cenler,.and an eye is thought to squint which is really properly
directed for perfect binocular vision. The cover-test is reliable for
the simple diagnosis of strabismus. The patient is told to fix bis
vision on an object and the fixing eye is then covered , and immedi-
ately the other eye will turn into position and fix while the other
deviates.

The movement of the sound eye when covered is called s
ondary deviation. In concomitant strabismus the sound eye makes
a movement in its deviation equal to that made by the squindng eye
in its effort to fix. In paralytic strabismus the paralysis in the affected
eye prevents full movement, and the secondary deviation is always
greater than the primary squint. The primary and secondary devia-
tions may be measured by marking on the lids the boundaries of the
cornea before the test, and the boundary of the cornea of the
affected eye when attempting to fix, and the boundary of the cornea
of the sound eye diverging under cover. The markings on the
lid of the squinting eye show the primary deviation, while those on
the lid of the other eye show the secondary deviation.

squint there at
t) Contraction of the

(a) Secondary deviation

than the primary.
(3) Dislutbiuice with

/«

It there arc :
(1) Displacement of the field of vi

sion, but no contraction,
(z) Secondary deviation equal to Ih

primary.
(3) No disturbance with doubl.

imi^ex.

It often happens that there is horizontal as well as lateral squin

I to study properly the exact character and degree of deviation
must try to compel recognition of the double images which are
received; unfortunately, after some time the image in the squinting
eye becomes suppressed, and it is very difficult to get tbe patient to
recognize two images ; but by placing a deeply colored gla;
the fixing eye its Image is so moditied that the false image which it
ordinarily suppressed may be recognized by the squinting eye.

Treatment. — As strabismus Is often due to ametropia,
commonly anisometropia, the first object should be to correct the
refractive error in both eyes and to strive to bring the squinting eye
into function by the blinder- exercise, in the manner described under
the treatment of anisometropia. The muscular insufficiency should
be treated by systematic exercise, at first by the thumb-exercise, and
afterward with prisms. Periodic squint is particularly Mnenable to
this treatment. In young children in whom there is a tendency to
strabismus, the constant use of a weak solution of atropin in the
sound eye will often bring the other eye into function and correct the
squint, or it may be necessary to completely paralyze the accommo-
dative effort for some lime by using the mydriatic in both eyes.

When, however, binocular vision can not be obtained by tlie fore-
going procedures, an operation must be resorted to. For miernal
strabismus, tenotomy of the internal recti is indicated. For external
strabismus, tenotomy alone of the external recti or in conjunction
with advancement of one or both tendons of the internal recti may
be necessary. In regard to the relative indications of tenotomy and
advancement it should be remembered that in concomitant squint
with relaxed tendons we should perform advancement, and with
tense tendons we should perform tenotomy. However, it is some-
times necessary to advance an apparently tense tendon and regulate
a tenotomy by subsequent advancement. The great difficulty with
tenotomy is that, despite the most careful and assiduous static and
dynamic testing and operative dexterity, we can not be absoluleljp^

dynamic testing and operative dexterity, we can not be absolulel;p^H
sure of the exact effect of the operation after cicatrization and coi^^H
traction are completed. Advancement seems to offer more dcGnit(^^|

PARALYSIS. ^M

Varieties. — Suspension of the function of a muscle or a set O^^H

muscles constitutes liue fiarafysis ; impairment of the function alan^^H

PARALVSIS.

is called paresis. One muscle alone may be paralyzed, or a set of
muscles may be affected, or there may be total paralysis of all ocular

Total ophthalmoplegia is paralysis of all the ocular muscles, due
to some destrueiive cerebral lesion.

Exteitial ophthalmoplegia indicates paralysis of the external mus-
cles of the eye — the four recti and the two obliques. Ills an occa-
sional symptom of locomotor ata?:ia.

Internal ophthalmoplegia, or paralysis of the ciliary and pupillary
muscles, is very rare, but partial internal ophthalmoplegia often fol-
lows an attack of diphtheria. We gentrally apeak of this partial
paralysis of the internal muscles as paralysis of accommodation,
which is discussed in another section of the book.

Paralytic strabismus may also be divided and classified according
to the nerve involved.

Paralysis of the third or oculomotor nerve causes paralysis of the
muscles of the lid (ptosis), and paralysis of the superior, inferior, and
internal recti and the inferior oblique. The manifestations of such
paralyses are inability to move the eye from its central position in-
ward and upward, and hence divergent or vertical squint with crossed
and more or less vertical diplopia. There are also mydriasis andJoss
of accommodation.

Paralysis of the sixth or abducena nerve produces convergent
squint and homonymous diplopia, due to a loss of power in the ex-
ternal rectus, which is supplied by this nerve.

Paralysis of the fourth nerve is manifested by loss of power in the
superior oblique muscles, causing imperfect movement of the eye
down and out, and hence diplopia and slight convergent squint.

According to A, Graefe, the proportionate frequency is as follows :

32 per cent., isolated paialysis of bd external rectus;
16 per cent,, isolated |iatalysis of a superior oliliquc;
8 per cent., isolated paralysis of one of the four remaining muscles ;
44 percent., combioed paralysis of all these four remaining muscles in one or
both eyes.

Symptoms of paralysis of an ocular muscle are marked and sig-
nificant. The objective symptoms are limitation of movement of the
affected eye on the side and in the direction of a paralyzed muscle.
This limitation can generally be perceived when the patient holds

■ 13°

his head still and attempts to follow the movements of the physician
in various directions. If the paralysis is slight, it may not be recog-
nized objectively. Another significant objective sign is the tendency
of the head to be inclined obliquely, in a. characteristic position for
each form of paralysis. The deficiency in ihe affected muscle ts
partly corrected and the diplopia controlled by keeping tlie head
turned toward the side of the affected muscle.

Subjective Symploms. — Diplopia, occurring when the patient looks
at an object situated within the sphere of action of the paralyzed
muscle. The two im ages of an object seen in the median line are
more wjdely sepataled^wlienjhe object isrnoveJyin. the, dire ction of
t he action of the para lyzed muscle. The image seen by the sound eye
is the true image, and that seen by the affected eye the false image.
A study of the relative position of the two images enables
determine the special muscles or set of muscles paralyzed.

Vertigo, nausea, headache, and incorrect estimation of position
space are disagreeable symptoms of ocular paralyses. As the patii
forms incorrect location of obji

Special diagnosis of the ocular palsies depends upon the relativB,
position of the images in diplopia. To determine the eye and
cle affected, we must remember that the loss of motility and d iplopia ■
increase upon the side of the paralyzed muscle. The imag e of the
affected eye is always found on the side opposite that to which the
cornea is turned. A ready method is to tell the patient to look straight
at a pencil, and to follow the movements given it, until two images
of the pencil are seen. Then one eye is covered, and according to
which image disappears, we know whether there is crossed or homon-
ymous diplopia, and the relative position of the two images will give
us an idea of the muscles paralyzed. To aid in the diagnosis we ap-i
pend a tabulated arrangement of the conditions in paralysis of ihi
ocular muscle, modified after Landolt, showing the nature and pi
tion of the images and other important correlated details.

Causes. — The lesion directly causing the paralysis may be
primary affection of the nerves themselves, or may be situated
cerebral centers from which the nerves originate. Syphilis and'
tubercular meningitis are probably the most common causes. Ofthe
infectious diseases, diphtheria is most active in causing ocular par-
alyses, which, hov/av&r, in these cases are Tnoie manifest
^hiternal muscles o/" accommodation, Influenia, x\ic\iTOai.i.sTO.\'i^'s

ige.
> to

ienl^l
tivB^I
.pi»M

j'oiJt^H

131

fever, and diabetes have a!so been mentioned as causeE. Poisons,
like nicotin, alcohol, lea.d, the ptomains, carbonic oxid gas, and e
posure to cold have all been reported as causes. Orbital tumors a[
abscesses, exophthalmic goiler, aneurysm, cerebral hemorrhage, and
fractures at the base of the brain may cause paralysis by pressure.

Prognosis. — The duration of the paralysis is more or less chronic
In the most favorable cases several months are required for a cure
The prognosis is favorable when a paralysis is a sequel lo diphtheria,
some mil J injmy.or tr;insii;iit intuxii.iilidTi. '.Ii"iil;vr p.Tralysis a
£iaieil wiili lociiMiutor at.ixia in tiie early iU^e^ is likely to disappear
as the dihca-e progrcssei. Tl:e pfo;;ii05Js i? unccitain wiien'lhe

3 be the

, The
iiiltofs<

when (he paraljsis is dis^
"orTefeLral lesion.

Treatment. — Treatment should be directed lo the removal of the
cause and the relief of the symptoms. Syphilis yields to mercurials
and iodids and diaphoresis. Meningitis must be treated in the usual
manner. Diabetes demands dietary and hygienic treatment. Par-
alyses of rheumatic origin require the salicylates, colchicum, and
other ordinary rheumatic therapeutics. Diphtheric palsies generally
disappear with healthy bodily nutrition and the best tonic treatment.
The influence of mercuric chlorid should never be overlooked. Both
the galvanic and faradic currents are sometimes of value. For the
relief of the diplopia it is well to occlude the unsound eye from vision,
either by a bandage or an opaque disc. The simple patch is the least
cumbersome occlusive bandage. In all cases we must remember
that a long period of diplopia and its consequent distressing symp-
toms will elapse before a cure can be effected. If the paralysis con-
tinues in spite of all treatment, we may try lo remedy the patient's
discomfort by prisms, but these are rarely of value. In cases beyond
the possibility of cure in which strabismus has developed, tenotomy
or advancement may be performed to relieve the disfigurement. In
cases of secondary contracture an attempt should be made to oppose
the development of the contracture by stretching the antagonist of
the paralyzed muscle, by seizing the overlying tissues with lixation
forceps and strongly rotating the eye several times toward the side
of the paralyzed muscle.
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P' • "l
136 EXAMINATION AND KItFKACTION OP THE EVE, ^H

modic jerking movements of the eye, not interfering with the volun- |
lary movements, but accompanying them. Itis the result of defective
coordination, The involuntary movements may be horizontal or
vertical, oblique, or rotations about the visual axis. Internal squint
is a frequent accompaniment, and there may be simultaneous shak-
ing of the head.

The commonest form of nystagmus is that following some de-
ficiency of vision in both eyes, beginning in childhood, particularly
amblyopia the result of the destructive changes of ophthalmia
neonatorum and of retinitis pigmentosa. It also exists in microph-
thalmus, albinism, and some varieties of congenital cataract. The
disease may be found in miners who constantly strain their eyes in
the darkness. Nystagmus from cerebral disease is only of symp-
tomatic significance. It is especially important in the diagnc
multiple sclerosis.

Treatment beyond simple rest and the relief of the distressing 9
symptoms is of little value. It must always be remembered that'fl
there is a possibility of improving the visual acuity and modifying the I
disease by correcting lenses. The prognosis of the nystagmus i
never encouraging, even under the most favorable circumstances.

W OPERATIONS ON THE OCULAR MUSCLES.

Tenotomy. — The eye should be thoroughly cleansed and rendered
aseptic. The section of ihe tendon is best performed under coc;
other local anesthetic, as in general anesthesia the result can n
seen during the operation. The lids are held apart by an
speculum. (Fig, 45.) The eye is turned in 3 direction away from tbe |
muscle to be divided, and held by fixation forceps. (Fig. 46.) A fold I
of conjunctiva lying over the muscle is grasped wiih the fixation for-/
ceps, and a short vertical incision is made about four mm. from the I
corneal margin through the conjunctiva and capsule of Tenon. Tlie J
conjunctiva is freed from the underlying tissue by means of a pair of f
blunt scissors or other blunt instrument ; when the muscle i:
posed, a strabismus hook (Fig. 47) is passed underneath the tendoi
which is raised from the globe and divided close to the sclera with aj
psir of blunt scissors. (Fig. 46.) If complete VencAotvi'j '\%Ae^vicd,3Lnyfl
jKV/s ivmaining undivided jJay be caught by a a\\a\j\sTOvis Vwitw

^138 EXAMINATION A

cut through with the scissors. As a rule, no conjunctival stitch is
necessary, although it may be used in cases of tenotomy of the interni.
After the operation the eye is cleansed and a light dressing applied
for a few hours. A mild antiseptic lotion should be ordered. The .
divided tendon becomes reattached at a point beyond its former m- J

Advancement. — In this operation the insertion of a muscle is "
advanced toward the corneal margin by means of a suture. It is
performed on weak and relaxed muscles, and in connection with ten-
otomy of the opposing strong muscle. The process of separating
the tendon is the same as in tenotomy, and the tendon is lifted away
from the globe by a strabismus hook. A needle threaded with silk
of sufficient strength is then introduced in the tendon near the upper
margin, from behind forward, and a sufficient number of millimeters
back of the insertion to produce the requisite advancement. Another
suture is similarly introduced at the lower border of the tendon. With
the blunt-pointed scissors the tendon is then divided near the sclera,
and the needle of the upper suture is carried beneath the conjunctiva
to a point near the upper corneal margin, where it is then brought
through, leaving the ends of the thread hanging free. In a like
manner the needle of the lower suture is brought out near the tower
corneal margin. The ends of the two sutures are then tied together,
the threads being drawn tight enough to slightly overadvance the ten-
don beyond the point of necessity. This latter precaution is taken lo
counteract the diminution of advancement with healing. If desired,
the tendon may be divided last, after the sutures are brought out
through the conjunctiva. The surgeon must be careful not only to
pierce the conjunctiva, but also the capsule of Tenon, as sutures
would tear through the conjunctiva alone. Some surgeons excise a
small portion of the conjunctiva and the capsule of Tenon, between
the insertion of the tendon and the cornea. The sutures should be
removed on the third or fourth day. A mild aniiseptic solution may
be used as a lotion. Various other operations of advancement have
been suggested. Landolc's capsular advancement is a deservedly
popular operation, and the student is referred to the modern text'
Kbooks for a full description of its lechni

PART II.
DISEASES OF THE EYE.

DISEASES OF THE EYELIDS.

Anatomy. — The eyelids are composed of the following s
from without inward; Skin, areolar tissue, fibers of the orbicularis
palpebrarum, tarsal cartilage, fibrous membrane, Meibomian glands,
and conjunctiva. The upper lid is the larger, and is freely
movable ; it is furnished with a special muscle, the l evator DalpebrL^_
5 u peri oris. The angles which correspond to the junction of the
upper and lower lids are called the canthi . The inner canlhus Is pro-
longed toward the nose, and the two lids are thus separated by a
■i^^triangular space called the lacus lacrimalis. The lacrimal papilla,
Br carunclh is a small conic elevation on the outer margin of each
lid, at the commencement of the lacus lacrimalis. The j^5(a£_
cartila^fs are thin plates of fibrocartilagfe. about an inch in length,
and give the main support to the lid. The cilia or eyelashes are
atlached to the free edge of the lids. The upper cilia are more
numerous, and curve upward, while the lower curve downward. An
excellent idea of a vertical section through the upper eyelid is given
in figure 49.

The Meibomian glands are situated on the inner surface of the eye-
lids, between the tarsal cartilages and the conjunctiva. Their ducts
open on the free margin of the eyehds, and furnish a sebaceous
secretion which prevents adhesion of the lids and epiphora. The
muscles of Ike lids are the orbicularis palpebrarum, corrugalor super-
^ii, tensor tarsi, and the levator palpebrs.

E DISEASES OF THE SKIN OF THE LIDS.

KPE3 ZOSTER OPHTHALHlCUa is an acOtft (t.Vll:\\t &.=*.^=«. "i
mpanied by herpetic eruption? extending ovftx -Crc ^i^i^'iv-i!.

DISEASES OF THE EVELIDS.

distribution of the supraorbital, supratrochlear, and infratrochlear
nerves. The nerve twigs supplying the cornea may be affected.
The symptoms are local inflammation, herpetic vesicles, and general
systemic involvement, t^p pnip tion does not pass the middle line of
rhf- nriti- and forehead . The prognosis is good, provided the cornea
is not extensively involved. The treatment consists in relieving the
pain, and the application of powders and ointments for drying up

softening the scabs.
ECZEMA OF THE LIDS begins

ides and pustules, and dries in

scales and crusts. All the various forms of eczema are seen in this
location; the chief subjective symptom is i tching. The treatment
n protecting the skin and greasing the lids with some simple
, such as yellow oxid of mercury gr. j, vaseltn 3ij. The
scales should be moistened with warm oil and removed.

AND PHLEGIMONS of the lid should be incised, and
itiseplic precautions.

dressed with :

HEMORRHAGE INTO THE L
may be the result of traumatisi
tures, or may be due to injury
skull. In ordinary " black cyi
follow soon after the injury,
after an injury points strongly 1
dyscrasias, such as scurvy, may ca
pedesis. Treatment is usually un
will disappear in a few weeks. _ II
be ordered to preveni
mote absorption and reli
a pressure Ifunii.ijrp . may be ordered. Incising very puffy lids

as the swelling soon disappears without
It least, on the application of heat and pressure. For
effect, the discolored lid may be painted a flesh tint.

EDEMA OF THE LIDS is a regular accompaniment of any inflam-
matory process therein. If there is inflammation of the bulbar con-
junctiva or of the cellular tissue of the orbit, edema of the lid is a
serious symptom. The treatment consists in opening any pustular
formation about the lid, applying a piessv«e-\i3.'n6'a^e,'i^, *s. ■»-^'>-'*J
le, incising the lid.

ily known as "black eye,"
I directly to the lids or adjacent struc-
o remote parts, such as fracture of the
" the extravasation and discoloration
' Black eye " appearing several days
fracture of the orbit. Certain
; hemorrhage into the lid by dia-
:essary ; the extravasated blood
en early, cold application s may
. Later, h ot compresses pro-
lead-water ^ni] Iniiilariim or

NONINFLAMMATORY EDEMA OF THE LIDS IB a sign of di
the heart, kidneys, or liver. The general dropsy of Bright's disease
is often first seen in the lower lids. •

KMPHvaRMA OF THE LIDS may be the result of making a fake
passaye in probing the lacrimal duet, or of fracture of the bones of
the orbit or adjacent hones of the face, opening the nasal passages or
sinuses. In such cases blowing the nose increases the emphysema,

I . DISEASE OF THE EDGES OF THE LIDS.

BLEPHARITIS is an inflammation of the free edges of the lids.

The synonyins are blepharitis simplex, blepharitis marginalls,
blepharitis ciliaris, blepharitis ulcerosa, blepharitis hypertrophica,
blepharadenilis, ophthalmia tarsi, tinea larsi, sycosis tarsi, and
eczema of the lid-edges.

CauscH. — Uncorrected ametropia ; ecxema ; some inflammatory
process, such as conjunctivitis, keratitis, etc.; inflammation of the
roots of the cilia ; or the condition may be the result of strumous
diathesis. The disease is said to accompany general disturbances of
the sexual organs and syphilis. Lice are sometimes a cause. There
is also reason to attribute it to special bacteria. Dirty children
very susceptible to blepharitis. Continued eye-strain undoubtedlyli
at the bottom of many obstinate cases. Obstruction of the laci
apparatus and intranasal disease are causes not to be overlooked.

Symptoms. ^The lid-edges are swollen and reddish, and may cause
intolerable itching and soreness. There is a gummy and yellowish
secretion in the lashes and on the skin near the lid-edge, which, when
dried, deposits as scabs and crusts. Thehdsare glued together after
being closed for some lime, particularly in the morning. The eyes
tire easily. The protean character of eczema may be present about
the lid-edge, and possibly in other parts of the body. The cilia are
often dwarfed or entirely absent, causing a disagreeable disfigure-
ment. In the hypertrophic variety the lids may be everted, exposing
the puncta lacrimalis and causing the tears to overflow, thus keeping

are

liet^

ima^H

»use^l

tup the condition, and, indeed aggravating il, as the edge of the lower .^^
lid soon becomes water-soaked. The most annoying sequel of^H
blepharitis is trichiasis, a condition In which the lashes become fnia^^|
placed and scratch the cornea, and wWch \eads \o acWiaV ^ntio^iai^^l

"43

s the treatment. These cases are sometimes very obstinate,
and despite all eflbrts at relief they cause the patient long years of
discomfort, and produce a most anrioying facia! blemish. We should
first of all search for one of the causes en umerated. It is advisable
to examine the refraction of the affected eyes, and be sure that the
lacrimal apparatus and nasal chambers are unaffected. Treat any ji'

possible cause. All the scales should be tem oved and the lid-edges,,-''^!^^
kept clean and fresh. For this purpose warm water or a weak boric Ct*lAj.
or bichlorid solution (i : 5000) should be used. In the eczematous S^y^^'
variety, bichlorid in itself is an efficient remedial agent. Thelocalireat"^'^'
ment by massage with a weak Pagenstecher ointment (gr, j to 3iij) is •* —
[)robably the best at our comriiand. Ulcers may be painted with a-'j
two per cent, solution of silver nitrate. The treatment of the trich-
iasis consists in epilation of the distorted cilia, their destruction by
electrolysis, or operation. Disease of the conjunctiva and cornea
should be treated simultaneously with the blepharitis. The treatment
of the sequels will he discussed separately.

HORDEOLtJM OR STYE. — A furuncular or phlegmonous inflamma-
tion near the hair.foUicles or margin of the lid. Eye-strain is a com-

Symptoms, — It begins with a pricking pain, soon followed by swell-
ing of the affected lid. A lender hard spot is easily located by palpa-
tion, and may be inspected by raising the lid away from the eyeball,
when a yellowish point will be seen.

Treatment. — If pus is seen, it should be let out, and. as a rule, the
symptoms will usually subside immediately. To prevent recurrence,
cleanliness and disinfection with a lukewarm bichlorid solution (i :
5000) are demanded. A ten per cent, sulphur ointment may be used.
Recurrence of styes is suggestive of refractive-error or constitutional
disorder, and the ametropia and general health should be looked after.
Small doses of calcium sulphid are said to be efficient.

CHALAZION is a small tumor arising from an
closiireofaduct of a Meibomian gland. It is the size and shape of a
split pea, the convex side being toward the skin. It usually points
toward the palpebral conjuncliva, It may be distinguished from hor-
deolum by its location, its chronic course, and noninflammatory
symptoms. The conjunctiva is often red and a'pot\5,'jAtt<iVw\'i,,Wi^t^
dally directly over the lutnor. The skm ovct \\ie \.\mvot \^ ^tt*''!
movable, and normal in appearance.

DISEASES O? T

Treatment consists in excising and curetting the tumor^moc
iing a special forceps. (Fig. 50.) In excising through the
conjunctiva, the scanficalian following an extensive excision may
cause entropion, and a simple incision should be made in the direc-
tion of the gland, and curetting alone should be resorted lo. In ex-
cising through [he lid, an incision parallel to the edge of the lid is
made over the chalazion, its capsule is opened, and the whole nr

^H lb.

MALPOSITIONS OF THE LIDS AND I.ID-EDGES.

NARROWED FISSURE.— Tlie normal palpebral fissure in the adult"

36 to 28 mm. long, and about one cm. wide. Narrowing of the

isure is either called ankyloblepharon or blepharophimosis. The

first condition is an actual union of the external angle of the lids,

and maybe congenital or due to a cicatrix following a burn or an

ulceration. Blepharo phimosis indicates that a fold of skin covers

/A« exlernal angle, and results from a contraction of the slctn of ths

after a chronic conjut

Treatment of ankyloblepharon consists Jn an operation called can-
tboplasiy. (Fig. 51.) Theadhesionsaredissecled up and theexternal
canlhus split, leaving a denuded V^baped wound, the conjunctival
edges of which are dra.wn together by sutures. Blepharophimosis
may be corrected by cutting away the redundant skin and stitching
the edges of the wound together.

WIDENED FISSURE is usually a cleavage of the external canthus
due to an injury, after which union, is not perfect. It is remedied by

an operation called tarsorrhaphy, in which both edges of the lids are
denuded and the raw surfaces sutured together.

LAGOPHTHALMOS is a condition in which the eyeball is so extruded
thai the lids can not be completely closed. The exposure of the eye
following this condition is accompanied by the greatest danger to the
cornea. Lagophlh almas may be due to staphyloma of the cornea,
ocular or orbital tumor, or paralysis of the orbicularis muscle.

EXOPHTHALMOS Is protrusion of the eye from the orbit, and may
be due to increase in the bulk of the eye by A\^ca.se, OT\i\'f(\wSv>icJws,
an orbiial tumor, a foreign body in Ihe oxto, w\-50V'*o-,'^

I the

the accompanying sign of exophthalmic goiter. It maybe present
a slight degree after tenotomy. If so marked as to cause delete-
us exposure of the cornea, a modified tarsorrhaphy should be per-
formed. Exophthalmos may cause blindness by excessive stretchii
of the optic nerve.

TRICHIASIS is a condition in which the cilia are misplaced
misdirected, and rub against the cornea, causing more or less comeaF
The condition may apply to all the cilia, or only a few
may be misdirected. The common cause of trichiasis is trachoma,

» although blepharitis or any inflammation about the cilia may produce
it. Cicatricial contraction after injury and operation is a cause. ThCj
treatment consists in curing the causative condition, and by cpili
electrolysis, illaqueation, excision, and plastic operation.
I

FlO. S».— EWTKOPIOH.

DiSTiCHiASia is a condition in which there is a double row of ciUi
one directed inward and one directed normally outward. The resid
of this condition is corneal irritation. The treatment is similar t
that of trichiasis.

ENTROPION is inversion of the edge of the eyelid. (Fig, 52.)
results from cicalriiation following trachoma, blepharitis, wounds,
burns, etc. Blepharospasm and pressure from bandaging are causes.
It should be distinguished from simple trichiasis, in which the cilia
alone are displaced. In entropion the edge of the lid is wholly or<
partly inverted, as well as the cilia.

Treatment. — If spasmodic entropion is due to a faulty bandaj
strcA caase must be removed. One end of a y\ect of adhesive pli
tgtened below the /ashes and the other end \o "-^ic t^intV TOa.-) ^

:ilia

DISEASES (

i EYELIDS.

14:

relief. The classic operative measure for entropion i

horiiontal fold of skin parallel to the edge of the lid, with suture of

the wound. Other operations are described in the following pages,

OPERATIONS FOR DISTICHIASIS, TRICHIASIS, AND CICATRICIAL
ENTROPION. — El ecirolYs is is performed by attaching the needle to
the negative pole of the battery, the positive pole being placed on
the temple; the point of the needle is thrust into the bulb of the lash,
and the circuit closed. Destruction of the bulb is indicated by
bubbles of gas about the needle. Each lash must be treated separ-

ately.

Illaqueation is a name given to a method of changing the direction
of misplaced cilia by withdrawing them, by a noose, through an
opening in the adjacent tissue of the lid. Unfortunately, the eye-
lashes freqiienti)' regain their abnormal position by reason of their
own elasticity.

Excision.— A V'Shaped incision is made in the skin of the lid,
including the misdirected cilia, the whole flap is excised, and the
margin of the loss of tissue is drawn together with sutures. Flarer'a
operation (Fig. 53) consists in splitting the lid into two portions as far
back as the ends of the hair-bulbs of the ciWa. TVe ■;
containing Ibe hnir-bulbs, is then cut awa^ b^ "\nt\^\<m. '^^aw^*

^^ skin i

OF THE EYE.

; the whole length of tlie

skin from above. In cases in
this operation is not advisable.

Transplantation. — The Arlt-Jaesche operation is performed 1
splitting the lid along the whole intermarginal edge for a'
deep, the anterior laj'er containing the orbicular muscle and the
integument with all the hair-bulbs, and the posterior containing the
tarsus and conjunctiva, A second incision is made about six mni.
from the margin and parallel to it, extending the whole length of the
lid. A third incision is made in a curved line from one end of the
second incbion to the other. The semilunar fold of skin thus formed
is dissected off, and the exposed margins are brought together by i

The height of the curved incision is proportionate to tl
effect desired.

Dianoux's operation is performed by incising the integument to
cartilage only, in a hue parallel to the lid-edge and about four a
from it. On the intermarginal edge the lid is split between the cartilj
lage and muscle until the knife meets the preceding incision at rigbl
angles to it, thus farming a bridge of lid-edge containing ihe cilia ai
their roots. Another and shghtly longer line of incision isnowmadc^
parallel with the first one and about three mm. above it. The St[iM_
of skin between the two is dissected up in the middle and leftl
detached at both ends. The bridge of the Sid-mavgin is then drawin
F|*Ji/ ot^er the strip of loosened skin, and ia.s\.tnei ^j-j w

DISEASES OP THB EVELIDS.

149

the upper border of Ihe highest incision, while the loosened strip ii
drawn down and stilched to the intemiarginal edge. (See Figs. 54 and
55.) The objection to this operation is that occasionally the cuta-
neous hairs on the transplanted flap irritate the cornea, and these
hairs, being much finer than cilia, are more difficult to remov

Van Millingen's operation consists in splitting the eyelid, a
Arlt-Jaesche operation, from end to end, sufficiently to produc
three mm. wide in the center and becoming narrower toward the
canthi. Sutures are passed through folds of skin on the upper lid,
which prevent the gap from closing. A strip of mucous membrane
as long as the lid and about two mm. broad is cut out of the inner sur-
face of the patient's under lip, and is slipped into the gap. Sutu
superfluous. In this operation
the transplanted tissue, being
mucous membrane, is free from
the objectionable fine hairs.

Streatfield's operation and
Snellen's modifiCHtion of it con-
sist in grooving the tarsus, and
removing a wedge-shaped piece
of skin, the length of the lid,
and about two mm, from it,
When the edges of the wound
are brought together, the cilia
are turned outward and into
their normal position.

In von Graefe'a operation tw(
the skin of the upper lid, Ihe lal
posterior leaf; the
along the vi
the skin of the upper

1
I

e made through

Ltter being split ii
margins are then entered higher
I. A horizontal incision is made through
triangular piece of skin, with its base

s removed ; also a triangular portion of the t
upward, is removed, and the wound sutured. This operalio
ommended in senile entropion, when excision of a horizontal piece

If skin or Ihe application of subcutaneous sutures are not sufficient.
■HoIi'b operation for the same condition consists in excising the
Itin and muscle down to the tarsus, some four to six mm. from the
i-edgc, laying bare the tarsus and drawiu^ ^V\e'."HO^'*TO-«vMiij,-(\^
peiher and holding fhem until union \5 efttc^fti, \)ri\i^^\i\Tv'{,i».v3ii*

fulcrum for the everting farce of the cicatrix and skin, which Hotz
thinks ia wanting in oiher methods.

ECTROPION iseverstonofihelid. (Fig. 56.) It is not attended by
the severe symptoms of entropion. Epiphora, with the consequent
eciema which follows it, is the worst symptom. In severe cases th
whole lid may be everted, leaving the conjunctiva unprotected,
condition popularly called blear eyt. This deformity results from
relaxation of tissues in old age, or paralysis of the orbicularis, cicatri-
cia! changes due to injuries, burns, etc., and follows chronic conjui
livitis, blepharitis, or other inflammatory conditions about the lids.
The scars of lupus and syphilis are occasional causes. Both lids
may be affected.

Treatment. — For eversion of the punc la —slitting the lacrimal
canaland clearing the nasal duct may give relief. Any discernible
cause should be treated. Mild antiseptic lotions should be used on
the denuded surfaces. The patient should be instructed to wipe the
eye from below upward, thus tending to reduce the eversion by asort
of massage.

OPERATIONS FOR ECTROPION are designed to raise the under lid
or to stretch it out horizontally. The usual plastic operation is
cision of a V-shaped piece of skin below the lid-margin. The edges
of the denuded triangular area are brought into position by suturi
as depicted in figures 57 and 5S. Snellen's sutures are threads e
tered on the conjunctival side of the lids from above downward, and
brought out on the skin at about the level of the edge of the orbit, the
ends being knotted over pieces of lubing or a ball of cotton. In
cicatricial ectropion, the first step is to sever the adhesion between the
lid and the bone, and to cover the remaining scar by a transplanted
flap or by skin-grafting,

PTOSIS is drooping of the upper lid. It may result from any
effusion or inl^ammatfon weighing down (he upper lid. Excessive
deposits of fat in the lid may cause it to droop, Ptosis also results
from injury to or paralysis of the levator palpebrie muscle.

The treaiment of ptosis consists in removing the cause if possible.
In paralysis of the levator muscle, strychnin and the galvanic cur
are useful. Several ingenious lid-elevators h.ive been devised for Ihe
relief of this condition. Operative interference has for its abject the
f a piece of the skin of the upper lid, or the insertion of

hold the lid up. The tendon of the levator muscle
may be advanced, or the tarsus may be sutured to the temporal
muscle. The patient can often relieve ptosis by learning to use the

Fins. 57 *ND 53.— Ophratioh for Ectropk

temporal muscle, or by throwing the head backward in order to see
better.

A simple and efTective operation for ptosis consists in passing a
stout silk ligature vertically under the skin from the eyebrows lo the
margin of the lids, and firmly tying the ends. The noose formed ii

I
■

this manner is tightened every day until it has cut its way through
the con lined tissues; the resultant cicatrix draws the lid to its normal']
position.

Ct,ONlC SPASM OP THE ORBICULARIS IS Called NICTITATION, and'
is really frequently-repealed involuntary winking. It may be
ciated with hysteria, chorea, or general neurasthenia; in fact, it may
be a symptom of nearly any reflex neurosis. It often becomes
habit. Clonic spasms of the orbicularis sometimes appear after the
use of eserin. In persons doing considerable eye-work, there is
doubtless some uncorrected error of refraction. Tlie treatment of
this condition consists in administering remedies alleviating the
nervous condition, or in correcting the ametropia. .

BLEPHAROSPASM is a tonlc contraction of the orbicularis, oReilq
affecting both eyes. It is generally reflex, from irritation of the con-
junctiva or cornea by a foreign body or from inflammation of some
kind in these regions. It is a. disagreeable accompaniment of phlyc-
tenular conjunctivitis and keratitis, and corneal ulcer. Often the
irritation caused by an inverted eyelash is the seat of the troublci
Photophobia often leads to blepharospasm. If no local cause
cernible, we must suspect ametropia, or some reflex from a distal
irritation, such as intranasal disease, or even a decayed tooth. Ths]
apasm may be of central origin. Treaiment of the cause
way to attack the spasm. Pressure on the facial nerve at
the styloid foramen is said to slop the spasm. Galvanism is nseful
By all means examine the refraction. In children with phlyctenuh
disease, plunging the face under cold water will often cause thsj
orbicularis to relax and permit examination of the cornc^e,

■ CONGENITAL AKOMALIES.

COLOBOMA is a perpendicular fissure of the lid, usually the upper fl
one. It is congenital, and is often associated with hare-lip or cleft-V

&PICANTHU3 is a condition in which a perpendicular fold of skin^
I extends from the nose over the Inner canthus. It causes the nose to

look broad and the fissure to appear small. It Is a racial character-
^ isiic of ihe Mongolians. When congenital, it may gradually disnp-

_- />ear. Excision of a piece of skin of the nose, caWei i'ri\Tio\i^\a.?'wj,^J

DISEASES OP 1

;s sometimes performed for cosmetic reasons. Eye-glasses wiih si
e-pieces are sometimes used for cosmetic effect.

NEW GROWTHS.

EPiTHELiaMA should be distinguished from chancre of the lid by
ili slower development, and the absence of syphilitic symptoms else-
where. In syphilis there is early involvement of the lymph-glands
at the angle of the jaw, and edema is more apparent. The treatment
of epithelioma consists of prompt and thorough incision, and, if the
wound is large, a. subsequent skin-grafting. In some cases a careful
cureting will suffice, but on the whole excision is safer. The applica-
tion of pure formalin is a substitute for curetment. After excision,
the conjunctiva and skin should be sutured separately.

OTHER TUMORS of the lids are warts, angiomas, and xanthomas.
All of these may be removed with ease and impunity. Angiomas
are bluish-red in color, while xanthomas are dirty yellow.

^f DISEASES OF THE LACRIMAL APPARATUS.

Anatomy and Physiology. — The lacrimal apparatus consists of the
lacrimal gland, its excretory duct, the puncta lacrimalia, the lacrimal
canaliculi, the lacrimal sac, and the nasal duct. (Fig. 59.)

The lacrimal gland is situated at the upper and outer angle of the
orbit. It is invested in a dense, Rbraus membrane, and is in contact
superiorly with the periosteum. The secretion of the lacrimal gland
is carried by 8 to iz small ducts, which run for a short distance
beneath the conjunctiva, and open upon its surface by a series of
pores, about ^ of an inch apart, situated in a curved line, a little
above the upper border of the tarsal cartilage.

The lacrimal eanalicuH commence at minute openings in the
lacrimal papilla of the inner canthus of the lids, called puncta lac-
rimalia. They are directed inward to the lacrimal sac. The superior
canaliculus at first ascends, and then, turning suddenly inward,
forms an abrupt angle with the nose. The inferior canaliculus de-
scends at first and then turns abruptly inward. These canaliculi are
dense and elastic tubes about twelve mn\. lorig, aui a.cx a.^ ta.ijHiQ.v^
lubes, being constantly open. i

^^f 154 BISEASES OF THE EVE

""^B

^^^M The lacrimal sac is lodged in a groove of the lacrimal bone, and
^^^1 when distended may he compressed through the iid. It is lined with
^^K mucous membrane, and is really a dilatation of the nasal duct.
^^H The natal duct is a bone-canal, about % of an inch long, through J

1 ^^

^1 J

^^^^^^^^H LACHYMAL

PtH^

^^^^H

^^^ BBir ^^^

'^i^,^!

^^■^IH^^H

/■

^^^^^^FIC^I — Rm^TIONS OF THB EVE AND TIIH LACBIM'

^^^r 1, 1. Canaliculi. i, i. FuncU lacrimslia. 3. 3. Inner t
^^^^m 4,4, Fr» borders onula. 5. LAcrlmal lac. e. Aiibi

iL Excretory ^fflB^^^H

iirfinil)' or Ursl rartOu^^l
chmeiii to m^ixlllary bone^H

which the tears are conveyed from the eye to the nose. It is liiU^H

with ciliated mucous membrane, continuous with that of the inferit^H

meatus of the nose into which it opens. Its direction is downwu^H

^^^oufivard, and backward. ^H

•* DISEASES OF THE LACRIMAL APPARATUS. IJJ

V»/c and Nerves. — The lacrimal gland is supplied with blood
.^c lacrimal branch of the ophthalmic artery, and with nerves
M lacrimal branch of Che ophthalmic and orbital branch of the
rior maxillary.
^ forces at work in the passage of tears from the gland to the
^ere capillary attraction as furnished in the canals, gravity caus-
:m to fall over the conjunctiva and through the canals, and
lar movement in winking. In winking, the tearsac is expanded
traction of the muscles, and the tears sucked into it. Con-
1 of the sac is passive, due to the elastic action of tense tissues.
latrimal secretion, called tears, is a faintly alkaline fluid con-
ig about one per cent, of solids, of which a small part is proteid
:oinposition. The lacrimal secretion is slightly antiseptic, and
chlorid.

DISEASES OF THE LACRIMAL GLAND.

ABSCESS AND INFLAMMATION of the lacrimal gland are very

are. The diagnosis depends on the presence of swelling or the

jig-ns of abscess in the region of the gland. An abscess should be

incised, and any inflammation of the gland treated with a mercurial

^ ointinent or potassium iodid.

^^^^NEW GROWTHS are mostly adenoids. A chloroma is a malignant
^^Heenish lumor which sometimes attacks the lacrimal gland. Sar-
^^^Kia and carcinoma are also occasionally found in Ibis location.
^^^^pwever, disease of the lacrimal gland is such a rare affection that
^^pa^ny men of vast experience have never seen a case. The treat-
ment of a tumor is prompt excision.
' DACRYOPS is a condition in which a lacrimal duct becomes oc-

cluded and the lumen full of secretion, forming a bluish tumor on the
outer upper fold of the conjunctival sac. It should be opened with a
fine needle.

FISTULA of the lacrimal gland is usually the result of injury or
*■ operation. The fistula should be connected with the conjunctival sac,
after which the dermal opening soon heals.

I DISEASES OF THE LACRIMAL PASSAGES.

' The all-important sign of diseases of the lacrimal i^a«SA<^(it

ovetSonr of tears, or EPIPHORA. The first purpose ot Uea

UtSEASES OF THE EVE. .

IS6

is to clear ilie passages so that ibe tears will run into the nose.
However, we must remember that in overseeietion the tears will run
cheeks. Thus, on a windy day or in emotional weeping,
there is not only extra secretion into the nose, causing sniffling, thus
proving that the nasal duct is patulous, but, in addition, epiphora.
of tears may be due to conjunctivitis, keratitis, an
especially irritable tri);eminus nerve, uncorrected ametropia, and a
number of other c ^

APPECTIONS OF THE PUNCTA l.ACR[MALIA.~Eversion i

puncta, or even of the lower punctum alone, will cause epipbor.
should immediately endeavor to correct any malposition,
quences of epiphora are very serious, eventually leading It
In culling operations on Ike lids, or in Ihr application of cautticsM
mits/ a/ways A' earffiil Ikat Ike puncta art nol involvtd.. a
tvith /(sannoj'ingsequel.-C, will resuU W \.\\is ?'[ccaM\:\oiv'wnu\\d«

Although it is always well to preserve the puncta, which have a.
physiologic function of importance in keeping solid, irritating bodies
from the nasal duct and lacrimal sac, it is often necessary, for imme-
diate drainage, to slit the canaliculuB involved. This simple op-
eration is performed as follows (Fig. 60) : The lower lid is drawn
downward and outward, and slightly everted by the thumb of one
hand, while the probe point of a canaliculus knife (Fig. 61) is intro-
duced vertically with the other hand. When the knife is well inserted
into the cana], its point is turned inward and shghlly backward,
reaching the inner wall of the lacrimal sac. During this manieuver
the edge of the knife is turned toward the conjunctiva, and the whole
length of the canaliculus is divided, close to the mucocutaneous
junction, by bringing the knife up boldly from the horizontal to the
vertical position. In dividing the upper canaliculus, the upper lid is
made tense, and the knife is introduced into the upper punctum and
passed into the sac in a direction downward and inward. If the
canaliculus is very small, a fine-pointed conic probe should first be
used to dilate it. There are various modifications of the operation —

with a groove director, fine scissors, etc. The wound should be ex-
amined at short intervals, and kept open with a probe.

AFFECTIONS OF THE CANALICULUS Obstruction of the canahc-

ulus is bften due to a foreign body, such as an eyelash, which not
only occludes the canal, but scratches the cornea. The obstruction
may be due to a stone in the canaliculus, called a dacryolilh. Polypi
of the canaliculi may grow so luxuriantly as to protrude from the
puncta. The treatment in these cases is to remove the foreign body
if it protrudes from the punctum ; or, if the obstruction is due to a
stone or polypus or there is absolute stenosis or obliteration of the
canaliculus, it should be promptly slit to its full extent.

AFFECTIONS OP THE LACRIMAL SAC.~Thc lacrimal sac is lined
wilh mucous membrane, which is subject to inflammation and catarrh
like any oilier mucous membrane. Any coi\iAUot\ 'K\i\i:^v sfeW-vis^a
tJie free passage of the tears predisposes lo dwtasa ol 'fee ^a-CiWo.^

infection,
ventualfu
ybeccNM

pa.r[icul3rly if the obstruction is in the nasa.1 duct. The sac also In-
comes diseased by extension of any inflaminatory process from the
:. iDflammation of the sa.c leads to blennorrhea, and this, in its
, leads to dacryocystitis, or abscess of the lacrimal sac. The
contents of a constantly suppurating tear-sac are very infectious, and
although the patient may go on for many years with epiphora, con-
junctivitis, and crusting of the lids in the morning, yet the infection.
may be so severe as to set up an inflammation which will eventuall
destroy the eye. The slightest abrasion of the cornea may b
infected and a dangerous ulcer result,

DacryocystitiB. — The initial symplomsare conjunctivitis, local pain, '
and redness of the skin. The distended sac soon appears as a tumor
involving the tissues near the inner canthus of the eye. If left to itself.
this tumor may ulcerate and the pus burrow through the skin, estab-
lishing what is known as a lacrimal fistula, which may remain
time, and become in itself a safeguard against a new attack,
the distended sac loses its elasticity and becomes a permanent l
called hydrops sacci lacrimal is. The diagnosis between simple
catarrh, blennorrhea, or hydrops, is easily made by emptying the sac
with pressure of the finger: in catarth, a watery secretion appears
at the punctum ; in blennorrhea there is more or less pus ; in hydro
the sac may empty into the nose and no secretion appear,
cystitis and fistula need only be seen to be recogniied.

Treatnicot. — Any nasal affection should be corrected, and a
passage of tears imo the nose established. The latter is generally
effected by the passage of sounds. Bowman's sounds or probes (Fig,
62) are usually employed. The canaliculus should be slii^and the
following day the passage of probes commenced. It is optional whidli ^
canaliculus is used, but the upper Is shorter and ei

To pass a lacrimal sound or probe, the point of the sound r
be passed along the floor of the slit canaliculus to the nose, until Qf
felt to strike against bony resistance ; the sound is then rotated «"
it points downward ; keeping close to the inner wall of the
sound is then firmly pushed along. Under ordinary circumstai^
if the probe is in the right position, it will pass along the nasal (
with a moderate pressure; undue resistance to a small probe indicates
stricture of the duct or a false passage; in either case the pressure
should be used cautiously . If the sound \ias ^asscA casiVj, U should
be left in position several minutes ; in fact. »«. ma.'j (fccii™ ?.\^aN.\\»Rfli\

niiijriJ

1 alnS

rnerally
es{Fig.
ind the
ilwhidka

al dffin

THB LACRIMAI- APPAIiATUS. 159

often to advantage. It Ihe passage has been tight, the sound should
be immediately withdrawn. The sounding of the passage should be
repealed every three or five days, and the size of the sounds pro-
gressively increased. In some cases it is well for the patient to wear
a leaden stylet constantly for several days. Theobald and others
advocate the use of very large lacrimal sounds. A special probe-
pointed knife has been devised for slitting strictures of the nasal duct.
In treatment of the lacrimal passages we should resort to frequent
syringing, various astringent and antiseptic preparations being used.
Weak solutions of silver nitrate are of benefit in cases of blennorrhea.
Recently there has been a reaction against promiscuous probing in
lacrimal disease. The results are generally unsatisfactory and the
case is often protracted. As a substitute there has lately beeri advised

copious syringing with a fountain-syringe attached to a hollow No. 4
Bowmari's probe. The canaliculus need only be split halfway, and
in some cases not at all. Boric acid and weak antiseptic solutions

nlhe

ngalio

A simpler treatment of lacrimal obstruction, which dispenses with
mutilation of the puncta and canaliculus and probing, consists in the
following manipulations:

First empty the sac and canaliculi by dextrous pressure, and
cleanse the eye and palpebral pockets of the unhealthy material.
Then cant the patient's head back and to one side, or have him lie
so that a teaspoonful of liquid will be held in the depression formed
by the nose, orbital border, and superior maxilla. Fill this space
with a weakly antiseptic solution. The so\ut.ioTV vte \i.^«\^ tft\ci^s«R&,
to the ounce of distilled water, of boric actd.lCTi ^aa^'s". wBoa

W:
I

l6o DISEASES OF THE EYE.

salt, three grains ; chlorid of zinc, one grain— all deeply tinted *
pyoktanin-blue, and doubly filtered after long standing. With the
little finger again slowly empty the sac and canaliculi by pressure.
and then, as slowly lessening ihe pressure, allow these spaces to refill,
by suction and capillary attraction, with the solution under which the
puncta are submerged. Again, in half a minute, empty the canaliculi
and sac by pressure, but this time beginning the pressure from the
canlhus toward the nose and downward, so as to force the antiseptic
solution downward into the duct. These alternate emptyings and
refiliings of the sac may be repeated several times and as often as
desirable to meet the indications of the case. It will usually be found
that the sac will soon become healthy and that pressure upon it will
not cause regurgitation of morbid material through the puncta,

A certain number of cases, however, will not yield to this treat-
ment. There is too great stenosis or spasmodic contraction of the
muscular sphincter of the punctum, etc., so that the cleansing solu-
tion can not be forced into the sac and duct. In such cases we are
accustomed to insert one sharp point of the iris scissors into the
punctum and snip it open about J^ of an inch, perpendicularly down-
ward toward the conjunctival fold. This gives a larger opening for
the indrawal of the solution.

Obliteration of the lacrimal sac is a questionable procedure. The
treatment of acute dacryocystitis consists in voiding the pus, either
through the canaliculus or by an incision through the skin. The
fistula is treated like other fistulous passages, and will generally heal
if the obstruction to the passage of tears is removed. Repeated Irriga-
tion, syringing, and probing are the important after-treatments of all
these affections.

DISEASES OF THE CONJUNCTIVA.

Anatomy, — The conjunctiva is the mticuus membrane of the i

and when the lids are shut, it forms a closed sac. (Fig. 63.) The g

covering the eyeball is called the bulbar conjunctiva, and the p

retlecled over to the inner surface of the hds is called the palpeh

conjunctiva. The part forming the fold between the two is called ll

yhrm^, and the regions between iVie Iwo ^aV^eX^iaV and bulbar p

l/ons are called the sulci, or palpebiaV sinuses, T^it ^-m^vii ■

DISEASES OF THE CONJUNCTIVA. l6l

IS Itie deeper. The conjunctiva covering Ihe cornea is thin, closely
adherent, and contains no blood-vessels. Upon the sclerotic it is
thicker and less adherent ; but upon the Inner surface of the lids it is
somewhat closely connected, and exceedingly vascular. The con-
junctiva is directly continuous with the mucous membrane of the
mouth and nose, and is sympathetically affected by disease of these
cavities and their continuations. Indamraation of the gastrointes-
tinal and pulmonary tracts may cause congestion of the conjunctiva.
The conjunctiva is traceable into the lacrimal gland above, and into the
lacrimal sac below. Immediately to the outer side of the caruncle is a

slight duplicature of the conjunctiva, called thep/ica semilunaris. This
is analogous to the rudimentary third lid or nictitating membrane of
birds.

Diagnosis of Superficial and Deep Congestion. — To distinguish
congestion of the conjunctival vessels from engorgement of the
deeper vessels, we must bear In mind that the conjunctival vessels
are tortuous, easily movable upon the sclera, are bright red, and may
be traced along their entire course. In deep congestion the indi-
vidual vessels can not be seen clearly, and t\iw5«a\'j,\&,».ix4.'Ct«stVa
a bJaish-red or violet injection.

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163

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J As ihe gravest m;

inexperienced are
characteristic featur
mation. the followii
on pages 162 and r
table before readin
however, that the t

I less modified or ab!
cesses are frequentl
KVPERBMIA OF 1
disease, and is gene
I>rane, such as foreij
etc. The treatment
to locale.

istakes in the treatment of ocular disease by the

due to a lack of knowledge of the salient and

es of each of the different types of ocular inflam-

ig table (a modification of that of Bruns) is given

63. The student is urged to review carefully this

table before reading farther on diseases of the eye ; rernerabering,

however, that the typical signs of each condition are often n

less modified or absent, and that combinations of the different pro- '

'cesses are frequently present.

SIMPLE CONJUNCTIVITIS.

KVPERBMIA OF THE CONJUNCTIVA is a symptom rather than j

disease, and is generally the sequence of some irritation of the meiri^

I>rane, such as foreign body, weeping, heat or cold, exposure to light

The treatment consists in removing the cause, which, in manyv

small foreign body which the patient has been unable

CHRONIC HYPEREMIA, OR DRY CATARRH, of the COnjul
caused in many ways. Irritation by dust, peculiar to such occupation)
as those of the miller, stone-mason, etc., is a fruitful source- Any I
derangement of the secretion or excretion of the tears is a cause-
Firemen, puddlers, and others who work continually in a strong light;
students, using their eyes excessively and often by poor light, and.
persons subject to any kind of eye-strain, may be afflicted with dry J
catarrh of the conjunctiva. The symptoms are itching and si
as of a foreign body or heat in the eye. The distress increasefj
toward evening, showing the indubitable presence of eye-str
upper lids feel heavy, and there may be blepharospasm i
degree. Upon examination, the lids are seen to be congested, ther
is a uniform redness, and all the accompanying signs of a catarrhal
condition. At the sides and over the tarsus there are often nodulcS
looking like raw flesh. There is no pathologic secretion.

The treatment consists in correcting any error in refraction o
cular trouble. To avoid the deleterious influences of some oi
tions, protective glasses may be ordered. If there is exposure ti
sunlight, smoked glasses should be prescribed. Astringent
antiseptic applications are advisaWt. Boi\t add. ?,r, x to Jj,
Be solution most commonly employed; iii^c sM\v'ha\i

DISEASES OF THE CONJUNCTIVA. 165

chloridigr. j to SJ. ^■'c useful. Camphor water is often used as a
base for eye-drops. Alum may be used in solution of gr. vj 10 3j.
In case the catarrh is persistent, applicaliors every second day of a

two per cent, solution of sitvi
the eyes with a pencil of all
and refractory

mended. Touching
Often, in old
in the astringent employed is of ad-

vantage. Irrigation with hot or cold lotions of plain water is always
advisable ; besides the pleasant local effect, absolute cleanliness is
assured.

Figures 64. and 65 illustrate the simplest and best mode of applying-
the alum pencil, which also dispenses wil\\ v\\e atino-ja^tt, tA CMWv.v^'i
Ihe upper lid. The skin over the middle o( V\\c u.^'p(i^\\6. '\^ fa-'w

DISEASES OF THl! EYE.

^^^1 between the thumb and forefinger of the left hand, pulling the lid

^^H upward and away from the globe. The patient is told to look down-

^^H ward, and with the right hand the pencil is inserted deep into the

^^^1 upper sulcus, especially in the direction of the canlhi, where the

^^H greatest congestion Is usually located. The advantage of this method

^^B overeversion of the lid lies in the fact that the remotest depths oflhe

^^B sulci can be reached. In applying the pencil to the lower sulcus,

^^H simple eversion of the lid by tension is all that is necessary,

^* lot

HOW TO USE HYE-DROPS.— When ordering astringent or antisept
for the eye, we should instruct the patient how to use them.
He should lie on his back without a pillow, and with a clean dropper
several drops should be placed immediately in the eye; the lids
should not be violently closed, thus squeezing all the lotion out, but
the eyeballs gently rotated, diffusing the lotion in all parts of thi
junctival sac. Instead of wiping the lotion out, it should be allowed
several minutes to dry in the eye. Surplus lotion should not be put
back in the bolde, but thrown out, and the dropper cleansed after
each instillation. The use of eye-cups is not recommended.

SIMPLE CATARRH is one of the commonest diseases of the
junctiva. In addition to being due to the irritative causes alreadi
mentioned, it is a frequent accompaniment of Ihe ordinary infecliottj
diseases, such as measles, scarlet fever, etc. A simple cold is a &«3
quent source of conjunctival catarrh. Tobacco smoke and other
irritant vapors are causes. Finally, any bacterial invasion producing
inflammation elsewhere in the body may cause trouble in the con-
Symptoms.— It begins with a hyperemia, followed by a profuse
watery discharge. The lashes are malted, and the hds are glued
together in the morning. There is profuse lacrimation, called forth
to remove the excessive secretion from the conjunctiva, and, as the
capacity of the drainage-apparatus is overtaxed, epiphora results.
Aside from the ordinary symptoms of conjunctival congestion, the
patient is annoyed by Ihe optic defects Caused by flakes of mucus
on the cornea. Photophobia is sometimes distressing. Again, the
symptoms are worse in the evening. The patients complain that
they have h sensation as of sarid in Ibc c^e, atvAftie-j uevacUned to
praJong the irtitAt'ion by rubbing.

DISEASES OF THE CONJUNCTIVA. 167

The course of ihe disease varies from one week to an indefinite

Treatment. — Ordinary measures with astringent and antiseptic
washes will alleviate the symptoms; but when there is a hidden
cause, the process continues. Occupation, habits, and continued eye-
strain are causes which are often left uncombaled. In such cases local
treatment is of little avail. Anointing the lids with pure or niedicaled
vasehn every evening should be insisted upon. Generally, [he use of
an astringent is advisable, — alum, tannic acid, silver nitrate, and zinc
sulphate are those most used. No rule can be given for the strength
and frequency of the applications. Each case needs a special treat-
ment. In intractable cases the application of a 50 per cent, solution
of boroglycerid in glycerin, once or twice daily, is often of great ser-

^V PURULENT CONJUNtrriVITIS. '

^FPurulent conjunctivitis is a term used to cover highly infectious
processes of the membrane. It varies according to the mode of in-
fection. The most serious cases are generally due to the gonococcus
of Neisser.

SIMPLE BLENNORRHEA of the conjunctiva is distinguished by red-
ness, swelling, profuse yellowish secretion, and involvement of the
lids, skin, and even the neighboring lymph-glands. Crests are
formed at the edges of the hds, and pseudomembranes on the inter-
nal surface. In the height of the inflammation the conjunctiva may
be so swollen as to push between the hds, constituting what is called
chemosia of the conjunctiva. The discharge is at first watery, then
purulent, and in the subsidence of the disease it is similar to that of
a simple catarrh.

aoNORRHEAL coNjtJNCTiviTis. — This disease is due to infection
by the gonococcus.

Symptoms.^For the first (wenty-four hours it may present only the
symptoms of a simple catarrh. The violence of the onset is depend-
ent upon the stage of the inflammation from which the inoculation
was made. Inoculation from an eye in the full stage of suppuration
may cause violent symptoms in six hours. The conjunctiva be-
comes congested and the lids are edematows atii s»io\Wi- t»a "fet
ses the signs of inflammal.\oivaTetftOTtTti^'Ciw&."'Cii«ifc

is grayish infiltration of the conjunctiva, intense pain, and
become so swollen as to hide the eye, and pioject
from the face. Between the lashes drops of yellow pus ooie. Upon
opening the eye pus gushes forth, "and the examiner must be
tious that none of the contagious secretion falls upon his face,
fact, it is well to wear protective glasses in examining such patients.
At this stage the bulbar conjunctiva is scarlet in color and so
chemosed that the cornea may be completely hidden. The disease
attains its height on the third or fourth day, and slowly subsides, the
catarrh usually running a course of from four to six weeks. Indica-
tions of abatement of the process are diminution of discharge and
Bigns of inflammation and the gradual return of the normal wrinkles
of the eyelids as the swelling subsides. There are often
slitutional symptoms. The temperature is elevated, and the pain may
be agonizing.

Compile atians. — The most frequent complication is corneal ulci
tion, which is due in great part to the deprivation of vascular suppl]^
to the limbus from the constriction of the conjunctival vessels by Ihfl
great chemosis of the conjunctiva. The ulcers may not perforate,
but when they heal, they leave a disastrous scar in the cornea,
Prolapse of the iris may follow perforation. If the perforation is
small, it may heal with synechial attachments of the iris; if large.
anterior staphyloma may occur. The whole cornea may slough and'.'
panophthalmitis result, leaving nothing but a sightless stump.

Diagnosis. — A history of gonorrhea or discovery of the gonococcirt
in the secretions at the onset of the disease makes the diagnosis posi-
tive. At its height the disease will be plainly recognized.

Prognosis is alw.-iys serious and is dependent entirely upon the
amount and location of corneal involvement. Large peripheral
leukomata are less dangerous to vision than small

Treatment. — The patient should be put to bed, and if one eye is
sound, it should be protected with a Bullet's bandage. This contriv-
ance consists of a watch-glass held in place before the eye by a
perforated adhesive bandage, tt must cover and exclude the sound
eye entirely, and must be Impervious to the irrigations of the di
eased eye. The attendants and patient must be cautioned against
the infectious nature of the discharge, and all compresses
destroyed. Iced compresses s\inu\d be 3.\ipV\ed Vo Ac e^e almost
continuously. This Ireatnient eases vVie pa.™. Vinvw^ (^xu&a£tra«

THE CONJUNCTIVA. 169

and prevents violent swelling and cotijunclival edema, so fatal
to the cornea. If the cornea ulcerates early, cold must be discarded
for hot compresses, wrung out in water from 115° to 120°. An atropin
solution may be instilled unless the perforation is quite peripheral.

The next important part of treatment is thorough irrigation at short
intervals. This is the fundamental principle in the therapeutics of all
autoinoculable and purulent processes. Remove the self-multiply-
ing cause, and assist nature to combat the original infection. Strong
antiseptic applications are usually unnecessary. The infection soon
gains access to tissues possibly heyond the reach of local antiseptics,
and, moreover, such substances in germicidal strength have generally
a devitalizing effect on the tissues, and this we wish to avoid. Let
cieaniiness be nature's assistant, and only when the curative process
is delayed, should stimulating applications be used.

In view of its importance, it is unfortunate that thorough and re-
peated irrigation of the sulcus is seldom effected. To cleanseat inter-
vals of a half-hour every portion of an infected conjunctiva in an
active state of purulent inflammation is a difScult task. The lids are
tense and swollen. The palpebral and bulbar conjunctival surfaces
are, as it were, glued together, making the depths of the sulci almost
inaccessible. The pain in the manipulation is intense. A child vigor-
ously resists all efforts to open the lids, and even in the case of adults
it is often quite impracticable under these circumstances. To be
effectual, irrigation must be thorough, and in the active inflammatory
stage it should be repeated at least every half-hour. What might be
called the " golden rule " in these cases is : Without careful irriga-
tion, ail ether treatment is unreliailc.

In the irrigation of the eyes we have had little mechanical or inslru-
menta! assistance offered us. Some surgeons advise against the use
of any hard substance in irrigation, as they fear injury to the cornea
in manipulation. Of the few methods suggested, that of Kalt, with
the irrigation -tube, seems to have produced the best results.

We have had made an instrument which seems to answer all the
requirements of a satisfactory sulcus- syringe (Fig. 66). It is, in all
essentials, simply a lid-retractor, such as every one uses in operations
and in examining infl.imed eyes, etc,, but made hollow for the pas-
sage of a liquid to all parts of the sulcus. It is perforated at its edges
and on both its bulbar snd palpebral surfaces, Xo aWo-oj 'C'
of liquid through and about it. The sYnaU \ia\es -axe, ia^jt^

prevent occlusion by close contact with the conjunctiva, and both J
surfaces are grooved to allow a drainage flow from the sulcus. There
are no ragged edges or protrusions lo injure the eyes, and there is
danger of the fluid being squirted back into the operator's eyes. The J
retractor may be made of metal or hard rubber. It is best used w
a fountain -syringe, the pressure being regulated by the height of thefl
reservoir above the patient's head, the current controlled by a slop- 1
cock, or by pressure on the tubing near the retractor. The ii
ment is also adapted for adjustment to a hypodermic syringe, having
a thread the same size as an ordinary hypodermic needle.

With this retractor-syringe the eye may be thoroughly washed al4
the shortest intervals, as there is little pain in its introduction. TwentyrI
minutes constitute the shortest interval ever required. At least a half-j
t of water should be used at each irrigation, and during

cleansing the retractor should be moved about slightly in the sulcus,fl
The liquid should be drained over the side of the face inlo a basin,
care being taken thai it does not enter the ear, nose, ormout
is particularly necessary in infants. Any solution may be used,!
although sterile water, or possibly a weak boric acid solullon
manganate of potassium, will be found effective. The fluid shoul
be used at body temperature, unless for special reason the applicatioi|l
of heat or cold is desired, which may be readily applied in this man-1
ner. The solution, gently run through the syringe, also offers anl
excellent substitute for wet-packs and fomentations in certain cas
of ocular inflammation.

In addition to the irrigation, the lids should be everted, if possibl^fl
and brushed three times a day with a top\ous ^o vti ttvii. solution^
of boroglycerid in glycerin. This so\iii\on ma^ o\\cTv\3e?iti(Ac&\t

OF THE CONJUNCTIVA. 171

the conjunctival sac without everting the lids. Tliis substance has
given us belter results than the belter known silver preparations.
Silver nitrate (gr. x to 5J) and its substitutes (such as protargol and
argonin) are widely recommended. Sometimes the chemotic conjunc-
tiva should be freely incised. As the disease subsides into a simple
catarrh, the ordinary antiseptic and astringent treatment is instituted.
In cases of corneal opacities, frequent massage with a weak yellow
oxid ointment (gr. j to 3iij) is recommended. An iridectomy is often
resorted to for optical purposes. An artificial pupil downward may
give serviceable vision, although the lower part of the cornea is not
always clear. The treatment of the other complications is discussed
under Iheir separate headings. In the course of the disease the pain
may be so intense as to necessitate hypodermic injections of morphin
in the temple. Constitutional and hygienic treatment is often neces-
sary. Pure air, cleanliness, light diet, free bowel- movements, etc.,
are demanded. The rigorous treatment prevents the possibility of
much sleep.

CONJUNCTIVITIS OF THE NEW-BORN (OPHTHALMIA NEONATO-
RUM). This disease is analogous to the gonorrheal conjunctivitis of
adults, although the symptoms are less violent, and the consequences
not so severe. It is usually due to the gonococcus in the secretions
of the parturient tract, although severe cases have been caused by
the secretions of nonspecific vaginitis.

Symptoms. — The inflammatory symptoms are similar to those of
a mild case of gonorrheal conjunctivitis in the adult. They appear
between the first and third days of life. Later appearance strongly
indicates postnatal infection. In lying-in hospitals the disease may
be transferred from one infant to another, unless the proper precau-
tions are exercised.

The course of the disease is shorter than adult gonorrheal conjunc-
tivitis. Both eyes are usually involved.

The diagnosis is easily made by the appearance of inflammation
of the eyes in a newly born child. A history of a vaginal discharge
in the mother or urethritis in the father is confirmative evidence.
Bacteriologic examination makes the diagnosis positive.

The complications are chiefly corneal ulcers, although destruction
of the eye may result. If the ulcers do nol pc"rt weave, >Jsvft ■^xn^-wasi.'i
as regards the scars becoming more or less Itans^iiie.^vV.v'^ mvi.'ia'Qe*^,

^~ ft

I
I

^^ the

■172 DISEASES OF THE E\

than in the adult afTeclion. Ferforaling ulci
mas, which are always great hindrance

Treatment. — As bolh eyes are usually involved, it is not necessary
to protect one ; in fact, this would be most ditiScull
care should be taken to avoid transference of
from one eye to its fellow, as there is not always the
of infection in the two eyes.

The prophylactic treatment consists : (i) If possible, in removinjr
the disease from the mother before labor; (2) thorough disinfection
of the vagina, before labor, with solutions of creolin, carbolic acid,
boric acid, salicylic acid, mercuric chlorid, or other antiseptic;
thorough cleansing and disinfection of the child's eyes as soon
the head is born. These precautions should be carried out
suspicious cases,

Ciede's method should be employed in all cases in hospital □
wife service, and in suspected private cases. In fact, ihere is a law
to this effect in many communities. It consists of dropping a few
drops of a two per cent, solution of silver nitrate exactly on the
cornea of a child born of a mother who is suspected of vaginal infec-
tion. Other solutions have been suggested, hut have no advanlages
over this simple method. We think, however, as a prophylactic
measure this strength is greater than necessary, and liable to
inflammation. A one per cent, solution, together with deanlin*
etc., seems sufficient until decided symptoms appear.

The routine treatnient is practically the same as that of gonoriht
conjunctivitis: cold applications, frequent and thorough irrigation,
the application of boroglycerid, silver nitrate, etc. At the first sign
of corneal complication, hot compresses should be employed and
atropin instilled. Massage with weak yellow oxid ointment is indi-
cated for the corneal opacities. The child must be well nourished and
kept clean and warm. Early operation is indicated if the opacities
are central and dense. The sooner an artificial pupil is established,
the better for the child's mental development. Of course, operation
should be deferred a reasonable number of months while waiting for
the opacities to clear up. In treating these cases, the physician him-
self should inspect the cornea, and make the applications at least
a day. Nurses or family attendants often fail to open the lids
fufSciently to c/eanse the culdesac and to administer the local

tim^

UICB^H

acid,

nid-
law
few
the

ifec-
»ges
tcli c

DISEASES OF THE CONJUNCTIVA.

173

; CONJUNCTIVITIS is an extremely disastrous disease,
due to infection of the conjunctiva by the Klebs-Loefiier or similar
bacillus. There is a painful, board-like swelling of the lids, and a
scanty, seropurulent or serous discharge. The ordinary constitutional
symptoms of diphtheria may accompany the affection. The treat-
ment does not differ from that of other purulent affections of the
conjunctiva, except in the relief of pain by atropin and the ordinary
diphtheric measures. Administration of the antitoxin is highly rec-
ommended by some authors. Disease of the cornea is seldom
avoided in this affection, and the prognosis is very grave. Fortu-
nately, the disease is rare in this country.

CROUPOUS CONJUNCTIVITIS differs from true diphtheric conjunc-
tivitis in that it is characterized by a soft, painless swelling of the
lids, and a membranous exudation on the surface of the conjunctiva.
It must be remembered that the secretions of conjunctivitis of the
new-born may take on a membranous appearance. The treat-
ment is virtually the same as for
other purulent infections of the
conjunctiva. Caustics are contra-
indicated.

FOLLICULAR CONJUNCTIVITIS
SymptomB. — Follicular conjunc

panied by the formation of follicles
or nodules in the conjunctiva (Fig
67). It is more infectious than stm
pie catarrhal conjunctivitis and is
more prone to relapses ahhough
no cicatrices remain after the foUi

cles disappear. The disease may be acute or chronic. The follicles
can not be seen until the congestion recedes, when they appear in
rows, glistening through the overlying membrane. Accompanying
pericorneal injection is a precursor of shallow ulcers at the corneal
margin. From its infectious character, a special germ is supposed to
be the cause. It is distinguished from trachoma by the small secretion,
absence of cicatrices, and appearance in the lower culdesat ovAi,
^C^ivsiment sbmild be first directed to mcasttiesXQ'pxeNfiA'C^*!"*-^'''^-

\ ci

J74 DISEASES OF THE EVE.

cia.tes of the patient from becoming affected. The secretion should
be removed as it appears by sublimate solution. Applications of boio-
glycerid, blue stone, or alum may be of use. Smarting may be
relieved by cold compresses. The conjunctiva may be
and the follicles squeezed out with cilia forceps.

TRACHOMA, OR GRANULAR LIDS.

Definition.— A disease of the conjunctiva, characterized by

unrestricted formation of foUicles, which, instead of being absorl

as in follicular conjunctivitis, pr^
duce permanent granular masses,
spreading over the surface of the
entire lid, and presenting, in ex-
treme cases, the characteristic ap-
pearance of a bunch of grapes
of a deep-red color (Fig. 68). The
upper lid is generally first affected.
Where the follicles are abundant,
the conjunctiva is destroyed. Ul-
ceration takes place, and the
necrosed membrane is replaced
by scar-tissue. The disease
chronic, and progresses many
years, new nodules forming wl
others are ulcerating
triiing. The bulbar conjuncd4
is not usually involved.

ith conjunctivitis, followed by

'ascular tissue over the cornea,

ng keratitis and conse-

itea,H

: begin

Course. — The

follicular formation and growth of
due to friction of the roughened lid, cau5
quent corneal opacity. The upper third

affected, and there is a distinct line of demarcation between the
healthy cornea and the vascular tissue, which never entirely diS'
appears. This condition is called pannus, and wilt be fully
ered under diseases of the cornea. The second stage of tracbi
is ulceration of the foUicles. The secretion, until now slight,
mucopurulent, and the follicles, inWead ol ^le^■n^ AK^.«\c^,ha'
tgged appearance and are u\ceia.Ved. T^ne ev.\:vxt cotv^MTitA

dis- .

DISEASES OF THE CONJUNCTIVA. 175

congested, and the lashes are matted togelher with the secretion. After
some months the disease passes into the third stage— cicatrization.
The granulations have now disappeared, there is little secretion, and
the conjunctiva is no longer actively inflamed and rough, but is dry
and dirty white, thickened, and rolled into line folds. This atrophic
condition is called parenchymatous xerosis. The entire lid is now
shorter from above downward, so that ihe lids when closed gape to a
slight degree, and are turned in. The lashes are sparse and irregu-
lar, and trichiasis results. Running parallel to the under surface of
the upper lid and a mm, from it a thiclc scar is sometimes seen.

The subjeclive Bjimptoms in the first stage are pain, itching and
burning of the lids, lacrimation, photophobia, and asthenopia. Later
on there is dimness of vision, which increases in the third stage.
There are also the annoying symptoms caused by the inverted iashes.

Cause and Distribution. — Poorly nourished and scrofulous persons
are most frequently affected. Unhygienic habits and contagion in
crowded districts are marked factors in the production of the disease.
Trachoma is rare in mountainous regions, and increases toward the
lowlands. The peculiar susceptibihiy of some of the Continental
emigrants is possibly due to their unsanitary habits, rather than to
any inherent racial peculiarity of temperament. According to Burnett
and others, negroes are particularly immune from trachoma.

There is unanimity of opinion as to infectiousness of trachoma, and.
although there is a.n inclination 10 consider the disease as due to a
special germ, the reports of bacteriologic investigation have not been
harmonious.

Prognosis is unfavorable. The disease continues for many years,
and there is rarely complete recovery. The dryness of the conjunctiva
is very annoying, and by the irritation and exposure of the corneal
epithelium, with consequent opacity, vision is affected. Entropion
and trichiasis are disagreeable sequels.

Treatment. — ^The patient should be informed of the infectious na-
ture of the disease, and warned not to wipe his eyes on public towels.
To the strumous and poorly nourished, change of environment and
constitutional treatment are of great value. The conjunctival sac
should be washed several times a day with boric acid or a weak
solution (i ; 8000) of mercuric chlorid. If the symptoms are acute, the
temples should be leeched, cold appUca.l\otis wSiftiiVti. -iwft. -4.\.i's'i\-a.
instilled. As the inflammatory symptoms svto^\ie, a. W^i 'j«s^«-'«^

I 1

176 DISEASES OF T[iE EVE.

solution of boroglycerid in glycerin should be appi
It may be alternated with glycerol of tannin, or copper sulphate,
alum in pencil form. Long application of silver niiraie lea'
Iressing scars and discolors the conjunctiva, and is not a(lvise(
Those who derive good resulls from this salt use it with great
and only after long experience, Boroglycerid is more efficaci<
and can be given to the patient to drop in the eye at home durii
the intervals of visits to the physician's office. There is diversity o(
opinion relative to the value of protargol in this affection. We have
seen little good result from Its use. Mercuric chlorid in solution of
I ; 250 may be brushed over the everted lids. Op«rations destroyi
much conjunctiva defeat their own purpose, as the previous desti
lion of this membrane by the disease is already the cause of
disagreeable complications. In cases in which the granulations
very profuse and have not yet ulcerated, the disastrous sequels rai

dis-

be averted by expression. A favorite method
the granulations with roller- forceps (Fig. 69), but

jutine practice. Tension may be relieved by splitting tbe
externa! canlhus and cutting the canthal ligament. Hyperemic
and soft granules must be more carefully handled. Massage with
iodoform ointment may be used, and is less painful to the patient,
and often gives good results in a very short lime. Pannus should
be treated by massage, peritomy, or jequirity-inoculation (see under
Oiseases of the Cornea), Distortion of the lids must be corrected
and corneal opacities treated. Constant instillations of glycerin
some bland oil are said to be palliative in xi

TUBERCULAR CONJUNCTIVITIS resembles trachoma, but is,

rule, confined to one eye. The ulcers are decidedly greater than
trachoma. The diagnosis may be definitely established by baclt
Jogic examination and by the symptoms of tuberculosis eUewh<
^^Ae prognosis is tinfavorable. Tte \oca\

rindH

F THE CONJUNCTCVA. 177

destruction of tissue invoVed. The general treatment is that of
systemic luberculosis.

VERNAL CONJUNCTIVITIS. OR SPRING CATARRH, is a COnjunc-
lival inflammation recurring each spring or summer and disappear-
ing with the frost, characterised by a pericorneal epithelial hyper-
trophy. The affection is binocular, and occurs chiefly in the young.
It is characterized by a swollen and injected linibus and the signs of
general catarrhal inHamniatinn. The conjunctiva is pale, and looks
as if it were covered with a thin film of milk. The cornea itself
is not involved. There may be localized hypertrophies on the con-
junctiva of the upper lid. The disease disappears spontaneously, only
to return in the majority of cases the next season. The average
duration is about four years. In a few cases slight opacities are \e{t

Treatment. — The refraction should be carefully examined, and any
ametropia corrected. In some cases it is even advisable to put the
ciliary muscles at rest for several weeks, by the daily instillation of
airopin. A mild, soothing lotion should be prescribed, and pro-
tective glasses ordered.

PHLYCTENULAR CONJUNCTIVITIS.
Synonyms. — Lymphatic, scrofulous, or herpetic conjur

-This dise

IS char

;riied by the

porary vesicles or pustules on
the bulbar conjunctiva {rig. 70).
These blebs are called phlyc-
enules.and are grayish -red and
flallened prominences, from
one to four mm. in diameter,
with deep-red surroundings.
Sometimes only a single bleb is
seen. When anumbercf these
phlyctenules are present, there

gestion, pain, photophobia, and
even blepharospasm. The lid

is swollen and red, Ihe conjunctiva injec\.ed tivvA vtVutA'j ,-m\&.'&wxi\«.
mucopurulent discharge. The vessels suppV^'in^V'Rc^'n^tt'i.e.ft.te'erao

F THE

^^Vare swullen and become tortuous as they approach the phlyctenule.
^^H In the purulent form the disease soon reaches its height, i
^^m severe for a few days, and then subsides. The milder varietii

the patient shght inconvenience. Scrofulous children are particularly
susceptible, and the disease is often seen in children with signs of
eczema elsewhere on the body. It may follow the common infectious
fevers. In debilitated children there is a tendency to relapse,
disease may continue for years.

Unless the cornea becomes involved, the prognosis is good. Bac-
terial infection has been suggested ai

Treatment. — The constitutional treatment consists of cleanliness,
fresh air, good food, tonics, cod-liver oil, etc. Local Ir
of the daily application of a mild Pagensiecher ointment, and irriga-

*tion with a mild antiseptic solution. Calomel may be dusted over the
effected area, unless the child is taking some preparation of iodin.
The applications should not be made in too rapid succession. Mas-
sage with a ten per cent, iodoform ointment, or with a weak salve of
the yellow oxid, is often of value. A I : looa aqueous solution of pyok-
tanin has proved useful. Boroglycerid, fifty per cent., is a useful,
application. The more severe applications, such as silver nitrate and
the zinc salts, were formerly used. Stimulating applications shouU
be avoided if there are signs of a corneal ulcer.

PINGUECULA is a small, yellowish growth on the bulbar conjunci
tiva, close to the cornea and usually to the inner side. It has
vascular supply, and is pale when the rest of the conjimcllva is ci
gested. Mechanical irritation is the probable cause. There is little

^^ discomfort, although it may lead to pterygium. No interference i

^^L nOcessary.

^H PTERYQiUH is a triangular patch of thickened conjunctiva, na

^m common on the nasal side ; the apex of the growth points toward lb
pupil, and the fan-shaped base radiates toward the canlhus. As
continues to grow, it resembles a mass of flesh ; and as years go on
partly atrophies, becomes pale, and appears tendinous. It is looself
attached at the limbus, and in this position a probe can be pai
under its edges. On the cornea the growth is firmlj' adherent and mu
be torn or dissected away. If the pterygium grows over the cornea,
aiaydmg the conjunctiva and carundc WaV "w Vo suiAi a.&«Gieti
to inierfere with the movemeTits of V\\e e-itba.\\."tae.^\4« \KtQtK

has developed

>t exlended upon the cornea and
lay be left undisturbed. A flat,
of growth, and excision need not
neans active progression. The
Grasp the neck of the pterygium
in perpendicular to the surface ;

unsightly. This affection is frequently found in elderly persons ■
have endured exposureinyearsof outdoor occupation. It is comi
in sailors. One eye is usually aflected, although the growth has h
seen simultaneously in both eyes, an
from the outer canthus.

Treatment. — If the growth has n
shows no sign of progression, it r
stringy head indicates a ce
be resorted lo. A vascular head r
operation of removal is as follow
with fixation forceps, making tra<
dissect up the head, and make
two converging incisions into
the body with a pair of scissors.
The pails between these inci-
sions are dissected away and the
loienge-shaped wound closed
by a suture apphed about the
middle of the wound. Another
method of removal Is by trans-
piantalion. The growth is split
longitudinally and is fixed in an
upper and a lower conjunctival

pocket with a suture. Ligation fic. 71.— Lioatioh oi' Ptebigium.

has also been recommended ; a

large part of the pterygium between the sclerocorneal margin and the
base of the growth is strangulated by sutures in the manner shown in
figure 71, It has been suggested that the whole trouble in pterygium
lies in the apex, and curetment of the affected cornea or the applica-
tion of the galvanocautery has produced good results. Under the old
operations pterygium was liable lo recur, and sometimes repeated
operations caused limitation of (he ocular movements. Electrolysis
is the most recent treatment proposed.

INJURIES OK TliK CONJUNCTIVA.

FOREIGN BODIES in the conjunctival sac are sometimes difficult

to locate, and the lids should be everted and the bottom of the sulci

explored. In case a /breign body resists re'mova\,\\.Ti\iK.'t'^t^»;t&»s&-

bered that il wilj cause disagreeab\e sytYXptotns, a.wi™^^- *^"'*-'***^

have lo be taken out ; therefore, in refractory c;
with 3. forceps and dragged out, even at ihe risk of laceration, j
Cocain may be u^ed in the removal of a foreign body, and a mildl
antiseptic wash prescribed.

WotjNDS of llie conjunctiva, if slight, need only s
vnsh. such as boric acid or a I : ;ooa mercuric chlorid solution.^
Extensive wounds must be closed with a fine suture. Large granu-
lations after wounds or operation may be cut off at the base with a
pair of fine scissors.

StJBCONJUNCTlVAl. HEMORRHAGES occur after Iraumatisni, vio-
lent exertion, or severe fits of sneezing or coughing. They disappear
spontaneously in two or three weeks. Subconjunctival hemorrhage,
coming on several days after an injury, is indicative of fracture of
the orbit. Spontaneous hemorrhage in the conjunctiva is a dangerous J
signal of an atheromatous condition elsewhere.

BiiRNS of the conjunctiva are usually on the bulbar portion, whicb
is most exposed. The

with a piece of cottor
neutralized at once.
Cocain and atropin a
plied in the form of ai

'^TTS^v "

cned conjunctiva i
pLintatlon of new s
the deformity.

n cleansing the eye, u
y lime, when the parts should be washed 1
■A in oil. Acids and alkalies should be \
oil or liquid vaselin should be instilled.!
isable to relieve the pain, and may be ap-l
Atropin, o. I; cocain, 0.2: vaselin, lo.Oi
of the lid to the eyeball, ihusi
'e (Fig. 72). It is cicatricial i«r
origin, following some i
jury, burn, or destructivein
flammalion of the conjunc-J
liva. It should be preventei
by keeping the injured o\
posed areas from being iaj
apposition during the heal-4
ing process. Symblepharoitf
is treated by dissecting
the constricting tissue anij
preventing the cut ends froitf
liting by transferring \oo^.

e surface. \n
mucous merobtm

s 1^**1 Vi

NEW GROWTHS.
TUUDRS of the conjunctiva are lipoma, polypus, cysts, dermoids,
sarcoma, and carcinoma. Lipoma should be turned out; ptolypus,
excised down to Ihe healthy tissue; and cysts, opened and their
walls cauterized. If solely confined to the conjunctiva, sarcoma and
carcinoma may be carefully excised, and the wound cauterized by
the galvanocautery. In cases of deeper involvement, enucleation
of the eye becomes imperative.

^'Anatomy.

DISEASES OF THE CORNEA.
—The cornea is the transparent tunic covering the

nrtor fifth of the globe of the eye. It is circular in form, t
vex, and, by the way it is fitted into the beveled edge of the sclera,
resembles a watch-crystal. When examined from its exterior surface,
its vertical diameter is about one-sixteenlh shorter than the trans-
verse; on its interior surface its outline is perfectly circular. The
cornea is one mm. thick at its apex. It is covered with the conjunc-
tiva and is itself composed of three layers (Fig. 73). The anterior
layer consists of epithelium, columnar in shape, supported by a homo-
geneous elastic structure cMed B<rwmart's membrane. The middle
layer constitutes about 95 per cent, of the whole cornea, and consists
of fine connective tissue and elastic fibrils, which are arranged in
layers; between these layers is a series of communicating spaces,
called lacunas. The lacunas, with iheir canals, constitute the lymph-
system of the cornea, and through them the nutrient fluid circulates.
In order that the cornea may be perfectly transparent, in health it is
devoid of blood-vessels. The posterior layer consists of a glass-like,
structureless basement tissue, called Descemefs membrane, which, in
spite of its exlreme thinness (.006 mm.), is very strong. On the sur-
face of Descemel's membrane there is a single layer of flat endothe-
lial cells, continuous with the anterior surface of the iris. The cornea
is richly supplied with nonmedullaled nerves, which extend to the
uppermost layer of the corneal epithelium, and are sensitive indica-
tors of irritation of the exposed surface.

INFLAMMATIONS OF THE CORNEA demand 9a.w!\«ia.X ■JM.eti'OiKrtii
as they are very hkely to result in opacities, Xeavvtv^w

DISEASES OF THE CORNEA.

optic disturbances. Since the cornea is inelastic and nonvascular,
the ordinary signs of inflammation are not present, and the diagnostic
sign is cloudiness of the tissue, resulting from a collection of leuko-
cytes that have passed into the cornea from the adjacent blood-
vessels. In corneal inflammation there is generally swelling and
inflammation of the lids and congestion of the conjunctiva. Peritor-
nealinjectioH is due to congestion of the deep conjunctival vessels,
arising from the ciliary arteries. Inflammations of the cornea may
be divided into two classes, supfrficlal znA deep.

PANNUS.

criplio

— Panni

;ula

the superficial layer of the cornea ;
the deeper layers. It begins with
which large areas become clouded
and infiltrated with superficial
blood-vessels. The newly formed
and tortuous vessels are largest
at the periphery, and are directed
toward the center of the cornea.
There may be only one vessel, or
the vascular formation may be so
luxuriant that a great part of the
corneal surface is transformed
into a fleshy-looking mass, having
the appearance of raw beef. This
condition is sometimes called ^unj

The cause of pani
lids against the cornea, or ther
matous process into the cornea
affected (Fig, 74). Prolonged

growth of connective tissue on

may. however, extend and affect
inflammation of Ihe cornea, in

IN Thachoma.— I.J/i'd-

generally the friction of roughened granular

nay be an extension of the tracho-

The upper half is the part usually

of the cornea by inverted

^^opai

lashes or entropion may cause pannus unassocialed with ulcers. The
eczemalous variety of pannus is a sequence of a phlyctenular process.

The aymptoma of pannus are p:iin, photophobia, lacrimation, swell-
ing, conjunctival and ciliary injection, together with lie character-
istic vascular appearance.

The prognosis depends upon the extent of corneal infiltration and
destruction of the epithelium. The important b«^u.«,1« »."!t •^tnwssi.
'.cities, and, rarely, conic cornea and cottiea\ «a.^\viV«a»"

\tS4

The treatment should be directed to the cure of Ihe granular lids, |
or to remedying tbe trichiasis or entropion. Should Ihe pannu!
last the causes of the disease, massage with yellow ointment o
application of such preparations as boroglycerid and copper sulphab
should be tried. Eserin, and iodoform or one of its substitutes, 3
constant bandaging of the eye are of value. The extreme measu
are peritomy, which consists in removal of a ribbon of conjuDctlvs^
about two mm. wide, parallel with the edge of the c
ing and obliterating the superfluous vessels (unfortunately, the vessels
repullulate) ; or the induction of an acute inflammation of Ihe con-
junctiva with an extract of jequiriiy seeds. For Ihe relief of pain, ^^
Latropin and hot-water applications a

INTERSTITIAL OR I'ARENCIIYMATOUS KERATITIS.
Definition. — Diffuse inflammation of the substantia propria of ll

Symptoms and Diagnosis. — In this disease the deeper tissues •
a became infikrated by lymph-cells, whicb slowly increa;
[ until the whole cornea becomes more or less opaque. Without alen
the cornea presents the appearance of 1
piece of ground glass {Fig. 75), but foe
illumination shows that the parts are ni
uniformly alfecled, and sometimes ui
affected portions may be seen betweel
local opacities. Pericorneal injection i
marked, but the conjunctival vessels lax
be but slightly affected. The epitheliuK
may be partly destroyed. The iris maj
be affected sympathetically and posleriof
Wjrnechias formed ; in fact, the whole ciliary region and the chora
■ may be affected and the nutrition of the vitreous disturbed. In ve
severe cases blood-vessels form in the interstices of the cornea. Tl
disease is Ihe result of general infection, and, according to Horner, li
at least 80 per cent, of cases both eyes are attacked eventually,
disease occurs chiefly in hereditary syphilis, and is associated 1
iheoiher signs of this malady, such as Hutchinson's teeth, thickeo
//}£■ of the periosteum, glandular swellings, middle-ear disease, t
A syphilitic history may be obtavned (rom v\vc p3.ieiM.&. tVit to.w;

^H DISEASES OF THE CORNEA. I85

^nay bear evidences of specific infection, and give a hislory of sickly
cliildren or recurring miscarriages. It is probable that some cases are
of tuberculous origin. The chief subjective symplotns are ditnness
of vision and lacrimalion, but there may be much pain or photo-

The prognosis is unfavorable, although complete loss of \
seldom to be feared. The disease is of long duration, and
tion of the visual acuity is doubtful, especially if the patien
very young.

The treatment Is directed to the systemic condition, and co:
mercurials, iodids, cod-liver oil, and tonics, cleanliness, good food,
and fresh air. The following is a good formula :

B- Mercuric iodid g'' '}

Poiassium iodid, gij

Syrup of sarsBparillo q. ».ad ^iij.

A leaspoorful in waler after meals.

The local treatment is by atropin, warm compresses, and protective
glasses. When the disease has passed its climax, massage with yellow
ointment or dusting with calomel are of advantage.

PUNCTATE KERATITIS is a disease of the cornea associated with
affections of the iris, choroid, and vitreous. It is characteriied by
the formation of opaque dots, generally arranged in a triangular
ir upon the posterior elastic lamina of the cornea, and hence is
i called descemetitis, which term, however, is usually
restricted to serous iritis. It is also used to express an inflammatory
affection of the cornea occurring in young syphilitic children, in
which isolated white spots, surrounded by cloudy areas, appear on
Descemet's membrane. There is a superficiiil piinciale keratilis
associated with severe conjunctivitis and catarrh of the respiratory
tract.

PHLYCTENULAR KERATITIS.
Description. — Although there is no especial reason for separating
this disease from phlyctenular conjunctivitis, it is usually also described
under Diseasesof the Cornea, It is particularly a disease of children
of scrofulous diathesis or improper nourishment, or who show signs
of edematous affection in other portions of the body. Adults and
^^aXihy childtea are also affected. \l va c^&'ia.OKiaj

I l86 DISEASES OF THE EYE.

I tiiore phlyctenules, or small cysts, formed on the limbus of the
junctiva, and extending upon the cornea (Fig. 76). These phlye-
tenules cause an opacity which may clear up or may be followed bj
the formation of a bundle of new vessels on the cornea. This leaih
of vessels may disappear, but the ulcer beneath them generally leav(
I an opacity.

[ Symptoms. — The chief symptoms are acute pain, photophoW
lacrimation, and the characteristic bundle of vesseb, with ~a yellc
crescent at the apex, its concavity toward the vessels. Every phlyc
tcnule does not necessarily change to an ulcer, but may be dissolve^
under proper treatment. The photophobia may be so intense as
cause blepharospasm, because irritation of so highly nervous
tissue as the cornea gives rise to severe reflex symptoms. Tl
blepharospasm may be so severe as to necessitate the administratic
a general anesthetic before the cornea can be properly examine
The treatment consists of good foo
improved hygienic surroundings, a.[
soothing local applications. Of ll
latter, atropin and warm compressi
areadvised. Theeyemaybedouch(
with mercuric chlorid. 1 : 8000. If a
ulcer exist, the general treatment i
before described should be institute
When the ulcer has healed, it shoul
be dusted with iodoform or calomc
and massaged with yellow ointmen
We have found that to promote al
ilillation of eserin into the eye, follovrc
ornea, and a constant applicatio
ng local heal, produce good results.

HERPES OF THE CORNEA is characterized by the formation t
small blebs filled with a watery fluid. It may be the general accon
paniment of herpes zoster or febrile herpes. The blebs should I
treated with the gentlest measures, such as the instillation of atropi]
disinfection, and a bandage. Should they form ulcers, they shoul
be treated as such,

NBUROPARAi,YTic KERATITIS is an ulcerative condition of tt
M, due to some disttirbance of ihtcomcaiTvctvt-sM'p^Vi. TV

^B DISEASES OF THE L'OBNEA.

^^prognosis and treaiment of the disease depend upon tlic
lesion causing it.

BULLOUS KERATITIS is characteiiied by the formation on tlie
cornea of large vesicles filled wilh a clear fluid. The vesicles break
after a few days, and the symptoms of irritation subside. This con-
dition has been seen associated with glaucoma, iritis, and inflamma-
tion of the uveal tract. The disease has been attributed to some
affection of the corneal nerves, and to malarial fever. A peculiar
chronic form is sometimes seen after corneal injury. It is called
recurrent traumatic keratitis. U is said that the recurrent attacks are
preceded by a peculiar aura, and that they may be aborted by large
doses of quinin. The vesicles should be incised early, and local
treatment instituted.

KERATITIS FROM LAGOPHTHALMOS is a Condition in which there
is ulceration of the cornea, due to exposure from incomplete closure
of the lids. The chief causes are lack of sensation in the cornea from
paralysis of the peripheral nerves, a condition in which the patient
lies comatose for a long time, and possibly some paralysis of the
lid-muscles. Protection by anointing with vaselin or a bland oil is
indicated.

SUPPURATIVE KERATITIS.

Corneal ulcer is caused by an external wound leaving an opening
for the entrance of a suppurative process, by intense conjunctival
inflammation, or by some deep inflammatory process which leaifs to a
destruction of the superficial layers and epithelium.

Diagnosis and Symptoms. — It is very important lo immediately
recognize any superficial loss of substance in the cornea. The or-
dinary optic aids, such as oblique focal illumination and high plus
lenses, or the ophthalmoscope, are generally sufficient. In doubtful
cases and in young children, a drop of fluorcscin placed on the con-
junctival sac, and immediately washed out, is a ready means of diag-
nosis. Any spot of the cornea denuded of its epithelium will be colored
green. If an ulcer is present, we must determine whether it is due to
external infection, from extension of some conjunctival disease, from
nervous disease, or from some systemic affection, as the subsequent
treaiment depends much on the origin. However, If pain, photo-
phobia, lacrimation, and attendant svjeWit^g o\ \i\e.\\4,^'4.tA.>^^'^'»K>

^^KSO.

together with extensive and progressive desiruclion of tissue, are
present, it is necessary lo proceed imtnedialely, regard!)
mode of origin, which may be left to a subsequent
ulcer with a ragged edge and a grayish, uneven base, with general
cloudiness around ihe circumference, and acute associale local dis-
turbance and subjective sytnploms, is probably in an active stage of
inflammation. If the cloudiness is clearing up, the edge round, and
the ulcer appears clear and smooth, and the patient's symptoms are
subsiding, the healing process has probably begun,
becomes filled up, the opacity becomes more dense ; the younger the
patient, the sooner the scar will clear up. Central ulcers result
most damage to vision.

The sequels of most importance are : corneal opacity ; staphy-
loma, or hernia of the cornea, due to weakening of its structure by
scar-formation, which condition sometimes includes a staphyli
the iris as well as the cornea ; perforation, followed by discharge of
aqueous and prolapse of the iris, which may remain permanently
adherent to the white corneal scar, a condition called leukoma mf
AiTCwj; atrophy of the eyeball, called^A/Arji>i«/i(', following i
destruction of the cornea ; and prolapse even of the lens and vilreous,

The prognosis varies with the age of the patient, location and
extent of involvement, and the general systemic condition.

The treatment is. first, to put the eye at rest, which is best accom'
plished by a pressure-bandage and by alropin, which subdues pain
and overcomes inflammation. If there is much congestion of the
conjunctiva, leeches to the temple will give great relief and hasten
subsidence of symptoms. Disinfection is best accomplished by a
mercuric chiorid solution, I ; 5000, or the ulcer may be dusted with
iodoform. After dusting iodoform on the cornea, the upper lid should
be drawn away from and down over the cornea, and held in position
a few minutes, otherwise movement of the eye will brush all the
powder off" the cornea. If the ulcer progresses, stronger disinfection,
preferably with mercuric chlorid, 1 : looo. boroglycerid 50 pet cent,
or formalin 10 per cent., will be needed. Finally, if the ulcer resist;
all treatment and is progressive, the whole of the infected surface
should be cauterjied by the direct heat of the galvanocaulery. Moist
heat, applied in the shape of mild antiseptic compresses, will lessen
ihe ;>ajn, increase ihe development of blood-vessels, and arouse a

\eral reaction in Ihe affected parts.

If perforation seems probable.it is best to haslen it by puncture
with a needle or small cataract knife, as experience has shown that
perforated ulcers heal quickly of tliemaelves, and better drainage Is
established. After perforation the eye should be carefully waStied,
eserin inslilled, a pressure-bandage applied, and the eye allowed to
remain untouched for at least twenty -four hours. If the iris prolapses,
it must be drawn from the wound and excised. When the ulcer
shows signs of healing, daily massage with a weak Pagenstecher
ointment is advisable. The membrane of Descemet is very elastic
and sometimes, instead of perforating, It prolapses through the ulcer
and prevents its healing, causing a corneal fistula. In such cases
the edges of the ulcer should be stimulated or cauterized. The treat-
ment of the sequels will be discussed separately. Constitutional
treatment, particularly administration of Ionics, should be inaugurated
al the beginning of the disease, and any causal disease corrected.
The patient should not be kept in an ill-ventilated, dark room.

ABSCESS OP THE CORNEA may run its course without ulceration,
or it may result in ihe formation of an ulcer— usually the ulcus ser-
pens. Abscesses in the superficial layers of the cornea are most
prone to ulceration.

The chief causes of abscess are infection through an abrasion or
distinct wound, or infection through the blood or lymph channels, as
seen in some acute cianthematous diseases, such as measles, scarlet
fever, small-pox, etc.

The appearance presented is that of a yellowish, circumscribed
opacity near the middle of the cornea, and surrounded by a grayish
zone. It is usually round or crescentic in shape. The surface over
the abscess appears elevated and dull, and the whole cornea may
lose its luster and appear as opalescent. There is usually much
conjunctival and ciliary injection. The abscess is attended with
severe pain, photophobia, blepharospasm, etc. Hypopyon, onyx, and
iridic involvement are usually constant altendants. The common
termination is ulceration through the superficial corneal layers; but
occasionally the abscess spreads through the corneal stroma, and
gradually becomes absorbed without undergoing ulceration.

The treatment consists of atropin. warm fomentations, iodofovm,,
and a light bandage. If these measures do noX. thtclt 'C^t^ofsisi,
resort must be had lo Ihe cautery. HypopV'^'" '^^ ■ctXvfc'Jti "fti ij-^^*'

■MR

DISEASES OF 1

nature of cinchona comp.
g diet should be instiluied.

t the

SERPIGINOUS ULCER, OR ULCUS SERPENS, is a destructive inilam--

n of the cornea usually attacking debililaled and aged persons.

Disease of the lacrimal passages predisposes to It. its chief chatacier-

s its remarkable inclination to extend and destroy tii
most commonly results from some injury to the eye, often only
small scratch, through which some form of infecting germ
duced. Infection may be derived from the article causing the inji
from some purulent discharge about
eye or its appendages, or from some
article used to wipe the eye. At the
posterior part of the ulcer thi
ally seen a grayish cloud, which may
tend into the anterior chamber. This
caused by a collection of pus-

I""['(((|i['|i[]r[i[\iV>' in the lamellas of the cor

Fic. 77-— Acute Ebsfiginoub onyx, or in the anterior chamber, whicb
Ulcer of the Corner. render the aqueous opaque, and, settling

in the bottom of the anterior chamber,
form what is called hypopyon. The disease begins as a round, yellowish
abscess near the center of the cornea (Fig, 77), which breaks and forms
an ulcer rapidly increasing in surface and depth. Serpiginous ulcer
often follows severe infectious diseases, particularly smalUpox.

The prognosis is unfavorable, as there is generally left an exten:
opacity, and most likely anterior and posterior synechias.

The treatment is the same as for an ordinary severe ulcer or
scess, Occasionally Saemisch's operation at the base of the ulcer';
required.

Rodent ulcer is a chronic inflammation, beginning 1

I of the cornea and slowly eating its way to the opposite margin,
rarely extending intothe deeper layers. Its edges must be
ANOMALOUS OPACITIES.— In this connection it is deemed 3d<
able to mention peculiar acute opacities, evidently de nutritional,
which can not be called ulcers or abscesses. They develop rapidly
MS white spots without previous signs of corneal inflammation, and
sometimes leave permanent opacmcs. Itta ^\\c'MiTOt:iv(iT^\\-aa'
noticed after adacks of severe conjuncCiN\t\5 ^^li IqWo^v&^i"

DtSEASES OF THE CORNEA.

iritis. Such denutriUonal ftpacilies are no more
ment than Ihe ordinary forms foUowmg corneal ul
use of mercuric chlorid in catnract-extrac
neal opacities, which may be permanent.

VARIETIES OF CORNEAL, OPACITIES.— Leukoma is the densest
corneal opacity, and appears as a white spot. Macula is less dense,
and appears as a bluish-gray spot, and is only visible against a dark
background. Nebula is a transparent and extremely delicate opacity,
which may only be delected by optic aid, and is often overlooked in
first examinations. The degree of visual disturbance is dependent
on the position and nature of the opacity. A considerable opacity at
the margin of the cornea may cause little orno trouble, while a nebula
in the center of the cornea markedly reduces the visual acuity.

TREATMENT OF CORNEAL OPACITIES. — The results of the treat-
ment of corneal opacity vary with the estent of the involvement and
the age of the patient. Fortunately, there is a strong tendency
toward clearing up in young patients. Absorption is favored by mild
irritants and absorbents, such as finely-powdered calomel or iodo-
form dusted upon the curnea, and massage with yellow ointment
or iodoform ointment, continued months and even years. By retain-

Fio. ;B,— Tattooing NKtuLa.

•ng heat, a hght bandage promotes absorption. The greatest degree
of patience must be exercised to produce a beneficial result.

If the condition of the retina is believed to be favorable, and
part of the cornea is clear, an optic iridectomy, forming an artificial
pupil back of the transparent portion, will improve vision. As yet,
I he insertion of transparent corneal grafts has not been successful.
Recently some progress in the clearing of corneal opacities has been
made by a special use of the galvanic current. Tattooing the opacity
with India ink is sometimes resorted to for cosmetic as well as optic
reasons. The ink is gently inserted by several fine steel needles
firmly fastened in a handle (Fig. 78).

X grayish-while opacU'^, £)AtTi&iv^».^wa.-a*i'&>e-

a 'about i.j mm. fronn ite botdet. T^e.

in aged and ^

STAPHYLOMA OF THE CORNEA is a bulging forward of a corneal

r wilti an adherent iris. It is caused by the weakening of the

I corneal tissue, which gives way to the intraocular pressure, pushing

1 the lens forward.

Secondary glai

mplication. The staphyloma
may be partial ortotal {Fig. 7g). The
pain, loss of vision, and repulsive dis-
figurement associated wiih this affec-
tion render the palientagreat sufferer,
Treatment.— Unless the condition is
only that of a simple prolapse of the
— iris, the treatment is of no avail

ir ~t-o iPLETH bTAPH^LoMA When possiblc, abscission of the sta-
phylomalous projection, forming 3
uitable stump for a glass eye, is to be preferred to enucleation,
I particularly in young children, in whom the presence of orbital ci
s is necessary for the symmetric growth of the face. If there aj
signs of infection or internal disease, enucleation is peremptoril
demanded.

inning and
:, without alteration
the transparency. It is the result of progressive weakening of
corneal tissues. It occurs in young persons between ten and twenty
years of age, without any evidence of inflammation. It eventually
becomes stationary, and perforation never occurs. The pathology
is obscure. It is readily diagnosed by the distorted image
patient's cornea, the depth of the anterior chamber, and by
relinoseope and ophthalmoscope; in fact, it is only necessary to
a side view of the patient's eye.

Treatment is of little v.ilue, although a high minus spheric
combination of minus spheric and minus cylindric lenses may
\ prove the vision. Hyperbolic glasses have been devised, but are
mt/e used. Trephining a fine piece o\ \\\e apex o\ ^nt
'Jiing- it wiib a special galvanocauicfj vi^^w. ai\i

or« [

TUMORS OF THE CORNEA are very rare, but the cornea may be
attacked by new growths which arise at the conjunctival Mmbus.

INJURIES TO THE COKNEA.
'OREIGN BODIES IN THE CORNEA, if not removed, aim
biy cause cell-intiltration and destruction of the adjacent tissue, tl
inviting infection. However, the subjective symptoms so well kno
to everybody are usually so severe as to demand immediate tri
ment. Although simple inspection may be sufficient, focal i
mination and fluorescin, for (he detection of the denuded area
epithelium, are sometimes necessary for locating abrasions.
every case it is safer to examine the eye by focal and oblique illumi

Foreign bodies in
out the useofcocai
is wound on itself oi

n the cornea can generally be removed with-
id without insUumtnVaX aS5i. K-«'\a'jiA tWisro.
a small stick ■,lhepa.<vft'iU.\a\o\&\Ki\'iOs,iiE™-5i-

DISEASES OF THE EYE.

I ward, and the cotton is pressed firnily against the cornea. The paiient^H

odyM

ward, and the cotton is pressed firmly against the cornea. The patient 4
immediately rotates the eyeball upward, and the cornea Is brushej^
against the fibers of cotton, which usually entangle the foreign body.B
We have found this simple method almost invariably successful, and ■
we urge its trial before resorting to the spud or needle.

The removal of a foreign body from the cornea by it
procedure that should be carried on with especial caution. If the
substance is embedded, the cornea should first be cocainized and ren-
dered aseptic.

Under focal illumination, a small curet, chisel, or spud will gener-
ally accomplish the removal. If, however, the foreign body is closBa
to the anterior chamber, it may be lost in the iridic angle. In such M
case a small keratome should be introduced ir
and pressed against the posterior surface of the cornea, thus prevenH

L iDg penetration of the foreign body into the anterior chamber,
c magnet is often of great value in removing pieces of iro

I- steel. A boric acid wash or iodoform ointment should be used for ■!

[ least twenty-four hours after the use

BURNS OF THE CORNEA are treated on the same principle
burns of the conjunctiva, already described. Ulceration , o pacities
and svmbl epharon a re the important sequels to be feared.

WOUt«DS OF THE CORNEA are always dangerous, not only fra
the destruction of corneal tissue and subsequent opaque cicatrix, I
they are also often attended by sudden escape of the aqueous )
prolapse of the iris. Results of infection through a corneal wounfl
vary from the formation of an ulcer to the destruction of the whoH
^eball.

The treatment is the application of a simple aseptic bandaj
The eye should be kept clean, and if there is much irritation, s
should be used. Should the iris become prolapsed, an effort nr
made to replace it and retain it in position by eserin, complel
I and a bandage. If this treatment is not successful^he iris should be
drawn out and excised. Very large prolapses^shonld not be excised,
as they will recur, and much iris tissue Will be needlessly lost.
In such cases no operative interference is indicated until the wound
closes. The cornea and iris are cleansed, an attempt made to par-
lra//y reduce the prolapse, atropin inW\\lt4, a ^xesaMrc bandage
applied, and the patient placed on hisba.A

'^'-^^

lmic banda ge J |

^^P PAI

OPERATIONS ON THE CORNEA.

PARACENTESIS OF THE CORNEA is an Operation performed for the
purpose of emptying the anterior chamber of aqueous, and thus reliev-
ing any increased intraocular tension, or for evacuating hypopyon. It
is best done with a paracentesis needle, a bentkeratome, or a slender
Graefe knife. The eye is thoroughly cleansed, and the point of a
aseptic kni{eispirprniiicu/ar(y introduced at the lower outer border of
the cornea. If it is introduced at an angle, there is danger of splitting
the layers of the cornea, and not directly perforating it. After per-
foration of the cornea, the blade of the knife is turned horizontally,
and a corneal wound of about two
mm. in length made. The knife is
then slowly withdrawn, allowing the
aqueous to escape slowly. Depres-
sion of the lower edge of the wound
by a curet will aid in the evacuation
of hypopyon.

EAEMISCH'S OPERATION is per-
formed for the relief of corneal ab-
scess or serpiginous ulcer. It con-
sists in introducing a Graefe knife
through healthy corneal tissue at the
margin of the involved area, carry-
ing it into the anterior chamber,
and making a counterpuncture in
healthy tissue at the other side of
the abscess. The cutting-edge is
then drawn forward, and the abscess
bisected. Any pus may be removed
by irrigation or by a scoop. The woui
completely so long as the disease is ac

id must not be allowed to close

TRANSPLANTATION of CO
trephine, a piece of a rabbit'

consists in removing, with a
nea. and transpbnling it ove
ibtfui value in any case.

ABSCISSION OF STAPHYLOMA OF CORNEA AND SCLERA, -
CRITCHETT'S OPERATION is the simptesl. and ■rooW. t'fi.e^t'oi.-ic- "SV

pthreaded needles are inserted, enu\A\sva.vi\. ^Tii Ya.xjSvi?i ■»rv«i

196

arolher, through Ihe base of ihe staphyloma (Fig. 81); the involvn
tissues are then excised with a knife or scissors, a.nd the needles
drawn through and the sutures tied. This leaves a very desirable^
stump upon which to place an artificial eye. This operation i
be preferred to enucleation of the eye in children, as the stump favors
symmetric growth of the face.

I DISEASES OF THE SCLERA.

Anatomy.— The scleraforms the euternal tunic of the posterior four- '
fifths of the eyeball. It is a dense, fibrous membrane, thicker behind
than in front. Since the surface of the sclera is partially protected by
the conjunctiva and partially by the capsule of Tenon, an epithelial
surface is unnecessary, and both the internal and external surfaces
of the sclera are covered with endothelium, which facilitates move-
ment against the capsule of Tenon on one side and the middle tunic
on the other. Anteriorly, the sclera presents a beveled edge for the
reception of the cornea, in the same way that a watch-glass is received
in a grooved case. The anterior surface is covered by a thin, tendi-
nous layer, the tunica albuginea, which is derived from an expansion
of the tendons of the recti muscles, and which, by reason of its bril-
liant white appearance, is commonly called " the while of the eye."
Posteriorly, the sclerotic is continuous with the sheath of the optic
nerve. At the entrance of the optic nerve the sclerotic forms a thin,
cribriform lamella, called the lamina cribrosa, which is pierced by
the filaments of the optic nerve and the central artery and vein of the
retina. The sclera is also pierced, about twelve mm. anteriorly, by the
posterior ciliary vessels and nerves, and still more anteriorly by the
vens vorticosse, which empty into the ophthalmic vein. Close to ihe
limbus, the anterior cihary vessels and nerves enter the sclera. The
fibers of the sclera contain numerous lymph-channels communicat-
ing with those of the cornea and of the internal and external struc-

SCLERITIS OR EPISCLERITIS.
Inflammations of the sclera are usually secondary to those of Ihe
cornea, cUiary body, and choroid ; in fact, all four of these structures
rnay be involved in anterior 8cleroctoTo\d\tt». \ivo^a3ii\c.Sisea.MeiA
the sclera is not common, and is ncvci dtSvjse.

DISEASES OF THE SCLERA. I97

Episcleritia is a localiied inflammation of the scleral tissue charac-
terized by a purplish injectign of the ciliary, deep pericorneal, and
conjunctivalvessels.

Symptoms and Diagnoais. — If the conjunctival vessels are kept
empty by gentle pressure, the bluish scleral vessels are seen more
clearly. There is considerable pain on pressure and some local
swelling. Carefully examined, a flat nodule made up of minute vesi-
cles is seen lying about three mm. from the edge of the cornea. There
are often adjacent slate-gray blotches, which are very diagnostic.
The disease is intimately connected with rheumatic disorders, and
with syphilis and tuberculosis. The diagnosis is easy, and depends
upon the characteristic local condition and rheumatic, gouty, or
syphilitic history. There may be confusion with phlyctenular disease.
A phlyctenule is not covered with a network of vessels, may ulcerate,
and is of short duration. The course of the disease is protracted,
sometimes one nodule after another being formed until a large por-
tion of the sclera is occupied by blotches. Relapses are frequent, and
are closely connected with general rheumatic paroxysms. The pain
is more or less severe, and for the time the eye is practically useless
for near-work.

Treatment is general. Salicylates and the ordinary rheumatic
treatment should be instituted ; or if syphilis or tuberculosis are de-
fined, their respective treatments should be inaugurated. Ordinarily,
local treatment should be avoided, but in chronic cases massage with
yellow ointment may be tried. For the relief of the pain, moist heat
and pressure are advised. If the choroid is involved, atropin is in-
dicated.

ANTERIOR AND POSTERIOR STAPHYLOMA.

aTAPHYLOMA, or, more properly speaking, ectasia, of the sclera ts
the name given to change in the shape of the eyeball due to stretch-
ing of its outer coat. The weakest portions of the sclera, are in the
region of the optic nerve, and where it is perforated by the vence
vorlicosE.

ANTERIOR STAPHYLOMA is an outward bulging of the sclera in
the ciliary region (Fig. 82). It is caused by prolonged, increased
intraocular tension, and scleral disease, TbtpToV:wS\^^^*i\wi\'a'C™&,
and the black uveal pigment is seen t.hrou^\\ \V, "^^t ^\'i\.\>i'ivi^"««eV

•98

DISEASES C

^^H be of small size, or may include the entire

^^^B involving the ciliary body, lens, iris, and

^^^B due to some intraocular growth, such

^^V pation with a fine sound will reveal a fii

' Ibescler

irhalf of the globe.
If the pressure is
of the choroid, pal-
yielding body beneath

iderlying portion of the ciliary body being involved
in the extension. If the bulging
is of small extent, the condition
causing the increase iti ten
which produces the ectasia shi
be treated. If the major porti
of the ciliary region
3.bscission or enucleation may

POSTERIOR STAPHYLOMA

nontraumatic sclera! bulging at
the posterior portion of the globe.
It is closely associated with high
degrees of myopia, and is the re-
sult of a posterior sclerochoroidilis,
&nd is further mentioned under diseases of the choroid and myopia.

HVDROPHTHALMOS is a congenital condition in which the whole
sclera yields to increased ocular pressure and there is more or lest
uniform enlargement of the eyeball. It is due either to intrauterine
iridokeratitis, or congenital deficiency or clostire of the drainage
canals about the iridic angle. Early iridectomy and the long-con-
tinued use of eserin are advised.

WOUNDS OF THE SCLERA generally involve the iris, choroid, and
vitreous, and therefore will be discussed under penetrating wounds
of the eyeball. If the sclera alone is involved, healing is very prompt,
and there are no disagreeable sequels.

The treatment consists of disinfection, closure of the wound, and^
bandage. If there is considerable gaping, a conjunctival or «
e may be necessary.

^^ Ana

3 AXD CILIARV BODY.

DISEASES OF THE IRIS AND CCLIARY BODY.

Anatomy. — The iijs is a circular, contractile membrane of elastic
and non^triped muscular (ibers, which forms a septum between the
anterior and posterior chambers of the eje (Figs. 83 and 84). It is
pierced somewhat toward the nasal side of its center by a circular
opening called the pupil. It is suspended from the cornea by the
ligamintum pccfinatum iridis, and hangs in the aqueous humor,
slightly in front of the lens and ciliary processes, and about 2.5 mm.
behind the cornea. The anterior surface is lined by flat epithelium
continuous with Uescemct's membrane. The posterior surface of the
iris is lined with a deep purple pigment, which is called uvea, from
its resemblance to a ripe grape. The iris is composed of two layers,
an anterior or muscular, consisting of radiating fibers, which converge
from the circumference loward the center and dilate the pupili^Some
authorities consider this layer fibroelastic rather than muscular. The
circular layer surrounds the pupil like a sphincter, and contracts the

The vascular supply is from two sets of anastomosing vessels, one
of which is located in the ciliary or peripheral portion, and the other
surrounding the pupillary margin. The arteries are branches of the
long and anterior ciliary arteries forming the circuli iridis major ,
minor. They are very numerous, and are provided with extraordi-
narily thick walls, so that they can maintain their lumen when
stretched.

The iris is plentifully supplied with nerves, arising from branches
of the oculomotor, trifacial, and sympathetic. The sphincter pupillas
is supplied by the oculomotor, and the dilator iridis is supplied by the
sympathetic. The trifacial supplies common sensation.

The spaces of Fontana are small cavernous spaces in the intervals
between the fibers of the ligamentum pectinatum iridis, which com-
municate with a somewhat larger space in the substance of the sclera
close to the corneal junction, called ihe canal of Schlemin, 01 si
circularis iridis. This latter canal has been described by some ;
lymph-canal, by others as a venous sinus. The pigment of the iri
situated in the slroma of the membrane, and to it the color of the
eyes is due. In light blue or gray cycs Ocieit « \«&e. ^\^^«w-% ">.■«.
albinos it is absent.

DISEASES OF THE EYE,

The ciliary body comprises the ciliary processes and the ciliary I

The ciliaiy muscle (Fig. 83) is a grayish, semitransparenl band of
iStriped muscular libers, about yi of an inch broad, thickest in front.

Kit consists of radiating and circular Rb«rs, the former the more
|%rous, arising from the junction of the cornea and sclera, to
backward lo the choroid, opposite the ciliary processes : the Utter
interna}, and pursue a circular course around the insertion of die

DISEASES OF THE IRIS AND CILIARY BOUV. 201

The circular fibers are sometimes called the ring-muscle of MUllfr.
and were formerly described as the ciliary ligament ; they are re-
markably developed in hyperopia and hyperopic astigmatism.

The ciliary processes (Fig. 84) are from 60 to 70 folds formed by re-
duplications of the choroid at its an-
terior margin. They are arranged
inacircle, and form a sort of plaited
frill behind the iris, around the
margin of the lens. They consist
of large and small processes, ir-
regularly alternating, the farmer
being about -^^ of an inch long.

Tht zone of Zinn is the name
given to the pigmented indenta-
tions made by the ciliary processes
in the hyaloid membrane. Its

: Ihe I

nule

pensory ligament of the lens.

INFLAMMATIONS OF THE

accompanying
of the adjacent
is recognized by the
and discoloration of
id the sluggish reaction
If the hyperemia be-
tense as to produce an

the pupil, a
to alropin.

PLASTIC IRITIS.
Definition. — An inflammation of the iris in which a scant, fibrinous
exudate is deposited on the anterior or posterior surface of the irja, j
the pigment-layer at the edge of the pupil thereby becomin^adhMi

in places to the capsule of the lens. This biniJinE down of the iris la
the lens is the cause of the immobile pupil.

Symptoms. — The patient complains of intense pain radiating o
the forehead and face, and which is not proportionate to the severity
of the disease. The pain is worse at night. There is lactimaiion .
photophobia, and dimnes s of vision. In some cases the subjective
symptoms may be very slight. The objective symptoms are petic
Ileal injection, h aziness of the pupil, l oss of luster in the iris , andci

un symmetric pupil- Hyperemia of the optic

traded , distorted, c

nerve Is said to accompany ir

Course and Sequels. — An uncomplicated iritis running its course
in from two to four weeks is an exception. Permanent adhesions, a
synechias, o f the iris, by organized exudate between it and the surface
of the capsule qf the lens, are often left behind, and render relapses
of iritis likely. The whole pupil may become blocked with organized
exudate, and thus produce loss of vision in the eye affected. If there
are many severe recurrences of attacks of iritis, circular adhesions
may form between the lens and iris, and destroy ci
tween the anterior and posterior chambers. In s
bulges forward from the tension of the aqueous which collects in the
posterior chamber, causing the condition known as " ballooned iris
or " umbrella iris." Unless an artificial pupil be formed at once by
iridectomy, reesiabhshing the communication between the chambers,
the whole eye will be destroyed.

Causes.— What is called idiopalkic irilis is
some general systemic dyscrasia. although e
affected. Syphi lis j
tuberculosis, rheumati sm, ]
infectious fevers. Often the only explar
to cold, or " i;atching cold " in the eye. Secondary iritis follows in-
flammation of the adjacent tissues; even a conjunctivitis may lead
to iritis. Traumatism, with or without infection, or a foreign body ii
the iris are causes of the inflammation.

Treatment. — The most important element in the treatment is tft
prevent or overcoine adhesjons of the iris. If possible, a history of
an injury or clinical manifestations of some systemic condition known
to cause irilis should be elicited. It is especially important to institute
immediately general Ireatment in s^pWvUs, ThtunvWJ^TO, itiA ^oMt,
The iodids, salicylates, salol, and mercuiva\a a.it >isc^\i\. X\ie S\«

lerally the result of

eye only is often

Other causes ate

tis, and the severe

if the origin is exposure

DISEASES OF 1

The H
to the ■
ected. V

should be chiefly of milk and broth during [he acute stagi
pupil should be immediately dilated by atropin, and if it yields
diug and is perfectly circular, a rapid improvement may be expected.
Caution must be used in the administration of atropi n to persons past
ron y-five, or in cases showing increased tension of the eyeball, or in
which there is idiosyncrasy to the drug. If the pupil resists dilala-
tion, the atropin solution should be heated, or a drop of five percent,
solution of c ocain every three or four minutes four or live times,
and then another application of atropin, should be tried. If the iris
is still bound down, six or eight leeches , or a mechanicalleech,
should be apphed to the temple, and mercurial inunctions begui
using a hot bath and profuse diaphoresis before 1
Atropin must be kept up throughout the treatment. If it causes much
conjunctivitis, s copolamin may be substituted. Thejiain is best
lieved by local depletion with leeches, or artificial scarification o
the temple, or hot, moist compresses to the eye for fifteen minutes
Anlipyrin, morphin, or other analgesic may be

administered! Profuse diaphoresis, with a Dover's powder, hot drink,
foot-bath, and blankets, is of great value, and may be repealed several "-i^*.
fail, puncture of the c

tension. IriQectomy is not indicated in the inflar
when there is a circular synechia obliterating cc
the anterior and posterior chambers. If there
left to warrant belief that ihi
should be performed after the
prophylactic measure of great
1 through the disc

ralory stage except
between

igh adhesions
e will be fulure relapses, iridectomy
flammation has subsided. This is a
mportance. ^mfi|fpri plan^f^ should
se. Alcohohc beverages should be

SEROUS miTI.'i.

which an inflammatory pro-

seltles in the anterior chamber, causing a haiii

id deposits on the posterior surface of the cor

of which the disease is sometimes called desce-

s and Diagnosis. — The chief obje
posits ill the aqueous and on the back of the
the agueous, the increase in the depHi o( the
Me signs of acute iritis in a milder degree.

signs are the de-
a, the haeiness of

Tain a.\\i ^ifia'" ^

20+

live symptoms ar
There is often a
changes in the aqueous,
pages 162 and 163).
The important sequel!

of li

srable, and the pupil may be dilated. '
iion, due .to the chemic and physical 1
ing simulation of glaucoma (see table, j

iated opacities c

I the back of the

r quite clear up, pos-
terior synechia, and, if the ciliary body
is affected, vitreous opacities, and pos-
sibly opacities in the lens.

Causes. ^Serous iritis occurs in debili-
tated and anemic young persons, and has
been ascrihed to syphilis and other gen-

f pi^ B";— Skbous Iritib eral dyscrasias. It is commonly bilateral,

^^^^ DKscEUBTins. which fact points to a systemic cause.

^^^L It may occur after cataract operations.

^^^B Treatment. — The patient's general health should be attended to,
^^ and good food and hygienic measures instituted. To keep the pupil
dilated and break up adhesions, atropin twice a day is necessary. To
hasten absorption of the inflammatory products, heat, diaphoresis,
and the iodids are useful. The depressed physical condition of the
patient generally forbids any rigorous mercurial treatment. The de-
posits may be mechanically removed by releasing the aqueous by
repealed paracenteses. If there is much rise of intraocular tension,
atropin must be suspended and eserin substituted. Repeated para-
centeses will here prove of great value. Iridectomy may be indicated
in the worst cases,

SUPPURATIVE IRITIS. "XO- .'it'-'^^^^
Definition. — A condition in which the inflammatory product is puru'
lent, and saturates the tissues of the iris and overflows into the ante-
rior chamber forming^ a hypopyon, whicli is more fluid than the
hypopyon following inflammation of the cornea.

Symptoms. — !n this condition the iris is highly hypereinic, and is
swollen and discolored yellow by the pus in its matrix. The chief
symptoms are: The marked changes in the iris; the swollen piipil-
lary border of the iris, which often occludes the pupil ; the fluid hypo-
pyon, which changes position, in disdnction to the stationary libriDoua
c/ot of pus in corneal disease; and Wa^w^ ot \i\(et<\«iT.,
ihroagb a wound. la ihis day of asepvic ^tctaviftotv*. wi^w

THE IRIS AND CILIARY BODV. 305

iritis after operation is very rare. Diabetes is said to be a systemic
cause. If the disease is due to infection through a wound or following
an operation, there is great danger of general involvement of ihe eye,
and such cases should be regarded as very dangerous. What have
seemed idiopathic cases, have often yielded readily to treatment and
left no sequels.

Treatment is that of simple iritis, and should be energetically pur-
sued — rapid mercurial inunctions, atropin, and paracenteses, after the
height of the inflammation has been passed. For idiopathic or dia-
betic cases, the salicylates have been used to great advantage.

IRITI3 NODOSA is an inflammation in which small nodes or tubercles
are seen on the iris. Nodules are sometimes noticed on the iris in
both simple and suppurative iritis, but the name is usually applied to
conditions in which small gumraata or tubercles are found on the

Gumma of the iris is a local expression of tertiary syphihs, and gen-
erally yields to antisyphilitic treatment. There is usually seen near
the pupillary edge of the iris a yellowish mass, about the siie of a split
pea, surrounded by a brownish-red base. A history of syphilis is
generallyobtainable.

Tubercles of the iris usually occur in groups, are some distance from
the edge of the iris, and are grayish or pale yellow in color. The
adjacent lymph-glands are swollen, and there is a history of tubercu-
losis. Tubercular iritis usually attacks young persons, while gum-
mala are mostly seen in advanced life. Gummata may disappear
under the iodids and mercurials, or may leave the iris atrophic or
immobile. In tubercular iritis the prognosis is bad. In severecases
the eye must be enucleated. Excision of the tubercles is useless.

CYSTS, ranging in size from that of the head of a pin to that of a
small pea, may form on any part of the iris. They may be single or
multiple, and are generally Ihe result of traumatism. They should
be completely removed by an iridectomy.

MALIGNANT TUMORS have been noticed in the iris, and are usually
)us. Rapid growth of any iridic tumor suggests malignancy,
val, together with the netgVibonn^ fcsxift.^s-j i\-».i'ip."'«^*>.'*.^
lomy is demanded.

^^m PE^

DISEASES Op THE EVE.

INJURIES TO THE IRIS.
PENETRATING WOUNDS OF THE IRIS are recognized by focal
id oblique illumination ; there appears a rent, through which the i
fundus-reflex shines, provided, of course, the media are still clear.

iRiDODiALYSia is a condition in which the iris is lorn awa.y from
ihe ligamenium pectinatum and ciliary body. It is usually the result
of a severe blow. It is attended by hyphemia, or hemorrhage into
the anterior chamber. The blood in the chamber will absorb, but
no treatment will restore the detached iris. In cases of hyphi
cautious prognosis should be given, for when the blood in the ante-
rior chamber becomes absorbed, more serious choroidal and retinal
hemorrhages may he found. Paralysis of the iris, or iridoplegia, may
be a result of traumatism.

FOREIGN BODIES in the iris, as a rule, cause inflammation, although
there are instances in which aseptic particles have remained for years
without causing any difficulty. As the aqueous soon becomes clouded,
removal should be attempted at once. This is effected by corneal
section and removal of the substance with a fine pair of forceps. Jf
the foreign body is a particle of iron or steel, the magnet may remove
it. If this fails, the fold of iris in which the foreign body is included
should be seized and excised.

CONGENITAL MALFORMATIONS.

ANIRIDIA, or absence of the iris, is rarely seen, and is u<
bilateral.

COLOBOMA is the most frequent congenital defect of the Iris, It 19 4
an aperture in the iris, generally beneath the pupil, and, unless very I
extensive, causes little visual disturbance. It is sometimes associated |
with coloboma of choroid or lens.

POLYCORIA is a multiplicity of pupils.

ANOMALIES OF COLOR of the iris are often seen, and have n
nificance. Sometimes the pupils are of difTerent colors, or one puptlJ
may be of several difTerent colors.
I Jn ALBINISM ibere is a lack of pigment in the iris, in conseqi

of which there is intense photophobia, nystagm
lessened visual acuity.

PERSISTENT PUPIL.I.ARY MEMBRANE is a remnant of a. vascular
connective-tissue layer that, in tlie embryo, enveloped the lens before
the iris was formed. In this condition very fine fibers, springing from
surface of the iris, pass over the pupil to be attached 10
surface of the lens. There is usually no visual disturb-

ClIANGES 'N Till:; MOTILITY OF THE PUPIL,
MYDRIASIS, or extreme dilatation of the pupil, occurs under the
tffects of drugs possessing a mydriatic action, such as atropin, hom-
alropin, hyoscyamin, etc. ; in glaucoma ; in optic nerve atrophy ; in
diseases of the orbit ; after fright; in neurasthenia ; after ir'
the cervical sympathetic, as hy an aneurysmal tumor ; and s<
in idiots. Permanent mydriasis has occurred after the instillations
of a mydriatic have been suspended. Mydriasis of distinctly cere-
bral origin is caused either by irritation due to some lesion in the
brain or cervical portion of the spinal cord, or by paralysis of the
oculomoter center, due to hemorrhage, thrombosis, tumor, or abscess
of the brain.

The treatment of mydriasis consists in remedying the cause, if
possible ; locally, pilocarpin or eserin is indicated, and the galvanic
current is sometimes of use. Exercise of the eyes with convex lenses
upon near objects may be of value.

MIOSIS, or permanent contraction of the pupil, occurs under drugs
possessing miotic action, such as eserin, pilocarpin, etc, ; in paralysis
of the cervical portion of the spinal cord, particularly in locomotor
ataxia ; in paretic dementia ; in cerebral syphilis ; and in bulbar palsy,
with progressive muscular atrophy. Persons who continually use
their eyes on fine objects, such as watchmakers and engravers, some-
times suffer from miosis. In opium poisoning the pupil is reduced to
the size of a pin-point, dilating just before death. Nicotin and alco-
hol in poisonous quantities may produce miosis. As contraction of
the pupil may result from irritating cerebral lesions similar to those
causing dilatation, it is important to have some means of differential
diagnosis. Berthold mentions that miosis occurs in a sudden attack
of paralysis due to embolism, and mydriasis in an attack due to

r308 DISEASES OF THE ^^^^^^H

beinairhage. The treatment is directed to the cause. Atrop^^^^^l
be used locally. ^^M

ANI30C0R1A, or INEQUALITY in Size of the pupils, may occur !^|
perfect health. In fact, it is much more common than text-books in- .
dicate. It is sometimes seen in eyes of widely dissimilar refraction,
diseases of the brain and nervous systems, and in insanity. It is not
uncommon in tabes, disseminated sclerosis, and paretic dementia,

WERNICKE'S SIGN, OR HEMIOPIC PUPILLARY INACTION, IS mei
tioned in the discussion of hemianopsia. Light is carefully throiri
onthebUnd side of the retina; if there is reflen contraction, the lesiql
is behind the pupillary centers; if there is no reflex obtaJned, I
lesion is at or in front of the pupillary centers.

• THE ARGYLL ROBERTSON PUPIL, is a name given to a rcflex pupi
lary rigidity producing loss of reaction to light-stimulation, although
the action to accommodation and convergence may still be present.
It is a diagnostic sign of value in locomotor ataxia, but has been
noticed in general paralysis of the insane, in cerebral syphilis, and KM
the result of poisoning by bisulphid of carbon.

THE ORBICULARIS PUPILLARY REACTION refers to contraction «1
the pupil when a forcible effort is made to close the lids,

HIPPUS is the name given to the oscillations occurring after c
traction to light. It is exaggerated in hysteria, disseminated scler
epilepsy, and in the early stages of acute meningitis.

IRIDODONESIS is a tremulous condition of the iris, due to lack tjt
normal support of the lens. It is seen In conditions in which t

I lens is dislocated posteriorly, in atrophy of the vitreous, in overripj
cataract, and after cataract extraction.
in glaucoma, In cataract extraction, for the removal of roieign bodi
and growths. In complete synechias, and for optic purposes. Having
first secured a lid-speculum in position, a fold of conjunctiva, near
die cornea and opposite the place wVctc v\ic Vnw'ildn. U to be made,
Js seized by fixation forceps. A ^teraVome ^s tWMti "Cmou'^ *

OPERATIONS ON THE IRIS.
IRIDECTOMY is the excision of a portion of the iris. It is perforn

de,

]

DISEASES OF THE IRIS AND CILIAKY BODY.

209

cornea at the scleral border, the point being kept nearly perpendicu-
lar to ihe sclera until it has reached the anterior chamber, when the
handle is depressed so as to bring the blade parallel to the iris (Fig.
86), The blade is then pushed forward until it has made a wound

lufEcientlj- large for the purpose of the operation; still depressing
Ihe handle, the blade is withdrawn slowly, and iris forceps (Fig. 87)
are thrust through the wound closed, and opened in the anterior
chamber to seize Ihe iris. The iris is tWcti i\?c»ia Q^S- "A -O^t
ivound, and as macb of it as desired is cKciseA. "tt-f ^^e, X'tAtttJaMxt j

DISEASES OF THE EYE.

sars (Fig. 8S) held firmly against the eyeball a.nd parallel to tbe
wound. The stump of the iris is tlien carefully returned to the ante-
rior chamber, no portion of it being allowed to become incarcerated
in the corneal incision. The delicate McClure iris-scissors are the
best for cutting the iris, but they are rather expensive, and not always
obtainable. The eye should be thoroughly cocainized, and the opera-
tion should be done under antiseptic precautions ; after the operation
the eye should be thoroughly irrigated, a light bandage applied, and
the eye kept closed until the corneal incision has become united.
The incision may be made with the Graefe knife instead of the lar
shaped keratome.

i, 89.— Dk

IRIDOTOMY is performed when the pupil for any reason is occluded
by a thickened and opaque capsule, or with exudations from the iris.
One mode of operation is with a needle-knife, having a double cut-
ting-edge, with its shank so constructed as to completely fill the
t corneal wound, thus preventing any escape of aqueous. This knife
is thrust through the cornea midway between its center and circum-
ference, and the occluding membrane is divided at right angles with
the line of greatest tension. When the itis is to be incised so as 10
make an artificial pupil, a lance-knife is used instead of a needle-
knife, and introduced in the same way as before, and withdrawn half
WMy, allowing some of the aqueous Vo esca-pc, ftiM-i ca.\vj\RS, \t\« iri«_
forward. The knife is thrust ibrougti *ew\aMvi'Oc«.B.-«iS&ftsM
De Wecka-s scissors for itidotomy tySs-^q^w^ ....«:t*iAa

opened in ihe anterior chamber, one blade passed through the cut in
the iris, and the blades brought together through the iris, thus elon-
gating the incision,

iRiDOCYSTECTOMY is preferable to iridotomy. An incision is
made with a Deer's knife through cornea, iris, and the thickened or
adherent lens-capsule. Next a Tyrrell hook, or one branch of a pair
of iris forceps, is passed into the opening in the iris. The edge of
the iris (and capsule) is drawn out of the corneal wound and cut off
close to the cornea.

IRIDODESIS consists of drawing the pupil into a new shape and
position, and is accomplished by making a small incision in the
cornea and drawing a part of the iris, including some of the pupillary
border, into it, and fixing it with a ligature. This operation is now
almost obsolete.

CYCLITIS.

Definition. — Inflammation of the ciliary body; the iris and choroid
are often simultaneously involved.

Varieties. — The seioua, which is comparatively benign, and de-
velops like a serous iritis ; the plaatic, which is a worse form and
produces a total posterior synechia; and the suppurative, which is
distinguished from the others by the presence of a purulent exudate
in the chambers of the eye.

Symptoms and Diagnosis. — Cyclitis is always a seiious and often a
dangerous disease, and should be differentiated from a relatively
benign iritis. Pain, photophobia, lacrimation, and visual disturbance
are signs common to both. The characteristic signs of cyclitis are
extreme sensitiveness to pressure in the ciliary region ; cloudiness in
the anterior portion of the vitreous ; and the noticeable changes in
the intraocular tension, which is increased at first and diminished
later. The aqueous is also lurbid, and may contain pus of the sup-
purative variety.

Causes. — Generally some injury to the ciliary b()dy or adjacent
tissues. Foreign bodies in tlie eye are almost certain to destroy the
eye by a plastic cyclitis. It is likely that there is more or less cyclitis
in most cases of iritis — that is, iridocyclitis is more freo^uent t.b.a.n.
simpJe iritis or cyclitis. Cyclitis may be d\ie\.o\T\ft'McvTO,-»;««i^ '^'^^
o/r/ie t/ssues in continuity with the c\\\a.T-^ \.o6-J . w \.q vj-m? 1

.313 DISEASES OP THE E'

ophthalmia. Idiopathic cases are said to result from syphilis, talM
culosis, rheumatism, and other systemic disorders.

Treatment is virtaally the same as that for iritis, although atropfl
lust be used with caution, as it is oftenvery poorly borne. Plastic ai
purulent cyclitis must be treated rigorously with mercurial inunctions.
For the reduction of tension, Ihe local use of eserin, diaphoretics, and
paracentesis are indicated. In purulent cyclitis, especially afleropera-
tions. antiseptic douches arc indicated. On account of the u
prognosis, the possibility of relapses, disorganization of the vitreotM|
and sympathetic ophthalmia, the patient must be carefully watched
and expectant treatment continued after the symptoms have subside

PARALYSIS AND SPASM OF THE CILIARY MUSCLE.

Paralysis of the ciliary muscle is recognized by destruction or
diminution of the normal range of accommodation that usually cor-
responds to the age of the patient. The causes may be peripheral,
as by atropin ; or central, due to disturbance of the oculomotor
nucleus. General intoxication by the poisons of infectious diseases,
and conditions producing exhaustion or debihiy, may result in par-
alysis of the ciliary muscle. Diphtheria is a common cause. The
iris may or may not be involved in the paralysis. In this condition
objects seem minimized — micropsia. The treatment is directed
toward the cause. Locally, miotics, convex glasses, and electricity
may be of value.

Spasm of the ciliary muscle is a condition in which the range of
accommodation is shortened, causing an emmetrope or hyperope 10
have myopic symptoms. In this condition objects appear enlarged
— macropsia. The causes are the miotics, strain on the accommoda-
tion, and severe disease of the spinal cord, The treatment is directed
toward the cause. Mydriatics give temporary relief. This condition
is discussed in the section on Ametropia.

fc _ _ _ _ ..___

tion, and severe disease of the spinal cord. The treatment is direc

^Lp«5i?5 from its inner surface antei\ot\^ . U "vs p\M«i \it\;\tvei,Vi S!n^

DISEASES OF THE CHOROID.
Anatomy. — The choroid is the vascular and pigmentary tunic
tJie eyeball, investing the posterior fiue-sixlhs of the globe,
tending as far forward as the cornea, atiAdevt\o^TO?, fee t\\\Tvvi ^rro-

DISEASES OF THE CHOROID. 213

optic nerve. Externally il is eonnecied tiy a fine ctllular web {mem-
hrana fusca) wilh ihe inner surface of ihe sclerotic. Internally it lies
in contact with the basal membrane of the pigment-coat of the retina,
as far forward as the ora serrala. The choroid is divided into two
layers : an external, containing the larger vessels and the most pig-
ment, and an internal. The external layer consists in part of the
larger branches of the short ciliary arteries, which run forward be-
tween the veins before they bend down to terminate in the capil-
laries; but is principally formed by converging veins called vena
varticesa. The internal layer consists of an exceedingly fine capil-
lary plexus, formed by the short ciliary vessels, and is known as the
tunica niyscfiiana. On the inner surface of this tunic is a. very
thin homogeneous membrane called lamina vitrea that separates it
from the pigmentary layer of the retina. The pigment of the choroid
consists of hexagonal cells, filled with dark.brown granules, and is
scattered throughout both layers in sufGcient quantity to absorb Ihe
light,

j^ CHOROIDITIS.

^P Causes. — Inflammation of the choroid results from general diseases,
V-such as syphilis, tuberculosis, scrofula, chlorosis, rheumatism, and
gout. Senile choroiditis is probably preceded by choroidal apoplexy.
Suppurative choroiditis is due to traumatism wilh infection ; to metas-
tatic infarclion, in pyemia and endocarditis ; and to severe infectious
fevers. High myopia, by causing extreme stretching of the choroid,
often gives rise to a local or diffuse inflammation. Choroiditis may
be an accompaniment of inflammation of the iris and ciliary body.

Varieties. — For convenience, choroidilis maybe divided into the
exudative and suppurative varieties, although many subdivisions,
such as disseminated, syphilitic, areolar, central, guttate, etc., have
been studied pathologically.

EXUDATIVE CHOROIDITIS is distinguished by the impairment of
vision due to the simultaneous involvement of the retina, and the
changes noticed by the ophthalmoscope. The disease runs its
course without pain and without external symptoms, and the patient
is only aware of his trouble through the impairment of vision. It
must be remembered that there is no definite relation hetweew (.W
^mmountof visual dislurbance and tine c\iat\g,es no\.e.&.\^ ■<!&-«. ^n>.'«>-*^"'^-

^K 314
^^ Aller;

OF THE EYE.

Alleration in the field of vision, the appearance of scotomas, )C

phopsia, night-blindness, flickering spots, and progressive lessen-
ing of the visual acuity, are the most important subjective symptoms.
The ophthalmoscope shows the presence of numerous dispersed
patches in the fundus, thickly strewn near the equator, gradually
diminishing toward the macula and optic disc, these being generally
free from disease. If fresh, the patches are round, sharply defined,
much smaller than the disc, and yellowish-red, lighter in color thui
the fundus. In addition, there are yellowish-white streaks along ibe I

I vessels. As the disease advances, the patches become larger KO*

I coalesce into irregularly -shaped figures, showing the white sderotici

beneath, surrounded by hypertiophied pigment epithelium of the
retina. In the majoiity of cases permanent white patches are |i
either due to exposure of the sclera or lo reflection from cicatrici

k(Fig. 90). The optic disc is generally slightly red and cloudy. The
lem) disseminated choroiditis Is oflen applied to cases in which the
Bjoots in the fundus are numerous and diffuse. Areolar choroiditis
consists of black patches and smaU pij;mcMV,-bloi.che5. gradually
banking to whitish blotches with UacV. eA^es. U "w o.oiv'iw.ti.

DISEASES OF THE CHOROID. 21 J

pole of the eye, and endangers central vision. The central
variety is located directly at the macula. Soinetimes retinal vessels
can be traced over spots of choroidal atrophy, showing that the cho-
roid is the primary seat of the lesion. The vitreous is generally clear,
and good ophthalmoscopic images are obtained.

SYPHILITIC CHOROIDITIS is diagnosed by syphilitic history and
speedy reaction to mercurial inunctions ; the most characteristic signs
are night-blindness and circumscribed scotomas in the field of vision.
Vitreous opacities are also said to be rnore numerous in this variety.

SUPPURATIVE CHOROIDITIS begins with hemorrhage into the retina
and choroid, which is soon followed by purulent infiltration of the
whole interior of the eye. Externally, the lids and conjunctiva are
red and swollen, and are covered with a purulent secretion; the
cornea is hazy, and there may be hypopyon ; the iris is inflamed, the
pupil appears yellowish, and the eyeball is hard. The patient suffers
intense pain, has acute febrile symptoms, and is blind in the affected
eye. Viewed by the opbthulmoscope, the golden reflex, due to the
exudative material thrown ont between the choroid and the retina,
confirms the diagnosis, although in children it may be mistaken
for glioma of the retina. The inflammation may subside, but it is
rare for any visual perception to be preserved. In the malignanlform
panophthalmitis ensues, and the whole eye becomes an abscess-
cavity, and is lost. The infection is often metastatic.

MYOPIC CHOROIDITIS is due to the ecLisia Or staphyloma of the
sclera at the posterior pole, and is usually present in high degrees of
myopia, and always in progressive myopia. The increased " myopic
" producing an enlarged blind spot, and the ordinary symp-
myopia associated with the atrophic changes of the choroid,
furnish a ready means of diagnosis.

ANTERIOR SCLEROCHOROiDiTis involves the anterior part of the
choroid, inaccessible to the ophthalmoscope. Itis differentiated from
episcleritis, which is a benign local disease, while the former attacks
the cornea, iris, and anterior portion of the vitreous, finally causing
anterior ectasia of the sclera.

Prognosis of choroiditis is, on the whole, unfavorable. In the exu-
dative variety and in high myopia, we can hope to retain only part
Bpf the vision left. In case of large ectasia \.\vc^e \s iiq-ss^t^.-W. ^.■i.-wjisi

ai6

,se in inflammation and glaucomatous symptoms. If
cclasia is produced, blindness follows through flatness and opacity
ea, increased tension, and distortion of the eyeball,
I purative choroiditis the eye may be preserved, but vision is ;
I lost.

Treatment of cboroiditis must be directed against any discoverable
:ause. In all acute cases, whether syphilitic or not, in which ihe
f patient is in fairly good health, mercurial inunctions should be begun.
In debilitated cases, constitutional and tonic treatment should be in-
stituted, diaphoresis provoked, potassium iodid administered, and
I rest, with smoked glasses, ordered. Confiner
innecessary. In subacute or chronic cases
following is advised :

Mercuric chlorid, P- 'j>

Eitract of belladouna, gr- 'v.

Make 40 pills.

Take one pill three timeE a day.

In the suppurative variety we can do no more than to quiet pats
by narcotics, or by the local use of atropin and hot compresses,
the eye is a virtual abscess, it should be incised or enucleated uni
the strictest antiseptic precautions. In the anterior variety, teoai
must be carefully watched, and if excessive, may be relieved m
corneal puncture or iridectomy. The treatment of progressive ■
high myopia is discussed under Myopia.

TUBEKCULOSISOF THE CHOROID is of two forms,
festing itself in small, whitish-yellow spots, that are minute tuberclq
near the posterior pole of the eye ; many are too small to be
by the ophthalmoscope. The second form is a spheroid tuberd
causing detachment of the retina, and possibly inflammat
eye. It is to be distinguished from sarcoma of the choroid, butfl
both cases enucleation is peremptorily demanded.

SARCOMA OP the: choroid develops slowly at first, but later €
involves the surrounding tissue with great rapidity. In the first si
ihe only subjective symptom is disturbance of vision, the eye becoi
ing more myopic, and distortion of images ensuing,
is usually at the posterior pole. Viewed by the ophthalmosco|
i« a rule nothing but retinal dtiac.'ftttveWw S^'u&'^A-i ■■■ "

DISEASES C

E CHOROID.

217

in the second stage, severe pain caused by increased tension is
noticed, and lotal blindness ensues. The media become so cloudy
that no reflex is obtainable. After this the growth penetrates the
sclera, the whole eye becomes a malignant mass, and even if metas-
tasis has not occurred, the patient may die of exhaustion. The disease
is unilateral, and should be distinguished from glaucoma. In which
there is no retinal detachment ; and from simple retinal and choroidal
detachment, in which there is no increase in tension. It is generally
followed by sarcoma of the liver. The mote fibrous the tumor, the
less the liability to metastasis. As soon as the disease is recognized,
the eye should be enucleated and the orbit thoroughly cleaned out,
as death will speedily ensue if
the disease is allowed to con-

RUPTURE OF THE CHOROID
(Fig. gf) is due to injury of the
eye, and, as a rule, can not be
recognized until the vitreous be-
comes transparent, after which
a recent rupture appears as a
yellowish, blood-specked stripe,
which finally becomes white and
is bordered with a black pig-
ment. The extent of visual dis-
turbance depends essentially
upon the portion of the choroid
involved. Peripheral rents have
little influence on vision. The
ruptures ate generally near the
optic nerve and parallel to its cii
sists of atropin and rest.

DETACHMENT OF THE CHOROID is recognized with the ophthalmo-
scope as a round or oval, brown, and smooth tumor near the equator

umference. The t

of the eye, that does not have the
panying movement of the eye, ai

mbling movements a
in detachment of the ri
Choroidal detachments may reunite. Loss of vitreous during c:
operation or an effusion between the choroid and sc\.w«iK.Va.N «.>=**». ^
causes. The trettlment is absolute n

COLOBOMA OP THE CHOROID appears as a large while or bluut.

glistening area, usually below the disc, and several times its diameter.
Retinal blood-vessels pass across it. It is simply a congenital defi-
ciency in [he choroid that allows the sclerotic to show through, and
often causes but little visual disturbance. It may be associated wilh.
coloboma of the iris or other anomalies of the eyeball.

DISEASES OF THE RETINA.

Anatomy. — The retina is the chief and essential peripheral organ
of vision, and constitutes the third or internal coal of the eyeball. It
is made up of the end-organs, or expansion of the optic nerve within
the globe of the eye. It is composedof three main layers: the inner,
of fibers and nerve-cells, the granular middle layer, and an internal
layer composed of rods, cones, and pigment. Microscopically it is
divided into ten layers, from without inward, as follows ; (i) Pigment
cells; {2) rods and cones; (3) external limiting membrane ; (4)
external granular layer; (5) outer molecular layer ; (6) internal gran^
ular layer; (7) internal molecular layer ; (8) a ganglionic layer; (9)
nerve-fibers; (10) internal limiting membrane; the exact construe'
tion of the retina is diagramatically shown in figure 92.

The rods and cones are the essential sight-elements. The retina is
about 0.2J mm. in thickness, and covers the under surface of the
choroid from the optic nerve entrance to the dentated anterior margin
of the retina, called the era serrata, a few millimeiers back of the
ciliary body. The most sensitive portion of the retina is a yellowish
spot, about 0.5 mm, in diameter, lying to the temporal side of the
optic disc, which, from its color, is called the niacu/a /uffa. In the
center of the macula is a reddish dot called \\\& fovea antralii, at
which point all the layers of the retina, with the exception of the
cones, are absent. The vascular supply of the retina is from the
central artery and vein, which, passing through the jiiorKj opticus of
the lamina cribrosa, divide over the optic disc, vertically into large
and horizontally into small vessels, which are distributed in the fibc
layer of the retina, anastomosing at the entrance of the optic nei
with the short ciliary vessels, and aniwiD>\'i a.i ihe ora serrata with t)
choroidal I'essels.

S, 5. Ouler and inner Etflnular Uytr*, 6. Ouler granular lB)^r. j. liitergranulHr
it.ytj. 8. Inner grsnulnr layer, g. Layer of Rray mailer, lo. Gninukr poiliun
of tliia layer, ir. Cellular [wrlion. 19, ii. Fibroui layer, ij. Membrana Umliann

14. 14- RatliBiins fiberi

itftsis-hyperemia the thickness of tbe veins in comparison with the
irleries is noticed. Irritation -hyperemia usuaU^ icc.QTft^amt'Si'w.^-a.'nx-
Tiaiion of some other portion of the eye, ot it vi\a'^\ie ^w^"^ sA t-^t-

220 DISEASES OF THE EVE.

quite common in persons with some uncorrected reftac-
muscuUr imbalance, who use iheir t;yes to excess.
should be directed to correction of any ameltopia or
muscular trouble, and the eye should be put at rest and shielded with
protective glasses. If the hyperemia is supposed to be a local expres-
sion of cerebral congestion, the treatment for the latter affection should
be instituted.

RETINAL HEMORRHAGE.

Causes. — Retinal hemorrhage is seldom an independent affeclioD,
but is usually associated with some disease or injury of the retina: W
it may be the result of some condition provocative of hemorrhage in
any other organ, such as atheroma of the arteries, hypertrophy of the
left ventricle, scorbutus, hemorrhagic purpura, nephritis, diabetw,
pernicious anemia, etc. In such conditions the immediate cauM
may be muscular strain, violent coughing, or sudden change in ihe
intraocular tension after operation. Hemorrhage following occlusioo
of the retinal vessels will be mentioned later.

Diagnosis with the ophthalmoscope is easy if the media are clear
and if the remaining portion of the retina and disc is unaffected. In
such a case a fresh clot appears as a bluish-red blotch on a white
background ; or, if the clot is old, a brownish-red blotch is seen ; or
the only remnants of the hemorrhage maybeaspot of yellowish-while
degeneration, perhaps associated with pigment deposits. The hemor-
rhage is <lame<shaped when in the internal layers, rounded nhen In
the external layers, and massive when between the retina and hyaloid
membrane of the vitreous {subhyaloid'). If other blotches are seen
in the retina and the whole fundus is hazy, the condition is called
hemorrhagic retinitis.

Prognosis depends on the cause and recurrence of hemorrhages:
unfortunately, the prognosis of affections causing retinal hemorrhage
is usually bad. The amount of visual disturbance depends on the
location and size of the clot. Hemorrhage in the macula is serioos.
Multiple hemorrhages may cause a glaucomatous condition, produc-
ing blindness.

Treatment must be directed to the general causative condition.

falienls sliould be put la bed and the eyes bandaged. Congestion

maybe reJieved by leeches ot drv cupsraWn temijks. Mercuric

aad iodids. together with diap\\ove5\s, vna-j piomavc s.Vaai'^v.tiw. ^h

RETINITIS.

General Remarks. — It is probable that idiopathic retinili5 never
occurs. Inflammation of the retina is generally due to some disease
of the general system, such as syphilis, renal disease, diabetes, leu-
kemia, etc. In cases of prolonged exposure or excessive use of the
retina, the resultant affection is more in the nature of a functional
trouble than a true inflammation. Retinitis may be due to an exten-
sion of inflammation from the neighboring structures, principally the
ciliary body, choroid, and optic nerve. Panophthalmitis produces an
immediate suppuration of the retina.

The subjective symptoms of retinitis ate usually dimness of vision,
scotomas, metamorphopaia, etc. The objective symptoma elicited by
the ophthalmoscope are sometimes quite characteristic of the causal
trouble, although differential diagnosis is at limes very difficult.
However, the condition discovered is often a valuable indicator in
substantiating systemic evidence of the general disease, and is an
important factor in prognosis,

ALBUMINURIC RETINITIS becomes almost always bilateral, al-
though a number of unilateral cases are recorded. The light-sense,
color-sense, and visual Reld are usually undisturbed. Dimness of
vision progresses slowly, and sometimes it is difficult for the patients
to count fingers. This affection often accompanies the nephritis of
pregnancy. Uremia, coincident with renal disease, may cause com-
plete blindness, but this can not be attributed to retinitis, but rather
to a transient effect upon the cuneus lobe of the uremic poison.

Ophthalmoscopic changes (Fig. 93) differ in the various stages,
although they are most marked in advanced renal disease. The
changes in the fundus are generally confined to the posterior pole
and region adjoining. Hyperemia is at first noticed, but in the ad-
vanced disease white spots or patches are seen about the papilla,
and later fine white dots are noticed grouped about the macula in the
shape of a star with the fovea in the center. Finally, hemorrhages
and fatty degeneration, with paleness of the disc and contraction of
the vessels, may occur just before death. In some cases, instead of
while spots there may be numerous wide-spread hemorrhages, or.
again, only congestion and simple redness o( 4«t.

Prognosis.— Tie exact relation betweeti tetvwA^saTiAfec'^^'^'^'^'^*'''

222

DISEASES OF THE EYE.

renal disease is not definitely established. However, it may usually be
said that a definite case of albuminuric retinitis will have fatal issue
within two or three years, allhough the visual disturbance may not
increase, and may even improve in fatal, chronic cases. We have,
however, seen cases in which the patients have lived from five to ten
years after typic albuminuric retinitis had been estabhshed. In in-
terstitial nephritis particularly, retinitis is a serious sign. After tecovery

from acute nephritis an associate retinitis may clear up and the visioD

become normal. The prognosis of both life and vision is better in the

albuminuric retinitis of pregnancy, and in cases in which only one eye

becomes involved.

Treatment must be that of i.\\e ori^iwa,l disease. In hemorrhagic

cases, rest, Oandaging of the ev*^*' '^'^^ poa?;\Wi'j 'ftve \T\ySAa,>:\inv ^

1 atropln, in weak solution (gr. ) lo ^iV are a-AviaiWc. TVt ^^S-™-

ance of albuminuric retinitis in pregnancy is regarded by many as
an indication for the induction of abortion.

DIABETIC RETINITIS is often indistinguishable from albuminuric
retinitis by the ophthalmoscope alone. The diagnosis can only be
made by Ihe test for glycosuria. The prognosis is possibly not so
bad as in the foregoing disease, and dietary and hygienic treatment
may establish a cure.

SYPHILITIC RETINITIS is a diffuse instead of a local inflammation,
as in the preceding diseases, and may be unilateral or bilateral. A
general cloudiness, most apparent at the optic disc, and gradually
shading off into the periphery of the fundus, is noticed. While lines
may be observed along the course of the blood-vessels. There are
numerous dust-like opacities in the vitreous. Hemorrhages are less
frequent than in the preceding forms. The treatment is purely con-
stitutional.

LEUKEMIC RETINITIS is characterized by the pale-yellow appear-
ance of the fundus, always bilateral. There is a marked tendency
toward hemorrhages ; sometimes circular white clots and prominent
blood -bordered spots are seen at the periphery of the retina. Diag-
nosis should be substantiated by microscopic examination of the
blond. The treatment is that of leukemia.

RETINITIS OF PERNICIOUS ANEMIA presents an edematous condi-
tion of the retina, diffuse retinitis, with distended veins and pallid
blood. The disc appears dirty greenish- while, against a yellowish
eye- ground.

RETINITIS PIGMENTOSA.

Definition. — A pigmentary degeneration of Ihe retina sometimes
found in descendants of consanguineous marriages, or of syphilitic
parents. It occurs commonly in members of the same family.

Symptoms and Diagnosis. — The chief subjective symptoms are
Kigkt- blindness, due to the reduced sensitiveness of the retina ; con-
centric contrculion of the field of vision, often coupled with nystag-
mus, causing Ihe patient great inconvenience from inabilit-V "-Q ^^^^
his way, although his central visioti ma.-) be atiAe. t\ic tQ'w^a-^A. ,
bowing of the head in walking is a c\va.ta.c\.w\?.'C\c sv^-

224 DTSEASBS OF THE EYE.

/uni/ttj has a. very characteristic appearance (Fig. 94). Thediicii
yellowish and lis edge Is somewhat obscured, and the vessels are
narrowed, accompanied by fine bands, and fade off into the per-
iphery. Dark streaks of pigmentation, beginning at the peripher)-,
trail over the fundus, and gradually progress toward Ihe macula. In
appearance these have been compared lo the Haversian bone-canals.

Cases of retinitis pigmentosa without Ihe distinctive pigmentation »
occasionally found. There is evidence of pigment- atrophy at l{
periphery, slightly subnormal night-vision, narrowed color-fields, 4
Treatment is useless. All that can be done is to keep the patB
in good health and spirits, and surround him with hygienic conditio
inducive to Ihe arrest of any degenerative process.

THROMBOSIS AND EMBOLISM OF THE RETINAL VESSELS.
Symptoms and Diagnosis, — Embolism of the central artery of the
retina is rare. Both the ophthalmic and central retinal arteries branch
at right angles from their parent stems, and an embolus is easily
swept by them. The characteristic subjective symptom is sudden
blindness in one eye, probably after some slight exertion. There
may be temporary improvement during the succeeding weeks, but
the prognosis is very unfavorable. The differential diagnosis between
thrombosis and embolism with the ophthalmoscope is sometimes diffi-
cult. Hemorrhages are more numerous in thrombosis, and there is
intense swelling of the nerve and retina. There is pallor of the disc
and retina in embolism, and marked diminution in the size of the
vessels. The veins become tortuous and very irregular. The cen-
tral portion of the retina becomes hazy and grayish, the macula
standing out in sharp contrast by its maintenance of the normal red
color, the classic " cherry red spot," supposed to be due to the non-
existence of the nerve-fiber layer at the fovea, allowing the choroidal
vessels to show through. Finally, atrophy of the disc and retina
ensue, and the vessels become obliterated and replaced by white
streaks. Involvement of only a branch of the central artery is fol-
lowed by an anemic and degenerated sector-like area supplied by
the affected artery. The diagnosis should be confirmed by the
discovery of some systemic source of embolus or thrombus, such
as endocarditis, or other organic heart- affection, phlebitis, pyemia.

Treatment is of little avail ; but sometimes in very recent cases it
may be possible to remove the embolus by massage of the eyeball, or
by reduction of the internal tension, as by sclerotomy. General treat-
ment is, of course, indicated.

DETACHMENT OF THE RETINA.
Causes. — The most common cause is disease of the choroid conse-
quent upon myopia of high degree. Chronic indammalion of the eye-
ball or of the retina alone, fluid effusions or hemorrhage between the
retina and choroid, injuries, new growths, diseases of the vitreous,
removal or dialocation of the lens, and parasites, are oltwx (lwjkss..
ondition in which ihe inlraocu\at lcT\5iotv\s^\xi&ieTCvi\i'»"««*-—
'S

j, for instance, by the rapid escape of vitreous after a corneal sec-

— predisposes to retinal detachment.

Symptoms and Diagnosis.— The premonitory signs are flickering?

I and the appearance of daiiling sparks before the eyes, and attack;

^^^^ of momentary blindness. The detachment takes place suddenly.

^^H and the field of vision is obscured by what seems to be a dark cloud

^^V before the eyes. The detachment is only partial at first, and the

^^* retina is still nourished by its own vessels, its functions being impaired

rather than destroyed. Naturally, the refractive condition of the eyes

is more hyperopic, but as the detached portion of the retina consiiliites

^irregularfolds which constantly move with every movement of the eye,
metamorphopsia and other anomalotis visual disturbances are present.
By the ophthalmoscope there is absence of the red reflex in the region
of the detachment. In advanced easel
^^^^^^^^ a bluish-gray curtain is seen floating

^^^^^^^^^^^ freely in the vitreous, and may even he

i^^^^^^^H^^ seen by the naked eye (Fig. 93). The
, ^^^^^^^^^^^^^^^ picture may be confused by vitreous
Q^mi^^^l^Q opacities, which frequently accompany
this condition.

Prognosis is dependent on the cause.
If caused by intraocular tumor. Ihe case
may be considered hopeless. If due to
uETAUHKu pronounced myopia, one eye is usually
^^^ Rhtima (Ebsct Imacr).— attacked after the other, and blindness is
^^L t'r.r' ^ '""<•" J<"' unavoidable. In the other conditions
^^H the progress of the detachment may

^^^f possibly be arrested, but we can hardly hope for improvement,
^^^ although instances of alleged reattachment without treatment have
been reported.

Treatment consists of prolonged rest in bed, with protection of tbe
eyes from light by a pressure-bandage. Antiphlogistic measures
should be adopted ; diaphoresis with the salicylates, or by hypodermic
injection of pilocarpin. may prove of benefit.

The operative treatments that have recently been r
ire puncture through the sclerotic, allowing escape of the subrelioal
fluid, injection of an artificial vitreous in front of the prolapsed ri
or injection of a few drops of iodio iti Ihe vitreous. The real v
I o/'/A«e /neasures is doubtful.

^_ of I

subrelioal J
sed retina, ,■
real valm^^

DISEASES OF THE RETINA. 227

GLIOMA OF THE RETINA.

DeGnition.' — A malignant tumor, soft and highly vascular, develop-
ing in the retinal connective tissue, which, in common with the cere-
bral connective tissue, is sometimes designated neuroglia.

Symptoms.— It occurs chiefly in children from one to four. On
account of the youth of the patient and the absence of pain, the early
subjective symptom — visual disturbance — escapes unnoticed. The
child may be totally blind for some lime without the parents' knowl-
edge, attention to the eye first being called by the bright shimmer in
the pupil, the so-called " cat's eye." In the first stage of the disease
the ophthalmoscopic examination shows a yellowish prominence sur-
rounded by small nodules, toward which dilated retinal vessels con-
verge. In the second stage there is probably increased tension, and
the growth begins Co push its way forward, carrying the retina, lens,
and iris with it. The cornea and the aqueous may become opaque,
and the conjunctival vessels intensely congested. Internal inflam-
mation progressively increases, and the tumor may escape through a
perforation in the cornea or penetrate the sclera, and appear as a,
spongy, bleeding mass between the lids. The final stage is extension
along the optic nerve, or metastasis to the neighboring structures.

DiBgnoHiH is easy after the second stage is reached. In their early
stages, suppurative choroiditis or hyalitis may produce symptoms so
closely resembling glioma that they have been called pseudoglioraa.
However, in choroiditis inflammation precedes the blindness, and the
eye is soft. If there is doubt as to the diagnosis, the case should be
treated as glioma, to prevent an error which may prove fatal.

Prognosis. — Unfortunately, it is usual for the child lo be broughtfor
treatment after the disease has progressed sufficiently lo cause the
" cat's eye " or other prominent objective symptoms, and it may be
too late even to save the child's life. There is absolutely no hope of
preserving the affected eye.

Treatment. — Not only should the affected eye he immediately enu-
cleated, but the optic nerve should be divided as far back as possible,
a nd if there is the slightest sign of invasion of the orbital tissues, they
^^^^ust be removed and the orbit cauterized.

INJURIES TO THE RETINA.
Ordinarily, injuries of ihe retina are coincident with injuries to other
parts of the eye, and the treatment is general rather than special.

DAZZLING from exposure to intense light may result in partial
complete loss of sight. Such cases often follow the observance of am
eclipse of the sun. In severe cases a central blind spot is produc
and the ophthalmoscope shows an opaque graybh spot in the maci
probably due to a definite chemic change of the substance of
retina. In such cases a permanent central scotoma remains, in spil
I of treatment by rest in a dark room, leeches, electricity, strycbi

^^F opAQtJE OR UEDULLATEDNERVE-FiBERa are sometimes disct

cred by the ophthalmoscope. They are seen as white, striated blotct
with fringed edges, along the direction of the principal vessels, a
together present a flarae-like shape. When they can not be dircc
traced to the disc, they may he confounded with pathologic chang
In the vast majority of cases they cause no visual disturbance. 1
condidon is due to the retention of the opaque medullary sheath
the fibers, or "white substance of Schwann," after they leave I
^^B lamina cribrosa to expand into the retina.

DISEASES OF THE OPTIC NERVE.

Anatomy. — The fibers of the optic nerves arise in two bands, calli
the ofilic tracts, from the corpora geniculata, corpora quadrigi
und ophthalmic ganglion, which in turn are connected by radtadi
with the center in the occipiioangular region of the coite
(Fig. 96). Each optic tract winds obliquely across the correspondill
id converges forward to meet its fellow, forming
the optic commissure or chiasm, which is
of six sets of fibers — viz., a set crossing from the right side of
brain to the left eye ; a second scl, pursuing the same course from
opposite side — decussating fibers ; a third set, anterior, connecting t1
two retinas — inlerretinal fibers ; a fourth and a fifth set, latera], «
nectiag the kemisphcTe of one s\de wU'b vW Te\;iTiTL q( \W <ava« sidt
f^rvf^/ina/ ,■ and a sixth set, poslerior , co-nivecvW^ one o^\t \

I with

DISEASES OF T

with the other — intercertbral. The optic nerves diverge from the
chiasm to pass through the optic fora.men in each sphenoid bone.

nerve is covered by prolongadons of tnembranes of the bialo. a.^

s the lamias cribrosa, at which poiirt iVie &\Hi ^a'fcVM ' -'*>^_

sclera, the oiher membranes are d\scoTiivec\ti, *

I cc

330 DISEASES OF THE EYE.

covering of the nerve-iibers ceases, and the axis-cylinders pass
through to form the nerve-fiber layer of the retina. The ophthalmic
artery and vein pierce the nerve obliquely about 1 8 mm. posterior to
the lamina crjbrosa, and are continued forward in the center of tbe
nerve, passing through the porus opticus to be distributed

INFLAMMATION OF THE OPTIC NERVE.

Synonjins. — Choked disc, optic neuritis, papillitis, neuroretini^
Choked disc is so called on account of the interference of
of blood through retinal veins, by pressure from swelling at this
point. Papillitis generally describes an inflammation limited toxht
intraocular head of the oplic nerve, although in all probability, in the
majority of cases, the nerve is affected throughout its entire length-
There is less swelling than in choked disc, the visual disturbance
appears earlier, and the disease leads to atrophy and blindness more
frequently than does choked disc. Ncurorctinitis and papilloretinitis
are terms used to describe an inflammation which involves the retina
as well as the optic nerve. It is characterized by hemorrhages,
patches of fatty degeneration that appear as white spots, deposilioii
of pigment, etc., similar to the changes in albuminuric retinitis.

Causes. — The condition often called choked disc may b« due
traumatism, but is usually the result of a brain tumor, and is almost
invariably bilateral. Tumors of the cerebellum and those at the base
of the brain pressing upon the sinuses are most likely to be followed
by choked disc, Some form of optic neuritis is said to accompany
ninety percent, of all cases of brain tumor. If unilateral, the disease is
probably caused by a tumor in the orbit. Other intracranial diseases
causing inflammation of the optic nerve are ; tubercular basilar men-
ingitis of children, epidemic cerebrospinal meningitis-r-in fact,
gitis from other infectious diseases or from any suppurative origin.
Infectious diseases, syphilis, lead-poisoning, and other systemic atTec-
tions may directly cause optic neuritis. Tumors or diseases of (he
orbit may have the same eflect. Traumatism and inflamm!

Pathologic Anatomy.— Cerebia.^ tumors iWAtfctt with the circut*-
n and distribution of subarac\ino\d ftvivA \tv We X^tov"^-
te sheath 0/ the optic nerve becomes rftttCus-waMcft^viiVi-

THE OPTIC NERVE. 231

It is supposed that the bacilli of the causative meningitis act directly
upon the nerve-head.

The line of distinction between retinitis and neurorelinitis is so slight
that we can probably associate closely the causes of the former with
those of the latter; however, in albuminuric neurorelinitis, the greatest
changesarein the retina rather than in the nerve-head, and the urinary
tests are quite indicative. Cases of inflammation of the optic nerve
in which the cause is unknown are sometimes seen. Occasionally,
several members of a family, the males particularly, and of appar-
ently healthy parents, are attacked between the eighteenth and
twenty-fourth years by a bilateral optic neuritis. In other cases,
"catching cold," suppression of the menses, lactation, etc., are given
as causes. In such cases there must be a suspicion that there was
latent inflammation which became prominent under the conditions
mentioned, and was not directly due to them.

Symptoms and Diag:nosis. — The systemic condition is often simul-
taneously affected. The principal ocular symptom is impairment of
vision, gradually passing intt) total blindness. In the early stages of
choked disc vision is not markedly impaired. Particularly typical are
liiminuiion of central -visual acuity, ititsymmetric contraction of the
visual Jield, and impaired color-sense. The ophthalmoscopic appear-
ance of choked disc is a swelling and opacity in the disc and its
immediate neighborhood (Fig. 97). That the papilla is larger than
normal and projects into the vitreous may be proved by \\ie parallax
test. The papilla, while undergoing inflammation, has what has been
called a vjoolly appearance, together with swelling and congestion.
The small vessels of the disc are dilated, so that many of them are
visible, unless masked by excessive edema. There may he numerous
capillary hemorrhages in the nerve-head. The retinal arteries are
diminished in siie, and veins are swollen and tortuous. The edges
of the disc are lost, and a striated flame-like or grayish haziness
spreads over the disc into the adjoining retina, nearly equal on all
sides. !n severe forms there are diffuse retinal hemorrhages and
perhaps macular changes resembling albuminuric retinitis.

In addition 10 the presence of choked disc, the discovery of hemi-
anopsia and use of Wernicke's sign will aid in the diagnosis of cere-
bral growth.
,Jn Ihe interstilial or descending neuritis \\\e fi\^t "vi xiov ■b■^^O^e■^. 'i-b
'\oked disc; k is dull and edematous \oaV\t\'£. "Nv-ivoTv va "iSi-S*n.

^^1

^V 232

.nd sooner affected, owing to the greater length of nerve st

Prognosis. — The course is usually chronic, finally ending in optic '
nerve atrophy. Naturally, the prognosis is affected by the catise.
Cerebral tumors are usually fatal in a short time. The various Torms
of meningitis arc always serious. Restoration of vision is doubtful;
there is little hope of regaining lost visual power. However, cuies
with restoration of normal visual acuity, ana cures of amblyopia of
every degree, have been reported.

Treatment is naturally directed to the c;

If the cerebral tumof

can be located, surgical interference may be of value, A sypbilij
gumma will yield to mercury and potassium iodid. If no cause il
discernible, diaphoresis, the mercurials and iodids, and tonics iQ&n
be tried. Blood-letting from the temporal region has been reporti
of value. Possibly mild cases recover spontaneously. If there i
;on 10 suspect that the neuritis is orbital in origin, systc
p(»;JJproveof little value; and in welKdefined malignant orbiti
[ disease immediate enucleation Is *impcta.v\Ne.

F THE OPTIC NERVE.

RETROBULBAR OPTIC NEURITIS.

Definition.— Inflammation of the optic nerve beyond the eyeball, in
which the disc is not involved at first, papillitis arising in the ad-
vanced stage.

Causes. — Acute retrobulbar neuritis is caused by exposure to cold,
acute infectious diseases, sudden cessation of the menses, and any
condition which leads to a sudden exudation into the sheath of the
optic nerve. The most common cause of the chronic form is exces-
sive use of tobacco and alcohol ; although lead-poisoning, syphilis,
quinin, and other toxic agents may produce it. As a rule, both
tobacco and alcohol are simultaneously used to excess, and act con-
jointly. The disease is often called tobacco or alcohol amblyopia, or
loxic or intoxication amblyopia, although many authors dlsdnguish
between intoxication amblyopia and retrobulbar neuritis from other
causes. It has recendy been suggested that the central amblyopia
is due to primary rather than to secondary macular disease — that is,
that the disease starts in the macula and ascends the central fibers
of the optic nerve.

S)'mptoma. — In the acute disease, total blindness results in a few
days, and there is often pain in the eye. increased by movement or
pressure. The ophthalmoscope reveals a papillitis of moderate
severity. In the more common chronic disease, the chief symptom
is slowly diminishing central vision. The patient complains that he
sees indistinctly, especially in bright light, and his vision improves at
sundown. This is explained by the dilatation of the pupil as daylight
fades, and consequent stimulation of the unaffected perimacular
region by the increased illumination. Examination with the peri-
meter shows a central scotoma, at first for color, and finally for
light. At the onset, the lield of vision remains nearly normal, and
only begins to be obliterated when fixation becomes impossible,
and nystagmus results. With the ophthalmoscope there is first seen
slight hyperemia of the disc, and later a grayish-white discoloration
of the temporal halves of the papillas. The outlines are obscured,
the veins are enlarged, and the arteries diminished in size.

Prognosis may be considered favorable if the disease has not pro-
gressed to atrophy, and if the patient can he made to stop drinking
and smoking'; but relapses are likely to dccmt ■wVewevt.xftvt lioSixEi-
ence is suspended.

THE LENS. 23s

Symptoms and Diagnosis. — The patient notices an early disturb-
ance of vision, consisting of tliminmion in the central acuity, concen-
tric contraction of the visual field, both for while and colors, and
irregular scotomas. There is no pain, and seldom photophobia.
Of the colors, green is first lost, and blue last ; light-sense is longest
retained. The ophthalmoscopic appearances vary with the cause.
If the atrophy is subsequent to papillitis, the disc is increased in
size, and there is more or less obliteration of its outline and disten-
tion of the veins. In simple atrophy, instead of the rosy healthy hue
of the normal disc, the papilla may be grayish-blue, or quite white.
The outlines have a striking sharpness, which gives the shining disc
its characteristic appearance (Fig- 98). The disc appears sunVen
and excavated, and allows the network of the lamina cribrosa to be
seen through the spaces left open by the disappearance of the nerve-
fibers. Tfae vessels diminish in size, and the capillaries of the
papilla are no longer visible,

Prognosis is serious. The probability of retaining the vision yet
led is small, and the result is usually total blindness.

Treatment should be directed to the cause ; constant, increasing
doses of strychnin should be given, orally or hypodermic ally, and the
continuous electric current should be applied until it is found to be of
no avail. Good results have recently been reported from the com-
bined use of mercuric chlorid and nitroglycerin.

^K DISEASES OF THE LENS.

Anatomy. — The crystalline lens consists of a biconvex, transparent
body inclosed in an equally transparent homogeneous capsule. It
varies from eight to ten mm. in diameter, and is from three to four
mm. thick from pole to pole. Its posterior surface rests against the
vitreous, and its anterior surface against the posterior surface of the
iris. The capsule is thickest at the anterior pole (o,di6 mm.). The
lens is enveloped at its periphery by the suspensory ligament and
behind by the hyaloid men;ibrane. The substance of the lens is
arranged in concentric layers, composed of minute fibrils somewhat
hexagonal on horizontal section, which dove-tail into one another.
The external layers are soft, the next fiimet, M\i'C[\ftceft\-i'jJv.\t«\& ft
hardened nucleus. Between the \ayeis ai\i anvonsj.x^fcWoS''^^''^'^'^

*■ »36 DISEASES OF THE EYE.

oil-like material called the liquor Morgagni, which permits chan{
of form of the lens without friction. The anterior capsule is
elastic membrane, lined on its posterior surface by hexagonal c
whose function, it is said, is to nourish the lens proper.

The zone of Zinn is the suspensory ligament of the lens, ai
to retain the lens in place. It is a transparent, fibrous, perfori
membrane, stretched between the ciliary processes and the len
Between the folds of this ligament is the canal of Pi til, encircling d
equator and containing a fluid supposed to assist the nutridoa of 4

^ CATARACT.

Definition. — A pathologic change in the lens or its capsule dimi
ishing its transparency.

Causes.— Traumatic cataract, due to injury of the capsule o
needs no explanation, as it is not supposed that the subsequent ci
tricial tissue will be transparent. If the lens or capsule i
injured by trauma, but is dislocated or its surrounding media dis-
turbed, it becomes opaque through altered nutrition, due lo the sus-
pension of the exchange of fluid between the lens-stniclure and the
surrounding media. Any chemic alteration in the fl
of the body in general may he participated in by the aqui
ous, and suspensory hgament, and may endanger the lens, as, (
instance, cataract due to diabetes. Inflammations of the uveal ti
myopia, retinitis pigmentosa, detachment of the retina, and gill
ct. Rickets is an almost constant a

The gouty diathesis is mentioned ■

Heredity is sometimes an etiologic fact!

r workers in great heat and glare are parti

Certain toxic agents, such as naphtb

There is no satisfactory expl«

ct. Old age predisposes to cataract, but wfaeth

, sclerosis, atheroma of the .

lin on the accommodation In presbyopia, w

" say. It has been suggested that as the lens grows by proliferation d

the epithelial cells lining the anterior capsule, these cells becog

more compressed and harder at the nucleus, the oldest part of ^

lens, and when the normal increase d( l\\tTviit\cM'iTL>.'CBe ti.^j«r,*a^

lAe cortical substance ceases, the feist ^tt^i^i-aVetv v

paniment of lamelb
a predisposing cause.
Glass-blowers and othi
larly susceptible to
lin and ergot, may i
tion of senile
by weakened

formation. It is the opinion of the authors that the disturbances in
nutrition, directly and indirectly brought about by prolonged eye-strain
due to uncorrecied ametropia, are not only possible, but general
causes of cataract.

Varieties and Nomenclature. — Opacities in the capsule are called
capsular cataract ; opacities in the lens-substance are called lenticular
t, and may be cortical or nuclear, or, if both cortex and nu-
re involved, we speak of complete cataract. Complicated
le in connection with other eye-diseases. If ihe diseased
IS adherent to any of the neighboring structures, the condition is
'n as cataracta accreta. A polar cataract is a cataract conlined
c pole of the lens. In psrramidal cataract the opacity is at the
■r pole, and is conoid, the apex extending forward. Recurrent
capsular or secondary cataract is a cataract of the capsule appearing
after extraction of the lens. Diabetic cataract is associated with
diabetes. Probably the most convenient division of cataract is into
Benile, juvenile, traumatic, and atationary, and this classiiication with
its subdivisions will be used later. An important distinction of cata-
racts refers to their maturity or ripeness, whence they are classed as
ripe, unripe, and overripe (Morgagnian).

Symptoms and Diagnosis. — Cataract does not cause pain. The
symptoms are disluibance of vision and reduction of visual acuity,
which vary according to the kind of cataract and its stage of maturity.
Opacities on ihe pole or on the axis between the two poies may escape
the patient's notice, if they are small, dense, and sharpiy defined;
whereas, opacities including the entire pupillary area cause great
disturbance of vision. Opacities at the periphery, when covered by
the iris, as a rule produce no obstruction to sight; but when
the pupil is sufficiently dilated, as in a dim light, these opacities be-
come evident, hence such patients see belter in a bright light wilh a
contracted pupil. Patients with an opacity in the pupillary area with
the periphery remaining clear see better wiih a dilated pupil-rs.'^^
under a mydriatic or in a dim light. Even a complelgly-opaque lens
does not destroy vision. If the retina and opa^ii>^ierve are healthy,
the patient should be able to tell the direction from which light is pro-
jected, and should recognize an ordinary candle-flame in a dark room
at six meters. With normal light-perception, a pupil of a cataractous
eye should contract distinctly if light is suddenly t.hrO'«v\ mv\o \V,
- 1 Objective Eiamination. — If the anterior po\ai l;el^^'iT^'\sCl■^■^c!(M■,'^«•

238 DISEASES OF THE EVE.

pupil appears grayish-white instead of normal black. It musC not be
supposed that every grayish discoloration of the pupil is caused bj
cataract ; indeed, in old persons some difTused light is always refleclfd
from even a transparent lens, giving the pupil a. grayish color.
The general plan in the diagnosis of cataract is to use both obliqut
illumination and the ophthalmoscopic mirror. With the first, opac.
ities appear grayish against a black background, and with the second,
black against a red background (Figs. 99 and loo). If the calaiadis
almost complete, the whole pupillary area is grayish under oblique or
direct illumination and black under the transmitted light of the

J. Op«e,

ophthalmoscopic mirror. When a distinct area in the lens appeais
^iiy or ivhitt by focalilluminalion and black to light thrown through
it by the opklhalmoscope, we are justified in assuming an opacity.
The entire lens can be examined only by complete dilatation of thf
pupil, and even then the peripheral edges may be hidden.

Cataract is most common in old persons, next in infants, and rarest
in middle age.

BENILB CATARACT develops usually between the fiftieth and seven-
tieth yesr, and may be cottvca\, nuclear, or mixed in origin. It geit
tersJly shows a hard, unclouded, and \.ta'n=.■p^■^fe^\\■^'4Ae■Qs,■

DISEASES OF THE LENS. 239

One eye is generally affected at a time. Early
symptoms are multiple vision in one eye, caused by opaque sectors in
the cortex of the lens, and shortsightedness due to a change in the
refractive index or expansion of the lens. Incipient cataract causes
the presbyope annoyance; he complains that his glasses do not fit,
and that dark shadows are seen before his eyes. As the opacities
increase, the visual acuity diminishes, and the lens swells from absorp-
tion of water in the cortex, causing the anterior chamber to become
shallower. After a longer or shorter time the cortex becomes opaque,
the swelling disappears, and the anterior chamber is again of normal
depth. By this lime the visual acuity is reduced to counting fingers
and perception of a. candle across the room. The cataract is now
considered mature, or ripe.

The test for maturity of a cataract is what is known as the iris-
shadow. By throwing a strong light obliquely into the pupil, the
margin of lhe.^«pfris made to throw a shadow upon the opacity. If
the iens is completely opaque, the white hght reflected from it and
the dark brown of the pupillary margin of the iris lie immediatelj'
against each other ; if, on the contrary, the external cortical layer of
the lens is still clear, there will be seen, between the white shadow of
the opaque pupillary portion of the lens and the pigmented edge of
the iris, a dark ring, which will be wider the less the lens is opaque.
The treatment for mature senile cataract is extraction.

An otJerripe cataract becomes smaller and more dense, due either
to a diminution in the aqueous constituents, or to the cortex becoming
a yellowish, mushy mass of fluid, with a brown ni:cleus floating in il.
This latter condition is known as the Morgagniari cataract, and causes
the greatest disturbance of vision and difficulty of extraction.

JUVENII.E CATARACT maybe congenital in all stages of its growth.
As the nucleus is not yet hard, it participates in the general cataract-
ous change in the lens. Any part of the lens, even the nucleus, may
bestrewn with punctate opacities. Juvenile cataracts become atro-
phied, liquefied, or calcified. In the atrophic soft cataract there is
found within the capsule a mushy degenerative mass; and In the
fluid cataract the same constituents are found floating in the liquid.
In calcified cataract the whole lens is changedloalumpy mass, look-
ing like gypsum. In some cases the contents of a soft catatacl wiV)
be absorbed, leafing' only the membranoua oi ca^%u\M ta,\.wa«, T^t

I age of ihe patient, ihe bluish white color, and general appcaranct,
I indicate

^H34i

^^r STATIONARY CATARACT includes any Condition in which there is*
fixed and permanent opacity throughout life, showin
progression as in the foregoing varieties. There are several kinds d
cataract that are stationary, and they will be considered sepaialely.

Zonular oi Lamellar Cataract. — This is the rnost c
of stationary cataract. It appears nearly always in both eyes, ai
may be congenital, or may be developed during the eady yea
of life, not being noticed until the child is sent to school,
as a delicate, gray, homogeneous opacity, restricted to a zone lyiai
between the nucleus and the cortex, and is supposed lo be produce
by a temporary interruption of nutrition during formation of the le
If light is thrown by the ophthalmoscope directly into the pupiLl
dark, circular opacity, brownish-red in the middle, is seen, 1
cortex is not always clear, but may contain dots and spokes and w
are known as saddit opacitus. Unless the pupil be dilated, the c

■ ractous shell may not be discovered, and the patient be considered!
myope. Discission is almost always the operative measure employa
i..h;.

Posterior polar cataract is characterized by a white, glisteninft
round opacity, situated on the posterior pole of the lens or its capsulli
and is supposed to be the result of some disease of the fetal hyal
artery. It is usually complicated with disease of the retina
choroid. An artificial pupil may produce relief in these case*, b
failing in this, discission is the final step.

Pyramidal cataract (anterior capsular or polar cataract) if
congenital, but is acquired in childhood arter a perforating ukeri
the cornea and escape of the vitreous, which allows the lens lo a
in contact with the inflamed cornea. Afier the aqueous reforms. A

I lens recedes, leaving a small, roundish, glittering opacity protmiiii
into the anterior chamber like the apex of a cone. Contrary t<
general idea, the opaque mass is inside the capsule, which is i
jured, save for the absence of its epithelium.
Congenital nuclear or ecniral cataract is recognized by a whU
circular, and sharply outlined opacity in the center of the pnpl
Vision may be good, as the patient, \oqV% ^.\^■IW5,h. the side of ij
opaque nucleus.

DISEASES OF T

241

TRADMATIC CATARACT results from a rupture of the capsule by a
contusion of the eyeball, by penetration from a foreign body, or frora
injury to the lens itself. The lens-fibers coming in contact with the
aqueous become cloudy and swollen, and If the wound is of any
extent, as is usually the case, the entire lens parflcipaies in the morbid
process. The Contents of the capsule gradually protrude into the
anterior chamber and are absorbed. Iritis is a frequent accompani-
ment, and if there is much swelling of the lens, glaucoma may be
produced. The younger the patient, the quicker the absorption and
the less inclination to increased tension. The slightest touch in an
operation may give rise to a traumatic cataract, and in elderly per-
sons a small aseptic foreign body rnay cause cataract so slowly that
the patient forgets about the injury long before there is marked visual
disturbance. The treatment in young subjects is to wait for absorp-
tion, while in elderly persons extraction is indicated after the subsid-
ence of inflammatory signs. Marked increase of intraocular tension
calls for early iridectomy and extraction, The general procedures for
associate traumatic and inflammatory conditions — such as co!d, leech-
ing, antiseptic douching, and atropin — are necessary.

TREATMENT OF CATARACT.

General Remarks. — The treatment of unripe cataract must be the
use of proper reading glasses, protecting the eyes from irritation of
any kind, and the maintenance of the general health of the patient.
In considering what cataracla may be operated on, we must first
determine whether any retinal, choroidal, or nerve-disease coexists,
which maybe discovered by examining the light- sensation or field
of vision.

Stationary cataract, in which the visual acuity is sufficient for the
patient's occupation, or in which an artificial pupil will suffice, should
not be operated on. If one eye is unafFeclcd and healthy, it is not
advisable to operate, for, even under the most successful conditions,
we can not expect perfect binocular vision, on account of the great
optic disparity between the eyes.

Ripe and overripe cataracts are best treated by operation. Unripe

cataracts should be waited for. or, if absolutely necessary, should be

artificially ripened by intracapsular irti^aV\on t,W.Of..tiv«T^i. t« ">h-(

Forsler's luelhod, which consists in pevioimTO^ aTi «\i,t0.tj^s\>i -ot ■»

2*2 DISEASES OF THE EVE.

paracentesis of the cornea, allawing the escape of aqueous, and imi-
tating the lens hy massaging the cornea against it with a strabistnui
hook or spatula and CKtracling afterreaclion has ceased. Beltmann's
method consists in "' direct trituration " of the lens with a spatula In-
troduced into the anterior chamber after iridectomy. AH these oper-
ations are attended with more or less danger. In fact, many oper-
ators believe it is safer to extract an unripe cataract than to resort to
artificial ripening.

The health of the patient and the state of the eye should be con-
sidered before proceeding with any operation. General debility and
any inflammatory disease of the eye or appendages are contralndica-

Preparation for Operations. — A gentle purgative should be given
the day before the operation. The head should be washed with soap
and hot water, and an antiseptic bandage placed ove
operated on. This bandage is removed at the operation, the head
enveloped in a cloth wet with sublimate solution, the vicinity of the
eye thoroughly scrubbed with a strong sublimate solution, and the
eye douched with a mild antiseptic solution. Anesthesia is produced
by instilling several drops of a four per cent, solution i
eye five limes, at intervals of two or three minutes, /
sponges, and dressings used should be thoroughly sterilized before
the operation.

Choice oF Operation. — Discission is applicable to the
and lamellar cataracts in childhood. The reaction an
tension in adult eyes after discission is so great as to be dangerous,
although discission has been successfully used before extraction of rbe
lenses of highly myopic eyes. However, in this case an early iridec-
tomy and extraction is performed.

Extraction •mithout iridectomy is a beautiful operation, and often
gives ideal results. Many reliable operators advise it, but it should
never be performed by a novice ; only by an expert upon selected
and trained patients. The tendency to prolapse of the iris a
secondary capsular cataract is greater than in the combined opera-

Exlraction with iridectomy is the safest of all cataract extractions.
It is absolutely demanded in complicated or difficult cases. The so-
called "njHli/alfon " of the iris \s s\\^\\i, ani vVe co^wittic disadvan-
tage is hardly noticeable, and is muc\v mot« Wao. aft^-ft'Vi'j x^at ^i&e^ j

DISEASES OF 'J

243

and good results. Prolapse of the iris is infrequent. Wiih careful
irrigation of the anterior chamber, the chances of secondary ci
are greatly reduced.

Discission \s the operation most used in lamellar cataract i
all soft cataracts without hard nuclei. The necessary ii

Fig. 101.— Nehdlb fob Sopt C*tab.<ct,

a lid-speculmn, fixation forceps, and a discission-knife needle (Fig.
[01), or Bowman's stop needle. The pupil should be dilated (o the
utmost. The needle is entered perpendicularly to the under and outer
side of the center of the cornea (Fig. 102). The capsule is pie reed near
its anterior pole, and is divided up and down by a vertical sweep of the
handle, taking care not to penetrate deeply into the lens. If neces-

sary, the vertical incision in the capsule may be enlarged transversely ;
the needle is then withdrawn in the same direction as it was entered,
avoiding, as much as possible, escape of the aqueous. While the
lens is undergoing absorption, the pupA mo* \iei V.t'^ SJttos^ -w&v J
airopin. If the swelling is too intense ani ittoa «u»w4,"Jd.«i '

DISEASES OF THE EVE.

action. If abso
: aqueous by paracentesis and re-1
Inflammatory symptoms a

I 344

mass should be let out by simple
obstructed, simple release of the
peated discissions are necessary,
in the usual way.

Extraction with Iridectomy. — The lids are fixed by a lid-speculum
or by the fingers of an assistant, and the conjunctiva is firmly held
with fixation forceps, at a point centrally below the margin of the
cornea. A Graefe knife (Fig. 103) is entered at the corneal margin,
just above its horizontal diameter, and is passed through the a
terior chamber in front of the pupil, making counterpunclure at

point exactly opposite. With the culting-edge upward, the knife b
gently moved to and fro, until the upper two-iifths of the cornea b
opened at the scleral border. The operation is then momentarily
suspended, and the patient is directed to look downward and keep
the eye quiet while iris-forceps are introduced closed through the
center of the incision. The iris is grasped at its pupillary border,
slowly withdrawn, and the portion to be removed is excised^
by iris- scissors, the blades of which are held in the plane of tliel
vertical meridian. The anterior capsule of the lens is then opene<i

by a cystotome (Fig. 104), which is Introduced into the wound to tl
edge of the iris, with its cutting-point directed upward ; it is tl
partly revolved, turning the point backward toward the capsule, o
which it is drawn in a horizontal and vertical direction, or around th«fl
circumference of the pupil ; another quarter revolution of the handlai
is made, and the instrument is withdrawn with its point downward.

The delivery of the lens is then effected by gentle pressure anftfl
massage with a lens-spoon until it is extruded through the cornea
incision (Fig. 10$). Counterpressuie toiy be made with one spooi^
on Clie inferior portion of the cornea, ■«\i\\«3-novWi s'5(««v^!e

DISEASES OF THE LENS. 145

the sclera above the incision. The anterior chamber is freed from
blood, and the remaining cortical fragments are expelled by stroking
the cornea with a spoon or by the gentle injection of sterilized water
or a weak antiseptic solution. Care must be taken that the iris is not
engaged in the wound, and if it can not be successfully pushed hack
into the anterior chamber, it should be excised.

If the vitreous presents at the corneal wound before the lens is
delivered, the speculum must be withdrawn, and the lens removed by
means of a wire loop, a spoon, or a special lens-extractor. In cases
in which, for any reason, prolapse of the vitreous is anticipated, the
Kail suture is sometimes employed. A fine suture is introduced into
the substance of the cornea, not penetrating it, below the line of ex-
pected section, and brought out and carried over into the tissues

Fig. 105.-EJ

beyond the limbus. After extraction, this suture may be tightened.
The Kalt suture has not found general favor.

Bxtrsction without iridectomy is suitable for cases in which the
operator is skilled by long experience, and in which a smooth and
complete delivery of the lens may be anticipated in a healthy, calm,
and intelligent patient, A Graefe knife is introduced near the hori-
zontal diameter of the cornea at its junction with the sclera, and a
flap made by transfixation as before, including about five-twelfths of
the corneoscleral margin. The capsule is divided as in the preced-
ing operation, or rather more extensively if a Knapp knife, especially
designed for this purpose, is used. The lens is expelled by slow,
steady, continuous pressure with a spoon otv \\vt \o"«e.\ ■^■ft,l^. <A "^^t
cornea. The rest of the operation and U\e com^Vvc

as in extraction with iridectomy. Eserin (gr. j
the eye and the eye bandaged.

Accidents During Extraction. — The corneal section may be made
loo small. In such case it should be enlarged by a knife
Hemorrhage into the anterior chamber tas^j interfere with iheoperi-
tion. Irrigation and massage of cornea with a scoop will dispel ihc
blood. Prolapse of ike ■vitreous before delivery of the lens Is a seri-
ous accident, as the lens falls back into the vitreous chamber, and
may be lost unless immediately extracted by a loop, scoop, or olbM
similar instrument. Loss of vitreous after extraction is not serious,
but is an Indication for Immediate suspension of further manipula-

Complications in the Process of Healing. — Pain may be severe, and
continued beyond three or four hours. It should be rnet with hypo-
dermic injections of morphia.

The anterior chamber is sometimes not restored for a week or mote.
This need cause no alarm.

Corneal opacities usually soon pass away, unless caused by strong
C chlorid solutions.

Suppuration of the ivsund is rare when antiseptic precautions are
used. Its onset is made known by severe continued pain and by pus
In the eye. It usually occurs between the twelfth and thirty-sixth hours,.
It should be combated by actual cauterization of the whole corneal
wound and mercuric chlorid irrigations. It Is a very serious compli-..

Iritis Is due to traumatism during the operation, irritation from
remaining cortical substance, and rarely infeclion. It does not ap-
pear for several days after the operation, and is ushered in by patA
and the objective symptoms of plastic Iritis. It is treated by atropln,
hot compresses, leeching, and salicylate of soda or the iodids intern-
ally. The disastrous results are generally due to organized exudate
in the pupil, obscuring vision,

Cysloid cicatrix \% usually seen at the extremities of the corneal
section. It does not appear for several weeks after the operation. 1'
the Iris capsule is included in the cicatrix, the eye Is exposed to th
danger of sudden attacks of iridocyclitis or iridochoroiditis.
Extraction of the lens in an unruptured capsule is an ideal opers
li'o/i, but is an]v applicable when ihe capsu\e\s\ia\i^ »T.i>i\e 'jah^u
mryligameni weak.or when ,hereis iftuvi WV««^ftv«NM,«^^,

DISEASES OF THE LENS. 247

lens. Instead of lacerating the capsule with a cystotome, a spoon
is passed behind the upper edge of the lens, and gentle pressure is
exerted on the lower third of the cornea. If the lens is not expelled,
the spoon is passed still deeper behind to the posterior pole, and the
lens slipped out by pressing it lightly against the inner surface of the

Descriptions of other operations for the extraction of cataract are
considered unnecessary in a work o( this nature. Suction is only
applicable to fluid cataracts without a nucleus, and is not recom-
mended. Suction by the mouth is a forbidden procedure in these
days of asepsis and antisepsis.

After-treatment consists in removing all shreds from the corneal
wound, cleansing the eye, and after simple exlraclion instilling a
drop of eserin to prevent prolapse of the iris. If there is much cor-
tical substance still in the wound, it may be removed by gentle mas-
sage of the cornea, or by c.ireful irrigation of the anterior chamber
with a special syringe. Lippincott has devised a most convenient
apparatus for this purpose. The eyelids are closed with adhesive
strips. A light absorbent bandage, consisting of a little absorbent
cotton and thin material, like tarletan, is applied over both eyes, not
to exert pressure, but simply to keep the eyes closed, at rest, and
moderately warm. The dressings may be protected by a pasteboard
shield. The patient is kept quiet in bed, and, unless there are active
signs of infection, the bandage is not opened until about forty-eight
hours after the operation. If there are no signs of inflammation then,
the eye is cleansed twice daily, and at the end of a week the band-
ages may be omitted altogether, and dark glasses should be worn
10 protect the eye from strong light. After removing the bandage,
atropin may be instilled daily, to keep the cili.iry muscle and iris
completely at rest. Strong convex lenses may be ordered after sev-
eral weeks, and the patient allowed to begin the use of the eyes.
Under ordinary circumstances the correcting lens for distance is
about -|- S. 10, and about -|- 5. 13 or 14 for reading. Some astigma-
tism is usually present, and should be corrected; this, however,
gradually diminishes, and a reexamination of the refraction is soon
necessary. Any inflammation secondary to cataract operations
should be treated on the general principles heretofore discussed.

^■WCl

:ONDARV CATARACT ii dvlC 1(1 lUeOp&WV^ o^ fee.T'^*^™'^^

DISEASES C

aule of the lens, with or without any remaining lens-substance, t
ract-dcbris, or inflammatory exudate. The treatment of an opaqire I
capsule in a pupillary space consists of discission by a. needle c
Graefe's knife (capsulotomy), or, if the capsule is tough, by dilacera-
tion with two needles (Fig. io6). Care should be taken not to
exert too much pressure and dragging on the cUiary body. Some
operators divide the capsule with a pair of Rue scissors-forceps, and
others extract the capsule through an opening in the cornea n
scleral margin (capauleclomy). Small hooks arc also used for tearing M

1 openmg ii

1 opaque capsule,

INJURIES TO THE LENS causing opacity are seldom limited
locality, but generally involve the adjacent tissues. Simple
should be treated like cases of discission, and may subsequently
quire an appropriate operation. The younger the patient, the better
the prognosis. The lens may be dislocated completely, in which form
the suspensory ligament is lorn through and the lens is crowded
of position, and may even escape through the conjunctival
or it may be simply subluxated. A lens displaced from its ntUut
lied sooner or later becomes opaqvie. Yoi (iiCviti ^vit^'o'SAQQ
/Am subject the reader is referred to tVie sccVvotv otv '

OF THE VITREOUS.

Tact. A foreign body in the lens causes cataract, and the c.

Dus lens should be removed before it becomes overripe, else the

foreign body may be released and become lost in the vitreous chamber.

THE CONGENITAL ANOMALIES OP THE LENS. — Dislocation is
generally associated with some congenital anomaly of the vitreous or
choroid. In this form the lens may retain its transparency for many
years, and Can be seen to move with change of head, and is visible
under transillumination. There is sometimes congenital coloboma
of the lens, generally peripheral, corresponding to coloboma of the
iris and choroid. Aphakia, or absence of the lens, is sometimes
congenital, but exists, of course, in persons upon whom discission or
exlraclion has been performed. It is diagnosed by the deep anterior
chamber,the trembling iris, high degree of hyperopia, and the loss of
accommodation. There is also the absence of the small inverted im-
age of a candle held close to the eye. The treatment
prescribing correcting bifocal glasses for reading and disla

^* DISEASES OF THE VITREOUS,

Anatomy and Physiology. — The corpus vitreum forms the principal
bulk of the globe of Ihe eye. It consists of 98,6 per cent, of water.
The remainder is composed of transparent fibers extending in all
directions. Between these fibers are the compartments in which the
nearly pure water or vitreous humor is contained. The vitreous is
pierced in an irregular sagittal direction by the central eanal A\io^\^
Iwo mm. in diameter. In the embryonic state Ihe hyaloid artery Xxa.-
verses this canal, and sometimes persists after birth. The vitreous is
contained in a delicate membrane called the hyaloid membrane.

HVAL.1TI3, or inflammation of the vitreous, is not an independent
disease, but is generally associated with inflammation of the uveal
tract, particularly the ciliary body, which causes disturbances of
nutrition. It is characteriied by change in consistency and partial
disorganization. Opacities are seen in the form of threads, clouds, or
separate flocculi, which cause subjective visual disturbance, ^'u^.
provided the media are sufficienl\y c\eaT,aTe de\et>.ti\i'i'Ci\twJ«*^'^-
moscope. The treatment is consl\tuViOT\a\, avi4 viTvift aKi <L«fa.-o

OF THE EVK.
mple.

MUSC^ V0LITANTE3, OR MYiODESOPSiA. — Microscopic vitreo
opacities- formed at the periphery are of normal occurrence, and a
found floating in the vitreous and can Ije readily seen in one's o«
eye, particularly if the observer be myopic. In certain cooditions i
a.metTOpia these opacities become numerous and annoyingandassun
different shapes, such as strings of beads, flakes, etc. They generallfl
disappear when the ametropia is corrected. By many observen
musca; are considered intraocular evidence of waste-tissue accuniul»
don, and diet, exercise, and eliminatives, such as sodium phosphate
are prescribed. Many patients complain of muses during attacks
of "biliousness." As soon as opacities are rendered visible by Ok
ophthalmoscope, they are termed ■vitreous opacifies and are always tl
sign or sequence of disease of the choroid, ciliary body or relioi
intraocular hemorrhage, etc. The treatment should be directed ti
the cause. Mild aperients, diaphoretics, the mercurials and iodid^
etc., may be administered. The eye should be used as little a
sible at night. Vitreous opacities only reduce visual acuity when lh(J
intercept the rays of light proceeding to the macular region,

SYNCHYSia is a name given to fluidity of the vitreous. Ii
erally due to chronic inflammation of the choroid or the ciliary bodj;
and in itself brings about no special disturbance. Fluidity of tMr
vitreous is significant in cataract operation, as we may expect c
erable loss of vitreous under such circumstances.

BYKCHYSis SCINT1LLAN3 is the name given to an acciimul.
of cholesierin, tyrosin, and other crystab dispersed in the vitreoii
constituting an ophthalmoscopic picture which has been compared
a shower of sparks in fireworks, ll may be dependent upon cb
roidilis. The disease appears in advanced age, without siga i
choroidal disease. Treatment is useless, and the condition is a CO
Iraindicalion to operation,

PERSISTENT HYALOID ARTERY is a rare anomaly, and consists i
a line, Jibrous cord with its anterior end either attached to the pa
lerior surface of (he lens or pnitruAma ^toto v'tvft Wtvi-iii \ti\ji <]
vilreous. It may easily be seen w\i\it\\e o?\v<,^a\TOQ^to^.

GLAUCOMA.

Definition. — Glaucoma is a disease in many respecis not thorouglily
understood, but characterized by the essential sign of increase of in-
traocular tension. However, every case of simple increase in intra-
ocular tension is not glaucoma, and in some cases oi simple glaucoinii
no increase of tension exists.

Causes.^The direct cause is increase of the contents within the
eye; either from Af^»'ji'iT«A'o«, due to disturbances of llie nervous
mechanism controlling secretion, or to relenlion of the intraocular
fluids by obstruction or obliteration of the drain age -pass age a at the
periphery of the anterior chamber. Conditions causing changes in
the composition of the aqueous also interfere with fillration^ — as, for
instance, serous iritis and cyclitis. There is so much discussion and
difference of opinion among equally erudite oculists about the cause
of glaucoma that an exposition of the numerous theories is not advis-
able in an elementary work.

Among the predisposing causes are mentioned old age {with nor-
mal diminution of the circumlenticular space), gout, rheumatism,
nephritis, certain cardiac diseases — in fact, any condition leading to
circulatory and vascular changes. The general tendency to waste-
tissue accumulation — the so-called uric-acid diathesis — is a funda-
mental cause in these cases. It is the opinion of the authors that
long-continued eye-strain, from uncorrected or improperly corrected
ametropia, is a potent factor^ in the etiology of many cases of

Pathologic Changes. — If there is a rapid rise in tension, the lens is
pressed forward, a fact proved by the shallowness of the anterior
chamber, and the suspensory ligament is stretched beyond the power
of the ciliary muscle to relax it, as is shown in the lessening in the
range of accommodation. There are marked circulatory changes in
Ihc eye. Pulsation is noticed in the retinal arteries, and the retinal
veins are tortuous and swollen from the increased pressure. As the
venje vorlicosic are also squeezed by the intraocular pressure, an
excess of blood is discharged through the anterior ciliary veins,
which, in consequence, become dilated and tortuous. The cornea
becomes cloudy from pressure, and even the a.t\uto\iL=, xcvi •jXwtwas.
participate in this change. From pressiwc oti ft\e cKvw^ -msn^s
neuralgia is produced, and paralysis ot tVe Si^VvncSAT "O'MaCi.'s^ '^^

Subjec

anesthesia of the cornea result. By increase in the vitreous Ihe in-
traocular pressure is raised. The most important diagnostic change
is the excavation or cupping of the disc and atrophy of the nerve-
libers (Fig. 107). The final result of intraocular tension is active
inflammation and swelling of both the internal and external coats of
the eye. Naturally, vision is very much reduced.

: Symptoms. — The patient complains of dimness of
vision, diminution of the visual field, and
pain about the eye, the intensity of which
varies with the aculeness of the attack and
the inflammatory symptoms accompany-
ing. The appearance of colored rings or
halos about any source of light, so often
noticed in glaucoma, is a phenomenon
due to the corneal disturbance, and is not
confined especially to glaucoma.

Objective Symptoms. — The tension of
the affected eyeball is abnormally high.
If the rise in tension has been abrupt, the
cornea is hazy and less sensitive to the
touch than usual. The pupil is sluggish
and ofien widely dilated, and has a greenish
hue ; the anterior chamber is shallow. In
the inflammatory form there is consider-
able superficial and deep pericorneal injec-

With the ophthalmoscope the most char-
acteristic symptom is excavation or cuppiog
of the optic disc (Fig. 108), which is to be
distinguished from the physiologic cupping
n extending the whole surface of the disc, and in having abrupt or
overhanging sides ; and from atrophic excavation of the disc, by the
depth and pecuhar "broken-off" appearance at the edge of Ibe disc,
so that no continuity can be discovered between the arteries aX the
bottom of the cup and the vessels on the edges of the disc. Pulsa*
tion of the retinal arteries is noticed, particularly where the Artery
bends over the edge of the cup ; it may be made more dlsiinoL^
b^ slight pressure on the eyebaU. T\ie de^ee o^ cuijvvti^ ■«.■».-) he
estimated by the parallax test or by conipa,t«cnv o^ OaeitUac&wn&
the edge ^nd bottom of the cup.

GLAUCOMA. 353

(gnosis. — In inilaminatory glaucoma, on hasty inspection, the
disease may be confounded with keratitis, iritis, cyclitis, etc. In such
cases it is well to discard the injection, and rely an the dilated pupil
and shallow anterior chamber, the increase of tension, the visual dis-
turbance, the peculiar ciliary neuralgia, and the characteristic cupping
of the disc.

For [he differential diagnosis between acute glaucoma and the

ordinary inflammalory conditions of the eye, the student is referred
to the valuable table on pages 162 and 163.

In the noninflammatory types of glaucoma and optic atrophy the
contrasted symptoms of the following table (Randall) are usually
found; but It must not be forgotten that they may be wholly absent,
or obscured if present.

Taiiulattiin of Symptoms.
ffoHiiftammalo-y ClaucoKia. Opiic Nmif.- Atrophy.

Tension increased, Normal.

Cornea hazy and anesthetic. Normal,

Anterior chB,mber sballon or obljteraled. Normal.

Iris atrophic and discolored, Nornml.
Pupil dilated and sluggish or fiied,
R<.'ffejc j-e/fowishgrccQ, "glaucous."

THE EYE,

Tabulation of Symptoms.— (CoHft'»«crf.)
NoxiKjIammstory Glaucoma. Oflie Nervi Alrapkf

Pedbratiiig vessels dilaled and tortuous. Normal.

Sometimes history of pain with obscurations. Painless loss of vision.
Uoilateral character usual al HrsL* Bilateral geneially.

Limitation of field usually to ulisiiI side. Concentric limitHlion,

Color-tields commcnstirate to form-fields. Disproportionate loss.

Rainbow vision about lights. No halos.

Knee-jerks unaffected. "'

Optic disc cu|>ped, margins overhanging.
Halo of choroidal atropb}' usaal.
Nerve-tissue greenish in ^hadovr.
Arteries and veins pulsating.

Glaucoma usually attacks persons past ftfly, alibough even childreo
may be affected. Ametropic eyes are most often affected,
eyes are generally attacked, although the second eye may not be dis-
eased until many years after. Prompt treatment and careful prophy-
lactic measures are important factors in delaying or preventing a
recurrence.

Varieties.— Acute inflammatory glaucoma is characterized by it
abrupt onset, the signs of intense inflammation, marked pain, an i
dilated pupil. It may result in a few hours in total and incurable
blindness, the condition known as glaucoma futminans ; or it may
progress through successive attacks to a condition of stony hardness
and total blindness called glaucoma absolulum ; or the inflamma-
tion may not subside, leaving what is known as a chronic inHam-
malory glaucoma. The general rule is a gradual subsidence of the
disease with a permanent increase in tension. Simple glaucoma, or
simple chronic glaucoma, Is free from inflammatory symptom
is of slow development. Often Ihe cupping of the disc is the only
sign; and when the media are opaque, the disease is easily over-
looked, or mistaken for amblyopia, optic atrophy, retinitis, etc., and
blindness results. The visual field contracts first on the nasal half.
Infantile glaucoma, or hydrophthalmos, is a condition In which there
is more or less uniform distention of the whole sclera as well as exca-
vation of the nerve-head. The eyeball is unnaturally large, the
tension is raised, the disc gradually excavated, the cornea hazy, bill
Ihe anterior chamber is deep. Malignant glaucoma is a term ap-
plied to a sudden and destructive omWist i.i i.'nc iva
sometimes shonly after the pettormav»c« o^ an miec\oift-i ,

GLAUCOMA.

355

Secondary glaucoma is due to an increase in tension from inflam-
matory changes about the iridic angle consequent upon diseases oC
the iris, lens, retina, choroid in high myopia, or intraocular tumors.
Hemorrhagic glaucoma is dependent on hemorrhage from the inlernal
ocular coats for the increased tension.

Prognosis. — Unless treated, glaucoma is almost certain to result,
sooner or later, in complete and incurable blindness. It is of utmost
importance to make an early and absolute diagnosis of this condition,
especially in the simple variety, in order to prevent a fatal termina-
tion. Strange to say, glaucoma has been repeatedly mistaken for
iritis, notwithstanding the dilatation of the pupil in the former discs
and contraction in the latter; and to the great injury of the patie
atropin has been repeatedly instilled, soon aggravating the con
tion to blindness. Generally speaking, if promptly and properly
treated, the prognosis of acute glaucoma is favorable ; it is doublfut
in simple and infantile glaucoma, and unfavorable in the other

Treatment consists in three methods: (i) Miotics, as eserin and
pilocarpin, to contract the pupil. (2) Operation by paracentes
iridectomy, sclerotomy, and incision of the hgamentum pectinatura.
(3) Massage.

Miotics are the first resort, and often cut short single attacks 1
glaucoma, and they are also valuable before and after operation.
Pilocarpin and eserin are commonly employed, and are long'co
linued. Paracentesis relieves tension only for a short time. Iridec-
tomy is of extreme value, and has some remarkable curative influ-
ence both in dissipating the increased tension and relieving the visual
disturbances, and even eventually curing the process. It should be
broad and done upward, for cosmetic reasons and to prevei
sequent dazzling. The earlier the iridectomy, the belter the result.
Restoration of vision can not be expected if there is much excavation
and atrophy of the nerve-head.

Sclerotomy has been advocated in cases of simple glai
which the visual disturbance depends on the changes of the optic
nerve, and in infantile and hemorrhagic glaucoma. A Graefe's
racl knife is introduced into the anterior chamber at a point c
spending to the puncture in cataract extraction, but onemm.remo'jed.
from the corneal margin. The couciVerpvmt\.iitt \s TuaifciS.^'^'*^
-.ponding to this at the olVier side ot the a,w\.ei\Qt '^^^■a.-Ktottt."

^igwresj

356 DISEASES OP THE EVE.

sawing motion of the knife, the section is enlarged upwar

ily a bridge of tissue, about three mm. broad above, remains undi-
vided. The knife is then slowly withdrawn from the eye, care being
taken that the aqueous humor is slowly evacuated through the lips
of the wound, A drop of eserin is applied and the eye bandaged.
Prolapse of the iris must be treated on general principles. lacision
of the ligatnentum pectinatum is performed by cutting through the
filtration angle, or spaces of Fonlana, with the point of the knife as J
it is withdrawn in sclerotomy. The good effects of sclerotomy havofl
not been definitely established, I

Massage of the eyeball, systematically pursued, at first by the '
physician and afterward by the patient, is of undoubted value. The
result of massage is almost instantaneous; immediately the eyeball
grows softer, but the effect is not lasting. However, five minutes'
massage, exerting considerable pressure, practised several times
daily, is an important aid in the treatment of glaucoma. Alternate
firm palpations with two fingers upon the portions of the eyeball that
can be reached by rotation of the eye to all sides, and through both
lids, is perhaps a better method of effecting massage than by rubbing.
Simple vaselin, a very weak yellow ointment, or a salve containing
eserin and cocain, may be used in conjunction with massage.

The proper correcting tenses, both for distance and for near, should
be applied in cases in which vision is still serviceable.

DISEASES OF THE ORBIT.
Anatomy, — The orbits are situated on each side of the cenlial I
facial line, between the forehead and face. They are formed by ihe
following bones: the frontal, ethmoid, sphenoid, lacrimal, superior
maxillary, palate, and malar. The first three are common to both
orbits (Fig. log).

The general shape of the orbits is that of irregular, rounded, quad>
ra ngu I ar pyramids, the apices extending inward and forming ai
at their imagined point of junction of about 40°. The average widtlj
of the orbit in adult males is 40.5 mm.; the height, 35 n
dimensions in the female are slightly smaller.
The orbit is in connection w\\h V\ie nei^Vfeorwi^ ^wwm:
I cavity by nine foramens, fissures, at-i ca-naXa— \\t.

257

sphenomaxillary, supraorbital, infraorbital, :
ethmoid, posterior ethmoid, malar, and lacrimal. The orbit is lined
with periosteum and contains a cushion of fat, upon which re^ls the
eyeball and its immediate appendages.

PERIOSTITIS is an inflammation of the periosteal lining of the
trrbit, particularly prevalent in scrofulous and syphilitic patients. The
I may be so extensive as to involve the frontal sinuses

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and produce necrosis of the underlying bones, A blow or a. fall is
usually the exciting cause. The symptoms are dull pain, swelling
and edema of the skin surrounding the orbital edge, and, if necrosis
has taken place, a fistula discharging foul pus and bony debris.
Cicaltiiation of the fistula may lead to ectropion. The eyeball
rarely involved.

Treatment consists of leeches to l.Vie \em9\«, c.o\4.t(>m.Tp«.'SiKa,-K^*i-v
jftoe palien t is syphilitic, the adm\T\isVTa\:iOn il ■mett\i\\si'= ■asvivs.Q^-'''"
'7

If the disease reaches a. suppurative stage, antiseptic poultices, ii
and drainage are indicated.

ORBITAL CELLULITIS, or inflammation of the connective tissue of
the orbit, is due to periostitis or to any suppurative or inflammatory
process in the vicinity of the eye ; even inflammations about the roots
of the teeth may cause it. Erysipelas, anthrax, and pyemia
result in metastatic orbital abscess ; and, finally, infection after injury
to the orbit or its contents is a cause. The symptoms are pain, fevei
general prostration, swelling and redness of the lids, edema and
increased tension of the conjunctiva and Uds, exophthalmos, fixatic
of the eyeball in a straight or deviating position, causing visual di
turbance, and, after the pus escapes, a discharge from the otbi
In unfavorable cases panophthalmitis may ensue. Metastatic a1
scesses generally lead to death. Extension into the cranium is always
to be feared.

Treatment consists in prompt incision, preferably at a spot showing
signs of pointing, drainage, and antiseptic irrigation,

INJURIES TO THE ORBIT may cause fracture of the bony wall
laceration of the soft parts. Foreign bodies maybe received a,
retained in the orbit for varying periods of time. They may escape
into the nasal cavities or they may cause orbital inflammation, and
even death. Luxation of the globe is generally produced by a wedge-
shaped foreign body crowding between the eyeball and the orbit.
Formerly, what was called "gouging " was resorted to by contestants
in brutal fights, the object being to dislocate the eyeball from its
socket with the point of the thumb. The danger is blindness from
laceration or overstretching of the optic nerve.

Fracture of the orbit may be detected by palpation. If the neigh.
boring sinuses are opened, there will be much emphysema about the
lids, made worse by blowing the nose. There is late appearance (two
or three days) of extravasation and ecchymosis of the lids. If the
optic foramen is involved, there is. sooner or later, blindness from
pressure or injury of the optic nerve. When fracture of the orbil
produces enough hemorrhage to cause exophthalmos, the prognosis
is bad.

Treatment.— After orbital injuries the affected parts should be

Ihoroughiy disinfected, and foreign bodies removed. The ptoxiinity

^ the brain to f he orbit renders the ptogivosis doM'ta\^»\ "w

DISEASES OF THE ORBIT. 259

fractures or infected wounds. Rest and cooling compresses are in-
dicated. In luxation, vision maybe lost through stretching of the
optic nerve, but may return after reposition of the eyeball and reten-
tion with a pressure-bandage. If the lids are closed tightly behind
the globe, preventing replacement, the external canthus should be
divided at once. The longer the eyeball is dislocated, the worse the
effect upon vision,

TUMORS OF THE ORBIT cause exophthalmos In the direction of
pressure. The other symptoms are disturbance of motility and vision
and pain, all of which vary according to the size and malignancy of
the tumor. The chief tumors are osteoma and encephalocele of the
orbital wall ; tumors of the optic nerve ; and cysts, sarcomas, and
vascular tumors, arising in the neighboring cellular tissue. Agenuine
orbital sarcoma is extremely rare, and carcinomas never originate in
the orbit proper. All orbital tumors of any considerable si(e or
malignancy should be removed after enucleation of the eye. There
is little hope of treatment of encephalocele.

EXOPHTHALMOS is protrusion of one or both eyeballs. If one eye-
ball alone bulges forward, there is hkely to be a local cause, such as
abscess, injury, aneurysm, or other tumor, and it should be treated
accordingly. Protrusion of both eyeballs is probably the result of
some circulatory disturbance, such as exophthalmic goiter (Basedow's
or Graves' disease) ; injury to the internal carotid within the cavern-
ous sinus (pulsating exophthalmos); or of some condition causing
thrombosis of the ophthalmic vein. In such cases local treatment is
of no avail. In exophthahnic goiter the significant symptoms arc
exophthalmos ; absence of the normal, simuhaneous drooping of the
upper eyelid as the eye is turned downward (von Graefe's sign);
greatly increased rapidity of the heart's action; and tumefaction
of the thyroid gland.

ENOPHTHALMOs is a term applied to retraction of the eye within
the orbit. It depends upon the absorption of the orbital fat, decrease
in the contents of the orbital vessels, or great loss of fluid from the
body after intense purging. Traumatism involving the walls of the
orbit may produce enophthalmos on the side affected. Senile enoph-
ihalmos is bilateral, and is due to the gradual absorption of orbital
fat in old persons. The same coTid\tio'[\.tev\\w. va t'm.'WiaSi.o-n.'iiaxs-
faslinff or disease.

IJAo DISEASES OF THE ^^^^^^H

INJURIES TO THE EYEBALL. ^|

PUNCTURED AND INCISED WOUNDS about Ihe sclerocorneal mar- ^|
gin are especially dangerous on account of involvement oriheciliary^
body; chronic cyclitis, and even sympathelic inflammation of the
other eye, resuhing. Wounds of Ihe sclera are accompanied by pro-
lapse of the choroid and retina and loss of vitreous. Detachment of
the retina is a serious sequel. Injury to the lens or its capsule re-
sults in traumatic cataract. Corneal opacity is liable to follow a cor-
neal wound, and the opacity will be greater if the iris prolapses.

One of the great sources of jianger in penetrating wounds of the ■
eyeball is the liability to infection, which is augumented by the im- H
possibihly of disinfection on account of the depth and narrowness of H
the traumatic canal. I

Treatment consists in thorough disinfection of the eyeball and ap-
pendages with a 1 : 50QO mercuric chlorid solution, closure of the
wound with a conjunctival suture, sprinkling with finely powdered
iodoform or one of its substitutes, and an antiseptic bandage- Pro-
lapse of the iris should be combated by restitution, abscission,
alropin, or eserin. If the lens is injured, atropin and iced com-
presses are indicated and the ordinary treatment of traumatic cataract ■
instituted. Injury of the lens through the pupil offers the best prog-j
nosis. In case the retina is completely prolapsed and much vitreout
is lost, causing blindness, immediate enucleatio;i may be necessary.

CONTUSED WOUNDS OP THE EYEBAi,L are the result of blows
from the fists or a blunt instrument, " Black eye " usually results.
There may occur hemorrhage into the anterior chamber, and some-

(Umes when this clears up, vision is lost by a coincident retinal hemoTrJ
rhage. The iris maybe torn from its attachment (iridodialysis), on
the lens may be dislocated. In severe cases the globe is ruptured all
the weakest point in the sclera, opposite the point of impact, about two
to five mm. from the cornea. In such case the vitreous escapes and
the iris may be prolapsed in the rent. The ciliary body and Ihe retina
are very susceptible to serious injury. A curious result of rupture of
the eyeball is seen in those cases in which, by an accidental blow, a
cataraclDus lens has been removed and vision thereby restored. The
prognosis of ruptured eyeball is aWays sevio\i^.an4 ^catiij injured |

K become sirophied. ^^H

INJURIES TO THE EVEBALL. 261

Treatment consists in careful disinfection, the application of ice,
eserin or atropin, a bandage, and rest in bed. A bruised iris must be
carefully excised. The various camplicalions should be treated as
they arise. If Ihete is an extensive rupture of the sclera, conjunc-
tival and scleral sutures may be necessary to prevent complete pro-
lapse of the vitreous. Nothing can be done for iridodialysis, except
iridectomy. A dislocated lens must sooner or later be removed.
Hemorrhage into the anterior chamber and subconjunctival hemor-
rhages will usually absorb without treatment.

FOREIGN BODIES IN THE EYEBALL.
It is always important after injury to the eyeball to determine
whether or not a foreign body remains within the eye. If it can be
seen by the naked eye, focal illumination, or the ophthalmoscope, the
diagnosis is easy. In other cases in which the media become quickly
opaque, or the body lies concealed in the sclerocorneal covering, or
is near the ciliary body, it may escape detection. In these cases the
patient's general and local condition and the nature of the injury
must be carefully considered. If there is no point of exit, and there
is absolute history of entrance of a foreign body, we must believe
that it remains in the eye. The surest way of locating a foreign body
is by the Riinlgen rays.

Prognosis depends on the location of the foreign body, its chemic
nature, and whether or not it was aseptic. Aseptic and chemically
unirritating substances, however, have produced alarming inflamma-
tions in the ciliary region. Infection from a foreign body in the eye
may result in panophthalmitis and speedy destruction of the globe.
Itut there have been cases in which small aseptic foreign bodies
have remained for years in different parts of the interior of the eye,
even in the sensitive ciliary body. According to reliable statistics,
the loss of the eye from foreign bodies in the anterior chamber is vir-
tually nil; in the lens, thirty per cent.; and in the vitreous, seventy-
It must be remembered that a foreign body remaining absolutely
quiet within the eye is at all times dangerous, both to the affected eye
and to its fellow.
Treatment. — Foreign bodies should aVwa^a \ie letouxti VtQwv'^e
mfaer. A lens with a foteigvv'feoA'i m"^'^t^*»-^°^^'^'^ "

^^ late

3 OF T

later be extracted. If the foreign body is in the vitreous, Ibe

treatment depends on its nature. In such case, if the foreign body
is of iron and can be located, it should be removed through a scleral
incision by the electromagnet. Aseptic substances, such as copper«
wood, stone, or glass, may be permitted to lie quiescent and be tr
expectantly. At the first sign of inflammation they should be r
moved by a pair of tine forceps through a scleral i
symptoms are indicative of much ciliary involvement, enucleation I
should be performed or active sympathetic inflammation may quickly
set up and destroy the uninjured eye. Of all operations, removal of _
a foreign body from the eye should be performed under the strictesi
aseptic precautions.

A good rule in cases of foreign body in the eye seen soon after ibel
accident is to secure the patient's assent to the application of themag-^
net, under anesthesia, and in case of failure of extraction, to submit
to immediate enucleation. However, if there is evidence of intense
ciliary inflammation in the injured eye or signs of sympathetic in-
flammation in its fellow, it is not safe to lose time in attempting C<-^
Eraclion ; the injured eye should he removed at once. fl

PARASITES IN THE EVE are usually the cysticercus, the larva offl
the tape-worm, which may also be found in any part of the body,
Li ebreich gives a good ophthalmoscopic image of a living cysticercus
Threadworms have been found in an opaque l(

»and in the vitreous. It is possible that remnants of the persisteni^J
hyaloid artery have been mistaken for worms in the vitreous. ^^M

SYMPATHETIC OPHTHALMIA. ^H

Deflmtion. — An inflammation of the ciliary body, iris, or chorot(^H
or a combination of any or all of these in one eye, due to injury ^^H
the other eye. ^^

Cause. — The usual cause is an injury to the ciliary body, or incar-
ceration of the ciliary body and iris in a scleral wound. A foreign
body in one eye. causing cyclitis, is often followed by sympathetic in- _
flammation in its fellow. The manner in which sympathetic inflam-i^
malion js produced is not clearly understood. Mackenzie suppose4^|
that sympathetic inflammation passed (torn ftie \ei.TO3. of the injurcd^^
^^^c. cbrougb the chiasm. tothe retina oU\icQV\itxc^c. Xltw-KV-roiaaM

INJURIES TO THE EYEBALL. 263

suggesledthat germs travel along the optic shealh through the chiasm
inio the sheath of the opposite nerve, and thence into the eye. Bac-
teriologic infection of the sym pat helically affected eye can rarely be
proved. A more recent nervous theory is that the path of irritation
is from the first eye through the ciliary nerve to the ciliary ganglion,
through the sympathetic root of the latter to the carotid plexus of the
same side, then through the circle of Willis to the carotid pli
the other side, and then in a centrifugal direction to the ciliary gang-
lion and the ciliary nerves of the second side. The time of outbreak
of the secondary attack after the original lesion varies from
On «ffct weeks, but cases have been reported from two weeks to forty
years afterward.

Symptoms and Diagnosis. — The premonitory symptoms are those
of sympathetic irritation — asthenopia, photophobia, lacrimalion, re-
duced accommodation, cloudy vision, and a mild pericorneal injec-
tion. The aqueous may be moderately opaque and the disc slightly
reddened. As the stage of true sympathetic inflammation ensues, we
notice signs of inflannmation corresponding to exacerbations of in-
flammation in the exciting eye. The ciliary region becomes ex-
tremely lender; cyclilis, iritis, or some form of keratitis become visi-
ble. The pain and cloudiness increase, and the visual acuity steadily
diminishes. Synechias may form, and the intraocular tension be-
comes at first increased, and afterward diminished, as atrophy begins.
It is the rule, after varying improvement and relapse, to find an
adherent iris, cataractous lens, or atrophied globe from deficiency in
vitreous, causing retinal prolapses and incurable blindness, despite
all treatment. However, it is possible to retain some indistinct vision
In favorable cases, but the process is always prone to relapse, and the
inevitable result follows.

Treatment is m^^n^^^nd must interrupt the nervous connection
between the eye first involved and the one showing signs of sympa-
thetic inflammation. It has been suggested that this be accomplished
by cutting the ciliary nerves. Several different methods have been
suggested, one of which is to cut completely through the optic nerve,
expose the posterior pole of the eyeball, and cut the ciliary nerves
entering at this location. Evisceration has also been proposed. The
only certain method of prevention and cure is enucleation of the eye
first affected. This Is so Important a aubjetV \.^ia.'>. \Vfe
laid down by Fick are given here as a guidf.

OF THE EVE,

(i) IF the first eye is blind, painful, and sensitive to pressure,!
cteation is to be advised ; it is to be urged if the patient lives away
from a surgeon, and thus may be in danger of overlooking the begin-
ning of sympathetic inflammation. If the patient will not consent,
he should he told to seek aid at the first sign of visual disturbance or
of inflammation in the other eye.

(2) If the first eye has a foreign body in it, is painful and sensitive
lo pressure, enucleation should be urged even if the eye sees ; it is to
be supposed, of course, that the foreign body can not be removed in-
dependently.

(3) If sympathetic inflammation or even irritation appear in the
second eye, the first must be enucleated at once. If the first eye Is
not blind, but still retains a certain visual acuity, and is lo some ei-
tent quiet, both patient and surgeon will hesitate at such radical pro-
ceedings. There is, however, no general rule for such a case; we
must carefully compare the visual acuity of the first eye with the de-
gree of irritation in the second ; the more there remains to rescue in
the second eye, the greater price can be paid by the first.

If the sympathetic inflammation is fully developed, enucleation
proves of little value, and we must lessen the pain by cocain. atropin,
warm compresses, and bandages, and confine the patient to bed.
Mercurial inunctions and subconjunctival sublimate injections have
been advised ; iodids and mercurials may be given orally, but despite
all treatment the eye is generally lost.

P OPERATIONS INVOLVING THE ENTIRE EYEBALL,

EVISCERATION OF THE EYEBALL is performed as follows: The
cornea is removed by making incision with a Graefe knife, so as to
include one-half of the corneoscleral margin, and complete the cir-
cumcision with scissors. The contents of the globe are then evacu-
ated by means of a special scoop, care being taken to remove ihe
choroid unbroken, by carefully peehng it from the sclerotic, backward,
until ii is only fastened at the lamina cribrosa. The interior of the
eyeball is washed out, and after all hemorrhage has ceased, the edges
of the sclerotic are stitched together and the conjunctiva united over it.
In Mule's operation the opening is enlarged vertically to admit of
lAe introduction of a hollow glass or s\\veT w iX'Msvvnvmv •■ijhi
Tbe margins of the sclerotic are now llT.Ueivert\c^\\^i ■0-5 '

^-^W

silk sutures ; the conjunctiva is then sutured at right angles to the
scleral closure. Two points of importance are strict antisepsis and
the checking of all bleeding in the cavity before the glass ball is
inserted. The advantages claimed for this operation are that it leaves
muscular attachments to the stump and offers a movable ball on
which to insert an artificial shell; that it keeps the orbit filled out;
and that it lessens the danger of meningeal infection, sometimes
following enucleation. The cosmetic improvement is by far the
greatest point in its favor. The operation is of particular value in
staphyloma of the cornea and in disfiguring leukoma. The disad-
vantages are the uncertainty of result, possible infection, and sympa-
thetic involvement, though the occurrence of the latter is rare.

Some operators practise insertion of the glass sphere in the
capsule of Tenon instead of the scleral cavity. The operation is simi-
lar to an enucleation except that the recti muscles are secured with
sutures before dividing them. The glass sphere is placed in the
cavity previously occupied by the eyeball, and the sutures holding
the four recti are tied tightly together over it ; care must be exercised
to secure adaptation of the sutures, so that [he tendons assume the
same position they occupied in the hving eye. This operation
eliminates all the dangers and disadvantages of evisceration or Mule's
operation, and leaves as useful a stump,

TOTAL COMBINED KERATECTOMY is the name given to an opera-
tion which Panas has most successfully used for several years
in all cases in which enucleation is ordinarily indicated. A half-
curved Reverdin needle is introduced through the sclerocorneal
junction, passed back of the iris and lens, coming out at a point
opposite. The needle is then armed with a thread and allowed
to remain in place. The cornea is detached as in evisceration.
The iris is removed by forcibly tearing with a pair of forceps. The
speculum is gently raised away from the globe by an assistant.
The lens is next removed with a scoop, care being taken not to lose
any vitreous. The Reverdin needle, armed with its thread, is now
withdrawn and the suture made is lied. Two sutures, one on each
side of the middle one, are made and tied. The projecting angles
of the wound are trimmed wiih scissors, and the wound is dressed
antiseptically.

.t;on,— The patient is placeil oiv ^n apetwitv^ vi£d«i-»-^ft|

1^ pre!

preferably, anestheliied with ether or chluroform, although st
local anesthesia with cocain alone is used. After thorough disinfec-
tion of the eyeball and neighboring parts, a speculum is introduced,
the arms of which are widely separated. A fold of conjunctiva is
seized by a fixation forceps in the left hard, opened with a pair of
enucleation scissors curved on the flat, and cut close entirely around
the circuiTiference of the cornea. The separated conjunctiva and
capsule of Tenon are pushed back with the closed scissors. The
tendon of the internal or esternal rectus muscle is seized by the fixa-
tion forceps close to the insertion and divided back of the forceps.
One blade of the scissors is passed under the tendon of the superior
rectus, which, with the tissues surrounding it, is divided close to the
globe. The inferior rectus is Iheri severed at one clip ; the globe is
then rotated forward and toward the nose, the scissors passed back-
ward, and the optic nerve and the adjoining tissue divided. The J
globe is then seized with the fingers and forced from the socket, and I
the remaining tendons and attached tissues separated from it. In- ^
stead of crowding wet antiseptic sponges into the orbit to check the
hemorrhage, it is better to simply irrigate the cavity with sterile cold
water, and thus avoid crushing and lacerating the remaining muscles.
These muscular remnants are then puckered to a point with a " purse-
string" suture, and afford a more or less movable stump. When the
bleeding has subsided, the cavity is washed out with a sublimate
solution and an absorbent sponge or wad of cotton is placed over the
orbit, leaving free drainage, and a bandage applied without exerting
undue pressure. The old custom of immediately applying a pressure-
bandage after enucleation to check hemorrhage is not advisable. It
is better lo delay permanent bandaging until the hemorrhage has
subsided. The dressing may be changed in twenty-four hours, and
the parts cleansed with a sublimate solution and a new dressing
applied. After the fourth day (he bandage may be discarded, and the
patient given a. mild antiseptic wash to use in the eye two or three
times daily until the wound is completely healed.

An artificial eye may be worn after a lapse of two or three weeks,
if all inflammation has subsided. Early application of the artificial
eye is advisable to prevent absorption of the orbital fat. It must be
remembered that the orbit is very tolerant of foreign bodies ; how-
ever, to thoroughly accustom ttie orbit, ^iie sTi^AcXaX c^e should not
be worn over a few hours al a. lime (m 'tbe %.\f,i. \fM ia.-^-., *\.<i'»,J

INJURIES TO THE EYEBALL. 267

sert an artificial eye, it is lubricated and the broad outer end slipped
under the upper lid, which is slightly raised. The lower lid is then
drawn downward, the patient directed to look down, and the eye is
gently manipulated into place. Irritation of the stump by an artificial
eye has led to sympathetic inflammation of the other eye, and must
be guarded against. An artificial eye should be taken out at night
and placed in water.

EXENTERATION OF THE ORBITAL CONTENTS, usually for malig-
nant growth, is performed by splitting the external canthus, separat-
ing the entire periosteum with all its contents from the bony wall,
except at the apex of the orbit. Enucleation scissors are introduced,
and the stump cut off close to the bone. Profuse hemorrhage is best
checked by actual cautery. If the neighboring skin or the lids are
involved, the incision must be made into healthy tissue, and the dis-
eased parts removed with the orbital contents.

LOCAL OCULAR THERAPEUTICS.

Airol is a. subslilule
the addition of iodin.
ind hypopyon. A ten

Alum i? a useful ast

for iodoform ; it is practically dermatol with
It is said (o be efficacious in corneal ulcers
per cent, vaselin ointment is used.

chronic conjunctivitis, and maybe

used in solutions of from two to eight grains to one ounce of boric solu-
tion, dropped freely into the eye three or four times a day. Crysiab
of alum cut into smooth pencils and fitted into handles are useful in
chronic palpebral conjunctivitis. They are applied to the lid in the
manner described on page 165, The point of the pencil should
never be allowed to become sharp.

Anesin is the newest local anesthetic. It is said to be an aqueous
solution of acetone-chloroform. A one per cent, solution is usedio
produce local anesthesia, and it is described as twice as powerful. Il

produces no local

Antioosin is a sodium salt of nosophen.
strengths (^ per cent.) in inflammations

Arecolin hydrobromatc has been used <
I : 100 solution,

Argonin is one of the numerous silver-
ing lately. It is used
gonococcus, in one to two p

Atropin is generally used

and does not produce

has been used in weiik
r portion of

a powerful local anodyne, and
and cycloplegic, As a ijiydr
of four grains to the ounce, o
i/iaes a day. From ten days 1

compounds appear-
conjunctivitis, particularly diat due to tlie

the form of the soluble sulphate.

commonly used mydriatic
c, it should be prescribed in solutions
drop of which is apphed three or four
two weeks ate required for the eye to

recover from the effecls of such a so\M\.\Dtv. 'We'ikGx MJiis.Sj.aa-.Vfiw

^^^K LOCAL OCULAR THEltAI'EUTICS. 269

grain to the ounce) ma.y be combined with boric Licid in cases in
which routine administration is desirable. The contraindication to
atropin and all other mydriatics is increased intraocular tension. All
solutions should be labeled ■■/oiicna'ro/j." In cases of idiosyncrasy,
the dryness of the throat, flushed face, general excitability, etc., are
indications for the suspension of the drug and the administration of
opium, its physiologic antidote. A full dose of paregoric is a ready
remedy in such cases. Often in cases of sluggish iris the atropin
solution should be heated before instillation into the eye.

Atrupin sulphate, gr. j

I>istiUi;d water, 3 ij.

Directions. — One drop in each eye three times a day.

For ordinary mydriasis and cycloplegia.

Atropin, BT. ij

Cocain, Kr. X

Vaselin gj.

Dissolve by warmlli.

For use when an oinlment is preferahlc to drops or when there ts intense

Bleeding, in ocular congestion, particularly for the relief of pain in
corneal and irilic inflammations, is a very valuable procedure. It is
most satisfactorily effected by the application of three or four leeches
to the temple of the side affected. The Heurteloup artificial leech is
really a cupping instrument, which exhausts the air in a long glass
cylinder applied to fine incisions over the temple. It draws the blood
more rapidly than the natural leech, but has not given us as good
results.

Boric acid is extensively used as a mild antiseptic lotion in solutions
often grains to the ounce. It is hardly to be classed as an antiseptic;
but on account of its soothing qualities, is to be recommended in
cases in which onl^ a simple lotion is necessary.

The following are common formulas :

Boric acid, i:r. si

Distilled water 5 iv.

Ifiaihe the eyes freely several limes a day.
Boric acid fir. xl
Camphor water,) , . ,..

'. DistiHed water, r^ "='' o'-V

fittbe ibe eyes freely several limes a day.

JISEASBS OF THK E

^^^r BoToglyceriil is made by heating together sixty-two parts of boric
^^H acid and ninety-two parts of glycerin at a uniform temperature of
^^H 300° F,. until the mixture is reduced to 100 parts. A glycerite is
^^H then made by adding loo parts of glycerin, warming and liltehug.
^^H This fifty per cent, solution in glycerin is the strength ordinarily used,
^^H and is conveniently dispensed in two-dram collapsible tubes. Boro-
^^f glycerid is a most valuable application in all forms of conjuaciivids.
I but finds its greatest use in trachoma, for which it is by far the most

valuable application. It is an excellent antiseptic, and may be pre-

I scribed in aqueous solution of less than ten per cent, strength.
Calomel is a valuable local application in phlyctenular ophthalmia.
chronic keratitis, pannus. and in small indolent corneal ulcers. It is
used as a line, dry powder, and is dusted direcdy upon the cornea
with 3k camel's-hair brush. It should not be used if there is much
ciliary irritation. A second application must not be made until the
first is absorbed, and the drug should not be used if the patient is
taking full doses of the iodin preparations.
Camphor water has been greatly used in combination with bone
acid solutions in the treatment of conjunctivitis. See BvrU acid.
Cassaripe is a concentrated semisolidjuice of the cassava-ptant of
the tropics. A ten per cent, ointment has been used in cases of ulca
of the cornea and purulent disease of the conjunctiva.

Cautery by heat is of great use in serpiginous and chronic indakal

ulcers of the cornea, in corneal abscess and fistula, and ia obsdoalt

cases of pustular keratitis. A probe or strabismus book, or aa;

properly shaped metallic instrument, may be used ; but tfa« galvaa*-

cautery is to be preferred.

^^^ Cocain. — The chief use of cocain in ophthalmic siugeiy is lo pm-

^^L duce conjunctival and cotneal anesthesia, citho' for the idief of pais

^^H in iritis, cyditis. hypeiesihesia of the retina, etc-, or to tvadiice loot

^^F anesthesia for operations on the eye. It is also ased as a teaipaaaty

^^^ wydriatk fioc ophthalmoscopic purposes, in wfaicfa case aay tettdea^

to produce glancoaia after the examination is taiAfd b easily averted

by a drop of a scdntioo of escrin, }j of a giain 10 the onacc Fat

anodyne parposes, swdi as tke use ia iritis aad cycfiti^ **«-, a n

better to asc atiopia, on account of the transaent aclioa crf'cBcam aai

tht possAh dangers from its long-continued ttse. In iiiiniiini^ ^ I

oocor iwo grains lo the ounce ~Aa»<f^>e a&die&xnvi4iBaiT aaixs^Mk <

•aodastrinfcotwasbes- l\ ta trt«io«iii-i c

LOCAL OCULAR THERAPEUTICS. 3?!

^atment of iritis, and with hamatropin to facilitale mydriasis and
cycloplegia. The greatest use of cocain is in operative ophthalmic
surgery; it has even been used in some cases of enucleation. It
should be prescribed :

Collodion is used in dressings for wounds of the eyelid or eyebrow,
and is freely painted over the skin In cases of senile entropion to pro-
duce contraction of the relaxed skin.

Copper sulphate (" blue stone ") is occasionally employed as a col-
lyrium.in the treatment of chronic conjunctivitis, in the proportion of
^ of a grain to the ounce. In the form of crystal or pencil applied
to the everted tid, it is used in trachoma. The old lapis divicus was
composed of equal parts of copper sulphate, potassium nitrate, and
alum, molded into a pencil.

Duboisin is sometimes used as a mydriatic and cycloplegic. Re-
covery takes place in from five to seven days.

Duboisin sulphale, gr. sa

Diililled wafer, 3ij.

ElectrolyBia has been used both as a means of cure in chronic in-
flammations and as a means of diffusing drugs into the eye, and
facilitating absorption. It has done some good in corneal opacities,
trachoma, and pterygium ; it has been recommended as the best
method of applying eserin in glaucoma and atropin in iritis.

Electrotherapy has been urged in scleritis, iritis, iridocyclitis, vit-
reous opacities, and purulent keratitis. The anode is placed against
the closed lid, and the kathode against any part of the head or neck.
Commencing with 0,5 ma., the current is slowly increased to a ma.
or more. Reuss believes that faradism is preferable to galvanism in

Ephediin hydrochlorate has been used in five per cent, solution to
effect mydriasis without causing ciliary paralysis — as, far instance, in
iritis or ophthalmoscopic ex.amination.

Eserin is the most common miotic. Its effect on the accommoda-
tion lasts only a few hours, but the pupil may be contracted for several
days. It is used in glaucoma, in peripheral wounds of the cornea,
and in some forms uf corneal ulcer, It is pl«»:n\K&'.

VistUled V

373 DISEASES O? THE EYB,

has recently been offered as a substitute for cocain ii
ducing ocular anesthesia. Although several enthusiastic reports of
its advantages over the older drug have been pubhshcd, its pOMlJon
in ocular therapeusis has not been definitely established. An espe-
cial preparation, Eucain B hydrochl orate, has been maitufacliued
for ophthalmic practice. It does not dilate the pupil nor affect ac-
commodation, and is less toxic. On the other hand, it possibly favors
hemorrhage, its anesthetic effect is less complete, and it is more dis-
agreeable to the patient than cocain. Both have the same effeci
on the cornea and upon intraocular tension. It is used in two per
cent, solution.

Euphthalmin is a recent mydriatic. It acts within two or Ihiee
minutes, and is supposed to have no effect on the accommodation,
corneal epithelium, or intraocular tension. Mydriasis lasts about
seven hours. It is used in five per cent, to ten per cent, solutions.

Fluorescin is used to mark out the precise area of denudation in
corneal abrasion or ulcer. It is prescribed :

Liquor potassa, 3J

Distilled water, giv.

A drop applied over the cornea, and washed off.
A spot denuded of epithelium becomes yellowish-green.
Formalin Is a forty per cent, aqueous solution of formic alddiyd.
It is a powerful germicide, and is valuable in the disinfection of in-
struments. Solutions of Ji per cent, are usually strong enough in
ordinary surgical antisepsis. For septic corneal abrasions and cor.
neal ulcers, the local application of formalin in 1 : aooo or 1 : 30CO
aqueous solution is of great value. It is also used in full strength to
limit and remove malignant growths.

The sterilization of instruments by means of the vapor of burning
paraform pastils is the best means we have. A number of conve-
nient formalin sterilizers have been marketed.

Glycerin is used as an excipient, particularly in the form of glycerol
of tannin and in boroglycerid. These preparations are valuable in
all forms of palpebral conjunctivitis.

Hamamelis (Witch Haiel). — The ordinary dislillale of hamamelis
/siip/eas/ng' anodyne and sedative application in acute conjuncti-
vitis. It should be diluted witb one or \"«o -^a-t^.^ o^ -water, and siaT_j
becombiaed with the ordinary bovic adi -bAutwiv. Tu'ot-a

id siaT I

W^m

LOCAL OCULAR THERAPEUTICS. 373

Heat and cold are valuable antiphlogistic and analgesic local
measures. In general tetms, ice-cold applications are more soothing
in conjunctival and lid inflammations, and heat in diseases of the

Holocain is an efficient anesthetic and germicide. Many observers
report that it is superior to cocain in nearly every operation. It has
apparently little or no effect on the conjunctival vessels, iris, or ciliary
muscle. It is used in one per cent, solutions. Hoti says that it is
more painful and irritating to the conjunctiva than cocain. Its anti-
septic properties are greatly in its favor. It has been used with suc-
cess in the treatment of suppurative keratitis.

Homatroptn is a useful mydriatic and cycloplegic. It is especially
serviceable in office practice, in which it is often desirable that the
paralysis of accommodation shall not extend over one or two days.
In such cases it should be prescribed;

Homatropin liyilrobroniBle gr. j

Cocain hydrochlorale gr- ss

Distilled water, 3ij.

Before refraction, one drop of this solution should be used in each

' the eyes, five or six times, at intervals of ten minutes. The ac-
commodation usually returns by the end of the second day.

Hydrogen dioxid is an excellent detergent in purulent ophthalmia,
sloughing ulcers of the cornea, and suppuration of the lacrimal pas-
sages. It is used in fifty per cent, strength of the ordinary fifleen-
volume solution.

Hyoscyamin is physiologically the same as duboisin in hs action.
It is prescribed as follows :

Hyoscyamin hydrobromate fir- ss

Distilled water, g ij.

Ichthalbin is a compound of ichthyol and albumin, said to represent
all the desirable properties of ichthyol without its disagreeable odor.
It has an analgesic action. Wolffberg has given it intentally in
about forty cases of glaucoma and iritis, in doses of eight grains thrice
daily. It has been used locally in pannus and keratitis.

Ichthyol has been used in fifty per cent, solution, to which a little gly-
cerin may be added, in all forms of palpebral can^^iiw.^VH'CWi. 'NS-'w.'*^"
Implied in the form of a ten per cent.ovnVnieiA'wi caat^ oS^J*^''

374

lodin has been used locally Iq trachoma, starting with >i per «
solution and increasing slowly up

lodofonn is a valuable remedy in almost all forms of corneal di
ease, and is used after operations on the lids or after enucleation.
is also useful in diminishing vascularity of the cornea, and in clearing
up correal opacities. It may be dusted upon the eye in fine powder.
or applied as an ointment, with or without massage, in strength of yi
to one dram to the ounce. After dusting iodoform on the cornea, the
upper lid should be pulled outward and downward over the cornea,
and held in place for a few minutes; otherwise tnovement of the lid
or eyeball will brush the powder off the cornea. The only objection
to iodoform is its odor.

Iliol (sUver citrate) and actol (silver lactate) have been used
purulent conjunctivitis and keratitis, but little is known of them.

Jequirity has been extensively used to induce acute purulent c(
jimctivitis in desperate cases of trachoma, and it should be resorted
lo only with the greatest caution and in extreme cases. It should be
used only when there is pannus. The infusion is prepared by macer-
ating three parts of the pulverized seeds in 500 parts of cold water
for twenty-four hours, and adding 500 parts of boiling water, cooh'ng
and filtering. A mild solution is applied to the eyes three times
daily for two days, or until sufficient inflammation is produce)
Each application should he followed by irrigation with a baric
solution.

Mercuric chloiid (corrosive sublimate) is probably the most salt!
factory agent for the disinfection of the diseased surfaces of the eye.
As a usual eye lotion in ordinary cases, it may be prescribed in solu-
tions of 1 : 8000. In such strength it can be safely used several times
a day without exciting or causing irritation. A solution of i ; 3000 is
possibly better for cleansing the eye and adjacent tissues before ao
operation, and for irrigation afterward ; or as a lotion when there is a
profuse purulent discharge. The stronger solutions, 1 : 500 and
I ; 1000, may be used for disinfecting instruments, and for irrigation
in dacryocystitis or in purulent ophthalmia. The 1 : 5000 sublimate
.s of especial value as an eye-wash in edematous afTectii

nes I
:e AM

I of the lids. The ordinary formula for a i : 3000 sublimate sob^^f
tionis: ^^|

Mercuric cblorid ^: Vk ^^M

Distilled water M- ^^M

LOCAL OCULAR THERAPEUTICS. 275

What is known as Panaa' solution consists of mercuric iodid one,
potassium iodid five, and distilled water 20,000 parts, Ii is used for
irrigation of the anterior chamber, and possesses no advantages over
simple sterilized water.

Mercuric oxid (yellow oxid) was introduced into ophthalmic thera-
peutics by Pagenslecher, and the ointment is sometimes known by
his name. In blepharitis and phlyctenular ophthalmia it is of par-
ticular value applied to the lids at night, using a piece the site of a
large pin-head. Massage with Pagenslecher ointment is of service
in chronic keratitis and pannus, and in clearing up corneal opacities.

I It should be prescribed :
I Yellcw mercuric o.id (amorphous) gr- X"]
I, Vaselin, gj.

Nosophen has been recommended in corneal disease.

Opium. — The wine of opium was much used by old surgeons as a.
collyriumin the treatment of conjunctivitis, but has passed out of use.
The acetate of morphin is a convenient anodyne in acute conjuncti-
vitis. Five grains of acetate of morphin, Ji of a grain of acetate of
zinc, and ten drops of dilute acetic acid, to the ounce of water, have
been recommended as an eye-wash.

Picric acid, 5 or 10 : 1000, has been used in blepharitis and as an
antiseptic collyrium.

Pilocaipin is a decided miotic, but much milder than eserin. It
can hardly be recommended in preference to eserin, although some
authorities claim thai it is entirely free from the tendency to produce
iritis. It is prescribed :

Piloca

^^Klocarpin is also often used systemically in cases of severe ocular
disease, to produce diaphoresis.

Potassium permanganate is used as an antiseptic lotion, in strength
varying from one to five grains to the ounce.

Protargol is a ptoteid compound of silver containing' eight per cent.
of the metal. It has many strong advocates as a substitute for silver
nitrate. It is not so painful, is more germicidal, has greater penetrat-
ing powers, and does not form a precipitate wlA. a.\W-wv«i- \V\i.-sa
been used in all forms of coniunct\v\\ts m s,\.\tu%'ii?. lA S.iq^i\ v^o "S

276 DISEASES OF THE EYE.

cent, to fifty per cent. A two per cent, soluiion is generally used as
a collyrium. Recently there has been considerable dissent from the
numerous favorable reports, and there has been an inclination to re-
strict its use to the milder inflammations of the conjunctiva.

Pyoktanin is an antiseptic and weak analgesic, and is used in solu-
tions of 1 : 1000 or 1 : 2000. It has been recommended in inflamma-
tions of the conjunctiva, cornea, and even in serous iritis and
choroiditis.
Sanoform has been recommended as a substitute for iodoform,
Sassafras, in the form of the officinal mucilage, is a popular domes-
tic remedy in the treatment of acute conjunctivitis. A very satisfac-
tory combination is :

Boric acid Rf, J^ij

Mucilage of sassafras pith, ^ij

» Mercuric chlorid, S'- A
Sodium chlorid, gr. x
Camphor water, 1 t .u x:

Scopolamin is recommended as a substitute for atropio, botli for
cycloplegia in refraction and in the treatment of iritis. It is pre-

ScopoUmin hydrobroamte, Sy- )i

Distilled water, 3 ij,

DfRECTIONS. — One drop in the eye every fifleeo minutes for an hour.

It is claimed that the ciliary muscle is paralyzed one hour after the
first instillation. The paralysis lasts about seventy-two hours, and
can be shortened by the application of a weak solution of eserin used
several times.

Silver nitrate is a valuable astringent and andseptic, and may be
applied to the lids in a one per cent, solution in ordinary mucopuru-
lent conjunctivitis. A two per cent, solution may be used in cases in
which there is profuse purulent discharge ; or a less strong solution
may be dropped into the eyes of a new-born infant, when there is
reason to anticipate ophthalmia neonatorum. Stronger solutions
may be used in cases of severe ophthalmia, but it is advisable to neu-
tralize it soon after application with a normal salt solution. After
application ofnhraXt of silver to tlieMsA^-^ sWvi\i\«;'«a.sted with
absorbent colton and warm walet before \ic\'ns ^^^-"^^^ "^^««^ "^^ J

LOCAL OCULAR

lunar caustic, or the " mitigated stick," is often of value in reducing
proliferated granular tissue in the conjunctiva of tlie lids.

Silver nitrate, gr. v

Distilled water, gj.

)ne instillation daily, in orilinary mucopurulEnl i^Dnjunclivilis.

Silver nitrate, fir. x

Distilled waler ,^j.

!>ne application daily, in profuse purulent conjuncliviti^ and opbTlia]

Distilled wnler, , 5j.

For aUernale use in trachoma.

Suprarenal capsule is said to be an ideal hemostatic and astringent
in all congestions and in operations. Ten grains of the extract are
macerated for thirty rninules in two drains of water and then filtered,
the filtrate representing a one per cent, solution of the extract. Supra-
renal capsule is put up in five-grain tablets, which may be dissolved
In a cold boric acid solution.

Tannic acid is u5ed in chronic conjunctivitis, either in solutions of
two to five grains to the ounce, dropped in the eye, or in strength of
ten to thirty grains to the ounce, painted on the everted lids. In cases
ofold granular lids, the full strength of jjlyccriteof lannin (Glycerinum
Acidi Tannic!, B. P., one part to four) may be applied to the everted
lids. The old domestic remedy fut "sore eyes" — tea-leaves — owed
its efficacy in some cases to the tannin in the leaves.

ThioBinamin, gr. j to gr. iij, has been administered internally or by
hypodermic injection to hasten absorption of corneal opacities. It is
of doubtful value.

Toluidia blue, a member of the anilin group closely allied to
methylene blue, has been employed as a collyrium in strength of
t : 1OO0, and as a stain for corneal abrasions and ulcers. It b a very
effective antiseptic, and is not irritating.

Xeroform represents fifty per cent. Iribrom phenol. It has been
used for its antiseptic action as a substitute for iodoform in corneal
disease.

Zinc acetate and zinc sulphate are used either separately or in cav\-
bination in the milder forms of conjuntimtKii'
■ of one to two grains to the ounce.

278 DISEASES OF THE EYE.

Zinc chlorid is a useful remedy in many forms of acute conjunc-
tivitis, or it may be applied to the everted lid in trachoma. Rather
weak solutions of X ^o two grains to the ounce of water may be
given to the patient to drop in the eye. This substance should be
avoided if there is any severe corneal affection. The following mixture
may be used freely in all mucopurulent inflammations about the eye :

Boric acid^ gr. xl

Sodium chlorid, gr. x

Zinc chlorid, ... gr. ij

Distilled water, Jiv.

Stain with pyoktanin, and doubly filter after standing.

The patient should be told that this lotion will smart at first, and
that he should instil it in the eye when lying on his back, and not
close the eyes violently and squeeze it out, but draw the lids together
gently and roll the eye slowly about for several minutes.

VALUABLE FORMULAS FOR INTERNAL MEDICATION.

Mercuric chlorid, gr* ij

Potassium iodid, . . giv

Distilled water, "^ ^ ^^^^ ^ -•

Syrup of sarsaparilla, / * oh

A teaspoonful three times a day.
Or—

Mercuric biniodid, ST- ^}

Potassium iodid, ,!^ i j

Distilled water, 5j

Syrup of sarsaparilla, q. s. ad 5iij.

A teaspoonful three times a day.

Useful as a tonic, alterative, and antisjrphilitic ; and indicated in all acute
and subacute attacks of inflammation of the eyeball in which internal medica-
tion is suggested. It is also valuable as a preliminary to operation on the eye.

Mercuric chlorid, g^^- ij

Extract of belladonna, gr. iv.

Make into 40 pills.

One pill three times a day. Useful in all forms of chorioretinitis.

DISINFECTION OF INSTRUMENTS.

Instruments are best disinfecledb7\mmws\oTv\xi^t.Os\5AA^xxcv7X\Tv,
bojJ/nff water, or exposure to supetVitaXeeL sV^am\xv ^. ^\«^y«x. ^

';st-

LOCAL OCULAR THERAPEUTICS, 279

•

malin sterilizers are now manufactured. They consist of air-tight
compartments in which paraform pastils are burned. Immersion
of instruments iit such solutions as pyoktanin, mercuric chlorid, and
carbolic acid are other less valuable methods. Corrosive action is
to be avoided, as the edges of ophthalmic knives are very easily
dulled.

ABBREVIATIONS USED IN OPHTHALMOLOGY.

Acc. .

. Accommodation.

m. . .

. Meter.

Am. .

. Ametropia.

mm. .

. Millimeter.

As. .

. Astigmatism.

O. D.

. Oculus dexter — Right Eye.

As. H.

. Hyperopic Astigmatism.

O. S.

. Oculus sinister — Left Eye.

As. M.

. Myopic Astigmatism.

O. U.

. Oculi utrique — Both Eyes.

Ax. .

. Axis.

OK .

. Both Eyes.

B.D.

. Base (of prism) down.

P.p. .

, Punctum proximum, Near

B. I. .

. " " " in.

Point.

B. O.

. ** '* " out.

Pr. .

. Prism.

B. U.

. " '< " up.

P. r. .

. Punctum remotum. Far

cm. .

. Centimeter.

Point.

Cyl. .

. Cylinder, Cylindric Lens.

R. .

. Right Eye.

D. . .

. Diopter.

R. E.

. Right Eye.

E. . .

. Emmetropia, Emmetropic.

Sph. .

. Spheric, Spheric Lens.

F. . .

. Formula.

Sym.

. Symmetric.

xl. . •

. Hyperopia, Hyperopic,

V. . .

. Vision, Visual Acuity, Ver-

Horizontal.

tical.

1^. • •

. Left Eye.

-f,-,=

= Plus, Minus, Equal to.

L.D.

. Light-difference.

00 . .

. Infinity, 20 ft. distance.

L. E.

. Left Eye.

c • •

. Combined with.

L. M.

. Light minimum.

• •

. Degree.

M. . .

, Myopia, Myopic.

2&0

GLOSSARY OF OPHTHALMOLOGIC TERMS.

□ Derivations a

I' of Medici

Abduction (ai-d„k''shHn) [ai, from ;
duttrt, to lead], llie power of
the ejitemal recti of drawing the
eyes outward, measuied by tbc
maiimuin ability lo preserre single-
ness of the image with prisms
place<] bases toward tbc nose; il is
commonly from 4° to 8".

AchromBlopsia {ah-kro-mal-op'.ii-
aA) fa priv. ; XP'-'I"', color; ijtic,
eyesight]. Color-blindness.

Adduction (ad-iiuk'-sAun)[adiiu-
etri, to bring forward] . The power
of the internal recti to move [he
eyeballs outward, measured by the
maximuro ability lo preserve single-
ness of the image witli prisms
placed hases toward the lempies ;
it varies from 15° to 40°,

AmatJToais {tim-aie-r^-iis) [o^ov-
p6ea; to darken]. Partial (or total)

Ametropia (ah-mit-rt^-pf-ak')\a

defoelive refractive power of the
media (or to some abnormality of

Aniridia (aH-i-rid'-i-ah') [(iii priv, ;
I/iif, the rainbow]. Absence or
defect of the iris.

Anisocoria {nn-is-ii-io'-re-aA) [avi-
DOf, uoeqnal ; Kiii^, P"pi']- 'n-
equalitj in the diameter of the
pupils-
Am sometropia {ati'is-o-Biil-ro'-pe'
ah) [fiiilffor, unequal ; /iiTpm, a
measure; iiV', the eye]. A dif-
ference of refraction in the two
eyes.
Ankyloblepharon {angkil-obUf-
flf-on) Faj-itij^, a loop; ^'ht^apov,
the eyelid]. Adhesion of Ibe cili-
ary edges of the eyelids.
AnophthBlmoB {an - off. thai'- mei)
yiv priv ; oifffa>.fi6(, eye]. Congen-
ital absence of the eyes.
Aphakia {ak-fa'-kf-ah) [n priv ; ^-
Koc, the crystalline lens]. The
condition of the eye without the

Aplanatic (aA-plan-al' -ik) [n priv,;
TrP.niiitiV, lo wander]. Pertaining
to rectilinear lens ; eoTTefted for
aberralion of light and color.

ArcuB senilis {ar'-ktis stn-i'-lh)
[anus, a bow ; sfiUs, of the old].
A ring of fatly degeneration seen
about the periphery of (he cornea in

Asthenopia (as-tfieH-o'-pi-ah) [a
priv.; aOevat, strength; uif', eye].
Weakness or speedy fatigue of vis-
ual puwer.

Astigmatism (as - liY - mal-izm) [a
priv.; miylia, a point]. The eon-
dilioii in fiVAcX* la.'j^ we\
IQ tt ^\nt in iota* "a\«m '

O LOGIC TERMS.

Blennorrhea UiUit-or-t'-ah) [p^v-
va, mucus; jihi-v, la flow]. Ex-
cessive tnucousdischirge.

Blepharadenitls ( Mef-ar-ad-eH -i' -
iis) [l3it<j,npoi', the eyelid; rirl^i-, a
glund ; iTif, infUiRinialioTil. In-
flammation of [he Meibomian
glands,

BlephBiilis {hief-ar-i'-tii) {l}lt(^a-
pat', ibe eyelid ; irif, innamma-
lion]. Inflammation of the eyelid.

Blepbarophimosis [bltf-ar-o-fi-mo' ■
sis') [pji^apav, the eyelid ; •fS/iuai':,
shultiug up]. AbnoTmal smallnesa
of the palpebral fissure.

BoUosa (i„l-/i'-!ni) [iulla, a blis-
ter]. With blisters or blebs.

Buphthalmos (Am/- thai' - mot )
[/Jo,->(, an ox i b0Ba?,^6i, eye]. Ox-
eyed. See A'trataffloius.

Canthoplasty [ian' - rko -ptas-le )
\<ia\Mi, the canthus ; wSnoOTii', to
form]. A Eui^ical operation fur
lessening the pressure and frictiiin
of the upper lid by cutting the

Canthus {kan'-lhus) [unifluf, car-
Ihiis]. The inner or outer angle
formed by the juncture of the eye-
lids.

Caruncle (kar'-ting-tl) [diminutive
offflr^, flesh]. A fleshy proluber-
Bnce U]H)n the conjuneliva. near the
inner cnnlhns, containing the lacri-
mal punclum.

Cataract [iai'-ar-akt) {KiiTapaKTii^,
B wBlerfain. Opacity of the lens

Chalazion (knl-a' ze-en) [j-n?.aCioi',
a small hailstone]. A Meibomian

Choroid (4-a'-raid) {_x^im

e)6o^, like]. The vasculi

Chroma tic {krg-mal'-ik) [xpi^K,
color]. Relating to color.

Chromatopsta {iro-mal-sp'-si-iik)
{xptjua, color; iV«C. vision). Ab-
normal sensation of color, due to
disorders of the oplic centers, Of
to drugs, especially santonin.

Cilia {iil'-i-ak) [Hlium. the eyelid
or lash]. The eyelashes.

Collytium {inl-e'-rt-ani) [mkLiituis,
an eye-salve]. An astringent, bo-
liscptic, or medicinal lotion for tbe.

Coloboma {kol-o-io' mah) [i
jideiv. to mutilate]. A fissure of'
parts of the eye, congenital or

Conus (ia'-nus) [lum;, a cone]. A
creacentic patch of alropbic cho-
roid tissue near the optic papilla*
in myopia. ~

Corectopia {ter-fk-to'-fie-ai) [bA
the pupil; ^xroirot, miliar'

Cornea ( ior' -ne-ah) [r*
homy]. The anterior transpi
segment of the eyeball.

CouchinE{,forw*'-i>(f) [Ft.,
to depress]. The operation,^
;, of depreasid

> the viliJ

chamber, where

absorbed-
Cycliiis isi-ili'-lii) [sfcu^nf, s

(around the eye) ; it'(, inRan

tion]. InflHmmalion of iht ci

l»dy.
Cycloplegia (sii/o/h'-JenA) nm

Sot, circle ; ■K/.riy'i, a slrok^

Paralysis of the ciliary muscle o

Dacryoadenltis {dak-re-o-e/t-ftt-i'-
lh\ {iaKpvnv, a tear ; lii^v.
^ini\. \iAwMMA\on. of a '

if a ta^J

GLOSSARY 1

f OPHTHALMOLOGIC TERMS.

383

DacryocyBtitia {Ja/^ re- -sis-li' -ris)

iiinpvnv, a te^' xbOTt^, a sac],
nilammalkiB'bf the lacrimal sac.
DacryocyjtCoblcDDorchea {dai-
ii'lB-bltn-or-f'-ah) {/'diiiivov,
nbaric, a sue ; jSiimn,
'ow]. Flow of
m Ihe lacrimal sac.
icryolith (dai'-rt-o-lith) [HAKpvov,
a lear; J-Iflof, a slone]. A lacri-
mal calculiu.
Dacryops (liak' -re-ops) [Jris/juw, a
tear; iii/j, Ihe eye]. Wateiy eye.
Daltonism {dal'-lim-hm) [Daiton,
an Eogliah physicist]. Color-
btindness.
Dendritica {den-drU' -ik-ak) {Aiv-

Apai>, a iree]. Tree-like.
Descemetitis {dis - im - et - i' ■ Hs)
\_Dtirtmft ; inc, inflammation].
Inflammation of Desccmel's raem-

Diopter {di-efi'-ler) [ii&, through ;
i^of'rii, to see]. The metric unit
of nieastirement for lenses.

Dioptrics (di - op' - Inks) [did,
through: ^^cafai, lo see], A
branch of optics treating of the
refraction of light by transparent
media, especially by the media of

Diplopia {dip-lo'-ft-ah) [<!(rt&c,
double! i^'C, sight]. Donbic
vision, one object being seen by
Ihe eye or eyes as two.

Discission {dis-ish'-uii) [disiistio:
discinderc, to lew or cut apart].
An operation for soft cataract.

Diatichiasis (dis-tH-i'-asis) [-!<(■,
double ; iTrijoc, row]. Double

Tpi'tiiv, to turn]. Eversion (of an
eyelid).

Eczema {li'-zi-maA) UkQclk, lo
boil over]. A catarrhal inflamma-
tion of the skin.

Edema [f-di'-mah) [oJitir/in, a swell-
ing]. Swelling due to effusion of
serous fluid into areolar tissues.

Emmelropia (cm-et-ro'-pt-nh) [iv,
iuj ,iiTi,uy._ taeasure; i^. eye].

BnophtbalmoB \en-off-lkal' -vw!)
\kv, in; i-fHal/iSi:, eye]. An un-
usually deep or posterior location
of the eyeballs in the orbits.

Entropion {en-lro'-fe-on) \tv, in;
TfieTTfiu, (o turn]. Inversion (of
Ihe eyelid).

Bpicantbus {tp-t-ian'-tkas) [^iri,
on ; Kave6<:, angle of Ihe eye] . A
fold of skin passing from the nose

Epilation (ep-il-a' -skiin) \t, out of;
/iVhi, abair]. The extraction of a

Epiphora (ep-if -or-ah) \km, on;
^c^eiv, to bear]. A persistent over-
flow of tears.

Erytbropaia (rr- Uh - rop/ - st-ah)
[ ^/jiiW/iiCi ted ; Bi(«(, vision]. Red

Esopho'ria {rs-e-fo' -ri-ah) [fou (or
einu). within; ^)tiiv, lo bear].
Tending of the visual lines in-
ward.

Exophoria (tks-o-fo' -ri-ah) fjfu,
without; ^£iv, to bear], 'lend-
ing of the visual lines outward.

Exophlhalmos (tk$-off-thal'-mos)
[ff, out; ii>PnV*C, eye]. Abnor-
mal prominence of the eyeball.

Kovea {fo-xx'-ith) Ifovea, a sn
pit], A depressed spot in
macula, at which there is the n

Eclro;>ion (fi-tro'-pe-on) Y'k

284

GLOSSARY OF OPHTHALMOLOGIC TERMS.

lus, Lat. (from Sanskrit), to bum].
A boil.

Glaucoma (glow-k(/-mah) [yA^vKdf,
sea-green]. A disease of the eye ;
so called on account of the green
color of the pupil.

Glioma (gH-</-mah) [y^m, glue ;
bfia, tumor]. A variety of round-
celled sarcoma.

Hemeralopia (hem - er - al-(/-pe-ah)
[i] fie pa J day ; wt/j, eye]. Day- vision
or night-blindness. (See note
under Nyctalopia. )

Hemianopsia ( hem-e-an-op^ -se-ah )
[?7/i£, half; dv, priv.; 6i/;«f, sight].
Blindness in one-half of the visual
field.

Herpes zoster [her^-piz zos^-ter)
[epizTjgy creeping ; Cuarypf a girdle].
An inflammatory skin-disease, char-
acterized by vesicles.

Heterochromia ( het-er-o-kro'-me-
ah) [eTepoQy different ; xp^f^^*
color]. A difference in color (in
the irides).

Heteronymous ( het-er-on^'imus )
[ETEpog^ different ; dvu//a, name].
Of a different name or character.
Crossed. The opposite of hom-
onymous.

Heterophoria (het - er- o -fo^-re - ah)
[erf/)Of, different; ^op^q^ tending].
A tending of the visual lines other
than in parallelism.

Hippus Qiipf'Us) [tTTTTOf, the horse].
Spasmodic pupillary movements,
independent of the action of light.

Homonymous ( ho - mon^ - im - us)
[6/t/($f, same; Sw/za, name]. Hav-
ing the same relative position.

Hordeolum (hor-de^-o-lum) [hor-
deuniy barley]. A stye.

Horopter (hor-op^-ter) [ppoq^ bound-
ary; dnr^Py an observer]. A line

representing the cunre along which
both eyes can join in sight.

Hyaline (hi^-al-in) [yaTio^^ glass].
Resembling glass ; referring to the
vitreous humor or a glass-like mem-
brane.

Hyalitis (hi-al-i^ -tis) \ya7Mq^ glass ;
LTL^y inflammation]. Inflammation
of the hyaloid membrane and of
the vitreous humor.

Hydrophthalmos (hi - droff- thaV-
mos) \y6opy water ; wjtOaXfjtdc^ eye].
Increase in the fluid contents of the
eye.

Hydrops (hi^ -drops) [ySpcjrjj, dropsy].
An abnormal collection of fluid m
any part of the body.

Hypermetropia ( hi-per-met-r</ -pe-
ah) [ynep, over ; fiirpov, measure ;
&ipf eye]. See Hyperopia.

Hyperopia (hi-per-o' -pe-ah) \ympy
over; o)^, eye]. That condition
of the refractive media of the eye
in which, with suspended accom-
modation, the focus of parallel rays
of light is behind the retina ; it is
due to an abnormally short antero-
posterior diameter of the eye, or to
a subnormal refractive power of its
media.

Hyperphoria (hi- per -ft/- re -ah)
[yirepy over; fpp6gy tending]. A
tendency of a visual line upward.

Hyphemia (hi -fe^ - me - ah) \{m6^
under; al//a, blood]. A deposit
of blood at the bottom of the ante-
rior chamber.

Hypophoria (hi-po-fo^ -re-ak) [wr4,
under; 0opdf, tending]. A ten-
dency of a visual line downward.

Hypopyon (hi-po^-pe-on) [v7r($, under ;
TTvov, pus]. A collection of pus in
the anterior chamber.

Iridectomy (irid ek^ -io-me) pp/f,
iris ; hKTopijy excision]. The cut-
ting out of part of the iris.

GLOSSARY OF OPHTHALMOLOGIC TERMS.

285

Ifideremia (ir-id-er-e^-me-ah) \ipL^ ;
kprifjua^ lack]. Absence of one or
both irides.

Iridocyclitis {ir -id-o- sik - li^- tis)
[tp^f, iris ; KVKkoq^ a circle ; iriq^
inflammation]. Inflammation of
the iris and ciliary body.

Iridodialysis [ir-id-o-dial^ - is - is)
\lpiQ ; dia^heiv, to liberate]. Sepa-
ration of the iris from its ciliary
border.

Iridodonesis (ir -id-o- don - e'- sis)
[Ipig; ddvffoig, tremblmg]. Trem-
ulousness of the iris.

Iridoplegia {ir-id-o-pW -je-ah) \lpiq ;
n'hpfii^ stroke]. Paralysis of
sphincter of the iris.

Iridotomy {ir-id-ot^-o-me) [ipiq ;
TOfiijf a cutting]. Incision into the
iris.

Iris (i^-ris) [IpiCf a colored halo or
circle]. A colored circular mem-
brane, placed between the cornea
and lens, having the function of
the diaphragm of a camera.

Iritis (i-ri^-tis) \lpLq ; irigj inflam-
mation]. Inflammation of the
iris.

Ischemia {is-ke' -me-ah) [iox^^^t to
check ; difiaf blood] . Bloodless-
ness.

Keratitis (ker-at-i^-tis) \i^pa^j horn
(=: cornea) ; ltl^, inflammation].
Inflammation of the cornea.

Keratocele (ker^-at-o-sil) [Kepa^,
cornea; k^Thj, tumor]. A hernia
of Descemet's membrane through
the cornea.

Keratoglobus (ker-at-o-glo^-bus)
[icepaf, cornea ; globus ^ a ball].
Distention and protrusion of the
cornea ; when cone-shaped, and
in the center of the cornea, it is
called conic cornea or keratoconus.

Keratomalacia (ker-at-o-mal-a^-
se-ah) [nipaf, cornea; ftahiKia^

softness]. Softening of corneal
tissue.

Keratoscopy (ker - at - os^- ko -pi)
\jdpag, cornea; (tkotteIv, to ob-
serve]. Examination of the cor-
nea.

Korectopia {kor-ek-to^ -peak) \K6priy
the pupil of the eye (so called,
like the Latin pupilla^ because an
image appears in the eye) ; iKTOKog^
misplaced]. Displacement of the
pupil.

Lacrimal (lak^-rim-al) [lacrimal a
tear]. Having reference to the
organs of secretion, transfer, or
excretion of tears.

Lagophthalmos (lag-off-thaF -tnos)
[Aaywf , hare ; 6^aA//(5f,eye]. In-
ability to close the eyes (from the
popular belief that the hare sleeps
with his eyes open).

Lens (lenT^ [L^^t. , a lentil]. A
regularly shaped transparent ob-
ject refracting luminous rays.

Leukemia (lu-ke^-tne-ah) [Aev/c(5f,
white ; alfiay blood], A condi-
tion of the blood characterized by
a relative increase in white cor-
puscles.

Leukoma (lu-ko^-mah) [\evKOfiaf
anything white]. A white spot on
the cornea.

Luxatio (luks - a^ - she -oh) [AcJ^of ,
slanting (Lat., obiiquus)']. Dis-
location.

Macropsia {mah-krop' -se-ah) [/zok-
p(Jf, large; 6V"f, sight]. Appar-
ent increase in the size of objects.
Megalopsia.

Macula lutea {mak^-u-lah lu-
te^ -ah) [Lat.]. The yellow spot
in the retina pierced by the visual
axis.

MalacVa ^mal-a'-se-aK>i \y*Ova»i.o.,

GLOSSARY OK OPHTHALMOLOGIC T

oftening]. Morbid softening of

Megalopsia {meg • al - op' - sc - :rh)
[,,f)nE, large; hi>i%, sight]. An
apparent increase in the size of
objects, ascribed lo changes in the
retinal ead-oigans and to spasm of
accommodalion. Maerofsia.

MetamorphopBiB {me/-am-or-/ofi' -
st-ah) [^ETQ/iop^iiEiv, to change
shape ; At/v^, sight]. Apparent
change in [lie form of t>biecls.

Microphthalmos {mi -Am/- thai' -
ma) [uwpdc, amail; o^oViC.
eye]. An abnormally small eye-
ball.

Micropsia (mi-krop'-se-ah) \_iiiKp6(:,
small; bi"(, sight]. Apparent
decrease in the size of objects.

Miosis [mi-B'-sis) [>i.JO(C, a lessen-
ing]. Ad abnormal contraction of
the pupil.

Mydriasis {mid-ri'-as-is) [y.ySt,ia-
D(f]. An abnormal dilatation of
the pupil.

Myodcsopsia {mi-e-dts-ops'-i-ah)
[pwMid^.like a fly; SV-r, vision].
Subjective lisual sensations as of
mnscx yolitantes.

Mjropia {mi-o'-pe-ah)\_niiea/,^a close ;
irf, eye]. Near-sightedness, be-
cause near-sighted people pertiallj'
close the lids.

Myotomy {mi-ol'-o-mi) [^it, rous-
cle; T-o/jiJ, cutting]. Incision of a

Nyctalopia (niklal-o'-fe-ali) [I'i'f,
night ; i^, the eje]. Night-vision
or day-hlindness. The condition
in which the sight is better by
night or in semidarkness than b
daylight. It is a symptom of cen
tral scotoma, the more dilated pupi
nt night allowing a belter illuniina
lion of the peripheral pottious i

Ibe Tctma. Dt. Greenhill and Wt.

Tweedy have shown l
ing to the quite universal uaagcM
modern times, the definiti
words itycialopia and hrmtn
have been the reverse of that oi
early Greek and Li
The proper derivation, ihetefolt,
of Hyclalopitt would be from i*f,
night 1 UKab^, blind ; &V> eye, the
word meaning night-blindnm,
Htmerahpio was likewise derittd
from i/'ift«, dny ; a^6c, blind ; M>
eye, and meant day-blindness. The
attempt to reinstate the andenl
usage can only result in utter con-
fusion, and i( wonld be belter lo
avoid the use of the words alto
gether. See Hrmeralcpia.
NyataginuB {nis-lag' -mus) [uwrni)-
;ioc, nodiling of the head]. Oicil-
laloiy movement of the eyeballs.

Ophthalmometry (off-lhat-momf-
il-ri) [if^ia^irit, eye ; ^tTiMv.teea.
e]. Mensuration of the ejcbit

■ the ocular muscles.
Ophthalmo scope (off-lhaP -mt-

lidfi) [h'fSa^ii: eKo^tJr. to *

serve]. Instmment for examininf

the interior of the eye.
Ophtbalmotonometer {eff-fhal-mt

lim-om'-ft-er) [o^X/zSr ; rimn.

tension.

Optogram {op' -tii-gram) \;
ibie 1 j-fjnfci', to write], A Mi
image stamped on the retina fat
brief perio<f.

Orthophoria {or ■ the -/o' -rt-^
[o/j^dr, straighi; 0op<^-, iendU
'^f:nd\n^ of the visual lineauii

Jftdiiri

GLOSSARY OF

Pannua (fian'-m) [Lai., doth],
Vascularization of the comea.

Panophthalmitis (/mr - c^- Ihat-
mi'-tis) [iruf, all ; oifKakfioz, eye;
inc, inflaiiiinalionj. InHammalion
of all the tissues of the eyeball.

Parallax (par'-al-nks) \napn, be-
side; !Mji^, othcrj. Apparent
displacement of an object.

Paralysis (par-ai'-is-is) {napa, be-
side; Tjitiv, to loosen]. Loss of
power of motion in a muscle.

Paresis (par'-a-is) \japa, from;
ihiai, to lei go]. Partial loss of
motion in a muscle.

Perimeter (ptr-im'-il-er) \jtfpl,
arooiid; ittrpov, measure]. An
instiutnent for measuring the ex-
tent of the 5eld of vision.

Periscopic (per-e-sko^ -ik) \j'tp>,
around ; okotiiv, to see]. Applied
to lenses having a concave surface

Pcritomy {per-W -o-me\ \jsci»,
around; raiili, a cutting]. The
removal of a riband of conjunctival
and subconjunctival tissue from
about the cornea, for the relief of

finguis, fat], A small tumor of
the conjunctiva.

Presbyopia, (/tj ■ bt - s' - pe - ah")
[upenliui, old ; i^, eye], " Old-
sight," due to failure iu accomuio
dalion.

Pterygium (lei-if-eum) [irrt/iuf,
wing]. A Uiangular patch of
thickened conjunctiva with its
apeic directed toward the cornea.

Ptosis (lo'-sis) [jrrijmf, mwrav, to
fall] . Drooping of the upper eye-
lid.

ball.

Retinitis (rel-in-i' -/is) [retina, ret-
ina; inc, intlaninialion]. Inflam-
mation of the retina.

Retinascopy {rtt-in-os' -ko-pe) [rel-
ina, retina ; nmirfii', to observe].
The method of estimating the re-
fraction of the eye by observation
of the movements of the fundus-
reflex ; skiascopy ; the shadow-

Soft CI

Phimosis (^-iito'-sis) [fiiiuAv, to
constrict]. Constriction; abnor-
mal snutllness (as of the palpebral

Phlyclenula {^fiik-ltn'-u-lak) [dim.

of ^ttraiwi, blister]. A small

vesicle or blister.
Photometer (fa-lam' -et-^r) [^'j;-,

light; /ih-pmi, measure]. In.^tru-

menl for measuring the intensity

of light.
Photophobia (fr-le-f^ -b/.ak) [^iir,

light; ^;3dc, rear]. Intolerance

of light.
Pinguecula f//« jjw,*'-«-/fl*) [Lai. ,

Scimillans [siniW -ans) [sdniil-
/u™, to sparkle]. Emitting sparks.

Sclera (skU'-rah) [oiiSi?/»ic. hard].
The tough outer coat of the eye-
ball.

Sclerotomy {skU-rof -o-mi) [mJ^-
pi<:, hard ; csrojiii, to cut]. The
operation of opening the eyeball
by incising the sclera.

Scotoma (sio-lo' -ma/i) {ntorUiv, to
darken], A fixed spot in the field
of vision, due to some abnormality
in the rMitva.OT o'^MitEii.wiwva'iat
brara.

288

GLOSSARY OF OPHTHALMOLOGIC TERMS.

Seborrhea {seb-or-e^ -ah) [sebum^
suet; poiay a flow]. An increase
of sebaceous secretion.

Skiascopy {ski-as^ -ko-pe) [<T/c/a,
shadow ; anonelVy to observe].
The shadow-test. Retinoscopy.

Staphyloma [staf-il-o^ -mah) {ara-
<^v7iijy grape; bfia^ tumor]. A
grape-like protuberance of cornea
or sclera.

Stenopeic [sten-o-pe^-ik) [(rrev(Jf,
narrow; bnaloq^ pierced]. A disc
with a narrow opening.

Strabismus (strab-iz^-mus) [prpap-
iafi6^, squint]. Squint.

Sursumduction (sur^ - sum - duk-
shun) \stirsum^ upon; ducere^ to
lead]. The power of the two eyes
of fusing two images when one
eye has a prism vertically before it.

Symblepharon (sim-blef -ar-oti)
[ffifv, together ; /?/li0apov, the eye-
lid]. The abnormal adhesion of
the eyelids to the eyeball in con-
sequence of burns, wounds, etc.

Synchisis (sin^-kis-is) [avyxvaigy a
mixing together]. A confusing
effect.

Synechia {sin-e-ki'-ah or si-ne'-ke-
ah) [(Tvv, together ; l;|fe«v, to hold].
A morbid union of parts.

Telangiectasis {tel-an-je-ek^ -ta-sis)
[rkTiogy end; ayyelov, vessel; i/cra-
mQy stretching] . Dilatation of cap-
illaries.

Tenotomy {ten-ot^ -o-me) [rkvuv^
tendon; rifiveiv, to cut]. Tendon-
cutting.

Trachoma {tra-ko^ -niahL) [rpa;fif,
rough]. Granular conjunctivitis.

Trichiasis {trik-i^ -as-is) [Opi^, a
hair]. Abnormal position of the
eyelashes.

Uremia (u-re^ -fne-ah) [ohpovy urine ;

alfmy blood]. Blood-poisoning

from retained urinary excretions.
Uvea (u^-ve-ah) [Lat., a grape (from

its color)]. The middle tunic of

the eye.

Vitreous {vU'-re-tis) [vi/reus ; vit-
runty glass]. Pertaining to the
transparent, jelly-like humor filling
the large posterior cavity of the eye-
ball. The vitreous humor.

Tarsorrhaphy [tar-sor^-a-fe) {rap-
a6q ; {ya^ij, suture]. An operation
upon the eyelids.

Tarsus [tar^-sus) [rapadg, the tarsus
(a flat surface)]. The cartilage of
the eyelid.

Teichopsia (ti-kop^ -se-aJi) [re/;^of,
wall; 6V"f> vision]. Temporary
amblyopia, with subjective visual
images like fortification angles.

Xanthelasma {zan-thel-az^ -mak)
[^avObq^ yellow; ihiafia, a plate
(lamina)] . Spots of yellowish dis-
coloration.

Xanthoma {zan-th(/-mah) [fav^,
yellow ; bfia^ tumor]. A yellowish
new growth on the skin.

Xerosis (ze-ro^-sis) [^^r/p6^, dry]. A
dry condition.

INDEX

Abduction, measurement of, Ii6

Accommodation, 31 ; association of,
with convergence, 33 ; mechan-
ism of, 31 ; range of, 32

Actol, 274

Adduction, measurement of, 117

Advancement, 138

Airol, 268

Alum, 269

Alum-pencil, use of, 165

Amaurosis, 100

Amblyopia, 100; ex anopsia, 100;
toxic, loi, 233 ; traumatic, 1 01

Ametropia, 30, 74

Anesin, 268

Angiomas, 153

Angle, apical, 22 ; refracting, 22

Aniridia, 206

Anisometropia, 95

Ankyloblepharon, 144

Antinosin, 268

Aphakia, 249

Arcus senilis, 191

Arecolin, 268

Argonin, 268

Argyll Robertson pupil, 37, 208

Arlt-Jaesche operation, 148

Artificial eye, 266

Asthenopia, 98

Astigmatism, 31, 84; cards for test-
ing, 89 ; disadvantages of, 87 ; ex-
planation of, 85 ; retinoscopy in,
56 ; symptoms of, 88 ; treatment
of, 91 ; varieties of, 84

Atrophy of the optic nerve, 234

Atropin, 72, 268

Axonometer, $6

Ballottement, ocular, 103
Bifocal lenses, 71
" Black eye,^" 141
Bleeding by leeches, 269
Blepharitis, 142
Blepharophimosis^ 144
Blepharospasm, 1 52
« Blind spot," 108
Blood-vessels of the eyeball, 16
**Blue stone,'* 270
Boric acid, 269
Boroglycerid, 270

Calomel, 270

Camphor-water, 270

Canaliculus, operations on the, 157

Canthoplasty, 145

Cardinal points of the eyeball, 27

Cassaripe, 270

Cataract, 236; causes of, 236; ex-
traction of, 244 ; juvenile, 239 ;
lamellar, 240 ; Morgagnian, 239 ;
posterior polar, 240; pyramidal,
240; secondary, 247 ; senile, 239;
stationary, 240; test for mature,
239 ; traumatic, 24I ; treatment
of, 241 ; varieties and nomencla-
ture, 237; zonular, 240

** Cat's eye," 227

Cautery, 270

Centering of lenses, 67

Centrad, 22

Cha\az\oti, i/^'i

Choked d\sc, a^o
289

290

INDEX.

Choroid y anatomy of, 212 ; coloboma
of, 218 ; detachment of, 217 ; dis-
eases of, 212; rupture of, 217;
sarcoma of, 216; tuberculosis of,
216

Choroiditis, 213 ; areolaris, 214 ;
central, 215 ; disseminated, 214 ;
exudative, 213; myopic, 215;
syphilitic, 215

Chromatopsia, 105

Cilia, examination of, 35

Ciliary body, anatomy of, 199 ; dis-
eases of, 211; injection, diagnosis
of, 36 ; muscle, 200 ; in hyperopia,
74; paralysis of, 212; spasm of,
212; processes, 201

Cocain, 72, 270

Collodion, 271

Coloboma of the choroid, 218 ; of the
eyelid, 152 ; of the iris, 206

Color-blindness, 103

Color-perception, 103

Conic cornea, 192 ; retinoscopy in,

Conjugate foci, 20

Conjunctiva, anatomy of, 160; dis-
eases of, 160 ; examination of, 33 ;
foreign bodies in, 179 ; injuries of,
179; new growths of, 181

Conjunctival injection, diagnosis of,

35
Conjunctivitis, catarrhal, 166 ; croup-
ous, 173; diphtheric, 173; follic-
ular, 173; gonorrheal, 171 ; phlyc-
tenular, 177 ; purulent, 167 ; sim-
ple, 164; tubercular, 176; vernal,

177
Consensual reflex, 37

Convergence, association with ac-
commodation, 33
Copper sulphate, 271
Cornea, abscess of, 189 ; anatomy of,
181 ; diseases of, 181 ; examina-
tion of, 36; foreign bodies in, 193 ;
herpes of, 186 ; injuries to, 193 ;
opacities of, 191 ; operations upon,
195; serpiginous ulcer of, 190;
staphyloma of, 192 ; tumors of,
ip4 ; ulcer of, 1 87
Corrosive sublimate, 274
Cover chimney, 5 1

** Cover-test," 119

Credo's method, 172

Critchett's operation, 195

Crossed diplopia, 115

Croupous conjunctivitis, 173

Cupping of the disc, 47

Cyclitis, 211

Cycloplegics, 72

Cylinders, 25 ; neutralization of, 67

Dacryocystitis, 158

Dacryolith, 157

Dacryops, 155

Daturin, 74

Decentering lenses, 69

Descemetltis, 185

Diabetic amblyopia, loi

Dianoux's operation, 148

Dioptric system, 25

Diphtheric conjunctivitis, 173

Diplopia, 113, 114; crossed, 115;

homonymous, 115
Direct method, 39, 45
Discission, 243
Dissection of the eyeball, 17
Distichiasis, 146
Duboisin, 74, 271
Duction -tests, 116

Ectropion, 150

Eczema of the eyelids, 141

Electric-light-blindness, loi

Electrolysis, 147

Electrotherapy, 271

Embolism of the retinal vessels, 225

Enophthalmos, 259

Entoptic phenomena, 102

Entropion, 146

Enucleation, 265

Ephedrin, 271

Epicantbus, 152

Epiphora, 155

Episcleritis, 198

INDEX.

291

Euphthalmin, 272

Evisceration, 264

Exenteration of the orbital contents,
266

Exophoria, tests for, 119

Exophthalmic goiter, 259

Exophthalmos, 145,259

Eye, anatomy of, 13 ; examination of,
33 ; general description of, 13; in-
spection of, 35

Eyeball, anatomy of, 13 ; dissection
of, 17 ; foreign bodies in, 261 ;
humors of, 15; lymph -system of,
17; nerve-supply of, 15; opera-
tions on, 264; tunics of, 15 ; vas-
cular supply of, 15 ; wounds of,
260

Eye-drops, 166 '

Eye-glasses, fitting of, 70

Eyelids, anatomy of, 129; diseases
of, 129; examination of, 35; new
growths of, 153

Eye-strain, 74

Far point, 32

Field of vision, 106

"Finger-exercise,*' 123

Fitting of spectacles and eye glasses,

70
Flarer's operation, 147
Fluorescin, 37, 187, 272
Focal illumination, 36 ; length, 19
Formalin, 272
Fundus, examination of, 46
Fundus-reflex, 46

Glasses, prescription of, 65, 68;

tinted, 71
Glaucoma, 25 1 ; causes of, 25 1 ;

diagnosis of, 253 ; pathologic

changes, 251 ; prognosis of, 255 ;

symptoms of, 252; treatment of,

255 ; varieties of, 254
Glycerin, 2^2
Gonorrheal opbthalmisLf 167

Graefe's operation, 149
Granular lids, 174

Hamamelis, 272

Heat and cold, 273

Hemeralopia, 100

Hemianopsia, 109

Hering's theory, 104

Herpes zoster ophthalmicus, 139

Heterophoria, 114; tests for, 119

Heterotropia, 126

Hippus, 208

Holmgren test, 105

Holocain, 273

Homatropin, 72, 273

Homonymous diplopia, 115

Hordeolum, 143

Hotz's operation, 149

Humors of the eyeball,- 15

Hyalitis, 249

Hyaloid artery, persistent, 250

Hydrogen dioxid, 273

Hyoscyamin, 73, 273

Hyperopia, 30, 74 ; axial shortening
in, 74 ; causes of, 74 ; ciliary mus-
cle in, 74; connection between
convergent strabismus and, 76;
diagnosis of, 76 ; disadvantages of,
75 ; prescription of glasses in, 77 ;
retinoscopy in, 55; symptoms of,
75 ; treatment of, 77

Hyperphoria, 120

Hypopyon, 190

Hysteric amblyopia, 102

Ichthalbin, 273
Ichthyol, 273
Illaqueation, 147
Inch-system, 25
Index of refraction, 21
Indirect method, 41, 49
Instruments, disinfection of, 278
Insufficiency of adduction, 116;

treatment of, \^^
lod\tv, 2.1^
Iodoform, aT\

292

INDEX.

Iridectomy, 208

Iridodesis, 211

Iridodialysis, 206

Iridodonesis, 208

Iridotomy, 210

Iris, anatomy of, 199; diseases of,
199 ; gumma of, 205 ; inflamma-
tions of, 201 ; injuries to, 206 ;
operations on, 208; tubercles of,
205 ; tumors of, 205

Iris-shadow-test, 239

Iritis, nodosa, 205 ; plastic, 201 ;
serous, 204 ; suppurative, 204

Itrol, 274

Jaeger's letters, 60
Jequirity, 274

Kalt suture, 245

Keratectomy, 265

Keratitis, bullous, 187 ; from lagoph-
thalmos, 187; interstitial, 184;
neuroparalytic, 186; phlyctenular,
185 ; punctate, 185 ; recurrent trau-
matic, 187

Keratoconus, 192

Keratoscope, 90

Knapp's roller forceps, 176

Lacrimal apparatus, anatomy of, 153;
diseases of, 153; gland, diseases of,
155 ; sac, diseases of, 157 ; sounds,

159
Lagophthalmos, 145

Lapis divinus, 271

Leeching, 269

Lens, anatomy of, 235 ; coloboma of,
249 ; congenital dislocation of,
249 ; diseases of, 235 ; injuries to,
248 ; removal of, in high myopia,

lenses, 2^; bifocaXf 7 1 ; classifica-
tion and numbering of, 25 ; decen-
tering of, 64; different forms of.

24 ; neutralization of, 67 ; prescrib-
ing. 65, 70 ; refraction by, 23 ; test-,
62 ; testing of, 67 ; tinted, 71 ;
varieties used to correct ametropia,

25
Leukoma, 191

Ligamentum pectinatum, incision of,

256

Light-sense, estimation of, 61

Lunar caustic, 277

Lymph-system of the eyeball, 16

Macula, examination of, 48

Maddox rod, 119

Malarial amblyopia, ioi

Malingering, 102

Massage of the eyeball in glaucoma,
276

Media, examination of, 46

Megalopsia, 103

Meibomian glands, 139

Mercuric chlorid, 274 ; oxid, 275

Metamorphopsia, 103

Micropsia, 103

Miosis, 207

Mirrors, action of, on light, 18

** Moon-blindness,*' loi

Morphia, 275

Mules' operation, 264

Muscse volitantes, loi, 250

Muscles, ocular, ill ; anatomy and
physiology of, ill; functional
anomalies of, 1 12 ; nervous supply
of, 112; normal balance of, 112;
operations on, 136 ; paralysis of,
128; strength of, 117

Mydriasis, 207

Mydriatics, 72

Myiodesopsia, 250

Myopia, 29, 78 ; axial lengthening in,
78 ; causes of, 79 ; diagnosis of, 87 ;
disadvantage and danger of, 79;
divergent squint in, 80 ; prescrip-
tion of glasses in, 83 ; progressive
or malignant, 80 ; removal of the
\tti^ Vcv, &\\ retinoscopy in, 55 ;

New point, 31

Nebula, 191

Nervesofthe eyeball, IJ

Neuritis, optic, 230 ; retrobulbar, 233

Nenrorelinilis, 23°

Nictitation, 152

Night-blindness, 100

Nodal point?, 28

Nosophen, 275

NfctRlopia, loi

Nystagmus, 13I

Periostitis, orbital, 257
Persistent byaloid artery, 250 ; pu-
pilary membrane, 207

Photi

Oblique illumination, 36; muscles.

Ocular ballottement, 102

Onyx, 189

Opacities, corneal, 19I

Opaque nerve-fibers, 228

Operations, practising, 17

Ophthalmia, gonotrbeal, 167 ; neo-
natorum, 171 ; sympathetic, 262

Ophthalmometer, 91

Ophthalmoplegia, 129

Ophthalmoscope, 39 ; description of,
42 ; direct method with, 39, 45 i
inditect method wiih, 41, 491 re-
fraction by, 48; theory of, 39;
use of. 45

Ophthalmotonometer, 38

Opium, 2;5

Optic disc, 46; nerve, anatomy of,
228 ; atrophy of, 234 ; diseases of,
228 ; inflammation of, 330

Optical consideration of the eye, 27

Optics, iS
■ Orbit, anatomy of, 256 ; diseases of,
256; injuries to, 258 ; tumors of,
259
Orbital cellulitis, 258; periostitis, 257

r,6i

Picric acid, 275

Pilocarpin, 275

Pinguecula, 178

Piacido'a disc, 91

Points, cardinal, 27; far, 32; n(

32; nodal, 2S; principal, 28
Folycorit '

, 13

■, 275

1 permangan
Presbyopia, 93
Prescription of lenses, 65, 70; in

hyperopia, 77; in myopia, 83
Principal axis, 24; focus, 18, 28;

■' Prism-battery," 117

Ptism-diopter, 23

Prism-exercise, 123

Prisms, 21 ; prescription of, 68; neu-
tralization of, 69 ; refraction by,
2(1 rotary variable, H7; strength
of, 22

ProUrgol, 27s

Pterygium, 178

Ptosis, 150

Puneta lactimalis, affect itws of, 156

Punctura proxim

Pupil, Ai^yll-Robertson, 37, 208;

changes in the motility of, 2Cfj;

examination of, 37 ; reflexes of, 37
Pyoktanin, 276

Pi^enstecher oi
Panas' sofulfon, 275
Ptnaas, 183

294

INDEX.

Recti muscles, 112

Reflection, 18 ; by a concave surface,
19 ; by a convex surface, 20 ; by
a plane surface, 18

Refraction, 20; by cylinders, 24; by
lenses, 23 ; by ophthalmoscopy,
48 ; by a plane surface, 20 ; by
prisms, 22 ; by retinoscopy, 54 ;
by a spheric surface, 22 ; index of,
21

Retina, anatomy of, 218 ; detach-
ment of, 225 ; diseases of, 218 ;
glioma of, 227 ; hemorrhage of,
220 ; hyperemia of, 219 ; injuries
to, 228

Retinitis, 221 ; albuminuric, 221 ;
diabetic, 223 ; leukemic, 223 ; pig-
mentosa, 223 ; syphilitic, 223

Retinoscope, 50

Retinoscopy, 49 ; diagnosis by, 54 ;
principle of, 50, 53 ; technic of, 50

Retrobulbar neuritis, 233

Saemisch's operation, 195
Sanoform, 276
Sassafras, 276
Schlemm's canal, 17
Scissors movement, 58
Sclera, anatomy of, 196 ; diseases of,
196; staphyloma of, 197; wounds
of, 198
Scleritis, 196
Sclerochoroiditis, 215
Sclerotomy, 255
Scopolamin, 72, 276
Scotomata, 109
** Second sight," 79
Shadow-test, 49
Silver nitrate, 276
Skiascopy, 49

Snellen's letters, 59; sutures, 150
Snow-blindness, loi
Spectacles, fitting of, 70; preferable
to eye-glasses, 70
Spheric surface, refraction by, 23
Spring catarrh, 177
Squint, 126

Staphyloma of the cornea, 192 ; pos-
terior, 80 ; of the sclera, 197

Strabismus, 126; in hyperopia, 76;
in myopia, 80

Streatfield^s operation, 149

Stye, 143

Sun-blindness, loi

Suprarenal extract, 277

Symblepharon, 180

Sympathetic ophthalmia, 262

Synchysis, 250 ; scintillans, 250

Synechias, 38, 202

Table of differential diagnosis of ocu-
lar inflammations, 162 ; of paralyses
of the ocular muscles, 132

Tannic acid, 277

Tarsorrhaphy, 145

Tattooing the cornea, 191

Tenon, capsule of, 13

Tenotomy, 136

Tension, measurement of, 38

Test- cards, 59

Testing of lenses, 67

Test-lenses, 62

Thiosinamin, 277

Thomson stick, 105

Thrombosis of the retinal vessels,
225

Tinted glasses, 71

Tobacco amblyopia, 10 1, 233

Toluidin blue, 277

Toxic amblyopia, loi , 233

Trachoma, 174

Traumatic amblyopia, loi

Trial -frames, 62

Trichiasis, 146

Tunics of the eyeball, 1 5

Ulcus rodens, 190 ; serpens, 190

V axv "^'vWYd^tTv' ^ Q^ration , 149

Wernicke's sign, 208
Witch hazel, 272

INDEX.

295

Yellow oxid, 275
Young-Helmholtz theory, 104

Xanthomas, 153
Xeroform, 277

Zinc acetate, 277 ;
sulphate, 277

chlorid, 278 ;

■

^ Hi

.'.1

CatalOBua No. B. October, 1899.

CLASSIFIED SUBJECT
CATALOGUE

MEDICAL BOOKS

iks on Medicine, Dentistry, Pharmacy,
Chemistry, Hygiene, Etc., Etc,

P. Blakiston's Son & Co.,

Medical Publishers and Booksellers,

1012 WALNUT STREET, PHILADELPHU.

SPECIAL NOTE The price* g"'™ in this catali^ue are

ibsolDtelf Del, do discount will be allowed retail purchasers
onder any consideration. This rule has been established id
order that everyone will be treated alike, a general reductioD
in forroer prices having been made to meet previous retail dis-
counts. Upon receipt of the advertised price any book will
he forwarded by mail or express, all charges prepaid.

We keep a large stock of Miscellaneous Books, not on (bis
calalogae, relating to Medicine and Allied Sciences, pub-
lished in this country and abroad. Iniguiries io regard to
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Special Catalogues of Books on FharmHCy, Dcntisti;,
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t-SBB NEXT PAOB FOR 3UBJKCT INDEX.

Oonld'M moOanariea, Ftgo S,

SUBJECT INDEX.

Opfalhalnobvy...... ....„ g

OiteoLogy (kc Aiatomy},,,,,^ t

PuholaE? .—■ —.^ _....__ li

Phannscv. _....„-.. i<

PhysicBl IMasnnab ><.->^..,-,r- tj
Fhyfiial Tnining (« aibal-

PhyiioloCT ■"™"-'-^^^~" 3

PnctiCE gf MEdtci«nZ™™ d

PmcripdonBoBki i>

Rallniul Injuria (usHcnotw

Dinsasa) ~. ■*

KEiiutloD (ne Xye) ....„.„_ g

Spectadei bet Eye) „.... g

Splac (hs Nbyoui DfwHa) 14
Stomach (hr: MlsfslkneoiuJ^ 14

Studcntt' Compends »..«i, aj

Surgery Hid SurgiciU Dl^

TtchDDloglcal Books —._. 4

Tcmpentam Cbaria. .-..».»... a

Thmpeutlci „ ic

Throu ...~.».^-»___ ■•

ToiicDlDiy ~_...~. I]

TuDion Ism Sartcrj)....,..^ »
U- S' PharDucopcBU..H...,wH». ■«

(SmS/ir^ciaiCtmUar.)

tar Thipricts as given in this Calalogitr are net. CJolA
iiniliHg, unless olhtrvrise sptctfied. No diseouttl can ie
ttllmnfd under any circunutancei. Any ioek luUl be tent,
peslpaid, upon rectift ef advertised frite.

r
I

sub;ect catalogue of medical books. s

49- AU baoka are Aeuiuf ta atom, uMleaa otharvHtB apwii-
itad. .111 prteai are nat.

ANATOMY.

MORRIS. Telt.Book pt Analamy. ad Edition. Reyiitd agd
y-K^Mrf^."" aoth,*6!™;'LMlhcr,»7,Dor ftUf Rimia, >8/)o

piaise ID this work, tl will nmk, we believe, wilh Ihe leadiiij[ Analo-

««i«i Mtdical and Surgical Jmrnal.
Himd»>iiiE Circuit of Man\s, with utmple pages and colated lOui-

1 Teeth. 1S4 llluetraiisu.
DEAVER. SurEical Anatomy. A Treatise on Uu
in \a Application to Medicine and Surgery. With 1
Haodioinc full-paxc IlIuiIriitlDiui Engnved from Otig

TnrM Volume*. Royal SquareOcuvo ''"''"
Clolh,«><.t»; Half Morocco or Sheep, (atw; Half
KCKl.Ey. Practical Anatomy. A Manualiut the 1

Qoih.lf.Da: Sheep, f; .so
HEATH. Practical ADatomy. ath Edition, jog IQiu. #4.'!
HOLDEN. AnBtomy. A Manual of Ibe DIssectianB of the Kuman
Body. Canfblly Reviled 1» A. HawsoH, h.d., DemonsCnilar of
Anatomy, Jeaenoa Medical Ccrilege, Phlladelpbia. iii lllustcatloni.
TlhEdiflon. hprii.

HOLDEN. Human OatEOlOEy. ComprUiuE a Deacripdon of tht
BonH, with Colored DeliDeallont ol the Atuchmenu of the Muscles.
TheGeoeral and Mieroscoplcal Slrnctiare of Bone and lis Develop-
ment, WithLlthographicPlalesandnumerouElUus. Slh Ed. fj.i;
HOLDEN. Laodmarka. Medical and Surgical, ,ih Ed. fi 00
MACALISTER. Human Anatomy. Syalematic and Topograph.
ical.includinE the Embryology^ HisLolofy, and Morphology of Man,
With Special Refeieoce to the Requirements nf Practical Suigery and
Medicine. S16 lIlusCratlonB. aotli,f].Do; Leather, ft.co

UARSHALL. PhyiloloKical Dlacrarai. Life Slie, Colored.

Inchei). Designed for Demonitratioc before the Class.

In sheets, ITnmounted.tio.oo; Backed wkh MusllR and Mounted

on RoUers, *6o,Do: Ditto. SpKng Roll™, in Handsome Walnut Wall

Map Cue. ^100,00; Single Pbites— Sheets, l^os; Mounted, |;.}o.

Eiplanalory Key, .50. Purchaiir mwlpay/reigM chatfis.
POTTER. Compend of Ao.tomy, Including Visceral Anatomy.

6thEd. i6Uih. Plate>andii70lherlllus. .So; Interleaved, fi.i;
WIL30N. Kuman Anatomy, irth Edition. 419 ■Uustcalloni, it

Colored Plates, and aGlossarr of Terms. (jxa

WINDLE. Surfaca Anatomr. Colored and other Illus. fi.oo

MEDICAL BOOKS.

ALLEN, Albumlnoui and Diabetic Urine. Iltuimied. I».
HARTLEY. Hsdical and Pbumaceutical ChemUtry.

d.DeouU.a. __

lUuEUaliou. Glossary, aad ComplFle Indet. Jth Edition, carefully

RcTised. JuitKtad,. Cloih.fa.oo:Sh»p,»3.So

BARTLEY. CIlBlcal Chemistry. The Examinsiion of Feces,

Salivi.GasUicJuice, Milk, and Unne. JulRiady. fi.Do

BLOXAU. Chemiitry, iDoreanlc and Organic Witk E>peri-

BUHU. Bth Ed., Kcvtied >Si Engnrings. Clo., ^i; : Lea., (j.15
CALDWELL. Elementa of Qualitative and QnaBtltative

Chemical A nalyaia. jd Edition, Btviscd. (1.50

CAMERON. Oils and VaraiBtaes. With lUustratiou. I^ij
CAMERON. Soap and Candles. 34 llluitratlciii, (a.oo

GARDNER. The Brewer, Dlitiller, and Wine Uaoiifac-

lurer. lilnslrated. (..jo

_. . _ _ ^^^^

:raied. Cloth,f4.<»; Half Muiocizaji.jo
tents, the ConmoB
cat, fat Laboralory Use. 'jth ^."lllusirated'w.d inteilMved. (i.oo

LEFfMANN. Campend at Hedlcal CbemlatTy, Inorganic
■□d Organic. licludiDC Urine Analnls. 4lh EdluoD, Rewnlien
and RevTssd, .Bo; Interleaved, (I. J J

LEFPMANN. Analyalanf HilkandHlIk Producta. ArTanged
loSuittheNeedsof Analytical ChemisB, Dairymen, and MiUtlnjpec-
lan. id Edition. Enlarged, lUiislraled, t'-^i

LEFPMANN. Water Analysla. For Suiitsiy sad Technic Pur-

LEFFMANN. Structural Fotmu la. Including iBo SimclunI

MUTER. Practical and Analytical Cbemlstry. ad American

m Americsn Mediul' Colleges bv Cuude C. Hahii-tdh, k.d. s6
lUustnition.. fi.>S

:b in Electro- Che mil try. tlluimied. .7s

by Edoui F. SiitTi

&I lUutttalJimi ond a Coloicd Piatt

IiaG.
BTAll

Ic Chemistry. 41b

rired translation by
and a Coloicd Plate.
, Organic Chemlatry. 3d American EditloD. Trans
from [be Bxb German by EoG.a f. Smith, lllusiraled, > Volumes
Vol. I. Aliphatic Seriei. 6»5 Pages, /uzl Riady. »3.e.

Voi. IL CarWylic Series. InPrts,

giClTH. Eleclra-Chemical Analysii. id Edition. Revised. 9:
lllustradoiu. ^ »>,.

BUITH AHD KELLER.

Illnsl

SUTTON,

SUBJECT CATALOGUB.

imotrle Aomlyili. A Svslemaiic Handbook for

— , r Efllmilioii (4 Chcmicsl Subsuncu by MeaiuK

Applied to Liquids. Solids, snd Giiscs. jih Etiiiron, RcVlsed, tis

SYUOND8. MbuubI of Chemlitry. for Medical Studeaia
id Edillon. f, „

TRAUBE. Physico-Chemicai Methods. TransLaied by Hardia.

ULZERAND FRAENKEL. Chemical Technical Aoalyiia.

TransbledbyHeck. lllustraltd. (,,,,

WOODY. EBicDtlali ol ChcmlBtry aad UrlnBlyali. uh

Edition. lliusMKd. IhPt.!,.

V Sticiid Calalsgui af Bosks on Ckimiilry /-« ii/an afpUsatum .

CHILDREN.

CAUTLI&. Peidine of Infanta and Youne Children by Nat-
ural and ArtiiiclBl Msthoda. |3.i»

HALE. On the ManaBement of Children. ,yi

HATFIELD. Compend □[ Disea>es of Children. With ■
Colored Plale. sd ESitioQ. .80 ; Interleaved. (...}

HEIOS. Infant Feeding and Milk Analyala. The Eiamloalioo
of Human and Cow-j Milk, Cream, Condensed Milk, etc.. and
Direciions at Bthe Diet of VounE Infanis, .50

POWER. Surgical Dlaeaaei of Chitdron and their Treat-
ment by Modern Methods. Illn^trated. fi.jo

BTARR. TheDigestiveOrgaiiBlnChlldhood. The Diuaiei ol
the Uigefijve Organs in Infancy an<i Childhood. With Chapien on

Ed ilian. Enlarged. Illustrated by two Colored Plates and numennn

STARE. Hygiene of the Nursery. Iscluding the Geoeial Regi-
men and FeeiRnE of Inlanisand Children, and tlie Domestic Manage-
ment ol Ihr Ordinary Emergencies ol Early Life, Massage, etc fith

SMITH, Wailing DlaeBses

Children. 6th Edition.

e Dlieaaes of Children

T11<t>

iraled. A New MannaL jifip

ges. Juii Rtad},

»«—

CLINICAL CHARTS.

QRIFFITH. Graphic CUnicnl Chan for Recording Temper-
.•»re, Reepiratfoi). Pulse, Day of Disease, Date, Age. £e>..

KEEN'S CLINICAL CHARTS. Seven Cull

free. Pnt up m loose packages d( fifty, .50. Price 10 Hospitals.
■ ' ^ ■ »,.so. With nan.- ' "— '

MEDICAL BOOKS.

DENTISTRY.

S^tcial Calalogiu oj Drnlal Baaks stni frti Kfiix afifilKallan.
RETT. Dental Sureen' for OcDeral PrBctltionera (od
idcniB of MedicloE -od Dentiitrr. EiuacHon of T«lh,
-■■ •---•■■=— 'UustiaWd. jVmW, //laJ}.

BLODOETT. Dentnl PatholDE?. By AtBKHT N. BLOoawn,
u D.. lale Professor of Pathology aod Therapeutics, B<WIOti Dentil
College. 33 lUu^ouions. t'-'S

BRDOMELL. Anatamy aDd Histolof^y of the Kumsn Mouth

[ructutn, 4tn Editir
of Operative I

itjil Faci

ties. lUustruled.
OORQAS. Dsntal Medicine. A Manual of Meteria Medlcaand

Therapentic filh Edition, Revaed. Clotli. (4,00; Sheep, IJ.DO

MAKRIS. PiinciplBi and Prastlu of DaDtiitty. tncludini

Anatomy, Physiology, PatholDgv, Therapeutics. Dentil Suiaerv.

and Uechanitim. 131)1 Edition. Revised by F.l

itiy. IncIudinE DefinltionioFSi]

fl. Revised and Enlaraed by Ki
s. Cloth. ( ■--.-- -'

!» of the Jaw

HEATH. Lt

TOHE3. DeaulADi
Sth Edition.
TOMES. □«
WARREN.

SUBJECT CATALOGUE

DICTIONARIES.

j,'|io.oo'; ThunS'^'iut'lii.oo
ilTKusiUi, Thumb Indei.lta.oo
QOULD. Tbe MEdiMi BtodCDt'i Dlctloiury. I

Sheep or Half Dark Green Leilt

» Geocinllv Uied in Medicine, wlA [1

:ludii« aU the

s of Ihe Badm Micii__

flHes, Hu&da, NBrveLGnneliB,

ll Spring

. ^ . . c. lathBilUaD,

RawrltteaandKalarKBd. CoinpleldvieaelfrDmiieirlyps. logpp.
Hall Darii Leitber, f j.as ; HolT Uotocu, Thumb iadei, h.oo
QOUI.D. The Packet pToaouncliiE Uidlcal Laideoa. 3dEdl-

tian, (ra,wD MedlcaL Words Pvopounced and Dcfiavd.) f'«»**iiit-j
all ihe WDtdi, ihcii DeGaiclcn and PraminclalioB, thai the MeAoT,

I pLma

iludent GenenllT domei la CoMara

In both Engliih and Metric' Sniau'
reDient ITorm rorReferenmand McDior
1 new type, enlarged by 135 p«g»

Qil( Edgn, |ijx>: Thumb Indei, fi.a<

HARRIS. Dictloi

MAXWELL.. Te

. applical

r/ofDentiatry. Including DcGidtlou aTSiiefa
of the Collateral Sciencn u Pertain to the All
tialry. fith Edmon. Revised and Ealarnd by

'-'-'- ■•---,! Leather, |6oo

lb an Appendii,

jut tise^In Pre-

Uolh, .n : Tucki and Pockel, f i.<x>

DolosiB MedlcB PolyglottB. Bji Dr.

' -aisled hy Olhen. (tog

._. .L j,„. . .j,y na^oiSDty

Aedical Dlctl

TREVES AND LANQ.

lish, Ktissiao, an<

ledical melt
:D languages, vit.: EnslLsh, i
i-Enellah Medlca

ctionjry.

c kIso Throat and Nohc).
and How to Keep II. lUuairale
nd Injuriea or the Eat. 4th Ed

EAR (ac

BURNETT. Heating

HOVELL. Dlaeaaea of the Ear and Naao-Pbarynic. Includ-

iDg Anatomy fiid Phyalalney of the Orean, together with (he Treav

A^ °D^e^se. "iMni^trtllons. ad Edition. Frtfarinf.

PRITCHARD. Diaeaaea of the Ear. id Edition. EniatBed.

Many Illustratioii! and Formula!. »i.so

WOAKES. Deafaeaa, Giddineas, and Noiaea ia the Head.

4lh Edition. Illiutraled. (>.oo

MEDICAL BOOKS.

ELECTRICITY.

BIQBLOW. PiBin Talks oa Medical Blgctridty ■
. With a Thenpeulic iDdci snd a GIdsutv. 41
3d EdiMoB.

JONES. Hcdiol Electricity. 3d Edlilon. 111 Illu^.
MASON. Klectrlcity ; Iti Medical and Suretcal Us«.
OU5 Illustrilions.

EYE.

A ^tciai Circular 0/ Btah on thi Syt iml frti ufim ap,
ARLT. Diteasea of the Eye. Qlidcil Studies on DIsea

Eye. Tninslatioii by Ltuah Wars. h.d. Ulusliated.
DONDSRS. The Natnre and Canaequencea of Anon

Refraction. With P^tttaii and oth<.i iTliijiKaiioni, a«o.
Ju!l Riady. Hair Mo™

FICK. Dlieaa« of th

e Bye a

nd Ophtha

Trans

lustra^ona, many o(wh

Ctoth

»*.5°; She

ep.'foiS

GOULD AND PYLE.

Compen

1 of Dlaeaa

e. of ibe Eve and

Refraction, Including

I and Opera

Section

With fo

mul=, Usrfg

whlLh at

in colon.

dEd. 'JU!

Riady

Cloth, .So; liitorlo

ed.»t.,s

QOWERS. Medical Ophlhalm

tA;^Tc- Pi^

d Allai

and Lith

ad.cula

uatlDns

Ihe ChaneB

of the Eyt

inDla-

eases Df the Bra^n.Kldr,

y.etc 3d Edition.

»4.0o

HARLAN. Byesiaht.

HARTRIDCE. Refra

lUustralionl and Te

Type.

glh EdUion, Enlarged.

»'-50

HARTRIDQE. On th

4CdloredPbI»and6SV

fnSKlfi

ImOBcape.

)d Edilio

(..SO

HANSELL AND REB

ER. Mu

cularAno

naliesoft

he Eye

HANSELI. AND BELL. Clinical OphthBlmoloey. Colored

JBSaOP. Manual ofOphthalmIc Surgery and Medicine. Col-
ored Plates and toS other lllustrationa. JuaRi^f. Cloth, fa 00
MORTON. Refraction of the Bys. la Diaenosls and the Cor-

L Types, eth Edition.' f t.oo

OHLEMANN. Ocular Therapeutica. Aolhorited Tmuilallon.
PHILLIPS. SpecUclea and EyeilaBaea. Their Frescripiion
SWANZY. DiaeBBBS of the Eye and Their Treatmenl. «[h
:

and a Zephyr Test Card.
THORINQTON. RetinDicspy. 3d Edit!
THOKINQTON. Refraction and Hdw I

WALKER. Studeau' Aid In Ophthaii

10 SUBJECT CATALOGUE. ^H

FEVERS.

COLLIE. On Fevers. Their HiilDrj. Eliology, Dlagnoiii, Prof

■

ncsls, and TtsaHnem. Colared Plates. fi.oa

QOODALL AND WASHBOURN. Feven aiid Their Treml-

GOUT AND RHEUMATISM.

"IT^^f;"^: * "™"" "" °-^- "^'^ '^'""■-a^

Rheumalic Arthrilis. dttb, fc.co

the Pathology of HiRh Ar.erial Teosion, Headache, Epilepsy, G™i,
Rhei,n.alisR.,Diab«a,Bright's Disuse, «c. ,ih E^lion, (3 "

HEALTH AND DOMESTIC MEDI-

CINE (see also Hygiene and Nursing).

BUCKLEY. TheSkin iTiHes1tbBndDl>e»e. lUus. .40

BURNETT. HcBrlDeaadHowuKeeplt. Iliucitaied. .,0

COHEN. ThcThro«l.ndVoiee. liluXrated .^

HARLAN. Eye.ight -od How to Care for I(. Illmtn.ed. .40

HARTSHORNE. Our Homes, niuslra.td. .40

PACKARD. Ses AlrandBathiDg. .40

PARKES. The Elements of Health. (...5

RICHARDSON. Look Ufe und How to Rescb It. .»

WE3TLAND. The Wife sod Mother. (i.jo

WHITE. The Mouth and Teelh. [Uuimted. .«

WOOD. Brain Work and Overwork. .40

STARR. Hyeiene of the Nursery, s'h Edition. f i.od

CANFIELD. HygleDcof IheSick-Roem. (1.B5

HEART.

3ANSOM. Dlseaaea of the Heart. The DiurDosii and Pathology
of Diseases of the Heart aod Thoracic Aorta. With Plaiei and other

THORNE. The Scholt Methods ofthe TrsatmsDl of Chronic

Heart Disease. Third Edition illustrated, Jusl S,a^y. f-ji

HISTOLOGY.

STOHR. Hlstoloey and Mlctoaeopical ADalomy. TiauUted

and Edited by A.&h««. «.n., Har«ird Medical School. Second

HYGIENE AND WATER ANALYSIS.

CANFIKLD. Hygiene at U

COPLIN AND BBVAN. Pncticn
Amtrican Tsn-Book. 138 ILIuslralions.

KEN^VDOD. Publfc Health Labor
lions and 3 Plaics.

LBFFMANN. EiamlDBtion of ^
Technical Purposes. 4<h Kdllion. II

LEPFHANN. Analysis of Milk an

LINCOLN. Sch

Mien

: of IsolatioD Hos

Hyeiene. A Compleit

ma of Wat(

ind thi Con

NOTTER AND FIRTH. ThoThco
( Being the oth Edilion of Psikei' Prj
\xanir.\ .<p lo dale.) 10 Plates and

PARKES. Hyelec

t and Public
Hyeiene. 1

Health. By Louis C. 1

PARKES. I

for Lay Reai

STARR. Tbe Hyeiene of the Nursery. Including Ihe General
Regimen and FceSiog of Infants and ijllildren, --^ ■'-- " --

STEVENSON AND MURPHY.

WILSON. Hand-Bool

Widi lllusntiiHis. Btb
WEYL. Sanitary Reli

liedTrambtgonby Hes

of Eaily Life, Missage,

™ ^.^-^ .<.,un.e. .l"««"'' ^'
", ie^rVnl^TC^i'.iH'; Vol. 111,(5.00
ately. Special Circular upon applicaiion.
if HyelcDC and Sanitary Science.

If the Coat-Tar Col<

SMANH.H D.PK.D. t'

^uthot-

LUNGS AND PLEUR/E.

HARRIS AND BEALE. Treatment of Pulmonary I

OWELL. Diseases of

Consumption. Colored I
USSEY. High Altitude

18 SUBJECT CATALOGUE.

MASSAGE.

KLEEN. Hand-BoDk of Mibsxec. julhonfed Inuuliljen b*
Mtissir Hartwull, m.i>., rH.u. With an LmTxtuctJDn bv Vt. 5.
W HI B Mitch KLL. [Uinlrated by a icria ol PhoWgiapfii Made

MURRELL. MaBiotherBpeutin. Muiage uhMdJi of Tmi-

Qicnl. 6.b Edilion. /» /y„,.

OSTROM. HBuarc and ths OriirlDBl Swedish Hotc-

Manual for SmdtnlT/NuisH, jnd Physiciansi^Fnunli Edilion, En-
WARD. Notes aa Maisaet. Interleaved. Paper conr.fi.oo

MATERIA MEDICA AND THERA-
PEUTICS.

ALLEN, HARLAN HARTE, VAN HARLINOBN. A

•uch'suOinlmemls, Plasleis.lio-ders.'LoUQM Inhalillloni
tories, Bougies, Tampons, and the Proper Methodi of Pre)
Applying Tticm. Cloth, f^.oo; SI

BIDDLE. Miieria Medio and Therapentl CI. Indu
List, Dieury fi ■-■"--■ - "

ance with Ibe i

LlDth, (4.00: Sheep, (j.™
BRACKEN. Oullinei of Materia Media and Phansacology. fa.;j
COBLENTZ. The Newer Remedies. 3d Edliioo, Enlarged aod

Revised. JmiRtddy. fi.oo

DAVIS. Materia Medio and PreicrlpHoa WrttiDg. ft js
flELD. Evacuant Medlcatloa. Caihanics and Enietici. I1.7;
Q0ROA3. Deatal Medicine. A Manual oF Materia Med ica and

QROPR. Materia Medica for Ntiises. |i.*s

HELLER. Easentlals nf Materia Hedica, Pharmacy, and
Preecriplion WriHng. (1.50

HAVB. Theioe latbcTieaimentDf NeuralBla. H bound, .so
NAPHEYS. Modern Therapeutlea. glh Revised Edidon, En-
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VoL""Gen"i^'M^icineand"lseasM'oraii1dnai. l,,oo

Vol. 11. GeoeialSuigery, Obstetrics, and Dinasetol Women, ft.oe

POTTER. Hand-Book of Materia Medi<», Pb*.rDiacy, and
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mulB. Tth Edition. Revised and Enlarged. With ThuEiblndei Id
eachcnpy. /uil Rtady. Cloth, f;aa: Sheep.ffi.ca

POTTER. Compead of Materia Medlca, Therapeulica, apd
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I
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MEDICAL BOOKS. 18

SAYRE. Orgaole Materia MEdic* and Pbarmacoinoi;. An

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^ ._..._ ^ Constiluenis. »nd Phannacopeial Ptepara-

SynthMlc Organic RemtdttB, IniccB In.
irmica] Bouiny. A GloiMiy and i43 Illia-
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WARINO. Piactlcal Thcfapnutlca. 4lh Edillon, Reviied and
Rearranged. Cloth, (9.i»; Luther, f 3 .00

WHITE AND WILCOX. Materia Medics. Pharmacy, Phar-

^ ,^ American Ediilon, Revised by

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MEDICAL JURISPRUDENCE AND
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REESE. Medical Turl I

^i^'b^ HiHRi Kfpk*nn,"h'b! "cIo
"To the fltudeni of medical jurisprudence a
valuable, as it is concise, clear, and thorough in
American Jewrnal 0/tkt Mtdical Scii^t!.
MANN. Forenaic Medicine and Toxicol
HURRELL. What to Do in Caua

MICROSCOPY.

BRALB. The Uae of the Mlctoicope la Pr
ForSiudeataandPractltioneTs.withFullDiiectioi
Various Secretioni, etc, by iheMICT^Cope. 4tbl

BEALE. How to Work wltb tbe Mlcroaci
Manual of Microicapical Monipuhition.cnnlainin
of many New ProccMei orinvejtigalicn. with Dir
iiH Object! Under the Highest Poven, and fbr 1
oTMictoicopic Objects, jlh Edition, too llli

CARPENTER. Tbe Mi<

Melhodi ot
Enlarged.

REEVES. Medical MIcroieopy, includli
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H_ WETf

WETHBRBD. Madica

.tz

U SUBJECT CATUX>GUK.

MISCELLANEOUS.

BI,ACK. Klcro-Orsi <>>■«>- The r«mni« «

B*'>l"»ICal STujJy nf Ihe Gfrm Tb*OTT 0* T^ill ■»

8RAHWEI.I.. Aazmia. Jutt SimJf.
BUXNETT. rood! aad DlMarica. A lfi_al W

BUXTON. AnzMhatica. IDuHiatcd. 3d Edhi«. /mPra,.
OOULD. Berdcdand Stadin. Mrrorlbaioiu AddmKt u>I

OOWERB. ThcDyiuiDlcaDfUl^ .„

HAIO. CauulisD of Diieue by Uric Acid. A CoatriboiBB 10

Iha Palbnlogy of H igh Arterial Tenuoo, He&dachc. EpOepnr, Gmi,
KVirunmtlini, Dubeiet, Briciil'i Diicsic, eu. (Ih EiAiioo. |].sa
KAIO. Diet and Food. Coniidered In RfUiuis u Sucnglh ind

HARK. HedUttlnal DiHui
KEMMKTBR. DiauMi of tbe Btomi

nl'Vv.piBK<i<"<>,»dTmiliDenl. With S

HBNRY. A Prietlul Treatise 00 Ant
LBFPHANN. ThBCaal-TarColare. '

thetr tnjiiil<>iui Qutlllin and the Reilrii:Iio _ _

lallsn of Thiodoh Wcvl's Monogiaph. ti.ii

MARSHALL, Ktatory of Womaoa Medical CellereorPeDD-

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■CHHI

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NERVOUS DISEASES.

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OORDINIER. The Oroai

tral NervDue Syatem.

'Book,
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u of Ihe Brain and Cm

OOWERS. Mai

Complala TmH

trrilten, With oiany new ilk

lih 3J1 Driainal (

do.h, t

■eaof the Nan

1, Enlarged^and il

vii.''i'i'' ii^

n,nc

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MEDICAL BOOKS. ID

HOR3I.EY. The BrXn and Spinal Cord. Thi Simctnn md

Functiom of. Nuntnui lUuilnllDtit. U-so

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03LER. CeribnlPaliilcMorchildren. A Dbical Study . $i.oa
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PRESTON. Hysteria and Certain Allied CondilloDS. Their

WATSON. CoDCUBslons. Au Eipciimental Sludy of Lesions AriS'
igg from Severe Conditions, Paptr cover, fi.oo

WOOD. Brain Work and Overwork. .40

I NURSING.

^icia! Calalcgm nf Buslator JVafj« «»(>■« ■/>«< affliiaH-m.
BROWN. Elementary Physloloey lor Nuraes. .75

CANFIBLD. HyEiene oftheSick-Roam. A Book [or Nunuand

tioe^B3CterkSoEy,"mniunfty.H<^(inEand°^«itilJtian|^'<i Ki'nd^'

Subjects for the U» oF NurleE and Other Intelligent Women, f-'i
CULU NO WORTH. A Manual of Numlng, Medical and Sur-

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CULLINQWORTH. A Manual for Monthly Nurses. 3d Ed. .,o
CUFF. Leitures to Nurses on Medicine. New KU, »i.=5

DOMVILLE. Manual for Nurses and Others Engaged in At.

tendine the Sick. Stli Edition. With Recipes for Sicfe-roomCook-

"" ' Sth Kd.

urilng. Comprising the Regular
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1 6th Ed. Iliuii

IHAWB. NDIes rorViBltlog Nunes. and all those Intereati
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cietiei, hy Helen C. Jenks, of Philadelphia. fi.i

^Idon. tj 1

1,» lilt
WARD,
BAI
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OBSTETRICS.

BAR. Antiseptic Hidwirery. The Principles oIAuliseplie M

-'- 'irfied to Obsletric Piacllce. Aathoriiad Translation

D Fal, K.D. , irith an Appendix by [he Author. f

If SUBJECT CATALOGDK.

CAZBAUX AND TARNIBR. Uldwttcry. , ... ..,,

MuNii*. ThE Theory ant! Pnctkcof Olnlclrici, including ihc Dii-
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LANDIB. CnmpeDd ofObitetrici. Glh Edition, Reriied by Wk.
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SCHULTZE. ObiletricBl DiBcruni. Being n loies efioCol-
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^ w''mdCliu"»d'E'evi<ea Edition. "^ ™"'

Price inSbeetE.tift.oD: Mounted on RoUen.UudlnBaeki.trf a
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WINCKEI.. Teit-BookofObKelrlcB, iDcludlnElhe Patbii^

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FULLERTON. Obele trie Nursing. 5th Ed. Illustrated. |i.»

PATHOLOGY.

BARIyOW. General Pathology. 795 pages. Kvo. (5.00

BLACKBURN. AutDpsiei. A Manual of Autopiiei Deaipied for

the Use Qt Hospitals for the Insane and other Public lutilutions.

Ten (uB-poge Plates and other lUuttratlons. ii.i.

BLODGETT, Dental Pathology. By Aukkt N. Blodoittt,

H.D., late PtorcBOT of Patbalogy and Therapeutics, Boston Dental

College. 33 lllustialions. tljj

COPLIN. Manual of Pathology. Including BaclcTroIagy.Techolc

of Posl-Monenis, Methods of FalhDlog.c Research, etc 97, lUm.

irations, many of which are original, id. Edition. N«trlt Rtmh.
GILLIAM. Pathology. A Hand-BoolL for Students. 47 lllui. .n
HALL. Competid of General Pathology and Uortald Aaatomy.

91 <cty line niuitratlons. 3d Edition. .go; InleHeaved, li.is

HEWLETT. Manual of Bacteriology. 7; lUustiations. ti.n.
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Elplanalion ot the Method of Feiforming Them in the Dead Uoiue

of the Berlin Charity Hospital, with Special Reference to Uedks-

Lecal Practice, 3d Edition, vilta Additions. ,7;

WKITACRE. Laboratory Text-Book of Pathology. With

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WILLIAMS. Bacteriology. A Manu.l for Sludenla. 7! fll«..

trations. |l.5a

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Sttciat CiUalafiu of Heakt m Fharmiay tnl /rti m^M affKtalitm.

, -- -(einediei. Includlaa their Synonyms.

iilon, Tests, Soluhillds, and Dose, u
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c6BL'EN'Ti£"'Maniiai'o. ,. .

Text-Book by [he ProfcKor in Ibe Hew Yorii College o[ PI

.,_j wji-r — n — [ 1 — J ff„i-_^.J . — Tll„- 'Todl.fo.SQ.' E

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MEDICAL BOOKS.

BE AS LEY. Boo

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Praclice of the M

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tory ot the Materia

Media, Lisu of .h

Officinal

of Discasei and lb

eir Reme

ie.. 7th Ed. t,^

BBASI.BY. Dru

EKiBtB' OeBenl

teceipl

Book. Comprising

tent«dp™p^em^

Hsdldaes. Dniii

rperfu

'^rade ChemicIS;

Beverage*' UieK

Tables.

■olh Ed. M-oo

maceulical Pan

'lalM"^

A SynoMi. of the

Bntish, Frtnch. G

rman, and United

yedinMedicine. nth Edition. >i(Km^>, (>.oo

PROCTOR. Prat

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nacy. W,th Wo

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and will.

ROBINSON. LatiD Orammar of Pharmacy and

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SCOVIL.L.B. The An of CompoundiDE. Second Edition, Ri

STEW^ART. Corapend of Pharmacy. Based upon " REming
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UNITBD STATES PHARMACOPmiA.

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PHYSICAL DIAGNOSIS.

:dical Dia^nosia. A Manual of Clinical Methodi.

PEN WICK. Medical DiacDoila. Gth Editli

Cloth, %i.i

:ry much Enlarged. 135 lirustrations. Cloth, (j.Jl

MBMHINOER. DiagnoalabrtheUriDO. idEd. >4l11us.fioc
TYSON. HaDd-BookofPhyilcalDiaEnoBia. For Students and
Physician.. By the Profesmr of Clinical TWedicine in the tlniverail.
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SUBJECT CATALOGUE.

PHYSIOLOGY.

BRUBAKBR. CampGDd of PhyBislQE;. gtli EdltioD, Rnaed
and Enlirgcd. IlLusuatcd. Just Stady. .Sa; InUrieaved, fu;

K1RKE. PtayBiology. (ijih Authorlnd Edition. Dark-Red Clotli.]
A Haad-BoDk dT PEniolDgy. 15th Edilion. Reviled, RcairangEd,
«nd Enlaiged. By Pkoi'. W, D. KAiijiiiniTDN, of KinE« Coikgt,

STAR LINO. Elcn

TYSON. Cell E

Kines C
1oth.»3.«,: Leslher,
1 Phymioloey, Ind
ritli Special Referee

-Ii^'bVc^'r

FOWLER. DicIlOBBry of Pcactiul Medicine. By varioui
writers. An Encyclopedia orMedidDe. Cla.,f3.°°: HnlfMor.(4'«
HUQHES. CompendefthePmcticeofMediclBe. 6ih Edilion,
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Pari I. Continued, Enipdve.aod Periodica] Fevera, DiseajHa or lb*
Stomach, Inteitines, Feriloneum. Biliary Pusagei, Livei, Kid-
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Part 11, Diseases of the Respiralory System, Circulatory Syllem,
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Prieeof each part, .Bo; Interleaved, (i.»i

Physician ■■ Edition.

parts, a Scalon on Sk

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ROBERTS. The Thco

SooUoiU on Treatment . , , .

with Illustrations. Cloth.»4.5o: Leather. (5.30

TAYLOR. Practice of UedlclDE. jih Edition. Cloth, ^4.00

TYSON. The Praclice of Medidna. By Uns Tisoh. m.d.,

Professor of Clinical Medicine in the Univenlty of Pennsylvania.

ACompkte Systemat.Q Tni-hoolt with Special Reference 10 Diag-

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MEDICAL BOOKS,

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SURGERY AND SURGICAL DIS-
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BUTLIN. Sutgtiy of Meliennnt Disoase. »cl K.liUon. Illu

CRIPPS. Ovu

□ EAVER. Append:

Jii' Colored Plata a
DULLES. W/hut ti

SlhEdiiion. New HI
FULLERTON. Sui
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Ihe Method in tiBE il
HAUIL

,d Surgtrr,
En^ravecf In

I CompUutiiiai.

d EdiUon

f OT^t'i,*l!./j?«!i.""'

'- -»; H>irKu»<ii,|i|.9n
Dl>inoili. rittb«l-
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Cloth, (I'M
Do Flrat in Aecldanti and PAlHalBf.

;icalNuraiDe- id Bdlilon. «« 1IW fi w
c TreitcDeal of Woundi, AcMidlnM W
ProfcMO. Billrolh'. Clinic, Vlonim, .(•

rea ao Tumori. from ■ Clinical Staad-

gsiy aad BiadiElnS'

iwa. t.1

Boardi,

■loa.

*■!• I

]

SUBJECT CATALOGUE.

HORWITZ. Com
JACOB BON. Op«

pumt
' 5th

Df a

■ of

ncnitUpDWocioiu, Surgical Di.-
RulH.elc.wllh DiffertntiBi Di»goo-
on, very much Enlarged and Rear-

MACREADY. A
MAVLARO. Sur
MOULLIN. Ten

clinical Surgery, '.
colon.
ROBERTS. Frsi

SMITH. Abdoi

Ih'AfedicalCDtleee.Chicago. 6>3 lUutlcaitoai,
Hsii^ome^^th, 116.™; i«i§in,|7.«.

I Sureary. Being a SyiMnuuii Description «

al OpeialiDus. 314 Illul. 6lh Ed. a Vtdl. Clo., fio.oo
gicBl Bmerginclii. Fifth Edition. Clolh.t1.75
iurelul NurtiDE. Second Edition, Revised and
l::nia<Eed. Ill [lluilniliiins. ImtKiady. fi.»

WALSHAM. Manual of Practical Surgery. 6<b Ed , Re-
vised and Enlarged. Wilhi.oEogTavings. (j.oo
WATSON. On Amputations of the KutrBtnlUes and Their
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THROAT AND NOSE (sre also E.t).

COHEN. The Throat and Voice. Illiu^irated. .«e

HALL,. Disease! of the Nose and Throat. Tvo Colored
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HOI.I.DPETER. Hay Fever. Its Successful Traalment. (..00
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Platen and 4a other musiraliaui. ad Edition. In Prta.

MACKENZIE. Pharmacopccia of the LoDdoB Hospital for

lose, and Ear. A Clinieal
,1 drswings. id Ed. »6.oa
Considered Fhyiiologically.

IRIDE. Dili

. oftb

Thro

mill colomJ Illus. from or

URINE AND URINARY ORGANS.

ACTON. The Fuoctions aad Diaocders of the Reproduetiv*
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1^^ MEDICAL BOOKS. 11 |

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foi <hc Hoip

laL, Laboralory, oi Surgrry

Paper

»J«

e, Ihe GiBtrl

d the Milk

Chun

ali.

Micro

icopl-

,lhEd

».,»

JACOBSON.

DL«««

""•" «"' °

"■"

o(G,

V-"

MEHMINQER. DlogD

c.»i.bytbeU

4lUw>

». »

ry. «iih Sptcial Rtl

Kid per and

Urclcr .ifd

10 (he Siogiul Tmunu

Anuria. ILuimilHj.

(>,«..

MOULLIN.

■;l,-S5"

BDt of th€ PrnlmU

twd

/«'

Hii^y

(■7S

MOULLIN.

ndlin

oaryP

»':»

of th. UriD.

ryOr

Bill Ed

»3"

TYSON. Gu

heUr

ns. F

Z^" <" ■

d SludcTits

WiU. CoLorsd

Piau

and N

IIIm>- ■

trations engra

d. 9th Edition

Re. is

|i.<9 1

.«d 1

Urine. Qii.

tatlvoQ

Qa.niit.tiv

■ 35

Uuilr;.

on..

..» 1

VENEREAL DISEASES.

COOPER. Sypbilli. >d Editioa, EDlarged and [lIuiIniEiI with
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QO^ERS. Sypbilla ind the Ncrvoui Svitim. i.oa

VETERINARY,

ARMATAQE. The Veterionriin's Pocket Remembnocer.

Being Concise Directions for the T.ealmenl of Utgenl or RaieCaies,

EmbTHd^ SemeiolDgy, Diagnosifl. Prognosis, Surgery. Treatment.

etq. id Edition. BoardB, (i.DO

BALLOU. Veterinary Aantorayaad PhyBioloEy. lo Graphic

llluilratloiu. .80^ Interleaved, ^1.15

TU80N. VelertDuy PhircDacopnln. Icdiiding the OatUnetol

MateriaMedicaaDdTbeiapeutics. jihEdition. |a.ij

WOMEN, DISEASES OP.

BYFORD (H. T.). Manual of Qyoecology. Second Edition.
ol"hi'ch'.^fn)m''oirginai'd'r"-i^E."' ' "' """"""^ "J^^
BVFORD (W. H.). DiBBaaea o[ Women. 4th Edition. jo«

DUHRSSEN. A Manual

WELLS. Compend of Qyni

^p*

SUBJECT CATALOGUE.

COMPENDS.

Lhoni Ollnta.

a Hriu oT hooki liiuul by any I
il u Ihae IQiHtCoinpendst.

BLAKISTON'S ? QUIZ-COMPENDS?

Tlie Beat Seiiei of Manuati for tbs Use of Stodeiiti.
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erience u Quii-MasleiJ and

Can be uied by studeots of <iny
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.oUegt

ere else collected In such

No. I. POTTER. HUMAK ANATOMY. Sixth Re«i>ed and
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TaWarelc!" By''^BU«L'a'L.''poTTlK,™D.7'p™fci»r*af the
Practice of Medjcine, Cooper Medical CoUege. San Francisco; lue

No. a. HUOHES. PRACTICE OF MEDICINE. Parti. Siitb

Edition, Eolai^cd and Improved. Hy Dahisl E. UuGuis.ti.ii..
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No. a. HUQHES. PRACTICE OF MEDICINE. Part □.
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No. 4. BRUBAKBR. PHVSIOLOQY. Ninth Edition, with
new lUiutralions and a uble of Physiological Comiants. Enlaced
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-ind General PaOiology in the Pennsylvania College of Dental
. .J. ..__( ^ Physiolc^y, Jeflenon Medical

Ca?<^. 'Ph ibi''d:1pbia ,''

^BTRICL.

idited by

J. LAHDIS. OBSTETRICS. Sixtb Edition. By Hittsi G.

.^ ,[, Philadelphia.

Gnlai^. 47 lUuHratlons.
0.6. POTTER. MATERIA MEDICA, THERAPEUTICS.
AND PRESCRIPTION WRITING. Sixth Revised Edition
lU. S. P. iBoo). By S*MOB[. O. L, Poi-rni, ■,»., Proleisor ol
Pncticc.CanpeT Medical College, San FraneiKO; tale A. A. Sur-

? QUIZ-COMPENDS F~CoDtlnued.

ELLS. GYNECOLOGY. Second Erfnion. By Wm.
S, H.D., Inilruclar af Obstetrici. JuSeisDn CoUege, Fhila

lllu»raIiD

o. 8. GOULD AND PYLE. DISEASES OF THE EYE
AND REFRACTION. Second Edition. IncludiDg Tnalmint

M. GouiD, iio., and W.T Pyl», m.p, Wilil Fwmute, Glossary,
Tubla, and III Illusmiion., lEVEial of -wlikh are Colored.
□. g. KORWITZ. SURGERY, Uinor Sursery, and Bandm-

Homit'z, B.s., il.D°|clini«fpro(™oro'f&Tn"o-"lJiiMrySu^ery

and Venereal DJseajes in Jeffcnon Medical ColleB= i Surgeon 10

Philadelpbia Hmpiul, etc. With g3 Formula and 71 Uluslratiou.

o. ID. LEFFMANH. MEDICAL CHEMISTRY. Fourth

Mik,°l*lDad, TluuH, ciie ^cre'tloni.elc. B^Hihrv Lufkahn,
B.D., Profeswr of OiemlMry in Pennsylvania Cnllege of Denial
Surgery and in ihc Woman's Medical College, PhiUd^phla.

o. II. STEWART. PHARMACY. Fifth Edilinn, Based upon
Prof. ReminElon's Teii-Book of PharmaCf. By F. E. Stewart,
H.D., FH.G-.late Quii-Matter is Pbarmscy and Chemistry, Phila-
delphia CoUese of Pharmacy; Lecturer at Jefferson Medical
CoQ^e. Cucftilly revised Is accordance vith the new U. S. P,

o; II. BALLOU. VETERINARY ANATOMY AND PHY-
SIOLOGY. Illustrated. By Wh. R. Balluu, h.u., Professoi
of Equine Anatomy at New Yotl: CoUege of Veterinary Surgeons:
Physician b> Bellevue Dispensary, etc. 39 giaphic lllusiratrcai.

a Section on Emeigenciei. Bv Gno. W. Warrsh, D.n.
ol ainica] staff, Fennjylvania College of Dental Surgery.
No. u. HATFIELD. DISEASES OF CHILDREN.
Edition. Colored Plate. By Makci/s P. HaTnaLO,
urofDIieaiet of Children, Chicago Medical Calkge.

PriM. ndi, Cloth, .80. Inlcrlcivcd, lor taking NolM. II,2B.

le particidar wants of the slufleol I

it aiepartr-' ' ■■- -"--- ■-- - -' ' - ' ■

Careful at

_ there is

a for eiory word. They

Morris'
Anatomy"

Second Edition,
Revised and Enlarged.

790 Illustrations, of which many
are in Colors.

From The Medlcul Record, New York.

■' The reproach that the English language can bonsi ot no
treatije on anatomy deserving to Lie laaked witb the masteriy
works of Heiile, LaschkK, HyttI, and others, is Cast laung
its force. During the past few years several works of grtiX
■ve api«ared, and aoiotig 'hese Morris's" Anaitoiny"
estined to take first place in disputing the palm in
cal fields »ith the Geiman classics. The nomeicla.
lure, arraDgement, aod entire general character resemble
strongly those of the aboie- mentioned handbooks, while in
the beauty and profuseness of its illustrations it Eurpassei
thern. . . . The ever-growiog popularity of the book
wilb teachers and stuileDts is an index of its value, and il
may safely be recommended to all iuterestcd."

.•HaniUome Deacriptlve ClrcaUr, with
Sample Pa|:caaiid Colored niuitralloa*,
will be aent (rea upon ■ppllcatlan.

Seventh Revised Edition.

A UNIQUE BOOK.

POTTER'S MATERIA MEDICA, PHARMACY. AND THERA-
PEUTICS. Seventh Edition, Enlarged and Revised, A Haod-
iiook, including the Physiu logical Action of Dnigi, Sfiecifil Tlierapeutics

»of Disease, Oificial iitid Practical Pharmacy, Prescription Writing, etc.
By Sam'l O. L. Potter, .m.a,, M.rt., Pnifeasor of the Principles and
Pmclice o( Medicine and Clinical Medicine, College of Pbyaicians and
Surgeons, San Francisco, etc. Octavo. 929 pages. Thumb Index.

Clolli, tte/, fS.OO; Leatlier, nft, {6.00

Thii edition coDtaina much new matarial uadcr the

headlagi " AlburaiD." "Animal Exlracta," "Antltoxina."

Dr. Pori'ltK has become well known as an able compiler by hlb Compeads

of Anatomy and of Materia Medica, both of which have reached six editions.

In [his booW, more elaborate ia its design, he has shown his literary abilities to

much better advantage, and all who examine or use it will agree that lie has

[itodiiced a work containing more correct information in a practical, concise

ibmi than any other publication of the kind. The plan of the work is new,

and its contents have been combined and arranged in such a way that il ofTerS

a compact statement of the subject in hand.

Part I. — Materia Mbdica and Therapeutics, the drugs being ananged
in alphabetical order, with the synonym of each first; then the descrip^on of
the plant, its preparations, Us antidotes and antagonists, physiological action,
and, lastly, its Therapeulks. This part is preceded by a geneial Introduction
and ft section on the classification of medicines as follows : Agents acting on
the Nervous System, Organs of Sense, Resphaiion, Cu-culation, Digestive
System, on Metabolism (including Restoratives, Alteratives, Astringents,
AnUpyretics, Anliphlt^slics, ajid Antiperiodics, etc.). Agents acting upon
Excretion, the Generative System, the Cutaneous Surfaces, Microbes and
Ferments, and upon each other.

Fart II.— Pharmacy and PuEHcmpnoN Writing. Written for the use
of physicians who put up their own prescriptions. It includes — Weights and
Measures, English and the Metric Systems. Specific Gravity and Volume.
Prescriptious : Their principles and combinations; proper methods of writing
them ; abbreviations used, etc. Stock solutions and preparations, such as a
doctor should have to compound his own prescriptions. IncompatitHlily,
Phannaceutical and Therapeutical. Liquid, Solid, and Ga-seous Eitempo-
raneous Prescriptions.

Part III.^-Special THEBAPEt;Tics, an alphabetical I.isl of Diseases— a
real INDEX UK DISEASES— giving the drugs that have been found serviceable
in each disease, and the authority recommending the use of each ; a very im-
portant feature, as it gives an authoritative character that is unusual in works
on Therapeutics, and displays an immense amount of research. 6<x> prescrip'
tions are given in this part, many being over the names of eminent men.

The Appendix contains lists Df*I.Btin words, phrases, and abbreviations,
with their English equivalents, used in medicine. Genitive Case Endings, etc,
36 FormulEe for Hypodermic Injections; a compariaon of lo Formulne of
Chlorodyne 1 Fortnulce of prominent patent medicines; Poisons and their
Antidotes; DifTerential Diagnosis; Notes nii Temperature in Disease ; Clinical
Eiamination of Urine; Table of Specific Gravities and Volumes; Table
showing the number of drops in a fluidrachm of vartcAK. Wojirfra ■Bs.&.'ftK '«'tv^»-
' le fluidrachm in grains, und a la.b\e tor cotixet^'n^ ttsOtattwrnei ■«•&*<>=

(»t one ni

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