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■ ^^ ^ww:r<-^m^^
(.LSPMOWJEfW^LUff/lRr
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A*
■s
A TREATISE ^^^ ^Hi
OXTBE
DISEASES OF THE EYE.
BY
J. SOELBERG WELLS, F.R.C.S.,
MWTOH OP HKniCISS OF TlIK I'SIVERBITT OF EDINBURGH J PBOFBHBOn OF OPIITIIAL-
MOLOOT IX Klao'X COLIBOX, LOXDOK ; OPHTHALUIC fllTROBOK TO XIKu'U
COLLEOX HOSPITAL ; AHD BUBOEOH TO TBS BOTAL LO^IDOX
OPBTUALHtC BOIPITAL, II00BP18LD8.
THIRD AMERICAN,
PROH TBS
THIRD ENGLISH EDITION, WITH COPIOUS ADDITIONS.
BY
CHARLKS STEDMAN BULL, A.M., M.D.,
■■I'KOKO:! AHD rATHDLn'tlUT TO Tim XEW TOBK CTE A^ID E«K IKrlRHAKV ; LKrTl'REH (>!l
OFUTUALHOLOUT IH THR aELLIVCI UOIPITAL MKDICAL COLI.UUB.
ILLUSTRATED WITH
JTbio jllunbrtli ant) Jiftj;-{sur ZnfliaiifitSJi on tOBoall anb %\x CoIokIi piatts.
TOOBTRlill WITH
SELEf-'TlOSS PnoM THE TEST-TVl'ES OF I'ROF. E. JAEOEH ASD PmtF. H. SNELLE.N".
pniLAPELPHIA:
HES"IIY C. LEA'S SOi^ k CO,
1880.
EDITOR'S PREFACE
THIRD AMERICAN EDITION.
The ladt edition of this work was published in 1873, and for some
years the book has been out of print. The great advances that have
been made in ophthalmology during the past seven years have rendered
necessary a thorough and systematic revision of the entire work, in
order to bring it fully up to the present state of knowledge upon the
subject. It was hoped that this revision would be from the pen of the
author himself, but his lamented and somewhat unexpected death has
prevented the accomplishment of the task, and the American Editor has
assumed the responsibility of the work with a very keen sense of the
many difficulties and great labor involved in the undertaking. From
respect to the memory of the author, as few alterations as possible have
been made in the original text, but it has been found necessary to omit
some passages, and to change the order of paragraphs in a number of
instances. Numerous and extensive additions have been made to every
chapter of the work, especially in matters relating to pathology and
treatment, and a number of new illustrations have been added. The
Editor has conscientiously endeavored to complete the task assigned to
him, and hopes that the present edition of the work will he found fully
up to date. All additions by the Editor arc inclosed in brackets with the
letter [B.], and wherever other sources have been borrowed from, full
recognition by quotation-marks, name of work, and name of author has
been carefully given.
C. S. B.
New York, Stptemlwr, 1880.
.•^Sl 47
PREFACE TO THE SECOND EDITION.
It has afforded me do small gratification that the first edition of this
work should have met with so very favorable a reception, both by the
profession at large, and by the British and Foreign Medical Press; and
especially that it should have been deemed worthy of being translated
into French and German, in both of which languages it will be pub-
lished in the course of this year.
Stimulated by such encouragement, I have endeavored to render the
second edition as com])lete as possible, and have made numerous addi-
tions, incorporating all the important facta elucidated by the most
recent researches, so that the work might be brought up to the latest
date.
10, i:>AriLLE Rtnv, Mny, 1870.
PREFACE TO THE FIRST EDITION.
Within the last few years the want has often been expressed of an
English treatise on the diseases of the eye, which should embrace the
modem doctrines and practice of the British and Foreign Schools of
Ophthalmology, and should thus enable the practitioner and student to
keep up with the knowledge and opinions of the present day.
I now venture to lay before the Profession a work which I trust may
be deemed, to a certain extent, worthy to meet this desideratum.
Whilst I have endeavored to enter fully into all the most important
advances which have been lately made in Ophthalmic science, I have
not contented myself with simply recording the views of others, but
have sought in most instances to make myself practically conversant
with them, so that I might be able, from my own experience, to form an
independent and unbiassed opinion as to their relative value. The vast
and peculiarly favorable opportunities which I have had at Moorfielda
of studying all phases and kinds of eye disease, as well as the great
benefit which I have enjoyed of witnessing the practice and operations
of my colleagues, have moat materially assisted me in the possibility of
doing this.
In preparing this work, I have steadily kept one purpose in view,
viz., to make it as practical and comprehensive as possible, and I have,
therefore, entered at length into an explanation of those subjecta which
I have found to be particularly difficult to the beginner. I have, on
purpose, occasionally repeated important points in diagnosis and treat-
ment, in order to render each article, to a certain extent, complete in
itself, so as to obviate the necessity of the reader having constantly to
refer to otlier portions of the book for explanation or information.
Moreover, I have thought that this would prove of great convenience to
those who may desire to consult and study certain subjects, without
being obliged to peruse the greater portion of the book.
The subjects of "Injuries to the Eye," and of "Congenital Mal-
formations of the Eye," have assumed such considerable dimensions
tliat I have been obliged to treat of them somewhat briefly, and would,
Vm PRBFACB.
therefore, refer the reader, ^ho seeks for fuller information, to special
treatises upon these affections. Of these, I would particularly recom-
mend the following excellent works: "Injuries of the Eye, Orbit, and
Eyelids," by Mr. George Lawson ; *' Verletzungen des Auges," by
Drs. Zander and Geissler; and tbe "Malformations and Congenital Dis-
eases of the Organs of Sight," by Sir William Wilde.
My best and warmest thanks are due to my colleagues at the Royal
London Ophthalmic Hospital, Moorfields, and more especially to Mr.
Bowman, for their constant kindness in permitting me to liave free
access to their cases, and for affording me much valuable information
and advice upon all subjects connected with Ophthalmology.
Owing to the great liberality of my friend Dr. Liebreich, and of hia
publisher, Mr. Hirschwald of Berlin, I have been able to illustrate this
work with 16 excellent colored ophthalmoscopic figures, which are copies
of some of the plates of Liebreich's admirable "Atlas d'Ophthalmo-
acopie."
As very frequent reference is made to certain Ophthalmic periodicals,
I have used the following abbreviations: —
R, L, 0, H, Rep, signifies " Royal London Ophthalmic Hospital
Reports," edited by Messrs. Wordsworth and Hutchinson (Churchill).
A. f. 0. signifies "Archiv fiir Ophthalmologie," edited by Profs.
Arlt, Donders, and Von Graefe (Peters, Berlin).
Kl. MonaUhl. signifies "Klinischc Monatsblatter der Augenheil-
kunde," edited by Prof. Zehender (Enke, Erlangen).
Tlie following symbols are also frequently employed in the course of
the work: -j-, means range of accommodation; r, punctum remotis-
simum (far point); p, punctum proximum (near point); oo (»= 0), infi-
nite distance ; ', foot; ", inch ; '", line.
The test-types of Jaeger may be obtained from the Secretary of the
Royal London Ophthalmic Hospital, Moorfields, and those of Snellen
from Messrs. Williams and Norgate, Henrietta Street, Covent Garden.
16, Saville Row,
Ltc(Tibtr, 1868.
CONTENTS.
Introduction.
PASS
Ererslon of the Upper Eyelid — The mode of ascertaining tbe degree of
Inlra-ocnlar Tension — Tbe Tonometer — The examination of the
Acuteness of Vision — Mode of examining the Field of Vision — Di-
plopia— The Compress Bandage — The Artificial Leech — The Eje-
douche S3-50
Chapter I.
DISEASES OP THE CONJUNCTIVA.
HypersBmia of the Conjunctiva — Catarrhal Ophthalmia — Purulent Opb-
tlialmia— Gonorrheal Ophthalmia— Ophthalmia Neonatorum — Diph-
theritic Conjunctivitis— Membranous ConjuECtivitis — Granular Oph-
tlialmia — Chronic Gmnulations — Phlyctenular Ophthalmia — Exanthc-
matoas Ophthalmia — Xerophthalmia — Pterygium — Symblcpharon —
Anchylobiephai'on — Injuries of the Conjunctiva — Tumors of the Con-
juuctiva — Syphilis of the ConjunctiTa — Rare Diseases of tlie Con-
junctiva 51-131
Chapter II.
DISEASES OP THE CORNEA.
Pannns — Phlyctenular Corneitis — Fascicular Corneitis — Suppurative Cor-
nc'itia — Non- Inflammatory Suppurative Corneitis — Ulcers of the Cor-
nea — Diffuse Corneitis — Opacities of the Cornea — Corneal Transplan-
tation— Tattooing — Arcus Senilis — Conical Cornea — Kerato-globus —
Staphyloma of the Cornea and Iris — Injuries and Wounds of the Cor-
nea— Tumors of the Cornea 133-103
Chapter III.
DISEASES OF THE IHIS.
Hyperirmia of the Iris — Inflammation of the Iria — Punclional Disturbances
of the Iris — Mydriasis — Myosis — Tremiilousness of tlic Iris — Wounds,
etc., of the Iris — Tumors of the Iris — Congenital Anomalies of the
Iris — Iridectomy — Iridodesis— Iridotomy — Corclysis — Iridodialysis —
Clianges in the contents, etc., of llie Anterior Chamber — Fon-ign
Bfxiies in the Iris and Anterior Clinmber — Irido-choroiditiB — Sympa-
thetic Ophthalmia 104-397
CONTENTS.
Chapter IV.
DISEASES OF THE CILIARY BODY AND SCLEROTIC.
PAOB
Inflaaimatton of Ciliary Body — Injuries of Ciliary Region — Episcleritis—
Bcleritis — Anterior Sclerotic Stapliyloma — Wounds and Injuries of tUe
Sclerotic— Tumors of Sclera 268-379
Chapter V.
DISEASES OF THE CRYSTALLINE LENS.
Cataract— Lamellar Cataract— Splndle-sbaped Cataract — Cortical Cataract
— Diabetic Cataract — Nuclear Cataract — Traumatic Cataract — Capsu-
lar Cataract— Flap Extraction — Removal of the Lens in its Capsule-—
Linear Extraction — Scoop Extraction — Antiseptic Surgery — Von
Gracfe's Operation, etc. — Reclination — Division of Cataract — Opera-
tions for Lamellar Cataract — Operations for Traumatic Cataract — Re-
moval of Cataract by a Suction Instrument— Sperino's Treatment of
Cataract by Paracentesis— Operations for Capsular Cataract — Disloca-
tion of the Lens 280-S56
Chapter VI.
THE USE OF THE OPHTHALMOSCOPE.
Theory of the use of the Ophthalmoscope — Ophthalmoscope of Liebreich,
CocciuB, Zehender [and Loring] — Knapp and Wecker — Metric Oph-
thalmoscopes of Lnring and Enapp — Fixed Ophthalmoscope of Lieb-
reich— Binocular Ophthalmoscope of Qiraud-Teulon — Ophtbalmo-
scope for two Observers — Aut-ophthalmoscope — The Examination
with the Ophthalmoscope^The Examination of the Actual Inverted
Image — The Examination of the Virtual Erect Image — The Ophthal-
moscopic Appearances of Healthy Eyes — The Oplic Disk — The Oph-
thalmoscopic Appearances of Diseased Eyes 357-304
Chapter VII.
DISEASES OF THE VITREOUS HUMOR.
Inflammalinn of the Vitreous Humor — Opacities— Foreign Bodies, etc, in
the Vitreous— Persistent Hyaloid Artery 895-410
Chapter VIII.
DISEASES OP THE RETINA.
Hypertcmia of the Retina— (Edema Retinte— Retinitis, Serous, Parenchy-
matous, and Purulent— Retinitis Albuminurica, Lcucsmica, Syphi-
litica, Apnplectica, Pigmentosa — Retinitis in Diabetes, Oxaluria, and
Icterus — Detachment of the Retina— Epilepsy of the Retina — IschfC-
mia Retinre— Embolism of the Central Artery of the Retina— Hyper-
Eestbeaia of tbe Retina — Tumors of the Retina — Atrophy of the Retina
—Cysts in the Reiina -Connective Tissue Formation in tlie Retina—
InjuriiM of the Retina— Cysticercus under the Retina . . 411-484
CONTBHTS. XI
Chaptek IX.
DISEASES OP THE OPTIC NERVE.
PAOB
Hypenemia of the Optic Nerve — Inflammation of the Optic Nerve — Atro-
phy of the Optic Nerve— Excavation of the Optic Nerve— Pigmenta-
tion of the Optic Nerve — Hemorrhage into the Optic Nerve — Tumors
of the Optic Nerve — InjurieB of the Optic Nerve — Opaque Optic Nerve
Fihres— Coloboou of the Sheath of the OpUc Nerve .... 4S5-493
Chapter X.
AMBLYOPIC AFFECTIONS.
Amaurosis— Hemianopsia — Amblyopia — Traumatic Ansstliesla of the
Retina — 1 1 emera I op ia— Nyctalopia —Color Blindncsa — Simulation of
Amaurosis 493-S24
Chapter XI.
DISEASES OF THE CHOROID.
Hyperseroia of the Choroid — Serous Choroiditis— Plastic Choroiditis—
Sclerolico-choroiditis Posterior — Suppurative Choroiditis — Colloid
Disease of the Choroid — Tubercles of the Choroid — Tumors of the
Choroid, Sarcoma, Carcinoma, Qranuloma, Enchondroou, Cysts —
Formation of Bone — Cotoboma of the Choroid— Rupture of the Cho-
roid— Hemorrhage from the Choroid — Detachment of the Choroid . 535-563
CUAPTEB XII.
GLAUCOMA.
Acute Inflammatory Glaucoma — Chronic Inflammatory Glaucoma — Glau-
coma Simplex — Secondary Glaucoma — Ophthalmoscopic Symptoms of
Glaucoma — The Nature and Causes of the Glaucomatous Process-
Prognosis of Glaucoma — Treatment of Glaucoma — Eserine — Iridec-
tomy-Sclerotomy 563-601
Chapter XTII.
the anomalies of refraction and accommodation
of the eye.
The Refraction and Accommodation of the Eye— Optical Lenses, etc. —
Mechanism of Accommodation — Ne;jalive Accommodation— The
Range of Accommodation— Myopia— Presbyojiia — Hypermetri>]iiii —
A Btigmatism— Aphakia — Paralysia, Spiism, and Atony of the Ciliary
Muscle— Sptctacles-Difference in the Refraction of the two Kyes , 603-GG'i
Xn CONTENTS.
Chapter XIV.
AFFECTIONS OF THE MHSCLES OF THE EYE.
PAGE
Actions of the Muscles of tlie Eye — Paralysis of External Rectus —
Paralysis of tbe Third Nerve— Paralysis of tlie Internal, Superior,
and Inferior Recti — Paralysis of the Inferior and Superior Otiliqno —
Nystagmue — Strabismun — Convergent Strabismus — Divergent Stra-
bismus— Operations for Strabiemus, von Graefe's, Critchett's, Lie-
breicb's — Muscular Astlicnopia — Latent Divergent Squint . . CCC-734
Chapter XV.
DISEASES OP THE LACHRYMAL APPARATUS.
Functional Anomalies in tlie Lachrymal Gland — Tumors nf tbc Loclirymal
Gland — Diseases of the Lachrymal Qiand — Stillicidiuin Lachrynmnim
-^Inflammation of the Lachrymal Sac — Catarrh of the Sac — Stricture
of the Lachrymal Passages — Fistula of tbe Lachrymal Sac . . 725-740
Chapter XVI.
DISEASES OF THE ORBIT.
luflammatton of the Cellular Tissue — Periostitis— Caries and Necrosis —
Inflammation of the Capsule of Tenon — Exophllialmic Goitre — Tu-
niora of the Orbit, Fibroma, Sarcoma, Lipoma, Osteoma, Encbon-
dmma. Cysts, Carcinoma, Epithelioma — Vascular Tumors of the
Orbit — Elfusiou of Blood — Empliyscnia — Pressure upon the Orbit from
JCeighboring Cavities— Wounds and Injiiriet) of the Orbit— Excision
of the Eyball— The Application of Artificial Eyes .... 730 7l»4
Chapter XVII.
DISEASES OF THE EYELIDS.
(Edemn and Inflnnimation of the Eyelids — Syphibtic and Exantliemstous
AHl'Ctions — Bleptiaritis Marginalia — Ephiilrosis and Cbromhydmsis —
Hordeolum — Tumors of the Eyelids — Ntevus Maternus — Ptosis —
Pamlysis of the Orbicularis — Blepttaroapasm — Trichiasis and Distlcb-
iasis — Entroplum — Ectropium — Injuries, Wounde, etc., of the Eyelide TOj-SSO
EXPLANATIOIt OF THE Platbs 850-869
Sbi-bctions from the Te«t-tvi'B8 ok Jai':gbr asd Snellen . . 869-878
Index 879
LIST OF ILLUSTRATIONS.
Fia.
1. Upper eyelid eyerted ....
2. Mode of evertiug the upper eyelid
3. Mode of examiniof; the eye by oblique iUuminntinn
4. Mode of examining the eye by oblique illnaiiuaUon
5. Mode of examining the visual field
6. Mode of examining the visual field
7. Diagram for demonstrating the pnnctsm ciectim
8. Diagram of Bmdenell Carter's perimeter
9. Diagram explanatory of homonymous diplopia ,
10. Diagram explanatory of crossed double images .
11. Diagram explanatory of action of prisms
13. Licbreich's bandage ....
13. Licbreich's bandage applied
14. Catarrhal ophthalmia ....
15. The eyelids in purulent ophthalmia
16. Chcmosis in purulent ophthalmia .
17. The eyelids in gonorrhceal ophthalmia .
18. Chemosis in early stages of gonorrhceal ophthalmia
19. Ophthalmia neonatorum ....
20. The palpebral conjanctira in granular ophthalmia
81. Pterygium tenue .....
22. Pterygium crassum ....
2S. Szokalski's operation for pterygium
24. Bymblcphsron .....
25. Mr. Teale's operation for symblepharon .
26. Mr. Teale's operation for symblcpbarou .
27. Mr. Teale's operation for symblepharon .
28. Mr. Teale's operation for symblepharon by transplantation
29. Anchyloblepbaron .....
30. The spud ......
SI. Mr. Haynes Walton's gouge
82. Dermoid tumor of the conjunctiva
38. Dermoid tumor of the conjunctiva
84. Dermoid tumor of the conjunctiva
35. PunnuB ......
86. Phlyctenular keratitis ....
87. Ulcer of the cornea ....
88. Prolapse of the iris ....
S9. Paracentesis comese ....
40, Notched teeth of congenital syphilis
41. Notched teeth of congenital syphilis
Pins
»8
34
34
3S
40
41
43
43
45
45
46
47
46
53
59
60
72
72
74
61
110
110
113
114
115
116
116
117
118
120
120
123
123
123
133
1.S4
151
153
156
164
164
XIV
LIST OP ILLUSTRATIONS.
no.
43. Partial leacom& ....
48. Knife for removing deposits of lead
44. Conical cornea ....
45. Keraio-globns ....
46. Partial Btaphyloma of the cornea (side view)
47. Partial staphyloma of the cornea (front view)
48. Total staphyloma of the cornea .
49. Operation of ezdsion of staphyloma
60. Mr. Crltchett's operation of abscission of staphyloma
61. Beer's cataract knife
63. View of the eye after Mr. Critchett's operation of absciosion
68. Knapp's operation for staphyloma
64. Wecker's operation for staphyloma
66. Iritis ....
66. Iritis with irregular pnpil and lymph near margi
67. Iritis with occlusion of the pupil .
68. Iritis with slender adhesioaa to the capsule
69. Serous iritis ....
60. Mr. Laurence's pupillometer
61. Rupture of the continuity of the iris
65. Rupture of the iris at its great circumference
68. Double pupil caused by laceration of the Iria
64. Cyst of the iris
65. Coloboma iridis
68. Weiss' stop speculum
67. Strught keratome .
68. Bent keratome
69. Slraiglit iris forceps
70. Curved iris forceps .
71. Iris scissors bent on the edge
73. Iris scissors curved on the flat
78. Iridectomy .....
74. Iridectomy .....
75. Iridectomy (Mr. Bowman's modification)
76. Iridectomy (Mr. Bowman's modification)
77. Appearance of the eye after iridectomy .
78. Broad needle ....
79. Diagram illustrating iridodesis
80. Broad ciliary forceps
81. Canula forceps ....
82. Pupil afler iridodesis
83. Artificial pupil made by incision of the iris
84. Tyrrel'shook ....
85. Spatula hook ....
86. Cysticercns in the iris .
87. Microscopic view of cysticercns ,
88. Appearance of the eye in sympathetic ophtlialmia
89. Anterior sclemiic staphyloma
90. Anterior sclerotic staphyloma
91. Annular staphyloma
83. Cataract
167
171
174
180
181
181
183
184
184
185
185
187
186
195
197
197
198
199
313
218
318
219
2S0
325
337
237
227
338
338
228
328
329
2S0
330
230
281
333
233
238
334
334
385
235
336
340
341
354
275
275
275
383
LIBT OF ILLUBTRATIONS.
XV
riH.
93. Diagram Bbowing how dUatatloaof the pupil in cataract tmproTes the
Bight .....,.,,
94. Diagram Bbowing how dilatation of the pupil in cataract improveB the
Bight ,..,..
95. Cortical cataract .....
96. Morgagnian cataract ....
97. Pyramidal cataract ....
98. BectioD of pyramidal cataract
99. Poaterior polar cataract ....
100. Flap extraction by the upper section
101. Flap extraction by the lower section
IDS. Sichel's knife .....
Ids. Flap extraction by the superior Bection .
104. The pricker .....
105. Oraefc's cystotome ....
106. Passage of the lens through the corneal incision
107. Mode of making the corneal flap
108. Probe-pointed secondary knife .
109. Hook
110. Weber's lance-Bhaped knife
111. Diagram illustrating Weber's operation for cataract
112. Mr. Crilcbett's scoop ....
113. Mr. Bowman's scoop ....
114. Mr. Bowman's scoop (another form)
115. Von Graefe's cataract knife
116. The line of incision in modified linear extraction
117. The line of incision in modified linear extraction
118. Diagram illustrating Wecker's operation for cataract
119. Diagram ilhiatruting Liebreicb's operation for cataract
120. Diagram illustrating Lebrun's extraction by median flap
121. Bowman's fine stop needle ....
123. Hay's knife-needle .....
133. Hay's knife-needle (magnified form)
134. Diagram showing how dilatation of the pupil in .cataract improves tlic
sight ......
125. Diagram showing how dilatation of the pupil in cataract improves the
sight .......
126. View of the artificial pupil made by iridectomy
127. View of the artificial pupil made by iridodesis .
128. Mr. Tealo's suction curette ....
129. Mr. Bowman's suction syringe ....
180. Extraction of chalky cataract ....
131. Corneal incision for Wecker's operation
138. Wecker's forceps-scissors ....
133: Partial dislocation of llio lens ....
134. Complete dislocation of the lens into the anterior chamber
135. Dislocation of the lens beneath the conjunctiva
186. Diagram illustrating the reflection of light from the eye
137. Diagram illustrating the principal of Hclmlioltz'a opiithalmoacope
138. Diagram illustrating the ophthalmoscopic examination of the actual in
verted image .......
885
885
286
286
896
296
297
303
303
304
305
806
306
307
308
308
309
323
328
324
324
324
825
325
326
331
333
334
338
339
339
341
341
348
343
344
345
349
350
zm
351
353
3:.4
358
3C0
361
XVI
LIST OF ILLUSTRATIONS.
no. PAQB
1S9. Diagram UlustraUDg the ophthalmoscnpic examinatiOQ of the virtual
erect Image ........ 363
140. Ophtlialmosnnpe of LJebreich ...... 36H
141. Ophtbalmoacopc of Coccius ...... 364
143. Oplitbalmoscopeof Coccina (original form) .... 364
148. Ophthalmoscope of Lnring ...... 807
144. Modification of Loring'a ophtlialmoacope .... 868
14'). Mr. Carter's dcmonsl rating ophthalmoscope .... 873
146. Ground plan of some ....... 873
147. Diagram iDustrating the mode of action of Oiraud-Teulon'a binocular
ophtbatmoscope ....... 378-
146. Section of the binocular ophthalmoscope of Messrs. Laurence and
Heiscb .875
14d, Diagram illustrating the optical action of the same . . , 87't
150. Manner of using the binocular ophthalmoscope . . 876
151. Diagram illastrating the optical action of Qiraud-Tenlon's aut-ophtfaal-
moscnpe ......... 377
153. Ophthalmoscopic examination of the actual inverted image . . 381
158. Diagram itluBtrating Mr. Bowman's operation for subretinal effusion 447
154. Glioma rctinie .... .... 456
ma. Fungus htcmatodes of eye ...... 458
156. Micrnscopical appearance of glioma ..... 459
157. Diagram showing the decussation of the fibres of the optic nerve . 405
158. Syphilitic choroiditis (Nettlesbip) ..... 539
159. De Wecker's trephine . 597
100. Diagram explanatory of the focus of a biconvex lens . . . 60S
llil. Diagram explanatory of the focus of n biconvex lens . . . 003
163, Diagram explanatory of the secondary axis of a biconvex lens . 804
163. Diagram illustrating the mode in which a biconvex lens forms an
image of an ot>ject in front of it . , . . , 605
164. Diagram illustrating how a biconvex lens mnenifies . . . G05
165. Diagram illustrating the course of rays of light passing through a bi-
convex lens ........ 606
166. Diagram illustrating the mode in which the reverse image of an object
is formed upon the retina . ..... 608
167. Diagrammatic eye of Listing ...... 608
108. Diagram iltuslreting the visual angle ..... 610
169. Diagram illustrating the elTect of accommodation 611
170. Diagram Illustrating myopia ...... 613
171. Diagram Illustrating hy)>enne(ropia ..... 613
173. Diagram illustrating the changes which the eye undergoes during ac
commodation ........ 614
178. Diagram explanatory of the ophlhalmoscoplc appearance of a myopic
eye ......... 638
174. Diagram explanatory of the ophtlialmoscopic appearance of a hyper-
metropic eye ........ 633
173. Diagram illuHtraling the focal distance In tlie vertical and horizontal
meridian in asllgmatism ...... 040
176. Diagram illustrating the focal distance In the vertical and horizontal
meridian in astigmatism ...... 640
LIST OF ILLUSTRATIONS.
XVU
ri«.
177. Diagram tUnBtrating the focal distance in the vertical aad hnrizanta)
meridian in astigmatism
178. Dr. Green's test object for detecting astigmalism
179. jRTal'a optometer .....
180. Thomson's optometer ....
181. Blackened disk for determination of astigmatism
I8'3. Diagram showing bypermetropia and myopia .
183. The muscles of t)ie eyeball
184. Linear measurement of squint .
185. Mr. Laurence's strabismoraeter .
186. Dr. Onlezowski's binocular strabismometer
187. Diagram explaoaiory of diplopia In parnlysU of the external rectus
188. Diagram explanatory of the difference in height of the double Images
In paralysis of the external rectus
189. Mr. Bowman's diagrammatic record of the extreme lateral movements
of the eye ....
190. Mr. Bowman's diagrammatic record of the extreme lateral movements
of the eye .....
191. Finely pointed forceps ....
192. Probe-pointed scissors, curved on the flat
193. Strabismus book with bulbous point
194. Straight blunt-pointed scissors .
195. StrabiBrauB hook .....
196. Tbeobald's crochet hook ....
197. Von Qraefe's test for insufficiency of the internal recti
196. Grooved director for slitting np the canaliculus
199. Mr. Bowman's probe (No. fl)
300. Weber's beak-iwinted knife
301. Weber's graduated biconical sound
203. Dr. Hays's probe ....
308. Dr. Stilling's knife
304. Manfredi's speculum
805. Eversion of lid owing tn necrosis of orbit
306. Kcltopium ilie result of caries of the margin of the orbit
207. Ectropium the result of caries of the margin of the orbit
808. Ivory exostoBis in the orbit ....
209. Cystic tumor of orbit .....
310. ScirrhuB of the orbit .....
21 1. Present appearance of patient from whom the above bone was removed
213. Appearance of patient with medullary cancer of orbit
31S. Appearance of same patient after operation
314. AneuriBm by anastomosis in orbit
315. Appearance of patient with abscess of frontal sinus
316. Appearance of same patient after operation
317. Portion of hat-peg whicb was impacted in orbit
318. Blunt-pointed scissors curved on the flat
219. Chalazion . . '* .
320. Cutaneous horn growing from lower lid
221. Tricliiasis ......
333. Horn spatula .....
228. Snellen's modification of Desmarres* clamp
h
640
648
644
645
646
647
668
678
074
675
676
677
688
688
706
706
707
707
718
718
719
731
739
740
740
741
743
746
755
755
755
765
770
778
778
774
776
778
788
788
780
703
810
814
83.'>
826
837
XVIU
LIST OF TLLU3TRATI0XS.
PIH.
234. Snellen's modtflcation nt Denmarres' clump applied
225. Mr. Laurence's mndiflcation of Snellen's clamp
220. Dlan^rara lllustrHlini; Herzenstein'K nperation for Iricliiasia
227. nia^ram illustrating Arlt's modification of Jaesche's nperalion fnr
tricliiasis ......
228. Diagram illustrating vun Graefe's operation for trichiasis
220. Diai^ram illustrating Anagno^itakis's operation for partinl tricbiasis of
upper lid
2S0 Ti>« same .
231 Tbeanmc .
282. Spasmodic cntropioin
33S. Kntropium forccpn
234. Another form of the same .....
33Q. Diagram illustrating von Oraefe's operation for spasmodic entropium
23B, Diagram illustrating von Oracfe's operation for spasmodic entropium
237. Diagram illustrating von Oracle's operaUon for spasmodic entropium
235, Desmarres' fiirceps
23». Ectropium .....
340. Krtropium .....
241. Ectropium caused by cicatrix
242. Sir William Adams's operation for ectropium
24.1. Appearance of the eye after Adamn's nperation for ectropium
244. Diagram illustrating Mr. Wharton Jones's operation for ectropium
245. Appearance of the eye after Mr. Wharton Jones's operation for eclro
pium ........
246. Diagram illustrating DiefFenlwch's operation for ectropium
247. Ap)>earance of the eye after DiefTenliach's operation for ectropium
24K. Diagram illustrating von Graefe's operation for ectropium
24i). Blepharoplastic operation for ectropium .
2'jO. Meihiid of fastening the flap in llie t)lcpbaroplastic operation
2.'»I. Dicffentiach'K blepharoplaslic operation for ectropium .
253. Dii'flenbach's blcpharoplastic operation for ectropium .
2M. Vertical cut of tarsal edge of lower lid .
2A4, Operation for epicanthus .....
sse
830
R30
83!
S3!
Ml
832
834
834
83S
835
835
837
840
840
841
844
844
845
845
845
845
846
847
848
849
849
854
855
COLORED OPHTHALMOSCOPIC PLATES. X1\
COLORED OPHTHALMOSCOPIC PLATKS.
1* L A T K I. to face p. 8'>8.
Fig. 1. — The normal fundua oculi of s brunetlp.
Fig. 2. — The normal fbndns oculi of a blnnde.
Plat K IL to face p. 8611.
Vig. 3. — Sclerotico-choroiditis posterior.
Fig. 4. — ChoroiditlB diBsominnta sypUilitica.
Plate IIL to face p. 80-2.
Fig. 5. — Retinitis pigmentosa.
Fi^. 0.— Retinitis aliiuminurica.
Plate IV. to face p. 8fi4.
Kiir. T. — Retinitis apdpiectica.
Fig. 8. — Embiilism of llie central artery of the rctinii.
Plate V. to face. p. HfiC.
Fig. 9. — CysticcrciiB in the vitreous humor.
Fig. 10. — Detachment of the retina.
Plate VL to fai-e p. 868.
FlgB. U and 12. — Atrophy of the optic nerve.
Figs. 13 and 14. — Optic neuritis.
Figs. 15 and 16.— Glaucomatous excavation of the optic nerve.
A TREATISE
DISEASES OF THE EYE.
I>'TRODt'CTION.
In order to aroid unneceuarj repetition in the counie of thin work,
I tiituk it advisable to give in this introduction a briuf do9cri;itioii uf
Bome of tlie more important nnd frei|nciit modi's o? fxamination of the
eye, lu well m oF certain remedies and ap)iliaiicf.s in comioon uae in
optitliilmic practice.
JCverthn .»/* thf upper ft/fHd has frcqupntly to lie prnctiacd if the
presence of a fur«;i;jii lw>d_v la suspected Ifeiieatli il, or if Certain remedies
are to he applied to \u lining membrane. Various contrivances have
been suggested for facilitating thi« proceeding, but it is best doue in the
followiii;; manner: Tho patient being
directed lo look downwanls, the «ur- IF'f- '•]
gtK>ii seizes liglitly the central lashes
of ihe uii(*r lid between the forefinger
and thumb of his left hand, and draws
the lid downward^, and somewhat
away from the eyeball. He next
4aee» the tip of tbe forefinger of his
Fii>[l)t hand on tlio centre of the lid,
tL\inat half an inch from itt free mar-
gin. WitJi a quick movement, tlio
edge of the Ud i.4 to be then turned
over the tip of the forefinger ('wliicli
sboiiM be simultaneously somewhat
presiM-'d downwiirds). By .-ilightlT
firoftiiing tlie margin of the everted lid
mcliwanls against the upper edge of tho orbit, the whole retro-tantul
f(^d will spring into view, and the lid become fully everted. [Fig- 1-]
In those exceptional cat^es in which tbo patient is very uiimamigeahle,
ind forcibly contracts Ihe orbicularis muscle, it may be nece*«ary to
a probe, or the end of a quill pen or pencil, over which to turn the
lid, instead of the forefinger. [Kig. *2.] But as a rule it is more con-
vciiient lo employ the latter, sa we may not atwava have a proW' at
3
i\
u
IXtROI»rCTIO*.
hami, nd u — jthiag m Ibe ihape of u in-tiwnent frijfat— womt
Mtmrtt, «b«rt«« «« Ml*; oA** Mecce^ in erertiBg tbe fi4 vkfa tfa*
•■gBTf Wfan th«7 bftre ere* ttae to reaist. The wrgeao baj ^aa
•taod bclifMl tl»e fmaeot, and ttOKlj tbe bead of ^ lasur ajafarr Ua
breaat, and errrt tbe lid fmoi btbind.
tF«»-a.)
N
/^
\
T'Af ofiittfue or /vetii Ufumimttitm u in oonscaiit rci)atriictou for aaeer-
uinihji; Ute conHilioo of the KnKturc« of the knurior lialf of tli« eve-
lall. Ujr iu aid wv trc rntliletl lu rxaoiiiie. with grett nlimtenesa,
(be apiicamnctTi (irciM-nicl l>y tin- contra, iris, pupil, lena, ftnd even the
nKMt uiitiTior |>'»rtifMi of thr vitn'oos Iiutdop [and todetect forci;;u bfKlies
[ami ciclicalc uxiiilatitniA.— It.J in the anterior chamber^ delicate falu
mem^jraiicB in ttic puptlUrv )i|ACr, minute dejioftttii u|<ou Uie irif and cap-
sule of tlic Irm, nitd ^lij^lit iKbula: t>f the comcAt «>l>>(sli vould uHcn U!H»po
the otM<>r\'allo:i of iliu ttiLaidL'd t^ye. — II.] 'Fliia mode of cxamittation
ia t<] W limit c mdiicU^l : A Lunii ttcirt^^ pUcL-d PunH-what in front and
to ooe aide of the jiatient, at & iiUUik» of from 2 to 2^ feet (Fig. ^),
Pig. 3.
and on n lerel with liin eye, the li;^]it ia oonoentrated upon the cumca
or tlm rrywtnUino leux by a rttroii'j bi-convox lotw of i— dj inches focua.
The nlwrver'd i^yt' in tlii-n t^i Iw pliicvd uu one side of tlic |iatietit, so aa
to cnti^tt the rnyn rinnnatin;; from tlie vye of the latter. Itj »hiftiii» the
cons of light from one portion of tlio conica or Uus to anoLbur, vrc m»y
ISTRODCCTIOX.
85
rivpidly, yet thorouj»hly. ciamioo ita whole expanse unil i)ot«ot tho
Riii»hte.-*t opacily. In ortlcr to gain a larger iimgc, wo may employ a
second lens nj a tna;^ifyin;; gln^s [irliicb stiouU be beM directly in
front of the patient's eye. (Pig. 4.) — I!.]. Opacities of the comua or
■-^_
i
-.'f/'.' '/'
>-///' '
1^
Icn^ will appear by the obIif|oe illiimiimtion (reflected light) of a llglit
^niT or whiti-ih color, whereas with the opiithalmoscofie (transmiltoi
light) they will appear &* Jark Bpota upon a bright reil back^roun'l.
The method of examinin,; the eye with the ojihthalmoscoi* will bo
found described, at length, in the section upon the ophthalmoscope.
The fttfufe of asrfrtitintny the dftfrre of intra-ofiular tfngi'tn is as
fidliiw*; The patient In-iiig din-cled t>' hjfik -sli;j)itly down«ftr«I.s, mid
i:«utly to cloite tiie eyi-lid«. the .surgeon iippliea hoth Iiia forvRnt^ers to
the iip|KT jiart of the eyeball behind the rejiion of the cornea [that is,
to tJie evlera ; for, if tlie premure be auplietl directly to the corner, tho
t^nfiion sccnia to be increased. — B.J. 'iTie one forefinger is tlion pro.i«ed
Mijrhtly against the eye so a» to steady it.wIiiUt tUv other presses gently
fftgniimt the eye. and e^tinialex tlie anioniil of tension, a'lci.'rlaining wlie.
ther the globe cnn U* readily dimpled, or whether it is pprlinpfl<'f a atony
haninefs. yielding not in the sliglitest degree even to the firm pressure
of the finger. The beginner will do well to make himaelf thoroughly
S6
IXTBOOOCTIOK.
oonreraBtit with the normal degrov of tension, hy the examination of a
ntimbor of healthy eyes, and then, if he should lie at all in doobt a« to
the degree of teiwion iu «ny individual c»ae, he should teat the tension
of the patient's other eye (if heahhi.), or ihai of sonw normal eye, 80
aa to be able to draw a romparison between them. If there is mach
ffidema of the lids, or coujuiictivHl chemoHtSf or if the eyes arc small
and deeply set, it may be difficult accurately to es^matc the degree of
tenaion.'
I vtould call particular attention to the 8i;!;nH which Mr. Bowman ban
devised for the designation of the different dejijreefl of Icoston of the
eyeball, as tbey will be found most lucful. not only in prautice, but al5o
ill the reporting of casea, or in the prcservatiou of an accurate record of
the state of tension.
Mr. Bowman intrmlnced this subject to the attention of the profession
in 18i)2,in hi* admirable pa|»cr " Ou Glauoomatoiw Affections, and Uieir
Tn-i(tmeiit by IridecKnuy." read before the Annual Meeting of tli»
Britixli Medical Atiwciaiinii.* in which be havj, *'■ I have ton;; {»aid itfte-
cinl attention to the subject of leunion of the globe, and particularly
since it baa asitumed $o much additional importance in the last few
years. I have found it pn^sible and jiractically mefut to distinguisli
nine degrees of teiuiion ; and, for convenience and accuracy in note-
taking, have desipnatod thorn by special aigna. The degroea may bu
thus exhibited : — *
"T repre*ent)j tmnon ('t' being commonly i»ed for * tangent,' Uie
capital T 18 to be preferred). Tn, temion i^trmnl. The inturrogntive,
T, marks a (/"mA*, which in such matters we may often he content with.
The nuinemU following tlic letter T, on tlto (tamo line, indicate the
Jrijrff- »/ inrrfa»rti tniginR ; or if thn T be priNicded by — , of Jl'riilli-
ithftl tfntvm, as further explainer! below. Thus: —
*'T M. Third degree, or extrvmetention. Tlie fingers cannot dimpio
the eve hy firm pressure.
"'f 2. Seeonit degree, or eonnderal-fe tciinon. The finger can
alightly impress tlic ooata.
" T 1. iVr^f dej^roe, Wri/Af but positire iH^-reate (jf tftutioH.
*^T 1 1 Duubtftd if tcusion is increased.
I In oHi*!, if jHvwilhlr, to r«tlaMit4' tlio di*ftp<> of iiilrA-nrtilaf tcnnloii with r-xtrrR>n
nln-tv, InklrunifDU, Iriruipil InnnnMlm, liarc (m-u ilirTiiinl hjr V»u llraiifp, Uuiulm,
Dor, I'tc. It iMHitt, bowcTcr, hv H'liitiitMl lUai ilie rifiilt* olitiitiiwl hjr tbnu ware not
■uffi<<i>-t>llv' NcrurBV to r<-UiloT ittnn ]ir<-(i-fa)ilr l<> iLi' [wil|iAtii>it l>v ilie flHgrra. lint
m r ' Uiiiiuih tiAK iiimilial » lutmuwler. xliic-U at'iM-ani !• knaKi-r ttpll, kiid
»'' i rrnih^l (in llu^ i>rin>-i|)|i' nf iiulu-Aiiiti: Hiw ik'|iili i»i whik^li A tuiuuli* ]un,
I » iilk tlkr liMtniiiirnt. 1:1 prtiswn) into Ititi wli'iotu-, mill altui tin- (■irci'' cm-
III JiiimIuk' llir <l>-[>i't-w:nn. . h'ur It furllirt A<Hfi()Ut uf it, ridt Kl. MnnnUilit.
Ml mihI .ttMtaI>-« 'I <.>rtilUllitu4>, I^SH, t^ ^r^. [Slill Utfr « lonninolcr lus
l''< •! Iiy Hu<-Ucii aivl I.Aiiilnlt. rin lliu ftMiif [iitnoi|>lo mi Monnik'n, wittoli
'*'■■ .wers ln«tlpt. Willi lhli« {iDtlrurmnit an iiupmiutiii or cli<|inHM>i"n i«
liid'f' lii will, B |;Ir<'ri iliHiiiic f)iroi>. IW <l>i))lh, Itmi'IDi, Kiwi gciKTal shape
ttfmhnli I , -utiiin* ran Iw* arv'iiralnljr nMiakur<«l. A ilmorifit i»ii of tho in»tru-
' ' .:>;ii4 tn Utarfo iimt Snnnlavli'a UiukIIkioI) d«r AugviiWilkauiU, B4.
.H.1
' ,-' ! -I Jrtoni*!, fM. II, IKh-J, [.. 37K.
.|-a>r via* ri-wl | liav-* ■itit|illit<<>l tlii' sltfiMt, litli lU(> cniiritrmioi* «f
^ ■ . : ' f IhiiiiliTH. lu ttnlor la aia)il lli>iU) fur piHvral umi. Tito aimplittoit
. ^mmi kUlMtitutMl abuira,"
I
A
INTRODUCTION.
37
*^Tn. Tension normal.
•'— T I ? Douhtful if tenftinn be less ihnn nalurnl.
** — T 1. First degree of reduood tension. Slight but positiTe re-
ilaelion of tension.
"— T 2 1 Successive 'Icfrrees of retlucotl tciwion. slmrt of sueti con*
" — T 3 f sidL-mhle softut-'ss of Ihe eye an iillows tlie finger to dink in
the coats, tt is le$8 easy to define the^e by wonU.
" Id common practice, some uf iliesc may be rcgiirdod as rcfiuemcnts;
but in accurate imte-bilcinp;, where the nattiro ami cmtriic of various di8*
easc« of tlie gloI«e are under itifestigntion, I have found them liii^hly
^acn'icealilc, and they have as muuh prcctsion iva purhaps in attaiuahic or
desirable.
" It it) also to be home in mind that the norroal tension has a certain
range or variety in peraonii of diRorent age, build, or temperament: and
according to varying tem(>orarv i^tatea of system as regards emptiness
and repletion. Kx|ieri(*iice will make every one aware of thenc var'u-tiett,
which do not encroach on the above ahnormal grades of tension. ^[L•di-
c»l men may understand how important is this matter of tlte drgrre of
ienMion^ by cnnsitlering how priceless would be the power of accurately
estimating it Ay thf- touch in the case of various head affecthn$."
For thf ejt'itiiimtiioH of the ai^utfufUM of cmiVm [which means the
power of distinguidiliing form.— B.l various teal-lypes are used, more
especially ihosc of Jaeger and Siiellen. The fonner do not, however,
afford a perfect clue to the acuteiiess of vision, for a person may be &\M
to read No. I of Jaeger with facility and yet not enjoy a normal acute*
UC9S of sight. Snellen has. however, devised a set of teat-types which
fulfil this deaideratum. The letters ai-e s<iuare, and their size incrcat^es
At a definite ratio, so that each number is seen at an angle of five min-
ute*. Thu.-*, No. 1 i« seen by a normal eye up to a dUtance of one foot,
at an angle of five minutes, Xti. 2 up to two feet, and so on. These
numbers cantiot, as a rule, be seen distinctly beyond these disbanceti.'
[.A-s commouly useil, the term a'jutf}y:9t of vi»t<m ts confined to rision
at the centre of the visual field; for the periphery uf the retina has
only an imperfect power of distinguishing the shape and sixc of ob-
ject*.—B.]
Now, if tlie eye is sufTering from any dimination of aoutcne9i.H of
Wtion, it will require to sec the letters under a larger angle than that of
five minutes, in order to gain larger retinal images. No. 1 cannot be
read at a distance of one foot, but only, perhaps. No. 4 or 5. Wc may
t&sily caculate tb« degree of tlie acuteueas of vision thus: —
I Al Prtifi-nuir Uinpnon^M flUKgv^tion, Dr. ^ni^llnn hss firtn in lilt iMKond ^dltlOD
«f tlic lnt-tV|iiTi fiiiiiif UMf* <^nl*iiiing a •vrUii n{ fi|;uri-» aoil itiii|;le niimlMrA for tbe
fxumitiHiioii i-f HuHi rwriiils (iir (hf llriliith ArmjAN »n> utiniili? to rwiil. Ft>r fwrllur
liifrrrmnlion w U> tli*^ rXAiniii&liAn of Itii* ni>;lil nf rnrruiU. I iiinMt rrfrir thf tL-iutor to
l>ni|>-i>i<'ir Nwipuii.iw'ft cxcHlIfiit " O^liilinliuii- MaiitiHl," ulili-li I would mUa nt-mn-
Btrii') ii> tlic n]">.ili1 Botio'^ tifllix aart;<-An)9or tb<! MilitiA and V->luiiii;<>f Corps. Ttn-tv
ti^X'iypt^t iitA; U' olil^itt^l ftt Ur*»n. Williuoa Jit Nuigaltt'«, llenmtta i£tri-«'t, t.'ovcat
fiarji>ii.
[A stJcwtloD frain llip teal-tTjMRi of both StLfgn nnd Snellen, taflotent (or dm in
orditlMj prMlloe, wtit be rouuil at the ead <if Ibia Toliinw. — H.]
S8
ISTI10DFCTT05.
V -
*' Tiio iilmost diatstwe at which the typM an? rccogaiud (d) divided
bv the distance at whicli tUe^ appear at ati atigle of 6ve minuter (D)i
gives the formula for tlic acutenew of viaion ( V): V m |-:'
"If d and L> he found e<junl. and No. 20 Iw tliu8 visible at a distance
of twenty feet, then V — " » 1 ; in other words, there is Doniial
acutencM of virion. If, on the contrary, d be ]vf» than D, and if No.
20 is only viaihie within ten feet, No. l()'f>nly witlilii two feet, No. G only
within one foot, these three cases are thus respectively expreftaedi—
I"-l- v= !-'• V >
:iO 2* iw 5' «*
tl may sotnetiroeB he greater than D, »nd No. 20 be risible at a greater
distance than 20 feet. In ihia case vit^ion is outre .uittu tlian the normal
average.*' [This comlition, a« a matter of experience, is not at all an-
comtnon, not only in hy[<Tuie tropic eyes, but in emmetropic eyes. — B.]
It mu«t, however, be confessed that ;»i>me patients (more Ci^pecially
amoDgst the lower classes) often e:c]ierience a diffic<ilty in Buently rcaii-
ing type composed of these sKjuare letters. They have alwavs beeu
accustomed to onlinary type, the letlt-rs of which are of nne(|itai thick-
ni»!*. and differ both in >lim<-n»ion and definitiou. I, therefore, Reneraily
employ Jae;;er"8 test-types for ascertaining the fluency with which small
print can be read, and those of tinellea for testing with accuracy the
acntenesfi of vision [at a distance — B.].
[Various modifications of these types have been pmpo«ed. Dr. John
Green, of St. Louis, thinks that the different sizes of types should hold
a certain delinite n-lalion of size to one another, awl thus f'tnu an arith-
metical series. He aU<i prefers, instead of ilie '' Mock letters" orlina-
rily used (£)> the simpler form ( E)* In makiii;£ practical use of tm^
of the various forms of test-type, a sheet of card-board, having on it
letters of various siuis, should l>e hung up in a good li;;ht, and tlie num-
ber of the smallest size should be Icsu than tl>e nuuiInT of feet in the iivniU
able distance. F'lr testing near vision, lue is made of the jaraphlet
test-type, published by Snellen in several lanj'UBges. These contain
not only letters, but dots and anpihir figures for the nse of those lumble
to read. If vision ts less than — , it is usual to discard the letters, umI
XX
test the power of counting fingere, and when they cannot be counted, ti
becomes not a question of viaion, but of Uie ({uantitalive or i|ualitative
perception of li^ht.
A very important point to be considered is the amount or intcitsity of
light under which the examination of the acuitr of vision is carried nn.
If daylight be used, it is not common to liave the same degree of illu-
mination upon different day<i. and heitcc comparative lestiiig is tu>t of
much absolute value. It has seemed best to some eiperts lu use only
artificial light for these examinations, and this light must of course come
from a lamp in which the same kind of oil is always used under the
same cirvumslaoces, iu order to reduce to a minimum any po&sihie source
of error. At the best, we must regard tliese te^ts as but approximative.
INTKODDCTION.
89
III i\m tost cxstnituitiQU of the acuity uf vision^ it not lufrvuuently
hAj>p(ru4 that it wouM be advftntageous to know die actual ecnaibility of
the t-jo to light. Fdrster, of UreAlan, ha.s coiminictcd an imti-ument
Tor thid purpose, a dosoriptton of which mW be found in Uracfp und
Siieiiiiscli'^ ilHTidbucb der Augenheilkundc, Bd. lii. p. 3tJ, He claitm
tliai iu uoe divides cases of impaired vision into two groups. In the
first, where sensibility w H};ht in but little diminished^ arc iDcludcd those
diseases in which the conductinfi portions of the optJc iicrvo and retina
are mainly affovtcd. In ttie second class are tliose iliseases in which the
perceptive elemenw of the opttc nerve and retina are involve*!. FSrster
gives a formula for the detenninatiou of h or the sensibility to light. — B.]
Besides examining the aeutt^ness of vision, it is often of much impor^
UKv to asoertaio with accuracy and care the condition of the field of
vision, which may bo readily done in tlic following manner: The patient,
being placed straight l*efare us at a rUdtance of frum Jitleea to eighteen
inches, is directed to look witli the eye under examination (cloning the
orher with his liand^ into one of our eyes, his* ri^ht eye Iteing tixcii
u[M>u our left, and I'lVr verrd. In this way any movometit of the eye
may he at once detected and checked. Whilst he still keeps his eye
steadily fixed upon ours, we next move one of our hands in different
directions lhrou;^hout the whole extent of the field of vision (upwards,
dowiiwanis, and laterally), and ascertain bow far from the optic axis it
iir !(tiU vi.^iMe ; we then appnjiach tlio hand nearer Lo the optic axis, and
exumine up to how far from it he is able to count fingers in difTcrent
directions. The number of the extended fingers is to be constantly
changed, and tlie examination to be repeated several times, so tliat we
nmr ascertain whether the patient can count them with certainty, or
whether he hesilalcs in his aiiawera, or only guesses at their number.
We may thus readily discover whether the field of vision is of nonnal
extent, or whether it is defective or altogether wanting In certain direc-
tions.
We may term that part of the field in which the patient can still
distinguish an i)bject (a hand, a piece of chalk, etc.) the ijUfmtitative
field of vinion, in eontrndi-itinetion to that small portion in wliiuli he xt
able to Count hiigers, utid wliich inuv be de^iignateil the ijnalita/ipi^ fieM,
The following raetbixl uf examining the field is still wore accurate,
anr] 1 should advise its adoptioit in all cases where it is of imi)ortance
to have an exact map uf the extent of the field, as in glaucoma, detach-
ment of the retina, etc., so that a reconl may be kept of the condition
of the field during llie prDgress of the disease, or that wo may be able
to compare its extent before and after an operation. The fkatient, being
iilflceil before a large black hoard, at a distance of from 12 to Iti inches,
u directed to close one eye and to keep the other .iteadily fixed upon a
chalk dot, marked in the centre of die board and on a level witii hii
eye. A piece of chalk, fixed in a dark handle, is then gradually ad-
vanced from the f»eripliery uf the br>ard towards the centre, and the s[>ut
where the chalk first becomes viable is then raarkei u|m)ii the hoard.
pnxecding is to be repeated throughout the whole extent of uto
40
INTRODOCTtOS.
field ; the different points at which the object Hret becotnos \'it!iible are
Ihrn to be uuitC'd b,v a line, which indicateH the outline of the ^Hantita-
five Belli of vision. [Hg. o.] 'JTie
[V's- ■'■] extent of the quaiitative lisuiil field
ii tivxt to be examined, uicl it is to l«
ascertained hovr far from tlie ccnmil
spot the |>atient can count fin;:er« in
diffi'reni directions. The iKjiiiu thus
found arc i\l:?o to be marked on the
board.aiid the marks afterwards united
with each other by a line, which should
ho of A dltferent color or character to
that indicating the extent of tlie quan-
titative fifid, «o that the two may not
be confounded. It need hanily be
mentioned that care i^ to be taken that
during the examination the patient'4
eye rcmaiua steadily fixetl upon the
central apot, that the other eye is kept
dosed, anri that hia distance from t'le board is not altered. The exteut
of the field inwards will, naturally, vary according to the proniineiKc of
the patient's fKuse.
The hoard is to be divided into four et^ual parts by a vertical and hori-
zontal line (of about 4 feet in len^h). cutting each other at the central
croM : each <]uadrant is then a}:ain to be divided into two e*\a*\ p«rt4 by
another line, so that the whole in divided into eif»bt equal Be{jraent«, as
in the accompanying figure {,Kig. *») which represent* the divioion of the
field for the left eye. For the riglit eye the position of the letters must
lie reversed, thus u i (upwards and inwards) would l»e u 0 (upwards and
•mtwanls). ami so with all the others.
The meaning of the letters is as follows: —
V ilf— Vertical >Ieridian, dividing the field into two lateral halves
(inner aud outer).
//>/-- J lorizontal Meridian, dividing the field into an upper and a
lower half.
The upper half of the field is subdinded into four segmeDts : —
u 0 upper atid outer segment,
p M outer ** upper •*
u I upper " inner "
i f( inner " upper "
The lower half is also subdividetl into four segmentd: —
0 / outer and lower segment,
/flower " outer •'
1 / inner " lower •*
/ t lower '* inner '•
The method of examining the jiatient's field of vision is to be the same
ft* that af-ovc described, when a plain boani was used. The object of the
divtAioitp ist only to furnish a kind of framework for the map of the field,
which enables us to sketch it with more ease and rapidity. 'i*he boundary
IMTRODUCTIOS.
41
HM
of the quantitative and qualitative fielcls is to be marked both upon and
between each of the divisional lines, and the distance of each of these
marks from the centre of the board is then to be measured, and it? ex-
tent, in inches, is to be placed against each mark. A small fac-simile of
the field of vision thus mapped out may then be drawn in the note-book,
the field being here also divided into eight segments, the boundaries and
meaaurementa of the map being likewise copied ; so that we* may pre-
serve, in a small and convenient form, an accurate record of the shape
and extent of the visual field.
But the sight of the patient may be so much impaired that he can no
longer count fingers, even in the optic axis, being only able to distinguish
between light and dark, as in cases of mature cataract, severe cases of
glaucoma, etc., and yet it may be of great importance to know whether
or not the field of vision is of normal extent. This may be readily as-
certained in the following manner: The patient is directed to look with
the one eye (the other being closed) in the direction of his uplifted hand
(held straight before him, on a level with his eye, and at a distance of from
12 to 18 inches). A lighted candle is then held in different portions of
the visual field, and the furthest point at which it is still visible in vari-
0U8 directions is noted, the candle being alternately shaded and uncov-
ered by our hand, so as to test the readiness and accuracy of the patient's
answers. Care should also be taken to shade the candle when it is re-
moved to another portion of the field. The light may likewise be thrown
upon various portions of the eyeball by the mirror of the ophthalmoscope,
42
INTRODDCTrOS.
and the potient rjuogUotivd as to the direction from which the light apjiears
to conic.
Mr. rrid<:iii Teale has devised a modification of the above method,
bv Bululividiii(! the board (already' divided bv verlicni, honiiontal, and
diagonul lines) hy a aeries of concentric circles. There la, moreover, a
travelling white disk of canMuiard, which can be moved froiu the outer
edge of the board to the centre along the- diagonal and other lines, thuB
fonning a very convenient and ea»ily recognizable object. There is also
a rest to steady the patient's bead, and maintain it at a certain distAnce.
He marks the existence of good vision bv a + sign, im[»erfect vision by
— . am) absence of visiou by 0. Blank dtugrams' arc prepared, which
ere a copy of the markings on the board, on a scale of | of ait iuch to I
iuch of the board.
WecVcr cniplDViA the following mode of taking the held. He uses a
birge black board, towanis the centre of which can be moved, in a radi-
ating direction, a nnmlier of small white ivory balU, thus marking ihc
extent of the field ; as soon as the ball reaches the limit of the field, it
is turned round, and presents its black posterior surface to the patient.
On the back portion of the board, tlio shape and extent of the field can
be read off from the position of the white balls, which give its exact
deliiicatioD.
ProfenRor Ffirster's perimetei' is, however, by far the best inatrurocnt
for measuring the extent of the field of vision. It consistii of a »eini.
circular band of brass, which is mounted on a stand. This band or arc
is a inches wide, and curved at a radius of 1'2 inches; it revolves round
a central axis, which permits of its being placed in different meridional
ptwitions. Kach hall' of the arc is divided into HO- : 0-' being situated
in the middle, at the central axis, and the HH)'' at each extremity. The
object for testing the field consists of a small black movable kimb, hav>
iug a white centre ; this knob can be rapidly run along to an}* point of
the arc hy means of a cou].]^ of strings worked from behind by a \tiuch.
At the back of the central axis is a graduated dit<k. on Mhicli a needle
indicate^ the tarioiis mendians in which the arc is placed, and its inclina-
tion to the vertical meridian ; also th« degrees, from U " to IbU', within
these meridiana. In order to nou' the extent of the field in different
directitms, and to record the results, Forster has devised umatl circular
maps, which are copies of the disk, and of the degrees of latitude within
each meridian. On these skeleton maps can be readily traced the ex-
trot of the field in any given case. In examining the field of a jiatient,
he is not to have his visual line fixed on tlic centre (axis) of the rvc^
but on R little buuon placed 1.5^ to the inner (nasal) side of the centre,
80 AS to bring the blind spot opposite the latter.*
> Tl>f«« majr be uliiain«-il tt U-i^rv. HitrTiMin'a, Ai St. Uarlin'e Lanit
■ Vat M rultof ilr«i*i'i|ilii)ii of ILU itialrniucul. ntxl tin- luvlkml of u*iBg it, I must
rrfrr tb*' i"«.I'T m I»r. t'jul Miis-cr'* InHU^urni I'lMi-nflimn on tlip P.-riiin-tiT ( Rr<i>iiiu,
)u,r> ...,i.ii-i'r«l l<v II, LiiLlrr) alui l<< ilic ('•<n<|>lx Ki-iiiln ilu I'ongr** I>'ll|>btli»l-
u> 7, p. ISA. Th« iHTiiii-ivr 1* tamiv hy 3fr. Mu>>, oittklau, d All« Ta*^«u-
air ' -liiu, kiid riMtn Kljuut £T.
* In onlrr tn arnwl nntiii-viianr;r rp)><*tiliD1l, I mupl tirm rsjilnin thv aignifiratinn nf
til* l«>nnf " vivual lluu" ftuil " liliiid ><|mI." Bv vUumI linr i*. uuilrrvlioi't III* iUAft-
inaiy Hue tlrawu trmi ttiv jrrllow ipol lo thu obJv<-t jxiilat, simI tlib Utur wm (ofUMftlv
■
ISTHOt>rCTIOS.
i%
OCI
I fici
m
9
Mr. Bradt'm,'Il Carter hfis re-
orotlir tlettseil 111 cxuelU-nt in'jili-
ficRtion of FCratcr's IVriincter
w bicb 19 more simple in coiiatnic-
in, leM cosdjr, nnd Ic^ liaMe to
t out of oitler. He pves the
oilnwiii;; <lftKri)Uioti of Oic ia-
fttnuntfikt in the " Ijaiicet," Julj
li. 1S7:;: —
" It coiidtsta of a Himple tripoti,
capporttti;; a hollovr stem ( Fig. 8,
a), in wbicb a iwcond 8t«m (l)
inoveA np aoti ilown, ami can be
fixed at any 'le^trci bei;gbl by the
Kjrcw (c>. At tbe top of tbe
Bt«m (u) ia a abort borizontal
>xi« (d), carrying tbe quadrant
(Ef b'), wbicb lunw in a com*
pWtc> eircli?, und movos witb jujit
atiifufatf uiiuiiiih tv reuiuin wbure*
Pig. 8.
•uppnMil tu In- lilontlenl irllh llitt opllo ftkln, In^nn- ft is iiflrti »iuil trliim ■ prreon in
lo(ikiii|| at HD oliji-ct, " that liU u|tl<« nxra urn (ixnl ii|iiin it." Tlii* is, h««i>*iir, ntit
ittrlclljr oi>m<oi, for Heliiili'ilti tiic* Nhowii ib«l thv vbunl line Jind ofrtic axi* arc not
Ideatinl, tnit thAt th<i fomtirr lit^ on tb« ooraua, ntunt or Iom inwitnla, niiiI noiuiMrliat
^'iJ: 7.
VpwaH* nf tliv opiie «sU : flit p>Nil«riar (tcliiiAl) <ixtnrntH,v oniiaaiqumllv' lyini; tv Ilt«
'aU« of th<- v[>tli: msw, wi ifiiiuiwtiiil below it. A rullrr cIusvri[(tiDii of this will
IArUmI ill C'liajitrf XIII.
Y\.., •!..,,.. HiHt-* of itif niitio tiefVfi (im noloxcitiKl l>jroliJfH:tiTM li({hl, himrt' lli^ligtit
T" 11 tlie i'n(rntii.-Fof llir optiv iirtvv {<>piii.< ilblt) it not p^rci-ivt-d, niid ii cor-
rr J i _;:ipi-si»t<i ill llir ft"-!'! iif riniiin. Thin );bp or-l'-flti'-iKyi* r*ni-.| Ihi'tiliinl
•p»|, in puiirtiiiii (irciiiii, »nil rorivupiiniU in nixm «itil jiiNiition l« tliv o]iti<;(lliik. Till*
tin is jimvod li;^ the following -xikHiik.'IiI. If Iht* l^ft w>>- <rf tlm oinM-rvt'r i& clwttvl,
ami ttii- tit^lil fft^ Dkiil nl^rai^ily itii Ibr rrrKv» in fig. 7. it will ■•- fmiml llmt viUvn llm
In-i'lc i» r>-rii><viNl ti> sIhihI 12 inolit^ froiu tlie ^yv, lliv wlill'- tirole ftitirclj iiiiMipp<?arii,
Ii* nf;uri.' ii tlnck. Tliis jiAp in tlin visaul firld is not ptrfiwivul tM-catiM!
- Iiliioi'ulnr, Aiiil lli*^ it>!rw;t in llivcitM «>/*■ ix miuprnsntml fiw by tha- "Ihvr.
pftjr but littk' ftl(4^iiiioii to itiipnasiwDS wliioli fnll upon tho6« pariri of
tli> ri'liiia witii-li H<< at a Ullli* 'li3inn>;i< fnttu ihv puiul of fixjiiicm. The dintii.ii-r nf
llii* Itlliiil «pu4 U, Aconrilliif; i» It>-Iinlio1ts, 1 mni, ttl. Anvnllng to l.taling, 1 nun, aj.
Vide HetulioHs, t'Uy>l<ili>(bfb« i>i>tlk.. p. 209.
44
IKTRODUCTtOlt,
ever it ie iilaced. Oa the i)iiBctmDt is a trax'ctlinj; slide (?), with a
white spot ; and a second iiHiepeiKlcnt axis is inserted in the axis of the
quadrant at o, and carriefl a short tube, in which mny be placed a «lera
to supiMrt the fixing point. The second or inner axis makes a complete
revolntion without affecting the position of the *|uadmi\t, and without
lit^in-; afTtfcled hy it. At ib< attnclicd extremity the (luadraut terminates
ill a oircular disV (e'), which is K'''*du«tcti into degrees at the back, and
a fixed index aUows tlie exact iwsition of the quadrant to 1* read otf.
The quadrant is also graduated from ten degrees to ninety, on iia con-
cave fact, no as to ahow the exact position of the slide. The fixin;;-
]>oint may be cither an ivory knob &t the end of a wire, or, what is for
moat purjKMea better, a email disk with a central perforation, as shown
at II, lfir«H;ih wtiicli the patient looki* at an object on the other side of
the room, inid obtains fixatiou without exercise of the accommodatioa
and con»c<iacnl fati;;ue to the eye. The travelling slide (v) may ba
niadu to carry a spot of any color or size that i» desired, and it in fur-
nished with a ring at the hack, by whiidi it may He moved hy mcann i»f
a hook set in a handle, 90 that i(« ixfsition may not be indicated by that
of the hand of the operator. For the purpose of takin*; exnet raeatiure-
mentd of the blind si>ot, the ipi.-idrant is graduated at the back fn>m
ei(:lit degrees to twenty-five, in degrees and sixiba of a degree ; and a
white ttpot is placed on the centre of the axis (u), to serve as a fixing-
point for this particular purpose."
[ ]<andull's jwrimeter has a double arm like Forster*s, and ts open to
some of ihK H»me objections.
Scherk's perimeter consists actually of a. hollow hemisphere, with a
radius of one foot, attached tangenttally to a vertical rod at its pule^
blackened inside, and divided into meridians and concentric circle*. The
hemisphere is divided in the vertical meridian, and the two iiuadrnnts
can Ik* pushed aside from each other, to admit of more light. The
method of examination is practically tlif ^nme.
The latest perimeter introduced is that of Dr. W. H. Carmalt* of
NfW Ilftvcn, Conn., which has the great advantage of being of rery
DKMlerate oo»t. The arc is cast accurately on a uniform curve of 35.-'J
centimetres radius. It includes 140^ of a circle, the face is blackened,
and a wliile line is <lrawn through its middle along \U entire length. ,\
full de^nplion of the instrument will be found iiv the "■ Transactions of
the American Ophthalmological tiocieiy," Fifteenth Annual Meeting,
1B79.
It is Tcry often necessary to test the sense of color, and ibis is best
done by testing the power of distinguishing between various color*
without naming tlium. The best tciit-objects are dyed pieces of silk, or
better alill, skeins of cidored wornted. such as are recommendeil by
Hidingrvn of Upsala. A i>erson wbn it* cuturblind will place together,
OA similar, certain colom which tit a normal eye are very different, la
the color- blindi»e«s which is the result of atrophy of the optic nerve and
retina, the defect will be detected by asking the patient t^t name Uie
color» ; but in congenital color-blindness it is best to examine the patient
witliout the colors beiug uaiood. — B.]
INTBODDCTION.
45
Double image* (diplopia). — An object only appears single when both
visual lines are fixed upon it ; any pathological deviation of either visual
line must necessarily cause diplopia, as the rajs from the object do not
then fall upon identical portions of the retina. The slightest degree of
diplopia is that in which the double images are not distinctly defined,
but seem to lie slightly over each other, so that the object appears to
have a halo round it.
We meet with two kinds of double images.
1. ffomoni/mou$ (or direct^ diplopia, in whiuh .the image to the right
of the patient belongs to his right eye, the left image to the left eye.
2. (S-ot«ed double images, in which case the image to the right of the
patient belongs to his left eye, that on his left to his right eye.
Homonymous diplopia is always produced (except in incongruence of
the retinte) in convergent squint, for if the eye deviates inwards from
the object, the rays coming from the latter will fall upon the inner por-
tion of the retina, and the image will (in accordance with the laws of pro-
jection) be projected outwards, as in Fig. 9.
Let I. be the right eye, whose visual line is fixed upon the object
(b) : II. The left eye, whose visual line (c d) deviates inwards from
the object ; the rays from b therefore fall upon e, a portion of the retina
internal to the yellow spot (d), and the image is consequently projected
outwards to f ; b and f are, therefore, homonymous double images, the
image b, which is to the right of the patient, belonging to his right eye,
the image f to his left eye.
Crossed double images arise in divergent squint, for as the one eye
deviates outwards from the object, the rays from the latter fall upon a
portion of the retina external to the macula lutca, the image is projected
inwards, and crosses that of the other eye, as in Fig. 10.
X. The right eye, whose visual line is fixed upon the object (b). II.
The left eye, whose visual line (c d) deviates outwards from the object ;
the rays from the latter therefore fall upon e, a portion of the retina
external to the macula lutea (rl), and the image is projected to f, crossin*;
the image b ; the image f, which would lie on the patient's right han 1,
46
i:tTRODUCTION.
woulil, therefore, belong to liU left eye, Uie image b, whicli would lie on
li'u left aide, to the ri;;ht eye.
If one eye Bi|iiinta upwards, the rays will fsU upon tho upper portion
of the retina, ami tlie image be projected hetfatJi that of the healthy
eye. The reverse wilt bo the case if the eye B(|uint3 (inwnwnnU, for
then the rays will fall upon the l«>wer portion of the retiiiii, and the
ims^e will bo projected ah^we that of the liojilttis- eye.
We should never forget to ascertain whether tW diplopia be monocnlar
or binocular; in the latter case, it will of course disapiwar upon the
closure of either eye.' [If the diplopia is monocular, the len;^ and
retina should be examined carefully, and the presence or absence of
nvrx'ouii Rymptoma aliould be looked into. — It.]
l>;t UB now );lancc at the action of pKsms. When & ray of li^ht falls
U|.«ou » prism, it is refracted towards iu biijtc. If. for instarjcu. whilst
we look at au object (i-.;/., a lighted cnndlo) at S feel di-Uia«c, with
both eyes, a prism, with itt l)ni(e towards (he notic, '\n )>laced before the
rijSbt eye, the rayn from the candle will be deflected towanis the biae
of the prirtm, nwl fall upon n portion of
Rr. 11. the relJiia int«^rnal to the yellow i»pol,
anil be ci}ii6ei|uently projected outwardfl,
giving rise to homonymous diplopia. As
we are, however, very susceptible of
double images, the eye will endeavor to
unite them by an outward movement (its
external rectus bcci>utiiig contracted),
which will ii^ain bring the rays upon
the yellow spot, but at the same time of
conrse cause a divergent squint. Fig.
It will explain this. Let a b be the
nsual line of the left eye fixed (with
the oilier) upon n candle 8 feet off.
Now, if a prism (with its base towanls
ths nose) be idaced before the right eve. the rays are refracted towanls
the bftM of tnc prism, and do not, att in the otltcr eye, fall upon the ycU
low spot, but upon a portion of the retina {d) intemal to the latter, and
tho image is prnjectedf outwards to e: liomonymous diplopia therefore
arises, and, to avoid this, thi- external rectus muscle contracts and move*
the eye outwards, so us to bring the macula lutea (c) to that t!pot (d)
to which the rays are deflected by the prir-m. As the ntya from the
object will now fall in both eyes upon the macula lutea, single vision
will result, accompanied, of couriie, by n divergent sijuini of the right
eye.
' In ai.imlnin;; tlin iloriblit lnit^«i of k palioni, il i* uriiiTi-iitiint to {il&eu * *llp of
rwl |t'i*»* l'"'"rf Ihrt codinl •■jT". tf'T wt* thtw t-iiuli]" him r-'uililj" lo dtalitifuish tho
Iwii ltit»i;i^ II)' Ihrir ml<ir, nml Wi- al«> wraki-n tlir inii'ri>lt,v f>l l)i" imAgy nf tin*
■••tinil vyi, ami a|>i>mxiiiuii*- ft timri' t<» thai o( tli« iiir(M-tL-<t vav, trltoBe inu);^' "wtng
Ui Itu' r«via fntin lli« n)tj<-rt billiitjt npiin sn c«ctM>trio )KirUon ot the rrtiua. will bt
Inw iulttiuw ill pmportirin to tlio <li»lAiir« of lliv Kpal, iijion wliirh lltt- ri>.v» taU, (rnin
tli« macniM Inica.
tTtiii) <liir.*rr<iu-i> fn th<> diitliBclnms of tli« itna^ i§ tiiil aWv" twitiord by th^
raliritl. an<l, wbiii llicv arc v«rr widi' nnntt, tlifl falM iuuwf tbay tioi bw aoil(,-Ml at
all— It.]
/
f^
i
ISTBODCCTIOX.
47
The rcTcrsc will occur if we tarn the prism with ita base to the temple,
for tlnrii the r»ya will be deflected lo a portiou of the retina to the outer
K'ie of the macula luten, ami the imn;^ will be projected iiiwnnls aeruM
llint of the left eye, ami crossed diplopia will lie the result. In order
III remedy this, the iiitenial rectus wilt contract and niov« tlie eye in-
wards, *o a<t to bring the tnncula liitrn to that !tpot to whieh the rays
are deflecteil. [^/'ritum are oceuioimlly useful in examining feigning
pativnu, for the correction of diplopia from alight stmbismu^, for esti-
laating the strenj;th of tbe internal and external recti, and other pur-
pwKs. 'I'he internal rectus can overcome a much stronger prism (^hasc
oatwanla) than the external (base inwards), whilst the superior and
inferior recti are ittill ivti able to cau« corapensalory niovimient* (baie
downwanls or upwartli^) ; and. in undeavorin;; to cause diplopia in an
cxaminiition for railingerin^, it i<t best to use n rather woalt prism (about
*»■'' or 8"') with its bjwe up or down (Nettleship). — B.]
Thr ijoinjfre** Bandatje. — The form of bandage to bo omployeil, as
as \U nwuXe of application to the eye, is of much practicnl imjior-
_ ce, niid it j^hoiibi vitry ncconling to the effect nhicb we desire to pro-
duce. If lliL- bandage is applieil only for the purpose of keeping the
dressing upon the eye, of preventing tlie movement of tbe tatter and of
tbe eyelids, or of guarding tlie cyo against tlie efToct of light or cold, it
ueed but be of a very simple kind, and I think Licbreich's bandage
auAweni these purpusea best. But Von Grtiofe has shown that the
compr*'HH nud Itandage may often be made of great therapeuticAl value,
especially in arresting and limiting suppurative indammaliou of tbe
coniea, such as is apt to occur in old and decrepit persons after injuries
to tbe cornea, or an operation ('.-. </., extraction of cataract). In auch
CA8C6 Iiiebreich's ban<Uge does not suffice, and wo must employ the
press n re. bandage of Von f5n>ofe.
I.ii'breicbV bandage [Kig. \'1\ consists of a knitted cotton Kami [a]
about \'l inches long and '1\ inches wide. At Uio one end are two
tapes, tl)c one [c] going round the back of tlie head, the other [nj form*
ing a cross-bar with the Rrsi, and pasiing over the top of tJic head. The
otber end of the bandage also carries a tapi- [kJ wliicb is to be tie"l at
the aide of the head, opposite the affected eye, to Uif lUte [ci>] coming
ronn>l from tbe back. [Kig- I't representj* the bandage applied. — H.]
The principal adrantages offered by this bandage arc — that it i^terfcctly
48
INTRODUCTtOy.
y^4
retAma its position witliout Alippmg, and that it can be undone and tbo
drett»in};s changed without the putient's bend having to he rai^^od from
the pil1o». If the thick knitted
[PIf. 13.J hand proves heavy and hot, 1 sub-
stitute for it a band of &uu iDualin
or rif elaHttc wch. The banda;*e va
to be applied ov«r thv following
dreastug: The patient being di-
rected gentlT to close hia eyes, a
iiieco of 8oft linen is laid over the
ids m m to soak up anjr discharj^e :
small oval pled;;ets of cbarpie' or
canled colton-wfiol are then placed
. m ^m over tliiii, more espreiiilly in cho
i V^^H holiowii al the intiide of the eyeball
and beneath tlie npper edge of the
ortiit, 90 a« to fill the«e out, and
bring the padding nearly to the
';imc level ns in the centre. The
_ j-rt'saure of tliis cushion should be
ii^BB^K 't^ite ui)iforiu,and not greater upon
one portion of the eye than another,
more especially upon tbe centre of
ilie eyeliall, ntherwieo it will pro-
iluei! )>ain and discomfort. The
fiueceiii^ion of tlie ptedgeta of charpie
flhonld he applied in sucb a manner
that the upper lid is j^ntlv stretched across tbe eyeball in a lateral
direction, and the lids tliu*t Kept immovable, 'flio two principal pointa
of pressure should bo at the inner and outer canthus, so that tbe eyeball
is ordy preitsed by tbe up[)er lid being stretched gently across it.
Von (iraefc' raakc!) u^e of throe different forms of compressivo band-
ages— 1, the temporary ; 2, tbe rej^utar compress ; 3, the pressure com-
press.
1. The tempvrnrif tutudaijt slioply consist* of a knitted cotton band
about ir> inches in length and 1} inch in width, which is to be placed
over the eye and fastened by a couple of la|ie3. For this pur|>ose I
think Liehreich's bandage is to be greatly jireiferreil, Imt with the next
two fomui of bandage il is difTerent, for here we can regulate tlic ilegrce
atul mode of pressure dcdred with a nicety and accuracy not to be ob*
tained with Iiiebreicli's.
2. Tfif Hftjular CmnjireM. — This lianda^ is about 1| vard long and
H iiicli wide. Its outer twn>third« c^nisiitt of 6iio and very elastic
Hanuel, its central third of kuitted eottun. The uyu having been padded
vW<;
4
■ Chnrple oonaisU et ihrMMla or very litfi llarn ; the 11um skould b« cut Into
•tnitll iW|il*r<Li« of Ahniil 3 «T 4 innhni in iliatDpl<>r, atul ihr iiKlirirliikl thrv«da «r«
llixii l/> lx> puUinl out, lltBf fortulHic ihi' otiat|>(<i, whirl* ulioul't h>* folttf^l luto sniill
Itl-Mfi'U. Tbii b luoch tu-lf-r aiul morw nnulnrtabla) Umu e«ll«n-wuu[.
* .\. f. O. ix. 3; TulomlaoKn KbrUgnMot «r thla |«p«, \>y \\\* autltor, In ft. L. O.
U. Krp. r. i.
tXTBODUOTIOH.
49
with cbftrpie or cotton-wool, m ntrovc directerl, the bandaf^e ia to be thaa
IjiKtcd; One eiitl ic to lie a|)|ilicil to ttic forcliwul jiiat nlxiro the
ft'cu'd cTc. STid i-« then lo be |nis'tcd w ilic opposite side of the fore-
licad mid alrave the ear to the bsck of tliu hcitd : tite ktiUled imrtion is
next carried on helow tlie ear mid hrouglit iipwanla over the comprcsst*
the bandage being then again passed across the forehead and tU end
iitr pinned. The opposite eye may bo closed *-ilh a strip of piaster,
>r, xhoiild it also require a compress, a sejtarate handa;;e ia to be applied.
3. The jtrraurf ftimia^/v in made of line and very elastic flannel, and
should be almnt. ;ij yanld Ion;; and 1^ inch wide. It is intended to pro.
duce complete inmiobility of the eye. and to exert a considerable degree
of graduated pru><>iurii. The one iix\i\ of tbo bandage is to be placed
Ofwiii the ehfelt, at n ]ioirit Bl>out midway between the angle of the jawr
and tho ear <if the affectud eide, and the liandage brought up over tlie
compreF« (but not applied loo tightly) awl carried acni88 tlie fondiead
to tlie back of the head : and then, paesing beneatli the ear, a «econd
turn ifl to ascend (somewhat more vertically) over the compress, proasin;;
firmly ufion the latter. The bandage is then again carried acroas tbo
forrht'ad (<■ (he back uf llie liead. and finally brouglil once more over
the c<)aipre!'.s, hut this time it 18 not to he pulled tiglil.
Bartm H«uritloup*t Ardtinal I^eeh. — This instrument is of the
Sreatest sernce in the alotniction of blood in deep-seated intrn-ocniar
iveaacs, aa, for instanee, in iiiHunnnntiona of the choroid, retina, and
optio nerve. For, in order to rv-lieve the intrn-ooubir circulation, it h
necessary tttat the depletion i^hould be rapitl. and we find that in the in-
flaiomadone of the dce|>er tunieg of the eve, depiction by leeches is
almost UBclcsa. whereas the effect of the artificial leech ia very consider-
able, llie instrument consists of a small sharp cylindrical drill, and of
a glafis exhausting tulw, with an air-tight piston. The drill can be »t
•o an to make the incision of the desired depth, and ia worked by a
string, on pulling which a rapid revolution of the drill is caused, and the
ekln conseiiuently deeply incised. The instrument ia to be applied to
the temple, and the hair should be previonaly shaved oflF at this ajxtt,
otherwise it will get between the skin and tIte edge of the exhausting
tube, and thus cau&e the admission of air. The incision should be made
tolerably decji (the depth varring of course with tiie thickness of the
Hkin), in order tliat the blood may tlow freely and nipidly. The air-
tight piiiton ia then to be applied over the incis^ion, and a few rapid turns
given. 5o that the skin may be somewhat sucked up into the tube. The
blood will now flow very rapidly, and the screw in the pi«ton must he
moved in acconlance with the flow of blood, ao that no vacuum exists
between the plug and the column of blood, nor should the screw be
moved rnu,:^hly and too qnickly, otherwise it may produce great pain.
The glass cylinder (irhich huKlM alxiut 1 ox. of Mood) should be filled in
from three to four miniitcfi. The plug of the cylinder ahould be soaked
in but water previous to the operation, so tliat it may swell up and fit
ver^' UghtJy into the tube, and the edge of the latter, which is applied
lo the flkin, should be greased i>r soaped, in order that it may fit chisely
to the skiu, and prevent the entranco of uir. With a little practice tlie
ISTBODUCTIOK.
oiK-ralion maj be gently yet effecltially [>ertoniU"il without gtviiig mucli
pain to the patient, ifot fomcutBtions should be applied afterwards, so
that there may he free after- bleedinj;. As the abstraction of blood near
the eye always vuuties considemUo incivai)« in the Qow of blood to thu
{kiirt Hiid iu viuiniiy, the pacii-tit should be kept in a darkened ronra for
tlie fir5t twenty>four hours, until the period of reaction is passed. At
6rst the sight will be a little dim and itidit^tinct, but »fter thirty or
thirly-six hours have elapsed, the beneficial effects of the depletion ntll
f;enerally be marked. [There are some objeolions to Ileurtcleup'a
leech, the chief of which ia that a pennanenc aciir often results from tfio
irrej^vilar incision made by the drill, which jj* worked by a lateral motion.
A moditicatioii of Lliis apparatus Uac; Ihwii made by Dr. F. it. Litrinj^, of
WojihingtoD, in which the lateral motion ha:^ been changed to a vcrtjenl
one, by putting the drill in a cyliuJer, and working it by two latiral
pii^tonH, joined at die extremiticft to a disk of the same diameter as the
iticlotiting cylinder. A full description of the instniraent may be found
in the " Archives of Ophthalmology," vol. viii. Ko. 1. — IJ.]
The Ejfe^Umvhe. — The best and cheapest form of this iustrunicnt
coiisiflts of a piece of India-rubber tubing about 4| feet in length, carry-
ing a ro«* at one end, and at the other a curved piece of metallic pipe,
which is to bo suit{>eDde<l in a jug uf water placed on a high shelf. The
fine jet of water thrown up Uiroiigh llio n>w will hi* about 1'2 or !.">
inches in height, and the force with which it jil.iyi!. upon the eye may f>e
regulated by approximating or removiug the latter from the rose. This
form of eve-douche is to be preferred to tliat which i» applied by meanit
of a cup to the eye itdelf, as the jet is in this case far too strong, and
often increases instead of alleviating the irritation. Jt \?. to he em-
pl»yed night and tiiorning, or oftener if the eyes feel hot and tired, for
two ur throe minutes at » time. The eyelids are to be uloeed, and the
stream of water is to play gently upon tJicm.
Mathieu's (I'aris) water atomiier, or the instrument used for Dr.
Kiohanlaon's ether spray, will also be found very useful and ^reeable.
[Vanoiis forms of atomixcrs have at different tJmes been recoin-
uended, and in stmie cases they are extremely useful adjuncts iu the
treatment of conjunctival and corneal affcelions, thongh ophthnImic sur-
geons are ilivided in opinion as to their practical value over the ordinary
way of employing moist eolil ami warmth to the eye. — B.]
HYPERAHIA OP THB GONJDHCTIVA. 51
Chapter I.
DISEASES OF THE CONJUNCTIVA.
1. —HYPEREMIA OF THE CONJUNCTIVA.
AVg not unfrequently meet with a hyperseinic condition of the con-
junctiva, and it is of practical importance to distinguish this from a mild
form of conjunctivitis. In the former condition we find, on everting the
eyelids, that their lining membrane is abnormallj red, and perhaps a
little swollen, and traversed by well-marked meshes of bloodvessels,
which render the Meibomian glands somewhat indistinct. This increased
redness may extend to the retro-tarsal fold, caruncle, semilunar fold, and
even to the ocular conjunctiva, so that the white of the eye appears
flushed and injected. The papillae of the conjunctiva may also be slightly
swollen and tur^d, which gives a somewhat rough and velvety appear-
ance to the inside of the lids. The patient is generally troubled by a
feeling of smarting and itching in the eye, and a heaviness and weight
in the eyelids, so that he experiences some difficulty in keeping them
open. These sensations become worse in the evening, more especially
in bright artificial light. Sometimes there is a slight tendency to lach-
rymation when the eyes arc exposed to wind or a smoky atmosphere,
hut there is no trace of any mucous discharge.
This hypersemic condition may he produced by long-continued work
at small objects, such as reading, engraving, microscopizing, more espe-
cially by strong artificial light. It is also not unfrequently a reHex
symptom of hyperBeroia of the choroid and retina. Thus, in very short-
sighted persons afiected with sclerotico-choroiditis posterior, we often
notice that the conjunctiva becomes flushed if they persist long in read-
ing, sewing, etc. Again, we frequently meet with the same thing in
persons suffering from liypermetropia, who cither do not use spectacles
at all, or of insufficient power, so that their accommodation is strained
and fatigued. [The presence of myopic astigmatism, one of the most
annoying of all errors of refraction, is not an uncommon cause of chronic
conjunctival hypersemia, wliich may end in marginal blepharitis if un-
corrected.— B.]
It may also be caused by an irritating condition of the atmosphere,
n. g., cold wind, dust, etc. Or it may be due to mechanical irritants,
such as a foreign body lodged under tlie eyelids or in the cornea, to in-
version of the lashes, or an obstruction of the lachrymal passages.
The treatment of hypera^mia of the conjunctiva is very simple, and
52
filSSASEB OF THE CONJCSOTtVA.
BlionM be cbioflir <lirectc(l to the riMtiovftI of the cause. If it be hrougbt
oil bjr overwork, cfssntinii from this must Ik- cnf"irce<i, and if the* patient
suflcra tVorn bypermetropia, tliis must Ke irviatcil hv tJio proper use of
Bpectacles. The eye-douche or the atomiser must be fretjni-ntlr asert,
and the evolida sbouhl be bathed with an evaporating lotion, which
greatly relieves the feeling of heaviness in the lids. The following
totions will be found very ufiefu! for this purportc: —
1. B Sp. scthor. nit. 5j ; Aeot. aromiit-^jti. vj ; Aq.dc3lill.3vj. To
be sponged over the closed eyelids and around the eyes 3-4 timea daily,
and allowed to evafmrate.
2. R ^^thcris 5ij-3>^ ! Spir. roaraar. Sir. To be nsed in the same
way aa the above, but in smaller i|nanuties. especially if the skin be very
dehoatc and su.«ceptilile. The boatasirin^icni loiiona arc those composed
of 2-4 grains of ««l]iliate of zinc or acetate of lead, in 4-C cm. of water.
A j»iec(' of folded lint saturated with this lotion ia to be laid over the
eyelids for In or 'ZV minutes several times a day, and a few drops may
be allowed to enter the eye. [A solution of one drachm of powdered
borax in four ounces of camphor water is a very useful and soothing
lotion in these caaes.-^B.'l
liiH if the hy|H>neniia has become cbrontc, these applications will not
suffice, and it will then he necessary to apply a drop or two of a weak
coUyriuni (gr. j-ij to 5j of water) of Kulpliate of zinc or cojipor, or even
of the nitrate of silver, to the conjunctiva :' or the sulphate of copjwr
or tlie htpis divinns' may be lij^htly applied in substance. The eye-
douche or eold compresses should be usetl after these applications. I
moat here call attention to a very prevalerit popular error, namely, that
it strcujfthens the eves to dip the face into cold w.itor with tJie eyelida
open. This habit is, however, to be condemned, as it often produces
much irritation and hypcrtemia of the coajuoccivB.
B.— CATARRHAL orHTHALMIA' [CONJL'NCTIVlTIS^a].
The term "simple conjunctiritis" should, I think, brf altogether dis-
carded. It ia, in fact, only the mihiest form of catarrhal ophthalmia,
and heDoe there ia no reason to make it a distinct disease.
* (Vtlttrrui km tw«t «i>)>1ic<I wiili a rxrarlVliitir Itruoli or ihp IidUuw |«rt of * qnill
jirii, M-liirh ie nwi k> W vat ]»iii>.i.tl (m tor «rriiiii»:) l>iii r\>iiii>l>^l ulT. Ji mull hole Mag
rni in lh<* Dpp<^r fiiirl. i- ilint llic air rihv ritli-r aitJ ruror tKil tlin iiqoM. TI» for-
g«-.iti »liiiiiM si.Miii rii fi-KEi; ,.f ili<>|Mlit»ii. iinil, <lirwtliig him to look upw»rt», rAtto
tbf H[>[HT 1i<l m'nh ilip f.irrliiii[.<r of his left han.i. .tn.l d<<i>rt«e (»nd uliirlitly cv-^rl)
111* lowft III! with ilt^ il.imib, in tliis »■,» a llitic i-.utli m ftinofol Wlwi-^n ll.e larifr
lul Btt<t llio xji'liatl, into wliii^h tliptlmpu i>i be [Hiiirvil. Tli^ pati>-nt ■Iioulil then
tub ib4' liila w«ll ivfrntlm, rm xhxl tlit* ralt,vrium nui,v mnip Id aidUcI with lh« whvlc
o( the MfiJuitiHiVftl sarl«c«. loiitMul of 'ihr qaill tir brtuh, iIm* >io]iiNft tif a dmp-
bultl*. k* k>>til lir itMBt rhviBisU. ni«» bi- u»nl.
* Ijit'"* 'llvinns !■ «iii»prti,»t (.rr.]ii»l pnrt* frf-nlptmt-of onppar, nitrate Of fOtim,
uid «liiiu, vkich : '• nrr l>< Ih- • li-ks.
[* Tb^ t»nm '•'■; twiuj; ttf v , it is a mistake ta OM Uwhcu
■p««klag«(nmjn: w,«. nnA, tiim^n n.^n.. mlv «o vin]>lnrHi, !l aMius brtUr
to Qielh«t«m ■• ^i»." mJ wiiiin* ih^ wi-nt '-ophthatiuia" to tli» gawwal
tnllMBiBrttocii of T I „., niMciatlv thiit fcriu wbkl> bu iu teal in tbv cOurj
boilr, aail vbldi u kaowo m '•»riiip«thiitw."— IL j
CATARRHAL OPlITBALMtA.
58
[Fig. 14.
'I yU
\
AfUrT.V. JouM.]
Tf the ocular conjunctiva 13
Od 4^vcrtinf; die eyelids in a cnso of cntarrhal ophtlialmiA, we notice
that Uie coujunctiva 'u reil, rastiiitar, aii<l swollen, no ttiat the Meiboiuiaa
glandtt art' nearly or wntirclv hiiMcn. The hvporKiiiift coniraeiicea at the
tarsal poriion of the conjunctiva, to wlilch it in.iy indeed remain con-
fined in very mild caaei;. (tenentHv, however, it soi)n extends to the
retro-taraa! fold, earunclo, sciuiliimn- told, and ocular conjnnciiva, reacli-
ttiK pGrha[)M iiutt« u)> U.} the eilge oT the
coruea. As the diseftRe suKtidcR, tlie vns-
colarity retraces its steps in the reverse
direction. It i^ iinfioriant lo di^^tin^uish
the vftflcularity of iho ocnlar conjunctiva
from that of the subconjunctival tissue.'
The former ia characterized by a superti-
ctal network of voaseU of a hrick-rcd or
•oltIvI color, which run up to the eii;2;o nf
tfie eoniva,and are freely movable upon
the sclerotic. [I'ifr. 14,] The meshes of
thid network are coarse and large, more
etpeoially towards the region of tlie retro-
tanal fold. Ou and between thcni are
often noticed coarse red fvatchea of cxtrav-
iTifd blood, particularly near the cornea.
I'i'ii them' vlTusiorLt an- aldo seen iin tlie
p:il|.fbr.'il conjunctiva and rctro-tarsnl fold,
■I'tia- nuplicated, tJie white Bclen>tic can he itnon slnniTi;; through the
vawular nie^he«. But it is difterenl if the gtibconjunctiviil lix^ue ia also
jjnjcctcd, for we then notice fine parallel vessels ot a ro^y tint, mdiatinj^
>w&rdA the cornea^ around which they form a pink zone. These vessoU
not niovabto upon the sclerotic.
Tbo eyulidd are generally eoiuowhat swollen and red, and their tem-
perature is perhaps slightly increased ; but none of these symptoms arc
#u marked as in purulent opiithalniia. Occa^ioQally, tbe ccderaa of tbe
^tdidH is so considerable that the upper lid hangs down in a mac^aivc fold,
and overlap? tlic lower. The edges of the lids are usually somewhat
red ami ©wollen, and at a later stage they often become mrc and exeo-
iated from the discharge and the altered secretion of tho Meibomian
laodx. Indeed, th^s irritation may in time give ritio to marginal ble-
ffibaritiii.
Thr ilegreo of stwclling of the Hds doe« not, however, ncccsaarnycor-
fVT*|)oud to tho intensity of the di9ea.se.0r the redness of tlie cynjuucliva.
Thoa, ia focble subjects we sometimes find thai there is great tiedema of
* W<' niKjr diilingiiHli ihfut kind^ of macalsrily on the ayi^liall : 1. Thr- raiijiin^-
UtjU <r*»«-U. ttU[<;li mv bri«k-r«x], Isrgt-ruMhoil, sikI fr.K'ly iuf>vi(bU'. Tliujr oiJii*i«t
^bMb al rcitu ind urtvrics. i. The Bubconjunuttval ynsi'Ib. whir)! ati? of a pink,
■T tint, tli^fr in«i>ii«H tM^liig sntnlli-r, luit) tlie vitsKvIa imliAtiiig in n jinrnlli»l dirr^tlnn
t II- of Ui(! p"rn.>«, arnuixl vlikli tliay form a rney ioue : llifsn vi«si>U
I <is. 3. Tilt! Hcli-rutiir 7i>KM'ls, wbioli ilo not n|>jwiir in tll(^ fonu of iliA-
I <ii.< -, iTiii . - — 1-I4, but a* aiuxll ill-ilvflue>) r>>il [iniijlit><t, which l>-iii| n btiiisli-i'pit
Iblti'tli tc f f lint nrlrrDtl'". For tiili>rniatii)ii (la lo ihc bliioilvsefiB of thif
'*yK, I wit,: . .■ rewler tu Lebi-r'» im|>ufUnl rviitiAreliM, A. L 0. x'l. 1, 1 ; and
tt«< to Uk»« of DoiKlen, Klin. Moiuteblitt., 1^04.
54
DISEASES or TnE C05JtISCTIVA.
the 1)(Id, leatiuij; »a to atupect a serera fona of the Ai^^ssc, nmi jret» on
oporiiD^ the eye, wt iir« Aurpriited to find but <ili^t injoction of tlie (>alpe-
hnil and ociiliir conjunctiva, and but little, if any, dLsi-harg?. In sach
cases wf slionid pxamitie as ii» tlic t'TisteTice of an liordt'olura. or whetlier
the patient baa been etong on the lid bv nn inwct.
Id the severer caaeB of catarrhal opiitholmia. we 6nd that the conjunc-
tiva becomes verv swollen, mow especially In tlie region of the r*tro-
tari)at fold, so that, on comiderahlo eversion of the cvelids. it flpnD;*K
into view in the form of one or more thick rod p^iniloa oncirclin;; the eye-
ball. The caruncle and ACmilunar fold are als>o snollen. an'I «59utne a
dark red and lleshv appearance. A t an early etajre of the affection, the
swelling of the eonjnnctiva in firm, and lends a peculiar lu-stroiis and
glixteaing appcarunoe to the inner eurface of the lids ; bat later it be-
comes more fiacoid and soft, and falU more readily into fohb. The
pspillte of the conjunctiva ;;enerally become swollen and turgid, often to
ft eonaiderabltf dc^jrce. so that ihey pve a roujjli, velvety, and ao-eailed
" granular'' appearance to ilic conjunctiva.' In severe ca«es, e<i]>ecially
ID old decrepit jwrsons, and after the lon;r-contiDued use of coM appUca-
tiong, tlif ocular conjunctiva may also become flwoHen (eheiii'>8i.s). whiob
h due to a serous, or perhaps even plastic, infiltration of the conjunctiva
and nuhconjunctival tisi>ue. In the majority of casoK, however, thcche-
mo^iii U but very flight.
llie discharge varies in (juantity and t^uality, acconling to the stage
and intensity of the aSeciion. In the early suiges, there is generally
only ail iocreaaed secretion of tcan, hut the di^harge soon becoroe» more
opaiiue and .-ttriuL'y, and of a veltowislwrcd tinge, conriiAting chietly of
albumen and broken-down epithelial celLs. Aa the di!teii:<(< advances,
and the inHammaiory mymptoms ii»crea*e in severity, the dischar^ lie-
comei^ more copioutt and of a muco-purulent character, the piu uelH being
9U!«pended in the mncus. It then also assun»*f( a light yellow color, and
a liiickcr and more creamy cou^iflteoce. In very mild caM;s it is oftea
*i> slight in quantity that it might easily escape detection. Pcrtiapa it
is only on very considerable eversion of the lids, that a thin yellow atring
of matter U ubserrcd to be imbedded and almost hidilen in the fulits of
the conjunctiva, or collect»'d in the form of a sranll yellow head at the
angle of the eye. The lashes are generally found to be somuwiiiit glued
together in the morning by the discharge, and the altered and increanetl
secretion of the Muibtunjun ^Innils.
There is generally very Utile pnin in catarrhal ophthalmia. The
patient only complains of u feeling of heat and itching in the lid^. which
causes bim to nib them freiiueutly. Hiose sensations increase towards
night, an<l manifest thenaielvcs osiK?cially during reading or writing by
artificial light, or in a croaided and smoky room. Tho eyelids feel stifle
and heavy, so that it is difficult to open tbcm, this is especially the casv
* In DoiiiK ihfi l«>rw "granulsr" for this s|>|M-sruuH.> of tbeflonjniwiiva, I miut
StroBglT inaiiit ii|H>ii ilii* uri-Jii tii'oiuijt/ i4 iu>i oiii(iruiiiliU)c iliU ciitultlion <alili Uuil
•t( tra** ^Mtnlar liiLt, wlikliit Imi loo >}t\ta tlvui; atnl wliinii liu l<-l t-> yty trri^l
(vmfnaiaii, »iit ni>l.v In tli<- <li«4(a»Mn, bai alito in ilii- trfatiiMiit r>vnRim<-n.|M fi>r tU'-*^
AlflnRtiuns. Ill tilt' t'nii'T i-iut, llm |[riiiiiilar .i|>|H<Atan<><* i* ■>iiii|ilj ilitr In tlu' inlll<
trattl Aiul targtil wii'litiiiD ^if tiw fNifjllic. wL«r«u Uie ttn« ,grauulBtKKi<i »<• a nt-w
binaalinH »T a |H<if«ctl/ dlffrroDt ckarKltf.
CATARRHAL OPnTnALMIA.
55
if Ihc liiU arc rather light ami jn-eM upou the globe. One of tlie most
chnnicteriftii; svmptoiiia i« the sensation as if a foreign boily, such aa
kvimI, grit, or finely-powdered gUas, were lodged under the Iid3. This
18 owiileutljr due, su vas pointed out by Muckenziv, to tlie friction of the
8«olicii jiftiiilljo [or mope likely of theenlBrj;edhh>o«lves.'»eI>* — B.] aj^ainst
ihi' ocular coiijunctiva. Tlus sensation shoiiKl, however, remind us of
the fact that tlie syin[i|i)tn5 of catarrhal o|»htlinIniin, viz., conjunctival and
wihconjunctival injection, lachrymatioii, pain, etc., mar he produced liy
a forc)^ body, and the inner surfaco of both lids, as well as the cornea,
ghoulil therefore bo carefully examined, in order that we may ascertain
whether a foreign body he pre*vnt or not.
There is generMlly only a (>li;;Iit degree of photophobia. If it is
Sfvnrc, and Accompanied hy much lachrymntion, subconjunctival injec*
tiim, and considerable pain in and around the eye, more particularly
over the hrow and down tlic side of the nose (ciliary neuralgia), ic is a
sijjn tliftC there i» much irritation of the ciliary ueri-es.
Vision 19 only in so far affected, that objects may appear somewlint
haxy And indistinct, aa if seen through <;round ^laiu, wliich is due t-o the
prestfucv Iff a little of the diiM:har};;e upon the conieu. The patients aha
notice u)um::L' viditanies in the shape of itlrin^ of fino hcaiU (lontiuj;
throu](h the field of virion, thcM arc produced by mucus and little Halccs
of e|nthelium bein^ washed over the cornea by the moTements of tJie
cyelidfi. For the same reason, the flame of a candle often appeam to
Irf- durroundrd by a colored ring, whicli. however, also disappears when
the liils are rubbed. I need linnlly point out that tliis should not be
confounded with the luminous ring round a tlame, which is one of tlid
[irvmonitory symptoms of glaucoma.
Catarrhal ophthalmia may be cauitod hy- sudden changes in the attno*
sphere, by exposure to cold, drau);ht, and wet, or to great heat and
part*, na, fur instance, frnm a blacksmith's forge, or a large cooking
fire. [It i.s a very common di^oi-der among cigar makers, who are con-
stantly exposed to an atmospliei-e loaded with fine panicles of tobacco
dost, and whose fingers, furthermore, being constantly coated with this
same dtist, keep up the irritation in the eyes whenever they are brought
in contiiet with them. — B.] l<ong confinement in hot, smoky, crowdeil,
and ill -ventilated rooms may Uki-wise pmducc it, aa also eTcesiiive use
of the eyes, esjwcially by artificial light. Or it may show itself in con-
junction with, and he a part symptom of, the affections of the mucous
membrane of the no«e or respiratory organs. As a continuation of tho
common integument, the conjunctiva may, moreover, become affected in
the acute exnnthemnta, as in smallpox, scarlatina, and measles, also in
erysipelas, herpes zo»ter, and ecaema of the face. It may suffer con-
Rrcuiively in affections of the eyolttls, as for instance in eolrojiiou or
di.MichiAjdii, or in those of the lachrymal apparatus. Indeed epiphora,
dependent upon some impediment to the free etilux of the tears, is a not
unfre<|uent cause of ob'^tinatc and chronic inflammation of the conjunc-
tiva, which readily dit^appeara as soon as the liiclirymil affection is
pnrcd. Undetected foreign bodies, or injuries from ineehauical op
ihemicnl irriu^nts, may aUo give rist' to conjnnclivitis.
Kiualty, it may be produced by contagion, more especially if tho difl-
56
D[ilEASB9 07 TUB CON JOSCTI V A .
cue is At all severe, if the swelling extends to the retra-toraal fold of
llif »p|)er lid, and the discliarge is of a muco-puriil(?nt character. It
ahuosi always repn>tlucert catarrhal opliihulmia, and mi\y in rara casos
giire« rise to the purulent or diphtheritic form.
The prv;fnon9 of caturrbal vpblhultnia it favorable, for the affection
18 very amenahle to treatment. The mihier forms jieiicrally run their
course in a few days, the more eevert* iu two or three week*. Th«
cornea becomcH but seldom iniplicatud, and oven if ulcere )>hould foriu
upon it, they are generally quite superficial and pfriphend, so tbnt nt
the worat ihey only give rise to a slight opacity. Unly in very severe
cases and under very injudicious treatment do the coniea and iris par-
ticipate to any dangeroua extent.
If the afTocliou is neglected, it may become chrtmic and prove very
obstinnte and iutmctaUe, more especially in old persons. The conjiuu;-
tiva btfconiL'S Haecid and rough, and this may g>ve rise to superficial
[Keratitis. — B.] or ectropion, particularly of tlie lower lid.
ITie trttUtHfHt must vary according to the stage and the severity of
the disease. If the eye is very irritable, and there is much photophobia.
Inciirymation. and ciliary neuralgia, accompanied by conjiinctivul and
marked dubconjmiclival injection, astringent lotions should be carefully
avoidcil, a* they would increase the irritability, or might even set up
iiiSammation of the cornea or iris. In such oases, the lids should he
veil everted, and a earcftU examination made as to the presence uf a
foreign body beneath them, or upon the cornea. If none is detected,
tlte condition of the palpebral and ocular conjunctiva and of the cornea
and iris should next be ascertainL-<l, as theao 8ym|)ioms of irriiauon
may be due to phlyctenular ophthiilmia, or to a commencing inflamma-
tion of the cornea or iris. In this condition of the eye, it is often im-
possible to decide whether it is simply a case of commencing catarrital
ophthalmia accom|tanied by unusually severe svm|>tom§ of ciliary irrita-
tion, or whether it is a case of incipient corneitis or iritis. It is, Uiore*
fore, always the wiaest plan to leave the ijuestion of diagnosis open,
until the real chamcior of the affection becomes mora prououuced, and
to cixleavor to alleviate the symptoms of irritation by southing applica-
tions (sQch as atropine and warm fomentations). By so doing, we guard
mirsclves against committing, perhaps, a serious error in treatment.
For if it should turn out to be a case of catarrhal ophtiialmia, astringents
may be <fmployed as soon as the symptoms of irritation liave somewhat
sulwided, aud the discharge bas assumed n muco-purnlenl character; if,
on the other hand, it should prove to be a vase of corneitis or iritis, the
treatment has been most appropriate and jwlicious, whereas the use of
astringents, more C5[iceially the more (towerful ones, would have been
verv injurious.
f he patient should be warned to guard bis eyea against exposure to
wet iir lold ; and to ut>stain from all reading, etc., more especially by
arti6cial liglit.
In order to relieve the ciliary neuralgia, hot poppy fomentations
thonid 1)0 applie'l to tlio eye ; but if tlie patientshould Wof a Hu'umatic
habit, the moUiure may produce considerable oedema uf the lids, aud
hot dry flanaela mre therefore to be preferred.
CATARRItAL OPnTHALMIA.
57
•
A flolation of atropine (^. ij (o jj of water) should bo dropped into
tlio L'jM two or three limed a d«y [Alropiiio is umieceAjary except when
thr |iain is severe, and shouliL not be used in these cases genomll^*, be*
caii«c of it^ I'tfcct on the vision, which is sometimes depressing to the
patient. — B.], uiid the follriwing oompound bcUadouna oincment shoald
Ue rubbed over the forehead : —
B Kxtract belhidonmc j;r. x ; Hvdrar^. ammon. chlorid. gr. v ; Adip.
3j. M. A fioruon of t}its itt to be rubbed over the forehead three or
four times daily, and shouM be covered by a piece of thin ti»sue-pa[)er,
so afi Ut prevvnt iti< drying and bt'ooming hard. It shoiiM not bo wuslied
off until it iH time for its re-application. In the conrne of two or three
dAYS a slight piipiilar eruption will appear, when the ointment is to be
diM.'oritiniieil. [Kt^'liefiu severe easei« id sometimea obtained by ptiiitting
the external surface of the eyelids and the skin of the forehead and
temple with balsam of copaiba. — 13.]
When the acute symptoms of irritation have subsided, awl those of
catarrhal ophtlialmia — more especially a muoo-pu rule lit diftcharjie —
begin Lo show them-ielves, astringents must be applied. In tlio milder
cases, in which there ia not much conjunctival reilncits, and the dischari^e
is oliieBy of a mucous character, lodging in the form of thin, yellowish,
stringy flukes in the retro-tarsat fold, or the angles of the eye, a solu-
tion ol dulphate of xiuc or copper (1 or 2 grains to tlie ounce of dis-
tille^l water) Kliuuld be dropped into the eye two or three timoR tbily.
[Solutions of xinc anil copper arc painful, and therefore often objection-
able. A solution of iiliim, grs. v-x to the ounce of water, is Uie most
useful application in most cases for the patient to apply. — K.] If the
bliio< I vessels are much dilated, and the conjmictiva relaxed and flaccid,
a solution of tannin (gr. iv-viij ui 3j of water) is to be preferred. I
have also fouiiil mucli benefit from the chloride of tine (gr. ss-j to 5j),
which ia Btrougl;? recommended by Mr. Critohott.
Uut if the inflammation i:4 severe, if the di-'tchargc is copious, tlnok,
and creamy, these remedies will no longer snlHce, and we must have
recourse (o nitrate of silver, the strengUi of the solution varying accord-
ing to the amount and thickne.ss of the discharge. ?'or general pnrposea
m «oluuon of two or throe grains to the ounce will bo found the beat. A
large drop of thi^ should bo applied with a camet's-hair brush or a ipiill
^to the iutide of tlic luwer eyelid three or four times a day. The li'la
'lould Lhun bo nibbed witli Uie finger, so that the solution may conic in
^ntJict with the whole of tlio conjunctiva. The feeling of grit and sand
in tliu eye as well ns the laohrymation are much relieved, and will dis-
j)}H>ar for five or six houw. On their ruapptiaranco, the collyrium
iould he again applied. It may, however, be necessary to apply a
tUll fttrouger solution (^r. iv-vj to .;j) if the diaehargo is very copious
and thick, and if tJie affection has lasted for some time, or the mitigated
nitrate of silver should he applieil in substance, vide p. ti5. Before tlic
ootlyrium ia applied, the di^tcharge must Ho removed by the injection of
lukewanu water beneath the lids. This renders the action of t|^e colly-
riutn far more eflicacious. After each instillation of the astringent
coUyria/ cold water cumpre^ses should be applied to the Uds for tho
t* OaU/rla of nltral* of Btlver «ru morv pmiHTly oaostlo tUau nilriiij^ut.— B. ]
prssAsn OP thi cajrjcscrtvA,
I
•pScO of from a qnart«r U) half an fioar, being chaiigvd as soon a» they
hwmte ni all wunn. Tliirt will ^ro jrrrat rcliuf to the patit^nl, aad
»uUliiv the pain uixl irritAlton pro<litce<l bv the lotion.
Lakewann water slioulU he injt-cteil hr-tween the liih everj tno or
tlire« hour*, no Ha to waah awav the diwharge. Or the fulloTriiin lotion
rocriniincnded hv Mackenzie may ho cmplovcd with aiivanta;{c for tliis
f)iir|Mifte : B ilydruK. bichlurid. gr. j ; Ammonia: muriat. ;;r. vj : Aq.
(leittill. Xvj. Miico, A talflespoonfiil of Uti>) lotion is to be uitxed witn
n lahk'itiKKmful of hot water. In inihl caaes the eyvs should Iw fomented
with it thrc« or four (imrs daily, a little being permitted to enter the
eye. In (Tvercr canos it shonl'l be injected over the whole conjunctiva.
A little Bininlu ecrute or unsceiited cold cream is to be applied to the
vd}(ea of the tlda Ui prevent their sticking. [Vaseline is a very useful
npplteiition for this pur|>o»c. — B.] If crust* have formed upon the
la*he«, Uiey are to bo soaked with warm water, and then carefully re-
niove<l so ati not to pnxhice any excoriation. If the edji^ee or angles of
the liilii are *ore anil excoriated, the red nrecipitato ointment (gr. j-ij to
the drachm of Inrd) iii to he applied ntght and morning, or the wfehk
tiitrnte of uiercury ointment may he UHed.
The attendants muHt be warned that the discharge in catarrhal
oplitliatmin it) corttagioits, and tliat the tipongex, boncU, etc., ilAed for
tho pjitient niuxt be carefully kept apart, and not employed for any
other purpose. Snmp Mithore have expressed a dotibc as to the con-
In ;;ioiiHue!4ii o( cntHrrliid ophthuluiiu, but in out-patieut practice wv have
very l'rtM|iient opportuuitiea of seeing scvernl inemlicrs of the same faniilv
at1ecl<'d coni«vcutively with the discaM>. Constitutional treatment will
haiilly be rtxiuired ; the boweln nhould Iw kept freely open, and, if tho
patient m fi;et>l« and out of benltb, tonics should he administered.
a^PlTRlTLENT OPHTHALMIA.
(Syn. Kf^yptian ophthalmia, contagious ophthalmia, military opluhal-
mia.) [The disease ropi-esoiited by thettc three terms is far oftener a
jiranular Mnjuurli>iti* tliau a sujipurative proccini". Pundont conjuncti-
vitis would be :i better synonym, (\>njuni!tivnl bleiinorrhira. — B.]
Wo cannot dntsr a tharp lino of domnrcation between acute cat.irrhal
and purulent ophthalmia. The latter amy indeed bo regarded as a
morr sorere form of catarrhal ophtlialmii, in which all the symptoms of
this afleotion arc int'-nsilied in degree. The Itdj are more ivdenuitou«,
hot, and red, the |)al|>flind and ocular eonjutictiva more injected and
awollon, and the pupijlte more tur^i<l and p^lnli^enl. 'I'he obemosis is
aliio murv eiHutidonibJe, and the discharge is Uiicker, more copjotts, and
more contagious. 7*hn intlammation is, moreover, not confined to tht
coiijunctii'a. but citembi deeper, and involves aUo Uie sub-conjunctiral
tiwie. So that tlierc is not only a secretion of mnco-pundent (li$charg«
np< « Aurfaee of tho conjunrtiva, but also an infiltration of fl«ro>
%• I li into tho aafaatano* of this iD«rabmn«. The comoa is,
freijafntly and laore arrionslj iin{dicmted than to
PCUULBKT OPUTHALMIA.
5»
At th
the
commencptnent
m£ in Ui« e;e, as i
I
I
patient cxDcriences a senflatinn of heat
ami netting in lli« e^e, as it a foreign bodr, more especially sand or
;rit, were IfMl^ed beneath the creliiia. The eA'^es of the latter heoomc
Bli,;hlly ;»liic(l io;:ethc'r, and small bciuls of matter collect aii<l harden on
thi- In-^lii's nii'l at the comers of tlie eye. On everaion of the li'ls, their
linin;* mi-riihraite w (ntitvi to he very vascular, liwollen, ami of a uniform
reilneiM, so that the Meibomian glands can no longer be distin;^ui8he(l.
The rvlro-tai^al rohl,thc c:»rnncU', semilunar fold, and ocular conjunctiva
arc also nbnonnallr rcl and 9Wf>llen. The eyelids arc rod, jilijitoiiinj;,
and pcrhajM aninewhat puffy. At first, there is only conHiderable
lachrvmutinn, hnt the discharge aoou asanmeti n muco-pnrulent cha-
rncter. Iinvtn); yellow (lalcos of pns and broken-dnvm epithelial cells
stu|ieiided in it.
l.'p to this |*oint, all iJieso symptoms are only those of eatarrhal ophthal-
nua. Bnt, as the disease advances, they soon become more severe in
character. The patient often experiencea great pain in and around the
eye, which may even extend to the corresponding half of the head, es-
pecially if the intlammation be of a
rthenic character, in which case mark- U''K- '^•
cd febrile itymptouis may also present
then»rlve4. (tencnilly. tho ]iain di-
miniKhes aji «onn a.< the discharge be-
comes putuh-nt. It may, however,
a^in increa.'^o in severity if the cor-
nea becomes aflected, and ei^j^cially
if the iria or other tissues of the t^lohe
thonld become involved in the inHain-
■nalion. In t^eneral inllniumation of
tlieeycbati ('iinnophtli&laulia)tho [uiiu
U often excruciating.
Tho lachrymaiion and photophobia
increase, the lidi» becfime very swol-
len, so that the nppcr hangs down in Afuiy.ify»pu,]
a thick heavy fold, and tlicy can only
be o|K'ned nr everted with difficulty. [Fig. 15.] They are rod, gli»t-
cnin^r, antl •rdematous, and, if deeply pressed, somewhat tender. [Fhe
tntdenie9s and pain on pressure of the swollen TuU is a very constant
sign in Ibia dise.'we. — B.j Their temperature, though markedly in-
rreaiwd, never reaches a very high ile;^ree, and this, to;^ether with the
ahMUt-e of tenderness, is of importance in the differential diagnosis be-
tween purulent and dii)litiieritic Dphlhalmia. The conjunctiva heooincs
vascular ami Hwtdlcn. and [■awhes nf ffficied blood are notice*! both on
it! pali>pbral and ocniar portion. The papillae are very turgid and promi-
Dcut, givin;; u rough and villous appearance to the inside of the tidti.
Aa thev increase in size they become flattened at the sides, from being
prp!W4><| a^;aiti5t each oUior. and they appenr arranged in rowa without a
distinct hnsc The prominence may he «o eonsidcrahlp that they a^isnrae
the appearance of caulillowcr excrescences. They often bleed freely on
the alijihtfdt touch, as their epithelial covering is very thin and easily
ahcd. Tlie rctro-tarjuil fold is mnch <«wol1en, and, on cversion of the lids.
%
IZiEAiSS .F THE :? ^ rUSCT: '.'a .
■;_,. •->■,.. .^. y^.^ . .;;iiji- ;■.■•„■; :;iit:^va .'tx"':ime:; 'rtrj '.■nae-iiir. ai-i a s^nxis
■ -- - ■ -i:w:L' inco :r. in-i :h«* jubcon-
-~ ■nncrivai ■isae. '¥\z. !•>.'
^^ .i^^^ ^^^^ riiii ;a*rEQOsis la Tar nnjrv c^rk-
^^^^V ' ^^^^^^^k. ''^ '^'^ '^^ '.-acarrrul ':'^c.:ha!mia.
^^T ^^ ^^^. "^h -o ;-ise [ike i bi:rb,. r^-i. 5<tmi-
iW^ ^^r^*^^^^^^fc Tniniparea: OQoiinti rrori-i the
.'onifii. 'V-jriappin;! it? if-lzr-s
3]'>rt T l«:r5s •.•'.>risi.Uin'/!j-. aii-l
■it.-ii -Hrrhar* pr'-nniili^ be-
.ni>i -.iiucr -ii'ie -r :::e o-mea. at
-ne -riaiii'uar ^rac-'s or. tr-site
rht; '>;iir*fbnii jrfm_-f : :":ir the
tilt .'iit;aiO[K- TWtjlIiii:; .I'-^tjire and
"lei'W. "nuccoimc 'ir uir ;rreat
■iive-iliuir ■itui weijit rt til-* eve-
"i'i^. Lii'i :i!e zr^-'ac L'ueiui'!*!^. me
.... ..... •■,. ... .■ ...-..■ . ..■ ■ .. . I- ■.-(■ssoi^ 'iiDr/iV'.D:; tiitf otrnea \-^-
." .;' ~"" ■■' "■" .--iiic m'lL'u ■-■'.'Dicr^sse-L and its
' '"" :iii:r.:i'»D cin.'pori''tui:clv im-
.i.ivii . iiui ■ -ivs .•\|->ai'i> '•\'i zs^Xi. :(.': ivi'.;-" *" uc-in""!! la-i sufpura-
i.'Li ■. Hi- .•i.<u\i II *t>rir ■'uniWu: pi'iir:;aim;;i. F>r :ae Mea tiiat the
[t.i.i.iik^ .kiiii iv>\i-.'w> ■i,t.;i*.>:er .u" :ut ti^'-ia^-j; ripj-i'iL--^ uie aflecdoa
•K .'i lu .i ■> i Miiii.ia.">.
ii».-.v. .u--; :'-\.v.:\) . ,ii!'i, 11 .tf,".>im; ■£' ::? .i'lmi-vrire wi:h
l\ •N^w■ll•"^ i •• ■:;L>ii-V'.-".l.'i» -.iiic, lt :i '"ei: ?•' \.*'.»ii>i'.i-
."> -.;... *!.'l> iu[ :"r»ui ">t""v .■•?!! tii-e ■^ve:':!^ when
.-.y. i><»- ;<■■»•'. nvr TUf .■■•.»fvi ; tiio .ai^i':* '-jcome
,i •>.■; i/i^v ./cr iiio 'it:;f 'iin.:!*.-*. I: ■:':[li^::* m the
; .. :;v -j.i,.'si,tf 'I :Ik' --'riea ;ii :i;e av-ll-w formeil
. .. - vj'i'*..i;'»;».'. :iiav oa^'iv '7e :uLjrak.e-j, -j i ?aper-
» >»,;'v.i ti»A;. T-'iii :ac ovriea ^ei'-™ aaj '>iiDion U
..■1 .-n i :K' s.sii-. t 'u ■ji»;ia*i::^ away the matter
• u- U\ ■• ''■^' •»*.;vv»».»l .■■■ii;rt-.i\.''.:va. '*■.■ ti-'rice :L'.a: the latter
'i-,\-. V.'. ..'..*i.">.x, »..!.■«>, i.i'i ■iiuv'i'i^ii:. *'Ke!i ■.'xi";".'.'* a< at a ::Ianoe
ii,« ..,^\' I'-iU is L'lUiK- ;••:;(.■ ,''.'ii:iiiivt:^'."5. Sjuiotitues,
iiwi. .». u.».i.<.v' '■■» '"^■'»' V'Wt-Ms. .i;i'i s.-i:'.i.x* :*» the ^iirtaee of
'i .■\,'. n."^.* »v * '^'i uvuii».M:n.-. ^' ::i.i: ■.; \.'a:i:i'.': "e ea*:ly wijieil
i.iiv, ■.. »»i.,;\.. »• V >-.iij<iv.i ■;!'. 1* icii :-, .■•-'iue* .iJ" :v. the t'>>rm of
'l*v- "»••' ■-*;*. :».i.v..t!. '•e 'v\A '.iui: ".i'.e aie:::"r.raue was .juite
t ti«.i •>»* -u- n-i'N.* .t;ivv >;' '-lie •■-'r'-iin.'si^a ^vTieath i? the
tb Uv\«.i»lSM ^-viv. UviK-e ;; --.s crr-.'ncv'U* to call this "Jiph-
•I. ;i ;..,>... :
, .»• \ , i ^1 »» •
..... t. »■ .K
Uk
PCBCLEST OPHTHALMIA. 61
thnitie conjunctivitiB," aimply hccauee the diechnrjie k more tenacious
anJ comeii off in tiakoa, for (he symptoms of true di|)lii]i<*ritic nplithaltnia
lire not uiily verv diHvreiit, but ilvuiaud u verj^ difll'ieiit courac of treat-
ment ; bat UiiTC can bo no objection to toi-niing ii ** membranous oph-
tbiilniii." Wc sometimes, however* meet with mucd forms of purulent
and dipbthcrttie o[ilith»liiiiii.
Thn chief diiii;;*T in finrnlcnt ophthalmia is the implication of the
cunii'n. Any cUmdincss uf the latter must, therefore, he nlwaya re-
garded na ftn untowani symptom, more especially if it olrcady ithows
itielf at an early atage of the disease, and if there i« any tendency to
a dipbtbcritic character in the ophthalmia. Ac a later {xiriod it is lc6S
to he feared. Tlie appearnneo of tlie cornea must be carefully watebed
from day to day, and in iievcre ca^e^ it« condition ttbould l>e examined,
if posKJbtc, at the interval of a few boure. Inipliuation of the eontea
U e«pecialW likely to occur if the inflammation ts very severe, the tcra-
pcrmture of the liils much increased, the chemosis cousidernble and fimi,
and accompanied by great j>hotophobia, lachrymation, and eilinry nou*
ralgia. 'I'Ue pain ts generally inlemiitteiit, and often very severe, espe-
cially towanis ni'»lu : it nmy extend deep into the orbit and over the
corresponding side of ttic hentl and face. On examining tlie condition
of the cornea, we may then perha}>d di^over aniall phlyctenule or intil-
tnitionH ai its edge or upon itii surface, which soon ])asa over into utcora.
SotDetimea thorc is a scrouii infiltration (ijcdcma) into the cornea, which
may rt-mnin t-oiifiued to the iwnphery. givinir it a fllightly steamy or
cloiidrd appt^arance. If this opacity is considerable, an'l extend.^ over
the centre of the cornea, the sight may be greatly impaired, or a cir-
camscrihcd light gray infiltration may show itself at one portion of the
COfDcat and disappear again as the ophtlialmia subsides, or it tnay Wome
tnore dense and assume a yellow tinge. Generally, the infiltration soon
change? into an ulcer, which may. tn favorable cases, remain snporticial,
and nltimately leave only a very slight, or even no opacity of the cnmea.
Hut if the iniiltration or ulcer is of considemblu iiixc and ratliur dceji, a
dcQfte npftcity may remain behind, and greatly impair the sight, if it be
utuated in the centre of the cornea. The ulcer, instead of remaiDiog
superficial, may, however, rapidly increase io circumference and depth,
atid soon lead to extensive perforation of the cornea, accompanied by
prolapse of the iri^, escape of the lens, and pcrhajw a certain ijuantity
of ritreooa humor, and Im followed probably by the formation of a con-
sidorablo stapbyloma.
When the cornea pves way, the patient exncrioncos a sudden remis>
noil of the violent pain, aocorapanicd by a gii*li of fluid over the cheek.
If the ulcer is large, the cornea, on account of being thinned and soft-
ened at thin point, may become somewhat bulged forward before perfo-
ratjiHi occurs. Th*^ dangerous character of the ulcer of course iucrea^es
with ita extent, as the perforation will be proportionate iu sixe.
Sometimes eeveral intiltrations are formed near to each other and then
coalesce, thua giving rise to one large ulcer. In many cases the perfo*
ration, if it be but of limited extent, is the best thing that can occur, for
. the ulcer, iiulead of iucreasiu^ in circuuifereuce, Lheu begiiui at ouce to
■ heal.
I
OF THE OOHJUKCTIVA.
Ptfrfunition of tite coniea majr gire rue to tlie rolluwtii;;! complications
1. Prii!n|i3e of tlie iris: 2. Antfrior s^vriechia ; 3. Central caiwiilar
cataract; 4. Ditijilaceiitent <>r obliteration of the [iu)>il ; o. Aiit«r|i>r
sutpiiyloioa. For furiJior infonaution upon thia subject, I muat refer the
reader to the chapter on ulcers of the comeA.
If the )>erforattoa of tlie coruea is email, a little portion of the iris
will fnll a^^inat it: when the wpicouii humor e«cape.4, Ivniph wilt be
eRuseil »t the bottom of the ulcer, and the iritf will become adherent at
this p'lint to the cornea, K'^'"o "'**' '*' "■" anterior synechia. The pupil
*ill l>e <li'ag;;cd tnwiirds the adhesion and more or 1^*3 displaced ; or it
iiiuy ho jtartiiiUy or wholly implicated in it. If the perforation was ex-
tremely small (iuch as would be produced by a fine nuedle) the reaccu-
mulation of the aqueous humor may tcnr through any little adhesion
that has taken place hetwcen the iris and cornea, and no niiturior 8yno>^d
chia will be left. When the perfuratipn occurs at the centre of the cor-^H
nea, the leiis will cotuo in contact with the bottoia of the ulcer, and a '
central ant<?rior cataract may be formed. If the cornea gives way to a
greater extent, a kocklc of iria may be pushed into the ulcer and came
n prolajMe of the iris, which may increase to a very considerable sine
from the iiijueous hntiiorcoltectiti^ within it and swelltni^ it oat. A umall
protnisi'Jii of this kind has been termed a nii/-tc(jifutlon. Or the lens
mny cscnpe together wit-li sutne of the vitreous humor, if tbo nipliiro of
tlieconica is largo, and then tlio cyohall may Itccomo atrophied. On|
the iris falls into the gap, becomes adherent to the ooniea, and covered^
with lymph, which assumes a cicatricial character, and yielding grado-
ally (f> the jntra-ocular prc:*3urc, becomes more and more prominent, and
a I'tartial or totjil stapliyhuoa results.
A very dnng.*roiis kind of ulcer is that which niitkcs itj appearance io
the form of a small crescentic ulcer near the edge of the cornea (generally
the lower), looking as if it had been scratched by a Bnger nail. Its
rApri* sotm heconie infiltrated, and assunio a yellow lint. It iitcreiisea
itt depth, anil rapidly extendi further and further round tlie cornea, until
h «• V give riiw to n very considerable perforation or slough of the tatter.
0« wev-onnt of its being situated so closely to the ed^e of the coniea,
^U9 f^^rm (if ulcer is often hidden by the ohemoais, and thus easily over-
hakctd at the outset.
Ik ^vrj* severe c:ises of purulent ophthalmia with intense inflammatory
\, aloughing of a great portion or even of the whole of the
ly take place within a few hours. The cornea loses its tnins-
M 11-1 . bV'omes of a grayisiiwhite color, which soon passes into ii ytd-
i~ '—'?. iwjd lo<ik« shrivelled and »piite opaijuc. It soon yields to the
'tt prvssure, gives way, and the eyeball becomes atrophied.
.tsjin »av nupervene when the ulceration has extended to the deeper
■^TT T'' ti« i-vniea, or when perforation has occurred. If severe, it
jTa'^ pvw >^ ^ great ciliary neuralgia, photophobia, and lachry-
H • portion of tJie conica remains sufficiently clear to permit
<^h^ the iris, we fiml the latter discolorud, and tho pupil con*
■ HA^Iar, irid perhaps bloekcd up with lyraph, or there may he
ior ohatobor. The inllaumiatiyn may extend from tlie
tisstioe of the eye, and general inflaunnatiou of the eye-
PUKULBXT OPUTHALUIA.
63
I
»
I
I
bftll (paiioplitlialmitiR) set in, accompanied by excruciating pain. Paimua
(Moun but HtfliJooi in acute pnruleni oyilitlmlmia, auil on\y in cases whei-e
tbo papillic huvc been tnucb swollen I'mni the verr commcnccnicnt of the
diavue, aiij from tiivir rubbing; agaiiut tbe cornea bave induced ■
superfii-ial vascular corncitis. It li more frequentlj met with in chronic
ojilitliiihiiia. It U an interesting circumstance, tbat if tbe cornea hafl
been i^ullvrin;;; fruni imniiuH before the altack of puruUint opbtlialmin,
then? is for lew dimger i>f its ulcerating or suppuniting tban if it 'n
quite transparent. This ioiportaut fact boa been utilixed in tbe treut-
ttient iiy inocolauoD of pannus dependent upon granular lids.
Purulent ophthalmia generally runs its course in three or four weelu.
It mar, however, become clirouic, and la^t for many mouths or even
years, aud prove very obstinate. This is especially the ease if the pa-
pilla? remain «w<.>llen and prouiineut, for by their coustani rricilon a;;Biiuil
tbc cuinica, pannuH is but too often pntduced. The relaxed condition of
the conjunctiva umy aUo give rise to ectropion, or this may be produced
hj tbc lids having becomo everted <luring tbe progresa of tbe disease,
not having been properly replaced.
(.ixii«>'«. — f i'uriilent opbtiialmia is generallv due to contagion from tbe
same disease, or from an acuie or cbronie discliarge from the urethra or
vagina, tihetber gonorrheal or not. (Ncltlesbiji.) — B.] It may become
develuin-d from an acute catarrhal opbtbuluiia, by tbe symptoms of tbe
latter increasing in severity, eitlier ibrougb a continuation of tbc orig-
inal cause, through neglect, or through a mistaken course of treatment.
Tbe same canaes wbicb may give i*i»e to catarrbnl opblliaUuia, vis,,
Mpo«urr to cold or draught, gi-eat glare, etc., may aUo produce tbc
paruleut form. We sometimes tind chat it occurs epideiutcally, and that
mild irritants, wbicb would at other timoa only bave caused n simplu
wuarrbxl conjtuictivitis, now pro«luco purulent opbOialmia. An un-
bealtby locality, a vitiated atnio&plicrc, crowded and badly ventilated
roouu, ejiposnre to grent heat or cold, duitt, and glare, inteusify the
cbaracti-r of tbc epidi-mic. Some of Ibeae causes are l'rei.|ueutly met
with in pbuTA where luauy ])er80U8 arc collected together, as in vrork-
bouseit, foundling b(>s|iital.s, and large barracks. If purulent or oven
catarrhal opbtbaluiia once breaks out io such establisbmenta, it is often
very ililHcult to arreat It before it has spread widely auiongei the in*
mates and committed great rasages. 11' soUUers on cbi-lr march or in
camp are exposed to great beat and glare, and to bot winds carrying
before tbcm clouds of aand and dust, as occurs in India or bigypt, oph-
thalmia will soon sbuw iuclf amongst tbero. Hence the teruks military
anil Kgyptian ophtlialmia. These namci) sbould. however, be aban-
doned, for this afl'ectlon shows no special cbaracteristlea 'warranting its
being cln:«sed as a disease aui i/fiitrrit. Tbe epidemic Is Id such cases
generally ime of purulent ophthalmia, but sometimes it may assume the
character of severe catarrhal or granular conjunctivitis- Or these afiec-
Uona may pass one into tbc other, or exist side by side in tbe same
army. This being so, we can easily understand how such various, and
often coiillictiug and confuseil accounts bave been given of the cbaracteff
the severity, and tbc contagiou-^nes^ of the ao^atlcd military ophthalmia.
Coutaglou is the most rre<tue:it cause, as tbe contagious power of tbe
64
DISBASeS OF TUB COSJDNCTI VA.
discharge i» often wry great. This variei, however, according to the
severity and stage of tlic disease. Piringer,' who nmde a ^jrcai number
of valuable and interesting DX|ierimenta to test the contagious p*>wer of
ttic diacharfft), found that during the earliest stage, and al.so in chronic
caicfl, in which the diBchargo 13 thin, watery, and transparent, it is
hardly, if at all. contagious. But it becomes slightly so when, though
still watery, it assumes a somewhat muco-purulcnt character, nnd then
it generally reproduces a mild fonn of the disease. Tlit- contagioiipm-ss
increases in proportion to the intensity of the affection, and the purulent
nature of tlie discharge. According to the «Hmc authority, the dis-
charge of a severe purulent ophthalmia, if appliett to a healthy conjunc-
tiva, may rcprcnluco thu disease in from 0-li iioura ; that fnim a mod-,
erately seven? form in from 12-8H ; the mild, in OO-TO ; and that from
chronic oplithalmia in 7:i-9'j hours. It ia of the greatest practical
inijHiriaricc to remember that the discliarge Frota purulent ophthalmia
does not always reproduce the purulent form, but may give rise to
catarrhal, granular, or even diphtheritic conjunctivitis^ — ^juut as the dis-
charge from e.itarrhal, diphtheritic, and acute granular ophthalmia may
produce purulent ophthalmia. Tlie i»[>ecial fonn of conjunctivitis wjiich
nmy aride will depend upon atmoaplicrieal, local, and coiwtitntional
causes, and also upon the age of the patient. Thus Von Tiraofe states*
that in Berlin the matter fn>m ophthalmia neonatorum, when applied to
the eyes of children of two or three years of age, generally produces
diphtheritic conjunctivitis, whereas when applied to adults it moetljr
gives riae to punileut or sometimcB (0 granular nphtUalmia.
Healthy eyes are more rapidly and severely affected by the inocula-
tion of contagions nuittor than those suffering from vascular forms of
comeitis, more especially pannus. liepcatcd inoculation diminishes the
contagious (rawer of the discharge. This is also diminished by diluting
the latter with water, tt being altogether lost when it is diluted with
about one hundred parti> of water. Gonorrhccal and vaginal discharges
may also produce purulent ophtbalmia. It appears certain that tlic air
is often a carrier of the contagion, especially if many persons suffering
from Hcvcre purulent ophthalmiii are crowded together in one room, and
this is perhaps small and ill ventilated. Von Graefc thinks that in such
cii.«es the j-ropagalion is partly caused by the suspension of the coMtit-
uents of the discharge in the atmosphere, and partly by the air expired
from the lung«, from the discharge passing down the lachrymal pa88a.ge9
into the nose — ^juat the same, in fact, as what occurs in common nasal
catarrh, the contagious nature of which depends chiefly upon the expired
air.
The proi/nonB which may he given in a case of purulent ophthalmia
vflll dt^'fM'nd upon the stage and severity of the disease, and also upon
the prevailing character of the epidemic, should such exist. It may bo
favorable, if tlic affection is of a mild muco-purulent character and is due
to spontaneous causes ; or, having been produced by contagion, if the
inoculating matter was mtid and chiefly mucous in character; also, if
' ririnjr<*r " P!» Wenniwho* Im M«i8clieniiagr," Grflls, IS41.
< •' DvniwlM Ktinik," lt<C4, p. 7».
I
PUaDLRNT OPaTIIALHIA,
GS
I
^
the rv'laess autl awclUiig of tiie ejelicU and coujuuctiva arc but slight ;
if the iiitfamtnuiiiii irt cliicfly coiifiiiml lo the [Wilpobral coiijiiiK'tiva, or,
iboiiM it cxtt'iid to the dciilar, if the chcmo.^is is serous ftitii soft, not
plastic and hani : if tlie discharge is thin and scant, the comoa unaf-
feccetl, the character of the epidemic mild, without any tendency to the
dipbtheritic form of conjunctivitis. Wc must, on tJie other haiid, W
exirt'imdy puanled in our prop^nsis, or even form an unfavorable one, if
the ii)riniiniiatiou is very intL'ttse, the chemo»i!t hant and Urduce<m», and
;•' :-:il]|r :lh eoiiijiU'U'ly to surroiind Ihe cornen and overlap it ; if
tf.. J ilV idccratioii of the cornea, e'<pecially if this he cousulerable
in extent, and occurB early in the disease ; if the inHammation shuws a
diphLheritic cbantcter.
Tr^'ttmmt. — ff tlio atUu'k is severe, the patient should he confined to
a darkooed room, or even to his bed. The room musi, howercr, bo well
Teiitilated, aud [dciity of fpesh nir be aduuued, particularly if it ia occu-
pied by doveml patients. Xho&e who have the dijea^ie in a severe furm
sbnuld, if p(}9sible, he deparaicd from the milder ca^os. I need hardly
pcint out that in harrackii, unions, school«, etc., the healthy inmatci
should be Ktrictly kept apart frum those kIio are KulTering from ophtbal-
nua. Their eyes should, moreover, he examined every day, in imler
tbnt the first svuiptuins of the di^ea'iie may be detected. The patients
»nd BtU'i«lant8 ahould be made aware of ttie contagions character of the
diM-asA, vhicb continues aa Ion<; as the di-(char><e remains opaque and
tuucoas, S[K.*cial care must be taken that the spon^it, toweU, water,
elc-T whicb are emjjloyed for the (KaLientii arc not u-ied by others. Tn
goanl them against the ritik of contagion, the medical attendants and
l)an!e& sb<mM wear the cuned blue eye protecLora, more e8|)ecially
whiUt applying (he collyria or syringing out tJic eyes, as a little of the
imticr luuy otherwise be easily sploshed into their eye's. If, by acci-
dent, any of the discharge should have got into a healthy eye. lukewann
water ahoold he at once injected under the lid* so as to wash it away,
and then a drop uf a weak solution (2 grains to the ounce of water) of
the nitrate <d' silver or nulphate of xinc should he applied to rhe eonjunc-
tira. If only tme t^ye i* afl'ected with purulent ouUthalmia, the ulher
must be at once, without loss <d' time, heniiiaienily closed. The connnon
eunipnrd4 bandage will not suffice for this puppt»so, for the di.ictiarge
wiffitt soak through, especially during the night, wJieu it may run over
t: ■ * ■ of the nose from the affeetcd to tlte healthy eye. The beat
[I- 1 a the fclhiwiiig compress, recommenled by Von Graefe. A
pad n| ciiaqiie or cotloii-wool sliouM he applied to the eyelids an<l covered
by iliftcliyloti pla-tter, which ia to be fastened down by collodion, so as
to C(>in5detely exclude the air. Thia compress should be removed twice
dailv, and the eye elcanncd and carefully examined. [Another protect-
i»« mt:tli0<l is that recommended bv I>r. Bidltir, of Montreal, which con*
a piece of maekintosti about four and a half inches square, with
glaflj* fastened to A hole in the centre, tliroiigh which the patient
can ace ; this i« lixed by broatl pieces of strapping to the nose, forehead,
and check, its lowt-r and outer angle being left open for ventilation.
' Ncttlcsbip.) — ■!!.] If there is any redness or swelling of the conjuuc-
tiTs, or any didoharge, the pad should bo discontinued, although In some
6G
CTFEASEE OF THE CONJUNCTIVA.
eaees the continuance of the firm pressure appearg to cat fihort the ni-
tack. A drop of a u-eak solution of nitrate of silver or sulpliute of zinc
sliouhl be at once np]ilic<l. Ice cimiprft^^eM may also he ap|>lieil to ibc
eyelids, as tliey, according to Pirinaer, will often cut short the attack.
There U gviiurally not much constitutional distiirhancc, excvpt the
dJAeaiLe t* severe, in which case, more eapeciallj in p^norrhccal ophtlial-
iDia, it is ofteu Bccompanied by markc^l febrile syiuptoms. If the
totipie is foul atiil hiadt-d.a hrittk pur^mtire sliould )>e administered, and
the howeU l)e kept well opened. If the jiritient is jileUioric and ffverinh,
cooling gahnes mast lie prcscrilied, and ihe diet Iw kejil low. Forroerly
the depletory plan of treatment WM carried to great exccaa, and venesec-
tion employed to such an extent that we read of caaes in which the
patient was bled ''as lon^ aa the blood could he got from Uic arm.*'
(Wardnip.) Now, however, this course of treatment haa fortunaiely
almost completely explo<led, and venesection is hardly ever employed.
Iiidecrl. wc not nnfre.|iiciitly find that ]>atientri suffering from purulent
ophtliidmia are of a weaklj- and cachectic habit, iu whom such a line of
ti-cniDienC would l>e most injudicious and injurious. In all such cases
totdcs, especially tpiinine and steel witti perhaps some ammonia, sbonid
be freely ailminititered, the paticDts bein<; at the Fame time put U[>oii a
j^ood, noiiriehing, and easily digosiiblc dtei. wiili meat once or twice ft
day. and if necemsary, they may even be alluwed a moderate ((uaiitity <tf
slituulaiits. In this ne must, however, be guided by individual crtnsider-
aiioiis. If the patient is rcstlrsis and sleepless, a narcoac should l>e
given at night, as it is a great relief if he can obtain a good night'^ rest.
The greatest attention mmi be paid to the local treatment. Tlio eye
sbould he frc'.juently cleanseil of the disehar;;c. Tlie eyelids being
opened, a email stream of lukewarm water or milk and water sUoubl be
allowed to play gently upon them, until all the discharge is washed
away. Still better is it lo employ for this purpose a small syringe, the
Doszle of which is to he gentlv inserted between the eyelids. Tb«
syringe shoidd ho very carefully and delicately handled, otherwise it
will bruise and irritate the eye. or even perhaps rub agiiiiiH the cornea.
The nurse must also V»e very careful that no drop of the returning tiuid
is thi-own into her eye. In severe ouca the eye should be thu* cleansed
every hour or two, in mihier cases three or four times daily will suffice.
Tlie bichloriile of mercury lo;ion may also be used for cleansing the eye
iiuitcad of warm water. The cnisti which fonn upon the cyelaebes
sh'-uild be well soaked with warm water and then gently removed, ftO aa
not to excoriate the lids. A little simple cerate ahimhl he applicl to the
edges of the latter, nigbt and moniing, to prevent their sticking, or if
they are getting sore the citrine ointment may he substituted. If the
temperature of the Iid« is but moderately increased, it in only necessary
to employ cold compresses for an hour or two after the application «tf
caustics, for we tbua aaaisi tlic astringent actitm of the caustic upon the
blooii vessels, and also moderate the reaction produced by it. But if the
attack is very severe, and the eyelids very red, swollen, and hot, a
tem|)Qrary Uite of cold water will not suffice, and we must have recourse
lo a constant application of iced ctunpres^es. They should be applied in
ibo following manner: slightly nioisi^ncd pledget* of lint, of a sufficient
PURDLBNT OPHTHALMIA. ^7
size to cover both eyelids, should he laid upon a lump of ice until they
are quite cold, when they are to be applied to the eyelids and changed
as soon as they get the least warm. Several of such pledgets should be
kept lying upon the ice, so that one is always ready for use. If the
temperature uf the lids is very high, the lint may recjuire to he changed
every three or four minutes. It is, therefore, absolutely necessary to
have a nurse for each patient, or at least for every two. Instead of the
lint, the small caoutchouc icc-hags igny he employed. If great attention
cannot be paid to the application of the iced compresses, it is better to
abstain altogether from their use, as they may otherwise do more harm
than good. We must then rest satisfied with the cold water dressing or
Goulard lotion. When the eyelids become cooler and less red, the pa-
tient begins to find the extreme coM disa<;reeahle, and then cold water
dressing should be substituted for the iced compress, or it may even bo
necessary to pass over to the use of warm fomentations. A constant
small stream of cold water may also be allowed to play upon the eyelids
by means of a small siphon connected with a little reservoir placed at
the bed head.
Local depletion is often of great benefit. If there is much ciliary
neuralgia, accompanied by great swelling, heat, and redness of the eye-
lids, and if these symptoms do not readily yield to cold compresses,
leeches should be at once applied. The best place for their application
is on the temple, about an inch from the outer canthus, for, if they are
put close to the eyelids, they often produce great oidema of the lids
which may even extend to the cheek. Tlicir number should vary from
four to eij^ht, according to the requirements of tlic case. They should
be applied two at a time, so that the effect may be prolonged, and free
after-bleeding is to be encouraged by warm fomentations.
If the eyelids are much swollen, very tense, and press greatly upon
the eyeball, and especially if the coniea is beginning to become affected,
the outer commissure of the lids should be divided. This will not only
mitigate the injurious pressure of the lids upon the eyeball and cornea,
but it will also give rise to free bleeding from tlie vessels which are
divided, and thus greatly relieve the circulation of the external portions
of the eye. The incision is to be carried tlirough tlie skin and fibres uf
the orbicularis, but not through the mucous membrane, otherwise an
ectropion might be produced. [This operation of canthotoray is ex-
tremely necessary in all cases where there is much swelling of the lids,
and should be done at once. — B.]
We have now to consider the most important part of the treatment,
namely, the topical application of caustics and astrinj^ents. At tlie
commencement of the disease, whilst the discharge is still but moderate
in quantity, we must be careful not to employ too strong a caustic, more
especially if the eyelids are hard and the conjunctiva and pa]>ill;u not
much swollen, for fear that there shoulil he a tendency to diplitlieritic
conjunctivitis, which wouhl be greatly aggravated by free cauterization.
As soon as the discharge has become copious, and the symptoms of true
purulent ophthalmia are well pronounced, astringents must be employetl
more energetically. The choice of the astringent ami the mode of its
application will depend upon circumstances. If we have to treat the
68
DISBASBS OF THB COKJUKCTI VA.
person as nn onUloor faoapita! patient, and Bhall perliape only see lum
cv«'ry second or thml lUy. it will he iuMjeaiiary to ^ive him a remeflyj
irhich can Iw roaiiily ainl effici«ullv api'lietl by some atteiulant. Cinleri
thctn' ctix'iimKtuiiccs 1 Itave fouiia tlio tnjeciion of zinc ond alum, at
employed at the Royal London Ophthalmic Hospitul. MoorBolds, by Far]
the he»t. Its strength, and the fn>(|iieiicy of its amiljcation, must varyl
acc<"inliiig to tho aevtrity of tlic disease. I gehemfly employ a solutiott]
of 2 fin, of sulphate of zinc and -I or 0 grs. of alutn to the ounctr <>f^
di.'*tii!eil water. This is to he injected between the eyelida with a siualt
glwM syringe every l"i or liO minutes during the day, and every two
hours at iiif^ht. As the condition of tho eve improves, it is to bo em-
ployed less frequently. Before it« apjilication, the discharge should he
thoroughly washe^l away by nn injection of liikewarm water, in order
that the collyrium may come everywhere in contact with the eiirfacc of
the conjmictira. Kvery second or third day, the surgeon should apply
n drop or two of a strong solution of nitrate of silver (gr. x to oj ofj
water) to the inside of the lida, or it should be brushed over the con-
junctiva with a camei's-hair brush ; the patient iu the interval oonlinuingj
with the iiije(aion.
Much henetit may also he derived from a sotntion of nitrate of silverJ
(gr. X to 3j of water if the case is aevere), which HhimKl he dfjpptd]
into the eye every tivo or six hours, wi^i a (|uill or canu'rrt-hair hru»t|iJ
But it n more difficult to apply these drops properly and efficiently thaaj
the injection, and it is therefore always better that the surgeon should,
if jiossihle, do tliis himself. My friend, Mr. Moss, has very successfully
treatcl, at the Moorfields llnspitrtl, out-iKitieiits Hufffrin;^ from very
severe purulent or gonorrh<pal opiithalinia, in tho following manner,
which was. I believe, suggested to him by Frofeseor Donders: Thi
lids being well everted, he applies with a camel's-huir brush a verj
strong solution of nitrate of silver (gr. .xxx-xl to (ho 3j) to tlie con-J
junctiva once a day. In the ina-rvala. the patient uses an injection of
alum every half-hour or hour. Quinine or steel is, at the same time,
given internally.
But if the patient is in the hospital, or can be freiiuenlly seen by tht
surgeon, I greatly prefer to apply the nitrate of silver in auhatanoe. It,
has this grcHt advantage, that we can regulate and limit its eFfect, and
prevent its coming in ef)ntactwith the cornea and the ocular conjunctiva,
which is quite iuqiof^sihle witli the solution. Moreover, the latter is cisilv
decomposecl if the discharge is copioiw, and ita effect is thus impaired.
It is, however, absolutely necessary that the surgeon or a skilful assistant j
should apply it, as it cannot ho eutrustt'd to a nurse. We are indebted
to Vou trraefe' for the scientific explanation of the action of the niirale
of silver in puriilent ophthalmia, and for very exact and comprehensive
directions as to it^ use. During n |trolonged stay in Berlin, 1 saw itl
employed most snccefsfully in this way by Von Gracfc in many cases of j
punttertt ophthalmia.
I'ure nitrate of silver is too strong to apply in substance to the oon-J
junctiva, m its cscliarotic actaon is too aevere. It produces a thick v9oha.r|
• Von Umvtu on Dfiilitfavrilio Cunjuni-llrltb (" A. t. 0." Tol. L).
PUHCLENT OPIITnALUIA.
89
I
I
I
»
¥
which U thrown off with difficulty, hence the ^iifterficial portion of the
eotijiiDCtiva %g venr liable to hecoiue ilustruycd, aiul deep cicalrjces may
he produced. Iw 8lren;;(Ii should, tlu-n-rore, he diliitetl by mixing it
with one-half or two-Ihirdfi of riitr«ic of j»otasli.
The application i-i to he nuk<U' in tlic following manner: Tlie eyrlids
borin^i; hren llioroughly everted, so as to brin^ the rotrivtar!!i:il fold well
into rivw. the folds of the conjunctiva of the up|)cr and lower lid shoidd
he allowed to cover ihe cornea, und thiw protect it from the action of tbe
eaiMtie. The crayon of miti^^ted nitrate of silver should then he ligldly
I«ii*i«fd over every jiirt of llic surface of tlic jKihiehral conjunctiva, espe-
dally in the n-tro-torMl region, A solution of jmlt and water slioiiM then
be freely nppli(.il with u large camclVhair hnish, in onler to neutralize
the nitrate uf silver. Tbe ca.scou3 shreds of chloride of silver^ which
are thoit fonncfl, should be wnslicd away with clean cold water, before
tbe lids are ropliice<l. Wo euii very easily re^uliite the action of the
canstin. When but a 8]i;;iil effect is vei|uired, the cmyon ^lionld W
jiasned but nm-c or twice very li;5litly over the conjunctiva. If a stronger
action is desired, it mity hi< nsitd with more freuvUiin. Tbn nt-utriiliza-
tion with the Kalt iind water should not tuke place tmntediately afti>r tbo
application uf Uie caustic, except whore the effect of the latter i^ to be
but very !<light. It should not, however, be pn3t{>oned longer than from
ten to fifteen seconds.
The caustic should not, as a rule, be applied to the ocular conjunctiva,
for, as this is but accoudarily aifoctcd, its swelling and inllamraacion will
geuQrally i^uluidc lut the condition of Uie palpi>bral conjunctiva imjirtivca.
It may, however, be necessary to do tto, if the cbemoais U so consider*
able as to protniile between tbe lids, and docs not yield to frue incisions.
But it should only be touched here and there, atid tbe isalt and water
should be i til im-d lately appUctl.
If the swellin;; of the conjunctiva is rery considerable, it should he
freely »eari6ed witli ii scnli>el or Uesmnrres' scarifier, directly afii'r the
tieutrali7«-itlon of tbe VJtufttic : and the hlec^ling should be encouraj^od by
the uppli<jntiou of hot s|>nu^c8. and by slightly kucading the lids between
I'" --. The inoi-^ions in tbe ]>aptl1iP should bo very supcrficinl,
oil deep cicatrices will be left. The li(U should on uo account be
Kanticd iH'forc the application of the nitmte of silver, for tbe lattiT would
act too severely upon the incited uonjutvctiva. If die cbcmosia is great,
inoisionfi radiating towanls the cornea should be umde in it. either with
a pair of acissora or a scalpel : or a small fold of conjunctira may be
liitftped out with scis^urv near the outer edge of the coruen. Ico com-
prrasca arc to In- applied directly after the i.-auieriMtion, for they diuiin-
t«h the inllnmni.ilory reaction, and assi.'tt in the contraction of the bhwMl.
vOMvls.
If we watch the condition of the eye, wo Bhall find that it becomes
very hot and |>ainfut directly ul\er the cauterizutiuu, and that this \s ac-
companied by increased lachrymation and a uuicotu discharge. Thi*
fr^cliarx wbicb are fonncd upon tlie jialpebral coitjunctiva are itlied in
from iJO-ttO niinuicH in tlic form of little vvllowieh-white, rollvd-ap
flaktw. Tboite on tbe ocular conjunctiva rciuiim somewhat louger. Tbo
inflamniatory symptoms st>on subside, the conjunctiva becomes Icsi Inr-
70
DISEASES OF TUfi 00XJUNCT1VA,
gi(l, the lachrvmation and purulent dittchar;;e dimtiii^h, xml the sUtgo of
remifwion »cxs in, durinj^ which the opithi-liunt is reg(!iierat<'d. When
thtK hits Uikett [tlace. tlio original cou'iitian, as it existed before tbe a|)-
plication nf the caiiatic, hc;,pns to reap[>ear. The coujiinctira becomes
more red aud awolleu, tJic discharge increases in (joantity, and the in-
flamouitory svmptoms in stvurily. U i« of coiiHui]uei>ce to endeavor, bv
rcu«wi*dcauti?ni:atioti,tocnt sbort thl-» thinl ptM-iod althe fmtH't,b<*fon* it
has rt-iiaini'd it:' oripual inteiisitv. Wv shall thus be able, by degrees,
to extend the duration of the atage of remijtaioii, and to diminish the in-
tensity of tlie inOairtmatory stage. Generally, it will siifHce to aj'ply
the crayon once in ^4 houni ; in very severe ca^'8 it may be neocsaary
to do »o iniiro freqiKMitly, but it should never be applie<t until the puru*
lent ilisclinrj^e has ajiain set iii.
Voii (traefe has shown that tbe oflect of tliti nitrate of silver (allbnu^b
it momentarily iiicreasca the congestion), is to contract tbe blootlvosscU,
and to neei-lcraie ilio circulniion, which ia retarded in purulent ophthal-
mia, the conjiinetivn hcin<j: at the same lime very vaMular and congealed,
nnd its vt?s.'^«ls dilaUr<l ; moreover, the seroius infiltration of the conjunc-
tiva is <;rcatly rflifved by the copiims scrmu cftiision which follows tlie
caiiterizalion. This i« tbe period nf remiiwion, during which Uie eptlie-
lial layer of the conjunctiva ia regenerated.
If the comoa becomua cloudy, a solution of atropine (»r. ij to 3i of
distilled water*) it) to be dropi>ed into the oye three or four tinier daily.
Where the crayon i^ employed, the atmpim' ^liould not be used until tbe
period of remi«*iori has set in. If tbe nitrate of silver drops arc used,
the atropine should tie applied during the intervals, and about two houra
after tbe former. [It is better to uae atroiiiue in all wises of purulent
coitjutictivitia from the beginning as a possible aid in preventing serious
eomcal disease. In cases where the cornea becomes infiltraletl very
eoon in the course of the disease, it lias been rccomraemled lo employ
eserine in jilace of atropine, jind much testimony has been recurdeil in its
favor. It waj( formerly Aup|x)4ed that it exerted a specific antiseptic
effect upon the imrulent iuSltrution, but thia idea is now generally dis<
creilited. Ii was aUo supposed that, owing to iw diminishing the intra-
ocular tension, it assisted iu tbe furtherance of the osmotic processes by
ccunieraeling the interfereuco in the nutrition of the cornea prwluce-l by
tbe disease. More exttnded ex|ieri»riice has not eubstantiated tbe former
erideiioe in its favor. The strongth of Uie solution used has been from
two to four grain.s of iJie sulphate to the ounce of distilled water.— B.l
If there is a 'Iccp ulcer of ibe cornea, which threatens to jwrforatc the
latter, we shnuM M onee ywrfunu pftraeenu-sis bv prickin;; tbe bottom of
tbe ulcer, and letting the ftijui-ous humor flow ofivery gently. Tbe open-
ing in the c^>mea will thus be extremely small ; a liule jwrliou of iris
will fall against it, lymph will be effused, and Uie intra-ocular presann-
twtng now taken off. the ulcer will begin to heal at the bottom. Tbe
re- accumulation of the aijueous humor will generally suffice to detach
tbe fortion of iris from tbe cornea. If, however, a small aiiWlior syitf-
cbia should itersi-^t. atropine dnnw should l»e applied, in onler. if possi-
ble, to tear it through. It may be necessary to repeat the paracentesis
aeveral times, if we see Uiat ilie bottom of tli'c ulcer is being bulged for-
J
GONOKHOfEAL OPHTUALMIA.
71
bj th« a^'iucous lumior. Bv sucb a timelv panicoiitetfU wo ofleu
liiuil tlic uluer to a stnill extent, nml Goalty litllc or no o|>acity of the
cornea may remain. Jtut if we permit the ulcer to pcrforiitc of its own
aoi-onl, th« opening will be much larger, for the bottom of the ulcer
bocome^i aUonuatoit ami oxttMuttMl in size before the roniea ^ives way.
TJic jiijueoiiH biiiuor will ihpn e'<c;ipe with considerable forcv, aii<l carry
the iris, or even, [K.>rliii{M, the leiu*. if the perforation lie lar^fc, iiibo the
oprniiip: in the cornea, au'I thu* a considerable anterior synechia or pro-
lapse of the iria, may occur. If the bttter is conaiderablo it shoulJ be
pnckcd with a 60*.' needle, and the aqueous liuraor distending it be
allowed to Hov, MfT, which will cauiie the prolapse to coll:ip5e. TIuh nay
ibe ri'(»ealetl Fevenil timefi, until it shrinks ami liwindles away. If ihia
tdnes not occur, the prolapse HhouM be atripped off with a pair of »ci«-
■lU, after having been pricked. Should the lens have fallen into the
Opening and be presentinn; tbrouffh, it ahould be at ooce removed, to-
lather, perhaps, with a little of the vitreous hutnor. Au inciaion shoulil-
be niinie tlinm>;h the ci'utral [Mirtion of the perforntcl cornea, wilii Von
(tniele'd nnrmw cataract knife. If a piece of iris protrudes, this sh'iubl
be Bomewlmt drawn out and snipped ofl'. The oiipsule should be freely
lacerated with the pricker, and the lens will then readily escape if a
little pressure is matle upon the eye. A little vitreous humor will gen-
erally exude, and the lips of the incision fall into close apposition. A
firm rompreas bandn:;e should be carefully applied, so as to keep the
eye iHiin'.<'rable ami (lie vitreous pressed back. Should the latter show
a toii'lcitcy to protrude thmii>;h the itteision, and llms interfere with it*
firm cicatri nation, it should be pricked, and a little he allowed to escape,
tbe bandage being llien re-applied. We tiuiy tJius Ih' able to save a suf-
ficient i-irlion of clear cornea to permit of the suhseipient restoration of
some useful degree of eight, by the formation of an artificial pupil.
If the disease has become chronic, the nitrate of silver must bo loss
freijuently applied, or it should be exchanged for, or alleniated with,
Uie use of Hiiiphate of copper in aub«tancc. A crayon of tliiit should be
passed liftbtly over the {utipehral conjunctiva, more particularly in tlic
retro-tarsal region, once every day. Or, a solution of sulphate of cop-
per ({;r. ij ad 3j) should he ilropiwd int« the eye once or twice daily.
The aBtrinjient roust Ije occasionally changed, as' the conjunctiva after a
lime becomes accustomed to it, and it loses its eOect. Thus, we may
alternate the sulphate of copper with a collyrinm of the sulphate, ace-
tate, or chloride uf zinc, alum, acetate of lea 1, or vinuin opii, or the red
or white precipitate ointment may be applied to the conjunctiva. If the
ipilhv are much swollen and very prominent, like caulitlower cxorfts-
jrmicSj it may be necus^sary 10 snip them olT witli a pair of sclsiurs.
4.— GONOKRtKKAL Ol'HTHALMI.V,
[Syn. (ionorrhival conjunctivitis. — B.]
(.ionorrbtvat ophibiilinia is one of the most dangerous and rirulont dis-
eases of the eye. In the majority of cases it presents the symptomi of
a very severe tinndent opbtbabma, accotiiimnicd somi'tjme^ by marked
ODttstitutional uisturbance.
72
DI8BASB8 07 THS COKJO^NCTI V A ,
10*
Shortly after the infection, the pnticnt experiencea a foolin* of tln-
jling and sraflrting in the eye, as if a liitlo grit or sand had bt-comc
cnlged Wiivath tliti li(bi. Tlie eye becouifs rvd, watery, und irritaljle,
and tlio od;!CB of the eyelida nomewliat glued togcUier by a sUjrht j:my-
ish-wliitc 'iiscljarce. llit-sc symptoms rajjldly incrcRSO tii sererity. ami
the disease (|uickly iu!aumes the character of puriik-nt o|ihUialmia of an
[Pig. 17.
FiK. 18.
X,
Afl«T Uklrrmple.)
'ifijIiravatM type. Tlie eyelids become greatly swollen, hot, red. and
imjcraaious [t'lg. 17]. the conjunctiva very vasL-idar. swollen, and vil-
lous : the chemosiB is niao very considerable [Fig. 18], cnvplopinj; and
overlapping the conica, and ]irotrudin}; Wtwei-n llielids. The discbarge
is thick and croamy, and [wrhafis no profuse that it oozea out between
the lidn, and when they are opened streanw over the cheek. There is
always ^'reat danger of tiie cornea becoming affected with deep anti ex-
tensive ulcenition, which frc.|uently (piickly lead.'i to perrnratton. The
constitutional symptoms are ofleu severe ; the patient* Wing generally
in a feeble and weakly condition, their general health having ]>erhaps
suffered from the exiateiwe of the fronorrhoea.
Sometimes, the didcaae shows from the outset a marked tcndevKy to
assume tlio character of diphtheritic conjnnetivitiA, and tlii»4 proves
r^pfciully dangerouti to tlie eye. In aiicli cattCA, we notice that the
conjunctiva, instead of presenting the unual red, vascular, Kucetilcnt
api>earanee common to purulent ophthahnia, l>Gconies pale, smooth, and
intiltnitud with a fibrinous exudation. The dtsclmrge ia alao qnite dif-
ferent, being thin, gray, and watery. The cantos of gonorrhoea! ophthal-
mia which prove MO virulent as to destroy the curnea in the coumc of a
few honrrt are probably mostly of this diphthi'ritic, or, at all evont-i. of
a mixed character. In Kngland, however, this form is very rare, and,
amonf^t the numerous ca.ses of gonorrhoea! ophthalmia which have come
OPHTIlALMTA >' BOX ATOKHH.
73
nniler my cAr« or observntiou, I h«v« oaty met will) the purulent die-
eaac.
Gonorrhital ophtlmlmia in alwnyn due to contagion, find the doctrine
of inftaataai!^ (wliicli was formL-rly mucli tii vnyue) is iiuite uiiteuablo.
It may V'C prixlHCed during nny stage of the urethral disoas**, but al»out
the third week of ilic existence of the latter is the most liangeroua
period, tbc discliargo beinj; then very copious, thick, tind noxious. I
ii»vr, however, i^cen the discharge from a gleet give ri*c to severe and
t^rrn dpfltnictive };oiii>rrha-:it ophthatuiia. Xlcdical men iMifortuiint<Oy
s ahogctlicr nrfjlpct to warn their pntients of the danger of
- . frnni the urethral discharge. I have met with sevcnil in-
stuiKH->t of tievere and de^istrucuve gonorrineal ophthalmia, in wliiuh the
patiotits had never heen informed hy their medical men of the very con-
tagiouii character of the discharge from the urethra, and bad accidenttdly
inoculated one of ilioir evca.
fiouorrhteal oplitbalnjia is fur more frequent amongst men than women,
lod tlie rigiit evo i.t the one uHunily Hitaoked, tbo corr(<^ponding hnni!
being moxt U9e<:l for the purpft^e of abhition, etc., and, coii»i)UODUy,
moat prone to \ie the oarriur of the virus tu the eye.
If wp rtpp the patient very shortly after tlie inocnlation, the eye shonM
he tborougbly syringeil out with lukewarm water, and a drop or two of
M weak Bolntion of nitrale nf gilver (gr. ij ad 31) be at oucc applied,
and repealed at the interval.ii of a few hours. [Stronger solution:*, of
the »treugtb of x-xx gniin-s to the ounce, are more useful in cutting
abort the di«cafte. — R.j Iced comprcMot) may nl$o be employed. The
other eye should be at once protected by the bermeticHl bandage (vide
p. ah) against the danger of contagion. The trejLtnieut mintt be iho
sittme sv< iliat for purulent ophtbnhnia, the patient'* health being bus-
tJiincd by tonics and a genoroua diet. But if the disease sboflrs a ten-
dency to aiwumc the diphtheritic character, the ibp of astringent* (more
Piipocially the nitrate of silver) roust be particularly avoided, and the
case muiit be trcatoil upon the same principles aw diphtheritic conjunc-
(ivit)!*, viz., by iced compresses, leeches, and, perhaps, the use of mer-
curials.
.'i.—OPIITHALMIA NEONATORUM.
Strictly speaking, we catmot recognixo thin as a special form, for it
assumes the character either of punitent or catarrhal ophthulmia. It
ilenuuids, however., ^me special remarks as to the treatment to he pur-
Med. Tbe inflammation, generally, uppoars 6rst in one eye, tbe other
becoming affucted a few days later it preventive measures are not at
once taken. Tbc symptoms of the diitcase vary from ilioac of mild
cutorrhal conjuuetiritii* to those of severe purulent ojilitlialinia. [The
conjunetiviti* of new-liorn infants U almost always of tlie purulent cha-
racter, iliougb the catarrhal type may be present in one eye and the
purulent in the other. — H.] <hi accouiit of the laxity of the tisHuea,
tlie re ii great serous infiltration and swelling of the eyelids, even per-
bnpt in tbe milder eases. [Fig. VJ.] The papillie of the conjunotivu
74
OrSBASBfi or TBC COSJPKCtlV^l.
uUtf }>ecnme very proottuent snd svollen ; and there u oflen a great
ifinlcncr lo i-ctropi«n.
It has b«cti «tal«(l hy wama antboritiee tliat lite eoraea is iBore Tre-
iiuentl}^ im]Jicatetl lu inraitb tbaii in a<lalt^, bat tbi» does not appear to
[Fig. 15.
«
W tlio CM©, aUbfiiinb niippu ration of the comoa is of but ton frequent
(ruciirnMK'c, from tliv ft'eblu itiul weaklv condiiion of man^' ofthu iuruntd.
iiml tbo n(rg1i{;uiicc arut waiti of care itt tbu nursing, which U so ofkeu
mot with flDiDiig^t the out-patient* of an hospital.
Contagion U a very freiiuont cnuao of Iho diacoAe. The infection
oftt'ii ocDurd from aoniu b'ucorrlK«al, oi" iwrba|w gonorrliftal lUjtchftr;?!*
diirin;; the pasaago of the chihl through Die va^^ina. But it uiiist \w
iilwiiy* n-memberod that other va;;innl disctinrgcfl hcsidcs the gonorrhccnl
mav induce thi« ophthalmia. The disense may ahg bv pro<luceil by the
obiid'A pycH belli;; iripcd rimI ctrnnsed with a spnngu or clotli n-hich is
Boileil with jtumc vii;i;iiiii1 ilisch»r)re. Frc()ucnt)y, the ophthalmia in not
du« til eoulA<()()U at nil, but ia eiiused by the euddeii exposuru of the
infimt to thi' irritntion of brif;ht dmnliuj; light, cold winds, <ir liy » want
of oU'«»li»«'M* ill wHJiliiny tlio eves. Thia is proved by tlie fact tliat the
iltAtraxe tiotiielimen dotiH not inaKe iUi npiioaraiicc till some week« after
birth; whereaa if it were due to coDta;;ir>ii thia would not be the oaae,
fur vn< liiid in iuocututiuu that tlie period uf incubation lasts from 12 to
70 houri. [The ilirtoaw 19 apt to make itd appearance on the third or
fourth day aftt<r birth. ~U.]
The course of ophthnlmin neonatorum is goTterallT much less intense
than iliot nf purnlent ophthiilmla (due to contapon) in adults.
Aliliou:{h the pun.' dlpUtheritiu coiijnuctivitis never occur* in new-
Imrn infjitiW, yet we stimelimes mevt with misud fomis, in which, during
the early *t«j:r*, the purulent ophthalinii* shows a more or less ruarlted
icudeiH'y ti> DAJtuini' a sonH'nlitit diphtht.M-ittc appearance. The lidj are
not fioft niid H»ci,'id (duu^liy } but stiff, and nither hard^ and their tetii<
iTwiMfv is hiyh. Tue (turi'aoe uf the ciuijiuicliva 'm of a pale or yellowjah
Mitt, tl)« papilhc W'in^ not much swollen : the diacharjce, instead of
thi<-k nil 1 ireamy, i« tliin, fibrinous, and rattier AaW, m that it
\'i r^'Jiuiiwhut to the ooojunctiYa, aud bas to be rctDorcd with for-
For- J
0PUTIIAL31IA KBONATOBL'H.
75
cc[*4, ox[iosi[i{i; bcuvnth it a red svicculvnt surface. These peculiar
Briupuxn^ &ri> i^iinplv due In a stBKis in tlie )>li>oilve9§pl.4, amlthi- filtrinou^
tuoJtii does nut fTiicirnU'' into the sulji:*tanc« of Uie conjunctiva, as u the
CBMT in tliG di]ii)thL'ritii: form.
Tilt? pogriosis will depend upon the gcvoritv of tlie attack, and the
cooditiiin of the cornea, llic saiuc i-ulcs hoMiri;^ jj;o(m1 as in purulent
opIilJialmia (p. 1*4'); and if there bo any epidemic, upon the nature of
thirt in general. [Ii is !■/ no means uncommon for the cornea tC' become
early intiUmled in UtiH di»^eiu«c, and the puruU'nt iiilikralion tiometiuies
IpftiU trt ulcpration. perforation, ami [irolap^c of the iris, in spito nf the
mo^t cureful and continuous treatment. The freijuencv of lar^^e leuco-
roala with adbe^iom of the iris, in children, which date back lo a puru-
lent iliitctiurg? in infancy, proves that this i* no uncomroon result. — B.]
Trrntmrnf. — The first indication is prevention. The eyes ("hould be
twndhcd with worm water directly nftcr hirth, luid ttd* should be rc-
fp<'iiteii frc'piently. The Kponges, lowtds, Unt, etc.. should be perfectly
cleiin, »nij uwd for no otlior purpose. The hands of thu nurse and
(he mother (more especially if shf; is suflerin;^ from any vaginal di*-
char;!e) should always be waslied before the infant's eyes are cleansed.
If tlie diseik!ie breaks out in a vrorklionse. or lying-in charity, the children
aufTerin^ from it should be sepuratcd fimn tlic healthy, and should have
l8jrt*ciat nurt^es. Moreover, they sliould not bo crowded toj^etiier into
'■mall, ill-ventilated ward*, hut enjoy plenty of fresh air.
If the eves louk red uud irritable, with a diBc!iiir;io at Uie coniera or
upon the laAhoB, a weak collyrinm of sulphate of stinc (ffr. j-ij ad 3.i)
ilioidd be used i~\i timea ditily,and the eyes fro^iueutly uleau&cd. 13ut
if the dtHchar^e is thick, creamy, and considernMe in {junntity. stronger
tstringents munt be employed. In ont-patient prnctice, whew the
patientA can only be ncmn two or three times u week, by far the beflt
rctncdy is the injection of the collyrium of alum and Kino (/inc. sulph.
gr. ij. Alum. gr. iv, Aq. dest. 3j]. A little of this is to be injected
with a glait* ayringe between the lids every (piartur or half hour diirin;^
the d«y, and every three or fnur hours during the night. The fre-
quency of the injection must be regulated according to the severity of
the duease. Tlie eyes are to be cleansed before the use of the collyrium
hv the injection of lukewarm water between the lids, tio that the dis-
cnarge may l>e washed awny. If the fmtient can be seen every day, or
even more frof|uent]y, tlie mitigated nitrate of ailrer, in stubiitancc,
ahonhl W uaed. lut we can reguliitu and localize it^ effect far l>etter than
can I* done if injection-'^ or collyria are employed. l>uring the early
stage of the oplithalnii.t, the nitrate of Hilver, eiUier in suKstAnL-e or
BtiVQg solution, should always be employed with great care and ciroum-
apection, erea although there may be a considerable degree of swelling
and succulence of the conjunctiva. For the reaction is apt to be too
great and pmlnnged, the eschars being only very tanlily thrown off:
and this great reaction may give rise to small marginal infiUration!* of
the cornea, which, if dne iirecantions be not taken, may easily pjws over
iDto Ute ulcers.' Hence it is always wiser, at the outset of the diseaae,
< V\it) Dr. Alfred Or«er»*« pnjwr. "Kl. Uonatftbl.," ISM, p. S74.
iC DISBA8ES OF TllS CUNJUNCTIVA.
never to uftc a stron;i;(>r nolution of nitrAte of milvcr than Z-^ gnim Ca
the ounce. Tlie odgeiit of llic litld sliouM be siuparvil night anil morning
with simple cerate, or, if they arc sore and exvonateil, witli a little
citrine ointment. [Citrine ointment is too strong an application in these
easoa, and it is scarcely ever necenriary to recommend anythin;; more
than a simple emollient like vsAtline. — B.l For severe cam-h. other
local remedies are alito iiidicuied. e. </.. Icecfici!, scarirication, cold com-
presws, etc. But wo unfortunately encounter great difficulty in their
pn>|H*r employment, except iti a special hospital, or iti private practice.
The mimes or pandits arc often so careless in the application of cold
corapi"C9W» that th«y do mnre liarm than good.
If there is a tendency to stasis in the circulntion of the cnnjunctira,
am) to the formation of the above-named fibrinous mendiraneii, the
a*)tritif^ent« miiat bo wsed with cai"e, and their effect closelv watched.
If miu>!nted nitrate of silver in suliHtance iri employed, it should he only
lightly used, at once neutralized by salt and water, and the cautcrixa-
ttoii he followed by free scarification and the application of eohl com-
presses to the eyelids. Weckor, moivover, nicnmmendis tlie administra-
tion of Binall dories of calomel during this condition of cvanosis of the
oonjunctivft. Affections of the cornea must be treated in the same way
as in purulent ophthalmia. The health of the mother or wei-nnrae
should also be attended to. If the infant is feeble, and the ophthalmia
fthowa a tendency to become chronic, and tlie mother la out of health,
tonicji and a generon-i diet should he prescribed.
[In ciises of perfoi-ation of the coriu-a and [irolapse of the iris, result-
ing in the formation of an adherent Icucnma, the vision can he improved
by the formation of an artificial pupil, by means either of an iridectomy
or an iridotomy. But this should tmt be dune uiLtil the child is at least
Mveral months old.— B.]
f;._DiriIT»ERITIC CONJUXCTJVITIS.
This extremely dangerous disease ia fortunately very rare in England.
I hare never yet met with a case of pure diphtheritic conjunctivitis here,
wliereaa, during my residence in Uerlin, I hitd the opportunity of seeing
many cases in Von (Iraefe's clininue. Indeed, it is of frequent oi:cur-
rence in that city, and often as^iniies a very severe and even epidemic
character. [Diphtheritic oonjunctiviti* is a rare disease in the United
Statert, and, though iwdated cases are sometimes met with, the disease
ncviT a.sKumes the </u<i«i endemic character that it does in some of thd
German cities. — B.]
The first symptom is very rapid and great swelling of iho cyelida,
which are also hanl and firm, very lu»l, and exc|uiiiteiy tender, so that
the patient shrinks back and trembles at the mere idea of their heing
touched. The swelling and stiffness of the eyelids soon become so great,
that they can hanlly be opened, and certainly not everted ; whereau. in
pnndent ophthalmia, we have accn that although the eyelids mny he
greatly liwollen, they are soft, flaccid, and not pninful to the touch, nor
is tJie temperature very high ; they can also be readily everted. [In all
DtPlITHBItrTIC CORJ0HOTIVITia. 77
tertTf* cues of purulent conjunciiniis tlicro is so much swelling of die
tiMiio? of the lida that they are very teiwo and difficult to evert. — B.]
Thi: coiijiiiictivii ii^ at lirst doinenhut red, but noon asBumeti a grayish-
rellitw tint, esfwuiitlly »t the retrff-tantiil fold. It in not m(t, red, succu-
lent. Ami villous, AJ* in purulent ophtlialmla, but thick. auiMth. and some-
wluit gliMtcniiij:. This pale, tirayidh-yuUow tint is cliie/iy due to the
fimi. getntiiio fihrinoua inliltnitinii of the substance of the cotijtinctivu,
wiiich cnuipreHjjes the bhHulvessels, aud j^ivea riwj to a great rctardntion,
or even atop|)ngo in the circulation. Numerous extra vasation:^ of blood
may he noticed on the conjunctiva. Tiio cliemosis is pale and yellow,
but the infiltration \» not serous and traiiHfiaroiit, ))ut lirm and tibniiuiui,
prel^^i^l;^ upon and alranj-ulntitij; tho iitoodvcsaols which nupply tlie cornea,
and Itcnce the jfroat d.'ui;;er uliich the letter runs in thisf disease. When
the lid- nrc u|K'tii*d, u Hlreaui of hot, Hcalding tear-t ^ut^he8 fortli, mixed
perhufi^ with a few yellow fibrinous tltikes, ijuite difl'erent to the tiilck
creamy dirchargc in purulent ophthalmia.
Kri'u di*rp acaritication of the conjunctiva fails to produce a copious
saiigniiirr>u8 dii§clifirge» for the latter i» cither thin, acaiity, and uf a rcd-
iiiBlwyell"w tint, or the inei^iouR retnnin idniOHt dry.
The discharge on the aurface of the conjunctiva often aasnrocs tlie
fomi of thill, yellowisl), reticulated patches, of varying i^ixe. In some
cuts, ihick o]uit|ue nivnihrani-.t are formed, which are so coherent that
they can be stripped oil' in hirge piece:*, forming caste of the lids and
the tnirfuee of the eyet>all. Their forcible removal may cause eonaider-
able bl.'eding, hn( v,e do not fin<l, as ii> the case in purulent ophthnlmia,
that the denuded conjunctiva pn'i»entii a red. succulent, villous surface,
but wo come down uf>OD another layer of yellowish.gray iihrinous iiifll-
tration. In fact, the IsLtor is not confined to tlie surface of the conjunc-
tiva, hut extendi more or les:^ deeply into its stroma.
The dincaBc is not always accompanied by severe inflammatory symp-
loms, but uuiy run a milder and teas dangerous course. It may occur
ks a primary aflectiori, or eiitnue aecondaiily upon purulent opiithalmia,
tlu- Inttor assuming a <1tphllieritic character.
In the primary form, it gcueruUy sets in with considerable violence,
all ihv characteristic symptoms showing themselves in two or tlirco days;
indeed, tliu disease may wku attain it.i :icnie in that tim^', remain sta-
tionary for a few days, and then gradually piuw over into the sccoikI or
bleiiorrlneic stJigo. The latter is ushered in by the following sycnptonis:
The li<li< diminish in hurdnuds and become more soft ainl flaocid, so that
tlicy can he everted with greater ease, and without much pain. The
surface of the conjunctiva assumes a more vascular and succulent ftp{K:ar-
luict* ; here and there fiatches of fibrinous* exudstion soht-u and liocomu
pdctached from the surface of the conjunctiva, which Meed? more or Ic-hs
freely. The deep-seated iiililtrutiun gradually dimiinslie.^, aud this is
accompanied liy a corresponding diminution in the firmness ami hanlness
of the conjunctiva, which assumes a more vascular, succulent, and villous
appearance, tlie discharge at the same time becoming thick, creamy, and
copiou'i. In fact, Hie disease now prosenls the characters of purulent
4>phth:dmia, with Utis peculiarity, honever. that there is a great tendency
to the fitrmuiion of cicatrices, aud slmtiking of the conjunctiva. But
I
somctimea tliore is a relapse after the punilent stage has act in, thai
dii'lilheritic s/m[it<m)» reappearing whli more or less prominettce, ami
siioli rc'la|isert iiiny occur uiitre ilum once. Thi» is especially the cbsp if
the use of antriu^cnt^ linn been commenced too early, or they have been
too etiergclicaliy eiupluyed. ^^
Diplitlientic conjuitcttvitia is a far more dan^^cmuit diMAAc than puriu^f
lent opbtbftlaiia. on nccoiiiit of the freniieiicy and sererily of corneal '
complicationa. Kxt*naivo iiloerattyu or a iippu ration of the cornea is but i
too frt'tucitt. Tlie denine, barl, itiBltrated conjunctiva presses upon the^H
cornea ami upon the bloodvc^uels n'bich supply it. hence the nutrition of^^
the conica is ;*rcntly iropnircNt, and its Bnppnration may rapidly ensue.
If the cornea is about to be implicated, we notice that its lustre is j*li;;btly
diaiinisbud, h» fiurface faintlv clumled.and itit epithelial layer rtoinon bat
abraded. A yrllow itifiltnttion npnears, which rapidly pai^os ovor itit*
an ulcer, the latter extending >|uickly in circumference and iWpth, until
a very considerable portion of the cornea may he involved. In some
cases, when the ulcer has extended nearly a^ far aa the membrane of
Descomcl, its floor hccoines somewhat more transparent, and bulj»ed for-
ward by the a(|ueou3 humor. The patient's sight is temporarily much
improved, and he i« buoyed np by the vain hope Ihat bis eye is safe ; but,
perforation j'oncnilly rapidly ensues. If tlic disease ia very severe, aitd
the cornea has become affected at a very early sta;:c, the whole conie»^j
may suppurate, give way, and a considerable amount of the contents o^H
tlie globe esi.'ape. The perforation is soon hlockoil up by a glntiiions^^
exudation, which also glues Aown the edges of the prolapsed portion of
iris (o the coniea. The earlier the cornea becomes aflecled. the greater
u the ilanger, for the niccrs which occur at a later |»enod of the disease
spread less rapidly, and show a greater tendency to limitation. We also
find, as in purulent ophthalmia, that those eyes are safest in which there
exist either vascular ulcers of the cornea or a vascular panmis, for then
the nutrition of the cornea is carried ou by the htuorl vessels u[)ou it^^B
surface, and there is far less danger of its undergoing suppuration. ^B
The prognosis is very unfavorable if the disease is at all intense, and
the character of the epidemic (if such) is severe, and if the piilient is
an adult. It is somewhat more favorable in children, and towanls the'
end of the epidemic; also if the first stage of the disease is not very
severe.
In framing our prognosis, we must be chiefly guided by the severity
of llie inllannnatory Byinptoms, the amount of the libi-inuiis esiidation,
llie jtwellihg and hanluess of iJie lids and of the oliL'mosis.and pspeciaUy
by the condition of the cornea. If the latu-r becomes affected very
shortly after (within 24-;l(i hours^ the outbreak of the disease, or'
during the first period, before that of vascularization has set in, we mmi
look upon the eye as all hut lost. If tin, cornea is not implicated until
the second period (_that of pumlpnt ophthalmia) haa set in. the prognosis
is more favorable, but even in litis case we must renjember that a relapse
mav occur, and the safely of the eye he again endangered.
•the cauae* of diphtheritic conjunctivitis are very much the same
those which may produce other inHammations of the conjunctiva ; but i
must be conceded that there is generally some constitutional peculiarity
I
nTTnTHERlTlC COSJCSCTfVITIS.
70
wbicli rletonnines tlie characicr of the disesBP, tlio siiine ciiuim?s — eiepo-
fluiv i» coM. (Irau(;liia. iiiiJCuUtion. etc.. producing in ddo case a purulent
or j^rantilar, in tlic othvr a iliplitlieritic oplilbalmia. moreover, it generally
affecM both evc«, however much rrc may guard the second. It nccura
('Wt frc'iuomiT in weakly and scrofulous jwr«oii8, more csipcciHlly in
lildrrn Krlwef-ii tlie a<^vs of two ntid ti;zht, of n delicate, feebU^ hahit. or
aRcctrd witli hcri-ilit:irv sv{it)ili.<4. In them il oftc-n oeciin in cnnjiittrtion
with rroii]! or diplilheria. [1[ is not an uncommon cumplication In cases of
ninligttant Ftcarlatina, and here the disease is met with in the no^c, pliaryux,
mouth, ami larynx, — R.J Contagioti is also a very fre<nient caiiee, for
the dtftcbar;jc from diphtheritic conjunctivitis ia cxccediii(,;ly contagious.
If it bo applied to a healtliy conjunctiva it ;;citernl!y reproduce,-* diphthe-
ritic conjunctivitis, hut liiis Utw^f not iivcewaiilv follow. The infection
miiy be carriei) by the atmonphere, and not be due to diroct conla^iion
from iiponj;cs, towels, etc.' Sometimes the disoAsc occurs epidemically,
which in especially the case in i^omc parta of Uormany, more particularly
in Berlin.
The infudictoua and exceseive Uite of ciutsticii in the treatmeutof puru-
Ifiit <i|>btliiilfflin (more [>nrticularty thai of children) may change Uic
diiH-anf iiit<i tin' diplithiiritic t'orm.
Witli rcgnni to the trentmfint, it nutft be confessed that we have, un-
fonuuaiely, but liitle C(»ntroI over the discaae iluriiig the first period.
Our ftr^t care mn^t b« to remove the palJcnt from all iio\ioU!S tuHu*
eiKf* that may keep up mid inten;iify the diaeaae, and every effort must
be made to prevent it* spreading.
We mual endeavor to diminifih the inflammatory symptoms, more par-
ticularly If they assume a itbenic type. If ilic eyelids arc greatly
swollen, and very reil, hot, stiff, and painful, iced coinpreMOB must be
rmploved almrwt without iutennissiou, being changed as aoon as they
brcomf at all warm. Tlicy must he less frctjuently employed when the
acC«>ni| period (that of viiscularixation) in setting in, and when thi^ has
Iwconie fnlly I'stabli-dicd. tliey mu.'^t be only used after Uie ca uteri 211 tion.
The effect of the cold is to counteract the stasia by causing; contraction
tif tlic vcftsels, and it aUo acts a^ a aedative, giviug great relief to the
intense itain. Bat if there is cxtctvsivc ulceration of the conicu, the
cold compres'^cs aboubl be replaced by warm fiMuenla lions, ao that we
Iiroduce an acceleration in the va-^'ulanty of the conjunctiva. Itidced,
aiely some *urgeon8, especially Berlit.* and Moorcn' have reconuuondcd
llie Bubatitution of warm fomeiitaiions for the iced camprcase«, on tbo
ground that they bring about tlic second period more rapidly. Tbua they
»y provp of advantage when ulceration of the cornea occurs during the
lri*l fwriml, and the ulcer nbow^ no tendtuicv m licconic limiled or vns-
pulnnzr.i, for the tonileney to neerosis ii markedly .nggrflvated by the
applicalion of cold or of caustics. Moorcn formerly always eui]'loyed
iced compreasea, hnt in later years lie has suhstituteil the u»c oV warm
jn>ultice8, together with derivatives internally. But then he biunelf ad-
' WA- Df. norntr* nriklr. "Kl. HonaUU.," Itt», May, p. 137.
• "KI. Mr.n«r*l.l ,'■ |^^M. [.. 2.*,ji.
• "Oiihtii«|.iiinlri«:h«B»H^t)»ohtHHgeu," p. 70.
80
DrSBABBS OP THE COSiOSCTITA .
niu, thftt tiie di»e«M never a]>pesr« in I>&iseUorf with the ajUieae iiw
tetmty which it no oflrn MAiiioeri in IWHJQ.
If the contea bccoiuci implicaicil, airojiine inu8i be u ODoe culojred
in conjunction with the other local rorocdiM, tad the coni«al a&dion
treatctJ tu the- nuiUDcr mrutioued at p. 70,
Local depirtioit nlM provcfl of much Berriec. Cnfortunairlj, die 4i*-
ouc occurs BO fre'jueutlv in aosmic autl cachectic in-lividuaU. that «c
f^crallr cannot rankt- a full usp of tliis. In adults, mow particulariy
if the iltMra^c is due to conta;j;)oii, and the patient rohiut ami atrong,
lo«cbra ithuuld l>e applied in large iitiantitic« to tlie temples, or at Uie
upper au;;le of the nn«e. 1*hrce or fnar Iccchon AhooM be applied at a
tioMr, and a« wxm aa tlicsv drop oflf thcr are to be replaced bjr others.
Bat care rauat be taken not to piuh thifl remedy too far, espeoialljr in
feeble |)crMMut, for by Rreuiiy weakening the patient we incr«««e the
danger of iitougliing of liw coniea. In very eeverc cases aa maur a*
90—4(1 leeches ( Wecker) nr eveti a greater <{itanttty ('iraefe') may bare
to l>e anplie<l before any impression 'u made upon the di^ea^.
ScanhcatioD ia of but little, if any, u«e iluriug the first stSj^, for only
a very hmall tiiiantity of blood i^ obtained ; indeed, lometimea it may
even du }*u»itive barm, being foltovied by a riiorc considerable fibriooua
infiltmiion : but when ttie aecond stage ha-s set in, when tlie conjunctiva
has become more vascular and there tit an effation of Mrum into it, «cari'
fication is 0^00 of much benefit. The incision should bo somewhat
deeper than in pumlcnt ophthalmia, and the bleeding be kept up by
kncadin;; the lidit. [Die divimion of the external canthus by the opera-
tion of onntbiitoniy i* not n^ 11 rule advisabK- in these c8.-*e5, even where
the lid-tension tf marked, for a diphth«.Titic membrane is alnxwt certain
to form npim the incised surfaces and complicate (ho case. Hence it is
l)Ctt4'r tit »enrifv tlie conjuiKtiva or apply leeches to the temple, where
depletion is dvAired. — B.j
In order tu huuten tnu variculariuitinn and the breaking down and
eliniiriAtioii of tlie hbrinouA infiltration of the conjunctiva, tlie itytiem
khnuld be )('tt as ijuickty B8 pooitible uuder the inthteoce of mercury. @o that
aalivaiion may be jiroduced iu the couthc of SO— iO hours. Tne mercury
may either be atluiinistered internally in tlie form of calomel and opiatn
(calomid ^^r. w-gr. j every 2-8 hnurd) in doses vnrving with the age of
the pAtiont, tir from 5*''>--5i "' l^he mercurinl ointment xhould be rubbed
in tlirec limes daily. In very severe ca*eb. the rapidity with which the
fibrinous inhltmtion per^'adcH the conjntictiva U often so great that the
COruoa bvcoujes implicated niul the v\/v lo*t, bcforu the system can be
brought uixltT the inllueiice of mercury. Moreover, the free use of this
nme<ly Is often contni.indieated by the vpry feebh- and cachectic condi-
tion of tlie patient, in which CAne touic*, more especially '[uinine and
prttpnraiioiui of inin, iibuuld l>c administered, and the patient may be
plnccd iHi a yfUfroiu diet. [In the t'nited Stoles, the mercurial treat-
tBcnl is not resorted to, for u&iiHlly the |>atienl8 need a decided tonic and
Itiroalanl treatment from the beginning.— B.]
When tlie disease is passitig over into the second stage, and is ossum-
ins loare nud more the character of puruleut ophthalmia, we must gradu-
idiy couiutence the use of Uie mitigaU'd nitrate of silver. Uuc at first
GRANULAR OPUTU ALHI A .
SI
tbc cauterisation tnuBt be eiuploycU uitli great care and diacretiou, as
_ liore is nlwayfl the risk of caumng a rclapHC if it he used wlili too great
frrctlom at once. Should symptoms of stasifi rtappcar, the cuiiterijtation
QioKt ^0 immeiliately abamluiied until these hare po&^eil nway, and the
di!*ea.ie again a^untea the purulent character.
[-.— MKMBRANOUS OK CUOCPOUS CONJUNCTIVITIii.
Tn a cortaiii number of cases of acute catarrhal and of purulent con-
juu<!tivitiA. the diAcharj^' as-suntcs the form of a niemhrane nltJiclied to
ttUv conjiUK'tiva, in addition to the Quid secretion of iimco-pus or pus.
■Tlii:« foiiii is to be earerulty distinguished fnini tlie diphtheritic form, for
there is no dense infiltration of the ti^iiues of the lid as in tlie Intter.
The meDihraoe may cover the whole iiutdo of the lids, or it may occur
in Miches, and 'a iieMoro met with on ihc ocular conjunctiva. It can be
fttripnt'd o(r. and then tlie cunjunetiva bleeds frecdy. In itome casvs the
mnnbrHne refomu repentiilly over the tiaine 8pot. This form of inflani-
mation has been rejianlcd by some Kn^jrlish and Continental authorities
18 a distinct variety of conjunctivitis, but there seems good reason to
donbl this. U it; mure probably a higher grade of inflammation in indi-
vidual cawSt resulting in the forinatioo of a more or less perfect mem-
brnne on the Mcreting conjunctiva. The treatment consist^! in stripping
oflT tlie membrane and cauterizing; tbc surface as in catarrhal or purulent
conjunctivitiii. — I).]
i— GltANirLAR OPHTHALMIA.
It haji been already mentioned that In catarrlml and purulent ophthal-
mia, the papillic of tlio conjuncliva are often much swollen and byper-
trophied, forming more or It-ss ]]romtnent
elevations on the palpebral conjunctiva. t^'C- *"•
[Fig. 20.] They aniwar in the form of
bright or bluish-rcii, vclvetv. succulent
elevniions. which have no distinct pedi-
cle, but seem to pass over into the tissue
ofUic conjunctiva. They are nuiged in
rowa, and are of course confined to that
portion of the conjunctiva which con-
tain'^ jiapillte. Commrncing at about a
lini' friiin ibi- free n'.iir;:in of the lid, they
extend slightly boyijiiil iw taiNal Imrtler;
their Ftdt>s are guneriilly tiattened, on
account of the papilhe being pressed
against each other. 'l*hey are often
Tory consptcuoiia nt the angles of tJic .« - « ,
teyc.and aasniiic also n considerable Kize
"near the rctro-tarsiil fold, louking ]>erha]>s like large warty excrescences.
The name of granular lids is but too often given to this hyportropbicd
* li
82
DI88ASB8 OF THB COSJUNOTtVA.
coTiililion of tlie pajiillie, iiiHtcAil of lieirifi; limited to the tme granulations,
which are neoplastic fftrmAtiotLS, anil iii>t swollen papillie. On account
of tJlis error, the gro&test conrusion still rui<nia upon Uuh ;suhject, a con-
fusion which not only matcriallv afTvcts the diagnosis but also the treat-
ment of the disease . What haH tendeil «till more to foster this inittcou-
ception of the real nature of j^ranulnr ophthalmia, is the fact that true
granulatiott5 are ^jfcncrally accompanied in lliu course of thvir dcvt'lop.
mcni, l>y a more or less swclleii and hypertrojihieil condition of tlic ]>apillie.
If the Utter gain a conaiderahic prominpnce, the granulations may even
be bidden by them. St«llwag von Oarion* applies the term of *^ papil-
lary trofhiyma or (jranulafions" to these hypprtrophied papilla", and I
sec no ohjcctions to rctair>in«; this name, if it he only remeiiiln*r«^il that
these diffiT altogether in their natuiv ami mode of dcvulopmonl from ihe
true granulationa.
Before proceeding to the conaideratton of granular ophthalmia, I ma^t
call special attention to a peculiar vesicular condition of the cnnjonctiva.
which iit frc(|»ently ])remoiutory of tJmt affection. Tl ii; a matter of 8ur-
priae that tliiK condition, which \\a» heen tio carefully and elaborately
described by severiil rminent conlinonfAl writers, more ositccially Slro-
meycr. Bendx, and Warloniont, should have apparently altogetlier escaped
the attention of many i'jngtish ophthalmic surgeons ; indeed, wo are
principally indebted to two diatinguiahed Kngliah military surgeon*' for
giving thit subject due pruminence in our medical literature, mid calling
the attention of tho j)rnfed^ion, and more especially of army medical
men, to a cotidition of tho eye which \i very im[KirtaQt to all who have
the charge of large btHlics of men, e. //., sohliers. paupers, convicts, etc.
This vesicular condition of the conjunctiva is distinguished by th« fol-
lowing aym[>ioma : On everting the lower eyelid, we notice upon it small,
rouml, tranBimrent bodies like little sago grains or her|K?tic vesicles, which
are wituated directly beneatli the opithelium. They mostly make their
appeariimT! first on the lower eyelid, and may. indccil. remain confinod
to it, but they gonorally extend to the upper eyelid, and I have seen A
few rare instances in which they encroached considerably upon the ocular
conjunctiva. The vesicles are aomctimce isolated, ami but few in number,
being sparsely scattered about the conjunctiva, especially near the outer
angle of Ihe eye. In other cases, Uiey are studded thickly over ihe
palpebral conjunctiva and retro-tarsal fold. They cnntioc be emptied
of their contents by pricking, and differ in this form from the sudamiiui
of heri>es, and die serous elevation of the epithelium of the conjunctiva^
which la occasionally met with in catarrltal ophthalmia ; moreover In the
latter condition the vesicles are much larger. The vesicles consist of a
stroma of connective tift^ne cnutainiug nucleated cells like lympli corpus*
cles, with a little tJiud. TliU'v are surroundc^l by a delicate layer of
condcn.sed conticctivc tissue, which has no proper enveloping mcmbrsne,
lint pusses over into the neighboring less condensed Ussue. With a fine
« " PrMktiMhf Aajtmln-ilknndc," 3<1 Mfllon, p. -iftl. IS6".
* [ rvfpr h'-ro to ihv »i<H>lli'nt iml VfTj luUircBUn^c srtfHrt on " yilimry Ontiibal-
tiiU," tir I)r. FrAiik, Ulw ot tli« Arrojr Medlcttl I>i-|>aMuiriit, nod br Dr. MAmnm.
Doth tl(«rrvt> i\w oarrful »tu<lv <.>( kU ■ntf«0H. Tli<> flrti MpfMarei) In tti<< " Annj'
Medteal Blu>^Hooh,"<rf \Wii Om wcond la BeUe'e "ArohiTMer McdldtM,'* Mo. si..
1&62.
QRAXCLAR OPaTBALMlA,
88
le w« nuLT often succeeJ iu removing; tbem eiitlro. Tlivy wem to
hv i>1fi>ticnl in structure with tKo cUiscd fbllicles of the tiitoatiitca, etc.
Kitrwtimca tlioac reaiclo* appenr without any change in the conjunctivii.
rOeneralty, however, there is »u increased vajscularity of thia nicrabranc
witli Bome swolHiiji;, more Crtju'cially at the retro-tjirsal fuhJ. Ilu- veswols
or the coiijiiriL'liva are very apparent, ami often of a dusky bliush-re>l color,
iiciuliiig Hmall braiichcs toward.-^ the vesicles, which may ap[>ear arrangeil
in rowd tike lillle tranii|iarent heads. Rut this liypenentic coiiilition may
affletimca maak the prencuco of the vesicles, especially if tbcy are umall
[«nd not very numerou-t, ao that they might readily bo overlooked by a
Icupcrticial ubAcrver. If the conjunctiva tg however examined tJintugh a
tm;:niryin;{ ;:lasH. they wilt be canity diH(iii<^ui8bcd.'
if ihe hy[H-ni-mia of the conjunctiva i^; hut itli^bt, these vesicles may
exiitt fur a very long time, for months or years, without producing any
sensible disiH)mfort or symptoms of intlnmmation. The patient may
either be ijulte itnuviare tliat there ia anytliiu^ the matter with his eyes,
ur he may only notice a slij'bt sonaiition or pricking or itcliiiij: in the eye,
tiie laalies being pertinpa somewhat glued together iu the morning. Tlierc
iiHiy also be a teiideticy (" irritability of the eyes during reading or writing,
iiM>re especially by artiheial light. Sometimes, however, even these
lymptnraii are entirely absent.
This vesicular eoudiciun of the conjunctiva is due to an enlargement
of the close<l lymphatic follielea of Kranse. wliicli are situated directly
lK>neat}i tiic t'pitheliiini. an<l wliich are not Ap]>;irent In a normal 8tate of
tiit conjunctiva, but become swollen and enlarged when litis membrane
is ill an irritable condition, ^tromeyei' culled special attention to theiie
vehicular granulations, but supposed that they were [Kithologiual products,
and did not exist in a healthy conjunctiva. The rcnearches of Kranse
aQ<t t*r. Schmidt, of lU-riin. have, however, distinctly proved that Ojey
are phyeiohigica! [slnictures], which are not apparent to the nakeil eye
vhilst tlu! eoiijiiiieiiva is in a normal condition, but are apt to become
eulargtfil into these sago grain vesicles from a proliferation of their con-
lenta, more especially of tlieir connective tissue elements, when tliere ia
any chronic irritation of the conjunctiva.
nov it is a very ira|>ortant t|ue.sliun, and one which lias not at present
received a deeidoil and satisfactory jia^twcr, whether the true gmnulations
arc develujK'd frum these vesicular bodies, or nither llie fuilicles of Kriiuse,
or whether tliey are a distinct neoplastic formation, duo to a proliforati<m
of the contents of the connective tissue cells of the conjunctiva. The
former view is maintained by several observers of eminence, more espe-
cially Hendit and Stri'>mcyer. But one weighty argument against tltis
view ia furnitihed by the fact that true granulations sometimes occur in
In a ncvnt nrtU-lf an trndioma. In Gravfr's Anhlv (xr. 1, 129), Dr. Blnnbcrg'
ki*4 (hat hi* roKt-Ariitii-^ liAVi' l>r>l him to (HinoidiT th» 1r«cliMtiA lira n ill Aifoni im nfr.
iDitaxriUM b V {'••rpltuitic vt tliv Irmphoid n-1ls, «tiii-li prtv^xitl in lli<.- nvrninl on-
IntiiiiivA, and «ri- s*'»tur>-<l atxint in im r-'iiTiilnUxl «>iiiii*etiFi' tl»ui*. In tbr fiirthpr
■«;ri-Aii i>r ItiM itJM'jui-, ihv iracliiHna titllirim iinil«>r^(i htlv Aiii) cwwiias (liilB>t<-iilnr}
' I 11, ntvl flimll.v cicatri<.-i;il c1iiiiii:fii. wlik'li li?a<t U> h ronlrtHrtioti uf ihf sar-
I •iiijunrtiviil tiKKiif. In this [ml ttagn. Hi>>'ti iMi»|il)i'fltlr>ti» lu iMitropinti,
ti- ,,1-v..-, |>*iiiiufl, 'l'*,, U';!lli III iN-iiiiri-nl liirniM'lvi^.
* dtrvoMjvT," Mjiximvu dcr Krk-tcHlicilkatiet." ItHSl,
84
9I8BABBS OP THB OOSIJDHCTrVA.
atualjoos where these follicles arc niore or less oomplrtdT vuithi);. ma
for instance on the ocular conjancdva. Weckor stron^iiT a'lrocau^ the
view that the true grauulatioiid are neo<^la«ttc fonnation^, akin to tuber-
cle, auri an> due to a [trolifrrstion of the cottteiiiA of the ewmeciire ti^ae
CclU, hoA that ihev consist of a nuiss of clo^lr [«eked nncki with little
VT DO connective tissue betncen them. At a later sia}^, the ccniBective
tiame becomes itKrewed iu iiaantitv. bimI fonn<i a ««mi-tratui|Armt. f*ela-
tiooos, gnuDotu nauB cuntainin^ a »uutll •jtiatitilr of fat. The nuclei
diminbth in namber, and ar? Hnallv only sparKeW scattered] amot^K tliQ
M»D»eo()ve tiasue. It U an im|>ortant fact that thU gelatiaottt nasa be-
coaes tranefonned at a latter §tagc into a denw fibrfllar tstnke^ and that
the latter Bhowa a j^at tendencj to contraction, thaa cwuiag tnore or
leM destruction of the true conjunctival tissue. A firm cicameial tiMuc
is formed, which ^vos a streaky. teu<liiioui> afi|icanincc («• the inner ior-
face of the li<ls ; the latter ijradiiftUy beconw- shortened, the rctro>tam1
fold almost obliterated, the tan»l cartilages incurved, thus ^ving riav to
tricbiaos and entropion.
I have never had the opportanity of diittitictlr tracing the transfonna-
tioii of the vci^icles inio tnie ^ranulatioiL'^. as tliej are far leas fmineiitU'
met with in civil than in militarr firactice. Moreover, we cantMM watch
tb« patients so con^jtantly and clorifly. They attend perhaps for some
length of lime with veiiicular granulations, anl are then lost stj^hi of.
The luunc lUfficultr exi^td with rofrani to tho dctenninatiOD as to whetber
a pven case nf acute or chronic ftranulatioos baa been prceedeil br a
vetiicuUr comlition of the liiU, fur it has been already sulcd tbat the
latter may exist for a long time without the knowledge of the patient.
The definite settlement of these (jucntions will, I think, dcpen<l very much
upon the observations mwle by our military ^n/rirft, who enjoy erwy
opportunity of constantly watclnns ^>^ developtoent of the disease froai
ibi earliest f ve:stcular > stii^e to tiic latent, and their experience Bpon
th«'«e pjtiits is, therefore, of the jircatcsl importance.
[Acp'plin;^ to inoft recent in ve>«tiga Lions, ^runuUr eonjunctivitts is re-
ganled as distinct fmm the fidlieutnr form of inflammation. The grano-
latious consist of elevstiotui. over which the epithelium paa»e«. due to
infiltratioa into the eonjunotirat stroma, which cxtenils to die papillie and
tutunocous ti^ne. thus producinj; more or leas or^idxed ue« tissue.
ThM iu61tratiun it afWrwanU partly absorbed and |>anlv' rhan^^M into
de&w ekatrieia) tiuue. whicli in passing throu;^ the shrinking; staj^
oeeaaums much troublo. Brietiy the granulation of the conjunctiva is a
neoplaoaa. Netih-^ip makes a ;?km1 jmiut in eistiuj; that *' it should be
reinerabored that these pwminenccs into the conjiinotira are lM>t tfranU'
Utiunt in the potholugical sense.'* 'E'bou^ thv!>e vehicular granulatioMS,
if wglectcil. tend to the development of true frmnnlar cotijimctiritis. the
latter is *-ery often developed in case* where tlie vi-sicular furuutiiMi was
not preaent. — B.]
But whether we accept or not the theory that vesicular granulatiotia
are the Bret symptoms of granular ophthalmia, and may herome derel*
tifMHl into trut' granulations, there cannot be the slightest doubt tbat they
mu»t Ik; n-^jpled as a stron;|ly pre<li9posia^ cause uf tlie latter. It is,
ance that their exu
therefore, of givat importance
enateaeo abould be detected as
aRA!)UI,AR OPnTHALMIA.
85
early M poadibk*. iiK>n.> ei^pociallv where a lai^' number of peraom nrc
[lUcct^fl together, as in barracVs, workliousos, anil schools. For thU
^ratcuUr state of the conjuncilva mnA be ^atc^tetI with care aud auxictj,
(|B it chiefly occurs in iiKlnirluaU living in n cotitiiieil anil viiialol atinoA-
>ti»rc, 30<1 under faulty sanitary arrangemenw. Proper hygienic Dwa*.
irv* shoiiM, ihcrefurc, Ite at once a(io[>U''l, :iinl Llic |Milicuts, if nccct»3ary,
itu)>milt4-.] to treatment; for if the^t^ ve.sicular gratin1atiriii<i I>l' allowed
tt> exiii imchvckfd, ami i^iich eyes are exposed to the usual irritating in-
fluences met with in marches mid encurapmeiitfi, as for inetaiice uxposurc
in wind, <lii$t, dr»ii<»lii3 nf cold air, or briglit gturin;; aunlij^ht, an opi-
dvroic of granular i)[i)it)ialniin h but Imi likely to break out. the ravajjea
and extent of which cannot he foretold. It is an intereslinj; fact that
Siromeycr' also met wltli tliede veaiuular granulation* aniougift many of
the domestic animals, more e.H[»cciully pi;^« and tJiat tlicy existed in pro-
portion to the dirty condition in which these animals were kept. These
obserratioiifl, moreover, entirely agree with those made amongst iiuman
,betng«,for he foinid that vesicular granulations occur esiH'cially amongst
rpcr^on^ inliabitiniT crowded, close, dirly, and ilUv«ntilate<l dwtfllings.
Mr. Mnraton, vrho has enjoyed great opportunities of studying the
phenomena of granular ophtliidmia. hol(U aimilar viewa. He found'
vesicular granulations very prevalent among8t the ixiorer claases in
Gtao, eniH'cially where there was a large family, who live in wretchedly
cortfineii cabiTL<i, often witlt their domestic animals. With regard to the
iiii)>ortniicu of vesicular granulations, a.-: being indicative of a vitiated
aiaie of the nimosphere, he says, *• So certain do I feel that the prcva-
Iniee of vesicular disease of the lids is in direct ratio to the amount and
degree of defective sanitary arrangemenls, that I conceive the palf>ebral
conjunctiva offers a delicate test and evidence as to the hygienic condi-
tions of a regiment."*
It is, tJiopefore, of much importance to discover the presence of vesi-
cular gninulatiouH as early a;i podi^ible, in orlor that the hygienic con-
diiioiit^of the ward or sleeping ajiariraent of the jiatient may he tJioruughly
examined. Such patients should be placed in largo, airy, well-ventilttcd
rooms, which are not exposed to the bright sunlight. Strict orders
Hhduhl alM he givcri that the same sponges, tuwel^t, or water are not
L'lwed fur others. Indeed, it la advisable that even lieallJiy [fersons
rfhoiild always wa^h in |K-rfcctly clean nater which has not been already
twed by others. It is better to separate tliose affected with vesicular
granulations fp'>m the healthy, for I think that tliere can be little doubt
titat Yei>ieular granulations are contagious, more es|ieciidly when they
are accomjianieil by coujonctival s^i^tling, and a little mucn-jmrulciit
discharge. The jhiktients should be in the o|>en air a.s much lut |)ossible,
can; being taken, however, that they are not exiMJSCiI t<i ilust, wind, and
bright sunlight. Their diet should be nutritious and easily digestible.
If they are weak or scrofulous, quinine, steel, coddiver oil, etc., should
■ Btnni<iv«r, " MKxiint'D <l*>r Krii^gnhWIkiinat," p. 49.
• flr'.'iti-jrrfr. "Maxiiiii^n ilrr Kri-g^li'-illtMiist," i>. 201.
• T* thr military xurg<i>n I wouhl pfli<4finllr h-rtiiinn-nil llic a-lmirablr article in
** L'll[>lil)ialiiiii> MitilHirt- ■•ri Bi.-ljjiiiiii'," \iy lln>. Warliiiii'Oiil Aiicl T<'>U'1iu, in llit-ir
Frem-)! lrnti<'l«li'iti nf MAtkouii''. AU» (1i'.> riitunM'* jmiwr bv Ur. lUiriui), paMntiml
*■ .trcltivi> tt.-ii;rs itv M^<lecin.! Mllilairf, ItMh."
86
DISEASES OP THE CONJUNCTIVA.
ht administered. If there is slight coujunctivitiB, with a liulc dischargv^
or »Taa\] vellow shreiht arc rnrtneil on the conjunctiva, a weak aAtnrigei
coUvriuni {Tine. «n!ph. or Phmi)>. acetftt., gr. 1-4 ad Sj At|. dcstill.,
Boracis gr. iv-vj ad 5j) shcuh! he used, or the lids tuny he very lightly
touched with a cniyon yf snljihate of copper, or Htill hetter, of the tapi^H
diviiias. Pricking the* vesicles "llh a needle does little or no goi^d^^B
The eye douelie or thf iituinizcr IB found to he very I«neficial aiij
agreeable to tbe fiatient. I have occasionally met with this vesicular
condition of Uic eyelids amongst wealthy ])crsons, lu wlir>m the con-
junctivn waa in n slate of Irritation from cxpoBurc to cold, hiight light,
etc., and where no faulty liygicnic arrangeniPnto could W discovered.
Tlie afl'ecitoii readily yielded to mild iwtringeiita, the eye douche, and
c.ircfnl giiariling the eyes ngainet expofinre and too much reading, etc.
Veaiculnr granulation may also be produced by the long-continued me
of atropine. 1 have lately met with some striking examplea of this.
The diduijo of the atropine and tlie enipluymuut of a weak astringent vol*
lyriuin, Koon cauKed tbe granulntionM to dit^ajipcar ; but, on the roappli-
cation of atropine, a fresh crop rapidly sprung up.
[The use of atrnpinw {sometimes gives rise to a peculiar irritation and
iiiHammation of the conjunctiva ami skin of the lids— afrvi^in<; irritation.
The conjunctiva U reddened, and on the lids it becomes tliickened, am^j
even granular. The skin is reddened, somewhat shining, though Ias,,j
and whilst not losing ilci wrinkles, it becomes glazed and slightly exco-
riated. This efl'ect of atropine is commonest \u old ]>eopIe. Some per-l
winst am very suMeptihle, nnd cannot. Lear even » drop or two withoiiM
suffering in some degree. Daturine is to be u^d instea^l of atropine,!
unless it tie safe to ilisuse all uiydratics for a few days. An ointment
containing some lead and zinc should be applied to tho lids, and an
astringent zinc lotion to the conjunctiva; in other cases glycerine to the
skin ia better than anything, and sometimes a bread potdtjce gives most
relief. — yefthrhi^.
The new mydriatic Duboisin has been i*ecommendcd in these cams,
but iLs use bn.-t not yet been exten.sivc enoiigh to enable us to judgaj
whether it is free from the same objection. — ij.j
Wc nivist now pass on to the consideritton of " (_iranu!ar Ophthalmia."'^
Ill practice we find that we may ilistingnish two specittl fomw under
which tlie disetLse shows itself, vis., the ttnite, which is often aceom[Hi-
nied by severe inflammatory symptoms, and the rhrunii', in which these ^
aro sometimes but moderate, aufl occasionally almost entirely absent.
(Jf conrse, wc meet with numerous cases which cannot, he praperly placed
in either category, but show a mixed cliaracter. Practically, it is, how-
ever, of much con»e(|uence to distinguish between the acute and clironic
forms, for great and serious mischief may accrue from a mit^taken dii
Dosis and treatment of a ca.sc of severe acute granular ophthalmia.
ACUTE GUANCLAK OI'MTIIALMIA,
If the Attack is sererc, there are generally marked inflammatory
symptoms : the eyelids are red. swollen, and wdemalims, and on open
ing the eye, we see that there u u good deal of conjunctival and subcoa
I
I
ACHTS nRAVULAR OPnTIIALUt A ,
8T
junetivAl injo«tion. Tbe degree of coiijiinctival swelling varies ; some-
tim(« it is c)it«i«lf raMe, nwre especially in tbe retro-Ur^al region, and
there mav »Un be nuirknl serous cbemosia. The photopbobia ami
lachrvmntton are often rerv great, go that the patient is nuile unable to
open tbe eyt, ami directly it in atlempli-il, hot KcaMiug teara flow over
the cheek. There i« ttften seroro throliWnj^ pain in ami aromitltbo eye,
ami [•crimps over the correspt.Mii ling half of tbe head. On everstvu of
ibc lids, we titid that the coiyutietiva is vascnlar ami swollen, ami time
the papUlfe are prominent, red, and flticcnlent. On closer inspection
(with or withoot a roagmfyinjr glass) we notice, scattered between the
papillic, and perliapa nliuosi hidden by ihcm, numerous small, round,
while HnJies, like sago grains, whieli are not, bowover, confined to tbe
pallfbrnl cotijiiiictiva, hut exU.>nd to the reiro-tarrial fold. They are
»b*o sometimes seen on the oc-iilar conjunctiva, and even on the cornea,
nbeni they give rue to a su|>erticial vascular inttammiition (paimus). If
we DxaniiDe the cornea in such a case by the ohiiquo illumination, and
ihrou;:!) a ntagitifying glait^, we fiml that ibis opacity is composed of a
((uantlty of small elevated gray dots, wjili tbe epithelium raificd over
them. Numerous bloodvcs*cN run over from the conjunctiva to t)ie*c
ipots, giving a more or less R-d tiut to Uie opacity of the coniea. This
Tticular Qpecity mav involve a considemble portion of the cornea, and is
tM>t chiefly confinc-ii to the upper half, as in the ciuic in the pannua
produced by tbe friction of gniiiulations or inverted eyelashes of the
Bpix-T lid upon the surface of tbe cornea. Sometimes small uk-ors appear
M tbe «dge of the cornea. When tbe acute stage iiRs lasted for a lew
days, the symptoms of irritation begin to diminish. The severe pain,
photophobia, and laclirymation decrease, tbe papilUe at the name time
beooming more turgid, vascular, and proininunt, thus biding t!ie grauu-
rklions ; whilst tbe ilischar-je, which has hitherto been chiefly watery,
Wth perhaps fiiily a few yellow flakes suspended in it. becomes thicker
ind muco-punilcut in t-bamcter. The intensity of the conjunctival in-
flammatifin varii-'.'j greatly; sometimes it reaches only the caUirrbal form.
Uotbcr5 it assumes a severe punilent type. The stage of purulent
ophthalmia generally lasts for sei'cral woek^, and then the aymptoms
fTaduallv eubsidc : the papillte diminish iu aizc, and the whit« aago grain
Ennulations are then pi-rba)is fnumi to have disappeared, they having
in fact been absorbed diiriog the iiiflaomiiitorv stale of the conjunctiva.
But to favorable a result is not always obtained, for on tlic decrease of
the inflammatory symptoms, and the diminution in the size of the papilb-e,
th« white, and dow nuttc prominent, sjwtia may reappear between them,
Iho in flam [nation having been iiuuflicient for their absorption. If the
jiatieut is exposed to any fresh exciting cause, a relapse may occur, and
a renewed attack of more or luM severe acute opbtlialmia may take
place. This is, however, far te^s comnir)ii than in tbe chronic fonu.
Contagion ia a very frctiucDt cause, for tbe discharge from an eye
aflboted with acute granulations is very contagious, mure ospecially
dnriiig the raiico-purulent stage. It does not necessarily reproduce the
same .iflectton. )>ut. like purulent or even diphtheritic ophthalmia, may
]pvif rise to catarrhal, pundenl, or diphcherilic conjunciivitis. [This
caiinot bat b«> regarded aa a questionable etatomeut, »o far as dlpbther-
88
DISBASES or THB CONJUNCTIVA,
itic cnnjunciiritiA is cnncorncil. If tlic latter could hu proflucerl by con-
tact with the <1isctiftrj;c of acute j^rADiilation-i, we miMt ncce^Atrilj Kj^anl^H
it us iL jiurely local diiii.>a.se, and iu iiu i^ense connroted with any coagd-^H
tutiotial symptom* of the severity that wo are apt to see in that form of
coujuiHrtiviliij. — 11.] This will depend ui»on local am! iiMlividual circuta-
stance~s, and upon the character of any epidemic of oonjunctiritis tb;
may he prerailinj; at the time. Another very frullful source of aca
graniilutione h defoetive hyj^iciie ; the long-t;o»tinue<l uso of airopiw
may fl1»o produce them.
The prot/HogiB in acute granular ophthalmia 15 generally favorable, i
the true nature of the afTeetion is recognized at the outset, ami a prope
course of treatment U adopted. But if the disease is mistaken for a'
case of purulent ophU^iolmia, and freely treated by strong caustics, thfl
intensity of the irritation will he greaily inerea-ted. nnd the iuflararaatjo
may even aaiiutne a diphtheritic character. .\t the beat, the salutary
inflammation of the conjunctiva will be suppressed, and the nbaorpiton
of the granulations checked. ^^
The treatment must vary with the nature and stage of the affectioR.^|
We must especially remember that, when the acute symptoms of irrita-^^
tion have subsided, our chief object is to obtain, if [ossible, the absorp-
tion of the graiiutatiotm by keeping up n ci-rtain amount of inllamniation
of tlie citnjimctiva. The degree of the latter should juat suffice to pro-
mote thi^ absorption, but should never be allawed to become so consider-
able as to arrest or retanl it. ^^
If there is much photophobia, lachrvmatiou, and ciliary irritation, tfaft^^
greatest care must he taken to avoid all -stimulating applications. Atro- ^^
pine drofw (gr. ij ad oj) ebould be applieil three or four times dally. If
tboy are, however, fointd to keep up or increase the irritability, tlioy
gliould be at once exchanged for a belladonna collyrium (Ext. Itellad.
3ss »d a<|. destill. 5J), which should be applied somewhat more fre-
i|uently, nnd iit larger «]nantity. At the same time, the compound
belladonna ointment should be nibbcl into the forehead every four or
six liours, until a sli^rht papular eniption is produced. If tlie pain iu
and around the eye is very severe, of a pulsating, throbbing character,
and increases much towards night, a few leeches should be applied U>
the tem]ile. Cold compresses are also of much benefit in subduing the
irritation and relieving Uie pain. They roust, however, be applied with
cirooiDspection, and their enVxt watched. If the cold is disagreeable to
the pttdcnt, warm poppy or belladonna fomentationi^ ^lould be suhstt-
tutod. If the conjunctiva is much swollen, more especially iu the retro-j
tansal region, it may be lightly scarified, care being taken to make th«|
incisions very super6ci«l,so that no cicatrices may be left. Much hen-
fit and comfort are often exi»crienccd from the application of a bandage,
for Ibis keeps the eye quiet, and prevent-s the irritation caused by the]
comtant movements of tlie lids.
When the symptoms of irritability subside, and the discaso assumes^
tJic character of purulent ophtlialmia, it must be treated on the same
principles as that affection. The same ruloA as to the choice and mode
of application of caustica apply as in the latter disease; the only dif-
ference being, that the cautcrisatiou must not be repeated so freqneii '
cndOytC OBAKULATtONS.
89
must rftnemher UiAt it U rloniraVile to mnintain a c(^rtA.in dt^grco of
inflauttnatioti in ortler Uy favor thu alMurjition of ttif granulations. litit
CAre niiidt \w taken not ti> coniraenco the u-w of caustics tun t^urly, whilst
tliere iit Ktill conHiderahle )rnt»bility of the eye, otherwise ihts will )>e
itlv increaspd. auJ infiUraiions, or even ulcers of the cornea, mny he
uHucc'l. In those cases in which we arc in liouht a^ to whi'lher the
irrituliilitv uf tlic cyv ts not ntill too ^^rcat for the application of the
nitrate of silver or sulphate of copper, it is always wiser tn feel onr way
with lome mihler application, ror this purpose wc may try a weak
solution (gr. vi-x ad 3j) of the acetate of Icail, a little nf which tthouM
be [liiintp*! over the granulaliona witli a hnish, and at once wnslied oft*
with witrm wnter ; an<l if this la well home, and c:iu:*e8 a siil'siilcnce of
the intliinjmatory tiymptoins. we may, in tlie course of a day or two, pass
over Itt the use of the stronger caustics. But if nny infiltrations or
tilcers of the cornea exist, tho acetate of lead should never be used, ns
U will be precipitated upon the cornea^ and t^ive hm to very marked
ataiDS. Von (InielV rttrongly recomrautids chlorine water fur tho pur-
poee of paving the way for the use of stronger caustics in acute gmnu-
iationii.
When the crayon of nitrate of silrer and potash is applied, it should
be at: on^e neutralised by the sppHcattOD of salt and water. As a rule,
the cauterization should not be repeated more frequently than every 48
hourf, tireat care must he taken if any ulcers of the cornea exist, for
thi-y may he easily ajrj^ravated hy too free a use of the nitrate of silver.
If tlii-re is a j;reat ileal of irritation, J often apply atn)piue ilni|)s in tho
interval of the cauterization. When the swclfinjiE of the conjunctiva has
considerably subsided, and the purulent discharge diminished, the sul-
pliate of copper iu substance, or a collyrium of aoetate of lead, may be
employed with advantage. If it is found that, together with the diminu-
tioii of the itiflauiuiation and the size of the pnpillic, die granulations
oasume a more promiuent character and increase iu size and number,
this tendency to a neoplastic formation muH be checked at oivce, and
their absorption ha9t«ued, by exciting a more considerable amount of in*
flamination by mcnnA of a freer use of some caustic, especially the snl-
pliaU' of copper, which possesses the great advantage of increasing the
iuHamoiation without sivinj; rise to thick firm eschars.
CnROXIC GRANULATIONS.
[Syn. Granular lids. Trachoma. — B.]
Instead of the very nrxuiounced syuiptmus of irritation and inflamma-
tion which ar<: met with in acute granular ophthalmia, the infl.nnimatiou
accompanying tlie chronic form is often very slight, and may, indeed, bo
almost absent &t tlie commencement of the affection. So that, in fact,
persons may be suflering from chronic grauulatious without being aware
Uiot there is anything particular the matter with tlieir eyes; the eyelids
being only & little glued together iu the moniing. or there being perhajM
< "A. t. 0.," a. 3, I9T.
DISEASBS or TBK CONJUNCTIVA.
a slight feeling of roaglmeM under the ejelids. At tbe same lime, the
uiiiicr till nwy hsiig dnwii riiiuuwhnt, its natural M<h lic-iuj^ morc or legg
ObliteraLtid, Anii the palpcbml a|iertMrc CAn!t«i|UL'ttlljr narrowed. Dunn;;
all thiH time th« conjunctival inflammation may he almost absent : indeed,
it is never very pmminent. or in projmrtton to the amount of the grantt-
lations. On eversion of the lids, we at once notice the presence of the
gmnulations in tlic form of small gravi^h-wliite bodies, like tapiooa
gruins, more especially at the retro-tarsal lobl. and iu the vicinity of the
angles of the eye. They tuny alwo awiear on the ml]K'bral conjuitctiv
which is somewhat injected and nwollen. In thiH situation, however,
their size and number are less than at the retro-tarsal fold. Theve ma^
be termed " simple granulations." or. accordin;; to Stellwag, ** granular
trachoma." [Thcae have been called frn;;.sfiawn grannlations, from
their resemblance to the spawn of frogs. — B.j tjencmlly. however, thi
condition is sooq followed by inflammatory symptoms. The eonjnnctiv;
hecomcs vascular, thickened, and swollen, and the |«iriU» hyijerlrophie
and prominoni, li»ving the granulations ftcattured hctwocn tliem. Here.
ihcrol'ore, we have true granulations existing Hide by side with the
swollen papillx, and hence Stellwag calls this form '* mixed granula-
tions." The lids are more or less pnlpy, the conjunctiva roil and
swollen, especially iu the retro-tarsal region, and there ia, perhaps, aoma
chemosis round the comea. Tlie discharge, which was at first thin and
watery, with only a few ^-ellow flakes suspended in it, becomes Uiicker,
more copious, and of a muco-puruleut cliuraeter. The eyes are t^ery
irriinble, aitd tlic patient experiences a tteuHation m* of grit or &and in
them, especially under the upper lid, and ie unable to expose them to
wind, bright glare, dust, or to long-continued work^ without their hecom-
ing very red^ watery, and inflamed.
But all these symptoms %'ary considcmhly in intensity, acconiUng to
■Uie degree of the accompanying conjunctival intlamraatinn. Sometiraea
tliis a*3time'* a mild catarriial form ; in other cases it is more severe and
of a purulent type. The citur.se of the <liscaM; iiH often extremely pro-
tracted, extending over many months, or even years. A source of
danger, as well as of annoyance and discomfort, is the tendency to re
lapses, the intensity of which also varies. Thus a nrihl attack of chroni
mixi^d granulations may be nearly cured when, from an exposure to »o
irritating cau-ie, a relapse occurs, accompanie<l, perliape. by a mor«i
Be»*erc form of conjunctivitis iJian the original one, and a fresh crop of
granulatioua appears before the former ones have been absorbed.
These inflammatory symptom} are, however, rattier due to a renewed
swelling of the papilla; than to a new formation of granulations. Some-
times these relai«e8 are accompanied by considerable infiltrations of the
conien. Such nrlapses nmy occur again and again, leaving Uie eye
each lime in a worse condition, and grailually giving rise to various
serious complications, such as panuus. trichiasis, entropion, etc.
If the attack is severe, and the crop of granulations very considera-
hlo, the infiUraUoo but too often extends from the surface to the sub*
stance of the conjunctiva. The granulations then become more velvety,
red, prominent, and diflused in appearance (hence the ''diffuse trachoms"
of Stellwag), and are often divided by deep chinka. They are, tliere-
of
°1^
CnRONtC ilRANCLATIOXS.
91
fore, Icm <)i9tiiigiiiHh»tile from tlie pnpillic. especially as the Utt«r often
■wiune'A a bnjwni«h-re<l color, and their epithelial layer becomes souw-
what thickened.
If the "levclopmeiit of tijo granulations cannot be checked, and they
extsDd deeply into the nlroma of :he conjitnetivn, the latter often con-
trwpte. Atmphieft, and hccomi\'» gradually chaii<iod info ii fihrotm cioatri-
' II-. Tiiese changes may even extend to the civrtilnire, and the
•- ' ' lend a p<.H:uliar •^lii^ttMiiiig or tendinous ap]ii<:arance to the ^^urfuce
of Uic conjunctiva. We then see tlie latter occupied hy narrow tendi-
nous streaks, the lonj^est and moet marked generally running; pamllcl
to, and about one line from, the edge of the lid. Other t«ndiiiouB streaks
Xtend ill n reticnl*u-d niaiuier towanU the relro-tarial fold. But if the
rophj of the conjuiictivu and caniln^o is wry coiitiidcrablo, the hlood'
vcKsel.s gradually hecorao obliterated, and the surface of the conjunctiva
ttieu a«duaie« a pale, waxy, uniformly tfudinauK appoarutice ; the papilla),
follicicft, and tiiially the Mctiwiniian glanda becoming destroyed. It ift
important to remember tliat too free a use of caustics (es]iecially the
nitm(4> of silver in substance or in strong atdution ) will destroy the dcU-
«* -lure of the conjunctira, and produce more or less extensive
These changes ofteii extend to the rctro-taraal fold, which Twcomc!)
contracted and tcndinoua, no that ita free border is ahortened and rounded.
It no lunger springit into folds at the point wliere it \g retlecled from the
lid on to ihc pyekill, hut, on account of thi» shortening, it pas-te!; Hlmosi
ftmi^^fit on, so that the Ibid or cuUie-sac which nhoiild tixhl at this point
M obliterated. Thin eonditiou ha^ heen tcrmo<l aymblepharon poaiorius.
Jf it i» very coDaiderablc, the lidd cannot be completely closed, and tliua
n certain decree of la;;ophthulmoii may liu produced.
'^lefl«^ c'huni^s in the conjunctiva are of courao accompanied by an
nitf^muou ni)d dimiuution in il« normal aecretiona. so iliai ita Burfacu he-
pflrjit?9 drv, rimgh, aud scaly. This dryne^ (xerophthalmia) is often
incr*?a«<^i ^*y *''« narrowing «r even obliteration of tlie ducta of the lach-
Tmal £;lAn<l by the inflanuuBtiou of tliis irartion of tlic conjunctiva.
On account of the atrophy and contraction of the conjunctiva and
-JWti.**.' t^*^ latter Itecomes shortened an'! iiiturvod. If this be but slight,
''iiiWV ottty prodtit'o an inversion of tlie eyelashes (irichiaais), which
, wJv<?*-''P *•■"'' '^''' aX'*'"** ^''* -'"""'''*^'' "' '*'* oornen. This iuverHoii
I 0 oori^D^'d to ono portion of the lashed, or extend to Ihu whole
r i" tli^ cohtmction of the tarsus is cou^lderahle, not otdy Oio eyc-
f>ut the frt'c edge of the lid will be rolled in, and thu» an entro*
*' 1 1 '»'^ produired. '''I'*' constant friction of the laches and tJie edge
-3 v*?1iJ iiiraiiist tbtf cornea irritates ilio latter, and soon gives rise
_.f|oiaJ Vascular comeitic (pannus). Thia {>auuna may be t«rmed
. _ _*^s»ti<^" (Arlt), being proiinced hy the friction of the inverted
!►*■ "\:>r <?'* pPiuuinent gniimlatiooa or papilla, etc., in contradisti action
' ^^unuji vrhich is du*^ ^ i^o extcn^on of the gmnulattona on to tlio
,,^i(t ■''^'ii^iiip iiivrMllK"*'""* '**'''>iiff *l)iwii thnt Ih«-m are no outilatl* t»\i^ iu
^,»»* "^ 'h** ii.ia tint I I'M ''"■ li'tl'.T t.i)iitilKt» niikiiily or A vvTj ileMo ooQtivuttv*
^^^.B-MSfHirr, 1^1^^. ^,,.m tMfMt iiirdlAg;.- m a uiisHoiu-'r.— B.J
92
DCSBASBS or TUB COKJUNOTIVA.
cornea. ['Y)\c tenn *' niechatiicnr* would lie better than ^* tmumatic*' as
poiuliug nM>re eupely to tlio cftu*e. — B.] Tlie*liffereutial diagnosw hetween
tliet^ two forais is geueniUjr' nut ilitlictiU. In tlie latter, we can trace
t]ie extension of the iliscnse from ilie ocular cottjunctiva on to tlie comen.
Small, round, elevated, grajr inliltratiouB are formed ou its surface jusC
beiieatli the epithelium, and extend over n conaidcnible portion or even
tlie whole of the cornea. Between thi-se little nodules, l.loodvcjiwU
ajipcar in more or le«s considemlile nuinlier. Those inliltnitiond often
leave behind them depreaaions or xmall ulcers on the surface of the con
nea. The traumutic pannus almost alna^-s counaence« at the upper por<
tion of the conica. extrndiiij; from the peri]ihery. This is due to the
fact, that the {»ninulation« are j^cnerally more prominent, and trichiasis
i» more rre<|ueut in the upper tid than In the tower. The (annus fre-
quently remains confined to the upper jHirtion of the cornea, tliO lower
continuing tran8|>Arcnt. Bcaided the incurvation of the edges of the
li([)4 ntnl con8ei|uent entropion, we often find that the pnlpehral aperture
becomeit much shortened (Mepharophymosis) in chronic p-anulations.
The prcMure llius e.xerted uii the eyeball iucrea^oa any existing {►annus,
and greatly reiard* the euro of the gmnulatinns.
Chronic granulations occur most fpe<[Urntly in adults, and are bot
lorn met witli in children or the verv aged. Both eve!> genenillv be-
le afTectefl either at the out^etoraflera time. It hasbern tnaiutained
by some ophthalmic surgeons of eminence (more especially ArU), that
the dijieasc is often due to constitutional caiwes, particularlj scrofula.
Thi* dr'C* not, however, apfvear to he the case, although it must he oon-
cedeil, that it is freaueuily met witli iu weakly, CAcht^etio. and scrofulous
individuaU. But illdicalth ia, I think, ratlier the effect than tliu cause,
for the very protracted course of the disease is stire to tell more or 1««
severely uj>un the health and i^pirits of the ]>aliotit.
I>ofet;tive hygiene and contagion are also the chief causes of chronic
granulations. The muo-purulent discharge U very conta^iou;^, and may
Sroduce a similar atfrction. or it may cnu^e catarrhal, purulent, or even
iphtheritic ophthalmia,* just as, conversely, these diseases may produce
granular lids.
It is ]irobnl>le that, as in purulent ophtbaltnia, the disease may also
be pro}m,!.'nted hy the nir, mon,' uiipccially if it is aceum[>anied by severe
purulent di-chnrgp, au<l the ea.ses are crowded together in 5mull. close,
lll'Ventilttrd rooms. The disease may occur epiilemically and endemic-
ally. It spreads rapidly amongst the inhahittiats of elosely-crowdod
dvelltngy, such as barracks and workhouses. It is very prevalent aiuongst
certain nationalities, where the [»e«ple are crowded together for a length
of time in small dirty cahinii, filled. jierha|ui. with smoke and ammnniacal
exhalations. Thus it is very common amougttt the poorer InAli.and also
amongftt the Uu^ian peasants (Wecker). [The prcralence of this dis-
ease among cerutin races is very marked. Tbus, m addition to tlte Irisli
aud Ktissiau peasants, it is very commoD among the Jew^ and certain
oriental races. On the contrary, it is exceedingly rare among the ne-
groes of the United States. — U.]
OHKONIC GRANULATIONS.
Aft
The protptoaiM of cbronic granulnr ophtbnlmia may be faroraljle, if
the granitlatiotm have been but limitfd in ntiinbcr, ami the patit'iit lias
been trentcil fnim tlie oiiUot, It miii<t. however, be alwavi r«memb«reil
tbni the course of the aisoBBc, even in the moat fnvorablo cabcb, ia apt
be vrry protrnctci!. Thia will be more especially the case, If the
nululianit liavL- H|>|H>urci| in vuiihidvrahlc i]uaiitiiy ; if Uiey have in>
vftilcil the ittronia of tlic CDnjunctiva. and if there i<i a tenrlcncy to
n.-lBp»eB. For (heti scri»u.i complications, 8iich as trichiasis, entmi^on,
and lunnits, are likely to occur, and will not only a^^ravate the symp-
tonw, but proaOy rctJinI the cure.
In Uie trftitment of t\}U rli^ciuie, our first care must be to place tlie
patii'tifs under tlic most favomblc saniUiry c^nditioni*. They should
laVf a j^mmI deal of oii(-d(K)i" exerciw;, their oyeu Wing protect*"! against
winrl, duiit, and brifiht Yi'^iii by blue ^^laiDws. They Bhouhl be warned
Dot to exp'iiie tboinsflvc)) to any irritating cftii«P8, as, for instance,
tobacco siuolce. I have oftt^n known the di^ea^c a(^.^ravated and kepi
up by the |uitiont s]>ondiiijZ much time in a room 6Iled with inlmoco
aiuiike. For LbiH n'^aHon no /smoking xhouM be allowed, except in the
open air, and then only to a limited extent. The pencrsl health must
also bo attended to. Not only may the patient be naturally weak and
feeble, but the severity and protracted course of the diwaae arc bnt loo
likely to alTi'Ci thu health, and at the name time to exert a niot«t depresft-
infi intliicnce upon the mind. The diet ahonid be nutritions, and eaaily
diKcstihle, and malt liquor and wine will ponerally he very beneficial.
If the patient is scrofulous, or weak and feeble, cod liver oil, steel, and
(|uinino should be freely given, and every care taken to invigorate the
constitution as much as possible by oi>en air exercise, sea-bathing, or
even a Toy»^c.
In our local treatment we nnist be chielly influenced by the fact, tliat
the roaiiitt^-nance of a certain degrne of inflannnation of the coojinictiva
is iiecetisHry and desirable, in order to produce and htisten the iibttorption
of the grnnulatioiu). Our chief efforts must, therefore, be directeil to
intain the re<)tiiHite degree of intlammatiou. and so to balance it that
it sball not on the one hand be too considerable, nor on the other too
alight for promoting tlie absorption.
The greatest stress must be laid u[K>n (lie fact, asArltand Strmneyer
remind as, that the pur|HMt; of the cJiutcrixation is ttft that of chernieally
destroying the granulations, for tliis would load to great and lasting
larr of the conjuiiciiva from the destruction of it^ secrctjng organs,
id tlic formation of dense cicatrices : but, its object is to maintain »
Cortatn dej:n.'e of hyi^eiieniia an<l iutlaniuintion of the conjuncliva, in
order to hasten the absorption of Uie >;ranul&tion». The nature and
strength of the caustic must vary with the effect we desire to produce,
if tlicrv is much awelling of the conjunctiva and papillio, together with
a thick, copious muoo-purnlcnt rli.>u.'barge, the crayon of nitrsto of silver
And potash should be applied, its effect being at once neutralised by the
flolatinti of salt and water. The cauterization may Im- re|H!ated every
Ihl hours. If the parient cannot bo seen sufficiently fre<|Ucntly for this,
he should use a collyriura of nitrate of silver (gr. ij-iv acl 5]), or of sub
phate of cop|)«r of the same strength two or three times daily. In those
DISKAflSa OP TUB COBCJUTtCTlVA.
cues ire m&T also first try ihe effect of a coU/riuni of acei«tc of lead,
gr. ij-ir ad 5j, or liie chlorine waicr, io order to see if tbe coDJanctiva
will bear the uitrate uf ailver, The use of verj strong BCp]ittioos of
nitnte of silror (f^r. x-%x ad 3j) are not jndicaons, an thcv are bat loo
lik«lr to deittrov the graDnlations. and wiUi tbem Um noraol structure
of llie conjnikcUva. in?t4.>ad of ^mplr fnt'oring iKnr alvoqitioD. I think
the crayon of nitrate nf silver or cdf-pcr i» alw»y» to be fin*ferred to th*
iMe of collvria, as we can regulate and limit the effect of the caoleriu-
tion according to our wish, eoMfiniog it, if Dcccwary, chieBr or cntireljr
to certain portioiw of the conjunctiva. If there is considvniblc ^wclltng
of the conjunctiva, ('fiiifcialljir at the rctro-tarHal fold, superttctal fcarifi-
cation nuiy be ctnploTrd with much advanta^. After the cauterization,
cold comjireoses itbould always be applied to the eyelidd. in onler to
ditoiiiisb the infiammat/^ry reaction: or the cold douche or atomiser
nay be employed. If the conjunctivitis is so eli^iht as not to prodoct
tbe absorption of the granulations, but rather to encourage their de-
Ttloproenti it irill be necos^ary to increa^ the bypcnuniia and inflamma-
tofy swelUog of the conjunctiva. The re[H*ated apjilicatiou of sulphate
of cop]M>r in 9iilMt(inCL- u very effectual for thiti purpose. The mow
effect mny aUo l>c produtreil hy the applicntion of w;imi compmsas over
the eycliilfi. Yon (rraefc* has found thi5 treatment very socceofal,
esjiiKrinlly in those ca.'vs in which the grannlations tend to extend deeply
into the conjunctiva, and in which there is not a sufficient degret of
byp'Tteniia and swelling of this membrane. These warm coupreasefl
ahoiiM, liowever, oidy \>c applied for a limited peri.>d, othervise diey
may produce too cuiuiidorabto an iuflamiaatioii and too great an irrita*
bility of tbe eye. [A aseful application in allaying irritation oud pbtv
lophobia may sometimes be found in the balsam of copaiba, applied to
the external hurface of itie HiU and forehea-I.^B.]
In treating chronic gmnulationA. it will be necc<t<tflry occasionally to
change tbe emstic, as it loses itit effect sfter a time, from tbe coujaocdra
becalming aocostoawd to it. Thm^ ulimi. acetate of lend, or tannin, majr
be substituted with adrantage for the nitrate of silver an«l sulphate of
copper, t^omc patients are more benefited when the astringent or caustic
ia applied in the form of an ointment than of a oollyriura. If it is, there-
fore, found iu obstinate cases nf clirunic granulatiou^ or cbnmic ojilithal-
raia liint thi> variou-s rultyriii are doing but little goml, au ointment innst
be nulistituted for tbem. ooiicaining sul; hate of copper, nitrate of silver,
or acetate of leiid. The strength of tli« ointmout must vary with the
severity of Uie case, hut aa a rule it is best to employ it rather
weak It first, for fear of setting up too much irritation. Tli« follow-
ing proiiorlions will be fotmd most generally useful: I. Cupri sulph.
gr.j-ivadSi oxung. 2. Argent, nitrat.gr. B*-iij ad 3J- -l. I'ltimb. aeet.
gr. ir-xij ad .^j. The glycerine piiwam may he »iil«3tilnted for the lard.
A small fKirtion <at>out the sixe of u split (»ea) of the ointment should
be placed with a proha or the ciul of a 'piill on the inner side of tbe
lover lid : the eye \» then to be ekaed and the lids rubbed orer the globe,
■0 that Uic ointment may come in contact with tbe whole conjunctival
I "A. to.," »i- a, 147.
OURONIC ORANDLATIOHS.
95
I
*
*
*
furrace. Great care miutt lie taken never to order an; preparation of
tbo oalta of leacl if there ia any abraiiion of the epitlicHnni of the cornea
or Miy ulcer of the luttcr, an it will produce au imlwUljIo lead stain.
Hairiui)^ >itroii;;ly ruooniiiiciidd the un<f of tannin in ease^ of chronic uph-
Uialmia. etc. etc. lie employs it in two fi^rmd, as a collyrinm an<t as a
mucila;*o. The former contains about 12 grs. of tannin to .^j uf diatilled
water, and ia chioHy indicated in cases of cntarHial ophthalmia. The
uiuciU(;e ia much stronger ami ia employed in ciironic granulalionfi,
chronic ophthalmia, punnus, etc. It is to he prepared in the followiii;^
wanner: One |iart of tannin ia u> Ih* diitiiulvcd in four part^of water and
this solution etraineii lhron>;h tine muniin, then two \nirui of <riini arahic
are aildrd and the whole carefully mixed and vrnrked up into mucilage.
A small •juuntity iff to W applied with a fine camers^hair brujh to the
conjunctira of the lower lid. In chronic granulations, etc., and chronic
ophthalmia mneh benefit ia often derived from the application of astrin-
p^nlf and cansticjn to ilie external surface of tfie Hds. Thna a sohition
of nitmte of silver (^r. iv-viij ad Sj) may be painted over the external
Surface of the upjier lid, or a compress of lint dipped in it and laid 'n'er
the clotted lidti. Care mu-tt, however, he taken that the solution is not
too «irong or repeated too often, otherwise it may easily stain tlie skin.
Compresses si>&Keii in either of tlic following lotions and laid over the
elcse<) lids will aliso be found very henelioial : 1. Liq. plumb, dincet. 5i ;
tij. demt. Siv- 3- \'i<^' plnnib. diacet. 5j; boracis, 3ij; ai(. amy^<lal.
uiiar. ( I'rnssian ritarniacopiria) i»a ; ai]. de^tt. 3V). These conipre».se.>4
»r« to be changed every 3-4 minutes and continued for 20-30 minutes,
this btiiug ro|ieatvd two or three times daily. In some caH09,the acetate
of lead should he rubbed in (finely powdered ) between the gi-anulationg.
This treatmeut, which was first adopted by ituys,' has been practiced
with great mncce^H, Cijpccially in Uclgium. I have employed it with
nuicb henetit in those cases in which, together with but a slight ijecretion
and lachrymation, the granulations are prominent and ficshy, being
arnin;;e*l in rows, with deep furrows or chinka Wtwecn ihcm. Finely
pfiwderod acetate of lea<l should be fretdy rubbed Into these furrows
until they are iiuitc filled up. The otFert of this ih.so to slH^1k.lo clmkc
the granulationtj. their vitality is itnputred. and they gradunlly dwindle
down in .oize and di.-<ap]>ear. After the application, the conjunctiva looks
marbled or tattooed of a red and white color, the cliink^ are filled np,
And it Aoon becomes smooth and even. An important fact in connection
with this treatment is, that the discharge is now no longer contagions ; at
least in Belgium it is ahvavji considered, when the acetate of lead baa
been rublted in, that the patients may go with impunity amongtit heulthy
persons ; m that soldiers affected with granular lids need no Iiuigor he
confined and iteparated from the others, but may, if they am able, re*
■amc their duties without danger of spreading the disease. The acetate
of lead in bcift applied in the following manner : 'llic eyeHd:^ having been
thoroughly everted and the retro-tarsal fold brouglit well into view, a
I Prvnrti Tramlftt i'lii vt Mm-konzlo, 1. p. 7ft3.
■ trent'lt Translation i»( Uttckvutiv't Tn-atifl«, 1. 748.
96
DI8BASBS or THK CONJUNCTIVA.
Bmall portion of verj finely |>ow(lercd acctnte of lend is tlicn bilcon nn
in a »m»]\ curette and duslvil over the ^nmulations, beluj; well ru))V>ed
into tlie cliinks eo aa lo fill them up. The watery discharge from the
conjunctiva changes the powder into a thin pla-sma, which runs tliroiigh
ami tilU up the fiirmwH between the granulations. When il has been
applied to every portion of the ^rannlar conjunctira, a small Btrenm uf
cold wiiter, cither from a fponj^e or an India rubber ball syriiise. shouM
he nwide to play u|Mm the conjunctiva, in onler lo n:M>li iiway any «uper-
Unoiut ((nantity of the powder, which cornea away in amall white tiakoa.
Both eyelids uaay be everted at tlic same time, bo aa to fold over and
protect the cornea, the pon-iler t>cing rubbed over both uyelids, and the
elr»-am of water applied l>eforc they are replaccil. But if theaimidtiineoiw
eversioji of Wtli lids i* diHicult, or the patient very restlesa and unruly.
it is liotter bo evert one lid at a time. It is best to commence with (he
lower lid, for if the lead be applied first lo the upper, the lower liecomes
reddened ami bathed in teara, so that it will not only be diHicult to see
tlie chinlts, bnt the pi>wder will be readily washed away by the tears,
whereas the conjunctiva of the upper lid, from Itm greater expanse, can
lie nion* readily ilried, and the tears are hence of less inconvenient^.
Ilirectly after tho application, tliere ia an Increaicd (low of tear.*, the
ocular conjunctiva boemnes injected, and this is accompanied perhaps by
considerable irritation, heat, and smartin;; in the eye, bnt thcw symp-
toms wdl soon yield to tlie application of cold compretise*. In nWnl half
an hour, tho lids shonld be everteil ami the conjuncliva a^ain wa>;hed by
a stream of water, in onler that any remains of the lead may be removed.
The conjunctiva will now be more t^mouth and even, the chinks between
the frntnulationa bcin<; fillorl up and obliterated by the powder. If the
application has been insufficient or too superficial, the granulations will
reapi^ar after a time and increase in sixe and prominence, rcnderin;; a
fresh application of th« remedy necessary. If the acetate of lofid ia
can^fiitly applied and the Hui'plus well washed anay, I cannot tuiy that I
bare over neon nuy di, -tad vantage arue from ita employment, nor have 1
found that it rou^ihens the licU and thus irritates the surface of the cor-
nea. The best mode of apiilyiii}; Uie solution of the acetate of load ia
to evert the li<U, and after aryin;; the conjunctiva with a fuece of linen,
to apply it with a small brush to the ^granulations, this being neutmliEPd
after a few aeconds with tepid water. The strength of the solution j^honld
vary from ti to 10 or ^U (iniins to the ounce, according; lo thv condition
of tlie conjunctiva, and it should be ajipUed every day or every other
day.
I r
I
mnet strongly object to the nnplication of undibiled liquor potosas
to the granulations, as this not only mon> or letis destroys the stmim of
the conjunctiva, but xivtta rise to very cdnstdorable cicatrice*, leailing to
rnlmpion, etc.
Should any ulcers of the cornea exist, the treatnwnt of the conjuncti-
litid by cauatic$ must be continued, but atropine i>hould be applied in die
intervals. The application of a firm compress bamlage often acts very
advn!itn;:eou9iy in checking the growth of the granulations, and hasten-
ing their aWtirptiou ; but other local remedied must he at tliQ aame tine
CHRONIC aRA!rULATIO!tS.
OT
ap|t1ifHl. It has even l)een snjj^ested to keep up a cimg'uleraUe degree
of comprefwion hy irory platu« adjtuted to the UiIk.'
[Mr. Gnder Bpcakd lii^lily of the npplicntioii oF tiiilplintc of tinininc tA
the conjunctiva m cnse» of ■'rftnular liil* ftccniii(«ftiiifil by pauniis. A hoiit
as niiicti as wimM f»o nri the jioiiit of a peuknift! is to he applieil, twice
lUilv. with a ctnii'l'-'i-hair hnmh, to thp inside of the lower liil.* Xagel'
bat al9c> fonn'l uollvria of quinine hencficial in chronic conjunotiriUs and
sappuratire keratitis. This is pmhably iJue to the inHucncc which
(inininc exerts in checking the ara.ijTH>i.l movement* and mi^^rattona of
Jie white Uooil-corpuscle)!. and in restraining the ililattttiuu of the blood-
seU, as shown by Itinz. — B.^
The treatment of the pannus mujut rarv aconling to its cause, \ta
"dcj;ree,and length of existence. If it he nepomlent upon the friction of
inverted liwhea, prominent granulations or papiiljc, or upon entropion,
rthe.'^e afiectioiu iniuit be treated, and when they are eiireil, the pnunus
rill soon 'liftappcar. Itut if the grannlar lids nnd the pnnnns havi- he-
very clironic, they may set an oh^tinate defiance lo the most varied
i?atiDeni. Caustic?* nnd fitimulnni application? of every kind may he
tried, and yet the diseaw prove intractaMc. In some cases, in which
the pnnnuB vra* not too dense atid vascular, I have found cousidernble
benefit fnim a coUyriuin composed of 1 pari of oil nf tiirpontinc to 2 or
4 partfl of olive oil. A drop nf it shouhl be appht-r! oiwo or twice daily
to til" inside of the lid. This collyrium was, I btdieve, first recom-
mended by Dondera. If, on the disappearance of the pannus, we find
Uio eurralurc of the cornea connidcrahly altered, or a central opacity
renminin". it may be nccoMary to make an artificial pupil either hy an
jridectomy or an iridodesis. If the palpebral aperture is much short-
iimm], and the eyelids thus press on the cyehall, the outer canthus should
diviilcil with a pair of scissors, ao as to widen the opening of the lids
relieve the prewure. (Vide operation of Canthoplasty.)
Von Oraefe* has fuumt great benefit from chlorine water in cases of
even severe complete pannns. He especially mentions two cases in
which the pannus was so advanced that the patients could onlv disttn-
.guish light from dark, nnd were quite uiuiblc to count fingers. In both,
>t only had various caustics, such as mlrato of silver, sulphate of cop-
per, acetate of lend, hecti npplicd for many months without avail, but
sjmdcctomy liad been performed, and in one inoculation, without any
DODQ&cial resalt. After using the chlorine water for six or eight weeks,
they were both so much improved as to be able to find tlieir way about
tolerably well. In other, less severe, cases of pannus, he ha* also ox-
iperienced much iK-ncfit. from it.-* use. The chlorine water itt cither lo he
used as a collyrium luul dropjwd into the eye once or twice daily, or it
U to he lightly bruslied over the everted conjunctiva.
For very invcicnitc casea of pannns, more especially if it only in-
volves a portion of the ooroea, syodeoiomy may he tried. This opers-
> Vid* I>r. Stukes'B lupor on tltia sulijvct. *• DaK Qn«rt. Joonuil HM. 9el.,"
XU.SB.
[• Unoet, <W. 28, It*7I.— B.J [• Kl. «oii»Wbt. 1689, p. 430.— B-l
• "A. r. O.," It. 2, ll»S.
7
9«
DISEASES OF TBS CONJUNCTIVA.
tion, which vfa« firnt introduced li^ Dr. Fiimari,' i)TOves useful in cams
of inveierale paiinua, in whicli a portion of iht* cornea is clunr, so that it
wonlvj not be aafc to iwrfonn inoculation, or, if the Utter U for some
TViuon inuppUcahle, in vusea of complete paunutt. The ohjeut of the
opcrntion is to cut off the supply of lihmd from tlic cornea b^' a. divtsiou
iiikI partial removal, n^t only of the conjunctival, hut aUij of the subcun>
jitncliviil vcR'^els. It is a less dangerous and troubleitoino iir<K:euding
(luin inocutiLtion. It must, however, be also admitted that it is not al-
urays aucvessful, the ea^es improving perhaps somewhat at &rst, and then
a relttpse takes place.
[Scarificaiion of iho large superficial tomcU of tJie cornea, frefjuentljr
Xapeated, has been advised in obstinate cases of jiatmus. and in some in-
'lAaticea has proved cfiicacinuM. It actA probably in the same way as
peritotny. — B.}
&^ytldcctomy is to be performed in the following manner : The parent
should be placed llioreiighly under tlie intlucnce of chloroform, as the
operation is very painful and protracte<l, nnd the eyelids should be kept
apiiit by the stop speculum. The operator then seizes with a pair of
fi>rce|>s a portiun of the cuujuuctivu and t«ubconjuiicti«ul tissue, near the
cornea^ so aa to fix the eye sieadily. He next witli a ]iair of curved
scissors makea a circular incl!tion through tlic conjunctiva, nil round the
contea, and about an eighth of an inch from the edge uf the btu*r, and
])arallel to it. This circular hand is then dissected off, and excised close
to Ihe edjie of the cornea, so thnt a wide circle of conjunctiva may be
removed all round the cornea, l-'or the i>ur[>u«e of more easily rotating
the rye, two small portions of conjunctiva sliould he left standing near
the coruea until the operation is completely finished, when they are to
ho attipped off. A circular portion of the subconjunctiral tissue, corre-
snoiidiug to the wound in the conjunctiva, is next to 1>e removed, quite
close to the sclerotiCf so aa to bare the latter completely ; if small |tor-
tions of subconjunctival tiasne remain adhcrinj: to it, tlioy may be scraped
ofl"witli llie e<Ige of a cataract or iridecloniy knife. Some of tJio larger
veii^L-ls upon the ci}mea may also be divided near its edge. l>r. Funuirt
advlsc-t that tlie exposed sclerotic should be cauterized with nitrate of
silvci:. This is, however, a most dangerous proceeding, as it is but too
likely to produce inflammation and sloughing of the sclerotic anilconiea.
Colli ciimpresses sbouKI Ur applied until the symptoms of inUammstory
reaction have sutr^ided. These arc, as a rule, but moderate, and the
pholopbobiat pain, and laohrymation gojierally disappear in about -18 or
t>0 hours. It is wist- to keep the patientt^ iu Uie hoapitol for a few days,
so tliat, if severe indamniaiory symptoms should supervene, they may be
treated at once.
In Uiose caM's of invctcrat* paunus in which the latter is thick, very
vOfU^ular, and covers the whole of the cnmra, and in which, on account
(•f the cicatricial changvs in the conjunctiva, it is inipc>S9ib1e to excite
sufficient bypcraiuia ai^ swelling of the conjunctiva lor the absorptioti
■ "(laiotio Jll,^:r-'- ■■ "•T*, So, 4, <^p. ; ridv «laa ui artirlrQpnn Ibf tnl^Jvct fcy
Mr. lUdrr, "K»t. l U. Ilwji. |t>>t«ru," U. 22. Tkb ofwratiou liu tv««dT«l
vufi'iu umtn , ui • .. :.t„ .t «u ivrmrd I'imiuKbioaof Uit contiM. It U uaw fcn-
•*ftll;r cslli>d «Uber B^udlcriotB^ «v fwriUia^.
CBBONIC OKANULATTONS.
fl9
of the j^nulatioiu, it muy be iiece»uiry to produce a purulent iuHnm-
iiiAiion of the coiijuiictiva \>y the inoculation of |iiia, in order that the
granulaliowi ina^, if {KtH^iblv, hn absorbed aud the cortioa cleared duriiijt
the pmgrL'dii nf clio inflammation. Tins procecdinj;, which vas firat ad-
^vocalcd by Hringer. h-AA lon;^ tHseii extensively and auccesafuUy practised
Belgium, whvrL' j^runulutiona are very common amon^^st the aiildier^.
Ill Kii^land it \iag aUo Iti-cii very lar;5ely and 8ucc0sj*fullv cmploypd at
the Koyal Loudon Ojihthnlniic Uo8|iitjil, M(K>rticld:«, where Mr. Ilader
fimt introduced it. 1 have seen numy admirable c-urea produced by It.
aud patieiita rc»t4re<t to the enjoyment uf excellent »i;;bt (some b«iiig
nblu to read No. 1 uf Ja^er) who had twun KitfTering from so dense a
i^pannus that they wtn^ imahle even to count ftn^^ra. In many of these
i9<.'S niont other remedieti had been tried iritbtjut aviiit. The chief
ui«;er \s, of course, tliat the purulent intlnmmalion which is induced.
'should be so severe a^ to pr<)<lucc suppuration of liie cornea and ]o$& of
the eye. But it is surprtt^in;* what a degree of inflaounatiou a very
vascular and completely pnnnous cornea will bear irith impunity, ana
he, |>erhapd, tiualty restored U> ahuot«t nurmat traiupareiwy. It may b«
laid down as n rule, that the more vjiscular the uonioa, the less danger
i» there of its sbiughing, for the numerous hbiodTesftcU on iU surface
will maintain if* vitality during the purulent intlnmmittion. Inoculation
id. therefore, much less safe where the vascularity of the cornea ia hut
tDitdcnite, aud is toadmisdible if a portion of it remains traneparent.
mother d.'kuger of imwulatiun Itt, that the matter, instead of scttin;^ up
'purulent opiiuxilmia, may give ri^ to diplithentic conjunctivitis. Hap-
pily thii^ djinjier is hut verv flight in England, hut we have i^'jun l)i»t, in
ceruiin part-t of the continent, more especially BcrHn, this affection i«
but of too common occurrence, and that the mild forma of oonjuucUritis
ul'teu produce the most virulent form of diphtheritic ophthalmia. For
thi^ reii»on, it 'n tliere hardly «afe to inoculate a case of pnnnus with
even the miMeHt purulent matter, for we have no guarantee lliat it may
notgiFcri^cto liiphiheritis. Von(!mefo has colled special attention
to this fact, aud baa been obliged, in consideration of so great a risk, to
atmndon almi>at entirely the employment of inoculation in the treatment
of pantiufl. In Kngland the occurrence of diphtheritic is extremely
rare, and 1 have not soon a single case of inoculation in which it lias
onaued.
Many surgeons are still very iimch afraid of inoculation, but, 1 think,
when we consider bovr utterly hopeless moat cases of severe chronic
|Ninnas are, that ve are juittilic<l in strongly recommending the patient
lu run some slight degree of risk I'ur the chimce of obUuning a useful
amount of sight. I do mit, therefore, hesitab! to employ it in cases of
iii\rterate, complete, vascular pannus, in which the other remedius have
Wen tried wiUiout avail, for in sucti we must admit that it is our last
rc3ourvc, and that tio other chance of restoring the sight remains.
Care must, however, be taken in the choice of the purulent matter,
and in regulating iu striMigth according to the exigencies of the case.
The more dense and vascular the paonus, the stronger may the matter
be. 'I'be best antl safest la that obtained from tlie eyes of an infant
suffering from purulent ophthalmia, more especially if the disease is in
100
DTSIA9BS or THK COKJUKOTI VA.
it« fJecline, and no ftffecti&n of the comen, or only a very sl)|!ht one,
cxiEilit, Yellow pus is more nctive ami [lonerful than llie wliitiuli di*-
rhar;^t!, as ia also thai wkeii from tlic eye iliiriiig llie aculc stage of ihe
lUstianA-
Tlie matter from an eye nufferiiifj; from inoculation is stronger than
that from an infant, aa its acti^nty appears to be increased by the inocu-
lation. (toDorrhwal matter is far too strong and dangerous. Kren tii
the worst cases, 1 prefer llie whitish discharge from an infant. Mr.
lAVfson, who has had very great experience in this subject of inocula-
tion, has aUo very Justly pointed out' tliat. in u^ing gonorrba*al matter,
there is the Hsk of its being tainted by the sypbiliiic virus through a
chancre [lerhaits existing in the urethra.
The nKHle of inoculation it) a>i follows: A drop of pufi from the eye
of an infant afibcted with piimltMit ophthalmia is to be placed with Xi\c
tip of the finger (or a cttmel'itdiair brush) on the insicle of the lower
eyelid, am! left there. Within *24 hours of the inoculation, the oyclida
generally begin to swell and become ^edematous, often to a very con-
Bidcrohle degree ; (bis is accompanied hv more or less irritability of the
eye, photophobia, and lachrymation. fn the courac of three or four
days all the symptoms of an acute purulent opiitlialmia »et in, together
with a copious, thick, creamy di)^!h»rge. The dii^cadc mostly runs it8
course in from three to four weeks, hy the end of which time the cornea
is generally much more clear, and the granulations diminished. This
improvement, however, continues to increase for many weeks, or even
mouths. No treatment is to b« adopted for checking the course of the
inflnmnuition. After the second or third dnv. the patient may be per-
mitled to wipe away the discharf^e with a sponge or a bit of linen, so m
to cleanse the eye. But, however Mvure the iiiHammation umy be. it
must be allowed to run its course unchecked by the u.4e of astringont or
caustic lotions.
(Uic eye should be imvulated at a time, the other being carefully
olosetl hy the hermetic collodion comprcjis. This must be more espc-
ciaUy done if this eye h sound. Indeed, in such case, it may be a
question whether the diseased eye should be inoculated at all, for fear
that, through any mischance or carelessness, tlie healthy eye should
hecnme affected. In deciding this point, we must he chiefly guided by
individual considerations. The compress should be removed every day,
in order that the eye may be washed and cleansed, during whicli pro-
cess, of course, the greatest care must l>e taken that no pus gets into it.
A very interesting and important fact has been |>ointed out by Mr.
liawsDD,' via., that a preliminary syndcctomy appears to render the
inoculation a safer proceeding, for, the conjunctiva and subconjunctival
tiisue having been removed from around the C4.>niea, the iutensity of Uie
inflammation at thiii. point is greatly diminished, and the cornea less apt
to suffer. In eases, therefore, in which the pannus ia not very vaaeular,
or does not involve the whole of the cornea, and where, therefore, inocu-
lation might prove dangerous, it would be advisable to precede It by ft
• *'l)qf . Umi. Opbtb. ]Ic*i>. Reports," ir. y. IfS.
nu., V, \».
PHLVOTEMILAR OPilTll A LU I A .
101
STB'leetoiny. and then, when the eye hits quitfl recovered from th'w, to
t!niT>loy inocultttion.
1^ Mention dbould herv be tua<lv uf tliuae vas(}« of oWtiiiutv piiiiiiiu in
mhich iriuit has 8U|ttTvcncil. ThU ia usually of the Bi-ruiui lorm, ami
nxcrts an inilutfucv u{>nn the cnntuiuuiKe of the puinitt». A atnnti iri-
dccKmiy in Uiese ca^vs will si>iiint,inu!tit c:iort u curativu effect upon butb
diseues where other means have failed. — IJ.]
9_PIILYCTENrLAR OPHTHALMIA [COXJUNCTIVITIS^n.]-
The diiteasc U >;cnerBlly uylicnsl iu by a ft'clinf; of he»( and iteliing
in the eyeliiU, and a watory and irritable condition of tho «ryc. Tbcftu
sviuptoni^ of irritation increase until there may be » very considerable
inionnt of photdpbobia, lachrvniation, and [tain in and aronnd tlie eye
frillary oeiiral;j;ia). The latter, however, is never »o severe when the
phlycteniiiiB are confined to tlic conjunctiva, as when tliey alao invade
tlie cornea. There ia also more or leas conjunctival and subconjunctival
injection, the degree and extent of which vary with the intenHity and
rxteni nf the {lisuase. Sonictimcs tlio injection ia only jartial and
confined to a certain portion of the ocular conjunctiva. We then notice
a uianjiular, fanlike bundle uf conjuuetivnl vessels, extendin;; from the
retro-tarsal ri'^^on ItiwanL-i the edj^e of the cornea. The base of the
triangle is turned towanU the palpebne, and the a\M!x is at the cornea.
Beneath the conjunctival injection is obmervcd n corresjiondin;; rosy stone
of subconjunctival veiueU. At iWn :ipat there ia also generally a slight
ii'dciuatiiui^ t^welliui; of the conjunctiva (HCriunt clieniosin). At the a|K'x
fif the trian;^le of vesiwl.^. one or more small liorfietic ve-iioles or pu.itides
ntiike their a[)['i'a ranee, which are 3euii-ti-anS|>»rent, or of a yelhrnish-
white color, and abuut the sixc of a small millet aeed. They are espe-
ciaDr apt to occnr at the outer side of the cornea, atwl are often
uTtuQietrical, being fomicd at the outer aide of each eye. The epithe-
lium which covers the pldyctenula is ^oon shed, IcaTiug a small excoria-
tion or nicer, which gradually dwindles down and hecoines completcdy
■t.si>rbt>d. In other caacA, the ulcer ,incrcaaca t^mnewliat in »i?.c ami
depth, and it:; contents become yellow and opat|UC ; but after a time it i«
ooverod again by epithelium, and its contents then gradually undergo
ftbtorption. With the appearance of the phlyetenula, the symptoms of
irnt.itiou generally diminish, especially when the epillielium is elied and
ti.r iMtnlent^ of the vesicle escajre. Aa the latter is being alisorbed the
ittiMMilnrity decreases, but at the same time the conjunctiva may become
ff'unvvfliHt awollen, es).iecially in the rutro-tantal region, and this ia aocoiu-
panied by a niuco-pnrulent di);ehar^ ; so that wo have in fact a com*
hinaliou of catarrhal and phlyctenular ophthalmia. The affection may,
hi>werer, have this mixed character from the outlet.
If the phlyctenulip are not confined lo one portion of the ocular con.
junciiva, but are scattered about on various parta of it. in perhaps
conniderahlo uumhera, the vascularity is diflWe and well-marked. The
*ymploms of irritation are more pronounce<l. and the ciliary neuralgia.
ladirynialion, and photophobia greater. The latter, indued, u some-
102
DISEASES OP TUB CONJUNCTIVA,
i
times excessive in phljctemilar opiithalmia, more especiallv in scrofuloua^
chiliJren, atnl in often quite (lis proportion ate to tlie amount of the ves^^
cles. The phlyctenuUe fpe(|uently form Ht the ed^e of tl;e cornea, aiar-^
roiitidiiif^ it like a row of Itentls, or ihi^v ni-cur at the limhus conjuiiciiTu-,
Ijing partly on the cornea anil partly on the eonjunotiva. Very oft
the affection appeal's aiimiltanpously on the conjnnctiva and tlie cornv
The* pnstulcts sometimes increa.ap considernhly in size and depth, the i
flammation extending to the subconjunctival tissue (epiwleritis). and eve
perhaps to the superficial layers of r.ho sclerotic. The correspondin,
portion of the conjunctiva anil sulicoiijiinc.[iv:tl tissue are then often ver
raaciilar, and conHidet-ahly titic-kencd »ud swollen, ao tliat the pustule
appear situated upon a prominent hase. Tlie vascularity (especially of
the subconjunctival tissue) is of a peculiar dusky, bluisli-red tinge,.,
which is very easily recognized. This form is extremely protracted am"
very prone to relapses, so that many months may pass before it is cured
When the pustules are very numerous, it has been termed paunit
ITie vroynont of phlyctenular ophthiilmia is generally very favorable,
especially if the ease is (weii early ; if the phlyctenule are few in num-
her and limited to one portion of the conjunctiva ; if the cornea is not
affected, anil there is no episcleritis. In favorable cases, the disease
generally runs its course in from ten to fifteen days, and riisapiveara^B
without leaving any tj-ace behind it. Very mild ca^ea, in which only f)n<JM
or two small phlycteimlic form near the edj»e of the cornea without much
irritability or vascularity of the eye, may even be cured in five or siic
days, simply by a few insnfHations of calomel, n-ilhout any other treat-
ment whatever. The chief source of trouble and annoyance is th
great tendency to relapses. Perhaps just as the disease seems to be all
hut cuivd, fresh symptoms of irritatiiui siipen'ene. and a new cn»p 0
phlyctenidfle appears. If the disease then becomes complicated wit"
episcleritis, its course may be very oltsiinatc and protracted.
Phlyctenular ophthalmia occurs by far most frciineutly amongst chi
dren, Cinpccially those of a feeble, serofuloxia habit, and of a highly
nervous excitable temperauunit. 8tellvvn;r is of opinion that local irri-
tanbt actinc upon the ciliary nervcii may give rise to it ; as, for instance,
the premature and excessive use of strong astringent eollyria ii» s^i
ophtlialmiw, whilst the irritability of the eye is still very great. T
irritation may also be propagated from other branches of the 6fth to tb
ciliary nerves, as in cases of ccKcma, impetigo of the cheek, the mucous
membrane of the n«we, etc. Indeed, he thinks that the disease is of an
herpetic nature, and hence terms it " her[K'8 cotijunctivae," Some of
its varictiea do not, however, bear any rcsenihlnnce to herpes in their
coumc.
The treatment must bo especially directed to the following points :
diminish the imt-ibility of the eye, to priM-ent any graver con>]>lication;
lo hasten the ab?orption of the ]ihlycteuul:e, to prevent if ffossiblc tl
occurrence of a rela|ise, and to improve and strengtlien llie patient's gc
eral health.
if tiie photophobia is very considerable, a conapross of charpic shoul
be applied to the eye. This will prevent the constant friction of th<
t-
i
J
i-
cc,
i
linst til* tyeball, which greatly increAsefl the imtiibiHty, and im-
pedrs the regenemtion of the ejiithetial liijor over the vesicle or nicer.
This prtim ahoiil'l l* more especially attended to if the phlyctenulte occur
nn the cnriiea. for Ihwn, as we tthall see horeafter. if their epithelial cor-
eriug \* ^hetl, tlie (Isrniiicii nerve fihres nf the comeii are exposed, and
thta fre«|iiently gives rise to great irritiibility of the eye, and the iiiust
intense photopholiia, these symptoma often rapidly 'lisappearitig as soon
w the phlyctffduhe arc again covered by epithelium. In children the
compreM is cspocially uacfiil, for it preroDtA their comtantly rubbing
the PTCB with their hands, which greatly nggnivat«s the irritability.
Moreover, the compress diinini»hca the lachryuiation, soakjt up the tears,
in<l thu« prcveiif tlirir fiowin<; over t!n; cheek, which often gives rise to
pscoriatioris and cciema of the lower eyelid and cheek. The compress
vhoald he changed every four or five hours, the eye washed with hike-
wftna water, and the crusts removed from the edges of the lids. If the
l«tcr are excoriated, a Utile simple cerate or weak nitrate of mercury
ointment sliouhl be applied to them. The same remedies are to be
applied to the nostriU if they arc oTcoriatcd, or a small dossil of lint
Kmked in olive oil ehould be inserted into them. If thei-e is much thick
difcharj'e from Llie nose, the inside of the nostril should he lightly touched
with a fanely pointed crayon of nitrate of silver. Ijicbrcich' strongly
rec<Jinmen<ls the ** Eau de Ijabamw^ue'^ (a solution of so<]a impregnated
with chlorine ga«) for tins pnrpose. If the lower Hd an<l cheek arc
much excoriated and ecxeinatoiis, a little violet power shonl.l be ilu'^tcd
over the sores, or we may u^e the following powder: /inc. oxid. 9j-ij,
Palv. amyl. .?ij. The following lotions wiH also be found very service-
able: Pltiinb. acetnt. gr. x., <»lyccr. Si}~^'^f A"|. dcsiill. 3*j. to bo
Implied three or four times daily. Instead of the acetate of Ica^l, borax
(5ij) loav be employed. Atropine dr'.«ps roust be applied three or four
(iniee a day, hut if they are found rather to increase than allay the irri-
lability "f tiie eye, a belladonna coUyrium (Ext. hcllad. SiS ad aq. destill.
Jij) mast be substituted for them. [Atropine is ont necessary in the
treatment, unless the vehicles involve the corneal margin or the disease
» ijf a severe type. — B.] The compound bollftdouna nliument should
W rubbed over the corresponding half of the forehead three or four
timtf* daily, until a «light papular eruption is produced. When the
fympbnma of irritation have subiiided. we must have recourse to the iiisuf-
Sittion of calomel, and the application of the red precipitate ointment,
i«ro remedieii which may be regarded as specifics for phlyctenular oph-
tfaalraU. Indeed the calomel often acts as a ohnrm, frctguently causing
a well-marked phlyctennla, toj^ether with the iiccora|.anying vascularity,
to disap[icsr c<'rii[,K'tcly in the courso of two or three day^. It sliould
iiot be ii|»plied whilst there is much vascularity, photophobia, or Iiichry-
■aation, as it is apt to prove too irritating, but when these symptoms have
sabfiileil, it should be tried in very small quantity at ^mi, so that wc
inay fed our way. Its beneficial effect appears to be chemical, and not
tbat vif a simple uicchauical irritant, for experiments made with other
finely powdered sulwumces (sugar, magnesia, etc.) jiroved ineffectual.
•■KUn. MonaltkL." 1864, p. 393.
104
DISBASES OF TUB CONJUNCTIVA.
It is supposed to acl ou tlie Mciboniiaii ^^lantls or on tliu epitliclial cclU
of thv cntijiincciva. T)nnilcni has ioiiiiil that aft^^r its iiae some of the
BmaUer conjunctival vessi-U a|>pe»r to bt-conte ohliterated.
The calomel shoulJ be finely powdered itiul porfi'cily iir_v, so tliaC it
does not form clots on the conjnnctiva or cornea, for these would act na
iiifchanical irrhantx. It shoiiM ha applied witli a ftuBll camvlVhair
brush, held li;^htly hctween the fnri-fanj^er and tlmtnh ; and a -dij^ht
quick fillip with the middle linger will readily jerk some of the powder
into the eye. Cure hlioidJ be tjiken not to dust in tuo nnich, more edjic-
cinlly at firjit, otherwisi- it may produce a ^ood deal of irritation. It
should be applied every day or every other day, ncoordiug to U»e re-
(luirementa of the case, but if the lidu become much gummed together in
the evening, it should be employt'd less frenuenlly. It i« an excellent
reuiedv Ui prevent r«Ia)i);cs, and should, then-'lure, be continued for eight
or ten days after the diAeiuie Is cured. I am in the linbit of direeliug
the patients to reapply it at once, if they e.\perieiice any renewed irri*
latinn in the eye, for itd timely use will generally snuceed in cnttiog
short a renewe<l attack of the diseaw, [The lest way to employ calom«l
in this dittease is to take a little of the dry powder on the tip of a camelV
hair bru«h, and touch each ve3icle in tuni, as often as may bo nccea-
sarv.— li.]
In children, it in often very difficult to apply any remedy to tlic eye,
on account of their great rcAtteiuneaiit, or tlie lulense spism of the eye-
lids. In such ca^es, the head of the jiaUent should be placed betweeu
the kiiec!* of the surgeon, who id to be seah-d ; in thia way it can be
linnly and atea-lily tixed ; an assistant seated on a chair opposite should
hold the chilli's arms and legs. The surgeon should then open the eye-
lids with Uesmarrcs' hroad silver elevator, which will enable him to
obtain a thorough view of the eyeball, and to apply any remedy. By
adopting tliis plan much time and trouble will be saved, and the eye \eM
irritated than by repeated ineffectual attempts to examine it.
Tlie r{'<l prfci|>itate ointment is altm an excellent remedy. Although
it haa long been employed in ophthalmic practice, we are indebted to
l:*ageDstecber for the more accurate indications as to its use, aud foe
showing the advantage of employing it in cotuidcrahty stronger doses
titan was formerly done. He ha« more lately substituted the yellow
anior|>hou!« oxide of mercury for the red oxide, which is in the fineat
poiuible Btate of division, ami, being entirely free from any eryat^klUnc
fonn, does not adhere by any fiue fwints iv the conjunctiva.' He u&es
an ointment of very con(>idend)le stnMigtIi, vi/,., half a drachm or one
drachm of the yellow oxide of mercury, to an ouitcc of lard.* 1 have
generally found that a much weaker ointment (gr. x-xjtiv to the oiukc)
was e<]Ua11y beneficial, atkd caused Icm irritation. It should be applied
once a tiny with a ^null brush to the inside of ttie evelids, which, ou
being cloaeil, will mweep off the oinimeul from the bruah. After a few
Djiuutes it should be wipvd ofl' from the lids (between which it becomes
I «t jf,„,,„.r «v.,pm,|,. Bi.," >'... in, IMS.
■ An ■ mil vtthiaMf iwii-rr, l-v I>r. PJifTt-nMCTrhcr. nu tbo u»c wf this oint.
tiM^i, <■ I < kI in lht> "(l]t|)t)iitlnilr Ueviitr," rnl. ii, 11& [kdi] in tliv " Atuw.
Jvam. vi Ued. act.," OrU IMi, pp. AOT and »do].
rnLVCTBSDLAR OPUTIlALUCA.
105
I
uxuilct)) with <i pivce of fioe liiieu. Tlie oiutmeat is especially imlicaletl
when tiie syuiptonw of scrcre irritation linvo «ulwitle<l, but it may vvvti
be Hpplicd will) odviiTilagc in the acute iitftgc,if care be taken to reuittve
it ci'inpteti-'lr Truui the ci>njuiKti%'al sac. Il io al&o of great benefit in
checking ttie tcniicnCT to relii|iise.s.
lu cases iu which tlie phlyctt-nular opbtbnlmia is accotnpaiiie^l hy much
:i«ellin<; of the cuujiinetiva anil symptoms of ciilarrlial cnnjiniulivitis.
Von (jraefe has foumi much bcnetit frum chlorine wntcr, m it <iimini.she8
the catarrhal symptoms, eApeeialiy the swelling, witJiout seUin;; up too
ooti!iitleral>lo a Je;;rec of irritation, wliich is the chief dan^r in employ-
ing the nitrate of niUer or any ittrong a^tringt^rito in tlie»c caseri. It i»
kIm) iit<liente<l in the prominiint nUtcnif accompaiiitiil hy episcleritiAf as it
eon-ii.lrnihly haatona tlie formation of tlie ejiithelial covering over Uie
ulcer. Some touch the latter with the poiot of a crayon of nitrate of
tiilvur, hut this is uot always free from ri»k, especially when the ulcer is
eituatiNl near the cornea, and the clilorine water appear* to act more
.i;6ciiilly. [With a finely ]>oimeil crayon of nitnite of ailver, this may
carijfully ilone, anil somciimcs renders great service in cutting short
the disease. — B.J
It is not advisable to apply bliintera V* the temple, aa dio skin i.4 often
extremely irritable, and there is frojuently a great tendency to eczenui.
iirrat attention uliuuM be paid to the cunstitutioiial trcatnieul of the pa-
tient. He {tbnuld he ))lacrd upon a nutritious and wholosome diet, and
be allowed ati much cxercisi' in the open air as possible. 01oiinliiies<(
should be Btricily iittended to, and cold bathin;; insisted ujion if the patient
ia not too weak. Nothing is so injurious nn to conBne him in the dark
account of the photophobia, for in this way the eye wilt become so
live that no light will be iMtnic. Children are especially prone to
M«k the dark, burying their heads iti their mother's lap, or in a sofa or
be<l in the comer of the mom, and oidy the strictest iiijmictiotirt will
make them face the light. They slioidd W gradually nccuslomed (o it,
t}icir eyes being perhaps protected by a shade, or a |iair of blue glasses.
The compress bandage should oidy be applied if (lie photophobia ami
iaehr_viii:ition aro very intense, and slioubl be Iel"l oft" when lhei<e »ymp-
tomii of irritation have diminished. (The local application of jtiliicarpine
iiv the form of a ittjiutioii of llic hydrocbb)raw has l*i>n rccornmciu'led in
tiieiiu ca.-iea, but its succusk haa not been especially gratifying. — B.J
The uSe of Bmatl doHt->4 of tartar emetic as a sedative is often found
betielicial, more especially if there is much photophobia, the latter beinjit
freijucntly very soon relieve<l by the administration of lt)~20 drops of
antimonial wine given '.i-l times daily. But care shouhl bo taken not
to t-outiuue this remedy too long, so as to debilitate and weaken tlie
ient, and it should not be persisted in if nf> inipmvumcnt takers place
the course of -l-o days. The Wwcls should bo kept reguhktcd, and
an occasional purge of rhubarb and jalap, or calomel and jalap, ithouM
bo given, |karticularly in ehildrcn. If the cbiMreii are very irritable,
and there i» much pain, sedatives should be prescribed, e. y., small doses
of hyoscyamus, conium, or mnrphia.
■ Tonics, more cspei;ially *iuiiiiiie, are of great benefit. This may '»e
^B fjiren in combinattuu with steel, or also with cod-liver oil. In iuittiiLs
lOtl
Or«BA«ft0 OP TUB OOHJUHCTIVA.
An4 y'luiiK cliililrvn tliv I'Kiimr cInclioriB or the vinum fei-ri should be ul<
iniiiiftti'nML [Thi^ MyNtiTinfttic aii<1 [inilori;;o4l n.'^* nf cod-liver oil itt these
oa*v» U |i«rhn|Mi tho mnitt iiitportAiit piirt of tho treatment. Thes« uaseji
*nj no Tcrv rriH|iu<iitlv of utrutnoiw nrigiii timt it is well also to combine*
wtlli tlir ml (tirltiT llip Myrtip nf t)ii! ifxlide itf iron, or tlie syri\]t of tbo
li/|i'ii>liiti>[>)iit(f* of liirir mill mn^iionifi. Id miiny cues of [jiiny, iii&ma-
iltf I'liil'lrctti, rk ilail/ ihunuttDii nf oiio or two ounces of cnd-lirer oil u a
|nmt iiid ill Imil'litin up n *»ti»fiiotory stato of health. — H.]
Tlir |)liut(ip)iobin nrioii proven ver/ obstinate and intractable, but as a
ritlf 1i>«i wt Umii when the cornea id also implicated. This spasm of tbo
lidn (l"l"plri»i''t»pnnTn> it a ri-Rex nourojiis, doe to an irritation of the
nervv* o| )lu' rmijuiK'tivn and cnnica. which pn>diif<*:( hvprra'sthrsift of
ihc orliicnlarin nnwoli- (ri./r Klophnriinpasm). Tito plioiophohiit drpeod-
«<nt U|Hi« oxjiocnri' of the denuueil nerve flbros of the coniea, sliould, ad
lia« Ihmmi rernmnteudeil ahove, be treated bv the anplicaiion of a cMim-
prvM. An the health of the patient iiu|m)vea, and he hccomea more
and nion* neeu«|onied to the lij;ht, the pliot'iplinl'ia will generallv disaD-
|war. In eliildiH'n it m.\v 1h» verv B>lvniitn<*eouj t» employ a r^TOcnj
whieh 1 Hr«t m« very *uo\'eitiir>ii in Von liraefe'* hands, vii.. the dip-
piii|£ their heatU nnder water, a« tltiA breaks tlio cirruitof rcfiex action br
the intents frijtht of the child. Th» nhouM, if necoaaarT, be repeated
i*evvnil linie.i, even al one xittin?. until the child oj«eD3 ila CVM pn>pcrfy.
1 hnn" oftt-n ne^n Kurf^riAtn;* results fn»m this trcaliuent. wben all other
reinrdie* t I, The head mu«l . hoir*T«, be well dip(<€'l under
«aler, m* \. . . th^ nose, and PTr« irr immerard. tbe ebil I t*rtng kept
tit thin uKtit'^n ft»r a few teoomU, which will rffcetnallf frisbten ii.
In adnltx 1 hair alsf -V'- — ! much benefit is severe Uepbarospaaa
(fom ih« «ub.*\itA»e>>u« . of morphia in ^ regiMi «f tb* nifff»-j
At^mIaI nenY>, T.^ diMM. >:i n; UikS MIT* Will Ml W ■lOfWfcty m ibt'
l^toiophi^Kia aci.-t^t&[anTing pbl^tTtTwrikr ^ikifaafanft.
l«V— KXANTIIEMATIMS onfTllAUIlJE.
•a4 auMhAoL Ib ijba
iirti ^T*a WW* hww<Be awKSp4 ib
irfUw BMW tW eay—rtim fcta— m Ii
nu ; t>.» 'ti WA?* r^jKK--.*-,. r li»Me v Awnr t» iilutAw rf
Wtnc Mt«nfHM4 Igra
«l» cMvn «r ntta ia* «m|t «# fid* '
Ik tW wMW^ tfnM* ibe maflnmtt «m4 «dhr V vi^aimBti.
ESANTilRMATOUS OPUTIIALUIA.
107
I
I
I
I
P
I
photophobia and lachrrtnation, together with plilvctoiinlre on the con-
jtinetiva or cornea, atropine or belladonna drops should he applied to the
tyc, and llie coin|ximid belladonna ointioeiit be rubbed iu over tlie fore-
head. The ^eni-rai health sliould at the «ni»e time be attended to.
Ill »mr»lIj)ox the eyes are apt to sufiVr iu a far nion* danjicRnu* manner,
for tliu ittllamnuiuon Ia not only iimre severe, but the variolous puetulen
nukj form on the lids, the conjnnciiva, and eron on the cornoa, leadinfi;
to ^rave. and often very dangeroutt complicatioiiB. Happily, sittce the
introduction of vncoiitatinn, the variolous ophthalmia is far \e.M dangerous
than fonoerly, when it led but loo fref|uently to destruction of t!ie pisht.
If a considerable number of pustulcsi form on the eyelids, the ewelling
of the latter ia often so great that it ia imposaiUe to open the eye. They
•re alito apt to form at the very edge of the lid between the eyelashes,
and often dwitroy Uie hair bulbs, thuH protlnciuj; ]ierha|U( penmiueiit losa
'jf the cyelit«hefl (niadaro!ti>). If they are situated on the plpcbral
coDJUDctivn near the eflge of the eyelid, they may obliterate the upeniujrs
of the Meibomian glands, and cause a stoppage and ultcration in their
«rcretions ; or tlio growth and arrangement of the laches may become
afleiHed. and diatichiasis or trichiasis be pro<iucefl. If the pustules form
on the limbus conjunctiva;, they are chiefly dangerous inasmuch as they
tntty extend to the cornea. The very |)n''valent opinion that variolous
puAtuleti often form on the conjunctiva and the cornea, iluriu;^ the erup-
tive *tarte, ha* been distinctly denied by Drs. Gregory and Marson. The
latter t-spi'ciaily (natiit»ins must strongly that nn pustules funu on the eye.
Tlie conjunctival inflammation met with in smallpox may assume the
catarHial, muco- purulent, or phlyctenular character. The latter ia per-
haps the most cnmmou. The eycliils and lachrymal apparatus are of\en
affected, and tlii^ freipicntly gives Hbc to very obntinato and troubles«inie
eomjdications. But the oyc may Income lm|iliented at a later «tagv of
the disca,4e, when the jwalc.^ have fallen off from the piistulcB. Hence
ihia has been termed by some writers, " secondary variolous ophthalmia."
Mackenzie mentions that ho has oft^'n ficcn both cctitml alisocss of the
cornea and onyx at its lower edge produced, after the general erapliun
has completely gone. Although this mostly occurs about the 12th day,
he states that it may even take place five or six weeks after the patient
has recovered from the prinuiry disease. At fir^t an infiltration of the
eomea occurs, which generally Roon paseeR over into an ulcer, and this,
increasing in cireumfercncc and dejilh, may porforate the cornea, pro-
ducing prolaiide of the irin ur [>artial staphyloma. If several Hiich iufib
inidons should coalesce, a large ulcer or ab^ee3.-t will be formed, giving
riae to an cxteTiflive leucoma, even if the cornea do not j>crforate. Should
the whole cornea be destroyed by suppuration, a complete stypliylooia
will bo the result. vXgain, the inflammation may attack the other stroc-
tures of tlie eye, and the latter be lost from [iiiuopbthalmitis.
The trmtmenf. should he much the same as that recommended for the
ophthalmia of measles :ind scarlatina. In orler to prevent the forma,
tiori of pustules on the eyelids, glycerine, olive oil, or unsuerited e<dd
cream should be freely nibbed over them three or fonr times daily,
MacketLxie recommeods that two or three leeches should be applied to the
108
DUKASBS OF THB COS JO KCTIVi ,
temples, or beliiml the cnrg. In the secondary vRrioloas ophthalmia, he
lias roiiiifl niuvh hcncfit from tartar emoiic, ^ivco so as to cause frre i
voniitmg iiiiiL (mrgio};. Tlic general healtii tibouUi be kept up hy toiitco,
an<l the bowels [iro|H<rly iittcndeit to. If piui>tlc<« form on the lids or
ooujitiictiva, they should he pricked and emptied of their content*. If
the cornea hccoroes imjiUcated, and perforation is threatened, tliis must
be treated uccortling to the rules laid down in the treatincnt of ulcers of
the conien. ^j
[En ecxcma of the acalp and face, Oftpeciallj in the bnd cases wbii^H
are bo fre<|ucuc nmong the infants uihI young children of the poor, a vet^^
.severe conjunctivitis of the phlyctenular and catarrhal type is a wry
common accouipnirMnent of the akin dueasc. Tlie eyelids «re tightly
chmed by i\v\\^i cru^^ts. and when these arc wasluMl away, and the lidd
o[>ciicil. a t|UutuitY of muco-pus exudes. When tlii* has been removed,
«o often find pu»tu1e« in the conjunctiva and not infrequently on tito
cornea. ClennlinesH ami atropine are the main reliance ait local meauB
of cure, while the ecteraa is to he carefully looked after. Though theM
uaitca arc iisnnlly cured without any worse result tiian a macula on tho
cornea, yet the comeiil infiltration may lead to perforation and prolapse
of the iris with it« consenueuces. — B.j
In eryetipelai) of the face, the conjunctiva in often affected, and this ie
accompanied l>y very groat swelling of the eyelid.^. The cornea becot
hut K-ldum implicated.
U X EUOI'HTE! A JM I A.
rSyn. Xerosis conjunctiva;. — B.]
in thi? condition, the conjunctiva is thickenetl, dry, and of a duaky
red color, its epithelial surfuce being rough aiid actly. If tlie affection
exists to a considerable extent, Inuh the pa1{H-tiral and ocular conjuiM:tiva
assume n dirty, grayish-white ap]>caraiu'»', an.! become rough, dry, and
ciHicular. 'nii* condilicn is due to atrophy of the conjunctiva, suhcon*
junciival tissue, and oven of the tarsus, all of vhicli undergo cicatricial
changes, the natnre of which his been already mentioned nndor tho head
of granular ophthalmia. The secreting apparatus of Uie conjunctiva is
more or less destroyed, ainl tliis membrane assiimes more the character
of the cutis. Ou n<.\'ount of tliis disturbance in the secretions of tlic
eye, the latter ftp[M>ar^ dry, and the patient expi-riences a most annoying
sensatii-in of beat, dryness, and stifTucM in the eyes, and the puncta are
generally much contracted, or even obliterated. The semilunar fold a
hnnllv apparent. There is, moreover, alwav* more or less posterior
symblpphamn.M ibal the hollow in the retrotursal region is obUtoraied,
and the palpebral conjunctiva [Hk-ises abruptly on U> the eyeball. Some-
tiuie.s tfnuill fntna exist helweeu the lid and the globe". l>iiriiifr the
m')veiuentft of the eye, tlie in-nlar conjunctiva is Uirown into small con-
centric folds mnnd the comea. The latter i» generally opa4|Ue, often
very considerably so. the opacity atismiiing prrbafis the character of
pannus, and extending over the greater in>rti<>n, or oven the whole, of the
cornea. The surface of the eoniea ia generally rough and uneven, and
A
PTERYOrUM,
109
ito MDsibilitv. a* irell as that of the conjunctiva, ia greatly itnpiiircil, so
that mechnniokl irritants, dust, dirt, foreign bodies, etc., are liMnllyfelt^
and escite tittle or no irritalioD.
XvrQphtliaimiii i? generally caiiaed hj Ifln^-contiimcd and aerere in-
Sammation of llie conjiincii%ii, more capeclRlIv by the clironic diffuse
;!;raimlar o|i!ulialiuia, wliicli xi so apt to ^vo rise to extoiisivo atrophy
unA cicatricca of the conjunctiva and tardus. It may nUo arifto after
diphtheritic conjunct! vitia, or be produced by injuries to the conjunctiva,
from strong aciitn, lime, etc., and the excessive and lon;^-coiitiiiued u«e
of rtrnnjr cauntics, more specially the nitrate of silver. In tlip latter
ci»e, we Bnd not only that the p»l[>cbral and ocular conjunctiva have
become dry and cuticular. but thai they arc very markedly discolored,
bein-; of a dirty, olive-green tint, which ia extremely unsightly.
Unhappily no treatment is of much avail. We can only endeavor to
rrmedy the dryness of the eye, due t<i tho absence of it* nonnal seorc-
tiotis, by the fremient me of wtme blatid fluid employed as a coUyrium.
I have found milk ans«cr far better than any other, which bin been a]«o
ftrongly rcconimendcd Kv Von Oraefe. Benefit a also gomctinifs ex.
perieiiced from tlie use of glycerine, which wa3 first propoi?ed by .Mr.
Taylor. The cflTect of these applications is to soften and wash away the
hanlencd epitlielial scales, and somclimcs perceptibly to clear the
ofNunty of [he cornea.
[Clinically it is poMiblc to recogniie two forma of xerosis, the epithe-
li«I ami Uie parenchymatous, though the latter is by far the more com-
mon. Tlie former is the more amenable t*i treatment, and Saemiwh
■Arms tliat a complete restoration to the normal condition of the con-
junettra results. This condition is probably what cxlst«td in the ctiscs of
diotcra pAtieots described by Voii Oiitcfe. The imrcnchymatous form
ii almost certaiTdy destructive of vision owin;; to the cornea being in-
rolred. FerimifS the best results in the way of treatment, in adilition
to the bland cullyria, have been obtained from the long-contiriued use of
nouit beat and the prolciitivc bamla^c. Kecently attempts have been
mde to replace the atrophied conjunctiva by transplantation of healthy
niucous membrane taken from the conjunctiva of a rabbit. Wolff was
ttie first to propose thin, and a full account of bis metliod may bu found
ill the .Annnics d'Oculisti'pio, Isix. and Ixx. Since tlicn a number of
others have attempted the same procedure, among them Von Wccker,
who is somewhat enthusiastic upon the subject, (riee Masselon's Rclev^
SU^tique, Paris, 1874.) The result*, when viewed fairly, have not
\nm «ry satisfactory. — B.]
i2._ptf.rvcu:m.
This affection is due u> an hypertrophy of the conjunctival and sub-
conjUDctiviil tiftHUt!, shnwinn here and there tendiuous or fibrillar exjian-
*iont. The elevated portion of the conjunctiva is traversed hy numcrtius
bWodvesscla, which run a horixontal conrae. It' the vascularity is but
Uight, HtMl the hypertrophy of the tissue but inconsiderable, it is termed
pttrytfium tenue [^ ■£• ^U. whereas, if the tbickeniug is excessive aud
110
1>I&EA8KS OF tne OONJUHCTtVA.
Uie developmcDt of bloodvessoU great, to that tt looks like a well-m&rkcJ
red clevaiion^sonicwliat rfisemljUii;; a iimiwle — U la called jiterj)tfium
cr(i»»Hin [Fig. 22]. Tt U aUva_vi» triangular or fandikc in 9hft|>e, having
ittt bade, wtiicli h oftuii vlt^' wide, turuL-d towards thu svmiliiiiar ur
rctroiarsal \oh\, and \t^ apex towards the cornea. It Hometimcd patisca
close up to tbe edge of tbe latter and stops abort just at tlie liiubus cou-
junctivic ; in nther catiea it passes beyond this, and extends more or lettit
on to tlie cornea, even reaching, pcrhapi, to tlie centre, bui very »eldoiu
extendiujr beyond the latter. Its apex in gonorully mil vury acute or
pointed, but rather rounded off or indented. The jkortion ftitnnt«?d on
the cornea looka tendinous rather than vaiicular, or is made up of looae
[Fig. 21.
Fig. 22.
H.
AfMf GxhH*.
Afi*t a«iirl*.]
vonuective tisjiuo lilco thnt nn tho sclerotic. It may be so superficial as
to be readily ahaved off. or it may extend deeper into the subatance of
the cornea, so that wlicii it is removed, an irregular hollow or furniw is
left boliiud. The pterygium is mostly but loosely connected with the
eclerouc and cornea, and with a pair of forceps it can readily be lifted
up in a fold. But if tbe tendinous bands in its conjunctival |)ortion are
couaiderahle and dense, this laxity is a jiood deal impaired and tbe ele-
vation is ratlier tense and stretched, tlius impeding the raovemenls of
tlio eyebsll to a certain exicut, which gives riee to a wnaatiou of tijjbt-
ness or drag^ng when the eye is moved. The ptcry;:ium is unwt fre-
quently met witji Bt the inner angle of the eye, corresponding to the
situation of the internal rectus muscle. It is occaaionaMy i»ymmetrical
in the two eyes. It is Ichi^ freipiently seen nt the outer angle, and still
leas upwarls or downwar»ls. In some rare cases, two or even more
have formed on the same eye. It occurs in adults, but is most fre-
({uently seen in pcrsoiLS beyond middle a;re. and very rarely in children.
The rau*f$ of pterygium arc often somewhnt obicnrc and uncertain,
as its formation la generally %'ery slow and gradual. There can be no
doubt that long and constant exposure to beat, glare, wind, dust, and
chemical irritants may produce it, by setting up a state of chronic irri-
lation of die conjunctiva, which gradually leads to a thickening and
hy|>erlropby of this membraue and of the subconjunctival tissue. This
I
*
occum particularly in situations vhtch aro specially exposed to these
iuduences, namely, at ilio inner ami outer angle of tlic cornea, which lie
in the palpebral aperture, and are UDprotcctcd by the liils. I have fre-
i]ueotly ravt with Uus afT^tioii iu persons who have long resided in hat
cliinatcH, especially in several natives of the AVcst Indies, and this
agrees nith the exjwrience of other obsvn'ers. I'terygium may also he
pro<luci*d by phlyctenular and even catHrriial ophthaltula.
Arit' hft^*, I think, offered by far the most reasonable and probable
rx pill nation of tlie formation of pterygium in many eases. He thinks
thnC it ii frequently produced in the fallowing manner : If a superficial
alc«r or abrasion (^due perhaps to soote chemical or mechanical injury)
rxialA at the very cdj^e of Uie coniea, the conjunctiva near it, particu-
larly if it be somewhat excoriated and rclaxeo, as ia often the case in
oM |K'"plo, falU against it. and btfcoineii adherent to the ulcer, U-iug at
the snnic time dragged somewhat towanU it. Tliis is always accum-
panieU by a certain degree of irritation and serous infiltration of the
conjunctiva, which, on the serum becoming absorbed, causes a certain
amount of contraction and dragging of tlie membrane. Should the
uxt4.>m3l irritants continue to act upon the eve, we can easily understand
bow Uiis ronditiou is not only munuiuucd but increased in (-xtent, tho
conjunctiva being graduxlly more and more dragged upon and im'olved
.the process. Jlasnei' has more lately poiiitoil out that the connection
roen the conjuttctiva and siibconjunctivnl ti&suc at the limbus con>
icliv;v i-* oflen reluxe<l. more especially in aged i>er»ons, and that this
forms u fre»(uent [jre(lis|Kising cnusv of ]ilerygimu. A simple liyper-
tn>phy of llie tisiiiic may then suffice to ih-aw up the neigiibi>ring con-
junctiva, but this niti, of counte, be much more likely to occur if an
nicer or excoriation is formed, for during the cicatrization the conjunc*
tiva will be more or \vs» dragged upon. The pterygium is often but of
slight extent, and may increase but very slowly, remaining indeeil almust
stationary for a length of lime, and without porha]w encroaching u]>on
the cornea. In other coses its course is more rapid, and it may extend
i|uitc to the centre of the conica, thus more or le-tis aifecting tbo sight
and impairitig the movements of the eye. Even if the pterygium is in
such cases removed, some oiKu-ity of Uie coniea will remain, so that it
may be ncccii^ry to make an arti^cial pupil.
If the pterygium is Imt smull, and is cliietly confined to the sclerotac,
benefit is often derived from the apj)lieation of astringent collyria, such
SB the -iulpliate of copjier or zinc, the vinum opii, or even the nitrate of
olvert more especially if there is any catarrhal ophthalmia. The appli-
cation of the powdered acetate of lead (as recommended in granular
ophtjinltnia) has aUo been advi>cated (Decond^). But if the disease is
eonsidiTable, ea that it annoys tlie pntient during the movements of the
eve, or if from it* position on tbo cornea tho sight is affected, these
ri»roe<Iiea will not suffice, and wo must have rccourst to operative troat-
roent. [As the tendem-y of the pterygium, when once it has encroached
upon the cornea, is to grow over the cornea towards the centre, it is
■ '• Di<t KnnkhKlten ina Anm," IMB, 1, p. IfiO.
* "Ctiuiwil nbRitratiuus," rntsUK, tSti&.
JIft
112
DIIIASIS 07 TUB CONJUIfCTl VA.
Wtter to remove it at once before it has covered the space in front of
ilitf I'Upil. a« it alwajk'ti Ifiives an opacity beliinil it. — B.j L'nfortunat«ljr
lliia is lint always 80 auccessful aa we coulil desire, for, if the pterygium
encroaclie^ mucli on tlie cornea, an extensive opacity will be left; and. if
the base of the pterygium k large, the los? of suhsitance will ho consider-
aMe, mill the rcMilting cicatrix will he deniie, tenilinoui*, and more or
low proininent, givinjr rinc to what has been termed '■ secondary ptery-
pnra," which may even necessitate n further ojverntion. This is espe-
cinlly apt t^) occur if excision has been porfonned, ami the womid has
been made trianjnilar in sha|K>.
Xumcrnus miidcs of operating for pt«rrginm have been ulrocated,
but I ^liall confine myself Co the description uf the lliree following, viz.:
1. Kxciaion : *2. 'iViUisplatitation ; 8. Ligiiture. Of these 1 have fouud
(he transplantation the most successful.
1, ICxcisioD. — 'fliis operation is to bo performed in the following
manner: The patient Kavinj* been placed under tlio inflnonee of chloro-
form, and the eyelids kept 8]wirt bv the spring speculinn, the ojMirator
seisea the pteryj»inm with a pair of finely-ioothed fon;e|i8, and, raising
it up, car<,M'iilly abscises the coniea) pairtion eiUier with a cataract knife
or a pair of curved scissors. When the pterygium has been retuoveil
from the cornea, its conjnnctival portion is to be excised up to about
1} or '2 lines from the edge of the cornea. The lines of incision should
run along the upjier and lower edge of the pterygium for tlie desired
extent, and shouM then be made to converge towardit each other, so
that tlio wound may not assume a trianpilar but a rhomhoidul ^bape.
The bypcrtrophied liiwne having been tfioronghly removed, tlie edges
of the conjunctival wound are to be accurately brought together by two
or three fine sutures. As tlie edges of the incision are apt to be some-
what uneven and ragged from the irregular dragging of the conjunctiva
into the pterygium, I have found it advantageous to pass the threads
through the conjunctiva prior to the excision, so as to embrace the
jilerygium to the desired extent, atid then to maVe the incisions within
the Uncs of the sutures, which will be a guide to the operator and
enable him to render them more straight and even. The suggestion of
making the wound rhomhoidal. instead of triangular, is due to Arlt.
The chief advantage of this is, that its cilgcs can thus be mode to fit
more neatly and closely together, that it yields a more even and
straightcr line of adhesion, and that the tendency to liie fomuition of a
thick, prominent cicatrix is thus greatly diminished: wbcreas, if the
wound is made triangular, the angles of the base of the triangle become
puckered and projecting when the edgea are unitc<l by sutures, and the
central |iortiou of the Kise is apt to be drawn towards the cornea, ihos
Increasing the tendency to a prominent cicatrix.
It is not necessary, nor indeed desirable, to n'move the ptaryginm ta
for as tiie semilunar or retro-tarsal fold, for the extent mentioned above
will generally suffice. I'agenstcchcr' does not excise the pterygium.
but, having separated it from the cornea and the aclcrotio to the re-
quired extent, he simply turns ii back, and brings the edges of the
■ "KllnlHch* BmliActilangvi)," IMt, 19.
PT8ttYlItl*U.
118
wound to^tliLT hy sutures. The pter^'gium hoou shrinks, dwiodlce
down, nmi gradiially rtisajijicira altogether.
2. Traii<iplHi)tati<)ii, which h cliioflv Applicable when the pter^'gium
u Terr lar^. was first introduced hy Dvsraarrcg.* lie detacheit the
plprjginm from thi* comet and sclerotic »|uite up to the base, and then
tiini^ it linck tovr.inls the iio8e. He next umke»j an incision in the eon-
junctiiik nrar au4 piinillul to the lower edge of the cnmoa, and siiffi-
cientlr large to receive the pterygium ; the latter is then inserted into
th« incision and retained in this position hy a few sutures. The chief
Iviinlaf^es of this proceodlnp; are, that thfl conjunctiva U presen*«d,
it the pterygium soon shrinks in its new situation, and that there ifl
ftu* leiis chance of recurrence tliuii when exci-tion is practised. To avoid
the proiiiineiice pr<>'iuce<l by the tran^plantatjon of a large pterygium,
Knapp' practiKett the following lunditication of De«nmrrcsV ofieration:
Huvmg diiuecced off the corneal portion of the pterygium, he makeii two
curved incisions running from the upper and lower bonleni of the bnite
of the pterygium towards the uorre.Hpomlitig retm-tarsal fold. He then
excises the corneal part of the pterygium, anri with a pair of straight
scisflora divides lite remaining portion by a horizontal incision. Next, a
itoull «i)uarc flap of conjui\ctiva is to be dissected off frotn tlic subjacent
tiMue above and below the wound, so as to cover the latter. The con-
traction proiluceil hy thi:3 cansrH the curved inciition^ to gapo sufficiently
to receive the horizontal halves of the pterj-gium, whicli arc to hv fant-
ened in these incisions by sutured. The line of junction of thu conjuno-
tivaj flaps is alao to he united by a couple of sutures.
3. The ingenious operation by ligature was suggested by Szokalski.*
A conplc of Aroall curved needles having been armed with the ends of s
fine silk ihreatl, (ho operator, lift
ing up the pterygium with u, pair
of forcepi), iii3«^rtJ* one needle at
its upper edge, near the cornea,
and pHsaing it beneath the ptery-
gium, brings it out at the lower
edge. (Kig. 2.'^.) The other nee-
dle is then panftoil in the same
miiuner beneath the pterygium,
ueiir its base. The needles are
next cut off. and the ligature will
consequently he divided into three
Itortions, vis,, an outer, an inner,
and a central one. The ends of
the Inner thread are then to bo
finoly tied, so as to tightly cm-
bneo this portion of the plcry-
^DTD, then the ends of the mitcT
thread are to be united, and final-
ly, the two ends of the central *ti.r8W)*M »■«<'»«''"-
Fig. 33.
I " tUUdiM .Im rrnx." 2. 109.
• " Aieh. r. riiyHlal-HvUkuudv," 1M». S.
• "A. r. 0.," 14, 1, 9ff?.
^
DISKASBS or TBB CONJUNCTIVA.
ligature, which We at the lower edji^c of tho pteryftjium, are to be Graly
tied. The ernh of the ligatures may be sitippr'l otT, or futened Co tlie
cheeks by sirija of adhesive plaster. At the LMid of four days, the
fttrangulatcd iKirtion of the ptery^um may f^onerally be easily removed
with a pair of forceps. The atfectioti is «aid aever to recur after tliUj
operation.
Viv miist not confound a Uttle yellow spot near Uie cornea (pingne-1
oula or pterygium ping^ic) with true pterygium. It often appears nti|
the conjunctiva of cldorly persons, near the edge of the cornea, in thft
form of a small yellow elevation. It i3 not of a fatty nature, but U du(
to an hypertrophy of the subconjiitiutival tissue, accompanied by tliick-
oning of the epithelium. It but »eldoni cauaes any inconvenietkce
should it do so, it may be snipped off with a pair of aciaaors.
13.— SYMBLKPHAKON,
In this affection there exiata an adhesion between the conjunctiva of
the eyelid anil that of Uie eyeball. TWi^ frsenum may be extonaive,aad
nearlv the whole length of the ])al|>cbral conjunctiva (of one or both
liiU) be flilhcrent to the oppositu sturface of tlie globe, producing a cou-
aiderahle limitation of the movemeni:^ of the eyeball; or, the adhesion ^j
may be very limited, so that only a narrow bridle exists. In the lattep^f
case, there may he simply a small bridge of conjunctiva passing from^l
the liJ to the eyeball, readily pemuttiog
the paas&go of a probe licncath it: or*
the adhesion may include a portion of the
retm-tar»al fold, in which case no passage
would exist. In some cases, we have a
combination of the two, the probe (Musing
only jMirt of the way. If the pal]>ebral
L'onjunetiva adherer to the eomea, it \\aa
been teiTued ■' aymbki|i!mn>n cum comei"
[Kig. S4.
<
[Kig. 21], and it then Hs»umeit sotuewbat
the charoeter and appearance of a ptcry*
num. 'Ilie uitut frui|ueut causes of sym-
and appearance of a ptcry^^H
bleiiharnn are injuries from red hot metal.
After ]iMii*Dit«.] ntolten leail, strong acids, or (juicklime
or from gunpowder exploding near the
eyes. Tlit'se prmluee more or leaa extensive sloughing and excoriatioi
of tlic conjunctiva of Uie lid and eyeball, granulations form, and tlio-
oppwite excoriated surfaces become firmly united. If these adhesions
are but of limite<l extent, the con-stant movements of the eyeball will
gradually stretch thotii. until tlie fnuMia become ptfrha[>s considerably
elongated. Wounds penetrating tlinnigb the eyelids into the globe may
also produce syuiblepharon. It is but seldom due to ulcerations or^j
pustules aecoin|>anyiug non-traumatic iuBammation of tlie conjunctiva. ^M
The effect which an operation will have in the cure of a symblepharon^^
will depend cbteHy upon the extent of the latter. If it is very considor-
ahte, embracing the rctro-tarsal fold, and producing a close adhesion
eVMBLBPnARON.
115
Wtwt'eti Uic ltd sud tliu e.vebaH, but little good can gciiemll^ Ira done
hy ao oporation. The mdnt favorable coAes are thn«e in whicli a narrow
hand paAoeti like a bridge from tbe pnlpf-brnl to llie ocular conjunctiva,
«ti that a probe can be froely inserted beneath it. But even those oasoB
in which the adhcuinn |taii8e« to the rctro-tarsal fold may somotimes be
much improvL-tl if the fr:c)nnti is but small. If one or two ntvrrow tiiem-
bratxius bands cxiftt. they shoubl hi- put on the stretch and divided
ckifv to the globe, and reunion should, if possible, Ijv prevented by fre-
quently pat«smg a pmbe, dip^H^d in a litile oil or fc'^corino, between the
raw jiiirtacos; or, ilicse may be touched lightly with a crayon of nitrate
of silver, tu order that aa e«cbur may be formed, and a<ibesion pre-
vented.
When the adhesion is more extensive, ft simple division of the frscnum
will not Auflice, for the raw gurfiices will be ao oontiiderable in eize, thnt
they are sure to reunite, for, as iliey contract during ^granulation, Uie
(ippotiu)! sorfucca will be agaiu dravu towards each otiier. Many of
thesff casTR spivrar lo do verv well at first, but, nf>er a time, a relajmc
SL'Ucrally occurs, »o that tinally they arc hardly, if at all, inipr«v(><l by
le operation. In order to prevent this reunion of the ntw j^urfaces, it
bna long be«n proposed to interpose a small shield of gl'Uij, honi, or
ivory between the lid and eyeball. Tht« has often b«en tried, but ha«
alaioHt always failed, except where the fnena are very narrow, for as
Uh* wound cicatrizes, the part« in its vicinity contract, and thus grad-
ually jiumIi out the tfhiold. Mr. Woi-dswurtli' u*vs a ^lues iua»k, indlead
nf a meial sliii^ld. It ia a glaiui shell, like an artilicial eye, haviug a
central a]ierture for the cornea. Ho has found it very succe.isful in the
treatment of e:tteu3ive fnenn. and in caoes of destruction of the epiihe-
linm of the conjunctiva, in which synnblcpliapon was imminent.
In onler to obviate this tendency to reunion, Arlt has introduced and
Sirarlipi'd with success the following operation.' The eyelid having boon
Irawn aw;ty from the gloljc, so as to put the fncnuro well on the stretch,
the o|)vrntor paiisvs a curved needle, armed with a fine silk thread.
ihrnugh the »ynibIepl)nrou. close to the cornea, the adhesion is then to
b* carcfnlly (ii*ftect»--d ofl" from the comcii and sclerotic as far a^ the
rvtro-tnrsal fold. Two curved neeiltes liftviug been armed with the
thread, the svinblejiharon i;! doubled down, so as to bring its conjiinc-
tivAl surface m contact with the raw surface of the globe, and the needles
mrv thvn |iasscd thrnugh the thickness of the lid, close to the orbital
edge. aii«l the sutures iied on the outside of the lid, so as to keep Uie
aymbleptiAron fulded down in the required porfition. If the fraiuura is
Dot very hn)iul, the edges of (lie wound in the ocular conjunctiva should
be brought tugether by two or tliree fine suture*. After the o|)cratioii,
col4 C'linpreases are to he applied. Wlicn the conjunctival wound is
haaled, tlie tunied down symhlepbaron, which will by this tJmc have
»lintnk coiwidcraMy^, may be excised if it should prove irksome to the
patient.
The opemtioQ which I have found moat successful for the periDanent
^ "B.L.O.II. Brp.,"3,2W.
* •• Frag^r V)erl«l)»tirsolirlft," sb 1«1.
lltf
DI8EA8SS OP THB COS JUSCTI V A.
cure of moderate caoos of syrablepliaron, 'm that of transpUntntion, ror]
which we nre indebted to Mr. Tcale.' Ho descrihea the mode of ope-
rating, AS follows: —
*'Uaring Qmt made &u iccUion through the adliercnt lid, inalinK|
coTTC8()ondin{5 to the mar>/in of th« concealed coniea (see A, Fig. ^), I
difrwctfd the lid from the evebnlt, until the glolie moved as freely* as if
there had bet'ii no iiniijitural adhesions. 'I'hus, the npex of the nyrotile-,
phanm (A, Fig. 2H), being part of the skin of the lid, wan left adherent
to tlie cornea.
Pig. 26. Fifi. 2«.
6ft
"In the next place, two flaps of coniiincUva were formed, one
the surface of the globe, near the inn-r extremity of tlic raw Burfacc.
the other from the surface of the globe, near the outer extremity,
first marked out, with a Beers knife, a llap of conjunctiva (B, Fig. 20)i
nearly a quarter of an inch iti breadtli, and two-thirds of au ineh ta]
length, with itts ba»e at the sound conjunctiva, bounding the inner cxA
tremity of the exposed raw surface, and ite apex passing t^jwanis tti«f
upper surface of the eyeball. Tiie flap was
^^' -"■ tJien carefully dissected from the globe, until
it was so far at liberty as to stretch across
the chajsm witliont grwat tension, care bein^
taken to leave a sufHcieut thickness of tisauc
K ^ near iti base. A second flap waa then made
on the outside of the eyeUilI in Uie »ame
manner, lu making the flaps, conjunctiva
alone was taken, the sulH;oiijunctival tissue
not being included. The two flaps tbi
made were then adjusted in their new situation (see Fig. 27). Thi
inner flap, B, was made to stretch across the raw surface of the eyelidj
being fixed by its apex to the healthy conjimeliva, at the ouU>r edge of
Uio woiuid. The outer flap, C, wa« fixed acroAi the raw gurfacc of tho^
eyelittll, it<i apex being stitched to the conjunctiva near the l>aae of the
inner flap. ThiLS, the two flaps were dovc-tailod into the wound. The
flafps having been adjusted in their new position, tbcir vitality voa fur.
tlier provided for by inciting the conjunctiva near their base, in
direction in which tliere seemed to be >nnlHO tension, and by stitcbvnj
together the margins of the gjip whence the transplanted conjunctiva'>|
hflS been taken («. ;/. D, K, Kig. '2~). One or two other sutures weraJ
inaei-icd, with a view to prevent doubling in of the edges of the trau4-J
» "R. L. O. H. B-i*.." 3, 2S3.
SYMDLBPnAIlOH,
117
A
|)laut«d cot^unctira." Tho apex of skm left on Uic cornea soon atrophiM
and dtaappeara.
More lately Mr. Tcale ha« devised Uie following rory ia^raious mode
of treating symblcpharon by tniii-splaiiiatioii.' Thv operation 19 to be
performed aa foUom ; 1 . Tlie patieiit boing under the influence oC chlo-
ttifurni^ tbf tfycl'Ml i* to be hrst iit*t perfectly free from the eyeball. Tbe
(teparation of the llil U commenced at llie margin of the cornea (A, Fig.
28), KO as to leave behind
auv skin or opaque material Pi«> 28.
adliercni to the cornea, and a
carried deeply into the fossa
(B^ between tbe lid and eye-
ball. 2. A nearly circular
band ((X'c) ie marked out in
the sound conjunctiva a)M>ut ^
of an inch in brvadtU by a
rcry .jharp sciilptd. the onter
incision In-in;; riiA<k- lirst. This
band commences at one end of
the gap rudultiug from tho lib-
entiou of the lid, pansen round
tbe sound margin of tbe cor-
nea, aii'l leniiinates at the opposite end of tbe grip. A. Fonr atitehes
are then inserted near the middle of tbe fiap, twi> on eacK edf:u in order
(a) lo prevent the flap from curlinj^ up with tbe miicou!) Narfaue dnwn-
wanb; (b) to facilitate tbe manipulation of (be Hap whilst it in being
separated from tbe eyeball. These stitches are to be inserted a? fol-
lows : A 6ne silk thread X9 pAiised twice through tbe eye of a small
cnr*xd needle. Tbe needle held in a bobler is inserted at the edge of
tho flap and tied in n siiij^le knot and allowed to ban;; down at one sidot
the needle being prevented alip]nng off the tliread by the double passage
of tho tlireail tlirungli the eye. The four aiitehe^ are thus attai^hod
Vftch with it^ needle ready to complete tbe snturc after tho flap has been
transferred to its new bed ; 4. tfcparalaon of tbe flap is completed by
Hnall curved scissors, the flap being held and raised by the foremeii-
tjoned sutures ; o. The flap Imving been separated on its ttmUr 9ut/<i<-f,
vrbiUt its extremities are continuous witli uoriJuiu;tivn, is then brouj^bt
over tlie front of tbe cornea, raw surface downwards, into tlie new bed
provided by the liberation of the eyeball from the lid ; 0. Tho sutures
already inserted arc i>on* nsed for fixing the flap as dcejdy itn possible
into tho fosAa lictn-i-en the lid aiHi globe- Other sUtcbea arc inserted ao
aa to 9teu<iy the fliip without niakiii}^ it tense.
[Knapp has describeil a somewhat similar operation for the relief of a
caje of broad ptorygiuiii-Uke synkblepbaron wiili graimlatioits growing
from its apox, atlnehing the lower lid to the cornea. Tbe details of the
operation, however, differ somewhat from TealeU, and the conjunctival
' Mr. T«mIc Cm 'IflBcri'ift tliis oiwrsiil-)!! in a puiwr rw/l K-fnu- tVin luiertuilluual
'l|>li|liiiliiH>|(^4.'a1 I.'oti);rr9». hv\d in lj(>iiil<fii. AuguM, 167-, ^>^ ahowrd some initl'-iiL*
■in wlioin it luul K'vu ttnoLTqnfullj porfonuMl.
118
DtSEASBG or THR OOHJU KCTI V& .
fitps have a sli^btl^v diflerent rlirection. Tiie description may W fout
in the Archiv Tiir Ophtlialmologie, xiv., 1. p. *270, 18ti>i,
The trnnsyilantalion without pedicle, or hcVtvr the graflitij! of sma
fiieecs of heallhv fonjunctiva, from the human eye or from some of tl
ower animaU, into tlie raw space made hr the dctnrhment of a .lymhU
K baron, lias been recommended as Ukely to prove succeaaful. and, in il
andti of several surj^eons, hna pvcn ext'ollent rceiilta. Mr. Wolfe,
Glasgow, nlio lintt brought this method to the notice of Ihc pi*ofc88ioB
operates as rollows:' The patient it> anie^Uietir-ed, and the conjunctii
adheAiun<t arc separated completely, so that the eyeball can move
every direction, and the space to be filled up carefully prepared. Mi
next nmrlia the houmlary of the portion of rabbita' c^^Mjunctiva, which
he wishes to trati«plant by insertin;; four black silk aiitHres, which he
Bccures with a knot, leaving!; the needles attached. Theee also indicate
the epithelial suiface, which woidd l>c difficult to diBtinguiBh afl«r sepa-
ration. The portion of conjunctiva from the rabbit which be chooses h
that which lines the inner an{j;le, cnveri* the inendirana nictilans. and
extends a« far as the conica, on account of it* va^tulartty and Ifmseness,
The suture-s bein-; jmt on the stretch, be separatea the conjunctiva with
Bciaaors, and transfers it quickly to replace the lost palpebral or ociilf
conjnnctiva of the patient, «ecurin;» it in its place by nieana of the sai
needles ari'l eiiturea, and adding other ►'titchcs if necessary. B<iih ey(
are then bandaged. For the fir.*t fortv-eight hours the conjunctiva hi
a jirayisb look, but graduiilly becomes j^lintetnn;;, and finally ussumei*
red appearance. If any irritation set in he uses warm fomt'ritations. ]I
considers i|uick trausplantation, without previous handling of Uie c<
junclival graft, very necesaary to success. — B.]
I4_ANC[IYL0BLEPHARON.
By Otis is meant a more or leu extensive, thin, membranous or ci
trinial adhesion of the edges of the eyelids to each other. It rretjueutly
coexists with symMcpharon, the same injury having given rise to both
these conditions, bouit'times the adhesion is confined to the inner angle
of the eye, leaving perhaps a atnall
[Pig. 29. opvniuj; through which the tear*
can escape and a probe may
pasi<ed. [Fig- ^^J Extenai
niernhranous adhesions hetwe
the edges of the lid are general!
congenital. The most frcnucni
causes of anchvloblepharon are
chemical and mechanical injuries,
Aiw u«^a.i such as bums or scahls from hot
iwn. molten lead, strong acids,
etc. In these case« there is generally also symblepharon. Blepharitis,
accompanied by ulccratittns at the edge of the lids, may produco it, i
[■ LaiHM, April K, If^Tti.— B.]
1
iiT
rNJVRIBS OP THB COKJnNCTl V A .
119
Uie ulcers are situated o|)poatte to each other on the two lids, nnd kept
ftvr ■ long time in contact b;^ the eye Wing bandaged (StcUwag).
BtlVire an oj*ration is attempted tor the cure of anch^ioW^pliarim,
Uif sur^ifon flhoiild ascertain Mhetlicr or not gymble|iliaron coexistp', and
it' »i>, what is Il9 extent, and uhether it involves th« cornea or not. For
if the lid be widi?ly adliL-renl In the cornea, little or no benefit will
accrue from an operation. If n small opening cxiatif at thi* nasal sJdp,
or if the iinchyloblcpbaron ia but pnrtiil, u probe should be paused in
ntidemcaili the tid, so as to a.'icertain whether any ndhcdions exist
between it and the eyc^MiIl. If ttic adhesion between the eyelids >«
comploU', iJie best way of dctcrminin;.' tliiii in to plncii tlic upper eyelid
into a fold (<o ait to draw it away from the globf. imd then to order the
patient to move his eye in different 'lirections, when we can eas^ily esti-
iaat« Uie freedom of the movements. We ttbmdd also examine what
perception of lij^tit the patient still enjoys, in order, if possible, to
aitcerukin whether the cornea and retina are healthy or not.
If tJie adhe.^ion between the eyelids i^ not very eoiisidemble, consii*t-
ing pertia[»i of one or luuru kiiihIL liamU, it should be simply divideil
elose to the e<i^e of llie lid. En itniep to prevent readheaton of the snr-
fmcea, thtae ahould he tout-hed with, collodion (Ifaynefi Walton). If the
aDchyloblejibaron is complete, but a t>nuill o|ieninj^ exists nmr the naaal
^portion, a grooved illrector siiould be pasH-d in through thirf, and run
't>ehin>l the aillicsinn, which ia to bo divided upon it with a scalpel. If
no opening exu«t§, the o|)eralor should at one point lift op the litis from
the eyeball in a vertical fold, and divide the adliOftion here, then intro-
duce a director through this incision, and fuiirth tJie of^teration with its aid.
[In any operative procedure for the relief of ftitchylohlepharon, it is
necewary that at least one of the divirled surfaces should bo covered
with epithelium, espeeially where the two surfaces come together, as at
cither cantbiis, otlierwiite it will be im|>0Mible to prevent readhonion of
Uie parts'.— B.]
15._INJURIES OF THE CONJUNCTIVA-
These may be of a mechanical or chemical nature. The former may
prove iujnrious by their contact with the conjunctiva, acttiug up irrtUi-
doo and inflammation, or from their wounding; and lacerating this mem-
braoo. The foreign bodies most frequently met with on the conjunctiva
mre bita of atcel, iron, glass, coal, straw, ilust, etc., which may remain
»Jgcd on its surraoo, or become more or less deeply imbedded in \la
Itructure. The presence of a foreign body in the eye generally set-' up
at once severe symptoms of ciliary irritation. The eyelids are spaa-
itMilically contracted, the ocular conjunctiva becomes injected, and a
bright rosy zone appears round the conica ; tlicre is nltw much photo-
phobia, lachrymation, and a feeling as of sand ami grit in tlie eye or
under thv upper lid. Sometimes, the pain and ciliary neuralgia are
uCoewidenihle, iiinl the pupil i» markedly contracted. If the foreign boily
•i» mimII, and simply lies on the conjunctiva, the movements of the eye-
lids, the rubbing of the eye by the patient, and the copious lachryma-
tiua will oHeu suffice to uxtmde it. If tUe surgeon sitsiwets tlie pre«>
cmro of n foreign bodv, lie must can.'fiill y nii<l cloiti-ly fxtiiiiiite tiic riurfucc
of tlie pftlpcbral conjunctivA of liotli lidn, as well as the oculnr coitjunc-
tiva unci the cornea. Tlie loner c^relid is to be depre:<f)C(] by the fore
and middle linger so as to bring its inner surface, and especially the
retro-tareal fold, well into view, the jjatieiit at the same time being
direeted to look upward*.
The uii|ier lid i« next to be well everted, and it« lining nieiubrane
thoroudily scanned, inort> [Kirticularly the retro-tAfHal region, within tha
folds of which the forcijjn body often lies hidden, and may easily escape
detection. Cases are narrated iq which an undiscovered foreign body
has set up a severe and obstinate ophthalmia. When
[Mg. SO. rig. 31.] fo„|i,i^ tt,c foreign body should be removed with the
^B spud [Fi^i^. 811], which ohoutd be inserted beneath it,
R and gently lift it out. If it has ^ot somewhat im-
U bedded in the conjunctiva, Mr. Ilaynos Walton's
1 gouge [Fig. HI] will be fuuTid verv rtervioeable. If
n A ^''^ foreign bodie<«, more especially shot or uraall
^ ^^ sp]inter?< of ;;lnss or steel, etc., are buried in the cod-
^^ I I junetiva, their ex.ict situation sliouM be ascertained
II MM by lightly paxdiiig the linger over the surface of the
I I conjunctiva, and tiicy i^hould then bo exciaod with
I II perhaps a <>mall portion of the latter. SoTDCtimeSf
r 11 inipalpahle bit!> of dust or dirt got upon the coujuuc-
I II tiva. and 84.>t up a gWHl deal of irriUitJon. The lidA
I II being well everted, a blunt probe »bnuld be passed
i I I over their lining membrane and behind the retro-tar-
sal fold, which will sweep off any »nch portions. The
surface of (ho conjunctiva ftUouhl Uicu be na.Bhcd by a stream of luke-
warm water, directed upnti it from a si)onge or n syringe. If sand or
grit hais got into the eye. it should also W washed away in this naiuier.
After the removal of a foreign body a littk* castor or olive oil ehouhl be
dropped into the eye, and if there has l>ecTi great irritation, cold oom>
prcttaes should be applied to the lids.
Ckemteat it\)'iiru'ii may produce a more or less extensive abrasion of
the epithelium, or excoriation of the surface of the coiijuncliva; if the
injury waji aevcre or the chemical agent very strong, a deep plough of
this membmjH- may occur, which, in cicatrizing, will cause a considerable
contraction of Uie ncigliboring tii^sues. Tlastic lyiuph is etTused, and
the opposite raw surfaces of the conjunctiva become closely adherent,
hence these injuries go fre.juently give rise to symhlcpharon ntiil anchy-
loblepbaron. Sometimes, deep and obstinate ulcers are t'uruiud, tht»
surface of which becomes coveri-d with sprouting granuhuiiuis.
lujuries from lime are uutortuuately of common occurrence, and are
very dangerous in their nature, for this agent is strongly irrib^nt. pro-
ducing not only destruction of the epitlielium and the surface of the
coiijunutiva, but more or less deep and t-xtensive tdougbs of this meiii-
hrane and of the cornea. It, therefore, frpijueiitly dciitroys the sight,
or in more favorable cases gives rise to an extensive symblepharou. If
the patient ia seen at otice, a weaV solution of vinegar and water (,5j to
TCMOaS OP XBB COKJCnCTIVA.
121
3j of waUOt or of dtlutG acottc actd should bo very fr«ely inj«ct«<l un-
der the lids : thiM vill protiiice an innocuoua scetaUi of lirae. Then a
lew dn>|i3 nf olive or castor oil shooKI he applied to the eye, ao fts to
Iuhnr«t« the surface of the conjunctiva, and (he aur^eon, everting both
lids, slioiild procec<l to remove every particle of Ume. This haviiifj; been
done, ihf eve should be well wsAhed bv lettiiifj; a (itream of lukewarm
water fr<tm a aiioii;;e or flyriii;^o play npnn (lie Burf'ace of the conjunctiva.
A few drops ot olive oil nhould he applied threo or four times a da;^.
Th« eschars which forni on the conjunctiva must be removed with a pair
of forceps. If there is much oonjunctivitia with a muoo-pumlent dis-
charge, rnild a9trinp;ent collyria of sulphate of zinc or nitrate of silver
must be employed, or tiie eye may be freijueiilly wafthwi with a glyce-
rine lotiiui (<ilyceriii 3j ad A«). dost. Svij) a little being allowed to flow
into the eye. But when the slouj^hs are deluc-hed, astringenttt should
not be tued, as iliev will excite tno much irritaiton. Nor hIiouM thej
be used if the eye itt very irritable and painful, or the cornea is affected.
In such c-iwivs siMjthin;; applicatioiui are tndicatcMl. t^uch »:< [he belladonna
lotion, com;K)uud bi'lladuuna ointment rubbed on the forehead, poppy
lomentationd, etc-
l^trong acids, such aa the sulphuric or nitric, produce extensive plough-
iog of the conjunctiva and cornea, accompanied by scvoro symptomii of
irritation. Generally, however, the eyelids sufl'er the most, aud tlie deep
£lun^b>i which miiy be proiliici^d fre<piciitly give rise to entropion.
^^KAft<)r an injury from strnnj; acid^t, the eye should bo syringed out with
^PHkeak solution of curbouute of Podu or pvLai«H (3j to 5iv-vj Aq. destill.),
W la order to neutralize the acid. Afterwards oHve oil is to be dropped Jo,
Polj/pi ant occasionally niel witli in the conjunctiva, especially at the
^cmiUiiuir fold or caruncle. They appear in the form of small piuk
lobulatvtl elevations or excrescences, and have a distinct pedicle. Al-
though they are generally snuill. they may reach the size of a hazel-
nut,' and jtrotrudc between the aperture of the lids. They may be
readily snipjied off wiib a jMiir of curved sci8@ors, or a scalpel, but arc
apt 10 bleed rather freely. The hemorrhage may, however, bo easily
KTHMted by u light touch with a crayon of niuate of (ulver, which will,
mreovcr. check the tendency to a recurrence of the disease.
Pitujiirfula [Sjni. Intcrpaljwbral blotch. — li.] might be mistaken by
a miperficial observer fur a slightly developed pterygium, as it is a small
triangular elevation, situated genemlly close to the edge nf the cornea,
towards which its ba«e is turned. It occure at the outer or inner edge
of the cornea, and is due to an byperti'ophy of the conjuucUvul anid
siibcor\junctival tissue, a4 well as of the epithelial cells, but it docs not
contain any fat, as might have been suspected from ib) yellow tint. It
is chiefly met with in old pcrson-s, au<l is due to a chronic irritation
of the conjunctiva. It generally remains small and stationary, and pro-
■ (irnvf*!. "A. f. 0.,"i. 1, 289.
16_TI;M0RS (IF THE CON-irNCTIVA. Etc.
123
DISBA8BS OF THB CONJ DNOTI V A .
(luces no pftrticularincoiivciiiciice or diBfigurcinont. SliouM it,ht>wevi
iiicren^e in fixe, or its appenraitce prove disagree nble to the patieut, it
may ea^Uy be excised.
Fatti/ tiimnr* are of rare occurrence, iind are moat frwjuently ob-
served on tKe ocular conjunctiva at some little difttaucc front the comea.
and hotwcen the recti rouaclcs. more eaiMjcially the «uperior and exlfmal
rectus, in the vicinity of ttie lacliryinnl inland. They are often du« to
ail hypertrophy and eritciiniun of the Hdi|Hii4c tiBsno of the orhit. They
appear in the form of smooth, yellow, liilmlatcd, elastic tumors, and may
reach a considerable size. 'liiey are raoutly congenital, and do not be-
come very noticeable or increase greatly in size until a much later period.
When they attain considerable proportiona, they may push the eyeball
a»ido, and by presKure impede the functions of the lacbrymnl giartd.
If the tnmor is inconsiderable in size, it may be easily reranved, bnt
care should be taken to preserve the coujuoctiva as much as possible, And
the incision should be clofled by a fine suture.
lierifitnti imtors are not of unfreijucnt occurrence. They are situated
at the limbus coiijunctivjc, partly on the cornea, and partly on the scle-
rotic [Kig. ;^*2], are of a [mle, wbitinh-ycllow
[Pig. 33.J color, ahout one or two lines in diameter, and
somewhat raised above the level of the cornea.
The surface of the tumor is r;cnerally smooth,
but it may bo lobulated. and from it one or
two short hairs may |)rotmdc, Wanlrop* men-
tions au extraordinary case in which twelve
vi-ry ionj; buin; grew from the middle of the
tumor, passed through between the eyelids,
and hung over the checks ; these liaira bad not
appeared till the patient was Ki years of ago.
at ttliicb time his bcani also began to grow.
ic t»m*»r is generally eongetiitol, and almost cmuplelely siatiunary, in-
creasing very slowly in size with the growth of the bnily. It may, how-
ever. Irt'come devcl«|>cd later in life, and augment considerably in sise.
The largest turaor of tlie kind that I have met with I saw in ^''on Graefe's
cliniquc, in 1860. It extended over the outer two.thirds of the cornea,
was prominent, b'bulated, and very disfiguring, almost hiding the cornea.
From their close analogy to the structure of the skin, these tumon* have
been called "dermoid." Tbey sometimes, however, appear to eonsiet
only of elastic fibrillar connective lisaue, rudiments of true skin, fat.
hairs, and sebaceous follicles. Marked increase in their sijte, or recur-
reuce after removal, appears to be due to an increase in their fatty con-
stituents. 'I'hey may be readily excised, Imi care must be taken not ta
endeavor to remove tbem llioroughly from tlie cornea, as they sometimes
extend deeply into its structure.' _
[Dr. Taliaferro, of Kentucky, has reconled' an interesting case of j
female aged 15, who bad a congeuicaJ dermoid tumor on each eye. 11
■ Wsrdrop'B " Uorbid Anatomv of tlie HiimAn Bv<^," ], 32.
» Vidr t»»*»;fe'« irtifirt "On K.-n.ioid Tum.ira,' A. f. r>., vii. 2, ssd kH. 2, SSR.
* "Ametit^u Jouriiil of M«<iical Srivucva," IMI, N. S., ii. HI},
TOUOKS OF THB C0!>- JUNOTI VA .
1S8
lamnrs were ora drlicAM pink color »t their W»e, becoming brownish tit
their ii[)icti«. The tmuor on the left eye. Ki-;. 34, at iitt luwe meaanred
five lines* in one ilinmirtor. hy three and' a half in the other, and rose in
a oonoidul fonn to about gtx lines in height. It almost covered the lower
ri>-lliirds ui ihu |niijil. From ihe ajiex jjrtjw Home ten or twelve hairs,
boui *ixi«cn linen ni Iciigih, and a alia^le darker than Uit- cilia. The
(ViK- sa.
ViK. 340
O.
tumor of the right eye, Fig. 33. was in shapw anil jiosition similar to the
one on the left, but of about half the ihe, and covering only the lower
sixth of the pupil. The luraoriwereexciHed with excellent results.- — H.J
[Dermoid (growth* arc goiiepftlly considered under the head of corneal
tumor.'*, A» they are almoiit alwayn KJtuated upon the corneal margio. — B.]
Wiirtt are occMionally iiecn on the conjunctiva, forming small, red,
fl»»«h-colorvd extreaences. heing met with eiUier singly, or in little clus-
ler*. They may occur on Uie palpebral or ocular conjunctiva, and also
on the seinilnnar fold, and boar a utrong rcsemhlancc to the warts upon
tli« prepuce. They are generally accompaiued hy a certain degree of
conjunctivitis, and n thin mucopurulent di.ichftrgc. They riiiould he at
one*' snipped ofl" with scissors before they attain any size, or have time
to fipread. and if necessary, tJie cut portion should be lightly touclied
with nitrate of silver.
[Mackenzie relates a esse in which the removal of a wart from tlie ex-
ternal surface of the lower lid was followed hv the development of a
number of wartA upon the ocular conjunctiva. — ^B.]
Otftf of the conjunctiva may be readily diBUn;iuirthed by their cir-
cuiu-Hcribed round form, and tiieir pink, traiielucenl apix-arance. the tnins-
pnrency of their contents being easily recognixed wiih the oblique illu-
mtQAtion. They may occur in diflercnt portions of the conjunctiva, and
Yury in siue from a small pea to that of a haxcl-nut, or they tnay even
joxcewi this. If they extend into the orbit, and attain a considerable
te. they canse more or leas protninion of the eyeball. The walls of
the miiitller cyst* are generally very thin, and only so cliglitly connected
with the Conjunctiva that thoy may be very readily removed.
[fbere are certain forms of cystic tumors, occurring beneath the oou*
124
DISBA8B8 OP THB CONJUNOTETA.
jtiticUva, oli'mri}' of the eyeball, but also of the ejeliils. but which occupy
c'«tm|ttiriitivelv little rouiri In the cBvity of the orbit, aiicJ hoiice may he
Pi'imrsto'l t'roiii the larger au<l helter known c\»u of orbital cysta. There
nre two fiirm^i of these cysts : Firat, those in whicti tlic sii&ce filled hri
the fluid ift a natural cavity ; and, aeconci, those in which the cavity it*
uf new fnnuution. Tliey an; always simple or barren ; tiiat is, they
crintftin fliii'l or unorganizoil matter. They seem always to he formed
by (he enlargumeut and union of the spacer iu areolar tissue. If thflj
pressure of the coiitaiiiod fluid continues, the cavity eventually stains ftt
perfect wall, which, under tlu- mlcro8eope, is seen to conaiitt of hue fit
cellular tissue, sometimes lined hy a sin;;le layer of ftijuamous cpilhi
Hum. Thi.-< whII i^. however, so thin that it is extremely difficult to remove^
the cyst entire. Their causation is still unsettled. They occur most <
often in children and youni.' adults, and are met with at the intenial antl]
extcntstl iiiigle of the lid. Tiiey are also foun<l overlying or iinnic<)iat4?1^ '
in front uf the lachrymal sac, but haviuj^ no connection with it. Their
eontcntii here 8tronj»ly resemble olive oil, and in thia they resemble cer-j
tain cysts of tlie thyroid liody and ovary. There is one caae reported
tif ilu' di'vrlopment of a sennw cyst in the lachrymal caruncle. A fcl
aoc'iunl of tht-sc suWoujniKtivfll cysts will he Ibund in the American'
Joumst of the Medical iwiences. January, 1ST8. — II.]
i.'jfatirrrri have been found several times beneath tne ocular conjunc-,
Uvt, and in one instance (^Sicliel) beneath the {lalpebral. There is seen
at some pan of the ocular conjunctiva, near tiie angle of the eye, a tranft^i
|>*rt'nt, cTiO'like ele\-ation, which is round, ahar^v defined, and Bone-J
.'Vhiit mnable. and vanvta in siae frun a pe* to « small bean. The coc
fiunctiva over the cr»t, attd in its rtcinitT, is aomewhat hypenemic, but if^
It u aaficieiiity thin and tnii»parenu we may W able to dininguiih at
iIm outer wall of the cyst a |ie^iar yellow or f[niyi«b-white spot, which
ia tbe head and neck of the eutott^oti. and Sicbel' states that this appear-
ance U qmte charactwistie.
fASCRiu^-^ Ti Moits are wictiita »et with aa primary affect4PDa,bi
for man fminvatW as EvcwRhry il'war^rn, after eaocer «[ tfae lads or of
the «r*ban.
JTjmiMmJ oawvr [di>e« Mcar] as a priaary ^aease in the coi>-
joMtaTm, tbo«gli ;r»erally it esteaAi fnm i^ ej^iida. h appears as a
MHftll, aBwoA, w »li^ttT iK^aUlrd mawMmet or totoa, at the edge
of dw coratw, and oA<« Vus a tot wtniM^ nMahluOT to a pnstulaJ
or pklyvceMdft. li May^ k»v«v«r, W AnA^Mbol htm tlw liuter bn
ibe aWnee o( all Jatiwiiiwj t^mmt^ and initatia*. and aitt-rial iii-j
JMtie*, enly a Sew di^Med ^flitwawa vaiw inwHMgi^g tov&ni the tittle-
iMMv; diert »«!!«« atM 9for OTn« i^BMM. SdbSMiBeBtly the
vamm mmmmm m nrnts mmi aanan m iiJilif nM, ni in ntface be-4
Mm aw* MMuerf ywaKirw ii «3ic«M0««ec*V ^^ evnnd by dry,
Aklr«M4«|MMMi; or thetf- ■•% be a WvBch af M&ee, wd a iUb» j
—CO iiifct dbeUrfie »w>4ot ft^ Ae okw. IW hmm- aay tsndo
tb« ^arM« to a rwaJdeffaMi MtoM. b« v MeraQy b«t J&gblly odbc-
wM to ii, M iliai it ai^T W MArty ewbwjy rrwmd. It toay, bow.
TrMORS OF THE CON JUHCXrVA .
125
I
I
«Ter, prrHloce a deuse opftcitj of the cornea beyond the limits of the
tumor, or leail to deep and extensive ulceration, or even perforation. If
the tumor is stnlked, it amy be freely raovablo upon tbo surface of the
eontea. Like all cancerous jrrowtlis, it should be removed at tlic ear-
liest iiossihit? period, and tJie edge^ of the conjiiiHTtival wound should be
cloned niih fine stittiroii, in order that the sclcmtic may not be expose*!.
It is, however, very apt quickly to recur, when ihc operation should be
repeated witliout loss of time. But if the tumor has invaded the vornen
to tt conwderable extent, is intimately connected with its tissue, and hus
greatly im|«iired thi" sij^ht, it will be Iwlter to excise the eye ; but even
this does not always ffuard against recurrence, the new growth springing
from the lids, or frum the bottom of the orbit. In such cjww it is,
therefore, alwayi^ advisable to apply the uhloriilc of zinc paste to the
orbit, after the removal of the lids, ['^"cording to Alt, the first begin.
nioji; of epitliclial tumors is an e.xcessive cell-formation, a tnic byper-
plartia of the epithelial layer of the conjunctiva or cornea. The next
•Uj-p 18 when the underlying tissue l>ecomes bypenemtc and shows a
lar;;e and abnormal auiotint of round celU. lie ihinkit that only in n
few instances do the epithelial cells tbemselvos show the condition!i of
proliferatiou, but that the latter mainly occurs in the round celU of the
ronjuiMTtival stroma. The formation of round-cell cylinderH and their
[Nirtial transformation into epithelioid celln show timt the connective tissue
iti<ctf is uUo Rctin<* in the formation of epithelium. (Tran^actiuns of
Canada Medical AMOciation.lHTT.)
Melanotic epithelioma in cxcci^iiivutY rare. An interesting case, in
which the ;;mwth involved the cornea but bej^an in the conjunctiva, and
was snccvp.-'fvilly removed with prefervntion of perfect vision, has been
reported hv I>r. H. I), Ntiyes in tho Archives of Ophthalinolugv, viii.
No. 2.— r:}
,\fff'tMotic [aareoma] appears in the form of a small darkish-red or
brownish-black spot or tumor in the subconjunctival tissue near the
cornea, at the semilunar fold or caruncle. As it increases in gixe, it
may implicato the lids, cxtondin]; beneatli tliuiu and ^ivin^ riso to more
or Icsa eonsiderahlc adhesions. The tumor may remain statioimry for a
long period and then rapidly increase, ami it is very prone '(uickly to
rwur afier remoral. It nmnt ho remembered that many of the little
black tumors which an often erroneously called melanotic cancer are
onlr mrcnmata.
(The development of aarcnmata in the conjunctiva is not very uncom-
mon. They tistwtly start fi-om the selerocorncal margin and ^jrow into
the conjunctiva, though ihi^y tuay lie;^in in the conjunctiva. The tatter
are generally pigmented, are iwually of the small-cell variety and very
vmscular. When situated in the palpebral conjunctiva thvy uKually
have a pedicle. Cases have been repnrtetl by Mtlller, Graefe, Homer,
Wet'ker. Estlander, Talko, and others. A ease of sarcoma of -the pal-
Mbml conjunctiva and tarsUH which had undergone amyloid infiltration
LS reported by l>r. J, S, Pmut, in the Arcliivef* of Oplithnlmoloj^y, viii.
No. 1 . The tumor develo|>cd from a trachomatous conjunctiva, and was
removed entire, leaving the skin and muscle of the lid intact. Another
caae, rejxjrted by L>r. E. Dyer (Trans. Amcr. Ophthal, Society, 1879),
126
DI8BABBB 07 THB CONJUtf CTIVA .
Wjvan in the ociil&r conjunctWn, e.xten<Ied to the eyobAll and nrhii aiut
brain, and ihe cliild died, Tliie was a spindle-ucll sarcoma.
Frimiirff farrnmrma of the conjunctiva is a very rare disease, as i
altnoat alwnjs startit from ilic lidtt, eyeball, or orbit. Conjnnctival ca
cinoiiiatik may bo pi^inorited or uiipigHieiittMl, and tnaj occur a^ a mixed
tumor with snrconmtons lltisue. A very interestinji; paper, by l*r. H. 1>.
NoyeB,on a critical study nf 127 cases of tumors crowing from tlic froril
of the eyeball and eyelidt^ (Archives of Oplitlialmolugy, vul. viii. No. 2),
gives some points in regard to the frequency and locality of these
growths.
MfduUarft eanrfr almost always extends to the coDJunctiva from the
lids or from the eyeball itsvlf. the cornea or sclera {;ivin<; way, and the
tniiior fiprouliitg forth and very rapidly spreading tbciico iuto the oeigh
boring tiitflues.
Von Wwker has ob8cr^■ed cases of growths in the ocular conjunctiv;
rcMnibling polypi, which grew very rapidly, and when removed soo:
returned. Tliey weru |>iuide»D, but were accomfKiitied by swelling <
thi- tonsils, 'j'hey (tprriid with great rapidity. ^IJ.]
SiFvi Bometimos extend from the external portion of the eyelid to the
pall>ebral or even wular conjuuctiva. and may reach a very considerable
site if ihoy are not treated at an early |>eriod. Thoy may, however,
occur primarily on the conjnnctiva or the semilunar fold, and should
removed as early as pos«ble.
{ f'fif'ilhrif fihromtttit are sometimes met with on the coiijnm^tiva
Ilorucr rept>rts a case which i-xteiideil Irom one cantlius to the Mtbc
and corcrvd the upper part of t)ie cornea, though il was not adherent to
it- It was reoiOTvd, but relumed, and the patient died subscipienlly of
carcinoma of the stomach. (Sraefe u. Sacmisch's llaQdbuch,ir, p. 152.)]
.ViiA--<>n)uiiiTtfd^ littfttmnra have been oWcn-ed in two coses. In al
probabilitv, however, these growths proceeded from tlie sclera. (_Graef(
un«i >!nunnwh's Handbucli der Augenheilk.. iv. p, 151.) — B.]
Liifn,i»i$ 19 a term applied to a hanlening or calcification of the
aecrctiun of the conjunctival glands, more especially the Meibo
glands. The affection appears in the form of white, round concredo:
of the siie of a piu'^ head, which may, hoviever, attain larger dime
aoQS oa the ituier surface of the conjunctiva. Tliey oct'ur either singly,
being aeattered aliout over the surface of t)to lid. or they may appear
amaged in single file along tlie tract of the ducts leading from
glaad. The tatter is. bowerer, much more rare. On account of
roughness which they produce on ibe ltd. coiui«)crable irritation and
ervD a certain degree of conjuuctiTilis may be hi ii|i. 'l*he little calculi
are easily ivmoved by inciting tIm eonjnnctir« orer tbem, and lifting
th^m nut with Uw point of a cataract nccile. or a groored s^wtula.
t^ometiuie-' the ecoeivtion is sofk ami semi-traib^fareDt, aad appears at
the opening of the diKt. whence it may be readily prcaaed oat.
The secrelious of the canincle also soroctioKS undergo cretification;
and chalky depoaits are likewise met with in tbe caroncle, oAen giving
ri*e to irritatioa and swelliitg.
Pcmjthi^u* of tbe coujuMdin is a very rare aliietieaf of mbicfa, 1
4
I
believe, only twft caam have been recorded, vin., one hy White Cooper.'
ihc utluT bj Wouktr.* Tbe symptoms are very oharaeterintk, for one
or more large vesicles form in ihc palpebral and perhaps also on the
ooalnr conjunctiva ; tliey contain a turbid serum and look exactly as if
the? bud been caused by a bum or scald. There is generally a good
deal of conjunctivitis, accompanied by lachrymation, pbolopbobia, and
pertiaps some muco-purult-nt 'liscban^e. On Imiiilinf;, Uic vesicle leave*
a rxw excoriated ititrfacc, which siccretos a thick inuct>-pundciit diMiharge.
If repeated crops of vesicles have appeared, they twit gniduHlly gjv*
rise to syiublepharoTi. The treatment slujuld cons'wt of mild astrioffcot
oollyria. and the frequent application of glycerine to nw^istcn the lid*
("Wccker"i. Internally, uraenic should be administered, for these pa-
tients always suffer fn»ni pemphigus of aotDO other part of tJie liody.
BtnVitfhaijf int" thr eunjuufrtiva '\^ generally produced by blows or
falls npon the eye or face, or by severe Atrainin;; ua in cou;^liin<;, sneez-
tug, etc., cauaiDf; a rupture of itome of the minute bloodve-tMls of the
«>iijutii:tiva. Such ecehymosoB are also often met with in the course of
infliiiniiiiitionn of the conjunctiva, or in prraons sufferin;; from scurvy.
In ()tli»-*r casc't. they occur spontaneously vritiiout any apparent can?«c ; I
havt.' toet with several instances of this kind in which the ccchymiKiiD
had come on (hiring the night. But the effusion of blood may not be
dae ti> a rupture of any of the conjunctival bloodvossuU, but have grad-
ually iiukile its way forwartls from llie orbit liemiith tlie conjunctiva.
Tims n blow upon the skull mny. by a contre-coup, proilncc a fracture
«»f some |K>rlii)» of (be walls of the orbit, this is followttd by more or less
severe hemorrhage, and the efTu-ied blood may make its way forwards
beneath the conjunctiva. The ecchymosis does not, however, in such
oaaes appear directly after the accident, but only at ao inten-al of
several houm.
The ecchyowsce are generally situated on the ocular portion of the
conjunctiva in the vicinity of the cornea:, or in the rotm-tarsnl fold.
The effusion nvwlly gives rise to uniformly red patches, which vary in
aiw ntid number, but it may be so considerable that ic exienda round the
wbolc coniea.
TbL* treatment should consist chiefly in the application of stimulating
lotions, f- ,<;■« 'I''"- Amic. 5j, At\. dest. ^W, to Ho applied to the eye, ur
a Oomprcs* moistened with this lotion slioidd be firmly tied over the
^yt ; indeed a fimi compress bamlage accelerates the abdorf^ion of blood
than any other remedy. A {loulticc of black Bryony root is also
.1.
(Ktii-ma of the conjunctiva is mot witli very frunpienOy in Uio course
of many intlitinmatioti!) of the conjunctiva and inner tuiitci* of the eye,
bat it niav also occur Bin>ntaneoualy» more especially in elilerly, feeble
pcreonst atfecte<l pcrliajM with disitase of the kidney. The Ux'atment
fhodfd eoiwist in the appliuation of a firm bandage, and the use of mild
a«trinj(ent I'ollyria. A few suporBeial incisions ntay W made in the
ohi'Huwin with a pair of curve! ^cijiora. The healUi of the patient
I "B. L. O. H. Hop.,*' t. IW.
■ -' Kl. MMiautil.," Idt;s, 232.
m
bt«EA«Be or TUB C09JCXCTirA.
•ItoiiM U ftt the Mim* tiiiM- Mtrndcd to. Dr Iawroii T«t< has <»\M
lUU*nUon to the importune fact that •*crere (demi of the cnujunctira is
viowtinMNi «. uymptam of »tir(^icnl fercr (pjietniii), bang dcpvuiletit on a
tlirointtiu in the cav«nK»u« or uphtlmlinic simu,
[<K<tema itr tho cdttjiinctiva in a very marlEcd BjiDptom in orbital ccst-
liilitii, Mii'l in li«<l CMiwH of ptinilvnt conjunctivitis. — D.]
.Sii/ifdniti nrfiifal rmjihi/tri/m i* cniiKi'd by fracture of tlic nasal pari-
(ito*, wliit'li A'tiiiiu tlir nir into the iittl>4-nnjunctivft1 tiMue, or bv a rupturi>
til UiB lofilirvniBl luio ; wlien tbe air is also ailiiiitti.'<l boiieatli the con-
JMikciira, if Uiti noKo ii blown. The nnture of the affcclion ina^ he reooe*
iilxcil by tJie (wunliar crackling which i« heard when the swelling is
firi'metl with thf fiu\icr : firm pre»ture causing it to dieappear. A band-
»Kt< ihoiihl be np|i1i(*fl, nntl, if neucfuary, the swelling may be pricked
Willi a tkccdic and llio air allowed to escape.
[17.— SYmiLIH UF TIIK CONJUNCTIVA.
Syphilitip lenions of the conjnnotivn existing indepondpiitly, and not
cuMiiicrled witii Icnioii* of the uyclids on the one hand, or of the eyeball
on (he iiiber, nrr not ennimon. In rtypbilitic ]iatientri an ofwtinnte cntar-
rlidl L'oiijiincttvitin h often met with, and ihU i^ c$pi'cinlly noticeable in
cai«*K of obAtinato iritis. The syphilitic lesions of the conjunctiva
rniplinnii. iilerrattoni*, and infiirnitions; and under tbe sceontl bend
to \»> incluilovt ni)t Hilly thiM'hniicrt'.but also «ecoiulary ulcers resolt-
Inff fntiii the brrnkin;; ilown of infillrated ma^cs. The chnni;re is a rare
lv«Un «n Ihi' conjnnctivnl mirfnco alone, M in most of the rejiirtod eases
tbe initial uloor wax on the marj^in of the liiU, and involved both skin
and niufouii tnembrane. Itut it iloex occur aa a conjuncd\-al le!«ion alone,
»« in caws rvjtorto^i by IV'!<m.irrcs. Stni^is, Galexow^ki, Bumstead. Bnll,
nn^l oiluTH. 'ITie cinjum-tival cbnncrc i^ apt to Iw a deep ulc^r, with
*harp %'*\c<^ and ertvie^l >aUs, the l«oltoin U-ing covered by a (icraj pub
lacrowa MMutfat and there ia en^ronreint^ni of the pTrauricular gland, and
AtWihMimM of lb* i^mtid. and even of the submaxillary gUuls. This
laltvr »ign ban c-oiue to b<> rrgantvd by authorities as patbognotDonic of
»\ '. ' ' There seemx (■> be ItUlc ilnqbt that either the ciliary margin
V- • or tbe cut d^'^Mic » the patrt BKwt fre^oentty the scat i>f the
co%ijMini\ial cbanere. IWre are m^om oases reponed vlwr* tbe lonon
«a« in the oewlar cM^vaelin at the cdgf of mt oofon, bat tkej wtvA
c^'tt&ifatioii.
T^i' ^'"mdgry immm of the coi^nnctira are waeh men frwyt tkaa
t kKMNu 1W; hmrt bertt <ie«-n1x^i by l^wwwaax w mhU
iMiwii iiln< «Mm •levMe4, iioi»-vitfcalftr, vti «( a wMwh-giij «r '
Mawwda afttw that «yfUibe mmviimt «r tW om-
4MHMMa tit MSMMA BHIBlMa, tVt Ik HMS wt IS IMS*
■1m %rr Ml fwc^ sMK We*, iw— f aying
OenuB sfwnie wcea witii ta*vay
wwfe^^^'^ are wel e«CT ■teiiix^ nrre. Mil an pwAalHy
Mfcett ^>->r n&r«lM aai
]U.a,^tM.
RAItB DI8BA8B8 OP TUB COXJ UKCTIT A .
129
coua piitcht!^. Thcfle iilcornte very easily, anil it ii tmt improbable that
•oine of tln! foiK>rt«<l ca**^!* of noft chancre of the conjunctivs are iik-er-
atcd niitcmiH patclifs. A sccondnry conjunctival ulcer \^ (Iii«tiii<;ui8)ied
hy it* fattv-Iookin^ coating, irregularly eroded edgea, and uh«cd hase ;
if ))ro|)erly treated ihey cicatrixc rM[>iilly.
A point of interest in these supurfirial ulcers on the conjunctiva is
(heir isolated t>ccurrLMit'e as a symptom of syphilis. The patient njay
have been free from all syinptoniH of tlie flitteuse for fieveml years, when
■nddcnly tho cnnjnnctival lesion makes its appearance, rung it« conrse, is
bealed^ and again the patient is free from all symptoms.
A thinl variety of conjunctival lesion in con.^ttiutional syphilis is the
gitmmy in6ltration. circuriijicril>e<l. and diffujte, and tliis la probably the
lea^t uoiDmon of all. Latu tutinifeiiCations of KynliiliH, occurriu;;; in the
tertiary period, arc rarely limited to the ronjunctiva ; hat usnally Wgin-
ning in other tuwueis, involve the mucous memhrane br contiguity of lis*
snc. The term ''conjnnctivitis gummosa," used by Ilirschberg, is of no
advantage over "gummy infillration of the conjunctiva," and hence the
latter term is retained. Thia gummy infiltration may be in the form of
small discrete tumors, or of a general thickening of the mucou.s mem-
brane. There is an infiltrated yellow ba^e, a more or loss marked swell-
ing of the conjunctiva around the infiltration, and ulceration may set in
n|Mdly. Gummy infiltration of the ocular conjunctiva is very rare, but
when it occurs tuay he entirely distinct from imlerul infiltration. (See
Aroer. Journ. of the Med. Sciences, (!)et. IHTS, p. 413 et seij,") For
ft more detailed account of syphilis of the conjunctiva the reader is re-
ferrod to a pnper on the subject in the Amcricnn doumal of the Medical
Sciences, October, IS"!^ ; and to the 4tli edition of Bunistcad on Vene-
real Diseases ; Chapter on Diseases of the Eye, by Or. Loring.
18.— RAKE1)ISKA.SKSOFTMKCON.M NCTIVA. Lri'IS. LEI'HA,
i-AHDACKOLS mSKASK. TLUliUCLLOSIS. I^SOKJASIS.
T.upH$ of tho conjnnctira, as an independent disease, is hut seldom
mot with. It appears first in the piil|>ebral conjunctiva, and oftener in
the lower lid ihan in the upper. Tho conjunctiva is injected, covered
by small and large prominences, which are grouped togrtlier and resem-
ble a granulating ulcerated surface. Ijitcr, the lupus nodules shrink
atitl cicatrize, while new ones art^ developed elsewhere in the conjunctiva.
The final cicatricial degenenition may be very extensive and destructive,
Generally the di)4eaM0 attacks tho conjunctiva secondarily from the Hds
or vicinity of the lace, though in very rare cases it may precede the de-
vclopment of the process in the skin. An interesting cafe of conjunctival
lupus is re[iorted by !>r. E.S. I'eck in the Archives of Medicine ,.Iunc, 18H0.
The disease occui's more often in one eye tliau in both. The treat-
ment is of course to destroy the lupoid formation, and the best agent is
prwbably the nitrate of silver in substance, though the growths may be
rrmovuu more rapidly by tlie knife or scissors,
/^j»iM, though generiilly involving tho cornea mainly, also affects the
ooojuuctiva. It is met with in those cases in which the skin is red and
9
130
DtBBASBS OP TUB OON JII NCTIV A.
svollen into folds, and appears as a eli^ihtly circiimBcriberl, circular,
Vfliitiah or pale yellow nvrcllini;, non-vasculnr, ami looking like the rit)4
of biition, wliifli fillier extentls into the uoniL-ii or towanls tlic cul-de-sac.
OIc Bull and lliinscfi, Iiowkvhf, tliluk tliiii tlic cmijunctiva is not involved
except iu CABC-a of nipid iiililtration of the coritca and sclera.
Lar<inrfmn. nr Amiflmd disease of the conjunctiva, is very rare, and
lias only vpry ret-eiitly been recogiii/.od. Durin;; the last Pew yeanj cases ,
have tVum time to tiiuc l)«en re|Hjrttiil, aud Lcl>er lias puldiHhbd the resulLa
of n very careful investij^atiou into iw origin ami mode of developiiuMit in
the coujuncliva as well a.-* in other parts of the eye. (^Arcliiv fur Oph-
thnlmolope, IJd. \\v. 1. pp. i!ri7--i40.) In re^nl to die origin and
devtdopiiieiit of the amyloid hodien, Leber helicves that thry are secreted
liy the cellular layer of the conjunetlvu, and that lardaceous dej^eucra-
tinn ia a purely local lesion, and not the expression of a disease of the
leneral organism. Cliiileally, the disease has by some authons bccuj
Kcrihed as resembling stmn^jly tmctmma, lunl by nthcrn as periclmn-
litis of the tarsus, but it differs markedly from both, thouf;h in w>mei
cai^es it may certninty Ih; regarded us the results uf triiehoma. It tnay
involve both ocular and pjilpebral conjunctiva, though it is usually con-
fined to the latter. The lid is hanl and swollen, the conjunctiva uol
much injected, of a faint yellow color, markedly thickened and inHU
trateil, and generally with a smooth surface. The whole lid may Iw
everted, but without any special increase in the secretion. If the ucitlar !
bonjntictiva is involved, it rises like a wall around the cornea. When
the conjunctiva is seized with forceps, i^ seems almont cartilaginoua or
like brawn, hut very brittle, as tiuiall pieces easily came away. If ihe
inliitnition does not involve the entire conjiuictival lining of one Hd, tliere
may be .»onietimes seen a trachomatous condition of the conjunctiva uoG
involved by the disease, and the lids of the other eye may be tracho<
matoud. When incised, it feels like bntwn, and there is no hemorrhage.
An iitcised surface, when treated with solution of iodine and sulphuric
acid, turris violet and then brown, thus answering to the tost of larda-
ceous disease. Under the microscope the amyloid lufiUration is seen
to extend mainly in the course id' the vessels, the walls of which are
also iufiliratcd, though detached masses of bodies which bare coalesced
are not unconiinon.
The treatment consists in a careful and complete rctnoval of the infil-.
tratcd tissues by the knife, either at one o|»eratiou or gradually. Tbft
disease does not show any tendency in return.
Cases have been reported liy Kyher, Maudelstamm, Tjcbcr, von,
Hippcl, Front, Saemisuh, and others (sec Archiv fUr 0|»liUialinologie,
Bd. XXV. 1 ajid 2; Anddves of Ophthalmology, vol. viii. No. 1). In-|
a case reported by Bull, the disease began in the orbit, and involved
the lid and conjunctiva secondarily (see TransactionH of the A morican
<)[i!ithalmo|ogical Sofdety, 187S).
Tnhrrrulnin'g of the conjunctiva ifl also a disease of great rarity and
comparatively recent recognition. Koester, in 1873, puhliahed a case
of tuliorcle in the conjunctiva without tubercular disease of any other
organ; hence a purely local disease. Sattler and Wiilh have botli Been
oases in which tubercles were fonnd in the bottom of a conjuTM;tivaI
RARB DISBASBS OF TBB CONJDHCTIVA. 131
ulcer, and the former has described a case of miliary tuberculosis which
involved conjunctiva, epiaclera, sclera, and cornea. Baumgarten'a two
cases are undoubted : in one the tuberculous infiltration was found at
the bottom of an ulcer : and in the other small tumors formed in the
conjunctiva, which were composed of small masses resembling in struc-
ture the giant-cell tubercle, and later underwent caseous degeneration.
A microscopical examination of all the cases reiwrted gives a picture of
a specific character, and proves that not unfrequently we have to do not
with a purely local process, but with the local expression of a general
pathological condition. The lymphatics of the eye are especially in-
volved, as may be seen in the enlarged glands of the ear and lower jaw.
If the case is at all marked, one or both lids are very much thickened,
and the patient cannot open the eye. The lids are reddened and feel
soft and elastic. When the lid is everted, the conjunctiva bulges for-
ward with luxuriant granulations, like the granulating surface of a wound.
The tarsal conjunctiva may be entirely free from granulations. There
is usually a purulent discharge, and some pannus. The tubercular
eruption may occur in the ocular conjunctiva. The proportion between
tubercle and granulation tissue varies somewhat, but the microscopic
pictures are all about alike.
The treatment is first constitutional, and secondly local. The granu-
lations should be cut ofi* before they have reached the period of caseous
metamorphosis, and the raw surface should then be cauterized ; and this
may be done rather freely without fear of producing disagreeable cica-
trization. For a full account of the subject, see Archiv fiir Ophthat-
mologie,xxr., abth. 4 ; articles by Hansell, Haab, Leber, and Deutsch-
mann, same journal, xxiv. 8; Bericht der Ophthal. Gesellsch., 1877 ;
Klin. Monatsbl. fiir Augenheilk., xiii., xv.
Psoria»i% of the conjunctiva has been described by some authors,
among them Terrier (Arch. (J^u. de M^iieeine, 187(j), accompanying
psoriasis of the skin of the face and eyelids. It is said to tend to a
consecutive sclerosis. — B.]
Chaptbr II.
DISEASES OF TUE COKXEA.
I._PANNITS.
[Syn. Superficial keratitis. — B.]
Tins affection is chamctcrized by a snperficial vascniar opacity ol
,the cornea, occiiji^'ing more or lesa of its expanse. [Fi^. y5.J Tlie
npacily getienilly cnmtiieticeR at tlic jioriphery, and gnidiiBlly extends
towan))! the centre, but tlic rovcrM may aI«o occur. It is* due to the
forroatton of a tieo-plastiu laver of cell^ beneiith the epilbelium, aud
also perhaps in the superficial layers of the cornea, ju^tt U>ncath the
anterior elastic lamina (mem-
brane of Bowman). 'J'hew neo-
plastic celU sliow a tendeitcy to
become developed into connec-
tivG tissue (Wedl), and Wood-
vesseU appear amongst them.
The bloDilvvKnelii are situated
beneath the cpithelitim, and iilso
somewfaai deeper, beneath the
anterior elastic lamina. On
closer examination, they will be
found to consitit of two sets.
The one is a direct continuation
of the cODJunctivnl ve*.*els, and
is almost entirely venous. It
forms a large-meshed, tortuoii?
network of vcsitels, covering a
considerable {>ortion,or perhaps
even the whole of the cornea,
which is seen to be opaque and
hazy between the meshes. The
[other TcsseU, which are chiefly arterial, are straight and paralte), and
[lie beneath those fnjro the ironjnnetiva. They prncet-d from the nnaato-
■ mosia between the conjunctival and subconjunctival ve.«clfl, at tho limbns
conjunclivre, where it tonus u bright rosy lone. If the vascularity is
coiipidei-nble, tliCHe parallel vessels are very numerous, and give a very
red iippeanincc to the edge of the cornea, which is often also somewhat
(Bwolten. When the eoniea is extremely vniicular and opm^ue, so that it
mmea a Tory red or even fleshy appearance, the di»eaao is termed
An»r T, W. JMM.J
PA NX us.
133
**^nnH« tvaMsun," whereas if the bloodvessels nre few Atirl scattered,
and the cloudinen:* inconsiilcrnble, it is called **■ paHHH$ f<r»Mtii."
In the acate form of tho disoaae, ihcre ix often considcrnhle photo-
phohin, lachrvnintion, itnd ciliary ne)Lrnl;^i&., nccomp&nicd hy marked
cuiijuiKtivnl and siilrcDtijiinctivul iiijvctiori. Hut if tliL- afluction ruii.-i a
very prr>tnicti'd and chronic coiirne, the irritrtbility of the rye is gen-
erally but alight, except if acnt* exacerbations occur. The surface of
thi! cornea <:milua1ly becoitic!) imir« 0[>a4pie, rough, and irregular, and ita
epithelial luyfv liypcrtrophied and ihickcticd, fwi that the cornea iiiuy
.finally asi^uiiie almost a cuticular appearance. Or the epithelium ninv
''be slicd ut difliTPiit pointe, pviiig rise to superticial facets and irrogu-
larittes. But the Iom of substance may e.ttcnd much deeper, and exten-
aive uLcent be formed, which may even lead to perfomtiou of tlio cornea,
uid subaequcntly to anterior synechia, staphyloma, etc. After the pan-
nua haa exidtcd for ^me time, the coraen 19 apt to become somewhat
thinned, and, yirhiinj; priidually to the intra-iwular prciiwure, to hwc its
nnrmal curvature and become bulged forwani. This fact is of great
practical importance, for even alihaugh the coniea should hereafter
regain much of ib^ tninsparency, this fauttiness in its curvature will
produce considerable deterioration of vision.
Amonj^Kt the eauses which may produce fiannus, granular ophthalmia
U by far the most fret|uent : in fact, in the voM majority of tiio.-m ca*c3
in which the opacity is contiiied to llie upjwr half of the cornea, it is
due to i^nitiular tiilq. When ti[K-akiug of granular oplitliatmia, I men.
tioncd that pannus might be ]>roduced by the frictioa of the rougheited
T^urface uf the lid on Uio coniea, or by a direct extension of the granu
lations on to the ocular conjunctiva, and from thence on to the cornea.
In the latter case, small gray or yellow inliUralionB appear near the
irgin of the cornea, and, if the attack be acute, may even extend over
ilQ whole of the conmu. Ijidtweeii thcac infi1tratiun« bloodvesoela are
jn to be ii)iA:4ing.
]*hlyctenuUr or pundcnt ophtbahnta may at-4o give rifle to pnnnus.
In the fonner case, the opacity ami vawulartty are not considerable in
Lextent, and the affeclion is chieHy characttu-ixed by the appearauce of
ittered phlyclenukc. or small infiltraliou^ on the surface of the cornea.
The disciiae may likewise be protlucod by tlie L-onstant friction and
irritation of the comea, caused by inverted eyelashes, with or without
entropion, by cretlHcaliou of the Meibomian glamht (chalazion), and by
the desiccatmn and cxpoitiin' of the cornea to external irritaut», at) in
cases of lagiiphthalmii.4, etc. In such cft»es, the diseanc may be termed
" traumatic pannus." In the chronic form, pannus may exist for many
year:^ without undergoing any particular change, except p<.>rlia|is tbiti-
ning and prominence of the cornea. Inflammatory exacer ha Lions may,
however, occur again and again, and each time leave the sight and the
opacity of the comea in a wor^e condition.
[In bad canes of " |>aninis cnwsua" it may be necessarv to »have off
the corneal granulations, and then apply carefully the mitigated .-^tick of
nitrate of silver to their base. — li.]
The proiftmnU is favorable in proportion as the pannus is inconsider-
able and of recent origin, and the cause remediatple. In rery chronic
DISEASES OF THB OORNIA.
«, ospectfttly of the pannus crajotuR, the dUe&ito, ercn if evcntuatly
ourL><I, ^ruiierullT lL'iLre.Hb<jhm<l it extviisivti and (lvii.>ieo|MivUies. If tlmrc^ is
central k'ucoma, or if iritis hiu uocnrred iluring the pmgresa of llio *Ii*-
c, ai>(l tlie [iu|iil 'n closed, it will be necessary to perform iriHectorny.
The treatmtnt to he adopted muitt depom! upon the cause, for if the
latter can he cured, llie ]taiitiijM uill hUu iliMtp)>i.>ar. A^ I have ulremlv
ill the article upon granular ophtiinliuia entered very fully into the modfl
of treatinjE pannun produced hy tliiit disease, 1 need uot recur to thin
subject, in cases of traumatic paninuf, our efforts must be at once
directed to the removal of tlic cause. «.,'/., the entropion, inverted lasher,
chalazion, etc. The opjicily of the cornea which may remain after the
disappearance of the urij,'inul disease, must be treated by mild Iwal irri-
tants, atnon<;iit which may be especially recommeniletl iii^ulllalinn of
loniel, the applicjitlon of iho red or yellow precipitate ointment, vinutii
i, nil of turpeutiiu', sulphati; of cop|H.'r, etc. These applications hnitteu
' abiiorption of the morbid products, Vty producing a t£ini>orary inftato-j
tory congesUon of the blooilveasels.
2._PHLYCTi:NrLAR CORNEITIS rKEKATITlSJ
(ItKKI'ES COIt>'KvE).
[Syn. Ptislular ophthalmia.
The term ** conieitis," aH applieil to inSanimation of tlio cornea, is
Bed almost solely in Kn^^land, mITiIc in the L'riiU'd Staie;it and on the
)nliiient of Kurojre the term '• keratitis'" ia employed, which is etymo-
jgically more correct. — U.J
Uliis discaiw often accompanies phlyctenular ophthalmia. In fact, tho
ro affectioiu arc alike in character, ami demand a very similar iuo<tc of
eatnii'nt.
Ab in pblyctentilar nplithalnua, the appearance of the vesicles on the
DnHta IB genenilly preceded by a sensation of heat ami itching in the
eyelids, which is soon foltoweil hy conjunc-
[Fjg. 38. tival ami subconjunctival injection, photo-
pliuhia. luclirymatioii, and ciliary neiinU-
gia. Tlie latter, which i» often but eili^ht
when tho affection ia confined to the con.
junetiva,iB frcijucntly very severe in horjie*
curueuj. The same is tliv coiie with the
phowphohia, which is often most intense
and persiittent. The characteristic little
plilycteiiuliu soon make their appearance
on the surface of the cornea. [l'"ij?. •W>.'\
Their number and mode of distribution
vary greatly. Sometimes, there arc but
one or two near tho margin uf the cornea^
AfixfT. w. jmm] in otlier cnsea tlicy are more nunicntiis,
and arc either iicattered freely over the
face of Ui« cornea, or are chietly conBnud to one pari. Or again,
liey niay be ranged along ita edge in single file, surrounding a moru or
rULTCTENULAR KERATITIS.
135
leiti conVidernble portion of the comcd like a string of benda. If Iho
pliIvctcimliB iir« luiinvrous, ami cxWud over h corutiderable vx|iiiri&v of
the rortivii (piiiuiiM DiTtifnlo^ns ), i\w VJi.-u.-iilHrity Ih >;ciii'riil, niiil the ror>
n*n !!• !»iim>iiiule<l Ijv a bri}j;lit, rosv zone of vcssclt ; Mheroi*. if ilio
piKtiiliv^ lire c<iiifinc4 to one portion of the coniea. Uie injoclion is }^»n-
illv nUi> partial. Sometimes, tlio phlyctcnulw are wry supcrficinl,
itppcar ill llio funu of siiiiill, trans pa rent vei^icles or blistpn*, whoso
ithelial cororin;! U iioon shetl, leaving n itnrall cxcorintioii, which maj
easily e.-tcapo <letvctioii, ai»l IcaU U> an erroneous liia^iiiioiid and mo<le of
ir' ' (reiKMitlly, however, the phlyrt^'iinlii is more appariMit, and
i- i'il ill the cornea, its summit ri^inj* -sli;:htly above the surface.
It Bppcani in the form ol' a »>mall, circumtcribL-'l, gray infiltration, snr-
n>nn<icd by a zone of slightly opa>i«o anil Birollcn cornea, the latter
bcitig cspectativ the case if several ^hlyctcnulfc arc situated close
to;rethor. At lU api'x it little tranttpiirent vi^sielc often forms, which
UiirstA and leaves an i>xcoriHttrd surl'aco, the liDttoiu of which io o]>Aiplo,
and t'fn i^rny or ^rniyisih-yellow color. This exciriatioii may gradaally
c.ttmi'l somewhat in circumferenee and ileplh, niiil a-wume the character
of a small ulcer, whicli U especially apt to ot^cur if the plilyctcuula is
»tUBted near the ecntrc of the coniea, and tbe affection has been iiiju-
•Itcioiwly treated by strong iwtriii-iienta. If no transparent vesicle forms
»l ihf iipex of the phlyctoiuda, this beeoiiies somewhat more 0|Mi'pie and
infillrau--t, and then, lo'tiii;: il4 epitlielial coveriu;;, \ri eliaii;;od into a
aujtorfieial, yellowish-gray ulcer. These nicer* generally run a very
favurabie course if Ihey are Judictou»ly treated, and kHow little or no
tendency to extend macli, either in circumference or depth. The ulcer
becomes covered by a layer of epithelium, and gradually fills up, and
the cornea regains more or less of its trniisparency. Mul if the inKllra-
>nj> »rx' situated vvrv elo*v to each other, two or three inav coidcscet
id thiu give riftc to one cxtcutiivv ulcer, which may increase in depUi,
and even lead to ftcrforation. This may nlito occur if the iiifiltmtionfl
■rx: situated liomewhat deeply in the cornea, and if strong local irritanti
(nitrate i»f silver, sniphat*; of c(»pper, etc.) are em[iloyod. In the
majority of cases there i* no fear of this complicntion, for under judi-
ciou.4 trcatmctti the eveorialinns or little ulcere sooi\ 611 up, the corneal
suljstance is regenerated, and perhaps no opacity is finally left. In
other vftites, the result is not su favorable, for a more or Inss dense
0|facity may remain behind.
There is gitat tendency to relapse. Just a« the symptoms of irrita.
tion and va.*cularity are tfub!»iding. the phlycteiiulie diiiapjieariiig. and
the discjwe flcem-t to he almi>iit cun-d. all the acute sympfMns of irritii-
lion return, a fresh crop of puntules makes it'* appearance, and a severe
relap!§c takes place. 'Ihis may occur again and again, and the aft'ection
gradually a-tsunie a chronic character ; vessels are developed upon the
cornea, which run towar<1s the infiltmtion, and this condition might he
mistaken by a superficial oKserver for that of fascicular oomeilis. On
cl'.>»cr exainiiiiitioii it will, however, be seen that the bloodvessels are few
in number, and im>re pcattvr^d, not rising prouiinenlly above the surface
of the cornea, and not pushing along the infiltration before them, but
mther stopping short of it. VVhen uuiuerou» phlycleuulie arc crowded
Jfa
ISfi
DISHARBS OF TUB CORNB&.
together (m the cornea, antl intewperae*! witli blooti vessels, it is often
termed *' herpetic or scrufitlmid" ihmhiiim, 11101% es|)eciall^ if they are
utuated tu the upper half of tlie comua.
The fiauaen nliich mnv produce this affection are tlie nsme w thoae
which give rise to phlyctenular ophthnlmia, and it nUo occurs mnat fre-
tjueully ainnnj*)«t chihlrcii aurl voiui;; pcrsonii of a wcakl}'. scrofuloun
constitution, and nervous, cxcitatilc teni[rt;rainout.
tjometiiHeB, as has been e»pefi«lly poiiiied out by Professor Homer,'
wo taevt with herpetic vtiiiclcs in the coriu-a in the courec of catarrhal
affectinng of the respiratory organs, alno in pneumonia, and they gfincr-
ally follow Hhortty upon, or occur simultaneously with, herpes of tlic lips
or noae. This form \i characterized by the fonnntioti of iiiiiiierouit trans-
parent vesicles on the coniOH, moatly arrange*! in ;Tro«p3 ; thoy are gen-
erally flituHtitl near the margin, but may ahu oucur at the ceiKre. The
vesicle* sntin burst, and leave behind tbcro small excoriations deprived
Of epithelium, followed pcrhaus by infiltratiouit and suppurative corneitU.
'Itie affection h very |>ninful and olwtinate, and cloAcly rcHemhlea the
form met with in hcqic* Koster frontalis, excepting, as Homer ahowii,
that in the latter then; in dioiinuttan of the intra-ocular tcuaiou and ex-
tensive Jimeslbefila of the coniea.
In the treittmrnt of berpei* coniere accompanying catarrh of the respi-
ratory organs, the insuftlatiou of calomel generally greatly relievos the
pain by causing rupture of the minute veaicle«. Atropine and a bandage
should also be applied. In the form accompanying berjies zoster injec-
tions of iijorphia and electricity arc often very serviceable in alleviating
the suflVriiig!! nf the patient.
The trcatmnU Khuuld hIm be similar lo that which was rccomiuendeil
for phlyctenular ophthalmia. I must here lay the fp^»teflt ntress upon
the necessity of avoiding the use of caustics, more especially the nitrate
of silver, fur this greatly increases the in-iiability of tiie eye, aggravates
the charnctrr of the disease, and augments any tendency to necrosis and
breaking do^vn of the corneal tissue. U may also cause the intiamiua-
Uon to extend to the iris and ciliarv bodv. Indeed it mav be laid down
as ft rule, that ill nil affections of the coniea, except those of a very chronic
oiiaractcr, the iise of caustics sliould be most stnctly avoided. In phlyc-
lennlar comeiUs our ehief endeavor must l>e to diminish the great irri-
tability of (he eye, to prevent the extension of the phlyctenulie or ulcere,
and to fnrilitate and assist the regeneration of the conical tiwiie. The
ttj^ent which wn slmll lind of the greatest service for these purposes ia
atropine. Indued this remedy is invaluable in the treatment of affoc-
tjona of the cornea ami iris. It exerts a beneficial intluence npon the
cornea by acting as a h>>:al auw^thetic during its |>assage through the
Qomea into the aipieous humor, thus greatly diminishing the irritahility
of the cornea and of the ciliary nerves. Thia ji) often wiliiessoil when
a drop of atropine ia applied to an eye affected with acute corueitis,
accompanied by int*inse symptoms of irritation; for if such an eye Is
Axamined half an hour after the application of the atropine, we tind a
Ttry marked diminution in all these symptoms : the patient exprcsainj;
•
■ "Kl. MonaUbl.," 1B71, 321.
rULYCTENULAR KERATITIS.
13T
himaclf pratW relieved. The atropine alao acta hy tiecrcaaing tlie intra-
oculnr t«n»ioi), aitd Uius ralioviiig tlie cornea of a corUtin (Ivj^roe of pres-
sure ;' lii-ncc its nutrition and the rc<:em' ration of its aubsiaiiDe are^
y„ f»tly fiu-ilitHted. Thifi diminution in tlio iittra-ocular tcoaion is or
e|)veiii1 a<lvant'»;{c- in lU-up ulcen) of clic cornea, tm will be readily under-
Blot>rl whnn wc remember tliat thr tbinnctit portion of the conicn (Uie
bottom of the ulcer) hait to sustain tlie same degree of intra-ociilnr pres-
sure a3 the healthy part.' The solution of atropine (gr. ij ad 5] uf
water) i^hould bo applied to the eye three or lour times a day. If it
should, after a time, be found rather to increase thai) alleviate tlie irri-
iHtion, a collrriiiin of belladonna must be subitlitul^^d. If it hnsnlrcndy
prnrluccd conaiderablo irritation of ttic conjunctiva and a crop of vesicu-
lar j;rauulacions, an aKlnn^ent cullyriuni of alum, iKirikX, or nitrate of
silvvr (gr. j ad 3j) Blionld be cmp1oye4l. The helladonnn ointJiicnC is to
be mbbeil 00 the forehead tJiree or lour times daily, until a elight {>apa-
lar eruption m produced. If there is much pain in an<l around tliu eve,
Biul mure f.tpfcially if the latter is very painful to Ihe touch, much ridief
itf oilen experienced from the npphcntion of two or three teeche-) to the
tompUrt*. or a blister shr.ald be applied behind the ear. If, together
will) the pliolophobia and lachrymatiun, the temperature of the lids is
much iiKTCuwd, I have niVn found very market! bcnctit from the |)erio(l-
ical apfilication of cold conijircsscs. These are to be applied tliree or
four times a day, for a space of 20 to ^{0 minutes, and are to be chau;!cd
every two or thr»ie minutes, as soon as they get the least warm. 'Ih©
photophobia is often, however, very oUtinatc and intractable. When it
M chiefly due to an abrasion of the epithelium and exposure of tlie cor-
neal nerves, a compress bandage should be applieil. Sut sometimes it
[• TWln »lAii-im>iil iior^U mwlill(.'ali«i). AwxirHiiig tw ihv am*) rt-linUv ■wt ivoj-iil
loiiotni-tficAl litvr<>lii^altf>t)f< atropine drroinislx.? ttii' iiitrAvn:H'ulAr t4-iif^ion l>^ )«rnlyx-
\ttif till- iiicut<-Lil9t iX'ut ■•( till- ri-*iu>tii, liiit lliit gftiiTAl inlrn-iH'iiliir tviiaidii in llitr viinu
oo» t« i iii;r>-a^"l l.iy its iwi*. — B.J [
* I iiiiiit, hiiwrrcr. strr-ngly iiaint «|">n the alatnlnir iiwwwitjr of th*" xolulion of
«(ni|>iiii- Ija'intt 4iiit» ))iir<-, mtd {wrftN'tl^r Iff tr>iiu miv ndinixtiiri- of ■tn>ii|[ iii:iil iir
:*t)iritK "f win*-. A few drv|>8 v( strong Fiitjiliuric »-id iir<.' ^oiiK-iiiixtf n-ldvl l>v rlir-tii-
bt« whi-n th» i>Hli>hjili' of ftltopitie i« Tint tjnitu n^-ultkl, nml lltt-rr'forf imf>or(<.vtly
■Alutild. 1 IiBV)- nivl widi •vvi-r.il iiisljinrv* in wliii-li a pixm M'lulinn uf ]ilr,>)>iiiv
prowl i>r the i;riMtpel Ix'tiudt iri nllaviitg the irritaMlily d( th<? eyu aiid iu ntloTiaUng
the I rill a mm A tin It. and in whicli a frvnli »i)|>|djr nf Btropinr (tiiadi- iiji Hftrr tin- •>aiiM-
]>raM:rl{ittini, but nliUiiNi) trtun .t dilTi'r-^nl c-liFinisl) liii» al (iiiru wl up M-very ir»ll«.
liMi nf Iho vy<: kcmnipntiiod i>y (oiiHiil-'mMK pain, ri-<lno##, Inclirvibatioii, vtc, but
Ihnt- •yiapU'iiiiA WHiii di>i>plH*«r>-il a^ain .iii llii.' us^'of a fmir itolutluii nf atrupiiui. <ID
■Xainliiali'>ii, tli" iinptirv ciiliili'm whh fi'iiiid to ■:i»i|aii] a sUiall iiuaulltj' uf atrnd);
«nl|it>Drio will. Sui-li cufH no lliifi rnmiilt'tolj-disprovo ihe theory it<at a antall (jtian-
ht; iif ■IruRg Bt'td or nf nl>'«1iol can bitre no prvjiidtfial rfftict u|h»i tliw lyn, tivi'ii ftl-
Uirfti}!li tliifTv niAjr t"- tntlcli •.'Diary trriUttioH and A (H^rt^re iiiflBtnuuiliuii «f tlie cornea
or irb. I mtut BlalL>, hovi'Trr, that we occiuloiially me«i wltli «xiv|>lioual cubm in
vhU'h Iti^rv irxinta a Jiwiiliar idloaynt-ra§y wliioh inndcm (li« pallriit iinat iiilnlrralit
ol ihv mi! vf K'wn a Wvak nnd imiKTft.-t'tly puri; »oluth>n ci( atnipiiie. I haw mnn
liat%acv» in vblch n drop of k w<-ak and qnitc pun.- solution ol Atropine hu prodneod
r^—' "■■■■itl.m mid piilti, or t-*"" »d •?ry»lpfl«iiiu« (^imliiiou of iliv vy^liiUimd vlitwlc,
11 '1 t>y r<'f|[iit« and rliitmotk swctltnRof the conjunctiva. Thiit is, howi-rvr,
1 ' ' plioiial tuvtirrrnrt.-, and iKrsra uot lli<- ImM analogy In IIkhi' cA*iit in whlih
itiv trriiaiinn I* i-an^iil l>y t'li- ini|inrity nf lb« atmplnv, for in kuvli, a purv tololiou
h not only wvll btirne, but ^n^ally all«vlat>» the ciliary irritntton and i nil am ma tor j
•ymptoiu*. Mr. I.awwin aUo mtiRtinns tumtia inti-n-xlriif; iriatsncn uf tUis pMiuliar
liltMyiirruy, in a paper iu iliu " R. U. O. II. Ki-'puru," vi. 119.
1S8
DtSEASBS OF THB CORNEA.
mists all remciHes, nnd a severe spasm of the Hiis (bleph&rospaira')
rcniain» even after tlie nffuction of tht< cornea is cured. In «uch ca^es
the different remedies which L have mentioned in the articles on jihlycto*
nular ophthalmia, should be tried, viz., subcutaneous injection of tnor-
phia. imiiiersiou of tlie face in cold waier, and if all these fail, and the
5[>:i;irii xrj, arrested l»v pressni-e upun the Bupra-orhital nen'o, «'e must Imve
recourse to a liii-'isitin of this nerve. I have oPu-ii found that a pn
longed Btay at the seaside, together with sea-hathing, tonie*. a generous
diet, and plenty of out-of-door exercise will euro cases of photopliobi
which have obstinatoly resisted all other remedies.
[.Sfdutioua of daturino and duboisine, in tlie form of the snlphatc
have huen U!^cd in pUcu of atropine where the latter has cau«eil irrita-
tion, but there seems to he no special advantage in eitlier. Buth irri-
tate the conjunctiva when used for a leugth of time, and often give ris*
to veiiculnr granulations, just as the atropine doea. Ouhotsine has oidy,
reeeittly been made known to ophthalmic suf'^'oiis, but it contains man
of ihe constituents of atropine. It has not, however, been suHioicntl
long in use to admit of definitely itcttlin;^ its place in ophthalmic thera-
jieutic^s. — B.]
^malt doget) of urtar emetic sometimes pmve iiAofnl in alleviating th
Shotophobia and ciliary irritation during tlie acute sta^e of the disease.
iut this remedy should not he persisted in if it does not produce any,
benefit in the course of a few days, as its prolonged use is apt to weake
and dt.'bilitate the patient. Arsenic has also been strongly recominrnded
in tliis form of corneitin, on the supposition of il^ similarity lo ecioma
This remedy often proves very serviceable, espeeially if the corneitis ii
aceom|)anied hy au ecuematou^ eniption of the forehead and face. In
the latter case the lotion of acetate of lead and glycerine (p. 1U8) should
be applied to the face ; or the following lotion may be used for the same
purjri>sc : U. Itomcis ,Sij. (ilycer, o^s. Aij. sombnci 5ijt Aq. dijst. jid
a»iij. A powder containing oxide of xinc may he dusted over the face.
The patient's general health should be attended to, and, if he is of a
weakly and scrofulous habit, tonics, coddiver oil, and a nutritions and
generous iliet, together with the use of ale and wine, should be pre-
scribed. The Iwiweld should be kept well re;'»lttte<I, unil dpcciiil iitien- .
tion should be paid to tlu- free action of liie skin, m this exerts a marked ^1
inBucuce uiKm the symptoms of ciliary irritation, especially the pliot<>>^H
phobia. When the acute symptoms have subsided, we must have ro>^|
course to tlie insulfl.-ition of cntomel, and, if this is well borne, the yello*"^^
oxide of mercury oiniment (gr. j~ij ad Sj) should be applied; this will
not ruily luLiU'n the abiorptinn of any remaining opacity, but cheek the
tendency to ndnpscs. Iti chronic and very olMtinate cases, especially
if they are aeeoiiipanied hy much vascularity of the cornea, great benefit;
b often experienced from n s«.'ton.
[Within the last few year* a great deal has been said and wri
upon the use of eserine and pilocarpine in conjunctival and corneal
affections. Dr. II. W. Williams, of Ito^ton. was the first to make aiiy
.extended exju-rimi-nts in this country, and he rej^rls very favorably on
Vith drugs as valuable in coiyuiictiTal ami corneal diseases, especially
olcera (Boston .^ledical and Surgical Journal. Martih 14, 1878; Trans.
d
PASCICOtAR KBBATITra.
139
of Amer. (>))litlial. Soc, lR7t*). In theac forma of diseaac mot wiUi so
frei|uently in Atnimoiu cliiMrett, the photophobia and blephnro^pasni are
very oftpii pelieve«l liv esvriiie tiul|iliMlu (gr. ij ad 5j). In tbo ordinary
form of coujiiuctival lici-|H*it, efli'niiR docs not ttL*om to do iiny (^ood, Imt
iho ve^iole^ ar* larj^o and t-oalesce, with zones of iii{iUrati")n,
■ 1.1'* acts like iL cliarni. In ulctrrt of cuniea, eserine someliuies diM;a
good, esp^-cially in the 8<»rpi;;inoiit» form, but, in the long run, heu«r
result* will Ik* obtained from atropine. Tlic hjdrochlorate of jiiUicar-
piiic. in flolutioDs of two or four gnuns to the ounce, scema tr» be of
tniirh mnn- liiiiiteil n|>{i1icnt!on thiin eserino, and, though tn the liamU of
r»r. Williitint* and soim* other ohservcni it has proveii very usi-rul, it han
not ntiswcred the expectations of ophthfllmie fiiir^etmn. An niiitmcnt of
jd»tfonn bus been recnnnended in these herpetic affections of the cornea
' couJDUctiva, and sucnti) in sorae cases to du good in atlayin}^ pboto-
bia iind irritation. 'Jlie chief objeclion to its use is its disagreeuklo
oilor (It*dyf»rni, ]^r». v-\ ; Vaseline, 5.i)- — B-]
In nire inslaiices, we meet with a jieculiar formation of transparent
vtfiiicleii ii|ion the xurfuce of the cornea, which arc produced by ttli;;ht
•ratioott of ilie epithelial layer and the anterior elaj^tic lainina from the
irface of ibc cornea jtroper. Tlie appearance presented by tbe*!' littlt*
bliaters is very oharacieriDlic, and is generally aecumpanicd by vet^
severe synipttimij nf iriilation, pspecially pliotopbobia and lachryniation.
'l'ber*e Hvuipl.ims subsitle wlien tlie vesicles burst, but a fi*et*h crop uf the
tatter is fjenerally formed every three or four days. In a case men-
liotu'd by Moorert the disease assumed the character of a regular tertian
lyiw, and was cured by the cnergotie use of ijuinine : indeed this
rrnu'dy, eombiniil pi'rhaps with steel, should he ^ven in all cases;
atropine and u compress luinduge being applied to the eye.
3._KASCICULAU COHNEITIS (KKRATITIS).
Tbiti peculiar form of comeitis, which is very common in (icnnAny, is
<>xtn-n)eiy rare in Kn^land, lor whilst I saw oiniiy itwtaiices nf it in
lit'rlin, I only rcniomber having nit-l with four pure eases in Kn^land
during the List cigbl years.
'Jtie symptdms of this affection arc very characteristic and easily
recof^izeil. The attack is generally ushered in by considerable photo-
phobia, lachrymation, and ciliary neuralgia. Uu examining the eye,
tJie ocular conjunctiva is found to be injected, and there is also seen a
bri;;ln rosy zone of subeonjiinctivnl vesseU round the cornea. N'ear
Uie etige of the latter may |Kirlia|w be uoticeil at one spot a few small
lylcienuln;, and tlu- linibus conionctiv^ is at this point also somowliaC
rollcn. The [tarallel subconjunctival vessels are seen at this a|iot to
pa«s an to the cornea and extend more or less on to itu surface, forming
a naifow bundle "r leash of vesseld (hence the term *' fascicular" come-
itis), wltieh lies in a somewhat swollen and oIcvilumI ))ortiun of the cornea.
This fa^eiciduH nf vessels consists iiotli of veins nml arteries ; at lU apex,
and rising i«)mewliat above the level of the vessels, is noticed a small,
erviioentict yellowish-gray inliltrationt surrounded ^>' ^ somewhat upu^uc
140
DIfiBASRS OP TUB CORSBA.
■ltd swollen portion of cornea. Aet the disease progresses, the infiltra-
tion is graiLuully pimliix) I'nrttier nml further on to the cornea \u Tront of
the vcsseU ; ittt epithelial covering; is sited, it Aisumca a ^vellowish tint.
and becomes uhan^^eil into n i<niall superBclal nicer. In some insuiaces
the orijjinul leash of vc<>seU may hifurcatc, «o (hat it aMUtnea a Y-«haf>e,
hatrin;; n separate iniiltration at each apex. The disuano mav exterul
far on to the cornea, ami prove diin^fcrouK from ittt leiivtnf; a dense
opacitjr' ill the centre of the cornea just over the pupil ; but the ulcer
generally reroaiiw superficial, and does not extend very deeply into the
cornea or lead to periforation. During the progressive sta^e, the symp-
toms of irritation are very marked and obstinate. When the disease
has n^ached its acme, it jiicnemlly remains stntionnry for some liltle time
(perhn^i^ even several week^) and then gradually diminishes in intensity
and slowly rctrfigrailetf, the ttyniptomi^ of irritation rapidiy disapjienrtn;;.
The time which elapses dnring the^so several nta^es will depend upon
the ttize of the fasciculus of vessels and of the in^ltration. The vascu-
larity t;nMl»ally diminishes, the ulcer is again covere<l by a layer of
epithelium, and begini*. to fill up from the periphery towards tlie centre ;
the corneal daanc is more or less regenerated, and after a time but little
opacity may be left.
Tbia disease is generally due to the Mime causes as [ililyctenular
nphthalinia. nnti is most frequently met wiili in weakly and scrofulous
pcreonfl, and in them il is very apt to run a most pr«traeted course.
If the symptoms of irritntion are ri<ry acute, only sooUnng remedies
should he applied, .\tropinc should be dropped into the eye, the com-
pound belladonna oiotnienl should be rubbed in over the forehead, a blis-
ter should be applied behind the ear. and a lc«ch or two to the temple
if the eye is very painful to the touch. If the vascularity is verv ronrked
and tlie case severe, benefit is often derived from dividing the Imn'lle »(
vessels close to the cornea, either with a small scalpel or a pair of curved
scissors ; for after this has been done, the bloodvessels on the cornea and
the infiltration are found to shrink and diminish in siicc. When the acute
symptoms of irritation have considerably subsided, the insufflation of
calomel Khnuld b<* at mice commeiice<l, or the \ellow n\ide of mercury
oinumnt ( jir. ij-viij ad 5J ) should be applied, ^th thc^e remedies, but
more especially the yellow oxide, are almost specifics for this disease.
The ointment may be applied from the verv commencement, if the symp-
toms of irritation are not very marked ; it must, however, be used Mith
care, and it« effect sitonhl ho closely watched. If we find the next day
that it has excited considerable redn«ss and irritation, its use should be
tempormily abstained from, and calomel should be substituted. It ts also
of much use in checking the tendencr to ndapses. in cutting these short,
and in hastening the al>*or|)tion of the corneal opacity. Fre<juently, wc
miuet ring the changes between the uintmrnt ana Uie calomel, us after
time they temporarily lose some of tlieir effect.
A seton at the temple sometimes also proves of much benefit in Ih
affection, not only in shortening the coune of the disease, but aldo I
preventing the occurrence of relafwos*
SCPPURATIVB KKRATITIB.
ux
4 SrPPl'HATIVE CORXF.ITIS (KKKATITIS).
[Syn. Abscttss of tlie vonieu. — B.]
Practirslly, it h nf im|H)rtaiice tn rlistin;iiii)th two priticipal rormi of
ippiimtive corneitis. The one b accompanied bv morp or less marked
"uitUniniiitftrv HyniptoiDS, wliitat in tlic other ihedt; nn> entirely absent, aiut
tb« cbicf ilari<:er nf the diseiue u found in tbeir ahaence. aa the ^uppu-
ntiun fipruiKln vor_v rapi*lly and an extensive abacesd or slouj^li of the
oomea ajifcdily endues. Tlieso two forms also demand a totallt opposite
pliti of trvattuent. In the inflaniamtory, we must (Mtdeavor to check and
ibilue the svropti>rnH of irritution and iuftunnnation by local iintiphlo-
Jfltic9 ; whereas in the torpid, noii-inflaiomautry form, wo must moAt
carvfully e»cbcn such treHtnienc. utid at once attempt to produce a cer.
taiit decree of inflammatton, in onier tu check the tendency to nc<:roai!4
luid purulent iitfiUration.
WhiUt drawing special attention to those two opposite types of the
diswfesi-S 1 must utate that In practice wc constantly meei with mixed
forai't. .■•bowing Hume of the symptom.* of each type. Indeeil tbe»iir;;eou
will cbietly dinpliiy bis skill and judgmcntt by distin^^iiiHliing whether
aiiy nf the symptom* have attained an undue prominence and rttpiirc to
cheeked in onler that a ju9t balance may be maintained between the
iry decree of inflammation sind the suppurative condition of the
~corBea : so that whiUt on the one hand, the inUummutory symptoms are
uot allowed to hecooie excessive, tbey are, ou the utbcr, not too much
lupprcs^ed.
T/ii- ivfittnimaOjrjf ituypuraiive ciTHriti* w often ]icvom[innicd by j^reat
photophobia, lachryinntion, and int«n.4C ciliary neuralfpa ; there is al^o
miu:!) conjunctival and subconjunctival injection, tlie cornea being sur-
roiuidei) by n bri;;bt ro^y zone, accompanied pcrhn|» by some ebemoais.
On account of the irritalion of the ciliary nerve-, the pupil i* often
f^nlly c<iiitmcl4.!d. On examiniii}^ the cornea, we uoliec a t,\na\\ circum-
scriWd iuBUTHtiun, which i* ;;cnerally ititiiatod near (bo centre, but some-
tJnuMj at the [>eriphery of the coniva. Its position varies, Hometimea it
is Mtnated in the tfuperficial layers of the coniea, and then the latter
may bei-nme xomowhat nii«ed above the level at this point, or it may lie
in the central or deeper portion of the cornea, in which case the surface
r^nuunti unalicred. The intiltration soon increa^eA in density and n^umet)
a creamy yellow iah-gray color, bein^ Kurrounded by a well-marked line
of demarcalinii to the torm of a li;:;ht-$;ray Mine, which f;nidnally tthmles
iiff into the transparent conica ; the latter aUo rthowi* a certAin de-tree
of iudummatory nwellin;; at the point occupied by this xone. The epi-
thelium may be shed, and a portion of the contents of the infiltration
break <b)wn ami be thrown off, »o that a more or less deep ulcer is forine^l.
Although the sulfconjunctival vesselrt may ]>a»i 6li;;hlly on to the cornea,
tbey never reach tbe nicer, even when this is situated near the ]i«riplicry.
When it ts in tbe centre of the vonien, the latter apjiears i|uit« free from
bb^odveaaels, except a few which may jiwt pass over it* niarj^n. The
retrogre^sivu stJi^e generally suon sets in, the iriQltnitiou cbange9 ltd
yellow hue fur a light gray tiot, and bccomett gradually absorbed, leav-
142
MBBABEB OP THE CORKBA.
itif; \tctiia\m Iisnllr an; opicity Uehiud. Tlie dUvate an n rule sbovrs a
leiiiifii4:v tn n-niHiii IncalixtNl. and wot to cxtrinl 3ii|ierHoialU. Iml ratlier
in <loptli. ll«ln{Mc>i arc »\>t U> occur aixI tltc affection ra;iv tlmn sAsuiue
a rtiroiiic ctiarncwr.
ItuC the <li«.>uc docs not always run ao favorable a conree. Thnot
Huvural nupcTficiiil inliUra(ioiia mnv lie formed cIoao to vacli other, »ndt
(znuluiilly i'xtrn<lin}{ tti circuinfcrcnco nnd dfr^iLh, may coalMCc and thus
jrivi' rixt: lo a i-"iipiitk'niM« abjwess of tlie cornea. Their content* nn-
rt<TKi» Hiipiiunilive and I'ntty dc;;ener»tion. llie cell* and nucli-i break
iloivn, llic' infdirdliou ajwurncs ft ye!l<iw color, being gorroiiudtid, liow-
vvcr, by n gruyiiili-wliiii; aonu of deraarcatioii. If tliia oecuns near tbo
ceutrR of the comen, it may prove daii;^eroni3 from its leaving a dense
opacity junt over tliu pupil, or from it** perb.ipt* lending; to an extcmico
al(iii;;th of Uie oonica. A;!»iii, if tlio inliltnition ii; situalod deeply in the
vorui-a, it may lead lo pi-rfonition of tlic bitter, or pvo rise to ouyi.
hypopyon, and iriliit. Tliv pus may sink down between Llie latncUtv of
tJtn tmmca to its lower margin, and thu-i proihice a ]K-cidiar opacity,
t4>>rmo(l onyx or uu;;ui8, on account of its siippotted resemMance lo tiio
white bmula of the (in^'or-nail. If the ouyx la but Amall, aud confinud
tn the very edge of the ooniea, it mav eaaily be overlooked, more eapc-
cially if it be doniewbnt covu-red by ttie Bwullen limbiis conjunclivie. If
it ic iiMtre eimBidoralih', so that it it-auhiM nearly up to iini'-thirtl of the
oontea, or even hitrhcr, it may be mi:«tnk(^n for an hypopyon. But on
can'ful examination (more e»|>ccially with the oblitjue illumination) it
will nitt be difficult to distinguish it fnuu the latter, for it will be eecn
to lie on the corneal rtide of the anterior chamber, n poruou of tmus|ui-
reut eonien perhti]« divi'linj; it fi*oni the latter, aud it is siluateil at ^omo
didtnmv fmiu (lie iri«. Itut the dilferential diagnosis is of courite more
difficult if, as \n somelimeH the ea»e, au hyjtopyon coexislx with the ouyx.
1*he liy|iopyon which not unfre<|uently noeompnnieji Bup|iunitirc oor-
neiii.i (morv especially the nou-iulbiminatory form) may be prodaced
i-iiber Iriuu the iris or fnim the cnniea iu tlie following ways: —
I. An iuHamnuitlou of the iri« may supervene upon the oonuttSf
lymph be effumed into the ai{ueous humor, and, falUng to the bottOn <ii
tlip anterior chamber, thus produce an hyimpyon.
*i. Tlu' ab«ovM may |>erforatc the contra, aiwl its punilrat conltlltf-
ba earned inln the a(iue<^us humor and Iw precipitated at the bottom
|1 ^lambcr. SottU'timea snoh a uiode of pr»luotion of hypop-j
; lely overh»oke'l. fr*>m the fact that the ei<aimamcati<ni
iwren the anterior chamber am) the ahactniaa in Uie coiikm is not
aud direct, but is br^tii;^it al">ut by a tinall s1opin|K canal, thrtm;;^
the ts>Dt«nts of the abbess harv made their way into the anterior cbam-J
) . ^ .-t'ial tttenttoo has been called to this fact by VTeber,^ vbe
. fmiacntiy pa«*d a mtnaia proW from the aleor IhnMtgk \
v*«tMl into the Miterior ehaBber, and thaaTwifad Amvam^mai€ '*
Witb iii« oMnfue illaBanakMO, this Util* canal apoeafs Gfca m
auralc, nuuxia^ froa the aboeew to the anterior chaatbcr.
S. \Vb«a the afaaoaaa u liliaan il deeply ia the oonMa, aear tha
SlirPCRATIVB KERATITIS.
14a
i
I
I
brune of DcMPmet, inflaiiinmiorv itrolifcnition and fatty ilegeneration of
the f ]iitln.'li;»l cells, liiiin-: ihi- |)<jsterior |iurlii>n nl' tlit* cornea, may occur.
TIiL'V nrv thrown ofl'. mxj, iiiixiii;j; witli the iii(ueoii.s Iiumnr, render lUis
lurMil, anil if tUe-te ilc|)OAits are coniiulcrable in ijiiniittty, they may fall
dowQ to tliu liottom of tlie atttorior clinrntwr ami tliuK produce un liypop*
yon. It lias been alao aupposoil that tiic latter is often tliio to n Iraina-
datioa of gomo of tbo coott'Uts of the dccp-scatcil abuccss into tho miueous
humor.' Weber, however, asserts that lie has never met with an in-
<tADce in which the cominunication Iwtncen the aWesa anil the anterior
ebambcr could not be (UiiLinctly pruvuil by tneiuis of |)robini<;. 1 liave,
however, met with cane* of abeceA^ in tlic miildlc portion of the cornea,
■wliicli have been accompanifl by an infiltnition i»ituat«(l at the membrane
of IK'pcemet, ami an hypopyon eviiiontiy proiluoed by the latti^r (for
tliere was no iritis), anri in which I have failed, on tlic most careful ex-
amination Iiy Ihir obliiiuu illumination, lo trace any cimmunicati'jn hv-
tweeu the alisccsa and ihe posterior infiltration.
Indammatory liiippnratire corneilie is met with in severe and aggra-
vated ea«C!) nf phlycu-nutar conieitiit, anil al>io in severe cases of puru-
leni, ;:runular, and diphtlii^rilic ophthalmia. It is very frc(]uenlly caused
by mechanical and chemical injuries, Hucli ua the lud;;ment ui' chips of
steel, a bit of «heat ear, etc., in the flubstfliicc of the cornea, which i>cr-
\\n\*» remain tliere undiscovered. This is enpecially Uie case in old or
very feeble persons, h may also follow o|)erationa ujmn the eye, tnoro
particoUrly those for cataract.
in llie milder cases of inHammatorv suppurative corneitis, atropine
should he aiiplied three or four time^ daily, and the compress baiidago
employi-d. If there if> much irriliilnlity an<l ciliary neuralgia, and if the
eye U very paiufu) to the touch, two or three leeches should be applied
ti» tin- temple. Subcutaneous injections of morphia may also l«« cm-
ployi'd with great ailvantage. If the absoesfi resists all treatment, great
bem'flt is often derived from slightly o|>cning it with the point of an ex-
traction knife. But. if it is deep-«eatc<l, and thrcateim lo perfomte the
oomea, pamccntettis shouM W perfiinned by (las^in^ » fine needle into
tbe anterior chamber through the bottom of the abscca.^. If a conftider-
able hy)K»pyon exista, paracentesis should also be porfomied, but with a
broad needle, the object of the operation being not so much to remove
tbe lymph from tlie anterior chaniher :%» lo diminish Ihe intra-ocular
pressure, and lhu« to arn-rtt the progress of the disease, to hasten the
abaorjitiou of the infiUmtion, and facilitate the regeneration of tho cor-
neal tissue, 'itii.t ojK-ration may huvo to be repeateil several times
(vide treatment of ulcers nf tho cornea by para ecu IcKis). In onler to
diiuinish the intra-ocular pi-esanre still more completely, and more cfTcc-
tnally to subdue the inflammation, it may be very advi!Uible to perfonn
iridectomy in cases in which i^uppurative comcitift is extensive, threatens
perforation, and Ls accompanied by hv{>upyon. This u more esix^cially
tlic case if tho ahscesii is deep, and situated in ttie centre of the cornea,
for oven if it ahoald not perforate, it will leave a dcuM letconia, which
will aubsequently necessitate the formation of an artificial pupil. It ia.
< Bt»tf, "A. r. 0.," iL 2, 181.
144
DISBASBS OP TBB CORNEA,
tlioreforc. much wUcr to make an iridectomy at oitce, as tins will exert a
bem-fieiiil luHuciice mKm t.lic coiime of ihi* iliaeade, anJ leavp an artifiinal
pupil oiipn-iite a clear (portion of tbei cornea.
/» the non-inftammadtrif supyiirative comeitis there is generally a
very marked absence of all the usual Bymptoms of irritation and intiam,
mation. There is no photnpliohta, lachryniation, or pain, and tJic ey
appean, in fact, abnormally iniicnsiMc to external irritation (brif^b
light, etc.). It may, hwwever. supervene upon a circumscribed inliltra>
tion of the cornea, nrcunpanied hy severe Bvmptnms of irritjition and
intense ciliary neuralgia. These symptoms suddenly yiidd, and the
abscess shows a tendency to necrosis, extending '|uickly in circumference
and depth. There is formed very rapidly, often in the course of a few
htHint, in the centre of the coniea, a 5mall yellow spiH, which is sharply
defined a^^fiinut Ihc clear and tmnsparent cornea, and is* not sHrniiiudcd
by an opnuno ^ray Kone, as '\.* tli« case with the inHiimmatory intiltra-
tion. Indeed, the adjtmiinj; portion of cornea may even appear abnor-
mntly lustrous, which is probably due to serous intiltration. The yellow
color is also more deep and pronounced than tn the intlammatory form,
The disease rapidly c\tenilH in cireiimferunce, and consecutive yellow
layers are formed around the ori;;iii!iiI infdtrfltion. The tissue of the
coniea becomes quickly broken down, undergoes fatly degeneration, ai
pus-cells arc formed in large ^piantity, and the ahBcess soon gains a con-i
aiderable extent, both on the surface and iu depth, reaching, perhapt,
nearly u> the membrane of Descemet. When the suppuration has
Attained a certain depth, the epithelial cells lining the membrane of
Descemet undergo inflammatory jin>lifertttion, and, being thrown off,
mix with the aijncons humor, rendering tlii< turbid, and pcrhajus linking
down in the anterior chamber in the form of an hypopyon. The iris
becomes swollen, hypertemic, and of a yellowish-red colur, dun probably
in part to the hyi«r»niiH, and in port to a purulent infiltration of i
tissue. There arc generally no firm ndhe»ioiis between the edge of tli0
pupil and the capsule of the lens. The tendency of this non-inflamrajt-
tory form <>f suppurative iTornfitis is to extend rathor in circumferenc*
than in depth, bo that it li*a(U to very considerable opacity or evca
extensive suppuration of the cornea, with all its dnngcrons* consoqucncM.
[In abscess of the cornea, iritis wttli adhesions is a very common com-
plication.— B.]
When the pniccss of reparation sets in, we find that the yellow and
rimrply defined infiltration becomes surrounded by a grayisli lonc. and
that there is at the same lime an inoroasi- in the vascularity of the eye.
Much of tiie danger is now past, for tiie disease assumes more of the
character of inflammatory suppurative itomeitis and shows a tendency to
become limited, and there ii«, cnnseijuently, much less fear of purulent
necrosis and sloughing of the cornea. Gradually the yellow color is
changed to a whitish gray, the purulent infiltration breaks dnwn and is
absorbed, and the corneal tissue is regenerated. It may, after a time,
even regain its normal transparency, especially in children, and if the
infiltration was but small ami superficial. Otherwise, a more or leu
densi! opacity iu left hchinil, which, if it be situated in the centre, may
cause great impairment of vision. But if a sufficient [tortion of tit
a
I
8U?PURATIVS KERATITIS — AB8CB88 OP THE CO»HBA. 146
mArpn of ihe comoa U trftns|>ftrcnt »nA of normal curvature, excetlvnt
aigbt tu»y orteu be reiftorvd )iy tht; formation of nn artificial |iu)iil. But,
unfortunately, su faroralile u result la not alwuTs obtained in i^^'verc aixj
uxtennive tiappurative comeitis. I'erfopatiou of the cornea but too fre-
quently lakes place, followed by anterior ayoccliia or stapliyloma. or the
iiiHatniimtion extcmU to tlie otiivr titfiiue5 of the eyeball, and panophthal-
mitis uccuiK, en-iing in atroj)liy of the globe.
Non-intlntumatory Auppum'tive comcitia ftccurs fre<-|iient.]y in very
ftged and fe«ble persons, more capecialljr after operations involving the
cnrnea (such ns those for caturuct, parliculnrly the flnp extraction), or
after injuries to the cornea from foreign bodica Rtrikiiij; it or U'coraing
■lodgeii on it« surface or in il« Hubstanuc. Thus, it is not nnfre'tnenlly
bnet with ainonj^t af^cd country people, if a bit of wlieat ear, or per-
^Iwp« the wing of an iudeci, becomeit imbdhlvd in the cornea and is not
Emnored at once. I have Hccn it pmducud in some instances by a simple
lion from » blow against the eye by a bit of wowl, tJie bougli of a
jjtrvc, etc., without any wound of the cornea. Von (iracfe jins alfto de-
scribed (A. f. 0., xii. 2. 2nO) cases of suppuration of the cornea occur-
ring iu infanta sufTcring from encephalitis.' It may likenise Hupenene
upon severe constitutional disca;!)es, which have greatly weakened the
general health, such aa typhus fever, cholera, encephalltiii, diabetes, etc.
It may also follow paralysis of the fifth nerve, and is tlieu termed
nctirft-|)amlvtic ophthalmia. Tlie affection of the cornea in genumllv
chronic, and occurs some time after the paralysis. If the tatter 'u par-
tial, the cornea is hut rarely affected, and then only jiartinlly, and not
to a severe extent. The eye loses ita sonsibilily, so tJiat when irritants
(p. </., astrinf^cni collyria) aro applied to it, they excite redness, but no
feelin;; of pain or diflcorafort, indeed their presence is unfelt. The cor-
nea then bfcnmes opa'jae, ulcers may funn, and suppuration may take
I)hive, le.i<linj: perhaps to perforatiyn, byjMipvon, etc., and the intiamnuw
lion may even extend to the iris. 'Hie epithelium of ihe cornea and
conjunctiva becomes rough and desiccated, so that a certain degree of
xorophthalniia is produced. One very interesting fact is, that paralysis
of the fifth ner^'e always produces a diminution of the intra-ocular ten-
cioD, and Uiis is a jHiint of the utmost im|)ortanec witli regard to the
vholc «|uestion of glaucoma tnil increased intra-ocular tension.
The afiectii>[i of the cornea which may ensue u)K>n {•aralysis of the
fif^h nerve is apjtarently not due to mal-nutriiiou of the part, but simply
to mechanical injuries, caused by the action of external irritants (dust,
pand, Die.) to which the eye is exposed, and whose presence, on account
rif its inseni^ibility, it does not reeent or feid. That this i« so, haa been
unconlrovrrtibly proved by the exi>eriment^ of Snellen* and others.
Snellen liividoif tlio fifth nerve in raldiiLs, and sewed tlicir ear* over
their eyes, so as to protect the latter from all external irritants, aiul he
found tliat when this was done the coruea did not become affected,
wherens it Wgan to become o|M»(|ue the very day after the eye wa.i left
uncovered. More lately he has rejiorted' a very interesting case, which
* VM«alw>Hinichb«^'tartIel»"Beri.RllR. WoeheiiK'lirtfi."1A4$, No. 31.
• •• Vlroltaw'i Arrbtr," to), xiii., 1K5S. * ■' JurlilkMh V(>nliu;," etc, 1663.
10
1-16
DrSBASES OF TUB CORNBA.
fully beaw out this v\vv. A num. S6 years of age, wm affecietl with
COni|'lcti? |jftral;,»i8 of tlie left fifth nerve, together witli jiaralysi* of ibe
«ix(lt nerve of tltu same siilc. In conse(|Ueni;e of tlie latt«r, tbvre vx-
isted a convcrgeiit stiuint of the loft eye, and on the outer ddc of the
ooniea tiier« M«a & ftii[>erficial ulecr, eurrouudej by a tolerably broad
gray w>no. The eye waii ijuilc iuscnsiblc. and the acutcDess of i-ision
inminiiilied to g'^'g, and its ten9ioti wai! much decreased. Tii order to
aw:erlftiii with ceitainty whotlier tlie aflectimi gf the cornea wad due to
mal-nutritton of the eye, or to it« exposure to external irritants, Snellen
fastviied, by mrans of atripa of plaster, o stenopaic ahell orer the eye,
in order to protect it. A small ceutral aperture iras lef^ for the patient
to nK-e th^Mllrb, ^to ibat he mi^ht nK-ertniii whether the sholl retained iu
Sirt«|H'r |H«iitiun, for from the want of aeusil'ility of the eye, he could not
letenninc it otherwise. The dhell waa remored twice a day iu order
tbat th« eye uiight be waahvd and cleaiu^ed. The ioiprOTcment in the
condition of the cornea and the ^ight was very marked, for witliin two
davA the viiiun « «f J, and the cornea cleared so rapidly, that in ei;;ht
days aftvr the applicutiou of tlie ghell Uie acutcuess of vuion was normal,
vis., «■ |{. Only a small o|iaeiiy remained at the outer side of ibe
cornea, but the lo«g of sensibility and the dinuniabed tension contiDaed.
The application of turpentine and nitrate of silver prodnced the saoso
symptoms of congestion as iu a normal eye, without, howerer, hetng feh
by the patient. The stenopaic cup was left off, and the eye expw«4;
wttiiin two days the eye became a^rain more inflsmrd, ud th« VUMO
jK«aB« diuiibishcd to ^^. It shortly n^gaulcd its nmaJ tuadarij
' tr the reappttcation of the shell.
Meisener' i^ however, of opinion that thJs tendency to tnflammaiiaa
^ the cornea is not altogether doe to the loss of svsinbiliky. for he has
vhscrved three cases* in which no oonieitaa ensweJ after divisioa of the
jihthaltnic branch of the fifth ncrre, altiiottgh the eye vac <|Ute tnMi»> ■
«ble, aad not nanlcd agaiBBl external irritaate. On -— — =— *^"- H
was faawt that tn all the«e instaBcw the inuemast porrim «f the uun
bad escaped division. He. therefore, coneiiderft it probaUe that the
fibres of this portion of the tterre tvikder the eye nore able to rasac the
elect Iff extrrnal irvitaQts, etc. This suppoeitMu is atmg^fanMl bj
another case, in vbieh Ueinaer iiHwaplefely divided the fiMi bcttc in
a rabbit, ai»>l, ahboa^ the aennbUiiT of the eye was tmt iapaired. the
iwfaiwatiwi of the cornea eosue-l in 'the cestiwaty ■■■ rr. On esaau. I
aatrai tt was found th^ ooW the mediaa (iaaifnst) pettioa of the
nerve had been divided. Schtfi' hu repeated these experimeats witli'
•nctly the aaase »«■>!».
TUa Terr daanmas efaaracwr of mkmi
aeiti* is ebieiT «u to ike lafidtty with vhieb the
■one especwfly ta ebcanlbRflee. aad to the gieak tcadenej t»
arvrosis of the coneal aes«e. wtueh lea^ has uo fre^atady to nrj\
lie swppMitiw of the eomeaf ar even to pardent
* Ikate a^ MeAr's •* X#teekitfl*- (»1. nla. M.
Ptii <*>•» "hasifcrtll" O}, suix. f- ST.
SOPPUBATIVB KERATITIS — ABSC888 OF TUB CORNEA. 147
of the eyehall. Thifi duciuc proves espccinlly dUastrous if it bo treated
b,r the vrdiiianr autipLlo;!;isticti, e. ij., cold compresses, leeches, etc.,
iDftre fiArriciiliirly Jii severe cines. TIma Von (Jracfc found, tlmt, when
\iv j.itrsiieil this mode of treatineut, he \oii about lhn.'t -fourths of the
•MviTvr ca*efl : wherc-u hts success was vcrv marked &s. soon as he
Substituted wsnii fomviitatioiis uiid the compress buiidnge. The objret
of the warm foraeiitatiyiis is to exeite n ucrUin de;;ree of inflamroatory
reaction and rtwclliii;; in the conjunctirn and cornea : for in the bolikl
absence of L)iv»e is tu be sought the chief danger of tlie disease. They
alMi haslt'n the limitation of tlie suppuration, expedite the absorption of
the infiltration, and favor the proceaa of reparation. Aftor Uieir appH-
untiou the ere becomes more injected, and this is accom|>anicd by in-
VamniHtory gwelliug of die conjunctiva. The vascularity also extends
more or less on to the cornea. The infiltration is no longer sharply de-
innl 8<!aiitfit the imnApHrcnt cnrnea, but a gray hain H|)|M.'jini around it,
tliis ['Ortion of the conica \» siiomewliat 8»ntlcn, and the line of dc-
niannilion aoou beconicM well marked. If an hypopyon exists, and h not
Tt-ry wnsidenible in extent, we often lind thiit it becomes rapidly ab-
>rh6tl after tl»e use of warm fomentations. Von Graefc' generally uses
tami camomile fomentations, viiryinj; in temiwratnre from about 90' to
104 - of b'alirenheit, aceordin;; to the condition of the eye. The leas the
symptoms of intliunmatury irritatii<ii, the higher should the temperature
be. 'i1iey should liu ohtinged every 6ve minutes, and tiieir uw. kuh-
*nded for one I'ju.irier in every fiour. The temperature should be
jwered and the fomentations changed less frm|nently, or a lotiger inter-,
val be allovred to elH[>se between their application, as soon as the eor
of demarcation and the inHuoimntory swelling make their appearancoJ
and the necrosed p<jrliou9 of cornea liegin U> be llirown off. If 1h(
points are not atU-ndcd to, we may set np too ;ircat an intlauunatory
reaction, so thai it may even liecome necessary to check it by antipldo-
^stic applications (cold comprcBfles, leeches, etc.). Saemisch,* who has
extensividv studied the effect of warm fomentations, advocates their con*
tinuativn for a somewhat longer period in certain cases, in order to pro-
rlBote the exfoliation of the necrosed portions, and to expedite tlie
kbMCrjilion of tlie nH>rlii<l productft. Their eOcct must tlieu, however, be
Blfwoly watched, in order that too much inflammation is not set np. In-
^Aoed, the em[')oyment of warm fomentations re<|nire3 great ciroums[>ec-
tton and attention, and eainmt be cntnL-^ied lo aetujiid or careless nurse,
for if they arv iipplied too liot, changed too freipiontly, or continued too
lung, tliey may produce an excess of inHamniation; or if, on Ibe other
ifcand, tliey are permitted to get cold, they are even still more irijurionSi
rby diniini)ihiug the vitality of the part, and thus incretising the tendency
to necrosis. Where 1 cannot rely upon the care and attention of the
Durse, 1 am in the habit of ordering the occasional use of warm poppy
or camomile fomentations at stateil iieriods ; for instJinee. three or four
times a day for the period of half an hour; the fomentations being
• " A. f. O..- ' ri. 1, 133. WAf sl«o th# aiitltor'a AlMtrMi nf thw papar tii " Boy.
L»u<l. i>|.|itlt. U<wi>. R''|i«rte." vo). Hi. YH.
■ " KlioLscbi; UvuliaditUDgvn vou Paj;rii9l«clicr und Sacmboh," ii. IDS; 16$2.
DISEASES 07 THE CORNEA.
Changed every five minntes during that time. In this way conwdei
benefit may he derived from tlicir iwc, vtiilmiit incurring any riak.
Warm fomentations are indicated in all forms '>f nitn-infiaiuinat
8U]>piirative conieitis, wlielher of ripoiitJiiioDUH orifpii, or canoed
iiijuricH to the eye or opfratinns (rspecially those for tlie removal
cataract). Tliey may tilno he necesMry in cases of inflammatory 9»
pnratire conieitts if the uymptoma of inHannuatiuu have 8uiik below ^^
certain point. ^M
Great advantftfie is aI«o experienced from tlio uue of a firm coraprc^^
or the '• prcasiiro bandage" (vide p. 47"). for this is of much Bervici' i^?
limiting the extent '>r the suppuration and hastening the formations*
the xoiic of dciuarcalion. Its application sliould alccnintc iritli the wanz:*
fomontation«.* Kven a certain dc^frce of iritis does not contra -indicate
ita use. According t'> Von Graefe, it is not, however, applicable ir*
those cases in which the purulent necrosis <»ccurfl rapidly, after tlio
eiidden cessation of severe symptoms of irritation and ciliary nciiralgia,
with which the disease was ushered in. After the pain had been alle-
riated by a sulicntaneous injection of moqihia, and warm fomentnlioi
bad been applied, Von Graefe found much bcuetit from the nse
chlorine water,' [Solutions of Baltcylic acid and of borax (the latter
the proportion of Jij to the Oj) have been recommended in these ci
when Ihe chlorine water provee too irritating. — U.j If there is as
iritis and the a(|ueous humor is turhtd. with or without the presence
hypi>pyon, it is most adviaahle to perform iridectomy without delayj
This will generally at ouce cut sliort the progress of ihe disease at
atop the extension of the suppuration. Tint if it is found that this it
provement is hut temporary, and lasts but for a few days. Von Graef
advises that the chhirine water shouhl be again applied. He lias done'
this even within thirty hours after the 0[>enilion, if fresh creacentic
infiltnitions showed themselves around tiie ori^^itial abscess, and hf
found that their extension was decidedly and niarltcdly checked by thij
remedy.
In the ncuro-paralytic fonn of corneitis, a light iHinda-jc sliouM b<
applied over tlie eye so as tu protect it against all extei-nal irritantjj
It should be removed two or three times daily, and the eye washed ai
oleansod. If the case be seen sufficiently' early and before any c<
fliderablc miseluef has been done, this remedy will generally suffice
rapidly to cure the affection of the cornea.
Atropine drojw sbould always ho applied, as they not only act as
anoilyne, bit also diminish the intra-ocular tension. They are of esj
cinl importance if tliere is any iritis. Dr. Warloniont apeaks vei_
highly of the vise of Van Kooaliroock's ointment in cases of indolent,
necrotic corneal ulcers. Iw compodition is as follows: Sub-sulplmte
mercury gr. 4, C, or 8, Axung. 3J8a,llals. Poruv. m. 10-15.
If perforation of the cornea appears imminent, and the ulcer is not
Coniiidcrable size, a parncentesis should he made with a tine needl
through the bottom of tbc ulcer» ho ns to allow the miueoue humor
flow off very elowly. 'fbis will diminish the jntra-ocular tensiou ai
' "A. t 0.," vol. la- '-i. 151. I ii,|d., rol. x. 2. 2it5.
Bp9
jV^rUktlV^j KERATITIS — ABSCBSS Of TUB COKNEA. 149
fBcittiftW *« ^^rptioii of Uie inBliration, and tJie filling up of the ulcer.
IWt i(0*'Y li^^u or ulcer 1? tleop rented, of coiifliilcraltle i>xtcut,aiHl
siiows * WBWMiy u> incrcue atiU more, or to perforate tlic cornpa, para-
^jcpw** *'*"''^ *«> 4t (fiu-o perfonnud. It ia aUo iiiilicaU<(l if a cerlaiu
degree ol njpupjou is present, with or without mm. It has boon
»lrcaJy 8»tel Uiat Qy,, ^bjei-t in tapping the anterior chamber is less to
reniii'^e the lyiujili tlian to diiDinish the iotni-ocular pressure, and thus
Ui t.top the p^>z^t!^ss of tlie disease, hasten the absorption of the morhiii
prodiicls^ Biui facilitate the rcf'eiic ration of the conical tissue. The
incision IS to he minit. w*n|, n Viroa«l needle 3n the cnnioa near it8 lower
edi>f.', and the a>|ueous humor should he allowed to flow off very slowly
iixlffil. It raajr be necciwiiry to repeat tlie upcmtion several timeg, or,
in order liiii it« effect may be more lastJn;j, the little wound may he
Ltf't fflU'Dt hy the occasional insertion of a small probe ouce or twice a
d«v.
But if the hypopyon li considerable in sixe, occupying perhaps one*
tJiinI or eue-ball'of the anterior cliambcr, if there itt much iritis, or if
tlw iWms m tlie eomea extends very deeply, and threatens to cause
M extetuire pertbrutjou, it u of great importance that an iridvctomy
akfultl be aade without lo8.<i of time ; for the iiunwicular tcn:)i<ni will be
thus ii'>n- completely diiuiiuHhed, and for a lon;;^]- period, than hy the
nnctuksis. We generally find that the iridectomy exerts a most
wioSdat indircnce upon the suppuration of the coraoa, ami also a^ an
Uft'ptdojfiitic ujwn the infiammation of the iris. 'Die progress of tlie
WppDntiiin, both in circmuference and depth, is arretted, the deeper
Ujrn of the coruea do not hecuuie necru.'^ed, and the abxorption of
uorliid protlueu and tlie procosti of reimir are hikittened. Indeed, I
liiiik tlial an irideetomy Alioiihl generally be preferred to a paroccn-
IMJH. if the diiteaiie be at all sevvi-e an-I threatening perforation, more
cq«ctally if the abscess or ulcer be uf considerable sixe am) situated in
the centnt of tlie cornea, for (hen it will leave a dense opacity behind it,
■lid. after all, necci^sitAte the formation of an artihcial pupil.
[Very unfortunate results i^omctimes follow an iridectomy in these
caa». The iris becomes violenllv iiiHamed, and the pupil becomes
blocked by a maAS uf pus, without any ccs^iation in tlie corneal process.
('h>ening thf anterior eliambc-r below, witliout the cxeiMon of any portion
of iris, i^ a hetlcr openition iu tlie ui;ijority of casus. — IJ.]
If there is a conaidernble h;ypupyoii, the iridectumy should he made
•iewnward*, or dowiiwanU and inwards, in order that tin: lymph may
cacnjie with the ai|ueoua humor through the large incision. Xf it does
»o readily, it is better to leave some of it in the anterior chamber
U> pull ani drag ui>ou it in the endeavor to remove it, for this
set Up j^reat irritation. I think that this h to be preferred to
nji; the iridecWmy upwanls and then endeavoring to reninve the
tympb by a pair of Toreegis, for this will drag upon the lower portion of
tke tri«, and may produce much irritation and increase the Intlaimnatiou.
Weber strongly recommends tliat the paraCButosis ahouM he made
with a broad uccdlo throngli the bolUini of tin- abscess, ao that it may be
split acHHs : the gush of ai^ueous humor through the incision will uarry
with it more or le^s uf the contents of the abscess, and thus cleanse it
150
DIBSAflES OP TUB CORNEA.
Awl furor its filling up, or SAcmisoliV operation maj he performed (vidftj
Iiitlic non-inflnmm&torjr supptiratire comeitia it is ifgrcnt imfiortanoo
to keep lip tlie pAtieiit'a genoi-al health. As ttti^ aflfection is mcwt prone
t« occur in delicate, weakly children, and in old and feclde JndiTiduaU^M
touicH and ditfunilile otiiiuibnt^ should Ue frcclr administcrcil, aud th^H
IjRtidit W placed upon a i;oin.*i-o»a did, with wine or iriilt Injiior. I
iRVc licen occAitionnllj- ohli<{pd to trt'iktcnse;^ of thin kind as hospital ont-,
patients, and have Bometiines succeeded in obtniuing very successfal
results, even althoii^'h the suppurattnn was already exteusive and accoii:
paiiied by some hypopyon nnd iritis. In such eases I have alwaj
applied atropine, wami l^pjiy fooieii tut ions three or fimr tjroea daily, aud
a compreft* iiandaj^e, and performed parnceiiteflis (perhaps repeatedly)
when the liy|>opyoii had reached to more than one-fourth of the anterior
chiimher. I have »t the Hanio time pn!Ki;ri))eiI full d<>H^ of ifuininc antl
Ateel, combined perhaps with ammonia or mixed ftcid>t, and ordered a
good diet, and stimnliinta. ^M
]tut only absolute necessity should induce us bo treat siich eases t^H
out-patients, as the disease is of the ^rave^t nature, and detnnn>U the
frequent attention of the surgeon and tlie constant care of a good nurse.
1
nt- J
5— ULCERS OK THE CORNEA.
Ulcers of the cornea vary much in importance ai*d dan;;cr according
to their extent aud their sitnation ; in son>e cascii their coarse is acnte
aud rapid, tn others very chronic and protracted, obstinately defying,
almost every roaicdy. Tlie sujterriuia) are Ic(>» im|)oriant aud dani^croii
than the dcep-Acatud iilccrt. In the former, we should not ttwiude roe
abrituions of the epithelium such na tnay occur after sli;;ht injiirie* fro
foreign bo<Itcs, or from the burstiuf; of the vesicle in pidycti-nidar ror-
neitis. The term ulcer shouhl, I think, be confined to civacs in which
there is a breaking down and elimination of the affected corneal tissue
BO that there is a distinct loss of substance.
When speaking of phlyctenulse and the inflamnmtory infiltrations
the eoiTica. it wai' mentioned thai their conteniw often break down, soften,
and are thrown off, J^iving rise to an ulcer, which mny either remain
siifwrficial or ertteud somenliHt deeply into the corneal ti»3ue. But the
tendency to ulceration may also show iuwlf from tlio outset. Thon there
is noticed, near the centre of the marj^tn of the cornea, a small opacity,
the ed<;yt; of which are S4>mewhat irregular, swollen, and of a gray oolor,
which shades (iff tn a li-jbter tint towards the centre, so that the latte
may even seem ipiile tninspjireut. The ulcer, whose epithelial coverin,
is loiit, is surrounded by a Eone of gray and somewhat swollen cornea
it gradually assumes a more yellow tint, and extemis in depth and cir^
cnmlerence, its contents breaking down and Iteing cost off, so that it may
reach a con.iidcrahle ext**nt before its progress can be stopped. It i
often accompanied by sever* symptoms of irritation, groat photophobia
lachryraation, and c^diary nenmlgia. When the process of re|taravioa
Bets in, we notice that the efuthclial layer is; gradually formed, thin ropt-
1
ite
I
ir- '
ch J
in
le
^
I
I
ULCBftS OT TnS COBNEA.
151
rmtion comtoencing from the {wripkery. Then the ulcer i
tint aii>) is gnxlually Hllctl uyi hy new tirtAae, wKiiih may resemble very
greatly the normitl corneal tl^iic, ii1thou;;li the intercellular substance ib
apt to be not f|uite tnuwpnrent. thus givin;* rise to a certain aiitiMiiit of
opacitT. Sometimea the process of repair is extremely alow, ilikI many
tuonths «la[)«o before tlie ulcer is healed. As
soon as Uie lajpr of epithelium xn regenerated, (Fig. 37.)
the aymptoins of irritation, more especially the
p«tn iin<l phut4i[)li<)hia. rapidly 8ul>siilo. ItltKvd*
Te!^.^'14 (both Yonnuft and arterial'} appear upon
the cornea [i'ig. 37] and run towards the ulcer, ^^i^^^^VL«^B0^
bftsteiiinj; the procesa of reparation and absorp- '^S-ft^Js^S^P^S^
tion, and dwindling down and disappearing when
their U«k ia done. iSomclimes the reparative
fkroccaa is incomplete, and a more or Icioi deep, opaque doprcaaioo or
acet, of a somewhat cicatricial apj>earance, remains hehin'l.
We aomvtimea meet with a |>eculmr fonu of funnel-shaped ulcer, which
shows a very marked tenrlency to extend in depth and perforate the cor*
oea.ubHtinately and persistently resisting all and every kind of treatment
until perforation has taken place, when it at onco bej;in3 to heal.
Aiiollicr and ver_v dangerous form is the creacentic ulcer, which com-
mences near the edge of the cornea, and Imilu a.n if a little (virlion hud
been chipped out with the fin;;^r-nail. It AhowA a great (cndoney to
extend more and more rouml the edge of the cornea like a trench (in
which the coniea h much Uiinnod), until it may even encircle the whole
cornea. The vitality of the central ]>ortion is generally grfatly impaired,
ami it tiecomu^ more and more opHipiu, and shrivels up nniil it may look
like a yellow, dry, friable, or cheesy substance, portiorut of tlic surface
of which may be thrown ofl', or it may give way and a very extensive
rapture of the cornea take place. This croscentic ulcer is extremely
dangerous and intractable, reiiidtinj; often most obstinately every form of
treatment. In wimc cases great adiantjige has been derived from syn-
dcclomy, oith^r pjirtial, if the ulcer was but of slight extent ; or com-
plete, if a con^idernblt! portion of the coniea had become involved. In
other cases I have, however, seen it do but very little good. Iridectomy
ha* also been sometimes found of benefit, and should )>e preferred to
paracentesis. The patient should be placed upon a very nutriiious and
jTcncrous diet, and tonics, together perhaps with mixed acids, should be
adniinisterud.
Whilst thcKO different forms of corneal ulcer are always accompanied
by uiorc or le^ irritation and intlammation, there are some forms in wliich
the inflammatory symptoms are almost entirely absent ; they, indeed, in
their character and conrse may closely resemble the non-inflammatory
suppurative corneilis. We notice that the ulcer is white in color, and
clearly defined against t)ni transparent cornea, and not surrounded by a
eray* swollen aiiiio of demarcation. It la accompanied by very little, if
iiidectd any, photophobia, lachrymation, redness, or pain; there i« also
more tenilency to necrosis, una cxteiuioa in circumference than in the
other forms.
Ouo peculinr and very dangerous kind of non-inflammatory or indo-
152
BIBEASBS OF TUB CORN'EA.
:4
lent iitfcr is that which is often met with in very n«^d and decrepid it
dividuala, ami 19 geiierallv accompanied by lijiwpyon. In character it
closely reaeaiUes the non-iiiBaraniatory siippurativ*' comcilis, in foot tlie'J
latter vert frequently passes over inio this form of ulcer, more especi-
ally when it ha« hceu pmdiiciMi by .in acciiletit. ituch ait a forci;:ri) body.j
Like it, it commences with a f^rayiith-'W-hite intiltrfition, pcrh&pit in thoj
centre nl' the cornea, which soon passes over into an ulcer and extemli
very rnpidly in circumference and deplli, the afi'ected titisue hrciikingi
down and being oaat o(f until a lar^e slouching ulcer is the refiult. Whei
it has reached a certain depth it very freimently becomes complicat«H
with hypopyon, which may tie due t<» iritis, to iutlamnuitiou of the |iostP-4
rior layers of the cornea and prMliferatiou of tiic epiihclial cells, or to
perforation of the ulcer and a discliar^c of itt«eonlciitM into tlie anterior
chamber. One portion of the margin of the nicer \n swollen and of a
gray iish- white tint, this opacity assuming; sometimes a seniiliinar or crea-^^
centic form, and from it small striated opacities run deeply into thn cor<^H
ncal tisane. Tlie coniea m the viciuily of the ulcer is generally clear ^i
and traiiaparenl nr only faintly clouded. From the dangerous ciiaraetcr
of the diaease, and its tendency to spread. Prof. Saemisch projMises tOj
call it " ulcus ser}>en6 comeie."' Tlieru in a marked abaeuve of all in-
flammatory ttymptiimg, and in thiii consistit it«) chief danger, as it loads to
rapid and extcnsii-o slou;:liing of the cornea. In other cases there are^^
gri'at ciliary irritation and neunilgia, and in these there is generally »0^H
liyjMipyon (Saemiscli). "
Siunctimes we may observe a peculiar transparent ulcer of the cornea,
in which both the margin* ami the bottom of the uleer arc quite trans-
lucent, and free from any opaque halo ; there is also an absence of *•»»-
cularity. These ulcei-s are very intrarlalilu, and may persist for a loi
time. They niny, however, heal rapidly if a sufficient degree of vase
larity can be established.
The crMn[>lii:)itions to which ulccra of the comeii may give riw* ara
often very Hcrioiw, and may even prove deatnictive to the eye. If tho
ulcer is supei'ficial, of hut slight e.xtent, and occurs in a young health
subject, it may heal perfectly, and finally leave hardly any, if iiidoc
any opacity behind ; the cornea iu time regaining ita normal transparency.'
Indeed, even amiill perforating ulcere which have given rise to antonor
capisulnr catamct. luiLy gnidiudly disap|)ear without leaving aloMat any
trace beliind tiieni. I have not unfrvqucntly met with cases of central
capsular cataract in nid person whoso conu'a wtiA apparently clear, and
it waa not until it wan examined by a ml rung liglit or with the obli<|Ui
iUumiiiation, that a i^mall opacity of the cornea could be detecbed jus
opposite the centre of the lens ; then, on inquiry, it wa<t perhaps asao
tainud that the patient bad as a child suSered from iuHaramation of tlie
eye.
When the ulcer has extended very deeply into the cornea, nearly as
far us the posterior elaKlic lamina (mcmbrime of I>ascomot), the lattnr
may yield before the intra-oeular prrssure ami bulgo forward, looking.
al
I
' ViAm a verjr iiila^rMliiig brmchiire, tir I'rnf'.utRnr RAvmlKli, " Das (ilous
S*r|njnji," uiul »viii0 TlicMpiu. Bwnii, Mux Coltwi, 1670.
ULOBRS or TUB OORNBA.
153
tbe
tlQI
like a aauiW traa^parcnt vehicle at the liottoin fif the ulcer. ThU condi-
tion lias been termed hernia of the comca, or " koratocclo.'* It tlie mom*
bntno of Dbdccuwt he vcrv tongh and elastic, it niay ]irotnide even he-
ymii) thu lerol of the cnniva, and thti.^ iirodnce a trnnuparent, prominent
veMcle, like a tear drop. This generally ttoon tmraU, and jjtvcs rii^e to
%n ulcer, nr a [i^tuloiia npeiiinir may it'mnin, and prove very iiitracUihle;
but it may e^'al for weeks or even motith:*, wlicn it f;ra<1ually 1>ocomes
thicker, flatter, more opai|uc, ami clvanued into a kind of cicati-iciat tis-
ane. U was generally anpiiosed lliat the walU of this veaiele consist
only of the mt;riibrauo of DeMemet pushed fumanj bv tii« n<pi^ous
hiiiiior. but Sti.-llwa}; stutett that they also always inulmio Homc of the
deepMt layer* of iho cnmca, traccii of which may even be found at the
nd(H of the resides, and sometimes uUo at the apex.
Tlie chief danger of the ulcers, apart from the dense opacities vrhieh
they may leave behind, la to be foxind in their perforating the cornea,
ancl the degree of this danger varies witit tlie extent and siiuatiou of tlio
|K.'rforalion.
If the perforation is but small, the iris will fall against it when th«
ueoiH huuior fluwH oFI', widiout pnttrmliiig through it; plastic lymph
ill be cS'ujed at tbe bouom of the ulcer and thi4 may at once commence
to heal, the ins becoming nliglitly glued ugainst tlie cornea. The at|ue-
nufi humor reaccunmlates, ami if the adhesion between tbe iris and cor-
nea i* but very Hlight, it will yield before the pressure of (lie fti|ueoug,
and the iris be iiberatc<l and fall back to its normal plane. 'I*he miiptcular
tion of the sphincter and dilatator of the pupil during the aetion of the
{nl will also assist in breaking through the adhesion, but if the tattor
at all considerable and firm, the iris will remain adherent to the cor-
nea, and a more or less extensive anterior synechia he formed. If the
nerfonilion is large, aa it must be if the irits falls
into it and protrudes tbrongb it [Kig. SS], tins
protrusion may gain a considerable size by tlic
collection of aijueous humor lH*bin<l it, which
causes it gradually to distend and bulge more and
more. The color of the prolnjise is soon elumgcd
from black to a dirty, dusky gray tint, and its
base is surrounded by a none of opiuine curnea.
Tbe portion of proiniding iris which lies against
the edgi^s of die ulcer, generally becomes nnit«<l
the latter by an eflnsiou of plastic lymph, tbe
jneoiis humor is again retnineil. and the niiterior chamber re-estnblisbedf
Vitb the esccplion of ibe portion in tbe vicinity of the prolapse, for here
the iris is lif'leil away from tbe anterior surface of the len*, and n more
less considerable posterior cbwmber is formed. Tbe pupil is distorted
1 dragged towards the perforation, and tlie extent of this distortiou
varies witli the *he and situation of the pndntMC. If a ]H)rtion of tlio
pQpil is included in the prolaj>s«, it will be irregularly displaced and
draggc<l towunls tbe latU'r, »n<i diminished in size correspondingly to the
amount of tbe pupil which is involved. When the whole pupil is in-
cluded, the iris will he tensely stretclictl towards the perforation : if the
latter is considerable in site, and the a«|ueoua humor has gushed forth
tFig. S9.
After Killer]
154
DI88A8B8 OF TBB CORNBA,
irith much force, the len», nnil even some of tlic vttraoiia humor, maybe
lost. If the prolapse is smikW and scon shortly after it has taken place,
it may often W replaced uudei' judicioua Ircatmvrit. uttd the ulcer p«r-
h&ps heal without even an anterior syiiechin remaining iH-himi, but if it
19 conaideraWe in size the result will be much less favorable, for tlic pro-
trudin;^ |iortioit of inn, exposed to the action of external irrituntd, e. ff.,
tlic air, movements of the U<U, etc., becomes inflamed and covcreil by A
Uiin f;rayisb-wbit« layer of exudation, which gradually becomes thicker
nnd mure orgmiixed, and assumes a cicatrical texture. Now, if this
cicatricial covering and tlio adhesions of ihe iris lo the edgea of tlic nicer
are not sufficiently strong to withritund the intra-oculai- pressure, tite pro-
lapse will gradually increase in size, and the surrounding fiortions of the
cornea will aUo Imlge more and more, until an e-Ttvusive staphyloma m&j
be produced. If the cornea is perforat-ed at several points, through whic
small portions of iris protrude, it is termed " fjtaphyloma racemosum.'
If the perforation is very small, and situated at or near the centre
the cornea, capsular cataract may be produced in the manner alread]
descriWd. Again, the suddeu escape of the ai^ueowi humor, and falltngl
forward of the lens, may cau<:<c a rupture of the ca[>sulo, and thus give
rise to lenticular cataract.
Willi regard to the trealroent of ulcers of the coniea, we must be chiefly
guided by tlie amount of inHammation which is preHcnt. Whit.H wo
endeavor to check an undue decree of inflammntion, we mudt be on our
guanl not to subdue it too much, as this would favor the tendency to
nei-rosis, and pmtrnct the process of reparation. In tlie progresaive
fltagc of an acute iuHammatory ulcer, the patient should be kept in a
mmcwhat darkened, but wcll-rcntilateii room, and ho guarded Dgaii
Uie effects of bright light.cold wind, and other external irribints. It m&l
be nccoss.'iry to aduiimster a brisk purgative au<l saline diuretics, togcthf
with a light, non^timulating diet, if then- aw marked inHninnutory srinf
tom!» and the patient is of a «tron;c, plethoric habit. Hut we must
u|Hm our guard not to prescribe this kind of Ireatinerit in all cases, fo
very fre<|uent!y ulcers of the coruea occur in persons of delicato, feeble
beaith, and then it would prove injudicious and injurious, for it would
iooreaac the tendency to necrosis, and retard tlic filling up of the ulcer.
In such cases, the patient shouhl bo placed on louics, aifl a very nutri-
tions diet. When the pn>cess of repair has set in, ho should he permit-,
ted to get into thci o])en air, indeed this is especially indicated if the difl^B
ease shows a tendency to become indolent and chronic. Much bene&V^
Is then osperiencod from out-of>tloor exercise, and a residonee in the
country or at the sea side.
The object of our local treatment must be to eiHleavor to diminish
mnrked symptoms of intlammatory irriintion, to stop the progress of the
ulcer, and to hasten its repair and the absorption of the morbid products.
If there is ranch injeotion, pliotnpbobia, lachrymation, and ciliary neu-
ralgia .'itn'pine should hv dropped into the eye, the compound belladonna
ointment should be ruhlied over the ftirvhead, and |KTha|i8 a blister ap-
plicNl behind the ear. If the pntn in and around the eye is very great,
aud enfivcially if tbe latter is very tender to the touch, two or three
leeches should be applied to the temple. Much relief will also be exp^
5
ULCSRS OP TUK CORNEA — TRIfATUe»T.
155
ricnccJ from Uie subcutaneous injectioti of murphin. A great amount
of miM:hi«f » liiit too often cauftOfI hy tin- ime of stroog caustic or astrin-
gent lotioim, (Inrine the acute, progressive stngc of tlic ulceration. Not
only do thfv greatly nu^^munt llic irritation, but tliey inorea^ the tcmlcncy
to neenwi-* ami pxtonsion of the nicer. It is only in the chronic, torpi.1
ulcer wliicli li»s nlrea'ly Iwcouio covered by epitheliuin, that caustics are
at all applicable, iind even then they must be u^ted with great caution and
circuuiHppction. In the chronic, indolent, non-iuHammatory nicer we must
apply atropine^ a comprci4r) biimln^i^e, and above all, irarm fomentationB,
in order to excite a certain de«rrce nf inflammatory awellinf^ ; or the
yellow oxide of luerciiry ointment may be employed, for this rem<'dy
lia^teni the proce»3 of ali^nrption and tendi< to prcveut ndap^ei^. The
pntieni'fl health must be ifivi;»oratcd by tonics, a generous diet, and
stimulantv : indeed the same lino of local and general treatment must be
wioptod a» in noo-inflammaiory suppurative corneitis. We must never
for^jet to .i]iply a couiproaa baud<igo over the eye, in order not only to
L^guanl it a;^iiin»t external irritanut. hut to riupport the thinned uleorated
'iportion of lJ»e cornea a^jainst the intra-oculitr pre.*siirc. and to prevent
the constant movements of the cyelid.'>, which greatly impede the forma-
tion nf an epithelial covering over the ulcer ; which, at* wo have 8con,
fonns the commencemcitt of the retrogressive arkd reparflCive «tage. If
the nlioto[ihobia \» very intense and obstinate, and the tirm prc»8iire of
the lids prevents the procerw of rajwiration in the ulcer, much benefit is
e3Cp*'rifriccd fmiTi the division of the outer cantha'^, as recoTnmende<l by
Mr. I'aricr.' which speedily relieveii the photopliobia and greatly accele-
rates tlie healing of the ulcer.
In all utcera of the cornea, but more capecially in tliose wbieb extend
deeply into its substance, the process of repair is greatly rctanlcd by
the bijih amount of iritra-ocidar pressure, which the thinned portion of
the cornea at the bottom of the ulcer has to bear. In come<|nenue of
thia, the tattt-r is very apt either to give way completely, and t^ per-
forale; or else it yicldi somewhat before the lutra-ocular pressure,
bulges forwanb, slougha, and is partly thrown olT, and thus the process
of repair iii mucli impelled. Now we p03«e*8 three principal means of
dimini!>liing tlie inlri-neular prc»«ure, vIk., atropine, |):irat>eiitei«i>4. and
iridectomy. The henc-Rciftl action of atropine, both a-i a direct sedative
and ill redueio" the intra-Qcular tension, has been already o^cplaiucd.
In very olifiiniaie and chronic ulceration nf the cornea in which iJie
corneal va<cuUrixatton ia either absent or very deficient, and in which
there is much lux swelling of the conjunctiva especially at the retro-
tnntal foht, [>r. llo:K':h .ttron^ly adviiea the application of pure nitrate of
silver to the retro-tan*al fold. It mual, however, be only applied to a
narrow rim of the latter hy meam* of a finely-pointed crayon of nitrate
of silver, and at once neutralized by italt and water. It $liould not ho
re-applied until the eschar h entirLdy removed.'
If the ulcer has extended nn deeply into the substance of the eomen
as to threaten perforation, no time should be lodt in performing para-
* "Prnotll(aN«>r,'*/«Dii«i7, 1S49.
> •■ Kl. MobJttaU./- 1S72. p. 321 : alao Otmofe, "A. t 0.,'* vl. S, 16S.
15Q
DISBASBS OF TUB COBNBA.
centusis at the bottom of the ulcer; by so doing, vc flhall he nble to
limit the jwrforaiion to a very small extent; for if wc permit the apon-
taoeoiM perforation of the ulcor, we fiud thnt before tliU occurs the
bottom of the ulcer exiemls somewhat in circumference, ami thus a con-
siderable ragged opening may rcmiU, and the latter will certainly be
much hir^ier thiiii if it hiul simply been mmlu with a fine uucdle. More-
over, tlu- L'-Viipe of the rti[iicous humor will, in the former camc, he more
Buihluii ami foreil'le, which b> apt to pnxiuce confide rtib I e hyperaemia ex
mcu'i of the deeper tuuica of the eyeball ; prolapse of the irii^, which
may lead to suppurative iritis or irido-cboroiditis ; or rupture nf the
capsule, »ud con8C(|Ucut cataract ; or, a<;ain, the suspcuiiory lij^amenl of
the lens may he torn, and the lens partially dislocated. The poraccu-
iCMi should not he |M3!it[?<Miod until the dee|>edt layers of the cornea are
implicated, for we tlirn run the risk of a lar^e a|K>utJinoou3 (terforatioi)
occurring before we liave time to interfere. The puncture should \k
made with a fine aecdle at tbc deepest portion of the ulcer, and the
aqneons hmnor allowed to flow oB* as gently as possible. The iri« will
gradually move forward, aud come in contact with the buck of tbe
oorneii; a tliin layer of lymph will be effused at the bottom of the ulcer,
tinilor which the ro{;eneratton of the corneal tissue will take place, the
iri« being geuerallv muru or Ittas glued to the p'.-rforation hy the efluaion
of lympl). An doim ais the opening is AlfipfH^d by cliia plug of lymph,
the ai|uoous humor will re-nccuuudatc, and, if tbc ailhcsion Iretwecn the
iria and cornea is but ^liglit, it will readily yield t», and he t^>ni away
by, the force of t!ie lupieous liuinor and the action of the musclei* of the
iria. Dui, if the layer of lymph at the bottom of the ulcer is thin aud
weak, the force of the inira-ocniar pressure may rupture it, or may
t;ause it to bulge forward, and Ihm ncc«a»itate ft repetition of the para.
ceutcsis. Tlio latt4>r should
[Fig. 39, alito be repeated, perhapa
even aeveral tinie», if we
notice that the process of re-
pair becomes arrested, stid
that the ulcer again shows a
tendency to increase in dcptli.
After the operation, a com-
press banilage should lie aj>-
jtlied. If the ulcer is exten-
sive, and if hypopyon or iritis
cooxiat, the puncture sliould
V made witli a broad needle
at tlie edge of the cornea
[Fig. 3'J], or an iridectomy
shoidd bo subsliluted. The
indications which should guide
tt« ill selecting between these two ojierationa Imve already been con-
sidered in the article upon suppurative coraeitia.
In the indolent hyjiopyou ulcer (ulcus serjiens of Sacmi*eh), described
at p. I't'J, a vast tiumbvr of remedies have hoen tried, of uhicli the most
successful have been warm fomentations, paracentesis, aud iridectomy,
AfWr Brtehwin.]
DLCBKS OP TBB CORNBA — TRBATUBNT.
isr
togetluT with tonics nnd a ([cnoroiis diet. Tt mufit, liowev«r. lie cnn-
fetMid tlmt tfiiali suceem has Wvn but limited, more especially ivhen the
nicer wns extensive?, rapidly aprciulitijr, and accompfinied by a consider-
nhU* hypi>[>yon. yaemiwh liua lately devised the followin;^ ofteratioii
for the pur|>oi*e of liividiuf^ tbe base of the ulcer and mainlaiiiiiid a
diminution of ibe intra-ocular tension for some length of time, so tbat
the pro;;regs of tbe disease may be nrrexted, and tbe process nf repair
nccelorate*). Wim resnil* have been very favoraSIc, for out of 'AH cases
in whicb tbe yp^ratiwn waa performed, the prflgrew of the affection wag
once arresied iu H4. The amount rif pi<;bt wbicb was saved varied,
coarse, accordin;^ to the circnnistAnces of the case. Tlie eyelids being
lopt apart witli tbe stop-Hpeculum. and the eyeball fixed with s ]mir of
forcc{M, a puncture is mad« with Von 1_>niefi^'3 narrow cataract knife at
tbe ti'inpfTftl aide of the ulcer in the hrahht/ jiortion of cornea, ahont
1 mm. from tlic mnrjrin of tbe ulcer. The point of the knife having
eiit<'red the anterior cbinnber, tbe Wade is to !«■ carried tbnmgb ibe
chanilier behind the bottom of the ulcer ( towanU tlie bottom of which
the e<lge i^ to Ih! turned), and the coniitur-puncturc made at a point
corrofl|)ondinp; to tbe puncture, and likewise situated in the heattliy
coniea. slightly beyond the margin of tlie ulcer. The fixing forceps are
now laid a^ide, and then, m'ith a alight savring movement, tbe knife is to
cut ita way out through the ulcer, the blade being Bcveral times turned
a little on its axia, so that tlio anueoim humor may How ofi' very gently
beside the blade. The last fiortion of the cornea sboidd be divided aa
slowly and gently as possible. If there in any liypiipyon, it generally
wc»[>cs througli ttiB incioion. A light comprcsw is to be applied, and
within an hour or two the wound is generally already closed, and then
Mrnpine should be useil. Tbe wound is to be opened twice <laily for the
firat few dftvs with a prob*. or, sill! better, with Weber's beak-|)ointed
canaliculus Knife, the blunt |ioint of which is to be inserted between tlie
lipd of the incision ; hut caro must be taken that this is delicately done,
so that the aqueous humor Hows oflT rerv gently. The wound must be
re-op«ned ererv dav until the process ol* repair has become thoruughly
estnididicd, which is known by the fact that tbe opaque and swollen
mardn becomes narrower and narrower, breaks up iuto punctated or
faintly striated opacities, until it finally disappears altogether, and then
the incision may be allowed lo close. This geaerally occurs at al>out
the second or third week. When the symptoms of irritation have sub-
sided, tlio red precipitate ointment may be npplied to accelerate the heal-
ing of the ulcer and the absorption of the opacity. [Continued experi-
ence with Saenii'^ch'tj uielhod of treating the serpiginous corneal ulcer
has not been very satisfactory, at least among ophthalmic surgeons in
the United States. Though the operation is very generally practised,
more reliance is placed on the local application of beat, and tbe
>iig tonic and titimulating general ti-eatmeut. — B.]
In cases of obstinate ulceration of the coniea, confined ebieHy or en-
tirely to one portion of the latter, nuich benefit is sometimes derived
from syndectoiiiy of the corrc^fKinding segment of the sclerotic ; so that
the blood supply of the affected portion of the cornea may be more or
less cut off. In obsttiuite, chroutc, vascular ulcers of the cornea, which
158 DISBABK8 OF TIIB CORNBA.
bare long resisted crery form of treatnient, and show a grcnC tcndcnrjr
to recur» the lUiserLion of a aeton at \h& lomple often renders tlie most
marked and striking benefit, the diEeaae bein<^ rapidly ciirc^l, and tlie
rclttiHes prevented, if the geton is worn for some time after the corneal
ulcer is liyftled.
Indolent Jfi/pop^ftn U^cer. — Operative interference is, however, only
indicated iti the more advanced and graver cases, wht>n the ulcer is
cuii:>iderabl« in cxtiMit, ltd Lottom and ed;;o8 iniiUrnted witli pus, and tlie
hyjwpyon large. In such cases cither a large iridectomy, or Saemiitch's
operation' should be performed ; on the whole 1 have found Cbe former
IDC more sncceaaful proceedin<^ of the two, although thi^ may to some
extent ho due to the fact t-hat I was not always able to insure the in-
cit^iiiu hciiig kept properly open for a suflicieut k-ngth of time. In tlie
milder cases, and duriiif; the earlier ata;:e^, wlien the nicer ia of a pniy-
iflh-white tint, not considerable in depth or trcadtb, accompanied by but
a siiuill hypopynii, a compress bandajiu, atropino, and warm fonientaiions
will suffice. The ]ialients are gem-rally in fcclile health, and should^
therefore mostly be put ujion a good diet, with »timulantt), and toniof^l
should be prescribed. Occasionally I have been obligcil to treat pcr-^
aouii suUering even severe forms of the disease as out- patten t-«, and I
have been surprised to gee Boraetiracs very unfavorable cases recover
under the above treatment, and without an operation. A very intcreai-^J
inf^ and valuable account of the patholo^jy and the treatment adopted i<^|
Professor Homer's prnuticc will be found in Mail. Boliowa's brochure"
on "Ilyiiopyon Keratitis."* Out of 224 ca*cs, \\6 were cured with-
out operation, lie has also found iri<Ieclomy more successful than
H.iemisch's operation; he, however, does not opi^rato in the milder cases,
whereas Saemisch operates even in such, which would probably do well
williout any operation at all.
Wo are espc^cially indebted to Mr. Critchett for introducing this mode
of troatmeni* in certain cuscs of chronic vascular ulcers of the cornea.
which arc particularly characterized by their protracted courae. their
great tendency to recur, and the oUtinacy witli which they resist all
I Alfrvd Uriicfe Tii-utniu«n4l tlinl in Sju-iultoli'* opi-ntlidii 111? fiidaiuu ftVinld uc4
he tn\A*- tlirnii|;li lln- uUvr it»i-U, lint vi<M<- !■■ it--* innr^iii in tli>' lu-ftUhj )'r>rn(-ii, fia ,
to cul off lht> Huiiiiil fruin tlio dinciist"! |iiirttc>ti. " K1. Moiinut)!.," 1S72, |i. IT'l.
• Profwutor lltti-iuT iK-lifViii llibt pun (-(iniU't niiik flown ln-Ivtrcli the latnollie of tl
CiirniM, UTiA lh.it thf* rAii only mT-iit U-lwitin lln' rnnn-it ]irn|>i-r nn'l tli« iiwiiilTiiiii* of
Dtwcvtnet. Ilu in, ui-orrstv^r, at opitiign lli.tt llii* |itirii1i>iil di-|x»it in caara of hj^'>]f'
l^CVt.-VLllPK. Iin «ll, UJUrv^lvri'T I'l UpiiJIVfl 1fL.'\l lit*" |llll'lll1*ail i4(*|K«lL in (^KTll <ri ujl^'tl* I
Wtirm-n the lami-llir nf llm n>mt-A, U ininlt/ r>-Allr nitiiAliMl in thr- jinl<TiAr i-liiu»lMi^H
yn>ui ill bring luii|;h aud It-niiciiitiii it. mllii-m Dnuly to llii^ nn-mltniiif <>r Urwrnirl^^n
Uid If it btf incouiiiil^TAUi; in i|uikntti.v, n upaw i» left lii-ln>-t'ii !i and ihv iri*. thus
c-Aiining it oloacl.v Xit ri-.i<-uiM<- iin nnvx : \\i\* littli- inti-r^pAC" i^ only fllini up vrlii.-D
Itui luirulont (ti-poafi b>T»iiieii uuuv aiiinidrnibli*, snil tlii>n iirmJno-a a, urll-ioHtkot
ltyi>ij|iyou. Vide ■' Hyyufiyou Kunitiii*," liy Ma<l. Warir HukuWR. ZutioL, ls71.
KUrctK'T .tml Furrer.
llurm-r t» uf ui>iiiiuu tliiti tli« h.vpu^iyun u uftun <luv lo i dlrvL-t iiii|[Tatl»n of cMt
from tlio UHtnin of ih.* tilicr into the nntcrior chmntwr : ihp ^plthfllal layt-r of
lupmbrnnfl of l>i-»(N-ini-l ( luidtillml) plajrintf Itnrn «nlj- n pauirL- |tnrl. TLU utnit
Im>oii Hub«t«n(ial<:>l l>t fX|i>.'riin*'iit« on rslAiito, nKv, (luo. dt.)-
* Mr. i*i>^ni-rr Watmm linn nUo piiblinlicd nnmc nbU' ]>iip(-rB upon ibU silbjuct Ib '
■■K. I» U. H. I{<-p. ' unil in tin; ■'HuhIIcjiI Mirror."
UI.0BR6 OP THB CORNBA — TRBATMBNT.
laO
I
(inlmsry methods of trvatniunt. Mr. Crilchett has favored me with Uie
following ilescription of the manner iti which the setoii is to be a|i[>l)eJ:—
"I getifralty use mthor stout silk or line twine, such att a large
suture needle will carry. I select a spot near the temporal region
wxlcr the hair, so &» to avoid as far as po^iblc a vigiUe »car. Care
ia rciinircd not to wound the temixtral artery ; thin piay generally bo
avoided I-jv drawing the flkin well awar from the temporal faseia, hoMtrtg
it firmly by the hair. The needle id thus pas&ed through at a loveU
anterior to the artery ; about an inch ia usually included, and a loose
loop 19 formed, which may he placed Whind the i-ar ; it re<:jnire« to he
dn.*i<'»cd and moved daily ; it usually uoiitinne» to di^harj^e for two or
three months, and then either cuta ittt way through, or dries up. In
•CTere and ohstioate cases, where it ia necewary, it may be renewed,
selectiu]^ a spot near to the previous scar. 1 have aomeUroes found it
dciirable to continue tho inflttencc of A xoton for twelve months. There
are certain inconveniences that occasionally arwc to which I may brieJly
allude. It will sometimes hapfjcn that in spit^; of every care and pre-
caution a branch of Die temporal artery i» pricked by the point of the
needle as it traverses the .^kin ; thia accident is at once recognized by
dur rapid outflow of arterial blood from one or both openings, tlirough
which the silk pluses. In the event of such an accident, it ts better at
once to remove the tiilk, and then moderate pressure checlu the bleeding,
arul ilk a few davfi a neighltoring apot may be selected for the reiniro.
doction of the silk ; but if this precaution be not taken, and if an effort
be made to retain the seton in spite of the liemnrrlmj^e, there is n great
liability to secomlary bleeding, to extravasation of blood beneath tlie
•ealp, burrowing abscesi^ca, and other untoward casualties, and in one
itiKtance 1 observed the formation of a small traumatic aneurism. In
certain exceptional cases the intnKluction of the seton is followed by con-
atderatile swelling of the surrounding parts, with a tendency to erysipelas.
d suppurative intlammatton cannot be eatablisltcd. As soon as tJicse
lymptoins show themselves tlie silk should be removed."
If an nicer is situated at or near the centre of the cornea, attd per-
foration appears inevitable, the pupil must be kept widely dilated with
atropine, in order thnt. when the coniea gives way anil the aqueous
hninor escapes, the edge of the pupil may not bo involved in the per-
furattnn. On the other hand, if tho ulcer is situated near tlie margin of
the cornea, the reverse is indicated, and the pupil should be allowed to
remain undilated, or even stimulated to extreme contraction, by the ap-
plication of the extract of the Calabar bean [or, better, a solution of iJie
Iphfttt! of eserinc, gr. ij ad aj «<(. dest. — li.], in order to renuive the
Ige of the pupil as far lu; [lo.'t.fihle from the e;)tuatiun of the threatening
[K'rToraiion. Kitherof these remedies is also indicatt'd when a cdight
adhfuiun exists lietween the cornea and iris (anterior synechia), for, by
the strong action of the muscles of the iris which tJiey produce, the au-
besion may be forcibly torn tUruugh. Mr, Pridgin Tealc informs me
UiaL he hari often derived much benefit from dividing anterior eynechira.
This is done Iwth with the view of causing a diminution of the conieal
opacity, at the site of adhesion, and of releasing the iris from its drag.
[Ttua ie a rery useful procedure in many oaaes, and uhanges a
A
160
DtSBASKS OF TIIK COKNEA.
** leucoma AclhasrcDg" iuto a ftiniple Icucoma. It c&n be done hi almo
all ctAba nf nli^ht anlortnr itviiucliifc, liy a simple iip)ilicalioiL of the
varioiM atcpit employed in Pniisavant'A operAtioti for die liiviAton of poA-
teriur syiiechiie. A small linear iiiciision is made io the ooruea, u«ar
the nmrg;in, ami then tlie adhesion of the iris to the cornea ilivtiled hj
the cutting book of Pasaavantf or torn airav from its attaclnDeot bra
pair of tk'licatc iris force]«. The division of theae adhesions in a case
of opacity of the cornea, often renders a Aubsetjuent iridotoiuy or irideo-
toiuy miieli slmplcr.^ — B.]
If a Alight prolap.<u; hafl occnrred, wc miuit »t once attempt to repl
it bj preasin^r it gentlv back 'with a spatula or prolie, or wc may eiidtra-
vor to cause it to recede by widely dilating the pupil by atropine. A
firm compress should be applied in all cases of prolapse, for it will fa*'<>r
the consolidation of the wound by the formation of a layer of lymph over
the prolapse, and will prevent the latter from yielding toilie inira-ocuiar
|ire&«nre and incrcaeing in e'lte. The protrui^ng jiortiou of iris should
aUo lie pricked nith a fine needle, and the ai(Ufou» humor be allowed to
escape ; for this will cause tlic prolapjte to ithrink and gradaally dwindle
down. This operation may be repeated several times, and ^icncrallv
with the be-tt rBSults; but if the prolapse ia large and prominent, ii
should 1)0 first pricked witli tlie needle, and then,wlien the escape of the
aqueoiui humor baa caused it to collapse, it should be seized with thu
indectomy forecpe, and snipped off with a pair of curved actssora qnibe
close to the cornea, a firm compress being at once applied. The same
treatment is to be pursued in staphyloma iridis.
Some surgeons recommend that the prolapse should be touched wttli ft
point of nitratu of ailver, or with a littie vinum opii ; but this is apt to
set u]i great irritation, and may even produce severe iritis. If it be
done at all, a weak solution of nitrate of silver should be lightly applied
to the apex of tlie prolapse, with a tine camel's hair brush, in a con-
siderable and obstinate prolapse, much benefit is genorallr derived from
making a large iridectomy in an opposite direction, for this will often
cause the prolapse to recede and fiatten. This operation is likewise in-
dicated wheu tlie pupil is partly or wholly implicated in the prolapse
anterior synechia ; also, when there ia a |>artial stajihrloma, and, abo
all, when this is accompanied by an increase in the intraocular tcnaioi
For, as has been pointed out by Von (iraefe, in cases of partial or co
plcte iitaphyltmui, or of lenooma prominens. the degree of blindnese is
fretiuently quite disproportionate to the optical condition. In such cases,
tiicre is often contraction of the risual held, eccentric fixation, increase
in the intra-orular tension, and excavation of the optic ner^"e. When
glaucomatous symjttoms supervene u|M>n partial staphyloma or leucuma
prominens, we fand the conien becomes at iliix fKiint markedly prominent,
even after it has already become thiekoned and con-tottdated.
M^atula vf the cornea often proves verv obstinate and intractable, and
even dangerotis to the eye, leading perhaps finally to irido-choroiditis
and atropliy of the eyeball. A fistulous opening ol the cornea may nf*
suit in consequence of a smalt perforating ulcer, or from a wound of the
cornea, with or without injury to the lens. The fistulous opening may
become temporarily elo4ed, so that the aqueous humor re-accumulates,
a««
I.... 1
in-
I
DIVPUSS KBBATITIS.
16!
but after a eluirt int«rva) it a^Ail) givos way, tlie aqueous Rows olT. anil
the anterior chiirnber is oblitcmtvd. This ntay occur over and over
aj^ain. When fistula oftliu coriit-a exists, tlie eye remains irritablo and
injrctrd, the intra-<K:tilar tt^niiiioD u greatly ditninislicd, the anterior
clinitil'cr 'ililitcmtvd, and a suuill <lrop of l]uid may be ttotic-ed exuding
liinpugli tilt; ajiertiire in the conica. Various tniKle* of tri'atnient have
bceu advocated. At the outlet, a finn Ci>rn|irvss lmndii;re uhould be
apfiliod. 113 well RR a stron;; sululiou of aU'Opiiic, and if thtt< failn to Ileal
liie fistida, the latt«r uuiy he touubod wittt thti [Miitit of a fine ciunel's.
I ' -ii iliji|i<.'d it) a, weak swlutioii of nitrate of silver, this buiiij^ re-
I ••vvra\ tiiiiet> iit an iniorval uf a day or two. 'I'Un di^idvnnta^
of tliifi mode of trr-alnient 19, liowcvep, that it often ]>roduci*8 an indelihle
ekatrix. An iridccloniy frequently proves of more aer\ico. Wecker'
cDDsidcn that the fiiitula id due to an cveraion of the uicnibranc of Dca-
ccmet at this point, and had tlicrcforc devised the following treatment.
Ill' tntroilticcft into the o))eninf; a very fine, smooth pointed, xtraJ^ht itair
itf forcc[w, and. neizin;; the w:ill of the fintulfius track, bniises its liiniix.
ani] tbuti denude.H the uorneal tissue. This havin;;; been done iit ^several
potntH. atropine and a cnmprcst) b:ind:i;;e muHt Iki applied, (jruat care
ant] dcHcocy are rcnuired not t« rupture tin- caprtule with tlie point ol
tliir forceps. He haii thus cured 11 eitse of fislula of the cornea, which
hail nv-tiiited for u-n montlis different modes of treatment, /jebendei' ha^
found the prolon^^ed u^e uf th4 extract of Calabar bean of grvHt donice
in onriag a corneal ii»tula.
6 DIKFrSE C'ORNKITIS ( PAREXCHYHATOUS,
INTERSTITIAL. SYPIHI.rnC). [KKKATITIS.]
Iti this diseaw we may also diMiuguish two principal forms. The one
ill aoctmi|ianied by miirke^l dynifitums of Jiiflatnnmtioii. and is hence
Called "diffuse vascular conieiti'*." In the other, or " non-va*cidar"
ronn, these Avoiptoius are entirely nt»cnt.
1, In the riiK'ufar ififfiiMf I'lirnettin we notice, to^iether with a certain
varying de^^ree of conjunctival and subconjuuctivid injection, a xone of
resseU {la^Mnf!; from (lie mar<;iii nf the cornea more or lod^ towards Uie
'CMitro, where they tenuinate in a sharply defined line. Tocy are not
situated on the suHnue of the cornea, a» those in pannna, but enter
deeply into ii£ 5ubMtance. ITiey consist in part of ve^els derived from
llic junction of the conjunctival and subconjunttivul vcs^U near the
larjiiin >'( the cnmoa, and in part al^> of branches coming from the
blo(HlvC3ittdi' of the olUfLry body. S'^nietimcit the vascutiirity at the ed^e
of the cornea is no great, that it looks like a bri<;ht red lotie uf extravu-
BMCil blood. Soon there \n notict'd at one or more f*ointd, a ftUj^ht
ttpaoity of the cornea, which generally commences at tlie margin where
i V itt greatest, and ;;rTidually shades ofl' towai^h^ the centre into
[ . r lit cornea. Sometimea. however, the opacity begins at the
oenuref whence it slowly extends towards the periphery. The cloudiness
1 ** Anaaltf tl'OouliNUquH." toI. Ivi. Mfi.
11
t •■KI.Hon&tHbl." lS6d, 31
1G2
niSBASBS OF TUB CORNEA.
gradualljT inorenseti in extent anrl Uiicknetti*, until die wliolo aurfiicc of
die cornea may bccrtmo fiiffusely ftimijuf. The density and color of the
opacity vary a good ikal. Tbus, U mny be but thin, and of a grayUh-
vf liite color, having very much the appearance of fro»t«d gla38, or it may
he thicker and of a yellowish creamy tint, more esptrciatty in the centr«
of the cornea. Indeed, at this point we not unfreqiiently sou a lar^e
circular patcli of a pale yellow color, which is evidently deeply Mat
in the Biibtttaiice of llic cornea. Tliis central patch may ^iu a coiuid-
crahlc aiso, even of two or three lines iu diameter. Sometimes acrcral
such denser patches may he noticed nt different pointo. The epithelial
layer nt first retain*; it» tiormal smiiolhn(.>38, hnt after a time it bccora
gcmewhai rough imd thickened, as if it ha^l heen lightly pricked by a
pin, or a fine powder lijtd been strewn over it. The disease shows very
little tendency to nlcerntiou or to purulent necrosis, unle.'<8 it has been
very injudicioiuly trented by caustics or stront; astringent collyria. But
the whole surface of the cornea may he awollcn and hecoiae Aooiewliai
prominent, yielding here and there to the intra-ocular pressure and bulg-
ing forward, ttencrally tliese prominences disapfwiir with infiltration,
hut if they have In-en considerable, they may leave l>ehind some itiiftair'
inent of the true curvature of the cornea. 'Hie amount of intlamniation
and ciliary irritation vary very much. Sometimes, there is very consid-
erable una obstinately persistent photophobia, together with lachrymation
and a certain degree of ciliary neuralgia. In other cases, these symp-
toms never n^i^nmu any jdirticulnr prominence. The sight is alway
greatly impnired. so tl'iat the patient can hardly see a hand moving,
which is duo to the difTuRO character of the opacity, for it ia as if he
were looking through a piece of grontid glaw. If both oyc» t»ecome
affected, which is geuerally the case, the cilect of this total luca <^ righ
is most deprei^sing, and demands the greatest confidence in the su
to prevent the patient from seeking other and perhaps injudicious advi
For the dii^ea^e iniiis n motit t^hiw and prciiracted course ; months and
months elapse before any, even slight, improvement begins to show itselfj
and during all tliii^ time no treatment appears of any special service.
Wo can but let tlie disease run it^ course, and endeavor to guide it in its
progress. It may take from six to eight weeks until it has reached its
acme ; the cornea being then, perhaps, almost covered with eloseljr
crowded bloodvessels, which reach nearly up to it3 rcry centre, where iS'
seen a thick yellow infiltration. Tlie red appearance of the cornea
ofYen incrouiwd by small exlrav'osationrt of blood, caused by the givio';
way of some rciuels. The diseoM may ttow remain stationary for a few
weeks, and then the process of reparation sets in. The vascularity,
dimininhi'« ; the vessels are less closely arrange<i at the edge of the coi
itCk, and shi'w mure or less considerable gaps between them; and the
iniiltration hvconifs thinner and lighter in color, gradually disa|i|>earing
more attd more frotn the periphery towanls the centre, which is the last
to clear up.
The proffnatii of the diitease is, on the whole, farorahle, for, although
it rufia a mo4t protracted course, which may extend over many montli
and although the i>]iacity of the cornea may be so dense as to proven
the patient from even cnuniing fingers, there is no tendency to ulceration
DirPUSB KEHATITtS.
163
of Ch« cornea, arut the opacity graduallv dUaitpears until Uiere is finatlv
perlia|i« only a aligKt clomliiiefta left, Botli eyod are generntW afrecL«(i,
and thU renders tlic diaoa^e of courite the more harassing and alarming
tA tiic patient, who mnr thiu remain for mnny works iilmo-it totally
blind. Iritid is a frui|iienl aecimpaniiiieiit nf the iiitlniniiintiou uf Uic
cornm. and may he quite nnsii-spccted dnrin;^ the pro^rf'"-'' "* ^^f canCi
as the iris is hidden froni view by the opacity of the cornea; and it is
only when the latter hecomes clearer Ihiit tJie irit* is fonnd immcwhat dis-
o>l«ri'd, and the pupil irregular and adherent. But a still graver and
mure danjii'nuw coniplicaiion \n inflaronialion of the ciliary hody, which
lA c8{>eciallv apt to occur it' the cB:fe has been injiidicionsly treated, nnd
caustic nr strcm;; iwtringent collyria have hcon ajiplicd. We mast ttus-
pect this ciimplicalifin, if the symptoms of infiamujatorT irritation arc
f^re&tly incrcn^u^d in intcnnity, tf the vascularity, photophohia, lachry*
mation, and ciliary ncuraljria ai*c aerero, if the siglil i^ rapidly dimin-
uhed, and the field of vision markedly contracted, and if ttic eye at the
region of the ciliarv body is extremely een^itive to the touch.
Difftute conicicit) ia cBpecially apt to occur between the ages of five
aud twenty, but it may he met wiili up to thirty-five or forty. It gen-
erally occura in pennons in a feeble, delicate state of health, which may
trt- due to humeronH caui^ef*. Hiich a^ wnut nnd privation, very liard and
fatiguing work, more e^^pccially in a confined or vitiated atmosphere ;
and it is often met with in pCrKont! affected with a scrofuloui^ diutheijiii,
or with inherited n'philig. 1 canmit at nil jigrpc with the view that dif-
fuse eomeiiis is alwnvs due to inherited syphilis, for although I hnve
often seen it n^ocinted with the latter, yet tn many cases not the alight-
Wt trace of a syphilitic taint conld he ascertained, and there wa« a
marked and eomplete alMcnce nf the peculiar i^ypliilitic features and the
notched teeth. Indeed, 1 think that wo are ofti-ii too apt hastily to jump
Ui the coricluciou that hereditary syphilis exist*!, when on a more careful
and searching examination into tKtmc of tJiese hitttoriefi, it would be found
that the miscarriages, early deaths of children, etc., were due to per-
fectly natural causes, and quite independent of any syphilitic taint. I
may of course be met with the constantly recurring argument that it is
inipoasible to get at the truth of the lii^t'^ry, but I think that we arc
jiistiflod in giving the pntient and hii^ parcnLs the hfiiofit of the doiiht,
if no reliable proof of the pre^tencc of inhcnted syphitia can be nuidc
out. For this reason, I mn»t completely disagree with those anthons
I who terra thia diwiu^e '* syphilitic conieilj^." For, at I have already
itAtod, it is frCiiueiitly met with in persons, in ivhom not the ^Hghteitt
['tmcv of a syjihilitic taint can he detected. Whilst combating Bi>uie of
^tltcse views, I nnwt, howtjver, seize this opportunity lo expn-sa my ad-
miration for the very im(iortaut and intere-ding researches of Mr. .Tona-
tlian llutohinson,' into the frequent connection between inherited syphilis
nnd many of the diseases of the eye, a discovery which has proved of
Bat iiniMirtanee and tise in the treatment of tht^e affections.
[If the corncitiri occur in connection with hcnMlitary syphilia, the ex.
* Viir Hr. Ilotcliinann'c admirnbli* work. "Sv|ilillttlc DiBoun of th» Bfo nnd
K»r."
164
DISBA8BS OP TIIK CORNEA.
iatence of the latter may generally be liiiigmwticaUvl, ns pointed out bjrl
Mr. IIiitctiiiiAiiii, \ty ccrt»in ijeculiaritiea presented by tlie jti^riHattfitti
teeUi, especially by tbo upper ueiitral incisors, wbJch arc the most relia-
ble for purposes of diagnoais. The characteristic mal formation of tlie
upper ceutral inciciore coDsiat uliiefly iu a ilwarfin^ uf tliu tootli. ffbiclt
ifl uituully both nniTow and ithort, and in tbo atrophy of itA middle lobe.
'Jliis atrupliy tcavta a single broad notch (rerticai) in the ed;;e of tbej
touih. TliiK imtcliing i» u<<ually symmetrical, as abo^u iii Fig. 4U. It
may vary mucli in degree in different caaes. Sometimes Uie teeth diJ
Tcrge, and at others they slant towards each other. The appended wood-1
cut. Fig. 41, affords a good illu:*tration ut'tJie defonnity. In the major-
ity of cases the condition of the teetb h »ufiicicnt onljr to excite au^picioti
Kifi. *i.
"9 jw
Fig. 41,
and not to decide the question, alUiough In a uiarked case of malfnrm
tion Mr. HutLdiiriHon st!it«9 that he would feel "no lieflltanon in pronoun-
cing tiiC posNf-ssor of tlie teeth to be the subject of inhcrilod syphilis, even
in the absence of other testimony."' In a considerable number of caaea
of hereditary syphilis, the teeth show no devialion whatever from the
normal i^tandard, and in such the diagtioais must h« guided by other a
veil-known symptomii. — H.J
[The interstitial keratitis, which is one of the symptoms of congenita
sypbitit;, in association with the notched iiici<4or teetb, is almost always
gymmi'trical, atui uaually occurs bt^wccn the ages of six and tifteen
sometimes as early as two or three years, and very rarely as lai*
tweuty-tire or thirty. — B.}
Mr. linulencll Carter points out thai tJie absence of «yphilia in tlia
parent!) does not necessarily preclude its existence ia children, as tho
taint miiy have been introduced by vaccination.'
In the treatment of tliis disease, we must be chiefly contented with
guarding the eye again»tt nil noxious inlluciices, such as bright light,
wind, draught*, etc., and must endeavor to prevent the inflnmmatory
sjmptouis from gainin;; an undue prnininf-ncc. Unforlunalelv we do not
at present know of iiiiv means of chrcliiiig tho pro-iireas and development
of the disease, or of curtailing its protracted course. The use of caustics
or astringent collyria must be most carefuliy avoided, as they only tend
to increase tho inflammatory irritation and to produce complications, such
as ulcers of the coniea, or inflammation uf the iris or ciliary body. M
the outset, atropine should always he applied, although when Uie conica
becomes diffusely clouded, it is but of little use, as it i^ not absorbed,
and it is apt to increase the inflainniniiou if it he too long continued.
Hut when the contca begins to clear, atropine or tho belladonna coUy-
rium should bo again applied. Local depletion and very aniiphlo^sUc
1 " R«jrnoli)i'8 fljstwia of Uedtclne," rol. i,
■ '■UtiMt," 186$: 1, 76$.
pagv 317.
DIFrtlSE KBRATITtS.
165
troaiment atc not well borne, on account nf (ho woftklj xnA feeMo healiti
of tilt? [latieut. Moreover, tliey teml (o imjiurk' tite tbntiation of bltod-
veMcli) on the conira, ajirl t» protract the coiirde of the disease. Hut if
ftvn)|itonM of e^'clit)!! nisVc their appcitnincc, leeches should be applied
to the t^'inple, Jiinl panicentesis shotiKl be performed: and if the ^ij^ht
idolcrinrat*.-^ ^ireatly, tlie fivM becomes contracted, and cspceialt^v if the
intrn ocular tenvinn increases, nn iridectoinir lihuuld be made at oncflo
When tlie conicn is begimiin^ to elear up, the absorption of the tnorbit
jrroduct^ mnv Ire hastened hy applvi";; «li};ht irritants. The best to cuui-
BMuoe with i» ihc iii>>uI]1alion of cabimel, which HhoiiUl be cinplnred oneu
h^ily. If the eye bearr* thi^ well, without becoming tf>o much irritritcd,
the ifi'Ilow precipitate ointment should be substituted for it. At fiMt, I
geiienilly eniplov it »f alwmt the strength of two grain.^ to the draelirn,
and UM" hut a verj- small quantity. If it excites much irritation, I
appl/ a atill weaker ointment, or postpone ita use for a few dnja. I
liavo found ii hy far the Wst remedy for accclcratinf; the absorption of
• i - uf the cornea. A eollyriuinof io<lidc of potassium (^r, ij ad
- . wrviccalile for thin purpoifc, fn very obstinate cases of diffuse
c))nicili>« I have also occasionally found much benefit fr«tra the applica-
tion of a seton to the temple, Ilasncr has practised panieentesi^.
In florae cases iridectomy proves bcTieficial not only m acevlnratin^ the
ertn, but al«> iy the early sta<;e «ometinie8 arresting the pro;j;resa of the
llil^!as4^ Mr. l*rid;;en Teale informs me thiit he has pmutised it with
I*ii4*ei-*s in ca.^es in which the progress of the disease was rapid and un-
ohtn;kvd by other remedies, and in which there had btM*n a diuiinution of
(be eye ten^tion before the oficratinn.
It ia of great importance to attend to the general health of the patients,
AS they are as a rule of a feeble cat-hectic hahit. Tonics, e5[>ecially die
Le%'rnp of the iodide of iron, ipiinine, or the citmte of fpnnine and steel.
Litutuld be administered. Cwldiver oil. with or without i|uinine or Bteolj
l^aJao of much bencKt. If a syphilitic taint is ^nsficcted. the ioilide
'bromide of potaaainm in combination with tlie bichloride of mercury
Mid cinchona, may be givon with much advauta;(c, [ These cases of con-
genital tiyphtlif) arc very apt in children to be complieated'Trith struma,
and hence all preparations of mercury must be administered with ex-
treme caution. — H.] The diet should he nutritious and easily di;;esti'
ble. Meat may le allowed two or tbn-*^ timc>i daily, and wine and malt
li'ptor may be freely administered. In fact everything should be duue
to atreugtheu t]ie piktient. In hospital practice I have often been ob-
bllgud to tnlce such patients into the hou^ for many months, in onler that
tliey mi;;ht have more attention, and a more ;;enerou9 diet than they
wtmbi have obtained at borne. When the acute ata^e is past, and the'
cornea m Iwgiuuin;.; to clear, the [Kitient should, if p<)s8ible, ho *eut into
the country, or still hotter, to tlic ecjwide, and enjoy a great deal of out-
of-door exerci9«. The obettnato photophobia anA chronic irritability of
Ibo eye, which oft«u proves so troablosome, yields eomettmcd most rapidly
to change of air.
Sllot fumentrtiiomt frequently repeated and kept up for a long time,
1 the inUrruptfd mm of atropine, are two extremely useful agents iu
treating this dleoaae. — 13.]
166
DISKASGS or TUE COKKBA.
2. In Uic nim-i^$enlar diffune c&meifit, we notice timt a small
appears in the ccntro of the comeji, unai:ciiiHpaTiit!il hy any Imt the sliKiil-
e»t symptoms of irrilation, aiifl tliorc u only a very faint rosy injection 1
amuud the cornea, but not extending on to it. In the coiirKc of ten or '
fourteen days the opncity extends over the whole surface of the coniea. ,
f;iviiig it the appearance of f:;rouud j^lass, or uf a mirror that ha» hc«ii
ij;lit!y breathed tipoii. The symptoms of irritation, ettpcciolly the pho-
to[>hobia, may now increase somewhat, but the vaBciilarity remaiiui sli);ht.
The vessels never heciime very numerous or cliwely crowded lo;^ether. as
iri the case in the va«:iilar form ; hut individual vessels stni;rglc on to>^^
waHfi tiic intiltratioii, and do not terminate uuiibrmly in a defined line^H
The opacity ^adually becomes somewhat more dense and yellow towards^^
the centre, and then, after a time, clears up at the periphery, and the
infiltration olovtly disappears iti a centri|tctal direction. The cuunto of
this form iii ahio extremely protrnetcd, and many months may elapse
before the conies re;^iiis its transparency. The prognosis is still more
favorable thnn in the vascular fnnu, for there is far loss tendency to com.
plications with iiiflnnunation of tlie iris or ciliary body, or to ulceration
of the cornea: altlioiigh the latter may be produced if atroug cau>tiicg oi^H
astrtnf^ents be employed. ^H
The causes are the same as in the vascular form. If lliere is any
marked irriiabiltby of the eye, this shonid he treated It^ atropine, cold
comprcRiea, blisters, etc. But in the majority of the case* just the
reverse obtains, the pi-ogrvss of the atl'ectiou lanj^ishes and becomes
toriiid, and there is a complete absence of all symptJtra^ of inflaratnatory
irntation. In such cases it is advisable to apply a slight irritant, more
especially the yellow oxide of mercury bintraeni, every day for a few
days. This will excite a little irritation, the central porUon of the infil-
tration will become somewhat more thick and yellow, and the progress
of the disease will lie accelerated. It has often been noticetl that a cer-
tain amount of conjiincciriiis is very favorable. Thus, if the patient
sufTerins from this form of conioitis, by accident, cmitracta catarriial
ophthalmia, the pro;(rcs9 of the affection of the cornea will bo greatly
hastened, and an infiltration disappear in a few weeks, which would
Othenvise have taken many months before it had become aWrhed. This
fact led Von Graefe to emplny warm fomentations in tliese cases, in
order to excite a certain dej^ree of infinmmatory swellin;; of the cinjunc*
tiva. They are indicated if the vascularity and irritation are but very
sli;;ht, and the proj^ress of the disease extremely ]»rotracted and slug- ,
gish. They must be employed with caro and circumspection, so tlial
they may not excite too much iuftammation of the conjunctiva, which
would retard tiisteiwl of hastening the absorption of the infiltration, tuid
perhaps leave it iiicnmplet*;.
[There is a peenliiir variety of keratitis known as " baud-shapeii**'
keratitis, which occupies the region of tlio centre of the cornea, the real
of the conica being perfectly Iniiuipurent. The opacity begins od the
nasal and tem|>oral sides, and slowly ativances tuwanls the centre. The
opacity is dull, and its surface has a stippled np|»earance. The pericrimeal
injection may he very !fli;;ht, and the progress of the disease very slow.
After a varying length uf time otlicr symptoms of a deeper trouhle a
'g
OPAOETIBA or TB8 CORHBA.
167
developed, mtinlr of a ^laiwuiuutous iiuturo. Tbv iruaUocnt eonsUts iri
iloiii;; an iriilecuiniv od eurl^ m (lOiMiblu in Ute [trugrcstt of tlic inflainma-
liou. — B.]
7^0rACITIES OF THE CORNEA.
Tli(->»e vkry much in situation, extent, and thicknetiA. If thoy nro qiiiU!
.iu|iprficiat mv\ thin, luuklu^ like a faiut, |£rayiHli-blue cloud, tUey are
ivrtuetl iiclnilie. If tlie o{Ku:ity i» of a ilcnser, wliite, [Warly, tendinous
character, and situated innre deeply in the subslnnce of the cornea, it ii
called an Blbu;:ro or Icucoma.
A temporary diffiwc opacity of the cornea may bo produced by sad-
den idcrcaw of the intra-ocular pressure, M in certain fcnns of glaucoma.
occ. This opacity is proliably due in |iArt to a displiicc-iiicnt uf sdiuq of
Uie corneal rlementA, and also, pcrbapii, to a dittCtirbaiicc of the nutrition
of th« cornea from the oomprciKiuti of the nen'es.
Wc meet with a very snjwrficial opacity of the comcn. which is due
In changes in llie epithelial hiyer. Here and there the epithelial celU
become thickened, «};j;rL';;ntc<l lo^^ethcr, and opaque, their contents hav-
ing perhaps imder^no fatty degeneration. These opacities are of a
faint jiny, or htuitih>};ray color, vritU an irregular margin. In tlieir
centre, the reflection of an nhject, for instance the hars uf a window, will
be found indistinct, or more or less distorted. Generally tbc opacities
a.re easiily observahlc. Thvy may. linwever, bo no alight a» to e^tcaiie
detection, except willi thr ohliinie illumination, when they become very
evident. ITiey are ctiicHy met with as the result of the superficial form*
nf conicitist especially punnua due to distichiasia or gramitar lida, and
alto of the superficial ulcers of the cornea.
The deejicr o|Micitics, which are mtuated in tho substAncc of tlie cor-
nea itKrIf, may he ootiRncd to a certain portion of it {jiartial leucomn)
[Hg. 4t!j.or extend over its whole
rturfnci; ( total leucoma). The cloudi-
ttCM may either be of a uniform
grayish blue, or grayish- white color,
or may l»e made np of several opaque,
white patches or ajwils ul" laiyiiig
extent and shape. 'Ilu; outline ot
iheie opacities is irregular and iio!
iharply iletined, being sliwled grad-
ually itif into the normally trani«|ia-
rent cornea. Their thiekncM and
color also vary much, fntm n gray-
ish-blue to a ycllnwish-white and
doiuK'ly oiwiue tint. The epithe-
lial layer \s ikften irregular ami punctated, aa if a fine powder had boon
daatcd ov»r it, and this causes n distortion of the reflected image. Or.
again, the Ofncities may look like little opaque, cluilky nodulett t>trewn
about on iliftercnt portions of the cornea (generally near tts surface), and
are the reiuains of phlyctenulie.
[Pig. 43.
16S
j)]SKASua or tub cornba.
Fine punctata opacities are also met with on Uie posterior eurface oO
the cornea. They arD generally arraii;'cil in the frimi of a pyramiil,
with its base downwaniji, and are chiefly 'Im- to a precipitatinn ot'lympli
nn tiie p'lstcrior wall of the cornea, but also jicniaps to iiiflainmiitnry'
changOi) in tlie posterior epithelial layer. These peculiar o|>aeitie« arei
oheerv<Hl in serous iritis (sometimes terineil otjiio-cupsulitis, cornvitis
punctata, etc.), ond also in inflsnimations of the ilccper tunicii of the
eyeliall, an-I in syin|»athetlc oplitlislinia. In tlie latter c«*os, similar .
ptnieiate opcities may nhn occur on the anieriur (<urfi)ee of the conica. ^H
Tlie different opaciticii which wc have mentioned are chiefly tine toin^^^
flaiinjiaiory cIiatigeH in the conieal ami epithelial cells, ami ai-e capable
of untlergoiiig almoal cariiplete ahsorption, t<o that they may lianlly leave
a trace behind them. It is necessiAry to Histittgnieh from them another,
form of opacity, which is dependent iifton permanent change, often of a
tendinous or cicatricial nature, and hence docs not undergo ahsorjttion.
M
but reiuaiits indelible. Tliusv opacities are more regular and sharply ^H
defined in their outline, and have a more uniforin, tendinous, ;*Iistcniiig- ^^
white or chalky appcanmce, havin;;, perhapi<t, a deposit of factj or
earthy matter in the centre. The epitlieljal layer is smooth and not
irrepdar. These cie:itrices \'ary in extent and shape, in aecontance
with tlie si/.c ati<l <li*plh of the on>;injil ulcer; tliey do not, however, cor-
recjMjnd exactly to it. beciiuse a portion of the latter is very fretpiently
filled up by transparent conical tissue. These cicatricial npacitie.i occur
very freijuenlly together with those due to intlammatory chan-^s, so
that we have t!ie two forms existinj; tojrothor. The cicatrix, instead of
bein;i sharply defined, is then surrounded hy a more or less wide, op:i'|ue
areola of inllammalory Infiltratimi. Tlic latter may in time became
completely ahrorbcd and transparent, and leave onlv the cicatricial
opacity, which will, of course, be now considerably less in size than the
orii^inal Icuunina.
In cases of perforating ulcers of the comeir. accompanied with ante-
rior synechia, the cicatrix to which the iris remainfi attaelied is termed
leui'nma itdihernin. If it be nituiitcd near the centre of the cornea, a
portion of the pupil will In; iuchtdud in it, leavinj^, periiaps, the other ^j
part of the pupd free, and oppin^iu! a transparent portion of the comen. ^H
A peculiar superficial opacitv of the eoriHta is sometimes met with, ^^
whtuh is due to calcareous deposits Cconsistin<^ of phosphate and car-
lionatc of linio) %n iho anterior elastic lamina. These opacities are of a
mottled brownish hue, with an indistinct mar<;in, which shailes otf. more
or loss abruptly, into the liealihy conien. Their conreo is very pro-
tracted, and they arc apt simultaneomly to affect both eyes. Two very
interesting cases of this peculiar opacity, which <K;curred about the same
time, bai-e been described by Mr, Dixon' and Mr, Bowman.* In each
of these cases a portion of the opacity opposite the pupil was scraped off
with a scalpel, and was found to cousint of liard gritty matter, situated
just beneath the epithelium. The result of tlie operation upon the si^jht
was excellect. Sometimes earthy or metallio incrustations are formed
■ "DIseasM i>r t1i« G^<>." 3d Mition. p. 114.
* " l.«>«:luiv9 MX partA c»&ci.-rn<Hl In tlir Oprratioils on tlt« Bjr«," pp. 38 uid 117.
OPACITtKS OP TQB COKNB&.
Itfl)
npdn the ci>n)ea, ami uire r\»e to ]>ecuUitr opaque or clinlkr-luikiog
specks. Thii? (wcasinnallv ocuiiro frmii tliu contarl of niiicklime or tlic
ucposiU formeil frotn loa-i lotion iii cast"* of ulecr-i or nliraaiotis of Uie
ooniea. Ucro 1 mtisl aj^nin vnm the reinK-r ngainst the iwe of colWria
coittiiiriin^ k-ilii in CMv* of iili'er of the corn^n <ir evi'ii nhriLsioii of Uie
corneal c'litllii^liuiii. for the precipitation of the lead give! rise to a very
marked white sliiin. which protlncvs •^rcnt iuipniniient of sight if it be
ittuatcii in tht centre ot' the cornea.
The fttvifntnit in caseti of opacity of Iho cornea will depend very
much upon the age and consiilutton of the patient, and upon the dura-
Uoti,oxifn(. eituatiot), ami nature of thv opncitv. Thu^t, in children
mtw\ youn;( )>eisonH in goo<l healtli, opneitieH. the rct^ult even of exteniiivo
conicitis or dee[» ulcers, may in ttnie iliftappoar almost completely, with*
oat iQaving. perhaps, any trace behind. I have already stated that thia
n»y even occur in small perforatin;* ulcers, which have given rise U)
ecnimi c.ipanUr cataract. With regard to the opacities due to iiiflara-
matory chaii;:e(' in the corneal tirfmie. it may he tai'l down m a general
mil- that the rnnre roee-nl, sii|KTliciftl, and limited aiich ojiacifie^ arc. the
more nipiilly :iud cnuipie'ely do they disappear. Hy the application of
irritants to tlie eye, we niav greatly a;it<i5t in removing the cloudiness
due to inflammatory changen iu tiiei conical and epitliolial cctU. We
tbiia excite hyperemia of tim parts, increaite the interchange of luate-
rial, and accelerate and stimulate the process of ah^oi-ption. When the
opacities are ilne to permanent cicatricial changes, tliesu application-* are
of no avail, aud we miwi tlien have reeoursi? to other remedies if the
opacity canxea any impairment of vImoh. If the opacity ia don^e and
situated in or very near the cemrc of the cornea, the sight may he rory
eonAJderahly affcctcl, a* it will more or less cover the pupil. But even
slighter opacities may i^omewhat iin[»iir and confiiac the vision, by the
dilTu-sion and irregular refraction of the rays of light which they pro-
duce. But, apart from this effect upon the sight, these opacities may
give rise to other complications. Thus, on account of the iuilistinctnetis
of the retinal region produced hy tlie cloudy state of the cornea, the
patient will bring -tmall ohjcctA (as in reading, oewing, etc.) very close
to the eye, in order to gain a larger and iii<in> distinct im»gi>. But thi-t
coTtstAnt accommodation for a very near |Kiiiit, after a time cau^e^ the
lens to forfeit nome of iti< elasticity, .so that it cannot resume ila original
fonn, and the aix'nmnnHlation cannot relax it#elf completely when the eye
is looking at distant objects. The lens remains too convex, aud the eye
has become myopic. The myopia may be alsr> in jiart due to a change
in the shape of the eyeball, prtKliicod hv constant and long-continued
»cicMnunod.ition f'tr near ohjecla (vide article "Myopia"). (Ip;icitie8 of
the cornea may also give rise to oscillation of the eyeballs, and to
tttrabismus.
Inniuuerahle local remedies have beon rocommcaded for the dispersion
of o|nu'itiM of the coniea. From awongst thcst; wc may select the fol-
lowing as the most tnutwnrthy and efficacious : The insufflation of calo-
niel, the red or yelhiw oxide of mercury otntmcitt, collyria of ioilide of
potassium, vinum opii, nitrate of silver, sulphate of copper, and the sul-
phate of soda. A scoall ipiantity of the Uiter may bi' dusted into the
ito
D1SKASES OF TUB CDHKBA.
Bed I
eve, or it may be xxw^ ili r collyrium. about 1-2 grains to oj of vniKr;
Togettier «it>i ttie ihc oF any of the.w agenM, acrofHoe shonll be applitMl,
M it ilimiui.-4lie9 tlie iiiti'a-vaft:ii]ar pre^nire, &ii<l thus facilitates the inter'
ohaii<;e of mnterial and the jirtwiesa of absorption. I have genemlly
found it best, fiwt to dust in calomel for n few daya, in order to ?ee how
the eye bearg thi^i, niid then, if it iloe^ not oxuitu urn much irritiition, lo
employ a «troTij;pr irritant, cfipecially the red or yellow oxide of mercnry
ointment. At first its strenj^th should not, I think, exceed one or two i
grains to the ilriichni of hml, A little portion, about the size of a coupla^^
of pins' heads, ehoiild be placed on the inside of the lower eyelid, W^^
means of a probe, and the lids Bhonld then bo rubbed over the cornea,
80 that the ointment may come well in contact with it. If the yellow
prccijiilate ointment lie used of greater ntronj;th than that mentioned
above, it sli(»ultl he rcniovoil after a few miiittteif, otherwiM it wilt p
duuc loo much irritation, If it i^^ found that the ointment excite.1 a j;re&t'
deal of irritatioTi. redncs.<<i, and pain, a smaller i|uantity, or a weaker pre-
paration i»houIil be nsed. or the calomel should again be substituted for
ft few il:iy?. Oeiierally. Jt is better if the surgeon cau himself apply
these remedies, am he ia llien able Ut watch ihelr action upon the eje ;
but if the proper moile of minj; the calomL'l or the ointment be explained
and shown to tlic patient, 1 have fouiul no diffieuUy in ;;ettini^ tliede reme-
dies applietl by the patient himself, or his friends. Kutif F do not apply
the oiEitniont myjitdf, I never prescribe it stronger than gr. j-ij ad 3j '*
hi the strtjiiger preparation rei|niro3 to be removed from the conjunctiva
after %^i mirtntes. I haxe also found advantase from the applieation
of iodide of {K>taaRium, either in a i-nllyrium or mixed with tlic yellow
firecipitate, In the following proportion : Iodide of |K)tasaium gr. j, Yel-
ow oxide of mercury gr. ij, Adipis aj-SJ- TI'C iustilUtion of a little
vinum (ipli also proves very userul. Nitrate of silver or sulphate of
copper i^ only indicatA'd when there is any inflammatory nwclling of the
Conjunctiva, aceoiupanicii by some muco-purulent dischai-ge. After an
of these remwlics jiiive been twed for some length of time, they shoul
be exehan;^ed for some other agent, as the eye S'fta accustomed to the
and they ap|»ear temporarily to lose their etfect.
Eleclrioity was formerly in vogue for the cure of opacities of the
nea. It has now, however, fallen into disuse.
Dr. Itnthraund,' of Munich, has strongly recommended the mi
junctival injection of tvpid Malt and water in cases of dense non-vaa-
cular opacities, such as Dt'ten rem:iin after diffuse eonieitiK. The stren;
of his solution varies from 9j-3j of Sslt ^*> 3j of Water.
[M. Wecker' has recently advocated the method of tattooing for
removal of the cosmetic defect produced by dense leucomala. The o
eration, which, as a rule, causes very little pain or irritation, is be
performed with a number of the finest needles firmly bound, with
points on a level, around a handle, sucli as a penholder. The itubstanct
which M. Weckcr recommends for tinting is India ink ; Mr. Taylor has
also employed* with advantage sepia, uUramarine, and other colors, and,
• '■ KllntKhe MmiktuMilttvr (. Aa)ccnlivilkando." 184R. p. 181.
I* ^rciliivis at Optitlmlmojo^y find Otdltigjr, toI, It., No- i, I>. 224.
* AuiiTluan Juuriiut ut Uiv Medidal Sdenooii, UuluWr, 1671, p. i6i. — II. 1
Bgtiij
thi
th<
OPACITIES OF ins CORNSA,
171
I
wWen an imnxMliftte anil deeply colored effect has been (le«re»l, a combi-
oittinn (if tain|ibtiiuk with India ink. and h aolittiou of nitrate of silver.
Tliu iiovdlcs act! ilippi-d into the pigment solution, which aliould be made
a« thick iw poAsibli", and, the ev« beiiij; Btt'adied, the superficial layers'
of the cicatrix arc rapidly punct«rcd in an ohIii|ue direction, and layers
of the solution applieil ju«t as in the onlinary tattooing. — H.]
[A better iuctho<l is lo use a Kinj^lo grooved noodle, rub up the India
inh to a thick Milaiion, and cover the leuooinatouit Apni thickly with it;
ttien 611 the groove in the needle with tlio pigment, and puncture the
cornea ohlitpiely in various directions. Tliis lake^ more time than the
other mcUiod, but the work in better done. The puncture of any'
bloodvessel iM of course a great disadvantage, as the blood washes away
the pigment. A number of sittings ia necessary for tho completion of
ibc operation, and, after a varying length of time, raii;^ing from a year
Ut uifibtcen ninnlhii, the operation must be re|>eatcdT aa tho pigment stain
wear* away. — li.]
The chalky iiicnwta lions, or deposits of Ictid upon the cornea, should
l»e carefully scraped off with a oatanict or ^cklc-shapi'd knife [Kig. 48J.
!f tiiey are exteu»ire, the whole need not be removed, but
only a portion snflicicntly large to uncover the pupil. Aa [I''s-^>]
this opernrion is sometimes very painful, it had better lut
done uncler chloroform, especially in children. After- /tj
wanl^, a little olive oil or atropine should be applied to
the eytf.
Hut if the opacity resists all these remedies, and mat4)-
riaJly impaira the sight, we must endeavor to improre vis-
ion, cither perhaps by some optical arrangement, or by the
formn'ion of an artificial pupil oppo*iK> a clear portion of
t A. For the purpose of diminishing the effect of
I i'liin and irregular refraction of the rays produced
by the cloudinoKx, the atcnopnic 8pectacle<t will ofci.*u be
found of groat une (Uonders).* They consist of an ovM
HH'tal plate, having a small central aperture. The effect
of ihi* is to [R'nnit only the central rays, which fall in the
optic axis, lt> ]ui^, wliercis all the [wrijplicral. diffuseil light is excluded.
If nectrttitary , convex or concave lenses may be applied behind the ap|ta-
nituK. AUhuugh lliese st«oopaic spectacles often answer uduiirsbly for
uiy employment at near ohjocLs, «•. «/., reading, sewing, engraving, etc.,
they cannot biD u-ied for walking about, as they produce too groat a con-
traction of the field of vi^on.
An artificial pupil may bo made eitlier by mcaivs of an iridectomy, an
irido<let^ie, or iriileiikleit^is. If the opacity is confined to the centre of
the cornea, it will ho boat to perform iridodesis or iridonkleisis. for. by
■o doing, we can draw the iris somewhat forward opposite the opacity,
and thus diminish the diffusion of liglit produced by the latter ; more-
over, the a(iex of the artificial pupil will l»e op|)ositc the Cilgo of the
leua, and will thus prevent the irrcj^ular refraction which would be
* *< A. r. O." L 1, 2S1 : vide bIsp Dnnders't " Anomallei of Acoonuonlatloa and R«-
bac^n of Ibn l^s." 1(0« ttjrdeu. Sooirtjr, p. 138.
172
DIBSASBS OP TUB COBItBA,
ca\iiieil if Uie periphery- of Ui« lens were widely exposed by ftn iritlec-
Kiiny. But if tlic ofKicity ih iiinm cnimidArnhlD, ftrid does not leiire »
wiile mftr^^iii of <?1cAr ermtt^n, the artificial pupil ttiu-s iiiailo will lie
uu-xitficieiit, more espt-cinlly with regard to the amount of light admitted
iiilu the oye ; and in such cases it 'in better to make ait iridi'ctomjr,
which should, however, be hut smalt. If the margin of trniiit|>arcDt
conioa is very narDw. there ia always the danger thai the wound made
in tlie porforniaiice of iridectomy may produce u certain degrev of fre«h
opacity of the smal] |»orti(>n of clvar coniea near it, and thus milibite
againt«t the benefit derived from the nperatioo. In onlcr to ob%'iat« thia
danger, we may make the artiticial pupil by corydialysis, which would,
of course, produce no clouiiincsa of the cornea opposite to the new pupil,
die incision bein;;: made at another portion of the cornea. An artificial
pupil should always be made opposite that portion of the cuniea whicli
is the most clear, and has the truest curvature. The direction itiwards,
or slightly downwards and inwurdst is by far the best for optioal pur-
fiosea, for not only does the artificial jnipil then com-spond t<i the visual
ine, but it also a.-tgists better in the binocular vision (Ijemeinschaftlicher
Seliiict) witli the other eye. If any anterior synechia exists, and its
extent is but siitull, it may be divided with the point of the bntad needle
or iridectomy knife, in the [lerfonnauce of iridodesis or iridectomy. If
it ia of recent formation (as after an incised or pmictured wound of the
cornea"), the adhesion is often so slight tliat it amy easily be detached
with a hluTit hook or a small spud.
[Autcnrieih hna ]tro[m.sed, in cases of total opacity of tlie cornea, to
admit light throiigli an openin;; in the sclem : but uo practical results
have ever been obtained from this method.- — B.]
[A mode of treatment of dense leucomata baa recently been dcvise^l
hy Mr. Henry Tower,* of [/>ndon. and practised on the human subject
with " promising; results." It consists in removing a portion of the
Opaque cnrnca of the jKttient with a sliarp puncli specially devisvil for
tlio purpiwe. and obtaining, by thi- wime nn-aiis, an exactly corre.spoml-
ing portion of a healthy rabbit's cornea and transferring it to the space
in the human eye. The Uds are then to be fixed together, and, in a
week. Mr. Power has found union to be complete. Whether the portion
traniiplunted will become perfectly clear he cannot yet, from want of
experience, say. — II.]
[TIte ofieratioii of " corneal transplantation" hns been perfected bv
Mr. Wolfe, of Glasgow, who has Ua^l ttjme cxcelluni results. ILa
instruments are a lance-knife with a stop, a broad grooved director, and
a doublc-bUded knife which fits into the grooves of the director. A
Uap, bnmd ut the base and converging towards the cornea, is taken from
Uio oculiir conjunetivK on each side and dissected up to the transition
fold. Tliese are turned over on the cornea and removed in the usual
way. The lanco is then introduce*! in the limbu^ so as not to injure tlie
conjunctival Sap, and pushed in as far as the slop will allow. The
director is then passed through one of the openings and pushed iu front
of the iris and leos out through the opposite side. The knife ia then
[■ MM. TimM aii4 du., Aug. 10. IftTZ.]
ARCna BBSELIS.
n«
t
jitnccd in the groove*, ami tin- corncfti flap scparftt*d and put in tepiii
water. A sitnilar coiijtinctivul ami corneal flap is then miioved fi-otn
thp nlhiT patifiit : Imt here the laiifc must be nseil fo m not t-) iiitcrforc
with the [lillMrs of the iris, and it lonst be rapullv withdrawn so as to
prevent as nuit;h im possilile the csca[>e of tlie iit|UC0U!i himH>r and con*
Be(|UOiit rrilltii;; forwart of the iri^. The trHn^puront graft 19 then placed
ID ]K)8ttion and secured h^v ntitches in the comcre of Uut oonjunctivnl
flapa. Wolfe tliinkit the riitcce^ dcpendti upon the ^rafc hetn;; taken
from a fri'shly enncleati^d hiimaii ev4>, the umoothuess of Ihu corneal
ittcUionit. and the cxainiiefw of the nif^a^urenient^ of the Ji^riift. More-
tirer. w» dama;5C must l«e done to the suhjjicont stnicttirea, and hence
tlttt whole cornea must not be removed, ticllerbeck has alwj ri?(M»rted
caam operated utuo in this wav (»ee Medical TiincA and (iozeito, Nov.
23. 1870 ; Arvbiv lllr Ophthalmologic, xxiv. 4 ).— U.]
I need hardly nay that the e.tpenrnon64 made by Niushaum and
othi'r», to Col a ludi.- in tlie opa<|Uu cornea and iunert a pii-co of glaM,
have oompletely failed.
r
8.— AltCUS SENIIJS.
rSyo. Gernntoxon. — B.]
Tliis pccitliiir luarjcinal njacity of the comea is due to fatty degene-
rmtion nl the corneal tissue, which generully commences tintt in the
up[wr portion of the cornea. It then nhuvm it«elf in the lower, and the
f xtremitiea of the two arc3 increase more and more, until at lost tliey
meet and encircle the whole coniun. We are chiefly indebted to Mr.
Canton' for an exact and extensive knowjod^e of thiit condition ; he has
found that it generally occurs about the a^ce of .'tO, but that it may flp>
pear at a much earlier age, especially in familietf in which it appear*
ta he heredicarv* lie al<M consideni that the arcu^ senilis alfonl:! us
th(» beat indication of the pronenesa of other tissues to fatty dcgenera-
lion.
The opacity ia iit firat of a li;;ht gray color, nppcarin;! like a narrow
silvery ritu near the ed^ of the cornea, but not renchin;r 4uite up to
the latter, hidn;; always divided from it by a tni.n>tparent portion of
comea. At a later |>eriod, the opacity a-t-suinen a deniicr and more
cresmy tint, and increases in deptli and width, being generally broader
above anil below tlian at the sides. It might be supposed that the fatty
degeneratinu of the corneal tissue would impede or prevent the union of
an inci.tion lyin;^ in this part of the cornea. This is, however, not tlie
caa4:>. for we find that a section earned throu-^h the arcus senilis heals
perfectly, as mar be often observed in casev of extraction of cataract.
• Viile Mr. KAwin CsntMi'a work, "Ou Uu* Areiii> S-mitiK." Untlon. lflC3.
174
DI8BASB8 OP THB CORNEA.
9— CONICAL CORNEA. [KERATOCOXITS— R]
^ When this afTection i& but slight, a cursory observer may eauWy orer-
\ook it, and mistake it, perhaps, for a case of mvopia, compHcftietl with
wcnkiM.'i4!S ol' tti'^ht (amlilvo]iia). But a marltcd case cannot uell bo
o%-erliifikeil. On regarding surh an eye from the front, wc notice that
llic centre of th« cornea appears uniMually ;{U?<tLMiiii}i; ainl briglit, aa if
a teanlrop were siuapundeii from it. If ne then look at it in nrofilr,
the Rtzc and rthnpc of the conicitv will bcconio
lFi(t. 44.] at once apparent. [l''ig. 44.] Sometiinea the
coiiivily is not in the centre, hut nearer the
ni.iry;in of the cornea. But by menus of llie
ophtiialrnoscope, even the tdiji^htesC ca«v8 of
^^^^^^^ conical conit-a may be diagno3ed with cer
'.-^^■-fy^^^^^K tuiuty, a« waa first {lointed out by Mr. Bow-
man.' For tliis pur|H>4C tJie mirror alone in to
h« iwed, without the convex lens in front. Ua
tUrowinj; tbi* VifiUi upon the coniL-a, we receive
a brij»ht red reflection lhrou;:h the c^-ntre of
the comea, which gradnnlly shiulcs off, and becomes darker towards the
base, m that the central bright red !>pot is surrounded by a dark zone,
which in its turn is again encircled by a red ring. If wo tltrow the
liglil ujmn the centre of the coniea at different angles, the side of the
cone oppfisite to the light ig darktsned. The central red zone (in which
\»e (ilituiii a revcrw image of tb« ilisk, etc.) is due to the reflection of
tho fundus through the central conical {mruon of Oic cornea, and the
outer red riuj( to the reflection through the normal peripheral portion of
the cornea. The dark zone between the two is, according to Kuapp,*
due to Uie diflusion and complete rctli*ction of the rays of light at Uie
bAA6 of tlie cone, where it fassea over into the normal curvature of the
cornea.
On the ophthaloioftcopic examination of the fundus of an eye affected
with conical cornea, we notice a considerable parallax on moving the
convex lens in front of the patient's eye.' In thiti way we can prKluce
a distortion and displacement of a certain |)ortton of the disk and retinal
VL'ssels, whilst the other part of the disk remains immovable, just as
occurs in gUucomatous excavation of tlic optic nerve.
Even in flight cases of conical cornea, the patients always complain
of considerable, and often great impairment of sight. On account of the
conicity of the central portion of the cornea, the antcro-postertor axis
is incnrascd in length, and hence the eye bus btniome more or U'«s
myopic, and the jtativnt i:on4(N|m'ntly holds small object«i (as in reading,
etc.) vvpy close to ibe eye. lint the irnphinnent of sight is chiefly due
t» the Ai-tigmatism caused by the irregular curvature of the cornea,
wliich gives rise to great distortion and confusion of the retinal images.
['fbe asiigmatisin may be simple myojuc, or raixed,or even simple hyfier-
' "R. L.O. H. Rf-p.,- ti. IM.
» "Kl. Monittihl.." IMU, 313.
• Duudt-n, --A. f.0.,"7, m ; alw> Dondm, op. dl., Sfil.
oonroAL conNGA.
176
I
I
I
inetTopic aatigiRAtiaiD. — B.] Concnvo sphprical Icnsm^ tiiercfore, gon*
«nilly produce but Ali-^ht improvement, hut Home benefit U occ Actional ly
derived Truro c;,-lindncnl ^eIamcs, ulthou^h tho astigmatism is as a rule
too irrcpilar to admit of mnch correciioti. Mi»r« improvement is found
irf*ttt tlie ii!<e of a circular or »lii-«li:tped stcnopitic ap]>»nLtus, Bttod, p«r-
liapti, with a suitalile concave lcii». as llud iliininislit.'^ iltt; circles of dif-
fiution upon the retiim hv cutting off tlie peripheral rays of lii;ht. We
often notice Uiat the ]>aue(it8 etuleavor to accumplieli IhiA fnr thcmsctvcs
by nipping their oyolitU toj^ther, so as to ohan>;e the pnlpehral aperture
ipio M barrow (tlit. After the diteaite hA» exlttted a certain time, and
rescheU a hi>?h ilejiroe of development, i-lie a]iex of llio cone often be-
comrs rtp.ii|ac, and thiiri itic night Ik ntill more itetcrinraCcd.
The bulging forvrarcl of the cornea is not <iiie to an increase in the
tntni-ocular tension (which is indeed rather slacliened), but to a dimino-
(ion in the power of resistance of the cornea, and as this bulging in-
crease;^, Uio [lortion of cornea emhracetl in it becomes ihiinier and
thinner. It is an interesting; fact, that, however altcnuatcl the apex
caay In-coue, it never give» way, except through an accidental injury.
Mr. Itowman thinks that the reaHim of tWin ia, that, '* as the cornea be-
come!) thinner, tlie encapc of the a<|ueou!) humor by exosmose ia faciU<
taled, and tliuti tlie internal pressure is reduced, so as to be no loiijj^er lu
excea-* of the diminished resigning power of tho coniea. A balance is
Mtablished like that of liealth, only that there is a more than ordinary
oDttlow of tho atjueous liumnr by transudation through the ornea. This
accor^U with my prerioua observation, as to auctt eyea being rather un-
July wft,"
'I'hc progrcw of the dtHcawe is generally very slow. It may become
■tationary at any point, stopping; short when the conicity is still but
alight, or ;;oing on until it ia very considerable and the apex has beeotne
cloHiled. It generally sooner or later attacks both eyes. It occurs frc-
ijuently, but not always, in persons of a delicate constitution, and com-
meDces chiefly between the ages of tifteen and lliirtv. Mr. llowman
baa observed a very fvw cases in whiuh it occurred in more than one
loenibrr of the Kanie family. Any considerahtu and pnitnicted use or
tttrainin;; of the eye in reading, newing, etc., will tend to increase its
development and prrjduce local irritation and congestion.
Innumerable remedies have been 8Ug;^«ste(I and tried for the relief
Mid cure of conical cornea, but almost all of tliem witliout success. If
the jndcnt is iu delicate health, tonios and a nutritious diet with plenty
of fresh air and cxerciw should be prescribed, and the use of the eyes
for reading, etc.. should be forbidden if both arc affected. In order to
neutraliite the mynpta prodiiet'd by the conieiiy r)f the cumea. Sir W.
Adams removed the lens. Mr. Wanlrop recommeTvlcd frc<|uent tJipping
of the anterior chamber. .Mr. Tyrrell was the tirst to make an artiticini
pupil in tbi<i disea'^e, and this is the treatment which has hitherto proved
most Riioei'^^fnl. The purpose we have in view in making an artihcial
pupil iA twdfiild : 1st. To nnprove vision by making a pupil opposite a
portion of the cornea wliich has retained its normal curvature; 2d. To
arrest the progress of the disease, and. if [lOi^ible, to cause it to retro-
grade somewhat by diminishing tho intni>oeular pressure.
DISBASK8 OP TBB COftNBA.
'Hie artificial pupil may be made either hy an iridectomy or an irido-
liu^is. By tlie former operntioii, wc cerUiiuly briD*; die pupil op|K)Kite
H iuarj;inal portion of tin* conica, but there is thid di^dvantiige, tftftt the
on};inul pupil retuuins opposite the coiiicity, aud thurtrfore the rays
which piiSK thnm}rh it iii-u dlRiii^eii »tid imr;rii|:irly refnioti'd, niul thus
confuse the retinal iaiage :iud ilitninish ico <.li!!.niictiieS8 ; wherua:!, by
means of au iridodei^id we uan draw the irie well forward lowank the
iucisiun, and thua displace tbe pupil towanU a portion of the coniea
which is leaa irregulai'ly curved, aod bring the Iris opposite the coue.
The itici-sion should bo made slightly in ilio sclerotic, so that the jJano
of the iri# may not be moved away from the lenm. The best din>t:tion
for the indiMlcsin is )«li;;iicly ■lowiiwiirti!' ami inwards. In order to oituiiu
the advantage* which aro derived from a sli^flhapcd stenopaic apparatna,
Mr. Bowmati has made a double iridodesis, so that an obloos slit-sbapcd
pupil is obtained. Thiii may be made either verticnl or bonzonlal. In
the fonner casic we have the adeautage that a considenibW portion of the
anjrled of ibe rdit is covered by the lid^, which render* it much less u«-
*ightly, more especially if tbe irides are light in color, than ibt* horizoD-
tal slit, which ^ivtfs the a|)pcaraiiee of a cat's eye. The operation should
not be performed in op|ioi)ite ilircctiona »t the same sitting, as the point
Srst tied i» apt to yield and be drawn into tlie anterior chamber attain,
when the iri« ih drawn tuwanitt the opposite incision. It id best to make
tbe second iridodesis about eight or ten daya after the first. Thi- in-
cision tihould \>e made in the sclerotic, so as to retain the normal plaue
of the iris.
Not only does this operation produce a beneficial effect in an optical
point of view, but it aUo sometimes causex a eoiisiderable diminution in
the bul;5c of the cornea and the prn^rejw of the disease. At presoni it
is very difficuU to decide upon Ibe point as U) which operation is really
the bo^t, a.-i the results have varied coiiHidumbly. For instance, in some
caites benefit bag been prwlnced in the sight liy Uie second iritlodesiit,
whereas in others again ibis has not been the case. Tae improvemcui
M. however, never so conspicuous as after Uic first operation. My own
experience rather tenrls to the opinion that on the whole the progress of
the diKeai^e i.i most arretted and tbe bulging of the cornea most ilimin-
i:*bed by an iridectomy. Care must, however, be taken to nmkt; it only
moderate in shv, and {wrhaps slightly ujiwards and inwards, au that a
part of the base of the artificial pupil tuny l>e covered by the upjtcr ltd.
[n slight cases, in which the conicity is either almost stationary or bot
very slowlv progn-asive, I think iridodesis is indicated, whereas if it is
considenihly and markedly progi-eaaive, an iridectomy is to b© preferred.
A'on (.fraefe has lutvly published a very iutvresling case of conical
cornea, in which he provinces ukeration of ibo apex of the cone, and
aufaafffueat contraction and flattening of the cicatrix. * Tnc fact tliac tlie
cicatricial contraction which follows extensive ulcers or infiltrationa of
tbe eoraei%. always produces a certain degree of diminution or fiattening
' -A. t.
1*2, '1, -lA. Mori? rowiitlv V»ti (Ira^fr Iik-h I'uMlatiMl an vlalmt-»i*
Mtf '''•v>ts^^^|jng iiajier uwm Ibta itubject tu th<- ■■ BcrllDt-r Kliiiiafhc WiMtittiischritt,''
■afe-1.
OONECAL OOR>'BA.
177
of the curvalurc of iKc comoft, le«l Vou Ornefe to the idea that u simi-
lar effect might ho brotijjht nlmut iii severe cvuMii* of conical cnrnea, by
the artificial |ir«iliicti*in of n liltle ulcer. The operation i* to W per.
formed in the lullowii);;! maimer: The point of a ver;p- i^mall knife, inadfl
of the shape of Von tiraeff'>i narrow cataract knife, hut stiialler in »\jx,
IS to be pasMil into tlie tiiiilJIe layers of the curuea, just at the apvx of
tlie cone, to tlie e:^teia of about a liiR', an<l then hn]ii';bl o<it H<;aii) ; so
that a very snull nuperlicial flap oiaj be foniicd, which i» then to he
seized with a very fine pair of forceps and snipped off at its base with a
pair of curved scitMwrB, thus leaving a superticial gap at tliis point.
(Ircrtl care must he taken that tlie knife dots not puuvtratc tlie cornea,
of whieli there i^ tlie ;;rcaleat rii^k uti aceonnt of ttie extreme tenuity of
tbe coniea at the a|iex of the cone, tihonid, liowevcr, j»oHV>rfttinn occur,
tliv operation sliould he pgatponed for a few dHjre, until the aperture is
cto-«d. Tliu day after the operation, the floor of the gitp is to he lightly
touched, at two or three points, nltli a Bnely jtointed crayon of militated
iiitrale of silver (nitrate of silver 1 pnirt, nitrflic of potash 2 parts), the
effect of the cauterization being at oiicr neutralised by the application of
4»lt and water. The appttcatjnii of the ciiualic is to be rejH'ated at in-
ten'ah of from three to nix day^, until a Hl);^lit, fainily-yellowiiih infil-
tration is formed, with hut a moderate degree of pcrieonieal injection,
when we may consider the effect as sufficient, and simply apply atropiuo
to the evL' ami gnani it ai^ainAt expnanrr, The cautemation ^tinrrallyi
pnxluccs but very little irritation. Shoidd tlie infiltration nbow a len-
rlency to iit^sume the elinracter of a perfoi-atin;^ ulcer, the compress
liAiiilup;c must be employed niteniately with wanii aromatic fomentations,
iiitd it may even be iieeet^ary to perforin iwniecntcsis. The improve-
ment of tbe sight will not be at once apparent, indeed at first it may even
be deteriorated, but at the vnd of five or six weeks, when the infiltration
Ueifiiis to conliaet, it rapidly inercasea. the liltb cicatricial opucity ^^riid-
luilly tliminislics in size and dcn.'tity, nnd leaves tbe iiiight greatly im-
prove<l. \'<>D Graefe ha« performed this operation with great success in
several ca^es of severe conical curnen, and hs%s gained much heitvr
re^nltA than from the formalion of an artificial pupil. Mr. Ciitcbett baa
lately likewise obtained a most suueessful result by this proceeding tn a
case of double oonical coniea.
Mr, Itadei' has obtained very favorable results from excising au ellipti-
cal piece of the apex of tlie cone. The oiieralion is best done by trans-
fixing Uic apex of the cone with Oraefe's cataract knife, and then calling
oat fn>ui within outvtanls; in thi^ way a small flap is made, which is
then to lie seiiseil with iris forceps and excised with a pair of acissom.
"rigiually hf iraiislixed tlie apex of the cone with a small curved needle,
earrying a suture, prior to mrikiiig tbe incision with the knife, so that the
t1ai>s could afterwards he united by suture. It has been found, however,
that the wounil heats very readily without a suture. A bandage should
be kej*t over the eye until all redness nnd watering liave disappeared : if
a suture has been applied, it may remain in for A-^'t diiys. but umst be
removed if there is anv cbemosis or swelling of Uie lids. The chief di»-
• " Lanntt." Jko. 20, lr<73.
12
178
BISBABBS OF TUB CORNBA.
a<Ivanta;?c of this operation is, that it often leaves a very extenuvc adhe-
sion ftf the iris to the cicatrix, which may not only impair the nciiity of
vision, but prove of Bultsef^ueiit daugt-r to llie eye, in tlie same w»y a«
ontinary anterior synechigf . As it id ortcn rliflicnlt in this way to get
hoth sides of the opening of equal size and «liape, Mr. Critchett has in-
vented the following iiigt'iiiouB knife, it conai&ts of twn Sichel'fi hlade*
(the bnckanf which touch, and the |ioiiit nf oiip heiiij; a litlh- tnn^jer than
the other), wliicli are set upon one liandle. They are hinged togetiier,
so that tlicy can be set at any required angle, and he fixed there hr a
screw. The operation i« to be portormcd as follows: "The blftdes being-,
-firmly fixed at the dc»ircd angle, the point!) arc to pierce the cornea afc
the point of the cone to wliich llie cxcinion is to reach, passed steadily
on tlirt>ugh the anterior, chandler, brought out ut the oppo,dt« jioint "f
the cime. and jiuslied un until they have cut their wiiy out. Tliua R
ain&ll elliptical piece (both sides of which arc exactly equal and sharply
defined) of the ccniea will bo excised. Should ono side of this picca'
remain slightly adherent, it is to be snipped off with scissors.
Mr. Bowman has lately cnjployed a drill for excising a portion of thft'
cone, anil ha? favored ma witli the following description of this opera-
tion : —
" In 18ti9 1 had some small cutting trephines,' made by Meggm.
Wcift<), adapted, aamng otlier ur<eK,to e\cit^i' a defined circular jiortiou oFj
tlie Apex of A conical conioa. The iuHtrumcnt.^ vary in diameter, so as
t<i remove portions of ditfereiit shes, an requir<.'d. They arc also p:
vided with ;i ninvahle * wtop,' tn regtihite the depth of penetmtion. The
are rotated by the finger and thumb.
** Having found the application of caustic to the abraded surface
according (o Graefe's method to be followed by prolonged irritation, ~
soon abandoned lie use, and employed tlie trephines Ui remove nt once a
circular piece of cornea in its whole thickness, the portion included in
the itistninifut being seized hy fni;il] forceps and excised by fcissors as
soon art the ewciipu of aqut'oiw (luiiior showed that tfie chamber was (tcne-
trated At any part of the circle. A satisfactory modification of the
curvature vi&m thus obtained, but with the occojtional disadvantage which
is apt to attc-nd the complete removal of an elliptical or oUier shaped
portion by any other method, viz., tliat during the bealing of the gap,
* D» Wei^krr has also 1ai>.-1v dvvit«d a m-phiU'' wliidi 'i» t'onxlrmrlfol im (lie suu«
Iirlncl[i)<« a^ lliinrflimp'H nrlifinlal l<'<<c.)t. Tht- rnttin;; c.vliTHlriial liliMlf i* ln«lua«<l
in n Molkl Idbi', from wliidi It iloi.|i nut [irnlniili-, i-k«>[i1 hjhui jir<-xiiirr> iif ■ apritigi
At |tr<:^cnt 1i« only thfiUui tli« limlrtitiinil iii<)i'-utr<l— 1. Id I'ajtt-M of 'vmiph'lr cicatrti
.^r llio rorni^a, ntorr oiaiic^islly il Ihi- Ir-iis lia:! ■wriifnti diiriii^ tIx- mi ppii ration, a aribIJ
i^irctiUr |j"irltiiii of Ilie ii^iitrr nf ilm cic-jitrix in l<i If |iiii.-lifcl nut, n> a.* to liiavif n [wr
tusneni ttAiiiIn. Bv this pt-Mi-rdiii); clii< [intii'TitD luiij Enin a fuir Liti»liUiliv<.' pvrwt
ti<tn (if Uf;U\, aiilHi'irDt ]ifrtia|>r( to tiinlili- Ihrm tti lliiil 11i>-ir nav ab»ut, or even
ileoipbM' larp' li:<tlt'rM. '2. Jii r.-uirii of alanniln fjlniiniiiin^ in wtiicii n •ntiiifAi-t<ii
IridwiUiiu; o«nnol b>t mailf i^ti ucLtiuiil tif tliv fi'lviiiiu-NJ ulrujitij <>f lh» irii. And
■•imjilu lu'lcruttiuijr woulil mil snSin-. Ilcrf th^ I'tiiff nlijvrlv of tin- opf-ratintt an*
rclivvi,- llie patient uf Ili« iipvre pain, niiil lu afold llii' iiec'*!"it,v f"r unucl<-nlu<ii
tlm «i]rt>luM. A drciil.w |>or1lnn of I to l| niill)Hii-tr>.- in dinnift.r n to bo r>-tniiv«I
the fiijf;" uf iHi' c»ruc>i, L-ari- liring tnki'ii tn aroiil all rl*k of injury to thf li>tiH, nr i
Bp^rniuitiiiiK u» tliwclv to tlif I'tlJnry biiHy. Thus b liirgf dltr&Chi); cH-atrix ie vclat
llitbed. Vide "Anit<i* d'(,>rMitlMtii)Ur.'''Oct. 1612.
I
CONICAL CORHBA.
179
lb* pupillarr Wfrion of the iris, always contracteti wiiile the iu|tieoii8
lemlu, ia liable to ht>conie en^in-ieditj the wniinci, and an niilcrior ttvnechia
TCftult. To |iTfTcnt tliii* I practi-ied iritleotomy fiimuluincoufilv in coro»
fnwes, but 1 have ret-ciitly opfratvi in aiiotlier way. luBU-ad of carry-
ing ihc trephinf (jnite tlirftiiffh the cornea, T withdraw it when it ha«
nearly readied the mombranc of Deseemct. and then, seizing the piece
with fine forucps, dissect it off with a broad needle. The floor thus \ett
imnM^dintcly bii);;eft tike a hernia, and is then either punctured at it«
I'eiitre, or a aniall central jiortion of it is excised, the object \mnji to
ilhm- lerofKirary drainajie of the aiiiieniis. and thiiji promote the contrac-
'tion of the coniea. without the ri^k "f aiitcriur itvnechia: for the small
orifice made oti<rht to cc)rn>R{Mniil witli the centre of the pupil, and, to
innure accuracy in this respect^ I would suf^est the use of Calabar im-
mediately before operating, so that the tiite of the contracte<l pupil may
he a i^iide to the surgeon. If during the ensuing two or three weeks
the a<]oe'*u» is found to have re-accnnmlated. the central point is again
opened at intervalii of a few dava, no pain or irritation lieing tiiereby
occasioned. Indeed it is remarkable how little inconvenience attends
the whole prf>ceediu^. provided ordinary prudence be obsen'ed.
" The improvement of the curvature goes on during several weeka
after iJio final clo)>nre of the orifice, and shoidd any conicity be found
renininin-; afterwartr, a repetition of the operation on a Bmallor scale
will Fumisti the moans of eorrectiufr it.
" The opacity renultin-^ from thia mcKleof opcratiu'; seem* to be unex-
pectedly slight, but, if nK|uired, it may he concealed by the tattooing
proccM.
*' My experience thus far induces me to recommend this ojwration in
even the earlier slagea and sligbtcr degrees of conical cornea, as a
Bninller extent of coniea need then to be involved, and there must be a
much better prospect of recoveririj; a finite normal curvature than if the
operation be delayed until the h»\^ (jrows greater. A considerable
aavaiitagCf therefore, of this method would fteein to be that, by itit Iiann-
leiwneaa. it will admit of being applied to a number of sHgtu and in-
cipient ca-iv*. whicli the nurgeon haa hitherto been very timid in meddling
mill, not witbstani ling that they are attended with great defects of vision,
which no optical contrivance will correct."
At prevent it miut be ailmitted that all these modern methods of treat-
iBMit of conical cornea are still npon their trial, and nothing decisive can
as yet be «nid u« to their relative ndvantages or didud vantages. Hie
BtmpIeAt anri eai^ir^it ii* without doubt the formation nf a central ulcer
<tini«'f.''* iiicfhod), e>t[K'cially if the denudation be made as T have sug-
gcatcd, by simply »:niping olf the epithelium and :>uperticial layer of
eomca. It certainly requires u longer time than excision or drilling out
of a piece, but it is al«o much easier. Should a central leucoma be left,
an iridectomy would improve the sight, and tattooing the opacity would
improve tlie ap{^H>anii»ce.'
f Annnlm irOrnliiiiiijan.lxviii, p. 137 : CI itiiifa'' Ophtlialinvlofriiine, Paris, 18T4. —
TiARM. VitUi luUTiiAt. Uplttltal. {'ongtvft; p. 72.— H.]
180
DISBASES UP TUB fOHMBA.
iO._KF,RATO.GT,OrtI'S aiYT>ROrnTnALMI A ANTERIOR
IIYHROPS or TIIK ANTKlilOK CIIAMUliK).
This dineate ifi characterized 1)V a uniform spherical ImlinTif; of i|
wliolo cornea, ao that it 18 incrpa^ed in aizc in all its iliiimeters. I^u
4.').] (ieiicrally. however, this increase in size
[?%. -45. not confined to the cornea, Imt extends to the noit,
borittg portion of the sclerotic. The Aiijpnentaiic
iti t!io size of the anterior hnlf of Uie cveball
often so coiisidcrahlc, that tl)« eye protrude* \k
tween the palpebral aperture, and |irt'vcnl« ihe^
caay cloBuru of the evelida. On aucoimt of tlie
].ecoliar staring appearance which this gives to iho
cyv, the diseast! Iiiu) also Iwen termed ^-huuhthat
*n«T,w.j«.»,i """•" '^""^ hydrophthjilmos or bu].hthftlmua i^
alvravs conji^^nital. bur an important and verv ll
terestins account of ibia ifiae&se, I wiiuld refer the reader to n ili^r.
tion on llydrnpthalmud con-jenitns, liy Dr. Wilhelni v. Murali, of /uHct
hased on case-* which oucurred in I'rofessor lioriicr'n Clini<|iie.
Tlie comen may either remnin traiiaparent or V*coiiie sti;;htiy opa^|(_
near the poripherv; in other caeets tlie cloudiness may he more cousie
enable, and extend over the greater portion of the surface of tlie cornea.
The anterior [wrtion of the Hclenuic i* much thinned and of a blue tint,'
which 19 dne to a shininj; through of tlie choroid. The size of the an- i
terior ulmmhcr is much increased, botli in de[>th and uin;uinference,^B
The B*|Heou8 humor in generally clear. The iris is also enlarged, anii^^
the fibres near it« ciliary iMar-^in are stretched and opened up : the pupil
i8 generally somewhat dilated and sluSw'*h, and perha])fl here and there
adherent to the capsnlo. The iris is often eoinenhiit cupped l>ack, which
increuses still nn>re the depth of the antcrinr chaniher, and it niav nlsa
be trcraidoHs. which may bo either due to ihslocation of the Icna, caiue4
by a stretching and ^viiig way of ita suspensory li}^ment,or to the iris
Iwidg no longer in c<intact with the anterior surface of the lens, but
divided from it by a ctdlcction r>f fiuid In the [itiinterior chamber. Some-
times, however, the iris is bulj^ed forwards. But as the diseastc aJ-
vaiiec)!, the optic disk Wcoines excavated frnjn the permanent increase in i
the intra-ocular tension, the lens becomes opaque, the vitreoua humor^M
fluid, the retina perhiips delaclitd, ami atrophy of the eyeball may close ™
the scene. On account of the great attenuation of tho anterior portion
of the coat of the eye, even a slight blow may suffice to rupture the
globe, lint whether this may occur sjiouumenusly is douhtful. The
state of the sight varies eoit-sidcrahly. In somi* cases, the patient can
still decipher moderate sixed print ; in othors it is greatly impaired, which
may be due to the ojiacity i<f tliu coniea, or to iuHummation of tlie deeper
tunics of the eye. As a rule the disease termhiales sooner or later i
blindness.
The aflection doo<t not appear to be duo to an tncreftsd aecreUen a
■ Znrich, publiih«d bj ZQr(rli«r and Knrror, 1069.
i
8TAPDVL0UA OF TUB CORVSA AND IRtS.
181
the fb[iiroa9 hninor, hut to a thinning an<l cUminndon in tlif power of
r««i»tnnoe of the conieH, following ^nerally u[kiii severe ami extonsivc
inflammation of tlic conien, n»), for instnnco, viiAculnr k«nititiH or piinnii!>.
TLo upai-ity may afterwards disappear, hot tli*^ bulKing remain;*, ami
eTen grailuiiltv ait;;mrntd. TrnituitMit, iinrortiiritttely. h hub t^iii often of
little avail. I'lift nmst is to bo cxpcct4>d from a lar^c iridectomy. The
pftticiit's ceueral bosllli should be strengthened, and the eves be but
modpmtely eraphiycd. If tlie protrusion ia very considerable, tho cor-
nea 0}ia4fue, and the sight nlmr>st entirely gone, an operation for stapby-
loDM may he indieated, not only for the sake of appoanincu of the eyr,
but abo tn allcvhite (he inoonvenietHre and coiifitant irritation kept up by
the iocompletv vlo«ure of the eyelidd.
il._STAriIVLOMA OF TlIK CORNEA AND IRIS.
Wo have already seen that wlien nn ulcer of the cornea cnusea perfft-
mtioii vi tilt- latter, the a<|ueous hunmr tiowji ofl'. the iris fallu forward,
aiwl may become adherent to the cornea. If tlie jN-rforation is of hut
)dit(lit extent, an anterior ayneehia will bo produced, vriiliout perhaiw any
balding of tliQ cornea at tiiis \m\iL But if the opening is lar^e, a coii-
aiderahlc (mrtion of iHa will fall against or into the gap, and perha[u
IPig. 46.
FlB- 47.
/
,.V
^^m^f
tMn *l*w. An*r Mackend*.
rr ui < .•in'Mfie.]
pmtrnde tlirou^h it. givin<{ rine to a more or Ie»i> extensive prolapae. Thi:f
ta 80*»n covered with a layer of lymph, which beooroes or-janisted, gratlu-
ally a«8uuies a cicatrici.il oliaracter, and replaces the cornea at this point,
to which it may indeed hear a certain outward resemblanoc. It is, how
ever, much weakt-r and le** elastic, so that it readily ytt^lds to the inlra-
crcular pretiHuro. >;radua]ly hulj^ufl forwanl, »ud givett rise to a |>artin1
Btaphyloma. [Fiics, -Jti. 47.] If the latter i» aitiiatcd at the margin of
the cornea, the pupil may remain partially or entirely free, and a cerljiin
I ftiDouui of sight be prciterved. But it the prolapse occurs in the ountrej
182
UieSASES OF THB COKNSA.
ly-
die wliolc pupil will be involved. A partial sUphylomn may gratlimlljrl
increase, iintil it impliciices tlte aurromidinj; conicft W a considuniMtt
extent, and if the pcrforntion was oripnally of krgc size, it may, fiually,
6%'vu iuvulvQ Lhe wliolc cuniva, uml becouiti cliau^ed luto li total Blapby-
loiiin. Wlu^n till! proit'Ctioii Iulj become ut nil coiiHiilurable, so as to pm.
truik' somtjwiiat between die liis, its exposure to the action uf external
irritants ia apt to protluve occasional iiiHamcnatory exacerbations, wbicbj
tend to cause a still greater increase in tlic size of the ^tApliyloraa.
The roost frequent causes of partial Btapliybtoa ai-e alouf^lia and ulcei
of the cornea, wounds and injuries, mid also certain operarions upon tliC'
eye. a» for instadce, flap extraction, whiclt may be followed by a coii-
aidoritblD prola])»i- of llio iris and tlic formation of a |>urtial HtJipliyloma.
No time ahoul.l he jtllowed to c!apsi> Wfore the tfiuUincy to staphylutoa^
is checked. Thu^ if a prolapse of the iris bus occurred, it ahoulJ
treat*.'d at oncu by the proper remedies. The best treatment for partii
staphyloma is undoubt-edly by iridectomy, as this, by diminishing thoj
intrii-ocuhir pressure, not only proventa tlie increase of the biiliiin;;. bt
generally al*o causes it (o decrease in size. The artificial pupil shoiiU
be luAde oj)]K)i«ite to the most transpiirent portion of the uoniva. I uiuat
here a<;niu mention the very lm|Hirt;uil. faet that ca^cit of |Mknial or coui^_
plctc Aiapliyloma are flomctimc-H uccompanied by marked ii>cre»Ae of ten^H
uiuu, t>o that Uie eye itf lu a glauuuumtoud uoudillun, and Uie degree oE^^
impainneiit nf vision tpiito rlitiproportionntc to th» amount of stapliyloma
and opacity of the cornea. In such cases there will be increase i>f tciisioi
accompanied perhnp* by contraction of the field, eccentric fixation, and
excavation of the optic nerve. In all oase» of staphyloma tiic de^
of tent^ion, the i^tate of tlie tight and of the fiehl of vision must titer
fore be carefully watched, and an iridectoniy iniwi be on no account de
layetl if sympt^^inrt nf glaiic^'uia su[HTvene. I think this treatment
pHT-tJnl rtt;ipliyl(Hna hy iriiiectoniy ;;ix'atly preferable ti» tliat which was'
formerly much in vojjue, vi/,., tlie tuiicliing the protrusion with nitrate of
silver, and thus changing it into an ulcer, which, on cicatrizing, would
produce a flattening ait<l slinnking of the staphyloniatous tissue. This
is apt to get up coui^idenible irritation, and proves far less efficaciuurt than
an ii'idi'ctoniy. Partial uhscU&iun may aUo be performed by a modilica-
tion of <Jritchctt*!t operation. -
IS— TOTAL STAPHYLOMA OF THE CORNEA AND IRIS.
This only occurs in cnsos in which there has been an almost total dc
gtruction of the cornea by sloughing or ulceration. Its shape is generallj
spherical [Fig. 4H3, itlthougli occasionally it may be conical. Tiic nuigU*
iHiring portion of iIh^ sclerotic unwily liccomes impliualed in the pr»H;e,)W,i
atid the stuphylonji) may, in time, involve the anterior half of tbe eyeball.
The tens inuy either have escHpud at the time uf thn perforation, or have
remained behind, in which oisc it often becomos opanue. Its posttton
within the eye varies ; it generally lies in close contact with Uie iris and
the cicatricial tissue, to wiileh it becomes adherent; it nmy, however, be
separated from the iris by a considerable amount of aqueous bauior,
TOTAL STAPHYLOMA OF TUE CORNEA A7C0 iniS.
1«»
wliioh forms a largo |ioatenur cliamUer ; or, a^in, it may have become
■leiaclieil from tike sii8{>eu8ory UgAtnent and liave sunk down into the
vitrcoiis humor.
Tbc prpacncc or akaonce of the lens aft«r an extomiivc perforation of
the comes exerw ^rcat hittnenco upon thu furmaliuii of a BtApiijrlotuii
If thf h>n8 eAcapCtl at the };tving way of
thecontea, a tirm cicatrix id formud, which [Flg*4t).]
will };rnerally resist die intra-oeiilar pres*
mir«*, luiii not bulj^ forward, hut will ott«n
liceome consolUmted, contract, and lead,
pt'r)ia]>8. to a CLTtain de;^ree of slirinkin;!
of the globe. It i* diderent. however, if
tlie lend lia« remained witliiu the eye, for
it then bulj^eii forward, and presses upon
the no«ly formed cicatricial tijwue. which
j»radiiiilly yiehU and becomes staphyloma-
tou*. If. therefore,* case nl'cxiensivfj pHrfo-
ration of the cornea, with a tendency to staphyloma. \s Heen at an early
sta^. and the lena i:^ fonnd pressing a^inst the cicatrix, it i^ he^t to
miiovc it at oiicc, so a« to allow the cicatrix to become Brm and cont^oli-
iLitttd. The luna may be removed hy luakiit^ an inciition into t-he ataptiy-
lom.i wiOi flmcfe's cataraet knife, dividing ibe enpsulc, and allowinj; the
len« til escape, Ur, it m ly he done a.'CorUin;^ tJ the following proceeding
of Mr. lionutaa, wliieh 1 have acuii answer remarkably well in Keveral
CMti. lie paases a bi-oad needle through the staphyloma into the tens,
ami breaks this freely up. The needle having lieen withdrawn, a curette
ia paftftO'l tlirou;;h the Hamc opt-ning, and the soft lens matter allowed to
e*eape. The brcakinj^ up of the lens may be repealed at intervals of a
few day9. The Htaphvlomalovu protrusion wilt ;;mdually sub-tide, the
cicatrix will bwume lirm find ctosolidaU-d, and the eye pt-rbaps shrink
aomewbat. When all riymptoin^i of irritation have auh-Aided, an artiticial
eje may often be wnm without the noec.t.'^ity of any further operation.
As we cannot restore any sigbt in c«de6 of total staphyloma, the ob-
J jct't of our trentraunt mnnt he t»i remove the. protnii^ion, so ad to free the
pa.tJciit from tbv pain and inconvenience which j;cnerally attend thia dia-
eiif^i:, and also to improve the per?i>nal ajipearanee and permit of the
atlnplAtion of an artificial eye. There are numerous modes of operating
fur atapbvloma, of wliich the following only retiuiru mention: 1. Ex-
cisioo. 2. Mr. Critchcti's o{>eration of abscitfion. 8. liraofe'a iteum
operation, -l. Borolli'd operation.
[ Total and even partial abscission of the 8ta|ibyIoiiia is dBn;ierou8,
when there arc flijpid of increaM-il intm.Dcubir tension and conscipient
amanroiiia; in other wonts, st;condary glaucoma. In these cases enu-
cleation lA the only permissible operation. — U.]
I. £rcithn. — This is beat perfonned in the following manner. The
point of a Ciitaract knife (the e<l;;e uf wtiieli i>) turned donnwardn, a>( in
rljl. II* > ia to be pjisaed intti the wlemtie, near the edge of the utapby-
loma. and tioniewhat abovu it4 horizontal diameter, ^> that about { of
tlic jtUipliyliona may he included in tiie inei.^ion. The blade of the knife
ia to be carried on parallel to the base of the tumor, until its point makes
184
DtSBASES OP TtIB COItNIEA.
its exit ot llie opposite sido, at a fl)Kit corrp^^ponrting to the puncture.
The knife shoulil then Lc pu-fliei) ^Inwljr on, until it liae cut its wav out
Hitrt (lividtiil tlie toKer | ol' the stnjiliylnnm. hv a lor^c flnp-iihnpca iu-
ciuon. Tlie remaining poriiou is next to W iliviilcd hy the aid of a pair
ofsuiiworB. A Ifaritinj^* is then
"■ to Iw! upplied, eitlicr to;refhor
vfiili water dressing or a (dimple
pledf^et of lint. I.vmph will be
effused from the edges of eJie
incision, and a more or less firm
cicatrix reAutt ; the e_ve>Nill will
uiirink somewhat, hut Ieav« per.
Iia{i6 a tolerably jn>od stumiifnr
the application of an artincial
eye. The result of the opera-
tion 18 tiot, however, alwava m
favorable. A coMsidenihle yugh
of vitrooufl hnnmr nuiv follow
upon the exci*iou of the ante-
rior portion of the ere, and in-
tra-ocular hemorrliage ensue.
Or, a^ain, soppiiration of the
eye may take pl»W' iiccompanied, porhiips. by very violent pain and
inHamnint 'Ui. The eyebftll then shrtiikn and dwindles down, leaving but
a very snirtll and inetticipnt atump, with a sli;:lit degree of movement, for
the applicntion o( an arlificial eye. To ohviaw these di sad vantages »
Mr. Critchett has emj'Inyed the following iupenious and valuablo opera-
tion of nhseisaion, which h-aves nn excellent, large, movable stump.
Yig. 5».
AnarBUII«itf.
AfUc LkWaoB.
2. Mr. Critchctl'i!.' operation of &l)»ci8«ion is to be performed tbas :
** Tlie patient being place<l under tJie intliienuc of chloroform, the staphy-
loma it freely exposed by means of a wire speculum ; a series of four or
6vc rather amal) needles, with a semicircular curve, aro passed through
> " Uoy. IfiOil. 0|iblh. iloBit. H«port»," !▼. 1,
TOTAL STAMITLOMA OP TBB C0RX8A AND IBIS.
186
tlie inaM, about eqiiitliatnnt from each other, and st sucli po'uits as the
lines «f inoiMon arc intcndefl to travorsc (Kig. 50). These nccHles are
left in this position, witli twtli trxtrvmitiu!! pn)tru'tiu}^ to ttii eiiuAl extent
from die etAphvlonm. The iiilv»ril:i;;t-.s }*;iiiitMl hy tliid )iart. of tlie pi'O-
ceedin^are: 1. That a sQiiilltiniintity of the flui<l partes of the (1i^t«>nile't
globe cscaiieH, thus (liiiiirii8liiii<: pi-essure, ami pri-vci)t.iii<; a ^iifMeti ;;iiHb
of th« contfnta, when ilie nmepior ]>art U removed. 2. That the points
of enicrf^ence iiulicale the line» of hicieion. 8. That the
[Fig. fti.] prcscnec of the neeiUeit prevents, or rather, reairaina, lo
some exteDt, the escipe <>f the leiix ami vitreous hiitoor, after
the anterior [tart of the Htaphyloma hns been rtMiiuvcil. The
next stage of the pmcrcilinf; is to remove the anterior part of
the ataphyloma. This requires sotnc judgment unil imxlifi-
cation in size onrl fonu^ in accordance with the extent of the
enlargement, w» as to leave a convenient glohe. My u^nal
plan h to nmke an openin;^ in the aclerotie. ahout two lines
in extent, just anlfrior to the tcnilinoua inwrtion tif the ex-
lenial rectus, made with a Iteer's knife [Fij;. •">!]. Into
thin opt^nin^ [ insert a [latr of small pm ho -pointed sciMon,
and cut out an elliptical piece, just within tlie fointa where
the needles have entered and emerged. The iiuedles, armed
vith fine hlaclc )silk,are t)ien dravn tlirongl) each in its turn,
and the ^iitnres are carer«lly tied, so «g lo approximate aii
cIo:i(dy aa |ioswihIe the divided edges of the sclerotic and con-
junctiva (.Fig- 52). The operation is now finished ; the
Fir. S2.
^
Attitr LkWM*.
ajiecuhini may he ronioved ao as to allow the lids to close,
and wet tint may he applied to Veep the parts cool. In a
large majority of cases, union of the divided edge« takes
place by the first intention.". ..." I gi'iicrally leave
the Butiires in for some weeks. Sometimes they come away
apontaneoualy, and when thi-i is not the case, they may read-
ily be removed after all irritation has paased away, and after
fino union has taken place. If the caae be examined Uirac or four
monthft after the operation, a movable globe is seen with a flattened ante*
18S
DtSKASES or TIIE CORHKA,
rior surface, traverwd hy a wliite line of cicatrix, ami baling nitluT t
prominent ext<'nial aii;;]e. V]K>n this an artificial vyo can fie rea-lily
ailaptetl, wliicK move* to a jp-caur extent than I ha*'c oltacrved previoiu
to adoption of my prcftfiit method."
Care must h« taken in making the inciHinti, m ti> HlofM and bcvnl oB
tite artfrles, tbnt the lips of the wound here tit very accurutuly and neatly,
fithorwise an awkward pucker may be left at those [ioint<), which will
interfere niat-oi-ially with the comfort of wearing an artificial eye. It ia
alwiiys Ifcst, except perhaps in younj; childpeu, or where the staphyloma
is small, to employ five simires, in order that too f^rcat an interval may
not U' left t>etween them, for if this} be the case, bvadn of vitreous wilt
iiri>trude, become covered wicb ^raiuilatious, and tnuppiirate Homewha;.
My experience of Mr. Criichctl's operation has certainly been moAt favor.
able, and I can entirely endorse his statement, that we gain by It a bet-
ter and more perfectly movable »tump for an artifieial eye, than by any
other operation. I do not, howi-vcr, tldnk it indicated in thu*e cases in
which the disease ig not confined to the anterior portion of tlie evcball,
but tlie inflammation has extended to the retina and choroid. For in
such cases, the operation is not only often followcil by perhaps iiuiue<liat«
and Hcvoni iiitrti-ticuhir lifmorrha^ie li-iiding to suppunitiiMi of the ^lolw,
b'lt we leave boliiud .1 juirt «f the dij-oaned Hlructiire, which may not only
become a;;iiin inflamed, but, wlist u* .-itill more to be dreaded, be tlie cause
of syiapAthecic inflammnlion in the other eye. In all such oaacs, it is
therefore undoubtedly by far the safest plan to remove the whole eve-
hall, as this frees ua from alt fear of sympathetic opbthnlmia. If tbft'
patient is in ;;or>il ciix-umatancea, uml i«i »o nituated llmt be can at once
apply to a surgeon, if the stump bceomCH iiittaiued, or i:>yinpti>ni4 of Aym-
pftthetic irritation show thcmst^K■c■s, artrl if he is extremely anxioiL* about
Ins pensonal appearance. ab)«ciifsion muy be performed, otherwise it 15
safest to ri'move the staphytumatous eye Rlto^iether. 1 must here state,
that in the " Dublin Quarterly .Toanial of Medical Science" for 18-17,
vol. iii. p. 212, Mr. (now Sir William) Wilde drew attention to a new
operation which he had devised for the removal of staphvlonia. Thiit
con^iitted in the introduction iif a curved needle tbnui^h the ha^tc of the
Btaphyloma, then removing the conical pnijt>etion with a eatamrt knife
and Bciftsors, drawing the needle thnuijtii, «nd tying the ligature. Sir
William Wilde Hubsei|Ueully sumeuines employed several ligatures.
In onlcr t« avoid, if powrtiblc, any risk of sympatlietic irritation of
the other eye, which mit;ht be awakened by the passage of the needle*
through the ciliary region, or the presence of the threads at this point
for S-14 diiys, Knapp' has devised the following modification of Crilcb-
ett's operation. Instead of pa««9ing the needles and sutures tbrougli the
ciliary region or cornea, he passes them tlirough the conjunctiva by
tm'iiii» of two needles, 'niis proceeding i« illustrat^'d in Fig. 63. A tine,
tbivaded needle is inserted in tite conjunctiva, about 4-0 mm. above the
ba<t4.' of the ataphyloran, and •lomi-what to the inner side of the vertical
meridian (Fig. 53, <>)■ '^ ^'^ pai^^ed beneath the conjunctiva and aubcun-
junctival tinsue towartU the nosu, and brought out at the inner edge of
the ba«e of the staphyloma (ft). Thence the wiino needle and thread
' *'A. t 0." xW. 2, 275.
tOTAL STAPUVLOMA OF TUB CORNEA ASD IKIS.
18T
I
ad over Oie HlA)iti^Ioma to it» lower margin l', and there again
itiflertcNi ill tlie conjunciiva and |)as»<.'tl K-ueatli it Ui d. The snxao jrru*
ec4?4liii^ IS repeated on tbu outer portion of tlie staplijlomn at e,/, g, A.
Tlie threads are then well
laiil baok out of tlie way of pig. 93^
tlie liue« of the incision, and
thv Htaphvlonm excised as in
Crilchctt'i* operation. The
two ends of tUo thread, f /'
and *« m', arc then firmly
tied, »o that tlio li|>a of the
im:i>4ioii arc hruu;;lit into
cloac contact. The threads
■re to be reniored at the
end of 'A-~\ ihiys.
8. Von (?nwf«V I'ptra-
ti"n Iti/ fief-m conriifitM in pass-
ing A •loiible threitd parallel
to the cornea, throic^h the I J \-jfi,
coata of thu eyobiill (hnt not
where they arc tJiinned) and
the vitreous humor, so as to include thciii within a suture to an extent of
four or five linos. The ihreiuls are not to he tied tighlly, hnt lelt in a
loo^c loop, ami their ends are to he snipped off close to the knot. A li^ht
ooraprciw ia to be applied to \he Vuh. Within froai l.i to S2 liours, acute
ayniptoma of suppurative clioroiditis generally iniperve'ne, accompanied by
flobconjiinetit'al clicmoais, sli^^ht iininohiliiy of tJie lateral movements of
the eye, and p<trhap* a certain degree of proiriL'sion of the glnhe. The
threads are then t^> he removed, and warm camomile or poppy fomenta-
tiona shonid he applied to alleviate the puiii. The eyehull after u time
hvc«iine)> j^hriink and atrophied. I linve seen one caM successfully treated
^by Mr. Itowman in a iiomowhat similar manner. The tht-eads wcre.how-
erer. left in for some time and occa,ti(mnlly moved. There vrcre DO
Mvere SYinpt<]OU of intluiiiiiialtnn, »nd the eye gradually diminiithed to
Pbout half 'n» ori>^nal rtize, nnd .<in artificial eye \s now uorn with enm-
fort. The i^reat advantjiye of this proceediiiy is, that there is no ton-
deney U) .-tympachetic iuHamniauon, which appeara uever to ensue upon
auppiirative choroidilijs.
4. Dr. Borelli transfixes the staphyloma by tvro neciUes, which aro
passed through the base of the proiruHion, ro as to cto^a each other at
rij^ht anj(k'3. The one is entered at the temporal side, midway between
the vertical and horixuutal meridian of the unniea. passed beneatli the
liinKir, .ind hrou;|rlii oui at a corresponthn^ point at tho opjHwite side.
Thiii pin may he entered either above or below Uie horixontnl meridian^
as appears nio»t convenient to the operator. Tlie second pin is then to
■ be introduced at right angles to the lirsl, so that they form a ci'wjis ( X ).
A Uireod is tlion passed round the stapliyhnua beliind ilie piiiit, and
tightly tiwl ; the ends may he twistcil ami fastened to the check. Sim-
ple cerate dressing and a compress bandage should bo applied. At the
• "An^ir f. Ophthaliuologjff," li. 2. lOS.
I
18«
DIABASES OF THE CORNEA.
end of the thirri liuy the protrusion, tof^cther witii tlje iiiiis tml thread.
is generwily foHiid to be detnchcd, aiifl on the eigjhth or iiintli liny ila-
wouud is firmly cicatrized. If the sta[>liyloiiift is total or lar^j*. a.* litik-
H& poi«sthlc ghotthl be included between the pina. and the threads i«hDulij
not be drawn too tight, lest the Ptrnngulated portion mij;ht give way, or
severe o|ihtli»lnii(ifi he Act up. In partial fttnphyloma its whole ba^e
shotdd ho included, and the threads tied cloao and ti^ht within the
mainirijj cornt-a. 1 have had no personal experience of thii* ofH?ratiDll,f
but it has been stroni;Iy recomnienilfd hy several eniiiieut anrj^eon*.
more especially for partial staphyloma, as it leaves a good portion of
clear comea, behind which to make an artiGcial pupil. The operatiou u
almoHt free from danger, and leaves^st the worst, a firm movable stun:
for an artificial eye.'
De Wecker has lately devised the following oitrratiim, and has favored
me with the subjoined description of his* mode of operating: The patient
having been chlorofonned, the lids are to be kept apart by Deeuiarres*
lid holders (as they separat* them very widely and thus affiinl more
room for the opemtion). The conjunetiva is tlien to be carefully divided
with flctsiwra all round the comen, and near the edge of the hitler, tl
goissont being pulsed freely between the conjunctiva anil itclerotie no
to ilotJich the foruwr as much as [rossible up to the ei|U!itor of the eye-
ball. Kour sutured are then to be inserted. A neeillu ithould be passett^
from without iuwardit through tho conjunctiva near tlio lower edge
the cornea; the same ueedU- should tlieu he made to jwrfnrate tlie con-
jnnelivii atmiit the upper mnrgin of the conien at an eijual distance from
the comer of the flap: this perforation must be from within outwards,
and Ao that the nee<lle isauett about *2 or A milliroetrea from the edge of
tJic tiap- Four loops arc to be made in thi« way (as is shown in Fig.
5-1, II Hy h h,e c, d (2), two of which should he tunicd over towards tbe
temple, the other two towards
Fig. &4. the nose, before we pfKvetl
to excitw the staphyloma.
The latter is to he done by
transfixing tho liase of the
tumor with Oniefe's kinfe,
and tlieu cutting straight
nut, the two halvea bei
llu-n carefully oxcii»cd with
scissors by two semicircular
incisions near the edge of
the cornea. If the lens is
iU)l sponlnneously expelled,
the capsule should bo opened
with the cystotomo, atxl
after the exit of the Ions the
sutures should be brought
together, in order to avoid
any mistake being made be-
' VIiIp nil rxcllitDt ilo^'rlptloii of lliis opprallon in iho PraiKU TrRUstkUuD of
M«tikifoik<''» DuKiMcti o( tiK' Kyi; vtA. Hi., IM?.
ed
id
IRJURIS8 AND W0U>'D8 OF TRB OORNBA.
189
twceri tUem, we razy empioy fine silk of different colors. On account of
ibc conjiitictiva Kliiling very rca<li1,v over the scterotrc, we can obtain a
nio«t Accumte coaptalion of the eilj^v» of the woiiitd, ami if the patient
baa bet-n chmr>u<;blj untler the inSucnce of chlorororm there will probably
^K he tin I'^c'Hiie of vitreoiH hnmnr. Shoiili] tlie vitrcoiM shnvt n tendency
^M to bulge between two of the smureit. aimtlicr rihuubl be itliortutl at tllin
H point, 80 as to coinpresa it and keep it biiek.
I
I3_1NMI'RIKS AND WOUNDS OF THE COUNEA.
F'trri^lH fH/flim are frequently met with on the onniea, and amongst
the tnottt coniHion are cWijm or splititeriK of iron, steel, wood, >;]a:!(a, etc.,
which have become lodged or impQCled on the suriace, or more or leos
deeply in iho HubKtanee uf the cornea. The presence of a foreign body
on the eomea i^CDerally at once excites coinfiderHblo reaction. The eye
btHJonieit |]ut;)ied aud painful, and this i» acconipanitul by photo|^inbia
and lachryniaiion. There \a a well-marked roay zone aroiin<l the cor-
nea, and, on a(^\-imiit of the ciliary irritation, the pupil ia contracted.
There is generally no difficulty in detecting the presence of a foreign
hody in the cornea, more eitpecially if the former is dark (e. g., a chip
of atcvl or iron)^ and if the eye id turned sideways to the light. But
if any dnuht exists aa to llic protencc and exact ttitiiatioii of a foreign
lMtc|y,Htni|iinp should be a|iplied. and llic eye exnniincd with the obliiiiie
illumination, and, if neccs^sary, with the aid of a inH^nifving glass, 'ihe
tt'tvantage of employing atropine is, that the dark backgrontid afforded
by the widely dilated pupil throws the coniea into strong relief, and
titus facililQles tJic detection of a foreign boily, parlJL-nlarly if this be
iigliC C'iloreil, m, for iiii)taiioe. a ^plintur of gtas^.
If the foreign body \* situated HiipurticiAlly, and is early removed, no
trace of it^ pri:-4L-nce may remain. If, however, it baa escaped iletec*
tion, or the patient baa not nought relief, aud the foreign body ia allowed
to remain in ttie ooniea, it may set up very considerable cornoitis. and
ei'en iriiia, accompanied, perhaps, with hypopyon. The cornea around
the forei:;n body becomea infiltrated, and eren a more or lesa extensive
nicer may be I'onned, or auppuralivo comeitis may supervene, with hypo-
pyon, iritiE}, and sloughing of the cornea. This is often observed in
aj^rd and decrepit individualii. when a foreign body {e. j/., a portion of
«r|t«at ear, a aplinlor of glaM) has Wcotne impacted in the substance of
tiie uomea. In other ami rarer instanci-d, a layer of lymph surrounds
and cricafHuJes the foreign btKly, which remains innocuius in the very
aubstmice of the cornea. Somctiim'* a splinter of fttecl or iron pasues
|iartly ttiniiigh the cornea, and projects somewhat into the anterior
ehaiuber. lying half in the latter, and half in the cornea.
There is generally no difficulty in removing chips of steel, iron, or
jtlOM Ui4lged npon the anterior surface of ttio oonica, close bonoatb the
epithelial layer. As a rule, I alwav-i prefer to keep the eyelids apart
with liie stop apcculnm, ami to fix ilic eye with a pair of forceps. Ity
ao doing, we avoid all risk from any sudden movement or utart of the
patient, and can accomplish [!;e removal of the foreign body very quickly
IftO
D18EASB8 OP TBB CORnSA.
ami cfTiciently. Tlic application of the spccnlum and foircpe undaulit-
cilljr eausts «omc tlcgree of pain, hut thii* is roorfi than counterbalanced
hy the axlvautaj^u of liavinjE the eye completely umler our control. I
have but too often seen that. afttT numerous ineflrctual and painful
attempts to remove the foreign body, they had. after all, to be emijloyod.
The putient should sit on a chair, cither directly facing the lisht. or if
the foreign tody can be Wtrer seen, with the fnce turned eidcwsy*
towanlrt it, and htii; head ^hoiihl lean Imck a^aiiiitt the hreast of the ofier-
atAr, who should stand behind him. Harin;; applied the speculum, the
surgeon steadies the eyeball with a pair of forceps held in his left han^l.
and endeavors to remove the Ibreigii body with the spud, by pa.sijiiig (he
Inatrument behind it and thus lifting it out. If the forei;rn IhxIv is iin.
pacted deeply tu tlic substance of the cornea, there arise* the danper
that in our endeavors to remove it we should piwh it further in, or cause
it to |>erforate and full into the anterior chamber. A broad needle
shoidd in ttucli a ca^e be CkrefitUy parsed behind the forei^ h<Hly, and
tliux bo lifted out. If it Itc» very near the pO!*terior w!»ll of the cornea,
tlic needle may Ik* passed into the anterior clininber and the broad part
of its blade pressed against that portion of the posterior wall of the cor-
nea which is oppofcite the rorei};n body, 80 aa to steady Ihie, and llieii it
may be removed with anotlier nee<lle, or a very fine pair of forceps. A
similar proceeding is to be adopted if the foreign body protrudes partly
into the anterior cliamlK-r. for then an iridectomy knife or a broad needle
should be paH.tcd iuto the latter and pushed behind the foreign bodr.
gently pressing this back into the coruea ; its anterior end should be
Beised with a jHiir of forccpa. and in this way it may be readily ex-
tracte^l. [A better way i« to transfix the corttca with either a broad
(rraefc's cataract knife, or even a lieer'e cataract knife, making the
points of entratKO and exit on cither side of the foreijrn body. ITien
press the flat side of the knife against the posterior surface of the o>r-
iiea. or ajrainsl the foreign body, if it reaches into the BnleriorchainlHT.
thns hnhlin;; it in place, and preventinjj it falling t« the liottom of the
chamber. Then enlarge the wound in the cornea made bv the foreign
body, and remove the latter either by forceps or acoop.— St.] If a bit
of steel is situated on the surface of the comeu. it may also be removed
with a nift^iet. After the removal of a foreifi^n Itody from the cornea, a
drop or two of castor nil shoidd be applied to the eye to lubricate the
{inrt«i. Afterwanici atropine should be applied, in order to allay the
irritation. If the latter is consitlcrabte, and accompanied by rtevoro
ciliary neural;;ia, cold compresses and leeches are indicated, followed by
warm poppy fomentations. The iwe of tlie eyes must he forbidden until
all .-tymptoma of irritation have Aubsided.
The eflvctst which bums, injuries from (ptickliiiic, rooUen lead, and
chemical a<,^ntM may have u[>on tlie cornea have already been described
in the section on injuries to the conjunctiva ( p. 1*20), and the lumc course
of treatment is to be pursued as was advocated there.
Woynti* of thf Cvrnct. — The dan^r to be feared from those varies
acconiinj; to their extent, j^ilnation, and nature. It occasionally hn] ■ ■■-
tliat a very sujH'rficial cut with a sharp instrument does not perforai'
cornea, but airoply penetrates into it4 sul*stance, and forms a small flap.
TrMORS or TDB CORNBi.
191
litoh may heal re»4Uy,^_y tlic first intention, wiilioiit leaving any trace.
Thtw ft dniall, clean uut or punctun.- uf the conioa rre<jiientlv Leuld without
any mark beliinti, a^ ift <luity cviilcmvd liy o|)(.'mlinni4 iifion llic
«a, fur iiisUuce. tlio.-<« for cataract, cither pci-formetl with a knife
or by the tiee<i!e. Tin- chief danj^er nf |>ciietnitiiig winnHlc nf the cornea
Is that they may ran^c c^nsiderahle prolapse of the \ ris, or lliat tin-y Hlioiihi
UDplicate the iri>s and lena, and thus set up severe iritis or traumatic cata-
ract. In Bucli casea the condition not only of the cornea, but also of the
irU attd lens, mtwt he csrcfully ivatched. for any implication of the struc-
turva of couriie jirvfitly enhuncc* the danger of the accident. Bruises of
Iho coniea by Minit instrumfiils also often prove very dangerous, as, on ac-
eount of the c>>ntiitiion of the injuretl part and iUs vicinity, severe inHam-
nntioii, perhu[H^ of » suppurative character, is set up, which may even
lead 10 xnppuratimi of the cornea.
/» (Ac irratiHtrit of injuries or wounds of the coniea the firt<t indica-
^on irt to suiidiie the dymptntiia of irritntion iind inflnmmiition. If there
U >:reat [-ain, coM coinpressca should he avtlulously e»iph)ye4l, or a few
leeches shouhl he apiilied to the tem[de, foIh)ttfd hy hot [K>ppy foracntn-
tioM, so that free »tier-bl ceding may he encouraged. A atrong sohilion
<if atropine should be prescribed, the com|>ound hoUadouim ointment be
nihbed over the Ibreheiid, and a light, thoni>;h firm ronipresit handngo he
applit^d, in onler that the parts may be kept fwrfectly at rest. If the
AVDiptoms nf intliimniatioTi do not rea<iily yield to 5uch treatment, the eye
■bould be again mt'M carefully examiiifd, in order that it may be ascer-
tained whether a little foreign body hn^ not remained undetected in the
eomcn, anterior chamber, or iris. The various complications, such as
prol»|»*eof the iris, iritis, traumatic cataract, etc., muni be treated acco^ling
to the g^-neral ruleet laid dnviii in the Hcctionn in wliicli tliCHC afTections
are ilcscrihed. If an incised wound is situatcil partly in the coniea and
partly in the ■lelerotic, it tn-'curs sometimea that the portion in the latter
«ituattun does not hi>al readily, and that a little fistuloiifi opening may
rt'main. In ouch caitea, the treatment ia to unite the wound in the jiclo-
niiic by means of one or two fine sutureM, according to its extent. This
«iU keep the li)i6 of the incision in contact, plastic lymph will he effuiiied,
and a firm union will soon be effected. Tlie thread ishould curry a needle
at eaeh end, «o thai wc may he able to innprt the suture into the sclerotic
^froa within onttcanin, othcrwii«c a sudden start of the patient might
cause the point of the needle tu penetrate tlie eye.
»
^
[H._Tr.MOR.S OF THK CORNEA.
Tumuni of the conicn are very rarely found originating in the tissue
of the cornea itself, but hcgiu iu the conjunctiva either at the Itmbus or
elarwhere, and involve the cornea through the meilinm of it« epithelium.
They may be benign or malignant.
'I'he drrituiid tumor is of the moat frequent occurrence, and has been
already described in detail in the article upon tumors of the conjunctiva
(p. 182). In its pure form it id acongential growth, but a mixed growth
Al dermoid and liitomatous ti^uc is somotimea met with after birth, and
vvea in adult life.
192
DISBASBS OP TUB CORNEA.
Fure Meian&fna mast be reganWi as n lieni;^ ^rovrUi, tliuugti it ml
lincoine ninlij^iuint. Tt is n ran; tumor iit tlie curiieh, atut geticralW ill
velopA from the ^iniall pigmuiit |iatcht^8 met with on Lho conjunctiva
tJie cornea, eitlicr spoiitniicixK^ly or :is the result of injur}*.
Sarrr/m«r of the comen is alinnst alwiiy^ of ihe |Hgmeiit*;d or melanot
\'»ricty. It proceed* from tlie limbus. jiasses over to the cornea, has
aomotinies a amooth, «t>metime» a lobukied surface, and w verj vascular.
It in of a brown or black cltir, and of varying cnwisteticy. TUoujib it
inny involvv die corrifal pari>ncliynia. it iii^iiHlly doea not, but pusliee in
between the epithelium and the- cnrneal tiA^ue proper. Tbo epithelial
covering is usually enormoui^ly hy pert ruph led, and the sarcoma is 9i1m«.i»t
always uf the small round-cell variety. It may involve t3ie sclera quite
extensively,
Kj>itheii-jma of the cornea bepins freiicrally as a small nodule on the
limbus, reacmbUnj; a phlycticnulc, and may remain for a long time ijiiiet
until it suddenly bej^iiis tu grow vurv rapidly. It may be very [laiuful.
The tumor \i ;;rayi»h-whit<5 »t reili[ish, «iid may in very rare oasen be
black. It lin^ an irre;^ilftr, fissured ^utfaee, and lA usually M>ft. These
tumora are frenerally removed with ease, niid the corneal parenchyma is
but very little changed. The ;5Towth pnshes in over the cornea lieneath
the epithelium, and the ocular conjuncuva is usually extensively inAl-
tratcd. When removed tiiey ;;;enerally return.
The Melfiihi-rtirrlnama he;;in* also at the limbus, and may grow to an
enormous sine, so that the eyelids cauntit be cluaed. These tumors are
always black or brown, soft, fuii;;iiid, and ^o VA.-Hmlar that they bleed on
the pliglitest touch. Thou^^h uifually growing; over the coniea under llie
epithelium, they may involve the parenchyma very e\tciuitvely, the me
brnna Hmitans externa being destroyed.
As reganls treatment, operative removal is the only method of aol
use. If the growth is seen early enou;;li, it can generally be removed
without any difficulty, and witli very liltlt- iliimiifie to the t-oniea. Even
if the tumor ia of iconic sixc, iis removal, l(;uvnig the eye in place, ahuuld
always bo attempted, and will generally succeed, though it will probably
return. Where we have, however, to deal with a fungoid mass of melano-
careinoma, 'il& removal will be of im uee on accrmut uf its rapid reappear-
ance, and the eyeball should be enucleated together with most of the iwular
conjunctiva, in order to prevent if possible its retuni in the orbital Us-
Bue. — B.]
In general leprosy tbe cornea in rare instances mav also show a
leprous condition. Professor Sylvester, of JBombav, has kimlly furnished
me with some particulars of leprous tvibcrclc of tlio cornea, with a very
few caecB of which he has met. In one patient, 3o years of age, and a
confimit'd leper, " Tlie tubercle on tlic rfclero-corneal junction of the left
eye is ahixit the itixe of a large split pea, «inootb mi the surfikct-, and
precisely resembles ihotie un tlie skin, e.\cept thni, wanting the brown
pigment of the demml coveritig, it is of a paler tiesli color, and is covered
with conjunctiva in which two stray, tortuous veiweU ramify, li has a
hard feel when taken between Uic blade* of the foreejis, and when pressed
gives little or no paiti ; it is but slightly vascular and firmly incorporated
niib tbu cornea proper ; it is, moreover, suri-uuuded by a sone of decided
It
A
TDHORS OF THE CORNEA. 193
opacity which extends completely through to the membrane of Desceraet ;
the opaque zone slightly overlaps the pupillary aperture, which is dilated;
the iris is as yet unaiFected, and the fibres of its stroma distinct." In
another case the whole cornea was involved, causing it to resemble an
ordinary staphyloma. Professor Sylvester believes that the disease
commences in the conjunctiva and extends thence to the cornea, and
that the eye may be lost by the extension of the tubercle, the base of
which presses on and involves the iris, which becomes inflamed, and
aubsciiuently the deeper tunics become implicated. He has never seen
the eye implicated in ttic atiiesthetic form of lepra ; Chisolm,,liowever,
has recorded such a case.' l>r. Pedraglia has published a very interest-
ing papei* on diseases of the eye in lepers, giving the history of 14
cases which he observed in Bahia and Rio de Janeiro. He found the
following the principal changes which take place in the eye: 1. The
et/elith lose their lashes, and become tliickened and red ; 2. The con-
junrttva also is thickened and red, which he believes to be less of a
tuberculous character than due to a proliferation of the connective tissue,
but this only occurs in thode cases in whicli the skin is hypertrophied,
for when the latter is pale and an;£mic both tlie eyelids and conjunctiva
remain normal ; 3. The cornea may be affected with superficial comcitis,
or with opacities due to the extension of thickened conjunctiva, tuber-
cles (?), or else it may become stretclied and assume a greater conicity ;
4. In nearly all cases in which there is opacity of the cornea, there was
also a chronic affection of the uveal tract, e. </., atrophy of iris tissue,
anterior synechiie, closed pupil, and in some even opacity of tlie lens.
Mr. Hutchinson has ob.^erve.1 one case of leprous tubercle of tlie cornea,
a portrait of which is given in the New Sydenham Society's Atlas of
Skin Diseases (PI. iiii).
' " R. L. 0. n. Ri'p-," vi. 2, Vlii. « '• Kl. MoiiaUM.," 1872, p. (J5.
lU
Chapter ITI.
DISEASES OF THE IKXS,
1 IITPER.KMIA OF THE IRIS.
Hyi'kH;Emia of tlic iris id of far more fretiueiit occurrence than U
Hetiemlly siipjioitcd. Nor can wp W siirpriscil nt this, when we remem-
ber the close coniiectioii which existi ht?t«-oen the iris and cornea on the
one hand, nml the iri«. ciliiir^v hoiiy, and choroid on the other. Indeed,
we may ref^rd (he irl-S as the anterior termination of the ciliary bf>dy
and choroid, the whole forming, in reality, one tiMue. the uveal tract.
Hence tlie frp.|Uoncy with which inflammation of the iria extends to tlie
ciliary body and clioroid, and r»V** tfrrfd. In a hypcrwmic cnndiiion of
the iris, we find ihni tliere is more or less ninrked snbconjiinclivul injec-
tion; that the pupil 13 somewhat eontracted and sliig;:ish. not reacting
freelv on the application of atro]ilne ; and tliat the iris is diecolorwl,
vhicn tA due to the increaiwd viktculnrity imparting a reddish tint to tht*
natural color of the iris. Thtut a Vdu« iritt will hi-come somewhat green,
and a brown iris a-'Wimie a Hti<;tit atlniixlnro of red.
All enii-*f.« wliicii prmlmre con-'cstion of the deeper tnnics of llic eye
may excile hypencniia of the iria. Of these the rao?t fn.'tjnent arv over-
exerliuii uf the eyes in reading, engraving, etc., and inflammatory affuc-
tioiM of the choroid, ciliary body, and cornea. Itiit this condition may
even he produced in acute jiraindar ophthalmia, if this ii^ injudiciously
treated by cauaticA and stronj; it»trinf;ent eollyria.
llio trestnicnt mn-l bt- ciiicfly directed towanU a removal of the cause,
and an aUcviation of the irritation; hence, dtricl and prolun;;ed rest of
the eyes $houl<l be t-nforcod, and they flliould »l*o be f*nanied againial
'pngiire to Ktmn^' light, cold, etc. Atropine should be applied lo
niniah the irritnbilitv of the eve.
a,— IXFI-AMMATION OF THE IRTS.
t ilitia there are euperailded to the nyniptonL'* nf hypcrncraia of the
So<»e of an effii^iott of pliu^tic lymph at the edge of the pupil^ or on
rfn-e and inW» the stroma of the iri»!.
lierly the inflummaliona of the iris were cla«sifie<l acconlin^ to the
Ria> fif wliieh they were »iipp08e<l to be mtho^i^iomonic, and a
itb|>.< nrray of diflcrent forms of irilia was in this way estaliliaheil.
tclljf luuiug our elaiiiiflcatlon on pathological anatomy, «c can.
INFLAMMATION Of THK nilS.
195
fPllf. ss.
bowprcr, ^oitlr simpHfy tlir anhjfcl:, nnd m cmhnicp all shades of iritis
witliiii tliv fulKiwin;r four gruuiK^: 1, Simjilo iiUopsittiu- iritU. *2. Sorouit
iritis (PescemeUlU, etc.). 3. l^eiicli^'inatouj iritis. 4. S,vpKilitic
iritt«.
In onlcr tn avoid unm-cessjirv reptition, I shall first fJrwrilM* tht*
vanouit Mvmptoriw which more or less accompmir nil iiiflftmmationa of the
iris, nii'i theu uall attention to those which characterize tim 8]i«ciul
Aiiioiiggt the earliest »>rn)ptoats of iritis are conjimctival, at><] C9p<s
ciall^- subconjuitctivHl iujcctiou, cilinrv iictiral;:ia. eoiilnu-'tion and flltije-
giahucsH of the pnpil, and a diicohircd, dull, lock-ltuitrt! appeoraitc*.* of
Uie iris.
There is generally pome injection of the conjiiiKtivn, which may he
chicifly confined to the palpfhral portion, or extend also to the oculiir
conjunctiva in the vicinity of the cornea, Itnt a fnr more coiuuint itymp-
toni is llic subconjunctival vascularity, ^jiving rise to a more or Ici*
hruu'l, rosy zone of parallel vesscU. closely
miif^iMi round thecomcii. [Ki^- '«*!.] Tliia
zone ijt goncrally of a brij^ht rose color,
■iid confi.-'ts chiefly '.'f i«nial! urterial twifis.
It mny, however, assiunc » «onicwliat. l.luo
hroiviiish tint, and llie Litter wa* for-
frly erroneously supposed to be pymp-
tnmatic of syphilitic iritis. Althoufjh
marked suhoonjnuclival injection \* prcftent
in thi* ;'reat miijority of caaes of iritis, wc
occasionally uicet with severe ciiHCff in wliicli it is not very conspicuous,
06 ill typhurt fever, pya-niia, elc. There in also mon) (tr less chemosis,
and this may he so considerable that the conjunctiva is raided like a red
or bluish-red mound round the cornea. The eyelids are often aUo
swollen and pnffy. In the milder cases they may retnin (heir normal
HM ■■•■, hut if the attack is severe, the upper lid fjcnerally becomes
t- iiin^E, and very u-dcmatous and kwmIIcu. Tliis Ih more ospe-
dttlly tiie ca«* in ?uppunitive iritis or iriilo-eycliti*.
The tnteniiity of the pain is very varinble, fiir although it in gonomlly
'«!Tcr*, ami often extremely so, it niiiy in Mmie ea.ws be nearly entirely
.alwenl. Tlie psttimt may At first only experience a feeling of itching
»l huruiti<; in tin- eye, but soon the pain becomes more severe, and a~^
Kimes a sharp, cutting. Uncinatins cliaracter. It maybe chieflv -'■iluntcd
deeply in the eyeball, or extend tu the forehead, temple, and correK|Muid-
in;* side of the nose (ciliarj* neural'^ia). Sometimes there is very ink-nge
noQralgia of the branches of ijic fifth nerve, extending over the corre-
ajiondiuj; side of the face and head, even aa far as the occipat. 'Hie
pain always increim*'^ in intensity townrclft evpnin;;, i-emaining very aererc
aurin):r the night, and diminiiiliing towarits morning. Although the
patient may cxjicricnve very acute pain in iritis, it is important to remem-
ber that the eye is not iiAtuful to tlie toitch in a ca^'^ of simple uncoui-
Sltoatetl iritis. If sharp pain is caused when the ciliary region is proa^ud
J the finger^ it is indicative of the cocxistcticc of infiamination of the
Afi«T pirfl«.1
ciliary body (cycllti*). Very fret|uently tliis UMidernets is partiAl, uid
confiiied to the u\>])eT [(Ortion of tlie ciliary region.
The fifvcrity of iliu paiit mtty give rise to soiiiu coiiUttutional dtsttirb-
aiicv. Hint tin- exacerltfttioita W atx-niupaiiietJ by feivrisliiiesa, a ItwuW
loiigiie. ini|pamnftit nP ftppetire, HtuI a iciulency to rctchinj* nnd voiuit-
iii^. wliicli iii^t imfre<|iit'ullY causes the (Ii»ea*e to he luirtlakyu for a aevure
!)ilioi|Li atlac-k.
Altliftugli considcrabl*; phoiopbnhia and I«brymation may accompany
iritis, they are seldom so severe and marked as in certwn foruu of cor-
ncitis.
We now come to the symptom? presented by the iris itself. Amongst
Ihu eurlieat arc discoloration and "lulnc?>s of tlit* iris, and contraction of
the pupil. The discoloration iif the iris U jiartly due to bypericmia and
|)(irtly to an effusion into il4 ^Iructurc. In ordor to estimate rightly the
ctian;!(>!) in color, we munt nlwAys compare the affected with tJie other
eye (if lliis be sound), otherwise an error may oa-*ily occur. We mnsl
also Ife upon our guanl not to uiisiake the dulne^s and change in die tint
of the iris, winch may be prodii:ed by c'lnndiiu'?s «if ihp cnmea and of
tlie aijuenus Inimor. a-s Winj;; resident in the iris ibjclf. Besides the dis-
coloration, the iris presents a peculiar dull, lack-lustre appearance, its
surface having lost its tmcural bright, glistening aspect, and appearing
bazy and dull, as if covereil by a fine veil. \Xi fibrilluo are alao Tiot
alinrply defined, but indistinct and blurred. Tnis depends in a great
inefisure upon liic byperiropby of the connective tissue elements of the
irii!, nnil upon thu elTu^i'on uf tympli into tliu str>>ua and upiin the surface
fif tlip iris.
The pupil is Blu«;gish and mare or less contracted. This generally
oucurs in all but the very tdiglitest ea^es of iritis, or in those in which
there is a tendency to increase in the intra-ocular tension. This immo-
bility of the pupil is partly caused by the hypenemia of the vesseU, but
chiefly by the serous or plastic effusion which has taken place into tho
stroma of the iris. a?id imp«.*de8 the »citou of the circular fibres of the
iris. If the inflamtnatioii is but partial, the immobility of Ibo pupil
may Ite the same. In testing the mohility of tho pupil, the patient sbonld
be placc'l so that the light falls eidewaya uiwn the eye. The other must
be nrnily cbwed with rnir hand. f»r by a handkerchief. Theaflected eye la^H
lo be shaded with tlie palm i>f our hand, which is then to be rapidly re- ^M
moved s<i as to admit tJie light, and the behanor of the pnpil accurately
watched, so that its size, mobility, and the extent of its contractions
may W ascertained. It must be remembered that contraction and im-
paired mobility of the jmpil may exifit without any iritis; for they may
be seen in comcitis, hyperjcmia of the iris, or if a foreign body it
lodged on tlic cornea, and are lu tb«M cases du« to irntation of the^H
ciliary nerves. ^M
The edge of the pupil generally soon loses its circular form and be-
comes somewhat irregulnr [Fig. iili], and we ;n;iy notice along it small
exudations or beads of plastic lymph, which tie it down to the anterior
capsule. These may, however, tie so minute as to escape detection, lUitil
the pupil is examined with the obliijue illumination, or atro|Hne is applied.
The individual exudations often increase in size and coalesce, atul, mori}
I
mrLAHMATiON tir tub iris.
197
lymph bciiiK pffnsMMl, tlie wliole circuaiftTt'tice of llit pupil may bo«4>nM
fnii;;r«l with llitfin, Bml Iw tied flown to tiic cajwiilc of the leiiii, the ceiitru
of till.' pupil perhajw remaining clear »rultlliw still permitting of goo<lviainn,
"nils I'ondlliori is tcrmcti " nrfuhr" or "fl»mu/rtr" »yuecliia,or*'«T^ijri"n
tif thr ptijiil." We mtiflt (listiiigtiish this frora the coudiiion in which the
[Pis. ae. Fig.ri7.
AflniT. W Juko*.
Xlvt Lkirraat*.]
effiuion invades the area of the puml, go ih%t a mor(^ or Iom conaidora-
bJe jiorUou of it in covered hy a tiliu uf lymph, or uven the whole of it
oorIndt^<l by a thick nodule of cxu<lation, th« etsbl being of course pro-
portiouatcly detorioraled; tliin i* called "orWMw'wn" of the pupil. [Fig-
.~>7.] Thr exudation of lymph hotwocn t)ie irtn and the ca|Mu1e of the
lenH i» nut atvray?^ limited to the edge of the pupil, but may extoud fiirtlier
back along tliu itOHionor aiirfikee of the iris, luid thuH produce l^roatl and
very flmi adhcAioikfi. Wc «ball we hi^reafter, that tliis faet is of gn'ac
importance in tliv pvrfonuanee of iridectomy for chronic iritis or irid<»-
ohon)iditiei. The pnrtial ailhcaions hotwecn the puf^l and oapsiile vary
greatly in thicknoiw, extent, and nuiulwr, and bci;«>me very apparent
when atropine is applied, as they then give riiw to various irregularities
in the :«ha]>e of the pupil.
[When ibe pupil is " excluded" or " occluded," Uie reuiaiuder of Uie
iris being free, fluid u apt to collect in the jKuierior chamber, and hy
bulging the iris forwards, and dinnuishiug tlie depth nf the anterior
cliainU-r, excepting at jid centre, to give tlie pupil a funnel shape. If
.«iK-h bulging It- |tart)al, or b<? diviiled by 1>andrt of tough meml>mne, a
ey-itic ap|>i-»rance is given. Sei:oniInri/ <//iik'-t«mj i» likely to follow, and
the tvuHon of the glohe &houM, therefore, be enrefully uoted whenever
this bulging is pri'-ient. *' Total posterior synechia" always shows a
severe iritis, though often one of chronic cour*e ; it often signifies deep-
seated disease, and may Ik; complicated hy neeondary opacity of the lens
(calanict). Helapsfs of iritis ure believed t** bu induced by the pres-
ence of Hyiiechiiu, erun wlum there i^ no [irotrusion of the iriri by fluid ;
but their influcitcc in thii* way has probably been much overrated. (Xet-
llciliip.)— U.]
The surface of the iris may h«comc covered witli a film of exudation.
ii^dita
mA
1»8
UISBASES OP TUB IKtS.
or t)ie lynipli ma^ mix with tlie ai|ueoiis bumor and reuiler tliU turbid
and c'limilod ; or it imiv W p[*fcii)icak'(i n>;aiiiHl tlic [lotttcnor wall of Ute'
COrnoa ill the form of smntl wliitisli opHcities ; or again, it ma; sinV to
the bottom of tbe anturior chamber, where it cotlecbi in tbt> form of an
hyimpyon. The amount of tliis ycllowi.sb deposit varios ; it may bo «o
slight a8 easily to eRcape detection, appearinj; like a small yellow fringe
■long the lower eil;;e of the anterior cbnmber: or it may attain sucb a
aiw tbat it tills buH" or even more of tlic anterior cbamher.
In ftiniple iritis the ciTium ix ^ciicrully (iiiile transparent, or showe
but the faintest amount of uloiiiiincfiii. Small portions of lymph may.
however, be deposited from the aqueous humor upon the ]wat«jrior wall
of tbu cornea, ^iivinj; ri«c to a piiiuiUile appenniitee. This ncrurs v»\k-
cially in tbc Huroiu form of iritis. Itiil thv. Crimea may, aUt>, bticomo
impliviitud in tin.' inHammatory |)roce»s.
Vi:<ion is often cont^iderably impaired. This may bo partly due to the
cloudiness of the aqueous humor and of tlie area of tbe pupil. If the
si<:lit if* much affected ami the pupil not ociclnded, we mnsi suspect Uie
coexistence of cycUtis. wliich ia often accompanied by diffu.« opacity of
the vitreoua humor. The powi-r of accommodation id then, moreover,
atm affected. It in, therefore, lury nei;o«sary awMiraiely to tcAt the
degree of Yi.<ion at the commencement of an iritis, in order that wc may
at once detect any marked deteriomtioti, and uiwertain to what cause this
19 due. The ten.sion of tbe eyeball is noimal in a case of comimm iritJa,
and the 6eld of vision, although it may be somewhat contracted on
account of the smallnenui of tbe pupil, or the presence uf eynechiie, does
not itbow the coiitniL'lion peculiar to a glaucomatous conililioii of tbe eye.
We inmit now uonijiiier tbe syinjiiomg by which tbe special forma of
iricitt are charnctcriKcd.
1. The Simple [Pfatftc] Jritit w sometimes very slight in degree,
and accompanied by only a very moderate amount of suhL-onJunctival in-
jection, photoplmbia, pain, or discoloration of the iri« ; indeed, its exist-
ence may remain quite unsuspected until atropine is applied, when tbc
pupil id found to be irregular, and shows here and ibere a blender adhe-
sion to (be capsule. [Fig. 5f*.] This mild form of irilia is
[Fig. S8.] oftt,,, met ^ jti, uftcr opcratious upon the eye (e. g.y cataract
®oporBtions), or after injuries. ITie affection may, liowevrr,
be more severe, and there is much ]>aiu, swelling of the lids,
injection of tbe conjinictiva iiml i^nt»conjuntitival tluAue, cbc-
mwis, pbotopbobia, and lacbrymation. 'I'be \r'w i* diitcol-
ori'd, the pnpil contracted ami inactive, having deposits of lymph at ita
edge an<] |>erbap5 aleo in its urea. A film of exudatioti cavers the sur-
face of the iris, rendering it dull and hazy, the a(|ueoua humor is Home-
what turbid, and tbe posterior surface of the cornea perhaps mottled
with fiinall dei>0!tits of lympb.
[In pla:stic iritis the exudation uccurs upon the anterior and posterior
surtaeeA of tlie iris, on jmpilbiry margin nrid aitterior capsule of tbc lens.
This form of iritis occurs idiopathically or in constitutinoal syphilis, or
as one of ihc signs of a rheumatic or gouty taint. — H.]
2. Serous IritU {^vn. I>esccmetiiis, aijuo-capsulitis, keratitis punc-
tata, etc.) ia chiefly distinguished by the absence of plastic exudatiou.
INFLAMUATIOH OF THE lUIt^.
199
ani] by Uie great tuudcucy to kyperaec ration of tlie nqutJous humor.
The symiiloaw of acute iritU are j^iierally not very [ironomiced. The
Mijucous liuinor U dccretod in gix-acer <|uniitity. And is Komewtiat clouded
mini turljid, and on vioser ob^vrvatiun wv van ufleii notice dmall |>arlicle8
nf lytujih lloiitiiig nliniit in it, iHifnre beuomiii^: (l(-)io>iiU-'d on tin; iwau'nor
Kurl'Hce of tliti cMiiiea, or at the bottoni of thv anteriijr cIihuiIk;!'. The
latter is ol'ten markedly dve]iene<l, anil the uuniea a{>|)can> soiiicwlmt
bulged forward. The cluudineM of the a<(neadii humor often varies con*
siderahlv and ranldlj within the coursa
of a few hours. 'J he cornea niav at
IFiK. 89.
.5ftf;:>
Aftrr U»iti»l-\t.l
fir^l ap)>ear abiioi-uiEilly hrilliaut, hut
it soon Idseii itif hif^irr and W-cotnes
•li;(htly cloudi->d. awl small punctate
o^HiciticA make their appearance upon
it-* p08leriur surface. L'^'S- ^^'-J
These may he situated opposite the
pupil, being periia|i.s gnntjied in a
niiiiill circle ; but tiicy nre generally
trruiiged iu the furiu of u pyraniiil,
'the haie of vbich i.i turned lonurda
the jkeriphcry of the cornea, and ita
apex tv»ards the centre ; the i^mallcr opacities heiu^ liitutled al the
a|K.-\ and the tar;;;er aitd coanter ones at the hmo. TWm prove* tJiat the
■ojtacities are com{>Oi^>:?d of small ma^es of lytuph, deposited from the
I at[ucijufi humor upon ilu* pomerior wall of the eoniea, and that they
arrange themiM^lve^ acuording to their size and weight, the larger and
heavier ouvi gravitating downwards. 'I'liu truth of tltis atworliou has
moreover been proved experimentally by Arlt.' He placed tlio head of
he (xitient in drIVerent directiena, dometiuied keeping it for a length of
tinto turneil to the right t>ide, sometimes to the left, and he found that
the bu-sc of the pyramid always corresponded to the side of the eye
vhtcb had been maintained iu the lowest position. But some of the
upftcittes met with at tJie jtogterior |M>rtiaii of the cornea, are not ilue to
Uieie defio^its from the aouoous liumor, but are caused by inflammatory
cliangca in ihc epithelial layer, or even iu the ]atsterior portion of the
imca proper. [This precipitate upon the podterior surface of the cor.
aMi, if exteuaivv, may cau.ie ituriou.1 disease of the cornea, uhich may
actually be uf the ]iarenchymatous variety ami lead to scleru-tis of the
contca. This aclerosis, by its localization in the lower part of the cornea,
uhI by ita triangular shape, with base directed upwards, often proves
the previous exiiitenue of a serous iritis. — B.]
The iris is hut slightly diocolored, and the pupil, instead of being
cnntnicccd, as is generally the case iu iritis, la somewhat dilated, often
iuarke4lly so. This is due to an increase in the inira-ocular tension,
which is often present in tliia diseaae, ami the manifesution of which
miiat l»e watched witli the greatest care, for this serous form of inftam*
tuatiuu sliuMs a great tendency to extend to the ciliary body and choroid,
witioh is accompanied by hyperscuretioit of Uie vitreous humor, uiarkcd
■ Au);eulipilkundH, II. 45.
200
DISEASBB or TQB IKIS.
increase in tlic iutnt'Dcular tension, bii<1 a glaucoinatotis conilition of the
eye. The degree oF eye-teiwioii, the alalc ol" the M'^\\t and of the fielil
of vision mitst. therefore, be frei|Uf»tly and onrefully examined during
Uie course of the diiieu«e, in onler thut thu enrliest syuiptouis of a glaU'
cnmncmis (roni|ili(!at.inii tw\y he ih-teeted nml at once arrested. Adhe-
sions between ihe ed;^e of the piipji and the eapsule are not of fretjuent i
occiirrenee in tiiis form.
Ssrons iritis occasionally accompanies decp-aeated inflflminationa '*f^J
the eyc« more especially chronic irtdo-choroiditta, and clioroido-retinitia. ^M
Moreover, sympnilictic opluhalmia aometirae? appear* in the Ibnn of^l
sciyiiw iritis. It has aUo been supiHMcd to he dac to constitutional or
hcrcilitary syphilid.
;I. PiireH'-hymittoufi and Purulent fritit. — Tn this affection tlie in-
flamnmiiou attucks the tissue of the iris, and its fihrilliK become much
swollen and thickened. The plastic exudation is poured ont into the
pMn'iichyma of the iris, along the edge and into the area of the pupil,
and also on the posterior snrfnce of the iris, giving rise to thick, broad
adhesions between it and the capsule of the lens. On account of tha
exudation into the 8ti^«nia of the iris, and the svfullen and thickened con-
dition of its iibrilla;, tlie ciivnhiiion is generally conBiderably impeded,
and large tortuous veins make their ap)>carAnce on its surface. Along
the edge of the contracted pupil are noticed a number of thick, firm
nodnlcft of exudation, of a creamy or re(ldi-li.bn>wii color, lying down
the edge of the pupil to the cnpsule ; or they may even extcmi ariinud
the whole edge of the pupil, and thus give rise to a circular synechia
(cxclnsion ot tlic pupil). The eftiision generally also invades tlie are*
uf Uie pupil, indeed the latter tnav be completely blocked up hy a thick
yellow noilule of jmrulent exmlauon. The surlace of the iris appears
indijiliiict and haxy, its tibrilUe are swollen, and it* anterior surlace is
covered by a layer of exudation, which varies considerably in api>ear-
ance. In some cfl.''c.'< it looks simply like a thin i^ray veil covering dif-
feix-nt portions ur even the whole of the iris; in others it asaunws a
thick, ci-eamy, purulent appearance, with small extravasations of blood
scattered about here and there. I Jltle yellow nodules (which arc not
to be oonfonniled with the syphilitic nodules) may also api)ear strewa
about on the aurt*ace of the inii. On account of the deuicbnicnt of iioma^
of these nodules, and the effusion of lymph and purulent exudation int^
■the aqueous huumr, the latter lieoomea turbid and discolored. Hakes o
.purulent lympb and globules of pus are seen floating about in it, and
unking <iuwn. give rise to an hypopyon, which may be so small as U
.appear only like a narrow yellow belt along the lower edge of tlie antc-
xior chftmber, or may be so considerable as to occupy onedialf or more
ol the anterior chamber, reaching jierhnps above the upper edge of the
pupil. This parenchymatous or suppurative iritis may be acwtrnpanic"
by a himUar form of intlammatiou of the ciliary body and choroid.
[The inflammatory product* consist of 1ym|>lioid cells, large raassee
free nuclei, and uwrked hypertniphy of the connective tissue .stronm
The latter occurs mainly in tliv vicinity of the pupil, ami almost alway
gives rise to a membrane in the pnpil which may become orgauizeil
4
tmm
INFLAMHATfOH OP THE IRtS.
:ioi
vuciiliLT. anH form p&rt anii parcel of the iria. This is the moat dcntrtic-
Uvc form of itiHartiiimtiou tn lli« iris itiflf.— U.]
4. Si/p!iitit.h Iritis (^eiiL'nilly attsiinieM tlic |iarenchynialon3 fortn. It
ia, however, capectftUr charnctorizcil by the formation of iwculiar tio.1u1os
(<;uiDiuy tiilw-n-li'i!, "V irchow). These nre scntlered about hiijuIt over a
certntii portion, or even tlic whole, of the snrfnce of the iria, in the form
of y«.'lIowisli-n,Ml coii'lylomiitoiw uodule:). 'I'hvy ap)ioar at firitt deeply
imhiMhled in the pareiichynia of the iria (orifrinnliiig in the deeper por-
tion of its connective tissue), and, aa they increase in sixe, they jitwh
Mdc the tibrilltc of the iris, and protrude ber,wceu them into tlie anterior
jber. 'i'hey may attain a vfry coiwiderahle maj^iitude, tlieir apex
e»cn toucliin;; the poAtcrior wiill of tlie cornea. They (nccuHiuj; to
Colbert) exactly renemhle in atructiire the j^Hnuny tuberclt'M (i;nmmata)
of Virchow. On account of the prenenee of pigment cflla. and the great
raKiilahty. the nodules frmpiemly aflHume a dark reddt-sh-hrown aarco-
matoa:« appearance. They often under;;o fntly and purulent degcnera*
tion, hreiikirij; down into a yellow, gruuioud, purulent mz^i, which be-
cuiscft mixed with the a<|ueoua hnmor. They may, however, undergo
j»id absorption. Tlicse noduleii,or condylomata as they are sometimes
lied, frequently remain contined to one portion of tlie iris, in which
tlie inltaromatory ehangcit are moreover nUo more pronounced, so that
tlie disease a»!turoeji a nomewhat partial character, whicl) 1.4 peculiar t«
the syphilitic form. We find, in such ca$es, that, although the whole
conu'ii may be mirrouiided by a pink zone of vessels, this is mont con-
■^»ituou8 at one point, and that the eorresj ending eegnietit of iris 19 the
ml thickened and swollen, and that the nodules are chicHy or entirely
ifined to tbi^ portion. [The^e guumiata are generally situateil on the
pupillary mnruin or in the peripherical zone of Uic iris. They aome-
timc-'( ftprini; from the posterior nurfnci' of the iris in the pupillnry xonc
and punh fnrwnnj into the anterior chiinilnfr. In rare cases lliese noilulen
have Iwen known to ociMir in such numbers and of ituch a nizc as Ui till
the anterior chamber and press against tlie cornea ; and the rapiility of
attch development might lead to perforation of the cornea and destruc-
lion of the eye.— B.j
It must be distinctly remembered that, although the name of syphilitic
iritis is given to the form of inttainmation above described, the iritis which
may occur in tlio course of, nint be entirely due 10, syphilis, docs not
uecvuarily always assume this tyiye. For it may appear us a simple
idiopathic iritis, or in a more or less severe (larenehymatoud form, so
that the absence of the [*eculiar gummy nodule docs not exclude the
pnncnce of syphilis in the ."vstem, or ic^ being the CHiise of tlie iritis.
Bni, on the other hand, the existence of these nodules may. in the vast
m,njoritv uf canes, be taken as a certain indication of the pypbihtic nature
of ilie intlammation. I can only remonibcr having seen one case (a pa-
tient of Mr. Critchett's) in which there were well-marked iiodnlcs witliont
the slighteBt evidence of syphilis. Some authors liave stated that, in
syphilitic' iritis, the circnmeorneal zone of injection Lt of a brownish tint^
and Uiat tlie pupil is displaced Mpwni-iis nnd inwards. This is, however,
not the case, for both .thet>e apiK-araiices may be met with apart from
syphilis.
202
DISBASBS OP TUB IRIS.
TOfltUiiMtit or SjHttiff^ IritU presents somo cUninil r^atitren diflTcretit
fiuin nuy other vsrietj, IIkhi^Ii it may he <lue to cnmnion coiwtitutioiiBl
enures. The exuijatioii is {K'culiiir. often occurs mmldeDlj, may lii-^nii iu
the ]nipiltury space or at the bouom of the anterior chamber, usually
ucciirs very rapidly, and fre^juently entirely fills the chamber. Tliii*
cxuilnttot) hn:^ a ;^latmuu« or s[>oh}!;_v appearance, and sonictiraca secou
to lie lootfcly like Itocculi in the anterii>r chaiubvr. Thi^ exudation has
hevn exumini'd by Kiiapp, Alt, and itthunj, and found tn be libn)u^, cm'
stHtin;:; of a notuorl: of delicate 1ihri1l:R, ineloAing viU'iUi iiud red h1oi>d-
corpuscles and u iinely granular eubdtance. All tlunks the presence uf
tbe fibrin ia due to heniurrlia;;et^ iu the iris, the fluid jiarls uf which
percolate into the anterior clinmhcrr and coagulate there. Hut thi» latter
may occur through tlie walls of inllamcd bloodvesseU without there being
any homorrhii;jo, an Burnett very properly atatcs. The exudation ia
uaually cuinpk'U'iy abjorltd, and sonivliiiieB with great rapidity. The
abH4>r|>tion gL-nerallj hegind at the [icriphery, and the duration cif tho
jtpnci'iis vanvA between two and three wcoks, tliou;i^b occasionally the
iitllaniniKtory ttigiis di&uppear iti a few days. The treatownt is the samv
as for pluHtic iriti;^. (See Archives of Ophthalmology, vols. vi. and rii. ;
Amer. Jouni. of Med. Ck'ioiices, Jan. lt«SU.) — U.]
Aiuoiij^t the caueea uf iritis, a very fretjueiit one is exposure tn sud-
den changes of temperature, cold draughts of air, rain, wind, etc. The
disease is, iu such cases, often termed rheuuuttic iritis. It oiay also
accoiu]mny rheumatism in other pans of tho body, bein^ evidently pro-
duced by the i^ame cause. It is erroneous, however, to speak of rlieu<
inatic iritt:- a.^ :i s|iociaI forai of the disease, for it has, in truth, no cha<
racterisiic symptoms ; it generally assumes tlic form of tiimple plastic
iritis, and may var; greatly in severity, but is not, as a rule, accoat-
panied by extensive ctudalive changes in the |iarctichyma of the iria, or
by considerable hypopyon. The ]iain is freijuently extremely severe,
lud may extirud over the corrcs|>oiidin;: side of the bead and face. Tlie
lisea^c often runs u chnniio and very protracted course., and relapses
niay take place on a recurrence of the rheumatic uttack.
[Jl/fumntiiim is porba^ics the most fn><)ui>nt caniw uf uionocular relapfi<
iog iritis, and the relapses may i.>ccur in rapid succession or at intervals
of moutliB. Gout is another undoubted cause of irius, and ia of an
inaidiou^t nature. The children of rheumatic and gouiy parents are
'.'-■■' ~ the victims of a very insidious chronic iritis, for which no
ii' , riecras to be of any use. — B.]
Mr. Huicbin:40n' has observed a jH-culiar fona of iritis occurring in
children of ^uutv [>areuts. It is chieBy characterised by oocurring at
an early ajiv, and by being insidious and persistent ; posterior Byuechis
gradually form, leading to occlusion of the pupil, etc., and tlicre are also
probably oitocitics ia the vitreous. The inHammation begins in oue eye
and generaJly almoat entirely destroys the sight before it mlvances to the
other.
Iritis is also oRcn of traumatic origin^ being caused by mechanical
chemical ii^urieSj which either affect the iris direetly or secondarily.
' " Uucel," Ju. 4, 167D.
IKFLAMMATIOX OP TUB DlIS,
Thiv Forvign bgtlicB miij remain loilged for sotue time in the conjunctiva,
eontvm, nnutrior clinmher, or in the dcepor tunica of ttie vyu, nml thvn
Ht U|) iritis. Clean lucidvil wounds of tlie ins are not ^i-one to give rise
to it, u b proved bj tito o|>oration of iridcctom.v, nor does Strang ulntltm
or coniprcAsion generally do 30, as is cviik-nced by iridiKlewa. Woundi
wiiicU Lii-ui:«u xtid laccriile iho iris are tin* ni'Hi api to ^et up iritiB. In-
jury of lilt' lorw, followL-d by trBumalic cntanict, very often produces it,
ttwire esjiecially if tlie iris luis lieen iinplieuled in lliu injury, or the lend
swells up very connidentldy and pres8e» upon the iria. It altK> ufien
unporvenes ftcconilarily upon other iiill:tniina(ion8 of tlic eye. Thus
conieitiH. especially the diti'use and suppurative fonns, and deep or
perforating ulcers of the coniea, are fnv|ueutly accoropanied by iritia ;
ibid is still more the case in intlainiimtioii of the choroid ftud ciliary
Ijody. [Iritin may aUo be secondnry (u intm-iicidar (uuiors. — IJ.]
[Iritis may follow a punctured wound of the cornea und len.-i cajtsule,
without any wounding vH the iris. It tXso Qfteti ut caused by the upeni-
tion of exirac'tinj: a cutaruct, and is often attended by cliemosig, conges-
tion, and the fonuation of ttnij^h meuibranifunn exudations behind tbo
iris. H.l
Sj/jifiifit is a very freriuent cause. When primary iritis occurs in
infantJ) or young children, it is aluiust iilnays due to :iy|i|iiliK, luid in
eaaes we f;enerally meet with other syuiptoniH palhognuuioniu uf the
hiliUc taint, such a^i condylomata, about cho anus, spccitic eruptions,
etc. In adults it but 8eld'>ni uccur.1 together with the primary ayiop-
Idtns, but gi-nerally durinj; the seL^omlary or tcrtiiiry xtage, being td"u*ii
the precursor of those sympiuiuB, when the primary have <li8aiijicftred.
The iritis frequLMitly occurs aimuttancoasty with the syphilitic erujilioiis
uf tlie eVin.
Some autfannt hare assorted tlial gonorrhoea Is sometimes the cause of
iritis. Tlius. Miixkonnic' describes n special fnnu, under the name uf
" gtinorrhn;:tl iritis." Mr. Wonlsworth' b«» also narrated three cases
in which iritiK iKcurrt^d together with gonurrhiua. It must, however, be
iitJLted that all three were complicated with rheumatism. I have myself
never met with a case of iritis associated with gonorrhtjea alone ; but
have only observed it in eases in which gonorrhu:a coexisted with syphilis
with rheumatism, either of which diseases, as [ have already stated,
a freijuent cause of iritis. Xor docs the so-called "' gonorrhieal iritis"
present any special or pailiogtionionic features. [The occurrence of a
apvuiul form of irilis, a luixture of the pla^itic and serous forms, due to
gounrrlura, is still doubted by many ophthatmolngista, es|)ecially in tlie
Unite*! States. The iritis occurring in the course of or following rbeu-
mallc arthritis, hn-s already been considered, and this may occur in the
eouFM of a gonorrhtca, but it is not yet proven that its occurrence at
this lirne is more Uiau coincidental. — ll.j
Si^mjuMthrtii' infiammtUiim of the iria is apt to occur after injuries to
the eye, or to (be lodgment of a foreign body witliin it, etc. The sym-
patlictic iritis may assume tlie serous character, but generally npjiears in
the form of suppurative iridn^rboroiditis. ( Vide article on " riympathctie
■ •* Hatrfcf nxitf on UImwm of ihi* Rx«/' ^92.
■ "R.UO. H. R«p.,"iii.301.
iil
2ii4
pr^EA^BS OP TUB mrs.
Ophtlmlmin.") [The form of iriiis wrrurring in fl)finj>aihc(ic nphthitltma
M Blnirwl ulwfivti |)Ifti»tic, aii'i tmt rftrcly fiippurative. — IJ.]
i'tifmir frilit \^ i>8|icc)ally •liittiiigiiislii'd by tlic fiict Umt die inQsm-
iitalorv syiuptomit nre g<?ncrftlly bm flH^hdy marked, or are almost so
otiliroly tilnviit Oiut Ibv fvntivnt i* not Hwur« tbat tberu is liiiytbing Uie
ninticr wUb bin eye, fxcpjit a slight wcnUnesa or *• cold" in U, as be fre-
ilQcntly exinciiacs it. Tbe ocular conjimcliva an-l siiIvoTyunctival ti««tie
art' bm ahj^hllv injected; there is only a fnint pink bliiiili arcimi«I tlie
ooniva ; tbcrc i» but Uttlo pliolopbohin, liicbrymatifm. itr eiliary itcuniU
gia. The pupil la eonivn'bat voutractc^ anil slui^gisli, and, at c-vrtain
points, pcrbnpti immnvahle. On exauuiiin<!; it with Die oblique illumina-
tion, wp may frc<)tienlly notice »mft1l adhesions between the eAge and the
cai>«ule.nhi(>h, B.* «i'll as tbe irrejrulariiy of the pnpil. become very eri-
deiil upon the application of atropine. Tbe color of the iris bccoows
f^rndually mori' cban^ed. an<l ihi^ altemtion in it* tint t» pcrrnanent,
wbemhH in acute iritis it |m*Aci4 nil' again with the ^utMidrncr of tbe dtit-
ea*e. uttbout, porha|». eventually le»viu;» any trace ttrliind. Tbe nor-
tnal bri)£htneji8 and lustre of tbe iris l>eeonie failed and dulled, its fibrillB
iltdiatinct and obliterated, and in tbe later .stages of the di^ase it pre-
MDtB a yelki»»i,*b '^T»y, dirty-bmwu, or sUtc-eoli>nNl apjfamnce, it* dft-
sw hrinj* tbinniM) and atn>{*liied, and irnver^ei, peiiiapf. by enlarji^
Mid «i\D>e>ibat tortuous b)ixKive**eh. The presenee of *»eh dilated Te»-
aeb always tndicaies a «tate of coa^estion aad itesH of tbe cnn:ulatiin ia
the iria auil eiliary body. Ac tliUadrancvd atagv, the iriiia b gvtM>rmllT,
however, no lonjiier simple in eharueter, bat bai becMBe co^i&cafied with
inflamtnation of the ciliary body and dtoniid. ( ViJe ifce aitide on
" lridt»«liafntditi«.'*>
Clinwir iriti* ma^ mperreoe upon ■ nan acvto fon* of iritia, or Iha
diMiaAe nay manife^it thtii rhnmte ■»! iwotfiova dmeter froa the very
<^t*ei. \\ aUo fr»{iient]y aeemB|Miw«« ioBaa«Mttio«» of the ojraom,
man eMprcially tbe difwe corsmtu. BeUpaes an tot apt to ecear a
ehrenie iritis : tlwiw wewieat iaHi—atniy vneertMiaaB hciag oAea
pmliK^) by rery >1i£bt caoSM, MClt t* MJlll «■» «f tb» «Te«. paitK*-
Iftriy by artificial h^tit. expaeoi* t» c«U. vwt. *». Thas 'teodMcy to
rxuTfrDce i» o^peciaUT marked u ibase eaaea is vUeh tmmtnta or
•ntwoitv poctcrwr syocvhi* exatC For thetr pwaeoca ia a nniarfcai
mmn* of irritaimi om MMiitf . as thej fnm a cWcfc to ihe frae, apa»-
laaMw wMwanta of the pvpd, aa4 ia Mch caaa* a abghtcaaw «ii airf^
■wtoTwfciaartWiHii— liii Uari^ tW rtcamacc «f lU Ma»
MtMu &Mb It«|4 mm W <«m4, aM iW paimriar ffM^ift «ifi
iacfwMe «iat fwlh«r n aMhwr aii4 f rMew. «B«a CmHt. ^Acr pcfftepa
fti^aiai rrbpFCK, tW whair i;in,wf)iin'> «f the pvyd «* anaH ae4 da««
4; iamiMiit It «« W ra iiiiaT^i
lh« p^ <«*akr f.TMfhia) '» «a* «r«h*
narcfcaaibar li wwfetol,
aaJ ihc
IKFLAMUATIOX Ot TUB IHIS — THEATMKNT.
205
I
I
brittlu u to be rcaililjr torn tKron^i hy tiie energetic iim tif atropine, the
]inigtir>]iU i« in every way very miicli more favornble, than if nuiueroiu
fimi posterior ^jTicchiic have nlrcatly been CBtablished. ami rvshi the
aetinti of ntropinc. I'artMicbymatdiiB and syphilitic iritis afford a 1m9
favomUf pmf^iiosif) th:ii) thv Hiiii|itc or llie 8i^ruiui fonii. as tlivy are ^on-
erally accompanied by very cnnsiilcniblr cxiiilationft of lymph at the edge
of the pupil, oti the surface and into the jtnictiire of tiic iris, oiid into
the antirriitr cbarabiT. The teudeney toiniplieation of tlif coniea,or the
dec[H.'r tunics of ibc eyeball ina'*t also be borne in mind. In traumatic
iritiR, the nature and extent of the injury, the pre;<ei>ce of irauinalic cat-
aract, or the i.'Xtrtt4<iK'L' of iriHamnmlinn of the ciliary brnly or choroid
niuat all he taken into consideration in frtimiii;; the pro;;no^i«,
TrfyitiHcnt. — The patient jthoiilJ be caivfuU^ jtuardud a^^ainst the
injurious iufloeiicea of bri;^ht li;;ht, and sudden chan;;eii of teiuiicrature,
w well aft cold and wet. Perfect real of both eye* iuu*t alw» tte enjuinod,
and if the jKitient hns to leave the hoit^e. a hnndage shonld be plaoed
over the siff(?t;ted eye, ami a shade over the other, or go;i;ilei» BhonU bo
ironi. Itiit if the diaen'^e is very soverc. strict nplers must he jpven
that till* patient itt lo keep io a darkened room. We are, however, very
fre«jnentiy obliged to treat even severe ca;«e8 of iritis ;w out-patients, and
way. wen, in such itittlniicca fre<|ueiitly succeed in effeclin^^ lui excellcnc
cure. This mode of treatment should however only be adopted from
necessity, and not fnmi choice, uud strict injunctions sltoutd be given lo
the patieittt) to j^ianl their eve^ ax much ait po^sihle agaiiiat all noxious
influenced durirt;; tlie intervaU of their vijit«.
The point of tlie very greatest irujiortaucc in the treatment i>f iritis is
to obtain a wide dilatttion of the pupil a« Mton a4 po^iihlo, and hence a
ftron;; solution of atropine should be at once eucn:otically npplied to
the eye. Ttio VieneRcial effect of iitropine i>t ihrec-fold: 1. Wide dila-
tation of the pupil is pnidnced, and the iris la, therefore, removed from
llie contact with the anterior ca|)Sulo of the leue, so that no adhe&ioiu
can lie fontietl between them at the cd;;c of blie pupil, or on the potttericir
•Uiface of the iris. Tbuu one of the chief dan^ienj of iritis, the forma-
tion of extensive pHterior yyneuhiie.ia prevented, and the numeroua evil
C*>i>«e'|UiMiCL<s iir diiii;ivroii5 complications to which they mav fjlve rise,
sre o)ivi:iied. '2. Rest will Ire alfordeil to the i'lHnmed muscular ti^^ne
of the iria by a wide dilatation of the pupil; for if the constrictor pnpilhc
U not paralyzed, ibi con^taut action in endoavoriug to regulate Uie sizo
of tlic piipii according to the stimulus of li;;ht, must of necessity ttiud to
increase the inflammation, just as would bo the caac in any other in-
flamed mascutar tiaauu. iT this could nut Ik- kept p'jrfectly at rest. •^.
The va-H^nl-ir tvnslon of tin- eye will hi- ilimini^flied, and the intra-twular
circubtion relicve>l, which will diminirih tlie Htnte of congestion of the
m» and ciliary body. Moreover, the irritjition of the eye and the ciliary
neunil:;in will Kenerally be alleviiit^td in a very marked nmnncr. It \«,
wewr, nh^olutely nece&iary that the solution of atropine' should bu of
sufficient stren;;th, and should he energetically employed. In the
fionnal eomlitioii of the oyo, an extremi-ly vcvak solution <sr. j-Stitj of
water I will suftice to prmluco a wide dilatation of the pupil, but In iritis
it ia vcrv different. Un account of the iudamcd and jiwullcn oonilitioii
1
206 DIBBASBS OF THE IRTS.
of the tiiwuc of the iris, of the lymph effused into its mcKliei*, and of the
hypericroia, great reaiatnnce is offered to the action of the atropine ;
hencL' 11 very strong oolution roast be m«A, and the application repeatftd
very fn.viiiPiitly, heforc we ean thoro«;^hly overcome this resistance. I
am in the hahit of employing a solution of from four to six grnins of
atropine to the ounw of water, and of applying it at the interval <if five
minutes for hnlf an honr at a time, this hi-iuf^ wpeatcil, if necessary,
three or four times u day ; so that altogether the atropine may have to
be applied from ei;;bteen to twenty-four time.-? a day. in order to produce
and maintain a sufficient dilatation of the pnpil. If tlie case \* flocn
early, before any ndliesions. or only very sliyhi and brittle ones, ar*
formed, we may generally succeed in pnntucin^ a wide dilatation nt the
end of a few hours, and then it is not difficidt to miiinttin it. I 6ml
that patieiita apply the atropine with ranch greater ref^ularity and exacti-
tude, if they are told to use it for half nn hour at a time, at intervals of
five minutes, and to rejfal this at staled periodii three time« a dav, than
if they are only directed in general tcrm« to apply it fifteen or Pi;rhtren
limes a day. As we haw fre^incntly ai the hospital to treat even severe
caaea of iritis us out-patients. 1 invariably apply the atropine myself at
the inter\-al of a few minutes, until either a decided effect has been pro-
duced upr»n the pupil, or the result is negatire. In tlie former caae, the
patient will himself experience the j^reat i-clief to the [laiu and irritability
of the eye which has been produced by the in<ttilUtions, and will readily
and jiludly carry out the treatment with regularity at home. Moreover,
the dtlaiatioii thus etfccu-d can •^etieralty be roatnUiined until the nest
visit, even if the remedy is not a]'plied in the interval <^iiite as fr«(ueDlJy
as directed. I have often been aide t*> treat even severe cases of irilia
with iiroftt fluccesa by ttiis simple means, without the emptoymont of
almost any other remedy, except perliHps the use of warm poppy fomen*
tationa ; the resvdt bein^ a perfectly circular pupil without any. or only
the sli-jbtejil, adhesions. I would a;piin, tlierefon.', urge in the very
«tron;;est terms the energetic use of atropine in iritis, a line of treatment
Kt present, unfortunat^dy. but too much neglecte<l in Enj^lish ophthalmic
practice, the evil results of which neglect are constantly evidenced by
the nunu'riuia cHtutii (if riHrurrent iritis, chronic irido^:horoiditis, etc.,
which we but too fre'juently meet with, and which mi;;lit have hven to a
very -^vat extent prevented by the early and efficient use of atropine.
It ia ipiite useless to prt*scril>e a weak solution of atropine (gr. ss-j ad
3j) to Im> used a few times in the course of the day; this cannot produce
a dilatation of the pupil when the tissue of the iris is inflamed, its offeck
will be nil, as can no easily seen by watching the state of the pupil in
cases where such weak solutions are employed.
Hut we sometime!) find that the action of even a strong solution of
atropine, fr«i|Uoutly applied, is resisted, and that it ptY>i]ut'es little or do
effeot, and increases rather than diminishes the irritability of tJic eye.
In such cases, its use must be desisted from until the irritation is re-
lieved by the application of a few leeches to the temple, or perhaps by
naracentesia of the anterior chamber, 'lliis relief of the iiitt annua lory
irritation und iutra-ocular tension, permits of a freer abttorption tlirougb
the cornea, aiui hence the eflevt of the atropine will now be often very
INFLAMMATION OP THB IRIS — TB8ATUBNT.
207
I
tDRrkri) ntvl rapid. Tliii* cfTcot. as Von (Jracfc han pointed nut, ia roido-
timee n»tjee<l without the reappliciition of the remedy. Tfnia atropine
may have been ap]ilieil iti cnseu of iritia or comeiti!< without pnwlHcina
any dilatntion of tlio pupil, hut many haunt aftons-anlti this hns i-'iisucil
after the upplication of l^ccli^s. We sometinius notice, also, tliat
»Uh<Mij;li ililalali^tii of the pupil may have boen produced, yet tliat it
euinot btt thoroughly maintninfd, the ntropino appeariu;; to loso iteioifeeC
In ?och ca«cs, it will hv found that this is likewise duo to the great irri-
tation of the eye and the iutrcase in the inlra-ocular tonsion. which pre-
vent the i»l>*iorp(ion of the remedy throii;;h the coniea. Whereas after
the appliciiti'ui of leeehea or tlic perfnnnancc of paraci-nteni^, the atro-
pine ivill ftjiain rejrain if* pnwrr over the irin. 1 noed hardly mention,
that if the pupil is firmly tit-d down by numerous and thick adhesions,
the atropiiin .^honld he npplit^d only in moderation, in order to soothe the
irritHhility and diminish the tension of the eyo. But if the posterior
synechiu! are of recent origin, and not very hroad and firm, hut narrow
and tonjiuo-likc the long-continued u«e of atropine sncct-i-di* iii tearing
ttiem through. It ia often Ibuiiil. however, that when this n-uiL-dv is
employed for a considerahle len;;th of tiuu*. it increasf-s, instead of aliay-
ing the irrilahility of the eye, and may oven induce conjunctivitis or
acute granulationa. Tlie hitter are, liowever. lesa fre^^uently met with
than a vaflcular condition of the lida, accompanied hy awelling of the con-
junctiva and great irritation of the eye. In such canes, the atropine
mufit be stopped at once, and a miM a-^tringcnt collyrium aulMtiluted for
it. The strength and nature of the latter muat vary with the degree of
coujunctivitiit. A solution of gr. 1 of alum, zinc, or nitrate of ttilver to
the onnce of water will he found the hest. In rcsicnlar granulations a
collyrium «.if from *> Ut lU gniin« of horsx to 1 ounce of water proves of
much eervire. The irritahility of ttie eye may alao be allayed anrl the
dilntntion of the pupil tolenihlj niaint.iined hy the use of a eollyrium of
belhidoiina (Kxt. hellad. ^ss, .\<). <le^t. .^j), which is to he afiplie*! fre-
(|t»ently in the eoume of the day. It is i^ometimea found that poiittorior
nytiechiic, which reaist the action of atropine, soon tear through upon the
appliention of (!ttlal>ar hean. Hence tlits remedy may be Irioa alter-
nately with the atropine.
The UM of ntr'>pine i.-* to he coutinue<l even for some weeks after the
Bnhsidonce of the iritis, ■w that iIh> wide dilatation of the pupil may he
maintained and the iris )>e kept iit a stat« of rest. It has Ireen nrgei}
by Bome, that the tnng-con tinned tute of a strong solution of atropine ib
apt to produce a permanent dilntntion of the pupil from paraly-ds of the
»phincl';r pupilliu. But this is a most rare and excc]itional utvurrence,
and if any tendency to dilatation slionld n'main, it may he ea^-sily over-
come hy the occasional u«e of tlie Calabar bean, which excites the action
of tlitfi muscle. AtUioug}i I am in the habit of using atropine most ex-
tenairely in the treatment of iritis and other affections of the eye, I have
no%'er met with a case in which tliis condition of permanent dilatation
wafi pr^vluccl, nor have I ever oltserved a case of (Hiitioning from tjie
excesjjive u»e of atropine. Such cases do, however, sometimes occur,
^ and are evidently produced liy the passage of the atropine through the
H lachrymal puncia to the throat. The principal •iyraptom.4 of poirtoning
I
I
i
208
DtEBJtSUS OF TUB IRIS.
hy Atrofiiiiu arc: jErc.it hicrtaise in tlie frequency of the pultte, drj-ncM
of tlio tliroiil,-i|yt%{>lin£t», great irriiabiliiy of itie blitltlcr mid ;;eiiitiii
or^tna, iiu|iAimiciit of memory, hnlUiciriatioiu, and exciting droanu.
Tlie pupils of Ute eyva arc very widely dilatod. Oeiior*lly, these »ynip-
toma ary mily inorUTain in cbanictcr when ihc poliimiin;; has occurred! in
the mode above dcscribdl. bu; their severity is very great if the atro|Huc
\tVkA been ^Malluwed by mifitiike, hiiiI a coii^iderahlu dose has lliud liecn
takoii. The I>ei4t and luo^l ntpid Antidote \a the auhciitanooua injec-
tion of mi>r|ilua' (J or J of a grain). W he repeated, if necessary — even
several times— at inten-al* of a few lioura. The effect of the remedy
is verv uiai'ki'd »iid rajiid ; withlti a few inuuitea ttie viuleuco of the
i^ymptoins ha.'^ ;;reatly Aulisi<Ied, uml tlie {>atjeiil is uiihn ami (|iiict. To
avoid the d:iitrrcr of [MHsoniiig, when stroii;; eoUyria of ati-opiiie are u*eti
with tiri.':tt f'renueiicy. V'tm tiraefe reeoiuim-nds tlie patient tu clwse tlie ey«
directly after the .■]|>pIiL-ation, and tiuWe<)iLently on reiipcriing the eye Id
vash it well. He also »ometinie« employe a subcutaiieotiA injection of
morphia at night, in order to prevent all ri»li. Itiobreich' has dciriacd a
small iimtrumcnt, like a 3crre-6ne. which is attached to the lower |miiu:-
tuui. and thi:! produced a flight ectropiuin of this part of tlie lid, tlioa
preventing l)ie entrance of the iiLn^[iiiie into the piuietiini.
I have already stated that we ocen-tionnlly meet with pcr^ton^ whoftC
eyes show an extraordinary antipathy to the use of atropine, and in
whom even a dmp of n very wt^ak solution suffices t" produce great irri-
tation uf Uie vyv, anil perhajM <tevore eryt^ipc-las >'>f the lids and faco-
In ^ucli eases it slmiild he stopped !it once. My friend Dr. Seeley, of
Cincini^.-ili, lirt.^ infotim'd me that he hnit found in »\icU idiimncraaies
much benetii from contbining the atropine with a weak solution of eul-
pluiic of zinc. [When atropine uct^ as an irritant in tJic ordinary solu-
tion, it ia soiiielimea adviaablu to u«e a pre|>aratlou of atropine disMlved
in retineil ca»tor oil, in which the oil acts hk a luhrieunt to the irritated
eonjuiic'tivft ; or solution* of datiirino or diihoininc may he employed for
a elmiige. In ea^es of extnuiniinary untipat))y to atropine, b'.<tli the
latter ilntgs, however, would pntbubly give rise to the tMitue unpleiuant
syinptjim?. — 11.]
The flcvore cUiary neuml;^a which so often aocompauics iritis is most
relieved by the application of 1eechc3 to the temple, nnd the mac of hut
]x»j>py or hiudauinii fontentatioii». The leeelies sboidd be applied towards
evening, so that tlie noeturnal exacerbations tnny ho relieved. Free
aftcr-blecding is to be encouraged by the use of hot fomentations or poul.
ticua. [The umi uf lleurtetuup's artificial leech has some advantaj^vn over
the live leech, and a recent modification of the appamtu» by Dr. F. It.
I<oring, of Washington, is an im]»rovemcnt upon the old instrument,
[jocal depletion in iritis it> a very valuable remedy, aud xbuuld bo fnr-
ipiontly repcau^l when the indications rei^uiro' it. — B.] The noctunml
pain and restlessness of the patient are also much alleviated by tlie use
of opium, and thia remedy dhould never be omitted in such oilscs, u it
' Viiln Dr. Brll, Bliii. Mrf. Cliir. aodHy, 1BB7, aiwl Vnii nr««lu*i. arlidv, "A. fc
0.," Ex. 2, TO ; iiInu u vrr h\u-tr^Ur\s tttv uf otivvm I'oitouiti); by Alrttiiliio, rvporivd
liir l)r. Sfhiikitl, ■■ Kt. Mui'iAtklil.," ISH, ii. l&tt.
■"KI.Uon«Ulil.," m(l4,411.
IHPLAMUATtON Of TBB IRIB — TRBaTUBNT.
209
w of much coiwemiencc that the piiticut $hmiM enjoy a good night's
rvat. I myself oucn employ tbe subcuUineous injection uf morphia for
this piirpo3i-.
A Mister may be applied hehiud tbe ear, and kept open for « few
daya, and the com|inuiid hclladoniia ointment shoiild be nibbed into the
for*he»*l. [It is sometime* iicccsian* to repeat the Misters frerpiently,
ami thuy may bo applied over the uyebroir and on the temple, placing a
anvM oitc one inch sifnare and repeating it by one of the same nize on
9<)itiid skill next it. — It.]
If tliere is a considerable tendency to exudation of lymph or jiiiti at
the edge of the pupil, eo that atropine doea not act on the lattor, into
the anterior chamber, on the surface of the iris, or into its structure, the
patient should be put rapidly under the influence of mercury. One grain
of calomel in combioation with one-fourth or one-fifth of a grain of opium
should l>e j^^'cn every two or throe houn, until salivation is produced,
which will generally occur in from dU (o 40 hours: even when thi« is
produced, a slight degree of tenderness of the gums should be mHintiilned.
I, howerer, greatly ])refer the treatment by inunction, a« the iligi^stive
powers are thus not impaired, and the constitutional effects of the drug
arc, moreover, more rapidly and «urely obtained. Indeed 1 have met
with instances in which mercury had been given by the mouth for some
time vrithout producin*^ any coiistitutiunul eR'ect, and where this rapidly
4u[iervened u[)on iiiuiicLion. Half h drachm or a dmchin of the strong
mercurial ointment shouhl be rubheil into the inside of the arms and
thighs two or three times daily, until the mouth becomes slightly affected,
the glims showing an indication of the bluish line ; when it Is to be ap-
plied once daily in much «maller quantity. In onler to prevent the
staining of the skin, the ointment may also be rubbed into the bottom of
feet, hut here it is absorbed with le-s rapidity on account of the
rater thickness of the skin. Mr. Pridgin Tealc' recomiucriils that the
mercurial ointment should be smeared on a broad piece of flannel which
is to be wrapped round each arm of the patient, who should reuMin in
bed : a small qimiitity of fresh ointment should be added every night.
In syphilitic iritis, with well-marked nodules, the use of mercury ahouhl
never be omitted, and I have also found much benefit in such cases from
the constant use of hot water compresses, continued without intermission
night and day for several days. 1 Brsi »aw this mode of treatment em-
ployed two years ago, by l>« Wecker, and soon afterwards had the of»-
|>ortunity of trying it in a case of syphilitic iritis with numerotix gum-
iDBta uf coiisirlemble size, which had to a great extent resisted the action
of mercury. I onlered hot water compresses to be applied to the eye
of as high a U'mfreratitre as the patient could bear, an<l these were
changed overy* few minuws, and continued for a great part of the day
ami night. Within the course of two days tlic gummata had diminished
cotisiderably in size, and within four or five diiys they had almost cn-
tirtdy disappeared. In another imtancc, the effect of the compresses
was eijualty fitvurable. Of course it is only in exceptional cases that
* Vidv Mr. T«*li>'s intofiwliug pap«r "On tbi> ReU(lreTalu« uf Atroplns and of
Mareiirr Im tli« Tt<*stneal of Mnu IrtLix. " '■ K. L. O. H. Reparts," r. lOS.
U
210
DTSBASSS 07 THE IRIS.
tliia mode of treatment cnn he employed, for It requires the constant &i»l
umltviiltfU attention of u nurse ; tnon'over. few patients will eittiuiil to
the trouble nnil incouvenience. Tiiift remetiy aim j;reBtly lisatt^n tlie
abflorption of hypopyon. Hot hrcad nnd water or linseed menl poultices
bIbo prove very Wncficiul in allaying the pain, li«.i(eiiin;j: the nlworfiiioii
of exmlatioii, and facilitating the action of ntropinc. They ^liouhl !«;
clinn^il every l."t-20 minutes ; at first they lusy hv continue'l all 'lay,
aud in severe cases at ni;;lit ; as tlie case pnigrei^se.'^ more or loss cou-
sidcrnble tntervaU may itiiervenc between tlielr application.* In th<t
rhoumatico-gouty form, preparations of guaiocum are often very scr-
viceivhie.
Formerly it was very muuli tlic custom to place all cases of iritia under
the iufluunco of moreury, ijuitc irretipcetJve of the fact wliethi-r (he ne-
cessity for it« me really existefl or not. Now, however, a ranrv rational
m':>dc of trentment obtiiins, and mercury is only used in thoite caitett in
which there is much eftiwiivn of lynipli. In spmfic caaea, the iodide ami
hroniiile of polasaium, together with the decoction of bark, should he
ftilmimstei-ed after the n»c of mercury. Whilst the latter remedy is
liein}! employed, it is also wise to nmintain the patient's «treiiii;th hy the
use of lonies. more especially prt^paratioiis of sleel and (piiiiine.
In tlie rheumatic form of iritis, hencfit ia often experienced from the
tue of oil of turpentine internally, ns waa firet rccoromendod hy l)r.
Carmiehuel. AUhou;;h 1 have often employed it witli advaniaf^e, I have
fre*iuenlly ln-eii nhli^^t-d to >;ive up il« nwi on an^unt of the deraii^^emcnl
of the stoiiiacli which it produces. It should be given in doses of from
half a drachm to one drachm two or three timeet daily, made into an
emtdsion. to which a little carbonate of soda is added to prevent the de-
rangement of the digestive organs. Mr. Pridgin Teale uses this remedy
very extensively in comeo-iritis, as well as in low fonns of iritis or cor-
tieitis. and sjieakA most strongly in it* favor. [The arthritic varieties of
iritis are always very oliatinnto in reaieting treatment. It it^ uece^^sary
in tJiefic cases to pay special attention to the free action of the akin,
bowels, and kidneys, tre^ueiit small do»e8 of Rochelle salts, tl»© regu-
lar use of the Turkiah bath every day, or alternating with a general
" niajwnge" of the entire body, and the prolonged administration of either
aalicylic acid ur the salicylate of 8oda, are all necos&ary and vnluable
remedial agenta. — B.J
If the aipiw>u)* humor is very cloudy, or a considerable hyp^ipyon 18
formed, jijiraceuiesis should be performed, and, if ncucasary, retteateii
several times. The same should bo done if the pain is very severe aiu!
docs not yield to the usual rernvdies. The broad needle shoulJ bo very
slowly removed from the anterior chamber, so that the ejucnpe of tlie
o.jneoui* humor may not be very sudilen, otherwise there may occur great
hji/'dTifmut ex vaeiti? of the inner tunics of the eye. In order to facili-
tate tlie escape of the stringy portion of lymph*, the needle ahouhl be
slightly tilled didcways. 50 as to cause the section to gape} or the same
may be done with a small curctu* or probe.
■ Vldn HooMii, "OpbUialmi»(rtHchv BcobaclilongMD," p. 134,
tas, " Kl. Mon»ubl..^' 1670, p. lOtJ.
sud Sobi«s»4}«cai)-
IVrLAMMATION OF TBB I1tl8 — TRBATMBST.
211
But ir the iritia ifi very intetiM and olifttinnte, rMiittmg nil nur remMien,
aii4 more csfwciHlly if tliv it);{ht is uiiicli impaired, if t)ie sjruccliiie are
numernii^ ntitl firm, rtr thi>re \a complete oxrltiHinn of the pupil, ainl if
tb« intrn-ociilnr tfn-titm in nuirkoillj iiicroflj^ed, a largo iridtHrtnmy itltonld
be nuido at once. I htive oftcti sucri this prndiice tlie most striking
b*'Tn?fi(, and it must be remcin!por«d tJiai if the mlhesinna between tlie
pupil and capsule are at all coneidorable and broad, or there i8 occlusion
of the pupil from deposit of lymph within its area, nn iridpctoray will
siilwoniK-ntly he necesaary. and the condition of tho eye will in all prob-
ability Ik* riuicli woi-so wbun tlio iiilbunmation ha<( run lifi cour»e ; and
bene*' the rrsnit of an iriib'ct«my be far less favorable than if it had
been made at un '.'arlier p'.'riod, before the changes of fttnictnro bad at-
lined any conaiderablu degree. MortMivcr, the iridectaniy generally
Eta as the best antipblogistic, the inflammation, which ha<l before re-
istvd nil our remeilinl nioasiireg, rapidly subsiding after tho operation.
In iririt arroaa much bunefii id often experienced from exciting the
free actinn of the skin and kidneys by diaphoretic and diuretic remfdles.
Atropine shouhl also be applied, as well as a suppnrating blister behind
the ear ; but it must be confessed that local rctnediea often prove of little
avail. The state of the intra-ocular leu»ion, of tliu sight, and of the
field of virtion mnat be narrowly watched, and if symptoms of glaucoma
■upervone. no time i^hiiuld he Io«t in making a lar;;e iridectomy.
The trwatmout of traumatic iritis miLst vary ncconling to the nature of
the injury. If n foreign body has become implanted In the iris, it must
l>c cAruftilly extracted, with or without the excision of the corresponding
M'gment of the iris. If the lens has also been injured and a traumatic
cataract has been formed, linear extraction, perhaps combined with iri-
dectomy, should lie at once performed if the lens becomes much swollen,
sets up great irritation, or tho intra-ocular tension is increased. If a
portion of the iris prolapses through a small wound in the cornea, it
should Ik' pricked, so that the ai)ueou3 humor may flow off, and the col-
lapsed protruding portion of iris shoidd then be excised, and a firm com-
proBS applied. After an injury to the iris, the inftammation should bo
C'liiiWi.-ii. acconling to circumstances, by cold or hot compresses, loeohea,
and atrupinc ; and. if necessary, rapid salivation should be induced.
In order to prevent, if pos.-4ihle, the recurrence of the inflammation,
>ro especially in cases of chronic iritis, tlie patients should be warned
gainst undue exiiosurc to cold winds, draughts, bright light, etc., and
Id be ordered to wear the blue eye protectors. Nor should they lie
littod to strain tlieir eyes with fine needle-work or rery small print,
nartirnlarly by artifieinl li^ht. Their iliet must also be carefidly regu-
lated, and any over-indulgence in wine or alcohol !«lrictly forbidden.
Inattention to these difl'ereul points fre'tuently causes tlie recurrence of
the inflammation.
212
DISSA9BS OF THE IRT8.
3._FrNCTI0XAL DISTUlillANCES OF THE IRIS.
Although the dilatation of tli« pupil ia geuerally oonsiderable, it it
not 60 extreme as tlrn-t pro<luce<l by a strong solution of atrupine^ where
the iris is contracted to a very narrow, hardly pcrceptiblo rim. The
dilatation of the pupil may be umfonn and regular, so that tlie popil
retains its circular form, or it may be partial and irregular, the pii]iil
thug aoiuirint; a somewhat ovoid shape. The pupil, besides being dilated,
18 more or Ice^d imuiovahle, acting but elij^htly, or not at all, under thu
inHuer.cc of light, the cfi'ort of accommodation, or the convergence of the
vii^ual lines. The »ight is aUo souiewliat affected, which is due in part
to the bright glare ivhich is experienced on account of the widencsa of
the pupil, and aUo in part to the circles of difTtmion formed npon die
retinii. If the impairment of sight be simply due to tiie oiydriasis, it
will be remedied if the patient looks through a small circular o])ening in
a card, or through the ateiio|aic apparatus, for then the glare will be
diminished, and the formation of circles of diffm^ion prevented. But
very freqiicnily paralysis of the ciliary muscle coexists witli the dilata-
tion of the pupil, aud the impuirmcut uf vision is chicQy due to the losa
of sccommodatinn. The features which disUnguiKh the symptoms due to
low: rtf accoromodauon from those which are simply caused by mydriasis,
are freijucutly overlooked by medical men, and thus nmcli confusion is
ofton produce<l in the narration of cases. Nor is it of unfr<>(|uent occur-
rence that the symptoms of amblyopia, produced by paralysis of accom-
nuKbitiori, are referred to some senous iiitra-ocular or cerebral lesion.
There is not, however, a necessary relation lictween the degree of
dilatation of the pupil and the paralysis of the ciliary muwle, for the
pupil tnay bo widely dilatatcd and the ciliary muscle but slightlvi if at
all, affected ; the converse is, liowever, of less frequent occurrence.
When tlie pupil is widely dilated, it no longer presents its usual bril-
liantly black apiiearance, but asiinmca a somewhat gmyish tint, which is
due to the greater amount of light rejected from the lens and the fundus
of the eye.
Mydriasis is generally monocular, unless it i» due to some cerebral
cause, or to a deep-seated IntraMicular lesion aifecting Iratlt eyes. Mon-
ocular mydriasis often produces considerable distiirltance of sight, on
account of the difference in the brightness uf the two retinal iiu.tges, and
the presence of circles of diffusion. For the purpose of accurately raca-
During the sixe of the pupil, Mr. Zachariah Laurence's '* Pupilloroeter"
[b"ig. Iju] will be found very useful.
["The puplllnmeUT consintd essentiiUlj of two parta: 1, ft pur of
indices or * Aiglitit :' and 'I, a graduated Kale. The sighta are formed
by two vertical, knife edged, brass bars (indices); the one (m) fixed;
the second (,;'_) movable by means of a screw (*), the head of which (A)
is furnished witJi several fiiuiU projecting spokes, by which tlie screw
tnay be turned with great delicacy by the tip of the finger. The hori-
Xontal plate (^). the ttcale to wtiicb these indices are attached, is of
MVDItrASIi.
213
&T1
m
wliitc awtal, iinil i» gnuluAtod intA whole, half, and quarter Hiien. The
scale ia gradiiatiMl on both s'ules, so that, bv sirajily revemiig the itwtru-
mcnl, the papil oF each eye may be siiccuasively measureiL The appli-
oatioo of t)ie pupillometer U obvioiM,
from the annexed fij^uro. The edge Fig. 40.
of the Hxod index (m) ia hchl in a
line with the inner t'd^y of the pujiJl,
and Uicn the nioralilo one (,/') ia
gradually screwed up till it4 edge
corresponda exactly with the outer
edge of the pupil. Tlie interval be-
tween the two indices represents the 3LL_^H_k^ a
diaoKter of the pupil.*''— H.] ^^ —
Cau$ei. — Before entering u|x)n the
Iflerrnt caniwH which may produce
lydriasis, it will be well hrioHy to
consider the action of certain sub-
stances upon the condition of tbe
pupil, either in increasing or in dl-
minifihing ita aizo. 4'ertain aub-
Btances, more especinlly belladonna,
hyoiicyanimi. and atramoniuoi, have
the |iowi*r of pmdnciii;; n marked
dilatation of the pupil, }in*1 arc hence
termed mi/iiriutirg. We shall here,
however^ confine our attention to the
acutin of atropine upon the pupil and the accominodation. In numerous
rxpcriuK'nta made by I>ondera.' it waa found that if a solution of four
ins of sulphate of aln^ipine to an ounce of water was applied 10 the
tlie pu[>il began to dilate within iifteeu minutes, arriving ai the
uwixitoum degree of dilatation in from twenty to thirty-fire uiinnres, and
Buaily complete immobility euitued. The younger the indiviilual and the
thinner Uie coniea, the more rapid was the actjon. The diminution iu
tlie power of accommodation commences somewhat later than the dilata-
tion of the pupil, but gradually returns, together with the mobility of
the pupil, after some days. After the lapse of forty-two hours there ia
geuerslly a iilight diminution iu the vixe of the pupil, accompauicd by
some HCCQoiuHidation, which incrcaaeti with toleraltU* nbpidity up to the
fourth day, but doca not become perfect till about the eleventh day. The
weaker the sotutiou of atropine, the longer will it titke to act, and the
U*iw and mure transitory will lie ita effect. By employing an oxtmnicly
weak solution ( <^r. j to eight or ten ounces of water >, we may dilate the
impil without iifTecting the ucc»mmudacion. That the action of the atro-
pine ia due to ita absorption through the cornea, Is pravcil by tbe experi-
[Dvnt8 of Von Graefe,' who withdrew some of the aijueoua humor from
the eyo of a rabbit, the pupil of which was dilated by atropine, and, apply*
I' ijiatrtie* and M<Hin'« " llnintj'-Bottk nf 0|i)ithKtiiiic Siir^rry," p.
r>vDdfrH, "Ai»'>iiiiilitr« i>r ftvfrnctiou and AccviumiMlativti," p. 56j.
■ "A. t I).," i. 1, 4(i2, note.
20.1
214
DISEASES or THE IRIS.
7
i
ing it to the aye of another rabbit, it vaa found to produce diliitation of
tlitf {m|iil. H
Tlie action nf the atropine appcara to be twofold ; if produces diliit*'™
tion of tlie pupil, partly- hy paralyxtng the sphincter pupillic, whicli i*
supplied by the third nerve, and partly by exciting tliy radiating fibrts
of the iris, which arc supplied by the sympathciic. The truth nf this
hyfHtthcsii appears to tuc to he i neon trove rli My proved by Uuete'g' oV
Bcrvatioii, tbat in dilatation of tbe pupil due to complete paralysis of the
thinl nerve, tlie application of atropine produced still further dilatation.
Tliia iH certAinly ojinosed to the tlieory advanco<l by some observera, vi«.,
that the parfilysiii of the sphincter pupillie permits the sympathetic nerve
to exert an unopposed action in dilating the pupil. Moreover, it is found
in mydriasis due to paralyHia of the tlilnl nerve, tlie ])upil is not ditatet)
ad in'irhnum, even although the affection may have lasted some time;
but on the application of atropine tbe wide&c dilatation at once onaucs.
Calabar bean produces excessive contraction of the pupil, together
a contraction of the ciUnry muscle, and an artificial myopia. Ita acti
will he more fully explained in the article upon the " AffectJona of
Accommodation. 1 think there can be nn doubt that it cldefly produces
lis etfect u{>on the pupil by exciting the nerves to the spttincter pupiilo},
although the myoais mil}' also be in part due to the |»aralysi8 of Uie rai'"
ating fibi-es of the iris supplied by the «ymp»tlietic. But the ^pasmodi
contraction of the ciliary muscle speaks strongly in favor of the exci
tion of the third nen-e.
Idiopatliiu iiiydriaKiii is not nufrequently due to rlieuroatic origin, tlte
naticnt having been cxjio-icd to cold or wet, and it U in such cases pro-
bably caused by rheumatic inflammation of the nen'O sheaths. It is
generaUy accompanied by more or Icsh complete paralvsis. of some or all
ftto muscles supplied by the third ncnx. !t may be also due to syphilis.
1 have met with a few ins^tances in n'bich a varying degree of mydriasis
appeared in one eye, and in which all the ocular muecles were unaffected ;
the ciliary muscle also beirtg either not at all, or only very slightly,
alfected. In these cases, the affection could be traced to no other cause
than syphilis, and the mydriasis had occurred some time after tbe sec-
ondary symptouu. The dilatation of Uie ])upil yielded gradually, but
slowly, to th» adininistratinn of imiiilc of pot&Ksiuin, ami the occaiiional
application of a bliittcr behind the corresponding ear. Mr. Dc ^[^ric, in
an interc-itiiig paper read before tbe British Medical Association at Leeds
(18(>y), reports several cases of syphilitic mydriasis. In one case,
the ocular nmsclea were paralysed, and the mydriasis was considerable
there had, however, been caries of the orbit, lu two other cases, th
mydriasis was accompanied by ptosis, in another tbe latter was absent,
but tlie dilatation of the pupil very ubsttnate. In two cases the secon-
dary symptoms bad t^uito vanished, in aitotber the tcrttariea wore on
wane.
Mydriasis may likewise be caused hy direct injury to, or comprussl
of the ncn'cs supplying the constrictor pupilisc, as, for instance, in con-
!US
:h™
nt,
on-
■ KUii, Bvitrags i. Falbol. ui>il Pbjviol, der Augvu. oud OIimd.
Bfftnustiliwclg,
MYDBtASIS.
215
Bei]ucnce of s4>vcre hlnwa ii|)on the eye, or of an inoreasc in the intra-
ocular ti>nsi<in. lit tlioso coiscs in wliich it is caused by a blow, tbe
royUriasitf is not uiifre(|uvntly pnrUuI, only a certain |wrtion of tlio Hphino-
ter ptiiiilln being aflccted.
[ruriber rvmarkx ii|>i>ii (bo oauiiation of mv'lnaitig will bo found under
the hcfcl of j\,noiimliL'4 of Aocoimiioiiatioii. — IJ.]
Mydria»in niay 1>© aluo due to irritation of tbu Hvmpothetio, as maybe
rseen in certain npiual diiteasea. Tlic epbenu'ral dilatation of tlio |iupil,
whicb opca-iionally occurn for a short lime at diftorent periods of tlie day,
ti probnbty due to this cause. Von Ui-nefc has called atteation to the
interi!8t)ng and important faet. that tins epheinarni mydriasis U Hometitnos
premonitory !!iyni[itoiii of iiiAtinity. more especially of ambitious niono-
inia. Tbe dilacuti<tn met nttb in belinintJiiasit! may aWi be obcribed to
irritation of the sympathetic.
[Cutti|ileto mydriasis, with unimpaired aecommodatiuu, miiy appear
ttfter violent perinrbiul pain, and in these cases a careful opjitliiilmo-
)pic examination simuld be made, for a ^lauoomat'xis eondilion may
lie at the bottom. Sometimes mydriasis, with other si^ns of paralysis
of the third nerve, precedes locomotor ataxia. Monocular mydriasis,
with »lu>:giiiih action of the iria, is to be re;;ar«led as a sunpicioiie brain
symptom in suspected diwaso of the nerve-centres, as pointing to bepn-
ninET panilyais; thouf^h Amdt rc;;ards it as a li^ of spinal irrii.'^tion.
Mydriasis is a fret|ucnt symptom in hysteria, and duriuj; ofrileptic at-
tacks. Partial mydriasis in pi'm*rtilly fine to compreswion or injury of
the ciliary iienes, as may be observed in division of the optic nerve, or
in the more modern operation of optico-ciliary neurotomy without enu-
cleation.—II.]
Dilatation of the pupil is also a common symptom in certain diseases
of tbe brain, f. </., meiiinj^itis, hydrocephalus, and diseases of the cere-
bellum, also ill many intra-ncular rli»easo8, in which the seiwiltveness of
the retina is mndi diiiiinislieil. In cxceptioiiul iiii:taiices, the pi)i>il may
still act porfootly, even althougli the eye is absolutely blind. In such
cases, the c«nductibility of the optic nerve, and tbe reflex action which
it produced on the ciliary nerves are unimpaired, but the image is not
perceived by the brain.
Tre'tfrNent. — -In the rheumatic form of mydriasis a blister should be
applied behind the car. and iodide of potassium, or a preparation of
j;;it:iiucuni, should bo administored internally. 1 have, however, often
found a more marked and rapid flffoet to result upon tlie paralysis of
tlie accommodation from the application of the blister, than ufion the
mydriasis. If the dilatation of the pupil does not yield to those rcme-
dien, but allows a tendi'ucr to becomo chronic, tinofurc of opium should
Ih? ditipiH'd into the eye, electricity should be applied, and the use of
Calabar Itean maybe tried. Tlie latter remedy .'^boiil.l not, however, bo
applied of too great a strength, or too frequently, otherwise it will pro-
duce loo much fatij^uo of the sphincter pupillai, instead of dimply mode-
rately stimulating^ it. Fre(|ucnt and firm closure of the eyollds^ con-
vergeitce of tbe visual lines, and repeated exorcise in rea<lin^, etc.. are
aUo of aiivanta;^' in siinnilalin;; the contraction of the pupil. [Sulphate
of pserine is a m^ire active ami iea irritating myotic tlian the mother
(Iroj? Cftlftbar. A solution (t cgm. to 5 grm.) should be dropped into
till- eyv as often a;; iicceHSiii'v, iitilcss it occa^ons too much coDJimcnval
»ml cilinr}* ii-rit»ttnn. It' t)u> mvdrinsis is ncQompanied by pnralyiia of
nccommodalion, tlie constdnt current of electricity should W resorted to,
or 8ubcut«neouB injections of strychnia may he Riven. — 11.]
In very rare inatanceg, the faculty exists of voluiitArily diUting the
pupil. 8ettx' mentions a c&^e of a youn^ RtiKJi^nt, wlio was »hh' voluu-
tarily tf> produce n dilatatton of about three millimetres by uVinji a .Iftpp
incfpiration, and then lioldiiig liii> breath, at the satne time niakintc n
Btrong eflnrt, during which the mut«cles of the neck and back hecaiue
very tense. The experiment succeeded best when he regarded an object
lying bat a short distance fraui the eye.
(2) Mtobis.
Idioi>»tliic myoNs \8 of rare occurrence. The pujtil m in snch euBi.'
often extremely contracte^l, perhft|>s to the size of a pin'ti head, or even
less, and actts but very slightly on the atiinuhus of li^ht. Even atrong
wtlution« nf alropiiH' produce but a very niuderate degree of diUtaUon.
On account of the extreme miuutcnesfl of the pupil, hut little light is
admitted into the eye: the retina! images are coiisetpienily hut ^tiglttly
illuminated, and the vision ott this account more or le^ impaired. The
small sixe of Oie pupil also causes a considerable contraction of t^
peripheral part of the field of vision.
Myojiia may be caused by a spastic affection of the sphincter pupillie,
or by a paralyitis of the radiating; fil>rei4 of the iriis. Tlie irriLition of
the hranch of the thin! nervi-. which rtupplios the i^phincter pupilUe, may
be due to some central caiu$e, or to retlex action from the hftb norve.
It may also be produced by too great and long-continued use of the
eyes at very minute objects, such as watch-making, engraving, etc. ; in
consequence of which, tlie sphiucter pupillw in time aci|uire» a prepon-
derating power over the diUtor, The myosis due to jtaralysis of the
dilator muscle is met with in those spiital li-i<ions in which the sYm[:ia-
thetic nerve is affected, so that its intluence u]io)i the radial hbras of the
iris is iro|rfiired. Dr. Argyll Robcrtton report.' a very interesting case
of spinal affection, in which there was marked myosis in both eyes, the
pupiU being a))Out the aiice of a pin's jHiint. Kven a strong solution of
atropine bad hut an imperfect and transient effect, but Calabar Wan con-
iracted the pupil still more, to about J of a line. A tumo.' or aneu-
rismal swelling* pressing upon the cen-ical portion of the sympathetic
mav also produce myosis.
In the peculiar condition termed htppH* Iheru is a chronic apaani of
the iris, producing rapid contractions and dilatations of the pupil, which
follow each other in i|uiuk xuccei^MOu, and are indvpemluul of the influ>
«DCC of light. It is generally allied willi nystagmus.
> " AogenhoilkandH," p. 315.
• " Kdliiburgb Mod. Jotirn»l." Feb. \M&.
> Will^liraua, "A. f. O.,' 1. 1, 319.
■ OainltM-T, " Uontliljr Joarnal vf Mvdicinvi" liii C*X>]. XX. p. 73).
TRBUULOUS IR[B.
217
The treatoK'nt of myoola must of course vary with the caiwe, which i*
often «tuat«(1 ai a distance from the eye. Periodic instillations of a(ro.
utie shuiilit he tried, although they generalljr have but a alight and only
ipotiLfT effect upon the luyoMs.
[Spa^mrtdic or spastic myosis ia of cerebral origin, am! is met with
irt coimnciicin;; meuin;;iti8, tii cai^ea of poisouiu*; bv alcohol, opiuiu,
nicotine, etc., and BoineUrnea at the lH-';;innin'; of an hysterical convul.
sioti. The paralytic form of inyotfit) i» uiuch coninif^ner, and is often due
to direot comprc8»ion of the cervical Hyinpatbutic, or to injury of tlie
apinal cord in the oerv'icnl reginn, and tn inflammatory di$ca.i09 of the
spinal corl. Monocular and binocular myosin is obderved as a very
early symptom of ataxy, and sometimes disap]iears when other symptoms
begin. Kven in casfs of marked optic nerve atrophy in ataxy, tJiere
niay be no myosis. Id the niyosis due to ataxy, atropine produces only
partial and transient dilatation, while eaerinc increases the myosis.
When the myosis is of tiie npadtic variety, there is generally more or leas
apnsm of the accommodation: but when the myoi^is is paralytic, the
accouuniMlfttion is alutost always intact. — B.]
4._TREMrL0liS lillS (IRIDODONESIS).
The UKWt frc(|nent csnse of this comlition is absence of the lens, or its
partial or complew dislocatinn. In such cases, the iris will be ol»ser\"ed
distinctly to nsciliat« and tromhle when the eye is moved in different
directions. In cases of fiartial dislocation of the Ictis, the tremidoiisncss
will be confined to that portion of the iris which has lost the euppcat of
tlie lens.
This condition may also be ohacn'cd in those cases of hydrophthalmos
in which the size of the anterior chamber is much incroase'I, aud the iris
is atretched sideways, thus losin;; the support of the lens.
It was fonnerly snp[>osed that a fluid condition of the vitreous humor
produces undulation of the iris. That this is, however, not the case is
proved by the ophtlialmoscopo, for wo often meet with cases in which a
fluid condition of a cousidenible portion, or the whole, of the ritrcous
humor may I* dia;^OH(>d from the wide excursion made by the floating
Mlpeoiis opacities, and yet the iris does not show the lea*t tendency to
trt'mukm^ness.
[A fluid vitreons would cause undulation of the iris, if marked trophic
changes, leading to marked reduction in volume, occurred in the Ions.
This form of lens trouble has been called I'tUanvrta uttfatilig. A Huid
vitreous cannot be inlerretl from a iromulons iris after extraction of the
lens, fur an oscillating iris de|ionds upon the integrity of the glass-mem-
brane lielitud the ins, and on the absence of adhesions of the posterior
inrfacc iind pupillary margio of the iria. There can be no question of
truotmeut for
upillary margio of th
tiiie symptom. — B.]
218
DIBEA8BB OF TUB IIUS.
S^WOUNPS OF THE IRIS, ETC.
Ptmchired or incised wounds of the iris are not generally followed W
9ucli »erioua consequences as might have been supposed, as long ms II14
lens hSH e.4ca[n''l injury. That the iris is not very im|Hilient '»f mi
wound-* is sufRcicntlv proved by the operation of iri<U'ctoniy, f>r the acci-
dental incision of the iris in the performance of extractinn of catariict,£H
aj'niu, the puncture of the iris which may occur during the needle Of
lion for tlie solution of catjiract, or the diriaion of n-mains of opa<]ii
cai«ulo. Such operations are. as a rule, not followed l>y iriii*
Woiimis which have toni and drajy^'wl the iris are more dangerous tbi
iboee which have siuiply produced a clean cut.
Blows iijion the eye from a Wunt foreign lK>dy, such as a pieee «f
wotwl, a cork from a pnyor-beer or soiia-water huttlef etc., may cause a
rupture of tlia continuity of the iris [Fig. til], hut mwrc freiiuently atill,
fPi«. 61.
Kfg. 62.
111(1^^^'
J.L'.'.i Lju «i.-u.
AHar biifMB.|
a niptnre at its };reat circumference, tearing it away from its ciliai
tachracnt, and tlms nrodiicin;; a more or Ii-m exteiuiivo curediiilyais [iri-
dodialysiii.^H.] [rig. i>'2.] This is the more likely tooccnr if the ed^^e
of llie pupil id tied down hy adhesions 10 the capsule. These secondary
piipiltj nuiy be refidily reco;^ized with the oblique illumination, and still
more easily with tlie ophthalmoscope, for the red reflex from the fundus
oculi wilt ap]iear likcwir^e lhrou;i;li thi>f pupil. Such accidents, a^ ncll
as the incised wonml't of the iris, are gcnerflUy accompanied by more or
lees effuMiun of blond into the anterior chumljcr.
Mr. Iriiws'in' narmk'H an extraordinary case of *' laceration of the
iris, without injury to any of tlie external coats of the eye, from the
splash of a bullet, after it had hit the target, striking the eye," which
was under tht* care of Mr. Critchett. The external coala of the eye
were ([uite uninjured, and tlie outer pari of the comes only presented a
slight unevenness of its epithelial i^nrfuce, without, however, showing
any ojiacity or any mark indicating the point wliich received the blow.
'* On looking, however, within the eye, two distinct pupiU arc at onco
seen, the one immediately above the other ; the lower is separated from
> " InJariM of th« Bye, Orbil, •!«.," p. 1S3.
V0DMD8 OF TSB IRIS.
219
[Pig. «3.
I
the npper one by a briilgo of iris ; *iul the upper pupi! U bounded hy n
bor<ler u( iria, so that it ifl distinct from, mid does not microuvb on tlie
ciltnry nttachraent of the iris [Mg.
tt.*).] The luarpins of the it«w pupil
whi'ii farefully rxatniiied mv found to
Lbc fllij;litiv lacerated and irrvj;ular."
[Itr. 4'hi»iilni' lias nscorded a re-
markable case of complete romoral of
the iru bv the fiuger-nait of an aiitag-
MUBt [iriiltTomin.— B.] WldUt under
pgtcitemi-nt liis |>»tici>t!#iifrerod uo pain,
and wiu not u>taru, nt the timu. chut
his eye had heon injured. The next
I day bo discovered the chan}!;e of color
in nis eye, and detectetl a itiired of luembraDP protruding from u scratch
oo the front of the oyehall. After one or tvro days this fragmeut eatne
away, leading a white scar over the ai;;lit. No setere inflammittion fol-
lowtfd the injury, and so little infonvt'nienco was oxpurieiiced that he
did not tliiuk it necesaary to seek professional advice, nor did he low a
day's work. — H.]
Cmca of rupture of the Bmaller circle of the iris, accompanied li^ dila-
tation of the pupil, have becu narrated by Mr. While Cooper, ^^eckcr
bofl, luvwi^ver, ^ecn a cii«e in which thu sphincter ]>upilla; wna ruptured
from a violent blow upou the «yc, without any coiuccutivc dilatation of
the pupil.
A very peculiar and rare condition is that of retraction or dcpn\*tsiou
of a portion of ilic iris, which is sometimes produced by blows upon the
eye. The portion of the iris which is depressed is folded back upon it-
self, and the inner pupillary circle disappears at tlie point where this
fohlint; occurs ; thu penrilieral jiorttou of the iris 'n (|uito iiivi:uhlu. hav-
ing sunk back out of sight, so that the eye at t)iii* point presents the
ap|>canince as if an iridectomy bad been made (|uitv up to the ciliary at-
lachnieut. On examining the eye with the oblitiue illmuinatiou or with
Uie optitlialmosofK;, we cannot, however, dotect a trace of the ciliary
pmceasi-f*, as woulil be the case if the iria had been removed.'
In .iucli eases the lens bos generally been found partially dislocated
or mucli diminislied in size.
The treatment of injuries to tlie iris must be directed to dimiui«hiug
any inflammatory symptoms which may supervene. Atropine should be
fraiuently dropped into the eye, leeches should, if necessary, be applied
to tlic tomplc. and. for the first few houra aftor the .iccident, cold eom-
prcBses will aflfun) great relief and assist in checking a tendency t*i in-
nanimation. If there is any pi-olapse of Uie iris tlirou<;li the corneal
wound, or if die lens hiia been injured, the treatment laid down in the
articles upon " Wounds of the Cornea" and " Traumatic Cataract"' must
be pursued.
n "Amw. Jonni»l of MM. Scl.," July. I«7a, i>. I'i5,]
■ Ki^r a di-scrliillon of cas<-it of tliim iiil(.*r>'>tinj; afT^'clion, vHf " Mmirtm'* OjiliUiil-
inialriai-l>» B*Hil>acbtunf;>ri>,'' ji. Ktl, and Wwlctr'* "TraJUiliifl Malwlicn drt Vi-UX,"
vol. i, |>. 4^.
220
ntSBASBS OP THB IRIS.
Small fr)rci;;n Ixxlteg, aitch a» Rpliutcrs of sbeel or glass, portions of
gun-cap, etc.., may Iwcomc lodged in llie iris, or may injure it in their
iHUKagv to Uie back of tlic eye. Tim preseueu of even a oiinutv foreign
tKKly in the tissue of the iris is a source of constant irritation, and coo-
eei|ueutlT soon sets up more or less severe lutlammatory cont plica dons,
giving; risa to comeo-iritis, or pcrtinps suppurative irido-choroiditis. It
19, therefore, most advitialle to extract a foreign body in tlie iris a« soon
as pOAt^itilc. Tlie licst mode of doin;; this is by an iridectomy, Uic seg-
ment of iris in which the foreign body in lodged being excised.
[For further vuDsiderudon of this subject, see section y of this chap-
>r.-B.J
G— TUMORS OF THE IRIS, ETC.
[Tumors of the iris may he divided into two classes : heni;^ and ma-
lignant. Among the first class are to be jilaccd the epidermoid growths
and the cysts, tJic piguieuivd u:i;vi and llic ;;ninulauon tumors. In the
second group Wlong the sarcomatuus and eareinotuatous growths and
tubercles of the iris. — B.]
CtfatM of the iris are uom[>aratively a rare affection, and arc almost
ftlwavA llifi renult of ftonu* injury to tlio iris. Thus they have Iw'cn met
with aft^T the Uwlgiiient of fon-ign bodies in the iris, jKM»etr«ting or
iucised wounds of tlie latter, btone upon the eye, or even after opemtioos
for cataract, such as the operation of division or the common 6ap extrac-
tion. Sometimes it is difficult to discover llie exact cau«e, or to ascer-
tain with certainty that any accident has ever occurred to the eye. In
such cases, a very careful examinHtiun may,
(FtK. U4. however, wometimeH lead mi bo detect a slight
opacity of the cornea, the retnainfi of a former
perforation.
The cysts generally appear in the form of
small transpnrf-nt vesicles, situated on the sur-
face of the iris, from which they may spring
from a hroadish base [Kig. B4') or a little ped-
icle. Their contents, iiutead of being limpid
After Ji»rk<ui«.i >"■! transparent, may he opaijue, canaing the
cyst to aitsume tlie appearance of a little pearl.
Von Ciraefd' rwconU a ca-te iu whieb the contenta were sebaceous, sofl,
ami pulpy. and in thiitcyHt there were aUo found a number of short illicit
hairs. .\ Kimilar case is described by Mr. White Cooper,' but in thiK
the cyst was tough and hant, like carlila^^e, and was torn away hit hy
hit with the canula forceps. The little growth appeared to be made up
of ei'ithvlial cells, closely packed together.
'Hie presence of the cyst may not be prwluctive of any particular
inconvcnit'nce or impairment of the sight, except inasmuch as the latter
may he interfered wiiii hy the cyst protruding more or less into the arcs
of the pupil. But in other cases, it setd up a considerable Uegreu of
' "A. r. O..- iii. 2, 412.
■ ** tmiao Joarnol uf Modldafl," Sojvt. 18S2.
TCMOBS or TUB IRIS.
221
irritation, occomponiod by cilinrr injection, pholophohta, lachrymftHon.
etc., or it raav pive rise to iritis. In a ciee iiirratvil by Mr. Ildke' syin-
pathetic iittlnmniatioii nf tbe other eye was set up, which yielded rapiilly
after tlic excision of the cyst.
[The tlerolopmont of a cyat in the iris must be regarded as generally de-
structive to the functions of the eye, tliough cases arc on reconl where the
disease lias coote to a statid-^till with partial pradervation of virion. — R.j
In an interesting paper upon cysta of the iris, Mr. Ilulke says: "An
examiiijition »( all the casi-s wriiich I have been able to collect shows : I.
tliAt cyiti*, in relation with the iris projecling into the anterior olianiber,
originate in two situations — 1, in the iris ; and 2, in connection with the
ciliary processes. The first lie hetween the uveal and the muscular
stratau) of the iris, and are distingiiislicd by tbe presence of muscular
6brcs upon their anterior wall ; the second lie behind the iris, and bear
tbe area) as well as the muscular strata on their front. II. U altto
shows that these cysts arc of more than one kind : that there arc — 1.
delicate uiembranous cyst«i, with an epithelial liniuj^, and clear limpid
conleuis ; *i, thick walled cy^t^, with ojuiipiu thicker cimtenti) (whether
thf«« are jffcncrally distinct from 1 we are not yet in a position to deter-
mine, but it fvem-^ probable that they are so) ; 8. solid cystic eolleotions
of epithelium, wend or dermoid cysts ; 4, cysts formed by deliquescenoe
in niyx'iiiiata."
Wecker' believes that serous cysts are never developed in the iris,
bat that they are the result of sacculation of the latter ; and that tlic
forauktion of tlie cyst does not inkt* place by the diittonsion of a prc-
exiseinj^ simco In the riitmie of thi* iris, but that tbU space (a fokl or juic-
dilation of t!ie iris) is caused cither by injury or inflammation, the serous
contents being the !U|uef»a-4 buuinr. [Wtieker's view of the cystoid de-
generntinn of a portion of the iris, has been confirmed in i>art by Knapp,
Altf and others. There seems to he no doubt th&c saoculatiou of the iris
cbrougb injury may lead to total cystoid degcnemtioii of the iris. Vet
Weclccr thinks it p<»!isible tlint, iuuluiling these cases, and all epidermoid
;nwths, real retention eysttt mav Ik* dcvt'lopod in the tissue of the iris.
Kothrmind'ii idea, that serous cysts are cnuseil by s hyperphu^ia of the
epithelium on Deseemet's membrane, has no positive basis to rest upon.
Tlie tissue of the iris co%-ering the anterior cyet-wall generally becomes
80 Stretched and attenuated, that the limpid conteiiCt> of the latter are
perfectly distinguishable, and we can often see ijuite through it to the
(Hjsterior wall. [The inner surface of tbe cyst is usually covered by
delicate epithelium, and destitute of pi;;ment. — B.j
Tlie boat mode of treatment is the excision of the cyst, togotlicr with
the segment of the iri;* to which it is attached. Puncturing or laceration
generally proves Hnsmvesuful, as the cyst very rapidly n'tilU. Rut ibi
excision, combined with iridectomy, is not always free from danger, as
wna shown in Von tiracfe's case ;* where the operation was fultuwod by
• "R. L. O. II. Rvp.,"*. 12.
■ Kuapp nii>l Hv.Hi' " Arvliiv. uf 0p)itiisli»uit>g7 and Otvloicy," f. 1, p. )^.
* "A. r.O.,"all. 2,:Ud.
ooo
M8BASB8 OF THB IRIB.
s«vere purulent C}'cUti9 ; )irol'Al>Iir from » portion of the cjst having beon
1cn bebiixl, and becomiDg the ^iii-ce or the iuflamtaatorf ootnplioattoiu.
Ctftticvrn of iho iris will he treated of in the article upoa " The changes
in iho eoQtents of the Anterior Chamber."
JVWi'of tilt' iria arc aliiiost always con;^nitaI,mKl present tlio appear-
ance of smnll black patches or elevations, which remain stationary anrl
cauee no irritation.
[These ntivi have been called " simple melanoma," and consist of a
circnmttcriWd hifpcrplasia of the nncolorod ami pigmented stroma cclU of
ihi' iriii. and, iicconUii<; to Kii»ii|>, do not ori;*in]ito in tho uvea uf the
iris. (Die intniocnlaren (ieftchwilUce.") — B.]
Teleangiectasis or ni«vu» of the iris is an extremtdy rare ftffectiou.
Mooreii' describes a very cxtrnordinary case of this kind in which a dark
tuntor, resemhliiig a blackberry in sixe and appcamnco, wait situated ou
the external jHinion of the iris, extcndiiijr somewhat into the pupil, wttli>
ont, howevLT. in the least impairing tlie sight. The tumor, wlmsc ante-
rior surface couched tlie cornea, was traversed by several dilated blood-
vessels, witich could be seen Co ahine through from the rusty-brown back-
ground of the growth in the form of bright red, wary Unc3, lo be again
lost in it after a sliurt course. The ophthulmoacope did not reveal the
slightext change in the fundu)4, Tho nuist extraonlinary feature of the
caHc wa< that when tho patient, after having shaken hi:4 head, !!it<io|K'd
rapidly forward, the whole anterior chamber became filled with ii;;ht--col-
oreil blood. Tlie flight (which wa« a few moments b(^fnrc perfectly good)
was at once reduced to n mere perception of the difference between light
and dark. When the patient liad held his head still for a few seconds,
the hemorrhage began at once t<i disappear, the upper jwrtion of the irU
lu'cauie np[>arent, then the upper part of the pupil, and so ou, uitiil, in
the cour-ic of about a minute and a h.ilf, every inico of tho hemorrhage
had vaiiisheil, and the si^lit ti.Hd resumed its normal standard. Kach
repetition of the experiment pn>duced the same astonishing phenomena,
nor was Alooron able, in spite of the most careful and minntc exnmint-
Uoo, to delect the Bource of the hemorrhage. The excision of the tumor
was proposed, but refused by the puticiit. Four yeara later he again
presented himself, the uppeaniuce of the eye having in the moan time
undergone a considerable change. The hemorrhage had entjrely dUap>
pcarcd since about a year, the tumor had become reduced to about one-
third of its original sixe, its color had assumed n dirty gray tint., ami, in-
stead of tiie dilated vcsseU, numennis isolated black deposits of pigment
were now apparent. The intra-ocular tension had increased, and tlu-
right diminished to the spelling with difficulty letters of 1t[,and tlie field
of rision was contracted. There was alight excavation of the optic nerve.
The patient again refused an iridectomy. Some montM later, the glau-
comatous changes having led to a complete losi; of sight, the jAtient Kub-
mitted to an iridectomy, on account of the very severe ciliary neuralgia
which liad super\'eued. The little shrunken tumor was seoC to Dr.
t "Ophtfaal. ficobMhtoikgcni," lafi.
TUMORS OF TQB IHIS.
238
Schw*i«;»or for Mamiiwition, who, as Mooren Bajrs. <loutitlcsily diJ Dot
rectfivu it, u tUi receipt wa^ nerer acknonlcl'^eil liv l>mi. The other
c^'e waa suhaeqtiently affected with aympntlietic irido-chomiditia, wluch
yielded to an iridectomy.
[The simple ifranufoma has only of late years been recopilzcd ae a
distinct gn>wth. It is a mru tumor, attd hence was cotifoiinded clioicnlly
vttb funf;nid malignant neoplasm:^, and hi^tolo^^ically with gummata.
MtcroKopicalty. there is very little difference between Uio granaloma
and certain sarcomata, for it coQ8i^t«> of a vascular fihroid tinsne with
anmll, round, and fusifoim cells. Wecker describe* threo varietit's: 1.
Siniiilc idiopathic f;raniil«m», occurriiij^ aliii<i!it exclusively in cliihlrcn.
2. IVIfan'iiL'Ctntic. M'len U'ading to upontaiicnufl hemorrhage into the
•nt«rior chamber, and hence diftcring hardly at all from vascular ncevi.
8. Traumatic granuloma, Ihi^ most frequent, and not uncommonly (»ccur-
ring after absciMiou of a corneal staphyloma. During the past three or
four yearn there have been published a number of articles upon ttiht-ri^ies
of the iri.-t, in which these tul)€rcle3 have been considered a» histolngi*
cally the wame as granuloma, anti one author, Dr. Haab. of Zurich, does
not hesiinte to describe tubercle of the iris a8 granuloma iridis. They
nuij occur in the iris alone, or in the conjuiKtiva and choroid as well,
and, Uiuifi thinks, nmy be regarded as the local manifestation of general
miliary lubea>ulo»iit. This question ns t^i thr real nature of the tuber-
culous nodules in the iris is still un^cttlcil. They certainly are verv
rare, ami, moreover, do not occur in Uic choroid with anything tike the
fre^iueney stated. JIim/* prtifers to use the term " irilis tuberculosa"
for this disease, (dee Annates d'Oculistiijue, Bd. (H ; Archiv fUr
Ophilialmologio, Bd. xix. 1 — xxv, 4 ; Archiv fur Augen- und Ohren-
heilkuniie, Bd. i. ; Annali di Ottalmnlogia, iv. ; Wcckur in <intefe mid
Saeiuiscli's Xldb. der Augenheilk., Bd. iv.) — B.]
Causer [Sarcoma. — B.] of the iris is almost always due to an extension
of Che disease from tlie deeper tunica of Uie eye; it is e^ctremcly rare as
s primart/ affection of the iris, and in then generally melanotic iu cha-
racter. It appears in the form of a small, dark, yellowish-hronn eleva-
tion or tiibtTcle at one point of the iHs, perhaps somewhat rciicmbliiig a
little syphilitic button or condyloma. The tuuior mny ri'main stationary
for a length of lime, or rapidly increase more nud more in Hize, and pro-
trude into the anterior chamber in the fonn of a dark brown or blackish
mass, which either perforates the cornea or tlic anterior portion of the
sclerotic, which becomes stitphyloniatous at this [toint, and, graduallv
yielding, the tumor njprouts forth. .\s soon as the true liyture of the
diaeaae is recogniiied. no time should he lo»t in excising the eyeball.
This ia much wiser than removing only the anterior half of the eye, as a
ilar disease may exist in tlie deeper tunics, llirschhorg' records a
ease of primary mc1nno.8arcoma of the iria, in which the latter was alone
implicated, the tumor having been developed from the anterior portion
of the iris, and the chMueuts of the ciliary body being perfectly un-
changed, lie moreover |>oints out with regard to the diagnosis betweeo
' "A. to.," 14, 3, SM,
224
DtSKASBS OF TUB IRES.
tho simplo and aarcomatoma (maliguant) minora of tho ii-is, thai they first
occur iu cliililrtn betwuoii lU« agca of 1 aiul V2, and arc of u light yellow-
ish-wliilo color, ntul often vorj/ vascular, thoir surfaco being unoven and
somewhat raggt-il ; whereas the sarcomata have a darker color aiid a
sniouth surface.
[Primary sarcoma of the iris, though a comparatively rare dlMaae, is
not 80 uncommon as was formerly supposed. Withiu the last five or six
years (|uit« a number of cases nave been reported, the most recent of
which arc by Kipp, three by Knapp, on? by Lebnin, one by Rooaa, and
one by Carter, o\' I^jiidun, (See Archix'cs of Optiihalraolojiy, vol. v.;
Annnlcft d'Oculisti.juc, vol. Ix. 1H(J0 ; Archives of Opiitbahnology, vol.
viii. ; Trans, of Amer. Ophthal. Soc, ISIJi* ; Carter's Tr«ati8« oo Dij»-
eases of the Eye, Amer. ed.. p. ilH.)
Sarcoma of the iris may be rcmnved by means of a lance-knife or a
narrow cataract knife. Tho incision should be iu the sclcro-comea!
margin, and should be curved so that the wound may gnpc and allow
the tumor and iria to prolapse on presaure of one lip of the wotuid. Iu
making the iiieicion the tumor should not ho woumied, as profiwe heraor-
rhngc may result and render the further steps of tJie operation very diffi-
cult. Iritis or iridocyclitis may result from the operation, but, even with
this possibility, the removal of the tumor should always be preferred to
enucleation of the eye, provided that the neoplasm involves the iris only.
L'-yra of the irii«, in which a degeneration of the iris witli the forma-
tion of nodules occurs, has received the faulty name of tubercle of the
iris. It has been obi«ervetl in Hraxil by Tedraglia, who Ihitiks the uveal
tract is only involved secondarily in the other parts of the eye. Bull
and Hansen have obsened it in Nt>rway. and cwnsidvr that the nodul*r«
lH'<;in in the corneal margin and thence spreiul to the iris. In the Utter
(he nodnlc^i always develop from the periphery and generally in the
lower half of the iris. They may grow so large as to fill the anterior
chamber. They consider that iritis with the formation of nodules, pro-
duced by the leprous dyscrasia. occurs very often in those who suffer
from the tuberous form of the disease, (i^ce KHu. Monatsbl., IM. x. ;
Bull and Hansen, The Leprous Diseases of the Kye, 1873.) — B.]
7.— CONGENITAL ANOMALIES OF THE IKIS.
Omgenital Irideremia [Aniridia} — B.], or ahuenet of the irity is occa-
sionally hereditary. I have seen one instance in which the iris was com-
pletely wantiug in both eyes of the fatlier, this condition being accom-
panied by a partial luxation and opacity of the crystalline lenses ; and
in ike son (an infant a few months old) there was total irideremia in both
eyes, but the latter appeared otherwise <|uite normal. iJomvUmeii the
iris is not completely wanting ; a small rudimentary portion, of varying
size, being apparent at the periphery. Absence of the iris is often
accomponied by opacity or displacement of the lens, nystagmus, and
[> SMHanAinOmorbunilS&iTiulscli** Hijb.d«r Aua«Rli«<ilkuuil«,]M.i. ; Zchemler'a
Uoniubl., 1871.— B.J
COHOBHITAL ANOMALIES OP TUB IRIS.
^25
ibB|ltrfect development of the cornea, which perh«p« does not M(|uire it»
normal size. The power of accommoclatiou xaa.y ol^o he imiiairo'l, hub
thin U not duo, aa iras fomicrly supposed, to tlic absence of ttie irt.s, but
may b« catuwd by an arre«t in thu developmctit of tJio ciliarj body. In
t}jo30 cascit in which iridcremia is not flcuoinpaniod by any otlier affec-
tion, the di^ht may be very go(;d, roorv especially it' the gtare of the light
anil Uie circles of dilFitHioD upon the ruliaa are diminished by the use of
At«.*noj>uic spectacles.
[Munz regards aniridia as the result of a check in dcvelopmont, and
tliuikis the cause should he sought for in Iho lens, wliich p1ay$ an analo-
gous role here to that jilayed by tlie embryonic viireoud in colobomu of
die clioroiil. — B.]
(.W'Vwm'i, or partial deficiency of tJie iria (cleft in?), ig almoiSt always
accompanied by a cleft in the ciliary Iiody and chorwid. It is tluo to an
arreat in the development uf the irLi, and may vary very much in dizc
•nd ihape. The coloboma is generally sit-
uated at the lower, or lower and inner, por- [Kg- 9&.
lion of the iris, and is irregularly triangular
or pyriform in :#ha|H.>, thu base uf the triangle
being turned tonarlit (lie |>n|iil, tlu' a)H!.T
towards the periphery, [tig. tt.i.J Colo-
boina of the iric generally afTwts both eyes;
sonu-tinics it is confined to one, generally
the h-ft, and is of'.cii accompanied by other
congenital nnomalies of the eye, such aa ^ —
cleft of The eyelidi, congenital cataract, Kiw T. w. Jobm.)
tnicrophtbalmos, uytitAgrnu.s, oleft palate*
oto. The fissure in the iris docs not ncc(>s.sarily extend (|uite U]i bo the
periphery, but at the latter noiitt a margin of irid may exist, uniting the
two edges of tlie cleft, ^loreover, the area of the cuUibonia may he
closed by a rndimcntary, darkly pigmented membrane, which might
C»U9« the deficiency of the ins al this point to be altogether overlooked
by a superficial observer (yeitz). If tho fibrous layer of the ins ia
deficient to a greater extent than the uveal layer, the edge of the cleft
is fringe^l with a distinct black margin. In simple coloboma iridis, the
acutty of rision is generally not at nil afFecie«l ; it may be very different,
however, if the aliVction is associated with a considerable cleft in the
ciliary body and cbumid.
[Tbc ao-ealied bridgc-coloboma conn»U> in the pillars of the coloboma
bcitig united by a narrow trnnsvcr^e band uf Bbres, which may be pig-
mented, though it is generally not. — B.}
Amongst the other congenital anomalies of the iris, we most call
attention to the eccentric pofiiiion of liie pupil {i^ornvtovia), and to the
c»BC8 in which there exists more llian one pupil (^{xiiifcona). The occeu-
ttnc dispbictfrnent uf ih» pupil may sometimes be bo slight that it is
hardly observable, but in other cases it is well marked, there being only
perhaps a smalt rim of iris at the side towards which the pupil is dis-
placed. Sometimes both eyes arc uffocte<l, atid then the disptatTement of
the pufwl may be symmetrical. I had, some time ago, under my can! at
the Royal Londou Ophthalmic Hospital, twu very interesting cases of
1&
M
220
DIBBASES OF TBE IRIS.
corectopia, occurring in two sidtere. In each eye tbc piipil wm dis*
nlaced, and the lone dislocated, both these conditions beiug congeuital.
The ejes of the parents were quite iionnal.
lu ca«e8 of yolycoria, a secoud pupil tnay exist at some little distance
from the orijpiml one, being separated frnm it hy n uiorc or leaa conaid-
craVde Land of iriit, the second pupil Wing, in fact, a partial C)loboma
(aiiiiular) of tlio iris. In utlier chhui^, sevcriil hiiiiiII pupils oxii^t near the
normiil ono, bcitig soparnt^'-d from it anr! each otht-r hv narrow trahociilse
of iris, and thia condition ib endently clost-ly allied to that of persistent
popillar}* membrane. Tlie existence of two or more }iupiU does uot
generally produce any impairment of sight, or give rise to monocular
diplopia or imlyopia.
\I>y»c'jTiii is the name given to that condition of the iria in which tJie
pnpll liact not the norin»l circular form. — B.]
Pirrfistnire of the pupiUiirif vietHbnin^ is a rare affection, and is char<
acterized by the presence of one or more delicate fibrillar bands, apring-
ing from the larger circle of the iris, and passing over the smAller circle
into the pupil, which they ^^y cither cross to be inserted at the other
side into the lar;;er circle of the iris, f>r they may paas over into a thin,
pigmented, cireuniacrihed uiembranc, ititnated in the area nf the pupil,
aiul perhafia attached to the capsule of ihu lens. These larjfc trabeculflc
arc ufteu conoectod to each other by numcn)U5 cro^sbsnt of delicate Bbril-
!«.' Weber* has described a vcrv inti>rcjjting case, in which the fibroa
formed a series of arcades. The Hbrillic were very thin and delicate, and
were iibout IH or 20 in nurabtT, and united hy numerous thin flbrillur cross-
bars. Tlicy aprinig fi-om the larger cii-clc of the iris, and parsed sti-ai;rht
over the lesser circle to the centre of the pupil, which was occupied by
a circumscribed, pigmented, membranous patch, fimily attached to the
capsule of the lens. Into this membrane the fihrilla; vrere inserted.
The remaining jiortions of the uapmde, as well as the edge of the pujfil,
were ipiitc free from any dcpfwtits or adhesions, and the pupil acted per-
fectly under the influence of light. It appears probable that these
remains of the pupillary meiiihrane are more JVeipient in young children,
giving Tfay anil disappearing as the person gets nlder. Their tnie nature
is. moreover, somciimes overlooked, they being mistaken for simple
adhesions between the pupil and the capsule of the lens.
8_0PER.\TI0NS FOR AUT!FIC[AL PITPIL.
It is unneceaaury to entor into a description of the varioutt mo<les of
making an artificiiil pupil which bnve been in vogue at different times,
as Uiey have now been all abandoned in favor of the foUowing ojn- rsliouis,
of which that of iridectomy enjoys hy far the widest and most varied
application, and hence demands at our hand.s tlie most full and exact
descriptiou.
■ Vat MtTiKral Imrr^Mtinp ca«(-s nf this affection, m well it» tar t. Iiriof rAtatni nf Uie
ca»>-» iilth'rto iiH»<!rili-il in ni.litli^tniv literature, viAtt two artideo ot Coha'a in " Kl.
Moustsbl,," im7, pp. irJ uud 119.
■ "A.f.O."Tiit. 1,337.
IRIDBOTOHY.
Vlg. M.
(1) JKIDECTOMV.
TIic fnllowinj,; in»it rumen U are re^iuirod For the operattou : —
1. A silver win; airtculuui for keeping open the cydift^. Wcim's
stop-8pi!c Ilium (Fig. IK!) will hf fouu<l Uie bcst,iu, bj mL>ans of an eadllj
a<yu8tnblc screw, it pcrmitji the eyelids to bo
kept fixedly apart at any (U>«ir«d distance, ao
that tlii-y cannot pre»4 the branches to-;etbcr,
ami tbua narrow tlie aperture. T\m form of
speculum IB secu in Fi-;. ii*i. If the patient
snoald straia very much, and the speculum
pre«4eA up(»D the eyeball, an a^isiatant «bonld
lift it forwani a litde, ao as to remove it from
the gbiU'.
2. A pair of i)xin<; forceps for steadyinj; the
eyeball. Tuey must outch accurately, and the
tooth should not be too shiirp and pointed, other-
wi^e it will easily tear throu<*h the conjunctiva.
If the Utter i* thin and rotten (as is often the
ca«e in elderly persons) Walduu's fixation for-
ceps are Ui Iw preferred, wliieh, instead of
Ueinji toothed, are finely serrated, so Uiat they
obtain a firm held of the couJuncUva without
tearing through it.
3. A broad luDce-shaped Icnife. It should be ahout the same width as
that represented in Fig. •>". If it is luucli broader, the internnl vround
will he ouiiMdentUly sinnllor than the external, ami iu order to enlarge it
to the same size as the latter, the edge of the kiufo must he ruucti lilted
rig. «7.
Flg.iW.
in vilhdrawinj;; the inatmtnrnt from the anterior chamber. Itul Hm pro-
cwliiig is of^on somewhat didicult, and may prove dangerous in the
handt of an ine?i]Hirienco4l oi>erator. The shape of tlie knife mu^t vary
witli the direction in which the iridectomy is to be mode. If it is ma<le
228
DISEASES or THE IRIS.
outwanlp (to tlic temporal eide) the straight knife is to be U8e<l. But if
tiio iriitcctoniy is nin<1c inwnnls or iipwanU. the btnde must be bent at a
more or less acute anjjle (Fig. 68), acconliiig to the prominence of the
noso or of ttie upjier edge af the orbit. If Die auleriur chuiutwr is eit-
Iremely slinllow, mo tliat the iris is nearly in contact with the cornea,
and especially if tlio pupil ie at the same time dilated, it will W better
to make the incision with Von Oracff's narrow cataract knife, than with
the lanee-shapcd one. For with the former we can skirt tlie edge of the
anterior chamber, and make a large iucieion vrithout any nak of wound-
ing tbo lona.
Pig. W.
Pig. 70.
Pig. 71.
(Pig. 72.]
4. The iris forceps should catch moat accurately, nnd when closed,
should be perfectly smooth at tlic extremity ; for if they arc rough and
irrcf^nlar, they will scratch and tear the iris and the Upi* of the iticisioQ,
nnd thu» perhaps set up some irritation. They may bcstraijjht (Fig. til*)
■when tbe iridectomy is rnaile outwards, although I, even here, prefer to
IRIDKCTOMV.
229
hnve Ihetn slightly l)cnt. For tbc upward nr inward operation tlioj
muDi be henl nt a HtUl more Bcut« atij^lc (Fig. 70).
6. Ttif iiirt scissora (Ki^. 71) should bo beiit at aii anglo, aud. thuugh
«qt, should iiot be too fii)t;ly [vointod. Cnro should he taki-ii thnt tike
blades ctode ti^litly. nud do uot override each other, which may eaaily
occur ill t<iic)i slight sois.sor3, if the joint is not sufficiently strong and
firm. Intitead of these, a pair of acissors curved on the flat [I'ig. 72]
may also be uiteiL
The operation u to be performed in the following manner : The pa-
tient is to he placed in the re<;umbent |K>itition, either in bed or ou a
conch, the head being Hlightly elevutcd. Unlettn there be very oxeo])-
tirttiiti reasons to the contrary, chlon^fomi should always be ulmiriiq-
icrvi. I prefer to lue it in all cases of iridectumy, especially if the eye
i» aeately inflamed, for the operation is ttien often very painful ; nnd,
howeTer courageous and detennined the pnticnt may be, be may tind it
iiu]Mv.ssibli' to control some sudden, involuntary movement of the eye or
head, nliich mnv endanger the result M' the operation, or even imperil
the sslety of the eye. Hut if chloroform ts employed, it eliould be given
M as t4i anjeathetize the patient ciimpletcly, and render him quite paa-
rire, otherwise he may prove far more unruly than if none had been
administered ; and the operation is of so delicate a nature that absolute
iiuii'tuile of tlie eye is necessary. If sickneiw sliould supervene, the
turtlier 8te|>8 of tlie operation must be debiyed until this has passed away.
Lot us now 8up{H>KC (hat an outward iridectomy is to be performed
upon the right eye for the cure of glaucoma. If the operator is ambi-
dexter, he may seat hiniself upon the couch or bed in front of the patient,
nnd make tlte incision with his tcfl hand. If not, he should place him-
self behind the patient. The eyelids having been opene<l to the desired
extent hy the stop-speculum, the operatMr should neixe witli a pair of
6)cing forceps the conjiuictiva near the inner side of the cornea, exactly
opposite to the nlaue where the incision ia to be made. The atraight
iridectomy knife la then to be tlirust into
the sclerotic, about half u line fnim the Kg. T3.
Bclero-ciinieal conjunctiva ( Kig. 7^5), and,
the handle of the instrument being laid
well back towanla the temple, the point
is Ui he passed into the anterior chamber
al it«rery rim,aud carried on slowlyand
steadily towards the opposite side until
the incision is of the desired extent. The
knife is then to Im jtlowly and gently
withdrawn, the ojpieous humor being allowed to How off as slowlv as
liossihle, so that tlie relief of the intraocular pressure may nut be sa Jden,
otherwise this will cause a rapid overfilling of ihu intra-ocular blood-
vessels, and perhaps a rupture of the capillaries of the retina and cho-
roid, prtiducing sumctimes wry extensive heni'tpi-hiigt;. When the knife
hoA biren nearly withdraw!! from the anterior chamber, the handle is to
be ffomewhut depressed, so that the upper edge of the blade is slightly
elevatc^l, nnd (he upper angle of the internal incision should then be en-
larged to n size corresponding to the external incision. The same pro-
280
DISBASES OF THK IBIS.
eeeding may be repeated dow-ninnrds, or tlio incision may be cnlar;^ to
the reqiiiivil extent witti a pair of Munt-poinioil scisnors curve*! oii the
flat, the one point beiii<^ introduce*! just Kttliiu th« anterior cliumWr, and
the incision then enlcirged upwards and downwards.
Oh tlie completion of the section, tlie forceps are to he handed o?er
to an aMistam, who should, if ncccaaary, fix the eye, being CJireful at
the same time uyt tp press or drs}; iij«:<ii
'^'" '*■ the eyehiill, t»ui sinijilv xn rotate it gently
in its bed. If H^c init does m>l protrode
through the lip;> of the wound, the ope*
rator should jmss ilie iris forceps (closed)
lnt« the anterior chamber, and then, open-
in;: tliem somewhat widely, he should seiie
a fold of the iris, and draw it j;entJy
ibrough the incision to the rerjuiVite ex-
tent, and cut it off with the twiseora iinite
cloAC to tlic \\\*n of tlie wound (Fig. i4).
The excision of the iris may b« done
either by the o[H'mtor hiniaelf, or by an aiwisuiut. In the former case,
the \r\s foivep^ hIiouM l>e held in the left hand, and the jtcidsors in the
rigtit. a& it n'<|uire» fioiiic practice to use the latter well with the left
liand. If a portion of ilie iris protrudes into the incision, there will be
iio occainon to introduce the forceps into the anterior cliiimher, but the
prolapsed portion in to be seized, and, if neceitsarr, drawn forth sodw-
what further and divided.
The portion of irtt^ may be excisiil wicb one cut, or e1.«u this niav be
done accorrlin); to either of the following modifi cations ititroduceil hy
Mr. Bowman.
The protriiiling portion of iris may he drawn to the right-haiKl angle
of the inciaion, and partly divided close up to the nogle, the other por>
tion beiny then gently torn from it« ciliary iuscrtiou (slight snips* of the
ficisaors aiding in the divtsion), and drawn to the oppo^iitc angle, to be
there completely cut oft". Tbia mode of operating is illiwlrated in FJg.
To, a, the prolapse drawn down to the lower (right-hand) angle, ii', of
the incision, where the inferior portion in to be divided, and tbo otiter
drawu up in the direction of 6, to the upper angle of the inctsiou.
Kig. 75.
Tig. 76.
Or a^iu, ibe prolapse (Fig. 7tJ, n), may be divided into two portiona
at f>. The lower portion is to be drawn in the direction of c, to the
lower angle of the incision, and snipped off. The upper |>orliou is theii
IKl
233
Fig. 77.
to be drflwn in the diroction of <?, and also divided. There U, howeror,
tliU 'tiiad vantage in Uiin mixle of operatitig, Hint, if thvtv U miicli bem-
nrrhflj^e, the »ii\>eT porlioii of iris in aoinvwliat liiddon, or it tuny slip
bnck into the anterior cbamlwr, and hnvc to be searched for.
IlTit either nu'thixl, if wt^ll acL'oin|iliithe<l, will ^ield an excellout arti-
ficial [oiitil. The iris will be torn away ijiiite
up U) iu ciliary attac-iimciit, and tlic pupil will
con«e(|uencly reach (luitc up to the periphery
CKig. 77).
If timre xs any hctDorrha<i^ into the anterior
chnmher, the blood sbouhl be permitted to cd.
cape Imforv coapiUtioii. A «mHll curette u
to be inaerteii belHv«n the lips of the wonnil,
slight prewure being at the same time made
upin tJie eyeball with the lixin<; forceps, so as
to facilitAtc the eacapo of the blood. But if the latter does not escape
ivadily. it should not be forced out, but be permitted lo reiniiiD. tui it
will soon be alxwrlwd. especially if a comprens bandage is applied.
[Rubbing the cb>scd lid^ over the eyeball from side to liide or in a
rotatory manner often laeilitates tlie escape of the htood from the ante,
rior chamber, and also assists in smoothing the pillars of the cotoltoma.
-B.J
I have described the lowle of performing irideetoniy in tlio outward
direction, Sjt this is the easiei^t, imd it may therefore he wise for a per-
fectly uiiKkilltMl opt^nitor to make it at hrat in thix direction, until he has
gaiticil A certain dcjiree of practice and dexterity, and then to pans over
to the upward or inward incidion. The operation in either of tlie latter
directiont^ is certainly more difficult than the temporal, on account of the
proinincnep of tlie nose or upper edge of the orbit, and the consequent
necetKtitv of employing a knil'c bent at a more or less acute angle, which
>n unskillocl operator rnay find somewhat difficult to keep quite flat.
The *ixo of till- iridectomy and the direction in which it is to W made,
should vary with the purpose for which the o]ioration is performed. Thua^
if it bo done solely for the purpose of arrcatinj; inflammation, or of di*
miniahing intm^^cular tension, it shouhl, if pussible. ulways be made
directly upwards, for Uicn the upper lid will cover the greater portion of
the itrtificial pupil, and thus not only bi<le the slight deformity, but also
cut off much of tlie irregularly refracted light, in these cases, more
especially in glaucoma, the incision should be made somewhat in the
Klenitic, .40 that the iriri may be removetl 'piite up to the ciliary inser-
tion, and should be of a gulhuient size to permit of the e\clsion of about
oiii'-fiftlt of iho iris. Wo find that if both these requirements are not
fulfilled, tlie beneficial effect of the iridectomy in chcekin;; the inllam-
tnati'itt ami llie increase in the tension is either greatly diiniuishod or not
penimuent.
But when iridectomy is performed simply for the purpose of making
an artificial pupil thriiigh which to admit the light, as in opacity of the
Bornua, lamellar caiiiRiet, etc., it should be made of a much smiiller size,
id. if jio-ifiihlo, inwiirdfl, a.-* the visual lino cuts the cornea slightly to-
wanU the inner side of the centre. But with regard to the position, we
S32
DISBASES OF TRR IRIS,
amst Ijc guided by the condition of the cornea, endeavoring to make the
artificial pupil opposite to tbiit jMrtion of iJie cornea uhicU is most trsti»-
parent. and rnoKt true in xta cur\'atiirc. The invisioii should in tlicie
cftAcs be slightly in the conjca, «o thnt a narrow belt of iris may bo left
ittiindiiig, And till' irrefi^nlar relrncLion prodnced by the jtnnjilicry of ths'
comeii and of tho Ions, and (.■nn!W*|nent confiiBimi of siji^ht,]
[Kig. 78.] be diaiinislied. For the same reaeon, the iridectomy shyulij
nut be liirge, otherwise its base wilt expose a considerable
portion of the edge of the lens. Hence the incision should
be made with a narrow iridectomy knife, or oven with o broodi
needle. [Fig. TH.] If a very small Incision is made, the]
iris may Le drawn out with a blinit ailvor or ]>latinum irif]
hook, iiiBtead of (he foreeps. jur't a» in tlie operation of iri-
dddesin. Tliis mode of opcratinji^ is nUn indn;ntx>d in those
cases in wiiicli there are extensive adhesions between the]
edge of the pupil and the anterior ea{isiile. In such caKSf]
the incision ghoiild. if powiUe, be maile at a spot corre*"pOiid-
ing tfl a point at wtiieli tiii' edjte of the pupil is unadherent,]
so thnt the hook may seixc this p<irtion of the iris. If the'
whole edge of the pupil ts adherent, and the iris is thin and'
rott4>n, it is often impossible to obtain a good sized pupil, for the irif
breaks down, and tears between the forceps, and only small portions con
be removed mcce-meal. Or again, tho adiieaions of tlic |mpil to the
cft|>siile may ne so finn, that they n*rtiwt the traction of tlio forceps, and
this portion of the iris nrniaintt standing. In fact wc have pcifonncd the
operation, which Desmarres has recommended in such caaes, and haS|
termed " iridorbexis." A portion of the iris is excised, leaving the ad-
herent pupillary edge standiug. In onler to overcome tliis difficulty in
seizing the iris, Iiicbreich* has derised a pair of iridectomy forceps, in ,
which tho teeth arc so situatcil that tliL- surface in which they grasp is
turned at a right an^le ; in lids way they can firmly seize tb« iris, juat
aa a pair of fixing forceps.
[It is sometimes necewary to make an artificial pupil in casca of »dhe-
aion of the pupillary mar^n of the iris to tiie cornea, and here the ante-
rior chamber is nAually so shallow that the incision is bc>*t made with a
narrow cataract kuifc, as there is thus less danger of lacerating the
iris.— B.]
(S) IRIDODESI8.
This valuable and ingenious operation was devised by Mr. Critchel
ftr>d is very UButul lu all cases in which we desire to obtain an artificial
[<u|iil for optical jmrposcs only, as, for irminncc, in caaea of opacity orj
coniciiy of the cornea, or of lamellar cataract, etc. '
The o[i«rutiou is to he performed in the following manner: The patient i
having been placed under the influence of rhloroforro, and the eyelids
kept apart with tlie stop-speculum, the operator fixes the eyeball with a
pAir of forceps, and makes an incision with a broad nocdie in the acloro-
' Knafip ud Hm** Atthit;, i. 1, 22.
• " H. L. 0. U. Rf-p.," I. 330.
IRTI)0DE8I8.
S88
corrtpal junction, flliglitW encroaching npon tlie cornea. If the incision
13 tnntiti mvtkrdi (which im the \}e»t direction) and the nose ia tm>ni)iietit,
Mr. Crituhctt eniplovB a broad needle bent at an angle on the nut. Willi
re;'»r(l Ui the nizc of t)ie incision, it is of importunco to reinetnhor, that
whilst, oil the One hand, it fthouM he sufficieiitlv InrfE^e to a«tinit of the
easy inlmdnction of the hook or fnreeia, it iniwt not, on the otlicr, he
tfto wide, otherwise the slranjiulated portion of the iris, with the ligature,
mav )>c drawn into the aittenor chamber when the aqueoits hntaor reao-
cuninlate!>. 'ilie ittcislon having;
been coroplt-'l«,'d, and the broad r^'ir- 79.1
needle renmvi-d, a ^niall hxin [A ,
Fig. 71'] of very fine Mack silk
is to be |)loced directly over tlie
wound. A blunt plntinuni or
f>!1ver hook (bent at the re(|uiaite
an|;le) is fhen to lie iittrndiiced
through the Irwip into the anterior
clianil>er to the proximiite edge
of the pupil, which is to he caught
lip by it, and then the portion of * .J,li«w ji
irw thus fiecured is to be care-
fully nrid ;»ontly drawn forth into the loop. If it is desired to stretch
the opjioaice [lorlion of the iri^, bo as to bring It op(K>«ite an opacity in
the cornea or tens, and tliiis to displace the pupil considerably to the aide
of the incision, the ofrerator must he extremely careful that, whilst draw-
ing forth the iris, he doeti not cauno a 8e{>aration of the opposite border
from it« ciliary attachment (coredialysis), which may be easily done if
the iris be put too much up^m the stretch, or drawn forth somewhat
roughly. As soon as n sufficient portion of iris lie* within the loop, an
■•uuslant, with a pair of broad cilia forceps [Fig, tf-t)] in facli hand^seiccs
Fijt. SO.
the two free endft of the loop and ties this tightly, no ha to irvclude the
Srolap«4cd iris firmly within it. In tighteniug the ligature, he should not
raw the ends of the loop away from the eve, but should follow the
curvature of the »clen:'tic. The ends of the ligature ar« then to be cut
off, the one huing left aumewhat longer than the other, in urder tliat it
may he readily seized with the forceps, if the loop should show a ten-
dency to be drawn into the anterior chamber. The little strangulated
portion of iris quickly t^hrink^, and the loop may h« removed on the sec*
oiiil or third day. But instead of the hook, the canula forceps [Fig. 1^1]
may Itc employed, the iris being aeized hy them, about midway Iwtween
the edge of the pupil and its ciliary attachment. The hook ia, however,
to he preferreil.
1 have above described the operation which is to be performed when
■I
234
OISBASBS OF TBB IRIS.
the aniBcinl pupil is to extend to the pcripherv. But if wc deatre sim-
ply to displace *iid enlarge tlic orij^inal pupil from ita central position
towards oivi sitU*. preserving al the eaine
[Pig. 81.] [Pig'. S3-] time tlie constrictor pti|ti}lii] intact, the
peripheral portion of the iris must be
seized with the canuln forvi-pij, nnd dniwii
forth thi-oiigh the loop until the pupil oc-
ciipiea the desired poaition [Kig. Hli], wheu
the lij;aturo k to be tjgliieued.
It mar occasionally occur tliat, although
the sight is considcraldy improved by the
mdmloals. the patient greatly feels the want of more light,
and a 8ti-<>nger illuiniuatiou of the retinal image. In
such cases Mr. Oritchett hntt succeeded admirably by
ranking a second tridodesis in the same eye, in such a
manner as Us enlarge the pupil and alter its shape, giving
it a somewhat crcscentic form, with the two ooraera to
the crescent cut ofl".
The operation of iridoflesis ia, as a nile, <^uite free from
danger, and productive of but very little irritauon. In
very rare iuBtauces it may, however, give rise to iritis, or
even suppurative iriilocyclitis. Such ca«ics have been
recorded by Alfred Graefe,' Steffan,* etc., but although
I have a large experience of the operatifm, both in the ItauJs of others
and in ray own, I have never met with a single case in which it caused
inflammatory complications. In order to avoid the risk of irritation, and
also to simplify the opemtion, Wecker has suggested that tlic prolapse of
the ins, instead of being tied, should be allowed to heal in the wound.
He makes the incision rather further in the sclerutic, ao as to obtain a
long track ; he then aeizea the iri* with a very fine pair of iridectomy
forceps, and draws it out into the incision. To maintain it in tbie jiosi-
tion, and to accelerate the healing of the wound, a firm compress band-
ago is applied. The prolapse becomes firmly adherent in the track of
tlie wound, and the little protruding portion soon drops off. This opera-
tion is termed " iridenkletsis."
[These two operations, iridodesis and irideukleisis, have been almost
entirely discarded. Not only have purulent iritia nnd irido-cyclitia been
observed to proceed from the cicatrix, but even sympathetic iridocyclitis
of the otlier eye has been observed on account of the extreme peripheral
nature of the wound in iridenkleisis. This danger is lews in the opera-
tion of iridodesis. (See .\rlt in Graefe und Saomisch'a Hdbch. dcr Au-
genheilkunde, iii. p. -llii.)— JJ.]
[(3) IRIDOTOMY.
The operation of division of the sphincter through a corneal incision
was pri>po««(l by von Wecker us a substitute fur iridodesis and iriden-
• "A. f. OV IX' 3, 1S9.
■ lUd., X. 1, 13S.
IRIDOTONT — COIIBLVStS.
kloisis. He recommpnils it egpeciaUy in sinall central opaciUca of the
comcn or lend. He mabos an incision in the cornea, midwa^v botwoen
limbus and centre, about 4 tout. lung. Ue tlieu introduces a ^lual) pair
of forccps-8ciiiSora through the wound aa far m the itujiillary maririu of
iri*. pawe? one blade of the 9ci»sore behind the iris »o aa to inclii'lc the
ahim'ter Wtneen tlie blailes, ami divides it nipitJIy. If the iris pmlapBes
into the <^imra! wrtim(l,it must bi- replaced liv u spatnta, anii atropiiit- at
once instilled. Thit» f>perat)L>n liaa al^o fallen into disuse in the Uuiteil
States.
The terra iridotomj, a« now used, includes any incision into the iri«!,
not only in ttic sphincter, hut eUcwlicre. Mr. Carter cuts out a V-
abapod bit of iri^t by means of Wecker's iridot-
omy scii4>-ior». Tbi« give* an excellent pupil in [fU^- 68. Fig. M.J
tboae uasefi where the lens has been either ex-
tracted or where it disappeared in the course
of an atrophic iullaramation, and the iiia has
been ehaugi^l into a dense loembnne stretch-
ing nil aoro»9 tlie anterior chamber.— B.]
We .^omttimes find, after a perforating! womid
or nicer of the cornea, or the common flap nji-
ention tor cataract with extensive prtdaifdo, that
ilie iria prcaentd a plane surface lighily stretched
from (he cicatrix to the periphery of tho c^miea,
and titat Uiere is no trace of a pupil. If che
lena id abftent, a very fair artificial pupil may often he obtained in thesv
euea by simply i<plitung the tibree of the iris ocroxA with a broad needle.
The cdf^cB of the incision will generally retract, and a very good-aixeil
pupil be lea [Fig. 83] ; if Uiis U not the caee, a Tyrrers hook [Fig. 841
may be [>a^»e(l through the corneal incisiori, and one edge of tho incised
portion of the iris be caught, drawn forth, ami excised.
(4) CORELYSIS.
Tlio detachment of a^lhosione between the edge of the pupil and the
itcrior cai<9nlo of the lens by operative interference, wa« iirst exten-
ively practised by Mr. Streatfeiid' and subsequently ol»o by Weber.'
^he pati«:nt having been chloroformed, and the lids fixed with the stop,
sptxuliini, an invi^ion is to be made in the cornea with u broad needle,
of sufficient sixe readily to admit the spatula hook into the anterior
chamber. Prior to the operation, a strong solution of atropine ahonid
be applied to the eye, so that any unatlherent portions i^f the pupil may
become dilated. The exact j>i>«iti(m and size of the different posterior
synechia) shimld tbt-n In: carotully ascertained with the obliijue illumina-
tion, for u]K)ii their position ami numlier muxt depend the situation of the
incision, and with regard to tlie latter it should be remembered that no
adhesion, directly behiml tlie incision tlirough which the R[)atula hi>ok
has to be introduced, can be torn through. It is best, therefore, to make
< '• R. L. O. II. R«p.,-' L 6, ADi) 2, 309.
' "A. f. 0.," 7, 1, and e, 1, 8M.
Uiki
or THE CRtS.
tlip liicUinn at « point iiituatcfl niddvayfiUi the principal ndlioiiona; thus
ir tlii'rc aru two adlivnioim oppcuitv lo each oUier, ttiu incUiun i^houM bu
mai|<* ItiMwiMMi itiom, no timi Uy a simple lintf rolntion of tlic ttfutula CJich
ma^Y Ix' caoily torn Uirouj^li. If there are Hcvcral adliosioiiA and one
liroarl uiiattaeliiMl ixirtion of t\\v pupil, tlir incision sliouUl be tnnile opposite
iIk' Idltor. Mr. StreiitfeilO recommeiids that the broad
PI** •"*' ncodlc ahonUI Iw rnpiiU^v wiib'lrnwn from the anterior cluuii-
licr, no flit to iiltow as little of the aqueoiu humor to escape
an posiiiblo. Wherpaa Weber prefers to withdraw Uie iu-
HtninK'nt vrrv i^Iowly, so tLH to ))ermit tho gradnnl ottcapc of
thit n<|viuouA humor, in nnler tbnt tbc crystAllinc tens mar
coiiH' ill coiitncl vrttb the conivn, aud thus he steadied : Uie
^L H|iatiilii will ^lidw tivvr the foruier. and there is lesM chance
H of iitinrvinj! the c«]i«u1e.
H The iuctsion having been finished, a small apatuU book
H [V\fi. 80] 19 introduced into the anterior chamber, and, with
^^ a aoocwbat Intorul " viri;i;i;ling" movements tbe ioAiruiaeiit
is pwaeil sli;;b(lv bcnvatb the iriii, at a jtoiut free of ailbe*
nionft. and U thru i^axsod iM'htnd the nearent adhesion, and drawn ^entlr
and aIhuIt loirarvis the o|>cnit(ir: so that it breaks duvn tJie ban<t bcfonr
ii, e«n) iMinjt taken to keep it quite parallel to the iris« leji cbe capanle
of ibe Un<i vbotild b^^ it^urc-d. The adhesion mar rield at <ntc« Wfure
the |in'Ktiin* i*( the !if«tuln. but if it rrsi5t», it majT be caogfit in tlic
biKtk iigb.
Vt :-.ot ttaeth^liook inperfunabgwrelrm. bnt aficr
t>:> ' I i>.le the o]ynin^ in ibc cornea wini Ae hnmA neeole, aeiae« tbe
iu> «ii.. i pair of irid«ctoiu<r forceps. atM). getrtir drawing it Mmewhat
lomirvls ihv imrinon, tbw iletacbefl tbr a-lbcnoD. Wbere seve-ral pD4-
t«T«n- cTMcim exiat, he repeMii tlw opennm after a daj or ivft. He
hM Ihwt MMfHted m^ swcMa m vore tkam fiftr c«mc.
[Seilber af iImm netfaoAi Ina net witli aMoli bv«r at the han^ of
.Mvl.tKkTm^ outY^ina. Dr. R. Jftj' Jeffnea, •( Boiloiu has practUeJ Pta-
><MBe«kat extenawlT, and rrfocw faroraUj* apoa it-
i.m-ttHuv b oa Um wfafile a Wmr aaeiatien far Awe raani
1 i«u corrlrsM Mr. C^nvrV a/t6mm tmtk u fnifcliMj hattvr
t l«at one of Mr. StraaiftM W ]
O) lUOODlJLLtSIS.
wviv tiic wvw ctniM it
InaMtnaarW
'**.l««-at» I,
miuoDiALysis.
237
c?p(i nr hook to he easilj' n]aiin>re(l. A fine pair of irideotoniy (ur caiiuU)
forceps 13 [Mkiseil into the anterior clianibor, a fold of iris seized, gently
torn from its insertion, ami a portion drawn forth through the inciMon
and snipped off. Thus u marpiinl pupil can be niadr opiiositc the tmns*
'nt edfie of the comejt. ShouM the vicinity of thi' incision become
iltle clouded, this will be at some dlstaiico from tlic new pupil.
I must now brielly enunicnite tlie different diseases in which an iri-
dectomy is indicated. TbcHc maybe itividud into two gronjies, viii.,thoKe
affections in which Uic opemtion is perfonned for the purpose of diniin*
iflhiiig inflammatory symptoms and an increase in the eyc-tenstou, ntid
those in which the nhject \i simply to make an artificial pupil.
In the jirst 'jr>nip it it ituiictitnt — 1, In ulcers of the cornea which
threaten extensive perforation, or cases of suppurative corneitis. The
iridectomy diminishes the intnuocular tcn<uon, and thuA affortls a faror-
able opportunity fur tlie process of reparation, and also improves the nu-
trition of the jiartii, 2. If the corm-a, after perforation, shows a ten-
dency to hccome prominent and staphylomntons at this i>oint, and more
especially if there is any increase in the inira-ocular tension. 8. In ob-
stinate fistula of the cornea, and in prolapse of the iris. 4- In recur-
rent or cltronLc iritis and irido-choroiditis, particularly If the communica-
tion between the anterior and posterior chambers is interrupted by
dreular synechia. Also in cases in which a foreign body has bcome
Iged in tlic in*, or a tumor or cyst exists in the latter, -i. In trau-
tio cataract accompanied by mncti swelling of the lens substance, great
irnUtion of the eye, and auf^atentcd tension. Also in various opentiioos
for catAract, tlie object being jiartly to prevent bruising of the iris during
the extraction of the lens, and partly to diminish the terMlency to subse-
quent inflammatory complications, ti. In the extensive group of j^lauco-
malous diseases, m which there is increase of the intra-ocular tension,
leading finally to excavation of the optic nerve and blindness. The im*
portance of an early operation in such cases cannot be over-cstimaicd.
In the M'-ond eJatg of cases, in which the object of the iridectomy »
8iiQj)ly to afford an artificial pupil, it is indicated in the following a^eo-
tinns : 1. In opacities of the cornea, also in conical cornea. In the
tatter case, the object of the operation is, however, strictly speaking,
twofold, viz., to diminish the iiitra-ocular tension, and also to make a
pupil op|KHitc a portion of the cornea whose curvature is but slightly, if
all, altered. 2. In ooclimion of the pupil after iritis. 3. lu lamellar
met, and in di.sloeation of the Ions.
[In iridectomy for artificial ]inpil, tlio coloboma shonld l>e small, so
as to avoid dazzlin*; the eye. and diminish the resulting circles of diH|ier-
Mon on the retina. HmnW pupils have the advantage of stenopivic
gUiises M«ithont their disadvantages. If in corneal opacities, the iris is
found to he adherent completely to the posterior surface of the cornea,
tlie formation of an arliHci.il pupil is ini|H>ssible.
In anterior central capsiihir eatanict, and in the secondary memhrani-
form cataract after extraction or irifhi-choroiditis, an iridectomy is often
very useful in improving the vision. — li.j
2Sd
PtSEASES OF TRB IKI8.
9._CHAKGES IN THK FOUSI AND CONTENTS OF THK
ANTKKIOU CHAMBER.
Tlie size of the anterior chamber rany undcrfjo conaideralile aUemdon.
Thua, if till! iiitra-ocular tension he tim<rli nnjimciitcl, or i\\c iri« is bulged
forwan) by a collection of Buid, or hy exudntioii-inas»eti betwvon tbe
pofiiorior surface iif Itie iris iiml Uie cajisnle of the Ions, Uio anterior
cliainbcr inaj be extremely sliallow, the iris being pcrhnpei almost in
contact with the posterior surface of iht* coniea. Whereas, when the
anterior portion of the eyeball ia diJ^tended and enlar;j;ed (bydroph-
thalmos), or when the crvKlalline lens is aV>8ent or displaced, the ante-
rior chamber incroa^oj; in depth. The sixc nf the latter aUo varies
aecordinj; to the B;;e. and the state of refraction. It diminiahes with
advancing yean, and is dee|wr in myopic and mora shallow in hyper-
metrnptc persona.
Effusions of lymph and pn? may take place into tlie anterior cbamher,
and sink doMn to the lioltom in the form of hypopyon, which may attain
a conaidernble aiic, and even fill the whole of the anterior chamber.
The lymph or pus may be efluded either from the coniea, the iris, or the
ciliary Itody.na h&a hcen describe^! at length in the articles ujitm the
diseases of these parts.
Klood may kIho 1h.> effused into the anterior chamber, this condition
being termed "liyperiemia." The hemorrhage may be either sponta-
TM4U8 or traumatic iu it« orijipn. In the latter ease, it may he due to a
wound of the coniea, iris, ciliary b*Iy, etc., or it may be pnxluceil by a
aimple blow or fall upon the eye (as from a cricket or racket ball, a
"cat,'^ or a blow from the fisi), without anv rupture of the external
coat^ of the eye. The anterior chnml*r is filled witli blood, and when
this has l>ecomo partially sbsorb^jd, we find perhap that the lens ba4
hcen dislocated, and that tliere ia also hemorrhage into die vitreoua
humor. Spontaneous hypenemia is of rare occurrence. It has been
known to occur periodically during the time of menstruation, perhaps
vicariously, or after the caiamoiua have ceased. Cases have been re*
corded in which the [tatient could vuluntarily produce au elfusiou of
blood into the anterior chamber hy stonniiig or rapidly rihakiiig his head.'
The best treatment is the application of a firm compress bandage to the
eye, for this accelerates the absorption of the blood more than any other
remedy. If there is much irritability of the eje or any iritis^ atropine
dr(i[>s ihonld be fre<iuently apf-lied.
f''>rfi<in finlirfit such as portions of metal, gun cap, splinters nf gUss,
eyelashes, et»*.. may [>fTictriite the cornea and become lodged in the ante-
rior chamber, lying either fre« in it, or U'lng |i«rhap8 partly adherent to
the coniea or the iris, and |)artly situated in the anterior chamlfer. Tlieir
presence in the latter frei^uently set« up severe iritis or irido-choroidiUs.
Itut in other cases, after the immediate effects of the injury have passed
away, die foreign body may remain for many years innocuous in the
• l^>^r•»'«of Ifato klM. tM* "A. f. 0.," vff. 1, CI; W«IItlier, '■S;«t«ni Jcr Ckt'
FOBBItiK DDDICS IN TUE AHTSKIOH OnAUUER.
239
anterior chamber, vithouc citlior provoking tmy serious injury to the
affoct«fl eye, or symptitms of aympathetic (liaeaeo in tlie oUut. Tlma
Sacmiach' records a case in whicli a fragment of stone remained twelve
years in the anterior clinmber without exciting any serious injury. The
forvigti body had originally Hecmnc lodj^ed in thv len!),thc lnM<T hocnroe
alw>rhcd. and then tlie fra;^ment of stone fell into the anl<?nor chamber,
reniainin;; attached to the secondary cataract by a fine fitanieiit. As it
hod set up some irritation a fortnight before the patient consulted Sae-
misch, the lattor extracted it successfully by a lar^ linear incision in
the cornea combined with an iridectomy. Weckei' cxtmcted with suo>
ce«s a fragment uf stone wiiich had remained fourteen years in the ante*
nor chamber, without causing any irritation.
In removing these foreign bodies from the anterior chamber, care
must be taken that the incision in the cornea is of a suiScient size, and
so flituate^l. that the foreign body can be easily reached; a large iridec-
tuiny should then be matlv, and the forei^pi tiudv seized with the
iridecioniy forceps or iin irirt buok, and cxiratited. if the foreign body
(*. _(/., a splinter of ,*teei) is partly in the cnmca and partly in the ante-
rior chamber, tlic blaile of ^le iridectomy knife or of the broad needle
should be passed behind it, so us to steady it and push it forward
tbrougb tbe cornea, when its anterior extremity should be seized witti a
pair of forceps, and then it can be readily extracted.
[Foreij^i bodies, not prone t^i decompfjsition, may remain encapsulated
for a long time in the anterior cliHuiber withuut causing any irritation.
The enoapsuliiting wall may ooiwist merely of connective tissue, or it
may be lined bv epitbelium, and should be carefully distinguished from
aa iris-cyst. Living organisms, as epidermis, hairs, etc., introduced
through injury into the anterior chamber, may lead to the formation of
efiidenuoid tumors. Splintere of metal or of wood, which so frc()uently
iienetrate into iho anterior chamber, very often in so doing wound the
iris or the lens, or botli, and tlius tbe accident becomes complicated.
These should not ho alloweil to remain. If tlicir presence h suspected,
hot they cannot be seen owing to oxtravasatcd blood or pua, means
should Iw taken to promote absorption of the latter, and when the foreign
body Iwcomes visible, the anterior ehambor should be opened Iwtow and
the |Mirtiele seized with foreepa and withdrawn.
Tlic prcficnce of a foreign body on or in the iris is not a common oocur-
renee. It produces great and constant irritation, leading often to Tiolent
inflammation, and this of a purulent character. ltd eueapsiilation here
cannot lie thought of, ami its ninMiviil should be attempted at once. The
incision may be made with a Unce-knife, or, better, with a narrow oata-
ruct'knife, upwards or downwanls in the sclero-corneal margin, as the
case may best indicate. If the particle h not firmly embwiled in tlie
iris tissue, it is better to grasp it with a pair of grooved forceps, or
attempt to lifl it out of \ta bed by introducing a BauicPs spoon under-
neath it; if this succeeds then remove liio lacerated portion of iris by
art iridectomy. If the {mrticle is firmly embedded, remove a broad
pieoe of iris containing i( at once, and thus cut short the operation.
• " Klin. M«i)at(it>Ultor," iftb, 46.
> -Kliu. llonAUb1.,"Ue7. 3G.
Zid
DISEASES OF TUB IKIS.
GrcAt care shotiM be tnken to prevent tho forei)(n body dropping into
thf p(i»tc*nor cti«tnber, where it woul«l uucjisiod stirious txoublu, and from
which it wohUI bo difficult to remove it.
If the Foreign body lia« penetrated tlie iris anj lens the latt«r will
become more or less completely opaiiue, and if the particle is siimll it
will be concenled from view. If the iria has been woumled an irideo-
toiuy should he done »t once, and titc lacerated portion of iris removed.
If tiic foreijrn particle can then he seen in the Iciw, or if there is ruBBon
to think that it u there, as complete an extraction as [losaible should be
made of the injured letia, and fur tliis rendon it is beUur that the or);;inal
incision should be made wiib & narrow knife, no as to insure a .tuffi*
ciently large wound. It is sometiaies possible, after the iridectomy, to
remove a forcip^n body from the lens by means of a curette or spoon, and
then extract the lens afterwards. Case* Imve been known in which
small particles have become encapsulated in t)ic lens, and surrounded by
a circumscribed opacity, while the rest of tlie lenji haa remained tran*-
parcnt. 'i'ho daiijjcr here in that the particle may subdeipiently Kiuk
through the lens, piTPorate tlie posterior capside, and fall either into the
vitreous or u[ion the ciliary proct^sses, where it is sure to excite destruc*
tive intlammation.
In rare cases where the foreign body ia of iron or 3teel, and lying in
the anterior chamber or on the iris, it may be extracted by employing a
powerl'ul nuij^iet. Casca have been reported in which the poloa of the
magnet have been introduced into the anterior chamber and llie particle
BucceitsfuUy removed. (Trans. N. V. State Medical Society., 1880,
Archives of Ophthalmology, vol. ix.") — R.]
Cyttieerci are sometimes met with in the anterior chamber, and about
twenty cases of this kind hare been recorded by difToreiit autliora. Tbe
diagnosis is not iliflicult, for the little animal i^ noticed in the form of &
gmall transparent vehicle, generally lying upon the surface of the iris.
The vesicle shows at timert very decided movement?!, more especially
when ihe pupil is stimiilnted to active coiitmction by thu action of strong
light, the head nnd neck of the animal laMng then perhaps stntiehud out
and moved about,. 1 he cyst^ccrcus coay
Fi«' 86. eitber lie free in the anterior chamber, or
be partly adherent to the iris or comea.
The following case of Mr. Priilgin Teale's'
ilLustratea admirably the symptoms presented
by the presence of n cysticercus and the mode
of treatment to be adopted: '■'• Mary Isabel
Batcraan, tet. 10, Hvin;' at Anerlcy, was
brought bo me on June 2, in conse([uencc of
tenderness of the right eye. On examiniug
the eye there w:ls seen (vide Fig. K([) on
the surface of tlie lower part of the iris an
opaque body, constricted in tho middle, and
rather longer than a hemp-seed, which was evidently causing some
distress to tho eye. Tho conjunctiva was slightly injecCod, the cornea
• -a. L. 0. H. a«i),," T. 320.
IRIDO-CaOROIUITtS — IRt1>0<CT0LrTI3.
241
X
\
was bright, but dotted oa it« posterior surface with miiiutP 8prtt«, m in
kcmto-irititt ; the iris was uciive, except at the sitaation of the vrbite
hiAy. near which it was aHhcrL-nt to the capsule of the lens. Tetwion
n«)rmkl. Readiiij; Ko. 10 Ju»er." Tlie uiotber slated thnt for two or
three years tlio eye had l>eeii occaaionally inflaraed. Six weeks aj^o
she Bnut noticed a speck mi the iris, about the nixe of a pin's head,
which iM'came doubled in shv at the end of five weeks. The child had
alwnv9 heen delicate, and had
long suffered from thrvadworoM, ^*$- ^7-
but never from tapeworm. On
June 9 Mr. Tealu made an in.
cirtiun nt the margin of the cor-
nea with n cataract knife and
withdrew the piece of irii od
which the anttnal was fixed,
and cut it ofi witliuut destroy-
ins the cysticercus. When re-
moved from (he eye, the Jtlow
ntovciuents of the body and
chanj^CH of shape were- easilv
detected. On exAmiuation with
the micr<>sco[)e, the head and
neck, snnnoiinted by the circle
of hookk't^* and fuur suckers,
were seen to project fnitn die
side of the l»odv (vide Fig. !*7).
The rrinoTal of the cysticercus was soon followed by the disappear-
ance ot" all iiymptomi of inflamtnaliun and irritability of the eye, and
four Diontli^ afterwards the i«ilient was able to read .7S.;er No. 1.
tin fclnglaiid and the I'lnted Staler, cystiecrcn* in the eye is exceed*
injily rare, but on the continent, and especially in Oennany. these cases
are not very uitcotninon. The passage of the larva of ii ta^ida into the
bloodvessels of the eye throii;ih the medium of the blood-current, is
easily undorslood. All parts of the uveal tract may thus prove a rest-
inji-plfiee for the cyslicercns. If the worm is in the luiterior charohor,
and not adherent to the irii*, it is better to iiiakc the int-ii^iou through the
oonica, B or 4 mm. from the margin, so as to avoid prolapse of the iris.
If it is attached to the iris, au iridectomy must always he done.
A worm known by the name of Kilaria medineusis is known to be a
not uncommon animal |Ani.<4ite in the eye of tlie horse, and eaitcs of its
occurrence in the anterior chamber of nian have been reported by Tlar-
kan. Kipp, and uther» in the United States, nn<l hv .\r<^vll Uobertson.
(See Trans. Fiftli Internal. Oplitbal. Congress, New* York, I87*i.).— B.]
1(1 — lUlDO-CHOltOmiTIS. [IHinO-CYCLITIS— a]
I have alreaily pointed out. when speaking of iritis, that on account
of the close relationship hetween the iris, ciUarj* b^vdy, and the choroid
(which in truth form one coniinuons tissue, the uveal tract), auv iufliun-
16
242
DISEASES OF TBI IRIS.
mation oriimencing ui ibe iris is very prone to extoud to the ciliary lio<!y
irl chunjl<l, ur vice vertd. Tlie most fretjuenl cause o( sucli an exten-
Binii of tilt! iiiflnmmation of thi' iriH to i]ii> clioroiil \s to W> sought in the
(iresciioi.' of connideraWc posterior svncclua;, or adll more iu complete |
exclusion [wcluslon — B.] of tlip ijupi!.' In aucU ciwea, the recurreiwe of
the inHammation and its extension to the ciliary hodv and choroid hTc\
partl^v due to the constnut irritation and teasinc kt-pt up hy tho adhe*
aions al tlie edge of iIr* pupil, prercutiiig the nurnial dilautioii ami cou'^
traction of the pupil, wliich take place in accordnnce with any allcration
in tlic degree of illumination, tlie niovcnienta of the eye, and the changes
in the accommodation. But it is still more caused hy the iDterruptinn
in the communicaLion between tlie anterior ami posterior chamber (in
ca^ci: of cwliision of the pupil), whicli prevenvs that rci^ulation and just
balance nf the intra-ocular tension in front of and behind the iriit, wliich
nlwaya existn in the healthy eye. Thus, if tlicre is any increa^w in Uie
vitreoiw himior, the anterior chamber becomes narrower, an<l eoniains
lew a<iiK'0U8 humor; if, on the oUior hand, tho quantity of tJie aqueous
humor ia inarea«ed, the iria is somewhat cupped backwards, and the
fluid in the posterior chamber diminished in ((uantity. In this wayj.
chungeii in the amount of the fluids in different parts of thv eye are'
jireveuled from exercising any deleterious influence, if their augmeata-
tion does not exceed a certain degree. For on account of the regulation
between the anterior and [Kfatericr chamtier no harm accrues. But ii isl
({uitc difTerent wluMi tliis cnmmuni cation is stopped, and the iris fonus,
*o to say, a firm l>arrier between tho ani^^rior and pfisierior chamb«r.
For, if there is any increane of tension in the posterior |Mirtion of the
eye, it cannot then be relieved at the expense of fluid in the anterior
chamber, eon^equemly a stasis occurs in the circulation of tlie iaocr
tunics of the eyeball, which is soon followed bj' intlnmmatory compli-
cations of a serious natur«.
[It id highly probuhle that the endothelial membrane lying upon and'
in oetwecn the ciliary pnicess. lately doiwribed by Kuhnt, ])!ays an im-
portant i>art in the changes in the amount of tluid in ditl'erent [tart« of
the eye in health ami disease, especially in coimeclion with changes ii
the vicinitv of Fontanu's space. {See Bcriclit der Ophthal. Geseluch.i
18751, Heidelberg.)
As in iritis, so in irido-choroiditia, tho inflammation may be either
plant i'\ K^ruuf, or mfenriiyiiiii('ju»; and the latter may be suppurative,
or the tissues may be the sent of dilt'use gummy iiililtmtion. Ktiologi'
colly, tho disease may bo citlter secondary to an inflanimntion in tbi
iritf, which is by far the more common; or it may be primary or apoti
taneons ; or, finally, it may be sympathetic from injury tn the fellnw
eye ; the latter will Ir* considered in a separate section.
Phisttr inJo-cfiomiiiitigf which may be oitlier primary or secondary,!
> I miut rMoioil tho TeotivT thai hy itiiB torm " extfla*(om of 1Ih> iiupfl" to »««b1,I
tlinl lh<r ailtiMinn t"'tiri<»li (tin nigt- of lliv (iu{/il Kliil iIr* vn)>»liK> of llic 1«t» vxtantdlT
(tiniiilHi'ljr nmti'l tliv elmiiiifi>r<>mv of tlir po|>tl, ami thntt uliutx ult th*^ cmunobl^
Utitm brtwtwii till- mitrriur kud posliTinr ctiatulnT. Tim an>» of llin |iU[>il tna;^, iB
>uoh a cMe, \» [iprfwtly ok-ar »ii<l uiKi'cuiiivl l-v ljiii|»t). If ihiv i» mn il)« c*m'J
bat 11 ia Allnl irlth a di^iMUit or pln^of l^in|»li, It » tvriuMl "Acoliiolon" ot Ihe pllplb
•Bit Iliki nivolTi-Ji tUo excliuiun.
IftlDO-CIIOROIDITIS— IRrttO-CTCLITIS.
243
in ndditton to the ordtuarT i'l^* of plaatie iritiii, is accompanied by ex-
treme Icridenii'M in the ciliary re;^i(m, turbidity of the vitreous humor
with fliMiting Hocculi, atitl a more or Iv^a marked recession of the iris.
Thf luirtHt form of luBammation is much more insidious and slow, the
STmptnm* of irritation ht*in^ much less marked. The pupiia may bo
modorali'ty \iiile nnd ^1ii^;ri8b, but the vitreous from the bcgtuiiing,
(•^iwcially iieur the b'us, is filled witli (locculi and gcucrally turhid.
The intru-ocidar teusioii u almost alna^'s increattt^d, and the corneal
eurfaee ia apt to asaume an appearance liko f^round gla»a. The deposit
the posterior Burfacc of the eoniea bt^comes much thicker, acid may
90 extensive as ti> reach continnoiiAty from comoa to anterior surface
of tlie irid, and 'X-casionally thit! deposit is seen opou the capsule. The
vitreous 0|»acities may bt-come like long threads or even membranifonn.
With all those ch.inge9 the circuraconioal injection may be very alight.
A mixed form of serous nod plastic inSammation is muc'i more fre<}ucntly
net irith than a purely serous form. Thia form of inflammation ia gene.
rally chronic, anX when will marked, ffres all iJie cbaracteriatic aigiu
of chronic intlammatory ^laiicouia,
PuniUut irid'hrkorutdttin, though usually of trfiumatic origin, may
occur primarily ai> the result of a thrombotic process iu the va.scular
dinribution of the eyeball or choroid ; or, better, as a metastatic pro-
ccm; or, still more rarely, a:* a not uncommon complication of cerebro-
flpinal meningitis. In this form of intlamaiation the proce»^ usually
starbi ill the choroid ami .spreads to the ciliary body and iris secondarily.
The aitterior cliaiiiber uKiy be in a xhort lime filled with pmt from the
inflamed ciliary body which may entirely disappear in the course of a
few boura. The tension of the eye is usually diminished. The proceas
ifl very apt to end in a panophthiilmitia.
!ridiy-rhor<nditi» ijMminom or Ki/j>liiliritvt is a rather rare disease.
Though in all probability beginning in the iris and subset|uenlly extend-
ing to tlic ciliary body and possibly to the choroid, yet there are cases
<m record in which the gummy nodules occurred in the ciliary body,
coalesced, and gave ritie ui a diiFusu iidiltration of both iris and cboroiil.
The progress is usually very rapid and the symptoms very violent, and,
ia apile of trvaUuent, is very apt to end iu destruction of the eye :
|AMgh, if rupture of the sclera can be jirevented, the re^iult may be
SwS' favorable. (For recent observations, »ee, 1, Trans. Amor. Opbihal.
Soo., 1H74, and, 2, (tmef'u und SaemJsch's lidb. der Augenheilk., Ud.
ir. p. 51tJ.>— B.]
In practice we can di^tingiiisb two prineipal forms of irido-choroiditis,
preseDting certain ehiir:ict<.<nst)c dilfvrenec!!, which it is of cansei')ucnce
10 observe, not only wi:h reganl in the prognoptis, but also witJ) regard
to the line of ojterativc treatment which in rei|uircd in each.
Id the /rst form the disease commences with iritis, and if the pupil is
npt kept widely dilated with atropine, posterior aynecbia; soon form and
rapidly lead to exclusion of tlie pupil from circular synechia. The pupil
may remain clear excc]iiing jiwt at its edge, where it fhowa a wcll-mtirked
boM'er of pigmenti-d exuihition. liradiuilly wc notice that smalt knob-
like bulginga show themselves in the iris, which may remain chiefly con-
•V Tftf TBIS.
■lea to t]io whole of it, «> that
fmmhieiices, like saild hefol^m
kjr firm exudation on the [>o«E^^
rfiu^ion heliilid it ; and tlic pnr*
JBC portions of the iris rcaiat tho
i. The appearance pmsuulcd b/fl
rriatic. ^
ft gf the whole circumference of the
:m this point yii.>Iil to thv pre-Si^iiru of,
Wtween the pupil and its ciliiirj m!-
kuoWike protuberances, which are
r aj to Comi' iiL contact here ami thtire
f contra. The bulf^e elope* grailiiullT
«f the cornea, hut parses bteuply down
ts-'ss^afr^kc depres.'tion. ■
maA ifiscolorcil, ami of a gray asli-like, or
■iMtinn, more ei*pccia1ly with the oiiUiiuc
:: its fibrillte are sonaewliat opened up and
Tuersc'l by a few dilated tortuous Tclns.
.•j*rally at first norma!, but may ilion be-1
.,MMav*> Saally, however, it diiuitiiiihcii more audi
^H> tfroplited. If the pupil is clear, the niight
„ Vit "hen the hul-riii;: of the iris occurs, it
atf refractive incdiu and the pupil are snffi-
ui oplithiilino^-opic exiiminution, the vitreut
■<• (Uffusely clouded, wiili delicate, tloating,
EB it, proving tlmt the disease is no longei
•^ M« extended to the ciliary body and chtiroid.
^atfia mch a ca^e, we notice that when the knife
^■oitt^ humor e!;ca[H?s from the anterior chamber;
s wi euiptieH completely, in consequence of thes
Hit beinj; able to affect the anterior chamber ouH
gf the pujiil. A sufficiently large piece of iri«
« .^jal witii the lorcepx an*! exciiied, a copious stream
;mnltaneously e«c;iiiiiig from behind it. The
iM its normal plane, even altliough, m Voo
^iDg part itself h»s not been exciitod, hut only
-is. flie artificial pupil thus obtained may h«
I'ttng jiwt at the eil;^e uf the pupil ; or. ne fre-
-- i-'onsiderabie portion of tlic uvea !■* fonnff"
.. uvea having been se[wraled from llie irll
~^j|i, .-coiiie attached to the cn[)«ule of tJie lens.
■i-!o-choroidiii8 presents very different appoar-
1 of Iveing ai-ched forward iu littEe knubUke
^^;h straight and even on its surface, ftlthough it is
1, irdi the comt-a, prwlucing great shallownoM of the
Uie pu|jil is not drawn back. There is oorapleto
;. and its area i» generally occupied by a more or^
'r»ntf, or by a thick plug of lymph [seclusion an^f
luc tJMue yf the iris looks stretched, it« fibrillte are^
IRIDO-CUOROtOITIS — IRIDO-C VCLITIS.
245
intliiitinct, ita snrface iliMolored, Mui of a iliriy reddish tint, which is
partlv due to the cloudinesi} of the aqm^'um humor, hut chif^By ti'> the
nuiueroitft lnr;;c ttirtuoita blootlvesiiels which traverse ttti surface : tliere
Wiii^ a eoasitlerahle aiiiji^ in the venous circulation and mechanical
hypenciiiia, on account of thv iuUammatory affection of the ciliary body
null ctiiiniid. Tlie pressing forward of tlio iris is not due to a collection of
fluid behind it, but to tJie pushing forwanl of the leiw («ilh the capsule
of which the jria in intimately connected hy means of extensive, tJiick
marines of exudation), which yields tn the intra-ocular prcsflure. The
faUe membrane behind the iris is generally very considerable, consisting
of a thick, organized^ feltrlike niais of exudation, which iidlu'rt'8 uiuwdy
to the capsule of the lens, &ui perhaps filh up a jjreat portion of tlte
posterior chamber. Tne iiitra-cap^ular cclU generally proliferate, and
tMcomo clouded, but the lend itielt* often remains traiisparant.
En these cases a simple iridectomy is of no avail, for even if we can
remore a |>oriion of tiic iris (which i." oft«ii very didicult), the opening
tbiw maile is n'jiniti rapidly closed by exudation, for lUc operation ex.
cit<r« a fre^h attack of inllammation. and tiuully such eyes will undergo
gmdual destruction from atrophy, if they are not operated upon in the
manner described beh»w,
! must state that the distinctive eliaracters of these two forms of
irido-choroiditis are not always so airongly marked, for wo often meet
with mixed forms ; or, aj;ain, tlie second may supervene upon the first,
forming, su to say, a more advanced and hotielcsit staj^e.
It baa been slated above, that indo-choroiditis nuiy ensue upon an in>
flammatiuri which primarily alTeccod the iris and then exlenued to the
ciliary Imdy and chor^iid ; or that it may he;i;iii in the latter, and only
8uhsei]ueiilly attack the iris. It is sometimes difficuU, at a late stajje of
tlio disease, to ascertain with anything like certainty, which course the
iwe had originally pursued. Tiie following facts will, however,
nl us some guidance. When the disease originate! in the iris, we
fflid that there were welUmarkcd sym|itams of recurrent inflammation,
and that the structure of the iris is tousiderably changed, being much
dii*colore<l, thinned, and alrophivd. The lens also becomes less fre-
i|Uently opmpie, and only at a mucli later period. Tlie dimness of siglit
is likewise less conaidonible, and depends at fir^t chiefly upon the de-
posit of lymph in the pupil, and only subsetpiently upon the cloudittess
of the lem or vitreous humor. Whereas, if the in^ammation commenced
in llie choroid, the train of symptoms is diifercnt. There are marked
symptoms of [plastici choroiditis, with opacity of tlic vitreous humor,
followed very generally by det;ichment of the retina, from a serous or
heinorrhagic effusion. The tension of the oyeliall iliminishcu. Then an
Mpacity of the loni* supervenes, very frei|uenily commencing at itfi pos-
terior [>uk% and gradually extending thence to the whole lens substance.
At a later stage, the len* umlorgoes further degenerative changes, be-
coming chalky, and triiust'ormcd into a *' cataracta accreta.'' The iris
nuy not be affected until a lace period of the disease, and not until some
time after the formation of cataract, or it may become inflamed at an
earlier sugo ; but the iritis is generally inttitlious, and not accompanied
by any marked inflammatory syraptoto.'i. The pupit becomes adherent.
SISEiSBS OP TnB IBIS.
■nteik t* fliiiRd in its aren And on (he posterior eurface of tbe iris,
•«ie6 awySie— e lm1g«<l fonvanl by tiiitd, or pre^acd forwanl b^ dense
^mmB rf csadation. Two rcrj inifKirtant guides bv which to dii*tin-
^M teiw«nt iksi form of irido-cl)oroi<liti8 and Ihut cominvnvin;^ with nn
m Am iris, nro the de;;ref of »\-'Ui iind tlH> etatc of tlit.< ticdd
<•- T^ perception of liglit will ho far less in the former case-
^e« «di W s (Barked coutructiun or Hbsciice of thut pan of die
7^ ^f*'^ which cnrre^ponda tn ibe detachwl portion of (lie retina.
f Arli^frMn the lamp is di^cln^^nished when it w held iit liie
~«yrdf ArSrid. but Ijecomctt invisible when it i-t removed into the
^JL*mJSe»te» a det^climent of the lower portion of the retina.
> -^^ m gMmntiy fcr^ mucli impnircd in cases of iridoKthunmliiia
K^te faMMcmn ouW perhaps rlistin^ish large letters, count fin>
V mm flair aaple (Krcepiion of li^ht. In irido-cboroiditiK un-
W vMbiMnt uf the retina, or ;;]aiu;omatou9 or atrophic
iw KiTiiM anil optie nerve, the (|uanttbitive 6eld of riaioi^H
ic, of conrse, very variable, aeeording to the ulagc and
■s*. If a case of irido-cboroidiLls (utieooiplieated with
•f the choroid, detachment of the retiiiii, or opacity of
^ ^«« al the outset, whiUt the chan<!C8 in the iri^ are ^till but
^_ .rtm^ U»e I'Hpil c1e.ir, or oid_v oeciipied by a film of exuda-
iMih ^Kk OX« »rr DO nasi'cs of exudatioii-me.mbmnett behind the iris.
^ — r- — ^ var h« farornble If the sight bo still tolerably good, and
ntmm m>tma\.
tf irido^horoiditis, in which the iria in balgcd forwar
1 nuch better |)ro;^»wis than the second. Tlie nioa
\.i Mtt of course the easett of iridn-choroiditis with detaeli-
-^'Una. Ill such a case, or if there is no perception of liphi
ihouKl be attempted excepting tor the sake of rclienng
.iwMtf7«ixt^ the riitk of 8ya)|>athetic opbthnlmia. A cci*tain de-
iHrrt;' «f tita eye (if it be not too far advanced, and the per-
-M^M*.^lw> W*' ^^'^^ "^ vision arc good) doeii not con era-indicate
■it - fci^n»*ia«» Rr »* fiml that the iritlectomy often arrests the atrophy,
rviTJiins its iibinipiioas, atnl n normal degree of teasioii.
,_. ^- tta.'hyuiatous indo-eboroiilitia frreatJy endanger the eye
-Mkw ai»l thv formation of a wide pupil by no means bnnga the
M 1 fiMwbtill or ■ftrevent* relajme?. 'Hie serous fonn of inflam-
jtuiK «^ a more lavornlde pn»jL,niosis, The most dcsti-uctive of
■ ■ r it tilniost always attauk;* the choroid tltroughonC^I
. -iinhnitis. Tliv non-lmiinmtic purulent form of in^l
i^a\<li less destnietive, thouj^h even here not much hope
.; >*.l iif my uiHjful vi-iton. — li.]
>v>|ueiit rttKjrc of irido-ehoroiditia is tiie prcRcnec of po«te*
ive all, the circular form. The presence of adhesinns
■if the pupil aii'l the cajisnie of the lens luailiU to fre-
* uf the iritis, more lynipli is cffuAcd, more ^yiiechisq^
>llr the pupil is excluded, luid theu, if this has imt al-V
■ iture intl«mmati(ULi are snro to extend fr^m the iris to
itiK cuuj.i >My awt the choroid. The best safeguard against a recur-
ina.
ani^
irdfl
uos^l
^
ItltkO-CUOKOTDITIS — IRID0-CYCLITI8.
247
nine of the iritw aivl the supervention of irido-choroiilitH, is to curt a
caw of iritis wUfaoirt tw Voitnatioii of anv posterior ayiMcbi:^. Of course,
iucb eyes "lo tK*t piyoy a perfect imimmity inim n recnrrwnco of iritia if
■ iuficicm exciting efi\we ahoii!.! arise, hut tlicy are far less prone to it
lb«n if a»Miefii"ns liavf reraaiueii behind. Iridfi-clioroi'liiia raay nlso be
caiued by injuri<?8 and woHn(]4 of tht pye, by the loilfi;ineiit of forei;pi
bmlics (more csfif-cially ajdinters of rat-tai, gun caps, or glfiss) within the
I'TC, and by ofwraticiis, |iarlicul»rly those for cataract. It may likewise
irve in coiiHci|iieiice of an injury to the other eye, thus conatituting
"STDipulhetic opiitlialmia."
If the adhesions bftweon the iris and capaiile of the lens bit not con.
siilfnWe, and are iliin and " toii^iied,'* it may be jiowible to tear Ihera
llirt'ii^'h by tiie ppolou;^ed uho of a strou); nutiilinn of atropine, or to
S'jiaraw them hy opfi-ailve intcrferonco (corclysis). But if they are
firm and broad, and especially if Ihey extend all aronnd the ed^^e of the
finj^I, am) thun cut oiT the communication between the anterior and po»te-
fwr chamber, wo must have recourse to iridectoioy ; for no other means
■ill fluffice lo guard the eye against the daiifrei-s of irido-cboroidilis, or
10 ilay the progreaa of this disease if it is already present.
in the eaHv stage, wlieu the ailbesrous are not very vxteiuive and
firm, and the tissue of tlie iris has not ycL undergone atrophic cban<^6,il is
^ncrallv not difficult to obtain a tolerably good artificial pupil, by means
«ff aa iridectomy. Frenueully, however, a small rim of iris, at the edge
of the pupil, is HO firmly atuuihud t^) the capsule an not to yield to the
tnction of the forceps, but is left standing;. Thia does not invalidate
the reault, if a tolerable sized piece of iri:« is removed, and a clear orti-
fia&l pupil and a free communication between the two chambers are eslab-
Usbed. If the pu]iil is only adherent nt ccrLaiu })oints, it will be best
to employ A fine bluni hook, instead of the iris forocp», for catching up
Ifae in9. Tlie hook !« to be passed carefully along to the edje of the
pnpil CUic [Kirtion wbiTu there are no Hyuot'liiiv)* gfitly tiiriieil over tlio
Durgin, and the ins thi-n drawn out and snipped olT. In this way, we
may often succeed in excising a considerable segment of the Iriei, whereas
from the rottenness of its Btructure and the firmnt'is of tlie adhestom,
it would probably have regi^^tcd the grasp of the forceps, and only small
ithmls have been removed. Care must be taken never to employ too
much force in the removal of the iris, otherwise a dialyais may bo eaaily
produced at tlie opposite circumference «jf the iriu.
We ;;enerally find that after the operation, the inflararaatory aymp-
toma (|aickly subside, that the sight improves, and that the recurrence
nf inflammatiim is arrcsteil. In »omc caaes, however, thio is not the aise,
Expo^iirv to cold, briglit light, continued mm: of the eyctt, easily repro-
duce ail iiillaniniatioii. If these rcenrriMices are frt^pu-nt and obi^tinate,
much hencKt is often derived from a second iridectomy, made in an op-
nmCe direction, so that the two halves of tlie iris are completely cut off
from each other. This operation has been practised with much success
by (Jraefe and Critchett (independently of each other), and 1 have oflen
fifund much lienefit from its performaiieo in cases of obstinate recurrent
iritbi. The line of tlie double iridectomy may be either horisontal or
vertical. The ulvantagc of the latter is, that a more or leas consider
DISBASBB or THB IRIS.
Upper In), wliict
In UiHt form
;lic iipfwr iiart of the artificial |nipil is covered bjr Uiu
<]iiuiiii^li<<9 tlic circles of (liffuition u|ion Uif rcrinii,
of iriiln-choroiilitis, in which the iris is bulgt'd fonrnnl
br knoll-like protobo ranees, and the cd-^' of the pupil is tic*i down tightly
^^y a firm circular synechia, it U geiierallr uut difficult to gra^^p (u>d
^Hcmove a considerahlc piece of iris, and tbii» to form a good-sixed arti'
^Bcial pupil.
^f Oil account of the ;;reat KhaHowncM; of the anterior cliamher and the
proximity of tlit- hiilpn;; iris to the posterior porcitm of the comoa, it is
ofteu very difficult to avoitl cutting tlic iris with the comntou iridectoiuv
knife. It ia hetter, therefore, to make tlie incision with Von iirsefe a
L^CMig, narrow cataract knife, for with it wc can skirt the edge of the
^^lambcr, ami gain a large incision without fear of injuring the irit.
^^ Wo unfortunate It not unfrci|uently find that, although the iridectoniy '
in large, the laight i* but little if at all improved, for the artificial pupil
bi occupied bv a thick uveal luombranc detached by the Huid from tlie
iriii. It 'i» of practical importance to remember the probability of tliii
occnrrence ou forming uur pro^^uosis ag to the effect of the operatiim;
y^KHoe wti should never itefinitively promise the patient great iinprovts
^^ent of sight aft«-r the first operation, hut prepare him for t}ie prohaU*
' ^ueccssity of a second. Ilie uveal pigment is so intimately coiiiteeti-d
^yitb the ca|kjule of the lens, that it ia generally unwi.4e to attempt to
H^rape a portion of it off, m rupture of tlie capsule and traumatic cata-
^TBCt might ensue. If we llierefore find that so conuderable a poriion of
the artificial pupil (the natural one being also blocked up by lymph) ii
occupied by the uvea as (greatly to impair the sight, it will bo bei^t, at » ,
ilator pirriod, t" make atiotlier iridectomy in a different direction, in th« ,
^Bope Uiat at this poiut there may be le»» deposit upon the capsule. 6y1
^^Diis means, ur even by a third iriiluctomy, wc may succeed in finally
^■living the patient a good clear pupil and a considcnibic degree of sight.
^^A most interesting ami instructive example of this kind occurred amuugst
I^ie patients at MoortiehU, wliere Mr. liowman repeated the o|>enktioT) ;
berforiniiig iridectomy twice u|>on tlie right eye and three timeit upon the
iett. The rcHuk was most successful. On the patient's ailmit^ioii his
light was M follows: Uight eye, letters of *2U (dEi;;^r) with diflicuUvt
iountH fingers within IV inches. Left eye — couiit^i fingers witli uiicer-
lainty within 3 feet. Seven weeks afterwards, on his discharge from
Uie hospital* he could read No. 2 with die right eye, and No. 12 with
the left.'
liren although the fini iridectomy may not materially improve the
ight, we find Uial it gvntrrally exerts a beneficial intlueuce upon the tis-
0 nf tlie iris and the general condition of the eye ; the iris gnkiliially
iliing a more normal color and appearance. Von (iraefe was the firnt
cull attention l<i tlie fact that u certain degree of atrophy of the eye,
boiifenuenl ujNin iridi>choroiiiitis. may be arrested hy the ]wriormi
>!' irideciymy, nnd the eye regain its normal tension. This fact
jLce been widely acknowledged by all liurgeous who have much expcri-
I* I h«v» r*D<>ri«<l thi» cm* at tnngtti io 1h« "Sojral tmdoD OjiIiIIikI. Iliiap, K«-
miDO-CJlOROEUITlS — IRIUO-CY CLITI8.
£49
^oftt on thU 8u*)JL>ct. Of courflc. Uie atrophy must ni>t have advanced
too far, otherwise \ta arreiit will W impoiuiMe, the Aainn licin;; tlio ca«o
if dctnchmeiit of the retina hatt ncuurreil. The benefit <Ierivud fnmi iri-
dectitmy (iKThaps repeated sevcnU times) in these caws, is that the HtJisis
anit congestion iu the choroidal vceaels arc relieved, which not onlv caiiites
an iniprovemcnt in the chorotilal circulation, hut also in tlic nutrition of
the vitrcou» humor.
If we cauuut Aiieceed in finding a portion of capjiule sufficieutiv clear
of uveal pigment to allow of much iraproromcnt of ai^ht, or if tlic leua is
oi«i|ue, it will he best to remove the latter.
Ill certain ciiaes of irido -choroiditis, demanding in his opinion an un-
usually Iftrjje iridectomy, Mr. lUwraan effects this through an incision of
moderate extent bv seizing the iris at a point beyond the incision and de-
taohiug it from its ciliary border beyond the ordinary limits before di-
viding it. The same being then done at the opposite side of the incision,
the removal of even half the \rh may be nccomplinlied by an incision
only extending to one-fourth or one-third of the cornea! margin. Slight
move incuts <}{ the curette efiuciually cause the cut ends of the iris to
r**tract within the chamber, and the blood effuaed is expelled by gentle
prcMure or traction made on the eyeball, while the edges of the iuctmion
are slightly separated hy depressing the posterior lip.
Ill other instances Mr. liouman makes an iridectomy at tnro opposite
|K>inu at the same time, by introducing two triangular knives simulta-
neounly, either alatve and below, or to the right and left ; tlie latter mode
being the more easy in manipulation, tiic former preferable cosmetically
and optically. One at lease of the two iridectomy ktiives is a tVip-knife^
i. e., is proi-ided with a ledge preventing its penetration beyond a certain
extent. The knife 6rst introduced a little way will hold the cyo, so as
lo give the i)urgcon command over tJie iniibsequent introduction of the
second knife, and the due compilation of the incision effected by both.
Tiie points of tlie knives are directed sligbtlv forwards so as Ui avoid
the lens if tninsparciit, and they ai-e never suifercd to be ab all retracted
until both inciaioiu) are complete, so that tlie ai|u40us may not prcnuttorely
eitcape. Connie iiiaiiipulntivti pnictice it; re<|iiiHito for thi>4 proceeding, but
it i» not difficult to avoid any injury to a transparpnt loiis. The object
here is to avoid the necesitity of a second iridectomy at a future time,
and the metliod is, according to Mr. Howmaii, especially applicable to
certain cases of glaucoma, where either a very large iridectomy is desir-
able, or where there is reason to fear ibat a single iridectomy pmciiscd
ill tlie ordinary fashion may be insufficient to completely abate the ten*
siou. and where conse<picntly the need of a supple muntury repetition uf
the iridectomy at a future pt-rind, and at an op|io-tite piiint, mav be ap-
__ jhende<l as likely to arise. Mr. Bowman applies lo this double siiiiul-
'taneous iridectomy at opposite purtj$ the term " diametrir"
WhiUt we may affoni considerable im|in)Vi?ment in the abore class of
BMCs from re|>caled iridectomies, this is by no means the rule in the
econd kind of irido-cboroi.Utis. Although in the former case the first
artificial pujiil often become* narrowed or even closed, yet the texture of
the iris iinprovu4 ; at a )«econd operation we mostly succeed in gaining a
trger pupil, and at a HubM4|uent oqg. a lolernbty good result as to the
260
DI8BASBS OP TilB IRIS.
m^lit. Bnt vbcn Uiick felt-like masses of exudation exisl lietween ibc
iris and capsule, we fail to remove a considerable portion of the rotten
iri», and this attempt, moreover, seta up renewed inflnmiiifttion, increased
proliferation of the exudation masses, and we iIiub, instead of iraproring
the condition, hapten the atrophy of the eye. It will therefor© ho neces-
sary, in order to liem-fii such can.*!*, lo remove not onlr the iris l>ut the
dense masspg holiind it ; hut they are generally ro firmly adherent to the
capsule tlint we are almost sure to rnpture the latter in ijiir endeavor to
remove tliem. A traiimntic cataract is formed, if the lens is not already
opaijne, and this complicates matters still more. But Von Oi-aefc huA
an opportunity of seeing that tliese false memhranes could he removed
with cnmpnrativo facility and success when the lens was ah^ient.' This
led him lo remove the lens, ni-ior to attempting the withdrawal of the
iris and exudation uiassos. In those CMCs Vim Graefe now operates in
the following manner:' With this narrow cntaract knife he makes the
section just as in his operatinn for cataract, with the exception that, di-
rectly tlie puncture is mad«, the blade is passed straight through the
iris, and brouyhl out at the counter puncture, thus freely ilividiuff the
iris. Iliis generally cikuses such a wide laceration of the capsule, that
the lens matter exudes even while the section is Wing made. A pair of
firnilycatctiing, cross-grooved forceps is then passof) into thtt iucisioD,
and one blade pushed boldly forwani between the iris and eonica, and
the other behind the rctroiritic ninsses of exudation ; tlu' Iria and por-
tious of faUc inembriiuv which are thus grasped are then to Iw genlly
drawn out. If they do not come readily, their removal may be fucili-
tated by making a cut with the scissors at each extremity of the iioear
incision, which had been made through the iris with the knife. The
removal of the iris and false inemhrano is often followed by the escape
of the remaining portion of the lens, in which case the operali^n may be
regarded as completed. If this does not take place, the capsule should
be freely lacerated with the prickpr (cyatotomei, and the lens evacuated
by a alight pressure of the curette ou tlie cornea, just as in Vontiraefe's
operation of cxtractinn of cataract. Should some opaqno portions of
cajwule remain behind in the lower portion of the pupil alter the removal
of tliB lens, ihey are to he seiw^d with ihc grooved forceps aitd gently
removed, if they are not too firmly adherent to the iris or ciliary pro-
cesses. If the lens is chalky, Von (iracfe passes in a curved hook, and,
firessing this somewhat on the anterior capsule, endeavors to free the
ens from any adhesions, and tliuit inikc it sulliclently movable to esca}>e
through the section by a liillo pressure of the curette on the cornea.
lie. however, strongly ohjocts, ovon lu these cases, to the introduction of
any instrument (e. </., a scoop) behind the Ions.
As the success of the iridectomy and of the extraction of the Ions in
eases of irido-choroidttis is often invalidated by the contraction and 8ub-
W!(iuent closure of the artificial pupil, Mr. Bowman has devised the fol-
lowing operation, termed by him, "excision of the pupil," which has
' " A. f. O.." ft. 2. S7. Vid« a\w tlw author'* al.lr«ct of tbU paper. " B. U 0. II.
R*p..*' ilL SS4.
' "A. f. O.,'* 14. 3, 141.
IHIDO'CllOROIItlTIS — IRIDO-CTCLITIS.
251
I
I
I
I
■Rbrded HirorablQ rcsalts : The pmictiivc and counter-puncture mny be
made as in Von (iraefe'a oftcrat'ion for extraction of catnract (anil with
the same knife). Tlie incision is not, however, concludeJ, but a narrow
biidge \f left dtantlinj; at its a]iex. which airlK in prevotiliut; the escape
»>f the vitreuus. The blades of a pair of fin« scisfwrs ure then introduced
ihniu;<;h the first incii^ion (the punuturc), and the one hiadu (blunt-
pointed) fwiMcd io front of the iris ; the other, which i^* aharp, pierces
liie iris and anterior capsule of the Icna, and runnin;^ down in front of
the uncleu.'^, and without rooYin<; it from its hed, a cut is iiiadi' diagonally
dovDwardx as far a« tlio centre of the lower part of tlie iris. The
scissors arc tlion Hitlidmwii, and next introduced throti^li the counier-
pUDcturc, and a similar inci.tion made on this side, so that the two in-
ct«ioQ0 meet at the lower part of the irii^, including between tlioma large
trinnf^ular piece of iris a^i well as tlie coii^triutor |in]iillie. Finnlly tlie
base of the triangle in divided by cutting tlirongh the upper portion of
tlie iris lyin<; between the puncture and counter-puncture, and the whole
triangular piece is then removed, as well as any false membrane attached
to it, with a pair of furcep». The bridge of cornea 'u then divided, and
tb« \em removed in die iLiual manner. The operation bos been varied
bv Mr. Bowman tn two or three ways, according to the cases dealt with.
Wlien there is no lens to be reniuved,the bridge of cornea is not divided,
na the opemti'iri i» already complete. Sometimes the cut acroAS the bn^c
of ihe iris or the thinl above describeil, is tiot lu-cessary, as the trlangu-
Ur portion of iris, including the pupil and capsule, admits of being easily
torn olF along the ciliary attachment. It is when there i« a very dense
and tough cnpitale or false uemhranc behind the iris, that the third in-
ciaoa with scissoM is cliiefly re<]uircd, a.^ avoiding the dangerous drag-
ging of the ciliary Btructurev. tn other insftances, thf entire section of
the enrneu hatt been made at one stroke, without leaving the temporary
bridge.
Mr. Bowman has also applied the same mo'le of operating to Qxsti of
memhranoua obstruction of the iris r«<rion, where the lens has
_ previously removed, and to these he considers it to he particularly
»|)]ilicable, especially if its perfi>rmance be delayed until all signs of in-
(lajnm:it<»ry tendency have entirely disappeapt-d.
[In tlie treatment of plaHtiu iridu-clioroiditis atropia sliould he used
fre«|ueuily and in Htnuig Hohiti(m>t uule.^s cMitraindicatod. Local bleed-
ing from the tcinpleg hy means of tin- nutural or artificial leech, and a
tliorougli course of nierv.'urial treatment by iminL-tion or tlie mercurial va-
pnr bath, should be per^istt'd in. Another valuablii remedy i^ jalmrandi
or it* alkaloid pl«Karpine. A hypoflermic injection of ten to twenty
tDiaims of a four-grain solution of the muriate of pilocarpine, every day
or twice a day, is very often of great value in cases of a low grade of
ebronjc irido-choroiditis. especially in clearing up the vitreous. It* ef-
fectrt should be carefully watched, for it occasionally causes unploaiiaut
•rmptoms of collajMc in canliac complications. A'ery often the more pro-
fue peni[»ration and (•alivatiou result from the sninller dose.
tn seroua irido-choroiditis frequent paracentesis of the cornea is some-
uioea of u«e.
A
252 p[6BA&BS OF TUB IBIS.
In purulent irido-choroiditis no trealnwnt Mema to be of any avail,
tlioiigh large doses of iiuinine would wrm to W indicated. — B,]
Mr. Jtowmau has made a further modification of the method described
on jHif/f 'JnU, adapted to remove a larger area of the pupillarr ^truccurtrg,
ana indeed nearly the whoW iris, witliont any traction on the ciliary body.
He makes an incision oti two opposite sidee of the cornea, as for dinmrtric
irS<Ievt>wiff, and tlien from the two ends of each incisiun, with tlic previ-
ouitly dcH:rtbed sciesont. incises the iris in «uch a vny an to mark out an
irrerrulnrly rhombuidal nr stpian- portion nf the iritt and attached stnictures.
the point* of the scissors-cnt meeting at the margin of the anterior cham-
ber midway between the two corneal incisions. The square portion tiiu*
defined is removed by forceps, after the hage of it has been cut across fts
above ; or, if the sciASors commence tlicir cut at the aame point opiwrit*
the centre of the conical nound, the portion romovcd would be about
sqnare and four inovemcnt<i of the scissors wonld eflcet it.
For these operations within the anterior chamber Ue Wecker's new
and ingonions "forcen* sciwora" will be found admirably adapted. Tliey.
an<l the mode of using them, are fully described in the ;8ection on sec-
ondary cataract.
n.— SYMPATHETIC OPHTHALMIA.
The name of " sympathetic ophthalmia" was first ap]>llcd by >racken-
zio to those cases in which an injury of the one eye was followed by a
peculiar inflammation in the other, winch generally en^ueit within a short
time of the accident, and proves extremely dan-^erous and intractable.
That such a sympathy cxista between tlie two cycG bad, however, be«n
previoimly poiiite*! ont by [limly and Beer.
Tlie L'baraeter of ftympatbetie inflamtnatinn ii^ m extremely dan^rouB
and iiididioua, that if it has oitce been lit. up. we are but seldom able to
:>iay itd iirogre«s before great, and often in-eparable. mischief has been
done. In the great majnritv of cases, the disease shows itself in the
form of a very malignant indo-cyclitia. accompanied by great degenera-
tion of the iria, total exclur^ion [and occluiiion] of the pupil, and ilie for-
mation of dense masses of exudation beiwoen tliC posterior surface of the
iris and the CM|»aule of the lens. This is the " Bymj)atlietic ophthalmia"
par rj.v//mrf, but it occasionally aptH'arA in a more tractable ami be-
nign form, Afljunun^ the character of iicroiw iritis [or irido-choroiditis].
Yon i.>nieri} han, moreover. ub»ervcO a third and still more rare affec-
tion, vix., sympathetic ehuroido-riilinitis [in which the inflammatory pro-
cess oecur-i i-xclu-iively in (lie j.B'isterior j,tjirl of the eyeball. A fourth
form of symjmtheiic intl»niuiatioii, rarer than nny of the otherrt, is neuro-
reiinicis or neuritis. (See Abadie and Oansart, *• Documcnij* pour
Hervir il rblatoire des affections eympa1bit|uvH de rt£il," Paris. 1HT3;
Trana. Fifth Inieniat. Ophth. Congress, l«7ti, paper by Alt.) — B.]
It ia of practical im{>ortance to distinguish the condltiou of synijra-
Btic irritation, which sometitnciH en^^nes u[ton an injury or inflammatiott
lie one eye, from sympathetic opbtliftlmia. In the former cu9e, thei
lietit Bnds that any intlammatcry exacerbation of ilio injured ere is
8Yaai>ATItBTlC OPUTIIALMIA.
2&S
*
soc'impanit-il hy more or le«a irntnbility of the otlier. He is imftble to
va|iloy the latter in reading or tine work, witlioiit itH soon becoming
tired and strained, owiuj^ to an impnirmcnt uf tbe ]>ower of acoouuuodn-
ttun. Tbe range of acvommodution ia generally also iiiurkedi^- diminished,
the near ftoini bein^ remorcd further from the eye. Every accommo-
dative cftort catisea the eye to fliwh up and become irritable, a bright
riMT xone appears around llie coniea, and photophobia and lauhrvma>
tion ft«KHi9U|>en'ene, toother «itli mori- or le»s ciliarv iicuralgia. These
syniptotod {generally nubeide, more especially at the eommcnceiuent, as
soon as the work is lairl aitidc,but<|uick]r reappear on itit beinj; resumed,
or when the eye is extn>sed lo cold, bright light, etc. The injured eye,
oioreover, often aUo befDriu-? painful an.l irritable, when the other Ih
iweil fiir rcnditij; or sewiny. Donder^ dcscribe-s a form of severe sympa-
Ibetic irntstion mider the name of '* sympathetic neurosis/' It ii
particularly di^tin^ui^bed by the intensity of tiie photophobia ami lach-
rymation, tli««e eymptoms being often so severe as to cause a violent
spoiim of the liiU. and directly any attempt is made to open tlio eye,
a stream of icaldinjt tears ponm over the cheek. There ia, however,
no im|<iirment of si^hl, nl(h(tugh from ita great irritability the eye
is i|uite unlit for use. D^inderd considers that thia ncuro^tiit never
paiwe« over into sympathetic ophthalmia, and yields in a very rapid
and marked manner to the removal of the injured eye. Whether or
not ca3ea of sympathetic irritation are to be regarded in the light of
a premonitory stnge of sympathetic ophthalmia, or whether they are to
be Iooke<l upon as completely differing from it in character, and as
ni'ver liable to y&n» over into it, is at present, [ think, an open iiueatioo.
'Whildl on the one liand, it mu^t be atlniittvd that ne occaaionaily meet
with iiuitances in which a state of great irritability has cxifitcd for a long
time without setting u]' fiym|>athetic ophthalmia, yet on tbe other, it muH
aUn be corweded, that the attack of inHammation is often tthowii to have
been clearly preceded by i*ymploms of irritation. Although thin qucs-
Uou is one of much interci^i and importance in tJie atudy of tbe true
□aturo of sympathetic inflammation, it is fortunately of but little conse-
«}iu)uce iu the treatment. For I tliiiik there can be no doubt that the
proper mode of dealing with n case in which marked and persistent
symptoms of sympathftic irritability ap|>car. is the immediate removal of
the injured eye. more especially if its sight ia lost or very much im-
paired. Indeed, it would be incurring unnecessary rii^k to neglect doing
so, on tlie 8uppo»ition tlial the state of irritation would never pas« over
into that of intiauimaiion.
Sympatheti*' iriJo ryfli'tit Is characterized by all the symptoms of a
sereni intra-ocular inll»mmation. The eyelitU are somewhat red and
Hwollcit, and then- iit mure or tt-ss photophobia, lachrymation, and ciliary
neuralgia. SomeUmini, however, there is not the slightest pain, so that
even iu children we hear no complaint, and ibis inveatti the diseiiMf with
a peculiarly dangerous character, as it is very apt to be long ntmoticcd
by the parenu. The ciliary region is generally sensitive to the touch,
aiid often acutely so. Soon there appear some peri-comcal vaecularity
and chi.-mosis, the iris beomeiii discnlored, and of a ycHowish.red lint,
the aipieuus humur is etouded, and the anterior chamber perhaps dimiu-
254
M8BA6ES OF TBB IBIS.
[Fig. 88.
--r^-«*^
wy
Aflar L>«(Mi.]
isticd in dtpth. Tbore U a rapid etTtutoa of Wmpli at the edge of (he
[lupil, s(Kiii Imuliiig to ilfl complcto cxcliiMion [Hj?- **^] ? 'nuicod the
actiou of atropine exerts but little inftuoiice upon the pupil. The ox-
udatioti is not, Lowever, confined to
tlie pupillarv edge, but ext<!inl8 to
tbf posterior surface of the ii'is and
the ciliary procpssea. The iris be-
comea firinlv <jlne<J down to the cap-
sule of tlic lens, and, oa the dtseuc
iulvnnccA, these exudations asauinc a
very deiwe, firm, and organized char-
acter. Lvniph in nlsn uffui^ed npon
the fluvfaec and into the stroma of
the iris, often to such an extent,
tliat the latter appears soaked in it.
The pupil is either covered by a film of exudation, or mav be completely
occluded by a dense yellow nodule. On account of the inBammatory
awcllin« of the ciliary body, this re-^ion is very sensitive to the touch,
and the circulation of the iris ia greatly im}>i'ded. and th« venous efflnx
ohstnicii-d : hence we soon notice the appearance of large tortnoiw veiiw
U[>on the iris. U* structure soon become-i dc-gencratcd and chaiij^ed into
a tirm, tcusc, fibrillar tissue, which cannot he caught up iu a fold by the
iridectomy forceps, but ia so friable and mtten that it tearj and hrt^aks
down under tlieir grasp. Ilcnee if an iridectomy h attempted, we shall
only succeed in tearing away a smitll jtortion uf the iris, and probably
(let up fresh iiillammatiou, which will lead to a rapid increase in the den-
aity and extent of the exudation inui^seK. If the pupil nud refracting
media arc sufficiently clear to permit of the use of the ophihalmoacope,
we may notice opacities in the vitreous humor, and inflammatory changes
in the churoiil and retina. Or there may be dense inaased of exudatioo
in the anterior portion of the vitreous hnnior. givinjz rise to a peculiar
yellow, lustrous reflex. At a later stage of the disease, when the mor-
bid products have hwonie more consolidated, the periphery of the iris is
often drawn back, which is due to a direct retraction caused by the adhe-
aion of its posterior surface to the ciliary processes ((inicfe'). Whereas,
on account of the increase in the exudation behind the iris, the latter,
and with it the lens, is moved forward. So that the more central portion
of the iris and the pupil arc approached n<'»rcr the cornea, and the
anterior ehamlier narrowed, whilst the peripliery of the inH may he drawn
hack towards tlie ciliary body. In other cases, Huid is effused behind
the iris, and the latter hecomea bulged oat into little ]»rotn he ranees.
The attack is often «o iiuiidious and painless, that the patient pays hue
little heed to the first stage of the inflaniimation, thinkin;^ perha[>s that
he has only caught a ulipiht "cold"' in the eye; and it is not till the
light becomes nialerially affected, that he ia frightened and seek* modt-
caI aid. In children especially (frnm their taking hut little heed of the
impairment of sight and from the absence of pain) the diwase is some-
times allowed to proceed very far imleed before nntch attention is paid
' "A. I. O.," rll. 2, IBl.
SYMPATHETIC Oi>BTUALMU.
255
to H hy the parenis. Bat althouj^h the spontaneous pnin is often aliscnt,
wo find that the ropon of the ciliary body n ijonemlly very souMtUe
to tbc toitcb. aifl Boiiiu tidies, m bu& been pointed out by Ituwman and
Von ilrocfc, at a spot corrcsftonding eymmptricallr to the point at which
the other eye bos been injured, or where it still remains tender to the
touch.
Tlie ten.'iiijn of the eye varies consideralily ; at first, it is generallv
luurv or less increased, but then it gradually dimiuiahes until ilic eyo
bircoiues ipiite soft, being ^till. however, liable to coibtidcniblc Huctun*
lioti^ in consiittoiioe. It '%», moreover, a fact of great practicul iuiport-
ice, that, if such eyes are loElt alone, and the acme of the inHmuma<
)ry process b aUowed to subside, aiKl the eye to become ijuict, grad-
ually and slowly its condition orten begin* to improve. The tension
become)) better, and gradually au^rmeiiis until it may even reach th«
normal standard ; the ti»diio of the iris improves greatly in appearance,
loses its dirty-yellovr hue, and as-^umes a fresher and more normal tint,
[h is probable that pure sympathetic plastic irido-cycUtia is rare, and
that tlie choroid is involved in the tnHammatory processt if not Ibrongb*
ont it* wlmli* extent, at least in its anterior portions ; thon;"!! the most
desinictive cban^ic.'i arc found in tlie ciliary body. From statistics of
lUl cases compiled by Alt, pure irido-cyclitis whs found ia only four
cases, or i>nlv ^ij per cent, (tfce Archives of Opbtbabnology, v. parts
3and4.)-li.]
Jn the tt/mpnth-'tir Kvoua iritis we find that the symptoms are very
ilifferent, and closely resemble those of serous iritis, or scrons irido-
cyclitis. Toj^ether with a certain degree of ciliary injection, we notice
ttiac tbe iris is somowhni discolored, the pupil pcHiajis dilated, the a4|uc-
ous bumor faintly clouded, and the po<ttcrior surface of the cornea dotted
by innumerable, small, pnnctiforoi opaciiiea, which arc perhaiis arranged
in the form of a pyramiil, havinjf its base downwards. The aepth of the
anterior chaniKer may be increased. If the iutlammation has extended
to the ciliary body, this is sensitive to the touch, and the vitreous humor
is likewise clouded, more e8)>ecially if there is also choroiditis. The
iutra-ocular tension is often augmented. This form is much less com-
mon, and much less (bingenms Utan sympathetic iridocyclitis, but it may
|>>S'< over into tbe latter.
Accordiii<: t<i Moorcn,' the cases in wliicb the sympathetic inllamniation
eitmmences in the iris allVird a more favorable pro^noiti:; than if it starts
from tbe choroid, the worst furm being where it begins in the ciliary
Im-ly,
Von Graefe' describes aiwther and very rare form of sympatlietic
opbtbalmin. under the name of " ajfmpathetie ehurnido-Tetinitig" and
narrates two cases, illustrative of tbe symptonn presented by it. In one
of ihi^e, the patient hud a dislocated chalky luua lying in the anterior
chamber <if tbe left eye, which was {lerfcctly blind, and snmcwbac atro>
phicd. The lens was removed with facility by Von Grnefe, but tbe
operation was accompanied by a considerable loss of tlnid, yellow ritro-
' vide Hoonu'a verv lnl«>rMlltt)t simI v*]asUe wark.
OMiohlMloriingvii." |t. 92. Hcrllii, HirMliWftld, ltW«.
<."Ar<-litv r. i),,"xH. i, 171.
' Ufflwr B/mpallilMbo
256
M6BASES OF TH« IRIS.
ou« humor. 'iTic eye remained in-itable, red. am! very sensitive to the
>uch for several wcvks, anil there were, moreuvi-r. Kymjitouis of plastic
jii:liti!4. Six wei-kit nfter the oiieralinii. when thenc tfyiiiploiiitt had mtme-
wliAt tftitisiilerl, hut the SGiv^iViility to the touch AtiU rcmnined, tiic sight
of the riglit eye. which had hitherto hecii perfectly good, began suddenly
to V>e impaired, hut this was unaccompanied hy any j«in. The aciiity of
vision had already on the Becond day after the attack sunk to one-iifih,
iLud there was considerable torpor of the retina, with indi^tinctnesa of
eccentric vision in the whole of t3ie temporal half of the ristial tiebl.
With the uphthalmoifcope. the retinal vciuii were iH^eii to ho very tortuotu
and dilated, more especially on the inner ftidc. The retina aUo shnwcii
a delicate and diftVise clouiliiu'M, which not only veiled the choroidal ring
of the optic nerve, hut extended to certain jKirtiunA of the rctinn, esjtc-
cially alone; the coiirac of »ome of the larger retinal vesseU. Slijijht
suvmptoms of iritis soon supervened, and very delicate punctiform opaci-
ties were observed on tbe membraiie of Desceraet. The power of
accotnniodation was almost completely |iaralv£ed. These symptoms grwU
iially Biihsided, and the nijjht became finally quite restored. Whether
tltia favorable result was chiefly due to the remedial mea^iurcs employed
(local depletion, bichloride of mercury, and afterwimU imlide of [lotas-
«ium), or to the extinctinn of the wensihility of the left eye to the toiieb,
■wa« uncertain. Von Gracfe himself lays the greater stress upon the la»t
fact. The morbid appearances of the retina disappeared less rapidly
tlian the functional disturbances, and then there were noticed pateliea of
choroiditis. [l*rohably a still rarer form of svmpathetic inflammation i«
jHiro and simple iieHro-ri'tinitig. Inflnmmation of the nerve and retina
ny doubt very often exists in cases »>!" jiyiupathetic <ir>h(halmia, but it i§
concculeil by the prmlucts of irido-eyelitis or choroiditis. In a report of
seven ca^es of sympathetic neuro-retinitut by Alt^ irido-chnroiditis ex-
isted in six. In five of the cases complete reeoi'ery occurred, and in
two the second eye was lost. In the tabidatetl statimiies of JlOea-HCfl by
Alt, before referred to (1. c. p. 4";i), simple ncuro- retinitis occunvd in
live eyes, or 4 J per cent., and in these live cases, in the eyes enucleated,
the ureal tract was affected in all, and the optic nerve and retina in three
cases. The percentage of aflections of the optic nerve aint retina coioci-
rlent with sympathetic irido-choroiditis is very largo. Alt havini^ foimd
them to reach 79 per cent. This is certainly worthy of considt'nition. as
is als4i the fact that in the five cases of pure ncuro-retinitis the retina
was detached in throe.
I If late years mention has been occasionally made of tt/tuf^hftir
•iftftOialmia affecting the rurne<t. or aympatlietio keratitis. There aro,
however, as yet no Hufficient facts, not enough actual obwnations to
tinbstaiitiate this stAtement. A case is reported by Maais, from the
Utreehi i-linic, in which the so-called symfuithelic corneal trouble wap
the appearance of phlycticnulre on one cornea ten months after an injury
to the other eye. Anoilicr case is rejwrted by rageimteeher, in wbicli
Uierc waa an obstinate superficial keratitis in one eye, after removal of
a corneal staphyloma in the other eye. Both cases arc referred lo by
AliO- c. p. 4iiH).— B.]
The atutfs ii/ tt/mjathttif opfithttfmia are to he sought in those lesions
*
SYMPATIIETtC OfllTHALUIA.
257
wtiicli may xet up n plastic iiifinininHtiuit of llie ciliary Ixxly. 1. Amoii^st
Xitt turiNt t'roifuctii causrs arc iiijiirivs to the eye, .-lucli m punetureU aii<l
,iucift«d wuundfi, iiioru e^^wciiitly in tlic region of the ciliary LuJy. If
ch wouiiiU an* extensive, the lens has generally escaped, ac«oinpfinied
irtiapa by coniiiilerable Iom or vUreuiu ami extensive intra-ociilar hcmor-
la^. ismall incised vouiuU of tlie ciliary rcj^iou, or .tituateil i>arily in
the latter ami jtartly in tlie cornea, are not iieceit»arity of so dangeroua
a clinractcr, ruore eapccially if tliey liave only {Hinctraiml the cimta of
iho eye, without injury of the lens or vitreous humor. In «uch c&fle8»
no time should be lodt in biingtug the lipa of the little wound to^retbor
with a suture. [It usutilly ?>titBces to bring the li|)3 of tlie oonjuDctiva]
wouiut lo^etlier, without ]ta*4in;j; the suture into or thp-mgh the sclera. —
ll.j I'liioii by the finit inteiiuoii will take place, and many an eye will
thu^ be ^ved, which niij^lit oiherwise have not only been iuelf lost from
cliorotditU, but might bare also proved a aoua'c of danger to the other
eye. In wounds which implicate the cornea alone, there i^ geiionilly
not .-to much (kuger of sympathetic ophthalmia, although, if they art>
accouifiamed by a coiLHidcrablc prolapse of the iris, atid this ia situated
near Uie jteriphery, it may, by digging upon and iiTitating the ciliary
procesMM, Mt up ttymiHithetic ophtlialiLia. But when tliere has heeti a
penetrating wound of ibc cornea (aucb a& may be produced by n pair of
!ictssoF9), and the iria and Icna bare been aUo injured, there ia always
8ome ridk. The diaca»e way, moreover* be likewL»e produced by severe
contuiiioiiri of the eye.
2. Foreign bodieit lodged within the eye, arc a most frequent cauac.
Amoii;;!^l dieac wc tnust especially enumerate portions of gun cup ur of
metal, and splinters of glass or stone. They prove a source of constant
irritation t^i the eye, more especially if they are considorablc in sixe,
and differ in their chemical constituents from the structures in which
they are imbedded. Inflammation of the irts and choroid supervenes,
and tlie eye may become gradiuilly atrophied, sbriukiug down to a small
shrivelled stump. Bm even ilicn, all danger to the other eye, if this
lias hitherto escapeil, is by no means passed, for such stumps arc a souive
of constant risk, as long as tlioy remain pitirifui to the tvufh, and show
signs of irritability. Years may elapse after the injury, and the patient
have bjiig since forgotten his surgeon's admonidon as to the danger to
the other eye, when suddenly the latter Iwcomes sympathetically in-
ttanie«l. and, in spile of all our efl'orts, perhaps destroyed. [The expla-
tuiliun of an outbreak of sympailictic trouble in an eye, occurring many
years after an injury to the other eye, is no doubt to be found in a change,
of ptisttiou uf chalky ur ossilied e.\udatious which have irritated parts of
the uveal tract hitherti) umlisturbcd and iio.ssihly normal. Tliis may be
occasioned by a fall or a blow on tlic beau, even without direct injury of
tlie dhteased eye. Ur even without this injury by coutre-coup, a slight
hemorrhage from some atrophic vessel may light up a fre^h cyclitis and
lead to sympatlietic irritation.— B.] The longest time which I have
knoirn to cla|isc between the injurv of one eye aitd sympathetic iuRam.
nadon in the other is :nj years, which occurred in the following case :'
> " Lancet," l>pcvmber 18, 18M.
17
S58
mSBASUS OF TUB IRIA.
J. K., let. 42, an ironfoiinrter, came under mv care nt the Rnval London
Oplithalmic ITospital, on March 2, lftt;9. Ho Imd lost tlic feft eve 2t>
years agu Uirou>;h an iiijur}' from a [lieue of meUil: the glnbs had
ahnidk to | of it) normal size, and was very painftil on pressupc. The
rifilit eye remained perfectly well after tlie accident until IhllW, when ic
was attacked with iritii^, for wliicli an iridectomy was performed at that
time ; it bein-;. liowcvcr, deemed unadvisalile tw do aiiytliiti;; to the Irft
eye. Since tlio iridectomy in IrtdU, lie had been aWe to follow his occu-
paUon tip to Cliriatmnj), 1M8K, when this eye iij^ain hecnmo inflnmed, and
ltd Bijiht failed more and more. On March ti, iSliO, it presented the
following symptoms : The eye-tension is normiil, tho field of vision com-
plete, hut the sight so much iinpuired that he cannot decipher letters of
Jager 2P, l)ut oidy see their black outline. The cornea is somevrhat
hazy, the iris inflamed, the pupil clouded, and with the ophthnlmoscope
bftrdiv any reflex can be obtained from the fuudua. No relief being
experienced from Uie application of atropine and warm foiiteritatioiu, I
nrj;cntly advisod the removal of the left eyeball, to which the pfliient
*uhniiticd on March H*. A piece of metal wiia fouuJ in it. firmly im-
bc<Ided in a mass of exiidation matter (on tlic inner side of the stdorotic),
in the centre of a firm fibrous cord, which appeared to be the shnuiVen
and disorganized retina. March '2'^. The rizbt eye has improved ao
much since the extirpation of the other, four days ago, that the patient
is now able to i-ead wordti of .Ia;er 10. The inflammatory symptoms
hare greatly subsided ; the conica and pupil are clearer; there is still,
however, but liitle reflex from the fundus. March 30. He now rcadi
words of .Jii;^er ID. The refracting media are nmcli clearer aud the onl-
line of the optic disk can be indistinctly seen wiili tlie ophthalmoscope,
llie patient ceased to attend the liatpital after this date, and returned to
Yorkshire. He writtii, however, in tlie middle of October, tJiat the rij^ii
eye ia strong and well, and its sight so much improved, that he i» able
to follow his employment (jupci-intendcnt of an iron forj^e). Mr. Lawsoii,
in his valuablo work on " Injuries of the Kye," also narrotes two inter,
eating cases in which sympnthctic rnlschicf did not follow for many year<
after an iiyury from a foreign body.
3. Sympathetic ophthalmia may also be caused by internal inflamma-
tions of the eye, more especially if Uiey are accomjtttnied by hemorrhagic
effusions, either conoid era bio in ijiiantity, or of frwiuetit recurrence, t<v
tfcther with rapid fluctuation!) in the intra-ocular tension. Also if a bony
deposit in the choroid has occurred, and the eye remains irritable to tke
touch. Indeed tlie continnance of sensibility in the region of the ciliary
body in c«^e» of irido-clioroiditis, or in eyes which have undergone atrO'
phy after internal inflnmmation, iit one of the moftt dangerous ^ymptomA,
an such eyes are ciiremcly prone to set up sympiithetic ophthalmia.
The latter may also arise in cujtea of sponlaneoua detachmt-nt of the
retina ; diilocstion, or rcclinaiion of the lens ; intr«-ocular tumors, if
oecoiidary irido-cyclitia supervenes : intra-ocular cyeticerci ; also it ppo-
lapsc of the iris causing great traction on the ciliary body, and conse-
quently irritation of the ciliary nerves. Hence some sur:geonfl aerer
» p. 321-323.
feYMPATHBTIf^ OPHTHALMIA.
259
SBrform iridodeais, for fear of setting up cyditia, and thus perhaps in-
ucing avmpathetir ophtlinlmift. If any of the»o causes set np plastic
^CyclitiH they may ^uo rise to syinj»atliettL' o|iIitli!iliiii».' IiKlced Moor«u
30 far aa to iM-lieve " timt evi'ry inflHmiii;vtioii in tlie coiitiif of tlio
uveal tract, quite apnrt from the primiiry cause of lie origin, is cnpahlo
of setting up sympathetic ilistiirhances if it manifests itself as a cyclitia
from the outset, or as soon as It, in the course of time, assumes this cha-
.tacter.'"* [It is necccsary here to indicate the importance of recogniz-
tig the influence of traction upon tlio ciliary region in prmjucing irrita-
tion. Tlji» may cme friim |>rola|>s« anil encapeiilatioii of the iris or
ciliary proce^scK in a wonnil ; or from a contract:n|i; cicatrix in the ciliary
region; or from contmctinf; inflammatory exudations hehtnd the iris and
on the ciliary processes, which exert a very 'langeroiw traction on thfl
ciliarv nervert. This traction may go so far aei to cauae detachment of
the ciliary body from the sclera. Of course, the more ciliary nerves
are invoked in ihe'proccds, the greater are the chances of irritation.— H.l
It is a very interesting and important fact that Iwanofl",* Ilirwhberg,^
etc.. found, on examination of some eyes which iia*l been excised for Bet-
ting up sympathetic ophthalmia, that the ciHarv IkmIv had not only under-
gone inflammation, but had hecome detached from the sclerotic, thus
causinj: great stretching and irritation of tlie ciliary nerves, and forming
the stanin;! point of the sympathetic nft'ertion of the other i-ye.
Mooreii'.iUo mentions a very interesting case in which tlic sympathetic
I'plithahnia was apparently produced hy the contusion of the optic nerve
in dividing it with the »ci«sors in excision nf the eye.
It was formerly generally supposed that sympathetic ophthalmia was
ftropagnted from the injured eye to its fellow tnrougli the optic nerves,
ly way of the optic commissure. But thii view hax Wen long abatidoned
as untenable, for cases of sympathetic nphthalitiia liavc occurred in eT«s
in which the optic nerves were not only completely atrophied, hut had
even tuidergone extensive chalky degeneration. It is now generally
hehl that tlie symjathy is propagated hy the ciliary ncHi'Cs, and this
view certainly receives tho strongest support from many clinical facts.
Thus we not unfreijucntly meet with eases, aa has been especially i>ointcd
out hy Koirman and Von (Iraefe, in wliich the starting point of the sym-
pathetic irritation or inllammation in the second eye occurs at a 9{>ot of
the ciliary region which eorreH)>on(U »yminetrically to that at which the
injured eye was hurt, or at which the ciliary region still retains its sen-
sibility to the touch. Moreover, as Von (.Jraefe strongly insists, tho
danger of the sympathetic ophthalmia shouM never he considered aa
passed, as long as the ciliary region of the injured eye, or its stump,
reroains sensitive to tlie touch, more especially if it is accompanied by
diminished tension, for it is then a symptom of plastic cyelitis.
[Our knowlodge of the nature and etiology of sympathetic ophthalmia
> V'lH'- ml«n T>r. [iJiqtirnr'o hmehiire on " Lm AWt^ctiona ivmpaihfiiUM do I'tBil."
fi«illirt« ml PiU. I'ArU, 1809.
* Op cit.. p. 5S.
* "Mnor^ti'H !^7ni)>alli)Mh»nMlcli'Biaran|^a," p. 16t.
* "KI. M<.n»Ul.1.," Oct. IPCS. |». 297-
* *'Opl)thalmUlrt«chG Bmbsclunngfn," f. I<t0.
260
DISEA588 OP THE IRT9.
hu of late rears become more miDutc and aatUfftctorr throii;;h the
lahore of Meyer, All. Wi-cktT. and ollicrs, but Mi>cciall/ Ibrougli the
masterly nioiiti^a]tli of Maiubtier. ciitilU-iJ •' I>io Sviniatliisclieii Aa-
genleiilen.'* 'Phe marked clmracteriatic of nympathctic irido cyclo-cho-
roiditia is the tcndene-y lo tlie rapid development of thick mcmbrBiious
exiidalioiie upon tbe |K)»terior surface of tlie iris and tbe ciliary pro-
cesMW, wliicb rapidly become or^atuKcd and forn) deit^c and brond adbe-
aiona of the iri« and ciliary prneefuca to the lens capatile. Complete
posterior eynecliiw develop very rapidly after the oalWak of tlio dis-
ease, and the iris bnlgeit at its pcnphery towanlH tbo cornea, while the
pupillary marpn sectnn retrncted. After a ahort period the lena, pushed
forward njrain. become!* adiierent more or less completely In the irii. ami,
ii-is and leiitu hiOng piislicd forwards tcvranltt tbe coniea. ttie anterior
eliamber is really sballovfeet at it* centre, while the peripheral partA.
owing to the retraction of tlie infiammatory exudation upon the ciliary
proceases, arc deeper. The pupil la usually com]>leteIy blocked by an
exudation. At this tln-^v of the procese the toiiMon, whivb nt tirst wa«
ralfcil, is very mueh dtminl^ilied, and the diAcaite may end in twr> ways.
Either progresnive plithisis >iulbi, Mcondary cataract with crctaeeoua
deposits LD the lens and capsule, and even ossiticstion of the choroid uiay
ensue ; or a condition of complete quiescence with even some Alight im-
provement in vision throufih gaping of the pupillary membrane raay
result. This latter termination is, liowever, uncommon, mtd may even
be succeeded by total loss of sight. One fact, which should W rcmem-
bere^l, it* tliat a i*erou« cycHtis of idio|>»iliii; origin aceom|>aiiying a ^Uu•
comalous process with dcvelopracrit of a ciliary staphyloma, scarcely
ever leads to sympathetic irritation; owing, as WecKcr tJunks, to de*
atniction of the ciliary nerven hy pressure. (Graefe und Saeiiiisch's
Ildh. der .\upcnheilk., iv., pp. nih-ii'Ai).)
As regards the method of propagation of irritation from the injured
eye to the sound eye, there is no maimer of doubt thai ibie is done
through the milium of the ciliary ner^-es. Many examinations have
been made by numerous observers of eyes enucleated for symf^tlictic
irritation or inflammation in the fellow eye, in which the ciliary nerves
have shown signs of inflammation. Thcv have been fotmd torn and com-
pressed ; tliey have been found embedded in the traumatic cicatrix ;
they have been found inflamed, atrophied, and the seat of fatty degener-
ation ; bchwann'it »hvatli has bven found thickened for a long difftaoce
from the seat of injury (Alt, I. u., p. 471). These changes are. however,
by no meatM always met with, for in Alt's statistics of 110 ca.^es, altera^
tiona of the ciliary nerves were found in hut 1H| per cent. Tlic old
view that the optic ncn'o was the channel of propagation has been again
advanced and defended hy Alt, as more probable than that by the ciliary
nerves; but for this idea to become a working liypttthesi^, we must
have more observations. His modified statement, that the entire uervoiw
apparatus of the eye takes part in the transmission of the irritation,
may perhaps be accepted until our knowledge hrcomea more nlit*
lactory.
'Vh\s question of the nerve tranamisaion of sympathetic ophthalmia is
one of profound interest. Many curious phenomena have been noticed
8YUPATHBTIC OfllTnALMIA.
S6L
in eftsea of injurj of the ciliary ro;;ion, with or without Uie presence of »
for«i;;o IhhIj,'. Olj^tiiiatv jitri-orbital jiaiiis, shooting upward aloii-^ the
(Mjurito and distritnitioii of the *m|ira-orKitaI nprve.are not uiKwniuioDly
obticrved ^vea in pmiKninccil phtliisiii liulbi. In this latter class of ca««4
llic shnmkon eydmll is iisuallj,' very sensitive, thouj*h iJiis is not always
so. TliC |«'riH>rKiu»l pain on the injnreil side nuiy li« acvonij^aniod by
the s:iuie puiu oD the otiier side, which of counie iti a prodromal symp*
torn. — B.]
Again, when fnippuration of the eyeball occurs, and the ciHary nervei
are destroyed by it. tlicre is no tendency to itytnpatlietic ophthalmia. It
is a widl-kiiown faet that the lattrr is never set up hy eyes lo«t from
ifenoral suppuration (panophthalmitis), as, for instance, after operations.
[According to n'<.'ent stati.-tticj, i)uruletit panophthalmitis, either tnLU-
mntic or uponuneona, may and does give riae to .tympathetic affections
of the other eye. ( Alt, f. c, p. 47;J.)~B.]
The profftu'gia of sympathetic ophthalmia is most unfavorable, if the
di»ca«e ba« once fairly broken out. In the atage of iympathelio irritar
Uon, the removal of the injnro'l eye arrcats the proj^ress; but it in ijiiite
dilfercot if the infiammation ha^ alrcndy HCt in, more especially if it
assumes thu character of plastic irido-cyclitis. For then, even the imme-
diaie enneloation of the other eye (renenilly fails to have any, or any
but a temporary beneficial effect. For a few days or weeks the iiiHam-
oiation appears tn be diminished, but then it breuka out again witlt all
its former se^'erity. The serous sympatiietlc iritis, being more benijcn
in character and more amenable to treiitutent, affordif a mora favorable
prognosis.
Sym[Mitlietic ophthalmia is more prone to attack youthful individaals
tli&D middle-a>;cd or elderly pcraons, Ita course also appeani to be
more rapid in the yonnj;. It generally occurs within a few weeks of tlic
it\|ury, but a long {teriod, even many ycar^, may olape before it is
excited.
Trftim»nt. — With rejjard to the general treatment of avmpathetic
ophthalmia, I must strongly insist upon the necessity of complcto rest of
the eye for a pndoiiged periotl, and this is to be continued for itotne
length of ttiuc after the eye appeani to have recovered from the inflam-
matory attack. Otherwise, thero ia the grcRtent risk of K recurrence,
which may prove most dangeroiw and intractable. Whilst the eye re-
nuiina irritable, the pittient should Iw confined to a darkened room, and
if he \\i\A to ^0 into tlie open air, the eye ahouUl either be protected by
ft bati'lage, or by a pair of tlark-blue eye protectori, or tlie wire goggles.
[In casrs of symjmtlictie intlammation in which the chronioiiy and alow*
nem of the proceM is marked, and especlalty in children, the potienta cannot
W kept confined to a dark room. Tlie treatment succeeja better if tlie
patient* are sent out regularly twice a day in the ojien air. Vey often
a swcnt-batli becomes ahsolntely nece»«ary in these cases. — !>,] In
order Ut allay the irritability of the eye, ))oppy or belladoima fomenta-
tions may be applied, ikSi also a solution of atropine (varying from ij to
iv grains to the niitict* of water), which should be dropped int*> the eye
several times a day. At the very outlet of the disease, we should en-
deavor to gain, ir possible, « wide dilatotton of tlio pupil, and bencs
262 DJ
OF TUB IRIS, CILIARY BODY, AND OHOROID.
applj it more frei|ueDtly and iu a atron;; ttolutton; l>ut lu baa already
bet'ii stated abovf, tli« pupil is generally very imperfectly acted ujwii by
atropine, and at a later stage, tbe adlteaiona lo the capsule are so firna
and extensive as completely to resist its action.
The diet sliould be mitritioiis and f^enorouB, rooro especially if the
patient ia fceUo nml ill nourisliud. Touics, tnore particularly <(uiniiu»
and preparations of steel, should aUo be administered.
^^e have luyv to cousider, in the 6rst place, whether we are enabled
by any o|>erative interference to prevent the occurrence of aympatbetJc
ophthalmia, and, secondly, whether wc can aiTest its progress when it
has once broken out.
With regard to the first point, I may state that, na far as I am avrarc,
no instance has beeu recorded in which syiojiallietic ophtlmlmia ever
attacked an eye after the iujuriiil eye had been removed, if at the lime
the other was still ijuite unaffccte«l. [This -ttaloniiMit is proved errotie.
oiia in the light of recent observationa (see below). — IJ.] Tliii being *o,
there cannot be the slightest doubt aa to the imperative adviiuibtlity of
the immciliatc removal of an eye which has been so greatly injured as to
have quite lost its sight, or at all events to leave no hope of any restora-
tion of a useful degree of vision. This is still more the case, if the
injury has been of a kind which is [irone to be foll<i«cd by sympathetic
ophtbalmift. For we have no guarantee that we tthall liave time to chock
the sympathetic inflammation, if it has once broken out, even by a apcedj
removal of the injured eye. For altboi^b symptoms of syiujtalhetic
irritation not unfretiuontly nijher in the inttannnation, and tlie latter may
he preventwd by the excision of the injured eye at this premonitory
Htagc,yct this is not always the case. The inHanunatiou may occur
vithout any premonitory symptoms, and advance so rapidly that in tJiO
course of a few days the integrity of the eye may he greatly, and per-
haps permanently, impaired. Thus, a caac ia narrated by Mnatd, in
■which within four days (and without any premonitory symptom*) an cyo
became so a(fecte{l hy sympathetic irido-cyulitis, that there was nearly a
complete posterior synechia, and the aight had i*unk to 5^5. In spite of
the itnmcdiale removal of thi- injured eye, and of every endeavor to
improve the condition of the other by iridectomy, and suhsuiinently by a
second iridectomy with removal of tHo lena, tlie cyo Ijecame atruphiedT
and only retained |>erccption of light. Such a case should tram us of
the danger of procnisti nation in excision of the blind injured eye, in the
hope that there will always be time enough for tUU when syrojitoms of
sympathetic irritation manifest themselves or during tlio earliest stage of
gympathetic inflammation, i-or the former may never occur» and the
latter may be so rapid in its development and course, that great and
irromedianlc mischief may be done before wo can enucleate the other
eye. Moreover, tliere ia another )K)int which weighs licavily in tfaa
scale amongst peraoiLs whose livelihood depends upon their work, aivl
that is tbo long time which is lost by them during tht^ treatment of the
injured eye. For it may remain painful and irriUible for many months,
and thus render the patient quite unfit to uae the sound eye. It may be
laid down as a fumlumontal rule, that as long as the injured eye remains
paiuful to the touch it is always a source of dauger, aul may at any
BYMPATHBTIC OPHtBALMIA,
ukfiment «ct up sympathetic opliUialmia. Tt shouM coii8ei|uenUir he re-
muvt'il if its fti^lit is lost, or greatly and ii-reaicdiably imiiairvd, this
being piirlicuUHy iiidicnted if n foreign body remaiit^ n-iihin the eye.
For ilitift only cati we iusure the patient against the dangero of ayuopa-
tbctic inllaiumAtion. The <iuciitioii as to whether the injured eye should
he n'niov(.'d if it itlill retuiuti some degree of vision 'us of course much
more diHiciitt aii<i einbari'as.tin;;. In deciding ulhiu thia point, we must
be chieBy guided by the nature and extent of the injury. Thu«, if it
M a jimall iucised wound of the cornea or sclerotic, and the iris, lena, and
vitreous humor have e3<;aped any severe injury, we may by careful and
judicious treutiuent avoid the danger of ByuipaUietic inflammation, and
ultiuMtcly, (wrhufw, rei^tore excellent vt^iioti. But if the wound h very
exuniiive, and impticatcti the ciliary region nttd aclvrotic, if the lens has
been lost or i» injurvd, u cousiderable amount of vitreous liu« escaped,
or intni<ucular hemorrhage has occurred, and if, conscipiently, the in-
juries are «o great that but very little if any eight can possibly be saved,
it is umcit better lo rcuiove the eye at onee, even altliough some degree
of vision may still exist. Still more imperative is iiuch a courrie, if
these extensive bijuries are due to a foreign body which lias become
luiiged in the eye and cannot be removed by operation, for although rare
iiuuincea occur in which fircign bodies remain encapaulated and i)uie«>
cent within the eve. such cases foim. unfortunately, the great exception.
1 would es)MHrialfy urge the necessity for tlie oiwration if the patient
resides at a distance from medical .ii-I, «o that a careful watch cannot bo
kept over the eye, and the tirdt symptoms of sympathetic irriiacion or
iuriammation be at once detected. The (piestion in all such ca«08 is,
whether it is not better to suxlain a small lo^.4 than to run the risk of a
Tery great danger. I, however, fully feci and admit the heavy respon-
sibility wliieh rests upon the surgeon who shall advise the removal of an
eye which stilt possewea pome sight, and when, as yet, no symptoms of
syiniatliecic disease have appeared. \\"e can in such cases only care-
fully and conscientiously weigh the differeut bearings of the case, and
idaee them clearly and forcibly before the patient and bis friends, and
eave the tlecislon in their bauds. I have entered wimewhat at length upon
this jiart of the suhjuci, because 1 feel it to l>o of great imjiorLnnco (o all
medical men, and one uftun which they shoubl hold strong and decided
views. For we never know at what moment we may not bo called u}ioa
to decide a (piestion of this kind, and what repmaches wi' may not have
to make ourselves if by our procrastination and indecision the second
eye is lost from sympathetic ophthalmia.
We must now pa^s on to the eonsideration of thct|Ucit)on.BSto whether
we have auy p<>wer of cheeking (lie progress uf sympathetic inflaminatioQ
if it liaa once broken out. If the sight of the injured eye is lost, itsliould
bi^ at oufe removed, for even although this proceeding mfty not always
stop the progress of the sym[Kithetic disease, but only perhaps arrest it
for a time, it will probably at least cxort a favorable influence upon it«
course, from the removal of the primary source of irritation. But it wUl
l»e different if some de:;ree of sight still lingers in the injured eye, more
e8iK'ci:tl!y if the 8ymi»atbotic iuflammation has already produced exten*
sive itijury, for tlteu it must be borne in mind tliat in uomc similar casos
361
DISBASBS OP THB IRIS.
tlic injured pye ercntnally provod of the most twe to the (uitienU h«
ha%'ing more fsij;ht in it than in Win other. It appeiirs certain, from the
Cic{>erience of nil authorittet^ ti|>nn the nulijoct of sympnthetic ophthattniA
(umongst wliom I would especially enumerate Mackeiwie, Bowman, Crit-
chott, txraefe, Lnwson. Dondere, Pajjcnatechcr) that any operative inter-
ference upon the second eye duriri{» the progrcM of the kviii pathetic in-
flammation is not only not lieiH-'ficial, l»ut even docs positive harm, iu
increasing the inflammatory proliferation of the exudation masses behiml
the iris, and thus hastening instead of anre^tin;; the progress of the dis-
ease. Von (Jraefe, however, mentions a case, in which the performance
of an early iridectomy exerted a beneficial influence upon the course of
the inflnmmntinn. Ue employed his narrow cataract knife, and nude
the incision very peripheral (juat, in fact, as for the operation for cata-
ract), and thus succeeded in selling and excising a portion of iris. He,
however, stmnjily Rdvises that the iridcetoiuy sTioufd be made as early
as pofHible, as Koon, in fact, as the ominous character of the disease mani*
fetits itself. Hut. when tim disease has become fully esta>dishei|, the
pupil and posterior unrface of the iria being tied down to the capsule of
the len^ by firm masses of exudation, and the tissue of the iris showj
symptoms of flisoi"{»aTiization, no operation should bo performed. It is
then far wiser to wait until the active inflammatory symptoms have suK
sided. Yon (Iraefe thinks that we should wait until the teinlemess of
the ciliary region has diminished, the development of the lar;j;e venoiu
trunks in the disnrj^anizcd iris he<?ome arrested or rctroj^nMlin*. the ex-
udations in the pupil have changed their yellow color for a more bluish-
gray tint, the iutra-ocular tension (which is jrenerally distinctly dimiii.
lehed) shows no fluctuations, and, finally, until at least three or four
months have elspsed since the outbreak of the disease. In op]tosition to
this, it might be urged that If the dls>ease is thus allowed to run iti4 course
uncheoko'i, the eye niij^ht become so atrophied, and its functions f>o much
impaired, as to he Wyond alt hope of improvement. Rut, in such niali;;.
nant cases, any operative ioterforence only acc«l<*rates this result, aud
then, n^tin, these are, according to Von Qraefo, ifuite exceptional cases,
for ^^ener^Hy the atrophy of the eyeball bocomes arrested at a c<»rtaiii
point, not reaching perhaps a hi<;h de<^e, and the quantitative iwrcep.
ti " t remains good. Under enoh circumatanoes, much advantage
u ^ ' y waiting as long ns possible with the operation, because, as
he states, " the vascularization and irritability of the esudalinn- masses
4imiiush when the acme of the disease is pa«ed, and besides, the exten-
•ire opemtivc interferences which will have to be undertaken will be
t«ome mnch better: whilst at an earlier period, hemorrhagic efl'usions
tax the delicate and newly ileveloped vessels, »nd the proliferation of
neoplastic formations again destroy the result of die operation.
>rer the whole tendency of the diffusion of the traumatic irritadou
he choroidal tract diminishes with the pmlonged existence of the
• ; and not unrrequenily the tension of the eyeball becomes in-
4intion which should be performed in such a case is th« removal
'"i. tO.,"xit. 2, 165.
I
4
frMFATIlETIC OPHTUALHtA,
2^5
of the lens, toi^ther with an extensive iridcctoni^ and a dilncemtion of
the nmsBCs of exudation. This may be [lerfonned acconliutt to Von
Oraoft^'f" method, dc^oriWd at pa;'c 250, or m that practised hy Bowman.
The modo of performing the opcrnlion of exoi*ion of the eveball is
dMcrihed in the chapter on " Diseaaes of the Orhit."
I havi? already stated that the sympathetic irritation is evidently pro-
pagated by the ciliary nerves, and this fact has led Von <Jra«fe to sug-
(tcst the d!vi«on of these nerves at the point where the ciliary rc;5ion of
the injured eye remains sensitive to the touch. Dr. Meyer,' of Paris,
has performed thin operation with marked succc<i;3 in sevcml uaiics of
ejmpathetie neurosis. After having mi^d and incited the conjutvctival
and tuhcoDJunctival tissue over tlie painful portion of the ciliary region,
joflt fts in me operation for strabismus, he introduces a squint hook nn-
demeath the tendon of the nearest rectus muscle, so that the eye maj
he well steadied. He then ohiiquetv piiticturea the sclerotic at the pain-
ful point of the ciliary re;pon with Von (Iraefe's narrow cataract Itriife,
ill such a manner that the wound lies parallel to the edge of the cornea.
The vitreous humor is at once exposed hy the incision. The book being
carefully removed the conjunctival wound is to he closed by a suture,
the sclerotic incision healing in the course of a few days. [But little re-
action follows the operation, and the only after-treatment required is rest,
the hypodermic injection of morphia into the temporal region, and, wlten
there are pninand restlessness, the application of a pressure bandnge.
This operation has been performed by IVof. Secondi, of (jcnoa. and
bjT M<** •'■ '^*- I'aureiice,' of Loodou, aud with a saUsfuctory result ia each
IB— H.]
[As it has lieen proven that purulent i^anopbthalmitiM may give ri^e to
sympathetic intlanmmtion in the otiicr eye, the plan of dc.->troying the
injured eye by passing a acton through it, as a prophylactic measure,
Diufll of course lie abandoned. The experience of modern ophthalmDiogy
would seem to limit the performance of enucleation to Uie following
eaies : 1 . When pmdromnl symptoms of sympathetic irritation have ap-
peared ill the sound eye. 2. When the injured or inflamed eve is the
sent of violent pain, which cannot ho allayed, and the vision is lost or
nearly so. 3. When there is a foreign body in the eye, and the eye is
sensitive and the seat of frciiuent exacerbations of inHnmnialion, jiro-
vidcd the foreign body cannot be removed. (Sec Chapter on Diaoucs
of the Vitreous.)
There ia one class of cases in which the reaponsihiljty restins; upon the
aurgvon is very grave. Is an eye to be enucleated, which has slrendy
Mtued sympathetic iiiHammation, but which retains a greater or more
Harfiil degree of vision than the sympathetically affected eye ? In otlier
words, are we in sucb a case to enucleate a stilt partially useful eye in
tlie hopes nf putting a ntop to an inHammntion which almost invariably
rest4l« all treatment V The enucleation of the injured eye in such a case
does not exert any good etfect uiwii the other eye, iinIe»H. perhaps, in
cases of severe pain, while some observers have stated ttiat it iocreasea
> "Annsl-ad'OonlliXkiae." S"pt. l^T, p. 139.
[■ " Tha Lucol," 1S68, II. 633 ; also -'Anw. Jaara. of Med. Sol.,'* Jan. ISflfl, p.
271.-11.)
^
DISBAfiBS OF THE tRIS.
dkt STupathetic iuBaaimation. (See Gmofe uiid Saemiscira Hdb. del
AoxRibeilk., iv. p. r>27.)
To sToiil cnuc1«atinf; diicli an eye, arid ut the same time allav irrit
tioa« it bas heen recoiDineiided by Von (fniefe to divide the ciliai
aerrcd near the aeat of injury through the sclera; hut experience hi
•bown tlmt this operation givea no complete security Uf^iiiiuit the pnipn-
fgation of the irritation. In crn^eit where it rcault^t favrtmlity, this U
proluthly due to a diminution of tlie inlniucular ttinsion hy the M.'lerut<mjy.
[DudU'U pnijK)»c<l to cut thenc nervcd externally to the eyeball, by first
dividing; cither the external or internal rectus muscle, and tlien with
pair of sciaiora curved on the Bat and kept close to the eyeball, anc
puMd h:Lckwanl beneath the conjunctiva until the optic nerve i« reached,
snip the ciliary nerves as far round as can lie rencheil withuut injuring
Ihe optic nerve. Thus the exii^tin;; amount of ai;,;hi in undisturbed. i
The fipcration known aa optico -ciliary neurotomy hiu been proposed
recently as a 6ul>«tilule for euueluatiun, in the claos of caties in wliicb
the latter u|>enitioii itt indicated, hut tn whicli it is de.'^ircd to avoid the
deformity of an empty orbit, or the annoyance of an artificial eye. The
u|H>rution U pcrfonnud very much a« Snellen's, except that when the
entrance of the optic nerve is reached, the blinles of the itcia^or^ arc
opened widely and the optic nerve divided, &i well as tlie ciliary nerves
An tlioy enter the sclera near the posterior [lole of the eye. All tba^
ciliary m^rve-t arc tn he divided, and of this the surncon must aiwui
himaetf by dislocaliii;; the eye for«ar<l and inward. The reiiorts nf th«]
results of this opanition, both as a prophylactic a^^ninst sympjithetic ii
flnmmation. and as a means of tiTn-llinj; pain in the injured eye, are very
contradictory. It haa one great diBadvantage : the retro-bulbar heroor-.,
rUa}{c is generally profuse, and may produce such a degree of exopi:
thaluuH and such severe pain as to uoceAsitate a subjei|ueut enucleation^
The operation cannot bt? ruj^arded a-* a certain preventive of *ympatheU(
uphthalmia, for lh« ciliary ncrve-^ miy be already in a dtate of irritation
postATior to the eye; a condition of affairs very familiar to all ophtliaU
uiic sur^'ons, as uxistin^ often in the stump after cnncloation. Thi»
irritable condition of the Btuiap necessitatos an exciiion of as long a piece
iw may Ih-> reached, and if the eye were still in place, enncleatiun would
fintt be necessary before the irritable stumj) coul.l be seiiod and excised.
Tho ojK'ration of opticociliary neurotomy has not yet bad a sufficiently
oxt^jurtivo trial to enable us t<i jud;^c of it fairly.
'Hie tenotomy of one of the straij^ht muscles is not a necessary step itfl
Ihe o|ieratton. Th6 optic and ciliary nerves may he divided through a
wound in the conjunctiva between the superior and internal recti mu-ncles
and |<nralh>l t<> the corneal margin, by means of a pair of euucleutioD
neiAMtrs with hkti^^ blades.
If mynifNiibotie intlammation has once betjnn, and the question of the
removal of the injured eye has beou deciiU-d, il retnaiiut to determine
what are the means at our ooiumand for allaying tlie inHnmmation iu the
loooud eye. These are unfortunately very few. Iu addition to the
(Wnpieut steady and Wng-oon tinned use of atropia, hot applications are
aUaypt agreeable and often beneticiaL Leeclic* or Ileurtoloup's appa-
ratus, applied to the temple every second or third day, are very oftei '
SYMPATHETIC OPUTUALHIA. 2A7
useful. Moat observers recommend strongly a thorough course of mer-
curial treatment, pushed to rapid salivadon, with frequent recurrence to
the use of the drug. In some cases this no douht does good, but in
man; cases exerts no appreciable beneficial effect upon the disease, and
in some instances does positive harm. No operation should under any
circumstances be done during the height of the inflammation, for it would
inevitably increase the trouble. After months, or perhaps years, an
operation may be done for artificial pupil, provided the quantitative per-
ception of light is good, and the globe not markedly atrophied. The
operation should combine the extraction of the lens with the removal of
a broad piece of iris, membramform exudation, and lens-capsule. If this
space close again by exudation, no attempt should again be male until
the eye is perfectly quiet, and then an iridotomy may be attempted.
(Mauthner's Die Sympathischen Augenleideo, 1878 and 1879.
Oraefe und Saemisch's Ildb. der Augenheilkunde, iv. pp. 520-o<^0.
Carter's Treatise on Diseases of the Kve, 187t). Nettleahip's Guide to
Diseases of the Eye, 1880.)— B.]
HAPTKR IV.
DISEASES
OF THE CILTARY
SCLEROTIC.
BODY AND
INFLAMMATION OF THE CILIARY BODY (CYCLITIS), ETC.
[TuE connection between the ciliary body antl sclera is very intimate,
80 that iimriy of tlie va.tciilar symptoms accomprmyiiig cycUti* are mani-
fested in tlic sclera and episcleral ti.'Mue. Many of tJie procensce in tJie
ciliary region tend to spread in all directions, not only in ihc loose stroma
of tlie uvcjil triict, but also in the dense structure of tbe sclera. — B.]
The congestion and liypenemia of tbe ciliary body which are met with
in eases of iritis accompanied by extensive posterior eyncchitc, noon ^ve
rise to cyctitis, tbe inflammation but too fre«[iicntly cxtcn(iin<; to tbe clio-
roid. Ag»iri, the rever^v may obtuin. the inllacumatJon miiy cuintuence
in tlie choroid, and extend thence to the ciliary hody, and ])«Hiapi to the
in*. But idiopattiic cyctitia may aUo be met with, more edpeotally aA«r
injuries to the ciliary region, such as contusions, incised or puncttired
■wounds, or the lodgment in it of a foreign body. The presence of
cyclitis is in such cases recognized by the fact that, to>;ether witli lh«
presence of photophobia, lacbrymation, and very nmrked Bubconjunctirol
injection in the form of a bright zone of vessels round tbe conwa, there
ia acute, often indeed tnt«iutc |iain, on pressure of the ciliary region,
great ciliary neuniljpa, and perhaps hypopyon. [Throe formi of cycliti<
may be recognized, the y'/*i*/i>, ttie rvrmt*, and tbe^Mnt^enf. The first
form \\as liofn i^omewhat uxhnuslively treated in the chapter on Symp^
thetic Ophthalmia, and, though occurring spontaneously, U not ootatnoQ
as A primnry inHammntion unless from injury of the ciliary body. — B.]
SerouM tyrtitin often supervenes in the course of serous iritJS, more
e«t|>ecialty if the latter is severe in character, and baa been negligeallf
or injudicioui«1y treated with ascringent or caustic cnllyria. Tbe coeiist-
«nce of serous cyclitis must be siisf»cotcd, if, together with the symptom'*
of serous iritis, there is acute pain when tlie ciliary repou is prcMe4|
witli the end of a probe or a curette. This tendoniCHS i« very fre'iiieniljr
lutuated at the upper or inner portion of tlic ciliary region, but wlier*
cyclitis is suspecte<l it is always best to teat the sensibility of the whole
ciliary body. Also, tf tbe tension of the eyeball la increased, accom-
panicri by uilatatiou of tbe pu[)il and shallowness of the anterior chaniKer ;
and if the vitreous becomes diffusely cloiideii, having also large fijted or
fl>»attng opacities suspended in it. The vein* of tbe iris are likewise
often ciil&tad and tortuous. Another rory important symptom is the
implaumateoh or tbb cJLCAitr boi»y.
209
Ktrtction of the cilianr margin of tlie iris, whici) i« due to it^ being
^lueil at tlii« piiint to the uiliary bj an efliision of l^vmph. Tim retnio-
lioti causes the anterior oti&mber to be ahnornially deep, anil the liga-
meiitum ftectinatutn to spriuj; forwaril like a ledge, giving the a[>f>earaiice
(aa Mooren apilv aays) as if tlio iris were act like a watt-li-^'lass in a
rim. He has otwen-ed this retraction even in »|uite acute caaea of cy-
cliiii.' There is at the siiiiie time marked and rapid detenuraiion of the
sight, irbich is in part dependent upon the opacity- of the vitreons humor,
and iu part upon the increase of the eye tension, trhich causes compres*
sioD of the retina. The accommoilation and field of vision are al;Hj moru
or less iniiiaii-ed- The supen-enlion of cyditis in cases of serous iritis
IB aiwavs to be reji^rded wiUi apprehension, and the state of the sight,
nf the lit'Id of vision, and of the tension of the eve, should l>e watuhed
wiilt great anxiety, for if the symptoms do not yicM to the usual reme-
dies, but rather increase in seventy, no tiuicsliould be lost in performing
iridectomy. Still graver is the danger in tiurulent i'ifctiti$y which is
chariR-teri/.ed by the following symptoms: There is very marked suh-
eoiijiiiu'Livnl injection, together with great ciliary neuralgia, photophobia,
and lachrymation. The cohir of the iris is aomevrhat changed, and, tf
there is considerable iritis, it may be greatly altered. The veins of the
iris arc dilated. This, indeed, ta a rery pathognomonic symptom of
eyditis, and it is due to the following cause : On account of the inflam*
natory changes in the ciliary body and the rclraceioii of the iris, the
renous effiiix from the iris is more or less impeded, arid the Uood does
not readily How oR' from the veinlets uf the ins, which, therefore, become
dilated and eii;j;orgi-d. The re^on of the ciliary body is very lender to
lb« touch, sometimes the pain thus produced is so exi(Utsitely acute thai
the |>atient shrinks back with apprehension. Pus makes its appearance
in t)ie anterior chamber, and sinks down to the bottom in the form of a
more or less cxieusive bypojjyoo. It should be remembered that an hy-
popyon may be due to a purulent exudation from the ciliary body; for
ai the rim of the anterior chamber the ciliary body is only separated
from the latter by the delicate division of the membrane of Descemet^
u;^ which pus uuiy easily exude into the anterior chamber, and then
me precipitated iu ^le form of hrpupyon. If wu can. therefore,
Mclude the origin of the latter fnim the cornea and iris, wc may bo
certain, even apart from otiicr symptoms, that it is due to cyclitis. The
edge of the pupil is often adherent, its area Uoeked up with a dense
plug nf lymph, and a purulent exudation ts but too fre<)uently poured
out behind the iris, and also j>erhaps into tlie vitreous humor, i'urulent
oyclitts is very apt to occur after injuries to the ciliary body, operationa
for cataract, and as sympathetic ophthalmia ; indeed, it is, as wc hare
aeeu. the form under which the latter most freiiuontly makes its appear-
ance.
[An important exciting cause of idiopathic cyclilis, especially of the
serous form, is found in diseases of the utenia accompanied by disturb-
ance of the menstrual function. Weekcr thinks this is tlie reason why
spoutantious iridocyclitis occurs with so much greater fre<|ueacy among
S^[nthis«tio GosiclttMtorungsn, p. 14.
270
DtSBASES OP THB CILIART BOPT AKD SOLBItOTIO.
iroin«n tban among men. Tlie restoration of the mcn-stniat flow in
these cases exerts a beiieticiiil influence upon the ciliarjr inflainnuition.
Pregnancy often causes relapses in case^ of oM clironic c^rclitia. In
girU from sixteen to twentv years of age a mixed form of aeroug anil
plastic iriiio-cyclitiji or choroiditis ia frc«inently oncoaiitored, almoat con-
stantly associHted with either amcnorrluva or irrcfrular menstruation and
chtoro;«ii(. Tliia form of inRainmaliim i<t also unt an uncommon c<mi)j1i-
cation of the monopaiisc, e*)pecia11y in ihnse women in whom the cUmac*
teric period comes on unusually early. (See Graefe untl Saeinisch'a
Hilb. ilcr Aiigenheilkamle, p. 531.") — B.]
At the commencement, the constant a]>|ilication of hot poppy fomenta-
tions freijucntly nffbpla very marked relief to the severe ciliary nea-
ralgia, and licnsiiiveness of the ciliary region. Mooren strongly recom-
mends the continuous use of warm jioultices, which he applies for 4, tl,
10, or even 24 hours en nuite if there is intense pain; hut great care
most be taken that they are kept nt an equal temperature, and at once
renewed when the patient complains of their being cold. If the pain
coniiniict, and if there in great hyponemia and conge-ntion of the sub-
conjunctival vessels, as also of those of the iris, leeche* nhnuM be
applied, and when tliey have drawn very freely, a strong solution of
atropine should be employed, in order to produce dilatation of the pnpil
as soon as possible. If there is much nocturnal pain, or the patient is
restless, a subcutuneouB injection of raarphia is indicated. If the pain
shows a marked periodic chamcter. full doses of quinine should be
given. When a ci)ii'«idenible exudation of lymph occurx into the anterior
chnmber, or into the vitreous humor, salivation should be induced as
rapidly as possible by the inunction of the mercurial ointment. It moat
be confeased, however, that in spite of every care, we are often quttfi
Tinnble to stay the progre*8 of the disen-se, and prevent the Iom of th«
eye from suppurative irido-cyclitis, terminating in atrophy of the globe.
As any accommodative effort of the healthy eye increases the pain in
the afl*ectod one, it is best to forbid all use of the former, or even to
cover it with a bandage, so an to keep it quite at rest.
An extensive iridectomy, if performed at an early stage of the disease,
often exerts a very beneficial jnfluence upon -ftlie course of the latter.
At a later period it is but too fn-quently followed liy a recurrence of
severe inflammation, with a fresh cxudattnn of pun, wliich completely
blocks up the artificial pupil. Mooren' strongly objects to any operative
interference (especially an iridectomy), for he considers its action not
only of doubtful benetit, but even in some cases very dangerous. Only
in rare instances does he perform paraccntesia. [llie general testiroony
of ophthalmic surgeom is against iridoclomr in this diiieascniwl it might
almost be said, again-^t all of>cnilive irited'ercnce; though favorable K*
suits have been re|K)rted fn)tn a sclerotomy through die sensitiro region;
at least so far aa the pain 19 concerned. No operation in this region
seems lo exert any influence apon the course or duration of the inHan-
mation. — B.]
■ Op. cit. p. St.
INPLAMUATIOK OP TDB CILIARY BODY.
271
Jnjurifg implicating the. filiary region are not only dnngeroiis on
account of Uio inflammatory complications *o which tliey may give rise
in the itijuivd eye, but also on account of the risk of ayiniiotlietic oph-
thalmia, wliich they »re very prone to excite. Simple incised vrouuds
of the Bclerotic at or near tlu* etl^ of tlie comea vrill often rapidl v unite,
on the insertion of a fine suim-c, if they arc not oxtonsive in size, and
hare not jK-iwlnitcil k>n deeply, and tlnu* caused sevt-re injury tu the
ciliary body, lens, etc. Such wounds \i\jiy be produced by fragments of
glacs or steel, or hy a clean citt from a small sharp instrument. In the
former case, a careful examination should always be made as to the
presonce of the foreign body, which may either have fallen out al\er
naving wnundcd the sclerotic, have entered the eyeball, or be lying in
the li|« of the wound, wheiiuc it may l»c readily extmcbcd. A bead of
vitreous ia seen protruding between the lips of tJie little wound, and this
constant oozing greatly diroinishea the intra-ocular tension, the eye being
zenerally extremely wift. But whilst the tuiwion in tijc vitrwjus humor
ui much diniinUhed, that in the anterior chamber may he augmented, the
irid beiiij^ cupped backwards and the depth of the anterior chamber
murh increased, and being occupied by yellowiah senim. This causes a
peculiar and markedly greenish discoloration of tlie iris, more especially
if the latter is normally of a blue or bluish-gray tint. In such coses, by
far tlie best treatment consiftts in bringing the lips of the little scleral
wound together with a fine euture. This is best and mo^L safely done
liy attaehing a curved needle to each end of a very fino silk thread, and
jjartsiugone needle through tlie one edge of the wound fr^m within mit-
irardi', an 1 the other needle through tbo opposite edge also from within
outwards. In this way we shall avoid all danger of injuring the ciliary
body or lens from a sudden Jerk of the point of the needle deeply into
llie eye. 'I'he sntnre generally produces Utile or no irritation, and may
Ite left for eight or ten days, until the wound ia firmly united. As soon
as the oozing of the vitreous la arruAted, the intraocular tension in-
creases, and in tlie course of a day or two it generally reaches the
normal standard. If the depth of the anterior chamber is much in>
creased by the accumulation of aenini, an iridectomy should be made
to re-caiahlish the communication between the anterior and posterior
ebambers.
[In traumatic irido-cyclo- choroiditis from a perforating wonnd, it may
be generally said that if the eye is not lost by suppuration, it will be by
progressive atrophy of the globe. The danger of this resuli is the
greater, the larger the wound has been, the more extensively the ciliary
region has been injured, and the greater the probability of a foreign
body being in the eye. If the wtmnd gapes, the symptoms of cyclitis
develop generally very rapidly: hence wounds in this region parallel
to the corneal margin are much more dangerous than vertical wounds.
The presence of a foreign body in the eye posterior to the lens ia in
almost all cases very difficult to make out. Unfortunately the cases of
such foreign bodies becoming encapsulated arc rare ; and even when
this haa occurred, some aubsequent shock may dislodge the particle from
its resting-place, and a cvclitis or choroiditis is t<et up whicli leadn to
destruction of the eye. 'The main symptoms which lead the surgeon to
M
ST2 DISEASES OF TUB CII.TAR7 bODT AMD BCLB&OTIO.
auapcct tli« pn'iieDce of a foreigu bodj are: Ist* Uie persbtenQv of the
jicrictirrieal injoctlMti bikI of a ruarkcit tctiili'niess on [irett^-ture even wliun
|>litlitsi,i biillii tiiis WjTun; aiitl 2*1, tlic tttcrcase of tciijiou witlt tlie ]tm-
encc of cvclitis, iustvad of a diuinuttoti of tciisiuii as we should uuturullv
expcct. A cun sill era lion of the removal of sucli foreign ho(lic8 bv opt-r*
atioii from the «ve vrill be fouud in the chapter ou the Vitreous Humor.
-B.]
A description of the tumort met with in the ciliary region mill he
found in the article upon '■'■ Tumors of the Choroid."
DISEASES OF THE SCLEROTIC.
1.— EPlSrr.KKITlS AND SCLKRITIS.
[Though L'piscleritis mnj exist alone, yet, if it it) at all chronic, the
superficial laj-ers of the ^tera are a1waj,'s involved, and liciice ttie pro-
ccsa may be termed scleritis. The injected ve^AcU are of three kinds:
first, the long tonuous conjunctival vessels; secondly, the episcleral or
subconjunctival ^eod^U, which arc shorter ; and, thirdly, ihe deep ciliary
resscU, short and straight, and only apj)canng when iris or cornea ara
involved. — B.]
Though not u dangerous afTcction, opiMileritia often pro%'es extreiuvir
troulile^mc on account of the pr>tract«d and ohsttnaie connte which it
runs, and also on account of the tendency to freijnenl recurrence which
It often manifests. It is disiin<!;uidheil hy the Hp|M-arance uf a small
diisky.red, or reddish-yellow clevntion on the »c1cr<itic, in close proximity
to (he in&crlion of one of the recti luuacles, and at a short distance from
the edge of the cornea. It occurs most frci(uently al the temiioral por-
tion of the sclerotic, near tlie insertion of the external rectus muscle.
The appearance of the little mHlulo is generally prece<Ietl and accompa.
ni<'d hy more or les.^ conjunctival and suhoonjiinctival rcilness, more vspo.
ciully of that sei^meut of the eyeball upon which the elevation is situated,
to which, indeed, the vascularity is often confined. 'I1ie subconjunctival
(issue is at this point markedly thickened and swollen, and of a peculiar
ruisty, dark, purplish hue, iu bloodvessels (as well, perhaps, as those of
the conjnnctivn) being here somewhat dilaied, tortuous, and of a dusky
tint, tre'iueiitly the conjunctiva is hardly at all aOected, the vascularity
and ttwelliii;; licin>; confined to tlie auWunjunctlvai ti<wuo and (he sup»r>
ficial layers ot the sclerotic. 'Iliorc is sometimes considcraUe photopho-
bia. UvhryiiMtioiuand a certain degree of ciliary neuralgia, but iu mauT
r-asex ihrse Bympu>nia arc almost entirely absent, and llie patient eijwn-
;«» only slight discomfort, or a feeling of dull, heavy p.iin in andarounl.
«ye. The affected point of the sclerotic may also he more or !«■'
«iUve ui (he touch. Ac the outset, the affection might be mistaken
jiMyclvnutur or pustular opiitbalmia, but the little nodule soon in-
ja in sise, and nsaumcs a dusky, reddish-brown ap|icarancc, having
id boso, and showing no tendency to ulcerate or suppurate. Gradu*
I becomes more pale, diminishes in sisc, and slowly disappears,
t bas existed perhaps for many months. Or it may recur a^in
DISIA9B8 OF THB SOLSaOTTC.
»
and i^in, either nt tlie Mime spot, or at some other potoi of the eyeball,
m that the ilisease nuiy travel rouwl Ui« coniea fn>ui poitit to puint.
[There is an acute fomi which iiiii^t tie diotin^iiinheu from tho chronic^
thoufjh it tend« to run into tlic* latter, aiiJ i$ wry rftre.
The coiuie>]U<!uce8 of a ohronic ^uleritis are iinfiortant. niid ^ometime-i
(lba«troua. 'llie corneal complication altnoi^t alwavs existing iti the I'ortn
of aa iuQItraiion, antl very rarely tendioj; to the developmeiu of ulcera-
tion, in hy no mcanit a constant result. It bc-^ns at the margin and
adrances towards the centre, and leaves t^hind it deep and puroianent
opacities.
Inflammation of the ureal tract, especially of the in«, according to
Sacmtscb occurs in all casea of corneal complication. Functional dis-
turbances in scleritiB rany be very pronounced or scarcely perceptible.
The disease may dt^utppcar without leaving any trace, but tliis is not
coratDon unlettii it i« of syphilitic origin.
As rare complication* may be mentioned: Ist, the ulceration of the
inflamed HclemI tiitnucK ; ami 2i\, the development of sclcnil ectaBia. This
Utter results from a thinning of tlie memhnine, is very mre, ami must
ho distitijirniglivd from that form of ectasia known as ciliary staphyloma,
ami due to other causes.
Sclericid is a mre disease, as a rule does not attack both eyes, and
occurs ofteneul In miitdle life. — B.]
The disease U not only rery protracted and obstinate in its course,
hoc alM very little intiuenced either by general or local treatment. It
occurs most frequently in femaleH of an atlutt age, and does not ap{>ear
to he due to any appreciable caudc, except that it is perhaps more ol'ten
met vriih in persons of a rheumatic or gouty tendency than in others. In
Bornc coses it vould also appear to be due to a syphilitic tflint, and is
then apt to prove extremely ulu-tinnlc, except it is (rested by anti>ftyf)1ii-
litic rcincvlteA. The cornea tiometimcs becomes iui|iUcau.'d, mure csjw-
eially the part nearest the elevation, the superficial portions of tlie conica
becoming cloudy, and this opacity asgumin;! »oinewh«t the api>ear»rice of
a partial nrcus senilis. If there is much ciliary irritation and pnin, atro-
pine dnipt sliotdd be employed, and warm i^ippy fomentations be applied
to the eye. The insufllaiion of calomLd or the use of the red-precipitate
oiotiuent bnve proved of tittle benefit in my hands; indeed, 1 think them
contra-tudicated if there ia any ciliary irritation, still more so is this the
eoMi! with ouiuttic collyria. I have, however, in some cases found marked
and Hiriking benefit from the use of a collyrium of chloride of sine. I
employ at finit a very weak solution (gr. ^ to 3J of water), and if this
is well borne and does not augment the redness or protlnce much irrita-
tion, I increase tlie strength to gr. i-ij to 3j. The patient should he
placed upon a generous diet, and tonica should bo freely administered.
Where there is a disrinct gouty or rheumatic tendency, preparations of
guaiacum. or oolchicum togvUier with the tincture of aconite, should be
given. If there arc evidences of syphilis, the iodide of potassium should
be preacribed, and perhnps v%'cn mercurial inunction, [fhe hypodermic
injoouon of the hydrocblorate of pilocarpine, in dows uf gr. ^ to gr. ^
daily, is i»omctime» licncflcial in cutting short the disease.
HcUritia $w)'fiilitif^, or gummy infiltratiou of the sclera, is not au
IS
274
DISEASES OF TUB CtLtART BOOT AND 60LBI10TTC.
unoommoD lesion in consUtutional sTpKitis. This mfty t>e ai circuniscnbod
gummy nixLutc or a liilTusc infiltration. When circumscribed, it usually
may he found on the temporal side, either in the course of the external
revtuK muscle, or between it and the superior rectus. Though somewhat
chronic, it yieUU more irailily to ])ropcr anti-i^yphilitic trcntaaent than
the other varieties of 9cl«riti9. If, however, the gumma start from the
ciliary body and spread later to the sclent, Its temiiDation is not ao
favorable, — B.]
2— ANTKHIOH SCLEHOTIC STAPHYT.OMA.
Staphylomatoua bulging of the sclerotic may be chiefly or entirely
confined to one part of the anterior portion of the sclerotjc. or it may
involve, more or less, the whole of the eyeball. The partial anterior
staphyloma is generally near the ciliary region, or further back, near
the eijiiator of the eye. It may occur at any point from the edge of th«
cornea to the equatorial region of the eyeball, and frequently shows
itself between the insertion of two of the recti muscles, as there is less
resistance offered at such a point to the protrusion of the sclerotic.
In the great majority of cases, staphyloma of the sclerotic is due to
irido-clioroiditis, accompanied hy an increase in the intra-ocular tension,
which leads to distension and bulging of the sclerotic at one or more
points, the resiat-ancc of the sclerotic having moreover been perhaps alao
weaken«tl by an iiiHainmatory thinning of its structure. The prominence
of the inflaramntory symptoms varies very greatly, according to the
rapidity and actitenesa with which the staphyloma is formed. If the
course of the disease is very acute, we tind that there are marked
symptoms of irido-choroiditis. Tliere is conjunctiva! and suhconJTincti%*aI
injection, accompanied perhaps by a certain degree of chemosis, more
especially over and around that part of the sclerotic which U beginning
to bulge. The ciliary neuralgia is often very severe, and the ciliary
region acutely sensitive to tlie touch. The edge of the ooniea may he
somewhat opa<|ue, the aqueous humor haxy, the iris discolored and in-
flamed, and its pupillary edge tied down hy exudations of lymph.
If the pupil is sufficiently clear to admit of an opbthslmoswpic examt<
nation, the vitreous humor is often found diffusely clouded, with large,
dark shreds floating about in it. The tension of the eye is generally
considcnihly increased, and the sight and field of vision greatly im-
paired. The increase in tlie eye-teiution is not, however, absolutely
neci'ssury to the production of a ataphyhiina. For, on account of an
inflnmmaiory thinning of a certain portion of the sclerotic, the latter
may not be sufficiently firm and strong at this point to resist the pre*
sence of even a normal degree of intra-ocular tension, and con8Ci|ncntIy
yields before it. lu such a case there would, of course, be oo augmen-
tation of the cye-tension, no hardness of the globe. Soch cases are,
however, rare in comparison to the others, in which the increase of the
tension is the chief cause of the protrusion. Besides the severe pain,
tiiB patient often complains of bright flashes of light (photopsics). Soon
there is noticed at one point of the sclerotic a shght proiiunence or
ANTBHIOR 4CLSR0TIC STAPBTLOMA.
276
bullring, the mitUno of which may be cireamscrlbed and clearly defined,
or be irregular and pass jirndually and iiiwDsibly over into the licalthy
eclerotif. As the Iml^e increases, tlio sclflroiic hccomea more and more
lliiaiie^l Cpartly |>«rh»jis from inflamtnattnn arid partly frf>m disteiiAion)
ftiid discolored, aasiimm<{ at thtd point a diii^ltyf dirty, hhiiith-gray hue,
which is due irt the shining thmugli of the choroid. Thus the staphy-
loma may attain a coniti^lerahle sixc even in the course of a few weelu.
I Fig. 80.] To^otlier with the increase in the size of the staphyloma,
Uie pn>ximate i>i>rtion of the ciliary region, and eren of the cornea, may
Iiectinie iuvdlvi-il iu it. and tie contiiih-rahly chaiif*i'd iu curvature, the
corrrsi^ndinir plane of the iris and the zonnU of Zinii lu-ing utrrtched,
and the attachment of the l«ua consciiuently relaxed and loosened.
tPNt. 69.
Fig. W.
Aflar MUl*r.
An«r trillm.J
A» ■ rule, Iioirercr, the progrew of the staphvloma is rery slow and
gradual. .After a more or leas acute and severe Inflammation of the im
and choroid haa existed for some lenj^th of time, an<l ita progress has
b«uit perhaps apparently arrested, it U noticed that the curvature of
one portion of the aclerotic is somewhat
altered and ra*ire prominent, and its 9ur- [Flj. 01.
face traversed by dark, dilated vessels.
liraduaHy and slowly the protrusion in-
creases, the sclerotic becomes more thinned,
and exchanj:;os it^ bright luistmns white
color for a dusky bluisli tint. Sometimes
the stajdiylomatous hulging is traver>«.'<l by
lendimtuft gli'^tcning trahecnlje, forming a
kind o( fr^Hivnork, tlirougli the interstices
of which the darker portions bulge out,
giving to the whole n fnint UkcncsA to ft
mulberry, [Fig. l»0.] The stB|>liyU]ma
may now remain stationary for a time,
and the infiftomuitory symptoms di^np^icar.
Then an iaflaminatory exacerbation sujier- aaoi M«(ikc»i>.)
venes, the eye becomes painful, irritable^
flushed, and an increase in the size of the .staphyloma is ooticod. Hut
these symptoms again disappear, ami the progress of the disease is
\
276
DT8BAB8S OP TBB OILIARS BODY AND SOLBROTIC.
tomporarily ftrrcated. Sucli exacerbations may ho of frei^nent ixscur-
rcnce, and load, finally, to a considcrnble and very pmuinent ataphj-
loma. SoDii'tiiun) the stanlivlomntouD bulgingit are imt chivlljr couhiivd
ti) one jwrtinn nf the nclerotie, hut occupy the whole of the ciliary
region around the cornea, and then tli« im«ase is tenocd **■ aunulur
staphyloma." [Kig. HI.]
The diatomion twn
d bulging are not limited to the sclerotic, bnt extend
to the choroid, which is generally adherent to the former, and coa»e-
qncntly siretclicd and bulged with it, undergoing in time pcrhapB almost
complete atrophy. Tht* retina TOHy eiliier be adherent to the choroid*
ntid thei-cfure aUo atretchcd atvd altered in structure, or it may be aepa-
rated from it at this point, and pOM straight acroM the base of the
BtapbylomatoU!« bulge, the cavity of the latter being occupied by seroutf
fluid. The vitreoue humor ia also more or less clouded and fluid.
Sometimes it is, however, quite transparent, and we can then distinctly
see (if the other refractive media are clear) the detaiU of the fundus,
and perhaps detect a deep excavation of the optic ncrre. Generally,
however, we are unable to sec the fundus on account of exudations in
the pujiil, or the opacity of the leTi8 and vitn.-riit>! humor.
In comptet^t wlerotic staphyloma, the anterior portion of the sclerotic
and lliu cuniea are greatly altered in curvature, being eitlier dibteuded
inu> a conical, or subovoid protrusion. The iris and zonula of Ztnn are
also much diatended. The plane of the irix is greatly increased in size,
and its surface is of a dirty elate cine, which iis partly owing to inflam-
matory changes, and partly to the stretching ami atrophy of its fibrillw.
It is, moreover, often tremulous, on Hccoinit of the partial or complete
dislocation of the lens, or on account of the latter b^ing separated from
it* posterior surface by a considerable amount of fluid, Krono the dis-
teunion and !»lrv1ching of the zonula of Zinn, the attaelimonta of the lens
are relaxed and weakened, and the Utter may he iiartially or completely
dislocated into the vitreous humor. The depth and size of the anterior
chamber are oHen greatly increased. Indeed the whole eye is much
enlarged, and on this account as well as the protruiion of the eye from
the orbit, this condition is often termed " hunhthahiios." Tlic sclerotic
is traversed hy dilated tortuous vesiiels, and is of a dusky, dark-blue
tint, which is either diffuse aud uniform iu character, or chiefly con6ued
to ccrtiiin pctinta, giving to the whole a dark, paiehy appcarHtice. The
pupil is often occupied by lymph, the capsule of the lens opaque, and
covered by masses of exudation, the tens itself being also frequently
cataractoiis. If the staphyloma has formed aficr an extensive perfora-
liou of the cornea, there will be no anterior chamber, the iris and caj>-
^^^ sulc of tlie lens ore intimately connectcil with and adherent to the cor-
^^B tival cicatrix, the lens is cataractoua, perha|)s shrivE'lled and chalky, or
^^H allogrtlier absent, having vtscuped through the cuna-al perforation.
^^H Botli the }kartial and conipltitc stiiphyluma may after a time become
^^^ an— wd, tlie inflammatory exacerbations becoming less and \viA frequent.
I «hI itttlly ceasing. In otlier cases, severe suppurative irido-choroiditls
m Mimnnim. and gradually leads to atrophy of the eye. Or again, tlie
I V^gr^ p«nion in a partial staphyloma may give way, either eponta-
I iwniMlit or ia consequence of a blow upon the eye, or » Buddeu and
WOUNDS AND INJURIES 09 TUB SCLEROTtC. 277
severe fttrain or exertion. A great portion of tlie cotitcntA of tlin cyetiall
escapes, this Wing often accompanied hj profnse intra-ocular liemor-
rhnge ; severe iaflamaiadon superixnes, and the globe sbtinks wul
airophiea.
With regarrl to the treatment. I need only say that at the very outset
of the disease, when the symptoms arc only those of irido-choruiditiSf
iJtie usual remedies— atropine, Itechtis. paraccnteisis, etc. — should !>6 era-
ployed, hut when the leniniun of the eye ia markedly increaet><l, and if
the sclerotic shows at one point a tendency to .bulge, tlie.4o remedies no
longer suffice, and a lart^ iridectomy should be made at once. If this
should Dot check the infltimmation and the hulpng of the sclerotic,
repeated paracentesis may W trierl, or a second iridectomy may be
made opposite to the first, so as to divide the iris into two separate
halves. But if the staphyloma is consiilerahlc and has existed for some
time, the iridectomy uo longer suffices to cause it to shrink, and we may
then hare t^i aWisu it. This should be done with a cataract knife, t^H
in the case- of stapliyloma of the cornea (l)ai;e 1$:}). Ai\vr the opera-
tion a firm compresji) bundiige U to be applied. In cases of partial >«ta-
phvloma, more csitecially if the hase is small, I should prefer Uorelli'a
o[>eration (page 187) to abscinaion. In those cases in which the sight
la greatly and tio|ielessly lost, ami the eye is a source of constant irrita-
tion and discomfoi*t,ab^ission by Critohctt'a method should be performed.
[Critclivti's method of abscisaiou is by no means a safo o|>erat)on in this
region, as the n'Ruhinj^ rirntrix cornea to lie in the vicinity of the ciliary
nervei, and may cfoltc ^viupiUlietic irritation. — B.] But if the disease
reaches far hiick. or involves the whole eyeball, it will he much wiser to
excise the eye, for by abgcising tlic anterior |«rt, a porUou of the dis-
eased straciures will he left behind, and the slump be prono to inflam-
matory complications, and thus prevent perhaps the possibility of wear-
ing an artificial eye nitli couifort, aud even cndanjrvr tlio sufvty of the
otiier eye.
8.— WOCNDS AND INJURIES OF THE SCLEROTIC.
Incised wounds of the sclerotic chiefly prove dangerous in so far that,
if tboy are extensive, a considerable jxirtion of the contents of the eye-
ball escapes, which is perhaps followed by profuse iutra-ocular hemor-
rhage, suppurativu choroiditis, an<l finally, atrophy of the eyob:ilI. Or
tgain, if the wound is smaller, its cicatrixation may, by involving a por-
tion of the retina, lead to n detachment of the latter, which, though lim-
ited at first, may gratlually extend and threaten the s-ifety of the eye.
Again, tlie instrument producing the injury may wound the leits aud
cause traumatic catanct, accompanied perhaps by severe inHammatorj
complicactona leading to the dcstniction of tae sight. Still greater is
the dan^^er if the point of the instrument is broken off and lodged in the
interior of the eye, the same beinji; the case if foreign bwlies have per-
forated the sclerotic and enten-d the globe. If the wound ia situated at
the anterifjr portion of the sclerotic near tite cornea, the iris generally
protrudes, and the lens may be dislocated under the conjunctiva: tliis is
278
SISBASBS OP THI CILTABT BODY AND BCLBKOTIC.
ciipeciAlly the case after severe blows from blunt instruments, prodociog
a rupture of the sclerotic. Indeed, ruptures of the sclerotic are goner-
ally far more ilaiigerous than incisud woumls, ou account of tlie great
force of the blow wbici) was necessary to caiue the sclerotic to giro
way. If the incised wound ia not considerable in siio, its edj^ should
be carefully brou^iht together by a fine suture or twu. Any portion oi
proti'uding iris or vitreous biuiior heiiifj aWised. cold compresses shoiilil
then be applied to allay the httlammatory reaction. In small punctured
wounds a little bead of vitreous may protrude through the aperture, and
if the application of a firm compress does not accelerate union, this object
may be obtained by Hjjhlly touching the wound with a crayon of nitrate
of silver and polish every second or third day. When the wonnd is
vury extensive and a large portion of the contents of the gloW has
esca{)eU, and there is no hope of rt'jtorin;!; any eight, it is better to
excise the eyeball at once, more especially if it is to the patient a matter
of great moment (as amongst the poorer classes) to be cured as soon as
possible, and to be free from further inflammatory attacks.
[A not uiicomnKiii occurrence itftor [jowdor t-xplasious js to fiud a
numlwr of gi-aina of powder imhodded in the sclera. These rarely ^ve
any trouble, and, as siiv attempt to extract them involves laceration of
the conjunctiva, they bad better bo left undisturbed. <_Krca»ionally
foreign bodies, os bits of stone or iron, have been found imbedded in tbe
sclera, though tins is rare ; for usually such particles impinge upon the
sclera with such force as to ])crfora(e it and enter the eyeball. Incised
wontids of the sclera arc best treated by aiuures, if they are not too
lai'ge to call for enucleation of the globe,
Coutu.<tions of the sclera are of no apecial moment in tbcmscWes, cx>
cept so far as they are to be regarded as contusion of the whole eye,
with more or less severe injury to the contents of tho globe » such as
diiilncation of the lens, rupture of iris and choroid, and intra-ocular
hemorrhages. — B.]
A {mrtion of the sclerotic may slough after injuries from bums, hot
metal, etc. The injuivd jiart becoujcs covered with a whitisli-gray eschar,
wiiich is thrown off togeUier with portions of l\n- svlcrotic, until the vit-
reous humor becomes visible. The irijury may be accoinpiinied hy ja-
flammatiou of the cornea nnd iris, uud opacity of the leus.
[4.— TUMORS OF THK SCLEHA.
^^^ Tumors beginning in the sclera arc rare. Tlioso which, starting fr^T
m some otber snurce, whether intra-ocular or extra-ocular,, involve the
I sclera secoikdarily, lind that the latter oilers considerable rcsisiatice to
I their progress. These usually begin in or near the ciliary and sclcro<
I corneal regions, may h« both benign and malignant, and may he classeii
I as tiernnnti, mflaiuimata, man'omaia, and cnrfinumnla ; and among the
I very rare fornu occur fibrumata, osteomata, and cy:<ts.
H The extraocular tuuion* which may invnlve the ncleni are the dermoid
I and the melanomnta. but bv far the lar^r number of scleral tumors are
of intra-ocular ori'nn.
TUHOBB 07 THB SCLERA. 279
There is a case of otteoma, which originated ia the sclera, reported by
WatBon ; but manj of the cases of scleral osteomata are merely caleifi-
cation of the sclera, which is not so very uncommon.
Gummy tumor* of the sclera have been considered under the head of
flcleritis syphilitica.
Tubercle of the sclera has been observed, bat only as a secondary
growth from some portion of the uveal. tract. — B.]
Chaptkb v.
dibeases of the crystalline lens.
1.— CATARACT.
Ti\ tliP poiiiTnl torni "caUrnct" is undcRtoofl nn opacity sitiiatc<1 in
\\\v crvKtnlliiii' Ion« : to sucli only ehoulii it Ke ajtiilied. Wlicn thtf
o|)iicitv \# in tliu ciipsulf, it in Icrraod "capsular camrnct;" whereas,
wlion Im^iIi the capanlo nnil lontt arc itwolrcd, it 'n designated '*■ capsulo.
l<*imm)lnr calaraot." Tlie term "^^ spurious cataract" of old authon,
which was the name pvvii to dupostls of lymph in the puptt, sliuuld be
alti*i;i-llHT ahotishtfd.
AVi"r.Ai./v. — h uiiist t»o frankly admitted that the etiolo.sj of cataract
H ilill shnuided ill much vilscuritv and doubt. It app^-ars m>it pmhahle
that Iho princi[4l cauatN* of th^ loss uf transparency of the l«its are to
Iw MuigUt in an iuiiiairnient of its nntrition, due to some morbid altem*
tioii in the rtttvoualiunior, and in inflnmniatory changes within the leoe
itself. The defeoi in the nutrition may be due to certain altemtiou iit
ihe eondition of the blood, to senile involution, or to inflammatory lenoiH
«C Ibe net^hboriug ttnuoa («. y., irido clmroiditis. sclerotico-choroiditis
ppeMriOTt retinitis pigwcatoaa, etc.)* [The uncompticate<l seiule cata-
nkct is the prototype of the piitnarv cataract. Aat ia, of that form of
lens oi«citY uot the con$e>|ucDce of some demoMOaUe diicMe of An
eye. The len^ depends for ite nntrition anoe the mmammt hmmor ani '
vitnotts hwnor. It ia abo posnUc that u« tmd mad hetween tlw
MiA of tl« sB0pei>K>ry li^uent is of inportuM* also for its aotntion.
.V »iui(>le o«aw^ process aot ouly take^ place (hra«^ the aoMile, bat
alsM thrvufEh the s}>acee between the epith^ial cells «f pMceaxt'a oica-
hrane. Any diMurhanc* in ti»e omodr m»ob of ihcK parts affwtn the
Dttlcknft of 'the t««*. and any dtssmrUnce in tha aMriikKL of the leas ia
slwaa by a dondiaeM. Hence &«a a tlMify baa ■&/ be iafietnU with
ao»e pmhahiKty a |witho>offlcal ehaaff iatbewttwaaraycaaa haaonu.
Backer thiski that «* aay intfiractly wttr wiaa dnaaaa of ifaa lemanl
orjIBUJsa ttom the oceamaee of biairnlar nnamaih cabuacL aad rvtea
eapevialH to ifce ttoahW aoA cabnict uf ynig ytopfe^ aad to ifca
rior eoRwal oataiarl of both ey<«. The owaitiata of fatantk pi
tiMa vith this Ibna of eattuact poiaiB aaniseakaUy to tiaraiia of
vttMviar fystvsk aad 1km nato m^ h* mid of tha baMaiai
wevnag «iih aotoo olMcwt fonw af chamiilirii — ft.] ilaiawiffin^ to
CATABACT.
S81
Sfooren' the formatirtti of cataract w alwavs ft secomUr j, nerer a yirimarjf
pheaomenon : its origin lieing nWays due to certain inflninmaUir^r or
mtrophic changes in some portion of the uwtt] rract. Simple affrctions
of the optic tierro or retiim, wliich are unaccompanied by any changes
in the vitreous^ do not exert any influence on the development of cata-
ract.
The pr*feiice of sccale conuitum in the Hystem may proiJiico cataract.
Thus, Dr. (gnau Mvye.' has sliown that the corwuniption of bread con-
taining ergot of rye may give rise to it. 'i*be ergotism has lasted in some
of theft: cases for two or three months, the principal symptoms being the
fita. The development of tlie cataract waa very slow, and always oc-
curred in both eyc'8. Tlio mode in wliich the ergotism ^ves rise to
cataract is still very nncertain. hut is pvohahly due to some impairment
of the nutrition of the len»- Wecker tliinks that this nial-nutrition may,
perf»aj«, be owing to ii diminution in the blood supply to the ant(>rtor
portion of the uveal tract, on account of the prolonged spasmtKlic con-
traction of tlie ciliary muscle. Roihmuntl' ha-! observed n rapid ilevel-
opment of cataract in children who were affected with a very peculiar
iliiie}<>)e of die &kiu, which sutuowhut reseuiblud icjithyo^is.
(Thi:! is conHidered dmihtful by Rccker oa tbo facts advanced, are not
convincing. Tic al»o doubt* the connection between rapidly developed
cataract and ichthyosis. He thinks there is more reason for recognixln!;
rickets as a cauM" of catarhcta zonulnrir*. (See Graefe u. Sajiniscb's
Ilnudb. der .\uyenbeilkuiide. Bd. v. p, 220.) — B.j
Cniaract is. n^ a rule, a diaease of old age. and the loss of transpa-
rency of the lens is probably chiefly due to it* deficient nutrition, de-
pendent upon nn inemcient lilood supply, and coiii4ei|uera dtuilnutiou of
the warory constituent* of the crystalline. Wc must not, however, mia-
.Ikkr for thi^ condition the small punctated opacities which are due to
^Senile fatty degeneriition of the fibrilla* of the lens, and which Honict-imea
Bpficar in old persons in the fomi of a fringe of small, yellowish, gray
dot«. situated ipiitc at the |icrif>hcry of the lens, where they remain
fttacionary for a very long period. It is an intere:*ting fact that Iwanoff*
oft«rn found (fideuia of the retina in the eyei* <d' old persouB atfected
ith cHtantct. iind it '\» a l|ue^tinM, as he pnintd out, in how far this morbid
proce*.4 in the retina may have been tiie cause of tlie cataract, by pro-
ducing some changes in the vitreous humor.
InHauitnations of tJu^ inner tunics of the eye, more especially of the
iria, choroid, and vitreoiw humor, may give rise to cataract, not oidy by
an iropaimjent of the nutrition of the lens, but also by the inflammatory
changes implicating the intra -capsular colls, and oven the lens itself.
Agmn, the cataract may he due to the presence of extensive depout^ of
lympli U}Hm the ca[>sulr, whit^h prevent the osmotic intereliango of mate-
rial bctweeu the l«n» and aipicons humor. If these cxmlatioiui cover
tho greater portion of the anterior capsule, the opacity r>f the lens gene*
']y aoon becomes complete, whereas, if the exuaation is confined to the
1 "OplHLalmintrUi'ln' Bmibiwliluiujen," p. 20B.
» "A. r. O.,' viil. i 12W.
* "IliiJ.," j[». 2, W.
' Ibid., xiv. 1, 1S».
282 LIBBASB8 OP TOR CBYBTaLLINB LBKS.
area of the \m\A\, the cxtarAct is oRen otily partial. Tn tho former cuo,
Uic watery cutiatituent* of tlie lens soon beconM; ab?r>ph«(I, tho Iciw he-
comes ditnimHhcd in bikc and shrivelled up, and may in time hn iilaioBt
entirely absorbed, there bcin« only an opaque, white, chalky disk left
beltind.
f There is a form of opacity occnrriTip; in tho anterior cortex op io tho
anterior capsule lu the imniL'Jiate (;'(uaCor of the Umis, which is not pro-
gressive, and which is met with very frequently in young pcrisous in
chronic ill-health or who are suffering from some slowly-wasting diica.sc.
These opacities never encroach upon the centre of the lens, and cannot
be seen except wlien the pu]iil i* widely dilated. They appear in the
form of dot* or atriie, and m'nerally are sprt-ad rcjiularly all around the
equator of the Icus. Tliey never increase, though watched for years,
and do not interfere with riition.
Anottier form of immovable or very slowly progressire opacity is met
with in patients who are highly myopic. This is a cortical opAcity,
pl^neraIIy of the striated variety : thoujih sometimes many of thedo
opaque stria) coalesce and then the opacity becomes much denser, aad,
Tision is markedly affected. Though this form of cataract is generally'
Iirogre*aive, iu progress is very slow, and though vision may be much
interfered with, the clear portions of the Ions may be oflen made of use
by the occasional use of atropia in keeping the pupil dilated. — B.]
Cataract is very fretjuently due to some injury to the lens, but tbi«
form will be considered more at length under the head of " Traumatie
Cataract."
[Before describing the varioHO forms of cotamct, mention should ba
made of »omo rare anomalies which have been described among the con*
genital defects of the lens.
lat. Con<jenital aphakia or complete abaence of the lena. Such an,
anomaly, existing alone in the eye. has never yet been described : but
there are cases on record where from some iiitra-uteritie proci^ss, an an-
lerinr staphyloma has been developed with total losa of the lens. (See
Graefe u. S»emisch's Hnudh., p. 229.)
2d. Cui'ihoma Lfnti*. — This defect in the lens may extend more or
less into the substance of the lens from the periphery ; may occur wi^
or without defect in other parts of the eye, as in the uveal traet ; and
may be either monocular or hinocular. Omcs are reported by Hirisch-
berg, Hresgen, Becker. Heyl.un<i others. (See (iraefe u. Sn^misch.l. c;
Archives of Ophthal. IV.', 1 ; Trans, of Fifth Intcrnat. Ophthal. Con-
greas, l»7ti.)— B.]
Oon<tidcrahlc difficulty ta experienced in attempting to clasidfy the
Iirincii>allbrnisof cutanict in such a maimer that their distinctive features
shall be eawily rcc<igiiizpd and rememlaTod. Not only are the minor
varieties numerous, but some of tJiem do not present any marked cbarac-
t«risiics, so that their description oflen proves somewhat confusiug and
unintelligible to the novice.
1 think it most pnictical to divide lenticular cataracts into two princi-
pal clftityes : 1. The cortical, or soft cataract ; 2. Tho nuclear, or hard
cataract. The former is the most frequent kind of congODital cataract.
I
I
OATAnxoT. 283
«uil is met with in various fornu up to the Age of 30 or 85^ And is chiefly
cbarncterized by the fact that, altnouf'h the whole Ions may be involved
ill the process, there is no hard nucleus. The nuclear cataract occurs
generally alter the 3t<^e of 85 or 40, and ia dialitiguiuhod hy the prudence
of B more or lean targe, yellow, hard nucleuti. I nm welt aware that 80
]^neral a diri!»iou is open to the objection that exceptional cases are not
iiDfre(|uentiy met with, so that all varieties cannot be embraced in it.
Vet in a practical point of view I believe it to be the best, as it enables
u» to by down broad rules as to the modes of operation to be selected.
For instance, the cortical cataract may bo operated upon hy division with
the needle, by suction, or by linear extraction; wherejw, the nuclwar
cataract, on account of the presence of a hard nucten.^, demands extrac-
tion cither through a corneal or scleral tlap^ or by the assistance of some
form of tniction instniment.
But tliere is one form of aofl cataract which reijuires a special de-
scription, as, on account of it« peculiar structure, it may often be best
treated by an operation which docs not interfere with the lens itself. I
mean the lamellar or lonular cataract. Cataracts produced by injuries
to the lens, and ojacities in the Oiipsulo, will be coiiaidtfred under the
beads of " Traumatic Cataract," and " Ca[wular Cataract."
Formerly, much attention was paid to the symptoms which distin-
guished cataract from glaucoma and amaurosis. But Hince the discovery
of the ophthalmoscope, ihe^ie di:<ease3 conld not he mistaken for cataract,
•xcept thrnujih the grossest ignorance or carelessness.
A fully formed, mature cataract may be at once rccogniaed even with
the naked eye. The pupil is no longer dark and clear, but is occupied
by a whitish 0|ialescent body, which licH cKmc hebind it.
[rig. yS.^ It is difficult, however, when the affection trt in* [Wg- 94.]
dpieut and but sligbily advanced, more especiiilty when the
opacity commences at the edge of the lens, for it mar then
be easily overlooked except the eye is carefully examined
with the ophthalmoscope and the o)di()ue illuraiQation. If
elderly persoiu complain somewhat of dimness of sight, the condition of
the lens should always be examined, even although they ntay Hpparontly
be only suffering fnun pri'sbvopia and are able lo n-ad tlie Biiuiilesit print
with suilJible convex gluitses; for amongst the aged, cataract in most
eotumon, ami often commences at the very edge of the lens in tJie form
of small s|ncular opacities, which might easily escape detection.
Wherever incipient cataract is suspected, the pupil should be dilated by
a weak solution of atropine, ami the Icna examined witli tlio ophthalmo-
scope and the ohluiuo illumination. If there is any objection to dilating
the pupil, a very fair view may, however, be obtained even of the
margin of the lcn.4. by directing tlic patient to turn his eye to one sidoi
and then looking very slantingly behind the iiis.
Care must, however, he taken not to mistake the physiological changes
which occur in the len.<« in old age, for commcncnig cataract. Tliese
changes consist in a thickening and cousolidation of the lens substance,
eapecially of the nucleus, which a^isuraes a yellow tint. If tlii^ physio-
logical cJoudineM is very marked, it might easily be mistaken for incipient
cataract. The chief distinctive features arc, that in the former case
IBi
DISEASBfl OP TBE ChlSTALUNB LBD8.
the wglit 18 perfect ("any existing presbyopia being corrected by suitable
elates), tlie opacity remains absolutely or alroott entirely stationary
for A very long period, and tlic claudinesa ia not observable wiib the
opIiUtalmoscope, altliough jtcrbapa very evident witb the oblii^ue illumi-
nanon.
The catoptric trtt, which was formerly much employed in the diagnosis
of cataract, has fallen into complete disuse since tbe discovery of tlie
ophthalnioitcope, and the introduction of the oblique illumination. The
catoptrioal exanunation depended upon the three imaj;e8 which may be
observed in a healthy eye when a lij^htcd taper is moved before it. Two
of these images are oixxt. tlie third i« inverted. The first i* an erect
imn;'e of the candle, and ift produced hy rcllection from tlio (Surface of
the cornea ; the second is also erect, and is produced by reflection from the
anterior flurfaee of the lens; the tliird is inverted, and is due to reBection
from the concave posterior surface of the lens. The firet two images
move in the same direction as the catidle, the third in tlie opposite direc-
tion. If the lens becomea o|)a(pte, of course the imaf^e from tbe pos-
terior surface ia lost, and that from the anterior surface also soon becomes
indistinct.
Willi tbe ohliquo illnmination, opaciues in tbe teiia will appear of a
light gray, or whitith color. The slighter forms are bc^t seen by only
ft moderate ntnount of light.
In employing the ophthalmoscope for the diagnosis of cataract, the
mirror alone is to be iwod (without aiiv lens in front). To gain a
larger imai;e, u convex lens may he placed Itohiud the mirror. Tbe
illumination ia to be weak. Incipient cortical cataract, composed of
centripetal stniies, will appear inilio fonn of welI-<lefinod dark streaka
upon a ivd background. Punetiforra opacities aUo appear aft dark aputSf
but are often not so observable as with the obli>^ue illumination.
t will now hricHy describe the characteriotie appearances presented _
by the different forms of cataract.
I. /.amed'ir or 2vnuiar '•atnrai-t (^tSehichtMUiar') is generally congeil
tal or developed in early infancy [and ia one form of partial eaiai-aot
— B.] Von Arltori^inally called aitenlinii to tbe fact that it of^en occurs il
eliildren who have siiffercil fnmi (;oni'ul.siinifl, Imt, the connection betweel _
the two lias not yet received a natisfactoi-y explaiL-tticm ; for it is difficult
to uuderstami why only certain perinuclear layers of the leiis 6br09
fbotkld be affected hy the mal-nutrition or sucuussion eonsci[ucnt upon
tto violent uiuscular spasniA during tlic convuUioiis. ^m
As lamellar cataract docii nut materiiilly impair the Fight, it oft4l^|
uaoBi detection until mneh later in life. Its appearance is very "
-Nnfinri'tir and Ua <lia>;iiosi8 easy. On dilating the ptipil with
0MM, wt nhjterve an o{Micity of the len.'^ measuring from two to three
■iah^ lines in diameu^r. It is ipiite uniform from the periphery to
* ^11. mil in ■'-"-p'r delined against the Lransparent margin of the
mm T^ eiiaract consists, in short, of a layer of opar|Ue lens substaiiM
. ^M^n tbe nucleus and a tnins|>areiit portion of the cortical
H«oce il baa been ducignaiod *' Scliichutaar," or lamellar
■^ aatleiu of the lens is traiwparent, wliicb is proved by
^^^Moetcr of the opacity, which is not more deiiae id Uio
CATARACT.
285
centre than at the perintierjr. ami by the relatively fair Mght which such
padenta enjoy even when the p\i\\\\ is ililnted. Morcowr with the
onblhilmoiicofw, a red<liah>browu reflex shines tlirough ttie central portion
of the leniv
With the obliiiue iltnmiaationj the opncify wppeara of a umfortn
lij^ht ^my color, 9har])lv ilvfiDcil, ami siirroiniilcd by a more or Ie«s
hma*l miur^iu of tranajnront cortical subataDcc. It will now alito be
»r«n tint there is a clear portion of cortical subBtance between the
opacitv ami the anterior capsule. Id the centre of the opacity may
often DC remarkc<l one or wore small white apota. With the ophthal-
moscope, the opacity has the appearance <jf & well-deBneii ilarli disk,
the centre nf which affnnls a reiJiiieh-brown reflex. If the margin of the
cortical pubstance he clear, the detnila of the fundus will be visible
throuf;h it. If there arc o)>acitiea in it. they will appear as tine dark
itripoa or specks upon a red background. Home of the varictie« of
lamellar catanicl arc very pretty. For instance, I have eeen cases in
which littlr AtrijiOH ran from the opacity iiit« tlic cortex, their extremities
heiipji HtuiltNl with siiniill pearl-like opaeilte?i. Ijimclliir caiaract is eillier
fltationnry «r very plowly progressive. It is. therefore, of conBei)Ucneef
before deciding upon an operation, to determine whether the cataract b«
pragmwin'o or tK>t. In deciding this, we must be chiefly guided by the
ciuilitioii of the marginal conical aub^tance. If the latter i» perfectly
clear and traix^iareot. the cataract i^ stationary; if it is JifTuxcly
I'louded nr prvsetitts puiictiform or striped opacities, it is progressive.
Von (traofe thinks tl>at its progre.sK i.< mast rapid when the ^tripi-s arc
broad, and the interjacetit lenticular substunce ia somewhat opai|ue and
nudde^l with coarse .specks. If the opacities consist only of very 6ne
doLi, or a few dulicfite narrow stripes, the progress is very slow,
Ai^conlin.L' to Vnn limefe. Inuiellar caiaract may alao bo fonocd later
iu Uff in .li^l.'L'ated lense*. and after iritis.
Vision may he relatively good if tiie ojacity U not dense : for in-
stance large print may be road. But the sight is always improved by
dihttatiou of the pupil with atropine, for thi^ permita the rays from the
object to pass through the clear marginal portion of tlie lens. I have
•ecu cases in which the diS'erence in the sight before and after dilatation
of the pupil, hns been most marked ; so thai persons who, prior to it,
rnuld milIi .hiSrulty d<-ciphcr large letters, were aftcrwardd able to read
tin. U3.
T\^. 0-1.
tlio smallest print. The accompanying diagrams (Fi^. 0-3 and 94) will
explain lliii. Fig. '.Hi (a) the utidilatvd pupil occupied by the opacity
ih}, which extemls heneaiii the irij as far as the dotteil line (<^), where
Um craiispareiit margin (</) commencca. Aa the latter is completely
mm
DI6EASBS OP THB CRTSTALLINI LSI^S.
corered bj the iria, the rays can only pass through the central opaqne
portion : heuce the iii<listiitctiiofts of si-^ht. But on dilatutioii of the
pu]iil (Fig. 04) the transparent mar^n (d) is exposoil. and the rays can
now pftM through it to the retina. The solution of atropine to W iweA
for dilating the pupil should be extremely weak (^r, j to eight or twvlve
ounces of water), so that wc may obtain complete dilatation of the pupil
without nny paralysis of the aeeommo<lation. if this point ifi not at-
tended to, we may easily ho minlcd by the fact of the patient's complaiti-
tng that after the dilatation the sight in dim and misty, which may be
due simply to the fact that the acconimodatiuu is paralyzed by \i>^m
atropine, which wati too strong. ^M
Persons suffering from lamellar cataract are often supposed to he
short-sighted, as they hold small objects (a book, for inatanci-) rery
close to the eye, in order to gain larger retinal images. In time, how.
ever, this constant accororoodatJoD for very near objects may really ^t^b
rise to myopia of even n considerable degree. ^M
In practice, it is important to remember two facts with regard t^
Iflmellar cataract— 1. That the opacity ta surrounded by a more or le«8
clear margin of cortical substance, which, if it be sufficiently wide and
traosparent, may admit of excellent sight when the pupil is dilated. 2.
That the greater portion of the lens is transparent and in a normal con-
dition, and will, therefore, swell up far more than a calaractous leiw,
after laceration of the cafiHule and the admimion of the ni|ueou3 humor,
as, for instance, in a needle operation.
[11. Another very rare form ia the spindle-xhaped or funifvrm cata-
ract, which is the rao.4C typical form of the axial cataract, running through
the entire diameter of the lens. It may be congenital or aci^uired, aud^
hafl been met with in connection with lamtdlar cataract. — U.] ^|
III. Cortical Cotarart. — The opacity generally commences at the
tnargin. Small, grayiah-wbite stripes are obaened running towards ibc
centre of the lena. At the very commencement, the interjacent let
subetance is either perfectly transparent, or but sparsely studded wit
little opaque dots, ^oon, however, the cloudiness becomes more general
and diffuse, until the whole lens is involved. Sometiuiea the stripes may
be observed both on the anterior and posterior cortical sulntauce, the
Inis between them being transparent. The difference iu their pogition
■av be easily recognized with the oblitjue illumination. The anterior
■inpea are close behind the pupil, whereas the others are far back in Ibe
and appear concave, the concavity being turned towanla tlic ob--
■j*»
I Pig. fifi.
Coruc»l c»ten«l.— K>Ult*hlp.]
^,_^ an incipient cortical cataract with the ophthalnM^cope
itufci well-defined stripes intersecting the red background, snJ
I
oatahact.
287
nulinting from the margin of the l«iia to the centre. Detiveen tliem, At
the YciT edge of the lens, Uiere ia often a fringe of sliort, stunted strifes.
Punctifonn opiicitif*i. which with the rthlifjuc illumination appei»red of
n finy color, now look like little tlark dots strewn about on anrl between
the *tri|i03.
In nir«- instances the opacity, instead of iKiin^ striped, consists of in-
numemble Utile dots with clear portion« of Iphk ituhtitance between them.
With the naked eye it looka like a diffuse uniform opacity.
The following symptomt are characteristic of a fnlly formed, mature
tical cauract : The opncity is of a gmy or hluish-whiie color, which
somewhat in density towards tlie centre. On ncount of this
while tint, the movements* nf the pupil appear peeuliarly marked and
dtHtinci. If the volume of the lens be increai^ed through the intbibition
of tluid, the iris may bo slightly arched forward, and tbo pupil some-
what dilated and slugiiish. 'Ilie stripes arc brond, wbite, and often very
opalescent, like mutber of pearl. There \» no artmixture of yellow in
the color of the opacity, which pnives at ouco iliat the nucleus is not
Lard. Witb the oblique illiimiiiation, we notice that the outer layers of
the cortical sulHtance. although opai)ue. are riomewhat tranitlucent, so
that wc can see through them into the deeper laycri. This is of im*
portauce with regard to the eonsiateiice, for iu the very soft or the fluid
catanict the dense wliite opacity reaches ifuite up to the capsule, and is
Dot at all ilinphanous.
Von (irnvre' calls attention to a pectilinr cataraet which is fometimes
met with in early infancy. Its disj^nosis i? of special importance, as it
M «ry frefiuently complicated witb lesious of the deeper structures of
the eyelMll. It commences as a milky- white cloud in the outer portions
of the cortical sulwitance. ami soon reaches ijuite up to the capsule.
'Hie opncicy is cither completely hoinr»;;eneou3, or studded with small
whilo (low which etlend close up to the capsule. The lens, wbich is nt
first somewhat iucreii^ed in volume, soon diminishes again in size on
account of the abt^orption of na ilui<l constituents. In eases, therefore,
in which the volume o\' the lens is much diminished, and considerable
opacitiea are lodj^ed in the central portions of the anterior capsule, the
degree of sight and the state of the field of vi^tiou should always be care-
fully tested prior to an ojwnilion, iu order that the existence of auy
deef^senUMl lesion may be detected. This form is not unfrequently con-
fioed to one eye.
The pmgresa of cortical cataract is generally rapid, more especially
in children, in whom it may become mature in the ciurse of a few weeks
or nioiit! ii. It) adults it may increase but slowlVi particularly if the
striiws are narrow and few in number. Broad etnpes and large floccu-
lent "iiaeities indicate a rapid progress. .\s cataract is not of very com-
mmi occurrence even before the age of fifty, we should always aH'ertnin
whether it may not have been produced by some special cause, such as
injury to the Icug or internal inQammation of the eye. If beth eyes are
aRucteil. the urine should be tested for the presence of sugar, as dis*
bet«s is a uot unfrei|ucut cause of cataract.
• "A. (. 0.,'* I. 2. p. Ki.
DISEASES OF TSE CRTSTALLIXS LBMB.
tea
ID,
Cortical cataract w always soft. In children it may be almost fluid.
Altfioii;,'li its consistt'nce iricrfases with advancing years, it i» generally
free from a hard niicleu3 up to the age of thirty or thirty-five, ami snffi-^j
ciently pulpy to be readily removed by linear extraction. ^H
Wlien a mature cortical cataract has exiaicd for some time, it raay^^
under;50 certain relroga-ssive changes. Il» fluid and fatly cwnetitucuta '
may hocoroe abBorbi-ii, and the cortiual ^uUtiince hccome m<tro dry and
consolidated. As absorption proceeds, the cataract •^hrircU u|>, the au
terior capsule becomes wrinkled and recedes from the pupil, »o that a
mure or lesd deep posterior chamber is formed.
The ca^wale sometimes looks tike a little wrinkled bag, containin,
sniatl white chalky chips of lens. In very youn^ subjects, the greate:
fiortion of the lens may hccome absorbed, so that finally there is noihi
eft but a small wliiie uhriyvlled disk, of a hard clialky considtence,
Tuia is the chalky or " siliculuse" cataract of old writers. .MtlnHigh^j
iim form may occur simply as the result of the absorption of the softei^H
constituents of an ordinary caiaract, it is still more frci|nently met wiib^^
in deep-seated inflammatory lesions of the eyeball, as, for instance, in
the latter itages of iridu-choroiditia. But the fluid constituents, in^tea
of becoming alworhed, may increase, llie eiructure of the Ions breakin
down, so that the catarnet m«y become extremely soft or even fluid, which
is especially the case in children. lu adidts, more jwrticularly after the
age of thirty, the hanler nucleus sets a limit to the process of softening,
which can then onty affect the cortex and not the wliole lens. Now, if
in such cascfi the curtlcul sub-
[Vig. Vti.) stance Wcomes Huid, the bard
veliow nucleus will sink down in
It, and thus the so-called "Mo
cagnian" cataract will be
^^^^^ ^^^ uiiced. [Fig. 9i.]
• 7 0%^S^^^^j^^^^ Thcchicf charactcristicfloffluid
l^^^i^^^^^^^^^^F cataract arc, that the opacity is of
a milky while or dirty-gray oolort
that it is homogeneous, aud tiiat
it reaches quite up to the anterior capsule, on tlie inner aide of which
are often observed small white dots. There are no cipKlcscent Htripes,
and the antcnor layers of the cortex are not trnnsiucent.
IV. Caiaract is not unfretjuently met with in those conditions of the
blood ;n which its watery constituents arc very deficient, so that it
assumes great den»ity (as, for instance, in diabetes). This gives ns'
to an exosrooais of the watery constituents of the lens, a loss of trans-
parency in its fibres, and a dojwsit of calcareous and other salu. In
diabetes, the cataract does not generally appear until a lale *.uvJ^<i iif
tlie disease, when tlie [latient is greatly emaciated and enfcehl«d. ami
bis health much broken. I have, however, met witii some cases in whic
the ojHicity of the lena appeared whilst the genei-al health was still gowl
The diabetic cataract i« mostly met with about or before middle ago
and docs not present any peculiar or characteristic symptom*. It gene-
rally afiecw both eyes, and is mostly of a so't consist .■nee, and rapid in
its formation. In elderly persons, however, it will be more firm, aud
III
c-
d
CATARACT.
289
contaiD n more or \esa hard nucleos. The porception of li^ht, and the
condition of the field of viMon should always be very carefully examined
in such cases, us ufTectiuutF of the rtfliiia and optic nerve not unfreuuetitt^v
oconr in tho conrec of dinbvwti, nnd may, thorefore, couxist wiUi the
CKUrnci, and thns render tlie pro^^o^l:) of the operation unfavorable.
Another fuct which shouM be remembered in o[>cratin<* for diaWtiC
cataract 13, that the iris U nften rery eusceptible of irrilntion, 30 that
iritis is t'xceptiniiall_v easily set up. The amblyopia which is aoraetimes
met with in {wrsiins affected with diabetea may, however, be simply due
to paralysis of the accommodation.
[From recent chemical invet^it^ations there is no doubt that the diabetic
cataract »omeliinofi couiain-t AU;{ar, and proltably always doc», thon^b
lht< quaiiUty may be so smitW aa nut to be detected. From statistics the
|)ea'eiita^c of cntnracl in diabetic palientti is Rmul), varyin;; from A.'JIH
per cent, to iK^ per cent. Becker rcgartis the prognosis of operfttions
tor tliu removal of a diabetic cataract as favorable, lie has never ab-
oorred suppuration of the cornea following an extraction} and plastic
irilia o(d\ occurred oiwe. — B.]
V. TV/*- Xiirhar </r ftarJ Smile OatnraH. — It boa been already
Btatcd tliJil after the a;;e of from thirty 10 ihirty.five the lena nndergoe.*
certain physiological ch»ii;;u9. The nuclear portion becomes tinner and
more contiolithiled, and atkiumes a vellow tint. This condition may exidt
fur many year* witliont any martc<l increase, without deterioration of
sight, ur withiiut any opacity beiii;; observable with ihe ophtliulmoscope;
hul the <livi.sion between the pbysiological and pathological coiHolidation
otw) cloudiuega ia only one of dcjtrce. When these senile chan'*es ti^
rri'&se lo such an extent that the si;;ht \» perceptibly impaired, and when
the opacity of the lens U progressive and becomes marked even by tiins-
nitie^l li;:hi, I think that we must Uieii uo longer consider it w^ a. phy-
Hiological condition, but aa commencing nuclear cataract. In the latter
die nucleus pi-eseot* a marked yellow or yellowish-brown tinge.
iS cosily distinguishable from the cortical suhstance. which may re-
main clear, except perhaps in the immediate vicinity of the nucleus.
With the obli<iuc illucDinaiion. the cataract wilt appear as 0 round yellow
upacity, AiUiatL-d at some distance behind tbe pupil. The anterior layen
f)i' the eorlieal ttuhtiiauce are Irauslucenl and transparent, so that we can
aee thrnugh ihcm into tho centre of the lens, and the pupil throws a deep
»ltadow u|>oii tho surface of the opacity. The nuclear cataract may be
very dark, even black iu color, which ia due to tbe imbibition of hu>ma-
tine. Tbe " black cataract" may easily be overlooked if the eye is not
examined with the microscope or the oblique illumination. In block
cataract the prognosis of the success must be somewhat guarded, aa it
is not uiifrei|uently complicated with intiammatory lesions of the deeper
tunics of the uyo, and a tluid condition of tJie vitreotis humor.
Pure nuclear cataract U but rarely met with. In tlie great majority
of coses of senile cataract tbe cortex is also affected, so that we have in
trath a mixed form — vie, a hard yelluw nucleus with a more or less firm
cortical subetjince. 1 tidnlc it well, however, to retain tlio name of " nu-
clear" cataract fur tbe senile form, aa indicating the presence of a hard
nnclciu.
200
DI5BASES OP TUB CRVBTALLfHB LBJiS.
Si'tiilp eatanict generally conimencpa at the periphery of the leiw in
tlic frtrm of small ctriitripcial stripes, TiPtwccn which we may often notice
amallLT »nJ shorter ppiken, situated lit tlie verv margin of the lerw.
Tlic fltripcH may mn along the anterior or posterior 8urFa«e of the lens,
the interjacent enbetance being clear. The opacity gradually hccomcs
more general, and Involves more and more the centre of the leiia : Use
intervals hetween the stripes hecoming clouded anil perhaps studded
with Ismail opnipic dotfl or patched. A& llic cataract progresses, the dis-
tinction liotween the nucleus and the cortex bcconica more marked, the
former showing a distinct yellow tint.
Sometimes tlie at-ripes commence in llie posterior cortex, extending
from tlie margin to the posterior pole of the leiw, where they coalciwc ;
the ojKtcity thus assutniiiga stellate appenratice. The iniervalit between
the stripes may remain transparent lor some time, as also the nuclear
portion of the lens, so thai we can see quite to the hack of the latter.
The view of the backjiround of the eye la of course obscureil in the cen-
tre by the confluence of tlie stripes, but if the aegmentd between them
are clear, we may yet at the periphery di-ilinguish the details of the
fundus: such form3 arc often csircmely slow in their progrotw. When
opacities commence at the posterior pole of the lens, either in the form
of cenlripftal stripes or uf circumscribed sp<)ts or patches, the general
condition of the eye should be cnrcfuHy examined, m this form of cata-
ract <_posterior polar cataract) not nnfrequenily shows itaiclf in H\e later
stages of sclerotico-choroiditis, posterior, retinitis pigmentosa, detach-
ment of the retina, and other deep-seated lesions. The coexistence of
any such complication would, of course, materially alfcct our progoosu
of the result of an opcnvtion.
Wc oceasionally meet with incipient cataracts in which there is a
marked difllTcncc Wtween the amount of the opjicily, according to
trhethcr the oblique illumination or the ophthatmoscnpc he used for ex-
amination. On account of the great opnIesceuce of the stripes, the
oi-acity is very apparent to the naked eye anil with tlie ohlitpie illumina-
tion : yet, on testing the vision, we find it surprisingly good, and with
the opbthalmoFcope we can, with a little managcuii-nt, clearly distinguiBli
the details of the fundus. I have noticed thia peculiarity several times
in myopic patients; the progress has generally been very slow.
In the majority of cases, one of the first fymptoma noticed hy a per-
son flfFected with incipient cataract is, that distant objects appear soroo-
wliat indistinct and hazy, or as if surrounded hy a halo. Alter a time,
near objects nUn become indistinct, and in reading, the print baa to be
approximated closer to the eye or observed through a strong convex
lens, in order that a larger retinal image may be gained. If tlic opacity
ia chiefly or entirely confined lo the centre of the lens, the margin being
clear, the patient will see best when his hack is tunied to the light, or
when he shades the eye wtlh his hanil, so that the pujiil hecomeii some*
what eidargcd. Dilatation of the pupii by a very weak solution of atro-
pine will have the aaiiie effect. If the cloudiness be confined to the
margin of the lens, the rcrcrse will obtain; the aight will be best when
the pupil ta small.
Sometimes, persons aufTering from incipient senile cat;t.-act, complain
I
CATAEACT.
291
that thvy are getting mjopio, ret^wnn;; tlie aid of a concave ^oss in
onler to (li3titi<;m)th tlistaiit objects. Tlic reason of this fact h some-
«htt »lotiI>tfiil, aitd cftii only be explaiiiecl upon the eiipt«OBilioii Hint tlicro
^ma eonic incrcuso in tlic volume ot ilic Icoh, which gives it a liiglier rc-
fmciivc power.
[t?iwcB curi-afiiojially come within tJie expencnco of ophthalmic au^
geotu in which the prt^'^encc of cacarnct has Ix^en dia^oAticntciI and %U
progrx'M predicted, und in which a varying time, extending soinvtinicd to
yesra, the uiKicities have receded and grown less, and fanally ctitirely
aisappt'iir. Tiie report* of the cure of Icnticnlfir caiaraci hy internal
medication and by electricity, ivhich have become of late quite fre<iueuC,
on donht may he referred to tliir^ niilural disappearjiiicc of the ojNicilies.
An actual progressive cataract, (^sjiecially one well advanced to maturity,
can of course be removed in one way only, that is, by operation. In
lome of these rojioned cure.*, a siih«c.|iient examination by a competent
Dphthalmoticojust would no doubt reveal the presence of the same opa-
niies that were recognised before.
In the er|uatoriat region of the lens we sometimes SCO in persont, who
bare reached the middle period of life or have passed beyond it. certain
bifurcated linear opnoitic^, which may extend entirely amund the Icna,
Ibotigb usually they are more marked above or below. These may exiat
for year^ uuchnngcd, but are certainly the beginning of a catjiract.
Tbey have been called tjerontAx^n hiitii or ari'UM aemlt't ffiitis, but a
better iKime is incipient cttlaract.—U.^
It viiirt toriui-rly thought that .senile cataract almo?(t always commenced
at the centre of the lens, ami extended thence towards the margin.
Tltis opinion led to great mistakes, and caused incipient cataract to be
often entirely overlooked.
On examining a mature senile cataract with the obli'juo illumination,
we at ODCC notice the prciicneo of a yellow nucleus. Its size may be
wtimated from the extent of the yellow reflex, ita hardness from the
dcptli of the color. Tho darker the yellow tint, the harder and more
compact will the imcleuH be. The cortical substance is of a gray or
bluisli-white cdor, tniversed bv numerous centripetal opalescent stripes,
and studded perba}ui with small wliilc dots or palehos.
'flie rote of progress of senile cataract is very difficult to determine
witli accuracy. It is far more rapid in the cortex than in the nucleus.
Sometimes years may elapse before it arrives at maturity. It may re<
main at an incipient stage for a very long time without apparently nuk-
ing any progress, and then suddenly advance very rapidly, arriving at
matarity wiiliin a few mor.tbit or even weeks. \Vc must, therefore,
always be n|>on our guard ag.LinKt giving a decided opinion aa to when
any given cJise of incipient cataract will be fully formed, luid fit for
operation. r.itients are sure to ask this question, and wc may fall into
great mistakes by giving a decided answer. This can only be predicted
with aiivtbriig like certainty, when the progresa of the ca^e lias lieen
Constantly watched. As a general rule, I may state that if the cortical
substance presents broad, white opalescent stripes and large flukes or
«poU, the progress la nrare rapid than if tho stripes or spots are smiU
and narruw, and the iuteniiediatc teua-substance clear.
292
DISEASES OP THE OBYSTALLISB LENS.
Senile cntaract occura mo«t frequently nfter the nge of 50 or 55, ami
aumior or liiler gcncnill^v nflectw liotli e^'es.
Wliitti n riiatiiiT soiiilf caUirnct huti cxii^totl for somo Icn;;tli of time, ic
may ftlso iiiiflergo some retro;p^s«i*c clianges; but these are far leas
th»n in tlie coniciil cataract, for they only affect tlic cortical Bub5tance
anii not tlio nucleus, which becomes liaHer and firmer. The fluid con-
fttituente maj he partially absorbeiU and aome of the olementa may
undergo a fatty or chalky dejieneralion, so that the cntnroct diminishes
in thickness and iMJcomei* Ualler, but i* vyry coherent. The moleeules
nre a;:;;regnteil together inUj small uiaMfies, whiuh bctiouic adherent to
the inner siirfac** of the capoule, or are often collected at the margin of
the lens. They may prove in so far dangerous, that they are very apt
to remain bt-hind in the enjisule when the cataract is extracted, and give
riee to secondary cntan^ct. In very nii-o inatAnces, a gpent portion i)f
the cataract may be absorbedj and [he siglil of the patient materially
improved. Jn the majority of such cases, the yellow nucleus may still
be seen ahiniiig through the cortical substance, hut now, however, no
longer tn ihe centre, hut sunk donti to the bottom of the capsule (Mor-
gaprnian cataract). If tlie cortical substance is gray, very opai|ue, and
jtri'tty uniformly studded with fine dots or psitcliL-rt. il may be considered
as ftoft ; not. Imwever, ]iulpy or diffluent, hut friable, so that small co-
herent portions are apt to remain beliimi, and adhere to the pnpil or the
corneal section after the chief portion of the cataract is removwi.
2— TRArMATIC CATARACT.
When the capsule \» perforated or torn by a sharp instrument, the
arjuvous humor is admitted to the lens substance, which may become
nijudly opaijue. If the perforation is extremely small ami superficial,
such as might be produced hy a very fine needle, the danger may be
but slight. The lips of the wound in the capsule may unite, and no per-
manent, or only a very Hmiteil, opacity may remuin; but if the uounil
is larger, much aiiut-oua humor is ndmitlfd, and the lens will swell up
very rapidly, and press upon the iris and ciliary bod v. The iris is often
considerably lacerated, or protrudes through the corneal wound, and this
greatly Increases the irritation and danger of severe Jntlammation.
Hakes of (wifrcncil lens matter, or broken portions of lens, fall into the
anterior chamber, and, coming in contact with the anterior surface of
the iris, produce great irritation ; or portions of lens matter may exude
through or become entangled in the wound. The inBaromation, which
may involve the iris, ciliary body, and choroid, may assume either a
purulent or serous character. In the latter ca-se, there may he more or
Jess increase in the Intra-oculnr tension, with the attendant train of
glaucomatous symptoms. In ehthlreu the danger of secondary iutlam-
uiation is less than in ndiilt«, as the lens is softer, the iris less impatient
of prcMure. and absorption more rapid; in fact, the lens may be almost
eiiurely absorbed, so that finally there only retnuins a small, hard, white
disk. The lens becomes more rapidly opa-jue in the young than in
elderly persons. I have occasionally met with casos in youthful iadi-
TR&UHATIC CATABAOT.
298
riilunlfl, in which, a few days aft«r the injury to die lcn.-t, the latter had
tKCoine alniost completely' cataractous. Ihc ewclling of the lena is ofteu
Terr cnnsiderahle, so that its volumo is much iiicroascii : the iris la coii-
(K-iiitcmly pii^hol forward and the anterior cham^fer diminished in m.c.
Till* |>rfaatire of the swollen Icua u|k>« tlit* iris ami ciliarv ImhIj pro-
dnot*3 great irritation, and may ^vl- ris« lo severe iriilo cyclitift. Tho
dan;;er ig vcr^- great when a foreign body — «. ,i/., a piece of gun-cap or
a irhij) of 8t«el — is Ia4j^ull in the lens, or, having passed through it, ia
fixed in the deeper tiftsncs of the eye, as it 19 frei(»enily followed by a
noal destructive inflannnation. After any injury to the lent;, the history
of the accident shouM he in<|uired intki.und if it wa-i cau.<ted liv a chip of
rteel, a shot, etc., the condition of the eye must Ix* carefully examined,
in order tiiat wc may. if jwaitiblo, a»icertain whetlior the foreign body ho
still in the eye, and whereahouts it ia situated. [It h well known that
small forcip) bodies way perforste tlie capsule, untcr the lens, and be-
come embedded there for a varying lime, soraetimea without causing Aiiy
special irritation. Generally their presence leads to clomling of the
entire lens, bui this is not always bo, a* the opacity may be limited to
the immediate vicinity of the foreign particle. The capsule may close
completely by first intention, and tliw cicatrix becomes scarcely percep-
tible. If, however, riome of the lena matter lia^ e^Euded and been z\>-
BOrbed by the a<|ueoiw, the wound in tlic capsule unites irregularly. »o
U to throw the capsule into ^mall folds. The appcarnDcc of a traumatic
cataract in that of the soft, cortical cataract, tor a consiile ration of the
tohject of the removal of foreign bodies from the lena, see paragrajih on
p. 23!»— also " Arehivea of Ophthalmology," vii., Xos. 2, ii, 4 ; ix. No.l.
— B.] After an injury to the lena, the condition of the eye must be
iDxioualy wQtche<l. The tentiion of the eyehnll, the atate of the sight.
and of the Beld nf vision must be frerjuently examined, so that Hie
earliest xymptonnt of any glaucomatous complication may he detected,
and. if f>»s»ibte, cut short. The danger of sympathoiic ophthalmia must
likewtae be kept in mind. A iranmatie cataract may alfto be produce"!
through a simple contusion of the eye, without any laceration or rupture
of the extenial coats of the eye. ITius a blow upon the eye or over tho
head from the tist, or some blunt body (a piece of wood, whip, etc.). may
ipw riric to traumatic cataract. S{>ecial attention vha railed by Mr.
LawHon to this fact jtome years ago, who recorded M'veral instances of
Ihia kiiMl.' In such cases, however, the capsule is genomlly ruptured,
in most iiwtances, as was pointed out by Von Oraefe,* at tho periphery
of the lend, just where the (hick anterior passes into the thin iiosterior
capoule. Sometimes, however, no tear in the capsule can be detocted.
rCaaeg of rupture of the posterior cajisule alone have been reported by
Knapp and .\ub ("Archives of Ophthalmology," i. 1), and an isolated
rupture of tho anterior ca^eulo from conttision has been reported by
Becker. (.Graefe u. Stemijich's Ildb. p. 2"ti.) — B.]
• YMi>"R. L. 0. a. R«p.," W. 179: also Mr. Uwwd's book, "On Injaria* aftbo
iyt," p. 13(1.
• ■■ iv-rllner K1ln(R<-W Woohi-nadtrlft," I8(:4, 19. A trnnslntion of Ihii Udnrv
upon Trnuinalic C'aMract will be fouml In the "Uith. It«riew," li. 137.
294
DtSRAHBS UP THE CRVSTALLINB LBMB.
3— CAPSULAR CATARACT, ETC.
Capsular nntarnct |irp»eiit8 a white, sonicwtiat clialky appcaraiicc, ami
i<i situated Id ttic area of the punil. Strictly speaking, titis term U in-
BcoiiraU'. for it woiiM aitpear uiat tiio capAule itflelf dws not Wcnmc
0]ia<[iir, for alilmiigK it may Wcome wriiiKlfrl and chan;z;r-<I in tliickncM,
it rttiiins ita trniispareticy. ii? has tuieri sbown by II. MulU-r' aod
Scliwcigj'cr.' According ti> Miiller. tlu-sf nimcities are not owia;- tu any
chan;!cs in the structure of the capsule itself, hut are due tfl tlie de]>osi-
tion on lis inner surface of new layers of a substance which is ufteo
nitu'li akin in Ita stnicttire to that of the capsule, but ia in other cases of
a fitrt.uii' chftracter. Certain hyaline chan;;;o» also occur in the cii|wule4
of olil ptrsiHiB, nliich are chiefly situated al the inner surface of the
anterior pnpsulo. If ihese tmnsi»iLrcnt hyaline dcportits shoulil uiider^jo
lu'if and there chalky degenemtion, Lliey Ikjciuiic manifest to the ob-
server, appealing as small whitish deposits ou tLe anterior surface of the
lena.
S^hwcipjrer insiatu stronjily on the fact that capsular cataract only
occuM n* a complication of a. previous cntaructous opacity of the leiw.
Tlnio. nhvn tlie tluid constituents become alisorhed in a retrograding
CAtaract, the hanler portions may become adherent to the inner ftortion
of the cfli>*ule, and thus produce an opacity at the inner side of the
latter, the capsule being here also somewhat wrinkled and perhap*
thinned. Thi.t opacity w chiefly situated in the area of the papil, atwl i£
of a whitish or whitish-bi-owii tint, and incrusted with chalky dej^wiw or
frn;^iit'ritd of cholesteariite erystuls, and its -tituation close beliiud the
anterior cftpsule becomes very evident with the oblitjue illumination.
The intra -capsular cclla arc generally unchanjred, exce])iin<; tliey have
beeomc destroyed during the process of Bilhciion between the inner sur-
face of the cai«vde and the Itni9 substance. The <liagno9is of this form
of rapsiilar opacity in rcinigrcBsive lenticular cataract ig of much prac-
tical imi»ortnticciii pr-rfornnnp; the operation of extraction, for. on account
of the toughnew and adhesion of the capsule to tlie sabjacent lens eub-
stancc^ 5ufiirieiit laceration with the cystotome will be very difEcuU, and
a displacement of the lens tnay easily occur. In such cases, it ia better,
iherrfort', inmead of endeavoring to divide the capsule with the pricker,
to iniri' its utiterior tuyer with a pair of fine iri-leotomy foi-cepn, ami
gently Mitlniniw it, which will not only afford a nufficient opening for the
ready exit of the leiw, bnt alw) rvniovt- the o(icii|ne thickened capsule,
which wouhl have 3uli!iw(ueiitly niJilcrijilly interfered with the sight. Or
ftjiain, in such a case the extraction of tlie len^ in ita cai^nle may be
iivdicflled. fr>r in ibew n*lrogre*.ive cataracts the adhesion iM-tweeti the
cap!*nle and the lonuU of /inn is generally S"> much loosened that the
Ien< r8ca|>es very readily in its eajMule, there being the h-tw fear of a
rupture of the latter as it is generally abnormally (oitg'i and adherent to
the lens.
[^ivJbri* holda that capsular cauraol najr be prinary aod remain eo
I " A. t O.," ti. 3, U, *aA til. 1. U.
■ n<U.rfii. 1.237.
CAPSULAR CATARACT.
295
for TCftn bcfoTO a Icnticulnr cataract malce^ it9 ftpj)«ai-iLnce. Tliis is
jiuru ptiakius, and uonsidts m&iiily in a proliferatiou of celU iifioii tKe
inner cclU of die anterior cnpiiiilt.'. It is not limited here, however, Lut
sprcadH to the ei|uator, ai»l even lo the posterior ca[>8ule. Not uiil^ U
tfaert' proliferation of xho intra-capuliir cclU, hut these crlU la'come
opaifiie. Such a pure jitiakitid provvt tliat thv tiyv n eUvwh^ru (JUua^tMi,
anil explains why tlie.-ii' eyes art- more prone to severe ruiiclion after
opcratioiLs. That capsular cataract may be primary, that in^ittdcponilcut
of lenticular cataract, u certainly true, and capable of clinical demoostra-
tion.— R.]
Cftjwiilar cataract is found mo«l frc<|ucntly in tho«o opacities of tJie
lens which are c<jai]ilicated wilh irido-clioroiditia, and here t;real prolife-
ration of the iiitra-c;i|wnUr cells occurs ; ihey may aiihM.|Ucntly undergo
fatty degeneration and tiimlly disappear and be replaced by calcareous
depoiiu; che ehalky de;{eheration of Uie \vui nut ui)frc(iuent1y taking
in start from the capitule (Sehwuig-^er).' \s capsular cataract occurs
motit fn>>{uviilly ill the tatter stn^ett orirido-clioroiditis. tlie history of the
case an<l the gi'neral conditioti of the eye, as well as the dejroc of sight
ami ihe exUMit of llie visual field must be carefully examined before any
operation is undertaken, in order thac iho prc^ncc of any deeji-doatcd
lesions (e. ,^., detachment of retina) may not he overlooked.
Aftterii'T ventnii atjitufar catanict uiay be congenital, but \s more fro-
ijuenlly formed in early chihlhood, in conscipicnco of a jwrforating ulcer
ol the citniOft. If it is conj;enilal, and there are no tracoa of iiiciri or of
an ulcer of the cornea, it is probaldy due to some intni-ulenne arrest of
development. But it 14 generally caused by an ulcer in the cornea, and
occurs in this way: if an ulcer, which id situated at or near the centre of
tlie cumea, |)erlbrate3 the latter, the n«incous humor escapes, the iris and
lens fall forwanl aiKl come in contact wit'n the comea. rlastic lymph U
effused in the ulcer, and a little nodule of ihi^ is de|)<>dited U|hhi the cen-
tre of the capsule. As the pupil contmcLi on the esca[>e nf che a-pteoits
humor, only the ccntnil ]>ortion of the cap.4ule remains uncovered by the
iris, aihl this is, therefore, the place where the cauiract is formed. As
the nutrition of the lens is impaired near the deposit of lymph from tlie
disturbance in the osmosis, the superficial layers of the cortical substance
in its vicinity become ^ih^iDowhat oiuicjue, the intra oapsiilnr cclU perhaps
alM undergoing proliferatiou, etc. Tae ulceration of the cornea heats,
and on the n4[ueous humor becoming again retaineil, it tears through the
adhcfiion between the cornea and the cipiule, the irii and lent recede to
their formvr pi;iition, but Uie cap^uUr opacity remains. Kre'iuently the
depi»sit of lymph (»h the capsule beconitM ali*4(rljed, and only tlie opacity
on the iimer :turface of the cajisulo and tlie con(igiion» jKU'lion of the luus
remains behind, the cajKSule though changed in its thickness being trans-
parent. Now if the cornea subse-piently clears, the true origin of the
capsular cataract may remain unsuspecu*d. But even in an apimrently
trans]iareut cornea I have often, with the oblii|ue illumination, been able
to discover a trace of a central capacity, showing tlie seal of a form4*r
ulcer. Even, however, if the cornea should in after years be quite
> hoc. dt., p. 23S.
29tf
DISEASES OP TSB CEVSTALLIHE LBy?.
clear, tliie woul<l not Ite a proof tliat there had not been a small central
perforating ulcer, for we constamly find exlenaivo and deeply Biiiiated
corneal opacii'ics clearing awav perfectly in the course of time. Another
objection wliicb \a 8omotiuie« urged against tliis viow of tlie otigiu of een*
tral anterior capsiilnr catiract is, that there could have been no perfora-
tion if no aoterior synechia remains. But the very fact of the formation
of tlie ua|ij(ular cataract in this way, precliideg the existence of an ante-
rior synechia (at leaal in the centre), for the adhesinii between the ante-
rior surface of tiiu cap^i^ulc and the coiTica luuat be so sliglit that lh«
re-accmnulation of the a<iuenni bumor U sufficient to tear it through ;
which could not occur if so much lymph w»s efFiisod a« to produce an
anterior syuecliia. Moreover in very rare iii«taucea. of which I saw one
several ycnrs ago at Prof. Von Ark s, in Vienna, we may trace a very
delicate thread of lymph from the anterior
rpj_ j)7^ ca[>&ule to the posterior [iortion of the cornea.
When the central capsular cataract is very
0 prominent, and elevated above the surface
of the capsule, it is tenned *' ptfraatidal
cataract'' [Fi^. UT and ii8l ; but even in
such canes MUller has fouuil it covered by
Atut SiuixMv ] transparent capAule.
IFig. 98.
MafmlBcd tfTtluiL of ■ pyn>nilJkl Mtarkcl, Tlir |>«mllal (IiwIIdk reprtwoiila Ika (lilrknr*i irf (be
npapllf . ^tlp .l»iiMi> lliUnk uiJ ■bit*} ■iuIIIbp !■ Ui<-iia|>«iil> . ou mrli aMv aro III* FvtIIpiI Irni Dblvi.
WKiijr bnUiR bruli*n op lul-^ ifl('t>ulwb»a*«th llie (•tttolty. Lylov apun lb* |>ui!k«K4 i«)>iuU i>T*t Ika
v{>wlt]r U bUUIo llmiu llMua, Uae rs«att«f ItlUi.^-SotilasblpJ
Very Hiipcrficial wounds of The lens may aUn produce anterior capsu*
lar cataract, if, together with the cataractous changes in ibe lena sub-
stance, the intra -cJipKiilar cellt« mider;;u i)rulifiTation. Mr. llulke' thinks
Uiat it is protluced in ophthalmia neoiuitorum io the followjn;]; uianner, it
beiD<; remembered that the space hutweeti (he cornea and the lens i^ only
very slight: " In ophthHlniia neonatorum when the cornea becomes
inllamed and swollt^n, its poislerior suHace may actually come in contact
wilh tlio front of the lenn. and then a dot of lympii poured out upon the
latter by the inflamed cornea, or es-en the mere prcAsurc contAct, may
give ri(H) to opacity by pruveutini; the proper nutritional osmosis through
the capsule/* Mr. Hutehinsun,^ on the other lianil, supposes that •' the
mere proximity of the inttiimmatory .-ictinti on the surface of the conjunc-
tiva and cornea suffices to disturb the nutrition of the lens capsule, and
to prutluce deposits." It isdifficnU to imderstand, however, why. if (his
wore so, the disturbance of the nutrition, and the dc[H»iit iihouM uhvays
be confinetl to a xmall pui'tiou of Uie capsule in the centre ol the pupil,
and should not also affect the more peripheral part^.
' "B. L.O. B„"i.l88.
■ Itld., t1. lit.
CAPSULAR CATARACT.
297
Anterior capsular cataract may al^o appear after iritis, if an effusion
of l^mpti tins taken plnc«< inio the area of the ptipil, ami tJie posterior
«Tiifchi» «iil««e<|Uciulv yield to the action of alr«ipine, etc.. tlie adlieaiona
an<i deposits of Ivmph at the edge of the pupil mav ■gradual Ij.' disappear,
while the ceiitrn! no.lnle of exudation in it* area remains, and, on account
of the disturhaiice of the nutrition <if tlie leiis aL this ]>oiut, ma^' give
rise to eatnraetoua chan;ies in the subjacent lens matter.
Chauf^ea in the posterior portion of the capsule are of far lew frequent
oecurrcnce than in the antvHor. The opacities which are met with at
tlio posterior pole nf the lens (hence termed posterior polar cataract) are
generally du« to clianges in the cataractous portions of the neighboring
rortival substance, which may become i!itirant4'ly adlierent to the capsule,
or hyaline deposits may h« formed upon the latter. In rarer instances,
(Fig. M.
FuatHfldr poUt ntUMcL 1. 8r«ttiH> at Urn* I i. (IpariXj wna bf lr>katDlll*4 light; S. Opartljr
•■■a bj nBMM^ noht.— 5ettt«ablp.l
a new formatino of celU is ohserved on the inner aurface of the posterior
ifcpsule, beiu<; due to a pndiferation of the intra -capsular cells which
fiave extcniU'il themselvea to the posterior capsule (Schweigger).' Hut
the posterior polar opacities may be eituated in llie most anterior
portion of the vitreous humor clo^ to the posterior captulc. being due
to inflammatory or nutritive changes in the vitreous. In such cases, as
Stellwaj^* points out, the opacity presents a smooth and somen hat glis-
tening aspect, whereas that dependent on de]iosits on the inner surfnce of
the capsule is (generally rougli and granular, ppyecting perha|>» Bome-
whal into the lens aulwlam'e. ! have already called attention to tlif fact
that these opacities, situated at or near the centr.-*! portion of the |»ofltc-
nor capsule, are most fn.«)ueutly due to some disturbance in the nutriitou
of the lea? or vitreous humor, dependent upon chronic inflnuiinniions of
the deeper tunks of the eyeball, and are often met witli iu the lat«r
stages of sclerotico-choroiditts posterior, retinirlA pigmentosa, detach-
ment of the retina, or remain after serous choroiditis.
in very rare insUnces the opiicity at tlie pcjstcritT pole of the leiu-t may
be congenital, and is tlieti in all probability due to the impurlvct retro-
greasiou of Uie hyaloid artery (Ammon).*
I will now pnsa on to the ilifferent operations suitable to various forms
of catanict, comoH-iicing with the Hap extraction ; but before so doing,
1 must touch upon eertain important prelimiuai-y conHideratinns.
It is generally det^med ini|K>rtant that a cataract, especially the senile
form, shuuld he mature before it is submitted to an operation. \u ma>
' "A. f. 0.,"tIII.
> "A. r,0.,"iT. l.M.
'Aa£viiht.-ilkud4<)," 3d edilioo, p. 1&3.
^98
DIBKASBS OP TDB ORYSTALLISE LBX8.
tore catAract the opacity iuvotres Oie whole 1«n8, and the tru throw*
litUo or no shallow u|>on it. The sight i» so luoch impaired that tiic
patient is unable lo di3tin;»iush the largest print, or to count tingors. If
the cataract is imriiature, it will not come out en nuute, hut the traiu»-
parcnt jtnrtiom; of lens AHbMtaiiL'C are Mrippcd off, and remain adherent
to the ca[:«ule or the ledge of the pupil. Thvy swell up very considera-
bly, and mar prmluce great inSatnmauon or a dotiM secondary eatnract.
These nhi*ervatii>ti3 do not of course ajiply to Bonular cataract, which
may never hocorae mature. The <(uedtion now arises, what should b«
done if the cataract remsias irooiature for a long time, yet i^ so advanced
as greatly t<j impair vision? Can vr« hasten its progreva? Uudonbiedly,
but we run some risk in so doing — a risk which sliould uot, I thiuk, be
incurred except un-ler ]>eculiar circnm*tance-*. If, for inrtance, a person
who i.4 entirely dependetit upon his slight for hid means of suh&isteuce is
aflfected with ilouble cataract, whose progress is extremely s]<>w, and
which, thougli very immature, is sufficiently dense to prevent his follow*
ing bin customary occujKition, it may he advUahle to baBioo the progreas
of the cataract. This t« to be di>iic by gently pricking the lena with a
fiw ueedle, ho sm to !«ligiitly divide the capsuK' aiul the \vm substance,
an<l adiuit a little a<iucous humor. Tliis may be rcpeaic4l several time^
care being taken not lo divide the lens tor* frcrly at one sitting, lert a
severe iritis or irido-ehoroiditis be set up. The pupil is to bo kept widely
dilated with atropine, and the state of the eye narrowly watched, for
fear of any severe inflammatory symptoms ensuing. It is safer still, a*
was recoMjmeiided by Vun tiraefe, U' miike a pi-ulimiiiary iridect<miy, so
as to affnnl more room for the awelliug up o( the K-iii ; m ireover, the
oxisieuee of an iridectomy would prnvu of advantage wheu ll»e final oper-
ation of removal of the lens is performed. Thw proceeding is, how.
ever, aecooipauied by the disadvantage that it necessitates two oper-
ations, with an interval of some weeks between them ; wlilcli ofleti prnvea
of much ineoiiveiiicnce and anxiety to patient* who come from a di:«tance,
or to those wtn are of a very timid and nervous character. Indeed, uot
many patients will submit to .tucb repealed o}>erations. Since the ia-
tro<lnction of Voa Graefe's new operation, I miut confess that t have
paid Icfu heed to the necefisity of waiting with the operation until the
Cataract is ipnte mature, for 1 hare ohuinol excellent results where this
has not been the case ; indeed, 1 have removed wich perfect success
lanu'llnr caturncts in persons abo\'e the age of '25. As a rule, I should,
however, y)r';/Vr to operate on a cataraci which is quite mature, as it
atTonl^ a bettor chance of complete removal. Again, instead of ba^
tening the progrcis of the cataract, the Ions may be removed in its cap-
snlo, which obviates the danger of unri|.)e pi>rtions bving left b(!hiud.
WliiUt <m the one hanit, it is diingerouti tu operate to*i early, it roiiy alsa
be wn.ng in nail too long after the cataract is fidly formOil. In thildreu
(.■-),vcially, we should operate early, for otherwise the siglit ainI iJic seii-
jiliiliiy of the retina may permanenily suffer, and oscillaticii of the eye-
ball (nystagmus) may also be produced. Later in life, a mature cataract
cuisl for many years without the sensibility of the retina being
reeled by tliis pMive exclusion from the act of vision, Hut in cbil-
it ii differeut ; iu them the piissive sujppn^saion of tlie retinal image
CAPSITLAR CATAKAOT.
produced hx the cauract, apij*ar« Ut exert a similar infla«ncc upon the
leiiMbilitv iif tlie retina, m tliu active ^upprussioo which occun^ in cased
4if s^iuint, and which often rapidly leads to great amiilyopia. A^in, we
have seen that when a niHture- cataract ha« exidtud for some timo, it cnay
undergo certain rctro^^reasive chan^^cs, its fluid constitueuis may become
abiorhfd, fatty or calcareous numdes may he collected at its margin or
adhoro to the capsule, and remain buhiiul whuu Die Icnn is rumuvcd,
j^trin^ rise U^ inftammatnry complications and secondary catanict. It is
wi»er. therefore, to operate before such secondary changes have set iu.
Shotdd we operate upon the one eye if the odier ia tjuite free from
cataract? I think it U advi^alile, where the operation is nhnost certain
of snceei'diiig, as, for instance, in llic division or linear extraction of
cataract of young inilividnals ; for the operated eye, although differing
greatly in itii ^taic of n.'rraciion from the oilier, will asitist itomewhat in
the ucL of vii^ioii. The visual field will be extended, ami (he fear of
amblyojiia will be removed, oa the eye may bo Acpanttoly practised with
auicable cuuvex glaauea. Moreover, the personal appearance will be
imprtive<I.
fciliould both eyes be o|x'rated upon at the ssme time in cases of douhle
cataract V It is doubilc&s gjifcr to operate only on one eye at n time.
Unanspretcd peculiariticii in the conxtitntion or the temperament may show
tliemsetves in the course of the treatment, a prior kiio>«le<lge vf wliich
miLY prove of great value in the treatment of tlic other eye, and lead us,
|*rliiiiis, to select a different mode of o|)eniti(in. On the other hand, it
has been urgiMl that it is very rare to see a bad result (c •/.,t^iippunition
of the eomca") in both eyes, if tlicy have been operated uj>on at one sitting.
In lhi» |)Dint we must be touch guided by pentonal cia'umstancea. It
may U- very inconvenient for the patient to have the operations diviiled,
an>l tlie treatment tliu^ e>;ten<led over a long jteriod ; or, if he be in a
weak and nervous coudition, iL may be unwise to submit him to the anx-
icty of two oiicrations. If one cataract i* mature and the otiier only par-
tially formed, but yet aufficienlly oj>a*iHe to prevent tlie |»ationt from
following hia customary employnient. it may be necessary to operate upon
the former, so aii tn euahle him speedily to resume bin avoiiations whilst
the other is advancing to maturity. If no such ueceasiiy exist, we gen-
erally wait till )>otli cataracts are mature.
It is of little conde«|ueiice at what time of the year extraction U pur-
fortuod. Formerly it was thrmght adviiuiblo to openite chiefly in tJic
spring and early summer, but we now operate all the year rouinl, except
during intensely hot or cold weather, fur extremes of temperature are
liol favorable lor the progress of the cane. If the weallier \a hot ami
oppreniiitc, the puticnt^ heiome very rvsthiss, irritable, aif^ exhausted.
The time of day is aUo of little or no moment, although I my.sidf prefer
tlie nK>rning. for we can then judge by the evening whethei' or not any
primary iuftammatory reaction Is likely to set in, atid if so, we can witli-
oat tods of time en<leavor to check it.
Befitre an ojioraliun is decided ujwn, tlie general health must be ex-
amined, and if tliis Ih.' at all impaired tre must eudenvur to iiupi-ove it as
mnch ai« [tosi^iblc prior to operating. It i.4 of the greatest ndvantige for
the result of the operation to have the patient in perfect health. The
Ml
300
DI8BASB8 OF THE CRT8TAI.LINB tBNB.
chief feiir is. that in a weak ami decrejiid person the vitality of the c(
ronv lie »a low that ita healing [Htwer in grcatlv impaired, or tliat it may
even slough after the operation. A symjittitn of some importftiKC, »» hc'in;jj
indicative of this low vitality, is the tos!t of elasticity of the skin, ko tlmt
if wc pinch up a foh! of akin on the back of the hand it doe? not fnll hnckl
at once but reainiiia wrinkled. Severe cou^b or chronic liroucliitis i:oiitra-]
indicfttt' flap extraction. If dn it hie cataract occurs in youth or early j
middle age (before tbe age of 45), and if ibs formation is rapid, we iniut
examine whether the patient is suffering;; fnjin diabvles, for Uiih is a
imfi-eiiuont caiine of cataract. The lens l»ocrtme affected cliiofly in ibsj
later stages of the disease, when the health is much broken. The cata*
met 19 generally softish,and its formation rapid. In ubl persouF) amurel
or hai* large and hard nucleus will be present, but diabetic cataract doc*
not show any special cbaractenstics. If diabetes is found to exist, special
care mtut be taken to examine the sight and the field of vision, aa affec-
tions of the retina and optic nerve not uiifreifuently occur in the cours«
of the diseafle, and may therefore coexist with the cataract and rciid«r
the prognosis of the result of an operation unfavorable.
The general condition of the eye »houl«i always bo carefully examined-j
before an operation for cataract is determined iiptm. 'llie tenriiou of Uio
eyeball, the degree of sight, and the state of the field of vision imuit ba'
aseertnincd, so tliat the presence of any dcej>-8eated lesion may not eseapo
detection. Otherwise, wc might fall into the reprehensible and nnjusti*
fiable error of ojieraiiug ujion an amaurotic eye.
Should the patient be snilering from efiiphora, dejtendent upon aoraa
affection of the lachrymal apparatus, or from inflannnatinn of the eyelids
or the conjunctiva, this shonhl. if possible, be cured prior to the opor-
ntion, a* any such complication not only enhances the difficulties of
after-treatment, but may even endanger the result of the operation.
The method to be pursued in examining the [lercepiion of light and]
the condition of the field of vision, in a [►erson affected with matur
catamct, has been already ex|<l»ineil in the Introduction (p. -10). SiKt
a person should be able to di.<tingiiish a low burning lump at n diatancsl
of 10 Or 14 feet, if his jterception of liglit is good, and there is no lesioa
of the deeper tlmic^ of the eye. If there is any marked deterioration
of the pcrveption of light, or of the field of vision, tlie history of the e*m
miMl Iw cftri'rnlly in<iuired into, inonler that we may detect the presenoe,
of any com|iIiciitinH. If the nj>per or lower half of the field is lost,
miut suspect detachment of the retina ; if the lateral halvea are want
ing. an affection of the optic nerves. Cerobral amauroais generally
cause* a conoi-ulrie contraction of the field, or the latter may eommenoaj
at tlie tvmpnnil .-tide. In glancoiua the contraction of thu field hegini
almost invariably at tlie nasal side. If such a contraction of tlic field
exiiits, the tension of the eyeball must be aacertAined, and the other,
symptoms of glancoraa searched for. If glanoonui attacks an eye aftecteil
with mature senile cataract, the glaucoma must first be cured by ai
iridectomy, and then snbsr<pienlly. at the interval of several months
the rntarnct should be removed. Hut thi;« muM not bo done until all'
symptoiDS of irritatiwi and increased tension bare subsided, and thi
CATARACT — UETOOD 07 OPERATINO,
801
improvement in tlic natrition and circuUlion of Hie eje lu been firmly
re-e^tnlilished. (I'irf^ the article on "Glaucoma.")
^1if [miiil should be liiluted hy atropiDc bvfon) tlic operation. In a
very prL'ahyo]iic eye, with an exceedirtgly dUallovf anterior cliamWr,
tliere ig alw»ya ^oiiie danger, even to aii ex[>ert ojierator, of wounding
tlie iris eitlter lit>r')re the countiT- puncture is mitde, or whiUt the flnp is
being formed. Wide dilatation of the pupil is tlie best safcguan! against
such a danj^er, for ttic iris will bo removed nut of the way of tlie punc-
ture, tbo eountor-puiicturc. and the line of iucittion. When the a<)ueou!i
humor tlowa ofi', the pupil a^in contracts somewhat ; but this will not
be uf much cuiiseiiuence, aa the section should by this time be nearly
completed. The de;?ree of rapidity with which the pupil dJlatea under
tlie intiuvnce of atropine also uR'ords us a hint as to the probability of
iriti3. Von Graefe has called atwntion to the fact that, if the iria a
aly and (luickly alfected by atropine, there is lesa tendency to sub-
ueiit iritis than if its action is tardy and im[K!rrect.
^he pntient should be operated upon in the recumbent position, being
plac(--d vither on a vouch or in his bvd. lu the boapilul I prefer uperat-
mf; in Uie ward, ae there 10 considerable ri.-ik of the dressing being dla-
lurbed in the removal of tlie patient from tlic operatinj; theatre. The
light should, if pot-sible. Dome from the side, for this dazzles the patient
left), and cnus4>B much \e-*s rctlection upon the cornea than when it cornea
from the foot of the bed or from a skylight. The latter, iadeed, is the
¥Dr8t ii;;lic of all for eye opermtiona, more especially those of a very
delicate nature.
The position which the operator Is to assume with regard to the patient
will depend upon which eye i« to be operated on, and njHjn the fact
whether the surgeon is ambidexter or not. tsomu think it a sine <fud
Tt&n that an oeuliitt should be able to use both hands cipially well : hut
litis U not the ca^e. By chimging his position, he may always operate
witli the ri>;ht hand upon either eye, either by the upper or lower sec-
tion. Yet 1 stroiij^ly advise every surgeon to practise operating with
the lef\ hand, for he wilt constantly find it a great ailvancage to bo able
to use it well. For instance, in |K-'rfortuin}; iridectomy, ii is very desir-
able that he shouhl be able to grasp the iris with the forceps tiutd in the
left hand, and snip it off with the scissors in the riglit, or vict vrnd.
Still, if he finds, »fter much practice on the dead nubject, that he can-
not operate for extraction nearly so well with the left hand as with the
riglji. he should not endanger the result of the operation by using the
k'fi hand. If thu left eye is to he operated on (either by the upper or
lower section), the Kurguon, if he is not ambidexter, is to seat himself
on tlic couch in i'ront of the paiient, and on hit lufi side. Jf ho operates
with his left hand, he will stand behind the patient. The latter position
i< aUa to be assumed when the right eye is to be operated on
[Since the general introduction of Lister's antiseptic method of opcr-
niimi and treiitmcnt into general surgerv. attempts liave been made to
introduce tills owthrMl or some modification of it into the field of ophthal-
mic surgery. Various operators have practised autisejitic operating for
cttlarnct. and some have convinced themselves tlial the results tlius uU-
laiucd were more favorable than by the oU method. Still the method
302
DISEASES OP TUB CRTSTALLIM LBXS.
has not met witli general ttiloption, owing to some potnta of difficulty.
Tlic iiicauttoua spongntg vritit solutions of carbolic acid cannot be allowed'
Oil »ncli a delicat* organ as the eye. A complete closure of the wound
against nil coiiinct with ntmo-splieriu air is not possible, owing to the
connection between the conjunctival sac and the nasal duct. The appli-
cation of a cuiistanl sprav of carbolic acid during the o[ieraUt>ti 18 vcrjr
irritating to the eye, and nlao tends to dull the cd;;c of thi* knife. The
use of boracic acid solutions, in place of either carbolic or salicylic acitb,
is letis open to thrae objections ; and the dipping of the instnimcnta into
ftbsolnte alcohol previous to operating i.s perhaps to be recomm**nded.
Gravfe, of Halle. Ita^j practised the anciseptic metliod extensively, and
gives the following directions in operating for oauract : The tjay before
the operation be uses a one per cent, solution of atropine in the eye,
null sliurtly before llie operation he washes tbo conjunctival eac carefully
with a two per cent, solution of carbolic acid, aa well as the external
surface of the tids and surrounding orbital region. The eye is then
closed and kejit covered till the commencement of the operation with a
aponge (loaked iu the same solution. The inslrumcnta are tlien dipT'^d
in absolute alcohol and carefully wiped with a clean soft cloth. The
spnngoa used during the operation are all inoisteiKd with the same solu-
tion, llie spray in ordinary use is not employed at all. Aft«r tbe
ojH^ratiou is completed, and all coagula are removed, the eve ts asaia
car^-fully wt«tied with the carboViaed sponge, and atropine a instilled.
As soon as llie sponge is r^'nu'vcl from the closed lids, the whole regioa
is ci'vered with a piece of Ivtrncic liui freshly >Kiaked in a four per cent,
solution of boracic acid. TUia is covered by a piece of waxed cloth
snaked in the sane solution. Tbe hollow is then Glled up with picked
lint, ami o^'er all a flannel roller is [Jaced over botli eyes. Tht« bandac*
it changed every day for tliree days, and replaced iu tbe aame careful
manner by a simiUr dressing. Graefe think* that by this method bia
perceutstfe of \"*s has been less and the general results have been better.
Ill the I bitcd States the antiseptic ntethod in opbthalmic surgery has
not fouud as vet nuiDT adherents, probably hccaose the additiotial
trouble aod care has not been answered by the expectvd improTctiicnt
b molts.— B.j
4.— FL.\P EXTR.\CTIOX.
rtn this opcratioD the entire sectMo is wityn the liouts of the cvmM.
Tbe section tray be made eitber opwards or ilownwards, as tbe vtria-
tages are pretty evenly balaaeed. The downward aeetiM ia, Wweer,
the easier of the two. There is often, woceorer, aa aaeoetrgllabte
leBdcQcy for the eye to roll upnanls beneath the lid, wbidi malrnaiW
enhancai the dificuliiN of the cperatioci, and ■■/ P**^7 eaiUuTBdt
the apentar, especially dariatg tbe lacentMO of the capi«k and the
exit flf tht lew. the «hi»f adeanajea of oacfc Mode of iiyafitiiijL — J
be hiiefly auad •• be M ftOowa : U &««r «f Ifaa apfar aaMiiooXFix-
2tO], it Mr he Tgml that the bnad aMoth aai&ea of iha SHda e^ the
4
FLAP 8XTRA0TI0N.
303
pppcr lici will lio in contact vith the section and support it, ami thus
faci1iiAt« the union ', whereas the ttlgo of the lower lid inny rub a^^ainat
l}ie lipft of the iiiciitioii, or uveu get between tbetn, set up coiuiii<U''raKlo
irritauoQ, ami prevent ilie union bj BrM intention. Agiiin, if in the
trig. 100-3
tipper Bcetion the wound does not unite by first intention, cither (Vnm
the ocQurrence of prolapiK! of the iris, or ituppunitioi) of Uie edj^u of in-
cision, the rricatrix thiu produced will be hidden bv the upper lid. But
to this it may be objected, that if the prol.i]i!4e has ]troducc<l much ditt-
tortion of the pupil, the Initer mny be ao much covered by the upper
lid aa greatly to impiiir the vision ; so that it «itl be necessary to make
an artitiuiul pupil iu another direction. The advantages oil'ered by the
lower section [Fig. l"l] are, that it U more easy of ]>crformancc ; as
(Fig. 101. J
\
are al»o the division of the cap«u1e, the exit of the cataract, and the
retDovnl of the remains of cortical substance. Ulie cornea itt, moreover,
Icaa liable to be bruised, and, »houtd suppuration of the cornea occur, it
is more likely to limit il^elt than in t)ie upper section. Bearing tbeoe
points in mind, I .-should advise tlie hf<;inricr at Orst to perform the
lover section, until he hag sccquircd sufficient dexterity and experience
in operating to give each method a fair Irinl.
Tin; inatrumenla rct|uire(l for flap extraction are— 1. An extraction
knif*. 2. A pair of foreejo for fixing die eyeball. 3. A pricker or
tJraefe'a cystolome, for (iividiii-^ ihe ciii'Biile. -1. A curette, vfhich, for
convenience sake, is fixed to the other en-l of the pricker. 5. A blunt-
pointed Aecondary knife, ti. A blunt-pointed pair uf liciasors.
804
DISEASES OF THS CRVSTALLIKE LBXS.
Various forma of extractlcu Icnlves arc recommcQilcd by differoi
openitora, I utYsvlF prefer ^icliel's knife (Fig. 10:2). It is ratbcr luii
and narrovr, iiml iiicrcaace regularly, liut not too abruptly, from point .,
liircl, ao tliAt tlie l)»p i.s formed hy simply piisliin<; ttie blade on througl
tbc aut«rlor chamber until tlic section is completed, ltd wedge sbape'
Ylg. 102.
fills up tlie gap, and prevents tlie premature escape of tlie ai|iienti
liuui-)r. Tlie liandle is to be lightly beld betvrecn the tbuuib, fore, aiv
miildle finger, tlic Ihumb being slightly bent oativards at tUc joint. T
elbow tuu>it be kc]it vhm to the side and the urist steady, m that i
movements are made from the fingcrit and hand.
I will now proci'ed to ii description of the operation, and I sbult
tliroughoiit suppose that the right eye U to be operated upon by th
u]iper section.
I shall enter somewhat at length into the description of tbe mode
&(.>eraung, tlic accidents which may occur, and the priuciplea whic
should guide us iu the afcer-treiitment, because tuoitt of these que^tionj
are of imjiortancc in every mode of operating for tlie extniclion of cata-
ract; lieiiee it ia ab-solulcly necessary tliat the surgeon should bo ac-
quainted with them, even tdtbou^^h )>e may entirely abandon the uomiuon
flap extraction for Yon Gracfe's new operation.
riie operator should stand or stt behind the patient, who ts to bfti
placed in the reeutubent position. If he ia about to operate witboui
tixation, he will Imld the ui>[»fr t-yelid with the forefinger of bis le
hand, drawing it npwiinis ami uway from tlie eye. The tiji of the so
ond finger in to be {iLiecd -gently ngaiiiAt the sclerotic on tlic na.sal iiida'
of the cornea, :tu as to prevent the e^e from rolling too far itiwards. An
assistant is tu draw the lower eyelid down without evurtiiig it. Many of
our beat operators do not employ fixation, and generally n».ike admirabla
sections; but yet cases will occur in which even the most skilled opera
tor does not make the counter-puncture just at the desired point. The
chief difiiculty in operating witlioul iixaiio i i*. lliat the eye iniiy ndl
suiftly iiiwar.U directly the puncture is m:ide, or cvun bulore, so tha'
tlie coi-nea beconii^s alino^t tiidden in the inner cnntliUK, and the Vuifi
has to traverse the anterior cbamliur and to make the counter-puneturu
wiUiout the operator being able to see its course. This will prove e
trcmely embarrassing to the beginner, and rai^y even unnerve him fi
the remainder of the o|)crniion. 1 should, therefore, strongly recoi
m.'ud him lo fix the eyeball, as this greatly facilitates the first part oi
the opvmtion, and as there is not the slightest objecliou to his doing so.
It has been ohjcct^'d that the fijcnnon often produces [>ain and much irri-
tation, but this will hardly occu*. if it Iil- genlly am) carefully done.
M'lreovcr, 80 aensitive an eye wmd 1 prove most difficult to operate upon
witlmut fixation. Afterwards, when tlie rtperauir has gnined more con-
fidence and dexterity, ho may do without it, if he cbooscj. ^'oriQUf|
FLAP BXTBAOTION.
805
irtatriiQi«nts have been tlevisvi) Ibr tUii) [lurpoKu, but the common fixing
forc4>[M are tlie best. Tliuir iiho in tliis oiivriitiiin hati long been advo-
cated by V.in Graefc, and more Ifttoly hy Sir. France. A» soon as the
couiitcrpmicture is ma«let they are to b« rviouved, for the eve w then
comj'letely iimler onr control. Tbe operator should rather fix the eye
himself than entrust thia to an assistant, for it is impossible tliat their
haoiis can work to;;cther with such unanimity aa if both hands are
guiiled by the eame volition. If fixation be vniployoj, au astiistaut must
hob) tfac lids. If tlie rtLibt eye ia to he operated uu, be shouhl eiand on
th«-' left aide of the patirnt, and plaec tlie tip* of the fore and aecond
finger of hi» rijiht hand upun the edge of tbe upper lid (without touch-
ing tbe lashes), and draw tl p;ently upnanli* and a little inwards, away
from the cyeWII. If the lids are at all moist, a piece of linen may be
folded round the fingent, so as to prevent their slipping. The lower lid
is lo be held with the forefin-^er of hii* left hand. But if the ajwisumt 15
not dexterous and truiitMortby, and the surjjeon cannot uiwrate wrlj
vithoiit fixation, the ttprin;; !!|ieculuQi may be employed t^t keep tbp lids
apart, but 1 am rather afraid of it, as it ia apt to iriitat^: the eye, and
to press upon the eyeball.
The operation is divided into three periods — Ist. The formation of the
*2d. The laceration of the capsule ; iM. The removal of the lens.
first Period. — Let u» again assume that the right eye is to be ope-
rated upon by the upper section, and that tho operator will fix the
eye. lloldiug the forceps in bi« left band, he seiices a foM of coujanc-
tira and suhcotkjunctival tissue near the lower edge of the cornea (us. in
Fig. 103, after Fra?ice), or, as
I prefer it, ratlier more to the *''*' ^^^
nasal side, and draw^ tlie eye-
ball gently down, so as to bring
the cornea well into view. Tlien,
holding the knife lightly in hU
light iiand. and steadying the
latter by placing his ring or
little finger agair1.1t the tenij>le,
he cnlera the [Kiint at the outer
side of the cornea about a ipiar-
ter of a tine from lie edge, and
jnat at its transverse diameter,
am) then carritrs the blade stead-
ily and rather slowly across the
anterior chamber to the |ioint of
counter-puncture, keeping it ijuite
jjarallel to the Iris. Special care mnst be taken not to rotate it or to
pn-fci upon its edge, but rather to press upon tlie back of tlic blade, aa
if, in fact, he were wishing to out with this. If thii he done, the blade
will he puihed steadily on and fill up the gap, thus preventing the prc-
maturo escape of (be a<|ueou^ humor. I find this preftsiiig ujion the liack
of the blade one of the most difficult things for tbe young operator to
acfiuire. The eye of the o[fcrator is not lo be kept fixed upon the point of
the knife, but upn the {wint ubere he wishes to make the counter -putw-
i^il
S06
DISBASES OF TBB ORV£TAtI.INE LEKB.
ture, for this will insure t)i« kuife being brought out at Uie dcaircil gpot,
wliicli idioulil lie ali;:lilly in the upper half of tlie cornea, about n (|u»rt*;r
of n line from its edge. Aa soon na the counts r-puncturo is auije, the
forceps are to be removed iiiid the handle of the kuifo ttirued )>ack to-
wanl» th(^ teiitple, the bla'h^ beiii^ pushed Ktcndily on uniil Oie seoiinn is
atl but finished. When t>iily a itanW bridge of oroea reui»)rii« undivided,
the section is to be slowly eompluted by tuniinj; the edge of the knife n
little forwards, and, instead of carrying it straight on, drawing it back
from bcel to point until the eection is finished. Von Gmofe insists cspc*
ciaUy upon the advantngc of doing this, for as the narrowest part of tbu
blade thus is^ucn la^t from the incision, the tiap will be hss elevated tlina
hy the broad jtart : uiurenvcr, ihe altered |>OMition and direction of the
ktitfe cause a relaxation in the tension of tlie muitclcd of tbe eve, aitd
Fip. I'H.
Fig. 106.
thiL>i diniintinh straining. When the inciKinn is completed,
the upper lid is to be gently and carefully dropped, so that
it may not caccb in between the lips uf the wutiud and
evert the 8ap. llie patient having been calmed by a few
wonlf of encouragement, wc pasB on to the
^'eeonJ Peri'id, the 0/iatin;/ iif the Captuh. — This may
boiloiR' oithvr with the pricker (Fig. 104, which rcprcucnts
thin instrument, together witli the curette, which is placed
at the otlicr cml of the handle), or with <lniefpi'a cysto-
tome. The patient is directed to look welt down to his
feet, and the upper lid being slightly lified, the pricker is
intrwluced with its blunt angle downwards. When arrived
nt the inner i^ide of the pupil, it is slightly rotated, so as
to turn its point against the capsule, which is to l>c divided
across RS far n« the outer edge of tlie pupil by one or
mon' incifliona. The iKiiiii i« then turned downwards, ami
(ho instrument carefully removed, so as not to entangle it
in tiie iris or cornea, r'or flap extraction 1 jircfer ^iraefe's
cy^totome (Kig. lU.'> — beside it is an enlarged view), aa
it m.^kcs a freer opening, and as we need not change its
hoHKontal position in lacerating the capsule, whereas tlio
handle of the pricker recjuircs to bo a liule elevated, which
causes more or lust) gaping of the section. Care muHt be
hik.ri not ii> press tlie fmint of the pricker or cyfltot'>me
agiiinat the lens in dividing the capsule, otherwise we may
t»iwe a displacement of the lens into the vitreous humor.
Third I'triod^ lieinnml of the /v«^i«. — The patient be-
ing again directed lo look downwanls, tlio point of IUd
forefinger, or the end of the curette, ia to be placed against
the lower Ud, ftnd a gcutle, but ateady, pressure made upon the
globe.
rLAP EXTHAOTION.
[Fig. l"fi.] Tlie point of the otiier furffinger may be placed on the tip-
per poriiop of the evfllMilI, so as to regulate and alternate the pressure
to a nicoty. Tlie pivusure nii the
lowi-r lid HhouKl he at fmt back- [Fig, io«.]
ward, in order that the iippf r eA^c
of the leDB may be tilted ^li;;hiiy
forward a;^iiist the upper |rf)rtion
of the pupil, which gradually di- ,^^^fc_,- a
}ute* and permits the prci^cutjition
of the lens. Tlie prcs-tiire is then
directed a little nmre upwards and
hackwanU, tv) that the lens itil-
vance^ through the pnjiil into the
anterior ebaniber, and makes its
exit through the incision. If it g f ^
hattH a little in its course through
the section, it may he extracted ""
with the curette. The prei^urc —
throu(!houl sliijuld be steady, but
very i;t'title, in onler that the lens may not he violently jerke<l out, which
le gencmlly accompanied by rupture of the hyaloid momhrane and an
ipe of Wtreoiis humor. When the Xvxn has been removed, we shouhl
lamine its outline lo see whether this ia perfect, or whether it is irregu-
lar or notehol, as the latter shows at once ttiat portions of the cortical
Eultstiince hare remained behin'l. If the cataract ts not quito mature,
fmgnientii of cortex are apt to remain in the capBule, or arc stripped nff
during the nnwjige of the leiw tbn>iigh tliP pnjiil or the conieal imiision,
to either nf which they may cling. These portions should, if posslV»le,
remored, as they are apt to set up iritis or to give rise to secondary
ttaract. The lids are, therefore, to be closed and lightly rubbed in a
circular direction, so that any little flakes remsuning behind the iris
nuy be brought into the area of the pupil, whence they are to W gently
retDored with the curette, as likewise any portjonn adhering to the lipa
of the wound. The vision of tlic i>aUent may aUo be tested by trying
if In.' can crmnt fingers, and if it is not as good as miglit he expectc"!.
wc may examine again a* to whether remnants of lens substance still
linger behind.
We must now briefly consider what course is to be pursued if any
untnvrartl circumstance* arise during the ilifl'erent. stejis of the operation.
Under the following eircum^^tances, it is advisable to withdraw the
knife at once, and to postp<jne the o|H'ratiuu until the wound is united:
1. If the puncture is tufj near the edge of the conien, or in the sclerotic.
2. If it is too far in the cornea, so Umt the flap would lie too small. 8.
If the Oi^neous humor spirts out when the point of the knifo bait oidy juist
entered the anterior eliamlwr, for the iris will then fall forwanl u]iiin the
knife, which would bc4:<ime cntnngl(>d in tt, so that it would be impot^>«ible
to dnish lUe Kociion without lacerating the iris considerably. 4. If the
piiini of the knife is so blunt that it will not readily make the couutor-
piiitclure.
bliould the nipicou.s humor escape directly the counter-puncture has
308
I>I8BABBS OP THE ORTSTALLIJtB I.BK8.
been maJe, the secUon may ^et he Bnislicd without woundin;! the in9, by
placing Uie point of the fore or middle fiii;;er of the other hand upon the
edge of the blade, and pushing the iris off from it as the section is lieing
;g1ow1v completed. If, however, it is impOMible to avoid wounding the
iris, it ia better to cut bohlly throufrb it, as this ia far less apt to exciw
iritiit ttian if the knifu becomes L'ntangled in it. If the count*-' r-puitcture
is too doae to the iwlerotic, the Unire must ho slightly drawn bact, and
another counter-puncture made, or the size of the section be diminiflhed
by turning tlie edge of the blade slightly forwariU id finishing the ftap.
This shoufd also be done when the counter- puncture is too low. If it lie
too high, tJio flap will be l^no small, nod this may be remedied (^1 ) by
makifig another counter-puncture a little lower down, (_2) by turning the
edge of the blade buck in cutting out, or (li) by enlarging the section
dowiiwardit with a secmilary knife or a pair of blunt-pointed scii^ors.
The Ia>tt proceeding in to be pret'errod if the counter- puncture is much
too high. If we purpose doing this, the iiection is to be continued until
only a little bridge of coniea is left standing (Fig. 107 a). The knife is
then to be withdrawn, and the section enlarged by dividing the cornea
to the re<iuired extent at the counter- puncture with the probe -pointed
secondary knife (l''ig. 108), or with blunt-pointed scissors. The advan-
tage of lcavii\g the little bridge stJiuding is, that it will keep the cornea
Pig. 107.
m. 1U8.
\.
tense, and prevent its yielding before the knife or Miason. The bridge
U then to be divided, or, before so doing, the capsule may bo o]wDCa.
The size of the Hap should always be noted ))efi)re the section is coed-
pleteil, BO tlmt we imiy enlarge it in the al)ove manner if nec«'ssary. If
tJie section i» too small U> permit the ready exit of Uie lens, there is much
danger of rupture of the hyaloid membrane and i-$cape of vitreous humor,
ami uf bruiKiug the iris and comea. It is also advisable to leave tho
bridge rttiiu'.hng if the {atient is very unruly, and strains greatly as wo
are uLaking the section. A few moments' re»t will generally sufllice to
restore his quiotmlc, and then the bridge may bo diviiled.
If the Icus docB not, at the third period, readily present itself iu tho
rtAP EXTRACTIOtr.
300
pu|Ml. we must od no acootint attempt to force this hv pressing etrongly
on (lie p^c; tiut we must Iaceral« the capaiile ngain, aod more freely
than Wfore. If the capsule be so tongli as not to be readily
torn vfith the cystolonic, it someliines cornea away with IJie [Pin. lOB.J
|en», or it may lie divided with the fioint of the Itiiife. or be
ll'lcrwanU rfiiioveil with a Imok or n pair of iris forceps. /
If a little vitreous humnr escape!^ with the lena, it is hut |
of slight cou9e<|ueQce aa far as the immediate result of the
operation is eouccmed. Some operators snip olT the pro-
truding |)ort.ion of vttreotis close to the incision, but I tliitik
it be^t not to do HO, as it is simply followed hy a fresh ooatiiig
out of vitreous; I therefore only close the eye at once, and
apply a finn compress bandage over it. But it is very dif-
ferent if it C8ca|>e8 before Uie len^t, tor then it will push the
latter aside, ho that it may even fall to the bottom of the
vitreous humor. If this accident should occur, a t>oolc [Fig.
10{*] or scoop should he pas!4e<l behind the lens, and the
latter gently ** fished out." It should be extracted at all
liBJtanU, for if it remains behind it is but too liLelv to sot up
a mo4t destructive and painful panophthalmitis. ^lany ope-
rators do not consider it of much coi>8e<|ueuco, if even a
conaidemblu amouttt of vitrcoiu is lost in an operation of
extrikction of caurnct. But there is no doubt that it is al-
waya a source of great dauger to the future safety of the
eye, for it not only freipiently induce:* an insidious form of
irido^:horoiditis, or inflammatory or suppurative changca in
the vitreous, but it is al^o, according to IwanofT,' generally
followed by detachment of vitreous, which may lead to de-
tabbmeat of the retina. This is likewise proved by the in-
teresting and important experiments of (iouvea* on the eyes
of animals.
After the exit of the lena, the comeHl fiap sometiines be-
comes wrinkled and collapsed, so that it tails away from
tba lino of incision. 'I*his wrinkling is due either to de-
orrase of tlic intra-ooiilar tcnsiiui, nr to a diminution in the
elasticity of the coniea. Von t.traefe by? great stress upon
the importance of this symptom, considering it uiifavoratile
if the collapse be at all considerable, for he has found
that supDurtLtion of the cornea often occurs in such
coacB. If wc thercfoi-e find, in a case of double cataract whicli
b to >>e ofieratet'l on at one itltting, that the cornea of the first
eye becomes much wrinkled after extraction, it will be wise to suit-
tnit the other eye to a difTeri'tit mode of operation. In such cases,
also, great care must be takvn that the flap is not turned back when the
upper lid is let down. If the iris protrudes between the lips of the
wound after removal of the lens, or if the pupil is distorted, the lids
should be closed and lightly rubla'd iu a circular direction, so as to re-
place the iris, and restore the regularity of the pupil. If the proUi>se
"A. f.o.,"a».S.
Ibtd.. XT. 1.
SIO
SISEASBS or THB CRTSTALLINB LBXS,
stitl persiitts. it mtiy he ^tmily replaced wiih the curette. But if all oar
efforin prove unavailing, ii t;^ hy far tbt* best c^iurst* to draw it out a.
littlo further and snip it (iff. The iriJectomy will not he of the slightest
dimulvantage, more especially in the upper secuoii ; in fact, it may prove
of positive ttilvanlage, not only in favoring tlie euro, but also in exposing
rcmiiHnt-'^ of Iciw autmtant-e which niAy be aitualoil behind the irin, and
hiivu, porlmpfl, cauHod tliv pr(>lai)He ; vrliereiu) the uccurruiicc of prolapse
after cxtrtwtion is one of the chief dangers and annoyanecs of this ope-
ration. The protruding portion of iris seta up uonsideraUe irritation,
and prevents, perhaps, the union of the section, the aqueous humor
flowing off throii;^h tlir fistulous opening ; and this constant irritation
may act up iritis or irido-cyclitis. Kvcn if the iria unites with the stfc-
tJon, a broad nnsij^htly cicatrix will he left, the pupil being, perliajw,
greatly distorted or iilmost obliterated. To prevent all these untoward
ciimplicntions, I ntrnnjfly nilvi^e the removal of a portion of the iris if
the prolapse cannot he easily retunieil, or if the iria haa been much
contused by the exit of the lens, or by our endeavors to restore the pro-
lapwd pi>rtion. Dr. Williams, of Boston, U. S.. unites the odj-trs of
the corneal wound by a very delicate suture, wliich keeps tlie li[ws of the
inciflion in contact, t'aoiUtates the union, and dirninishes the risk of
prolapse, [!n the United States the flap operation has been very gen-
erally diacarded For either the peri]iherivsl linear operation of Voo
firaefp or some mntlifieation of It. — B.]
Ilcmorrlinge into the vitrcoiw hnnifir is a disastrous occurrence. Ic
may take platie either ut the time of the operation, or some lioui-s after-
wards. The patient complains of a sudden sharp pain, a gusli of vitreous
takes place, followed by blood, and the eye is lost. In such cases there
generally exists a diseased condition of the choraidal and retinal vessels,
detachment of the retina, etc.
The iif(«r-treatmcnt of flap extraction is a subject of great importance,
BA much may be done hy timely care and atteniion. As the rules with
regard to the after-treatment of cases of Hap extraction also apply more
or less lo those in which some other mode of extraction is performed, I
shall enter somewhat at length upon this subject ; and as the after-
treatment of the diflerent operations for cataract involves the same
principles, 1 shall lay down certain broad general rules of treatment,
which will, however, reipiire modification according to the exigencies of
pnrtienlar cases. It being of con8e(|uence to detect and combat any un-
favorable symptoms at the eariiest stage, the surgeon should visit the
patient very frequently during the first few days after the operation,
and. if possible, himself change the dres.Hingi, rio that he may watch the
condition of the lids, the quantity and character of the discharge, etc.
At one time the antiphlogistic treatment was in great repute. Local
anrl gencRil depletion were had recourse to, and perhaps reiieatt-^d scv-
eral times, upon the slightest appearance of pain or inBammatorr symp-
toms. But now this mode of treatment has justly fallen into disuse.
Our primary object Is to obtain adhesion of the corneal Hap hy the first
intention, attd this will take place far more readily in a strong hculUiy
person, than in one who is weak and decrcjdd ; nearly one-half of the
cornea has been divided, and for a time the other half has to c&rry on
VLAP EXTRACTION.
the natrition of the whole. nnH to assist in the process of union. It
mtist also lie reracmberorl thai this operation is gcncrallv perforrocil in
persoiit «|)ove the age of 5U or r>5, and even iiiileed iu the very aj^d,
wIhisc vital powers will not bear dopression. The <renera1 hc&Ith and
tiir reparative priwcTs of tin- jtystunt imwt therefore U* auataiiicd. The
U'tltT iin-l stronger tho pntii^nt's coiwtitution is, the more favorahlc mny
W the ]iro;pio«i9 of the rtmiU of tin,- ojtcratiMii. Even the florid, turgid,
apopk>ctic-lookiii<* individual narrankt n hettur prognosis than the very
aji^d. ilecrepid person, whose general health is poor and feeble, whoso
cheeks are pale and shntnken, whose arteries are rigid and skin nu<
elastic. Vou (rraefe also ennsiders (lie prognit^ia less favorable if the
eyohall is det-p-set and Biinken, and the diameter of the cornea short;
for iu such casei* tlaccidiiy and wriuUin;; of the corneal Bap, aod sup-
puration of the cornea, are of not unfroiiucnt occurrence on account of
it» feuhle nutrition.
The aficr-trratmont must be varied according to the general health,
constitution, and hahits of the patient. The diet should tVntn the com-
menceirieiit be light, nntritioiiiii, and easily digestible. Meat tnav ho
allowuil once daily; it sliould. however, be finely minced, so that there
ill iMi need for ma!*tication, which would disturb the quietude of Uie eye.
Uooi! beef tea or mutton broth may be given occasionally during the
day, but alops are, aa a rule, to be avoided. But whilst we endeavor
to au«taiu the patiout'a strength, wo must not fall into tlie opposite error
of over-feeding him. In a very pletlioric and full-blooded individual,
especially if marked inflftmmatory and febrik symptoms manifest them-
selves, a strictly antiphlogistic regimen must be oliserved. With regard
to fltimulantii and beer, we must be entirely guided by the patient's con-
stitution and habita. It ifl very unwise to cut off all atimutante from an
individual who has alwnys, and perhaps largely, indulged in their tuo :
mv shuuM allow hiui a moderate amount of Iu* customary beverage,
ttclitng the while its cflcet, and diiuiuishing or inereasing the >)uantity
the ca^ may demand. In feeble, deerepid ])erson3, stimulants and
matt Ittpior, together with a good nutritious diet, often prove of great
Mrvicv ; <iuiniMe and ammonia being also given.
It ijt well to administer a gentle purgative the day before the opera-
tion, so that the bowels may not require to be opened for a day or two
after the lauer. A mild dose of castor oil should then be given, in order
to prevent any straining ; and this may W repeated it' necessary.
When the operation has been concluded, tlic [tnticnt is to l>c placed
in bed in a darkened room. At night, his hands should be tied to the
side of the bed, to prevent his touchiug his vv^a during sleep. The litis
of both eyes may be fastened with a strip or two of slicking pLisier.
although thitt is apt to irritate from it^ shrinking and hardening. I my-
ilf prefer a light handoge, especially Liebreicb's, which is the most
jTenicnt for this pur^ioac. If this is found to be too hot. I employ a
^ry thin gauze bandage. \ piece of sofl linen is to be applied over the
eyelid to soak np any di-seharge, and prevent iu clogging and hardening
th^ charpic, a little pad of wliich is to be next applied, the whole being
kept in place by the bandage. But if wc deairv to exert mure pressure
812
DtSB&SBS OP THE CItTSTALLiyif LENS,
npoTi tlie eye, we miwt employ Von Gniefe's compress bandn^e, the
npplicutioii of wivicli, lio><crert deinainlK t'ur more cure ami [iraotict*.
Hit iimcli nicnly ntnl iitiL-iitioii aro reiiiiiivil in tlie npplication of these
bAiKtagcj, and in ihc regulation iif the amount of preitsurc, tlmt wo are
hut acrtiom able to entrust this to a nurat'. If we cannot cliange the
compress ourselves, or leave tbia duty to a practised and Irostworthy
assUtant. it is far better to abstain altogether from its iiae. It should
be chanjred night and morning, and, if the eye fcela uncomfortable, ercn
more fr«*mently. The ijuantity and character of the discharge upoQ
the liiion and charpic should he examined, as it affords a clue to the
condition of tlic eye. The od^os of the Itdn should be softly (tponged
with lukewarm water, so as to remove any hardened discharge from the
eyelashes, which may also be smeared with a littlo cold cream or simple
cerate. This will prevent thetr sticking together, and tlins interfering
with the ready escape of tears or discharge. Great care must, however,
be taken not to rub or press upon the upper eyelid, otherwise the coap-
tation of the tlap may be disturbed aud union prevented. Much comfort
and relief is nffordcd by the tipon^ng and cleansing of the eyelids and
the change of the compress. The eye shouUi not, however, Itc opened
or examined unless we speciallv desire to ascertain its condition. Union
of the flap generally takes place within the first forty-eight hours, or
even sooner. Then it is advisable to apply a drop of ati-opine onco or
twice doily to the inside of the lower lid, without widely opening tha
eye. Thii soothes the eye and dilates the pupil, so that there U lew
chance of a secondary cataract, &s the torn edges of Uic capsule h&n
no point to adhere against, and will therefore retract and shrivel up.
Moreover, should iritis^ occur, it will be of great advantage to have the
pupil already widely dilated. It is an inten'sting fact that if atropine
was applied before the operation, if effoct upon tlie pupil partially
returns when the section is united, and the a<iueDUS humor reaccumulated.
Hhould the atropine cause any irritation, a solution of belladonna should
he sul»:*tituted. A few hours al'ttr the operation, the [latient generallr
ex|>criences a slight sensation of pressure and smarting in the eye, whicn
lasts for a few minutes, but reappears at interi'als of an hour or two.
It is due to au accumulation of tears and aqueous humor. If the pain
increases towanl night and iMJcomes continuous, and the eye is hot,
and the pittient restless and uncomfortable, morphia sbonld be adminis-
terfd either internally or endermically. I generally employ the subcu-
taneous injection, varying in strength from Jth to JtJi of a grain. It may
be repeated if necessary. If the eye is very hot and painful, much relief
is often experienced from cold-water compre^ej*. Hut their use re(|tttres
much care and discretion, for if they are applied for Uto long a (irae,
tliey miiy ttepre»s the circulation of the part to« much, and thus increase
the danger of suppuration of the cornea. I have also sometiuu>s foitnd
great relief from Llic ajifilication of two or three leeches to tlie temple,
es|H>cially in plethoric individuals. I must, however, state that Von
it raefe, after having for many vears employed leeches, has now etuirely
abandoned their use during the first three days after the uporaiion,
lie thinks that they provi' injurious, inasmuch as liicy produce iu die first
itiatance an incrcaseil congestion of the infiltrated structures, aud thus
FLAP BXTRACTIOK.
313
fnvor Bupfturation of the eAs^es of i\\o wound.' In sach eatcs he much
{■refers, if tlio patient be j)Ivthoric uml rubticit, a kiuuII veiiet^ccti«ti of
t'miti four to oi^ht oiiiicrrt ; altio iT there its much iHiiti ACCmtipAiiit-d hy
coii«iil«raVi1e lichrymatinn niul Rwdliiig of the lidii during tlie lirsl tliirtj**
8)x huur!< aftur the operation, for during this period suppurative inflAia-
RMLtion generally commences. But it is not to he employed if suppu-
ration has already set in.
If the case goe4 on Trctl, vithout the appearance of any unfavorahic
#ymplf>m!i, such as severe puin lu and around the eye, rtwelltng of the
lido, unico- purulent dischar;;^, or eojiiou^ lachry motion, the eve should not
be opened during the 6rst five or six days. Nothing is so bad as being
too curious as to the re«ult, and opening the eye too early to assure our-
selves that everything ia going on wtdl, for this iniiy easily set up iritis.
It ia very different if imt'avoraMe symptonH arise, for then it is best to
o\iea the lids and carefully examine the condition of tlie eye, 80 that we
may know what is really the matter, and what treatment should he
mdopteil. The ujtper lid should be gently lifted, and the state of the cornea
and irifl examined. Tlii-t is best done by the li^ht of n candle, which
should he shaded hy the hand of the nurse or assistant until the moment
that the surgeon is ready to examine tlie eye. In this nay. the latter is
cxjioHed only for a few secondti to the light, iind the glare and intensity
of the illumination are far less than if rlaylight is admitted into the n'lom.
But the case may not run »o favorable a course. The thinly cicatrized
wound may yield, and a portion of the iris protrude through it. This
frcnuoutlv hapjjeiw a few days after the operation. The patient exj*ri-
eDcea a feeling of grit or sand in the eye, as if a foreign body were
lodged under the eyelid. The lids become swollen, the eye painful, and
there is a copious, clear, watery discharge, which, after a time, ottsumes
more of a muco-purolcnt character. These symptoms nmy arise suddenly,
perhaps nfter .1 fit of coughing or sneezing, which has caused the section
CO yield. If the prolajiee is large, and produces a wide gaping of the
wound, the pain and irritation are otion very great. The eye should be
opened and the real condition ascertained. If protrusion of the iris has
occurred, the lids must be gently closed again, and a firm compress
applied, which will not only fuvor the consolidatiori of the wound hy the
formation of a layer of lymph over the prolaiuo, but will prevent its in-
Creniting in Bii:e ; and by the continuance of gentle prewurc will even
cause it to shrink. Afterwanis, when tlie wound is (|uitc coutolidated,
and a firm layer of exudation covern the prolapse, tlie latter mny he
pricked with a fine needle, as bos been recommended by Mr. Bowman.
eo as to let the a(|tieous humor, which is distending it. How off. The pro-
Upse then shrinks and dwindles down, Tliis pricking may be repeated
■everal times. If the {)n>lap$e is large and iridely dii»tcnds the section,
it may he necessary to remove it, either with scisAors or with the cxtnic-
tion knife, a comprc** l)eing afterward-t applied. Some surgeons touch
the prolapse nith n stick of nitrate of i^ilver, hut thit; often produces
great irritation. The prolapse may have so drawn up the pupil tliat it
• Uf««r»> aink'kl LwUrv, "Kl. Uon«l*U.," 1803, t*knaUle>l in "(>|J)U»lniia
BU
UISE.A8R8 OP THE CRYSTALtlNB LBNS.
is ijiiite covereil by the upper lid, or evoii mvoU*ed iu tiie spction, wliicb
will afterwanUrt iipccssitatc tlie fonnation of an arlificial pupil, and tliis
will often nlso Ciiuec the pmlapse to sliriiik. Fmliip^ie of" the iria, occur-
riuir ttficr extraction, is not only a suiirce of louji-coutiiiued trouble
to tlie patirnt, but may even prove very dnngennw, l>y setting up pro-
tracted inllainniatory complications — e. {/., irido-choroiditis—uUicli may
fVfniually destroy the eye.
IJut still ninre dangerous io the occurrence of suppuration of tlift come*,
whicli i(» to l«! uiiiffly frarcd iliiriii^ ttu- first two days. It inny be diffuse
or cinKnnwcribcd. The former, noeordtn;» to Von Graefc, occurs ;;ciier-
ally in from twelve to twenty -four bnurs after the uperaticm, tlie latter in
from sixteen to thirty-si.t honrs. Tlie lids become .swollen and re<i, the
eye painful, and there ia a more or lew copious muco-pnrulcnt di<)ehnr);e.
Oil opening llie eye, we may find a considerable de^'^*' of chemosis 8ur-
roiunlin;; the cornea. If the Ruppiimtion is partial, the edges of the
wound will sIkmv a yellow |iuruk'[it iiiGltratiou, whlcli extends deeply into
the HuhtttJince of tho conu'a, the whole of tlie flap ))erhap3 aUo hucomin;^
opa<iuc. The remainder of tho cornea, however, rctAins its transparency
sufficiently to permit our seeing the iris at this }Kiinl, But if the sup-
puration is diffii3e, the intiltnition is not confim-d to tlie line nf incision,
iiut extendi- round the cornea, the wh«il<- exjiansc of which assumes an
opn<[ue yellow tinge. We must consider diffuse suppuration as lio|jelc»s»
for the inflaramntion j^enerally extends to the iris and ciliary body, and
in the woret casea geueriil inflammation of the eye (panoplithalmitis) en-
sues. If tills occtin, the inflammatory symjuoms become greatly inten-
sttietl, the pain is often excruciating, the lide gieatly swolU-u, tlie discharge
Ihiek, purulent and profuse. We can then »inly endeavor to alleviate the
sufferings of the patient by the application of warm sedative poultices
or fomentations, for all hopes of saving the eye are gone. IJut the par-
tial Buppuration of the cornea must also he regsirded with great anxiety,
for it may not only pa*« over into the diffuse form, but it may j^ive rise
to suppurative iritis or iridocycUtif, which may end in atrophy of the
glol e. It has been Ion;; a keenly -debated i|ue!'tiou whether tlie suppo-
ration commences in the iris and paasfs thence ty tlie cornea, or whether
it originates in the latter, and extembt secondarily to the ins and ciliary
body. Yon Gracfe maintainn the latter view. According to him, the
iritia which occurs at this early stngo i.-; pro|Migated or secondary, whereua
that which comes on at a later period is primary or simple iritis. In
partial ■'uppuration of the cornea we must endeavor if possible to i)revent
Its e.\tension, and this can only be done bv auj.porling the pjitient by
iiuiritioiis diet, hark and ammonia, and slimulantd, and by the application
of a prcMure bandage, ^o otlier local remclies will prore of any Brail.
Von Graefe first pointed out the advantage of the pressure bandage in
such cases, and I have myself freijuently seen it, in hiit practice, of the
greatest beneflt in limiting; the suppuration of the ctirnea, and can there*
foro strongly recommend it. In very feeble decrepid individual* it may
be alternated with warm chamomile or poppy Ibnieiitations, which should
be applied for an hour, at iniervnls of two or three hours. I know that
many surgeons will view the application of a jn-essiire bandage to an eye
affected with suppuration of the coniea with aijtoiiishnient and incredulity ;
FLAP BSTRACTIOS.
315
it ii, however, certain that it often pmvM very heneficinl, and tctwls more
than any other reuwtjjk- to diuiinish the SMflHiig »if the lids luid the liis-
char};c, nnil to lira'it tlio su|)|mratiiiii of the cornea. So much care and
nieety arr rcc[mroU in H[)pirmg the presiire baiulage, thai ttie surgeon
«hoiihl alu'iiys do thi^ himself, unlpei^ he has an exceptionally trustworthy
and flextcrnu;^ nurse. Yon Graefe has also called attention to tlit; very
irii[<orlant fact, that in very ohl and feeble in^Uviiluald suppuration of Uie
contea may oceur without their having experienced the alightcst pain or
TiDea^tiiew in the eye. The surgeon, perhaps, congratulates himself upon
the apparently excellent proj;rc98 of the case, and tJien, on opening the
eye, finds the cornea suppurated.
The primary or t^imple iritis which may occur after the extraction,
ihwa not Boncrally come on heforu the fourth or fifth day after the ope-
ration. It may be due to the bruising or contusion of the iris hy the
instrumenta, or hy the nast^i^ze of tlio lens throuj^h tlio pupil, or it may
be set up hy the irritation produced by portions of lens suristance which
have rvmainod behind. Tlie patient experiences piiiii in anil around the
oyc; the Iid--i became swollen, and there U more or lea,^ photophobia and
Inchrymatitm. On opviiing the eyo, we may find a considerable amount
of cheraosLS surrounding the cornea, which is clear, but the ntpieouit
humor is somewhat clondcd. the iris djjscolorcd.and the pupil contracted.
If tlie patient is aufficieuily strong, much benefit is derived from the ap-
plication of Iccchea to the temples. A stron^; eoUilion of atropine (four
grains to the ounce of water) should he frfi|uently applied, so that the
pupil may he widely dilated. Belladonna ointment .sliould be rubbed
oTcr the forehea«l three or four limes daily.
If, after flap extraction, the case has throughout pn>gressed favorably,
the patient may he permitted to leave his bed for an hour or two at the
end of the fifth or itixih day. He should, however, wear a light hand-
age, and the room he sotnewhat darkened, but it should at the fame time
be kept cool and well ventilated. If the romaiiiing in bed prfives very
trkiume. which \» apt to be the case in country people accustomed to an
sctire life, it mar he well to permit the patient to get up oven on the third
or fourth day. lint then he mnat be very carefully watched. In a hospi.
tnl in which there are no special eye wanls, the bed should have dark
blue curtains round its head,»o as to afford a protection againjtt cold and
draught, and t)ie bright light of the ward. In such a case, I think it
also very advisable to keep the patient in bed some days longer Itian
wouhl he ncccasary in a private r»wm or a special ward. At the end of
the first week, the l)andnge may generally be exchanged for a shade,
and the ])atieut he gndually accustomeil to the light. Should, however,
any inflammatory symptoms appear, such as photophobia, lachryroation,
swelling of the licU, etc, the bandage should he reapplied, and increased
care be taken of the eye. If the weather is favorable, the patient may
go out into the air nt the eml of a fortnight. This often proves of great
benefit, especially if there is any conjunctivitis, which is apt to become
chronic if the confinement to the house has K'en long. In such a case
a weak astringent collyrium should he prescribed. [Von Arlt prefers the
flap opcratinji for caiaracta accreta,with annular or total |iofteri<ir ^yiie-
ohiie, whether there are extensive post-iritic membranes or not, and has
si
316
DtSEASBB OF THE CRTSTALLCXS LBN8.
uever oWrveil eujipuratiou of the cornea in tltese cafic< after aucb an
opcratioD. — B.]
I have already ui«utiuiicii Uiat, in certain cases of immature senile
cataract, in wliicli tlic pro^rcMs m extremely slow, ami tlie o))neitA' so
advanced or situated (c. </,, at Uie posterior ])o1c' of the lenit) u» to impair
viaion coDsideraljIy, it ma}' be ailviKahlt! lo hasten chu progrusa of the
cataract b;f pricking the cap^uto ami iidiTiitting the atjucous humor to the
*" substance. Great care must, however, be taken not to divide ttte
ipsule too freely, as ihis may cause considerable awelHiig of the lens
substance, and give rise lo severe iritis or iridocycUtia. It is much
bolter to make only a small opening in the capsule, and to repeat the
operation if nccc«Hary, several timea, more capeciaUy if a considerable
portion of the lens is still tran^tpHrcnt. If ncvere itdlammation su|>«r>
veni'8, and if it docs not yield riipidly to iintiphlugiKticK, it is advisable^
wore especially if the tension of tlic eye is increased, lo remove the lcn«
at once, either by the tiap extraction or Yon Graefe's operation; in the
former case it would he well to make at the same time a large iridec-
tomy.
Von Graefe' has rocommeiidcJ that a downward iridectomy should
precede the laceration of the capsule. About 6ve or six weeks after-
wards a superficial crucial incision is made in the ca|j«ule with a fine
needle (the pu()il having been previously widely dilated by atropine).
This wide dilatation is to b^ maintained in order to aflbrd plenty of room
for the fiwelliug of the lens, and prevent its pressing upon tlie iris and
ciliary body, (renernlly, but very slii^ht irritation follows the lacera-
tion of the capsule, and tiap extruciion may be performed from about sue
to twelve days afterwards, when the cataract will readily escape. For
reasons already stated. I should prefer to make the iridectomy upwards.
I have before mcnlioncd that the chief dangers to be feared niter Hap
extraction are suppuration of the cornea, proUpsc of the iris, and iritis.
The principal causes which may produce tin: l»tterttre 1. Bruising uf tJie
iris by the iuHtnnuuiits and by the piuisage of the cataract tlirough the
pupil, more cspccinlly if the latter is somewhat small and rigid, so that
it dilates with difhcalty. 2. The contusion and irritation which the ilia
may suffer in the attempts to replace a prolapse. 3. The irritation set
up by puriiuiis of lens matter remaining behind the iris or adhering t<i
the pupil, wliicb is especially apt to occur if the pupil is small and rigid
and the cataract immature, or if it poi^iiesses a small nucleus, with a con-
siderable portion of solXlsb cortical substance. Now, iuacconUuoe with
the fact that tlic segment of the iris corresponding to tlie corneal section
ii the portion most ex|>osed to these differunt inlluences, we hnd that tttts
altoot-t always foniu> the starting-point of the iiifiummalion (iritis). lu
order to diminish these dangiTs it hm been proposed to remove this por-
tion uf the iris prior to the extraction of the cutunict — to perfonu, tu
fact, a preliminary iridectomy. Von tiraefe originally pointed oat that
■ " An hiv f. OpblhnllDoloKia," z. 2, 209 : tmJo altw ■ pap«r a|iion tliii Bab)«v< hf
Vr. Maniilmrdt lu ilio "EJiuaugsljiTieht (l«r OplitliAlumloijiiK'litfU 0<»«llHcliaft."
FLAP BXTRACTION.
SIT
such a proceeding mt^lit b? advnntAgeons in some CABes, Jind Dr. Moor«n'
iiubBei|iienUy submitted this plan to an exteiisive trial, witli raarWi sue-
ccas. Mooren makes the iridectomy about "2-G weeks before the extrac-
tion. Bm it raiiat bo admitted that few peraona arc wilUnj^ to undergo
two separate operations for the c-ttracttoii of cnUiraci, except this bo
tbftoliitelif nccesaary. To avnid this inconvrnienre the iridectomy may
{be cotobined with the operation of Bap extraction, aa waa advised by
JacobsOD, who introduced the following moditicaliun of the Hnp extmc-
tion.* The patient hnnng been placed under chloroform, the h>wer flap
extraction is to be performed, the puncture and coiiiiti'r -puncture, how-
ever, lying about lialf a line below the horizontal mrridian of the cornea,
and not in the substance of tho latter, but in the sclero-conieal junction,
as he believes that union takes place more readily here tha.ii in the cor-
nea. The lens having been rctnored in the usual manner, he excisea
the corrc8[>onding segment of iiis, in order to diminiah the risk of iritis,
prnlapfio of the iris, and suppuration of the cornea.
I have mentioned tliat I'l-ofvs^or Jacobaon places the patieut thorouiihly
under the iriHuence of cldomform. Most ojieraiors (amnnnHt whom [
must include myaclf) have biiborto been afraid of giving cblorofonn in
Hap extraction, on account of tlie danger of vomiting or retching during
or after the o|tcnition. Tho wound i^ so Inrge (embracing nearly half
thi' cornea) that a fit of vomiting or severe retching may cause a gi-eat
loits of vitreous humor, and may even force out the retina and choroid.
'mfesHor Jacobson states, however, that there is no danger of vomiting
if the patient be thoroughly narcotixcd, and Mr. Windsor, of Man*
cheater, has published' a aeries of twenty cases of flap extraction suocess*
fully performed under chloroform. If cbbinifonu in given in eye opera-
tions, the pfttient should be placed tboniughly under its influence;
oiberwi^ie it h better to abstain altogether from it« use. These oj«era-
tiims, more espe^-ially those upon the iris and for cataract, are of so
delicate a nature, tliat a surhlen start of clio patient's head, or a fit of
vomiting or retching, may not only endanger the result of the otteratitm,
but oven the safety of the eyo. When the i>atient \e m deeply narco-
tized, the sudden inhalation of n strong dose of chloroform may prove
very dangerous : and it is therefore of great itn|>orlaDce to know exactly
what pen-ienta^'e of chloroform the patient is breathing. For tliis reason
I greatly prefer Clover's apparatus for ulminiiitering chloroform. It is
not only the safest metbotl, but by no other have 1 unilbrinly seen auch
perfect tranquillity and unconscioupneM produced, without there Iteing
any cause for fear. There U tittle or no struggling or straining : the
itiunt breathes calmly anc] cjuiclly : and when he is thoroughly under
[ts infliiLMii-e the most diffiLMilt and delicate ophthalmic operations may bo
ttertbrmed without fear or risk. In onler tliat there may be no vomit-
ing or retching, strict onlers should he given tliat the jialient does not
take any food or drink for three or four hours prior to tlte operation.
> "Pto Tvrmludmvii OrfKbruii cinvr nnriihaulvonllOTaug \»i d«r Suan-xtrao-
Ifon." by I>r. Mr>orrn. HiM.-hwitl.|. ll<Tlin, lr*«^
* " Kin iii>Mfni nnd g<-lahiti»<-* npprntinns— Wrfuhreii xttr II«llniig; (1m grauvn
StAnriw," vvn l>r. JawlM-xi, P«u>r«.. I1»rliu, ]9(I3.
* "0))hthuliiiw R(<vl(-w," vol. ii. SfjS.
818
DI88ASBS OF THB CRYSTALLIKE LKN6.
I
[Kdwani von Jaeger has recently invented a knife which from ita ahape
eflcctH what Lebi-uTi has sought to o1>tain hy iHp j^rathml rotation of the
hiailc. The knife looks like a lleer'e cataract knife, hm one surfKcc of
the bhide concave with a radius of (1-7 mm., the other convex with a
radiaa of 6 mm. The hack is straight, thin, and blunt. The knife ia
ititroduced with its convi>x ^idu towiirds the ;^U)he,und h pushed forward
horiznutjilly like Bcer'.t knife. Jnegcr ni.ikcs the section upwards, and
hence, owing to the curvature of tJie blade, there must be a different
knife for each eye. 'I'he openition is complet<?d without an iridectomy.
(See vofi Jaeger, Der IIohlMUuitt, cine neac StaarcxtractionsracthoJo,
1873.)_B.]
5.— EXTKACTION OF THE LENS IN ITS CAPSULE.
This operation was first practised by Kichter and Be^r, hut fell into
disuse until it was gnmc yeare a;^o rcintniduceil, amongst others by
Sperino, I'agenstccher, ami Wccker. Dr. I'agenstecher' originally re-
moved tlio lens lit its cupsiile with much success by the lower flap opera-
tion (the Bcclioii lyinj;;, hnwcvcr, in tJic sclerotic), combined with a large
iridectomy, the patient beinj;; chloroformed, lie has favored mo with
iJie following description of las present mode uf operating, for duriog
the laat 18 months ho has a4lopU'd Von (iraefeV n]»Hard linear incision,
and he has found that the delivery of the lens in its capsule ia (crff^n'*
parihus) as easy ns with the flap operation. Indeed, he has observed,
that loss of vitreous is leas fre(juent, and if it does hajtpen, less copious
than with the flap incision. In those ca/itf, in which the conuectioQ
between the cajisule and the sHspenaory ligament is not sufficiently re-
laxed lo pcrniil tif the easy extraction of the tens in its capsule hj shgbt
pi-CASure of the curette on the lower part of tlie coniea, he eniplova a
large, but very ahalhiw, round curette (made by Messrs. Weiss). This
is to be very carefully passed behind the e<{uator of the lens' and slid
downwards alung the posterior ca|)sule, until its free margin omhtaces
the lower circumference of the equator of the lens. After n slight rota-
tion, produced by turning the handle from the centre towards one angle
of the incision, the lens is gently drawn upwards, the handle i>f the
curette bciug at the same time somewhat depi'esaed towards the edge of
the orbit, thus pressing the 1cn» slightly against the conutn and preventing
its slipping out of the cavity of the curette. Since employing the lin*?ftr
incision he ha.*^ abandoned the use of uldoroform, as there is generally a
great tendency for the eye to roll uiiwarda during the narcwiH, which of
course renders the rojiiiipulation of the curette wry iliflieult. The eye-
ball, even if the curette is used, is to be steadily Bxed with the foa'eps,
which are ti> he applied at that point of the sclerotic wliich lies c:cactly in
the same meridian as tlie centre of the Linear incision. After having prac-
'Kllnlsi-Iifl B«)l)nrhtunKen," Wip«luuien, IHiJfJ.
' Till" mima^nrrt" in fnntitalfwl, a» Ilr. I'.ip'iwti-irUcr pnintu owl, if s lillle in-#a*nt*
b esorUi'l mi llu- lower ij»r(i«ii t>f tlir k'Ub. wliii-li cuuio-s llic ixiiiiiuU of iW i.o|Uiil<ir
to be tilted forwards, autt (re^iicntty di-tiKlii^a Ulu xounU fruiu tlie |>erip)ierjr of tli«
I
i
81TBACTI0H OF TUB LEHS tX ITS CAPSDtR. 819
ti^cil llic extraction oT the lens in its ca|)niile for a period of 6ve years,
X)r. Paaonstecher lias nrrivcrd at tite foUowing conclugionii as to the cases
iu which it is indicated: I. lie prcfora tlie extraction of Uic lena in its
caf>itulc tn that with Incerntion of thv latter^ in all thoso «a^cs in which
ii innv \te prL-sntucd tlint the Capsule is firiuvr than lia Bttachiiienl with
till* ronnlti of /.inn. Tlii:< jit'iieraUy occur in ca^es of over-ripe cataract,
tioth in thoM which are han) and noinewhat ohnnikeo, and those which
are Koftiith or partl,v fluid ( Mor<!agnian oalamct). 2. It i^ al^o very
BuitaMf in those casea in which the pntgroM of tlie opacity is extremely
olow, and certain portions of the lens always remain traD9|>arcnt, bo that
tht* cataract never becomes |)erfectly mature. Such cataracts are gcncr-
allr Htnall in sixe, and the capsule, is hut very slightly attached to the
sooaia. '1. It will, as a rule, be found suitable in thoac cases of cataract
vhich havo hveome developed after irido-choroiditis, and iritiji vith |>o.4.
torior circular synechia. The adhesions between the capaule and l]i«
iris niufli of conrfic be detarhed prior to the extraction of ilie cataract,
for which purpose a !*mall l»lunt-point*:il silver hook is to be employed.
1. It may be rccomraendt'd where, t^^gether with the cataract, there is a
tn-mulons iris ; for it will uftcn h« found that the latter is caused by a
shriukin<x in the size of the lens, or a diminution of the vitreous humor,
which should generally lead us to susijeet atrophy of the xonula. The
Vmt two eatojrorics are. moreover, also suitable for this mode of opera-
tion, U'i:nuse at the tendency to inflauiniatory complications of the iris
which extAiii in them ; in consetnicnce of which, it ia » niatier of much
iroportaikce to ^uard the iris against the irritation prcHluceU by remnant*
of cortical nubstance or portions of capsule.
[Jncohson'a operation closely resembles PageDAtdcher's. Macnamara
ban latclv advocated for this operation the use of a broad koratome in
" iling tiie incision, and extracts the lens and capsnlo without an iridcc-
' my. This iji the m'xlcl opcnition in theory. — uA
■Mr. Bowman has also occasionally extracted the lens in its capsule by
Grai^fe's ftfwratton in cases of over-ripe cataract, in which the connection
between the capsule and the suspensory ligiiment was relaxed.
Wi'cker' performs the lower flap ojienitioii ; the incision does not,
hnwever, lie far in the sclerotic, nor does he leave a conjunctival bridge
sitandin;;. A |iortion of iris having been excised, he passes a curette
In-hind ilie lens and draws it uut iu its caiuule. When tlie lens has
reachod the incision, an assistant, grasping its edge with a Daviet's
curette, oxtractii it. His results have also been very favorable, and he
ha^ often succeeded in extraotiog the lena without any loss of vitreous
humor.
[The desire to have a clear movable pupil has ted many sur^nns to
sitempt the removal of the lirns and capjtulc in various ways. KU'^hlrr
utidertouk to extract lens and ca|M>ule by splitljug the cornea in its hori-
fonul meridian, as in his operation for the cnre of corneal atapliyloma,
iiii thwn reinovin;* the lens without an iridectomy. (*' Graefc u. Sae-
ii.i-i:h'»» 1Mb, ilvr Angenheilk.,'" iii. p. 314.) ^f *rt^»/(i nmkes the pertphe-
rical linear incision as von Orucfe did, but the resemblance ceases here.
■ '* MftbulU-ff •!•!■ Vgux," 2d iidit., p. S2S.
mk
820
DteBASES 07 THE CRVSTALLtNB LSNS.
lie neither pcrfonnfi an iridectomy nor opens the capralo, bnt romorcs
leiw ami cajpsule witli an iustruiuvnt rcsciiibliu;^ WaiJ»u'» itpoon.
Ill lilt Chene caned the opt>rator sliotild (Lati;4fy himsctr tlmt ilie connec-
tion between capsule and zonula is a looiie one before attcinpUng tbe
dislocation of the leus and capsule en moMe. — 1).]
e^LlNKAR KXTRACTIOX.
Before describing tbis mode of operatinK^ I will glance for a moment
al its histor}-.' In 1811 Gibson introduced it ns supplcinent»ry to tbe
noodle operation, in lliose cases of *oft cntiiract in wliieb the lens (after
liaving been divided) waa not absorbed with tbe de3ii'ed rapidity or suc-
cess. He also employed it in capsular and niembranaceoug cataract.
His mode of operating consisted in removing tbe lena tbrougb n small
corneal section, wbich was about tbree linos in extent, and was situated
about one lino from the sclerotic. In lt^l4 Travcrs, after diWdin;^ the
capsule, displaced the Icuit in the anterior chamber, and then remowd
it Ibrough a small <.v)rneal section. He, however, aubaequrntly gave up
tbis metho<l, and, making a <|uarter dcccion of tbe corneii, divided tbe
capsule with the point of the knife, and if the lens was sulbcicntly soR,
let it escape throngh the section, but if it waA too firm for tbis, be intro-
duced a curette into tbe anterior chamber, and by its aid retnoveil tb«
lens piecenienl. Botli tbe opomtionfl of Gibson and Travors fell into
disuse, until about 18'>l, when Bowman and Von (jracfe, quite inde-
pendently of each otlior, reintroduced limuir extraction. Von Graefe,
having worked out tbe subject extensively and with great care, states,
in bis Eirst essay upon it,' that tbe linear extraction is especially in-
dicated in the cortical catanict of youthful individuals, and also in those
cases in which there is so much ftwcllitig up of the lens sulxstancc (eilber
in consequence of a neetlle operation, or of some injury to the lena) aa
to threaten the safety of the eye. But he thinks it unsuitable if llic tons
retains its iKjnnal consistence, and sUll more so, if tliere is a bartl nu-
cleus. As a general rule, linear extraction is, therefore, indicateil in
ctaea of cortical cataract, occurring bctw*een the age of ten und thirty,
or even tbirty-tive. It i." ali><> often employt'd with advantage as wipple-
mentarj- lo tin- needle opt-nitinn. I.inenr extmetian is to be performed
in the following* manm'r: The pupil having been jirvviously well dilated
witli HtTDpine, and tbe patient placed under tbe influence of cblorofonn,
the eyelids are to be kept apirt by Wcif^s's spring speculum, and the
eye steadied with a pair of forceps. An incision is tbeu to be made in
the cornea, at its temporal side, and about one line from the sclerotic,
with a hroftd itrni^iht iridectomy knife. The incision should he from two
to two and a half lines in extent. The capsule is then to be divided with
the ovsKHorao, and tbe lens removed. In order to facilitate the exit of
the cntnraot, tbe convexity of the curette is to be plaoed against tbe
edge of the comea, which causes the section to gape ; a slight countor-
' Pt>r on int^rMtlng htslorii'Bl A)t«tcli of thla o|M.-r«tiMi I muM rvter tlie roadtv to
Von OmcIt** jmi-T on " UmlllM I.iaaar KxtrKtton," *'Ar«h. f. Ophlhitlra.," xt. 3.
• "Arrti. 1. i>|>litbtJ.," i. ::.
LINEAR BXtRAOTION.
821
?
pTMcure h6tng at the same time exerted by the foreBnger of the left
DUiil, which is to lie lij^hlly ]>lHce(I a;^iii4t the inner Aiile of tlie o^ehall.
By nitornately proMin;; uith the curette anrl the finger, tlie soft lens
btftsucv will readily exude through the iucietiun. If jwrtions of corti-
cal subetanco remain hehiiid the iriti, the liiU are to he closed, and the
globe lightly rubbed in a circular direction to bnng these flaken into the
Mpil or anterior chamber, whence they hwit be readily removed. Or
Mr. Itovrman's suciion syringe may bo employed for this piirpoae. Should
the iri« protrude through the inciKton it must be gently replaced, but if
it Una iMien much bruised by the exit of the lens or the movemeuts of the
caretto, it will be wi»er to excise a portion of it. A light compress
baud:ige li to lie applied after the operaUou, and the pupil should he
kept well diluteil with atropine.
Vitn Graefe found that, although occasionally a cataract possessiog a
firm nucleuti may be removed tlirougb a linear incision witliout danger^
tlii« operation in, as a rule, inapplicable vrlien the nucleus i« hard, for
the iris mui-t then be more or Icae bruised by the passage of the lens
through the narrow aection. The acoop may nUo have to be introduced
into the anterior chamber behind the loud, ^o aa to facilitate iu removal,
and thiii, of course, achU cti tiiu coniu-«ion of the iria. Great irritation of
the latter is likewise often producer! l>y jiortifms of hard lens substance
remaining behind the iris or in the pupil. Now, att the seguiuiit of the
iria whivJi corresponds to the incision is the niwt expoised to bruising,
and interferes the most with the ready use of the »coop, we find that this
is alm<>«t always the atartiiig-jMiint of any subse<|uent iritis, hi thuse
caset« in whicii there was a somewliat firm nucleus, Von Graefe was
therefore led to modify the linear extraction, and to excise a {Kjrtion
of iris prior lo the laceration of the capsule, and then to remove tiic lens
with a broad flat scoop.' The stages of tJiia oi)eratiou were as follows;
1. The incision wa^ made at the edge of the ooniea (temjioml ^ide), and
embraced ahont a rpiartt^r of it* circuraference. '2. X portion of irin was
removc^I, the »i»e of which did not, however, quite ctjnal the extent of
the incision. S. The capsule was freely divided (|uiLc up to the margin
of ibc lens. 4. A scoop was then introduced at tlie free edge of the
lens and gently inserted between the j>osterior cortical substance and tbo
iuiclcu:<. and the cataract llf^l into tne anterior chamber and extracted.
The dccKjp which he emplnycl for this purpose was shallower, broader,
and Bharjier at the extremity than Daviel's curette. Thiw originated the
modified linear" or *' scoop" extraction — an operation which afterwards
umvd so important a position in ophthalmic surgery. By this modi-
''fication Von iiraete greatly extended the applicability of the linear
extraction, for he wa^ now able to remove through a linear incision cata-
whose cortex was of a pnlpy consistoooe, and the nucleus mo-.lerately
rgc and bard ; a form of cataract which would otherwise have nccessi-
tated the flap extraction. I would here remark that to Vun tiraefo
belongs the credit of having first suggested, in some cases, the combina-
tion of an iridectomy witlt Hap extraction, and also of having introduced
the modified linear or scoop extraction. The principle of iho latter oper-
".\rcliiv f. Ophlhalm.," r. 1.
h
822
DtSEASES OF THE CRYSTALLISE LCXS.
Btion is t>33cnt'mlly his, whatever changes may be made in the shape of
thv scoop, ari'I it ia worthy of remark that the lateral operations andinii-
laie it more (o tliat oripunlly u^eil hy liiin. Mr. Critchctt lina already
pointed out these faca in his admirahle paper upon -woop extraction.' in
wJiiuU he says: "'nm-s there sudiK-uly appeared tliree new uiuthodn of
Operating for cataract, bearing the name of their nevenil champion* — the
method of Mooren, of Jacobsoo^auJ that of Schuft (W^hlau); but Justice
compels me to state that these gentlemen lighted tlieir bipers at the torch
of tlieir great master Professor Von (.Iraefc. Each of these methods had
been previou-tly au^csted and practised by him, but only in exceptiomil
caace, instead of as a general rule/'
Wnldau shortly afterwards contrived a different form of scoop, of vary-
ing (tize, which was (U-eper, broader, iiml flatter at the bottom than Von
Graefe'n. Iia cdjjes were, moreover, hij^h and tliin. so as to bite into
the lemi, the anterior lip being the highest, and thus facilitating tlie
removal of the cataract hy pressing after it. liy its aid he proposed tu
remove even the lianl senile cataract. It was soon found, however, that
this form of scoop was too lnrj;e and euniberaome, and its edges too high
and i'harp. and that it was therefore difficult to introduce it readily
behind the lens, more espvciully in Imrd senile cataract, in which it may
»ery easily caiise displacement fif tlie lens or rujiture of (he hyaloid
memhmue. ^Ir. Bowman and Mr. Critchett have since devised some
forms of scoop which Are far better and in nil cases preferable to Wal-
dau's. The scoop operation, as performed at Moorfiehln, has proved
reuiurkahly successful in the hands of some of our KngHiih ophihatniic
Burgeons, more especially in those of Messrs. Bi>wmaii and Critchett,
who have worked out the subject luost thoroughly, and have done the
most to bring this operation to perfeclion. As my description of it must
be necessarily brief. I would refer the reader to their admirable articles
upon this subject in the " Hoyal Loudon Ophthalmic lloi^pital Keports,"
vol. iv. p. 4.
Dr. Adolph Weber has lately introduced a mode of extracting hard
cat»racts through a linear incision made with a lance-shaped knife,
without any excision of the iris or the employment of a traction instru-
ment. He speaks in the highest terms of its success in lOd cases in
which he has performed it, and some other operators arc also very warm
in its praise. Dr. Wehcr has favored me with the following outline of
his present mode of operating ; lor a fuller description of [»n ypenition I
muitt refer the rea<ler to his valuable and very interesting article in
*' iJraofo's Archiv.*"' He employs a large lauce-shaped knife" (P"'^- ^''^)>
which is lO.l^'f mm. in length, and is 10 mm. broad ut a distance of t).5
mm. fnim its point ; and this width it retains for a distance of 2 mm. in
onier that the internal and external woimd may be of exactly the same
BiKe; thence it heconu-s narrower to pass over into the stem. The back
of the blade is not Hat, but hollowed out (Fig. 110 e). The blade is
bent at an angle of abiuit I'M'', in order that it may be readily used
> *' Royal London Uphthaltnic llMpilxl RopaMs,'* Ir. 3111.
« " A. r. O.," xiii. )S7,
■ Wlicn tht- cnlaract h uoi very lAr|[e and hard, Webt^ ums a somewhat muUliir
knito, whidi ia howwvvr ct>usiraci«.-d on the sunv principle.
LINEAR EXTRACTIOK.
323
from abore or the na»nl side. The pupil sbonlrl be kept widcW dilated
witli strojiiue fur a dav or twu U'rort' Oie operation. Tbe eifoball liaviiig
been Btc!idil,v fixed below thr coiitro of tht-! lower marjEiii uf ibo comoa
with A pair of brond fixation forcepd, ftml gently dravrn down, tbe point of
Fto. 110.
Ibe knife is to be entered in the centre of the upper margin of tho cor-
nea, just in tbe sclerfKronieal junction ; if ttie diameter of the Qomoa is
lesit than 12 mm., the tneiRion is u> lie a Utile further away from tbeodg»
uf tlie cornea. The Made U to be earned ttlowly and titvadily forwards
across the anterior chamber as far u.-^ the ba^e of tbe instrument; its
point will tlien have nearly reached the opposite (lower) margin of the
cornea. The knife is then to he fcrv »l"tvlff withdrawn. This will pre-
vent the sudden c«ca[>e of tbe atfucou^ humor, which, from itsi dtimulating
the cvnatrictor pupillu!. would eaunv ilie pupil to contract. Moreover,
during; the mIow and gni<lnal withdrawal of the knife we van pre» the
back uf the blade aomewhat a;;ninsc tbu cd^o of tlio .section, and thus
prevent prclapsc of the iris. The capsule is then to be very freely lace-
ratei], for which purpose AS'eber uses a very mitiutc double hook, the
stem being bent at an angle, ao as to permit of its being readily turned.
Tbe capsule is to be divided in tlic following way, the liues of inci»ion
lying somewhat Wneath the iris, as shown in Fig. Ill, where the dotted
line indicates tbe pupil. Tbe hook liaving liecii [lassed
down to If, Fig. Ill, tbe capsule is ia he divided fmm a ta
1^, and thence to ':,- then the instrument is to l>e again
passed to <i, and the capsule divided fmtu a Ui d, atid thenco
to r, the last incision lying, of course, along the inner
marj^n of the section. If, on the withdrawal of the hook,
the capsule does not present in the section, tbe instrument
is to \k reintroduced. pa,t!)ed down to e, and the sijuare,
torn pitrtion of capenle drawn out in tlie direction of /; or tb may be
extracted with a small pair of iridectomy forceps. The anterior thin lip
of a pccaliarly constructed curette is Uicu to be placed on the extenial
lip of the wound, so as to press this bsck a little, and thus facilitate the
presentation of tliw etiuatur of the lens in the incision, the exit of the
catanict being a8si!tu><l hy a slight simultaneous prcsi^ure of the fixing
forircj«s below the coniea. I)uring the exit of the lens, tbe iris generally
protrudes a little into the wound, and if it docs not retract at once when
the catanict has escaped, it should be replaced hy applying Oraefe's
vulcanite curette, and gently moving tbis from tbe angles tuwards Uie
centre of the section. Ttiis will soon cause the iris to retract, and the
punil to resume itsnorin:il position, a |K>int winch ithoiild He always care-
fully attended to before the u|)cration is considered as finished. ["Graefe
n. Saetuiseh's llnndh. dor Augenlieilk.," iii. p. lUilMt 1. — B.J
zu
DISEASES OP TUB ORYSTAtLIRE LBXS.
7— SCOOP EXTRACTION.'
Prior to thia optTation the pupil should ho widely dilated with atro-
pine, and lh« calnract examined with the obliijuc illumination, so that
the size and hnrtlncsn or the nuclcut;, and the consi^tetice or the cortical
suhflCnnco, mny he ascertained. For the mxc of the incision shoiihl he
apportioned lo that of the riuckus, and to the extent and consistence of
the cortical substance. The patient shnuhl he placed thoroughly under
the influence of chloroform, for any sndden start may endanger the
safety of the eye, more especially durinj; the period of the intrcKluctioii
of the scoop. The incision is to be made in the upward direction wiih
a hroad lauce-shapetl Icoife in the aclero- corneal junction, and should
avera;;*! rn)m 4 to 4J[ linen in extent. A corresponding portion of the
iris having been removed, the oapaulc is to he freclv divided with the
pricker. The next and most difficiitt step uf the ojicration is Uie re-
moval of the lens with the scoop, for wliicli pui*pose either Mr. Critcheti'a
(_Fig. 113) or one of Mr. Bowman's (Figs. 113 and IH) scoop« may bo
Fig. US.
FfK. 113.
Fllf. IM
employed. The eye having been fixed with the forceps, the scoop is to
ho introiluccd into the section, being turned directly towards the back of
the eye, so that it.s anterior lip ma)- glide past the free upper roar^^n of
the lens exposed by the iridectomv. When the edge of the scood has
passed the margin of the lens, it Is In be turned quite flat, and slowly
and gently insinuated with a delicate, somewhat wriggling movement
into the posterior cortical substance between the capsule and the nucleus,
until its further end has passed the margin uf the latter. When the leits
is well grasped by the scoop, it should be slowly removed, care beiog
taken that its anterior surface is not pressed too much forward, otherwise
it will hruise the iris and cornea.
8— VON GHAEFE'S MODIFIED LINEAR EXTRACTIOK
A' on Graefe has lately devised a very important mudification of the
linear extraction, which combines the advantages of the flap with the
scoop extraction. For whilst the section lies ahuoat entirely in the
sclcro^omeal junction, it yet, on account of its shape and mode
OMTmtioR, vid«> thp vnlimMp articlm hr Mr.
}t I„ 0. 11. Rep.." It. 4, pp. 31k ftiiil 3:12. [Aim Am
• For n full d»cripiiou pf Ui[n oi
eltetl and Mr. Bowman,
d'Oculistique, UJ. p. US ; and Ktfn. MMiatibl. f. ADs<:uli*rilk., l^l^. p. 340.— B.]
VO:i URAIFE's PBHIPHBKICAL linear EXTRACItOS. 825
fnrination, gapes sufficiently to permit tlie r«Aily exit of even a harrl
srnilc cataract without ilie aid of any tnictioii iiiatrumciit. The success
of this Qpenition hus. hccii so ;rrc&t that moitt ophihalmologiitt^, amongst
vriiotn I luay nMiitiou Mr. Bowuiuii. have- ctitirely aWu'lonocI the scoop
pxtmclion, and nren to a ^rojn extctit tho flap opcpfttion. My own cx-
pvrit'uce of it has aliw been extremely faioraMe, an<l I prefer it greatly
lo every other mode of extraction for Hciiilc cataract.
The operation is divided into four periods : 1. The inci$ion ; 2. The
iridectomy; 3. The lacerathm of the capsule ; 4. The removal »/ the
I. The patient harin<; been placed under the influence of chloroform,
the eyelids are to bo kept ii|Rirt wJtJi tho i4to|h8peculuiu and tiie eye
fixed and j^ently timwn down with a fmir of forceps, which are to be
applied close beneath the centre of the cornea. For thin operation I
prefer Dr. Noyea'a (of New York) specultmi, the rack and screw of
which arc on the nasal side, thus leaving the temporal side of the ^ye
<}uite free for the manipulation of the knife in forming the aoction.
AnotJiiT advantage of this form of speculum is. that it does not press
upon the eyeball, but lit^ the lids away from it. One and the same
s|K>culum does not, however, suit hoth cye^, but it mast Itc made right
and left. The same is the caxc with Weiss'* stop^peciilum, for the knob
of tlie screw i«hould always be on the lower bnuich fif the upper section
is mule), For if it is on the upper hninch its pn)je<;tion will eoiiKiderably
inoomniode the operator during tho making of the incision. If it is
fijtind during any part of the operation that the patient is straining a
j^ood deal and that the speculum is pressing on the glohe, an aHsIsiant
should \ie din-cied to lift it Forward a little away from the eyeball, and
keep it thus until the operation is completed.
'! In* point of a long uarroM knife' (Fig. Itft), with its cuttiiij; edge
npwanis, is then to be entered in tho sclerotic near the upper and outer
portion of the cornea (it tJie point A^ Fig. llti, which represents the
Fig. lift.
■
left comen), alwat one-third of a line from its edge, ao that it may enter
the anterior chaml«er ipiite at the [leriplierv. The point of the knife
ahoiild be at 6rst directed downwards and inwards towards f, so as to
enlarge the inner incision, and then, when tlic blade ha-s advanced aVKiut
Mj lines iulo the anterior chamber, the handle is to be depressed and tlic
point carried up and along to B, where the counter-puncturc is to bo
made, at a point lying oppooite to that of the puncture (^1). lii-eat
■ Till' kniff tbould Iw tny narrow. nra<liiaU,v Romn iii!>triiiiii'iit-mMc(>ni lure
•lc|>ttrt<^>l initTr- ttUil tnorr from th«^ nHi-iHiil mudd, aud likvn niEulx it iiint-h Iim» I>i<ku1.
Von (irM>fn Inj-s KT<*nt *lrifl»« n|if>n tin- ailvKiilAi;!* of Imviiii: lli« iiivtruuiviit vurj
narrriw. m Its »uiil|iiilMlnii al Die exln-niu pi^riplx^r/ »f tlio anu-rior ohamtmr Is
m(iL-I> iiuwo cuj", aud the (acUiljr of lurnlog it nmdi gnuilio- Ihan nlwn tli« I*Im]u la
bruai.
326
DI&BASBS UP THE ORYSTALLtN B LBKS.
(Frjr 117-1
care mmt be taken that the cottnter-puiicture does not lie too far in the
sclerotic, which may easily occur it' the presentation of the point of the
knife U not carefully watched, or the hiade is parsed too far downwards
and inward*! l)eforc it \» turned upwards lo mnke the connier-punctnre.
Such an error will (jive riiw to a wide gaping wound, and in a1) proba-
bility, if the patient strains* ut all or the sneculuin prusws on tlic filobe,
to great la-^a of vitreous, even perhaps hefore thi; irin has been cxciacd,
and almost with certainty during the pressure which has to be made on
the eyeball to facilitate the escape of the lens. In onler to avoid any
irreguhmty in the lieij;ht of the corneal flap (Lappenl ohe), Grnefc re-
connucndii that when Uie point of the knife is carried downn-anU and
inwards (towards f:. Kig. 11'*), through the nnierior chamber, ita edge
should not be kept tiuit« parallel to the iri», but tuniod a little forwaril.
By 80 doing, we give to the temporal [uirtion of the wound a more hori-
zontal direction, so that it lies in alniiwt the exact contimiation of the
l-emaiuder of the section.
Aa soon as the connler-imncture ha3 been made, the edge of the blade
ia (o be turned somewhat ftbliquely upwanU and forwanls,and llie knife
puiihed Htmight on uuiil its length is nearly extiausted. when the section
IB to be finished by drawing it slowly and gently backwards from heel
to point. [In Fig. 117, tlie section is rcpre«enl«d by tbe
nppi'riniist undom-d line. — H.] The knife will now be
bcneatli tlic conjunctiva, which if next to bo divided io
such a manner as to leave a conjunctival' flap of from 1
to li line in height. In order that it uuty not exceed
this extent, the edge of the blade must be turned hi>rt-
zontatly forwards or even downwards. If tbe cataract is hanl awl the
nucleus very large, it is advisable to make the points of puncture and
counter-puncture about |^ of a line loiter, so at; tu obtain a somewhat
larger section. Directly the counter-puncture is made, the a<|ueons
humor escaneit beneath the conjunctiva and bulges this out, giving rise
to a considerable tlironihus, which somewhat hiiles the exact point of
counter-puncture and the line of section. This is often very embarrassing
to the young operator, and apt to mislead him as to the true course of
the section he is making.
By this incision the track of the wound lies almost perpendicular to
the hurface of the cornea, and i« more steep (less slanting) than ibat
made by the hinco-shaped iridectomy knife. Thus the exit of the lens
is much facilitated, for ita enuator passes more readily into the track of
the wound, and the cortical substaitcc also exudes more easily. There
is, however, the ilisadvanta;;c that if the st'Ction is made too steep the
BU5i>ensory ligament lost-s Its support, and hence there is a greater
tendency to los« of vitreous humor than if the incision is made with the
lance-shaped ktiife. Von Graefe' does not now give the knife en steep
R direction in making the section as originally, but turns its edge sorao-
what more oblitjiuly upwards and forwards; in this way the external
wound lies throughout in the sclero-comcal junction, tlie conjunctival Dap
"A. f. 0.," xiii., 2, p. a», aiid " A. t. 0.," ilv.. 3, 100,
V09 ORABFB's I'ERIPIIKRICAL linbab bxtbactioh. 327
is more easily formed, and the section gnpos less than if it be made more
fttecplj.
If the cntarnct has a bi^, firm nucleus, care must be taken that the
incision is* anfficicntly tar^c to permit of the reaily exit of tlio l«nB with-
tjut the in'cessily of employin;; raucli presAire upon the e^-e, or tlie use
of a Bcoop. In nueh cnscH f always make the puncture and counter'
ptioctiire somewhat^ lower down, and a little nearer the liorizontal diNin-
eteruf thecomea, whieh is, I think, to be preferred to a more peripheral
position tkf the Heettnii. For b largo hani cataract titc incision tihould
lueasuri.' dbout ."» lines ; hut if the ciitaract. though iierfectly bare), i« some-
what lliktteni'd, one of about 4j Uik'h will suffice. This will permit uf
ilie vnAv exit of the cataract, a very gentle pros-*upe with a curette upon
the lower portion of the cornea sufficing to " coax" it out. If it is found,
liowever, during the fourtji stage tJiat the aection is a little too small, it
u better to enlarge it somewhat at each angle with a pair of blunt-pointed
Bcisanni, than to endpaviir to /'>T<^f out tlie lens by an extra dejiree of
pressure on the cornea, as tin* will bo almost sure to cause rupture of
the hyaloid, and an escape of the vitreoim huumr perhaps even before
the t-xit of the lens, in which case we dball he obliged to pass in a scoop
behind tlic cataract and tlin^ remove it.
Mr. Crilchctt prefers to make the section throughout in tlie coniea,
r|nite close to its ed^e. a he thinks that this diminidhes the chance of
losa of vitreous and uf prulapse of the iris, lie alao uiakcs but a small
iridectomy.
•J. T/i»' iridtctftny. — If the section does not come well into new, but
U BncDL'what bidden by the upjwr lid. an aasistant is to draw tlio eye
grntly down with a ]>air of forceps, taking great care not to prwui upon
rtr drag down the eyeball. The operator sboald then tarn down the tittle
conjiinetivnl flap over the cornea with a pair of very small iris foreepSf
for Tliii> the prolapsed pirtiun of the iris will he laid ipiite bare: the iris
should then, if necessary, be drawn forth a little more and excised to the
r»]iiire<l extent t|uite close to ita ciliary insertion. This is not, however,
Ut be done by one cut, but by ^-A succetisive snips, the scissors beinj;
slightly turnotl so bb to follow the curvature of the eyeliall, which allows
of ilii> blades being applied ipiite close to the jiection, or even peHiaps a
littk< ht.'tween tta lips. As it is particularly at the an;;ltis of the wound
Uiat little portions uf iris are apt to rein.-iiii involved in the section, spe-
cial attention should always l*e directed to these situations, and any little
protrusion be snipped carefully off. For if little portions of iris remain
m the incision, tliey may retard the firm union of the section, be pro-
ductive of much irritation, and ^ivc rise to a crstoid cicatrix, or to a
more or les» miiFiidurabte pnd»[iKC of tItc iris, which may nut only prove
HKTy troublesome by keeping up n long-continued state of irritntiou, but
CTvn danguruus U> the eye, by giving rise to iutlunimatory complications,
siieh M iritis serosa. Another point to which Von (Iniefc calls [»articu-
tar attention' is the position of the cut angles of the sphincter pupillK
af^er tlic excision of the iris, and lie always looks, before he passes on
to the laceration of the capsule, whether or not tite s|>liincter has re-
' "A. r.0.."il».,3, 13«.
U^
828
DrSEASER OF THE CRYSTALLIKB IBNS.
trtctod tft iUi proper position. If one or both angles of che aphinctcr
uro (linplacvil u[jn-aril» or iurulvod in tbe tiection, tlie convex durface of
tlio riilcanite curutte iiliould ))0 placed on the conioa cloric io tlic angle
of tlie wound towards wliich tlio pupil is displaced, n»d then gently |>A^ed
from tlie peripberv trnvards the centre of the conieii: this will not onlv
tend to piisli the ivia down, hut will ivlso stimulate the action of tht* wn-
Btriccor pu|iilhc, nud thus as!»isi in cauain}^ the retractiou of the angle of
the sphincter. li" only the nasal angle of the latter is involved, we may
punh this gently down and smooth the iris with the back of the oystototne
before we proceeil to lacerate the capsule.
The oxtent of the iridectomy must vary somewhat accnrdinx to the
siM- and hardness of the nucleus, and also aceonlin;; to the position of
the upper lirl. If the nnekMis \h hir^e :uul hard, I tliiiik it better to re-
move a considerahle portion of iris, even perhaps almost corresponding;
to tlie aixB of the incision. Kor this will permit of the ready exit of
eren a lar*»e hard cataract, without any bruisin-; of the iris. Moreorer,
if the upper Tnl hau;^ dowu sufficiently to cover the upjier third of the
cornea, no unsightliiiBSs or inconvenience will he produced by so wide
in iri<lectomy. But it will be different if the pulptdind ajierturc is wide,
80 that the whole cornea is exposed, for then the large artificial pupil
may give rise to a considerable and nnnoyinj^ sensation of glare, and also
diminish the acuity of vision by prorliieing circles of diffusion upon the
retina, on account of the irregular refraction at this portion of the peri-
plierj* of the cornea.
3. Lareniti'm of the ea/fsule. — The operator, steadily fixing the eye-
ball with the fort'cfis, next freely divides the capsule with the pricker
or Von (jii-aefe's cvslotomo by three successive incisions. Tlje one is
to commence nt tlie lower edge of the pupil, or even a little below it
beneath the iris, and extend upwards along its inner side, the other
passing to the su.aie extent along the outer margin of the pupil. Both
mcisinns should reach quite up to the periphery of the lens es|>osod by
the iridectomy. An expert operator may even carry the incision be-
neath the iris nearer the jieriphery of the capsule, so as to obtaiit a very
free laceration of the latter. IJut this requires considerable dexterity
and delicacy of manipulation, otherwise the pricker may easily bruise
the iris, or press so tiiucli upon the lens as to displace it. If there are
slight adhcflions between the iris and tlie capsule, they should l>e divided
by pasaiug the instrument a little beneath the edge of tiic |iupil. Finally,
the capAuTe should he lacerated at its periphery in a line corresponding
to that of the incision. }n using the pricker, it« edge should always be
turned in a slanting direction, and not be pressed firmly backwards,
otherwise the eatariict may be dislocated into the vitreous humor, or its
up]>er margin displnced beliiuii thu upper edge of the incision.
De Weekcr ha« lately devised an instrument for lacerating the capsule,
which Lc terms a '* pince-cystotome." It closely resembles a ]>air of
cune<l iridectomy forceps, each branch of which is furnished, on its
convexity and its estpomiiy on a level with its internal teeth, with a
email triangular cutting blade, like Von Graefe's cystotoine. It is to
be used in the following manner; The branches liaving been introduce<l
closed and Hat aa far as the lower border of the pupil, jt j« to be tunivtl
VOH obagfi'b pebipubbical limear e^etraciion. 329
to bring tbe triitngiilar extrcmitr of tlic cyiitotome in contact with
the UDterior capsule ; the Hrnitclies aro tlicti to be opene^l (wli'ilst they
■im-ise Hie c.ipsiile iilon^r the lower otlu^- of the pupil) to the width of
lliout 4 Diillimetre^ ; Win^ kept thus openetl, tjie capsule 19 to be iTicised
by them IVoin hetow upwnrcU, pnrFillei to the inar<;in of the iirtiHciul
pupil 08 far n# tJie iiji[>er clge of tlic leiii>, wtien they are to be closed
an 10 aeixe tlie flap of tlic capsule thun foruied, ami then Uie eloM-d
'fbrcops arc to be removed in the tiaine way act an ordinary cyHiutome.
We can thus excise a ftjuare liap of tlie capsule.
[PeripluTal cy^t^jloiuy for ctilaractri in generjil has now been practiced
«>iiicwliat extensively for about two years, botli in Kmnce and l\ic I'nited
Stales. Or. Oruenin-: first applieil ttie jK'ripberal division of the cop-
enlc to the cxtructioii of ti Morgapiijui cataract in 1^77, and since then
Kiuipp and utbera have employed it for all liard catA.ractd. (See ft
liajwr hy Marliniu the " Aiuiales d'0culisti<iuc," January and Fe.brunry,
|K7f* ; and, aUo, »rtii:lc« by Gruening and Kuap]> in tbe " Archives of
Ophthalmology,'* vii.) — ]J. j
4. liriHitK'ilaf the Ifiis. — During tlie earlier period of perfonnin;! hia
ucw o|>enLtion, Von Graefe wa» in the habit of aayinting tlie exit of the
tirns by pressin;; upon the upper portion of the wlerotic with a broad
curette, iitid aiding this by u coiintor-pressnre with tlie foa'ep8 below
the coniea. When the eil^if of the lens iiad once presented itself in the
section, its delivery was tttill more aaaiftced by ^lidinj; the cureito in a
lateral direction alon^i tbe sriorotic to the anjjles of tiie incision (this
Wiia lenned llie Si-htiUni-m*iiinnirre). Il was fuuud, however, that tlio
removal of the lens wan often difficult, without exerting a dan;ieroii»
decree of pressure, und that, occasionally, it was necessary. tQ onler to
cxtmrl the lens, (o pass in a scoop, or a jteculiarly shaped hook devised
by Von liraefc,
lie has now. however, substituted for this mauicuvrc the uite of a
rulcanitu curette, which he prc^mca a^tinat the lower portion of tite
con)ea, and tbrnt aids tbo removal of the cataract. It is to Iw used in
Itie followinj^ niannttr: The evv is to be fixe^l with the forccp:^, which
are not to In- placed 'lirectly Wlow the coniea, as they would then inter,
fere somevthat with tlie manipulation of the curette, but .slightly to tlkB
inner or outer side of the centre. The curette is then to be placed upon
tlie lower margin of the cornea, and pressed slightly backwards and
upwards, so a& to cause the upper edge of tlie lens to present itacif in
the section : and then the proiisuro is to l»o made directly backwardj,
iu order that the leiui may be rotated niund it4 trauitrer^e axis auri tilted
well forunnl into the wound. When this has ooourrod, \\a exit itt to bo
ItenllT aided by pushing the curette slowly iipwanls over the surtace of
(be cornea, lio that it follows step by step the delivery of the lens. If
the upper margin of tlic lens does not present in the section, but shows
a tendtrncy to get bcbiud ita up[>er edge, tiic latter should be gently
Lprcaxed back with the cd^e of a curette by an a**i»tant. which will gene-
illy cautie tlie lenn to enter the incision ; or the o|M.-rator may do thia
hiipfwlf. and exert the oountiM'-prOiHsure just beneath tlie cornea wiUi the
foiicep)*. t»r, again, the ten.H may bo gently pu^ihed buck a little with
the pricker, until its upper uiurgiu agaiu lies opjMsite the inuisiou. If
380
DISEASES OF TUE CRYSTALLINE LESS.
it U founil tltnt pfirtionii of the Inwer corticnl sub#tftncfi arc stripped off
and aru incliiietl to lug behiiHl. the cun-tte itliould lie drawn a Uttlu buck
again, and the fragments of cortex pusliod along after tJie liody of the
lens, and in tliis way Jie whole calamct may genoralty be removed. If
the appearance of the cataract indicniea the presence of a goo«I deal of
soft ai:itter. it i;* well to work this ;iently towards the centre, bv pn-iijtinjj
the curette lightly from the lower and lateral margin of the cornea
towanU its centre, before attempting to remove the lens, for thus we
may often 5ticceed in getting the $oft matter to exude, together with tb«
firmer nuclear portions. If small fragments of lens matter still linger
behind after the body of the cataract has been remored, they ahonM I*
coaxed out by again passing the curette over the cornea, and poshing
them in front of the inHlnnnent. Or, as Von (Iraefe advisee, the lid>
holder having been removed, the operator should gently rub the lid«,
more CHpeeially the tower one, in a circidar direction, and thn<i loosen
the marginal portionii of cortex from behind the iriti, and bring them into
the area of the pupil, and thence out through the wound. Von t»raofe
attaches great importance to the removal of remiiiints of cortical sub-
stance, and ofti'n devotes some length of time to tliis purpose.
I'he object of making the curette of vulcanite instearl of ailvor is that
it ia more rcflitient, and the degree of prepare can, therefore, be regit'
lated with the greatest nicety, and it« touch is moreover more agreeable
to the cornea. The vulcanite has, however, the dij*advantag<! of being
x*ery brittle, «o that it breaks very readily. For this reason I hare
lately preferreil Wriss's tort^jise-shell curette, which offers all tlie mivan-
lagc4 of the vulcanit*, without its brittleneas.
The lo«8 of vitreous humor has diminished very considerably since
Von (iraefo Bubetitnied the latter moile of removing the lens (by
preiti^iiig from below) for the *' Schlitten-mamcuvre ;'' indeed, in the
last 2110 oficrations. he only lottt vitreous humor in nine caue^. which
^vca less than -I per cent.' In three nf tbeAC tJte vitreous humor
waSf moreover, Quid. If this occurs, the vitreoub may escajw directly
Uio iwciinii IB Kniahcd, anil even before tt is attempted lu excii«e a por*
tinn of iris. In nnch a cane it ia heot t^ excise a portion of iris, if this
can be done without a very great loss of vitreous, and then to remove
tlie lens in its capsule hy pn.4t4ing I'ritehett'^ ."tcoop behind it into the
rilreous humor, and lifting it out. A considerable quantity of vitreous
will, of eourse, escapi*. but any subse'|uent inflainmalion is likely to he
l-'-* "v'-re, if tlic entire lens is removed in its ca|Mule, than if more or
rikblti frrvgmenbi of lentt Kubsliiiicc andcajwule remain behind.
ml '>r (he bent o|KTators Hlill differ in opinion att to the adrantage
m: tbi- rioiMiori in the «rler«)tic or in tlie cornea ; for wliiUl (*raefe
iT, rritchelt and Arit are in favor of the latter prvicecd-
:..L hat tlie e\a4.*t line and extent of the incision should vary
VXD and hardness of the nucleus, and Hie diueimons nf the oor<
the nucleus b) lai'ge and firm, and the dtamoter of the cornea
'i-ti-ui shniild \tv made slightly more in the sclerotic, tlie pune*
nter-pmtcture being also ooiiiewhal lower, for we shall thoa
' •M.r.O.,'*aiii. 2,UII.
TON ORAEFB'S PEKtrnEBICAL LIXSaR cxtraction. 331
^ van
^B era
I
I
gain % larger nccUon, and the dcliverT of the lens will be P««y, and free
fnm all Miueesitig and brtiisiug of the parte. If Uic eection h made in
the i-onics, nud laon; oi;[H'ria1l^ if a (lortion of comea is left st»mliiif; nc
the to|),tlie exitof thti k-tis i.4 oftonditTiciiltaiid lAl)ored,aiidacooiiipfttnc(l
}>\ 11 g^Mid deal of bruising of the ptirtrt anti ^tnppinjr off of tin- surface
roniter of the lens, which, if it remains i»ehiud, mav set up very consid-
erable irritation. Moreover, the upper edge of the lens may be caught
bind the portion of the cornea which has been left standing, and Im? firmly
dged iu between it, or the lens roar even be dinplaced upwards behind
lie sclerotic. This in tlie uiorc apt to occur if the first pressure, which is
made with the curette upon tbc lower portion of tlie comea, is not mnde
backwards and upwunls, hut only upwards, for then the 1en:< will be
pusheil directly upwards, and niay become lodged behind the upper por-
tion of the cornea. TIic object of the backward pressure upon the lower
{Hirtioit of Ibc lens is to tilt its upper edge into the section, for wlieii it
iiaa onec gained thiii position the escape of the lens is easy enough, pro-
vided the section be of a sufficient »ize. My own c.\i>erieuco, I uiust
admit, lA greatly in favor of the KcltTntic section tying in llie »t-1er<)-cor-
nenl juiM:tion, or very slightly heyond it. But where a conitidcrablo
rection is retjuirud, I prefer to obtain this rather hy making the punc-
ture and counter. puncture tower, than by making the incision more in the
M-leroiic. for in (he latter case there is always a greater nek of losa of
vitreous.
For a long time 1 made the section strictly according to Von Graefe's
directions, but I found occasionally timt, in s[titc of every care, vitreous
wan lost if the patient suddenly strained very much, or nipped his eye-
lids firmly together, or if he retched or vomited from the chloroform.
For fntm the rcry peripheral pofsition of the incision rupture of the hya-
loid atid escape of llie vitreous arc but too prone to occur under the
aboro rireuinstances ; moreover there is also a greater ri*k of prtdapse
of the iris at ibe angles of the incision. Hence 1 have been gnulually
\cf\ to iMlopt a less peripheral section, and now generally maVc the j«mc-
ture and counter- puncture jwit external to (about i a \iuw from) the
sclenxomcal junction, and aliout IJ or H line below the summit of the
comea. hut the centre of the section lie» at the upper edge of the cornea.
I, however, vary the situation of the puncture ami count* r-puncture^
according to the size of tlie comen and tlie sixe and hardncM of the
nudeus. If the comea is large ond the ducIcus but moderate in sise. I
make both the punctures nearer the comc&. and a little higher than when
tlie comeu is small and the uuclctu big and tinu. I think it htftter some-
trhat to varv ihc shii|>e, position, anit site of the section, acconling to
the peculiarities oi' the cJise, lliau to lay down a hard ami fast rale ha to
these points, ijince I have made the section lew |>eri-
pheral, I have certainly lost vitreous much lens fnspuuitly
than formerly. De Wecker likewise advocates a very
similar seclion. nlthougb he makes the puncture and coun-
ter-puncture slightly more in tliC sclerotic than I nni in the
habit nf iloing. In his operation ** Tlie iiuncture ami coun-
' rpuncture lie in the sclerotic 1 millimetre outside tlie
Ige of the cornea, in a borizontal line, passing *2 millime-
Flg. lie.
ZHi
D[SBA6BS OP THK CRYSTALLtNB LBSS.
tres from the upper margin of the cornea ; the exit of the inatmmcnc
corres|)Oiuluif; witli tlic upper uiar^iti of the coniea."' Whilst (Traufe'ii
tiictsjim (if the cornea liatt a liiamcter of 12 niillimiUn^a) is 10 milliiiittiro«
In cxtoiit, Weckcr'H is ahont 11^ millinietres, the sixe of tho cornea being
tJir sanu* (vide Kig. IIH). Oli n ti inm.. OC»T mm., 0Kn4 mm.
(KB -.2 mm.),llC=0 mm. 25, or 9 mm. J, CD = 11 mm. 4891, or
11 mm. ^.
Till' after-treatmetit of this operation is geuemlly extremely simple.
Ltehroiuh's laiidage sliouKJ hv Rpjilieil dlrccllv after tlie oi«ratton, and
if anr aeverc pain »iioulit arioe in tlie coiiriio ot ttio dav, cold water dress-
ing (frciiuently chaiij;;ed) should he applied, cure l>cinji taken tliat it ia
iiol. persisted in loo long. If the pain does not yield to Uiis treatment,
a leech or two slioiild be applied tu the temple. On the second dny atro-
pine drops glionld he prcacribod. The patient may generally leave hia
lied on the second or third day, but this will depend upon indiridnal cir-
cumstances, and upon tho fact a.4 to whether he can have proper super-
vit^ion. With some patienUi it \i^ udvisablv tu permit their leaving the
bed even the day after the nprration, hut it is always wiser to err on the
aide of safety. The general rules laid down for the after-treatment of
flap-exinitti'm alao apply to Von Graefe's operntioTi. [IJribosia proposes
tvFo nmdifi cations of the periphcrical linear optTation. He advices ad
tlic first Htep the laceration of the capsule by a 9to|>needle through the
cornea, lie then introdneea the narrow knile, and in jiassing it across
the anterior chamber, rotates it iilightly, so as to cause a prolapse of the
iris upon the knife, whieh he tlius excise:). This is not to be recom-
mended.'—K.]
I)r. Taylor, of Nottingham, baa operated by a method somewhat sim-
ilar to that of Von liraefe (but ijuite Independently of him) since the
summer of 18(3.'>. iudeeil both nppear to have begun abont tbo Aamc
time.* lie more latelv, however, substituted llie following operation:*
The eye having been fixed with a pair of sharp force|w at the upper and
middle third of the margin of the cornea, he cntcra a pointed knife (a
line in widtli and bent at an augic) In the sclero-comeal junction, 1 or t!
Ilnea from the forceps at the summit of the cornea, and thi;*, being |tasaed
^«ell into the anterior chamber, is putthed, with a sawing moremeat,
along the i^nnmiit, for a distance of <i liuct^. If no iridtHitomy is In be
made, the capsule is now to be opened nitli the prieker; olhcrtriac a
portion of the iris, having been, drawn out of the wound, is to be excised,
and the caiL-tulc then laeenitcd. Finally the section is to be auflicientlv
enlarged with a nam>w, blunt-pointed knife, to pennit of the ready exit
of (he lenn hy simple pre-^sun- on tbo lower part of the cornea.
[Dr. TayloiMias latt-lv moJified the above method, by excising a small
portion of the peripliLTy of the iris instead of its whole breadth, the pupil-
lary margin and portion of iris attached to it being left untouched and
free in the aulerior chamber ; tlie tens ia then extruded through the gap
in the ordinary way, gliding behind the pupil so that there is no stretch-
1 " Atinnlxi il'IV.[ili»ti<)ii»," Uar»-Arrll, 167S.
• (-Itoport "f Finirlli Itilunmi. Opbthnl. Coaerow," Lominn, IS72.— R.]
> •• niihilmliiiic Rrvipw." N«. 9. < *• R. L. 0. H. Bvp.." t(. 3, 1&7.
< "Tbe L«no-l," Nor. 4, l»"l.
VQV ORABPB^S Pt^Ktl-IIERtCAL LIHKAR BXTBACTIOM. 3!t3
ing of itie sptiincter. Id tlii« wxy Br. Tajrlor lielieves he bas «ecun.'(l
Hlithe ailvaiita<:e8 in tlie wrv aT atifcly anil cortaJnty of nn aaaociuteil
iridcctoroj, nnd at tlio xame time attained i\\e grand desideratum, a cen-
tral aixl movable pupil.
To avoid tlie disadvantages in Graofe's opprntion anAinf; nut of tlio
peripheral position of the wound, and the disadvantages in Hnp extrac-
tion arising out of the heijrlil of the flap, Dr. Lit-hreich was led to devise
a new method of extmclion.' He found that without actual fortitatiun
of a flap thut mecliunixni can be brou<;ht about, by meaUH of which the
odvaocinj; eijuator of the lens overcomes the obstacles of the iris and nf
the -ipliiiicter pupillre in onler to enter the wound. Avoiding iridectomy
he fnniHl he couM do without elevntorrt and foive[i8, '' and thus change
the whole operation into n le-Sf< violent and almost painlcM one."
The incision is situitted entirely witliin the c<>niea, with the exception
of the |K>intd nf jmnctnre and contm-pnncture. wliich are plaeed about
one millimetre beyond it in the eclerotie' — the whole remaiuing iuci8ion
piBainj; with a rcry p]i);)i( curve throu^^h the cornea, ao that Uio centre
of it 19 al»out \^''2 millimetrc.4 within
the margin of the cornea (Fig. lU*)- Kig. nil.
AH the inatrumenta reipiired are two,
uamelyT a very small (.rraefe's knife, and
a cystotome which has a common Uaviel's
spoon at the other end. Sappoain;; the
right eye ia ta l*e operated U|k>u ; the
operator, standing behind thi^ (taiieut,
lakes hoM uf the upper eyelid with the
index finger of bis left hand, whil-it he
sli}(htly ppcftses the middle finger against
the inner canthus of the eye. The knife, held in the right hand with its
hack horizontal and bnckwards, the plane of tiio hiado making with Ihu
borinontal meridirtti of the eye an angle of about Ai)-", enters the sclerotic
at the iKjint indicated. *^ Without nUertiuj the lUr^rti'm, the knife
pBAscs through the anterior chamber in order to make the enntra-punc>
ture on tlie oppoetite side, so that the point of the knife becomes vifihle
in the sclerotic about one millimetre (or less) distant from the cornea.
The knife is now pushed forwards, so that its retraction finii^hes the
incieion, Ab soon as the incision 'm mndf, the eyelid is to he dropped.
'* The second port of the operation consists in the careful opening of
the capsule.
** In the thin! part DovieVe spoon Is slidiily pressed agiunst the in-
ferior margin of the cornea, atwl the index finger of the left hand, which
holds the upper eyelid, through it exerts a very flight pressure on the
higlu'Jit point of the coniea. Thus the lens is mnde to rotate a little, its
lowtT iiKirgiii presses in the manner already described, against the jkw-
terior surface of the iris, pushes the iris forwanl, paascs along it to the
> "Hi. Thotniu'* HuapiUil llfnt>rt>," Now .'«oriix>. vol. ii. p. '25!l.
' Of mim>* onlr Kg rvsnnls lliB ttuUMir nf Wim wonnd ; as n>t[iLnl« the tn^Mc, »U
tb» H-bUii'l, ••rr>n lh» puni'tun>. is •lilnfttnl in ilii^ oorni>ii, llm p>Ti]ilii:-rAl \t»t\ n(
whirb canitot lii- m-nrlirxl hr ■ kti'fi' intTf«)nrr«l In th,t iri'liratw) fMitian witfaout
preHoualj pawing tlmugb • »uall ]wrtion uf the aoltffutle.
zu
DISEASBS OP THE CRVSTALLINB LBItB.
margin nf the pupil, ovcreomeA the olmtacle nnd places iticlf frocly in
the wound, which is made to j^ape by DavicT* spoon pressin-; a;^ain«t it.
A slight pressing movement of the imifx linger ol" the left haud, by
ineatiB of which the upper eyelid h shifted (ntai above downwanis over
tlie cnmea, dervea to expel the lens. Similar movetoentd of tlie WAn arc
employed for the purpose of forcing out any d&trt'K of the cortical «ul»-
stance, after pushing them from behind the im towards tlic pupil, by
gently rubhiii;^ tlio kIiuI eye)idi>. Should the pupil then not appear
romij. but iu marj^in dntwn towards the wound, it regains its normal
piiditi'Mi by an outward shifting of the lower lid ; or, if that bo not fluffi*
cieiit, by tlie introduction of Daviel's spocm. Immediately afterwards I
put some atropia into the eye. and close it by my compresMve Iwindago."
This operation is well adapteil. Dr. Liebreich says, for the diflervnt
cataraetrf, with the exception of — *'l. Those laminar cutaravte, which
need only be treated by iridectomy. -. Cataracts which in earliest
cliildhninl ha%'e to be operated upon iiy repeated division. 3. Perfectly
li.juid cataracts (division with n broad neet^le). 4. Partial calAract^,
without a nucleus, already absorbed to a great extent, and therefore
chiefly traumatic uatariicts, for which aliiio divi-tion HufTioc3." — II.]
More recently Heveral ttew methods of operating; for the extraction of
cataract have been introduced, of which I will briefiy describe the fol-
lowing.
Dr. Lchnin's operation' closely reseinblea Liebreich's, except that the
puncture and counter-puncture lie nt the edge of the cornea, that the
section forms somewhat more of a flap, and lies in the upper half of ths
coniea. The operation is to be perfonned as follows : The lids iK'in;; kc[>t
Bjmrt by the speculum and the eyeball 6xed,Gracfc's knife is intntduce«i
1 or '2 inilliwietres below tlie extenial extremity of the transverse diam.
eter of ihc cornea. Fig. I:i0, the cutting edge being tiirued upwards and
slightly forwards, »o that tlie plane of the blade forms an angle of about
80° Willi that of the iris. The anterior chamber is to be traversed
rapidly and the cuunter-punetnre tnnde at a corresponding point of the
opposite side of the cornea. The incision is then to be continued up-
wards in such a manner tliat it de8cribe<4 a circular curve, wliose summit
lies slightly below the upper edge of the pupil when in a medium state
of dilatation, viJe Fig. l'2lt. Dr. Lebrun term!t this "extraction by a
Fig. 120.
I
tfuiall median flap." [See Report of Fourth luCemat. Opiitbal. Congna^
p. 2i»5. London, 187:i.— B.]
The following are some of the advantages claimed for the openUc
of Licbrctch and Lebrun : That they are easy to execute ; that no iH'
dectomy is raadc^ aud that the pupil, tlierefore, remaiua central and
*' Dv U CatArule," pu 1« I>r. W«r1ouunt. Mamob, PKtis, 1^72.
TOR aitAKPB*H PER[PnKRTCAL LINEAR EXTRACTION. 835
tnnvahte : that there is tio risk of loss of rttreoiis, nt least prior to llie
exit of the lens, or of suppuration of the flap ; aii<1 tliHt the woanil heals
very readily. Of tlie two, Ijichreicirs is the easier, as the section is
niAiliL- downwnnls, anil, conseijucntly, hoth tht? speculum and the fixation
of the eyeball by an insti'umvnt may hi' more ruaUily cliepoujed with.
AnKvn'ptt the disadvantages which nny he urf^^l against hoth proceed-
ings. tho chief are: The temluncy to a more or less cmsidenible adhe-
i?if.>n of tiie iris t«i the edges of the incision, pruiluciiig, perha[>t4, an ux-
t^'tL'^ivc anterior synechia with all its attending evils — evils not confined
ly the present, but which may prove a source of danger to the eye here-
after, just the same as in cases of leuvoma adherens ; or a prolapse may
occur. Again, if the section does not heal kindly, but its lips become
clouded and somenhat infiltrated, an u;;ly cicatrix is left, giving rise,
perhaps, to an irrejrular curvature of the cornea niid more or less asti,^-
nDati»iD and impairuu-ut of vi-tion. Moreover, if the nucleus is small and
there is much soft matter, it may be difficult to get the latter away on
account of the iris falling into the section, and we must tixcn either leave
more or less of the soft matter, or repeatedly irritate and bruise the iris
by pushing it back with the curette, or we must excise a portion of the
iris. Some of the above dJsad vantage* are of less moment in Lebrun's
operation than in Liebreich's, as an anterior tfyiiecliia, a whitieh cicatrix,
or an irregular cur\'ature of the conica, would fall in the upper aegroent
of the curnea. It is evident, however, that no true estimate of the real
ralue of these o|tBmtiitnri can \n> arrived at, until we are furnished with
full and accurate statistics of the results achieved by them.
1 will now brieHy mention the principal arguments which may be ad-
vanced in favor of, nr against, the dift'eront operations for senile cataract.
In lining this, 1 shall confine myself to the flap extraction, the scoop
operation, and Von (iraefe's now modified linear extraction.
Therv cannot be any doubt thai the common fiap extraction is tbe
most perfect operation of alt, when it turns out iwrfeutly successful. It
is nearly free from pain ; it docs not in the U'a.st interfere with the ap*
pcaraiK''- of the eye ; the pupil rcmiius central and movable : the sight
IS pcrlect, and is not at all deteriorated and confused by circles of diitii-
sion upon the retina, which are always more or less present when an
iridectomy has been perfonned. It must, however, he confessed that
these great advantages are ftflon more than counter-balanced by the con-
siderable dangent which beset the ojieratJon. On account of the great
Htae of the flap, tlicre is much risk of the vilality of the inirnea becoming
impaired, and of its umlergoing partial or even diffuse suppuration, whieli
may l»e accompanied by suppurative iritis or irido-choroiditls. Again,
proUpAc of the iris is a not unfrctjuent complication, proving a source not
only "f tireat amioyaiice and irritation, but even of danger to the eye.
The artor-treatiiit^iit al*) demands imicli care and attention — more, in-
deed, than can generally be liustowed in an hospitaU especially in a
general niip, nitb )>o sjteciat nurses or ophtlialmic wants. Now. in the
»coop extraction, these two principal dangers— suppuration of the cor.
noa aiu] [iruhipse of tlio iris — are nearly completely eliminated. On
nccmni of the position and shape of the incision. suppuraUon of tlic cor-
Doa, even of lioiit«d extent, is rare, and a prolapse of the iris can only
336
DiaUASBS OP TUB CRYSTALLINB LKVS.
W sli^jlit. aud U confine^l to tlie angles of the section. Moreover, cUlor*-
furui mi\y Iw ailmii)i.'4t^ro<1 niiliotit any fcnr. Hut it miijjt lip aitiiitttoil
that iritiit, chrnnic and inAtdions irida^clioruKlitU, inHnmrnntion of t\tff in-
tnk-cn[i6uliir celli, anil secondary cataract are more uotoinnn than in flap
cxtmotion. Von Oraei'c's operation, however, nffera nil the ailvantai^ea
of the scoop extraction, rii., adntiiiistration of chloroform, linear shape of
the incision, involving but a small portion of the cornea, and iriiU'Ctomr»
and yet one more most important one, power of removinj; the lens with-
out any traction instruniu'nt. It i» in my opinion to )ii> preferred, a9 a
rule, to any other mo<le of extraction, more espcciiilly in hospital prae-
tic«, as llie patient rei^uire? far less watching and attendance, and the
aft^^rtiisatment is extremely simple. The contiiiemetit to the bed and
honso iii aUo much shorter than in Hap extraction. I think it ia eape-
cially indicated in very feeble, decrepit, nervous, and unmanageable
patients, or those suffering from severe cough, or bronchitis ; als^v if the
pupil is adherent, or small and ri^id. so that it dilates but iniperfoctlv
under the intliience of atropine, or if the cataract is complicated witn
some choroidal or retinal legion. It is aUo the safest operation for div
lietic cataract, for in the Hup extraction (even with a preliminary iri-
declomy), there is always some risk of suppuration of the cornea in
those patienU, as they are gonerMlly in a very tcrhlc ntalc of health.
Aa the iris is exceptionally iniftaticnt of irritation and hniii^ing in cases
of diabetes, it may be advisable, in order to secure the greaie.it immu-
nity from this danger, to make a double iridectomy, viz., upwardit aud
downwards, so as to f^t a broad vertical pupil, tJio two opjtosite iMirttons
of the iris being tliug completely cut oft* from each other. I am some-
times aitked by mcilical practitioners and Btudciit« which operation 1 con-
aidi-rtho easiest and safest ftir an inexperienced operator. I think that,
all things considered, the downwai-d flap operation is the easiest, for
when the section has been successfully o^mpleteil, the chief danger and
difficulty arc past; whereas in tlie modified line-ar extraction the m-
dectomy is superadded. I should, therefore, recommend that when the
surgeon has operated several times by the lower flap extraction, and has
ac'juired some experience and dexteritv, he should pas^ un to the upper
flap extraction, and Von (iraefe's operation. The only two {xiints in
the latter which demand practice, care, ami dexterity, are the tnctsion
aufl the removal of the lens. If the section is too small, the delivery of
the lens will he difficult and forced, and will necesi^itnte enlargement of
the incision, considerable pressure ujion the eyeball, <>r the introduction
of some form of traction instrument. If, on the other hand, it is too
large and lies too far in the sclerotic, there is imminent risk of losing
much vitreous humor, perhaps even before the removal of the leua is
attempted. Coniiiderahle nicety and care aro also reipiinHl in coaxing
out the lens by pressing u(K)n the cornea with the curette, for if this ia
roughly and clumsily done the hyaloid may lie ruptured, the vitreous
escape, and the lens wilt probably be pushed somewhat aside, and •
Bcoop will have to be employed for its removal.
[The model o^tcratton, towards which the eflorts of every ophthalnric
surgeon are directed, is the retnoval of the lens and capsule through a
corneal or sclercHiorneal iiKi^iun, aud without an iridectomy, ao that the
DIBCIttStON OF OATAKAOT.
ss-;
imtient may poswss a circular and movable pu[jil. The ]i«npbencai
linear inciaion, alightlj iDodilie<l to suit tho special caso, gives, all things
cobsidered, the best reaulu, iliougli it necessitates an indccWmj-, which,
of coure«, is a di&adva[ita;;e. Il hud becu suggested that the irit< should
be detached from its jierijthoml attachmfiit for a space correapo ruling to
tiie sclero-comeal incision, instead of excising a piece of it; and that
thnMigb thia (lial}rsis the capsule may he opened, and the lens extruded.
Ttiie haa been done bj .several surgeons, but owing to bruising of thv iris
tifiJBUe, the success ha» not been such ls to wnrraut ita continuance. — B.}
9— RECLINATION OR COl'CinNO,
1 only mention thia operation to atate tliat, in my opinion, it should
tio completely abandoned. Although it may appear to be temporarily
ttunce-tiiftil, it has been found that ultimately about 50 per cent, of the
eyea liave been lost from chronic irido^horoiditis, etc.
It*,— DIVISION OR SOLrTIOX OK CATAKACT.
[OJSCISSION^B.]
Tins operation ia more especially indicated in the cortical enutract of
children and of young persons up to the age of twenty, or even twenty-
five ; also in those forms of Samellar ctitarnct in which the opacity is too
extensive to allow of much benefit being deriveit from an artiReial pupil.
After the age of thirty-fi%'e or forty, the lens is generally too hanl to
undergo anything but very alow alworption, oven after fre(|ucnt repcli-
tiouA of the operation ; the irift is also more impatient of irritation and
|*reaaQrc. so that the danger of netting up iritis is much increased : ami
there arc otlicr operalionfl which are mucn to be preferred for cataracts
occurring at this time of life. In infants nnd young children, an opera-
tion for cataract should not be unnecessaiily postponed, as the presence
uf the cjitaract is very apt in infancy to give rise to nystagmus, and to
that form of amblyopia which is dependent upon non-use of the eyea,
«ihI which is similar in character to that so often met with tu stra-
The object of the operation of division is to lacerate the anterior eap-
snle with a fine needle, so as slightly to break up the surface of the lens
and to permit the aiiueou.*; humor to come iut4> contact with the leiut sub-
sia.nce, which, imbibing the Quid, softens, and becomes gradiuilly nb>
•orbed. The time reipiired for the al<sorption varieit with ttic age of the
patient and the consistence of the cataract. In infants and young
children, the lens is often absorbed in from six to ten weeVs, and one
vperatioii may suffice for this pur|K>se. But in a-lnlt;* it may have to be
repeated several times, and in them great cnre should be biken not to
•iiTtdc the capisule and the lens too freely at one sitting, for this will
caufie great swelling of the Icua substance, or the exit of considerable
Hakes into the anterior chniuber, and cither of thesi- causes may set up
*tnn iritis or irido-cyelitls. The same caution is necessary in cases of
limellar cataract, because iu these a large portion of tlie lens is trans-
22
838
DISEAgSa or THE CRYSTALLJ
parent and of normal consistence, and will therefore hnliibc much
u<|Ucou9 humor and swell up very consiflcraWy.
[There are two operat'toiia for division of caUraci, vii. : Division
through the cornea, or the anterior operation for absorption ; ami divi-
sion (hrougli the sclerotic, or the posterior operation for absorption.
[h'ernt'm^xitt — R.l Diniti'm iliroutfh the Cornea.— \\.'\ — Prior to
the operntinn. the pupil xhould lie widely dilated with ntropino. The pa-
tient, more especially if a child, should be placed under the influence of
chluroform. Infanta should be Rrmly rolled in a blanket or eheet so that
their movemente may be controlled. The eyelids are to be kepi apart
with the spring apGCulum, and tlie eye fixed with a pair of forceps. A
Tery fine needle is then to be parsed somewhat obHunoly through the
outer and lower i|U»drant of the cornea, al a point lying well within the
diliitcd pupil, 80 that tho iritt mav not be touchetl by tlio atcm of the
needle ciurin;; the brcakiu;; up of the lens. The track of the corneal
wound must not be tt>o slanting, otlicmise ita channel will be too luug,
and tho tiHBue of the cornea will be stretched and brui»ied during the
working of the needle, and this may produce an opacity in the cornea ;
nor must it be too straight, othcmiae the aqueous bunior tni<;ht easily
escape. The nixe and number of the incisions in the capsuK- itiii.-4t vary
wiih the amount of eflcci lliut wc Jesire. If the latter is to be but very
ali<;bt, a ein<;le small iioriitAntat or vortical tt^ar may suflice, or a crucial
incision of limited citcnt may be made. But if we dct^iro a more con-
siderable efffct, more especially iu tlie cortical cataract of children, the
iiH-isiuns must be more cxtenidve, or the superficial ]ioninn of the lens i»
to be gently broken up or comminuted by a series of short sufK-rficial
incisions, which converge towards the centre of tho cataract. In infants
and younjr children the needle may be far more freely used than in
adults, or in cases of lamellar or partial cataract. In such, it is always
safer to repeal the operation, even several times, than to do too much at
one sitting. It may be repeated at intervals of three or four week^, if
it is found that the absorption has become arrested or progresses but
very slowly ; but all irritability anrl redness of the eye should have di»-
appeariMl before the tieedle is again introduced. If the opening in the
capsule is too large, or tlie cataract broken up too freely,
the lens will imbibe unicli a<)ueous huntor, antl, swelling up
verv considerably, will press u[wn the iris and ciliary body,
and may thus set up severe iritis or irido-cyclitis : or if the
incisions in the capsule are too extensive, fragmeuts of lens
substance may fall into tJie anterior chamlwr, and tliero act
up great irritation.
QThc needle used for this operation should b« v«ry small ;
ltd cutting, spcar-ahapd point should only extend to al>uut
Villi or j'oth of an inch from the end, and the stem should
be cylindrical, so that ibe aiincous humor may be retained
Uiroughout the operation. I always use Bowman's fine atop
needle (Fig. 121). which fulHIs all these intlioations.
lA'elfruni/rl». — B.] [Dtvinionthrnu-ih the Self rntir. — The pupil shovM
he widely dilated with alropia, and the patieut prepared for tho oper-
atiuh precisely aa for tlie anterior puncture. The knife-ue«dl« {Vif,
Piff. 121.
M
DISCISSrOM OP CATARACT.
339
12-2), with
'Ige tooVi
ird?, is then pMSCd through the
l^g*. 122, 1S3,
i
cutting
sclerotic at a poini on its trnuaverae lUameter a line aiwi a half or two
lilies from the temporal margin of the cornea, and perpetMiicnlarly to
the siirrace of the ervhalt. ** 'Hie punctuniUoii tshould he matle quickly,
aitd the neerlle intrmliiiieil onlv a .ihoil diiitAiice. Thia accomplished, the
surgeon slioiiM steady the eye with the needle, and wait an inatant until
the iMilient has recovered I'nim the shock. The direction of the ncivlte
•houhl then he changed, so that it« point maj he advanced hctwcen the
tris ADd the leoH, then the ingtrument should be steadily pushed oa
until its point reaches the opposite papillary margin of the ins. In ex-
cctiting this step, care nuwl he taken neither to wound the cillnry body
iris, nor w spit tlic Ipiis on the needle. If thu former accident hap-
ix&y injurious infiammati-m muy result: if the latter, especially if thfl
I«n« be hard, it will pivhaMy W dislocated, and in this
case it should he at owkv extnicled. When the needle is
puithrd into the lens without dislocating it, tlie instrument
should W carefully withdrawn until its point is free, and
then pushed on again in the proper direction.
"This step being aceotoplislied, the needle should be
rotated onc-4|uarler round it« axis, ^o tk& lo present its
cutting edge towards and exactly over the diameter of
tlie Icnft. 'IVis last movement iii highly important, as the
lens will thus offer the finnest resistance, and will not
tilt over and he dislocated in liring cut; a free incision
should then bo made by wiihdruwing the needle a short
distance, pressing firmly its edge against the cataract.
If the lens bo hard, several incisions should he made in
the anterior capsule, and then this membrane freely laccr-
ateri crosswise with tlic point of the instrumeDt ; this
accomiilisheil, the instrument hhould he withdrawn. The
Irtis I'xposed ti> the aqueous humor will become softened,
partly absorbed, and at a subawjuent period tlie oper-
ation may be repeated, and the lens completely broken
up."'
Tlie instrument recomroeudcd for this nperatioii la the
knifo-needle, deviled by Dr. Isaac Hays,* ot^ Philailelphia.
Tlie common straight needle does not cut well beyond a
short distance from the point, unlosA it Ite made so thin
as to endanger its breaking ; and with a curved needle it
IK impossible to divide up the lens. By means, however,
of the knife-ncetllc the division of a lens of even consid-
erable hardness can he satisfactorily accomplished.
The actual size of the knife-needle is represented in
the accompanying cut (Fig. 12*2). "This instrument,
IVom the point to the head near the handle (a to A, Kig.
12^), is six-tcntliB of an inch, its cutting edge (a to <:) is nearly four-
tenths of an inch. The back is straight to near the ftotnt, where it is
) " UwTvncv "u tha Bye." edited \rf Mtiyt, Phtli.. \hU, p. 7S7.
< "AmvricBii Jonm. of Mnd. SetrOMV," Jnljr, \hii, p. 81.
340 ]>ISBA8E8 or THE CKYSTALLrNI! LBXB.
truncated, so w to make the point stronger, but at tlie »arae time ]ea\-ing
it very acute ; and the ei]|^e of this truncated portion nf the buck t^ made
to cut. The remuiniier of the back ia simply ronnded ofl'. The cutting
edge U straight, and is made to cut up to the part where the instrument,
becomes round, c This jHirtion rci|mre8 to be carcfnlly constniclcd, so
tliat a« the irutniment enters the eye it shall fill up the incision, and thus
Iirevcnt tiie e>!capc of tlie hunKtrs. In the tniignified view of the inHtrn-
mcnt (Kij;. 111:?) iKc proportions of the hla<le are not very nccuratcly
represented, the rounded part being rather too slender, and the bnndU
should he octagonal, witK e<(ual aides, and of the »ame thickuedd its whole
length.'* — II.] [Scleronyxid is a more serious operation than kerato
nyxis, and is really only applicable to parUally absorbed cataracts,
which lie moro deeply behind the in^. — IJ.]
The after-treatment is generally very simple. The pupil should ht
kept \«idely ililatcd vritli ati-opine, so ibat the iris cannot \k pressed
U|>on by the <iwo11en It^ns or any flakes that may have fallen into th&
anterior chamber. A bandage should be worn for the first twenty-four
hours, and the patient should be kept in a somewhnt dnrkened room for
the first day or two, especially if there is much reaction. Generally,
however, this is hut ali^lit, the eye only looking fluslied, and watering
somewhat on exposure to bright lijiht. My friend, Mr. Lawson, has
even sucvesstully operated by this method upon some cases of monocular
cortical cataract in adults (between the a^^ea of twenty and tliirty), aod
treated them throughout as out-patients- Theso were, however, exc«p-
tional cases, in wliich it was absolutely necessary that tJto ]>atienta
should follow their employment. In order to exijedite the cure, which
is often of conseijuence in patients from the country, it is a very good
plan, after the lens matter baa become softened by the admission of the
a<|ueous, to remove the whole cataract by a broad linear iucision. In
chillrcn this may generally he done within a week after the division,
and thus the sight m»y be restored in a few days, whereas, otherwise,
many weeks or even months would Blive elapsed before the cataract
would have been entirely absorbed. The same proceeding may he em-
ployed in cases of partial cataract, the transparent portion of the 1en«
Wing made opa<]ue, and softened hy titc introducuon of the needle.
This moile of operation has been very succcasfuUy practised and much
advocated by >lr. JJowman. who also often advantageously employs the
8ucii{iii syringe for the remnvnl of the softeneil lens aflcr it has been
previoiutly broken up by the neeille.
If symptoms of irritation and inflammation should set in after the
operation of division, and they do not readily yield to an tipb logistics,
but increase in severity, and more especially if tin? tension of the eyeball
is augmented, the eaiarnct should be at once removed through a good-
sized linear incision, miide near the periphery of the cornea, with an iri-
dectomy knife. This ia also to be (bmu if the capsule has been too
freely divided, and the nucloUH or considerable portions of lens substatwe
have fallen into the anterior chamber, and are setting up much irritation.
If the lens is so finn that it caimot all be reailily removed through the
linear section, it will be wiser to combine an iridectomy with it. than to
endeavor to remove the portions of lens by re}icateil introductions of the
tRATtONR FOR LAMELLAR CATAKACT.
841
curette into the anterior chani'jer. An iridectomy is also indicatefl if
an incPCMse of tension lias existed for some litUe time, and if the perecp-
tioii of light and the extent of the field of vision are markedly dete-
riorated.
Two special fonua of inflammation may follow iho operation, and
'endanger the safety of the eye. In tlic one, the tnflummatton is chietly
plastic or purulent in character. Tlic iritis or irido>cyclitiii is accomfia-
nicd by pla»tic exudations behind the iris, and into the vitreous humor,
leading crentuHlly in all probahtlity to chronic irtdo-chorniditi^ and
atropby of the gl'^hc. In the other form, the inflammation is of a seroun
nature, giving riise to &.n increased secretion of the ntrcous bumor, and
an augincntjition of the intm-ooular tension — in a word, to a gtaocoma-
tou» condition of the eyeball, which may cause irretrievable destruction
of the sight if timely relief be not aflbnled.
As these inflammatory complioationa are mont apt to occur in adulta
above the age of lil'tccn or twenty, more especially if the catnnict is
only partial or of a lamellar nature, Von (Jraefe advises that in such
caaeit, or if any poRtorior Aynecliiie exisat, an upuanl iridectomy shonid
be made a few weeks before the operation of division. By ao doing,
plenty uf room will lie afforded for the swelling up of the lena. and if
fnignienta have fallen into the anterior cliamber, tbey will produce far
Ic88 irritatioD.
n— OPKRATIONS FOR LAMELLAR OR ZONULAR
CATARACT.
\^'hen describing the nature of lamellar eataract, I mentioned that in
cases in which a sufficiently broad margin of iranspnrent lens sub-
IDce exista, ^^eat tmprori-nient uf vision may often lie attained by
dilating the pupil l>v atropine. A glance at the acuorapanying figures
will explain this, fn Fig, 124, d repreaenb* the undilated pupil occu-
pied by the opacity If, which e.\t6nds beneath the iria as far as the dotted
Fiff. ifti.
Tig. 1SS.
line r, where the transparent margin d comniencea. Aa the latter is
completely covered by the iris, the rays of light can only pass through
the centinl opa*jne [lortion ; hence the indiiitinctiioits of vision. Hut
when the pupil is ditiited (Fig. l'2'i) the transparent margin of the lenn
li t* unc'tviTi'd, and the rays cmi now pass through it to the retina.
ThU fact ia of great praetiwil ini|Mirtaiice. for it furnishes lis with a very
valuable indication as to the treatment of such caies of lamellar cata-
ract, for we may often succeed in restoring excellent vision by simply
making an artificial pupil, without opcmting upon the lens itself. Such
342
DISEASES OP THE CRVSTALLINB LBKI
a proceed'mg possesnes very marked advantages over any operation for
the removal of tbe lens : for the patient retains the power of accommo-
dation, and is freed from tlie necoiisit^- of wearinj; cataract glaRseti,
which arc not only inconveniont, 1ml also unsij^iitly, more especially in
youthful individuals. The artificial pupil may hemade either by m?-jii<i
of an iridectomy or an iridodcuia. 'J'lic rormur operation has the diwid-
vantage that the base of the artificial pnpil (Fig- 12")
Fig. ]2rt. is opposite the periphery of the lena d, and may
therefore giro rise to u certain indiBtinctnesg of vision,
on account of the ray« being irregularly refractc^l hy
(lie cdfto of the cornea and lens, circles of diffusion on
the retina being tints prriduced. In onlcr to diminish
this defect, the iridectomy iihould he but small. In
mtiHl cast's I think Mr. Critchett's operation of iridode*
Kig. 137. sis is to be prefeiTed. A considerable portion of iris
shoidd he drawn out, in order that the entire pupil
may be drawn near the margin of the cornea, for the
iris will tliuij cover a largo extent of the o))atiue por-
tion of the leiia. There will Ifiuft result a pupil like
that in Fig. 120, having its apex, and not ita base,
opposite the clear portion of the lens. Mr. CrttchcU
has aUo in tM>nie cases obtained great improvement of sight hy making
a second iridodesis cloae to the other, thus gaining a somewhat broader
pupil, and admitting more light.
If the trnmiparent margin in lamellar cataract is not sufficiently broad
or clear to adroit of much improvement of vision by an artificial pupH}
the Icna itaelf must be operated npon, either by division with or without
iridectomy, or by Von Gniofe's operation.
In poi-sons Htnler 2"), I think it best slightly to divide the lens with a
needle, and to repent this severKl times, and then, whi-n the wholi- lens
hai^ iH-come opat^ue and softened, to remove it through a large linear in-
cision^ or with the suction curette. It is never wise to operate ou both
eyes at the same time, for in some cases eyes affected with lanteltar
cataract are extremely irriUiblc, and considerable irido-choroiditia, with
or without slon^rhiiig of the cornea, may supervene and destroy tho eye.
If this has occurred in the one eye. we should be greatly u|>on our guanl
in o|>eriiting upon the second at a t«uhsc«|ucnt period, or devise some other
mode of opcmting. In peraons above the age of 25, 1 have succeeded
very well m removing tho lens by Von Gracfe'a operation.
I2_0PEUATI0XS FOU TllALMATlC CATARACT.
If the wound in the lens is of but slight extent, and the patient young,
the cataract may be 161*1 to absorption if no ttymptonta of inflammation
net in. The pupil should be kept widely dilnted with atropine, nnd the
condition of the eye can-fully watched. If infiamraiitory symptoms
supervene, it may he necessary to remove the lens hy linear pxtniction,
more especially if it swells up considerably, or large portions have fallen
into the anterior chamber and are setting up irritation. Ilih operation
QPBRATIOSS FOR TRAUMATIC CATARACT.
343
shouUl also be at once perfornu^d if the vound iii ttie lens has been con*
Aidernble, »o that Ute latter, imbtbiit); naiicli aipieoiu humor, becomes
rapidly swollen and proflBcs upon ihc iris nnd ciliary body. The simple
liuoar extraction will gcnenilh' suffice if the lens 18 so softened that it
will readily escape thnm^Ii the incision. But If the nucleus or the
;2ri<iiter jwirtian of the lens U still firm, it mny he more aiIvi<iahlo to Tnako
a larf^c iridectomy, in order to afford more room for the swelling of the
)un», and then to leave the latter to undergo abtturption, which will now
W attended by far loss risk. In those caaei in wliich great swelling of
tUi? lens is accompanied by severe inSiimmation. it will be beat to make
a larfre iridectomy, and remove the cataract, either with or without the
aid i>r Uie scoop. If there is much soft matter, tliiit may be removed
witb the suction syringe, nlthoiii^h 1 urn rather afraid of iu use iii eiich
oases, eiipccuklly if there u any iriii.s or irido<ehoroiditi>i, a." it may easily
produce hvperaemia rr ettcuo of tlic Inner tunic.i of the eyeball. If a
foreign body — f.tf., a chip of steel, glass, or gun-cap — is lodged in the
leui-. ii is wii»er to endeavor to remove it, togetlier with the lens. This
should le done by jutroducing a acoop well behind the foreign body and
lifting; it out ; for if we permit the len^ to undergo absorption, the for-
vi^ body wilt ai la«t become diden;;iiged and fall down into the interior
or posterior chamber, and proliahly set up severe anil even perhajts de-
tructive inflnmiuation. TJie situation of a bit of moial in the lens may
ifU'Q be rec<i;^iizcd by the aid of the ubliijuu ilhuiii nation, when we uiay
>litiorvc a little brown upot in the tena, or a little dark line showing the
^track of the foreign t>04ly.
If tbe foreign body has passed through the lens and la lodged in the
vitreous humor, retina, or choroid, great attention must he paid to the
omdition of Uie eve, as severe and destructive inflammation is but too
likely to ensue. The degree of sight, the state of the field of virion,
nnd the tension of the eyeball, should t»e vS]>ecially watched. If in such
a case the Icna swell up very considerahlv, it may he wise to perform
linear or scoop extraction combined with a largo iridectomy, in the hope
that the absence of the lens may diminish the inflammation, although it
mui*1 be remembered that the chief oxoiting cause — the foreign body —
iitill riimnins behind, and may at any time, even after the lapse of ycjirs,
.igftin set up inflamraarion. In all such cases of injury, the condition of
the other eye must also be anxiously watched. At the eariiest symp-
toms of »ym]>athctic irritation, the wounded eye should be at once re-
moved, for only thus can wc insure iho safety of Uie other. If the in-
jury ia so aerere tliat the sight is greatly, and proliably ]iermaiicntly,
imiMured, the immediate removal ot^ tlte eye may be indicated, erOD
.ilthough the eye does ii«it sympathize. 'I his is especial! v the case
amongst the laboring clai«ses, who cannot he under our imroediat« super-
vii-ioD, or cannot afford the time to undergo a lengthened course of treat-
ment without the hope of regaining any useful degree of vision. The
inie course luay be advisable amon-^4t the higher chu-iscs, if from cireutn-
Itanees — such as officers htdu;" ordered ahroail, oece*^ily for a long vny.
age, etc., — they cannot >>e undi-T constant supervision, eo that the earliest
eymptoma of eympaihetic intlummaiiun may be detected.
844
DISEASES OP THE CRTSTALLIMB LENS.
IS— KEMOVAL OF SOFT CATAKACT BY A SL'CTIOX
INSTRUMENT.
In the extraction of eofl cataract throuj^h a simpio linear nicision, gom^
difRculC}' 18 oooaeionall}' experienced in removing tlie Hrioer [loriiong villi-
out exerting a certfliii amonnt of pressure upon the glohc, or introducing
the curette into the anterior chamWr. This diflicidty lias led Mr. I'rid*
giti Tealo' to the ingoniotw omployinoiit of a suction curette for the more
easy and complete extraction of Hf»ft cataract.
The itiatnunent now used by Mr. Tealc is almost identical with the
oite described iu hie original paper. It is reprvaeated in Fig. 128» and
Pig. 126.
consirtta of S parts : ( 5) a stem, formed of a ylass tuho, witli ( /I > a tuho-
Inr curette at one end, and ( C) an India-niliber tuV* with a moHth-j.ieoe
at the other end. (a) Tlie hollow glass stem (if) is 5 inches in lenj{cfa,
and allows the operator to watch the progress of tho auction as the
material is drawn into the transparent tul>e. (/') The India-ruhber tube
(f7) La about 1^ iiichon iu length, and fumislied with a nwuLh-pieee
which enables the operator to apply the auction either with consiilorablo
force Mr the moat exi^ui^jite gentleness, using his tongue as a piston, under
tJic most perlVct control, (c) The curette {A) is about | of an inch in
length and of the same size as an ordinary curette ; it is alightjy con-
rex on ita upper surface and not flat, and ita whole calibre iloes not
require a larger ojtcning in the comea than the common uurett«. Tliv
point should be as round ami blunt a8 |>r>ssibte, and the 0|>euiug on tJie
np[»er surface (iliould he espial in size to the acction of the tube, and as
near to the extromily as iJic reouired bluntne** will permit. Mr. Teale
performs the operation in the following mauuer: The puptl having been
well dilated hy atropine, a puncture is to be made in the cornea with a
broad needle at a point op(KMite the margin of Uic fully dilated pupil,
and, {KUtsing obliquely through the substiincc of the cornea, the instru-
ment -ibould enter tho anterior chamber at a point opjxt^ito tlie margin of
the pupil when of medium size. Such a valvular opening will prevent
any 8car in front of the pupil, and diminiith the risk of prolapse or an
anterior synechia. The capsule having been freely divided, tlie curette
should be carefully introduced tlinuigh the corucat ftouiid, and its end
■ "R. L. a H. R«p.." It. 2, IVT.
RBUOVAL OF SOFT CATARACT UT SUCTION.
345
Tthe opening loriking towanls the cornea) held steadily in the area of
the pupil ami ^ciatv hurled in the opa'iac mattur, (he convex surface
hcing proHscd somewhat hack towards the poa-
teriur capaule. The auction power shouUl then ^*'
W carefully ^ppli^■(l an^i continnccl in pentle
inspirations as long on any opa<[ue mntter
conies forward into the pupil, and, when llie
inttor 1!) quite clear, the instniment is to Ije
withdrawn. On no account is Uic curette to
sweep either in front of or behind the iria in
search of oitaijue mutter.
Mr. Toale has found this (node of oper-
ating extremely successful, the recovery l>etng
very 8[>eeily. and the operation followed hy
little or no irritation. He coniiders it appfi-
••tthle in all fiill-l>v<lied conijilete cataracts in
persons under the a^c nf 4ii; including in
this category fponmncou:*, diabetic, and those
traumatic cataracts in which, from the rent in
the cnjii^ulc hoing of nimlerate extent, the eye
remains quieiwent unlil the cataract i« com-
jdetely f'lriin."! : and finally, incomplete cata-
TWM which have been rendered complete hy
diriiiion of the cajisule. He think* it mm-
MHiUihU in those forms of complete or imma-
ture cataracts in which portions are trftimparcnt
and gluuuou><, and require great fnri^o to draw
them into thi! curette ; also in trnnmatic catn-
ract, if thvre is much irritahitity or iritis, if
there haft heeu mpture of the posterior cap-
]e, or if 00 much of the lens has hcen
iWrbed that the anterior and posterior cap-
sule are nearly in contact ; or in dcgenorat«
cataract.
Mr, Bowman has devised an excellent suc-
tion syringe (Fig. ISH), the use of which is
very uaay, and which can be regulated with
great nicety.' The operator, having mode an
incision in the comea with the broad needle,
aud freely dirided the lens, can introduce the
nozale of the instrument (which is to he hcM
in the right hand) in the corneal aperture,
and gently "suck out" the soft lens sub-
stance.
A tthough it appears that the idea of employing suction for the removal
of cataract dales hack as far as the fourth century, and that it ha* since
been advocated by several authors, more cnpeciallv in later years, by
Itlunchot and I^angicr, it never attained a recognixed position until it
ktVIt L«V*OB.
* Botb BIr. T«>alB'ii ami Mr. BowmKH's tnB(rani)<tila wn nuulv hy Massra. W«iM.
S4ti D18SA6BS OF THE CRY8TALLINB LBR5.
was introduced by Mr. Tcale. Thia opcradon has now met with much
ami deiicrved favor, uiorc espociallv at tlie Ro^al Luudou Oplitlialiuic
llnd|iital, ^[^orl1(■^U, where it has Leon cniphivcd witii markod siicet'se.
It i* cs|>ectallv indicated in soft cortical cataract, which may t^cnvrally
be very readily and completely removed hy tlio suution instrument. If
the cnt-iract bo somowh.'it more firm in consistence, it will he well to
hreak it up with the needle a few days previously. 1 have also used it
with much advantai;e in removing portions of &oft cortical suhstaoce
which have remained hehind in tlia pupil in the oporationa for senile
cataract, cither in the common flap or Von liracfeV oiicratioUf for auob
portions mny often ho raoro readily and ilioronshly removed in tiiiaway
than by ruhl/mg the eyeball or the remtroductiun of the eic«iop. Somo
care and delicacy aiv, h«>wevor, reiiuii-ed in the use uf this instruincut,
for, if too great a snction power is employed, hypenemia (rr nicuo') of
the iritt and the deeper tunics of the eyeball may easily be produced.
H^SPERINO'S TREATMKNT OF CATAKACT BY
PAKACENTICSIS.'
This mo<]o of treatment is chiefly based upon the theory that
imgiairment of vision in cataract id partly dependent u|M>n a tempctniiy
disturbance in the intra-oeular circulation, especially an occasioniil stAte
of congestion of the choroid, and partly upon the opacity of the Icna,
L>r. Sperino holda that the opa*pie lens Hhres may rc^in their tramt'
paronoy as lonj; as their intimate stnictnre is not disorganized, which
always follows, more or less rapidly, upon tlie opacity, but less so in old
than in young jversons. Now, as the operation of tapping the anterior
clianiher relieves the intra-ocular circulation, itoflen produces a inaHced
and innuedinte improvement in the dt;{lit. ami in Bome cases olteD-reiicated
tappings have at last offoctcd a complete cure. In others their effect
has been but moderate, or even ne;j;ativc. The operation consistd iu
making a saiall puncture with a broad noodle at tlie edge of the cornea
or slightly in the sclerotic ; a blunt probe is then inserted between (he.
lip; of (lie wound, and the a(|Ueous humor slowly evacuated, llie e>-aci]»-]
tion< hy the same opening may be made repeatedly dnring a siiij^i
sitting, followed by an iut<*rva[ of sevural days, or Mngly at an iDterVali
of a day or two. Tho operations in cataract were repealed a great
number of tiroes. In one case IGT tappings were made, and finallv
linear extmctiou was jwrfbrmcd. I am not awaro that this treatment
as been adopted by anv other surgeon ou a sufhcientty large wale tOi
warrant any exact conclusion a« to its efficacy. It would be, t UiinU
very diflicukto find patients who would submit to such a very protnolell
course of treatment and such numerous operations.
I Vl<lf a newt iiiU-n-cthiK vr«rk by Pr. S[K'rinp, rntlllvH " Klatlfi C1itii>|iiv9 «ur
t'Krivi-iiatinn td|>^lJ''p il<- t'llunif-iir iu|ni'iiH(- lUns Ira MalibllcJi dr I'lKll," Turkii, 1882.
Mmi a rfTU>w at Ibu work in ibv " U[}hlliaJiiiiL' Itoviuw,'' il. |>. 294.
CAf&ULAR A^tD BBCOHDARV CATABACT.
»4T
IJ^OVF.RvVTIOXS FOR CAPSULAR AND SECONDAKY
CATABACT.
T havo ainmily stated that capHuUr cataract nften oocura in rctro-
grcsdivo lonticiiliir cataract, aii^l that in ftiich ciucr it mnr be advLsablv
to riMiiuve the lem id its capsulu. If, In au operatiua for svmle cataract,
the cHfuule is found ao tough mid liuokened that it resists the priuker,
it should he torn across with a sharp book, and then, nfter the extraction
of the Ions, tlic capsule should he removed hy the hook or a pair of
forceps. In such cases, tlie connection between the posterior capsule
nod the b^valoid is not unfreuueiitly loosened, and the Ions maj often be
readily cxtractod in its capsule \ty the hook. Some operators, in making
the M'ction, divide the tough capsule acro^tA iK-ith the {toint of the kuife.
Secondarj cataracts vary much in tliicknegs and opacity. Tliey may
bo produced hy portions of lens substance rrtnnining behind and becoming
ontangled in tlie capsule, by the deposition of lymph upon the latter, or
by the proliferntiou of the iiitra-CAfiaular cells.
Again if the more 6uid conatitueats of a cataract become absorbed
and tho cortical suhstiincf underguud chalky or fatty degvneratiuu, tliO
Knia );;radually dwiinllvs down, and usumca Uic ap]>oaraucc of a Qaitcnod,
flhrivelled di«k.
Mr. iJuwtnan' has also caUed special atteotion to another form of
iary cataract, in which the capsule, though qnite transparent, is
mpled or wrinkled, and thus produces much confusion of vision by
irregularly rcfractin); the rays of lij^hi. This condition of the capsule
nay easily escape <lutectiou, even although the eye be exaiuitied with
the oblit|ue illuiuiiiatiun, and is nut pcrlinps noticed until the oplitbal-
moAcope u employed, when the observer finds tliat he ciinnot obtain a
oloar and distinct view of the optic disk, but that it looks somewhat
distorted. i.>u then getting the CHp6ulo itself into focus, the wrinklus
may be readily observed.
iio operstioD for secondary cataract should be perfonned until the
eye has ifuito recovered from the cataract operation, and is entirely
free from all irritation. Generally throe to four muiiths should he
allowed to elapse between the two operations. Nor should it be done
if the area of the ])u|iil is not of a gao<[ sixo. If it has becoinc con*
tractvd, or is partially occu|Hcd by iyiuph, ur if there are extensive
posterior synechitu, a preliminary iridectomy should be made, nnd then,
when the eyo has become <piicsceiit, the opi'ratioii upon the capsule may
be pertbnnod.
Konnerly, the favorite mode of operating was by tho removal of the
obstruclitig membrane. But this is falling mure and more into disuse,
as it often proves a very dangerous operation, and is far less safe than
opening up the membrane by the needle, which is attended by much less
nsk of setting up iiiHnmniation. Moreuver, it is a well-ei?tal>lis)ie>l fact
that a small clear aperture in tbc opaipie membrane will atfonl iuu.4t
excellent sight.
kMr.
imp
» " S. L. u. H. tt«p.," It,
348
DT8BA8K8 09 TUB CRYBTALLIHB LESS.
For tbc n«C(Ile operntion, chlorofonii is IiarJIj,- nwcuMrj, unless the
patient proven very iiiiimtingcaMe. TIm- eyrlids tihould be Icopc njiart
willi tiiR stfi|vs[>eo Ilium, and the eye mar ho stcadii^cl wjtli the forccp.
Uowinairs fine 8tn)K-iieedle (should then 1>e passed through the coniea at
a short dUtAnce from the margin, and the operator should endeavor Vt
tear a hole in the centre of the op^ue membrane. The portion which
is thinnest, least opat|ue, and con-sistd chiefly of wrinkled cupsulo, should
be selected for this purpose. It is to be torn across in different direc-
tions, the pi)int of tlie needle coimnitiuLiug liie membrane, witliuut, hnw-
tvoT, \mx\<i allowed to gn deeply into the vitreous hnmor. If iho o[)erator
finds, after one or two iiiellectnal attempUj to transfix it and tear it
tlin>n<.'h, that the faUe memhrane yields hel'oro lite needle and eludes it,
or if it is too tough and finn to bo torn through, ho «hould at once have
recourse to a second needle. This is to be passed into the anterior
chamber from an opposite point of the cornea. Transfixing and steady-
ing the false membrane with the needle held in his left hand, the ojieralor
cmi'loya the other needle to tear tlie memhrnne ainl open it up. t)r the
points of the needles may he made to cross each other, and then, after
being revolved a few timea round each other, bo separated, nhich will
cauae the membrane t^i he torn across, tireat care must lit* taken to
MM the needles with extreme delicacy, and not to draji; roughly upon
the adheaioiis between the c;»|iflule and tiie iris, oUiL-rwisu severe infiam-
tii»tion may be get up. If any p«irtiou of the iris Bliould have been con-
siderably ar»:j;g(.(| upon during the utte of the needlesi, it may he advU-
ahle to excise this segment, in order to allay any tendency to intlam-
rnatory reaction. This ingenious double-necille operation was first
deviated hy Mr. Bowman,' and has proved a most valuaUe uhliliou U\
Ophthalmic Sorgorj'. KhouUl the false membrane he found but sli;^htly
adherent to the iris, so that it floats almost freely in the pupil, the,
adliceiioiLs may be torn through hv the needle, and the whole membratis
extnicted hy the canula or amalf iris forceps through a linear incision.
If the adiiesions are found to be so firm that a good deal of force woold
have to be employetl to hreak them down or to divide them, tJiis shoold
on no account be attempted ; but the free portion should bo caught by a
sharp hook, gently drawn tliroiigb the liiu-ar incision, and e^riipped otTi
which will leave a f^ood-sized opening in the capsule.
In eases of chalky or siliculu^e cataract, in which the capsule toofca
like a little wrinkled hag containing 8mall chalky chifM of lens, it may,
be possible to remove the whole Ckjiftute with a sharp hook thniugh ■
goml-fiized linear incision, as in Kig. loO. llut it is often a very dao-
geront* operation, netting up perhaps severe irido^shoroiditis, which tohy
even lead to atrophy of the eyeK-ill.
After an operation for secondary cataract, atropine should be applied,
the patient b« kept in a somewhat darkened room for a fow days, and
carefully watched, in unter that the firxt symptouu of intiammatiiry
reaction, ntsrompiinied. perhaps, hy incn'^ascd intra-ocular teosion, nuty
b« detected. Within from twelve to tvrenty-four hours of the operatioD,
the patient may experience a good deal of pain in and around tiic eye,
< " Ued. Cblr. Trsna.," 1S&3, p. 31S.
CAPSTTLAR AMD SBOOHDART CATARAOT.
S4fl^
AA«r *Mll«M>
ftu'l down the corrcapomling eitle of the ^^s- 1^-
iM>fte (ciliary ncunil^'ia) ; th«'re is per-
h]i|ie some subconjuitctiial injectioit and
lachrvmation, ami Uie ai;;lit npppara some-
what cloudy. (Jroat benefit i« ofion cx-
pericncml from Uio use of very cold (iced)
comnrcsws aft4;r thi-t ofMsmtion, as thoy
dinunish the irritation, and often cut
short ail ntuick of severe inflamiuatioii.
On trying the tension of the eyeV»aU it
is found increased, and the iris pushed
forward (sometimes iiartialty), so that
the anterior charahor is narrowed. If
the iotra-ocular tensiou \& coiisiderahly
iocroawd ( + T :i), and thi* perflisw for
twelve hours from the commencement,
Mr. Rowman' strongly advises that the
bulging part of the im should 1)« punctured with a broad n6«dl«,
thus eatablistiin^ a communication between the autenor and poMerior
chamNers. whii:li will generally diiuii/ish the intra-ocular pressure and
cut short llie iiiHaniiiiiitioD.
l>r. Agnew,* of New York, has devised the following ojicration : He
Eaaaes a atop necillc throuj^h the ceutrc of the membrane, chmi fixing
oUi the ere and the lattisr; he then makes a linear iocisiou on the
lem|ioral side of Uie cornea, thnfu<;h nhich lie passes a nmall Ahar[>-
pointed hook, the point of whitih i^ jm^ed into the same opening in the
membrane as tlie needle. Uf unu teant the membrane, and by n rota-
tory movement of the \ukiV rolU it up round the Utter, and then cither
draws it out altogether, or, if this cannot be done, he tears it widely
open.
For thoM esses in which severe and protracted ioflammatioD has fol-
lowed the removal of cataract, giving rise t^» a deuse secomlar^ cataract.
Dr. Xoyos, of New Ynrk, ha.1 <icvi:*cd the following operation.* which
he has performed with much success : lie makes a puncture at the
centre of the outer margin of the cornea, witli tiraefe*s cataract knife,
carries it across the anterior chamber, aud makes the coutiu-r-puncture
at a corresponding point on the opposite side ; he then [tarUally with-
ilrawfi the knife until itji point arrives opposite the middle of the iris,
when he pluuges it l>ackwBrds through the false membntne into the vit-
reouSf making the wound art hirge as possible. After withdrawal of the
knife, a unall blunt hook i« tu )*o passed in through each corneal wound,
and caught in tlie wound made in the iris (false membraae ?), and trac-
tion made in opitosite directions, so as to drag out a portion of tiaflue at
etch cmeal wound, wliere it is to be snipped oflF. Xliu.s a large central
pupil will be made.
When the natural or artificial pupil heooines closed by deuse false
membrane Uirough the occurrence of irido-choroiditia after extractiou of
• "B. 1. O. H. Kt.," i«. Still.
■ "B. L. O. II. Bei..,"Tt. 3, aO!>.
* "K1. Moaatalil.," 16«5. p.39t.
350 DIEBASBS OF TUB CRTSTALLINB LENS.
pig. 131. Pig. 13a.
'cAtaract, we must eixlcavnr to mak« a
new artificial (nipil, ami to rcuiovo jjor-
tions of the faW momhmiic h^- one of
'tlic operations describe-l at pp. 249,
250. De Wecker opomtes in atich
caacB ill the following manner, employ-
ing his new forceps scissors. Let us
suppose that Von (Jrac'le's operaltnn
lias l>een pert'ormeiU ami the pupil
closed hy faUe raenihniiic«. An inci-
sion of 8 millimetres is to W m^le
with ttraefe'a knife through the cornea
and iris, about '2 millimetres from the
lower margin of the cornea, vi.le Fi;i.
llil. The forceps scissors, Fig. 1:-J2,
are then to be so introduced that one
hiade pituses behind the iris and exuda-
tion masses, the other along the po«te-
rior surface of the cornea. With two
incisions which meet at the apex, a tri-
angular portion of the iris is to be ex-
cised. The forceps scissora are bent at
an angle, and can he passed through
a t-mall corneal opening, and yet be
widely opened in the anterior chambtT,
and are therefore of tlic j^rcatcst nse
for any operation with the latter. The iniiotomi/, or incision of the irif
to produce an urti6cial pupil for optical purposes, mav also be made
with Pe Wccker's new forceps scissors, which would, I think, be very
useful for this purpose.
[Strcatfeild employs for this piirpooc two " needle-hooka," made of
two cataract- needles bent at their ends into two small hocks. The book
part is j'a^hs of a ceniimctre in extent, and should maki> but a small
section of a large circle. He places the sharp parts of the hooks one
on either »ide of the coniea near its margin, presses them into (he
cornea, and on towards the centre of the anterior chamber. The hooked
extremities are then turned down into the membranous septum, and then
drawn slowly in opposite ways. By this method the lateral and hack-
wards dragging arc both obviated, and tlic at|ueoua humor is retained.
while the ins is unaffected. (See '• Report of Fourth Intomat. Opblhal.
Congress," I*ndon,1872.)
'Weber, in these cases of secondary membramform obstrnctioa, uses «
two-cd<;ed lance-shaped knife, 4 mm. wide. This he plunges through tho
cornea and membrane on the temporal side ; pasaea it behind tlic obstruo-
OfStOCATION OP THK LBNS.
S51
tion arwi then out again on the nasal sido. Then with a pair or Wfcker**
forceiKi scissor* he cms tlirouyh the lueiuhniue above aud below, ami tbiis
excises a i|uadrilaternl piece. — B.]
U^DISLOCATION OK THE LEXS (ECTOPIA LENTIS).
The rlislocation of the lens may either be partial or comjilete. In the
latter case it may be displaced into the vitrcons or affaeoas humorSt or
benesU) the conjunctiva.
l*'triial Ditl'xration. — In the slightest degree of partial diapK-tcenient,
the lens is simplv turned ■winewhai upon its axis, one portion of its i»eri-
pliery being tilled obli'|iieIy forwards against the iris, the other back-
wariU and awuy from the tatter. Or again, the dialooation may be ecoen-
tric, the lens being Bonicwhal uliiftcd
towards a oertuin direction, bo that [Fig. 133.
ita centre no longer correaponda to
the optic Axie, but liea more or less
cuHNiderahly to one side of it ; iJic
peripliery of the lens may even lie
across the normal pupil. [Fig. liWj.
This form of diftplaoemeiii generally
occnra in a downward direction ; hut
ii may also take place upwArds and
inwardft, or npwanU and ouiwanla. in»rL«w»iiB.j
Snch partial displacement of the lena
may be occasioned by ranous cauHes, among-it others by anterior syne-
chia, for if in such a caae an adhesion exists between the iria and the
capsule of the lens, the IniCer in drawn forwanls with the im at this
[Mtint, and therefore somewhat displaced or tilted. It may also occur, ne
tilcltwng baa i>oint«d out. in cases of anterior *rlerftl s^lapliyhmia.
On examining nn eye aBected with [lartial displncement of the tens,
wc find that when it is moved rapidly about in diftbreut directions, the
iriit is ajigbtly tremulous at the point where it has lost the support of the
lena, where the latter has receded from it, Mureovor, it is here also
•omewhat cupped or curved back, Wing on the otlier band pushed for-
ward and prominent at the point where the edge of the lene is tilted for-
ward against it. In the foi-mer ifituation, the anterior chamber will con-
sequently be slightly deeiwned, in the latter narrowed. If the pupil is
widcl}' dilated with atroftme, we can easily recognize the altered ])osition
of the lens by the aid of the oblique illumination, or still better, by the
direct examination with the ophthalmoscope. With the latter, tliu free
edge of the lens will be noticed as a sharply define*), dark, eurvi'd line,
triiversing the red fundus, and forming the outline of a transjuarent or
opat[ue lenticular disk. If the displacement is to great that a consider-
able portion of the background of the eye can be examined tlirough that
part of the pupil in which the lens is absent, a distinct erect image of the
detoils of the tundns will be obtained. In the reverse image, tJie pris-
matic action of the edge of the lens can b* easily observed, for then the
double image of the fundus will appear, and the two images cannot bo
352
DISBASBS or TUK ORYSTALLINB LBNS.
aimulUnoousl^ distiucUj seen : for whiUt the one U cleurlv dcGacd, tbv
otiirr will apjwar Hakv, ami id order to rcmlcr tlic latior iliAtJiict, oiilier;
tlic |>09itioii of the observer's eye or of the <>culftr Ions must W clian>;ed.
Sucli a purtial di^plncenivnt of the leus will aUo have a peculiar ulfect
upon the patient's titght, for he will generally he affected with tnfinocular
diplopia, or polyopia, which is due to the differetice in the refraction of
tlie two portions of Uie pupil, and to the prismatic action of the pcriphe-
nil portion of lens which lies acro«» it. The slate of refraction will al*»'
differ in the two portions of the pupil, for in that in which the \ci\i is
alwent, a very coiwideralile dcjrreo of hypermetropia will cxi^t. Von
fjraefe' nieiitiotttf a c.i»e of diitplucemenl of ihv lenA, in which, when tlie
tiatient watt endeavoring to disliu^uiiih a mnnll object, the eye deviated i
m a cei-tain direction, in order that the rays mi;(ht impinge upon the cen-]
tral portion of the len«. If the pupil is small, the jKitient may obserre
the edf^o of the displnced Icus eiitoptiually. or the tiante phenomenon majr
be proilutied with a dilated pupil, if he looks through a minute apetturtj
in a card or a stenopaic ap{>aratu8.
If the dislocation of the tens is due to an accident, etc., e. g.^ a sever*
blow upon the eye, the sight is often greatly imjwiired directly a(U<rward>^
by hemorrhage into the ai|ueous and vitreous humorx. Att tlie blot>d>
hocnme^ ahAorbed the ^igbt may gradually improve, if there ia no other
deep-seated lesion.
17.— COMPLETE DISLOCATION OF TUE LENS.
/h(o th4 Vitrtn'Ht Humor, — ^Tlie iris will be observed to bo markedly
irenmloufl when the eye is moveil in different direcuims, ami the anterior
tfhamher will be somewhat deepened. If the catoptric test bo employerl,
it will be found that the lenticular reflections are wanting. On oxamiu-
inj; the eye with the oblique illumination, the absence of the reflection
from the anterior capi^ule will aljo be noticed, and the poe>ition of the dis-
placed lens will in roost cases be easily recognised, more especially if the
pupil i.^ dilated, m a portion of the lens generally occupies some part of
the pupil, i.>r tl»ald w:t<>m it when the eye ia moved. If lite len8)sopa4tte,
the 4tght will of coune be temporarily lost when the leus lies across the
IMipil. The |>06iuon of the lens will vary with that of the head. If Um
atter is held erect, it «ill sink duwn into the vitreuus bumur : if the head,
\3 bent forwanl. tlte len^ will fall against the pupil, or may even pass-^
lliniu;£li it into the anterior chamber. With tlie ophthalinoKope, the
aituatiou of the lens in the %itreous humor can lie very easily •wrnained,
for it will appear in tbe form of a darkish lenticular body, generally
lying iu the lower portion of tbe vitreous humor. The latter is of coutm
more ur \v*a fluid, gcnentUy entirely so. In ti|H>ntancous luxations, tho
lenn ii> fre<{uently opa*|ue. and in such cases the sight will be greatly
improved. Kven if it is tran«{utrvut at tlie time of the displaoemenC it
generally ht'comoa opaque in U>e course of a few monilu. In such caiie*
the cataract may aMume the lamellar form, only some layers around the
' "A. f. 0.,"1. 2.291.
COUPLETS DtSLOCATtOn 09 TOB IeHS.
853
I
[Pig. 134.
bucleus becoming clomlcd. But a dislocated lens toky ntmo its trans-
(mrencj for very many years. If iu capaulu is uniiijun)d. Xlooren has
aeeii a case in which uie lens remained clear for Hfi yeara.' When the
lens haa »un\ into the vitreous humor out of the area of the puiul, the
eye will be extremely by perme tropic, in fact, in a stutilar condition to
one operated on for cataract.
Dislncation "f the Lem into the AnUrior Chamber. — Although this
condition may occur in a transparent lend, it is mure fre<(ueot when the
latter is chalKv, and perhaps diminished in size. The diiplacement is
moreover generally biKintaneoua
and gradual, and not dae to an
accident. There can be no tlifli-
cultvtu recotriii:iing tJieafTeotion,
for m the anterior chamber will W
observed a lenticular disk, cither
transparent and dia[>hanou<i, or
white and opa«mo. [Fig. 1:14.]
If the lens ia in \u caiisule, b
sharply defined yellow Iwrder
will be noticed encircling the disk
(Graefe). The lena may be
either entirely in the autfrior
chamber, or a part may He \x\
and behiii'l the pupil. The latter
condition i» c*peciatly dangerous,
wilie presence of the lens in tlie
pufnl \s a|)t to set up irritation
ftnd tiifliuuuaiiun of the iris, from
maintaining n constant " te.t»)ng''
and coutufiion of the edges of
the pupil, fn some cases the
lens dues not retain its position
tu Uio aiucrior chamU'r, hut falls
back again into the vitreous humor, and it may tlius frequently alternate
ID its position, being sometimes found in the anterior chamber, at others
in the vitnious. Its pre^nce in the anterior chamber will cause a con.
siderable deepening of the latter, and u cupping buck of the iris. Ad-
hesions are sometimes formed between the ca|>dule and tho voniea; the
latter may even ulcerate and tlie lens escape through the perforation
(Graofe).'
Severe inflammatory symptonw may also supervene, implicating the
cornea, iris, and the docker utructurKs of the eyeball, and accompanied
perhaps by an increase in the intra-ocular tension. There is oflen alsti
very severe |>erio<liu ciliary neuralgia. But the inSamiuation may even
extc&d sym pathetically to the otlier eye. On the other hand, the leits
may remain for a very long [vcriod in the anterior chamber without pro-
ducing any irritation or pain.
■ OplithalmUUische BeoVac1itung«n, 257.
» "A. f. 0„"l. 1,343.
33
Afut T. W. JoM*.)
854
DISBASES OF THE CKYSTALLINB LBVB.
liitJ/wttion of the 7,«i« undrr the Conjuntrtira. —Thh is always du»]
to ai) accident, g(.'iieraU}' to a licavy blow from some blunt auMtanceJ
hitting the eye bi'low, luni kiifickiii^ it forcibly agnJnst the roof or upporJ
edge of the orbit, hmcf' tlie most frc-nucnl sent of this displacoraent isl
upwards and inwards, or upwards and outwanU. Tlie ruputre i» the-]
choroid generally occurs quite anteriorly, between or in fimit of the
insertion of Uic recti niusclcg. The form of tlislocation is most frequently
met with in perxona after the age of thirty or forty, when thi- !*ctcrotio-j
has tiist its elasticity. It h charaetenKod by the following appearaiicr*:)
Beiienth the conjunctiva is uoticcd ft small, well marked, promiDent-
tutnoT [Kig. 135], which luay even
[Viiz- IM'. cause a little circumscribed promi-j
ncnue of the Hd. The color of the
tumor rarifit, it may be dark from
the preacnce of effused blood id aod
beneath the conjunctiva, or of a por-
tion of pro1a)>-ed iriii ; or the coii-i
jiuictiva mfiy be transparent, and
only slightly injected, and then the^
grayish-white len« cau be ea^sily re-
co<mlzed, But in some casc!< only a
AtKei t>w.wi J part of the letis has escaped beneath ,
the conjmictiva, the rest r\-iuaiuirigj
within the eye. Whilst, the sclerotic has been ruptured, the eouJHtietivatj
on account of iw laxity aud elasticity, has generally yielded befui-e ihej
leiiH, Hti<l has not given way or been torn, but covers tlie displaced Ivoa..
The pupil is mostly irregidar and drawn up, and there \i a more or le«t.1
considerable prolapse of the iiis. If tiie ciipsulo has been ruptured and
the lens escaped from it, the remain.^ of the torn shreda of GajMule will
be »ecn with the ophtlialm<-»8cope, juat us afler an operation for cataract.
Dislocation of the lens nmv he tipoiitaueous, and ia tlien generally du9]
to a gradual relaxation or elongation of the suspensory ligament, or Ita'
iiartial rupture. In Duch cases tlie lens is often opaque, and the vitreous
Inimor perhaiiw fluid. Mnreo%"er, in such a contliiion a very slight shock
to the eye, wliich has perhaps bf en unnoticed by the patient, will produi^e
dislocation of the lens. The nffection mny also Ite congenital, and BV«n
hereditary, occurring in several members of the *ame family. Tlitts, .
Mr. Dixon' mentions a case iu which a partial displacement of the lenij
existed in a mother and three sons. Mr. Uowmitn narrates a case in '
which a paiient, suffering from dislocatiou of tlie lens, had two uncles
affected with the same diseaae. If the affectiou is congenital, it is geue-i
rally necompanied by more or less amblyopia, and (lerhaps nysiagmus,!
and such eyes are tf, a rtde also very myopic. In auch cases tlic dlslo-
CHtiou mostly exists in both eyes. Hut the mojii frequent cause is an
injury to the eye from blows or falls upon this orjjian, which cause a rap-
ture of tlie suspensory ligHuierit, and a more or letis complete dislocation
of the lens, .Vr. Kowmai>' has called attention to the fact tiiat glauco-
matous symptoms occudionally arise in cases of dislocation of the lens.
• "Boy. L'^id. Ophltml. Hn»p. tLtvarU," I. 54.
■ "R. L. 0. H. E.,-' V. 1.
COMTLBTb' DISLOCATTOir OP TUB IBNB.
865
According to Von (fraefo,' partinl diitplvcements of the leos, depending
upon relaxation or nipturc of ttu- unnuh, appenr to be more prone to
excite an iticreasu of tiiu eye-teusion, thiin if the disloeiition is complete,
ami the Ipiw Ik fived from its anacliiiicnt and floats aliout. For in the
latter inatanccB. glaucomatous symptocos [generally only supervene if tlie
lontt pcriotiicnily pushea tho iris forward or hocoroes jamtned in the pnpil,
or beiweeo the iria ami the cornea. As loug as the capsule remains en-
tire, we must aiwuino that the eccondary ;{laueoma nhtch sometimes super-
VMwa on diiKphiccnient of the Iciw in pniiJy due to a stretching of tho
xiinutn and ciliary processes, and pjirtly to the pressure of the lens upoa
t!ie irii* and ciliiiry region, which seta up irritation. Tlie ^liiucotna some-
tituea assumes the simple form, in other cases the infiammalory, accom-
panied by serous iritis.
The tn'atniettt of dislocation of the lens mast ?ary acconJing to the
exigencies of the case. Wliere it is but j*!iglit, the sijjiil may not be
materially affected, and no ojicrative interference may be imlicaied. If,
however, the dUpl.i<:eroorit is so coiwiderablc, that ihe free e<lge of the
lens lies in the pujiil, and tlius ^^Ives rise to great itupairuient of lliu sight,
and very annoying diplopia, an endeavor should Ihj made to remedy this
defect. The bc-st mode of treatment is that originally adopted by Wecker,*
ru., an iri<lode»iH made in tho opposite direction to that in which tho lens
lispllvccd, 90 that tho artificial pupil will be brought oppoiite that pot-
of the eye in which the lens is deficient, and the iris will be drawa
over Uie displaced lens, and cover the latter to a more or less consider-
able extent. The patitnt will then be in the coiiditJon of a peraon whose
lens has been extracte<I, and he will ho able to see well both at a disl&nce
and near at hand through suitable convex glasses. For obvious reasons,
indodenis is in such caaes to be preferred to an iridectomy. If the lens
ka 4;ompleiely ili^looated into the vitreous humor, and is setting up no dia-
torbnncc, it is wiser not to interfere. Hut if inflammatory complications
■rise, or tho sight is much impaired fay the lens floating about across the
pupil when the oyc is moved, it will be best to roroovo it. An iridootomy
shuuld be nisile opposite the point towards which tho leus is displaced,
and the latter is ilien tn hf rfmovrd hy Critchett's scoop. The operation
is, however, often very dangerous, for a considerable amount of fluid
vitreous will be lost, and severe irido- choroiditis, with subsequent atrophy
of the globe, may supervene.
When the lens is luxated into the anterior chamber, we may endeavor
to obtain its reposition into the viirooua humor, by making the patient
assume the horizontal posture, and applying a compress bandage. If it
falls back into tlie vitreowj humor, its mainteuance in this situation luay be
assisted by an iridodesis, or teuifmrarily hy the application of tlic solution
of Calabar bean. If the presence of tho lens in die anterior chamber
sots up inflammatory reaction, or impairs the .sight, it should be e.xtracted
with the scoop, and it will be better to combine an iriiloctomy with this
operation. The incision should be made in the lower part of the coi-nca
with Uroefe's cataract knife. To prevent liie escape of the lenn into the
ritreotis humor, Wecker advises that it should be transfixed witb a needle,
' "A.f. 0.,"a». 3, 15S.
■ Vide W(K.'l(er, 2a •.NlUton, p. H.
856
D[8BASS8 or TUB 0RY6TALLINB LEN8.
and kept in its position in the. anterior chamber, until the Koop can he
iotrnduced bcncnth it. If the lens simply disturbs the sight without
seltiog up any inftammation, we may endeavor to gain %\b abttorjition bj
the operation of divi&ion. caro being tukco not to lacerate the capsule tooJ
freely, but rather to repeat the operation several tiniee.
In Uic suhcoiijuiictival dislocation, an inciaion tiliould be made, and the
lens removed ; and the prciliiipscd portion excised, so that the wound may
be quite smooth. If a tolerably {irm union of the Up« of the wound bat
already taken place, it will suffice to apply a uompress bandage ; but if]
tlie rupture in the sclerotic h gaping, it will be better to unite its edges
with one or two fine sutures, in the same manner as has been advised for
incised wounds in this region.
With regard to the treatment which is to be pursued if symptoms ofJ
glaucoma arise in cases of displaccmont of tlie lens. Von (iraefe' advises
tliat where the displacement is moderate, and tlie iris partially pushed
forward, an iridecLomy should be made, and tlie portion of iris which is
pished forward removed. It is of importance that the incitiinn should^
be very perijiberal, for otherwise the entrance of llic vitreous humor into
the anierior chamber pushes back the iris, and renders ita excision very
difficult, lie points out, moreover, that the removal of the lens is apt,
in such ca^cs, to prove especially daugeruus, for as there is a free com-
municulinii betweitn the ant-erior chnmlicr and vitreous space, and the
intra^ocular tenition is incrca'ted, it is impoiuible to prevent a greac escap» <
of vitreous humor, which may be accompanied by serious intni-oeularl
hemorrhage. But if the iridectomy proves insufficient to stay the glau-
comatous symptoms, or if tbe lens is completely luxated, it will be neces-
aary to remove the latter.
[It has been asserted by several observers thai in death by banging
ni|)lurc of the capsule or fracture of the lens in occasioned by the shock..
Dyer has published the results of oltservatioiw upon ten eyes of fiva'
criminals executt-d by hanging. In one eye, where the lens was opaque,
it was dislocated downwards and uulwanU. In six eyes either the an-
terlor capsule was ruptured or the lens was fractured. In two cases i\m
occurred in both vytiA. In experiments upon dogs by banging, the first
dog presented the same lesion in both eyes ; the second dog in neither
eye; and the third dog in one eyconlv. (See "Traiu. Amer.OpUthal.
Soo.," IStJti and 1869.)— B.]
' "A. f. 0.,"XT. 3, p. 157.
CUAPTEE VI.
THE USE OF THE OPHTH ALMOSC 0 F li.
I
It v&s formerly Bupposerl that the black appearance of the pupil is
do« to the fact that all tlio light which enters the eye is absorbed by the
chomiil. and conK(!<|uentty that none is reflected towards the obsorrer.
This, however, is not the case, for a co»*iderahlo j)ortion is diffusely re-
flected, and may be caught up by the observer's eye if this is placed in
the direction of the emerging myA. In such a caae, the pupil no longer
appears black, but is luminou.s, baring a bright red glow. Cnmniin:^, in
lH4ti. pointed out that all normal eyes are luminous, more especially if
the pupil is dilated : but that it is nece»iary, in order to obtain this
luiBiuo«ity, that the eye of the obaerver should be placed parallel to the
incident ravs, that h, an nearly as posttible in the direct lino between tho
source of light and the eye observed. But in the ordin&ry mode of
examination this is next to impossible, as the observer's head must he
placed between the light and the patient's eye, and will, therefore, cut
off the rays passing to the Utt«r. Moreover, even if some of the re-
flected rays could Ito caught up. they n'ould only afford tlie appearance
of a bright red glow, or. at the best, but a *'ery confused and indistinct
image of the fundus, owing to the insufficiency of the illumination and
to the direction of the emerging rayH. For in conKei(nence of the opti-
cal condition of the eye, the incident rays, if the eye is accomntodateil
for the object, are so reflected tliat they einergo again in enacily the same
direction as they entered, and would, therefore, be brought to a focus at
the point whence they originally emanated, that is at the source of light.
Tho object and its retinal image are, in fact, in the position of conjugate
foci, fhe pupil of tho patieut's eye will therefore appear black if it is
accommodatetl for the pupil of the observor, as the lattor will then only
•e* the reflection of his own pupil.
A glance at Fig. l-'J*i will reailily explain this. If F is the objt-ct.and
rt its image formed a|>on tlie retina, rayd refleL'tci! from r will be brought
to a fi»cu» at F,8o tliat whichever of these two |)oints is the railiant-point,
the other will \te the fooal point. N'ow, if we place our eye at F. the
luminous rays emanating from our pupil (which is black) will be insuffi-
cit:nt to illuminate the fundus of the patient, and hence his pupil will
a1«o appear black.
liut, in certain conditions of the eye, a considerable amount of rrflec-
tion may be obtained, as, for instance, in the eyea of albinos, and in
eases in which tho retina is bulged forward by morbid products. It U a
well known fact that the pupil of the albino ia maritedly luminous. This
S5S
TOB USE or THE OPBTHALUOSCOPC.
18 not caused, as is often supposed, \v a pvatcr reflection of the ray*
which enter the ](Upil, on acuounl of tin.- ilelici«.Mit'v of the pij^iuent in the
ctiornit), but is due to the great Amount of Iiglit which pas8i« through
the iris and sclerotic. The truth of this statement was proved by Doo>
Pl(. 136.
Tr
derSjWho plaoed before an albiiiotic eye a small screen, haiing a circular
aperture for the pupil, but covering the iris iitid ctelerolic in such a mfta-
ner that no light could pass throuj;;b them. It waa iheo found that the
pnpil lost its luminosity, and at oncu ac(|uired the usual darkneett of
Other eyca.
Again, if the position of the retina is altered, it being Imljied ronrnnl
by ft tumor behind it (amaurotic mi'n eye) or by fluid, ovure light will
be reflected, and tbc fundus will appear luminona. Moreover, on ac-
count of the wore anterior poHitiou of the retina, the eim-rging rays will
be divergent, aud hence eiisily brougtit to a fouu» ujton tht retina of the
obsen'er.
Briicke, in 1844-47, made a series of interesting experimenta with
regard to the luminosity of the eye, and shovrcd that if tlie eye under
examination i.s neither accommodated for the light nor for Uie pupil of
the observer, but for some other nearer point, a portion of the light re-
flected from itu background raay l«c caught up by the oljcwrver. aud the
pupil will then apituar rt'd atul hiiiiiiums. 'iUU is shovrn in the precod-
mg figure (Fig. lilrt). If F is a luminous point for which the eye under
observation (^It) is accommodated, the rays emanating from t will bo
brought to a focus upon the retina at c, at which poiut u clear and dift-
tiuct imago of F will be formed. Tins being so, the rays reflectt-d fr">m
c will unite at K, for K and c ore conjugate foci. If the eye of thu oh-
Bcn-er (A) bo placed beside F, it will receive no luminous ray* from B,
and will hence see the pupil of the latter black. Now, if whilst the eye,
It, remains accommodated for the luminous point, F, the latter i» brought
nearer to the eye, to K', the rays emanating from it will no longer be
brought to a focus on the retina at '-, but behind It at d, and a circle of
difl'asion, a A, will be formed upon the retina. As the eye is accommo-
dated for the distance, F, the rays emanating from the points of the alt-
cte of diffusion, a i, will be brought to a focus at a' b^ and there fonn
an enlarged and inverted image of a h. Hence the eye of the obaerver,
placed Hi A, will receive a portion of this reflected tight, aud thereforo
the pupil of B will appear mure or less luminous.
>Vc Hhali see, hereafter, that Ilelmhulti turned this expericucv of
Ttttl USB OF TIIB 0PEITUA1.MUSC0PB.
SfiS
Urtickc's to a procUcil tuc, auil conatructed his simplest oplithcilmo^cope
ufKMi Uiifl principle. Bufnrc cntfring upon eliia, I mint state tliat Helm.
Iioltjt, in 18.')], acvi!w<l an .ij.jtaratns by which the observer was enablvd
tu place his eye in the lUrect line of the eniergiii;; >^vh, and thus ;{ain a
view of the fiitiilns. The accompanying figure and description of this
instmnient are from Mr. Carter's admirable translation of Zander's wi»rk
on the ophthalmoscope — a work t caiuiot too warmly recommend tn all
wlio wi?h to gain a thorough knowledge of the tbcorr of the ophthalmo-
scope, iU UAC in practice, and the difTi-reiit morbid chHiiges of the fundit^
wliioh maj ho recognized with it. The atiidcnt will aUo derive great
tienefit from the perusal of Mr. llulke's and Mr. Wilson's excellent
work» on ibo ophthalmoscope, which, though shorter and less exhaustive,
yet contain a great amonnt of information, conveyed in a very clear and
concise manner.
" I'ndor certain conditions, however, we may see the fundus of the
human eye shine with a reddish lustre. Such cuiiditlons are shown iu
Fig. 187, where ^is a lumiimus point, and S a polished plate of glasi^
which reftcct« the light <i A falling upon it, into the obscrred eye 71, in a
direction as if it came from a point f lying a« far behind the plate S as
the actnal point /* ties In-fore it. Dii^rtiganling the IohjI of light caused
by irregular reflection and other circiinwtjiiicea, the ray-t a d and ft ir, re-
flected froiu iS', enter the obi^ervcd eye, and become united at if. The
emerging rays in their exit from B, must take precisely the same course
as in tlieir entrance; they proceed, therefore, in the converging cone
f> A (I f/ to the plate of glfla?, by which they are partly reflected back to
F, while the reiuiiinder proceed in an unaltered direction forwanla, to
unite ill a focus al P ami then again io become divergent. If noir the
eye of the ob!)cr\'cr he placed so as to intercept tliem before their union»
ad at A', it receives from e convergent rays that, made more convergent
by its own refractton^ are united before they reach its retina, u|K)n which,
aner crossing, they form only the dispersion circle o' a'. The eye of A'
wuuld certainly, therefore, receive no image, but only the sensation of
light — it wo\ild see the eye B illuminated, and the same would happen
if it were so placed as to intereepl the diverging rays Iwliind the point /*.
" After this princijilc was announced by Von Kriach, Vrofoasor 11.
Ilelmholtz, then of Konig3berg,and since of Heidelberg [and now Pro-
fetuor of I'bvHics in the University of Berlin. — B.], was the first to dis-
cover the reason why the retina was not distinctly seen, and to find the
lueaiui of rendering it visible. The problem was threefold : the observed
eye must be sufficiently illuminated ; the eye of the observer must be
placed in tlie direction of the emerging rays, and these must themselves
be changed from their convergence, and rendered divergent or parallel.
The solution of the main dilHcuIty was obtained when, iu a darkened
chnral>cr, the light of a lamp was allowed to fat! on a well polished plate
of glajss ill such a manner tiiat the rays reflectt-d therefrom entered the
eye to he ohsenx'l. The observer placed himself on the other side of
the glass plate, and maile the con%-crgetit rays divergent by a concave
Icna. Thus iu Fijj. ly' we place the concave glass o before the eye of
the observer j-l, ana convert the convergent pencil Ajjf/a, coming through
360
THB UBX or THS 0PHTHALH0800PI.
S, into the divergent pencil gikf, wo that the eye A may form apon
its retina e' a clear im^e of tiie point e.
Hg. 137.
After ZftDder.
" The combination of such an illuminating apparatus with suitable
1<'n3e3 forms an instnimcnt by which it is possible clearly to see and
examine the details of the background of the eye of another person.
TBS DS8 OP TBB OPnTHALMOSCOPB.
S6:
To thiii instmrncnt KclmholiK g&ve tbo name of E!ye<mirTor, or Ophtfaal*
niojwojie."
In onler to obtain a better illumination Ilelmbolts aflerwania employed
threw plates of glass instead of a single slip. A still greater advance
wna made when llelmholtz utilizetl Brtickc's experiment alwve refeiTed
to, and emplo_ved a strong convex leiw, held before the patient's eye, to
converge the rays reflecte<l from a largo cJR-le of iliffiwion forined upon
the retina. In thU way an enlarged and inverted image of the fundiu
vrait formed between the lens and the observer. This coiutitatos the
"examination of the actual inverted image."
Helmholtz placed the flame of a candle before the eye under observa-
tion, and a screen behind the tiame. so that the observer's eye could be
brought cloae to the source of light, and thus catch the rays after they
had been united by tlie convex lens, and formed an image of the fundus.
This point of union lies at the focal distance of the lens. This mode
of cxaminadon wait, however, troublesome and inconvenient, and hence
Ruete had recourse to a concave mirror having a central aperture for
the observer's eye. and he thus still more increased the illuminating
power. Since then different forms of mirror have completely superceded
the plates of polished glass.
The following description and illustration from Zander clearly explain
the action of the concave mirror in the inverted examination, i. e., the
use of a convex lens jilaced a short distan<;e from the eye under obiuir-
vation. so as to converge the rays emanating from the circle of diffusioti
formed upon ita retina. 7^he patient is to accommodate tor an infimte
distance, so that the rays issue parallel from this eye.
" £j:aminaihn of the actuai Inverted linage. — In Fig. 13S F is again
the flame, S Uie mirror, L the convex lens, and B ^e oyo observed.
The rays a « 6/, proceeding convergent from the mirror, and rendered
more convergent bv their passage through the lens, atrike the cornea of
B\i\ c aod d. Rendered still more convergent by the dioptric apparatus
of B, they intersect at some point in front of the retina, for example at
0, and form on the retina the dispersion circle a J. On account of the
fMuaire state of accommodatioo of the eye, the rays proceeding from it
,will follow courses parallel to the lines of direction a x and |3 x, and after
8fi2
THE USB OF TUB OPHTH^LUOSCOPB.
t.
tb«ir rcfractiou hr ilie lens L urill unite to Forni at*' ' an aciaai iorcrted
image of a J."' Ill this inode of examination it will be observe*! ihiit
the aerint image of the funilos
Fig. 13S. )g situated between the observer
I : and the convex Iciu, and that
\ \ it is inverted and enlarged. If
; ^——--^ 1 * we desin to iucrcusc tiie siie of
the imas;e, a aomcirhat weaker
object le»9 (3J" or 4" fociw)
shnutil be eniplo^-ctl, for aa tliia
rendfrs tbc rajs less contorg-
ing, the image will be propor-
tiotiately enlarged, bat will at
"" ' the aanic time lie somewhat far-
ther from the eye ; thu U, how-
ever, accompanied by the dia-
ailvantage that Uie field of vi-
Aion id much dinuni^hed in size.
Tlence the best plau is to um
first a lens of 2 or 2\ iach«6
focaa, 80 as to gain a view of
the wholo fundus, and then ta
chnnt^e thU for a weaker lenA If
wc desire to examine anir special
part of the background with par^
tioular care and minutenew.
'Hie size of the image muy also
be oouaidenbly ma^ified bjr
placing A convex lens of K or
10 inches focus in the little clip
behind the mirror. In tliiscasa
Ihe observer must, however, ap-
pn.tnch somewhat closer to the
patient.
" Jh the exoMination of tA/
virtual erect ima;fe the mirror
alone is used, without the aid
of an object lens, the observer
apjirttncbin;- very closolv to the
patienffl eve. Ho will thus
\ W \ \ obtain an erect, geometrical
\ \ \ \ image of tlie frntdus, the iotaga
being apparently situated bo-
hind the patient's eye, as in
Fig. 139.' K is the examined
eye. and R the position of the examiner's eye ; r r are divergent rays
from F, a flames incident on tim concave speculum A B, which reflcois
' I'srlcr'* Tr&ii*I.ilii'ii ft ZitniU'r, ji. 20.
* TIiiK llgurt.- niid iis i-xiitiiiinlwn »« froni Mr. Hulkv't abl* wurk ou tli« 0|>Utlial*
TUB FOBTAULE; or hand Ol'llTUALMOSCOPKS.
tbem conrergiiigly as r' r* to E^ about two inches di»tiuit, upon the fundus
of which they fonii the circle of lUspersion d d' . The rays ri'llecttvi from
any point ah-* itiiin the circlt;, ufter leavin-; K, nmwwv a diructioii parutlel
U> the prolongations of tJie lines ache (which pass through i:, the optical
centre of K) and reach the observer's eye at A', on the retina uf which
they form an iuvorUid itnaj^e of a h, which \i uieninJly projected a« tJte
enlir<jf<l, erect, j^comctrical imaj;e n fi." It will be cxpmincd liewafier
that it \s geuvHilly neuessary to make ti^e of an ocular lend beltiud the
mirror, in order to gain n clear and diminct image of the fundus. The
nature and tttr^'ngth of this lens dt^peud upon the state of refraction of
the eye of the observer and that of the patient.
I mittit now pass on to a brief description of the difTei^nt fomw of
Ophthftlniosco[>o wliich are in moat fre<|UL-nt use. For a full and accurate^
description of tlie various kiuilfi of o|)hiluilmoi»cope which have been in-
vented, I must refer tiic reader to Mr. Carter's translation of Zander.
Ophthahuoscopes may be divided into four different ctaMes: —
1. The jtortiihic or hand n[>bthaImo»copi.>s. 4>f thesu 1 ahall notice
thoae of liicbreich, Coccius, and Zeliendcr [and Loring. — H.j, [and
Knapp. — It.]
*2. The fixed or stand ophthalmoscopes, such as Ijichrcich's and its
excellent moditiuatiou by Smith and iJeck.
3. The binoculikr ophth&lmo-icoijes of Giraud-Teulon, and of l^urcDce
' Heiach.
4. The aut-ophtlialmoscope.
All ophthalino,wopeft may alao be divided into two principal classes,
the h-wf-rrtttric and the heter'Mcentric. In the h-nvh^-entric the mirror
is coiicnve^and it^ focus, calculated from its surface^ is Bxodaiid definite;
whereas in the hetero-^^Urtr the mirror is plane or convex, and the focus
is negative, situated behind the mirror, aivl can ho altered acconling to
tlie strength of the bt-couvex lens which is fixed beside the mirror.
1 lUE PORTABl.K OK HAM) OPHTHALMOSCOrES.
(t) Tke Opiitiialmoscopb or Lieubeich.
As lias been already mentioned
above, Ruete wafl the first to employ a
concave perforate*! mirror (which was,
however, fixed) as a substitute for the
slips of glass of Helmholtz, and this
principle has formed the base for the
numerous modifications at present in
ns*?. Of all the different forms of
concave mirror I think Licbreich's
(Kig. Urt) the moat handy and useful.
it cotisisUl of a concave metal mirror,
about 1| inch in diameter, and of 8
inches focal length. Its centre ts per-
forated bjr k small aperture, about 1
Klg. 140.
S64
THE nag or THB OPHTnAtMOSCOPE.
line in diameter, the edges of which are exceedingly thin. The bronre
back of the speculum around thia opening is bevelled off towards the
edge, so that the latter m&y ho m thin as possible, in onler that the
peripheral rays of the cone of lifrht, which passes through the aperture,
may not bu intercepted and cut off by a thick broad edset which would
give the opening the character of a short canal. Behind the apeculnm,
which is fixed upon a short handle, is a small clip for holding a convex
or concave lena.
C2") The OpnrnALMoscopE op Coccnis.
This instniment conaists of a plane mirror combined witb a lateral
hi-convex collecting lens, lis chief advantages over the concare mirror
are: that the obscrver'B eye is placed within the cone of r«'flecied light,
instead of being behind it ; that the focal distance of tlie mirror can be
altered according as the lens at the aide is approximated or placed far
ther from the speculum, or as the power of the lens is changed : the light
can be more concentrated upon one point of the retina; and the cornea)
Ftg. 141.
(Pig. 142.1
reflex is far lew. These advantages over
the concave mirror arc especiallv marked
in tlie examination in the direct image.
With the concave mirror, only a cone of
light corresponding in size to that of the
pupil ia admitted into the eye, and as the
aixe of this cone diminif<lies with the ap-
proximation of the mirror, it follows that
in the direct cxiiniiuatiun the illuminatioQ
of the fundus is bnt slight. Moreover,
on account of the very close proximity in
which the mirror has to be brought to the
Mtleut's eye, much of the light from the
lamp is oucn intcnicpted, whereas tliis
i<i obviated }>y the collecting lens inCoccius's instrument. The latter is,
therefore, to be much preterred to tlie concave mirror for the direct
THE PORTABLE OR HAND 0PDTI[ALM0S00PB8.
805
■Dctboil at cxaniiDation. For tho indirect method the advantages are
lesii marked, hut even for thU I prefer it, for rcaaotii wliich I aliall men-
tiou bereaftur.
Cowiiis's nphthaliDoscopo (Fig. 141), as nuule at present, consists of
a ]i1atie metal mirror, having a small central aperture. Behind tlie mirror
is a hiu-^ed clip to bold a convex or concave leiiJ. A lateral biconvex
lens of 5 or T inche* focal length ia held in a large clip mounted on a
joUitcd bracket, which ie so connected vriUi tlic neck of the handle Uiat
Vit permits of the lens being moved to cither aide of tlio mirror.
Die original form of Cocciu^'s opbthalmoacope [Fig. 142J differed
Trom that whieti I have dexcrilied above, and which is at preacnt in gene-
ral use, Iwth in being s-^uare in shape, and in being made of glass
iiut«ad of metal. The square mirror was inconvenient, and could not
[hv steadied so well against the orbit as the circular. But the great
disadvantage of the glass mirror was (as UetmholtK pointed out) that
tJie aperture could not be bevelled down to so jinc au edge as the metal
one, in oon3c<|uenct- of which mt>re or less of a canal existed, which inter-
cepteil many of the {leriphenil ru_)'d, and produced considerable diflnicliou.
The mode of using Ooccius's opiilhslmoaeope is as follows: The eol-
lecting lens i« to he turned towards tiie 6ame, which ahouM be somo>
what more tlian twice tlie iliatance of the focal length of liiu lens from
the observer. Tlie mirror is then to be »et somewhat slanting to (he
.lens and the e}re of the patient. If tlie mirror is properljr adjust«d for
the lens and the fiame, wo shall obtain, if we throw the image of the tiaine
upon the palm of our hand or the check of the patient, a bright circle of
li|;fat, with a small dark central sfMt, which corresfHmds to the opening
in the speculum. The dark spot is then to be thro\vn into the pupil of
the vye under examination, the surgeon placing the mirror close to his
own eve, and looking through the aperture into the patient's eye, which
sliuuli) afford a bright luminous reflex. For the indirect mode of exami-
oatiou a bi-coovex lens of from 2 to 3 inches focus is to be held before
the eye under ubaervatJan. I, moreover, also use a convex lens of 8 or
10 inches focus behind the mirror, in order atill more to magnify the
image. If llie direct examination is cmployetl, a concave lens will gcn-
'erally be retpiired behind the s|>cculmD. At first thiii instrument may
Im- »uravwhat more diilicult to usu tlian the uoiicave mirror, on accouut of
our having to regulate Uio position of the collecting lens with respect to
t))c flame and the mirror; but a little practice and per8everat>c« will
rery soon overcome this difficulty.
(3) Tor OpninALMOscoPB or Zeuesdeb.
This consists in the combination of a slightly convex mirror with a bi-
convex colluctiug lens. The illumination of the retinal image is thus
[greatly increasea, for the whole of the cone of light reflected from the
mirror can be collected into a narrower section, and can l>e tJirown into
the eye without the ffcripheral ravs being intercepted by the edge of the
pupil ; more light can also be difi'used over the fundus, and it can bo
more strimgly concentrated upm one point.
This ophthalmoscope is, in fact, a modification of that of Cocdus, and
366
TIIK QBE OF TBB OmTH ALMOSCOPB.
it very clfudy resembles tlio proaent form. Indeetl, at the 6nst gluice.
they may he rcailily mistflkcn for cnch other. On closer obaervaUon it
will be, liuwcvcr, noticed, tliat i^i.>bender's mirror is convex, wliereu
llmt of Cni^'iiis is quit*' pliiiii. Moreover, on lookiii;; into Zolionder*^. we
get A smaller image of our face than it the case with that of Cocciai.
It is certaiiilv the bent oplithalnioi^ope for the direct exaiiiin&tlon. but I
prefer rocciii«'ii for the mdiroct inwlo of observation. Indeed, tbp latter
answers so vrell for both purposes, that for the general surgeon it will
amply suffice.
[(4) The Opiitbalmoscope op Loarsii.
Tills instrument is extremely useful for the direct method of examina-
tion, as it avoids a coustnnt change of lens behind the mirrnr, and expe-
dites the determination of errors of refraction. It is so constructed' as
to contain the re^juisite convex and concave glasses in three cylinders
placed behind the mirror, and their rotation ennbles the .surgeon to rap-
idly obtain the proper lens for bis exuniiiiatiun. Kach cylinder is
pierced for eight glasses, forming in tlie a^^regatti a series of lenses
dXlendinK with but comparatively jtKgbt differences in focal value, from
convex ,'b to li and from ui>ncav« fg to |.
The manner in which the glasses are divided among the cylinders will
\iQ reailily understood from the accompanying figures (l''ig. 143). The
first cylinder is made up entirely of convex glasses, by means of which
all ordinary degrees of hypermetropia can with sufficient exactness be
dotvnnincil. One hole (0) is left vacant to represent emmetropia, with-
out the necessity of removing the cylinder, and for examination by the
inverted imwge without an eye-piece ; should, however, the bitter be de-
sired, the observer hni* a large selection at his command. The second
cylinder contains the connives of moderate focal power, an<l tJic, tbinl is
composed of the high numbers, both pot^itive and negative. The««
atroDg numbers are designed for the determination of the highest degrees
of errors of refraction and for the measurement of the ine^pialities of the
fundus, such as excavations and elevations of the optic nerve, projec-
tions of tumors, r<>linBl detsehmcnts, membranes in the vitreous, etc.
The mirror, being contained in a separate case, is made delacbatde from
the re«t of tlie inHiniment, which can then be used as an optometer, the
patirnt himself revolving the cylinder till the suitable glaAs is obtained].
Besides the common eoncave mirror, Dr. l>oring has had another cod-
•troclcd, which was originally designed for a stenopRJc slit Uf be n^
with the in«lr\inient when employed as an optomotflr for the dctennina-
tinn of astigmatism. It consisted of a Ibin plate with a slit in it. whose
length was etinal to the diameter of the perforations in tlie cylinder.
'Vbis «us mounted like the mirmr, and made to &t in Uie mirror cell in
which it revolved, so aa to allow the slit to conT.*i»ond with any given
meridian of the cornea. Tlie meridian once determined, the (atient
tunied the cylinder till the suitable glafis was obtained. Thi5 plate wan
Mib»e<|ucnl1y made with a polished surface in front, and ilien «a« made
> •■ An«r. Journal of M«d. 8d..** April, 1870, |>. 940.
m
THE 08B OP THB OPHTUAtMOSCOPS.
[The modification of Uie Rekoas syatem adopted bj Knapp constate of
two uudctacliable, rc-volviiig diiiks, one contaioing concave and tlie oOier
.convex ;;lasa(?a. ThcAC arc placed upon each other so tliat tliey rotate
pa<it each other, and thus the strcngtli of each glaM can be diminiiihed
ay addiug the diiTurent gUa»ea of the other disk, litis, however, tiece»<
eitates considerable calculation to determine the actual ralue of the glaM
LQaed. The advantage of this instrument is that it is in one piece, and
'taa no detached cylinders. (•' Trans. Amer. Ophthal. :>oc.," 1873.)
Wccker's modification consists in a revolving disk with *24 convex and
concave glasses, vrhicb can be set in motion by a cog-vheel apparatas.
The disadvantage consists in the very small sise of the inserted ^asacs.
,<;"KI. MonataU. f. Augenheilk.." 1873.)
IiOrinsV fir^t luodificatiou of his original instminent consists in re-
placing mc detachable disks by a single stationAry one, one inch And a
half in diameter, in which the glasses are arranged iu two concentric
circles. The glasses consist of 12 convex and 12 concave, the weaker
ones being arranged in the outer circle, and the stronger ones in the
inner circle. The outer or inner circle can be rapidly brought into
powiion by sliding the disk upwards or downwards on the hand, without
Iremoving it from the eye. (^'^ Amer. Jouru. Med. Sciences," Jan. 1874.)
Fit^J
tFlj. 144.]
F^S
MW, HUNTER
-' /'
X.
Knapp has also adopted an instrument similar to Wccker's. Both
iieae instruments have the glasses covered by a piee? of metal to pr«-
TBB PORTAULB OK UAKU DI'UTU A LM08C0PBS.
869
veut MratchiDg au<l eoUing. (" Arch, of Onbtlial.," Ui. No. 2 : lb. ir.
No. 1.) _
Lorinji'ji inntn)nK''nt liibt also b'Con pravhlod with n cover in die shape
of a tlitii lliit riiij^. wtiich Kwiii;^ rouii^l oti a pivot, oiid, when closed, \n
hoW in position by sliding nnder the edge of a second pivot. Fl;?. 104.
(5«e *' l>e termination of the Kefraction of the Kyu wttli the Ophthat*
nMMCope," New York, 187(J.)
The inatrnmetit recommended hy Mr. C. J. Oldham consists in a simi-
lar UHiilitication of the ort<;in:il irmtniiut'nt wicli thu diaka, and has no
iidvantajre orcr those already mentioned. ("Trans, of Fourth Opth. Con-
>;reM," London, ltl"2.)
At the Fifth Ititeniational Ophthalmol ogical Con^re-ss, held in New
York in 1S7<>, Dr. IiOriti<; presented an ophlhalmo8co)>e for determining
rtffrnclion, in which the glasses were numbered according to tlie metric;
pjstcm, the ^la?«c« l»cinj( dioptrics or fractions of ft dioptric. This ad-
»it» of apjilicalion to his iiiBtrumeut with twenty-live perforations, by
faavin;r the disk coittain a m^^nlar iuirie!i of wholo uumbcrri, and addini; a
clip behind the mirror, provided with two glasses, + and — .ft, or half
s diuptric.
The metric ophthahnofwope of Knnpp contains S2 glasses, running from
0.5 dioptric to IS iliopirics, posiliv** and negative.
A modification of l,orinj;V last instrument by Ur. Wndaworth, of Bos-
ton, consists in an additiorial mirror for uso in llio upright iraa;te. it is
very small, circular, and has n diam(>ter of 15 mm. It rotates from
right to left, and admit-s of an inclination of 2t)° ; but ncces:<itatc.>) the
tiae of two mirrors for the instrument. Luring has himself modified this
in two wnya. as follows : be 6rst cue off a lateral segment of the ordinary
circular, concave mirror, and swung this on two vertical pins, or hy a
hinge from the mirror case. A second modification consists in cutting
off both sides of the orrlinary mirror, so that a circle is chonged to a
parallelogram. This is swung on two pivots, and admits of an inclina-
don of ;!o'^. It tilt.s both ways, and can bo u^od for cither the upright
or inverted method of t-xaminatinn.
The latest niwlificiition of the ophthalmoscope adopted by Dr. lioring,
in some respects the be.^t. is a sucooasful attempt to combine two
esaontial points, vix. : Hret, that the glasaea should have a diameter of
Dot less than ti mm. ; and, seooodly, to have a sufficiently large number
of glasses. This is done by a single disk and the segment of a disk,
the tatter buing the quadrant of a circle. The single disk contains
1*> glasseii on the metric systetn, the convex being numbcretl in a dif-
ferent color from the concave. The first row of numbers, just beneath
thu glass, shows the real value of the glass ; the iuner row shows the
result of the combination when the <[u&drant is in position. Tho latter
rotates over thedi-ik and around tlie same centre, and contains 4 glasdca,
—.A, — 1)1, and +.6, -t-lti. By the various combinations a total aenes
of Hft glasses can bv obtained. By a simple displacement of the <iiiad-
rant. tlie instrument becomes a i^ingle-diitk opbtlialmoscopc. (See " Trans.
Fifth lutenint. Ophtlial. Congress,*' 187i», and " Tmns. Amcr. Ophth.
Soc.," ISIK.) (These various mo«lifications made bv Dr. Loringof his
24
S70
THB USB OP THE OPHTB ALMOtiCOPK.
original instrument can all he obtaineil of Mr. 11. W. Ilantdr, 1132
Broadway, N. Y.)— B.]
a— THE FIXED OR
DKMOXSTRATING OPHTIIALMOSCOPI
OF MKBKEIGH.
This iTislrunient is coiiBtnictcd upon the principle of the concave mirroi
as it is eniphiyed in tbe Inilirect mode of examiniition, and is ao arranged
that the whole Appftnitu<t (mirror and ohject lotks) \n fixed to a tahle, thiu
allowing the surgeon freeusL'of his hands, and. when il is properly adjusted.
cnBhhii>|: even an ntit^killed ubserver to see the details of the funduH.
The instnimenl consists of two tubes, mo^-ing one over the other.
Tliat neareat to the gur^^eon has a small ohlong portion cut out of ita aide,
in order to admit the light to the concave mirror, which is attached to
ittt extremity. Behind the irpeculuni. there in a small clip for an ocular
lonn. The other tuhc carries, at its free end, a hi-conveit object lens of
from 2 to 2h inches focu^, which iit to be pUced about 2^ inches from
the patient's eye. The two tubes are movable, one upon tbe other, by
a rack and pinion, so that the mirror and the object lens may bo an-
justed to any required distance. The whole apparatna is supported on
an upright stem, and may be fixed by a damp to the comer of a tablo.
This stem is also supplied with a movnSIc rest to receive tho jwitienl's
chin, and thus to steady tiis head, which purpose is likewise assisted by
a small arc, supported ny a i-od adjusted to the upper end of the stem,
the arc receivuig the {vatient's forehead. Two small black shades are
adjusted to the tiihes, ho as to cut ofi' the light of the lamp from the
eyes of the patient and the observer. The Inmp is to he placed a few
inches from the itistrument, and nearly opposite to the 'jpeiung in Ute
tube containing the mirror, so tliat its rays may fall direct upon the
latter. The patient is to be seated at the other end of the apparatus.
having the eye under examination ou a level with the object lens, and
about t^l inches from it. Before illuminating his eye, it will be best to
throw the light ufK>n the palm of our Imiid, u^«on which it should f-f^rm a
bright circle of light having a smalt central ilark s]K)t ; if this is obtained,
the instrument is properly adjusteil, ami the light should be thrown into
the patient's pupil, which chuuhl be widely dilated by atropine. If the
reflection is not round, but jagged or faint, there is some fault in the a-l-
iustmcnt of the lamp, mirror, or object lens, which must be corrected
before the examination is commenced. If the retloctions of the lamp on
the retina confuse the image, the object Ions should be slightly tnniea, so
as to separate the two reflections and remove them from the centre of
the field of \iew.
This instrument is especinlty useful for demonstration to a class ; or
for the purpose of drawing the appearances of the fundus, as it leaves
both bands of the surgeon at Uhcrty. For common examination it is
too tedious and inconvenient, as we are completely dependent upon the
|)atient, for the slightest tnorement of his eye will throw tlie object out
of view, whereas with the hand upiithalmoscojie we are chiefly depetident
upon our own dexterity.
THK FIXBD OPIITHALSIOSCOPE OP LIRtlRBtCH.
371
I
I
A verj excellent nH>4ificntioii of Liehroich'g itigtrnment has been miule
b^* Me-9«r8. Smith ami Beck, as sujy^estci by Mr. Kilbura. It h more
sily atljusialik'. and iUt poHilinn with rc^ftrii U> Uie jiaucnt and obncrver
^ti be more ren^lilv clinrifjcd. Instead of hcmf^ screwed on to the edj^e
of the tftble, this Instrutiifut is fixud upon a Rm;ill boanl Biipjilicd with
rollers, which cnahh\'» its p4witinn to be changed with groat facility, and
■(nite independently of the patient. Moreover, the itandard carries a
panifBii l»tnp, so that the position of the ophthalmoscope towards the
li;;lit always remains the same, even aIthou*(h the former may be moved
nearer to, or furtlicr from, the patient. This arranj^eiiient saves a great
deal of tiaie and trouble, oiid obviates tlie copstaiit change of position
between tlie lamp and the ophtlialmoscofie, necessitated by any move-
ment of the latter. Tlie rest which fiupport* the jmtJent's chin, iiutcad
of being attached to the instnimrnt, if; independent of it, and iit iiu]k
ported on a separate standard. Thie permits the position of the inittru-
ment U\ he changed without affecting that of the pu-tienl.
l)r. Lionel lU-ale baa devised a very ingenious oplithalmoscope, which
cao be used witliout darkening the room, and which will be fount) esjie-
cially useful in the light wards of a hospiul, and in the physician's con-
sulting room. I have been able to see the detaiU of the fundus perfectly
I with it by broad lUylight.
H Dr. Beale has obtjtiiied thi« rcitult by inclosing the reflector and lens
^1 in a tube, to tlie »ide of which is adapted a auiall paraffin lamji, with a
^M largo planoconvex lens. The illumination is so strong that it ta not
" necessary for the tube to fit at all accurately to tlie margin of the orbit,
uid, indeed, the iu^trumont can be used ijuiie successfully even if two
Jh or tliree inclies tmuvcrrtu'l by daylight inter^'cue. The reflector i* fixed
^M in the tube at the |)ro[H>r angle, and tlie lens \a made to inclino a little, so
^1 BS to remove the reflections upon the retina out of the field of vision.
" Witli this instrument the optic disk is at once bRuight into view without
nay difficulty, and as the lamp n>oves with the mirror and lens, oxperi'
enoed persons can u«e the apparatus succcssfnlly almost upon the flrat
trial. Tlie instrument weighs nearly a pound, but it cau be made very
loucb lighter. The lamp is tlie same as thai which Dr. Beale has adapted
to the hand microscope lie used for the demonstration of objects in his
lectureg. For making ophthalmoscopic drawing)), the instrument can he
fixed to a pillar and stand. Tlic artiM can work in daylight with very
Httlo effort, while the patient can retain tlie eye fixed in the proper posi-
tion wilJiout exertion.
The iiijiiiniment has been made by "Mr. Ilawkeley, of Blenhcimstr«et,
Uoiid [*trcct, who is uow engaged in simplifying the arrangements, as
luiicfi as i>o«sibte, and in carrying out some improvements and reducing
the weight of the metal work. Mr. lUwkBley thinkii the cost will b«
■ loan tiian two guineas.
Mr. Brudenell Cartcr^s new demonstrating ophthalmoecope is by far
oiiu of the best. "The apparatus rennires the use of a table, which
shouM l>e 4 foot long, and which need not be more than IH inches wiiie ;
f^r It mny lie nrrangcd across one end of an ordinary dining-table. The
jiertfon nrhoftc eye is to be observed should be seated comforUbly, as
tshovta ^^ ^ j„ "^ig ij-^ ^.jjIj j^jg ^^^.j^ supported by a cliiu-re^t, which
U
872
TBS U8Ii OF THE OPHTHALMOSCOPE.
can be fixed at anj desired heiglit, nnd which should render the plane
of tb« face vertical. The mirror (u), of IS iucheti focul length and i
inches dinmocer, Hhotild thi^n tic arrttn;;ed with ha ccntni! aperture nhout
the iiftmc hcij^ht as the eye to be examined, and should I* placed oppu-
Bite the face :U the other side of the tahle, about 40 inches from the
chin-rest. The flnine of the lamp (f) should he placed at the eaoae
height, distant about 13 inches in a direct line from the centre of tha]
mirror, and about 8 inches to the right or left of a line drawn from the
mirror to the cbin-rcst. The screen (s) should cut oil' all direel tampligbl
Fig. 145.
4.
itfoa the patient; aii<l the stand (u), which carries a equarc of blael
^hsa, ahould be interpo4<-d between the flame and the mirror, hut cIomi
to the former, and with the glass at auch an angle tliat it shall not rctleot
light to the patient. The lens, of K inches focal length and 4 incheen
diameter, roughly set to the height of the eye by the screw at h, is then]
placed aliom K incbee from the imtient, with its long double handle OO]
tiinicd towanlit tlie observer, who fir^t ao <lisposes the mirror and lend bs]
to throw a circle of light about the size of a shilling upon the eye of lh(
patient, ami then M'nU himitclf behind the mirror to complete the adjust
mcnta required for a jieifeei view of the fundus oculi. Whilst lookii
Uirough the aperture he may imprvi(!> flight movements upou Uie mirror^
turning it either u|ion the vertical axis of its ntem, or upon the boriitoiii-J
tal axis on which it swings in ici> gimbnl. By meann of the handh; (ri)]
with ita terminal pillar (i), he may move the lens nearer to or lartherl
from the patient, or across the table in such a manner as to tranHfcr the
light even from one eye to the other. By causing the [Hilar {y) to more
in an are he may render tht- plane of the lena obliijue, so a^ to displace
Tcflectod iroagesi, and, by tl>e fine adjustment governed by the screw (k),,
he may reguliile the height of the lens with oxacuiess. 8o complete ts'
tlie mastery over all parts of the apparatus that a very little practice
renders it possible to follow all slight utovements of the eye as readily
as witli a hand ophthalmoscope, while the resulting image is altout fonr
limes as large as any that an ordinary band ophthalmoscope will aflbnl.
The largQ mirror and tbc ])ositiou of the lamp combine to iuruish a veryj
BIirOCULAR OPUTHALUOSOOPBa.
a78
powerful illumination, and the ahanrpttnn of yellow rays bv tlio blno
glaM rondcra the lij^lit so little irritatin;; that it lias acarcely any ten-
dency to produce conti-sotion of tlte ])ut>iU and the use of atropuic is
tliernforo in moiit cumd unnecensary. The arrangement of the apna*
ratua is shown in ground plan in Fig. 146, where u ehowa the poeition
Fig. IM.
^
^ a*
_11
4
of tht? mirror, R tliat of the chin-rest, F that of the flame, witli ile screen
£f and itri blue glass ■) ; L shows the lens, and I the position uf the
itiverte^l image."
3.— BINOCULAR OPflTHALMOSCOPFS. Ktc.
We are indebted for ihid valuable
and iiigeniouB instniment to Dr. Giraud-
Tculoii, who was the first to mlvc the
difBcnIt problem how it watt possible to
gain a binocular vieir of the detail:! ol'
the fundus, and tliuit give a Btoreoacopic
effect to llie image.
The annexed dia^^nun (Big. 147)
■will explain its mmlc of action. Let 0
be the eje of the patient, L the object
lens, and m n, the concave mirror, hav-
ing a central aperture. Ilchind the
mirror are two rhombs (It It) of crown
glass, ground so h3 to alTonl a doitblo
rvfniction at an angle of 45-. These
rhombe are in contact at the edge n,
thus otjaally diriding the aperture of the
mirror. The effect of this arrangement
is that each pencil of ra_V8, diverging
from the actual image (<i) of the back-
ground of the eye, after falling u|ion
llie mirror, is divided into two — a right
ftnd left half — and \» tlieii rcHfCtod IfV
the op|KMiite sides of the rbombs in Biwh
a maiinor that it will emerge parallel to
its original direction, and give riac to
two iuverccd imitgcs d and </. The one
Pig. 147.
Ql
I>
AU*tt 0ln«il-T«iil«a.
874
TBE USB OP TUB OPBTUALHO&COPB.
(if) belonging to the right eje, tlie other (//) to the led. In order to
caose thesie two imager to become united, two dccentrvd lenses ire kd*
jiiii'ted bebiTKi tbe rhombs. The tTso images d and ;j are consei^uentlr
united at a', and tlic obsen'er thus gains one stcruoscopic view of tlie
(leiuils of tlie fundus.
The disadvantage of this ophthalmo-tcope, m originally conatrueted,
wnd, that m the rhombo wore adjusted for a certain lixed dintauce. tt
only Hiiited [wrsonM whoee eyes were a c»rre(i|»onding width ft])ari from
eacii other ; for if they were either iiptirer or further apart than the
ocular opeuings, tbe surgeon either found that uue eye was a]togetb<r
excluded from pirticipation in tbe visual act, or that he saw double.
This difficulty lia* now been removed by a division of one of the rhombi
into two parts, the outer of which is movable, and tbus allows of dM
instrument being adapted to all eyes.
The mode of using this instrument diffiera somewhat from that of the
ordinary monocular o|ihthaltTiOHco|>o. Before atlcinpting to iisv it, the
oliscrvor i*hou!d accurately luljust it for hU eyes, so tliat when he is
looking with both eyea at an object, he receivet) a eiugle, clearly dcGoed
image. The reailtest nio^le of luljusting the instrument is, to pull out to
it* furthere«t extent tbe screw at the end, wliicli governs the poaltion of
the movable hulf of the priam, and then to look through the oeular open-
ings at the flame of the lamp placed at a distance of from 12 to 18
inches. If the observer only sees one image of the flame, be most
okernutely close each eye, and notice whether the image romaitw ap>
parent on the closure of either eye ; if so, the iiisirament is projienT
adjusted. Rut if tbe image disappears when the one eye is ttbui, it
shows at once that tbe obsierver was only looking through one ocular
Opening, and that the position of the rhomb must be changed. If two
images are seen, the screw must be gently pushed in (or out, as the case
may l>c) until they are brought closer an<l closer together, and are at
last fused into one clear and well defined image, which must remain ap-
parent on the closure of eitJier eye. The lamp is then to ho placed
directly behind the patient, so that its rays may pass over his head to
the observer, who is scatcil straiglit hefoi-o him. Before the examin*-
tion is commenced, the surgeon should again convince himself of the
projier adju.'^tment of the instrument, by throwing the light into the puptl
anil noticing whether or not he sees one image of it, and whether this
remains apparent when either eye is closed. At first, it is better to
dilate the pupil with ntropino, ns this greatly fociliiatoa the examination,
for even to an accomplished ophthalmoaeoput the binooolar opblhulmo*
scope will prove somewhat strange at the commeucemont, and wiQ
reijuire to be used a few times before he becomes Uioroughly familiar
with it. In the more recent form of Giraud.Tculon's instrument, th*
mirror admits of a lateral movement, so that the lamp may bo placed at
the nde of the patient. I, however, much prefer the illumination from
above ; still this is not always convenient, and therefore it is ni-ccssary
that the mirror should have a lateral movement, more especially for tbe
direct examination, wliich it renders more easy.
A very c\CL>lleut form of binocular ophtlialmoaoope has been invantcd
hy ^Tessrs. I*aurenco and Hoisch. [Fig. 148.J h consists of k set of
BINOOULAB OPflTIIALMOSCOPSS.
S7S
prisms amnged so as to divide the raya into two. T)ie two central
prinnw are fixed, but the two lateral ones are roovaWe in «uch a niannur
tliat t\wy not only allow of a lateral movcmeut, but their inclination can
aliio be changed, so that Uie aii;;le of divergence of the rays tVum the
(Pig. 148.]
[Pig. 14S0
median line can bo altereil &a may be nece8«ary. On account of this
irran;;en)ent, the decetitred IcntioA of (riraud-Tuulon are unneceiiBary,
ind. inatoad of thc^e, convex apherical len»ca may be employed, and
the image be thus considerably enlarged.
**The inatnitneiit' conAitita of a horizontal metallic plate [A B] 1}
centimetre wide and lo centimctn'-!) lone, with a central perforation.
Behind this plate Uie central pri^m^ [K \\] are
fixed, and the lateral ones [F V] A'v\e in mov.
able !;ettin;:4, fumii^hed with an index and
gniduated scale, by which their distance apart
can be read off at a glance. Their inclin»tion
in regulated by a screw [0 d] that acta upon
both of them at once. The mirror [K"| turns
u|»on a pin on the upper part of the phite. nnd
the instrument is comjileteil by a movable
wooden handle. The metallic portiona are
constmcted of aluminium bronze, and the total
weight lA thus reduced to "Z ounces and 50
(grains. The ca'te, a« fitted up by Messrs.
Murray and llrath, contains alao an object
lens, and two pairs of oculars, and is made
n( % shape and size convenient for the
po<'ket."
[The optio/il action of the instrument in
represented in Ki;;. I4!». " 0 A un<l 0 U
are the extreme out«'r niys of a pencil pro-
ceeding from a point (0) of the inverted image
formed by the ordinary object lens ; the ray 0 B is reflected by the
priim B to the priftm D, and hence to the ob»5vor'« right eye placed
behind 1*. Similarly, the my O \ is reflected to the obwrvcr'a left
eye. Up then Jieeji ttm imngcfi of the fnndufi oculi. By Inclining the
ocular prixm^ (D nnd C) inwards by the mechanism dewribod at Fig.
1-48, the two image? are fused into one,
' Vkl« Cutcr'9 traoiUtion of Zaadc-r, p. SI.
•if
/6
^
376
IHB 08B OP TBB OPIlTtULUOSCOPE.
"Thfi mnnncr of annj^ tliijj iiuttruroont ililTcrs but little (rum that of
luiiig the ordinary u}i)itii!ilmudcu|)e, excepting that tlie light is plucoil
above the hend of chu pAticiit, am) in Uie dame vertical plane us that of
the eje to be examineii. (^t'i^. 150.) The oUerver buldis th« iu-ttru-
Fig. IW.
.-■'V
f \
ment horizontally, vith the ocular prisms opposite bia eyes, btmI reflects
the light into the eye of tlic patiuut by tilling the mirror on its hinge;
in all other res|:KictA it ia used as an (iniinary ophthalnioecope.'* — H.)
This ophtlialmoMopc poaacascA ci^rtainly several Mlvantagea over tliat
of Giniud-Teulon. In the Brat place, it in much lidit^r, wh'iuh is verjr
convenient if nuineroua catws have to be examined, for tiicn a heavy
ituttrument provea irksome and fatiguing. Again, on account of the
altenition wliich can he made in the inclinaUon of the prisms, the straia
npnn the inttTTial recti niiisclea, in nuuntaimng a forced convergence in
order to unite the double iuia;;e(j, is duue away with. But this iu-tlni'
mctit is niUter more apt to got out of onler than that of Giraud-Teulon^
if it be carclesAty handled, as is apt to be the case in a class, where it is
used by many diSerent pur^oiu^.
[Cocciiift baa ciin9tnict«-il ii niixliticBtion of Girawl-Tciilon's inatniment,
as foltov!^: Immediately l>eliiiiil the mirror of <> iiichua focus, and in
front of the prism apparaiii.-^, ia a convex lens of 12 inches focal lenj^Ui,
vliich imparts greater distinctness to the image, and, at tlie same time,
admits ot a greater magnifying power. The latter is obtained by a
stoall opera>glass adapted for near objects, which is connected with the
mirror and prism-apparatus. ("Trans. Fourth Opbtlial. Congress,"
l/oiidon, 187ii.)
Schweigger employed two mirrors, separated froca each other by Uie
BIMOCOLAR OPUrnALMOSCOPES.
877
idit rli9t«nc« as exists betnecii the two eyes, each mtrror turning upon
a horistfirital anil a vertical axU. This instrument is net appliuahitt fur
the exnmination in the inverted image. (" (iracte mid Sacmiitch's Hdl>.
der Atifivnheilk.," iii.)— B.]
The i^reat .tdvantage of the hinoi'iilar <)[)hthnInioHCO[>o conitisis In \m
afTonling us a stereoscope view of the details of the fundus. »o tbnt thejr
are bnjn'^ht into relief. We are thu^ enahlcd to judge of tlie re»l thick-
ness of the retina, and can readil^r determine whetlier this i« atmormalty
increased or diniiniithed. The slightest degroe« of detachment of the
■tina arc aUo easily rcco<;rniKed. llie optic diak shows itself in ita
eality, and we can detect at a sjl^^ce whether \U surface is lev«l,
larcbed forward, or oxcavnted. Wlionrafl, with tlig nionoeular onlnlial-
fmo»co}ic, slif^ht changes in the level of the dink are often very difticidt
to dotermine with certainty, even by an accomplished ophthalnoscopist.
.Again, we can ascertain with facility the exact position of extmvasa-
Itions of blood, exudations of lymph, or collections of pigment, and
whetli^r they arc situated in tlie retina or the choroid, or perhaps in
botli the»e tiiBues. Those pointft in the iliffei*cntial diagnosis are often
of much importance in frainiti;; the prognosis.
[An opiitlialnioscoiw for two olctcrvers was first attempted by von
Wecker and Roger m 1870. Sichol hui aince oonstrtictcd one which
admitfi of iiscftd a]iplic»tion (see Graefc uiid Sacmisch, 1. c, iii. p.
l<tl). lliirko's iiistriinient is aiiKi adaptetl to this purpose. All instni-
luents for two ob*ervei"s du'ide the rays of li;^ht c<tining from the olyect
into two (!««.■(; tlie imiiges are. therefore, of a lower dc^^ree of iUumi-
natiou, and hence tnore indi»<tinct. — B.]
Variims forms of aut-itphthnlnvnt^prs^ by which the Bur;»eon could ex-
amine his own eye, hare been devised, the first who <(iiccceded in con-
structing auoh an tiii<itru-
mcnt heing CoL-cius ; siiwo ^'g- IS*-
then Heymann, Giraud-
Tenloii, and Zvhender have
iuventt^d diderent V\m\s of
bu(-ophihatiii09C4>pot>. The
i atut Nimplnst of the^o
is, I think, Giraud Teulon'd.
It} uction is explained by
the accompanying diagrtm
(Fig. 151), copied from
iiirand Teuton's article in
the Trench translation of
Mnckciizie, The tnstru-
mcnt consiHfi of two ]>lane
mirrors m m', inclined to
one another at an angle of
SlO^, and placed in front of
the obnervcr. A concave mirror (c c') ia held obliijuely before the left
eye ((/). *o that the rays from a fiame {V) are rcflecti^d on to m, and
thvnoe on to m\ which will rofteot them into the right eye {d). A
double cuorox lena I \a placed between d and tu^ by which an inverted
a78
TUB L'&B OP TUB OPIITU ALMOSCOPB.
Acrial image of A is foraicd, vhich is situated in realitr at a' between
the two mirrors, but which will appear to j; to be situated b«Too4 tbe
mirror ;« at a". In fact the rayii emanating from d, iostead of punng
DCraiiiht on, arc bent twice at a right angle, and brought back to ^, with*
out baring ondergone anj change in tbeir relative pocitioos.
4_THF, EXAMINATION WITH TUB OPHTilALMOSCOrE.
In the selection of a portable monocular ophtbalmoiscope, our ch^uee
for the examination of the inverted image lieti, I think, between tbe in-
gtrum<^ntA of Coccius and Liebreich. The latter, on account of its beii^
somewhat easier to use, ia the one moet generallv emplcired. But w
certain difficulties in the use of tbe ophthalmoiitcogM? Iinvc alwajs to b»
overcome bv beginners, I think it just as well that tbcr rhouM oonK
menee at once with the best inatrutnent} even although the tlif&cult^r of
the examination be thereby somewhat enhanced. 1 have for manj jean
mje-l C"jcciu»*8 iustruuient for the inverted image, in preference to aojf
other. Hit it poBiMiswea certain decided advantages over tJie concave mtrn>r.
Thus, on account of the lateral oollecring Icm, *e can alier tbf f<tcal
length of the mirror and the intensity of tbe illumiuatiou to anr de'Sirvd
extent, and we can also more fully concentrate die jMincil of tight upon
any given portion of tlic fundus which we wish to submit to special ex-
amination, l^e corneal reflex is aUo much less, and this is uf great
impftrtance if the pupil is very small, as is fns|ucntly tbe case in elderlj
peoplo, in whom, with the concave mirror, we can often obtain, on ac-
count of the great corneal reflex, but a very imperfect view of tbe foo-
dua without artilicial dilatation of the pupil.
CnociusV ophthalmo«ciipc is also decidedly better than Licbreich'g Tor
the cxaminntion of tbe erect image, although it is for this purpose some-
what inferior t<i Zehender's. But to persious who desire to have wdy
one opiithiilmoscope, which shall serve them for all pnnxiecs, I should
recommend that of Coccius, as fiilBlling Uds desideratum better than any
other. [Any of the modem ophthalmoscopes are better for all purpose*
of examination than the instruments first invented. Ilie introtUictioo of
the principle of tlie Hekoss disk, or of any apparatus at tbe back of the
mirror for holding tbe necessary glasses, ts an nVwolute necessity in the
practice of modem ophihslraology. All the modem instruments In use
are good, hut special preference ahould bo giveu to l>r. Loriitg's. — -IS.]
For condmaing an ophthalmoscopic examination, a darkened room and
A bright, steady-burning lamp arc esscntinlty necessary. In arranging
a room for this purpose iu a public itihtitution. care loust be taken thai
a brigbt stream of daylight docs nnt enter directly in front of the patient,
as this prodiici'ii gn^at reflection, weakens tiie illumiuatiou of tbe fnnilua,
and renders the examioaUun far more difficult, and ueedlossly trying to
tlie eyes of the surgeon.
The best gas-lamp for ophthalmoscoiiic purposes is tJuit employed U
)loorftetd!i, which has an Argand porcelain burner, perforated by a num-
ber of siuail apt^rtures. and closed underneath by a very fine wire gatise,
fto as to regulate the draught, and tlias &teaily the flame. The burner
4
XUt-T
THB BXAHlNATtON WITB TUB OpnTlULMOSCOPK.
879
slioulil not he too stnall, Imi hIiooIiI <;ive a full round flnmn, as ttiis aflbnU
a much better ill umi nation tlinn if the flame is long anfl thin. It \a at-
taclicd to a bracket, wliicb admits of a universal uHM-cmcnt in all direc-
tions. In Uio coiutiihtii;^ room, a HtiLiidnnl upright hunicr. ennnccted
with a jitas-pipe by mean.1 of au elastic lube, vrilt lie, however, perhaps
more convenient. Or a ^ood, briglit^biiniing tnoderalor lamp may be
eroploye«I. The Inrop or homer i» Ut be covered only by a chimney, and
Dot a ]flobe. In order to decrease the intensity of the lij^ht. and thus to
diminisli the contrnctioD of the piijiil, a blue chimney may be employed,
or what in »\i\\ better, a blue object lens, as sufi^st«d by Mr. Carter,
which m uiade by cLMuenting » ])Uiie, light blue glasM (A tint) butwocn
two plano-convex lenfies of the required power.
It itt be«t for the beginner to have the pupil widely dilated by atropine,
a« this greatly facilitates the examination. But when he has acquired
aome dexterity in the use of the ophthalraoacope, he must learn to ex-
amine with an untlilatcd pupil, for the uae of airopine proves very incon-
venient to the patients. It should, therefore^ only be employed exoep-
tiottally, and when it i« ossiMitiiilly necessary, as for instance when the
rpupil is very smalt, nnd the pt-riphery of the fundus has to ho examined
for a suspected xlij^ht detachment of the retina, or morbid changes in the
OQtlyiug portions of tlic choroid and retina. The examination in the
region of the yellow spot is also very difficult, on account of the great
reHoction of the li^^ht. and the great contraction of the pupil when this
part of the eye is illuminaiod. If atropia is uaed, only a weak i<oUitton
should be employed, otherwise the dilatation of the pupil will not only
lasi some time, but there will aluo be much inconvenience from the |)n-
ralysis of the aecommo^lation, which will, perhnpA, prevent the patient
from using his eyes for reading and writing for several days. For the
'p'ir[Hise of simply dilating the pupil for ophthalmot>copy, a ilrop of a
!4iilution of 1 grntn of atropine to tO or 12 ounces nf water will suffice
to produce the ru4|uiait<' degree of dilatation in al'out an hour, and it
will contiinie from 12 to 3U hours. Tlie atropinizcd gelatine disk-s will
be foiind v'cry convenient, aa the patient can himself place one in tlie
eye, before his v\»\t to the surgeon.
[By f&t the licst explanaiiou of the princiijca of tlie ophllialraoscopic
diagnosis of refraction han been offered by Dr. Loriug, and it is, there-
fore, liere pven in hitt own worda: —
" Ophihalmnscopic diagnosis of the refraction of an eyo can only be
doDe accurately when the accommodation h at rest. As a preliminary
to such an examination the olii^erver must have a thorough knowledge of
Uie stiUe of his own refraction and acc-niimodiition. flenenilly sufficient
relaxition can he ohuincd in emmetropia by uialcing the jHktient took at
ft distance, or into vacancy. This ia much easier for a myope than for
ft by perme trope, lu ho lia5 only to look at mmv point beyond U'a far-
point. In the observer the ability bo relax the occominodatton varies
very much, from the power to relax it entirely to a partial ability or
DOiK) at all, or to an ability to relax at times and not at otJiera : thit« par-
tial ability can he increased by practice. If a certain amount of invol-
unLary contraction of ibo occommodution always reumius, the observer
380
THB USB OP THE OPnTIIAl.l
will Hoon Icam to recognize this as a con^nt [laantitr, which is to be
taken inw account in tlic examinatioo."
*' Ir lUc observer in either luvopic or hypermetropic, his error of refmc-
Uon muBt timt be correctdd hy the proper friasa. In looking into an e^e
for the purpose of detonoining ita refraction, the point best adapted for
cxnminntioii is the choroidal epithpiitiin in the region of the vfllou smit,
because of its fineness, tliongh the difficnitles which attend itfl exflmina-
tion are very great; hence this jioiiit is only adapted for the skilled
expert. Ttio optic di>tk itself, though the most conspicuous object in the
fundus of an eye, often protrudes far forward above the plane of the
retina, and Ihuu an error might very easily occur in estimating ita refrac-
tion. For the ordinary ohscn*er the best adapted objects are some small
horizontal vessels running out from the edge of the papilla upon tlie
retinii. niid the focuseing of these vessels is much easier than tliat of the
choroidal epithelium."
*^ If the obserror is emmetropic and knows that his accoinmodation is
relaxed entirely, his eyo is adjusted for parallel rays. If be sees ibe
fuiidua of the |tatient*8 eye diatiuctl_v, lie concludes that the latter is
eninn'trnpic, for pandlel rays can only fincrpc from an emmetropic eye."
" If, on the contrary, his own accommodation being completely relaxed,
be does not sec the fundiut of the jfatient's eye distinctly, but does aet
it when he exerts his acuomnio<lation, he utmcludi'S that the patient is
hypermetropic ; for his own eye in accommodating has become adjusted
for dirergent rays, and such rays can only emerge from a bypermelropic
eye."
'* If the observer finds tliat he cannot obtain a distinct view of the
patient's fuiiduii, eitlier by relaxing or u^ing his own aecoinmodatiou, he
Knows tliat tlie patient is myopic ; for tJie rays coming from the latt«r*s
eye arv neither parallel nor diver^^entf hence tliey must be coDvergeot,
and such raya can f>nly emerge from a myopic eye."
" iH course these conclusions presuppose that the media in the patient's
eye are clear."
" If the oWrvcr cannot relax his accommodation completfly, though
he may be emmetropic for distant objocts, lie ia niyoptc for ophthalmo-
Hcopic work ; and in order to bring parallel rnvs to a focus nn his retina,
he must use tfau troakeet concave glass behind the mirror which will do
** In deti'rmining the ilojirec of myopia in a given case, account ba* to
be tjiken of llie dtittance between the nodal point of tlic eye examinetl
and the correcting glass necessary to see distinctly the fundus of this
eye. If the oUerver be emmetropic, and have a completely relaxed
accommoilation, and the patient ia myopic, the degree of tlie myopia il
given by the weakest concave glaas through which the fumlus in ftcen dis>
liuctljt' , plus the distance of this glass from the nodal jioiut of the patient's
eye. On the ctmcrary, the oliaerver being emmetropic aimI his accommo-
(Ution entirely relaxed, if the patient is hypermotropio. the degree of his
bypcrnmtrnpia is represented by the weakest convex glass whioh will
reixlcr tin.' fundn.4 of Ins eye distinct, minufl the distance of this glass froo
Um' iio'lal jjoiut of bio eye." (•' The Determination of the Refraction of
Ihe Kvt; with the OphOmlmoscope," by E. it. Loring, M.D., Now York,
d87ti.)— B.j
BXAMIHATIOS 07 AOTDAL IKVEHTBU IHAOB.
381
-THE EXAMINATION OF THE ACTl'AL INVERTED
IMAGE.
^e patient is to be 8«at«<1 on a cltaJr, ami the lamp should be placed
beside, iin<I sotucftlmc t>elnti(l him, at thu aide corresponding U^ t\w eye
which ia tn he examined. The surgeon then seat^ liimself directly op-
posite to tbe patient, and, holding the mirror ui bis right hand, plnce^ it
close before his eye, so that its upper edge reata a'^inat the superior
Dtargiii of tJifi orbit. T}ien, turning the mirror dlightly towanU the
lamp, he ihrowtt tbe rvtlecuon of the thimu into the eye, the pupil of
which will bo bri<^htly illuminated. ThiA movement of the mirror must
be very slight, and !>imply made by rotating the handle a very little be-
tween the fingers, otherwise tlie roflevtion will be thrown conBidvrHbty
above or to the side of tbe patient's bead. The beginner always finds
Bomc difljculty in acnuiring these alight movements of the mirror, as also
the power of moving his own head in different directions, and yet cod-
Htautly keeping the eye woti illuminated. When tbe fundus i& thoroughly
lighted up, the rim of the bi-convex object lens ift to be taken lightly
reen tbe forefinger and thumb of the left band, and held about two
[Fig. wa.]
f^
W
/
/fur^
,\
tncheii from the eye under examination. Tbe ring finger is to be placed
ftgaiiutt the upper edge of tJie orbit, in order to steady the band, an<l thiti
leaves tlie litUe finger free for lifting the upper lid if uecessftry. [Kig.
152,] The object leus should Ik; held at such a lUstancc from the t-ye,
that ita local length coincide.! with the pupil. A 2-inch lens shoultl.
therefore, be held a little less than two iiKbes from the cornea, and a
382 THE G8E OP THE OPHTBALUOSOOrB.
g.inch !cii8 a little Iftw tliaii three inches. At first, aomo difRcultv w
alwRVS experienced in keeping the eye iltuiDmatcd during tlie !k<)ji]j«linent
of tlie object Ions, aa the observer's attention is apt to bc i>iitirel3r di-
rected to it, and he forgets all about tbe illumination. Indeed one of the
chief difficiiltieit that the bcj^tiner has to overcome, is that of Icaniing to
Vfork both batuht readily together.
^Vln.'ll the fuiidiia is well iJIiiminatecl, we uliould firfit endeavor to f^io
a view of the optic disk, and tbe patient should therefore he directed to
look at the ear of the observer which is on the opposite eide to the eje
under examination, so that the optic axis of the latter may be turned
somewhat inwards. Thus if the ri-^ht eye is to he examined, the patient
should look towards the surjjcou's rlglit ear, and vi':e verrd. For as the
entrance of the optic nerve 13 not aituatod in the optic axis (centre of
the retina"), but towanls \U nasal side, it 13 necessary tiiat the jwlient
bIioiiIiI look inwardft, in order that tiiv disk may be brought directly opnn-
eite to the oliAorver'a eye. To gain tbi-t poMtion, the patient may aW
be directed to look at the uplifted little finger of the hand hohling the
ophtbalmoscope. In this case its handle may he hchl horizontally, and
the left hand ui»ed for holding the mirror when the left eye is vtnder ex-
amination. It is still more convenient to have a screen or board, divided
into differently-numbered compartnienis, placed at some distance behind
the surgeon. The patient is then directed to look at a certain figure
upon the hoard, acconling to the part of the fiiuduft which we dasire to
examine. The ohjcct should always be placed at some diatance, in order
that the patient's accLmmiodatioii may be relaxed to tlie utmost. The
entrance of tbe optic nerve is readily recognized by its prt^senting a
whitish reSex, instead of the red glare reflected from the fuutlus. As
soon as tJiis white retlex is obtained, tbe object lens should be adjusted,
and we shall then have no difficulty in finding the optic nerve entrance,
which appears in the form of a circular pinkish-white disk, on whose
expanse are noticed numerous bloodvesacU, which diverge from it to be
di*ttributcd to difl'erent jKTiions of the retiiwi. If the disk is not in view,
it may also be easily found by traviug some of tiie retinal vessels up to |
the point towards which they converge — i. f., the optic nerve entrance.
'J'he disk having been found, the obser^'er should very carefully study its
color, the appearance of its surface and margin, and the course of the
blotwlve.HseU iifwn it, in order that these ditferent points may bo well im-
pressed upon his memory, in the next place, passing from the disk, the
different portions of the fundus should be successively examined, and the
appearance and mode of distribution of the retinal vessels, and the differ-
ence fietwcen them and those of the choroid he carefully studied. The
beginner should at first alway-i examine a considerable number of healthy
eyes, and study very attentively tbe physiological appearauces of the
fundus, and the various peculiarities which may occur witliin normal
limits. And then, when he has become thoroughly conversant vfith these
diversities, ho should pass on to the examination of the pathological con-
ditions. The examination of the rabbit's eye, also, affords excellent
practice, and in tbe Albino nibbit the distribution of the choroidal nod
retinal vessels can be most hoautifully seen. As the opportunity of ex-
amining a considerable number of human eyes is not always to be bad,
^
KXAUINATIOH OP TKS VIBTUAL ICHBCT IMAUB.
88ft
Ibe followins ii)«trument, made hy Nacliet. of Paris, will be fouul ex-
ireinvlj iDwful for practiain;; opbthalinoflcopv, ami for atmlyinf^ manv of
the n)orbi<l appearances of ttie fumlua. It coiisUu of an artificial eye,
or ilauimy, madv of bmiia, bimI fitted in front with a k-na in lli« aituntion
of the cornea. This leiM tft covereil n'it}i ii bl.ick riietnl cnp, haviii): a
central aperture oorresponding to th« pupil. There are two of thei^e
cap!), the one having a very small central opening corresptjnding U> the
normal sixe of the pupil ; the other a large aperture, like a widely di-
lated pupil. By changing the lens, ne may convert the eye into a hypcr-
■ metropic* myopic, or oatigmaiic one. 'Hio posterior half of the eye opens,
M to admit of the insertiou of a papier niacliL^ cup or disk, colwrod to
[ivprest-MiL the appearauctt of a hvatthy I'uudiiis, or of ftoiiie |iattioto>£ieul
iCondition, as for instance, retinitis pigmuntoAa, excavation of the nptic
nerve, posterior Btn]ihyk>ma, etc. In the box containing the iiitftrunivnt,
them is a series of theiHi colored disks, illiuttrating many of the morbid
ophthalmoscopic appearances of the fiindui^. The eye is 6xed upon a
etandant for pla<:ing it upon a table. It \» termed I'errin's artiHcial eye.
t liave already mentioned, that if we desire to increase the size of the
image in the indirect mode of examination, we must employ a weaker
object lens, «. //. of 3 or 4 inches focus, which must bo held sotDenhnt
farther from the eye. In order to magnify the ima^ still more, C'oc-
cicua' haa devised a compound object lens which consists of two convex
lettses (tine of which haw a focal length of 2, the other of 2| incheft),
Ninserted in the extremiticii of a braAn tube, comiHtsed of two portions,
each of which is 2J inches in length, und made to slide, one within the
Other. The effect of this Is, that parallel rays reflected from an emme-
tropic eye will be united within the tube into an actual inverted image,
the rays from which will then pass through ilte second letia, which will
afford a magnitied virtual iioage of the actnnl image within tlie tube.
The disadvantages of this compound object Ictiri are, that it is expcunive,
and very cumbersome, proving very fatiguijig, if many patients have to
be examined in succeision. I lind. moreover, that we miy gain almost
aa great an enlargement, by using an ordinary object lens of four inches
focus, and a convex lens of eight inches foctis behind the mirror.
6._TIIE KXAMIXATION OK THE VIKTUAL EUECT IMAGE.
It baa already been stated, tb&t in this mode of examination the ob-
server must go very close to the patient's eye. The lamp mu« tliereforc
be placed on the side corru:«poiiding to the eye under examination, and
the surgeon will find it most convenient to examine with his right eye
the corre9|X)iiding eye of the patient, and P(« vcrrd. For the examina-
tion of the erect image, the ophthalmoscope of Coccius or Zehender will
be found preferable to that ot Liebreioh. Not only is the illumination
better, and the corneal reflex considerably less, but it is also easier, on
^account of the lateral collecting tens, to maintain a good illumination of
t Sir. R. B. Carter haa giv»n &n «xiA<)l)>nt (lM«nption of Ihut »pi»rfttii« snl its
mod* of aotJva hi th« " Uiiwt," Uvdi 18, ies&.
3B4
TUB UBE or TUB OPIITU ALU08001-B.
the eve, nml to keep the optic axia of thv oWrv-er's eye in n liI«^ oorre-
Bpoiiiiitk<; to tl):\t of Uiti patifiU, whioli h ofutii difRciilt, if thi* mirror has
to be coiiitiileniUy turned in order to c'xtcli the rajs from tlur lamp. If
tlie sorseoii is not much accustomed to this mode of examination, and
tlic pnptl i>* small, the latter should l>e dilated with atropine, for tliis
Mill increase the sikc of the field of riaion, and facilitate the lighting up
of the fundus. If the observer and the patient are both emmetropic, and
their accommodation ti suspended (T, e., if they art? accommodated for
their far |M»int, in this cftse lor pstrallcl rav«) the surgeon will receive a
clearly drfined and distinct imago of tho details of the fundrnt. The be-
ginner, however, generally finds con-^iderable difiicultj in completely
relaxing his accommoilation, more especially as bin close upproxiinatioo
to the patient leads him involuntarily to accf>mmodate for a point con-
siderably nearer than his far point, i. c, he is accommodated for more
nr less diver;^ont rays. This will render the image indistinct, and neces-
sitate the use of a concave ocular lens, in order to give the ret|uiait6
degree of divergence to tlie parallel rays emanating from the patient's
eye. In certain conditions of the refraction either of the patient's or
surgeon's eye, a concave ocular lens ie ahsidutely necessary to render
the image of tlie fundus distinct. Thn.s, if the patient's eye is emme-
tropic, hut chat of the surgeon myopic, tlie rays from the former will be
parallel, nnd be consequently brought to a focus in front of hia retinft,
and a concave lens will be reijuired to give them the necessary dcg7««
of divergence. The strength of this lens should be sucb as to ucutmlise
bis myopia for distance. A aiill stronger concave lens will be rpijuired,
if the eyes of the surgeon and patient are both myopic, for then the rays
will impinge in n convergent direction upon the surgeon's eye. Hut if
the surgeon i» myopic, and the patient hypermetropic, the former may
be able to see the fundus distinctlr without the aid of a concave lens,
for the following reasun : the focus of the dioptric system of the eye
under examination, will in this case lie behind tho retina, and the eye
will therefore be adjusted for more or less convergent ravs. The
emerging rays will coosoifuontly be divergent, and will be readdy anited
ujion the obsen'er's retina, if his myopia is not too considerable in de-
gree. The same wilt occur if tho surgeon is hypermetropic or enune-
tropic, but then he will have to u.ie his |«owcr of accommodation, in order
to bring the divergent niys to a f'>cus upon his retina, if, on the other
hand, the observer is hypennetmpic, he may also be able to examine a
myopic or emmetropic eye (if the myopia is not too great) without the
aid of a concave lens, for he will be able to unite convergent rays upon
his retina, and also parallel rays by an effort of the acconunodntion.
The caeea containing the portable ophthalmoscopes are supplied with ft
si^ricM of concave ocular lenses, varying in ftical length from 4 to lU or
1*2 inches, and titting into the clip behind tlie mirror. The surgeoa
ahijuld .-select the strength of the lens according to the state of the re-
fraction of his own and the patient's eye.
The chief advantage of the erect image is, that we obtain a much
larger image, so that the minute details of tho fundus can be studied
witli much grttatcr accuracy. This mode of examination ts therefore of
much imfH>rtaucu in solving any doubtd which may exist with the reverse
OrnTBALSIOSOOPIO APPEAXA!fCBS.
865
image, u to the exact n«turc or nituation of any morbid appenrnncca.
But the field of visiou is more Uuiiteii, aud tbe exaatioatiou eomewli&t
mora flifficiill. Moivovcr. it U not uIwu^a convenient or af;rocal>te to
exnmiiie all patientu in Ditch dose proximity. The latter mnj be one
reason why this modu of «xamiimtioii iit far too much iieyU^otod in
]-ii;jl.'md in favor of the inverted image. As a nilc, it is hest to obtain
^t'm*n\l view of the appearnnctis of the fundus in the inverted image,
lid then, if we desire to examine any particular point with greater
mtniiteneas and accuracy, to have recourse to the direct method.
[The decree of enlargement produced by the upright image, and the
methotl of a^ertainiug it, does not admit of an explanation within the
»pacc of a few lines. The first thinj; necessary to determine tlio siite of
a retinal image is lo know the ditttaiicfi at which the object i» Been, for
the- relative ntxe of the imaf^es of an object on the retina stand in the
same proportion to each other as the corresponding distaticea of the
object in front of the nodal point of tbe eye. Hie distance from the lat-
ter to the retina of the human eye is a known (juftntity (ii-'t Paris Hues).
The magnifying power of a glass for an object seen at its focus is ob-
tained by dividing some arbitrary distance assumed as a standard by the
focai length of tlie glass. A standard of eight inches has been assumed,
and dividiiug this by the focal length of tbe dioptric system of the eye,
the magnifying power of the latter is found to be 14 J. Hence the
retina uf an emmetropic eye is seen to bo enlarged by tbe upright
method of examination 14J^ diameters. (Loring'a "Detormiiiationof the
Itefraction of ihv Eye with the Ophthalmoscope," 1876.) From observa-
tions made by Mautbner, we now know that tbe image of a myopio eye
seen in the upright image with the error of refraction correctetf is larger
than the image of an emmetropic eye, while the image of n hvperme-
tropic eye is smaller. With tlic inverted image, the reverse is tne caac.
(Mauthner's '■■ Lcbrbucb der Oplithalnioskoptc,*' IStl"-)— B.]
7— THE OPHTHAI.MO.SCOPrC APPKARAN'CKS OF
HKAUIIV EYRS (I'late 1. Figs. 1 and 2).
^V Before commtmcing any ophthalnwscopic exauiinaiirtn of the fundus,
^M the condition of tho comca, iris, pupil, and crystalline lona should be
^M examined by the obliijue illumination. This having been done, tbe
^^Lpiame structures should be viewed by transmitted light, i. e., the surgeon
^Hpb'iuld examine the eye by tbe direct meUtod (uiihout the interposition
of a convex lens between the mirror and the patient's eye), but the
mirror should be held at some distance (14 or 1*1 inches) from tlic eye
under examination, lu this way ao opacity of the refracting metlia can
escape detection, which is nol unfrftpicnily tlic caac if tJiese modes of
examinatjoo are neglected, and the fundus only examined with tbe in-
verted image. We can also in this way readily ascertain the state of
refraction of tbe eye.
The examination of the refracting mcltn in a hcallhy condition, of
eonrse, affords a negative result. Sometimes small Dakus of mucus may
36
386
TBB uss OP rns opiithalmuscopb.
it a somewhat irregalar ttppeArancBJ
be noticed on the conica, pv
Tbey disappear on closure of
It boti been slrend.v Btated (p. 2i^ii) tliat certain phvaiological chnngeaj
Wicur in the Icna in advancing age, and we must he ufion our goard
to raistftke tht'jte tor commencinjr cfttamut. The Icii!" siilwtanee Iwcomea'
tliiclcpned nnd t-onsorukted, and the nucIeitR Rssiimcs a yellowish linl,
which is espvcially apparent bv reflected light. lnde«il tlii* opHcity
soiiielimed av ei.»u.-«iderable, that it may be nii^biken for a tolerably a<
ranced cataract, hnt on examining the lens bj trannmitted light (with Ui
mirror only) it will be found pert'cotly transparent, and the dotaib of Ibfl''
fundus i|uito distinct.
On the oilier hand, the healthy appearancca presented by the fundue^H
DCitti deserve and demand the closent and unMl attentive study, iti onlui^l
that the mnnj" divcraitiea which thny may present may not he mistaken
for morbid phenomena. It in only by an intimate knowledge of the
many physiolojrical peculiaritiea which may exist in a perfecUy normal
eye, that we clui avoid committinjj grave errors in diagnosis. Jtefiinnera
are but too apt to huri'y over the examination of hesilthy eyes with a
careless, •' Oh, there is nothing the matter; the fundus ia (|uitt' healthy ,'*J
craving only after the most marked patlxdo^cal changes, such aa larg«j
poatcrior staphylomata, very deep cxcavaiionn of the optic nerve, ar "
huge patches of atrophied choroid; and completely overlooking !h«^
minuter shades of difierence between a healthy and morbid eoodilioci of
the fundus, a knowledge of which proves of tlio greateat impoitaace in
practice.
On Uwking at No. 1 of the ophthalmoacoplc plates, the reader will he
at once struck by the marked •liRerencc in the appearances presented bjr
Figs. 1 and 2, and yet both illustrate a perfectly healthy fundus. |
In Fig. 1 (which is taken from a person with black hair and a darl
brown iris) the optic nerve entrance appears circular, and of a yellow iih
white tint. The bloodveaseln emerge somewhat to the left of the centre
of the disk, whieh is here of a deeper white. The paler ve.-tsels are the
retinal aitt^rie*, the darker ones the veins. They paM over the diak to
the retina, where they course and divide in different directions, chieHy
upwards, downwards, and towards the left. At some little distaitce
the right of, and slightly below, the diak, is noticed a large dark-red
H]int, with a small white dot in the centre. Tlds is the macula lutea, or
yellow spot, with lis [fovea] centrailii. It will be observed that the ves-
sels course round the yellow spot, leaving it free. The fine gray film in
the region of the disk and the vellow spot i» due to the reflex yielded by
tlie retina ; it in only obsenjiule in dark eyes, and is cuuseijuently
gelher absent in Fig. 2. The fundus of the eve is of a rieli d»rk-re'
unt, and only the retinal voA<iel!4 arc apparent, tho.se of tlie choroid hoiti
hidden by the density of the [Hgment m the epithelial layer and t<trom
of the choroid.
[An explanation of the glittering ring or halo eeen round the macnl
lutea with the inverted image waa first given by Dr. Tjoring in lH7
whose words are as follows : " This region of the fundus bears in its fo
mation a strong reM-mblanee to a shallow cup, of which the rim is
sented by a convex and the howl by a concave aurfac«. If wo look upo
-kfl
hJm
'4
th^H cnrrcd surfaeM m mirrorv, the,y would each have their foci, one
Iring behiitU umt the other in front, ncconling to their respective degrees
oif carvature. And if light ehould be thrown perpendicularly against
sneh A combination of curves, the apex of the outi^ide rim or convex sur-
face would, from well-known optical laws, appear illuininatcd, while the
inside or concave surface would Hppear more or less in !«tiadaw. Thus,
we should have the effect of a darltcr centre, RurrnuiuU^d liv an illiitni-
tnitiated edge."' Vroni these considerations, which were illiwtraloii by
practical ex]ierimentt) upon eve-phantoms, he is of the opinion that the
halo round the nuwula " is the product of rcftection and refraction from
the combination of curved surfaces which enter into the construction of
tJii«t portion of the retina, and tliat the principal sources of light frmu
which these retiectiom are produced are the images nf the oplithiilmo-
Kope and lamp situated in the media of the eve."' ( See " Trans. Amer.
Ophthal. Society," 1H71. atid " Kepitrt of Ui'c Fifth Internal. Ophthal.
CongrcM," 187tJ.)— B]
In Fig, 2 (taken from the eye of a person with very light hair and a
blue iris) the apfiearancc^ art' (piite different. The di^k is of a more
ro*r tint, the retinal vessels, although very distinct, are less marfcrdly
M than on the darker background of Fig. I. The region of the yellow
spot is of a bright rod color, and the foramen centrale appears in the
fortD of a little light circle, but the greatejit diR'erence is noticed in the
pale, brilliantly red color of the fuinhiH, and the distiiictnc^a with which
the finest branchcji of the choroiilal veMolfi can be traced. The ciliary
arterie* enter in tlic region of the yellow spot, and, niiiiiiiig towanls the
|Kriph»rr, ramify in various directions, and pnrtly paas over dirocttj
into the larger brauches of the vaaa vorticoaa, situated at the equator of
the eye.
The red color of the background of the eye, as seen with the ophthal.
[Qoscope, is duo to the retlectiun of the light from tht* blood vei4r;nlH of tho
retina and choroid, more eflj)e«ial]y the latter. As the retina is very
translucent, but little light is reflected by it, and the sclerotic can only
be scon through the choroid, and will therefore be the more apparent the
leas pigment there is in the Intter. The appearance presented by the
timdua will, therefore, vary greatly according to the degree of pigmenta-
tion of the choroid. If its epithelial layer and stroma are darkly pig-
raeuted.tiie vessels of the choroid may Lhj complettly bidden, even at the
periphery of the fundiu. Itut if the cptthotial layer contains hut little
jrigment, and the stroma in. on tJie other hand, richly pigmented, the
diorotdal veaaels will appear like bright red bands or rihboiw, divided by
dark inlets or intcn*!ils. the so-called intra-viiscnlar s|Hice^. These vessels
ire chiefly situated in the i-troma of the choroid, for they arc less cor.
ered by the pigment than those of the venic s'orticot*re. which lie dee|)er
{neawr the sclerotic), or the smiiUcr vessels (Schweig^^er). The intra*
vascular spaces are of a longitudinal shape near the etiiiator of the eye,
ud more oral or circular in the vicinity of the disk, if the stroma is
light, and the epithelium but moderately pigmented, the epithelial cells
may be well seen willi a considerable magnifying power, as has bi*i'n
I shown by Li«hreich, and may be recognized a.-* small circumiicribed dots
H uuifonoly studded over the fundus, giving ic a markedly granular appear-
I
I
888
TBI tI8B or THB OPIITHALMOSCOFR.
ance. In eyea in wliith the pigmentation of tlie choroid !s but ver
8li;;]it. the clioroidal vc8St'l« mny he moat beautifully trat'cfl to Uieir
mmftllo-tt iUvi:(tonH, as nlio the larj^c ««nis of the venie vorticosaj aa they
j«.'ri"(irttte the sclerotif. The red color of the hackgrouiid U alan iuflu-
enced I>t a^e aiitl the itliitiitn»tion. It is of a ttri^rhivr tint In you
persons thnn in ohler individuals. If the illumination is strong, tli
I)ri;;htnes3 will he unifonD. if it ia weak, it will decrease from the disl
towards the ]ieri|ihery of tlie fundus.
The retina is extremely trauxlucent, and reflects hut little light. On
this account it is not visible in lif^hl t-yes, but becomes so when the fun-
dus ta dark, appearing like a thin gray tilni or halo over the backj^round.
In very dark uy©B, such as thone of negroes, the retina is very distinctly
ftpjisn-nt, ahowinj^ a gray striated appearance, especially in the vicinity
of the disk, lliesc strife are not, ^chweigger thinks, due to the nerve
fibres, but to the peculiar arrangement of the connective tissue.
8._THE OPTIC DISK.
The normal disk is ^nbjoot to numerous aud sometimes marked differ
encen in shape, co1or,and sisse. An exact knowledge of nil the pocniiari'
ties which come within the normal and physioloQical standard U ab«o<
lutely necessary to prevent the !»urgeon from falling into errors in diag-
noKi-t, nnd mit^tnking some perfectly physiological appearances as bcin
of pit t ho logical im|K>rt.
Tilt' entrance of the optic nerve iji generally round, but not perfectly
circular ; it ta often oval, having the long diameter vertical. This ova
appearance is particularly striking in casee of astigmaiisni. The diak i
gonernlly of a tmnRparent, grayish-pink tint, with a slight admixture n
blue. This tint varies in apjwarance with the pigmeatation of the cho-
roid ; thus in dark eyes the disk appears white and glistening, whereas
in very light eyes it assumes a more rosy hue. The admixture of the
color of the optic nerve entrance is made up from three sources: tbe
white is due to the refleotjon from the connective tissue of the lamina
cribrona, the red to the blood in the capillaries on its expanse, aud the
blnish-gray to the nerve tubules lying in the mcrthea of tSe cribrifonn
tissue. Tlio imiline of tbe Ahk appi-urs shaqdy dofined, hut on cloaer
observation we notice that it may be divided into an internal gray ring,
the real boundary of the nerve ; outside this, Is the white line of the
sclerotic Hng, which varies somewhat in sixe, being broadest and roogi
apparent at the outer side of the disk. Kxtemal to the scleral zone, is
the diirk-gray line of the opening in the choroid. This choroidal ring ij
goiuewhat irregular in sliape aud culor. being most marked at the outer
Bide, HI which there is nften a well-dellned dcfmsit of pigment molecules,
assuming the appearance of a broad black cre&ceiit, which is frequently
niiataken by begiiuicrs for some pnthological change.
The retinal vessels generally emerge from the central portion of the
disk, or somewhat to the inner side of it. If the division of tbe central
artery takes place after ittt ])asfiage through the lamiiu crihrosa, the
diriaion of the main trunk into the dilferenc branches can be distiuctl
TUB OPTIC DISK.
889
Bired. Whcrcis. if the divUion oocnrs before the passage of the
trunk throuj^li the latuina cribrosa, the uiaiii braiiclica pierce the dink ia
BD iaolttcd inanu«r, go timt tlicir point of iliviitioii from the trunk ciuinot
he (lUtini^ifthcd. The number, mode of diviiiion, and coiin«o of tlic rc<
tiiin] vtj.tsi'U vary veri,' coiiBiderably, being constant only in this, that the
princififtl branches r«m upwards and downwanls. Aa a nde, no mnin
branch runs inwards, but only k considerable number of gmaller vessels ;
wberesB towanU the outer aide only a few very small, short twig-* are
sent. The moat frequent arrangement is, that an artery and two veins
pass upwardfl, and the &amc downwards; but somotinics there are two
lartcrieii and two vein*. The arteries may be readily distinguifthod from
the veiiw by being lighter in color, smaller, and str-iightor in their cour^.
Moreover, along the centre of the veasela ih noticed a hrifiht streak.
Variouft opinions have been advanced as to the cauw of this central
white stripe. Von Tript and Jaeger originally explained it thus : That
the raja of light which fall perpendicularly upon the cylindrical walls of
the veNols are retiectcd in a per|ieitdicular direction ; whereas the rays
which fall external to the centre of the vessel are reftei-t'i'd laterally, and
hence cause the m<]o.* to appear dark. Thiit eTplains the rcaaon why the
whitv stripe varies in position acconliug to that of the visual line of tlie
ohacrver, for if we look at the side iiwtead of the centre of the vessel,
the light stripe will also shift to the aide. More recently, Jaeger has
f^iven up this opinion, and believes that the column of blood within the
vessels and not the walls of the latter produce the reflection.' Ijoring,
on tlie other band, believes,' " that the light striking tlic wall nearest
the ob»erver passes through this on account of ita transparency, williout
being reflected to any appreciable degree, traverse« the contents of the
vessel, and is then reflected hack slightly from th« opposite wall, hut
'principally from the enhjacent ti-ixnes." This view hiw been apiiii op-
''^pOBcd mere recently by ^cbiicllcr.' who maintains that the light streak
IS due to the reflection of light from the anterior wail of the artery.
rSchneU«r'fl views have been carefully reviewed in a later paper by
Luring, wbo dove not consider tbcm tenable, either from a matliemaiical
or physiological point of view, ilia own explanation baa been accepted
by tjiraud-Teulon, who bas also a<Muced some additional cxjxriments of
his own in support of it. (riec "Trans. Amcr. Ophthal. Soe.," ^^S7;{,)
^B.j Til© retinal veins are of a darker tint, larger, and more undu-
lating than tlie arteries. On account of Uie greater tenuity of the walls
of the veins, and of the blood-tension heing less in thiMn than in the
arteries, they are somewhat flattened and not cylindrical in form, Hence
the refliTtion of light is very alight, and the ccutml bright streak hardly
oK-M.-rvflfile. Kvon on the normal disk the sheath of the vessels is some-
times ap(iarent. giving rise to a double contoured white stripe at tlio
edge of tlie princi|>al vessels, arteries, ami veiiw. This ia generally con-
fiued to the disk and ita immediate vicinity (MauChncr). Tlic blood
aappljr o( tha most anterior part of the optic nerve is maintained not
• "0[>liUmIiii>"«Mi|>iM'h»r tlniia. Allu," IBSB, p. 32.
* "Trnui. lit Atu-rk-»n 0|>)iilialinologl<ial ewjielj," 1970, p. 122; alto Kaapp's
■ "A. L 0.," xvlii. I, 113.
890
TUB USE OF Tan OPnTllALHOSOOI'B.
onl}* br the small twi«3 given oif bo it from the central veAwlii of the
retina by llie vessel* ol" tlie external ami internal slieath, hul also hy a
Beries of l>nincl)lL'i<) ciuanatin;; from a vascular circle, which is situated
cloM to the edge of the opcto nerve, and which is forawd by three or
four of the i«liort posterior ciliiiry Hrterici*.' Leber, tooreover, has found
th»t nuinernu.i arteries nnd some vein.s also jiatus directly from the oho-
roi'l to the '>ptic nerve, anastoimtsing there with the network of rewoU
whicli BurrouniU the nerve fibrei^.'
On closely regftrding the snrface of the disk, we notice thnt its color
raviea at different points, and that it prcsenw, moreover, towards the
outer side, a somewhat mottled gniyish-white appearance. Thia gray
Btippliiig is pro<luced by llie nervo tubules »een in section, and the whil*
dotti or liricii between tliom aru due- to the tra1iecula> of the Kieve-lik^*
laminn crihrosa. At the point of exit of the retinal vessels tlic white
apfiearance is very marked, and often presents a little pit or hollow.
Wliiliit the outer portinn of the <HHk presents n mottled grayish-white
appearance, tlie inner half .issumes a much redder tint. The reason of
tliij is easily explained. As a greater number of the optic nerve tibres,
after the entrance of the optic nerve into the eye, bend over to the inner
side, the transparency of tliis ]>ortiou of the nerve is much diminished
by lhi<) close su|>er-imposition of the fibres, ami hence the details of the
lamina cribrosa are hidden. Whereas on the outer half, the latter are
still very evident, as the layer of nerve fibres is here much loss consid-
erable and more arched iijiwanlw and downwanls, and the white rutlcc-
tion C0Dscc|UcDtIy much more marked. Inattention to these facts may
lead the observer into considerable errors of diagnosis, lie may con-
sider the nonnal rt^dneas of the inner half of the disk as patholoE^cal,
and assame the presence of liypencmia, or even inflammatioQ of this
part of the nerve ; or he may mistake the white appearance of the outer
half for commencinfi atrxipiiy.
We must now notice two peculiarities of the optic disk which arc often
met with in perfectly healthy eyes, viz., 1, spontancons or easily pro-
ducible pulvatinn of the retinal veins ; 2, physiological excavation of the
optic nerve. [A third peculiarity of the optic disk, known as *'opa<|ae
optic nerve fibres," will be considered under the head of diseases of the
optic nerve. — II.]
The venous pulsation is characterized by an alternating increase and
diminution in the calibre of the vein. Tiio emptying of the vein com-
mences at the centre of the optic disk, and extends to the {teriphory ;
tlie refilling, on the other hand, begins at the periphery and extends
towards the centre. The venous pulsation is generally only visible in
the expanse of the dt.>;k, but in very rare cases it may even extend
beyond its margin. It exists probably in all eyes, bnt does not gene-
rally ap|>ear spontaneously. The pulsation may, however, be made
> Vide Ji£«r, " Bln«t«IIang des dloptrteobttu Appnr&tM," p. Kfi ; abo Lcbnr, "A. f.
O.." Hi. 1, fl.
* Oftl«zoWB)(i'a opialon tli» tli« minuter rtuuM-tii of ihn dlxk, through whtc-li thv iMSt^t
Ol)UiTiB it« mldisli Lini, MtL' not liranobtoi of tli« iwutritl vkupIm at tb« twtiiin, tml nf
tlie v»up)« oT tli>! I'in lunUfr 4ii<l tirniii, is dU|jn>*od by Lvbor, "A. f. 0.," xviii. 2,
25 ; vide also Dr. WaUrlng's uUdu, lb., p. 10.
THE OPTIC PrSK-
391
_ irent, or rendered more marked or distinct, bv slight prcasiire with
"tlie finger upon ilie ejeball, and we may ttiiu alLeruatelir produce a
oompletL' emptying and n-lilliii;; of the vein. On a sudden relaxiitioii
of proasuro which haa been continued for a little time, the veins become
raptdlj overtilleil aud awollou, ttiiit dilaiatiuu last^i for about a miuuto,
ftnd then they n^umc thoir normftl calibre. The roApiration also some-
what MflVrclct the retinal circulatiou : thiia, an increase in the aixe of the
vein Ilia/ be m^liced during strung expirauon, whereas a deep inspira-
ition caii)>cs it to diminish. The vein and artory arc in an opposite
vtatc of fuUiess, the arterial syatolo being aynchrououa wiili the vcnuua
dimU)\o.
Whil^at spontaneous puUation of the retinal reiiw h a perfectly
tiphysiolof^icnl pbunomiaion, this is not tbe uat^u with thu arterial
L, pulsation, for thin {{encrnlly only exists when tlip intni<4KMil»r tension
ts abnonnaily incruudcd. it is, tlieretbre, a symptom of great im|>()r-
tance in the diagnosis of a glaucomatous condition of the eyeball.' The
prettence of venou« pujaation was supposed U) indicate & fluctuation iu
the iotra-ocular preesurc, but, accordnig to Mumorsky,* thia is not so.
IIo considers it to be a visible exprciuion of tlie action of the forcei
which rc;.'ulalo the hliKid-presaure within tlif eye.
The f'hifKi'ihtifical excaration may be known by itii being limited to
tlie central portion of the disk; it is, munsovcr, generally very smalt
Land hIihIIow, and may oontintic throughout life without undergoing any
change. Sometimes the cxcavauon is well marked and eadily rccogniz*
able, the ccntnti portion of the di:ik preseuUng u peculiar white, glisteu*
apiieamncc, of varying size and form. This central glistening spot
lay be oval, circular, or longitudinal, and its sixe is genci-ally vory
It >■ n vrrr itHt-nnitiiiiC >i>d inporUnt bol ihftt iu vnam of in»ulBai«iii]r of t1i«
tie TalvM ttierr u m&rkiM tiMiiiUinooiia puliation of th« r^linal nrtrtriifi. Tliis
rit» Brat pointiwl out (ir Dr. II. (Jiiiiirkfi (" IWIinwr Kli[lilU^)lo WiicliiitwiJirin,"
I6M, No. 54), but wu ulso diMWTervd iad^pciKkiitljr t>y frufLiuvr llf>cl;<T, w)io hu
^XU^if vrrv vxtrnstve ftntl VAliiftltlo rc»c*roh«« npon tlio sabjoot ("Kl. MonaLtttl.,"
1871. p. 3>tO. anA "A. (. U.." xvill. 1, p. ffl)il>. Tbii piilMlion, thoufili iihkI ni.trki^
on aad omt Ibtt dink, oxtatuU far into the rtrtina. ^iiu>tini(« it it "iil.r •o.-vui'^nallr
|krM«nl, bal l> hIoatb inoreibtol hjr Any oxciti^ment or Ai^cItTfttlon of Ilia hi«rt's
actioo. B«ck#r olw^rvv) tt in ^lliuMor iii«uffici«DC]r of tli« ■•■ttii: ralTnn, wliloti
w«r« nncninpltc*ti<d witb liwionn of ihc other vaIvm ; the pulMtioim Iwiii^ lb*
iitri>ni;Hr and iLo iiinrv otiM^r/khk' tlio ttvite thv ftccoiiipniijring tiypfrlmjihy (^ (l,a
loft wt'tiirkle yiu devvtoped, Oulj in those eastit In wliinh, tngiitli»r with Ihf sortlo
ratrntu- afftciiim, thpr« was gn^nt anBinIa or fatty dug^neration of thu heart, Ibera
<WM no pulnathMn. In *t>uiu rarv iiis(snre» lh>>r« \% nlno m «y»tolJc rr<ldrnin^ Mitd
ctlaatoliv liIaDcbiuR of thr dltk. which Kppi>ara to (m dui* to a mpillnry pulsalHio
In Iho diAk. Tb<.-4<! pulsntkonii aro boat Disin in tho «r«ct imictf ; indt-^t, tliu <>aplU
ry pakaliuti Lt only Ihii* rbitil*. Tiiia HponUnuuua arUtri&l pnl»4t)itn " di>ns nut
Mnbla tb« to-callvj arlvrtal paballoii aa it vcvxin \n kIauooiiui. Whil«t thv latt«r
I oaXj an InlArmtttonl Indux i< nrtrrlat hlood into ihu •>/«, the fornKT n-voala to ttie
»/•< nil Dm Indiviitiiiil i(uatittm, which thi' nii^or iu nhl<< V< diiilingniMh in the radial
'.puli«. We van count ibe ftrtiur'ncy uf thv vunlraotion of llie hwirt, wc ruco|[iiiie
Ihr uidonin^- and «tongatlon of the arti'rlal tuho (greater and lowor pulae) : wo can
bIw i)i«ltnEuipb li>m sn-al a |Mirt thu KxpiuiNinn i-f Ihi* arU'ry, «■ eoatraotlon (skmu-
tnnnninken), and iiu* patiKc taki.- in Iho dnrntlouof a uuuph*te puls^-warH (pnljiu
(«-liT "i lutdnit). Wit cj>n th<>ri-r<>r« oluiTvr din-i-lly with thr oplithalinoooopo thft
tin'lulali'.'tia of thv )>iil<i--ttiirv<.<" ("Kl. M»natibl.," 1^71, 3S1). Ufl«n Iboro b slao
Vl'IV niArk--<l ngointanr-omt vcnotia pnloaliuD.
I -M. r. I).," XI. •!, 107.
892
TUB D8B OP TBB OPIITU ALMOSCOPB.
inconeiderablc in compariaon with that of the tUak : it ia surrounded hy
a reddish zone, which may be ulmost of the anme color aa the back-
ground of the eye. The width of tliis Koue varies with the ext«tit of
the excavation; if the latter is gmall, tlic zone will be vorj conaidernbte;
but if it is larj?c, the xone will be narrow, ami limited to the periphery
of the di«k. The od^e of the ouj) are gouorally elinhtly sloping, and
never abrnpt or Hteep, so that the excavation pas-ios over ^inulually into
the darker zone without tiiere being any sharply -defined uiargiu. Uut,
if the excavation ia conical or ftinnel-shaped, the ed^^s are more abrupt,
and the margin more defined. On tracing the retinal resseU from the
periphery towards the centre of the disk, we notice that they under^
peculiar changes when they arrive at the margin of the excavation, for,
instead of passing straiglit on, they describe a more or lens acute curve
aa they dip down into it. This curve may !« very elighi and gradual
if the cup is flhaltow ; but, if it ia deep and extensive, the cun'e may be
abrupt and give rise to an [apparont—B.] difplacement of tlie vesself
at its edge. In the expanse of the excavation, the vessels generally
assume » slightly darker »h»de, hut they sometimes appear of a lighter
and more rosy tint, and seem to be enveloped by a delicate veil. The
excavation id fre<{nently not in the centre of the disk, but nearer ita
outer side. A verv peculiar appearance is produced, if a glaucoinaiuus
excavation occurs in a nerve having a pliyaiologicol cup, for then the
two conditions may for a time exist side by aide ; the phyriologicftl
excavation is, however, suhsetiuontly merged in the deeper g^uootoa-
tous cup.
-THE OPHTHALMOSCOPIC EXAWINATIOX OF
DISEASKD EYES.
TuK Rkfractixo MKPia.
Before commencing any ophthalmoscopic examination of the fundus,
the refraciiiig media should always he examined by die obU'pie illumi-
nation and hy tranaraitted light (vide p. 385). By making thi» a
constant rule, the beginner will avoid falling into many au error in
diagnoais which might otherwise occur, such as mistaking opadticA
of the cornea, the c.tp«ule, or the lens for some deeper seated Icsiou.
In making an examination of the lens or the vitreous humor, the putnl
ahould he widely dilated, although an expert obscn'cr will often bo aide,
even with an undiluted pupil, to detect 0[)acities nliich are situated at
the margin uf ihtr lenK, or the porinhory of the vitraouit humor, by
making the patient look very far in the opposite direction, which
will enable the surgeon to look quite behind the iris. The color of
opacities in tlie refraeting media «ill vary nccordin;; to the amounl of
illumination, and the fact whether they are examined by reflected or
transmitU'd light. In the former case, they will appear in their true
colors, the fundus being in the shade, so that they will look like gray or
whitish opacities situated ufton a dark hackgrounu. It is different, how<
ever, when the fundus is lighted up with Uie opbtbalmoscopo, for then
OPIITUALHOSCOPIC BX AMINATIOM .
the opitcilips will appear like dark epeclcs, of varying sire aud forin,apon
a lin<;hl rc<l background, Tor ttioir siirfacca can reflect but Itttlo li;;ltc,
nnri iliev are rlius seen in aliadow. On this account, very smnll opaciriei
are bust seen hy a weak illuniinatioTi, lor iu cuiiiwqueiicu of their very
sli^lit roficctinu, ibcy liecoiiic iiivUihlf if tin; illniiiinatioii is too bright.
]l i'S of much importance to be able rigbtly to estimate the depth at which
' liy o[>n<-ity in the refracting media is sittuited. There cannot be tlie
Ii;;hte3t ditHcultr about this when the opacity is in tbc cornea, the cap-
sule, or the anterior portion of the Icna, for with the obliijuc illumination
we shall be able to aacortain the position of the opacity in rebitioa tu
the pupil. Indeed, for opacities in the anterior half of the eyeball the
oblii|iii' illuminntiun ik of nioHt aorvicc, hut for those in the ^toatcrior half
the ophthalmoscope fiboiild bo xmctl. Hut it is bcAt to avail ountclres of
both modes of examination. When the opacity is situate! in the vitr«-
oiiA humor, it is more difficult tu ascertain its exact depth. The two
following OHithods of examination will, however, enable m to decide this:
If, for instance, the obsener (uainf: lUe direct method) looks in auch a
direction that his viftunl line pa!»cs throuf!;h the turning point of the
patient's eye, it will be found that this [xnut and the corneal reflection
of the mirror will aluiic remain ittationnry when Uto eye is moved in
different dircctiona. Any opacity which i.i situated in front of tbU point
will move in the saine direction as Uie cornea, whereas any opacity
ntiiaCod behind the turning point will move in a direction opposite to tbac
of the cornea. The furtiier the opacity is from the turning point of
the eye. the greaier will iis excursion be. Now the tumin;^ point cor-
responds as nearly as possible to the posterior polo of the crystalline leiu.
If thert^ should consetiuontly be an opacity ditualed at this B|iot (postw-
rior {H>lar cataract), it will remain stationary duriiif; the vnnouH move-
loents of the eye. If the ojutctty is situated in front of the [losterior
jiolc, it will move in the anme direction is the ooniea. if the latter moves
upwanls the opacity will do the wime ; the reverse will occur if the
ojHiciiy is situated behind tlic turning point, for then it will move dowo-
wanb as the cornea moves up, and vice veryd.
It is more difficult to detennioc the exact iK»ilinn of the object when
it lies very clOKC to tJie retina. Th'Mt is IicaI luinc by the surj^eon making
~ .9li};ht movement witli tlie object lona (in the examination with the re.
trse image), his own and the patient's eye being at the same time kept
stationary, llie nearer that the object is to the observer, the more
marked will be its movement in the same direction as tbe lens. To illus-
trate this, Liebreich' cites the following example : If we suppose that a
filiform opacity wore to extend from the posterior pole of tlie len.* to the
centre of the R*tiua, it would appear like a [wint when sewn from iu front.
If we were then to m«vo tlie convex Icna from right to left, tJie anterior
extremity of the opacity would pass to the corre9|>ouding side, in front
of its posterior extremity, so that the opacity would no longer appear
like a i»oint, but a line. The depth of opacities in the vitreous ia, how-
ever, be«t determined by the aid of the binocular ophthalmoscope.
OpaeitUit f^f the cornea are best seen with the oblii|UO illumiiuition, and
■ FrpiMh TrniiKUUoo of Unekotiaia'a "TtmUm on tli« Dli<wawtof tho Rfa," p. 31.
Chaptek VII.
DISEASES OF THF. VITREOUS HUMOK.
l._INFLAMMATION OF THE VITKEOUS nUMOK—
IIYALITIS.
It wns formcHv stipposcd ilmt the vitrcfma humnr viu incnpahic of
oiMlt.'r<;oiii)^ intlaiiiiiialioii, on account of the absence ol' uitvi's kikI blond-
vc«si-U in ibt .structurt'. Tliankn, however, to the rescnrches of Virehow
■Qil Wvber, it huA been proved bevond doubt that the vitrcotii* humor
ba« hccuine iiiHamed. Altliougli Uiese inflammntory changes gviieralljr
either accompativ or sa|)en'eiie upon inflammation of the deeper tunica
of the fvvhall, vix., the rettiin and choroid, yet many hfUeve that idio-
pathic hyalitis may occur, and ihat it may he ijuitc impon-il)lc to trace
any participation of the other tunics of tJic eye. Dr. ilcrmanu lS}:cn-
etueht-r baa, however, made a iwrlcH of very tDtere«tii)g cxperimcuts
upon rabhibit, by introducing; i-arioun foreign bodice into the vitn'ous,
watching witli the ophthalmoacupe the changes thus pro-luced, and
finally nxamiiiiti^ the eyi;3 miunwcopically. These experiment-^ have led
him to the opinion that the vitreous cannot undergo primary inflamma-
tion, )>ut that it is always secondary aod dependent on chaugea in the
nei;^)ihoring tisi^iies.'
Ihe inflammatory changes consist chiefly in a proliferation or hyper-
plasia of the cclU of tlio vitreous humor, which become opnr)Mu and
granular, and u!ider;,'o. perha[«, fatty dc;;ene ration. Sometimes, there
16 a confiidiTuhte devek>|jmiMit of connective tissue eiementa, or there
may bo a great teiidencv to tmppnration, and large quantities of pu^ cells '
be formed. [A'^on Wcclcor thinks that the difference between the inflam-
mation uf any dense tissue and that of the vitreous humor is, that while
purulent infiltration uf the former causes destruction of the inflamed
tiMue,in the vitreous there is a displacumcnt of the structure, with rapid
ahsorptioii of the watery constituenia. — B.]
The progress of hyalitis is heat studied by w'atehing what changes
occur when a foreij'n body {e. ^., a piece of gun-cap, ste'd, etc., or a
displneed Ichk) is lodged in the vitreous humor. If the refnicting media
are sufficiently clear to permit of an ophtlialmoscopic examination, wo
find that soon after the accident, the vitreous humor in the vicinity of
• A I'riel Hiimni«ry of lii* vtevs will !■« founil in llm " r>>iitmll>lKll PBr mnlisin-
Im-Iihm Wi>t«»ti«<!liancii," Itj'jft, Nu, 43 ; 1ml a full nccouiil of llii- rX|>ctiiii'.-nrH, irt«.
Is pfil>luhud In Kiuj>ii'h " Arcblr for OphtU&liuotog/ and Olologjr," ISGD, tuI. i. 8.
390
DI8BA8B8 OV TBS VITREOUS BUttOR.
tbe foreign bodj loses Uh transparency, anil becomes somewhat liaz<r*
wliich is (lue to the proliferation of the vitreous cells, ami an increase ot
their nuclei and molecular content*. The foreign body appears to be
enveloped in a thin mittt or cloud of bluish-gray tint, which as^umea a
more dense and firm appearance if moch oojinectlre tissue Is developed,
and a creamy ycUow culor if suppuration sets in. The track of the
foreign body is often visible, in the form of a thin whitinh-j^ray opacity,
like a thread ruimiiig towards it. We sometimes tind that these inflam-
matory changes in the vitreous humor, consequent upon the lodj^nicnt of
a foreign body within it, aro idiopathic, no trace of inflammation of the
other structures of the eye being visible, either extemaUy or with the
oplithahnoscopi'. Generally, however, tins w not the case, for symp-
toms of iridci-cyclitis or clioroiilitis 9i»on supervene, and the eye is but
too fre(|ueQtly lost through suppurauon.
The simple (non-Buppurative) form of hyalitis may be either acute or
chronic, and the opacity of the vitreous be either diffused or circum-
scribed. On ophili!ilmoficojiic exaniination, we may find the whole vit-
reous humor tliffii-sely clouded, which renders the details of the fundus
either completely invieible or very indistinct, so tlial they apiwar to be
covered by a thin gray film or veil. In thlt diffuflc opacity may bo
noticed dark, Uireaddike films, of varying size nnd shape, which may be
either fixed, or float about when the eye is ((uickly moved. NeoplasUo
formations of connective tissue are often met witli at the anterior portion
of the vitreous huuior.close to the posterior pole of the lens. They give
rise M a more or less extensive opacity, which is sometimes termed pos-
terior-polar cataract. But connective tissue is also formed in other
portions of the vitreous humor, often in very considerablo ipmmitics,
giving rise to membranous and filamentous opacities, which, traversing
the vitreoua in different directions, may peHiaps even divide it into
fibrillar com[Hirtment!». The true orliular gelatinous substance of the
vitreous humor disappears in pniportion to the development of the con-
nective tissue, and generally becomes Quid (synchysis). Id such cases
tlie retina is ofWn found to be e.\tensive]y detached, and the vitreous
humor shrivelled up to a very small space ; and chiefly consisting of
connective tissue, of an almost tendinous structure, interspersed with
loculi containing cells which have undergone various changes, and not
uufrei|uent!y pigment molecules.
Although simple hyiilitis sometimes occurs idiopathically, yet gener-
ally it is dependent upon an iuflammation, of the retina, choroid, or
ciliary body. [Serous hyalitis, with liipiijfactiou of the vitreous humor,
and more or !es» ojiacity, is met with most fr<:t(|uein1y in sorou? intlam-
□lations of the eye, like glaucoma, or with progressive staphyloma jkis-
ticum. — B.]
Still more so is this the case in the sappuratire form of hyalitis, which
is but seldom idiopathic, being mostly associated with purulent irido-
cyclitis or irido-clioroiditis, which supervenes perhaps upon operations
for cataract, injuries, etc. As tlic cornea is but too frequently o[ia<fue,
or the pupil blocked up with lym[)h, it is often imnosaible to trace the
course of the disease with the ophthalmoscnpin If we arc, however,
able to do so, ve sometimes find (hat the anterior portion of the vitreoua
OPACITIES OV TUB VITRBODB UUMOB.
397
humnr, close to the lens, yiolils a yellow, crramy reflex, which may bu
very veil seen with the ohHt|ue illiiminntion. It is calleil pottU-rior
hyuojiyoD, aud is due Co pus in the antcnor portiou of the vitreous,
which may have made its way from the ciliafy hody or anterior segmeat
of choroid, having burst through the reiiua. lu such a case, tlie other
jrtion^ of the vitreoua may be found comparatively, or even completely,
llthy. In other instances, the suppuration occui-s at tlio |)o»terior or
?ral portions of the vitreous, to wfiivb it may remain titiielly contined,
but it may also become general, and involve the whole of the vitreous
humor I'aDophthalmttis generally ensues, and the globe gradually be-
eoiiiu» atrophied, with or without jin-vioua perforaliou of the cornea or
lerotic.
|£Wheii purulent hyalitis is circumscribeil, in other words, forma an
I, the contents of tbiH alisce^^ may eventually be absorbed, t)io
vtlle of the abscess collapse, and by their traction occasion partial or
total detachment of the vitreous. The same may occur from the con-
traction of membranous hands in tho vitreous which hare become organ,
iaed.— B.]
Tl)e prognosis of inflammation of the vitreoaa humor will depend
chiefly upon Uie caiiae, and the extent to which the deeper tijsutis of
tho eye are implicated. I must therefore refer the reader for a con-
siderotion of these points, as well as tlie i^uestion of treatment, to the
<lis«a»e.4 of the choroid and retina. With regard to the treatmeut, I
maj, however, state that in the acute cases of dilfuse hyaliti;^, much
beneflt is often experienced from aalivaiion, and the periodic application
of the artificial leech to tlic temple.
2._0PAC1TIES OF THE VITKEOUS HUMOR.
fSyn. Myodesopeia. — Tl.]
The presence of opacities in the vitreous humor IB easily detected
with the ophthalmoscope iuthe direct mode of examination. The patient
fthould he ordered to move his eye quickly and repeatedly lu varioua
directions, and then hold it stilt. Tliese movements will cause the
opacities to be ahaken up, and they will float about in the field of vision,
and we eih&Il Uius be enabled tu judj^e of their sixe aud density and to
distinguiHli Iwtweeii the fixed and movable ones. When the eye is held
still, wv latter soon i-iiik njj;atn to the lower portion of the vitreous.
The excursions which these o))aeitle5 make are often very considerable,
aul allow us to estimate approximately the de^^ree of fluidity of the
vitreous. The binocular oplithalin4:iscope is particularly useful in the
examination of vitreous opacities, and iu determining the ditferent depths
at which they are situated.
[Vitreous opacities are of two kinds : let those which have migrated
into the vitreous with subsequent transformation of the cellular elements ;
2d. tbo0c which are the results of disluteg ration of the normal elemeoU
of the vitreous. The first k represented by purulent infiltratiou and by
bemorrtiagc : the latter of which is shown by the presence of crystals,
(]oubtlc4s hematine crystals, the residuum of old hemorrhages. The
898
DISSASES OF THE VtTRSOOS HUUDR.
opjicitioA innv he very fiiio. aImo<4t molecular ; or they inav bavo die form
of fiiic liiips flni1 threails ; or they may he mo mh rani form. (*'(f raofo und
Siemisch's llandb. der AugenheUk.," iv. pp. li7i<-t>HH.) — B.]
Wc have seen that in simple hyalitis the opacity of the vttreona
asstim^g a ilitTitiie r;ray appearance, shrouding the whole fundus in a fins
veil, the ai^lit heiiij* at the same time j^reatly afl'ected. Sometimes the
opacity \m cliiefly confined to one jiortion, perha[)8 the central, in which
caae the vellow sjiot and the retina in ittt vicinity will appear hasy, whilst
the detftiU at the periphery of the fnndtLi can he clearly seen. This
partial nniforra opacity may shift somewhat when the eye is moved. A
peculiarly dangerous form of difTuse opacity of the vitreous is that wtiich
occurs suddenly, and, after clearing somewhat, recurs pcrhap* nei'cral
times, for it is hul too often followed by detachment of the retina. We
TTWist not, however, confound with this tlie temporary cloudtnesB of the
vitreous which occurs in glaucoma, and whicii la due to a aerotis hyper-
soorction, evirlently dependent upon irritation of the ciliary norvos.
To!»ether with a more or Ichs diffuse opacity, we often moot with
various circular, membranous, or filiform opacitios which are due to the
remains of blood-effusiona, or alteralinn-i m the cclU of the vitreous
humor, which may have undergone fatty, purulent, or pigmentary
chan^ea; or connective tissue elements may have been formed, 'i'hese
opacities assume very various shapes and forms. At firsts perhopi), the
patient only notices a dark speck before his eyes, which he cannot wipe
away ; then thin, flaky meinbranea may ajipear, which float about and
assume different forms and positions with every movement of the eye.
Between thcHC oiiacities, the field of virion may either appear clear or
he more or less diffiisely clouded. The nearer the opacities are lo the
retina, the more will they throw a shadow upon it. If ttiey are some
distance from it, they may not throw individual shadowH, but ordy give
rise to a general dimnew of vision. The patients, as Von (iracfe haa
pointed out. often tlirow tlieir eyes periodically upwards in readiuf;, etc.,
in order to caii^c the opacities to move and shift their position, so that
the field of vision niav he momentarilv cleared, which of course enables
them to see more diBtinctly. This periodic upwarl movement of the ere
is accompanied by an elevation of the upper lid, and j^ives a {leculiar
and chanicturidtif appearance to the patient.
Witli the ophthalmoscope, we can readily <]istinguish those opacitiefl
aa dark, fixed, or floating bodte!i, assuming various shapes, like dark
spotij, threads, or reticulated Qbrilltc ; sometimes, however, they ara ao
delicately fine that we cannot individualize them, and tlie whole fundus
only appears to be hazy and veiled.
The disease, in whieh opacities of the vitreous are by far most fre-
quently met with, is sclcrotico-choroiditis posterior. The posterior
portion of the vitreous fre'iueutly becomes fluid, and the opacities way
be seen floating very freely about in it. 8ometime», however, the syn-
chysia extends to the greater portion or even the whole of the vitreoud
humor.
Extravasation of blood into the vitreous humor is a very freijuent
cause of these opacities. The hemorrhage is generally due to a rupture
of some of the vessels of the oboroid, more especially at ita anterior
J
»
portion, «her« it is most v-ft»;iilar, and at which situation the rctinn is
lliiiiitc^t, and therefore mo»t rt*ndily gives way; wliereai!, when tiic
effusion takes \i\»ce in the posterior portion of the choroid, it is more
prone to cAiise detnclmieitt ol' t)ie relinn than to iterforate the latter and
tunke ita way into the vitreous. Thw is duo to the fact, that the con-
nection between (he choroid and retina is at this point very lax, and
tlio retiiia thicker than in the re;:ion ot the ora itcrraia. Hence a more
or leas coiutrdernMc detachment of the retina i^ fcencnilly producod at
th« posterior portion of the fundus, before perloration takes placQ.
When the blood has become Hbsorhcd. and the vitreous is at;ain trans-
parent, we can always discover chanj];es in the choroid, such as ecchy-
tnoses, etc., showing whence the hemorrhage has proceeded, and we are
aUn Boniutiines able to detect a cicatrix in the retina, where the latter
had been nipture-1 by the extrnvasation of blood. Schweig};er' lia«
pointed out that heraorrha>;o into tlio vitreous hnmnr occurs far more fre-
quently from the choroidal vessels than from those of the retina, for the
latter are not only ttmaller in size, but on account of the peculiar
arrangement of the connective tissue fibrillie (Stiitzfasem) of the retina,
and the resistance otlered Ky the membrana limitans interna, hemorrhage
from the retina extends generally towards the choroid, and not into the
vitreous.
We are generally able, with the ophthalmoscope, easily to distinguish
extravasations of blood into the vitreous, as tlicy yield a peculiar bright
red reflex. But if the hemorrhage is very extensive and difihse, it mny
not be possible to light up the eye at all, the fundus looking i|uitc dark,
and not affording the least reflex. The sight is generally very greatly
and very suddenly impaired, the patient having the seosation as if there
was n dense red mist or veil before his eye. When the hlootl is begin-
ning to be absorbed, fixed and floating opacities of a Bliform, retlcnlaied,
or membranous character make their appearance, and become n:ilU'd up
into dark fantuatically-shaped masses when the eye is moved. Soroetimes
when the absorption h:w gone oa for some time, and the vitreous has re-
jiained much of its irans(»arency, a fresh extravasation takes place, and
uiis may reenr several times. Although the patient may regain a con*
aiderable amount of sight during these intervals, the recurrence of hemiT-
rhage is always to be regarded with great anxiety, as it but too freiiuendy
]ea<ls to detachment of the retina, glaucomatous complications, or atrophy
of tlie eyeball.
When the hemorrhage has been at all considerable, permanent opacitiea
are generally lert behind, and may proiluce great imj^aJnuenl of vision
j^uivven detachment of the retina by imctinn. H. !^lUllci' waatlie first
' %Hlfal>w that the latter is a not uufrcipicnt conse<^ucncc of opacities iu the
rilreouB.
ExtmvasaUons of blood into the vitreous humor are very often of trau-
matic origin, being produced, for instance, by severe blows upon the eye,
oaosiug a rupture of the bloodvesseU of the choroid or retina. They
may, however, arise independently of this, if there is much congestioik
» "A.L0.,"»LS,2a».
• ]bi4., Iv. 1. 372.
400
DtSBASES OF TBI VITItEODS nCHOR.
of the internal tunics of the eyeball, or if the coats of the vessels arc
diseased.
In the treatment of opacities of the vitreous humor, ve nuut be espe-
cially guided by the cause, and whether they are due to, and a part i^ymp-
torn itf. iiitlnrmiiiitcry rtfTectii^iis of the ilwefwr tiiiiicd of the eyeball, or,
perhaps, to intrA'Ocular bemorrhagcs cfiuscti by rupture of some of the
choi-oi<lal vesacU. lu the former cikse, our attention moat be chiefly
direetoil to the treatment of the primary tliaease. The abeorption of the
vitreous opacities may, however, be greatly aided by preventing all con-
gestioii of the choroidal or retinal ressels by the application of the
artificial leech. I have often ji^nined great honofit from its uac. aa ii fn-
cilitaiea and hastens the absorption, and rirlievea the intra-ocular blood-
veaxels. If the [Kitient is weak and iiniemie, I goncrallv prefer dry
cnppinf; at the temple, makin;; nso only of the glass cviindor of the
Heurteloup. This may be repeated once or twice a week, according to
circamstances. But if the patient is strong and plethoric, I inmriably
lake blood away by mean? of the artificial leixh, one cylinder full being
the uaual (|uaniity. In those cases in which the affection of the vitreous
13 dependent upon derangement of the functions of the uterus or liver,
tlie general heaitli must be strictly attended to. Much benefit is experi-
enced from the use of salino mineral waters, as the Pullna, Kiasingeo,
Kreuznach, etc., and the tendency to congestion and hyperacmia of ibe
vessel:) of the eye should be relieved by hot pediluvia or hip-baths. The
aliitorption of blood into the vitreous may also be hastened by tbe appli-
cation of a 6rm compress bandage. In case of dense membranious
opacities of the vitreous which had resisted all efforts of abaorption.
Von Graefe has derived much bcneSt from tesring them through with a
fine needle.* This produces not only au improvement in Ibe sight, but
renders the opacities more amenable to irenimenC, and prevents their ex-
ercising any deleterious inffuence upon the retina by Irartion,
[If the upHcity is recent, the |>atient should be kf
comprc9s-bandage and the uac of atrivpinc and leeches i<<
the more chronic form:< good results have occasionally been
hypodermic injections of the hydrochlorate of [i' -;'
with a small dose and increasing it lo tolcranoD, b<r
duce no cardiac collapse. 'Die infusion
Uiv mouth in its place. (See"Traiu. N.
''N. V. Mod. Joum.." April, l«7U.) U
the n^v of the cotiaiant current, as an i' "I
and have spoken highly of the renultt
.l>dy II, 1^74; "La France Mel..
never seen any rapid re,*alw frnrn tbi*
liiuiger of increasing the opttci'
rent.— B.]
It is of much practit
logical opacities of '^-
muBcie volitantes ( '
eye«. These aMui
. with a
1.. In
::oa»
OPACITIES OP TBC VtTRE0tT3 onMOR.
401
I
iinm thej look like small transparent diaka orcirt'Ica, which may he
isolatotl or arranged in groups ; or they amy resemble- strings of bright
boadn. or tilamentoutt bamU, which float ahont in all dircctioii.'i tliroiigh
tlift fiehl of vii^ton. They are generally due to minute beaded Blaincnu
or groups of granulM iu the vitreous humor, and are quit« pliysiuJogicaU
occurriufi more or leAS in all eyes. They are so minute that they are
pcrfeetlv inviJtitilo witli the ophtlialnioacope, and this instrmucut is, there-
fore, fif the (ireatest use in enabling us to diatinj^uish between the physio-
lofcical and patholopcal mufcar voUtuntes, for directly it reveals to us the
re!>enOD of opacities iu the vitrcnus, however slif^ht tlicy may he, wo
lUsl rcjtard them as pathfilogical prodiicw. 1 must, however, mention
in passing, that certiin changes in the clioroid and retina may give rise
to fised dark spots in the visual field (so-called •' scotoniata"). Ko care-
fal observer could, however, confound these with the opacities in ques-
tion.
Muscffi become very evident when the person regards some light and
bighljf illuminated object, as, for instance, the bright clear dky, a very
white wall, or the brightly illuminated field of the niicroscopo ; wlicreaa
in a Dubdueit light, the floating bodies may lic lianlly, if at ;in, observable.
They are also increased by fatigue of the eye from overwork, or when
the retina is very sensitive and irritable ; the same often occurs if there
ifl any derangement of the nervoui system or of the digestive organs.
The situation of the mmwre may be a[}proxiraBtely ascertained, as was
^bnwn by Listing, by making the patient look through one of the minute
apertures of tliC steiu>]».'iic appunttux, or a pin-hole In a card. Now, if
the card is moved in a certain direction (e. if., upwards), and the objects
also move upwards, they are situated behind the pupil, whereas, if they
tttove in the opposite direction, they tie in front of the pupil. The
greater the degree of movement, the further docs the ohject lie from the
pupil.' Tbe position of the objects can be estimated with still greater
aocanicr by Dondcrs's mode of crimination d douhU viie. He employs
a diapliragm pierced by two small apertures, <iituated about one line from
each other, so that two shadows are thrown upon the retina, and cover
o»e another hy nearly one-half.* We must diatingmsh the muscas which
have their seat in the vitreous humor from tlie appearances produced by
eyela.-ihi'8, nmco- lachrymal drops on the conjunctiva and cumea, and the
railti and spots situated in the lens. For full infonnnlion upon this lu-
Mreating subject of Entoptics, 1 would refer the reader to Dr. Jago's
exeellent and exhaustive treatise.*
Short-sighted persons are especially troubled hy muscse, for even the
physiological motes arc rendered peculiarly marked nmi dii*tinct by the
*ige of the circles of diffusion upon the retina. In con!*ei|uence of this,
they often prove a source of the greatest anxiety and trouble to tlio
pauent. Alrcjuly. perliapa, in coruitant ilread tliat hiti myopia shouhl
rapidly increase, and lead eventually to great impairment of vision, or
even total blindness, tbe appearance of these muscie often frightens him
■ HcltnlioltE Ph;r9i(>Iogi<>oltc Optik,, ISO.
• I>tin'l«r!«'H ■' ApoiHftlip'i of ArcmtnmcKliitinn and Refraetioii,"' 301.
* " Ki)tapU», with He nac In Plivslalog/ tmi UcdloliU'," hv Juats Jmo, U.D.,
IflM (Cbui-chlll}.
36
402
T>I8BA8BS OF TUR VITREOUS HUMOR.
greatly, anfL causes him to yiuUI undividtid attention to bis eje«lgfat»
and to watch every symptom witli atixiety. This h more particularly
the case with those pt^reon^ who aro df|ieti<lcnt u|>on their sight for their
livelihood, or are natiiraHy of a nervous and auxiouH temperainent. Kv«ii
although we may earnestly and repeatedly assure them that these physio-
logical motcB are nut of the slightest importanue, and arc a source of uo
daoijer, we hut ton fre(|iieiitly fail to alleviate their mental distre*?.
They seek advice from others who, in their opinion, are more competent
and willing to understimd the nature of thiiir compltiint. Amouj^l such
patiL-nts the charlatan finds lila most fervid and prcifitahlo follower*. I
have met with several moat distreMing casee in which advertising quaclu
have greatly frightened patients who complained of these motes, assuring
tliem ttiat they depende<l upon *ome secret disorder, and if not speedily
and properly tre:it«Ml, thiil they would lead to amaurosis, of which,
indeed they were tlw' anrc precursory symptom.4. Such patient.3 must
he cheered up, and jirevented as much as |ji)S»ihle from thinking of their
ailinenta. Their general health miii^t he titreugtliened, and any irrc<;u-
Unties of the circulation or digestive organs removed. Much benefit
ia of^en also produced hy the use of dark blue or neutral tint eye-pro-
tectors, as they diminish the intensity of the light, and thus render the
inuscie Ie*8 visible.
It tias been already mentioned, in speaking of the opacities in the
Titreoua humor, that the latter may loic iu normal gelatinous coosiat-
ence, and become partially or wholly fluitl. This cuitdition, which is
it-rmcd M^fnchysis, cannot be iliagno»ed with certainty if there are no
floating opacities. Au erroneous opinion sometimes prevails, thnt the
eye is always soft in all cases of fluid vitreous. But Uiis ia iioi Uio
case, for the tension of the eveball varies nocnrding lo the amount of
the vitreous humor, and not according to the nature of its con»istCDce.
TI1U8 in glaucoma, the tension of the eyeball may bo very greatly in-
creased, owiiiy lo the liypcr-secrelion of the viti-eous humor, which may
be perfectly fluid. Again, diminutiun of the iiitni-ocular tensiou only
proves that the contents of the vitreous are diminished \n i(Uantity,
although it must be allowed that in such cases the vitreous is often fluid.
TrcmulousncKs of the iris ia also an uncertain oymptom. It can exist
only when the irij has lost its natural support fi-om the crystalline leoa,
either through abaence of the latter, or througli iu having become dis-
placed. Together with fluidity of the vitreous, tlie diameter of the
eyeball may have become iuereased, and tlie positiou of the lens with
regard to the iris somewhat altered, and therefore, on account of thi^i
loss of support, the iris may be tremulouif. But the moAt reliable symp-
tom is the presence of floating opacities. In staphylomatouH enlarge-
ments of the eyeball, the vitreous is always fouud more or Iojss fluid.
The same occurs if a foreign body or a displaced leui» has become lodged
iu the vitreous. Moreover, wiien viti-eous humor is lost, as for instance
during an operation for cataract, or owing to a wound of the eye, tlii*
loss is always made up hy fluid. It h of importance to be aware, if
possible, of the consistence of the vitreous humor before undertaking tui
operation for cataract, in order that we may take every precaution to limit,
as much as {Mssible. the loss of vitreous which must inevitably occur.
OPACITttS OP TDB VITaBOl'G nOHOR.
40S
[TfaiR senile synclivsia ia often met with in ejes in which the viireoos
lameila of the choroid is thickened, or in other wonlit f^landtilar degene-
ration of the choniiil. — -B.]
Acoording to Iwanoff.' fatty degeneration of the stroma and cells of
»e vitr<.'0U9 hnmor, with siihsciim-nt flniditj' of the latter, is not of
lufre-iueiit occurrence, more es[ic-ciall_y in the aged, in whom it is due
to senile decay, and ia here a ()uasi-physioloj^icaI condition.
A most beautiful and striking appearance is presented hy the presence
of crystals of cholesteriiie in Hie vitreniis. As this condition generally,
if noi indeed always, occurs in a fluid state of the vitreous, it hati been
termed sparkling synchysis (synchysie ^tincclant). The exact mo«le of
liigin of these crystals is not at present knovrn, hut it seems that they
"ten occur aft^r hemorrsge into the vitreou?, ami arc therefore very
probably deposited from the blood : or they may be doe to fatty changes
in the vitreous humor. The appearance presented by choleatorine in
the vitreous is moat characteristic and striking, if the ophtiialmoscope is
used. On every niovcHicnt (tf the eye, a shower of iiri;5ht, Bi)arlilin;5
crystals is seen flouting through the field «f visifln, which gmdiiiilly
sink down to its lower part when the eye is ft;;ain held still. Sometimes
the crvstala float about in un otherwise clear vitreous, or thoy may be
intcrmixc*] with darker fihimentous opacities, to which they may even
adhere, fringing them with a sparkling lustrous border. Thoy have also
been met with in the retina and optic nerve, and even between the retina
and choroid. When they are situated at the anterior portion of the vitreous,
elose behind the Ions, they m.iy be noticed oven with the obli<[UL' illumi-
nation. Von G raefe mentions a case in which they gradually disappeared.
Dettiehment of tfif vilre'm« humnr is altogether [lalliological in ita
nature, and is of serious danger to the safety of the eye as it frcqviently
leads to detachment of the retina. It is mostly due to some injury of
the eye. but is aUo occasionally observed in cases of staphyloma of the
cornea, and of posterior staphyloma, as well as in consequence of ex-
traction of cataract with or without the loss of vitreous. Iwanoff, how-
wrer, states that detachment of the vitreous humor is of rare occurrence
afWr exiractiou of cataract, if uo vitreous has hccn lost, whereas it
occurs, as a rule, in all cases in which there has been a cnnsiilernble
li.tw of vitreous humor.' lie divides the detachmetits of the vitreous,
which occur after injuries of any kind, into two categories. In one
class.' the detachment occurs itamediately after the injury, inconsequence
uf the diminution in the contents of the eyeball and the vacuum which
is thereby produced, and which is immediately filled with a serous fluid.
In the other, the detachment is formed gradually, and depends upon
slowly progressive changes in the vitreous huiuur, which may pn^bably
be set up by various morbid jirocessca in the other membranes of the
eye. The detachrocnt which occurs after extraction of cataract may
belong to either category. At present, no exact data can be given for
the oiihthalmoscopic uiagnosis of this detachment of the vitreous. Von
U raefe* thinks it probable that the auddenly-fonncd, tolerably unifona
' •' A. t. O.. xr. 2, 4.
■ Vidrtlso Dr. di- UouTeS's Artie!.:, "A. f. O.,'' jct. 1, p. at4.
• Loe. di., 1.. (H. * -Kl. Muiiaut;).," 1866, i>. 301.
404
DtSBAUBS OF TUB VITKBOUS UltHOR.
Opacity in tliD posterior sepinent of the \itreoua which is fiometiniM
oWrvcd in sclf^rcctasia posterior, is a detachment of the vitreous. 'Fbift
opacity is especially characterizeti by the sndilenness of ita appearance,
liy ita di-Rned line of ilcmarcaiion against the heahhy vitreous, although
it may be of considerable extent, and by the almost constaot Buperveo-
tLon of detachment uf Uic retiiui.
3— FOREION BODIKS, ETC.. IN THE VITRKOl'S HUMOI*.
If a foreign body becomes lodged in the vitreons humor, it but too
freiiiiontly exuitu.^ the mottt sovci'O ami deMtruiitive inflammation of the
ti»9no.<t through ivhich it has pa^ttc-d, or with wliich it lies in contact.
Thna if it lian entered through the cornea, this and the iris often becoiM
violently intianied; tlie lens, through wliich the foreign body has aim
passed, becomes cataractons and swells up, thus tending to increase sdU
more the severity of the inflammation. If the injury has been severe
and the foreign body lies in the vitreous humor close to the retina, it
often excites intlammution, perhaps of a supfjurative character, in this
and the choroid, which mav lead {>nrhap!t to aln)|ihy of the jilnW, If
the media remain sufficiently clear to permit of an ophthalmoscopic ex-
amination of the fundus, we genernlly find that for the firet few days
the foreign body may he iseeti of its natural color, mostly sunk down in
the vitreous humor. Then, ihe latter liecomeg t^omewhat clouiled in the
Ticiniiy of the foreign body, surrounding it with a thin, grayiiih-blue
halo, which, as the plastic nature of the exudation increases, assumeif a
denser and more npa4iue yellowish-nhite ap[>earanco, hiding tlie foreign
body from view. It has in fact become cncvsted. At the same time
the vitreous humor la often more or less difi'ueely clouded, and dark,
filiHiieiitoua opacities Boat about In it. When it regaini* suflicient traoa-
parency to permit of an ophthalmoiM:opic examination of the fundus, we
not unfrei[uently find tlmt a detachment of the retina has occurred
(perhaps to a considerable extcnt^^and that a more or loss oxtonnve
inflammation of the choroid has taken place. In some rare instances,
however, the course maybe moro favorable; so that, although tite injury
may he followed hy severe infl.immation, the foreign body bccotma
encysted in the vitreous humor, which gradually regains its transparent
as the inflammnlory symptonw subside, and finally the slglU may bo
restored to its norm»l condition, the foreign body lying ianocnotii} lu the
vitreous humor, iiuch instances are, however, very rare, and can only
occur when the foreign body is but small. The following is a brief
oolltne of such a case, which came under my care at the Middlesex
Hospital in mvi.^
" .Samuel 1' , aged 20, was wounded in the left eye by a chip of
irtui flyitig oil' a hanuuer. Thi^ was followed by severe inflaimualory
symptoms, great swelling of the lids, lachrymation, photopliobia. iritis.
At the outer and upper side of the iris, quite close to tito periphQnr,i
there was a small triangular opening, showing the passage of tnc foreign
I
> Vi(l# " L*nert," Aug. 23, IBSS.
rOailON BODIES, ETC., IS TBE VITRBOUS nUHOK. 405
bodv, ftDiI, CArrespondin-; tA it, there «n« a small cicatrix in the cornea.
Od ttis adroisnioii intu the hospital (about a week after the ticciiient) he
eoiiM only count fingers up to a ilistaiicc of 7 or 8 feet. Tho tetwion
of tlie eye was then, and renwineil throui^lioiit, normal. When the
inflamtnatory sjroptoma had greatly subsided, a short ophthalmoscopic
examination waa made, and it was found that the vitreoni; humor was
clouded, with a few Hlamentous opacities floaiiug about in it. The con-
dition of the eye wa.9 !toon <u> raucii improved that tlic patient could read
No. 1 of Jii^er, and No. 19 at 18 feet; tho lens waa clear, the vitreous
Blii^lilly haxy, yet permitting the optic disk to be seen diBtinctly. At
the outer and Inwpr portion of the vitreom* was seen a white, opalescent,
oval DUUH, the encysted foreign body, whose passage throagh the vitreous
conld be tmced by a faint bluish line runnins; towards it. A local, cir-
cum^ribed iuflaromation in the choroid had occurred in ita vicinity, and
smalt portions of choroidal pij^monl wero agglomerated around tho fon^ign
body. 1 «aw the pfitient occa^iionally for some years after the accident;
the last time was about three years ago, and the eye waa then in pre-
cisely the same cotnlition, and he could use it perfectly."
T mtiftt mention, however, that even after a foreign body has Iain
encysted and dormant for many years in the vitreou'^ humor, it m*y give
ri^e to severe inHnmrnator}* symptom^), which may lead to atrophy of the
globe, or awaken sympathetic opbtlialmia.
Dr. Berlin, of Stuttgart, lia)i lately called attention to a fact, with
regard to thi- courw often taken hy foreif^ bodies in the vitreouu. which
liad hitliertn bBeii overlriokeil.' He haa found, fram hid dissection of eves
wounded by foreign bodieit, that, when tho latter lay in the lower portion
of the ntrcouB humor, they had, in moat caBcs, first struck the retina and
choroid, and. havin;^ rebounded from the posterior wall of the eye, had
(lien sunk down in tho vitri-ous. This was proved by finding a «tpot on
the retina and chnniid whore these had been wounded, lytnj; in a straight
line with the entrance of the foreign body. I>r. Berlin, moreover, point*
out the great importance of accurately testing not only the acuteness of
vision, but also the condition of the visual field ; for a ditficicncy in a
>rtain portion of tlie field oi-cnrring immediately aft-er the injury, may
tide na in discovering the presence of a foreign body in the vitreous,
u well as its poiiition. Thus in one case in which the field was wanting
outwards and upwanU, he ilia*nio«ed llie foreign body aa lying at the
inner and lower >|uadrartt of tho eyeball. An incision was made at Ihiit
point, and the edge of tho knife struck a;;;ain-4l a bard body, which, how*
ever, eluded the grasp of the forcejw. The eye was excised, and then
it was found that the incision liad actually grazed tiie bit of steel. If
hemorrhage has t.-Lken place, the greatest <|uantity is found about the
foreign body. Dr. Berlin* now employs, like Von (iraefe, the narrow
extraction knife, making the aection downwards, but otherwise tho same
sa in Von (imele'it operatiou for extraction of catanict.
The treatment mujit be chie6y directed to subduing tho inflammation.
> VUlo hU TalnklJo pnpora on " Koratgn IMIm in th« Vitrwni*," " A. f. 0.," ziij.
3. 273. uid lb., xir,. i. 27b.
• Kna|>p'» " ArcliiTM fur OpMbalmology uiil OUiiagy," 1.1, 30.
40B
SISBA9R9 OF TRB TCTRBOVS BUMOH.
Cold compresses should bo applied to the eye, aud perhkpfl leeehes to
tlie teDQple. The pupil must be kept wulely tlilated by ntropnie. K
suppurative iritis or irido-cyclius ia set up, ic may be necessary to put
the patient rapidly under the influence of mercury. Or, if there is a
considerable hyiHipyt^ii, repented piimcente^ia, or a l:irii;e iridectomy may
be indlcftted. I'he latter should norcr be iieju;lcctcd if die teusiou of the
eye is increased.
With regard to removal of the cataractoua lens, or of the eyeball,
from it« setting up sympathetic irritation or inflaioiuation, I must refer
tbe reader to the chapters upon " Traumatic Cataract" and " Synipathetio
Ojihthahnia." The ((ueslion may arise a& to the advi-yibility of rcmoiin*
a forei;;u bi)dy in tbe vitreouM humor, and we mu^tt be principally guided
in drcidin;^ this by its position Hud nature. Inti-rutfting c*ae» of ihU
kind have been reported, amongst others by Dixon (''R. L. O. II. Rep.,"
Ho. G) aud Critchctt ('' Lancet," 1854).
[The removal of forci<^ bodies from the vitreous is a qnestion of great
im|>ortance lu ophUialraic surgery, for two reasons: firat, because of tlie
possibility of preserving a certain amount of vision in the wounded eye,
in spite of severe infiaramation ; and secondly, because of tlic possibility
of preventing »ympathutic icillammatioii. The ]>reiience of a foreign body
in any eye M not only almost certain to cau^e destnictive inflammation
of that eye, but is an exceedingly freipient cause of nyTipatJietic iiiflam*
Illation of the fellow-eye. W'hi-re tlie foreign body can be seen with the
Ophthalmoocope, an attempt should always be made to remove it. Where
in preitence is auapected. au o[«nition in almost always justiliable.
Gently probing a wound through tiie coats of an oyc, from which ritrooiu
is protruding, is under certain circumsumces atlmitmlMe and eren wise.
Kven when a forvij^n body has become enca^ntutnted in the vitreous, the
eye ia never ."tafc from dan^*?rrtu3 inflammation. (For a more full dis-
cussii.>n of these poinUi. see Knapp's articles in the '" Arch, of Opbthal<
uwlogy," vii. i, 3, and 4; viii. 4. Ako a pa|>cr by C. S. Bull in
*» Trails. N. Y. State Med. Soc," 1880, and " Arch, of Ophthal.," \x.
1; Graefc und Saemlscb's "llandb. der Augenhellk.," iii. p. 392 ft
Although cy»ticerci have been met with in various parta of tbe eye,
as the cornea, anterior chamber, iri^, and lens, as well as in the orbits,
their moHt frei(ut;nt si^at appears to be in the back';ronnd of the eye.
Thus A'on (JraefL-^ status that among 8U.0t>() jiatients, he lias found a
cysticerciu in the deeper tissues of the eye in rather more than 8U cases;
in the anterior chamber three times, beneath the conjunctiva 6ve ciines,
in the lens once, and in the orbit once. The youngest individual was
nine years ohl ; about SIO per cent, of the cases occurred between the
a;ie8 of 15 and 55, and nearly two-thirds »jf the cases were met with iu
inen. In England tlie disease would acera to be very rare. I iiave only
met with one case of cysticercus in the vitreous diagnosed with the ophthal-
moscope, which occurred in a soldier who wa» sent eo me for examination
by Professor Longmore. If the membrane which envelops the cysticer.
cus in the vitreous humor is not too dense, the ontozoon presenta a very
peculiar und characteristic appearance. Iti^ original seat appears gene-
• "A. r. 0.," jtii. 2, 174.
:
■i
PORBIGN BODIES, BTC, ItT TUB TITRBOUS HUMOR. 40?
rally to be tencnth the rclinn, an«3 U U only at ft later stage of its exist-
ence tliat it pcrforntee the latter (with it^ head firet), and makes its way
into the vitreous humor. Sometirups it carries the retina with it, and ihua
produces an extensive iletachmvnl, by which it is covered. In other caws,
it tears throu^ the retina and lies free it* the vitreous humor. Here it
freinKMilly becoraes encysted, being surrounded by a more or less dense
memliraiie, which niay prevent the recognition of the real nature of the
a6cction. If this is not the ease, bnt the entozonn is without an invest-
ing membrane, it presents the appearance of a pale grayish-blue or greeu-
ish-lilup vesicle, somewtiiit circular or flasL-shaped. with a short neck and
round head, on which the suckers may be «oen. If the animal i» nlive,
we may, by closely watching it, obmorvc diacinct undulating, :rcuiul(ni»
movements of its outline, the head being perhapti altcniatoty •ttrett'^hed
0«t from, or drawn into, the receptaculum. The position of llie latter,
in which the head and neck lie when they are retracted, is indicated by
A fmall whit* spot at one |»oint of the veBiclc. The slightest movement
of the head causes a gentle (quivering motion of the vesicle, and, on bright
illumination of it^ surface, wc notice, especially near the margin, a pe-
culiar bright iridescence, th« play of colors constantly changing, but
having a decidedly red tint. All these niinutiic arc more easily distin-
^lislicd when the cysticei'cu» lies free in the vitreous humor, than when
it \i covered by the retina. If, in the latter cace, ita movements are very
marked and conKideriible, the ^superjacent retina may aLso undergo a dit<-
tinctly tremulourt motion. Von <}i*aere has been able in four canea to
watch the development of the entozoon from the very commencement.
At the outset, there appeared a delicate grayish-blue opacity at some
jrtion of the fundus, situated evidently in the retiiui or between the latter
" the choroid. In the course of three or four weeks, the little cy^ticcr-
cna vesicle escaped, in two cases from the roost pr(»niinent |Kirtirui of the
opacity into the vitreouA humor, to the other two canes, the outline of
the vcHiclc became gradually more and more apparent from beneath the
>pacity, and waa distinctly situated beneath the retina, the latter lying
Either in tense atid close apposition to the entozoon, or being aeparuled
"fiy an effusion of suhretinal fluid, in which case there exists a greater
ninbility of tlie vesicle. The latter gradually glides along further and
fuiiher beneath the retina, until at last, after perhaps several months
have ela]>sed, it breaks through into the vitreous humor. The origin^
fioaition of the cysticercus Imncath the retina is indicated by the faintly
rci-ogniiahle remains of a *niall grayi--th-white sf)Ot, from which can be
tracod a dialinct grayish track, if the animal has made its way for some
di-iianoe beneath the retina before perforation. .MtJiough opacities of
tin- vitreous may appear at the commencement, this is not the rule, but
at n later period the vitreous generally becomes clouded, and the eye is
finally lost from slow and insidious choroiditis. Generally this occurs
withiu two yenrri of the outset of the disease.
The presence of a cy-tlicercufi being so extremely dangerous to the
eye, V'oji tiraclV* was led to attempt its extraction. By no doing, it may
•'.A. f. Q.." lil. 2, 330. aod ib., It. 2, 171.
408
CIBBAdKS or Tns VtTKBOtIS HUMOR.
l>e possible to rotaitt a certain degree of vision, to preserve the sbflpo of
the eye, or at the worst, to dimiiuBli the pain ami protracted coufmj nf
tho airopliy of the cychall. After a time, however, he altooat eiitinti/
abandoned his former modeii of opcratin);, and more receutlj ado])ted tlie
same oiethoil as in Win operation for cutAract.' The section was maile
downwards with the narrow extraction knife, the iris excised, tho ca|<sute
lacerated, and the lens removed. He then tore throuj^h the hyaloid
fossa with the blunt traction- hook which he formerly employed for the
removal of the h-iis. and passed it on in the direction of the e vat ice reus,
alternately drawing it hack a little towardfl the BccUoit. lie watched
with great attention the Uttle fiocciili of vitroouji which are thiu broaght
towards the iround by the retraction of the hook, for as soon as yellow-
ish threads and portions of ini^mhratie appear in tliem, it is a proof that
the close vicinity of the entoitoon has been reached. Wheu the cyst
itself apjM^ai's near the wound, the book is to be laid asidCf atid the vul-
canite cnrette pressed a little upon the cornea, so aa to cause tlie lips of
the iiiciaion slightly to ti^pe, and facilitate tho exit of tbe eutozoon. He
recomraciuU the same funn of incision for tlie removal of foreign ImmIics
lying in the vitroou-i, when such an operation ajipeant advisable.
In Plate v.. Fig. [i, will be found an excellent illastrHtinn of the ap-
pearances preBCnUnl hy a cysticercna in the **itreou8. Liehreich says,
in explanation of this plate, " The parasit«, which was originally ilevel-
oped beneath the retina, and thou, after perforating ic^ pciietratod inio
the vitreous hnmor, couM be seen with such perfect distinctness, that
the uniiulating inovemeuts and coarctations of the vesicle could not only
bo olwcrvcd at iti outline, but alxo at the posterior wall, which could Ite
distinguished through the anterior wall. This was ej>pe«la1ly the cm«
towanis the centre, where, as Uie red tint in the illustration shows, more
light can shine throu;;h than at tbe margin, on which tbe light falls morv
oblitfuely, ami oon8»|uently suffers greater retleotion. The neck, ea-
pecinllv at it^ junction with the vesicle, is of an opaifuer tint, and etad-
dod with minute white dots (chalky particles). This more opaque por-
tion, where tho neck joins tbe vesicle, is also llie roost finn. and we must
endeavor toseizcit hcrc,if we wish toextJ'act the animal. lnaca.4c upon
which I operated last winter, I succeeded in seining it at this point with
the canula forceps, introduce<l through tho sclerotic. My means of an
0|>lithalnioscope, which was Bxcd to the forehead, I illumiuateil the animal
and the instrument, so that 1 could sco them accurately. In tho illua-
tration wo rccognixe at the head two suckers (the other two being placed
poatcriorly), and tbe buccal extrenuty which is directed upwards. The
shape of the bca<l did not always present the appearance depicted \a the
illustration, but varied in a very remarkable manner."
[Tbe_/[7<(rffl spirnlir has been olwervtid iu the vitreous in rare caoes,
but Von Wecker thinks none of the rc|»orlfl are reliable. Snob a worm
might ophthahnoj^cnpicnlly be easily confounded with a persistent bjaloiil
art«ry. See CJraefe u. Saemiwh, 1. o., p. 714. — B.]
> "A. t. O.," ztv. 3. 143. 19^ also "Ou, H«baoa.," Jan. II, 1872, athl OTaHi
unl SMtHiNch, loc. dt., ir. p. Tll.^B.]
^1^
PBK81STBNT HYALOID AKTBBT.
400
Id rare instances, tliQ formation of nov bloodrostwls in ihc Titreoin
jOMy be oWrvcd witli tlie opIithaltnMcopc. Tlius Becker' mv now vt!ii>
sets formcil upon lliu aiiU'rior surface of an abscess in the vitreous hn-
mor, mill ii^itin in purulent infiUnition of the vitrooua : in the latWT case,
ihc %'e!«^<.'>Is W4>re Rituate'l cl'Me behind the lens, un<l were tli:jtiii.i;uii«hab1e
with tho naked e^'e. lleclicr,* moreover, narrates an extraor*iinarv east:
of an indei»endont neoplastic forrnattoii, in wliich the connection between
the newl^-tormod veHseU of the growth and tho»e of the retina could he
distinctly traced.
[TI)ou|j;h these cases of vascular new formation are rare,, vet enongh
have been reported to admit of a positive opinion as to their occurrence.
lliev almost alwajfl occur near the optic disk, are connected with ihc
npitlji or the retina, and arc developed at the expense of the vitreous.
If the latter is hazy they might be mistaken for a detachment of the
retina. — B.]
4.-^ERSISTEXT HYALOID ARTERY.
TTie hjaloid artery generally shrivels up and disappears dnring the
later period of fuetal life. In some rare instances, however, remains of
it in the vitreoua humor have been 8ubiie>(ucntty (raced witli the oplithnl-
moscnpc, either in the form of a short, dark stripe, or of a dark thread
running tlirou^'h the vitreous humur from the o]jtic disk towards the pos-
terior ["ortion of the lens. If the vciwel is »rill patent and carries blood,
oe was noticed by Zehender,' it appears like n red conl by incident
light ; which in tliis case underwent considerable undulationa when the
eye was moved, the vitrcoiu humor being evidently fluid.* Liebreich
reconls a case in which there existed a physiological cup of the optic
nerve, together with the persistent hyaloid artery, and the latter could
hn distinctly traced up to ita point of origin from the central artery uf
the retina. A remarkable case is reported by Weckcr.* in which a
transparent hyaloid canal existed in botli eyes of a patient. A unique
case of persistent hyaloid artery was under my care at Moorfields about
two years ago. It occurred in a lad about 113 years of age. Arising
from one of the arteries in the disk, was seen a small arterial twig run-
ning with n slight tiend for a short distance into the vitreou)) humor, end-
ing in a loop and passing over at once into a vein, which, twisting itself.
like a corkticrew, tliree timen round the artery, terminated in one of the
large central veins. An oxcellont drawing of this case, made by Mr.
Liebreich, will be found in the ** Transactions of the Pathological So-
ciety," IHll. p. 222. Saeraisch* baa recently recorded a very interest-
ing case in which the ophthalmoscope revealed in one oyo the presence
of a grayish-blue niem>>raiie in the vitreous humor, whieh was coniiecte<l
poetcrinrly with the retina in the immediate vicinity of the optic disk,
vetUug the upper third of the latter. More anteriorly the membrane
I "Boriclit Qlwrdfo Wicnrr AugcDklinih," 114.
• '> Kl. M.'niitAhl.," l.>i<!3, 2i9. * lbi>1., lt>(>3, 349.
•Ibid., ID6!), p. »n4.
> lt.ld., 1869, p. 310.
■ I6EA5ES OV TUB VITHEOUS UUUOH.
D narrow cylindrical canal, whicli, spreading out again
ed near the posterior pole of the leiH. Wiiilst the an-
S >|uite devoiil of bloodv^i^'aeU , the s&me vi^ ni?t tW case
pr part, for on the pale blue niembrane iii-ar the retina
.^e ohaervcd, which could be dUdnctly traced as passing
■ 44ito Ihoae of the retina. This membrane was probaWjrdue
of development in connection with the hjatoid artery, and
ie\y a case reported hy Becker.' [A caae is also reported
w. a persistent fcetal artery in each eye. See ** Archives of
jlogy," iii. 3, p. 190.— B.]
<■ "Kl. MoWaUbL," 1868, p. 354.
Chaptku VIII.
DISEASKS OF THE RETINA.
i^hyi*kr.^:mia of the retina.
VTb may distinguish two forms of hyperEemia of Uie retina, viz., the
trterial or active, aiul the venous or passive. The former is generally
acute, ami is cliaractcnzcfl hy (be patient cxperiuuciug some symjitoma
of trritahility in the eje, such as photophobia, Uchrrtnation, suhcon-
r juuctival roUuess, aii<l an inability to coutiuue for any leii;;th of time
'any work ^^hioh ncccMitatcri a )4tron<; oilbrt of Uio nccommoilauon.
There are often aUo suhjectivc syropioinj of an irriublc atat* of the
rvtinii, such as tlaslies uf li);ht. etc. Ou examinint; tliu eve vriUi the
ophthnlmosoopc, vtv finfl that the optic tlisk is nhnorinnlly red and
flushed, oil account of the increased injection of the capillary twigs upon
ita surface. If this increased vascularity is very prooouuced at the
,IDart;in of the disk, ita outline becomes somewhat iU'dcfiiie'l from its
'similariiy in tint to the aurroutnling fundus. Tlio size of tlic arteries
may be slightly incroH.<wd, antl the smaller branches arc more numerous
and apparent, which is especially observable in the re^on of the yellow
spot. The retinal veins are also somewhat dilated. Aooording to Scell-
iirag, more or less considerable portions of tlie fundus are rendered
[almost uniformly red by a very delicate and close-meshed network of
veiiaels. It must always he reiiiemberedt tliat the de;;reo of vascularity
of the retina and optic disk varies niucli in diRerenl individuals, mid lu
persons of dificrcnt complexions. Thus, it is less marked in palo and
iltniemic individuals tlian in the florid and plethoric. If only one eye is
fftfieated, the ap|>earanoM presented by it ahoiJd always be compai-ed
with those of the other eye, as this will enable us more accurately lo
MCimate the degree of vascularity of the retina, and guanl us against an
error in diaj^noeis.
Arterial hypencmia of the retina ia generally dependent upon oausea
which excite an increwed vascularity of the eye, thus it may be arti-
ficially produced hy the application of a drop nf some astnit);ont colty-
rintn to the conjunctiva. It u often duo to proloii<;c4l 4>xpoiture to very
bright light, more especially if the eye;? are at tlic same time employed
in some small and delicate wurk.as for instance in micro.4co|iixing, en-
grftTing, watchmaking, etc., by artificial light. U is also frei^ueatly
net with in hypermetropic persons who work or read much without the
^ftAsistaucc of glasses.
In the venous or passive form of hyperemia, we notice tltat ttie retinal
412
DIgEASBS OF TUB EETtfTA.
veins are Bbnomnally Ltrge. dark, and perhaps tortuoiiSf which is espc-
ciallv marked in llie smaller veiiileta, which m»y present a »i>raewhat
spiral appearance. There is also cither a spontADcoiu, or a very eaaily
finxlucible, rcnouit puUation. If the venous congestion has lasted aoinc
ength of time, wo fret|iiently notice a slight uodematous condition of the
retina ronnd the optic disk, or along th« courms of some of the larger
vessels, which appear to lie fringed by a delicate grayish-blue opacity or
lialo. Care must be taken not to nilfslake this for another form of
opacity along the edge of the vessels which is due to hypertrophy of
tlieir coats, and which will be noticed hereafter. The sight after a time
generally becomes somewhat impaired, bnt this disappears again when
the caufie is removed. This form of hy|»cra'Uiia \* mostly slow in ltd
development, and is due to a slate of veiioiw congelation dependent per-
haps npon some disturbance in the general circulation, caused by an
affection of the heart or Uver ; or again, it may be dependent upon local
causes, which, by imfieding llie efflux of tdo<Hl from tlie retinal veins,
give r'lM to a mechanical venoiut bypor«eima. Amongst such cau»es, we
may instance intru-cranial tumors which press upon the cavernous sinus,
or tumors situated in the orbit and compressing the optic nerve ; or
again, an increase in the intra-ocnlnr teiiKion (a glaucomatous condition
of the eye). I must here point out that it is (|uite erroneous to nsMrt,
that the tension of the globe is more or less increased tn the pauive or
venous hypericmia of tlie retina. This is in fact mislJiking cause and
cffcei, and such a mistake is apt to lead to great errors in diagnosis and
treatment. The intra-ocnUr tension U never increased when ilic venous
retinal hypenemia is simply due to disturbance in the general circulntion,
to tumors pressing upon the cavernous veins, or to intra-orbital tumors;
it is only iiKreased in a glaucomatous condilioo of the eye, and here iho
venous hyperiemia ta due to the augmented tension of tho globe, and
does not produce it.
If tlic arterial Lypcncniia of the retina is considerable, the patient
should not be allowetl to u^e his eyes at alt, more especially by artiScial
light, until the symptorai* ha%'e <[uite 8ubt^ide<l. If ttie affection is du« to
Bome defect in the accommodation or refraction of the eve, as for in>
stance presbyopia or hypermetropia, this must be corrected hy suitable
glasses. Blue or smoxe-colored eye-proteetora should bo worn to zuard
the eyes against the irritating inttueueo of bright sun or artiticial light,
and the eye-douche will be found Iwneficial in relieving the irritability
of ihe eye. In the treatment of voiioiis hypenemia, our attention mutt
be chiefly directed towards the prevcntio i of auy disturbance atnl con-
gestion of the venous system. 'i*he functions of the heart, liver, and
(Items must be rt^gulated. and special care be taken tn prevent deter-
mitiation of blood to the head. Sluch benefit is often derived from bot
stimulating foot-baths, and a course of mildly purgative mineral waters.
The congestion of the retinal circulation is best relieved by Ueurteloup's
artificial leech. It should bo applied ])orin«lieany, at intervale of six or
■even days, and, if the patient is attfemic or in feeble health, bat little
blood f ^ or f of a cylinder) should be taken or dry cupping should bo
Bubsd tilled.
INPLAMUATION OP THH RETIMA.
418
[la casoB of congenital tnalformation of the heart with general cya-
nosis, the roiinal vessols are always very much engorged, both veins
anil arteries, but without any disturbance of vittion.
According to Leber, in cases of teleangiectasia^ of the lids and con-
junctiva, the vc^aela of the interior of the eyeball may be similarly
nffWcted. Si-'himier rvportA a chhc which was hvdn)[tht]ialmic aiid blind
from birth, and the opbtluilmoscope showod deep exaivation of the
nerve, and very marktii distortion an<l dilatation of the retinal veins,
witl) normal arteries. (^'Arcliiv f0r Opbtlial.," vii. 1.)
Varicosities of the retinal veins have Wen occaaionally met with, and
in rare cases something like a cirsoid formation has been observed, simu-
lating a hemorrhage. Id glaucoma^ especially of the hemorrhagic typo,
these raricoaitics are not very uncommon.
Ancuri.sm of the central retinal artery or of its branches is one of the
greatest rarities in this domain of pathology. They have been observed
in a few oatses ophthalmoscopically, and have been found at autopsies.
Multiple roiliarv aneurisms of the retina have been described by liou-
ville. (''Gax. des Ildp.," No. 30, 187l>.) The cases have all been
patienu^ advaitced in life and with atheromatoua vessels, 'riirombnsis of
the retinal vessels has al.so been oliserved in cases where wai* marked
renal or cardiac disea^, and also in cases of amyloid infiltration. Car-
diac hypertrophy with sclerosis and fatty degeneration of the retinal
artorien ia not infrc^juemly accompanied by thrombosis. Sclerosis of
the walls of the vc^-sels is only to be suspected o])hthaliiio.Hcopieally in
these ca-wa from a marked narroiTJng of their calibre. Sjiontaneous
thrombosis probably plays a prominent part in many inflammatory con-
ditions of the optic nerve and retina, especially in cased of so-called
hemorrhagic retinitis.
The development of new vessels in the retans and optic nerve has in
a few rare instances tHMtn obsen-cd as a result of inflammntion of the
retina and vitreous. They are very small, arise from the vcsseU of tho
disk usually, and project as fine UH)pg into tlie vitreous. Ciujes of Uiis
nature have been reported by Mauthner, Von Jaeger, Becker, and others.
(See *' Graefe und tiaeroisch's Handb. der Augenheiik.," r. p. 533.)
Letter has seen choroidal vessels growing into the retina, in a case of
severe exudative indammation, with partial deslrucliou of the retina.
(Sec " Gmefe und Sacmiach," I. c.) — JJ.j
2 INFLAMM.VTION OF THE RKTINA.
Before I pass on to the description of the different forms of retinitis
which gain their distinctive charaelera either from the anatomical changes
which accompany them, or from tlie constitutional affections which have
given rije to tlieni, it will be well to coimider tho various symptomSf
ophthalmoscopic anil nnatonucal, which are more or has common to all
forms of inflammation of tlie retina, and which may bo very well
grouped under the head of "iJiopathir retiniti$"
4U
DI8EASEB OF THS RETIJIA.
Idiopathic RCTruma.
Practically we may divide this into two principal forma. In thi* one,
the ptttliological clianj^es are cliiefly those of ceaema of tho retina or of
a aerouB in6UrAtion of its connective tissue ; in the other, the iuflamma-
lorj cliangcs affect the proper stnicture or parenchyma of the retina ;
w© mny, therefore, flisliniruish a geroug ami » fHtrrnchtfiitatouf form of
idiopathic retinitis. The former is generally acute, the 1atu>r more
chronic in iia course.
As the s^tnts retinitis does not give n»e to strilcing ophthalmuscopic
srmploms, it is not aluraya easy to diagnofie this diMas« tf the cffuinon
ifl but slight. This is especially the case if a strong illumination ia em-
ployed, for these delicate changes in the retina are heat ohsen*ed br a
iDmlernte degree of illumination, and in the erect image. Serous retini-
tis is characterized by the appearance of a very delicate, blui9h-';ray or
Woiah-grccn veil, which is spread over the surface of the retina, lutd
hides the epithelium aud vessels of the choroid. The opacity, which
may affect n more or less considemMe portion of the retina, is 4|uiM
uniform, and pivsetits no marked strije, dots, or patches. It is only
with a very weiiic illumination and a con^iderabW magiiifyin;; power that
we can obaen'e a faint striation of the opacity. Mauthner' mentions
two cases in which the retinitis presented verv peculiar greenish striw.
This was, however, only observable by a weak illumination, and in the
direct mode of examination. The opacity shades off towarda the
periphery^ (gradually and imperceptibly, into the transparent nomuil
retina, which not unfrcnucntly remains ijuite unaffected. The serous
infiltnition is especially marked iu the vicinity of the optic disk, but
gradually diminishes in int«nsity towards the region of the yellow spot,
on account of the decrease in the thicltuftss of the retina at this point.
Hence the choroid also shines throu;;h more distinctly here, and thus
lendH a redder tint to the macula lutea. Indeed this redness U some-
times so very striking, more c^pecial1\ on account of its conirasi with
the neighhorin-; grayish opacity of the retina, that it might be reailily
mistaken for an effusion of btood. The periphery of the retina is often
(juite free from serous infiltration, and the details of the choroid can then
lie plainly distinguished at this point. Tlie optic disk is always some-
what Hwolleii ami ce<lematous, and its outline indistinct and ilUlcBned,
the choroidal and sclerotic margins being rendered unapparent by the
serous infiltration.* The retinal arteries generally show but little altcr-
) " Lfhrbuch dvT Oi>hll>a1ino«Mp(#," 361.
* (Kititiiia of the retina t> rliU'd.r t«c<i|jti>li'«l Willi l);e o|>lithKlino»o9|ic \ty thr cr**!
rtirvm wbiclt tli" rtillnst T«tna d<4<<rib'>, fur, altlioitsh tli^ rollnft tiu^ \n> rrry ttin-
nidrraliljr tliii^ki-tiM) by •pmua ItillillTBliun, it yet iTinaim traii«|inrr(it, or uutjr kbnwa
thw funttnt vi>il-lik>' ililfnio upadty. Uwiic<> a->NiiK of |li« r<-iIuK luny euUy Im uk<>n
fnr « v.-ry fili^hl ilpln<:hmKDt of ihf lAtt«r ; Iti'lm-l, It would W nliii'Ht liiitHMilblr to
<li>ttiiKtil*)> (wtHVi'ii lli(i*« twuditioiia ; uioro<iTi>r, uxlriiia of llto rrtinn iiiay ImhiI to
detAc luiixiit. IwAiioir tlfKcrll»4 (in a rrry intiT-.-Jiiibg p»\wr on Uvli-tuA Itriiaai,
"A. f. ').,'■ XV. 2, KS) till- ohangi-* whirli thr r.'lina unili"rgn»™ firan Ih.'sr unrmu
indurations, arxl •hnw* bov.- vvty largu laruiiir art) lorni»<l in It. Inadlx^ (o iU Imwhov-
tag very ci'iikiilrratily thti-)c«iiH. II.- fnoinl tIi<Hir InntDn eliirfly at III" pwiph^fy at
1l)M rFttnn, at Ibf n|tiktnr, and qtiitv cloao to thi> oplio nwm*. Vitlo alao a p«pnr by
Ur. NiKilafali*. " R. L. 0. II. lt«i».," rUl. 3. [Ttic dividing lln« betwwQ wvll-maikKl
J
l!IPl.AMMATtO!( OP TJIB EBTIHA.
4I€
ation in their appearance, being, periiapa, only ilightly %eilcd, and a
licUe ttHcnumcti. 'ITie veins, on the otlipp hand, are stiikiniilv hvner-
Bfflic ; thc_v are Iar;;c, dark, tortuoua, the Utter being especially marked
ill the smaller bniuchcs. On clo^e examination wo may often notice
'lat the TeascU do not, ihron-^hout their whole course, He always on tlic
kine level, btit here and there dip a litclo into the effusion, or are
'pnshod a Iittl« outwanls (toward-s the vitreous) by it. In the former
case, they will seom slightly indistinct and veiled, in the Utter, the por-
tion which is nearcit to the observer will appear peculiarly dark and
visible. The^ peculiarities are bedt distinguished with the bitiocolar
ophthalmoscope, or in the erect image. There are also sometimes small
extravasations of blood on or beside the vesscU. The ei^ht is always
much affected, aometimea ao considerably that the patient cannot distin-
guish the largest tetters, or count fingera. Tiie field of vision is al40
contmcied, hut if the periptieiat portion of the retina is unaffected, the
corresponding jiortion of the field will not be impaired. The first com-
Elsint of the patient is, jteiierally, that he notices a gniy film or veil
eforc his eyes, which gradually increaae^ in thickness and surrounds
the various objects, hiding them more and more from the sight, until he
becomes almost totally blind. With all this, the external appearance of
the eye remains normal and henlthy, excepting that the pupil generally
bcuocnes sluggish and somewhat dilated, but even this is not always very
laarked, »ihI might be easily overlooked. 'Diorc is no marked photo-
phobia, lachrymation, ciliary injection, or intense pain; none of the
svmptoms, in short, which are still so often erroneously described as
characterii«tic of intlaminalion of the retina, hut which are not dne to
relinitis, but to hypenesthesia of the retina — two perfectly diflorent
affectiooa. Wo shall see hereafter to what grave errors in treattiieiit a
diag;nosis of retinitis from these symptoms but loo fre(|uenlly leads. It
must be particularly remembered, thai in serous relinitis the ophthalmo-
scopic symptoms are never so marked and striking as might be expected
from the great impiiiniivnt of sight, tliv latter being probably chiefly due
to the CMmpression of the nerve elemeiili^ by tlic serous efinsion.
The ffriitjuogis should always be very guarded, because if the affection
la«b3 for some time, the nerve elements of the retina may become atro-
phied, and the sight be permanently destroyed. Or again, this form
may |>ass over into a more chronic inflannnation, affecting ciiiefly ihe
parenchyma of the retina, and giving rise, perhaps, to dist-a.'ies of the
choroid or tlio vitreous humor. The danger of detachment of the retina
must also be borne in mind.
The trfotmmt should be chiefly directed towards relieving the con-
Rtion of the retinal vessels, and for this purpose local depletion by
'means of the artificial leech will be found most efficacious. The free
action of the kidneys and skin should be ninintained by saline diuretics
and diaphoretics, A pair of dark blue glasses should (« wnrn so us to
protect the eyes against all glare and bright light. All cmploymont of
the eyes miist be forbidden until they have quite recovered.
vdmui of (he rMlna and Mrous ntiuitb I* vvrj dffllcult. nay. well-niKh impouilrlp
111 draw. Ilin iitfillrtlinn nuir hn i-ircnmiitn'ihrrf ordilTiiBv; uiav he- ni&rk<^1 IniuiiBr
)>lac><a and awarljr nbwnt in olhi.'m, aimI tnitv ixK iiituItp tin- <rpl!ii *liik at nil — U. |
416
DIflBASBS OP THB BBTINA.
In tlie paratcht/matoua retinitis, the changes are not confined to a
Mrous iiifiUration of the connective tiiisuc, but this and the nerve ele>
meets uf tht> reliim undergo other inflammatory cbangeB, such a« pro-
lifenition of the celln, hyjiertrophy, sclerosis, and fatt^v or colloid de-
gcncTfliioii. The sclerosis of the connective tixsuc maj, aocor^ling to
IwanofT,* be chiefly uonfiucil to the menihriina liiiiitaUH iiitenin, or afToct
tlie basic connective tissue which pervades the retina in a vertical direc-
tion, and supporta the other elements like a framework. On account of
these various changes, the uplitlmlmoscopic appcarance-a are far more
marked and striking than in the serous retinitis. [It is much more cor-
rect to t4])eak of this form of inQaiumution aa ncuro-retiuitis, as the retina,
from it^ anatomical rt^lations to the optic nerve, is almost never involved
atone. This interatiUal ri(.'uro-retinitis is to be distinguished from the
so-called n euro- retinitis deseendvns or choked disk ; it usually extendi
but a short distance into the optic nerve, and hence is a purely localised
i nil m lima tion. — B.] The optic disk is opaijue, swollen, somewhat hy(»er-
a^mic, and of a reddish-gray color ; its outline is irregular and indistinct,
passing insensibly over into the retina, without any clear Hue of demar-
cation. The swelling is due lo serous infiltration or iuSammaiory exu-
dation, which may have extended from the retina to the optic nerve, or
vice rtfiytf. If tlie effusion is serous in character, the opacity will be of
a pale, grayisli-pink, or fawn color ; but where there is much exndation
of lymph, it will be more opaque, white, and perhaps somewhat glisten-
ing. If the exudation occupies the more external layers of the retina,
the vessels may be obscr\-ed to pass distinctly over it without any dip-
ping ; wherva^i, if it is situated in the inner layera of the retina, or i|uite
on the Biirface of the ilisk, the vcsscIm will be more or leas interrupted
and hidden by it. The retinal arteries are sometimes but slightly changed
in appearance, in other cases tlivy are more or \om diminished in siie,
and renilered indtstincl hy the exudations. The veins are increased in
size, darker in color, and their tortuosity is generally very marked.
itiood extravasations of varying size and extent are strewn alwut on
and around the bloodvessels in different portions of the retina, aa well
as on the optic disk and its vicinity. If these extravasations are situated
in the inner portion of the retina, they will present a peeuliar striped or
striated appearance, their edges being irregular ; which ia due to the
radiating course of the optic nerve fibres, t)eiwecn which the blood is
effused. If tlie hemnrrhages occupy the more external layers of the
retina, the effusions will be round, and have a smooth uniform appear-
ance t|uite free from strirc. [Interstitial neuro- retinitis may proceed
from onset to termiuation without any hemorrhage. In this form of
retinitis occurring in syphilitic patienta, with or without a coexisting
iritis, the occurrence of hemorrhages is a very rare excejition. Where
the hemorrhages occur, they are usually the result of thrombosis of tiio
veins. — B.] The exudations into the retina also vary much in size and
appearance. Sometimes, they look like small white or grayish-white
dota strewn about singly or in small clusters. In other oases, they are
' VIdr lirnnoir'A vitv inli^rmlmg paptim on R«>tiuitut, in Ihn " Kl. MonatAlvliKfr,"
1864, 41.'i. urul «l«u In thn "Arvliiv I. c>plitli>1mO'l'<glir." xl. 1, 130.
IDIOPATBro RKTINITIS.
417
larger, ftttd form well-marked vhtte patches or flakcg of considerable
size, Ihe edges of witich are perhaps fringed by tlie siualler doU. The
>lor of these cxudallons varies from a grayitdi-whitc U) a creamy tint,
' they often have a peculiar glistenin;; appearance, whicli la due to
their containing tatty civmeiits. They are met with in (iifferent [lartaof
the retina, hut especially in and around the optic disk, and in the region
of the yellow spot.
Althoogh I have used the term osudation for these patchea in tho
rolina, I must state that tliis h not always quite correct in the strict
accrptatiou of the term, for they arc often due to inflnmioatory changes
in tlif connective tiHsiie or nerve elcmcnta of the retinn, }^vtng rise to x
proliferation of tJie cella and tlicir content*!, or they are caused by a
dc[;cnerativc inotjimorphouis of a fatty or colloid nature. Hut as it is
difficult, and often quite impoRsihIe, U> dintingiiish ophtlialmoscopieally
between these different productii. and as the term exudation has been
generally acceptdl, [ have thought it heat to retain it.
When the exudations are situated in Uie external [wrtion of the retina
(in which case, they arc generally due to proliferation of the coIIb, and
fatty or colloid degeneration of the external granular layer with sclerosis
of \hv mcmbrana iimitana externa ; the bacillar layer hocoming itubae-
qucntly affi'cled), we tind that they afford tliu H|ipearance of smooth
grayish-white or crcain-<"olored, perhnpa glistening patches, which do not
show a titriatcd arrangement, and arc c-videiitly situated beneath the
retinal resaels, fur the latter pans over them witJiout dipping into them,
ur being interrupted or veiled in their course. We may at the same
time ofu'n notice that tlie choroid in the vicinity of the exudations is
uitdi;rgoiiig certain inflammatory changes, which consist chiefly in a thin-
ning of the epithelium and ait aUsorption of il« ]>igmeut, so that the
choroidal vcMeU become more api)apent- The stroma of the choroid
iiUo becomeii affected, and it is now no longer a case of simple retinitis,
but of ehoruido-relinitis. When the retinal exudations subsequently
Itecome ahaorbeil, we find that extensive changes in the choroid have
taken ])lace beneath ihcm. In such cases the inflammation, although
apparently chiefly affecting the retina, often commences in the choroid,
attd exlen<ls thence to the retina.
The iiiBummatory changes may, however, be chiefly confined to the
inner portion of the retinaj giving rise at first to hypertrophy of the
stroma, formation of nuclei in the laver of the ot'tic nerve fibres, and
neoplastic formations of cnmiecUvo titisuo (Iwanoff ).' The^e fibres of
coiiiifCtive tissue are often arranged in bundles, and, if they incrcaM
very greatly in quantity, they may gradually comprees and duetrov the
nerve fibres. Tin* opiic nerve fibres and gangliun cells may also undergo
proliferation and sclerosis of their elements, and sub«eijuuntly, perhaps,
fatly degeneration. Another very interesting fact is, that in this form
of retinitis the mcmbrana liroitJins interna becomes thickened, and (wca-
Mooally shows, at certain |)fiints, small excrescences which bulge into the
vitreous hmnor. llio latter is often afiected, becoming hazy and per-
vaded by opacities, which are chiefly observable at its posterior portion.
» "A. f. 0.."ai. 1, 13*.
27
^
4t8
ntesASBs OP tub bbtika.
Dt'tBuhment of tlic retina may also oocar. This fiirm of rcttntCts is very
freciufnily OBsociatcd with indo-cyc litis or irido-olioroiditis, and then it
genernlly comuienc«a nt the peripheral portion of tbe retinn, near the
orii ferrata, ami exiouds frfim tlionce towards the centre. When diese
int1»mniatory exudations are situated in the inner layers of the retina,
we tiiiil that they lire rather Ktriiited in appearance, and that the retinal
ressels, instead of passinj; fitntight and uninteirnptcdlv over them, are
seen to dip into them here and there, becoming indistinct or oven iuriai-
blo at thei>e pointa.
After the disease has lasted for »omc time, the exudations and ttcmor-
rliH^te eflusiona uiuy undergo absorption, the ftAsin in the ciri'ii)»tion he
relieved, the blood veasela aasumc u more nonual appearance, and tlie
8wt.-lliiig and a-dema in and around tbe optic di»k iiuWnle, so that it re-
f^aina a more sharply defined outline. Tlie si^lit mt Uie same time
improve:; considernbly, anrl this amelioration may become pornument.
Uut tbe diseaM doets not alwavt) run so favorable a course, for tlie nerve
elements of the retina may have suft'ered 30 considerably as tn render
any improvement of tbe sight impossible. Thi< may be due either to
tbe inltammiiiory chanties (sometimes even afisumin" a purulent character)
which they have themselves undergone, or to the great hypertrophy and
Klerosis of the connective tissue, which encroaches more and mora upon
tbe nerve elements, compresses them, and {jmdimUy leads to atrophy of
tlie retina. If the optic nerve has been much implicated in the inflam-
matory process, the ntniphic changL-it may also cumiuencu in it.
The coats of ihe bhuMlvessels often under};o scleriisii* and fatty de-
generation, becoming tliickeiied, and the channel of the vessel perhaps
luirrowcd. The blnodvee>seIs tlien assume tbe npjK-aranoe of whitiib
l»ands. with a small central red streak of blood flowing through them.
As this change in tbe coats of the vessels may take place to a (greater or
less extent in alt forms of retiiiiiis, I do not Ukink that it is desirable to
make a spn-ial form of it, even in those instances in which it assumeia
Trry cuiihidenibli.' e.\tent, alfeeting iwrhaps nearly all Hxc retinal vpsseU.
as in some rare and very exceptional cascjt recnriied by Wccker,' Saj(^.*
nnd IwanolT. The latter ha* riroposet.1 to call it " Periviucular retinips."
In the case menlinned by Nagel, all tbe retinal nrt«riea and their
bnniclic* were cliangtjd in IkuIi vyea into white haml*, «hich, on closer
examination, were observed to be pi-rvaded by a central red line or blood'
current. Only very few of the small arterial twigs were of a red color.
Tlie veina, on tbe other hand, were normal in appearance, allhougfa
somewhat narrow and irregular iu calibre. At Uie [icriphery. there
were a few 6ne veinlets changed into white handd. Uu account of thi«..
white ap}>eanince of the bluodvcsacls, it might easily be suppomd titatj
they were hlomllesii, nnd the case be mbtakon for one of embolism
the central artery of tlie retina. The differctKe between theite two con-^
didous may, however, be best distinguished, as has been shovti by Ijts
' . ' ' V attention to the two following points: 1. If tbe vcaiet is not
I > . Ill ite entire course, wc should cummencr the uphthaliix>s0O|M
■ IW Worker, ofetiitlM OpbUuiltiMlociqira," M «dlt. II. SIS.
■ ■■ KllaWfae MiuiatiUkttrr," 16M, 3M.
IDIOPATHIC BKT1NITI8,
419
examination from a point whoro it is slill red, and truce from ihcnco the
fvintourn of the voasel. If it ii bloodle^a. vo can ohiterve tltc outliiio of
tlie ve^M'l g4iii<! on, and the thtckno^a of the [aiter remaining the tiame:
wherein* if ilierr h hyj^rtrophy of th« eojit there ia an iijcrcaae in ita
thickneM, 2. Another methoit i:*, to throw a v«rj small pencil of light
close U> the point uf the reesel which we wish to examine, hy this
means wo can illuminate the parte lying behind the veAsel, and then, if
Uie latter is i-mpty. it atiU looks like a white streak, whereas if its conts
arc hy{KTtropiiied, it will ap])car red, on account of the column of hlood
shiniii;: thmu<;h.
^J'urtiUnt retinitit \i, as a rule, accompanied hy and is the conBefpience
of purulent choroid ilitc. It in aUo combined with purulent inlillrauon of
the vitreou!!, and tends tu panophthalmitu. A true pui-ulent retinitia
mxy occur fmui embolism, as in a case of embolic (nnophthalinitia
reported by Virchow, and observations have since I»een made by Knapp
in metastatic inti am -.nation, and by Berlin in tranmatiu inflammntion,
which corroborate the statement. The infiltration occurs, first, in the
nerve-fibre layer, and hence the choroid may not be affected. The pro-
cess of destruction may he a very rapid one. In all cases of punilent
panophthalmitis, whether of tmnmatic or embolic origin, the retina is
inore or tevs iuvolred,llion<;b, sometimes, to a remarkably sli;;ht dej^ree,
incases rc|iorteil by llnrh and Voti Arlt. Tlie pro;;no-iiii is unfavor-
^abto, oa the layer of i-ods and cones i^ very soon ilestmyeil, and blind-
DOM aupervvnes early. — B.]
Rotinitis i» but rarely met with as an idiopathic alfection, but nome-
luncs it ia diflicuk to determine ita exact cause. It ia probable that it
may be produced by prolonged exposure to extremely bright light, as
from a furnace or lnr;;e coukinj' fiiv. or by execiisivc use of the eyes,
vapecially by strong artificial li;;ht. [A dilUixe chronic retinitis of a low
gnde is somelimos present in patients who are suffering from hemural-
Opia, or Itigh^blind[te9a, due to long-continued exposure to the burning
imya of the sun in tropical climates: es|)ecially the reflection from the
••ujface of water, as iu sailors who make very long voyages, — B.] At
first only a hyi«?r!cmtc condition of the optic nerve and retina is noticed,
ami then, if the employment ia persisted in, retinitis may ensue. Hut reti.
nitia is far more frei|uentlT duo lo some constitutional affection, or con-
sequent upon some other disease of the eye, «. y., choroiditis. Thu4, it
may be dependent upon irregularities of the general circulation, and is
Uierefurc souiL-times mot with in at1't.>ction3 of the heart, or iu disturb-
ances of the iilerine functions, and in the Inter stages of prcgiiaiiey, in
which case, however, albuminuria is genenilly present. It may also he
Oauaed by syphilis, by certain affections of the kidney, especially iJright's
disease and diabetes^ and by cerebral diseases. In the latter case, it
generally assumes the form of neuro- retinitis.
The prognosis will chiefly depend upon the cause and severity of the
disease, and tlic extent to wbieli tlie nerve elementa of the retina are
. iBtplicated in the intlamnintory cliauKOS. We ehall see, when consider-
dng the different spooial forms of retitiitis, that the serous infiltmtion of
^the retina, blood extravasations, and fatty degeneration of ita connective
tiaeue, etc., may become absorbed, and excellent risiuu be restored as
41ft
^erod much. For cbang«aj
itl^ the M^hi rcma)D4 per-i
t Ter^- greatly affected, if the
in iho disease ; so that the
^■Atj fine print. But his gcnoroli
-^vBoelly indistioct nnd hazy, th<
« mn or cloud. In other cases, tb«
• ciwnt U concerned, be nonnal, hiitl
^iit rally somewhat diminished, often
. ■ afao be gups in tht.- field, the situa-
rdf the more extensive exudations ii
■■etiaea observed, as cotutoquent upoB
jM e( tlie jreltow spot, either (lei>eudeii(^
I mna mierojigia^ so that object** ajipoai
» w a»T rrally arc. If he be directed to copy]
--^T- ■«■» at a circle or i-iuadnint), he will alffnva'
r?4nB it is in roalitji'. The difference in Uie
. =s rffaet ia the two eyes (if oidy one is affected]
»«M IvflEtianted, as has been suggested, by bolil4
i»ar««anl!!, iHifore the affected eye ; this will
." a little below that of the other eye, and the
■ amm^tt their relative siKer*. This micropsia is
■^ fltel ibe position of i^otnc of the rodit and cones
^^■■Blory cliaD^cs in the retina. Besides the
«f tkt objects, the [Hiticnts often notice that hori-
.i aMwring straight, seem bent and crooked ; thii
^Meta,"'and is due to an alteration in the positiot
vkich may be cau-tod by the presence and pre!
mmtrnttt or by shrinking and. contracljoa of
.j^H^Tt^ ALBl-JIlNKRICA (NEPHRITIC RETINITIS,
Plate III. Fig. 6).
.^^ |k« of inflaiDiDfttion of the retina is often met with il
«#the kidney, and as it presents some special and cbai
jl has boon designated " retinitis a!buniinnrica.'^_
And localization oi the pathological changes in the
r^.'tfdT 90 marked and constant in this form of retinitis, cliat
^fc especially pointed out by Ijiobreich, the presence
iMe mr be diagnosed with certainty by means of the oph-^
^Imc. [Iu the light of nur present knowledge on this snb-
-—^ BOW speak with equal positivcncgs in this matter of diag-
tht tir" rariety of retinal cxudaljon has been observed in cer-
l^^ir'fl •«rr lotarMling psp«r upon Uiia nibjeat in his "Opht
B. I. SIMMONS MEOICUL IIBRIM
HCTINtTIS ALBDUINUniCA.
491
lain chronic diseaf^cs of the ^encrnt organism and of the ftrain and mpm-
br&nca. in which there wait uo rcnAl (titteaso of xny Vind, or ac least none
tliai could U? dotfctod by fri.'<|uent and carcfi]! examinations. Another
point t*i be rt'iniMuiipred is thai chronic nephriti* alimwt alway* affeols
both eyes, though it may not be to the Bame decree, or exacUy at the
samo time. But casea of tliis form of retinitis have been repeateilly
ob«erred confined excluaivcly to one eye. Hence it cannot now he said
tJiat *' the presence of Bnglit'a diseaito of Uie kiihicy may he dia<^OHcd
with certainty by mcana of the ophthalmoscope alone." — B.] ,\t the
outset of the dici-as*' this La not, however, the case, for then ilie appear-
ances rlo not yet aflbrd any special characteristics. The affeftion com-
raenecs with a fnlncgs in the retinal veins, which are dilated, darker in
color, and more or less tortuous ; whereas tlie arteries are either normal
iD appearance or hut slij^htly narrower in calibre. 'I'he optic disk is
bypertemio. and ihi-i i» soon followed by a faint, bluish-j^rav.serom* infil-
tmtion of die oyuc ucrvc and the retina iit im vicinity. The ouilinr of
the di^k then ttccomos Aomewhat veiled and indiiitinct, so tliat the cho*
rotdal and Bclurotic rinpt arc bidden from view, and the optic nerve
aptx-am to \iiksa gradually over into the retina, without any sharply
denned line of demarcation. The retinal vessels are also 8i>mewhat
veiled, anil covered by n pale bliiigh-gray film, which extends to some
distance fnirn the disk (pcrhnjs three or four times its diameter), and
hides the detuilx of the t^uhjacent choroid. l*be retinal hyperscmia may
extend a c<m»derablc diatiiiice licyond this serous infiltration, and a few
extravaKatioiui of blood are often noticwl scattered about on different por-
tioiw of the retina. Ah the disease advances, the (lymptomK of venous
hyjtencmia becomes muoh more marked, the veins look tnrgiil, dark, and
uiore (ortnous, the smaller veitdets assuming a corkscrew appearance.
~ie arteries, on the other hand, are narrowed and more or less hidden
the infiltration. The optic disk becomes more swollen and infiUntted,
and its outline gradmilly merged into the retina. The infiltration of the
disk and of the retina is of a acrous character, and givos to theite pnrta a
faint grayish-red or fawn-colored appearance, interspersed with delicate
grayiah-whiie atrim. wliii:h are due to sclcroeis of itio connective tissue
and of the optic nerve tibrc;*. The retinal vessels are frequently inter-
mpted at various points of their course, by being covered and more or
leas hidden by the exudation. As a rule, the swelling and InRltration of
the optic nerve are not very great in retinitis albuminurica ; but we occa-
sionally meet willi cases in which the reverse obtain:^, and the disk aitsiimca
the peculiar appearance met with in optic neuritis. It is very promiiieut,
awollen, and" woolly," and of a grayish-red and niarkeil striated appear-
ance, which is chietiy due to hy[)ertropliy of the connective tissue elc-
rncnta of the optic nor\-e. The outline of the dUk in indistinct and irrcg-
lUar, and il<i bloodve.tKels more or less completely hidden by Uie infiltra-
tion. According lo Liebrcich, this form of optic neuritis may occur only
in the later stages of nephritic retinitis, after extensive degcnerativ*
changes in the retina have existed for some length of time, or it maj
precede these, or even exist hv itself.
Numerous extravasations of blood are noticed in different parts of the
retina, and oven on the optic ilisk. They var^- muoh in sine and shape,
^^m
422
MSEASBS OP TBE RSTIKA.
■ml lie chieB^f tn tUe internal lar«r« of the rctinft, as i* kIiovr hj their
striated afipearaoce, and tbe fact that they are situatcil on the aame
level B8 ilie retinal vessels, Borae of which may ctoh !>* jiartly covered
and hiddc-Q by thucn. 'Hie liemorrhage may, however, also occur la the
external layerH of the retina, or iH-'tween ttie latter and the choroid.
'iTieae blowl extra rasa tioiu into tiie retina are often very nunienin*, and
of cmirtideralde sixe, a fact at which we cJinnot he suri'riifed when wr
remember thnt the coata of the retinal vcsficlii aru frctjucntly extctwjvcly
duwased ; that there is always a certain degree of stasis in the retinat
circutatioD produced hy the swelling of the optic nerve ; and, finally,
that there m mostly -i more or lets considerable di-^tttrhance in the
Kuncral uireiilation, owiiij; to the hypertrophy of tlie left ventricle, which
IS w> frcijiiently met with in Bri;iht'« diseaae. If the effusions of blood
arc very extensive, they tony alter the appearance of tlic exudation rer^
considerably, giving to it a iliriy, yctlowish<rcd tint.
A-t the diiiease of tlie retina progrca»es, we notice Uie appearance of
small white y|<otd or larger [»atches iu different portions of the retina, at
sonif little <lii<tanco fnim the oplic dii^k. Thede gradunlly increase in
size, and, coalescing with each other, finally form a bro»d whit« mound
or wall round the optic disk. The opacity extends especially towards
tbe inner side of the retina, and somewhat further alon<; the sides of tbe
rotiital vessels. This white tnound does not reach close up to the optic
di«k. but is always sejiaraled from it by a broad tvxw of the fnini gray
or fawn-coloreil infiltration, iu the centrf; of which can he iiniiAnncOy
traccfl the oiiiline of the disk. The peripheral iiortion of the mound is
irregular, aiul broken up here and there into small circumwribed dots of
exudation, which form a kind of fringe round the larger figure. In the
region of tlie yellow spot we notice a very peculiar appearance, which,
as was first i)oinied out by Liebreich, is especially charactcrii'tic of
nephritic retinitis, viz., a collection of small, stellate, wliitc, t;lt!^leuing
figures, which look just as if they had been lightly splashed in with a
small brush. Subsetjuently, if Uie exudatiun increases in size, these
stellate sixits may become merged into it, and this peculiar appearance
be completely lost. The two ophthHlni>osco[>to symptoms which are most
charnctrri^tio of retitutis albuniinunca are these bright eitellale dots in
the re^^ion of the yellow spot, and the bniad glistening white mound
which iiicircles Uie optic disk. [The tenu " stellate dot»" conveys an
erroneotLs idea. The mosses of exudation are yelhiwish-whilc. vary
¥ery raiich in extent and prominenc-e, are generally elongated, and are
not stellate in shftfte. They are, however, arranged in a radiating or
■tellau- manner arouml the macula lulca as a centre, the rays btung
generally ]on;;or towards iho temporal side of tlie retina. They are
luually accompanied by hemorrhagea, and may even be covered by •
large hemorrhage or scvonil sraallor ones, ihongh there may be no
hemorrhages throughout the entire cotirse of the disease. Neither Ihs
general infiltration of the disk and retina, nor this peculiar exudation tn
the region of tbe yellow sjK>t, is palhognomonic of chronic renal dii^casc,
but, when the two occur together, chronic desquamative nephritis is in
the mnjnrity of cases the cau.-'e. — B.I But it must be stated that
similar appearances, especially tbe stellate dots, may be met with tn
RETrNITIS AIBUWISIJRICA.
42S
other forms of retinitia, more particularly in neuro-rctinitis ; with tins
diSercuc«, liowev«r, tiiat tlie peuuliar grouping of tlie opbtlmluioMopic
apfwamnce^ is not the aame. In a case: of neuru-rclinilis recoMdl by
\on (Jnififc,' these peculiar white apot* in the macula lutca were very
(•viilcntf but. as bo {Xfiiits out, such oasos m%j bu iii»tin;rui(4betl from
nopliritifi retinitis by the foHowinji; cbaracteri.sticn : (a) that tlie wliite
spots due to degenerative cbau;;cB in th« retina (neun>-retiniti» ) are
aitaateil tiiiicb cluaer to the optic disk; (^b) that tbu awolliiit; of the
retina in the vicinity of the di^k is more considerable; (c) t))at the
awellin}; of the optic nerve is tUm more pronounced : and (i) that the
vein.4 are much mor*.' dilated and tortuous, which lend^ a far more red
and vft!«*,'ular aii[«oni-Mi!ce to tlie optic outrance.
Rctiiiitin alliumtiiunca doeti not, Iiuwcvlt, alwaya manifest itaelf iu so
very charaoterifttic a form. For the different aympt-ims above enumc<
ratdl may assume conitiderHbly less prominence, or aoiae of them raiiv be
altogether absent. Thuit tJie optic disk, and the retina in ita immediate
vicinity, mav appear almost normal, anil there umy only be a ^li^hl
alteration in the retinal vcesela, a few hemorrhasitf effusions, and ber«
and there while pntclies of exudation, lyinj; either isolated or aloiij; the
coattf of the vesseU. In the region of the yellow e{>ot these jfatcbes
assume a AtroaLy np|iearanee (Mautlmer).
Nephritic rotinitin may become complicated with indammatory cbanj^ea
in the choroid and vitreous humor, or with detachment of thu retina. At
a lat«r stage, atrophy of the optic nerve and of the retina may close the
scone.
In favorable cases, the serouB infiltration, the effusion of blood nud
certain of the white patches may aulweijueotly become absorbed, ao that
ike retinal vcaacis, which wore previously bidden at certain |>oints of
their eounto, a^piin become perfectly apparent. The veins diminish in
aixe and tortuosity, mid ttie arteries become more filled with blood. We
may now, pi'rhii|)s, aliio discover chan<:eK in the epithelium and titrottin of
the cboniid, which bail been previously bidden by the exudations in the
retioa. Sometimeii, we moreover find that sclvrosia or fatly degencra-
tion of tlie coata of the bloodvessels has taken place, so lliat tbey show
a distinct and well-marked white margin. WhiUt there can be no doubt
that the Berouit infiltration, the hemorrhn;;ic effusions, the fatty do;;oncra-
tion of the granular layers, and the hy|iortrophy of the connective tissue
may undergo a more or less considerable decree of absorption, this does
Tint apfwar to bold good with regard to the sclerosis of the optic ncnre
fibrc-t, which remain umiltered.
Ii«t us now briuHy L^lnncu at the patholi><;ical chanf^es which occur iu
the retina in nephritic retinitis, and j;ive rist- to thexe ]ii-cull«r and ehar-
ftcterii^tic ophtlialin'^copic appearances. The serous infiltration of the
optic uen-e and retina occurs principally in the connective tissue ele-
ments, and especially in those which support the optic t>er%'e fibres ;
hence the striated character of the ojuicity, which is partly due to the
serous transudation, an*l partly due to sclerosis of the connective tis-tue
tlemeuta. The while patches, and the large white glistening wall which
' "A. (. 0.," vi. a.
424
VISEASKS or THB BBTINA.
encircles Uie optic disk, arc tlu« to fatty dcgeoeration of tl)« cellular tod
connective ti-isuo eleiiicntt< of tlic retina, more eji]M.*cia1ly of ilie externftl
gnmulnr layer. The strirttcd ajipeiirftnce i* due » hjpcrtrophied neno
fibres, or sclerosis of the connective Ubsuo. The [leculiar [stellate
arrangement of the yellowtsh-whito masses nf exudation. — B.j in ihr
region of the yellow sjiot is owing to fatty degcucratioti of the radial
connective ti^^sue fibres: the sttdlate nppearuiicea being probably due,
according t" Scliweij^'^i^r,' to the i>eciili«r Jinatomical armn^menl of the
radial fibres at the yellow .spot. Far Hergmunn' bag shovrn time these
do not pass perprndienlnrly through the retina, but arc -ilightlr curved,
in 9uch a manner tiiat, a5 they pass from the inner to the outer j>ortioQ
of the retiiini, they converge towards the i:cntrc of the yellow spot. The
optic nerve fibres aUo undergo sclerosis, which gives ri-te w pecnliar
opalescent spots. Tiieee are often arraiiged in little clusters, and thus
produce a svirelling of the layer of the optic nerve fibi-es. Witiiin these
tittle clusters of sclerosed u«rve tibrea may also b« noticed globules of
fat.. It is of great imporutnce, ns far as the prognosis! of the ca»e with
regard to the restitution of vision is concerned, lo diagnose, if possible,
IbiH condition of sclerosU of the optic nerve fibres. This is, however,
diibcult, as th« clusters or nests of sclerosed nerve fibres appear with
the ophthalmoscope simply as little white spots or patches, very like
those which are due to fatty degeneration. Our princi{Kil guide must be
their position, for being situated iu the innermost layer of the retina,
they will lie in front of, and upon, the retinal vessels, and they are often
accompanied by small extrava-satinns of blood (Scliweigger) ; whereas
the white palclivM due to fatty degeneration are generally eitunted in
the moro external layers of the retina, and therefore lie behind tiie
vessels.
The extent to which the connective tissue and the nerve elements of
tlie retina an- affected, doe^ nol necessarily correspond. Sometimes, the
latter may be extensively implicated, the connective tissue being at the
same time but moderately or only slightly affected. In such a case, the
sight will be much more serioualy and permanently impaired than if the
reverse obtains.
lleinrich MUllei^ has also noticed sclerosis of the cliorio-capillaris, on
account of which, the calibre of the vc*aels is greatly narrowed, or they
are even oblilcrated at certiiin points. The jwculiar librillar appear-
ances occurring at the peripbcry of the viin-out4 humor which ho dc*
wrihed, are supposed by Scbweigger to be probably due to post-mort«m
changes.
The coats of the retinal vessels are also freipiently affected with scle-
rosis or fatty degeneration, and in the larger branches the tunica adven-
titia i« often considerably hypcrtn»pliied, so that the calibre of the veascl
is diminished in sixe, and it Jippears like a white bond with a central red
line.
The sight U generally cousidorably impaired, and the; patienta have
• "A. r. 0.." rf. 2, 312; Irfwtnrw an the OphttiJiImoiiooiif'. 107.
> lli^iileaud Pr<<nfvr's "ZeilBvtitift." ISM, uq<1 3 RiAUv. ii. &3.
• WUrtbtiTi^iT, " MfHiiciuiftthe Xfileclirifi," i. 1, 1800 ; vido also tfuislaUon of tUt
pniwr hy the «Dlhor, " R. L. O. ReporU," Ui. &0.
SBTISITIS ALBUHINURIOA.
425
ttometimes become bypermetropk'. whiuh is eviilontly due to the thicken-
ing of the retina, in consequence of which, it now li(!s within the focal
itsnce of the e^e. This hypeiine tropic state of ihe rcfrnclion is very
ridont with the Dphthalmo^^opc, the retin&l tckbcIs and details of the
adus being (|iiite vjgihle in the erect image at some little distance from
the patiout, hihI moving in the r:)Iiic direction att the lii'iid of the ohttcrvor.
SometimcA the patient is still ahle to rend medium-sijted typo, in other
cases he can onlv decipher the largest print, or count hgures with dif-
ficvilty. The field of riaion, on the contrary, is ol'ton not at all con-
tracted, and only perhape somewhat impnired at the very periphery,
whilst the central vision may he greatly deteriorated. We ohun tjnd,
however, that there are '^jn in the field, certain |>ortions lieing mnre or
impaired, »nd that the*e correspond to the [w>rii<.nsi of the retina in
lich the inflnnimatory changeti arc most marked and extensive. I
list here call i^pecial attention to the fact, that tlie impairment of vision
doec not necensarily correspond with the striking clians^ in the retina
ptVBcnted by the ophtlialnioscopic tippearancea. For tJie moHt marked
and conspicuous symptoms, the white patches and the gliptcniug wliite
tnound, an.- chietly due to fatty and hyjwrtrophic cban^^et; in the connec-
tive ti:(suc and cell elements of the retina, and arc capable of ah3or|>t-ion.
And heuce tliese pathological changes are not of such imiMrtaoce, with
regard to the state of virion, as those which implicate the nerve elements.
But these alterations in the nen'c elements afford far Icii striking oph-
thalmoscopic iipiiciirsuces tliau tliese duo to fatty degeneration. 'Ilie
impnirinfiit nt'. sight in nephritic retiuitis is p*nendly shiwly pmjiro'wive,
and this will guard us against confounding it with the sudden attacks of
amaurosis which are met with in cases of Uright's disease, and which do
not depend npon inttnmmation of the retina, but upon urfomia. In the
latter caiKe, the attacks occur with startling suddeiincBS. so that the
patient may become perfectly blind within a few miuutes or hours, tlio
recovery being ad rapid, ^foreovcr, there are always jiresent marked
general sympioms of uriemic poisoning, such as inU'Use headachbf ver-
tigo, lo«fl of consciousncas, sickness, epileptoid convulsions, etc. The
ophthalmoscopic symptoms in these cases of unemig amblyopia are. more-
over, iiuite negative. Hut we may not unfre(|uent.ly have a mixture and
BUccewtf'u (jf sympl'.iiiis of amblyopia dependent upon (he retinitis ami
upon uricraia. Thus nephritic retinitis lias ]ierha|ii« exi.sted, to a more
or less advanced degree, for some time, giving rise to a certain amount
of amblyopia, and suddenly the latter is greatly increased by an attack
of iira'iiiia. Mooren' has noticed iho very rapid development of a high
degree <>f hy|)ermetropia in cases of nncraie amblyopi.i.
It was at one time supposed by some observers (especially Landouzy')
tiiat the amblyopia is Aomeiimes premonitory of. aud precedes, the ilis-
eaee of the kidney. But this is not so, the affection of the retina occurs
only when the nephritis (cither acute or chronic) is already fully devol.
Dp«d, and also in its later stages, more especially together with the small
contracted kidney. It is, however^ also observed in thu largu Hubby
kidney.
> Mooren, "OphthAlmiatHaciM Bmlinohtntigmi," 1RR7, p. 287.
43S
OF TUB KBTI.NA.
Sometimes, indepd, the aroblyopis is the oiil^ marked symptom,
ftBeciion of the kidney bein^ unknown and un-^u-ipecled by the patie
mmI bis medical adviser. In iMme of tbeae cases tliere are, however,
STUpiAins of doran^mcnt of the dt^eative ruiictions. nauaoa, siekne.
rtc. Wc arc cousuhed as to the coodition or the si^^ht, the ophtliaUo
•oope rvvimU the symptoms of retinitis albuminnrica. tJic urine is te
for albumen, and then it is discovered tliut the p«tiettt ia suflertDg fron
Brigbi's disease. The affection of the retina attacks both eyes, either^
siMultaneoudly or at n .-bort interval.
Hyi^rtrojihy and dilatation of the left ventricle are almost coiwtantl
net with ; imieed, in ^2 ca^s Von (rracfe found tbcm pre>H'!nl in all.
The frcjneni nccnrreiicc of c:sten9lve retinal bemorrhat;ri* i» likewi«
probably due to the disturbance iu the circulation caused by the hyper-
tni{ih?, althou-;h it must »l:ui he remembered that the coats of tlie blood*
Te«deU are often diseased. That nephritic rctiuilia may, however, occur
vilhouE hypertrophy and dilatation of the left ventricle ia proved by
cues recorded by Mandel-itamm and by Homer. The former' found
that oul of 18 cades of reliuitio albuminuric^, hvpertrophy of the left
rentricle was oidy present in two. [The retinitis i» sometinies compli-
cate«l by subi-oiijunctival hemnrrhage«, and more rarely by extra va<ation«
iabo the ca|isule of Tenon causing exophthnhnus. In these caoes the:
w alrayi a canliac complication, and posaibly ulao a tetidcttcr to
liemorrbainc dialhe»itj. Kmbolism of the ceiiti'al retinal artery has
olnencd by VfiSckera in two oaaes. — B.]
lirvat uncertainty mill exists u to the connecting link between tl
«fectiou of the kidinry and tlint of the retina. The cnuao itt yet unkno
vbv. I0j!i.-ther witli Hrigbl's disease, wc should ao frofuently nioet wiA
a special Form of retinitis, the ophthalmoscopic iivmptoraa of which are
«• eoiHUni an<l pecidiar, both in the grouping and loualisation, that froni
ikvir appearance alone wc are able to diagnose with certainty the pre-
avDce of albuiuinuria.
It hu bevn supposed by some, Uiat the inflammation and degeneration
of At retina are due to an impairment of the nutrition of the latter,
tiBpeodeot upou the great amount of urea in tbo blood. By other ob-
■tmis t^rspecially Trimbt*^ it lias been thought thai the secondary in-
^^m in the leitsimi of the aortic ivsUm forms the starting point of Uie
JbiMv. 1*) fDc<>r <>f t'>*^ latter opinion, wc munt admit the extreme
YiiiiWT of bvpertropby and dilatation of the left ventricle aa an ai>
a^pMaBM»( of Qep)iri(iu retinitis, as also the constant occurrence of
^mt 't !»»» extensive extrara.'^ations of blood in the retina at the out»cl
!>c>as«>.
cM^tMMU as to the degree of sight that may bo regained by the
I JajR'ud Upon the extent to which the pathological changes
, ^are aJvanci-d, aitd still more upon the degree to which the
«f the retina have suffered, [flie fact that visiou is
,atid oven restored in some of these cases, proves
of the retina were but slightly injured, and that
^
r. *■ KlitiiHrhi.' DmbaohtDDiren," l&tiS, p. 60;.
XUaik," ls»,p. Sli.
KBTIN1TI8 LBVOSMICA.
427
the violeDM of tlie inflammation was nwitil^ id the connective ti»9ue
elements of the retina. Vision may return to a very marked ilcjiree. while
opbtlialmottcnpically the imiiviilual spots of exudation ghow little change,
except that they have become more UattenoJ. — B.] It has been already
9tnt<<(I that iniMiy of the inllftnmintiiry iirnihieLt may heeoine almorhed;
tlius thi* white j>atches due to fatty dej^eneratlyn of the coiiiieclive tissue
eletitentBof the retina may ili^apfwar eiitiri'ly.and the Bi;^ht Ik> coni|iletely
restore*!. On tlie other hand, if thore ii* sclerotic of the retinal nerve
elemcnta, we find that, even althouf^li the Urge white patcho»i. the eeroua
lltration. and the blood ostravaaations become to a jjreat extent ab-
rbe<i, serioni iro|ittirmcntof si;;lit remains be)iind, pomotimcs atropliy
of the optic nerve may even ensue, CKpecMiilly if it hai4 beun tmich im-
plicated in thi- inflammation. An a rule, however, ncpliritie retinitis) Icaits
only very exceptionally to complete blindneuu. In very nvre instances
even very extensive detachments of tlie rcLina luay entirely disappear if
there ia no e1on',{atioii of the optic axis.'
There ii( no direct connection Iwtwccn the improvement tn the sight
and the absorption of the exudations, etc., and tlie amount of albumen
in tJit* urine or llie condition of the kidney disease, for tiie former may
occur without any amelioration in the coiii^tituLiunal alfectian. Tlio beat
prognmtiii u aflfo^led by thoM cases in which the albuminuria oceura in
pranced ]pre;inancy, after scarlatina, typhoid fever, etc.. for hero we
letimeH lirid that the [uitholo^^ieal ehan<;(M in llio retina m:iy ilisappear
"ifltogether. and ihi- si;:lit hi.- entii-ely restored.
The treatment must be directed chietly towurda the primary' disease.
I have found most benefit from the tise of tonics, more especially tlie
tincture of the muriate of iron, or from tlic citrate of t|uininc and steel.
The frco ikction of the akin should bo cncoura;*cd and maintnincfl. If
sYmptoni* of nnemic |k>ij(oning *ii|K*rveiie, diaphoretic^ and pur^itives
eliould bt' fri'ely administered. The oidy IcHtttl application fnuu which I
have found any benefit is the artificial leech. In tho«e cases in ivhtch
it is unadvidalpje t<> abstract bbM^l on account of the an.-emic condition of
the (Mitient, I apply the dry cup to tJie temple, luid hav« olVen seen tliia
followed by marked improvement in the virion. It is to be repeated at
iiiicrvals of five or aix days.
4.— RETINITIS LEUCjEMICA.
Altliongh Licbrcich, a^ far back as 18t>l, deacribod, and gave an il-
luatration' of. a peunliar form of retinitis which sometimes occurs in leu-
cocytlH-mia. this fact ha^ not received all the attention it deserved, either
from ocnliiiti^ "ir the prnfe:*>*ioii at large, ['llie fre«-[uency of it* occurrence
ift not as yet aatisfactorily spilled. It appears to be always bilateral,
but does not affect both eyc$ to the same extent. Tlic changes consist
in a didiise rviinitii;, in wliicb the vcitseU and blood extravasation? appear
uniuualty pale. Sometimes the hemorrhnp;c:i arc very extensive. The
' Vi<I. "A. f. O.." xviil. B, 103.
■ Uubrakb'i "Atlu d'OpbdialiiioMopi«," pUt« z. Vi$, i.
42S
DI8BA&B8 OP THE RETINA.
ulomling of tlie retina is, m » rule, slight, radiating in slrealis, especial! j
in the course of the vesseU. The presence of the hemoirhttges in the
EoRterior port of ihe retina is not distinctive of Icukicmia. In hue! cases
emorrha^es may occur iv llie choroid and vitreous, and this eeems to
he an expression of a homnrrha;iic dialhesia, for extra vaaalions are a|it
to occur also umler the skin in various part* uf Uie boii;f. aiiJ nmier the
conjnnctiva of the glolte. — B.j LeucKeroic n-tiuitis is chiefly character-
ized by the peculiar pale orange-yellow tint of the fiindufl, which l^ e«pe.
cialty marked, aa liceker' points out, if the ophthalmoscopic oxniniaatioD
ia conducted by daylight (entering a darit room through an opening in
the sluUter), instead of artificial light- There is also great pnlhtr of tho
retinal vessoU, especially the veins, which lire of a faint ruse color, even
although they may he very dilated and tortuous, llie optic dijtk is al**
pale, and ita outline indi^ttinct, and hidden by a Herous effusion which
may extend to aonio distnnco on to the retina, the Utter pn-ttenting
Mnatcil ojkacitieit in the vicinity of the (tiak. >fore or Ioah coniiiderabl*
hemorrhagic effusions are strewn about the fundus, but they are bIm of
a pale pinkish tint. In the region of the yellow spot are obnencd sntall
irregidar pale patches, or large, prominent, round, white s|>ots, fringed
with a red areola. These white circular spola are still more fr&juem
towards the periphery of the retina. Becker haa given two a<lmirab1a
illuatnitious of them in Knapp'd Arcliiv. He expresses the opinion that
they, as well as the white stri|>cd which lie along Uie sidnn; of snme of
the veaaela, are produced by an agglomeration of lyiuphnid cells (color-
leas blood coqjusctes), which be thinks have exuded through the coats
of the bloodveswls, the red fringe being due to a deposit of red corpus-
cle*. That these white ciivular patches are really due to an agglomera-
tion of iymphobi cells has lately l>een proved by Leber,* who tlissected
tlie eyes of a person aflected with retinitis leuca-uuca. [This infiltration
of lymphoid cells is ia the ndventilia of tliu vch.4els. The c:ipilliiri«4
very often sliow varicosities. The white spots in the retina arc masaea
of sclerosed and hypertrophied nerve fibres. Masses of fat granules
have also been found in the external layers of the retina. In marked
hemorrhagic cikcs there is thickening of the int4?rna! granule layer, hy-
pertrophy of the interstitial connective tissues, cellular infiltration of the
papilla and fibre layer, and anteriorly sometimes cystic degeneration of
the retina. — B.] i}aeiui»ch* found, ou microscopical exuminatiou of the
eyes of a ca^c of leucicmic ralinitis, inflammatory and atrophic changes
in the retina, choroid, and vitreouii dependent upon previous hemorrhagic
efiuaions. In the right eye intra-ooular hemorrhage had occurred, which
had, through ]tr«'s^ure, cau.4ed atrophy of the retina, and at on« point
oven its totitl ileslrnctinn.
[In L'rogressive I'eruicioiis Anaemia the retina Is apt t'> be the aeat of
hemorrhages, with more or less prouotinced inflammation. In this dis-
ease there is a diminution or destruction of tJte red blood corpiiscles,
which is no doubt intimately oonooctod with the beomrrhages. The re-
Unal veinj are greatly engorged, there are sometimes small white oiasae*
■ "On Rviintti* l«u<?»iuica." Eaapp's Arotiiv, l^i, 1.
• •• Kl. Honstsbl.," 1MJ», p. 912. ■ IbUl., p. 905.
RBTISITtS xrPniLtTTCA.
429
of in6ltratioD. The hemorrhages nre always exteiuire, and the fundus
resembles that found iu leukaemia aud diabot«d. Tbu extra vaaations
arc in Uic inner layers of the rotuta, but there arc sonielimbfl heioor-
rhaj^ci Itctwecn thu retina and choroid. Ilic disturbance of vinon ia
very marked in mrrst oatws, but does not always occur. ('^ Graefo uud
Sa«mtwh'5 Ilaitdb.." v. p. 604.)— B.j
5— RETINITI.S SYPHILITICA.
A peculiar form of retinitis is eometitncti mot with in pcrRous suffering
from cntL^titutirmal syphili:t, anrl it is occaHinnnlly pntptihlc to dia^rnow
the nature of the ni»1mly from the oph thai u]o!k:() pic appeaninceii alone.
It muHt he admitted, however, tliat the latter may in Home cases he so
alightly marked, th.it our diagnosis as to Uie syphilitic nature of the dia-
eoae muat chietly depend upon the gonoral history of tho caao, and opon
presence of other sympioms of constitutional ;*yphili9. [I*ob«r think*
bt cvt-ry caite of pronounced dill'ude retiuilia ])uiutti very strouj^ly to n
ayphiliiifi ori;^in. I*, c. p. (ill*. — B.J
At the outset, there if^ simply hy)ier>cmia of the optic disk and retina.
The retinal rcina arc eumewhat dilated, durk, are tortuouii, bqt not
raarkudly so, and tlic venous congestion dimitiishes as the disease pro*
grc»e«. Sometimes tlie venous hyperemia ii^ only partial. The retinal
arteries are utteuiiateil and ilimiiii^heil in i^ize. The ojitic disk la ali^tly
swollen, and iljs ontliikc hazy and ili-dt-tined. The disk, as well as the
surrouudinj^ retina, is veiled by a faint bluish-gray film, which in duo to
a scrnuH transudation of the optic nerve and retina. Thi^ film is often
extremely delicate and faint, asttumin;; i>eriiaps only the appearance of
an exaj;;:e ration or the phy<)iolog)cal grav rctlex which the relina of nor-
mal, darkly pijimented eycH pro«ent». 'i'hi* nniform bUiiHh-gray opacity
does not extend regularly in nil directions fp.<m the optic nerve, but is
often principally developetl in certain parfai of the rt^tina, and more espe-
cially along the course of the vessels, whence it shades off gnidnnlly and
imperceptibly into the healthy retina. In the vicinity of the disk, the
opacity is roarkc<lly striated. Although uiinule punctiform opacities genc>
rally occur in tliv re^jion of the yellow siwt, they are not so brightly
gliNteiiing. iir itrrangeil in the {Kcnliar cttellate manner as tliose met wiUi
in nephritic retinitiit, hut are strewn about irregularly. They are, more*
over, distinguished from these, by the fovt tliat tliey undergo very rapid
changes, perhajis disappearing and reappearing in the course of a few
days, the ^iijiht at the eame time undei^oing correaponding Buctuations.
The spots in Bright's dideanc arc on the other band very pcrsi-ttent, and
their rcmaiiu may often bo distittctly traced even many months nf^er the
acute rvUnids baa paasod away, and iw residua al<jue remaiu, or atrophy
of tho disk has sot in. Wo also in syphilitic rctinilia somciimea meet
with a peculiar tawny, reddish-brown tint iu the region of the yellow
spoL
The tnflnmmiitory changes in syphilitic retinitis consist chiefly in a
serous infiltration of the retina, and sclerosis of the connective tissue
elements, more especially of the rcrtical trabecular fibres (stOtz faseni).
180
MBBASBS OF TOE RETINA.
hence also the striated cliaractcT of the opacity- Tlio other portioM of
Uie retina are ^nerally exempt from iaflammatorj and du^enerntive
changes ; but thU is not always the case, atid thus may arise a mixed
form of gypiiilitic retinitis, in whit-h tlie special and pathugitomnnic symp-
toms are accnm|iani(.'ii, and perliftpft somewhat masked, hy other chm);;p8
in the parenchyma, and (^eat swelling of the »)ptic nerve. Thus white
Bpots or piitclmn may hv noticed in the retitia. The«e may occur in small
isolated patches, or in the form of large striped opacities situated in the
inuermost Inyers of the retina ; their pressure perhaps causing complete
emptiness of some of the vessels, which are changed inU» while bloodless
bands (Uebreich). These, however, are never so brilliantly white as
the spots met with in cicphritic retinitis.
Ae a nilf, retiniU hemorrhages arc not U3ually oliserred in syphilitic
retinitis, or only to a very moderate extent. Sometime*, hovfever,ca«e8
occur in whicli nimieroiis and exteasive exiravaaatinns of blood are
noticed, whicrli may be Mttiated In diflferent layers of the retina, and also
between it and the choroid. Syphilitic retinitis is not unfrenuently as-
Bociatcd with inHammation of the choroid, and occasionally with irido-
chorniditis, or iritis. If Uie symptoms of the inHammation of these
tunica are very pronounced, the aftccuon of the retina may be overloobeilt
more especially if the vitreous humor, aa is often the case, is diffusely
clouded and traversed \.>y dark (lakes, and the details of the fundus are
thus reiulered iiiiliHtinct. Cnre must l>o taken not to mii«take i^uch an in-
diatinctnesfl of the optic disk and ivtina for that dependent upon reti-
nitis, or lo dia;rno!i(.' the presence of ihe latter simply frwn the great im-
pairment of virion. A practised and careful ophthalmoscopist would
not, however, fall into such errors of diaguosis.
Together with the symptoms of syphilitic retinitis, we o(\en notice
certain more or less extensive chanKes in the choroid. These may occur
either in the vicinity of the retinal o[iacity, or at some distaucc from it.
or be chiefly confined to the periphery of the fundus. These changes
consist principally in a thinning and discoloration of the epithelial layer,
tlie pigment celU of which are collected together into small masses, giving
rise to more or less considerable gronps of small gray dots intermixed
with little bhick spots, which are aggregations of pigment cells. The
latter may. perhaps, subsequently invade the retina (Liehrcieh). In other
cases, the iiiBa minatory changes aQect the deeper portions of the choroid,
and we then notiee large gray patches in which the pigment cells of the
epithelial layer and stroma ot the choroid are absent, so that the cho.
roidal vessels can bus distinctly seen ; such patches being generally fringed
by a dark black zone of pigment.
Syphilitic retinitis generally occurs together with, or shortly after, the
appearance of secondary .<tytiiptomi>, and is tiometimes, as has already
been stated, accompanied by intlammatiou of other tunics of the eye,
such as choroiditis or indo-ohoroidilis. It may also be duo to hereditary
syphilis (Hutchinson'). [It occurs in the proporttOD of about S to 4 ii
tiioiwand cases. — B.]
The course of tlie disease is generally slow, lastiug many weeks
even months, and relapses are very apt to occur.
The sight often diminishes rapidly, so that id the course of a few da
BBTIMTre SYPUTLtTlCA.
4«1
tliu pKttcnc may be only able to decipher No. 10 or 20 of Jiisor, and
may become greatly impaired, more eitpeciallT if die region of die yet-
lot* spot \» niucti affected. We (\xxd a1»o, tlint the coinlition of the sight
flactuatcs considerably with the presence or absence of the Httlc puncti-
foriD opMcities in the macula lutea, [Oentnil scotomata (loraetimoa occur
in both eyei),aiH! may be of uoiitiidcnihle siz«, and dicre is iiiittally <|uali-
tative lij^ht-peroeption thmo;(h them. Thi« sootoraa infty He aiinidar in
ahnpe. The color »eiisc is at 6rst nonnul excejit in the scotomH, but if
retinal or ncrm atrophy be^^in, color- blindness alj^o npjwiars. ISubjective
pbolopHio nianifesUitiona ar<> ^ometimeA compliiiucd of. — H.'] A notlicr in-
tt.'rt*9Uii;£ phenomenon U tim freijuency of micropsia in syphilitic retinitis.
[Tbii^ \i fxpliiined by the tncc tliat Lhe rods and cones are separated more
widi>ly from each other, so that the image of an object meets a smaller
number of sensitirc elements which by the stretchiiij; stand further apart
than in the normal condition. Metamorphopaia for parallel lines ia cx-
pUitifd in the same way. — B.] The Held of vision is often either not
at all. or only )<li';htly. impaired, but it frei|uendy rihowii preiiliar eir-
cumscrihvd zoimliir defect* in the vicinity *»f the yellow spot, to which,
aa well ns the frequent presence of pbotopeics, particular attention has
been called by Mooren.
The proj^osts of the disease ia favorable, more es]>ecially if die patient
18 seen at a very early period of the aitauk. AlUiouf^h the sight may
be considerablj impairea, the inflammaiitry changes in the retina do not,
as a rule, afl'ect the nervou* cU-ments. but cliieHv consist of a serous in-
filtration of ihc retina, and hyix-rtrophy and wlero^is uf the connective
U»8ue. But if the latter \t greatly iiypertropliied. it will press ujrtn the
nerve eleroenta.and mav thus even lead to their airophy. There ia much
ti'ndency to relapnea, either after the attack has entirely, or nearly com-
pk'Iely. subsided. or as the disease ia progr(."S!-ing towards recovery. Hv
the ni-urrence of such relapses, the nltiinate functionol condition of dio
retina mny, of course, be lEreatlv eiMlangcred.
In treating syphilitic retinitis wc must place our chief reliance upon
mercury, for the jireatcst benefit is generally experienced from bringing
the patient rapidly nn«ler its influence. This may be dono eiUiur by ita
admnii.ttrutioti ititerimtly, or by the inniiclinn of the mercurial ointment.
1 my*elf prt^firr the latter method, and geriorally prescribe from 5*8 to
5j of the uintmont to be rubbed into the utsuli: of the anus and thighs
three limes daily, and diis mostly causes salivation in the course of a fev
days, if the patient has been recently salivated, a combination of
iodide of potassium and bichloride of mercury should be given.
[In all cnaes of retinitis it is better to use atropia to prevt-nl the ciliory
muscle pulling on the choruid aud tliua iudireclty ou the retiim, and the
patient nhould wear dark glasses. — B.]
Aa the hypcnemia and congestion of the retina are generally not
marked, the application of tiie artificial leech is not alwavs indicated.
Under the name of " frntral rfurrrni rdinitit" Von Graefe' has
described a very rare and interesting form of syphilitic retinitis, which
is ftspecially characterized by its being confined to the region of the yel-
■ "ArahiT f. Ophthalniolaglv," ill. 2, Sll.
432
DtSBABBS OP TUB HBTIKA.
low spot, and hy its marked tonJenc^' to recur very frequently. He has
known it to rt-cur 10. 2U, SO, inid in one case more than 80. times. The
attack h gcneralljf v«ry sufMcn, and diitappeftnt again in the course of a
few i\a.ys, but a rcIik[Me occurs in from a fortnight to three months. At
first, there is gcTiemlly irn impiiiinnent of sight during the intervals ho-
tween the attackB. hut afterwards, when the latter hecorae more pro-
longed, some amblyopia reraaiiia. When the attack is ahout to occur, the
patient notices a dark, irregular et|K>t in the centre of tlic Held of vUion,
or certain ]iortioiLs of the latter arc ohscured. The sight ta alwajs
greatly impaired, »o that the largest letters can hardly he deciphered.
If both eye8 are affected simultaneously, the patient is almost perfectly
hliiid, mid quite unahle to guide himself. During the attack there ib
genendly 9ome phntnphobia, and perhaps some slight ciliary injection.
more especially in the morning on awaking. Opl i thai moscopic ally, the
atlection may be distinguit^liud from the common syphilitic retinitis, by
the fact tliat the delicate bluish-green Glnt of opacity is confined to th*
region of tlic yellow spot, culminating around the fovea centralis, and
gradually and uniformly shading off towards the periphery of this region,
'ilie vicinity of tlie optic disk is iimt« free from ojwicity. Somctimei,
small, delicate, white dots are noticed in the opacity, which are, perha|»,
arranged in little groups, hut they do tu>t present the hrillianily white,
lustmus appearance of fat granules. The offosion in the yellow epot
becomes developed during the attack, but is preceded by the functional
disturbances, and theite again dlsAppear sooner than the effusion. In
tlie mure recent cases, the latter dLsitppeara completely during thr inter-
vals of the attacks, but .-^l a later stage a faint, gray opacity remains l«e-
hiud in the close proximity of the fovea centralis. In one case, in whicb
a great number of relafjses were closely watched during six years, the
opacity contained irregular masses of dark blue pigment.
Tliis aSeclion Is undoubtedly due to syphilis, but does not show itself
until ft very long period (sometimes many years) after the a«contlary
constitutional symptoms.
Von Uraefe has only found the long-continued or repeated Dse of in-
unction of mercury beneficial. The intervals between the attacks he*
come longer, and the latter less severe, until thoy are gr&dually cxtin-
gniahed. Whetlier or not the sight is completely restored, will depend
upou the fact lohetlier jieiioanent changes have taken place in the retina
or not. Marked micropsia was noticed in several cases.
[There is a form of diffuse chronic retinitis, referred to by Ijeb«r
(loc. cit., n. 4317). which he calls vttmyathetic retinitia. It is caused by
aympaihetic iridtvcyclitis, is a ])husc of sympathetic ophthalmia, and
reaembles ophthalmoacopically syphilitic retinibs. It may lajit for
months, and eccentric vision is very indistinct. — B.]
6.— RETINITIS ATOPLECTICA CHRMORRBAGICA—B.] (Flaw
IV.. Kig.7>.
In tliia affection we find, that, together with more or less fayperKoia
and (cdema of the optic ncrro and retina, there is an exlrome icnd^-ticyj
RETINITIS APOPLBCTICA.
I
I
t4> extravasaiion of tilood into the retUin. Tlie oondition of ^e optic
nerve varies conifiiderahlv ; in .smiii! camu tlicre h only a mitrl«rate degree
of hyiwnenua and serous itittltratiott, rondi^nng tiie disk somewhat todia-
tiDct, and its uutlincs irivgular : Id others, the disk is of a deep red tint,
and it^ margin so ill-deEiued, ttiat it can only l>e di8tin^uiKbed froni ti\e
smroundins retina by tlie eraerj^ence of the rclinel vciwels. Tim veins
are ilnik, much ditiLt^-'d, and very tortuoit^, and aloti;|i; tlit^ir coune, iiinre
iMtpecially iit Uieir poinUi of diviKion, arc ncen nuiQeroiis extra vaKations
of blood. The nrtcrien may mtain their normal appearance, hitt j^ne-
nttly become attenuated, and S(>iuetiaie3 changed into white, bloodlcM
banda. The extravasations of blood vary ttiiich in nnmber, extent, and
situation. Tliey occur very frc«|aetitly in the inner layer of the retina,
and are then characterised by their peculiarly irregular and striated a|i-
pearance, and al.-w by the fact that they cover the bloodvcsscU more or
less completely, or that the continuity of the latter i» interrupted, the
>ra]> being occupied by the lieini>rrha;;e. The bhwd fre<pienily makes
its wtir from the optic nerve layer through tlie retina, the elements of
vrliich it pu!<hes niiidc, to tlie outer hiylK.or even to the choroid. so that
the heiiiorrhH<|;es may he situated in the more external portions of the
retina, or between tliis and the choroid, lu such caaed, the eHuaious
will be more sharply defined, uniform, and circular, and ho distinctly
situated beneath the retinal vcaaels. Effusion?) of blood into the retina
always shuw more tendency to extend outwards towards tlie choroid.
than inwanli tinvards the vitreous humor, where the internal membrana
limitans otTers a. stnjuger barrier to tliem. They may, however, break
into the vitivous, and produce dense opacities. Sometimes, howevor,
lliey extend alonj; the inner surface of the retina, and then give rise to
targe^ uniform. smtioth-lnokin<; red {Kitclies, which completely cover and
hide the vessels. The heniorrbaj^ic effi«i.»ns occur in different portions
uf the retinii. and may Iw chiefly contiued to the licinitv of Uie optic
disk or yellow spot, or ti> the [»eripliery of the fundus. Extravasations
may abu> occur on the di!>k.
[Itetiniti« bemorrhafcica must not be regarded as » distinct form of
intianiniatiou. All varieties of retinitis may he accompanied by hemor-
rhages, and with the exception of the syphilitic, they generally are. — B.]
The effusions of blood retain their color for a very long time, more
especially in old jteople, and then, hreaklnj; up, they either slowly un-
derjio absorption, ur become changed into a dark crumbling mass (l^ie.
brcich). In tlie former case, they gradually as.tutne a lighter, grayish
tint, which, commei>cing at the edge of the extravasation, slowly ex-
tends to the whole, the blood being gradually absorbed. Sometimes
these extmvasatinns undergo fatty or pigmentary degeneration, in the
lallvr case giving ri^ to more or less cmi^iderahle black patches. The
latter occurs sooner in bloo<l cHuscd into the vitreou-!, than when It is
situated in the retina (Liebrcich). The disease shows a great tendency
to ruln|i«es, and in this is to be found one of iK chief dangers, for if they
occur fri'<iuently, or to a considerable extent, the function of the retina
may be greatly inijiaired, and even atrophy of the optic nerve and retina
ensue. The prognosis should therefore always be guanled, especially if
the extravasations are numerous, and situated irt the vellow s{>ot. The
28
434
DISEASES OP THE RBTIKA.
sigtit is ill some cases nob very marke<11y aScct«d, or not in a degreu cor*
ro)4poii<1in;4 to the strikuig D|ilitlialmo8copic iippeaniiico^ preitotitPil by the
numerous und cxieiisivc hcmorrhftK*"- This ()opGn().i entirely upon
which part of the retina is thu seat of the eflVisinns. If the latter hare
occurrt'ii ar. the porijihory, the mj^ht mtiy Iw unite uiiafTccteii ; if in the
yellow apot, it will be greatly impaired. Sometimes the attack ie ex-
tremely Biitlilen, a patient fiinling that in the course of a few inoineutd,
or on awaking in the morning, he Ims become ah*olutely Wind. The
patients at tlie snine time often experience a feelinj; of (lizicincss and
fainineiis. The field of vision ia not unfrcf|uently somewhat contracted,
anti «iiowft more or lew extensive interruptions or jjajm, or there may ap-
pear in it }^r»y HhadowH or hkek ripots^ which arc in all prohahility due.
as wiifl pointed out hy Ht-ymann, to cntoptlc ahadowA thrown by the
bluni) extrava4atioi)!> u]>on the seii»ltive eleraenta of the retina.
<Jceai:«ionally ne find that In the course of retlnills apopleetiea aymp-
touie of glanconm supervene, the diuease then cons titu ting that very for-
mldalile affection which ha^ been termed ** liemonHiapc i^lauooiua," a
description of whith will be found in the chapter on Glanconu*.
Ketiuitis apopleetiea often occurs to^'utlier with dtelurbances of tiie
general circulation, wtiieli may be due to affections of the uterus, liver,
or the heart; thus it is not unfrei-juently seen together with suppreiisiou
of the iiieiii^es, hypertrophy and dilatntiou of the left ventricle, alfectious
of the aortic valves [extensive arteriu! sclerosis, and aneurisms of the
■^rciit vesselj^. In by fsr the larjie majority ff caees hemorrhage
rcunilis occure in one eye alone, «hen cardiac or vascular legions exist.
Cardiac hypertrophy would cause the stanie trouble in both eyes. Athe-
roma of the vet^selit of one eye is hanlly a t?up|HNiahlc lesion. Ileoce we
muKt look to an embntic origin. Midtlple emboli of the smaller branchea
of the central retinal artery produce the same appeantnce* ; but autop-
sies of such cases have not yet been made.— iJ.] Also, if there exi»ca
any impedimfiit lo the venou3 efflux from the eye, either from tumors,
etc., pressing upon the optic nerve wliliin the orbit, or situated within
the cranium. In such cases, however, the blood extravasations are
geuerBJly soon followed by oedema and inflammation of the optic nerve.
Another fivijuent cause is fatty or aihcromatfiua degoueraiion of the
cohw of the bloodvessels, and it is consc«|ii(.'nily often met with in old
Ijen-oiirt.and in such casee it may be of prognoslic importance, as it leada
lis to BUrt|H?ct tlmt tlie vessels of the brain may aUo bo degenerated, and
that imminent danger may congenuenily be apprehended. The treat-
ment must chieHy consist in attempting to remove the cause, aud pre-
venting, if possible, a recurrence of the disease. Diuretics and saline
aperients, more especially mineral waters, are often of rnoch benefil.
Locally the artificial leech should bo employed.
4
-.—RKTINITIS IMGMENTOSA (Phiie III., Fig. 5).
[lletlnitis pigmentosa, <ir j'igmentary degeneration of tbe retina, con-
sists in a chronic iuttralitiai councetivc tissue prollfenktiuii of all Lite
RETINITIS PfQMBKTOSA.
435
UycM of tlio retina, witli atrophy of the ncrvft (elements and tlie develop-
ment of pi«nient from n proliferation of Ihc pi^ent epitlielium. — U.]
Thi» iii.se»se ia principally ciiaracteriwd, as ita name augjicatti. hy the
presence of pijimt-itt in the retina, wbieh yi^es ri«e to a most peculiar
oikI immistiikiilile appoftniiioe. more especially when the pigment is
dcp<'»ite<l in considemUe ipiaiitity. In the latter cjise, we notice that
the greater portion of ilie retina is covered by largo hiack nwHses, which
•re arranged chiefly alnng the course of, and in close proximity to, ttie
reiiiml vessels.
Ou clo«e examination, we find tliiit the3« hhick niaa^es of pijnnent con-
MRt of circular or irreirnlar i*haped (upota; of larjjjer hlaok spot* with loiig
narrow prolongatiorw, which are benco often likened to bone corpiwcles;
and of narrow black lines running; along the «ide of a veascfl or completely
covering it. On account of the deposits of pi^ment along the eoatti of
the vesweU, the latter ufu'ii appear, for a certain portion of their coiirae,
cliaiiK''d into fine black lines. At the division of the vciweU, the pig-
ment deposits assume a pecniinrly charact4<ri.-tic etellate npiH-arance.
The pif^mcnt is sometimes dep^wited nlong the course of ves-tcls which
are still pvr%'toii8 and carry blood. For an illustration of tlie ophthal*
moMnpic ap|H>arancea of retinitis pi;;mentosa, vide Plate III., V'l^. 5,
These defHisitd of pigtnent always exist in the greatest number nt the
periphery of the fun<lus, where they firist make their appearance, and
whence iboy gradually extend (ownrdi^ the p4iBtcrior polo of ilie eye, so
lliat tbcy form a more or loss bro-id ;iirdlo, winch encircle* the central
portion of the retina : hut at a later ])erinil the re;^ion of the yellow siiot
kIm becomes invaded by the dJAeaae. The pigment app«ani to be as ft
rule first developed at the inner (nasal) side of the retina; indeed, it
atwuys remains more extensive on tiiis than on the temporal side. Tbo
retinal vessels undergo in this disease certain constant and marked
chanj^H, wtitcb cviilently greatly iutluenec the condition of hemernlopia
nnd tbe contraction of the field of viition. These chanj^s conduit in a
bvttline thickening of the coats of the retinal veweU^ and ft consttpient
diniiinition in their calibre ; tbey, however, retain their traiut|«irenov,
nn'l i*iuip1y ajipcar diminished in siKe, and tliin condition \» consopientiy
frt'nuently dedcrihed as being doe to atntphy of the optic nerve. The
fnialler branchea arc often completely obliterated, riehweigger* has
more eitpeciaUy iiointed out this fact, and considers that the (leciiliar
terpor of the retina, which w noticed when the illumination is raodomto,
ii due to the fact, that on account of the diminution in the calibre of the
arteries an inauliieienl amount of blood it supplied to the retina. At a
later atdgo of the disease. atr«)phy of the optic neri'e and of the retina
altm»3t always occurs. Change;* in the choroid arc also not unfrci|uently
met with. These may be chiedy confined to a thinning and atmphy of
the epithelium at certain points, so that the choroidal vessels Wcome
appAreul, and are seen traversing tlic^ic lighter patches, which are often
fringed by a dark zone of pij-rneni ; or the stroma of the choroid may
become aflected, and, if It be much thinned, the white sclerotic may he
seen glistening tbrungh it. In such cases, the fundus affords a very
' " Vorlcsnngen Olier dcu Augmipii-pil," p. 117.
4m
DI8EAB8S OF TUB ABTIKA.
marked unci striking appearance, being marbled with more or les* exun-
sive, rcddt^li-^ray, or gruyisli-wtiito "listening pntches, in Uie cxpaiiac
and at the edj^e of wbieli are aggloineraiions of (Mfpnent. It is now oo
louder u case of isiiiiple retiuitie pigiui-ntusu. but of cboroido- retinitis.
At a lat«r stage of roliuiui^ pigmentosa, we often find (bat an opocitjr
makes its appearance at tbe poHterior pole of tbe lens, irbicb remain*
either istatioiiarj' or ts but very slowly pro^rt-saive. The retinitia aluiost
always affects hoth eves. In rare inDtances, the vitreous humor alto
becomes affected, and small gray, circumscnbed flakea are seen BoaUng
nhoiit iu it. Kxtenially the eyes present notbiug abnormal, exceptiiig
that the pupil is generally small, and the anterior cham1>er ftomewhut
flballow. [In a few iiiHtaiit'CS defects of dcvetupnietit, especially mi-
crophth»lmii<4 and colobotna of the hns or choroid, hare coiuplieated the
disease in the retina, though tbe latter may have been acuuired. In
congenital rctinitiH pigmentosa, tbe eyes are apt to be «iuall, and nja-
tagmus is aluioet always present. — B.]
(jreat diversity of opinion still prevniU as to the formation of the pig-
ment, and wbetlier it is primarily developed in the retina, or whether it
makes its way into the latter from tbe chonjid. Tntil several eyes, iu
wliich the typical form of retinitis pigmentosa bos been diagnosed during
life with tbe ophthalmoecopc, have boon submitted to careful microscopt.
cal examiiiatiou, this cannot be decisively ttottled. At present it appears^
certain that the disease may arise iu lH>th wavrt. Thus Donders found
that the |>igmcnt may bo developed in the retina itself, pr»>l>ftbly in con-
aecpiencc of a cbrunic intlammacion of this membrane. Hial such may
actually be the case, without any panicipaiion of the choroid, w aUo
proves! by a case of Sehweigger's.* in which be found, on microscopieal
examination, that the deposit of pigment on the retinal vessels may occur
ipiilo independently of any changes of the chi>roid, for in this ca^e tlic
choroidal epithelium was |Mirfcelly normal, even iu spots where the retina
was pigmented. The pigmcniation wa* confined to the retinal vcjweU,
the coats of which were thickened and tlie smaller branches obliterated,
these changes ext«ndiiig beyond tbo |nginentation. In llioso cases In
which irregidar roundish masses of pigment arc strewn about the retini,
Scbweigger tliitiks that tbe disease is always due to choroiditis, and tbat
the doportitj uf pigment partly become develoftcd in the firm exudatiot\3
wlitch liiivc forced their way into the retina from llie choroid, or an; duo
to the fact timt the proliferating pigmentary opiUiclial cells of the choroid
are floated into, or grow into tbe retina. Jungc thinks tbat a deposit of
pigment along tite retinal vessels can only take place iu Uie retina whea
the cxtcnml layers arc more or let^ ilotitroyed, m thai tlie pigment caa
ni.-ike its way from the choroid into tlie n-lina. Dr. LandoU' bcUere*
that Ibu disvado is due to a very chronic perivaaculitia of the retinml
VCtiscld.
There is, mortorer, another way in which an iuGltratioo of pigmeat
frvm the choroid into the retiTia may occur, for an accurate knowledgo
of which we arc cbieflv indebted to tbe valuable researches of II. M
i
" Vorlraungrn," p. 113.
« "A. (.0.,"jt*Hl. 1, S25.
11ETINI1I9 PtOMSytOSA.
48T
ler in«l Pope.' Tt appeam that a prolifcrntjon of the fi^niilar cdlfl of
thp retina, ttioiilur tu that in ncplmtic retinitis, nmy take place inilepen-
dciiUv, a*:coin|»inieil fiv hypertrdphy of tlic railiating connective tissne
filtros in the cxlomal y;raim!ar layers, which becoror bent in an arcndo-
likc manner. The bacillar layer of the retina bccomea destroved. and
the hypertrophied granuhr Inyer pmtnidcs above the exienisl layer of
tb« rctma ; between these protrusions there exist corresponding dcpres-
aioDs, into which the pigment cells of the epithelial layer of the choroid
become pushed and lieaped up into little black maAsea, which lend ft
peuliar marhlcit appearaitce to the retina. It is doubtful, however, as
Sohwei^er points* nut, whether this morbid procens yield* the peculiar
opbthiilmoBCopic appearances characteristic of retinitis pit;nientosa.
Leber has quit* recentJy had the opportunity of microscopically ex-
amining the eyes of a person affected with retinitis pigmenloaa, which
he ha*! dia^inosed iluring life with tlie oplithaliuoscope.' Fto found the
fnllowing ehanjtes : 3. Atrophy of the nervous etemcntA of the retina,
which was more complete in the e.sternal layers than in the ncrce-fihri)
layrr, and increa.'ied Knidiially fmm the centre to the periphery; '2.
llypi-rplasia of the connective tiiwne framework of the retina, together
will) a neoplastic lamina of connective tissue on the inner surface of the
nerve-fibre layer : 11. Thickening and sclerosis of the conta of the blood-
vesseU ; 4. Ueticulated pi;inieiitation in alt the layers, which follows
especially the course of the bloodvesscja ; o. Extensive chnn^^es in ihe
pi;»mcnt of the choroidiil epithelium ; fi. Very nuraerouii excrci»ooncc«
on the elastic lamina ; T. SmalL circuni»cribed exudationa (which had
undergone fatty degeneration) between the retina and choroid. He
points out' the probability that the very great development of the ex-
crescences (drijien) of the elastic lamina (which has been observed in
nil ca.*r9 of retinitis pigment^^n accn(n]ijiiiicil by chAtifies in the pigment
epithelium) plays a more important part in this dUea^o than hus been
hitherto supjiosed. It may he assumed that their ji^rowih causes changes
in the epithelial layer of the choroid, proliferation of its celU, and the
disappcarnncc or new formation of pigment. Mon^ovor, the destruction
of llir liaeillar layer of the retina, and perhaps even of a pari of the
exl<'nnil "granular layer, might Iw protluced by the sjime cause.
The earliest and mnst striking symptom of which the jwitients complain,
is that of liemeralopia, or night bUndncM [which may last for yeans be-
fore the timiintion of the viaua) field becomes marked. — H.]. During
the day, or in a bright illumination, they may ho able to sec perfectly
well, but as soon us it bi.*comc5 dark, or they arc taken into a diinly-
lightrd room, thrir sight hi-iMmcii gn*at!y imiuiired, I need hardlv
point out that thii* iM.'Culiar inijminiK-nt of vision is fjuite independent of
the fact whether it be uight or day, and is simply due to the retina being
m a condition of torpor, which demanil»t a very bright illumination in
order to enable it to distinguish objects which a healtliy eye could see
with ease even by a moderate amount of illumination. This tor]tor of
I "Wiintti. MM, ZciUrlirin," iii. ; al«'i"0|.h. Hmp. Ri'jiort*." It. p. Tfi.
* " A. t. o.," XV. 3, 1 [nnd Oravfi- a, Siiv«ui»cli, lUml. i)"r Aiiit9ub«'ilk., v. p. itM
«l M>q.— II.).
■ " A. f. 0.," x». 3, p. 21.
438
DISEASES or TBE KKTIIIA.
tlie retirm is in all probability not due to tbe piginfttitation of the retina,
but, m Scbvrigger iiisisis, to the obliteration of Uic rvtiiml vcm^vIk or to
tlie diminution of tbeir calibre throngh a hynliix^ thickening of their
uoatd. BO Uiat, tlie retina receives only a diininielied »nd in«ufficient sup-
ply of blood. The tnitli of this opinion is proved by the fact that
Sclivieij^ger lia« notiued the presence of henieralopia and contraction of
Ibc field of vision in cliililn^i befoix* the appearance of any pi;!nK'nt in
tlie rrlina ; but in all ibcitc CJiscn there was a marked contraction of the
retinal arterites, whilst Ibe older brothers and sisters bad rctiuitis pig-
mentosa, lie also observed tbi», in some rare instanced, in older per-
Bons (between tbe ages of forty and fifty), who suffered from all tlie
symptoms of rctinilia pigniencofia, «..'/.. hemt'ralo|>ia from torpor of the
retina, j;reat contraction of the visual field, wilbout any trace of pig-
mentation of the retina or any other aymptom except coiitraction of the
arterii'K and pah-nesH of the iliak. In similar cases Von Graefu Las
finhse(|i]vnily ioun<l a dcponit of pigment in the retina.
The field of vision is often very greatly contracted concentrically in
retinitis pigmentosa, so that there may only ho a very small portion rs-
maining, tbe diameter of which perhaps measures only a few inches ;
whilst the central viaion may yet be excellent, enabling the patient to
read the very finest print, although for objects around be is absolutely
blind, on account of the marked contraction of the field, theee pntLcnto
sct|uirc a vi?ry awkward and rcwlois appearance, for their eyes are
alwayfl tnmiiiit about in various iHrectiona, so as to bring the visual lino
to bear u|)on surrounding objects, which they otherwise might not see
or might stumble over. They therefore oxjmriciico great ilifficutty in
crossing the street or in passing along a crowded thoroughfare, as al-
though they may neu well straight before them, they cannot distinguish
tliat which lies in the lateral parta of the field. [In rare cases, in place
of the conceutriu limitation, there ia an annular detect in the visual
field. In very rare cslscs we meet wiHi a central scotoma without any
other limitation of the field. Tlie limitatiun of tlio field in all ca^es U
duo to dei^truction of the layer of rod^ and cones, a^ proved by Leber
and Landolt, The condition of the color-sense varies very much. — B,]
Kven in very high degrees of typical retinitis pigmentosa, Lel>er bad
found tbe appivciation of color normal in tlie central portion of the
retiiiu. But in the mixed forms, iu which central vision is greatly irn-
piireil at an early stage of the disease, the color-bliodneas was oElen
very marked.
As long as the region of tbe yellow spot is unlm|iaired tbe sight may
remain good ; but between the ages of iVi and 5U tlie dL-^ease almost in-
variably leads to complete hlindnesi*. tlie retina and optic nen-e becoming
atrophied. The disease, as already stated, generally attacks both eyes.
l\'dr»glia nieniiinis a case in whicli it afTccted mily ono eye, and I have
also met with ono among my patients at Moorfieldfl. Tbe affection »
rre>[Qcntly congenital and also hereditary. [The congenital form i«
peculiar in that the pigment i^ not present at birth, but Appears during
the firet year. This disease may cause congenital blindneiis fn)in
atrophy of the retina or of the optic mTve. In rare cases hememlopia
may bo a congenital symptom, without timitation of the field. Aciiuired
HCTIKITtS PIGUKKTOSA. 4S9
retinitis pi^cntosa is often nlso herodiwry. — B.] Althou};li it m»y ho
presuiit at birlti, it alivAyii slowly and grnilually iiivr*;:ti«s in extent witli
advancing jeara. Scliwui'^cr haa noticciL lUai pi^niontiitioii o( tlic
rctiii* is not only preceded by cc»titraction of tlic arteries, but nlso by
amiill ligbt-colored dot* or faint Btripus in tliu clntroiii, wliicli are closely
strowii alwiut tiie periphery of the fundus ; they may be isolated or coa-
lesce and form larjicr spots.
The description whioU I have j;ivcn here is that of the typical retinltia
pjsmeiitoMi. But we occasionally meet with caae^ which nhow marked
aDomalicA in ilicir eoune: e. //., the impniruiLMiL of the si^^fii niay bo
typical, but the ophtlialmascopic ap{»earanec iiEionvdutij, and vice vend ;
or a^Jiiii, both th« impairment of vision and the ophthalmoscopic a]»pear-
aiiues may l>e aiiornalous, this lieing especially observed in certain uasea
of conpjniul amhlyofria and amaurosis. (I''or further infomiation see a
paper by Leber on Anomalous KormA of liccinitis I'i^raentosa, " Arch.
f. Ophth.,'* xrii. 1, p. 314. ■) In regard to the apols occasionalty ob-
served ill the choroid, siniiUr appearances, accordiu}! to Leber, are
oliflerved directly after birth iinil durin;^ the earliestt joiir^ of infancy in
eaaea of con^^enital amaurosis or amblyopia, in vrliich symptoms of retini-
tis pigmeutoaa afterwards supervene, lie thinks that these pale, puuc-
tifono «iKit4 are pnibably due to the excrescences of the elastic lamina.
(Sec "Arx;h. f. Uphth.,'^* xv. 3. p. -I'i.)
{ICtioln'j^.—^n the ;^reat majority of cases the cause ia unknown, bat
in AsmiU proportion of cases syphilis seems to be the cause. — B.] The
disnue may first show itxelf about Uit: ixyy. of H m- 10, or even later in
life, at 30 or -10. It frei|uenlly otretirs in several member.* of the same
family, and is then often hereditary. Such cases are mentioiicii
amiiiij^t others by Laurence, Mourcu, and HutohiiHon. Laurence' iimt
with it in four members of the same family (of eight) ; in this case it
was not heroditiiry, Mooren ha» aUo seen it in four pcrs'in^ of the
same family. Liebreicli has ]}ointed out the important fact that it
ow^nrs very fre«picntly in raarriajjes of consanguinity, and often together
wttJj deaf-mutiem. Other malformations, such as i!U|)ernumerary fingera
and toes, are also sometimes seen, tof^ether with rcLlnltis pigmentosa.
[According; to Leber it also ncuuro with eonj:enital or acquired defects
in Uie nervous i^ystcm, as idiocy and irielancltolia. Direct hi^rediu is
not a coraraun caose, as Leber found it oidy ouct! in i^O casen of the ills-
ease. About threo-fourths of all the cases occur in men. Some autltors,
as Perrin and Mautbner, are inclined to consider long residence in hot
climates a cause. Liebreich asserts titat the disease occurs very fre-
(|ucutJy amon;; the Jews, and attributes it to the great frei|ucncy of coD-
sanguineou^ marriage amon^f them. — ^B,]
The j.'r'i;in"tig \i of coufso very unfavorable, as tiiese cases alwuys
end sooner or later in tola! blindne^t.*. With re;:;ard to treatment, I can
onW recommend care of the eyes, more especially against bright glare
and overwork^ and attention to the general liBalth. Occiisioiially some
t«mponiry improvement of the central vision has taken place after the
application of the artificial leech, and the administi-atiou of the bichloride
I " Opiithalcuio Bevluw," U, p. 32.
440
DI6KASB8 OP THK BBTINA.
of raercurv. iodulo of ])0ta88iuni fn'O" *"J strycliniaj, etc. ; bot it htts.
been iioticdl lliat thU im[irovem(?ni hn* >ieen followed by a ruarkfl and
rapid dotcrioration of tho field of vision (Mooren). ['Jraefc uod Sae-
uiiscb, Ilaiidb., v. |i]>. 0-38, G5il.]
[8.— RETINAL DISEASE IN mABKTES.
Tlie form of lesion in tbo retina is uot always tbe same. In many
cawB hemorrhagcu only are jiroHent; in otlierrf, in aiMitiwn to ibo Kumor-
rbnges, tben; nppenr vrliiu* nia«e» of cxndfttSon ; in others, difTiwe hemor-
rbnf;ic retinitis with exudations stmngly resembbiigtiie picture of nejdiritic
rclinitifl. TIip wliite epot^ of exudation are never very lar^e. iiml do not
coalesce, 'the retinitis is sometimeB followed by atrophy of the optic
nerve. Opacities of the vitreoua arc very common, and are probably of
hemorrhfl^^ie origin, llarc complications are iritis and hemorrhagic
glaucoma.
Lesions of the retina are hy no moann Invariable sympiomj in dinb«l08.
The prognosis is doubtful or iinfftvorable. The treatJnent is solely that
of the constitutional disease.
Id oxalurin certain changes have been reported as ooourring in titc
retina, winch are probably tbe remains of hemorrhages (Graefe u. Sae-
mij^ch, V. pp. 51)3-598). In didcaaes of the liver acc<»m|\anied by jaun-
dice, horaorrbafica are said to occur in the retina, wirii ilcgenerafum of
the grmiule layers iiit« omleKceiit bodies, but without any marked dis-
turbance of vision during life. — B.]
ft—DETACIIMKNT OF THE RETINA (Plate V., Fig. lit).
If the detachment of tlie retina from the choroid is very extensive and
roacbcrt far into the vitreous humor, the svmptoins presented by it are
!fo marked and cbaractenHtic that it may sometimes be recognized wit))
the luiked eye, but certainly witli the gn^atext eaae by the aid of the
ophtlifilmoT*cope, On exarniuing in tho direct method an eye affected
willi an extensive detnchmont of the lower half of the retina, we at once
notice that, when it is moved in different diroi^tioits, we see the usual
brij^ht red rellex from tbe ujiper part of the fundus, but that in the lower
half this in not t)ic case. Jlcrc, on the other hatvl, tbe refiex baa a
btuinh-gi'ay or greenish tint, and on closer inspection we observe &
blui;«li-gnty, Houtiug, wnvelike opacity, which is thrown into marked
unduhtctng foldin with every movement of the eye, and which is Iniver^ed
by dark, cnxike<l, And distj^rtcd veitsela. On account of tlie bul^g
forwanl of the dutaL-hed reiinii into the vUivous. these details can bo
readily seen with tlie direct exanttnation at ^ome litiJe distance from the
eye. The detached retina also retleuts Uio li^ht very strongly, whioh ts
ciiit-rty due to the difference between the color and refracting power of
the fluid gituatc^l between tlie rt^iiia and choroid and those of tbe vit-
r(M)iH liumor. The miiitite dvtiiU mny he exaruiucd either in the erect
or reverse image, and tho extent of the detachment, as well a^ the course
DBTACfiMBNT OF TDB RETINA.
441
and ili:<|ilacement of tlio veasoU, aliouM he carefully atnlicl. It will he
TioMcdl that the vessels are- darker than on the normal reUna, ami that
tbev are verv crooked niul tortwms. ricttng. so to speak, on the folds of
the ri^ltnn. hutwecn which thvy may even !« completely hidilen for a
irt of their c<)ur«. They, as well as the muhilatiiij; jrray foMs of
stina, nnivcr ati'l iremMe with erery ranvemeni nf the eve. On tracing
ont Ui*- limit* of the delaehed jiortioTi, we generally find that, even l>e-
yond ib marked eoniiuenceincnt, then* U a f»iiit grayish ojiacity or
thickened ap|iearance of the retina, and that the vc44olj are aotnewhat
darker, and show a slight tetwlency to be curve*!. Thi* opacity of the
retina is line to seroua infiltratioti. If ihe detached fold of retina is
lar/e ami prnmincnt, it throws a distinct d»rk line of shadow upon the
Tiei^hborins fundus.
Whilst little or no difficulty can be oxporicnccd in reco;rnmng a con-
sidenihle detachment of the retina, the ^tame cannot always be said of
the slighter deforces, the diuj^nosij! of which (iften demands considerable
dexterity and experienoe on ihc part of the olwfTver. ThiJi is more
e9|>ecially the casie if the suhretinal Huid is transparent, and the vitreous
humnr is itomewhat clouded. [The cotiilition of the vitrenns U of great
imporunce in the-ie CA»t;s. Anythin;^ which lessens the intra-ocular
tensiun would render a detachment more ensy. Thi^ would nntumlly
occur after a diminution of the volume of the vitreous in consetjuence of
comiectivo-tiiisue degeneration and shrinking. — B.] Sometimes, it is
only by trscin;; out m'>?i cnrefullv and with the jrreatest exaetiiuilo, the
course of each individual retinal vessel from the optic di*k towards the
periphery of the fundus, that we are enabled to detect a very alight
degree of detachment. In auch a case, we notice that as tiie rosseU
reach the detached portion (which is generally somowhiit opa«|Ue and
thickened, or thrown into a slight fold), they auume a darker tint, and
JMte.'ii! itf preat-rving a straight course, they become tortuous and bent,
formiitg a more or leaa ronrkc<l dcBcclion.
On close examination, we also notice that the ve»cU lie on a difToront
level to those which retain their normal position, being closer to the ob-
server, who haA consenuently sliglilly to alter \m accoinuiodntion in
order to obtain a.-* distinct an im;ige of them. Indeed the appreciation
of thin difference in the plane of the vesflelit i« one of the most delicate
aidn in the iliagnosi^ of commencing detachment of the retina. We can,
moreover, detect a well-marked parallax; for if we make a lateral
moveiuent with the object lens, the jiortionof the vessel which i« elevated
by the detached retina, will be seen to make a greater movement than
that pni't which lieit in the normal retina. The detiiched |K>rtion of retina
alsf» rrtiiM'l.-i the liijbt more strongly, which is (wpecially appreciable in
tlie direct examination.
(.>ii tracing the course of the vessels further, we oflen find that as we
approach the periphery of the fundus, the detachment becomes more
coutpicuuos nud extensive, the retina being, perhaps, nenr the e(|ualor •*
(if the eye, thrown into distinct whilish-gniy folds. In the portion of
retina which is Ktill i>» titn and in eloie proximity to the detachment,
we may sometimes notice small, rctlilisbwhitc exudations, and also, oa
44S
DldGAflliS or TnS RKTIKA.
wafl especially po'iiitwi out by Von Gmofe,' anmll red, wolated |>atab(w,
wliicli are in»iU> up of miiiiiu^ly colleil hlooilvcsAeU. i^maW partial
(leinvliments of the reLina are oftuti difticuU tu recognize, a& tliey uiay
simply appear in l!ic form of little, faint, gray streaka. The deUiils are
best appreciated vritli the biiitKruIar oplithalmoscopo. Tlie color of the
detach in t-nt iIojhmhU chiefly ujion that of the fluid which lies bencatii it;
~kt fii'tit, the dvU-iulied portion of the retina u generally ti'aii;4|)areiit, but
It a later period it becomet:* more or ivins opaiiuo and clouded. Ttits
may, however, be the cace from the commencement, if tJic delAchmcnt
supervenes upon inflammation of the retina. The »ub-retinal fluid aUo
variei) eonsiilenihly in cnuiposiliuu. When recent, it is tnias|iareiit, or
of n faint straw color, and of a seroua nature, eonloinin^ a ^ooil dual of
albumen (IJowioan),* wbicb coa^^ulates on exposure to heat, or may evea
do 8o in the eye, and then it becomes ailherfiit to the walU of tlie de-
tachi:d retina ii) tbe fonn of opa((uc Sakea (Liebreich). It may also
contain hlooil, tibriii, nuclei, piginenl and fat mtdeeidcs, or cbolesierioo.
The detachment mn,*t frequently occupie.i the lower portion of the
fuudiiA, and its extent varies con^iduriibly. It may fur some time
remain eonlined to the periphery of the fundus, and then grailually
extend further and further, until it reaches the opiic nerfe, anil ihu^
iuvolves the whole of the lower half of the retina. It oflcn, aUo,
mounts up somewhat on one or both sides of the di^k. When the detach-
ment occurs in the up|H>r |)urtiun of the retina, it soon exten<U from
thence ilnwnwunin, which is due ttt the ^ravltiuion of the fluid, and in such
a case the yrcaler portion of the retina runy become detached all round
the optic disk, funning a funnel-shaped detachment, whojc u|iux is at
the optic nerve. Hut we may sometimes also observe tJi.it as tlie fluid
gravitates downwards, the upper portions of the retina fall again into
apposition with the clioroid, regidning perhaps a considerable or even
normal de;ti-ee of tianaparency ; this being, moreover, accompanied hy
a great ii[i))i-ovument of vision. This, I may state, in passing, is a moit
important point with re^aril to the indieatiotui of treatment, f Tbo de-
tached retina shovrs itigns of dilTuse inflammation with interstitial cou-
nective tis^nu b^jiortruphy, or there m^iy be cystic degeueratiou of tbc
various layers.
When the retiiin is entirely detncbed, as is not unfre^^uently the case
afu'r long-contiTincd iiiU-a-oeular inflRmination, especially of the ciliary-
body, there is no reflex from the fundus, and hence no ophthalmoscopic
image. I'sually in these cases the retina bas one poiQi of attachment
behind at the optic disk, and autcriorly is adherent all round to the ciliary
processed, though thi^ is not aNays the case. It is greatly tbickened,
tlirown into foldi«,very hyitencmic,and sometimes contains hemorrhagea.
t^umctimes. if the retina bas been teusely stretched by the fluid beneath
it, a rent nmy occur in it, and we can then observe with die ophthalmo-
scope that tberv exists a gap, withiu which the vessels and intra- vawalar
' "A. f.O.," 1.1,367.
■ BuWinaD, " Ofililliahnic HoapiUl Be|iort«," vd. I*. i>. 134.
lSfi4.
Ji^
XiKTACBMCNT OP TllS RETINA.
443
fipacen of the cbamid aro rliittincdy Apf>arcnt;* the c4gea of the torn
rvtiiiA lieiiig curled or rollvd tij) iiitu litUe folils.
Tliii lir.'^i symptom whicli the [>at.i«ia j^nernlly notices U that of a faint
gray c]o\u\ floating liefore liiro, or of a dark spot, S1l^^)u^ded by a lighter
hido. This cloud hm a wavy, indistinct outlino, and ita position in the
field of vision corrc8rK:indit accurately willi the situation of tliL- rivtaclicd
portion of rutina. Tliiu, if the deULvluuuiit hu situated ni the Iowlt part
of the retina, the patient noticed a little eloud or curtain haiii^ini; duvm
into the upper part of the vl«ual Beld, liki- the ed^ of a veil, or peak
I'Of & cap. lie aUo notices that linear oUjcctA, irntnatl of prcserv-injc a
jisenight outline, appear to he wary and hrok<?n. This mot.iniorphop'iia
lA pruhnhly ilue to a cKau^e in the nortnal poAitioti Qf the nerve elementa
of the retina in the close vicinity of the iletaclimetit, this di^pliiccment
[beinjj, porba]*, caa^ed hy a 8li;^lit <lnigging upon that fiorlion of tlie
retina wliicK iit no lon;;er m ni/u. Knapp* |»ointi« out that the metamor-
pbopsia due to detaclimcnc of the retina, U di)itin^ni»lied by the fact, that
the yhji'cts are friuf^eil with a colored rins, and uuder};i» 8li;;iit iiinlulatiii,
□lovenientA. Sometiincs. this nietaiuorplioii^ia is the ]irinci|)al t^ymptoi
tirbich lirads us to dt-tcct a ^niall cirunmscnhcd detachment i>f the retina.
The patients also often oomplaiu of bright Qu^hes of Hj^ht, bright circlea
or 8tar», etc., these photopsies being due to the irritation and stretch-
ing of the retina, produced by the change in it* position. The black
SputH and flalics which float about in tJic Held of vision, assuimng various
peculiar forin^, are caused by opacities in ihc ntrcous humor, which are
very freipientty met with in detauhnieut of thtj retina, and niuv even ))«
[the caujtc of it. [Chromatopaia in the region uf tlic detached retina iatl
lao complaineil of by p:itients; soiuo speaking of a blooil-red appoar*-
Lauce, others of a dark violet or intense blue.
Tlir- detachment gencndly occura suddenly, though itmav be preceded
hy floating vitreous opaciiiea, especially in myopic eveu. In some cases,
ol'cener than lia^ hitherto been sup^iosed, the retina hccoraes reapplied to
the choroid without spontaueous ))erfuratiou, and rciuains {>i.Tmaneully
attached. The dotachmeot somctimea complicates a retinitis alhuuiinuria
or an orbital abscess, and the prognosis ia hero mo re favorable for its
t'Tvattachment. Sometimes after a detachment has existed for some time,
fltgiis of irido-cyclitis appear which usher in a phthisis bulbi. Another
complication of chronic delachnient is cataract, uf somewhat rapid de-
Tolopment and soft coni^i^tence. — U.]
On examining the field of vision, we find a more or less marlteil im*
paimient and contraction of certiitn portions of it. which correspond to
tlic situatiou of the detaeliment. Thus, if the latter has occurred below,
the upper portion n{ the field will be impaired, and wVs vertd. If iho
dclachmeitl U very irregular in its outline, the field presents correspyiid-
iug irregularities, the outline of the ilefectivo portion rising ami failing
Kconling to the rise and fall of the detachment. We find that the field
of visifm is contracted not only <{uantitatively, but also qualitJitively ;
although tliere is no doubt that the retina, even wbeu actually ruined by
• VMfl Lw.wich'» Atiw. put« VII., vie> i.
■ >■ KliniBC-hn Moi)«Ut>l»ller," ISM, p. 3l)7.
■444
DtSBAHBS OF THE RBTTKA.
fluid from the clioiYiiil, may retain a certain degree of i»erc*ptive power,
tiie patient b«iiig able to tell the moveuients of the band or eveo to conut
fingers.
The ini]istinctne»sorcoatractioD of a certain portion of the nsiial field
is also seen occasioiiaUy to precede the detachment of Llie retina, and is.
therefore, of great jirogfiotftic importance. Thus, in caws of extensive
sclerectasia |KMterior, we may somennieB iletect a marked contraction of
the field in a certain direction ((wy npwardi), or upward* ind inwanla^
but the mot«t careful and accurate ophthalnioscojHo exaiuinntion will fail
to discover any detachment. But some time afterwanla this nuiy occur,
and at a point of the retina corresponding lo (liat porlion of the field
which was dci't'ctive.
Kti'doijtf.^.'V\\c causes of detachment arc numerous, and aoinotimes
obscure. It may l>e produced by b!o»a upon the eye, or by j>enetr8ting
wounds of the itoAterior portion of tlie cyehull, iu which case there is
odoQ a cicatricial coittraction of the retina : aUo by cffnuona of blood
or serum beneath the retina and choroid. In such a cuAe, the bemur-
rha^ gctierally occurn fr()m the choroi<l, on account of the ^'reater raa-
cularity of this membrane. When speaking of hemorrhage into (he
vitreous humor (p. ;iltS),it was mentioned that when llie bleeding occurs
in tbe central portion of the fundus, it is prone lo lead to detnchment of
the retina : whereas, lu the Ci|UiiU)nRl region it U uiore apt to break
(lirough into tlie viircnui* humor. But hemorrhage from the retina itself,
by making itit way outwards between the choroid and retina, may lead
to a detachment of tiie latter.
The -tcroiw cRJision between the retina and choroid which pi-oilucca the
detachment, may be the prwliict of inflammatory lesions of these tunica,
ur may be due to a sudden compression of the vessels of the eye and au
impediment of the venous reflux, an, for instance, in caaes of exophlbol-
mos due to iutm-orbitul tumors, etc.
[Acconling to Iwanolf ' ledema of the retina may easily produce de-
tachment of the latter; the seroaity of the lacuniu perhaps ii rat sepa-
rating the retina into two laminic ; and then detaclting tt. — ^11. J
Ilic most frev(uent cause is undoubtedly an elongation of the optic
8X19, as in cantos of sclerectiiftia posterior, for the elongation of the sele-
nitic is nccnmptiiiied by a corresponding stretching of the choroid and
retina. The f"rnivr, on account of ii« firm union with the sclerotic, and
its grrater elnstioity, fnllovrs this gradual distension, but the retina
is less elastic, and will, therefore, have n greater difficulty in following
the traction uf the Hclerotiu and churoiil ; ita connection with (lie latter
will be rendered lax, and anj^' slight elTm^ion or exudation fntm the cho-
roid will f'lHice t*"! pruduce an extensive detacliment. Such efTa^ions
are llie tiM>rc likely to occur in these advanced CAses of sclereetiiMa pos-
terior, as there is generally some choroiditis preacnt, or a disturbance of
the iutra-ocular circulation.
[ A nothcr cause for retinal detachment is found in chronic infinmmation
of the choroid or retina, and in cystic drgeneration of the lattvr. — B.j
A cysticenuin, m:ikiii;:; \t^ way thmu;;!! iiit't lliu vitreuun humor may
jive rise to a conaiilerable detachnunt of the retina, which will be tenw,
V -A (. 0," XT., U, 103.1
DBTAOUUENT OP TUB RETINA.
44ii
iiid not uDtlulfttinjz or falling into foldti. It may aUo be prodaced hy a
limior springing I'roiii tli« clioriid, and here tin? csrly diajiiiosiH nf the
cauao of die iloUchnienl 'a of nmcli conBtijuerico. This may be difficuil
whfii the tumor is Hniall, H5 the detaclitiieiit may then be loose nml uiidu-
Uiing: whereas, when it inoreasei^ in size, und protrudes mure into llie
vitreous hmnor. the rctiaa mav he stretched tcuttely over it. and not fall
into wrinkles or foUU ; or distinct noiiuli-a, pcrhap* of a dark pi>:niented
apjicamuce, are Avon iitr«tchiu^ out the <U>taclted retina here mnl tlier«,
Tbe dia;(tio8i4 of a tumor ia Htill more »tren>;tbeQed, if. uitli the increase
in the jiiw; of these nodules, the oyc tension progrossivoly anient*
(Uraefe).* Indeed the tension of tlie eyeball is of groat importance in
the differenliul i]i.ipii».-titii b<^twcen a simple iletuchment of tbe reliiia.and
one prn<liiei'.l by a ■mbretinal tumor. In tlie former ca^e, tbe eye-tension
^is almost alKay:^ decidedly diminished ; whereas, the reverse obtains in
cases of intra-ocular tumor, the tctksion being either normal, or, as the
growth advances, markedly augmented. Bowman' has, however, in a few
rare iiLstance« uict wiUi a tendency lo increased tuuoioii in casod of sim-
ple detftcltment of tlie retina.
The retina may be also detached by traction from in front, thr<.'U^h
the contnurtion and shrivelling up i>f ojiacities in the vitreous humor,
which are by one extremity attached Ui the retina. In contracting, they
draw the latter from the choroid, its connection with wliich ts often al-
rcuily but very slight, as, for instance, in cases of sclerectasia posterior.
Iliu [<n>;]H'j)iiji of detachment of the retina is uuravorahlc. In some
very rare instances the disease luay retnHin statioitary nt an early !4tjij;e,
and ifhitst the detachment is still bat incuiuiiderable. Or the detach*
nient iiuiy even disappear, the subretinal fluid having become abdorbi-d,
or |HMictrat«d into the vitreous hnmor after a spontaneous rupture of tbe
retina. In such cases, the retina is reapplied to the choroid, and may
regain its functions, even after the detachment has lasted for some time.
for the rods and bnllw* retain their anatomical cltaracter?* for a long lime.
Such cases are, however, very rare. t>ne ia described by Von (irnefe, in
which the detachment occurred in cousc*)ucncoof an orbital abseefia, and
where, after the escape of the dischari^e, the retina became re-«tlaclied
to tlie choroid, and the sight restored.' A similar case is recorded by
Dr. Berlin.*
Mr. Itowman has also mentioned a case to roe, in which he has ob*!
Served the total spontaneous disappearance of a considerable detachment.
Oilier cases have been narrated by Liebreicb, tialezowakt, Stoffan, etc.
[Cases have also been rejioricd in ibis comitry of spontaneotis recovery,
both before any treatment had been undertaken and after all treatment
had failed. IIjc editor hii^ seen several, nutably, one of total detach-
ment in »no eye and partial in the other, in a young niiin of 'JO, in wh'im
the retina becanw !ilni.»i»t entirely re-attached in tlie worst eye, and par-
tially in the other, nftiT all treatment, except puncture, bad proved futile,
and the patient was discharged from observation. — B.]
But in the great majority of cases the natural course of the disease is
■ - JSrrh. f. (>|>hlli.," ail. 2, 33».
* •• Klin. UiiiuiUbliUcr.," l^XA, p. 40.
* ••OnhllwI. If'wp. Ueports," W. 134.
• IWd., 1W(«. ].. 77.
4-16
DISEASES OP THE RBTtKA.
slowly but surelj pm^resstrc. leading finallj to total blindness, Bnine<
times in consenuence of iri'lo-clioroiJilis ami atrophy of the glnbe. Al-
tlinitgh the detachment generally remaina cooBiiefi to one eye, it may
extend to tht» other, and this is to be eapeclally feared, if tlio same cause
«,\ist« ill the latter, f.tj.f Cxtenxive Acleret-Uiiiia.
Until the Inst few vears, the treatment lins been cntirelv dirocicd to-
wanls endeavoring to |jr(>cure the al.'3«>rj»ti<tn wf the oubretinal Rnid, or
t<i prevent and retard the pro^^ress of the detach me lit. The chief reino-
diea that were employed for this purpose werf dorlvatiT«s, mercury, the
application of the anificial Icccb. etc. The pationtH being at tbc sudo
time strictly ordered to abatnin from all employment tliat necessitates
any prolon;;id efi'ort of the accomtiiodatioti, or that might produce con-
gestion of tiie eve or hcntl. The results, however, of this mode of treat-
ment were not (avorahle. and only i» veri' rare in.'itance* did the detach-
ment disjippear. I mu-it confess that I have never succeeded in achieving
this reault by medicinal moans, although I luive been sometimes able to
retanl the progress of the disease by suitable treatment, to;rctlier with
complete rest of the eyes, and the occasional and guanled application of
tlie artificial leech. The latter sboiilil, liowever, be employed with ex-
treme care, m its application is always followed by a certain degree of
iiitni-oeiilar hypcmimia, which mi<;ht easily tend to increase the detach-
ment. For this reason, I often prefer dry cuppin;^ at the lomjile or the
back of the neck, more especially in those cases in which llie hypertemia
nii<|;hi [ynivc particnlnrly dangcmua, r. _7., flclereciasia posieriur aecom-
paiiicd by marked symptoms of congestion and vascular excitement.
Tlic fact tliac the uluorption or gravitation of the subrettnal Knid, or
its escape into the vitreous after spontaneous rapture of the retiiin, i*
followed by a marked return of eenaibilily in the re-attached retina, haa
led some of the moat dislinj^ished ophihalraologiats, especially U<>w(uan
and Gracfe, to endeavor to gain a similar favorable result by o|KTauve
troaluient, by dividing the retina and permitting tbo fluid to escai« into
tlio vitreoii!) humor.
VoiiOraefe,' in onler to gain Ods end, divided the retina witlt a pecu-
liar uuttiiig needle having two sharp edges. Tbo eye bving HiemliiKl
with a jiair of forceps, the needle is entered in the sclerotic about -l-fl
linos from the edge of the conien. and in the meridian corresponding to
the mo»t prominent part of the detachment, and if the j>itiiarion of the
latter |K'rinit8 it, the puncture should be made in the outer hemisphere.
The needle should be passed perpendtculnrly behind tlic leiut into tlio
vitreous chamber for about l5 lines, and then, the apex Iwing tumed, by
a simple lever movement towards the fundus, the one edav is to lie
pressed ngaiimt the retina. Thi-t mnvoment h U) be continited whiLtt the
needle is slmultaiu-ously withdrawn. By the latter retracting incision,
the continuity of tlie protuiuent retina is to he divided. Care must be
taken not to bring the point of the needle in contact with the choroid.
[This operation of puncture or laceration of tbo retina has proved by
no means so succcaaful in the hands of other surgeons. Though tliere u
• ".Awli. f. Ophlhftl.," iM. a fiS ; TitU »I«i Mr. VLOgwa
cl« In *' Opiiihsl. Hmp. Rvp./' rot. 1*. p. 213.
kIiIx traiuUUon of tliU Aril-
I
I
I
Fig. JW.
rarely ftnv j^riive reaction, the improvement in most cases Iihs Wu but
mtxlvrate, and a pertiiaiient cure )ias been very rarely reported. — II.]
Mr. Itowman ^tme^ Uiat his object in operating in dctaclimoiit nf the
retina *' h»ft never been to give external vent to fluid, tliough this baa
almost always been one immedlHte effect (if my piinetnreH. but raDior to
open a |)ermitnei)t c<>ii)mutiicatioii inwards Trom the stibretiual ^piice,
under the idea of nlUiwiii;i the effiiKtuI Hiiid to escaiie into the vitreous
cbamher, ruthor than to sprciwl further between the rellna and choroid,
thereby farther severing their organic connection. So slight ia this
connection that fluid eflfused at one port easily graviifttes to another
more dependent i>art."' At first Mr. Bowman only use'l one needle,
simply pnneiuring the retina through the Kcleroliu, but be nnn employs
twn, tnceratiiig the retina in n manner Aintihir to that in bi.i double
needle operation for ujj.i<juc cufwile. This operation ia performed in
the following iimnner: 'llie lid^ ara to he kept apart with the spring
apcculum^ and the eye, if necessary, fixed with a pair of forceps. The
needles, which should have a fine lancet point, are then to bo introduced
separately through the ^^clerotlc at a short dii^tance from eacli olber, and
at a j>oii)t corresponding to the inosl pronrinuiil part of the delacbmeut ;
the points are then directed townrdit i-acli other so that Uiey may piorco
the retina at the same npot ; by then «ef>arating tlieir points tlic retina
U torn between tbem (as in Fig. loS), Generally a
little ooxingof the silbretin«l fluid take.i place under
the conjunctiva, indeed it ni.iy even give ri»e to a
small elevation. The vitreous often becomes some-
what turbid after the operation, but soon clears
again, and then the small tear in the retina may
aoroetimes he detected. The jiointa of puncture of
the sclerotic muttt vary of courije with the position
and extent of the dcuichment, but they will gene-
rally lie friini I to I an inch from thi; mikrgin of the
cornea, and between the tendons of Ibe recti rottscles. As tlie opera-
tion gives but little pain, chloroform need not, aa a rule, be administered.
The operation is generally followed by some, often by very cen«iderablo
improvement of the sight and the state of the field of vision. It is tnie
thot tliia impTOvemcnt is mostly but temporary, and that the operation
may have to K* rej>eated several times, each repelitiou being again lol-
loved by a diminution of the detachment and amelioration of the sight ;
fuch repetitions fthould not, however, follow too closely upon each other,
otherwise serious irritation of the eye miiy be set up. I have scon in-
stances in which the improvement after one operation has las^ted f<»r many
mouths, and Bowman and Graefe have i^bserved cases in which it has
been maintained for about two yean*. Aril* mentiona one in which the
cure still continued 14 months after the operation.
ITie operation is I'mv from danger, and is generally followed by hot
alight symptoms of irritation.
' Villi' Mr. nownixii's rcry In (••rating Artioir "(In Nf^edl^ OpwrntioM fn Cum of
lN)i«ol.«l Rt-niia," "OpIith.Hoep. Ri-pona," iv. 134.
448
JIISKASBS OP TUB RBT[XA.
If ve coiiftider tlie striking roAulU often nhtained hy it, ami compare
tliL'SC with the want of jiiicoes^ accompiiiivin^ tiie former pinn of tM»t-
nient, it muiit be convi>'ti.M], 1 ttuiik, ttiiiC its ailu[)ti(jii h to hv n.'coiiiaii>uiU-<l.
from my nvrn fuvoralile experience of its resnlta, 1 Iiiive no lie« union in
B)H:ftkin;r in it« favor. We should, however, be ciireful liiiitinctly ut warn
our |)ntients tliat thu effect may oitly be alight ami temporary. The
O(iieratiort should, if po-wible, ho done at an early etftjie, eo na to limit
the extent of the detachment, and |ire^'eiiL the ri«K of tlic retiita uwlvr-
goiiij; or>;uiiic cliaiij^eA, leadinji; to the pcrmanont iiu|)ainneiit of it>i per-
ceptive functiona. Kor a more complete ex|KKtition of these poiufa I
Tiiiii!t refer to the articles of Boniitan and Vun Gracfe already quoted.
I shouhl mention that Wccker employs a umall trocar for puncturing
the retina, which he entere fpjiu the opposite side of the eye, and. after
withdrawing the subretinal fluid, tear^ the retina in removing the inatra-
ment.
[The mi-'ihod introduced in 18"li by Voti Wecker, and called the
** system by draina^^c," conftiatii in the introduction of a loop of vory fioe
gold wire through the sclera and choroid, utid leaving it m n'/fi, thus
providing for a coiiAtaiil drainin;; of the Hulin^tinal lluid. It haet iwt
proven piirticulnrly sucociuful. and a number of Aorious lo»tie$ have bei'O
reported from violent choroidal iutlamiiiation. Ilir8cliber;i; six-ak^ highly
of a return to the old ttrferal jmai-turt;, first nrartised by Sieliol in 1H'>1I,
and elaborated by Von Graefe, Wecker, and Von Arlt, and more recently
by Wolfe, llirachbcr^ thinks it may be resorted to iti every case of
detachment, that a preliminary cure will h« obtained as a rule, but that
rulapsea «ill recur fnun the nature uf the affectii»n. The time at which
to pcrfonn the operation scoma to be a subject of difference amun;; <iur>
geoDS. Von Arlt favored it iu recent cases, while Von Oraefe advised
waiting until the fluid has descended by it9 own gravity, and in this
Ilirflchberg agrees with him. In any event it is not atlvisalde to ope-
rate during an attack of retinal or choroidal inflammation (»ec '* A rch. of
ttphthal.," viii. 1 ; "(Iraefe und Saemiiwli," v. p. 704). Samelaohn has
a<Lvigcd the omplovmeut of a pressure l>anda'.;« witii coidinenient to the
bed for a long period (see "Cenlr. (lir Med. Wins.," No. 4it, 1ST.>^. — B.]
lO— EPILKFSy OK THK KKTINA.
Dr. Hughlinga Jackson has describol a very peculiar condition of lh«
retina met with during the epileptic fit, and has given to it tlie name of
" epilcpay of the retina.*' With regard to it he «aTt:' '* In one caj*.
however, a case of ' epileptiform convulsions,' I had the opjtortuniiy of
examining the fumlus uf the eye, if not during a genuine fit, at IraM
during a condition in which consciousness was lost, and in which the
pupils, ordinarily small, were diluted as if under tlie influence of atro-
pine. The optio disk^ were extremely pale. Once the vesjels dis-
ap|>eared for an appreciable time. After a wliile. howuver. tbry re-
appeared and were found to vary with tlie respiration, \^*he^ tb«
I "Ophtli. Hoai>. BrparU," ir. p. t4.
m
ISCn^MTA RETINA.
AA9
patient I'n-spired U\e vessels disappeared, rctumin" again on expiration,
liki' lined of rod ink on whih; paper." It appears to be & Kmporar^r
complete anremic condition of tlie retina, dependent iu all proljability
ujn)n a contraction of che retinal veasols, just aa ihe iinconj<cionsue88
oconrrinj; during the epileptic fit ia, Hcconlinj; to Brf>wn-S(S(iuard. dne
to a ooutraction of tlic ressels of the brain, ai»d consequent aua;mi& of
the latter.
11— ISCIL^SnA RETINJE.
Id this affection the retina is also extremely an;omie, the arteries
beiDj; yearly attenuated and altnodt blnoillejLs, tiie veins bvpenemic, hnt
irregularlv filled, llie optic disk either noriual or hut slightly pale, with
lis alfttd iH'rhnns faintly indistinct, the tension normal ami the dioptric
mfdia clear. The blindness comes on very suddenly^ aftVcU both eyes,
and is complete. Such at least nere the principal i>ynipcomg in cases of
this very rare affection recorded by Alfred (Iraefe,' Kothtuund,' and
ileddii'i^.* In Graefe's case the patient, a little girl 5^ years of age,
fttddenly orerni<rht became totally blind in both eyes, so that not the
faintest perception of lij-bt remained. On examination, the eyes prc-
seiit^-d the following uppcarance: The tenition of the vya uormal,
cnnjunctivic very [»Hle, the eyeballs of marble nliitcneifs, piipiU mnch
dilated, without any reaction on the stimuluii of light, but a faint uniform
contntction on the anjilication of laudanum, only slight increase tii
dilatation on the applicauon of atropine. With the ophthalmoscope,
tlie dioptric media were found transparent, the retinal arteries extremely
attenuated, the veins tortuou:! and dilated, but irre^^nlarly m. The
retina ainl optic nerve were normal, tbe outline of the latter being, how-
ever, very slightly indistinct.
Tlie color of tlic skin, hut c<ipeciAnv of the mucous nicmbranea, was
extremely pale. The child was otherwise perfectly well ; the only
peculiar symptoms being the extreme rapidity of the pulso, which was
very Kmnll, and numbered ItlO beatx in tlie minute, draefc considered
that the probable cause of the blindnctis was an insufficient supply of
blno«l to the retina, the faint and rapid contractions of the heart not
twin-; sufficient to overcome the normal, hut proportionately too con-
aiderable, intra-ocular tension : he therefore gave the name of *' ii^cha-mia
rotina-" to this affection. The eorreetncM of this view of the cans* is
strengthened by the fact that, after all other remefUes. such as mercury,
aujipuraiing blisters liehind the ears. artificial leeches to the temple, etc.,
had failed, an iridectomy, made upon the right eye ten days after the
complete loss of sight proved successful. The object in performing
this itpi*nitinn was to iliminiih the incra-ocular tension, nod thus to obtain
im'tfjiaiuialty a greater filling of the ve^cls ex vacuo. Paraccutvris
was |»erfonncd on the left eye. The cflect was most marked and
interesting; twenty hours after the operation (he child could, wit)) tlie
> ■' Areliiv r. Ophtbalm.." vtli. 1, 143.
* " Klin. HoiuiBh." ivm, p. IDtl.
• lb., 18«(S, V SS5.
29
460 niSBASRS OF TUB KBTIHA.
right eje, see the movpincnts of a hand, anrl in two days count fingers
up to 2 feet, the pufwl aciing more freely. The pa rtceii tenia having
proved ineffectual in the left eye, which wis still abM>Iulcly hlinjj,
iridectomy was niso performed on thi« eye on the Rcconi day. Thu
waH altto succe£:jfu1. The ophthahtHMcopic syniptomf) wen.* ei(tial]y
favorable, for on the third day after the second operation, the retinal
arteries were found to he nornml, m aUo the veinu, excepting a slight
irrej^ularity in their fiiltiean. In three months, the eiglit was perfcctiv
normfil in each eye. Uothmnnd mentiims two oiniiliir cases of t!*chnemia
of the retina, in which paraeent^aia proved effectual, having, however,
to be repeated in the second case.
[If embolus or thrombosis of the central artery i« not the cauae, the
opttc nerve is probably compre^iscd between tlic point of entrance ofliie
central artery into the nerve and that of the vein. — B.]
la^EMHOLlSM OK THE CKNTKAL AUTKRV OF THE
RETINA (PlalL- IV., Fig. 8J.
The first case of embolism of the central artery of the retina leading
to sudden and complete blindness was dini^oscd by Von Graefc'
The patient generally comjiliuus th»t the Ion of sight ujion the
affected eye has tnken jilacc very »md<lenly, and is ao great, that he can
hardly diatiugui^ih between light and dark. On o|ilitha1nM>3copic exami-
nation, we notice very marked and characteristic appearancea. The
optic diflk is very blanched but transparent, the vessels upon ii being
greatly attemtnteil. The retinal arteries are extremely thin, resembling
smalt narn^w threads, and are perliaps, to a greater or \eas extent, blood-
less and changed here and therr, for the whole or a certain part of their
course, into white bands. Sometimes small red plugs or ooagnln may
be noticed in the vejwela. The retinnl veins arc aUo thinner, irregularly
filled, and showing in some of the brancheii a complete «m[»tine89 for a
jiarl of tticircour^c, alienialing with a column of hlood or plugn of co&g-
ula. In Von (iraefe's case a very peculiar condition wa.-) observed in a
vein, viz., a very irregular movement of the column of blood, wiuch moved
with a sudden start towanls the optic nerve, and then again became sta-
tionary ; the altematingly full and empty portions of tlie vesseta rcmainiiog
t» before, excepting that thoir situation wan changed. The next change
is observed in the region of the yellow spot, which some days after the
outset of (he affection becomeii opat|ue and covered hv a faint bluish-
gray or blni^h-jireen tilm, hiding the Kuhjacent choroid, and gradually
shading off at the periphery into the normal retina. This opacity ia
due to a serous intittnition of the retina at this point, and varies con-
siderably in extent, reaching or even exoeeiling somewhat the sixe of
the optic di^k. It is generally ovoid in shape, with its longest diameter
hiirizontal. It often shows a somewhat mottled ap[}earance, being studded
with .small, gray granules. In the centre of tlie film, at the foramen
centrale, is noticed a marked, bright cherry-red spot, wbioh ia not ui
» "/reWv r. Opliih," t. 1, 1S«.
KHUOLISM OP TtIB CKNTRAL ARTRRV OP IIRTINA.
451
ctnivasalion of blooH, U3 is often erroneoti.>^Iv siippo^f><l, liut in, due as
]>iirlirrK-li liH9 pointed out, tn tlie fact that at tln^ {loint the retina U
inniKiiarcnt. permittitt;{ tlie choroid to shine Uiroii;^h, wliicli a«^iiii>e8 a
irddtr tinge ou account of the coiitraet with iJie surroutidln^ jrrnip'ish-
hltie opfeciiy. Tlie vcMelti running towards the yellow Kpot Hre often
kii'pcrnMnic, so tliat thrir finer braitchlvta can be (liauiictly U-aced, ami
they often also ^how wrU-m&rkod tiKfod coagnla.
"hie fulloiviiij^ case, which came under mv care at King's College Hos-
|iititl, illuHtraleH well the iippearancea presented by embolism of the cen-
tral artrry of the retina: —
W. 1'., iet. 42, married, has always been in good health. About the
beginning of April, 18ti7. he had a severe cold, which kept him in bed.
(>D the second mitniin;; he noticed that the ri^ht evo was somewhat
infiBmed^and smarted, and on tryin<; hi^ i^ight he found ibnt it wan mneh
affected. No more reliable liint«»ry could be obtained. On May Ititit
be tirat came under luy care. The right eye looks healthy, the pupil
somewhat dilated aitd slu.^sh, refracting media clear, lie is, however,
totally blind, being hanlly able to distinguish between lii^ht and dark.
The ophthnlinoscope shows UiaL it i:^ a case of embolism of the central
artery of the retina. The optic disk is very pale, but transparent, the
vessels, on its expatiae, much attenuated and tiuiemic, so that it is 8«>me-
vhat difficult to tnice their exact reliitinns to each olher. The outline
of the disk and tlic retina in iwt vicinity are somewhat haxy. This film-
like 0|>«city increases in density and extent towards the region of the
yellow fijiot, whrn* it assumes a grav''*h-bliie tint. The vessels running
fniin the di^k towards the yellow ^^ol are numerous and somewhat hy-
[wrsL'tiiic. so that their tcnniiial branches are very nbdervaMe. In wime,
the blood current is distinetly interrupted, small red portions of vessel
alternating with bUHKlless ones. I could not, however, on the cloKSt
examination, detect any jerky movement of the blood in these veascia ;
and as the red portions of tl.e veifsel did not appreciably alter their
position during several weeks, I attriltiiteil them to Mood eoagula in lite
vessel. In the centre of the yellow spot is noticed a red. chcrrv -colored
irregular psitch, which evidently depends ui>on the contrast in color above
referred to. Another smaller red patch U observed somewhat above
and to lU outer side, resembling it in upiiearauce, but being due to an
effusion of btooil. The whole a:4[»ect of this region otherwise resembles
rery closely the appearance prostntcd in the figure illustrating embolism
of the centnil artery of the retina (I'late IV., fig. H). The appearance
of ilie retinal veusels is aUo very charauteriHtic of this affection. Thua,
from the lower ^ide of the disk a small art«ry emerges, which is perfectly
white in the disk and for some portion of ittt course over the retina (about
twire theiliameter<d' the disk^ where it becomes again filleil with Idood.
It looks, indeed, like a small while band. The accom|iaiiviug vein it
filled for a short di:<tance from the dir^k, hut at its firal. division there is a
welt-marked plug, and on the peripheral siile of this, it is bloodless for a
considenible [Kirtion of its course. Siune of the other vessels in Uie
ncinity of the dink ahow marked irregularities in their fulness, being, at
certain points, hardly apparent or resembling small white threads, anJ at
others well filled. These irreaularitiea extended even to sonw of thu
4S2
DISBASHS OF TUB RETINA.
peripheral branches. The k-ft e^e was quile uormal. The heart wu,
exnmiticd hj Dr. iHiflin, anrl fuun<l healthy. Although the |<atit'tit'!! healt
is good, he appeaiij suftVriiig from some cerchm! affection, M he U vei
for;*etriil, iiiCDiii<-c'i|ueut, ami somewhat watulering.
The case was kept under constant olxsorvation, anrl examined with the
0]ihtha1uio6co|je at intervala of a few dav». Althougli t3)e state of aome
of tlic htoDilveitaela chaT)j;od somewhat, no tnarkcd alteration in the ooo*
dition of things took place until the la-ginning of June, when the disk
hecatne more vtiMular, hut itfi outline mure indistiitct, the ii'iiiia at its
margin, more especially npwards, laokin;j ccdoinatoiw. The vitreousi
humor became clouded, showing difl'utie and floauDg opacitiei). At the
lower portion of the finidua, ^uiall eircuiimcribed specks of dift(M>niiii)it«(l
choroiditis were observed. In about a fortnight two lar^c extra vndatioiiA
of blood appeared, one at the periphery of the fundus, the other running
from the disk to the upper part of the yellow sjiot. They were evideiiil/^
situated iu the retina, juist beneath the internal elastic lamina, act thej
covered the retinal v&K^eU, and were uniforni and smootJi, without anj
Striated appearance. At the commencement of July he wa« sent to \Vi
tun Convalescent Hospital. In the beginning of October his eye pre-
sented the following appearance, which it hftA retained more or leiw up
to the present time. The vitreous its (|uitc clear, the retiiuk is undci>
going transparent atrophy, the vessels are extremely ^mall, and th«j
retina is so thin that the epithelium of the choroid can be abnormatl]
veil seen. The inner half of the <li»k is covered by a thick network of
bloodvessels (collateral circulation), wliich arc so closely arranged tliat
tbev present the appearance of an extra lasation of bluod, but on pro«.->ing
u|>on the eye, Ihey can he emptied, and lie ohttorved to refill ivheu tl
pre!U)ure i.i relaxed. The extra vacation running from the di.tk to
yellow spot has disappeared, but that at the upper part of the fundus,
though smaller, is yet very apparent.
[In vet^ rare instances the embolus is not aituated within the central
artery of the retina before Its entrance into the eyeball, but in one of it«
branehea within lltc eve. Then, the swelling and ucdemu of the retina, the
alteration of the vessels, and the loss of sight are coniiQed to Uu <l,
pigment of the retina. Such cjises have been reconled hy > i ■ .''
lliritchman.* and Knapp.* The latter insists strongly upon the imporianec
of testing whether any pulsation can be induced in the retinal urt>;rios by
Sresdure cm the eyehnll, for this symptom is of grunt diagnostic valiw. iti-
ieatiog the alfseiice or pretense of circulation in the retinal vesst-ls. KocJ
if n» jiiibation can bo protluced, it shows that the circulation in tliv artei
is arrested. Knapp says, "■ In such eye^ only whose retinal artery wi
obstructed by embolism or injury, I never could produce a visible beatii
of the retinal arteries during the first week. As a rule, it is not befortt
the end of the second week that pul^tion could again be ^een by applyin:;
preiisure to the globe ; and at this lime, too, the calibre of tlie retinal ves-
sels had regained half or cwcihirds of its normal site." Where the ei
[> "Kl. MonatiM.." IHHH. p. 3&. ■ tU'l., p. ST.]
[* "An-liJvvs" urOp)iilisl.,t. 1, 04; vJdv alsn bte anlel«« on ButUilun, "jt.f.O.."
KTi. i,ao7.]
BUnOMSM OF THB CENTRAL AltTERY OP RBTISA.
4fiS
I
I
boUsm is confined to one lirenoh of the ecntrnl artery, we find that tbo
convajionding portion of the retina ia mor<» or less ocdenmioua and opaiiiio,
tliU extending. [*riiape, to aotne coiwiderahle diatance. TIio caliliro nf the
flffectcil vefwel ih ;;reatly diminitthed, and it may, aa well iw its lirani^hiw,
be partly or entirely Moodier, in the last case looking like a tliin white
banti. In (he corresponding ])Ortiou of the field of vision, the si^lit is
entirffif nnd tuiliUttlff hat, tliere being not the fainl«8t glimmering of
perception of light ; but tlie central vieioii may he normal, aa also tliat in
the other portions of the visual field. In Knapp's ca7>e. there were very
extensive venous licinnrrhagcs in tlio corrosponiliug segment of the rctJna.
It appcurt that, even altliough the morbid changes in tiio retina mHy di>4>
Bppf'nr, the serous and hemorrhagic efTtutinn!* hecoming absorbed, the
retinal reins losin;: their dilatation and tortuosity, and a collateral circu-
lalion being estahltiihed. thia ncgnient of the retina never regains its func-
tion, and a correii|>nnding portion of the vi.4nnl field is entirely vanting.
The oimcity of the retina may appear vriiliin a few hour?. Hemor-
rhages in the retina freqnently occur, hut are few in number and amall
in ni%e. Sometimt-i^ signs of a returning circulation appear, especially
in the veins. When the cloudy infiltration of Die region round the
macula grows leas marked, the red spot in ita centre also becomes less
noticeable. Eventually the optic papilla becomes white and opa(iue,and
the vL>>)><elH arc in |iart changed intocorda. Atthtit stage the opbtltalmo*
ftcopic picture is that nf optic nerve atrophy.
''nnipb'ti' L-uilxjIiKm of the trunk of the central artery causes total and
incumble bliiiilne.t.t. The numher of eyes that have been examined
microMiopieally is small, and although the presence of the embolus in
several of them has been demonstrated, the results of the examination
have not been entirely satisfactory.'
Kti'ii'uj^. — The most frc<"|uent cause ia aome cardiac disease, especially
valvular disease with hypertrophy, or recent cuilocarditia. Anotlier
Muse 'n extensive atheroma of the large vcs?>cls, another aneurism of tlie
atMTta. Kmholu$ of the central artery of tbo retina is also mL>t with in
the conrne of febrile disca<iea, and during pregnancy, and hna repeatedly
been seen in Itright's disease, and here l-eber thinks it might be doe to
a detached venous tbromhits. Knibolus of the arti'rics of the bniin with
attacks of ajK)|>le.xy is a not uncommon complicatit»n. Seconclary glau-
coma has rei«aledly been observed, in which an iridectomy proved nsc-
Icaa, anil the eye had to be enucleated to relieve the pain.' As regards
treatment little can be done. Faracente«is of the anterior chamber and
iridectrimy have been recommended, but any benefit resulting from them
baa bven tran-ticnl. and thoy have frcnuently done positive harm. Hence
dieu'tic advice and controlUug the action of a diseased heart is about all
that can be done.— B.]
P "np1ith.l!'»p.R«p.."Yiti. 1 aiKia: "Bri1.M«l.Jflwni.,"Anr, 4, 1874; "A«li.
th.." XX. 2, 267 : Un^iv dim) 8A«>iD>s«ti, ]laii<ll>. t. |>. Ml.]
[' '• Amin-. Joarn. Mnl. &«ii.," Apcil, 1&74; "Ojililli. Uwp. B«p./' tUI. 1 and S.]
454
DtSBAfiES OP TBK BBTINA.
IS^HYl'KR.F-STIIESIA OF Til K RETIXA.
Before the diacoverjr of tbe nplittialmoMope, Uiis afTeelioii was ^ner-
all}- raUtakun for iuflammatioii of tlie rettiia. and we still meet wttli thi«j
error in »ome booka trealiii;; of diseaacs of iIip eye. tiucli a mUlaku il
a grave one, as it hM leU to a niD^it uijuiliciotii* atitl iinpro|icr tre&ul
ttiPiic of eaiics of hyportestliesia reiinie, viz., >)^- tititiplilogistics, dejik-cionr.
Milivation, etc., thus incrcafling the severity and the duration of tbe
livmptoms.
Il}-I>eiffi.>thcdia of tlic retina general!^ uucurs in ^ouu^ perwinti, espO'
cifllly in feinsles of a very excitable, nervous, and hystericHl tcinpei
mciit. and in delicate, feeble bealtb. It u sometimes dtie to an neeidetitil
eliock, or a blow on the eye, etc.. to exposure to very bri'bt light, sach
&A a l]a:*h of lightning, or to prolonged use of the erca by atron;^ arti-
ficial li;;ht. U may aUo occur without any apparent cauAO, except some
derangement in the general health, more especially of tbe utrriue
functions.
On examining the eye, ve find that there ia intense photo pliohia, to-
gether with lachrymation, acoompaniod, perhaps, by a tipai>modic twitch-
ing of the eyelids, or oven a severe spasm of the orbicularis muscle.
There is often great ciliary neuralgia, the pain extending to tiie face and
the corresponding side of the head. The retina h extremely irritable,
and tho patient is greatly troubled by photopsic!), tiuch m bn;^lit. dazxling
stars, colored rinj^, etc., before the eyes, these photops!e» bt-ing either
B[Kuitan<-Mu.'<, or very easily producible by the t:1i;;iite»t prfttsure uiKin the
e^'oball. Moreover, the retina retains impre.t.<non.4 for an abnormally long
|>eriod, so that if any object is regarded, itd image U retained for a very
appreciable space of time. Tho eye itself will be found quite normal,
the retracting media clenr. tho fundus perfectly healthy. 'Hie sijibt is
but very slighlly, if at all impaired, and is always greatly improvi-ij when
the intensity of the li^ibt is diminished by the use of blue glaAses, with
which the i>Htient will l>e able to read tho sinnllvtit print. But whildt the
central visiim is perfect, the peripheral portion of tlio retina is aiUL'sthettCfj
80 that the field of vision, a.4 is pointed out hy Von Graefo, in mnrkedh
conecntrieaily cnntracted. This fact ini-.'ht eiwity mislead a superficii
observrr t« mistake it for a case of conununciiig anuinmsis. The ph<
phcneii' are, however, very marked in the ywrtion of tlie retina which ia
anieathetic, and arc very readily produced by alight pressure upon the
eyeluill.
The photophobia ts often most severe, the patient being i'[mt« anabla
face the light, or it comfs on directly he attempts lo use hU cyuifi in Tfad*'^
iiiC. etc. It is Btway_4 greatly relieved by the use of dark bin.
M'jureti* mentions a u extraordinary case of hy{H.*r]esthe:fia, in v. ■•
8un<tibility of tho retina was so greatly increased, that the patient ooald
[!ad large print in the dark, in which a normal eye could not distinguish
letter. It was.indeetta true caao of nyctalopia. All these aymptoots
I TIm luminou* rinn whkb appear H-ttrn tho v/ubkll in flnnl/ pntipl
* "<>|rliltialinl»lri>«)iv Btsoluclitungvn," |>. XTt.
TL'UORS OP THB RBTIHA.
455
hft<1 hecome dcvelnped in a very «liort time. The troattnent must consist
chieHy in improving the general hvnUh, eiiooiira'^iiig tlie |ialient. and
Jiminishing the excitaViiitr of the retina. If the photophobia is aovere,
it Bwy he n«ce*8arv to confine tlie paiient in comjilete darkneni for six
or eipht davs, and then (gradually to accu-iiora hira to an increasing amount
of light (Von liraffi'). In the (y\>vn air he siiouM wear blue ;;ltt*«c«.
Internally, tonics t^houM hu mliniui^tcreil, more i'^pecially prcparutiom
of zinc or stcol, according; to the itpecial iixlication-t of individital cajca.
Zinc (either the vnlerianate or lavtatv) shouhl be given in incroa«ing
doacs. commencing with ^ to 1 grain twice a 4)ay, and gnulually iiicreasiiij^
thia to 4 or even o gmiiw. Siih,ie juently, steel and ciuinia will he found
very uacfdl. ilreiit cart nnHt be taken not to weaken the patient, espe-
cially by depletion. Although llie urtificiiil leech may be ucenitionally
employed with hi>ri<.->fit, it mnat be u^cd with extreme care, otherwise it is
apt to iiicreartc tlie severity of the eymptom't, and retard the ourc. I
prefer dry cupptng, either at the temple or the back of the neck. If the
patiunt'a spirits are much depressed, everything mu^t be done to cheer
him Dp and enoourage him in believing in a speedy cnre.
H.— TUMfHiS OK THE HETINA.
[1. &iiania or OlioMarcom<t{:iya, Fungun Iliematodes Oculi — Small-
cell Sarcoma of RpUdh). — TJ.]
According to Virchow only two kinds of tUTDor occur in the rctint,
viz., (ilioma and (ilioAarcoma. The intra-ooular tumor, generally
known as medullary cancer, vncephaloid tumr^r or fungua hictnatodes,
ia in reality, as Virchow has shown, developed from the retina. As it
originates in the interstitial connective tissue {nturo^flia) of the retina,
nn<i in lliia, aK well an in it^* nntinte structure, closelv resembles cerebral
(l^iotnii. be has termed it (fliumn rftin-i^, a name winch has been already
'exten-tively adopted by Tlriti^h and fareign patliologists.
[Histologically it is identicnl with the small round-cell sarcoma, and
clinically it is characterixfd by very rajiid growth, great tendeiivy to
spread ar»d to the development of metasiatic tumors in distant organs.
iCooont inve-iligaiions on fresh and hardened specimens have led Dela-
field to call these tumors s-ircomata. and in this opinion Alt and Leber
are both inclined to coiiHiide. Microscopically there is no diBerenee
between the two. (Kor full information on thia stihject, see Virchow'a
"We KrankhaftenfJeschwalstc," Knajm's " Intra-ocularc (joMhwUlsto,"
Alt's ''Lectures on the Human Kye,'^ New York. 18H0, llirsohberg'a
" Mark«:hwamne der Nelthaut," '*Graefe und Saeuiiscb's ilandh.,"
V. p. 717 ft 9e</., and the important papers by Von Graefe, Iwanoff,
llirscbberg, and others, in the later volumes of the **Archiv f. Opthal.")
-B.]
The symptoms presented by the disease are generally very marked
and characteristic. In the earlier stages, the external appearance of the
eye is ipiite heallhy and normnl. there being, as a rule, no pain or symp-
toms of inHamniation. Ilul the niglit in lust. The pupil ts more or less
widely dilated, and shining, from the bottom of tlio eye, is uoticod a
456
DISEASES OF TBB EBTIHA.
[Pig. IM. >)ri<;ht, glifttoning, jrclIowiah-wliUc reflection,
whicli is often ain-ftily noticc^nblo at some tit-
tle distance, [t'ij;. l-^4.] Oil acoouulut" lUii
yellow himinons reflex, this coii'Iitioti was
furiuerly called " amaurotic CAt's-eye." With
the oplithnlmoscope, the details of the growth
.'i MBBa^k. tail he beautifully seen. At rhc outset, the
ili-seasf i.s liiniteit to one pcntion of the retios.
which hecftmcfl o]>a(juc, thickened, and some-
what mottled in aj'pearance. The nwrbid
gruwtli gradually increiitK's in extoiit and promi-
nence, until it protrudes in the form of a yel-
lowish-white nodulaCeil masa into the vitreoua
ATMr Awwoik-] humor. According to Vii-cliow, the increase
in the *ize of the tumor is partly due to the
growth of the ori^iinal mass, and pnnly to the forniatiun cd' new foci of
disease In its vicinity ; and hence, oti hecomin*; larger, (he growth
assnmesi a lohulated Kiipeiiraticc, certain porlious of tlie retina being
thicker than lUhem. On (lit! expanse of the tumor, we can generally
observe with the 0|>blhiv1ni(ii4cope numerous hloinlYesM-lit, which anuto-
mose very freely with each other, and between these veMcls are often
noticed small effusionei of blood. Indeed, these tumors are very vancu-
lar, and this fact, as Hirschherg* points out, is not only valuable in %
diagnoatic point of view, hut tends to explain the rapidly developed glau-
comatous symptoraa and the temporary atrophy of the eyeball, which ore
oflen noticed in cyee aflTcuteil witli glioma.
The above arc tlie symptoms generally presented by the disease when
the surj^eon Hntt »ovs it, for as it occurs in the vast majority of cases in
children, little heed ia paid to the condition of the sight, and the affec-
tion is unnoticed until the attention of the parents is arrested by llie
Lriglit-yellotv reQex coming from the bottom of tlie eye, an<l only ttien is
medical aid s<iiight. Hence we but seldom enjoy the oppurtnniiy of
seeing the earliest development of the diseaae, and of following; its ;^i'ad-
oal progress. In the very earliest alage, tlicro arc noticed, according
to Von Gmcfe,' numerous snmll white patches, of varying siio, which
li« (>artly behind the retinal vesselt^, and partly pervade tlie rotina us far
as it« inner surface, and then give rise, alread'v at u very early stage, to
a marVed t-lt-vation. They may be di.'itingiiiiiUed from in Ha minatory in-
filtrations of the iietina by their circular, sharply defined outline, Uie
periphery of such figures not being broken up into punctated or striated
Opacities, as occurs in the latter case. Moreover, they aiv of a de-
culedly white tint, and not of the creamy yellow hue met with in inSaiD-
matory in^ltrations. The»o flmall patches soon coalesce, and increase in
size and tliickuesa, but spread at first uidy along the aiirface. But as
the disease advances, tlie posterior surface of the rotina hul;i03 forward
(Uirschberg).' the little individual uudules which are thus formed, coa-
leaoe and give rise at a circuutacribed B|H)t U> a lobidatttd catdiflower
growth of Uie external surface of the retina (glioma retinie <»ruum«cri|K
> "A. f. 0.," xvi. 3, so. ■ IbM., p. l».
(bid., p. 88.
i
TUU0II8 or THB RBTIHA.
45T
turn tuWronuin). At thia period, there is already noticed a consideraMd
diii^cniiniitioii of socondnry foci. The retina is (generally already par*
tiully detacKcd at n very early ainge, and the tension of the eye mostly
somewhat increased. The detachinvttt is often peculiarly defined, per-
bn]is foriniiig an acute angle, at the apex of wliiuh a while pitwh may be
noticed <Oni«fe).' The peculiar reflex ai»d ibe details of the tumor are
renden-d niill more nuirked and contiipiciioiifi on the retiiui hi-i:oii)in<( do-
tuclied. When tlie di^eittip is more advanced, and the wh'de retina \*
iui| licHted iu it aQ<l thickened, the dclachnient \s ffenerally complete and
funiiel-dha]HHl, tlie apex bein^ sjtnated at the optic nerx'e. atul the base
at the ora serrata. Knapp' de«crtbeg a very curious case in which the
glioma sprung from the inner layer of llic retina, protruded into the
vitrcon^ liumor, and was covered not only by llie portion of retina which
it impticatcd, but hy a ticcund eni-c1oi»e of detaclied retitia, includin;; itd
ciliary [wrtion. A« a ndc, the morbid (»rowtb eau be very readily de-
tached from the choroid, but in come cases the retina is firmly glued in
the iHtter(Virchow)* the tnmor ;;radually tilliTig the eyeball and eau5in^
the vitreous humor to shrink Mnd become absorbed to a coiTes]ifmiHn;;
dcKree. The retina in nuch caws becomes folded inwards, so that the
dini'i-ent fohls are su|)er- imposed upon each other.
When the ;irowth eulnrj^ea still more, the lens and iris become pnsbp 1
forwanl towardit the cornea, the lens oflvn becoming opo^^ue and partially
or even completely atniorhed. The iutra-ocular tension, which na8 j^en-
erally hecn for some length of lime au;inientod, become* now very
markc'lly increawd. and iIiia may he uecompanied by more or lean acute
inflammatory symptoms and icvcre pain. The slJile of the oye-lensinn
is of couBCiiuence with regard to the diflercntinl ilia*,:nosis betvrcen an
intra -ocular tumor and » simple detachment of the rctiiui, for in the lat-
ter ca*e it IS a^i a rule nlway* diminished. As iliomu occurs in tJie va*t
majority nf coses in yonii;; children, in whom j^Iaucouia h Imnlly ever
met with an a primnry afleetiou, nn incr<-n.4c in the inlm-ocnlar tension
(otiivr caates for this being absent) should at once iirouue our euspiciona
(^Graefe).'
When the tumor lta» filled the cavity of the vyehnll, the latter f^ncr*
ally <HM>u gives way at some point. The perfurntton lHk.cs place al the
comeii or near its margin, or at the anterior [wrtion of t)ie sclerotic, and
but sehlom at itj* jK>»lonor |nrt. I'cr font linn »t the Utter situnlion, and
tlic extension of tlie j^rowili int(» the orbit miwt be fius|*cled if the move-
ments of. the eycl>all arc markeilly curtailed, and the eye protruded.
Wben the tumor hu« oncu burst throu-^h tiie coat4 of tlie vyvltall, \\a
[rowtli is rery rapid. U itprouts forth between the eyelid)^, which ore
catly itwolten and often much everted, and ttC<iuireA, from iu cx{>o«urv
thi' atntM!ipbcre and external irritants, n dii8ky-re<l. fleshy, and very
vaacular iippean»nct>, and lieiice the name •• fungus hienwlodes." [Fig.
tr>o.] Knnn it there exudes a saiiious fluiil, which becomes crusted on
ltd surface, and if any cucortation of the latter occurs, the tumor btceds
very freely.
< "A. f, 0.," xti. p. I«.
■ Ufi. elt., p. 1<M
» Kii«pp'»"AK-lifv."(i. t, 15ft.
• "A. r. y.," xir. i, 130.
468
DIBKABSa OF THE XBTIHA.
Sometimes, however, the dieease does not ran m regular » ounw, for
after the tumor baa attained a cerUiin size wittiiii tlic eye, Bvmpu>in3 of
irido-clioroirtiti* mpervt-tio, th«
[Pig. l&S.
[lupil becomes MockeJ up with
V
/,.
M
lymph, tlie oje-tension falU l»fr-
low the normal Btoodard, and
the discoBe for n time o^amee
the character nf an irido-cho-
roi'litie, [inking on to trmpors*
rif atrophy of the ej^cball. Tnc
latter i» generally diw to sup-
purative choroiditis, hitt may,
in rare instances, be aUo caii9e«l
\i\ suppuration of the comua
(Von (Jraefe). Tojiethwr wiih
tJiis atrophied condition of the
eyeball, then? are nfwn very
intense, npontAneoua paroxycm*
AnArarow.} *f pain, the e_ve itself bt-in;; but
elitrlitly, if at all, (wimitivc to
llie touch. Whereas in the atrophy dependent u|M>n irido>cyclitjs, tb«
reverse obtains. But the mnst intense and sudden pain occurs if intra-
ocular hemorrha^> takes place. At a subae((ucnt period^ the symptoms
of nil intra-ocniar tumor 8;^iln maiiife^l tlieriisejvcg \u the partisUy
atrophied eyeltall. the tension increu^tes, the tumor au'^iitorit^ iti »\ti>, the
cornea or wlerolic gives way, and a rapidly increasing morbid growth
sprouts forth.
Virchow conxiiier:* that glioma commence^? in the extemnt layers of
the retina, more e^pectnlly the connective ti^ue elements of the granu-
lar layers, and Knapp believes that it hegitis in the extenial granular
layer. I>cliwoi^;;e)' thought it prohabU' liiat it ori^inAtrffd iniheintenial
granular layer, atid Jlirrsciiber;;* has succeeded iti proving the truth of
this stippoiiiiion, hnvin;; found in one coao that the disease commenced in
a pi*<)liicratioii of the cells in the iimer granular layer of the ivtina.
[lAdH'r has foiniil primary tumors at the same time in different layers.
The probability is that the tumor, hciiij; a coniiectirc>tts4iie growth, may
and doe-* siirini; from the connectivc-tissnu elements of any or all the
layers nf tnc retina, as Iwanoff Has su^i^C'tted, The growtli niiiy l>egin
in tlie ititcnial lityurii, and grow to a eonsiilerahle site without iiivolvin)*
tlje layer of rods and cones, iis in a case reported by Dolafield. — B.j
At a more advance<l sta;3;e of the disease, tbe retinal tissncs often ttia-
appear atntoit entirely, so that It is then ipiite iinpoMitde to trace iU
origin.' The membraiia Uniitans interna and the innermost portions of
the trabecular connective ti-wuo fihrci < Slutzfasern), «eom to resist the
longest, and may. accjniin^ to Virchow, be often traced within the
tumor, and are scon to divide it into segments. Iwanofl* distinguishes two
< " A. f. ».," vi. 2. SM. « lb., xlf. 2. 40.
* forftirihi-r iiifonnntion a|Hin th" nti Atomic kI charMnir of ilt>-titf tiimor*. I would
«!••> nifi-r itip r^adwf tu Hr. llulki^'s v»luftl4o uspcrt oa "Iulra-o«ulu CauoT,"
•K. !..(». II. R-i..." Hi.. I»., Bnil «.
• "A. f. 0.,*xv. a.
TDUOBS OF TIIK RBTINA.
459
fonns of glioma ; one, ia which the iliscnkse commences iu the iniernat
rsraniiUr layer and extendi outwnrd ; the other in whiuti it begins in the
layer of the optic nerve tibre^ aiiU extvmls inwanU.
The prinoiml ninsaea of tunmr arc coin|H>gcil of ajy^regatioiw ot" nuclei
god cells. [I'ig. 15G.J The latter arc romul or oval, small in sine, ainl
iJOOcasiotmUy have t^iimll pniloii;;ations. Thev an;
flometinie:! arran;;;cfl in rows, .itiiI cftnlJiin one i>r more IPig- l^*-
nuclei. The free nuclei are small ami i-ountl, and, ac- ^ Z!^i'
coniin;; to Virchow. correspond exactly io the little («^ff*SSS!Lafi3>
li'^ht' refracting nuclei of tiie granular layer. The
iQt4.'r-cc1lnlar sulrstaitcc is ao scanty that it can be
banlly diMin'^i^hed. hut on adding chromic acid it xa«'Ji*"«"i""'l
' becomes fiiielv n™""'""' ^" 'he soft variety of the
tumor the cells are lar::er than in the hanl, and in the lattor the cellular
t)»sue is fihrillatcd. [These tumora arc sometimes very vascular, the
hloodvcsseh? being very large. During thoir growth, hemorrhages often
occur both npon the surface of the retina and within the tumor. These
latter are recogiii;icd after rvnmval by the jialches of blocKl-pigoient
which i« sometimes incWmed in cclli*. and somctimos is found in free crya-
tal*. — B.] The tumor may i*ulisc.)ucntly undergo fatty and chalky
degeneration. Sometimes the cells augment in aizu or as!<ume a spindle
shape, and the nuclei increase in number, and then the morbid growth
must be considered to be of a sarcouKitous nature. Indeed Virchow
has :4linwn that the tumor sometimi^ assumes a mixed characler. one pcirt
retM-mhliiig glioma in !>truct(ire, amithcr sarcoma, m that it nuiy be
termed *' glio-i^arcoma," and he thinks thin to he far more dangerous in
character than simple glioma.' [Tiiis teuiiency to limit the tonn " sar-
coma*' to a larite round cell or Bpin^lle-cell growth i» histologically itKor-
recl, ami slioubl not Iw perpetuated. — R.]
Virchow thinks that a sharp line of demarcation cannot be drawn be-
tween glioma and intlammatory neoplasms of the redna, 08 the former
may in its course be uticompjuiied by inttammatory symptoms, lie con-
siders *' that the name glioma is apixiVite, as the neo-plastic furumtion,
even if of an inttamniatory nature, assumes a more perumuent character
and tumor-like form, it being, however, of courae, alwa^*^ undcrsl^tod
that its structure iim.'^t be cnm)jOseil (.d' homologuus elements. A suppu-
rative retinitis can never ^\p rise to glioma."'
Von Graofe, however, d<w8 not believe that glioma is due to an inHam.
natary hyperpliL^ia, and think-s that observations which hare iM'cn ad-
vaitced in support of such a view, have depended either upon the fact that
the 8e<|uelte of intra-ocular iitflnmmatious, e. tf., plastic inHammations
of the vitreous humor, or subretiiial de[>o^ittt, have been mistaken for
gliomata ; or that the first period of the tumor has been completely over-
loukeil, and tlie vousevutive inliammatury eomplicalioiis were suppusud to
form the origin ol' the di^tea-'ie. Moreover, a-t he [wints out, clinical ohsor-
ratinn shows a marked difference Wtween tlie &rst period of glioma and
an ihllammatory hyperplasia.
The tpicstion whether glioma is to he reganled as a malignant disease
< "EraukliAnQ0v»c1iwalit«," ii. I(!7.
> Loe. cill. 139.
460
DISBASBS or THK RBtrHA.
is Mil! consiiU'red doubtfol by some obeerrers. Von Graefc,' howerer,
epeak« in the most <U'ci'Ie<i matmep »« to its tnaliKuancy, anil thitiks th»t
this increases wiih tlie length of it^ existt'ticf ami the iucroast' of it« ile-
velopmeTit. It has been thouj^ht that glioma ctiffure from Asircomaloua
tuiuoFB of the clioroid, etc., in tliis, that it iJoe« not appear secondarily to
affect distant organs, being only prone to local infection :* but lliiH hu
been prcivec] to W erroneous, ({iilke* mention)) a case in which the reti-
nal ^;lionia in each eye extcixleil beyond the optic nerves uithin the skull,
and in which h(> distiiK-tly observed tbe gniwili of the glioma in the ooo-
neCtive tissne separating tlie bundlefl of nerve fihres in the nerve trunk,
in front of the optic coniitiissure. Tbe pni|iagalion of tbv disease front
the retina occnrs in two dircction9^(l ) towards tho choroid ; (^2) to the
optic nerve, and the implication of the latter is. according to Hirschbcrg,
far more frequent than haa been generally supposed, oct-nrring almont
without an exception and in a tolerably short space of time after tiitf
origin of the diiH<a»^c in tlie retina. Out of the eight cafiea which he re-
portn.' the optic nerve was implicated in six, and in mo«i to a very c-on-
siderable extent. [Both choroid and optic nervo may be involved ver^
early in the course of the diAcitse, and later, the ciliary boily and ins
may become infiltrated before tin: growth [w'-rforfltes the ficlora, though
Ibis in not common. The optic nene in rare cmvs bucornea enonnonaly
tbtcketied. the infiliration following maiidy the medullary sheath of the
nerve fibres. OccaMonally we meet wiUi «maU iiecondary tumora in lb«
aclera, usually on its external surface, which have no connectioD with tho
internal growth, or if they have, it is microscopic. — B.] In this tendency
to extension of the diiteaite to the optic nerve ami ihcncc to the bmin. is
to be sought the extreme danger of retinal glioma, for n siecondary tumor
of till' brain may be formed, or aff/^/mUtin ensue. [Thej<e iutra-cranial
tumors may grow to a targe eize without cauKing any brain symptoma,
though (bis is not usually tlie case. The exicn.-tion to the chiasm and
optic ncrre of the other eye may lead to complete Ainaurosia, though
there miiv Ite no tumor in the second eye itself. — -It.J Hence the neceS'
0ity of excising the eye at the earliest opportunity, and dividing the optio
nerve ati far hack as |>o8E>iblo. The hret retro-ocular extension of tb«
di^eanc U very difficult to diagnose, but Von Gmcfi* has found that when
degeneration of the optic nerve has «UKued, the eyeball become* slightly
more priiminent, and it« lateral movements somewhat cnrtailod. There
is also more r<'nist:inci- iVlt, if the eye i» presided buck into the orbit, and
the little furrow Iwiween the eyelids and wall <>f tbe orbit is ohlitcmttNl.
When the orbital adiix^HC tissue is once implicated, the pnigrcss of tbe
disease is very rapid. Knapp* has shown tl>st the pro|>agation of th«
dist^asr to Uic neighboring tissues »ccur« in two ways: 1, by diaseniina-
tioti of geniu; 2, by direct contact.
' "A. t. o.." liv-a. lilt.
* Rii«|ip nc(»Ms ft «■»•• of gtiaaiA of tbe r«liaa in whloti ilieri! wvra foand. aft>r
dMIli, 4MMd<Urjr ({llaiiiAU in the llv«r, loiti;, nud tbe dliiliif of tbo skull. Up. dt.,
p. ».
* •' B. L. a. U. Hty.," T. 173. • " A. f. O.," «Jt. S, M.
* inid., xlv. It, 137. ■ Op. 0(1.
TUM0R6 09 TUS RBTINA.
461
[Tbe extension of tlio fj^wth ta the tissnen knd bones of the ftce an<1
skttll is Bometiuies ver_v rapi'l. The paroti>l and submaxillarj glands
become iufiltrateil nn<l form the origin of lttr;;e stfomlnrv tnmors.
SuCOiiiliiry dtpodit* also oct-ur in tlie Ixmes of tlie »kull entirely ilitwou-
n<.*eic<l nith tlie orbital tumor. They ori^nate sometimcfl in the (lipldii.
somfliiiiee in the periosteum; are very va^cularauil Jirc often acconij»aniwl
by the <tcvc1opRient of osteopliytes. >tetaiitatic j^rowths have been found
in the clavicle, the ribs and llieoshrachii. The liver is the mo»t fretiucntly
involvetl of all the internal or;£aii«, chough kidneys, Uinffii, and oraried ar«
not uiteowraonly invaded hy the metaBtatic growth. — ».]
The rtiunif* of glioma are quite obscure ; but in some cas** it appears
^to bo due to a traumatic origiu. It occurs in children l>etweeD the ages
of two and eleven, and, according to ilirschberg. no authentic cose ia
reconled in which it was observed aft«r the age of twelve. It tnay, ac-
cording to TiTivera. be trnmetimea congenital, he having extir|wited such
an eye in a child of eight months, [When it ia cinigcnitnl itt develop.
iiment ill very Blow, ;ind never goes beyond the first eUtgc during fujtal
life. — B.) riomeiimi's hntb eyes are aftecled with the disease, and in audi
cases Oraofe tliink-t that we must not conaider the aifection as having been
propagated from one eye to the other by way of the chiasms, for in the
CMes of Saunders and l{aye». rejinrted by Wanlrop, the optic nerve of
Ithe eecondarily affected eye M*a* found to be .piite normal. Nor doei* the
lea of a dyscrnsia hold good, on account of the general immunity of
Cother organs from met-astAtic gliomnta. Von tiracfe rather secki* the
explanation in the peculiar symmelry which exists between the two eyes,
the influence of which ia srt often aitd very markedly illuAtrace<I in inflam*
mntory diseased of the eye. In some instances, glioma appears to be
hercditjiry, an<l occurs in sti%'eral memlH>rs of the same family. Tiius
Ifcrelie mentions four chihlren b4Mng affected with it out of a family of
seven ; Sichel i*aw it in four children of the same mother. The childreu
affected with glioma arc often of w peciiliurly fair and Iwautiful curo[>lex-
ion, although perha]>s ^mewhat delicate in constitution. [The male sex
seema »omewhut more di^po^^ed to Iw attacked than the femiile sex. lu
freijuency a.t coirp\rcd to other eye diaeasos varies from 0.04 to O.Uti per
cent.— U".]
Tlie pr<>;f»f>gi» of the diseane i? always extremnly grave, aa the affec-
tion is very apt to recur, and wc have no guarantee that tlte optic nerve
ia not already implicated, even although the inlra-ooular tumor nuiy t^tiU
be very small. For this reason, the immediate removal of the eye should
be very »trongly urged us »oon as the diagnosis of glioma ie estHblished,
for t)ii» is the only chance of saving the patient's lite. The opinion that
the disease tnav Itecnmc sjiontaneoiisly arrested, or may retrograde, is,
according to Von iiranfe, quite en-oneous. For be' has found that the
nftection progresses steadily an<l surely, indeed with greater steadiness
than sarcoma of the choroid, and that, reckoning from the earliest ap.
?anince of the disease, when the lumor still only occupies a smuU
)rtion of the eye, frumone to three years elapse before its extra-ooular
t "A r. O.," xlv. 2, 135.
i62
DI6BASB8 or TUB HgTINA.
development becomes manifest. In tlio«c cases tn wbicli tlii? occurs ut a
vury early age, if, (/., at iho tcrmiiiaimii of the fiwt jrcar of die child's
life, he consiilerit it ])rol)n1>le that the glioma was coii;;eniCal.
Treatment.- — It has beeu ur<^d by muw eurgeona. that tlie extirpation
of the eye ut iihcIo»h, as Llio disease i» Hiirc i|uickly tu recur and euil
latally. But cases are on reconl in which peventi years have eUjised
after the operation, vtthout a return of the diseatte.' The rule ifi, there-
fore, to remove the eye at the enrliest |kO/isiK1e period, so that there may
be ilic chance of the optic nei've bein;; eUll uimffecteil.
The cliief danger ia, that the disease should extend Ui the brain, or
(}iat thv tumor, increasinji more aud nwre in giae, should perforate the
eyeball, and from the severe pain^ the j^reat enlarfx^uictit of tbc luinoff
the occurrence of hemorrhage, etc., umlorminc the patient'* health.
Cerebral complications should be ^lupected, if the patient becomes
drowsy, languid, and otiipid, lyin^ nhont and slooping a groat deal, if
there i» great and constant heftiUehe, or if eymptoma of paralymt
manifest theniiielves. Itut oven when the tumor ha» burst thrnugli the
coats of the eyeball, and 13 fnngating extensively, it» removal i» advi>»blt,
more especially if tliere is much pain and hemorrhage. It must,
moreover, be remembcre<l that it is the only chance of proloDjdng life,
aiid of alleviating the dreadful suffcringfl of the patienL In oxcUing
the eye, the optic nerve should be divided very far back, iu order, if
portsible, to remove all the diricaste. Von (iracfe waa in ilic haltit, in
Ruch cases, of passing a neurotome (after he ha^t divided the conjnricliva)
along the outer wall of Ihe orbit to the bottom of tlie laller, then pulling
the eye Hsfar forwards as possible, and dividing the optic nerve quite
close to the optic foramen ; he then proceeded with the excision in the
UKual manner. If the disease ba^ cxlendetl to the tissue of the orbit, it
will be a-lviHible to Apply the cblotide of^inc j>ii«te aft«-r the removal of
the eyeball, so as to destroy, if possible, all the morbid tissue. [In
n^moving the contents of the orhtt, the pcrio.titntm niiL-it always be re-
moved us completely as pOMible. If the eyelids are involved, they are
liest rvmovet] close to tlie orbital margin, and if tlie subjacent bone lookfl
diseased, it must be scraped clean. When the dideano has not been
entirely removed, the growth recurs rapidly, ufiually within a few
weclu.
'2. Sarcoma of the JUtina. — In rare esses sarcoma of the choroid
ia accompanied by small sarcotnatous deposits in ibe retina, which nuiy
be direct prolongations of the clioroidal growth, but which occiwionally
arc isolated nodulea. Cases have been reported by Klebs, Kitapp, and
Uirscbberg. (-'Arch. f. Ophth.," xi. 2, xvi. 1; "Archircs of OphUial.,"
iv. 1.)
H. .V(7/.irv Tvherclf/i in the Rrtinn. — Only a sin-^le authenticated
case of \\\M kind has been reported by IVrU, in which the iru and ciliary
body were aUo involved. ("Arch. f. fiplitlial.," xix. 1.)
4. ytmnilar (} rawthi, uf the liriinu. — Muliiplesmall vasculartumors,
prolifu rations from the arterial nulU, have been met with in the degene.
Vklv " R. L. 0. H. Rvp,." It. 87 : alM V. Onwh's Article, loo. du
OrSTS IN TUB RETIHA.
•tea
ntion of the vasculiir wall^ occurring in chronic glnucnma. They are
lid to he transformed later into connective tissue (^"Kl. Mon. f. Aug.
I«71,'* p. ■li'i).— B.]
IS^ATROPHY OF TIIK RETINA.
Atropliy of tlie retina is met with as the final stajje of many oftheintra-
ocnhir infliiinmiitionB, of glaucoma, an<l ceri-hml aiiianrosiB. It may be
{>artinl aiul confined to certain portions or cletnenU of the retina, ur
onmpletc, the whole rciina hecomiu;; g^rcacl v altcnuated and changed into a
^thin, trans ftiLrent. fi))nl]ar connective tissue, uhicli '%» so delicate that tlic
IctaiU of the churoid can lj« seen with iinnHinil tlittinctncM, and the
faint, normal n-tlcx of the retina is entirely ahwrit. The retinal vessels
become excessively attcnviittod. and at lat<c cliani;cd into thin streaks or
1ine«. or disupiwar more or less completely. The optic nerve at tho
same time shows nil the symptoms of advanced defeneration (perhaps
^fuiconiatons excavation) and alrojiliy. In tlie retinal atrophy which
enanes upon inflnmmatinn. the retina is fienerally for a time more or leca
opai|iie, and tttiiddod pcrhn|ia here and there with pnlches of eKndtition,
but !inl>s«ifucnlly it bccouifS nitirt) an<l luoro thinned and tranxjfarcnt.
DefMK^ils of jiij^tuent and chulcoteriuL' arc Aomctimeii noticed in tlie
atrophied tiiiiuc.
16._CYSTS IN THE RETINA. [CYSTOID
I>K<;KNKHATION._lt.J
These may occnr in varying number, and differ in size from a smalt
pea to a hazel-nut. On a section of the g1oh«, they appear to the naked
eye as iimall tramparcnt vemicles. ntuddcd over the outer portion of the
retina. They »re proliahly prmluced hy the development of colloiil
vinaterial in the external granular layer, and hy a ]miliff ration of the
radiating trahcculur Hiirei* ([wAnnfl').' The latter form the outer nud
lateral walls of the cyKt, the inner wall bcin^t formed by the intertuil
lay era of the retina. .Mr. Vernon ha« met with cysts in the retina in
four instances.
[The anterior portion of the retina is in old a;:o the flcat of a peculiar
cysioid formation, dc8cril>ed hy litnnoff anuxlvnia. IJetwenn the ora aer-
rat& and pnra ciliaris retina; the retina bcoomes decidedly thickened, and
here spaces develop. The defeneration aFfects mainly tliu inner granule
Uyer. and the bacillar layer ts ;j;cncrally intact. This cystotd ilcgen-
eration ia also met with in caaes ol dctachincnt of the retina, both idio>
'{»thic and traumatic, and in j^lBucoraatous eyes ; and here the degeneni-
tion bcgiiifl gem-rnlly in the exteninl granule layer, ami the e\H\A
»nmetimea reach a very large size. In some coaett there u no tnce of
any in£ammaiory origin, though usually this is not so.— B.]
■ "KI.H«nat*M.," l^U, p-417.
[17._C0XXFXTIVE TISSUE FOllMATION IN THE RETINA.
After injuries of tbe eye with extensive Iieionrrhagea into the ritreong
and retinii. there sometimes remain dense, pigmented connective tis»ud
baiidjt ID the retina wliicli dip dovru into Itio choroid. Occaaioiiallj/' t)iew
arc mot with idiopathienlly. Tlii* condition liaji been called rctiiiitia
proliferans, but Lvber tliinks the membrane* are alwava the rum»iii» of
lieinorrha^cH. ThL> retinal vessels Bometimea ororlie tliem and some-
times run beneath them, and occasionally the optic disk in entirely con-
cealed by one of these new formations. Usually the vision is markedly
ofTected, but tumictimo^ iin amount ef virion h retained out of all propor-
tion to tbe condition revealed by the ophthalmoscope.- — B,]
r
[l8_INjrRIKS OF THK KKTINA.
BeHides the wonnding of the retina which ro<9ulta from rupture of the
eyeball, thi^ retina lA often woitii'leil by .luiftll bits of steel or glass which
have penetrated tbe eyeball. '11iH.se mny remain sticking in tbe retiiUL,
or rebound and fall to the bottom of tbe vitreous. Foreign bodies may
become encapsulated in the retina and remain quiescent for years.
Particles of steel have also been removed from the redna. ^" Trans.
Amcr. Ophthal. Soc'y," 187«. "Arch, of Ophthal.," vH.) TTonnding
of tbe retina is usually accompanied or followed by itucb destructive in-
flammatioti of the other tissues of the eye, that ita individual conitidera-
tign may be omitted.
Kuptarc of the retina alone and in connection vritb rupture of the
choroid from a blow, has been known to occur, but tliese eases are ex-
tremely rare. Usually the ejctcrnal layers next tlic choroid are the
parts involvetl. Tbe virion is usually very much disturbed from the
effects of sncb an injury.— H. J
eii
[19._CY.SriCERC[:S UNOEH THE RETINA.
This was first described by Von Graefc. Tbe worm occurs much
oftener lietween retina and choroid than in the vitreous. At first the
retiua over the bladder is transpBrciic, but il jiradually becomes opaque,
and the vitreous begins to grow turbid. The visual held is interrupted,
and when the animal tnovea, as it frequently does, it Icures behind it an
ofAque Spot. If the retina becomes totally detached, the cystkercoA
becomes eiicnpstdated and does not penetrate into the vitrcou*. When
the vitreoufl remains transparent, tbe animal may nceasiunally be seen to
movo iti* liend and neck. Vininn steadily diniinisbes, and eventoallT
violent itiHiimmiitori.' symptoms supen'ene, acute irido^horoiditis. An
attempt shoubl be made to extract the cysticercus by an incision through
the sclera in the region of tbe sac, or by an incision in the sclero-comenl
aiur>;in, extraction of the tens, and subsequent removal of tbe entoxeoD.
lliift latter operation, however, is only suitable when the auimni ha*
entered the viirvons. Tbe prognosis in any e«eut u unfavorable. — B.]
i
d
Chapter TX.
DISEASES OF THE OPTIC NERVE.
J._HYi'ER.1-:MIA OF THE OPTIC NEUVE.
IIvPER.KMlA of the Optic ocrre i« a part eymptomof hyperwuiiaof the
retina ami chonii>l. This ctindiuoii ih clijiracierizod hy the ojitic AUk
Wing much retMen^Kl, il« minute vei)S()1.4 Arv fiitU-r aix] more cori«picu-
am. an<l iU) margin ta indtdtitict atid hazy, so tliat it is nut sharply de-
fined agMin»4t the surrounding retina : this haxiiicsa is least marked at the
temporal itide. [It should b« remembered that the nai^al part of the
optic disk u naiurally redder than iho temporal. — B.] In 8ome cases
faiiil radialinj; 3in|)«a can be seen pnjsinf; slightly over into the retjiia.
Id that lorni which accoiupunicd hypertumia of the choroid the disk is
alw rrddetied, but thirt craj^cit at the aolcrotic rinj;, and tlie nurj^in of
tlie diok is everywhere shm-ply and clearly defined (Mauthner).
.^.—INFLAMMATION OF TIIK OITIC NEUVE (OI'TIC
NEL urns. NELliO-KKTlMTIS) I'l»iw VI., Fig*. 1.1 mid H.
Inflamm.ation of the optic nerve is distinguished by the follon-in" oph*
lhalmo.4copic symptonw. At the outset, there cxisft a certain dejjrce of
by|>erivmia and uidema of the opiic nerve entrance and of the retina in
hi vicinity, so that the disk appears abnormally red and somewhat
»pHi|uo and swollen, its outline being hsxy and indistinct. In soma cases
the tieuritii) 'n partial, the serous infiltration and swelling t)ein^ at first
chiefly or entirely confined Co one portion of the disk. But ihc inflam.
raatory syroptouis soon become mure marked. The optic disk bewmies
enlarged, ttwn]|c'n,ttnd prominent, and it>j outline irref^ular and iudlilinct
(from proliferati«'n of ihe conncctivr tisauo clement*), so tlial tt |>.-uises
over inio the retina without any sharp line of demarcation. .Moreover,
Cbc smooth, transparent, delicate pink appearance of the disk is lost, and
it assumes an op3t|ue reddish-gray tint ; the hypertrophy of its connec-
tive tifttuc cam>iii}; it to appear striated and " woolly." On account of
the ^rcat swejlin;; and prominence of the disk, it can be itoon at some
little distance in tliu L-rvct iiimge ; tlie refraction Imvin;; in fact become
hypermetropic. The inflammation generally extends more or les.i on to
the retina in the vicinity of the disk, rendering the former hazy and tn<
distinct. The appearnuee of tlie retinal Tcssels is also markedly changed.
The veins are much dilated, dark, and often very tortuous, dipping here
so
466
DISEASES OF TUE OPTIC XBRVI
and there into the infiltration, so as to be more or leas C6vercii and hid-
den by it, nud intcrnipted in tlic-ir course. The urteries may, on the
otiicr hand, be ?,o much dimiiiisheil in calibre as to be hanllj distingoi^-
abU'. On account of the development of numerous emaU vei^seU on tbe
disk, the lalttT ia very red and vascular, its ed^e lookinj* perhaps as if
it were covered by a reddish fringe. Ou and around the di^k are scat-
tered liuinerous striated blood exlravadatitins of varyiiij; sixe and sliajie.
Oh using a high mapiifying power, wc arc often able to make out that
the apparent hemorrhagic eflusions in reality consist of miimte, closely-
packed, oewly-dcvc loped bloodvessels. The inflammatory ewelling and
exudation may, however, be so considerable that the vessels are com-
pletely hidden on the dii^k. and can oidy be followed up to ita margin,
and only here and there can the outline of a vessel be fainily traced oa
ita expanse. Althouyli caaes of retinitis, more especially the jiarencliy-
niatous uiid nephritic, are geuernlly accompanied bv a certain decree of
inflammation ot the optic nerve, 1 shall here connnc mjaelf to the de-
Ecnption of optic neuritis as au idiopathic disvaae, aud uot aa a part
symptom of inflammation of tbe retina.
We may dietinguish two principal forms of optic neuritis, viz., 1. The
** ent/ortjfii papUla"' (Siauung's papille of V. liraefe), in which tbe
inflammation commences in the papilla (optic disk) and extends upwanb
along tlie trunk of the nerve, but geuerally stopping short at the lamina
cribrofla. Hence it might very well he termed "ascending" neuritis.
rTiic tcmi usually emiiloyed in the text-books for %\m form of inflamma-
tion haa been *'cliokedHlisk ;"' but there ha.t recently been introtluoed
into our terminology the word " papillitis" to dewribe the aame ophthal-
moscopic symptoms. — B.]
2. The " deMivnttinff 7ieuritis" in which the inflamtoation commences
cxtra-<^>cularly and extends downwards* m the optic disk.
The eu'/oryed yamlla is almost always due to an impediment to the
oirculntion within the nen-e, which may be caoaed by an inira-orbitnl
tumor pressing upon tlie latter, or by an increase in the mtra-crauial
pressure, and cotweimenE retardation and ohitruciion to the circulaiiou
in the optic nerve. ThiH raechanical obstruction to the circulation in the
central vessels of the retina is soon followed Iiy serous infiltration of the
optic nerve, and siubscijueritly by inHtiuimutory proliferation of its con-
iM^ctive tiiwne element*, llencc, there is a coii*idera.bl« swelling of the
nerve, and aa the firm scleral ring cannot yield, hut oloacly embnices it,
the nerve is here more or les^ strangidated, which impedes tho circola-
tion still more. The irritation proiluced by this coiupresaiott is soon
followed by inflammation. IwanoR,' however, narrates a case of neuritis
optica in which the ophthnlmoAcopic symptoui'* of cngoi^ed papilla aad
hyperKuda uf the optic nerve and retina wore very marked, and lasted
for more than twelve months ; and vet, on niicnx^copical examination, no
inflammatory changes were found lu the nen-c, but otjy hy]tcrieinia of
the votfsels, great dilatation of the capillaries, and slight hypertrophy of
the connective tJasuc, but tbe nerve fibres were quite unaflectcd.
■ Th« " toehMnia of tlip diik" of Dr. Allkutt, whow work vu Hie otihthtlnrawoiM-
1 wftubl r«o«»UM-[i(t to Hie ntu-ntion Af lli« rwftiiuf.
' "Kl. MoiiM«U.,"|&68, 421.
INPLAMMATIOS OF THE OPTIC SBHVB.
467
Von (Jraefc' wns tin; first to recognixe tlie connection lietwecn optic
neuritis and afTectionit of the brain, as well as certain inorbiil conditions
of lliK orbit. According to him, the enj-orfied p;ipilla is chieflj dtetin-
guishtil hy great, hut jtcrliapi^ p«rti»l, Hirelliii^ and prominence of the
didk, nurncroua and coni>iilcrable hr>morrhn<j;eit on nnd Around tlic pa|tilla,
and fircat dilatation, dnrkncftr), and tortuosity of the veins ; the aricrios
heinz on the contrarv very amall, attenaatcd, and often almoflt htoodleas.
The inHatnmatory infiltration of the retina ii contine'L to the close vicinity
of the nerve enlnince. [In the choked diwk from cbninic meningitis,
wish or withont tnmora, tio«idc« the ni;»nfl already mentioned, tht^re may
also be nini<ses of exntlntion in the retina between disk and nincnla, re-
sembling very markedly the appearances hitherto regarded as patho-
gnomonic of Bright's diseajte. A rare occurrence in pftpillitia is a
B|)ontAtieDU8 arterial jtuUation from obstructed circulation, due either to
neuritis or nrhitAl tumors. — B.]
In the dctcnuthij neuritis the tissue of Uic nerve is more diffusely
clouded, hut the swelling and redne^ift of the di>4k are much le.ix, and its
tint 19 of a faint gray. The opacity of the retina i.-t more ditTu^i'; an<l
extensive, and reaches deeper into its structure. The retinal arienes
are consiili'rably diminished in calibre, but the veins are less dilated and
tortuou<) than in the engor<i;ed |>apilla. On account of the more exten-
sive implication of ihe rcilnn, as well as the appearance of white iratches
on it, the disease aometimet* aii^umca a certain ^imilaritv to nephritic
retinitis, and might even be mistaken for it by a superficial, cartdess ob-
Aerver. The chief points in the diflerential diaj^noitis of these two dis*
cases have been already mentioned in the article upon the ** Retinitis
AlbuHiinnrica" (pa^e -lliO). On account of its involving so coneidem-
ble n jwirtifin of the retina, lhi« form mny be called " nouro-retinitis."
As Iwanoff points out,' the iiitiammntion of the optic nerve which ensues
secomlarily upon inflammation of the retina (e. .v.. nephritic retinitis)
or choroid might justly and appropriately be termed " intm-*K!utar neo-
rilis."
It must be stated, however, that the distinctive characbent of these
two forms of neuritis are not often i^o stroof^ly marked, and also that
the one may pos^ over inin the other, and thus gtvi^ rine in a mixed group
of ophthiilmoscopic apjiearances. Sometimes in the 'ies^-ending neuritis,
the opacity, swelling, and rodnes^s are chiefly couhoed to the periphery
of the disk, the central portion being relntively but little involved, and
tbis has hence Wen called "peri-neuritis,"
In some cases of optic neuritis in cliildrcn^ Mr. Hutchinson has met
with a peculiar appearance of the retina in the region of the yellow spot,
vis., a group of highly refractive globules, reserabliri;; at the first glance
a cluster of spider a cgga ; tliese groups are almost symmetrical and very
deflnitc.'
When the inflntimmtory symptoms subside, the morbid prodocta be-
come gradually abfirbed, the swelling and prominence of llio jtapilla di-
miuisb, and it gradually becomes llaiiencd ; at the same titue assuiniug
" "A. f.o.. -riLa^as.
* "KI. Honatsbl.," 186S, 433.
468
DISEASES OF TBB OPTIC KBRVE.
It pnler tint, the neigliboring retina remaining perhaps a little cloaded.
The rciinnl veius diminisli in sise and tortuoitity, tjie blood uxtravKsatiouft
bccAino absorbed, the opndty of the retina disappears, and the diiik iiuiy
gradually regain a more nunnal appearance, awl vision may be re*ioreci.
As the awelliog and infiUmtion of the nerve are far more considerable
in the eagorgod papilla tliau in the descending neuritis, Uie absorption
is aUu luM rapid than in tlie Utter. In severe cases, recovery is, bow-
ever, the exception, not the nile, for the nerve generally becomes atro-
phied. Even in those cases in which vision is restored, the disk remains
somewhat opaijiie and of a pale-creamy lint. Wo arc, however, gener-
ally able fnr a long time to distingnisli the atrophy ensuing upon optic
neuritis from that which is met with in cerebral or cerebro^piaal aiuau-
rosis, and which is termed simple or pro-^resaive atrophy. In tJie atro-
phy consecutive upon optic neuritis, the outline of the disk remains
somewhat hazy and indistinct, and docw not show the clearly cut, aharjdy
defined contour so characteristic of the other form. The disk may aUw
remain somewtiat swulk'n.anil it-i whitcttott.s lacks lniu«[>arencT and lustre,
being dull and of an ojiaipie and somewhat <'n''amy tint. The retinal
reins, moreover, retain tor a long time a certain degree of dilatation and
tortuosity, but, as time pusses on, these dilferences gradually fade away,
and finally the dii^k assumes the appearance of tliat met with in simple
progressive atrophy. When the infiltrations into the optic nerve and
retina become absorbed, we often notice a slight thinning and atrophy of
tiic choroid at these points.
The disease generally affects both eyes (especially where it is due to
cerebral causes), cither ^multaneously or at a very short interval, being,
according to Bouchut, most marked in the eye corresponding to the liemi-
sphere which is must sovercly involved, if tlio cause ifi intra-orbitJii, it
is, of course, ijuite rliffit-rent. I have, however, met with an instance in
which the disease (the cause of which could not even be surmised) re-
mained entirely confined to one eye.
The sight is often greatly impaired. Sometimes, the loss of vision in
very sudden, the patient becoming pcrhajw so blind within a few hours
or days, na to be i|uitc unable to distinguish between light and dark.
But the impairment of vision does not necessarily correspond to tlic
striking morbid allerations presented by the disease; indee<l, the sight
may even tje perfectly normal in cases of marked optic neuritis.
1^ had lately a case of monocular neuritis under my cure, in which the
acuity of vision remained perfectly normal thmughout, and I hare also
seen two oaaes of optic neuritis witii iJr. Hughlings Jackson, in each of
which the patient could read No. I of Jailer; indeed. Dr. Jackson as-
sures me that sueh cases are hy no uiL'sina of unfreijnent occurrence, but
are not often oI)serveri by the oculist, simply because the latter is only
consulted when the sight is beginning to fail. Whoreaa the physiciaa
IS called in on account of some other symptom, he suspects cerebral dis-
ease, examinen the eyes with the ophtlialmodcope. diiicovers optic neuritis,
and yet finds that Uie sight \& unimpaired. Mauihner' narrates an inter-
esting case, in which a patient aftected with optic neuritis retained a
' '• Lehrbnch deF OpblliAlniosoopi^." p. 999.
INFLAlfUATtOlf OP THB OPTIC NERVB.
460
norninl noutcncss of rision tip to the time of liis death (which vaa snd-
d(!ii). The iKiBt-nKirtfm exumitiAiion rpvcntpd the existence of intcr-
«tiliul optic neuritU, hut the retina vra» healthy quite up to tltc optic
nerve.
Tiie ficW of vision is generally also more or less affected, and this is
a point of much prii;riif)Htii:: impnruiice, for, ncconliiig to Von (.iniefe.'
we ttlmost nlwajs find that, in those casL-s of optic nMiritis in whicli the
fiehl nf vi((inn i» contracted, iit least a partial atrophy of the optic nerve
nnil retina eiittue^. The pupil \s, as a rule, dilated and fllnggisji, or even
perhapA almost immovnhle. Rut, if the sight is good, it may be hanlly,
if at all, affected. The patient is often much troubled with aubjectire
appearances of light (photopaia and chromopsia), which, from tiicir
funtiutic sliapea and coiixtHut presence, may ])rove a 90urc<f of great
di))tre}w and anxiety. If the ncuritiii in due to a cerebral cause, it is
generally accompanied by more or lees marked symptoms of brain dis-
ease, such as Id^s of uwmory, giddinetta, roniitin;;, impairment of the
senHC of smell, taste, ur hciiring, opileptoid fits, paralytic affections,
severe headache, etc. The hea<lache is often very great and protracted,
the patient (teing. perhapi*, unable to localize it exactly, na it extenda
over ihc whole head. Von Gracfe calls attention to the fact that, in
cases of cerebral tumor, the poxition of the latter may soniutimus he
aacertaincr) by the acute ]iain produced by almrplv tapping with the
finger the eorrciipoiiding (Mrtion of the cranium, which aUo tcmjtorarily
incr«ai>eA the severity of the general headache.
Cdttgfu. — The engorged papilla may be caused hy morbid pmceasea
within the orbil, which give rise to great protrusion of the eye, or prea-
Huro upon ilic optic nerve, and conscqiicnily impediment of tlio circula-
tion. Amongst such causes mu^t he especially instanced tumors, and
inftammation of the [>priostoum or the cellular li&suc of the orbit. In
such cases wc oftf^n have an opi)ortunitT of wntchiag how Uic symptoms
of optic neuritis riisappear and the sight becomes re^itorc't, when the
tumor ha.H been remove<l, i.tr tliu iiitlaniiimtion ha.s sub-iided an I the eye
returned to ic? normal position.
[In "choked disk" due to orbital disease, the lesion is confined to
one eye. Though the optic disk may he intlaincd here, it is usually
compro«tsed by the growth or the exudation; but this uwy not occur
even when the growth ii« large and the exophthalmuit pronounced. In-
flammation of tlio capnule of Tenon may produce the same result by
causing thromlKMi!* of tite vcssoU of the optic nerve.
Papillitis has also been obscrveil an a result of facial erysipelas,
douhllesn through the me<lium of orbital cellulitis. Michel has reporte*!
a case of choked disk in a very young child, which was caused, as the
auioprty showed, by hyperostosis of the hones of the skull dosing or
narrowing tlie opiic foramen; and several other cases arc ou record
where atrophy resulte^l from a deformed skull (see "Arch, dcr Ucilk.,"
xiv. ; "Beitjige zur prakt. .\ugenheilk.," 11S76). — B.]
It was for a lon^ time supposed that Lbo engorged papilla is v
i|nently prt>dnced by certain cerebral affections, which cither
cry f re-
exert a
1 "Kl. MoiiJiUbl.," 1993, p. 9.
DI8BASBS or THB OPTIO SBKVB.
^
thi
IT**.
K
»'
direct prciHure upon the enrernous stnuA anil tlins impede th«
irculntioii in ttie optic ticrve and retina, or effect thiit hy ftn incrOH!^^ in
iiitru-cranial tvn^iun. It was thought that this iiupudiiiiuiit of tlie
cirnilation of the ophthnlmiu votn gives rise to mechanical con^^estion of
tht! papitla, wliich, as has been already meutioued, U 8000 follow**! by
serous inBUration, and Aubsci^ucutly by inflatamatory prolircration of tlie
connective tissue eleuieut^ of tlie optic i»«r\-o. The tendency to tftiwis in
the eirciiliLtion of Ihc nerve irt, mareover, increainod l>y the unyiehliiig'
lerotic ring, whieh, lut Graefe h&.'t happily cxpreitttt'd it, nctti here the
rt of a multiplier. But more recent researches appear to enlirel
isprove this causation of the engorged papilla. Thus Seseiuann' hi
found that the superior ophthalmic vein as well as the inferior not onli
anastomose freely with each other, but also with the facial vein. And,
although the central vein of the retina mostly empties itself directly into
tbo cavcruoui^ sinuit, it snastuiuodcs freely with the superior ophUialmtc
vein. On account of tlu^^e numerous aQastomn^c^, an ImjH-dimeut in the
cavernous sinus cannot produce iita.iis (or only a temporary onv) in tlie
retinal veiii^t, as they p'>ssess other channeU for the efflux of the vunoos
blood. The vtjry important reHearches of Schwalbe, Schmidt, antl Mans
have, however, thrown a new light n\Kni the (»ul«ject of optic neuritis in
connection with eerei>ral aifections. Schwalbt' duMX>vered that a cum-
muiiication exi^^ts hetneen the arachnoid space and the optic nerve, for
c found that fluid injected into tlie arachnoid d|>aee passed down be-
tween the external and internal stieatlis of ttie optic nerve (Schwalbe*!
subva^inal space) to the ocular extremity of ilie nerve (optic didk), whet
the tluid iKieomos collected, being unable to pass on into the eye.
Schmiih^ verified these facU by further experiments, and found, more-
over, that the injection passed into the lamina cribroaa, and hence b«-
licves that there exists in the lamina cribroaa a unnal-syBtom, whic
iinds in direct communication with the arachnoid space. *' Inct
lutra-crauial tciimon will therefore press fluid from titu arachnoid
into thid canal system. If we suppose that the latter Lt always
ith fluid, even a slight increase in this rn)m tht^ arachiKtid space will
reduce a coiK^idcnildu swellin;:, and extension of the close tiet«ork in
tbc latninn cribrojia.** These facts afTord quite a new eX|ilAnation u lu
tiie cause of the inoarceriLtion of the intra-ocular extremity of tlie optic
nerve, and it^ attendant symptoms of engorgement of the disk. If the
bydro|w of the sheath of the optic nerve iM-uouioa considerable, it pro-
duces not only a bulging ouiwai'ds of the shoalh, but aUo, pressing in-
wards upon the conienCs of the sheath (optic nerve fibres and hlood-
TeMeU). it causes an impediment in the venous ulBux. followed by
welling of the disk, dilatation and tortuosity of (be retinal vtTin^,
diminution in the 4ixe of the arteries, etc. If the liydrop» of the she&i
continues for eume time, the oedema may filter through into the roiinB^'^
and, besides the tliiiii, formed elements may pns^ through the walU of
tlie bloodvessels. Mauz' has found hydrops of tbc sheath uf (ho optic
» " AtcMv far An»lomlf>. Phymlolojrte." wc,. I«fi9. S. IM.
' "(ViilnUUftir tOr in«l. WiKwMwoban-iu," 1&G9. No. 30.
» MxiiMl. '•.^. f. O.." XV. 1, VXi.
* "Veatche* ArrhW far Kiln. UmU«1u," fr. 33!>, 18t3: vld<9 alM fab valn.lilw
Am, "A. f. O.," xvi. I, 2tfl.
INPLAMUATIOK OP THB OPTIC KERVE.
471
nerve in so many cnaes of iiitra-cmnial iliscase, that he siipposes it to be
of very frt^i^ncnt ixxurreiwe in ucrlain cerebral lesions. From ti»e alxivo
facte it viill be evident that byilropft of the Bhcntb of the optic nerve
(loading to engorj^cniont of the paitilln, etc.) may probably occur, not
only in those cerebral (liseaseA which arc acconifianied by & serous
uffttsion, hut it mny al?ui accompany intra-cranial afTcctionn (if. ,v.,
tiimora), which iucrt'»>te the intracranial t«nflion, displace tho normally
vxtatiii;; cerebral Hniil, and mm^ of this may [mss down the sheath of
ilie optic nerve (Manz). Ilenco thi« form of optic nouritiff (<*n>;or;;ed
papilla) ithouhi make lu suspect the presence of a cerebral tumor. Dut
»ut:h tumors may also prwluco simple atrophy of the optic nerve by
dircft jiressure ii|»on it ; or they may set up indammation of the
nieniiigc:), which, cxtcndiii;; to the optic ncrvo, jiivea nae to dnacendiug
iipuritis. The latter di!fcaji« \i therefore sometimca met with in cnsoa of
meningitis or arachnitia, in which the inflammuliou exUm<U to the optic
nerve, ami travels ilown to the papilla and retina. Optic neuritis has
also been met with in cases of cerebro- spinal meniuptis.' Wc may,
liowcver, have mixed fonns of optic neuntis, tn which llie phenoiuuiui
preaented hy tJie disease are partly <lnc to inflammation of the trunk of
Uio nerve, and partly to obstruction in the circulatiyii.
i Microscopical and anatomical researcheit made upon t}tc human
ivcT and experimentally upon nnimahi, have proven to the satisfaction
of most ophthiilmwlo;;iMt3 that any di!*ea8e which causes an increase of
the inlra-craiiial prpft«ur<> may exert a direct influence upt>n the optic tierve
throujjh the medium of the lymphatic spaces hclweou the shcatlis of the
optic nerve, which are directly continuous with the aulKluml and sub-
aracbnoidiil spaces in the brain. This effect upnn the oplic nerve, most
marked in the Jntro-ocular part, it* a aerous exudation into the nerve con-
8ei|uent uj>on the drnpnicul distension of tlie interva^inal space. In ad-
dition there may resnlt a real vaginitis which may lead to oldileration of
the iiilerva^rinnl Kp«u:e, ami con4Ci|uent inflnniination of Uic connective
tii-iue of the optic non-e. The distension of the Intorvaijinal space may
he Tolhiwed hy a simitar distension of the lymphatic channels within the
optic nerve, and if this condition lasts for any cntisidemhle time, it always
causes atrophy of the nerve fibres. Inflammation of the optic nerve
fthres themselves is an exceediuj'ly rare diTiease.
A few words on the exisiiri;; views of ophthalmologists as to the con-
nection hetween iutra-cninial tumorn and optic neuritis are all-inipurtant.
Brain tumors are probably t)ie most fru4ptcnt cause of choked disk. In
CUM of chronic brain disease, hUatrrtU ffntked^dUk almost alwnyi means
cither a tiimor or 8ome other mans of oxuilation in the cranial cavity.
Ann\iake has conclnded from a very Inrpc number of cases that pa]iillitia
is an almost constant symp(<*m of brain tumor. But there are exce|itioiis to
thia ride, and they are not very rare. Cases have been reported where all
the Bymptoma pointed to an intra-craoia! growth, and there was no ophthal-
modcopic evidence uf diseaac, yet the autO{K!iy revealed n tumor. The
reverse is t\Uo true, for marke<l papillitis haa cxintod in both cyca, which
>"A. f. 0.." iTll. 1,178; ana " Kl. HonaUbl.," 18«5, p. 275; Ul»o, "Aowr.
Jmtm. M«d. SdenoM." iaa. 1B7S.— B.]
D18BASES OP TUB OPTIC NBRVI
l!ie courep of the disease or an autop«y has proven to be due not to
intra<craiiial growtb, but to an orbital ;;roivtli, tiu urbiul iuUaouiistiol
or to a huflilar mcrtin<;itiA with cxttMisive oxtidatii'tii.
Furthermore lot it l»o distinctly iindcrstood tlmt tlie iiituiition of *
tumor cannot be determined wit!j any iicuiinicy by tlie pretteuw) of opttC,
iieitntis. Tumors of the cerebeltura, of the convexity of the ceronrolj
lobes, and of the base of the skull ma^ cause papilfitia. Indeed tb<
latter may by direct compression of the optic nerves or tracts lead tttj
ntrophy of the optic nerves without ever cauifing any papillitis: ihcstfj
eases are, however, rare. Moreover it ahould not l>e forgotten that)
Bri$;hrs diBcaac mny cause in tJie eye an exact picture of choked disk.
-B.]
In one cage of descending neuritis narrateil by Von Graofe,' tiie cit
cum>tcrihed basilar menin;;itiH whs found to be caused by a jM-cuHar ento
tooti, Kttuuted partly iu the ri^bt bemtBpbere and partly at the base
the cranium.
Indeed, accoHing to Dr. Hwghlings JacVaon,' who hts made so maxif
interesting and valuable regcarchea upon the affections of tlic eye met
with in cerchrnl diseases, optic neuritis may bo produced hy '' coarse"
disease of ulmoat any part of the cerebrum, or cerebtdlum. Tbict beiug
HOj I cannot do better than give the following summary of hia exiHrienc
atid views, which appeared in the Hospital Ueporta of tlic " Britisl
Medical Jounial" (March '2H, l«)i8) :—
" We now report remarks on an acute condition of the optic nerves,'"
which is followed by another kind of atrophy. It ia to I»o kept in mind
that the following remarks apply to casus of optic ncuritit* ('des<M'riding
neuritis') seen in physicians' practice, and contain an accurate, iiUh-iimb
a very brief, etatemcnt of the chief conclusiomt at which Dr. IIugbling4
Jackson has arrived. Optic neuritis from intra^^ranial disease is always
double, even when the disease giving rise to it is <{ait« limited to a single
cerebral hemisphere. Not unfre(|uenlly one eye suffem more than the
other, hut even when one ccn-bral hemisphere is alone diseased, there
docs not seem to be any constant relation betwixt the side of the brain
affected and the eye more atfected. Although, in physicians* pmctice,
the local disease causing optic neuritis is most often of the cerebral
hemisphere, it may he in part of either the cerebral or cerebellar bemii
f)herc8, or at the haae of the skull. Dr. Hughlinga Jackson has noty*
i'und optic neuriti!*, nor indeed optic atrophy of any kind, with diseas
limited to the optic tlialamus. to the pons, or tit the medulla ohiongalaj
The inira-cranial disense is almost always (YHirw'. The inlra^oranial dia
ease may be of many kinds, probably of any coarse kind. Thus I>r
Hughlinga Jack«)n has found optic neuritis with tumnr, with absces
with blood-clot, with syphilitic 'Jdeposit,* and with hydatid cyst, and al
these of the cerebral hcmiBphere. He hai not found, witli one exccj
tion, any but the most trilling unusual intra-ocular appcarancea in th<
IKFLAMUATIOH OP THE OMIO N8RVB.
473
ffhorca of ctiitdrCTi ; a disease wluch he supposes («ftf * TiOndon Uoj^piul
iU'ports,' rol. i. 1H)!4; ' Uncet," Nov. 2<[, IHIM: 'Me^}. Times aiirl
Oawtu?.' Jan. 28, IHtio) to depend, at least fre*(tieTitIy, on plugging of
fltnull 1irnncli«8 of tlie middle cerelii-al art*ry. Cliorea in children d^es
not at all events de|M>nd on cfwrw diaenHfi of the hmin. From a stipcr-
ficial point of view it i». Dr. Hughling^ .Jackrion ttiiiiks, noniewliat rttrikin<!
that luiirktvl pnlhohi^tcnt Khiiii^e? in the optic diinlc* are not unfn'iiuentljr
found with uTiilaternl iqia^in.and witli iinilflternl palnr.and scarcely ever
■with iHitlatvral irrepiilnr raovcmentB. Chorcifomi mnvemente are »oni«-
tiiacH obwrved during recovery from the 'epileptic hemiplegia' which
oeca!»ional!y occurs vrith optic iienritis. Uowevor, the real aMocifttton
is not of optic neuritis with one-sided njiaaui or jwiUy, hut with intm-
cranial coarse dlseaite, vrhirh coarse disease, when it is of one cerelirsi
heniii»phero, may produce both optic neuritis and the condition (corpus
striatum neuritis?) on which the one-siddl spasm, or |ia)>«y, or both de>
pend. We nhouhl not, he thinks — making a mistake analogous to that
the old astronomers made — consider amaurosiB, from oplic neuritiB, or the
atrophy which follows it, to be the centre fKiint of a case aminid which
all the other avniptoms 'revolve;' but rather try to find the central dis-
ease— in physicians' practice often coarse disease of one cerebral herais-
pherp — to which each of the symptoms (headache, connilsions. amauro-
sis from optic neuritis) i» cfiually subordinate. He thinkji it is not war-
rantable, even when we find a himp of syphilitic diiufa.sc in the cerebral
hemisphere post-mnrlcm, to nny that optic neuritis is 'caused by flvphilis,'
since just the fame opbihalnioscopic appearances may occur with other
sorts of 'foreign bodies* in tlie very same part of the brain. How it
happens that a foreijtn bwly in the brain sometimes 'excites' changes
about itself, and sometimes docs not, is the subject of speculations of very
different kind? into which we do ni>t now enter. Optic ncuritia doe* not
depend on A»*jt of funi-tion of the part wliich the coarse disease destrovs,
as does loss of power of intcllccliuit evprcssion (aphh^ia). Optic neuntis
requires time for iiji production, llius, although il occurs with blood-clot,
it never, in ])r. Hughlings Jackson's experience at leant, occurs with
r^rtnt hlo^d-clot. When coarse disease of one cerebral hemisphere gives
riae to headache, vomiiinjr. unilateral spasm, amauroois from optic neu-
ritin: or. let na say, to the larger uproar called 'cerebral fever,' involving
all or most uf these, the pn-'l»ability is that tlicre is but one idea thrwugh-
out, vis., a 'foreign hotly,' and changes diifuded from it in different direc-
tions, on which diffused changes the symptonw directly depend. The
most important clinical fact about ojitic neuritis is, that it may exist for
a varying tiuu- — a few .Inya, a few weeks, or a few months — without
any appurenl defect of siylit. If mmd ftr ht'-ked for in every case of
cerebral diiicaae, at all events in every case of cerebral fever. Il is
necesttary to look for it in cases of loss of speech from disease of the
hemisphere. As implied in the foregoing, it is only likely to occur in
cases where the speech defect depends on eoarat diiwaAC, let us say on a
large clot, and then only »ome time after the seizure. A blorMl-dot
caufien Io«B of speech as a destroyer of an elalmrate structure, and sub-
ftcfiucntly optic neuritis in ita character as a foreign body. However,
optic neuritis is rarely associated witli blood-clot."
474
DISBASKB OP TUB OPTIC NBRVB.
[Hemorrhages nt the base of the brain maj caaae mnnoUteral or tri*
lateral pft|>iiyiti8 by the blixwl [fflsrtiiig ilirectly into Uie iiitervasiiial upace.
Oervlinil alwccss is not infrc<|iieiitly faiinil in cases of rloiiblo papil-
litU, but usuitlly there is an injury to the vault of th« skull in these
cases.
Though *' choked diak*' occura in hwilar twningitiii, whether tnii-
mntic or dpontancoue, it is eifpecially common in tiibercuUr uieningiti*,
lievt'Ioi'iiij; sometimeB within a few rtnys, hut rarely Ti;a«bimr a hiefa
lU'-irof of swclliu;! of the disk. In xomc CH*e*, when there was no |iaul-
litis, tlie autopsy itrvealud ilro|»jy of the alieaih of the optic nur\"e, vrhicb
accounieil for the Iima of viAion. Cases of choked disk from meniii^tu
of the convexity fotlowinji injury have also beon reported. (See " Amcr.
Jouni. >lcd. Sciences." Oct«ltor, IK'T.)
In hydrooeplmliis intemiLS pnpillitia bnA Komecinieii been met with, and
it aliuujl alwftyii ymis in atrophy of the nenv. Usually, however, the
leaion of the optic nerve is a simple atrophy in tliin diaeaae from the
heginnini;;. (See " Graefo und Saemisch,'* I. c. p. T?o.')— B.]
Heueiliki' couHiderit that, bcitidc the optic neuritis which may be pro*
duccl by mechanical moans (i. «!., hy an obstruction to the circuladoD
producing ttie en'^ir^ud papilla), and thai due to a descending tntinnuna-
tion of the optic nerve, we miHt dislin-^uish a third form, in which tlic
cerebral affection lies altogether out of the course of the optic ner\'L*. In
such ca^ea, the symptomatic optic neuritis itf due to neurosis of tlie v«m>-
moLor nerves, causing hyperajmia and swelling of the optic nervo. He
point* out aUo that widely extendinjj and pcrioilical aymptonw (f-ii-i
intense heailachc, Itv-t^ of consciousneds, paralysis, amblynpia, amaurosis,
etc.*), wliicli often apjiear diirinj; the dovvlopment of a cerebral tumor
and eorres|H>ncl to itH more rapid t^niwth, are not duo to direct irritation
produced by the tumor on eontijcuous parts, but to wide-spread byjwr-
reroia and iiwellin}; dependent nii neurosis of the sympathetic fibre*, or.
So to ri|M?ak, a Iwal fever. It is just in these cadee of sympioiualic Ufuro-
rctinitis due to neurosis of the 9ym|>athetic, that Ikiiidikt has often
found great bcnetit from galvanism of the sympathetic nvrve. This
Uiuury of Itenedikt's receives some 8upt>ort from Leber's* observatioUf
that an optic nerveVhicb seems to the naked eye to be perfectly healthy,
may show, on iDicmscopIc examination, very marked pnthologtcal oliaojjea,
such as interstitial neuritis and ]»enneuritis, fatty degeneratiun of the
bundles of nerve Bbres, etc. Now as he has, nwreover, met with Mtme
of tliese clian};eit in cases of tpiite rnvni o)itio neuritis, iu which it was
im|M>ssibIe to aAsiiine that the iuHamtnatory process had ascended from
within the eye to the optic nerve, and the mechanical theory of the cau-
sation could not, therefore, hold good, I^ber thinks that *' in ibcm no
Other explanation is possible than that which has been alreitdy itointe*!
out by Ileneilikt, vis., that cerebral aflfoctious in p-'ueml miiy cause
direct intiiimmaiory changes in the optic nerve and papilla throu<;h irri-
tation of certain nerve-paths (Merreu-bahnoii J which are still unknown
to us."
I VMo n.-n«1ikl'> " KUetroth«nipiir." u. 2A3.
> '• Kl. Muusut^l.,*- lll«9, p. 302.
IMPtAMUATIOR OF TUB OPTIO IfSHVS.
475
Dr. Korraann Pasonstet'^^icr >M;lieve*' " l)ia( the irriution conveyed
thruu;i[i liie iiervv-tract uf the HTtnpatlietic to the di'tic, itiduc«s tbe
change's nf tJie nerve-Hbres, the hyperjemm, ami even tlie development of
new vc«4e]», ami in tliis manner, a swelliu); and ctouiIiiieM of tlic di«1c
Bod the adjiicont parts of the retina are lirfm;;ht aliouc. The latter tnjiy
then for its purt bavo as a coiiHp<|iii'nco an extreme degree of coit^^e^tjon
of the venous B_vsteiu of the retina."
[In many caries, perhaptt the majority, of nenro-retimtis with choked
di«K, and al!K> in cn»e& of descending neuritis, perineuritis ia also present.
The inLerva^final iipace beeotne^ His(rnded witli a cloudy^ celltdar fluid,
and the nhentha themwlve* infiltrated witli Ivniphoid cells. The imer-
titiat cuunective franie-worlt of the optic nerve ia kouu iuvolved. and
ecomes liypertr<iphied,and the cells and nuclei proltfcrate. 'X'hid la the
Hsual rei»tilt when the cause lias been periostitis of the orbit.
lA'licTr hUo sp4>akB of a niodullary neuritis which rebuild in dostructioD
of the medulla by fatty dej^cneration, and the proco8>i cndd in f^ay atro-
p]iy. Cliuicully this variety ofiiptic nerve iiiflninmation is not to be iii&-
tiajruinhed from other forrn^. and it U mainly interestinj; patlioU>j;icnlly.
Thi» form nf dtf^eneration has been traced back uf tlie chiasm a* far as
the corpus ^eniculatum. This inflammatjon mij^i ari^c from dropey of
tlie nhi-ath, or from meningeal inflammation, or be caused by any intra*
oraiiial proce««,but thnmgh the medium, probably, of an interstitial tiou-
ritis. This dcf^eiieniliou may affect the chiasm and optic Iracw. and
leave the optic nerve iiself untouched. Some authors roeution amon;^
the \aricticK of neuriti-s without ophthalmoscopic t^ign, the rheuoiatic,
and thift always aflfecta both eyen.
Among children, ueuroretinitis, with all the si^^s of choked disk in
one or both eyea, is aometimea met with, in which it is impossible to dele^
mine any cause ; the patients bein;; and remaining otherwise perfectly
well. In the-ie oaeea the prouiiosis ii^ bad. — B.]
Itut we 5f>metimes meet with c&acil of 0|>tic neuritis, in which it is (|uite
imfHiAstble to detect any cause or any impairment of the health, except,
perhaps, some deranjiement of the uterine functions, f, g. in^ufficieocy
of the catamenia. I have seen iieveral instam'en of thi-i kind in young
And <lelicate lemHles. who otherwise enjoyed perfect health. Such caaes
recover completely, if they arc seen at the outset of the dinease, and
are actively and efficiently treated. [The neuritis in these ca:>e(t umy be
caused either by a sudden cessation of the meni^trual flow during a period,
or by a iion-apjtea ranee of tJie flow at the usual period, or, Bnally, by a
condition of metrorrhagia. 'ITiese cases of neuritis are generally accom-
panied by headache with heat and fulness in tlto head, and -(omctimes bv
graver cerebral symptoms. At the climacteric perio.1, alio, ncuro-reti*
uitis with choked di^k its occasionully met with, and Mooren cluinia to
have seen it in cases of uterine displacement, ami states that with the
cure of the uterine difficulty the nearitiit disappears. (See '* Opbthal.,"
Mettheil, 1874.) 'I*he prognosis in all these cases depends upon tiie res-
toration of the mcnstnial function promptly, and rocnna should be taken
lo that end. Where the process is a chronic one, Leber advises a seton
• Vidr bis valiuUtt u-UdIo, " R. L. 0. II. Reports," rel. vlt. part S, Vi&.
476
DISEABRS OP TUB OPTtC HERVB.
in the temple and Iceclics to the nasal septum ; and Mooren advises ired
applications to the head. — B.] Mr. Ilulke, in an itit«re«tJnj{ (Ji]*r on
optic neuritis,' narraica t^uch coautt, and also oilicra, in wbich Jt oocurred
in connection witli diphtheria, rheumatic fever, etc.
To prove th«t the diittinetioii hBtwi-on tlic enjrorj^ed jiapiUA and the
dcftconditij; nciiriti.-i '\<t not a thi-nreticnl or .irhitrnry otie, we need only
pa_V attention to the difTerences in tlie anatomical chan;**.';* met with iii
these two torme. In the enj^orged paj;iila, tlie intiamraatary chatifjcs are
jjenprally chiefly confined to the intra-ocular end of the optic nerve, ami
do not, as Q nde, extend backvrarda bevond the lamina cribroiia. although
the intimate structure of tlie latter Is often greatly changed, atxl its char-
acteristic features rendered indistinct.* Mauthm-i* lias seen some pr»'p.
amtion^ of Iwanoff^K, in which the prolifcnitiori of the connective tissue,
instead of Rtoppinj; »hort at the latntna cribrosa, had extended sctmewhat
along the trunk of the nerve, and had thus given rise to aMeodiog
neuntin.
In descending nenrili^, Virchow* found that, besides hypcrtniphy n(
the vessels and increa.se in the width of the nerve fibre;*, tlie whole trunk
of the nerve had undergone inflammatory chants. The neurilemma waa
thickened, and showed cysloid detachments. Besides this i)eri-neuHti4,
the elenicnta of the inceratiiial connective titu«ue liad underj^ne prolife-
ration, producin;^ dejicnemtion and de.itnicuon of the nerve tubule*."
The proytumf must in all vamni be extremely doubtful and jiuardcd,
and in the great majority unfavorable, for, aa a rule, optic neuritiii omla
in more or less complete atrophy of the nerve and loss of sight. Beside*
the (|nestit>n of vision, it must also be remembereil that there arises the
still more important one of life, for but too rre<|ucntly optic neuritis is
caused by most dangerous and incurable alfeciions of tJie brsin. The
must favorable caaes are thoite in whteh the diMase is due to some tcm-
f orary and relievable cause, audi a* irrejiularities in thecatamenia, etc.,
or a tumor or intlanimatinn in tlie orbit. Itut even in the^c, the morbid
changes in the optie nerve may have been ao great a« to prevent any
restitution ati iHtr'jrum. and the end ia, more or leas atrophy of the
nerve. On the whole, the cases in which the progress of tlie disease
and the luss of sight have been very rapid, aft'ord a more favorable prog-
nosis than thn^e in which they have been slow and gradual. In the
former instance, a perfect recovery mnv result, even although all (|nan-
t)t.it)ve perception of light has bven temporarilv lost.* According to
Von Graefc, the prognosis is al.-to more tavorablc in cliitdrcn than in
adults. The condition of the i>npi1, with n^gard to its reacting or not
on the admiri^ion of light, tut of no im|X)rtauce in the prognosis.
With regani to tlie trmtmruty we can only lay down general rules, as
it muift bo varied acconiing to the nature of the cause and the exigt-neies
and peculiarities of individual ctutes. If the disease is seeu at tlif out-
«
■ Sobweifi^ Vorlaenngou, P* 13<>*
• "B. L. O. 11. R^p.," vi. 3.
* " Lt-ltr)>uch dt-r 0|)litli»luio(MW{>fv," p. 3^,
* "A. f.O.,'' lii. 2. 117.
• Vld«*lMDr. Ubt-ts iiHtfrpfllinc imiwronOplic Nmrilb, "A.f.O.," )tl». 2. 33.1.
■ " A. r. n.," xi\. 'J,, 133: villi* alxn H «t\*'- uf ititK kind reported tiv IlinoliWrg ia
IW " Korltiivr GUaiwili« Wocbeiuwrin," t^oplcmlxT 111, \S0.
ISFLAMUATtON OP THE OPTIC KEKVE.
47T
«etf the patient shoulil be placcrl as doon as {xiesihle uniier th« influence
of luen-'ury (iiiuiictioii). If tho pntioiit is deliaito, tonics fttiouM lie at
die i&me time ad minis tert'd- I liftve Hf-veral uuia ohserved ih&t tins
Uuc of treattiieut has exerted a markcdlj^ favorable iiiHueiice upon tli«
prnpi.>MA n( the disease and the mor)>i<l eHuBioii, tlte absorption of which
it Lasteua and facilitates. This is es]>e<:iallT the case when tlie disease
occnra without any spisiial Jntra-orbital or cerebral cause, as in Fcmalea
gaffering from dcrangcuiful of the uterine functions, or persona affected
with the i«unpreraion of some customary discharj^e, or great inaction of
the skin. In some of theitc caites I hnvc »ccn a complete recovery re>
suiting from the combined influence of mercury and the local appHcatioa
of the nrltticiul leecli. The action of the ttkin should be stimulated by
diaphoreticit, and, if the patient will submit to it, a cnuHe of treatment
by Zittmanu's decoction, which proves especially benelicial in syphilitic
eafiUd. If tlie disease is not seen till a later sta^e, when permanent
changes in the nerve have already occurred, I do not t)iiiik thai any
bencht will be derived from mlivation, and should prefer the administra-
tion of small dodca of the bichloride of mercury, perhaps in combination
with the iodide and bromide of potawium.
The severe and often very violent pain in the head, with which Uio
patienlii ar« frctpicntly aflVcted when the discAi^c de[)endjt upon a cere-
bral lenion, is generally relieved by a suppurating blister, or^ still better,
a acton in the naffc of the neck.
To alleviate the congestion of Uie optic nerve and retina, the artificial
leeeh should be appUetl several timea, at intervals of a few days, but
l^h<ll|ll] [hen lie desisteil froui if no benefit re;«ult3. If the patient is weak
and delicate, dry cup|)in;; should hu substituted.
tialvaniuation of the KymjMkthctic by means of the continuous current
may also be tried ; it is strongly recommended by Benedikt. [This
mothiKl haa been tried by numerous observers, but there are no recorda
of any favorable results, and it is now practically given up. — B.]
The fact that hydrops of the sheath of the optic nerve has been so
ofU'u found in pott-mortem examination of cases of optic neuritis, has led
De AVecker to suggest incision of the optic nen-e in such Ciwcs.' For
be believes that acconling u> the theory of Sshwalbe and Schmidt there
are two tndicntionii to be fulfilled: 1, to give eiit to the accumulation
of the cerelirai fluid by making an incision iuto the external coat of the
opiic nerve ; 2, to relieve stningulntion of the nerve by incisin;^ tlie
sclerotic ring at the point where it forms the junction of tlio .sheath with
the extenial enveloping membrane of the eye. lie thus hopes to re-
lieve the symptoms of compression, not only of the nerve itself^ but also
tlioae of the cerebral centres (headache, etc.). lie tried it first on the
dead body, and then in iwn patients. The operotion was performed
thus: An incision was made between the external and inferior rcctiu
miudc about one centimetre from the cornea. Tht^u, cutting through the
conjunctiva and subconjunctival tissue, a pair of sciisors (closed) are to
penetrate botwoen the eyeball and capsule of tenon uutil the optic nerve
IS reached. A spatula is then to be introduced and the eyeball dis*
■ Inicrnxlionfll Opltl1i«liiM>lo(lcal Cuojrcga. LaixIou. 1672>
ii^
ar TiiR opTio
AAer the diiiplaccnH^nt r>E ^
Ae <ii»ternle«l nerve, aihI fv7 _^
amUnmtDi sptciallv niade tor th^^
k of the optic nerve and scl*^f\^
b*ing prMt^ed from beliiiir/ ^'^'^
imrodiicing die finger iin to t" ^,
tfte iietntment in its proper positton- j
;h the flight <loc« not seem to ''"^'^f-/
Rficf of the inteiiM* hcadnche, enpevi*"'-
wai papillitis are aIao met with in avpliilitic
-^■^tfcl and norjuirpd pyfihilis. It mav htf enti
fkull, and is generally a papiltitU. Tlii» i-^
_ l_v from so-callnl neuritis svphilittca, in
MpDitid, ttut ill which the main change iit a
of both optic uervea back U> the chia,'^
•^ ^» «» -tfim V*et>. In rtome cases the Ktnrting point of
i) gumma which has grown iiilu the optic tt
of inflammation cannot bu distinguished from '
correctlj speaking there is no such dise
mt^liB^ The prognosis is rao<leratelv favonihle if trua'
«Bfy «B*agh, but if not the tendency is to atrophy
wm vvparted cases of hereditary nouritifl opticft, both
^Kk IMU9 Mhar. It manifesci itself luuAtly after p
a cause is, however, not common. It Httnc
■f K fusily almost exclusiveiy. In m»ny of the^c pa
5TiB[rtoms of nervous disorder, lloth eyes are i
tke' vision ta usually markedly interfered with. la
cctttnl vision remains permanently aholiahed. but eca
llv restored if treatment i& rctiorted to in time. 1*ha
IP apecial treatment indicated in these caacs. (See f]
01^ I. 0. p. HU. "Archir. f. Uplithal..*' xvii. 1
fwhr nr bc»d of optic neuritis Von Graefe' has called atteuti
«^h there was an extremely sudden loss of sight, thv p|
without snv clearly defined cause, so absolutely blind fi
a few hours as to be unable to di^tinjiuish between ligbj
^^tmffs. Ue says: " After ccnstitutiounl diwaBcs of different
^Jl»rved iC occurring aft*r measles, febrile gastric catarr
I, but without any marked disturbance of tbe general bcall
•f Vision becomes clouded, with or without the presence of
and photoptiia, and within the course of a few hours orj
f blindness ensocn. Both eyes are generally symraotH
^tltttd, and only in a single case have 1 seen tliu disease confioj
OW tTf . This case, however, presented some slightly irregular cV
wnu * The puml geucmlly beci>med uuuAually dilated, and ijuite it
•» the stimulua of lighl> rvtaining hut a slight degree of mobility
•*Ar«hi»r. 0^-xU.''.13«.
rNFLAMMATIOEt Or TUB OfTIC NBBVB. 479
the Tnovementti of the eye or the iniputsc of MComnKvIation. Tlipre is,
therefore, reason to assume tlie exMlence of a special Dtntti of irriuition
in the fibres of the i^ynifinthetic. With the ophthalmoscope ma^' bo ob>
served undoubted, though not verjr conspicuous, chnnges Id tlie pnjiilla,
which are, however, ot a markedly transitory character. Its tisitue ia
veiled \>y a dflicate, difl'use opncitj, as is also the neighboring retina,
the level of the disk i», however, hardly rairted, or onljf- in a ver^v slight
degree, and only for ii few days. Tiie arierios are narroMn'ii, hut by
preMib]); upon the eye we can still Kuoceed in producing a flight piilsn-
QOD (the surest sign of t)ie existence of a continuous circulation),' the
veins are dilated and tortuous, but their course is toleruhly regular on
account of the hut flight oi^city of the risiauca." Von Uraefe nnrriites
four cases of this kind, lu two, a complete recovery occurred, altlioui^h
there had fR-en absidute loss of even quantitative perception of light for
eome little time. In another case, the absolute blindness couttuited, and
tho disease passed over into rapid atrophy of cho nerve. In the foorth,
there was incomplete recovery with |:>artiiil atrophy.
Von t.Jraefe considers that iu all proliahility ttivse were caaes of retro-
ocnlar neuritis, llie swelling and dittuse ojmcity being due to nn intersli-
tial serous infiltration (tetlema). Tbe ditii.-iijnce between this form and
the descending neuritis consists principally in this, that the more marked
tissue ultemiions do not extend to the papilla, that the disease occurs
only at certain points, and does not involve coatiuuotislv the whole trunk
of tiie nerve. In fact, the degree of iiiflam million is only very ra*Mlernte,
and the disease but seldom depends u]>on grave intra-cranifil lesions.
[Ketro-bulbar neuritii4 is now reuogiii^tud by all ophtbaluiidcigistH. It is
chronic, at first has no opbtbnimoscopic symptoms, but generally ends in
partial discoloratiou of the papdta and limitation of central vision, and
in almost always bilateral. — It.]
Von Oraefe thinks, moreover, that certain cases of iscliremia rctinte,
u also perhaps of embolism of the central artery of the retina, may
hare been in reality instancca of retro-ocular neuritis.
Tbe cases of circumscribed central acotoma (interruption of the visual
field) combined with amblyopia, which arc imt unfret[uent]y met with,
would appear from recent researches, more especially those of Leber,'
to be generally due to retro ocular neuritis, the inHatnmation being situ-
ated in that portion of tbe nerve which lies between the eyeball iind the
commissure. From this category must, of course, be excluded (he aco-
*
' If x tlin>ml<u> lu th« ixntrAl attory of Ike rvtinu liaa pmduoKl iBchirtuiii of tlio
retina, th« arli-rli-A ol tlir iuwt trill kIso tir< exxtviuviy nnutll, but rvm a iioniil(lcr«bltfi
prvsiure uii tlin i-j-i-lialt trilli tli« llii|;rr urill iiul bum-ithI lu nrmlucliig artrria) piiUa-
t^l^ or euift^rliig ol ilia BCturxm. With fL-f^anl lo till* suDjevi, Von Oriicf« »iy» at
anolb«r pUce: "If, litgrllirr willt a ttnt vnnoiii efflux, iliroinlinnU fXHiurn in thA
rwgWio of tli« lainiiiA cribr'D^ or ti,.|iliiil it, irti riiMut HXiwi-t lo Hd'I tlir r«liiiitl nrtormi
Dpiv. Hut If l)u* Tution* offluiL liaa bv«ii luiixvlivl hy tlie «vrlliiiK of ttii^ iImsumi,
tbvr limiiluiiroasly ur .tt an i-Arli.-r daw, thn nrti-ili-it iimj rHunlii )>ArtiikU>- Ullnt,
11 va Ihv vllirr hand pmsurv upon tlin v.V'ftiBtl wilt iipI pnuJucv ihv uttiml pli«-
ooibt^iia, nn Bnumnt of tbir itloppagv In the Indni of ihu blood," (" Ar«h. f. 0.." xll.
a, IH nol.-.>
■ Vidv L«lnr'B tvty vilaable and hitvri-Ktlng papi-mn CoIvr-lMindnosii in cvrlain
DUeaJB* of Ihi.' Kyv ("A. (. O." xt. 3, 26). in vrliub Uu giw* a fall and trxtwllvut
doMriplioQ of Uib luno of aiiiitljvpla.
AS
DISEABBS OP TSB OPTIO NBBt'lt.
toraata which arc due to changes m the external layeni of the retina m
the ri.>;:imi of iJte yellow sjiot. Acconiin;^ tn LvWr, Ux* lUsoaHe ia espe-
cial!}' i'haract« fixed hy the following iiyniptonts. At the very outnet,
there are rre((iiently no abnormal oiibthalmo^copic symptonis, exceptiu^;
porbapii a certain degree of hjrpenemia of the optic disk ood retina,
soon* however, a faint, somewhat striated cloudiness aiipears at the nur-
gin nf the diAk, extotiiling more or leiu on to the neighlKirin;; portioti of
the retina, and resembling somcwhal the opacity met with In syptiihlic
retiiiiiJ8. Small, white, ofubpie otriie uro noticeu nn the dij^k. envelop-
ing and hilling the point of exit of the vesftcU, and extending )>erhapi
aotnewhat along their walb on to the retina, 'i'ht.'se opai^ue striie are.
according to Von Graefe, esftccially pathognomonic of the existence of
rotro-ocnlar neuritis. [So-cnlled " penvaM;u]ids retinie/' — It.] Her»*
and there small extra vasatjoua of blood may be strewn about on ibt
retina in the vicinity of the disk. At a lat^T period, hut in some oases
ev«u lulwraldy early, a white or faintly bluish discoloration of the n|ftic
disk HU|terYeneH, which almost alwarn remains conHned to the outer lialF
of the disk, reaching closer up to the edge of the latter than a pliyitio-
logical oxcitvation. Whilst the outer half of tlie disk becomes bhiDohed«
the inner retains it^ red tint, and thi9 is very chantctcristic of e«iitrml
scotoma. The diiense, which m a rule atUick* both eyes, oiiher giroul-
laneously or at a short inten'al, generally becomes gradually tlevctoped,
prngri'^ini; slowly but steadily for weeks or months, during which time
the partial discoloration of the disk becomes more and more pronouoced,
and then remnin?i Ktationnry. Sometimes, however, Uic attack is very
auddeii. the ;ilTeeU<m rvacliiug its acme in the course of a few tUys.
This is vtspeeiully tlie case in tlie aniblyo|ii» of drunkards. The degree
of impairment of vision varies, but, as a ndc. a medium amount of sight
remains. The disease is nlmo«)t entirely conlincd to adulta and men,
being especially met with in drunkards, heavy smokers, or persons who
an.' much cxpowd to cold and wet, such as gamekeejiers, engine driven,
etc. Out of 60 ciwes whieh T^'bcr observud, ho only met with it ibrec
times in women. It is probably in most inittimees due to rctro-oenlar
ncuiitii^; but often aU), especially in tbose cases which occur in dnink-
ardu, it is simply produce<l by liyiK>nemia, ihi.s causing a disturbance in
the nutrition of Ute twrve elements, which may gradually imluce ulropluo
change.t.
[The color-*cotonm resembles that in the ordinary form of acquired
color-blindneiii. TliL-re is no ciinstaiit relation existing between Ibo
amouui of central vli^ion and the degree of color- hlindne:^. 'iliere may
be an extensive central color-scotoma with slight amblyopia, and markfd
amblyopia with uo disturbance of the oolor-Mu«c at alt. The form of
the colo^8Crtto^ul is generally a horitontAl nval. These paUeitta wee
bettor in a mo-lcrnle li;jlit than in a bright one, The rttinitit Htfrl'th*-
pirn of Arlt is probably the same disease as retro-bulbar Douritu.
]A*ber offers the follnniug explanation of this scotoma. Aasuow that
tlie fibres which supply tlie maculn and apace between it and the optic
disk lie next each otlicr in the optic nerve ; ilie discoloradon of the teio-
|K<ni| half of the disk proves that they are situated in this part of the
nerve. .Now these fibres which end around the nerve and in the macola
ATROfUV OF TUB OPTIO NERVB.
481
ran in th« optic nerve ntxt the shenth, while those which supply the
aoteiior part of the retina run in the centre of the opcio nerve. This in
a settled anatomical fact, ilcncc the central scotomuta occorring in dia<
easetf of the optic nerve are due to an isolated le«ton of the bundles of
fibres next ihc sheath, vhich would naturally and erutily result from an
ititlammation of the sheath. This putholoj^iciil r.ondition is not an nn-
common find in microecopic cxiiniinalinns of uptic nerves. The shnpe of
die Hcouimii, A horiKontal ovitl, lichcr tliiiilc-i is due tOAHf>ecinl participation
of tlie fibres of the fasciculus cruciatus which supply the corresponding
lart of the outer half of the retina. Theae fibres, as demonstrated by
Ueliretcb and Michel, paa^ in a horirontal direction outwards, while the
fibres of the other fasciculus run in an ohli<]uc direction upwardd and
outwania, curve r^jund the region of the macula and then run in the
liorii'mtal meridian. An atropiiy of theae bundles of fibres would cauito
a marked discoloration of the outer half of the- i>apilla. (See " Bericht
dvr Wiener Aujjicnklinilc," 186t>, pp. 125-132 ; " Graefe u. Saemiech, I.
c." p. 834.)— U.1
Leber' has found that the appreciation of colors 19 more or leas im-
paired in all casfi< of central scotoma, for in 31 cases in which he made
an accurate investigation upon this ]>oint. it was deleriomted in all. In
some instinces, the color blindness ltd to the detection of a scotoma,
which waa unapiureut by the usual modes of examination. In the
slighter caees, red c-»inld not Iw a|i[ircciated; in the severer, the appre*
claiinii of Colors gradvially dintinishi;<l more and more from the red to
tlie violet end of the spectnnn, just ils occurs in atrophy of llie optic
nerve. The treatment must consist in local depletion bv the artificial
leech, the u^e of stimulant foot-baths, perliajH altio the Turkish bath,tlic
internal administration of iodide of [Mtjuwium, or of tonica if the patient
is feeble and his constitution much shattered. The most stringent rules
must also be enforceil as to the nu)de of life, and the abHtiuence fnnu
tobacco, stimulants, and debauehery of every kind. The profjno^is mn^t
be guarded, but even in the severer cases need not be absolutely bad^
for the disease due«4 not lead to complete blindness, if the field of vision
remaius unimpaired for some length of time (Von Graefe).
3— ATHOl'UY OF THE OraC NKIIVE (riale VI., Figs, 11 and 12).
I shall here confine myself to ft description of the \'ariou3 ophtbat-
moscopie aymptouM presented by different forma of atrophy of the opUc
nervt.', and reserve the confide rjiliim of the causes, progniww, and course
of this disease until we come to treat of tlic amblyopic and amaurotic
aflections of the eye.
8ome observers hare thou;;ht that the atrophic chati^s in thu opdc
nerve are mually ushered in by a well-marked byiieraeoiic condition of
the pa|Hlla. (Ireat care is, liowcvor, r,!i|mred, not to mistake physio-
logical [K-cnlijiritietf in the color of the disk as being of pathological
imj^Mirt. Thus, at has been already slated, the naeal side of the disk is ofu-n
considerably redder tlian the outer side, its edge being thcrefora alightly
> " A. f. O.." XT. 3, TO.
31
48S
OISBASGS OP TUB OPT[C NBHVB.
indifltitict : fttiit jot this ia r|uilc n phj:<io1oj;tcnl Appearance. In the
amlilV'iiia depcnilcnt ti|H>n irrej;iilaritieft (congestion) in the ccroViral
circiiliitioti, livpLTieniiH of the jmiolla is uftvu tsveu, us also after pro-
lon^c-rl stnuninj*; of the aecommoilntion ; but I <1o twtt tliirik that, B') a
rule, it is met witli as a premonitory 8la|;c of the primary, progreMin*
atrophy of the optic nerve. The more intimate anaiomicnl nature of
the simple, progrOMive adopliy of tlie optic nerve is still very iloubtfiil.
Same observer* believe that there exisij* a primnry tita^c of irriuvtion
in t))C interfltittnl cellular Uttfiue, which leads aecondarily to the tliiuip-
pearanee of the conducting nerve elements. In favor of this view
miglii he urgeii tliu symptoma which not nnrre(pu*nilv occur in tlie pro-
gress of the (Jisease, e. if., pairn* in the head, uncniisciousness, etc. But
neither in amsuro!ji» nor in tabes dorsnlis doet* there appear to be in-
flaniiiiation of the cellular tiac«ue of the nervet), in the ordinsry sense of
the word.'
The oi)htbalnios.i;opic syraptoma which especially chanictcnM atrophy
of tlio optic nerve arc a pale, white or blnish-whiic discoloration of the
[tiipilla, iliuiiiiution in Itie cnlibre and number of the little nutritive blood-
vCKAidn upon the expanau of the ilisk, alienuaiinn of the retinal ve^ela,
more ci^pecially the arteries, and rrei|UC-ntly a [fcculiar excavation v( the
optic nerve.
In atrophy of the optic nerve (more especially the fonns met with in
cerebral or cerebro-spiual amaurosis) the papilla doeu not present Uie
normal, jirayish-pink tint, but looks pale and white. Sometimes, this
whiteness ia so great as to cause the Msk to roacrable a piece of sroootli
uhite |ui.|aT, Init there in fn><|ueiitly a bluish-white ur };reeni#h reficx,
yifldinj; it peculiar lustre. In the former ca^o, the plane of the disk u
quite level, and the dead white color is chiedy due tM tlie atrophy of
trie ncr^-c tissue, and the hypertrophy and thickening of tlie oonneutire
tissue elements of the ■ner^'c. The bluish-white reflex is, on tJie otJier hand,
due to changes in the nerve tubules between the meshes of the lamina
uribrusB, which render the details of the latter peculiarly distinct. In
such cases there is always excavation of the nerve. \ ery frequently
these two conditions coexist, so that we have a shallow excavation, with
the details of the lamina crihrosa only partially exposed, the oihor por-
tion buiug covered by a Uuck layer of couueclive tissue (Oraefe).
Beside!^ being nali' ami dirtcolorcd, the (lixk hait n\m lost its trans-
parency and peonliar cleametis of tint, m that the retinal vciucU cannot
be distinctly tniced passing into the substance of the papilla. Altbougb
the outline of the disk may be somewhat irregular in slinpe, it is very
clearly and sharply deOtied, and the choroidal rinjj appears unusually
distinct. The size of the papilla may also seem to be somewhat dimin-
ished, hut not much Importance should be attached to tliis symptom,
nhich id, mnri'over, often duu 10 causes situated in the refraction of the
eye. The hlui-'^h, or bluisli-;!rcen tint is often met with in cases of spiaal
hniaurosii, of which iudeed some authors consider it almost pathogno-
monic.'
' Vidn (Irarfr'a Leulurei. on .AmantmU, "Kl. M.," 1866, p. 157.
• Msullmi^r •.■all* Kll4'iiliiiii («• ili«f Mup or blu i>h-i[rei>n dtniviinratian nf tho pajiilU,
wlilvh w«H flml (t«fecrllK<l Ijjt itgrr, but dorri not oanetder Uut it \a pathcgaviuiiDiv v(
ATROI'HV OF THB OPTIC NBRVB.
48&
The retinal ve^n^U arc (^nornllj dimin^hcd in fitEC, and oft«n con>
sidei-alil^ BO. The little hloodveKKels ufHui the d\nk are attvuunu^il or
hav(! rlidanpcared, atid thiit of course aUo tends ntill more to blanch the
pa(iilla. The retinal arteries are often so narrow, a« to reiiemhlc iuinnt«
threads, being hardly troceahle upon the retina at some little distance;
from the di»k, hiit their f>riiici|>al trunks can cencr»lty he easily recog.'
iiizcd u|>oii the pa|itlla. Tlit- retina] vcina arc mostly ulsct somewhat
diminished in ealihrc, hut to a Icha extent than the arterieH. We. how-
ever, sumtftimes meet with cases of clirouic, complete amaurosis with
■*ell-mar1tcd syroplnms of nerve atrophy, and yet the principal retinal
ttcwels retain tlicirnormal diameter. The most marked attenniition of
[the Tesacl is seen iu cases of atrophy conse<]uent upon reliuttia or cho-
f^Tiiido-relinitid.
Whilst the ahove are the symptoms presented hy progTesaive atrophy
of the optic nerve, the form of atrophy which is oonHevutivc ufion o[itic
neuritiii ratainit for a lonj; lime special characteristic peculiarities, which
rnerally enahte up to disttn}ruit:>h it i'n>ui the former kind, and aUo frot
liat which enaues uixm pctinitis ])ii!menni!fa, etc. Kitially, however,^
thexp distinctive characleristics gradually fade away, and it aasiiroee tJie
appearance of ])ro«ressive cerebral atrophy. In the earlier sta;^e. it ia
chieflv distinguished from the latter by the fact that the papilla remains
slightly swollen, havin;* n dull and opaque, grayish-white, faintly clouded
appearance. Ita outline, moreover, i« not sharply defined, but uneven
Lftlid indistiiH!t, pa-iiting over j:radii»11v and almost insensibly intd the
rfsintly clouchi^l nrtina. so that the di-ok a)i[ieant Kurroiiinled by a Hli^lit
bain. Tlio retinal veins al^o n'main somewhat dilated, veiled, and
tortuous. Sometimes we may ilistiuctly follow the atrophic chan^t*''* 'i>
one portion of the papilla. wliiUt the other still retiuins the |teculiar char-
acters of nenritis. Theite np{>earancea aK well illustrated in IJehreich's
Atlaa, Plate XL. Fi>;s. J* and H.
1 roust here call mtt-mion to the fact that Mr. Word«worth, Mr. Hutch-
inson, and some other oh-iervers, consider that a ^leculiar and uharacter-
tstie form of atrophy of the optic nerve is mot with in tobacco amaurosis.
Mr. Ilntchinnon, in a paper on Tolwcco Aranurosis rend hcfore the
Koy. Med. and Chir. Society,' says : *• The ewes which form the subject
of this paper are recognized by the loss of vascnlar supply to the optic
nerve itself. There is not usually much diminution in the sire of thu vws-
seU which supply the retina, and often these remain of gowl size when
tlie neni'o itifclf is as white as paper. The first stage (one which is
tisually very transitory, and perhaiw often altogether ountted) is one of
congL'siion, during which the dink IfKika too red. Then follows pallor of
the outer half of the nerve disk, that part which ia nearest to the yel.
low npot. During these stages the patient complains of dimtiesd of vision
Airiipliy "f Dm ixTT" rsiv]>l iiUiit 9Tinploms (m.j?., A(l«>titiAliint of the r«litiAl vockoI*)
lif till? Iktl'-r .ilfi-cl loit nre dIhi iirr-ai'iit. WUclv litis iit mit tht- riui*. U» allll (|i>iikI<Ipiii
tW |)n/);ii<MiU li<)[M-(til At n jianlii iIil' ttli^lkl. for not onl^ nu^y ttirt •l<-);rf« of vUiou rumaiti
•titiKiiarv, liiil tirmi (in']>*r|:i> woiiitrrfiil improvrtiii^iil. Hv jidiiitA out, iiiAru'vi-i',
lltkt ihi-wt- vtiAtijtrB In C'iut of llir ilUk an- Vimt «<m>d in 1)11; cn-rl iiuolo nt ■•K«ininntti<ii
KDil toy Wfjik illuiiilitAlloii, M with lli-hiiholti's or Ji^itr's njilittiaUnaHoope. (" ].<ilir-
hntlt diT 0|ilithi»liiiii«oiipiM.'* [I. SiU.)
' ''Tr«n>iK-tlutia of Uxr, Hoy. .MchI. «n'L Cblr. Sucletr," IStTT, p. 411.
484
bISBASBS OP THB OPTIC KSRVS.
merely. Everythiiij; seems in a fog lo him, but he has no paid in the
eyes, nor any photophobio or photofwieo. In a later st8<;e. the whole of
the optic disk hns become pale, even to Wue-milk whiteness; ami later
still there is proof, not ouly of aiasmia of the aervo, but of BilvaDCC<l
fttro|iliy. The stages generally ot^tnipy from four tuoiillis to ti year. In
many Q^ae» the patient becomes at len^h atsotntely blind, but in others,
the (liseasi;, having advanced to a cert:iiii {mint, is arrested. There is
from first to last no evidence of disease of any structure in the eyet»all,
excepting; the optic nerve, and even after years of absolace blindness, the
retina^ choroid, etc., rcmntn hoalihv and their blood supply good. Almost
always both eyes are affwied, and proyrosa almost /«ir( /KiMt4. Sleepi-
ucfiH, a little jriildinesA, and a little headache arc usually Die only eoiidti-
tiitional symptoms which attend it, and these disapp(^ar at a lat«r atajje
and the paljent regains his usual health. As there is no tendency to fatal
complications, opportunities fur postrmortem exarainatioti of the brain are
hanily ever obtaitied."
Ill eases of lateral heraiopia, wc may also in rare instances meet with
a partial atrophy of the disk with excavation, which corresponds Ui that
half of the optic nerve which i« supplied by the fibres from the afTecteil
optic, nerve. But a Inn;; time daiises before symptoms of such atrophy
be;;:in to shovr thcm.selvcs ; indeed, hemiopia may exist for a very long
period without the slightest trace of atrophy being recognisable.
4 EXCAVATION OF THE OPTIC NKUVK.
There are Uirec forms of excavation or cuppinj; of the opUc nerve, vii.,
1. The mtujfrnittil jihyaiuhijictd exiHivatton. -. The exrticatifm from
airaphff of the optir nerve. 3. The fflauromattm* or prrsmre ejeeofo-
titm.
In the eon'jpmdtl jihf/^'ohuff'ytf ezfamtioii, we find thiit the cupping
jfenerally limited to the centrni portion of the optic disk; that it is
mostly very small and shalloiv. and that it may continue throughout life
without undergoing any changes. In some eases, the cup is not situated
in the centre of the disk, but slightly towanis the outer (lem|>onil) side.
Sometimes the excavation is \v<dl marked anil easily rceogni/.ablc, the
central portion of the optic disk prest-nlin;; a peculiar while, gli.4toiuug
appearance, of varying; t^ize and form. This central glittlening s^wt may
be oval, circular, or longitudinal, and its size is generally very incoii-
ilderable in com}»arison with that of the optic disk ; it is surrounded by
a reddish zone, which may even he almost of the same color as the baoK-
gronnd of the eye. The width of this zone varies with the exicnt of the
excavation; if the latter be small, the zone will be very conblderable ;
but if it be large, the zone will he narrow, ami limited to the periphery
of the disk. The edges of the cup are generally slightly sloping, and
never abnipt or steep, Che excavation passing gradually over into tlio
darker none, without there being any slurply^efined margin. But if
tiie excavatiuu is conical or funnel shaped, the edge^ are more abrupt,
and the mar>;in more defined. We tinil that the retinal vessels also
undergo peculiar changea in their course from the i^riphery towards Uie
SSCAVATtON OF TUB OPTIC XBRVE.
48S
centr* of the dwk, for wlion they arrive at the marjpn of the excavation,
itiatvad of passing straight uik tliuy tiesvribc a more or leiw acute curve
as tliey dip down into it. Tliis curve miy he very s!i-/ht and gradual if
the cup is shallow, but if it is deep and cxtttisive, the curve may be
abrupt, givinj; rise to a disphicetnent of the vessels. In the BXpaiise of
the excavation, the vessels •jenerally assume a slij^htlj darker slmde ;
soinetimes they, however, apiwar of a lighter, more rosy hue, and seem
to be envclopcil by a delicate veil.
fit is not alwiiyB eaiy to determine that an excavation is purely phy-
aioinpcai, for the Ciute may prove to be otic of nmlplyopia without opii-
thalmottcopic flign bcKidcs the excavntioii ; or there may he added to a
phvsiuloj^cal exciivation either an atrophic or a pressure excavation, or
litert' may be a simple diseoU)riilioH of the optic iierre present. — B.]
In .4ome cases, as wa^ first pointed out by \l. Miiller, the surface of
the same disk may show a ]>liysiolo;5ical depreaaion and elevation. Tlie
outer portion of the disk is slightly excavated, whereas the nasal half is
elevated, and the two halvuH of the papilla present mo^l marked and
Btriking diitercnces, which mi^ht easily be ntislakcn for patholoj^icnl
MppcAratices hy a can-loss obscn-cr. In sucli a cane, we find that the cup
ha« DO sharply -de lined bonier, and tJiat in its expanse, the peculiar stip-
pling due to the lamina cribrona is very ohaervable. which is not the
case in the other half. The color of the excavated portion is pale and
whitish, bein;^ in atroti;^ contrast with the elevateil part, whicli ajiponrs
ahnonnaUv red and vascular. The outline of the disk aUo differs, for
at the temjHiral side it if* sharply delined and the scleral rin<r vcrv appa-
rent, whereas at the nasal side it is indistinct and more or loss hidden.
The retinal vessels can be seen to mount up from the centre of the disk
over the edge of the elevation, at which point they are tinraewliat bent,
letintes to such a de;frec that their continuity may be slightly lost.
Ju the ex':amtion from atropfit/ of the t'/itiv nercc, we also meet with
woll-marked and very cimraoleristic symptoms. Toe retinal vessels will
be ft>iMiil ;jn.?atly diminished in calibre, the arteries small and thread,
like, per hafis hardly apparent ; the veins may at fii'st retain their nor-
mal size, or be even .slightly dilated, hut in the course of the disease
they also diminish greatly in diameter. The color of tlie disk is like-
rise changed : instead of the riisy-ycllow appi-arance which it prcsenta
[u the tii>rmal eye, it assumes a more or h'ss grayi^h-whit*^ or bluisb-
.whtte color, which may be limitutl to a portion of the disk or extend to
its whole expanse, lending it a peculiar glistening, tendinous, or mothcr-
>f-pearl ap|)earance. The bluish-gray color of the optic nerve, as has
aeu alreatly stated, is often met with in spinal amaurosis; being by
>inc considered almost characteristic of this affection. The atrophic
exeavaliuu. although pcrltapn cxtvnsive on the surface, is generally very
shallow, the dc^-ent being graihial and .slojiing, not abrupt ; coiwe-iuently
the retinal vessels, on arriving at the edge of the cup from the periphery
of the disk, do not show any mnrkcd displacement, but only describe a
more or less acute curve. Sometimes this curve is so slight that it is
hardly jtercvptible. Even iu those rare eases in wliieh the cxcav»tii>n is
tolerably deep, the descent is not abrupt, and for this reason tlicrn U no
tuarked dis])l<M:eaient of Uie vessels at its edge i and on moving tho con-
486
DI8BA8KS OF TUB OPTIC NERVK.
vex lerM of the ophthalmoscope to nnd fro, so as to make it act as a
prifliD. the bottom of thv excavntioa ito(r» not iiinve &» a whole, but ou\y
certjiii) pnrtimit) nf the excavation uiiilergo a 8li|;ht d'u>|i1nceiDcnt; and
this parallax U vcrj dilforoiit to, am) cosily diaQn^uishaUc fram, that
met vfith in the glaHCOtriitoiis cup. Mi>re(iver, the siiiiden inturnitittoii
of the cverfillod veins at. tlic od-ic of thi* *'xcavation, which is so very
cliDfactomtic iu the ^Inucomivtoui* foim, is >il.so wanting.
7't\f ^/faufoindt'iita or jirfBsurf esraviitinH {}'[a,te VI., Figs. In and 16)
is cliAtlnguisheii by the fol1otRin>r typical symptoms. The cup is not par-
tial and confined to tlie central [Kirtiou of the optic disk as in the phy-
siological form, Imt it cxtend.-i <iuitc to the edj^e of the disk, ita diaraetor
e4|iiat1iri;; Uiiit of tlie !»tl«r, and the lamina cribro^a being strvtched and
pushed backwards. Kvcii aUhnugh it may not yet have attained a cou-
sidcrnble depth, the cdj^c is always abrupt and pi-ecipitous, tliuft differinj^
greatly from the atropliic excavation, in which the descent is gradual ami
sloping. The edges may also overhang the cap, which has undermined
the margin of tlie papilla. The disk is surrounded by a li;;ht yelluwiah-
white ring, which is due to tlie reflection of li;^ht from the arin-rior
Inmiifo of the scleral rinjj, the choroid being thinne<I and atniphied at
this |K)int. Tbid zone varies iu width according to the depth of the
excavation ; the deeper and more advanced the latter, the brniider and
more marked will he the ring. The color of the disk is aUo much
changed. liie>teail of the ycllnwtsh-pink appearance of the normal disk,
the central, brightly ehiiiimg. stippled portion is snrrounde*! by a deep
bluish-gray or bhuitli-green shadow, which gradually increases in dark-
ness towards the periphery of the disk, where it may aiwume the ap[*ar-
ance of a dark wetl-detincd ritu. On slightly moving the mirror or the
object lens, tiiis shadow will vary in intensity, more particularly iu ilie
central |wtrtion. On account oi this peculiar shading of the disk, the
latler looks, ni the first glance, rather arched forward than hollowed
and excavated. The conrtie of the retinal vessels at the edge of the
cup is alrto very jkccnliar. They do not pass, as in the normal eye.
Straight over the margin of the disk on to the retina without allowing
any curve or displacement ; but if we trace their course from the retina,
wo find that when they arrive at the margin of the excavation, the di-
latcil reins increase somewhat in sixo, and, making a ranre or Irtis abrupt
curve, descend into the cup; at the point of curvature the veins also ap-
{tear eomewbat darker iu color. If ttiu excavation is deep, the veius seem
to curt round over ilic edge, ami are considerably displaced, so that the
prolongations of the veins on the optic disk deviate so considerably from
those at the retinal edge of the cup, that they do not appear to belong to
the aauie vessel. Their continuity seems interrupted, and this displace-
ment of the two portions may cijual the whole, or eien more, of the dia-
meter of the ves.sel. The extent and suddenness of thi^ displairement
vary with the depth of the oop. In the di^k, the vessels appear iodia*
tinot and fadcd^ and diminished in calibre ; Hometimes they may almost
completely disappear, so that they can only be traced with difficulty. If
tlie object leus be moveJ, so as to give it the action of a prism, a very
markeil parallax will appear: the whole bottom of the exoavation sbifls
itfl position, and the broad scleral ring may seem to move over it, as if a
■
BXOAVATlOtf OF THB OPTIC NBRV8.
487
frtiw were mored or«r a picture, the differe&t poriiona of the excava-
tion, however, 8hiftinj» their iii'lividunl poditioas but very «Uj»litly. 'Hie
degree of the pamllax also varicB accoiilitij^ to tliu ileptli of the excnvu-
tion. It ie particularly well seen, atereoHcopicitHy, wiih the binocular
■ Ophihaltnoscnpe. The peculiarity of ilm jwrallax distinguiabei, in a
■iDarked manner, the glauci>uuiti>uM i>xcavalii)ii frtim that uuH with in
alTophy of the optic nerve ; for in the Utter CA^e, as haa hecti alr*'a«ly
pDint4;(] out, although eertaiii portions of the excavation may shlfX thc-ir
ipositioii, the bottoui of tlie cup dov^ not move a^ a whole. Ihc diisplace*
'Bent of the vesnels in the glaucomatous excavation will aldo enable ui* to
diatinguish between this and the physioloi^ical form. In Uia former, the
rlinplaci'nient is more or le^ abrupt, and occurs at the edjje of the disk,
whereaj* in the partial or physioh»j;iyal cup, the displacement or curva-
ture ii< not abrupt, but i^H^ht and gradual, am] does not occur »t, Ute
edge of the disk, but within iw area, at a greater or less distance from
the uiar^n, acvonliug to the extent of the cxcavatioD. Should a ^lau-
comatoiw cup snjien-ene upon a physiological one, we may at the outset
of tlie disease sometimes observe the two existing togolher, the vessel
t»bowin[5 tlie douMu diaplaeemeut — ilie one at llie ed;^c of the pliy>*io]<igi.
Bal excHvation and within the area of ihe |«ipilla, the other more abrupt
and marked, and 8ituat«d at the ed^e of the optic disk. Hut at a later
period the appearances of the phyriiohtt;;iual eup arc lost, the latter be-
oomiu;; involvetl in the f^laucomatouit excavation.
lu tliu inujority of caaas it id not difficult to distinguish the <;l»ucoma-
touB excavation from the others, even befnre it has reached any consider-
able depth ; the extent of ihe cup. ihe abru[>t and precipitoun eii;;e)i, Uie
peculiar ditiplacement of the ressels at ita margin, and the spontaneous
or easily producible arterial pulsation, will be found the surest guitles.
Where syrajitomi* of atrophy of the optic nerve accompany the fonmitiou
of a f^Ittueomattnis excavation, there nisiy 1m* some difficulty in ascertain-
ing which is the primary affection, more pnrticularly iu those ca-es in
which atniphy of the tiptic nerve, de|x'ndeiit upon cerebral amaurosis,
[luiii become compliaitcd with intiammatorv glaucoma. In such, a coa)>
^liftrisou of the two eyes and a careful and searching examination into
the history of tlie case, will generally clear up the difficulty. Hut wc
DUift remember, that in glaucomatous excavation the optic nerve often
lergoefl atrophic changes and bceomeK very white.
At the commcncemeni of the glaucomatous excavation, the cupping
nav be partial, being conttued to one ]>ortion of tlie optic disk ; but it
will alrenily show ilic typical nymptoms of tlic pre^ure excavation.
The opiic disk is pcrhap<i completely surrounded by a broad scleral zone,
the vetiie bvcooie somewhat dilated and abruptly displaced at the edge
of the cnpiu'd portion, Hml there U ;i bluish shadow at the peripherv of the
latter, wtiich i^* gradually sliaded oil to a lighter color towanla the centre
Von (iraefe has |)ointe<l out the very interesting and im|H>rtanl fact,
that a glaucomatous exciivation may become shallower after tJie opera-
tion of iridectomy, thus proving that the cup depends upon an increase
in the intra^ocular teiu^ion. The bent ca-'tes to illustrate this fnct are
those in which acute symptoms liave supervened u)H)n chronic glaucoma.
Iu such cues, the excuvatiun becomes more shallow and aaucer-likc, the
A
4Sft l)[&BA6Efi or TUB OPTIO NEHVE.
etui? of ttie veasels less abruptly displnced, and their ititorrufttions div
ap|tear. an tlint itio rniitiiiiiatioii nr ihe vease) from the redtta on to tlie
disk can be di^tiiiL-tlv tmcol, altlioitL^h it m»y be somewhat cunred. We
may aUo notice that vessels which were slightly curved at the edge or
the disk, DOW become straight again.
6.— PIGMKNTATION OF THE OPTIC NEHVE. [IIEMOUUU.VOE
INTO THE OPTIC NEKVE.— B.]
When deKurihiii^ the normal a]>|>oamnce-; [trcRcnicd hy Uie rundu
oculi, 1 mentioned itiat we freipiciitly meet with a more or less marked
and exteiiMve deposit of pigment at Uie edge of the optic disk, and tliat
this is tjiiite phrsintogical, and lias no patliological si^inificatioit. Some*
timed tliis def>o^it ia hnt alight, and forma a narrow creicent at »nc ptrt
of llie inarjiiii of the disk, just alonj; tlic choroidal rinj; ; in other oa««
it h more conaiderahle in size, and may embrace a largo portion of the
edge of the optic ncno entrance.
In very rari' instances, a coiiMderahle ainntmt of pi};mpnt has keen ob-
served to be def,oi)iu-d in the cx|>niiAe of the di^k. ThuA Lichreich' hae pub-
lighod a case in which, after a severe accident, there endued, in lioth erca.
atrophy of tlie optiu tiervp, with marked pi{!;nient di'po."tit within the disk.
'XhiB wa« etifteciiilly the case in the left eye, in whiclt the whnW of
the disk, eKteptin;; the very centre and a portion at the tcm[ioral
aide, waa occnpied by dense black pigment. Licbreich auppoaea Uiatthe-
black colorniioii of the dink wa« due to pij^ment eelU, which liad heoome
developed in the connec'ive lismic whicti replaci-.i the uorve fibres in
atrophy of the optic nerve. Knapj'' also reports case* of exteiilive
pignicntatiim of the optic diak, wliicli had (occurred after an accident, bat
confident that it iri the result of hemorrhagic elTuition within the Alieath
of the optic ucrrv. which afierwarth! undergoes pigment degeneration,
the same thing, in fact, a* wo so often find occurring in blooil-cffu.'iion in
the rvtina. Aiiothvr instJincw i* recorded by Iliritcbherg,' lu which a
lar^e dejH^sit ul' |ii;;uicnt tfccurnil In the optic disk, in an eye which had
received a scvorc bhiw from a piece of iron.
[Uemorrhagvs iitt" the medullary sheath of the optic tH>rro fibnra un
rare, bm homnrrha^.'es between the sheaths are more fre«]uent. Tbow
are genendly bilateral, and come from an extravasation of IjIm^I at ttM
ba^e of the brain. 1lie ophthalmo,»copic sigu« are very vagne unleag tlie
IiUhmI is cxtravusaled up<.^n the j-apillse. There may be a slight cloadi-
ntis of thr reiiiiit near the di»k, and possibly a by|«neuia «<r the vehia.
The pigment which results from thi'Ac lu'im^rrha^'a may show itMsIf in
the |>apilla iuelf as wtdl x» Id the connective Uiuue ring around it. In-
Jurivs. whether coniuAioua or jwrfonitiug wouivlti, are very liable to cause
T _:>'3 a|K)ii the pa|iiUa. which b'ave behind nuwsea of pigmeut.
'1 nene may also become pigmvuted from melanotic inti It ration.
(.Sec tiraele und Saemipch's Ildb. v. jjp, yOtl-lMJit.) — B.]
>!authuei* haa once observed, in a perfectly heftlthy eye, a minale
•'ABB«l*rt'CWi.Il.tt<|M,'- lfl.31. « ■•A.tO.,"»vi, I.
*• KL HouiUbL," Ucl. IMS, i>. 324. * Op. tiu, p. V».
n
4
TVllOnS OP TUB OPTIC NBHVS, BTO.
brightly ■glUtoning speck at tbv margin of the disk, which wks evidoiitly
a cholof^terine crvHtnl ; it 'a less rarely mot with after certiun nioriii'l
cl)ann>os in the optic nerve, e. .'/■» neuritia. Dr. Tweedio, of I'niveraity
College Hospital, hac rocuntly ha*! umler his cart* a case of oj>tic neuri-
tis, in the course of whi(;li fiv(^ hrillinrilly-i;nsteiiiii;x '*peck» of ehuIesU*.
fine crystals were formuU on the disk. i5uljset[uently four of them dis-
appeared.
6— TIMOU.S OF THE OVTIC NEUVE, ETC.
Tumors of the optic nerve are of rare occurrence, and difficult to diag-
nose with the ophthalmoscope. [They may occur in the pnpilln fid
gnuiuloina ; or in the intra-orbilal part of the nerve ; or iu the intra-
cmntal part of the nerve. iSumetioioi strHlified concrctioiitt from the
vitreous lamina of l)ie choroid j^row over into the pnpilla. In the orhit
we meet with primary tumors of the nerve or inner sheaUi, which are
myxomata, or myxonnrcomata. or glin-sarconiata, or in rare instances
neuromata. Alt the^c tumon^ stArt cither from lite inner «heath of tho
nerve or from the neuroglia. The Derve-fibrcs are either lost in tho
tumor or they arc pushed naidc by the prowtli. When the lumor springs
(rviu the orbital tiiwue ur the external Kheath. the optic nerve, mure or
fcaft atrophied, (lajtsea lhroH}»h the j;rowili. The myxoma or myxo-ssar-
couin may t^^rovr to the «ixc of a lien's e^rjr, arc very gelatinous, nnd may
contain cysts. They gniw somewhat filowly, the cxoplithiihuu^ which
results* Iff uiaitnlly in the direction of the axis of the eye, and the motility
of the eyeball may not hv markedly impeded. Diplopia may, however,
present even from the bcpunin;^. Vision may be very ilefectivc, or
in entirety lost early in tiie course of the diKcase, from papillitis or
from simple atrophy of the optic nerve. There ia iwually no [lain until
the j:rowth has reached a considerable size, though tlicre may he Rovere
heudat'he. The growth, however, may be so ra|iid as to compreM the
eyclctll, cauhe perforation of the cornea, and pltthi'iis hullii may be the
result. An early extirpation of the tumor may prevent itj» recurretwo.
True neuroma is very rare. A case is reported by TerU. which oc-
curred in a child, was as large as a pigeon's egg, was covered by both
«li«athi), and consisted of gray medullary nerve fibres and nucleated cells.
It wa." removed with the eyeball, awl there was no return.
S'tr'-'iiiui utmnlly sprinj^s from the orbital tissue and involves the optic
nerve secondarily, or the nerve becomes the «eul of secoudary duposilis
jift4<r a choroidal sarcoma. Here the growth is mainly along the intcr-
TAgiim.1 <>|)iic«. In c&AC* of glio-^arcoma of the retina, deposits are very
often found in the medullary sheath of tiic nerve-Iibrvs themselves.
Tumors involving ihe inlra'iTam'd fwrtion of the nptic nerve are not
very intcommon. liuioumta of the brnin or meningoit not infretjuentlv
involve the optic nen'cs and chiasm, and tlie latter may he the acat of
chectiy tul>ercutou^ ma-sses or of melanotic growtJis.
Knapp hiui refMrtod a caso uf cait^inoma of tho sheath of the optic
pve.
A very marked hyperplasia of tho chiasm and optic nerve has boeu
doicribcd by Michel in a patient sulVering from elcphnatia^is.
4£M)
DISBAUBS OP THE OPTLO KBKVK.
For (Ietai1e<l accouuts of cases of tumor of tlie optic nerve, see Aroh.
f. Uphtli. xis. 2: xix. S; Kl. Mon. f. Anj;. 1H74, p. 4S9 ; Oraefe u.
Saenii^oli. v. pp. <i12, 014 ; Arch, of Ophtlml. iv. g and 4 ; v. !) and 4 ;
vi. ! and '-', 3 and 4.— 1*.]
Vfin (jraeff' records a case in wltioli there was a large retro-ocular
orbital tumor, causing a prou-uaion of the eye to the exU'nt of y'". The
Bif^ht was completely lost. With the ophthalriioiicoi)C, the retinal veinawcre
found to he dilated and tortnoiiM, hut llic arteries attemmtcd. At the
inner half of the dit^k (to which it wag conhntd] was noticed a peculiar
steep and ahrupt rlcvalion. The latter prujoctud ahout 1'" above Itic
peti'ectly level outor half of the disk, and hung slightly over the inner
ed^e. Wiliiin this elevated portion, the sulwtattce of Uie disk waa of on
opanne prayish-red tint, and the retinal vessels were completely hidden.
Ou uiiuroscopic e.\amination by Drs. Hecklin;;hauw;n and Schweigger, it
was found to he a tumor (myxoma) of the optic nerve. In another case
of orbital tumor reported hy Or. Jacohson,' the ophthahuoacope also re-
vealed n Rtrikiiij* projcclioti nf a portion of the optic; dJak, in which the
retinal vessidn were lo«t. Tlip whole appearance of the disk, the varia-
tions m color of different [Mirtions of it, as well aa the course of the
retinal re^sets, wore mont peculiar. This waa alcto found to be a oiyxo-
sarcomatous tumor of Uie optic oerve.
[7— INJURIES OF THF OPTIC NEKVE.
The optic nerve mny he injured iw it enters the eye, in the orbit, in
the optic foramen, and at the but^ti of the skull. The nerve may be sim-
ply conlitsed ; or it may he lorn in t)ie orbit, either by a |»erforatinj^
instrnment or by a shot wound ; or by a fracture of the sphenoid hone,
especially of the cUnoid process. If the nerve is injured anteiiorly to the
point of entrance of the central retinal artery, the ophthalmoscopic
apii'aranccd are similar to those of emh(du«. If the seat of the injury
in piii4tcri(>r to the entrance of tlie central retinal artery, either in the
orbit or in tlie skull, the ophthalmoscnpo at first ."thows nothiuj^ ; hut
after some weeks tbe papilln begins to gnjw pale, at first on the tem-
poral side, but kter the whole di.-^k grows white and atrophic, IjO-u of
vision is, of course, present from the beginuing, tliougli this may be
|iartially reeovered from, if the nerve waa not divided. — B.]
A very extraordinary case of injury of the optic nerve, with rupture
of the central vessels, liaA been described by Dr. Ilormann P«;,:i'nflt*cher.*
The injury occurred in a girl, aged 12, who wa« hit on the right ey«
with the sharp point uf au iron rod. which entered tlie orbit just below
it» upper margin, causitig a wound of rather more than an inch in length.
The lids were much swollen, the eyeball slightly prominent, it8 move-
ment upward somewhat im|Hiired. but nu direct injury of the globe could
be detected. The pupil was dilated and immovable, and the sight C0li)>
plelely lost, there being not the faintent perception of even strong sun-
light. The ophthalmoscope revealed a mo.-tt peculiar condition, of which
I
i "A. r. o.,'' ». I, IM.
■ Ibkl., X, 2, ».
I Ibid., XT. 1, S23.
OPAQUB OPTIC NERVB PIBKBS.
491
I
I can here only ^ve the briefest outline. The optic disic was com-
pleicly hidden bv a brightly-gltatening white effiuion, which extended
in a bruad zone over the reliiiu, uieasuriiig ahout four limes the diameter
of a iiomuti nptic |>apilta ; no trace of an^v rvtinal vettsul wnd evident on
this patch, with the exception of one veiwel miming upwards (reverse
ima>;c). lit the course of h few d&ya tlie effti^icin t>etfanie slowly
■bsorbod, tlie optic AUk t-eappeared, the vcftsol* ehowing, however, very
peculiar interruptions on and near its expanse, and gradunlly the coU
latornl circiilation became eaialiiiahod. Very extenaive pigiucut depoaita
were formed in the choroid* and nubdoi^ucntly on the optic disk.
8 OPAQIK OPTIC NERVK FIBRES.
Amon^ the physiolo^cnl peonliaritieti of the retina which are some-
times met with is one wliic-h, if it be at all fully deveIo[ied, may l^a8ily
be miAiaken for an estidation into the retina. It itt a well-known fact
that, in the human suhjeet, the nerve tnlmles of thf f>pt!C ner^'c lose
their medullary sheath at the erihrilVirui pUte, pajssin;; on to tUv uiutft
anterior [lortion of the papilla, and thence t^t tlie retina, denuded of their
»l>eath, i. It., simply in IJie form of tran.4|>arent axin cylindera. In certain
animaltt, however, especiiilly ruUhlts. tlie sheath is continued on to the
retina. Now, this siinietiine^ »Uo liappenj in the hnman subject (a.t was
firet [(oinled out by Virchow). the optic nerve fibres retainin*; tlieir
mediilUry slieath for a short dislnnee on lo the reiina, so ihat the latter,
iutttend of t>eing transparent, will at such poiuki show a marked, white
opacity. Tlte ophthalmoscopic ilia;riiosui of opaipie nurvo fihrei* is by no
means difRcult, and a little care and reflfctioit rthnuld piard anv obMrver
from mistaking the!<e np{>enrHiR-e5 for morbid changes in the retina.
We notice in such cases that the uptic nerve, instead of bein>; sharply
and ch;arly defined and surronndod by trniwparcnt retina, shows at cer.
tain pointa jteculiar while, )«triated, tongue-like projections, which extend
a little way into the retina, llieae pntehes terminate in an irregular
manner, their outline showing faint *' feathery'' stria;. It is a fact of
much diagnoAtic imjxirtance that the retina in tin* imiuodiate vicinity of
thetie patches in [M-rt'cctly henltliy and tran.<tpart'nt, tliere hoiiig not the
fainleat trace of Jiiixiiie5.s of tlie retina due to serous intiltnitiun. Whereaa*
in exudations Into the retina, the contiguous portions always show a cer-
tain degree of clondinefls.
The retinal vessels may be partly or complet«ly hidden in theso white
patches, which is especially the ca^c if the latter are coiHiderablc in size.
We then find tli»t the ve^^els pass from the centre of the disk up to the
edge of the ojiauity, hecomc hidden by this, and reappear at its per-
iphery, lK.'ing tlirnce di.'^trihiitcd in a normal manner over the retina.
Tbcse opacities vary much In size and nuinlier. In some cases there are
only (wo or three small patches : in others tlierc is one large, irregular
white figure wliJeh surrounds the greater portion or even the whole of
the disk, and extends, perhaps, fur u considerable <ti.stance on U* the
retina. (For a boautifnl illusii-alioii of such a condition, vide Liehreich's
Atlas, Plate XII., Figs, t and '2.) Sumotimcs tlic little white patches
Chaptkh X,
AMBLYOPIC AFFECTIONS (AMAUROSIS
AND AMBLYOPIA).
r'siiKH the vapio terra •' amnnrosia" wore formerly inclmlcd al! kinds
of Iiitni-ociiUr diseacws tlmt vrcrc not diatinguishnUe with the naked eye ;
but since the diat^overy of the oplitlinlmoscope has revealed th© trac
nature of the (lieeasea of the iimcr tunica of the eye and of the optic
nerve, we sro ahle to confine the term '• an)auro«i(t" to very niirrow
limits. Indeed i( is of great practical importnnco, that a definite under-
stAmling should he arrivud at, nit to what diseasec) are to hv included in
the group of "amhiynijic affections." Thus only can wc remedy the
confusion which fttill exists, from the fact that 6omo vrritem Apply tlie
name amaurosis indiscriminately to all ca^ca of total blindness dependent
upon dt'i*p-a*'atcd intra-ocnlar affections, whilst others give to it a more
limited aignilii.-ation, and confine it to the Iom of sight dependent upon
intnt-cmnial diBea«c. I think, therefore, that Von (irnofe's signification
should he universally adopted. He excludes from the term ■■■ amblyopic
^flections*' (umblyopiu and amaurO(}iiii)all di^turhttiiceH of si^lit dejiendent
upon material, perccptihic changes in tlie refractive media, in the internal
tunicH of the eye. on neuro-retinitia and embolism et the central artery of
the n^ina.' It may be v|ueationed whether n'e should exclude uae>es of
optic noiiritt!* from thia group, as they arc generally due to intracranial
disease, nod hut too fre<|uently pass over into coiisccutiTe atrophy of the
optic nerve and retina, and more or less complete lilindness. But even
in tliese c&ae^, X think it would be better and more definite to term such
blindncait, »m»uro.-ii;4 fmm optie neuritis, junt us we uliould 6|ieak of
amnnrosiri (or amhlyojiia as the case may be) from retinitis pigmentosa^
from glaucoma or emU'lism of the central artery of the retina ; in fact,
timt we should strictly confine the term amaurosis to cases of blindness
from primary atrophy (degenerative atrophy) of the optic nerve, and
that of amblyopia (in a special sense), to impairment of vittion produced
by irregularities in the circulation of the nervous system, which may
lead in the end to primary atrophy of Uie optic nerve.
Amhlyopic affection.-^ are also sometimes classified according to the
degree of impainncnt of sight. Thus the term " amaurosis" is often
confined to cases of absolute blindness, in which there is not the faintest
' Vide Von arwf.'"» Uvtnt** on " An.l.lirojMC Affivtionn," " Kl. M.," ISflS. An
able traRNlaii'm nf lli'4>- iniiMruni iiixl vntiiabk- Lvciurat t>v Mr.Z, Lkurvnw will Iw
raiiiwl III lli« " Optttlmlralu Ititvi'ir,'' II, Zii.
AUBLTOPTC APFBCTIONS.
perveptioa of even Tcrr strong light ; the name *' amblvopia" embracing
■11 <itf;;n;e» of impaired sight.
l.iehreich' distinguisliea three diflferent forma— Ist. Ajntiurotii^ atn-
My/ia, in which the sight in so much deteriorated thnc even Urge ob-
jficta are onljr di^tingiii^Knble with difficulty, or t^e patient ii< not nhle
10 guide himtietf. 2d. Auiaamitis ; in this condition even lar^i.'i' ohjccU
can no lonj^er lie distin;iiii-tho(l, there heiiig no .(Unlitativf but only i^nAii-
tilative perception of liglit, wiiicli niajr vxist cither in tlie whole or only
a part of the field of vision. Hd. Ahg'ilutf aiHaurdgit^ where the patient
has not the faintest power of digtinguishing between light am] darkness.
In examining the sight of cases of amaurosis and amblyopia, it is
very important to ascertain the condition of the field of vision with the
greiitt?.-it accupacy. In these diseases, it does not suffice to examine tlie
tictd tiy dayliglit, hecaiiM! itliglit contrnutioni^ or iiiterruptioiiH may tlius
easily escape detection, which will become at once apparent if the field
ia tested by a mi)re subdued light, for which pHr|M>8C Von Graefe'a
graduated disk of liglit will be found tlio beat. The moile and extent
of the contraction or interrupttnu of the field of vision, are of grCAt im-
portauce in enabling us to form our prognosis as to the ri^k of a t«iul
losd of vision, or the chances of an improvement, or even a rctttoraciou
of the sight.
In the fijllowirig description of the different kinds of contraction and
interru|uiou of the visual field, and their bearing upon the proj^iosi* na
to the ultiuuitc contlition of the sight, etc., I Imve mainly followed tbo
views of Von Graefe, ns expressed in the above-mentioned lecinrM on
nuiblynpic affections; indeed, he is tlie first writer who has attempted
to lay down anything like definite niles with reganl to the chief poinia
that should influence our prognosis in this class of diseases. Tlii*, in
fact, could only be done by one who had for many years closely watched
the course of a vast number of cases, and carefully stvidicd their minutest
details. A mere hypotiietical generalization, not founded ujiou absolute,
sufficient, and closely scrutinized data, would be ftimtily valueless.
Several different form'* of contraction of the field of vision may be
observed in amblyopic affections.
The contraction I'rcipicntly commences at the tcm[H)nil side of tJie field
of vision (the nasal portion of the nHina being the first to suffer), and
from thence either pas!»es on laterally towanls ihe centre, or along the
periphery in an uiiward and downwani direction, extending finally to-
wards the nasal side ; and then, when the whole periphery of the field
has become impaired, the contraction advances concentrically towanls the
axis of vision. The outline.-* of both these forms of contraction of tJie
field are often very in-egii!ar ami undulatory. The contraction of th«
field in cases of amaurosis generally cnnmienccs at iho temporal side,
but this is not always the case, for it may be:;in at the na*al. Whereas,
ill the contraction met with in glaucoma, it is a very characteristic fea-
ture that as a rule it commences al the nasal side (the onter portion of
the retina becoming first impaired). We occasionftlly find that some
time after the firat eye hati become affected (and perhaps even amaurotie),
• *■ Noureaa Dk lionMlre de MM. et Ar- Chir. Prat.," 7S5.
DBCrSSATIOS or OPTIC NBRVB riBRBS,
495
a gndimllv prof^re^sivc contraction of the fiel<) dhows itself in tlic second
eye, commciicin;; pi.'rtiu|>ti :it a point (piite t^ vinuH-tricul to that in wliicli tho
coiitiiictioii lic^aii in tliu t-vc ori;tiiiaII_v Mfi'ectcil. l^ticii cdAfH iiffonl ;i most
unfavorable progno^tis, mot-c «Apecintly if tho ceiitrnl virion is greatly
iiupaireiif or alrea<l_\' |)erhiL{>5 sunk U-low that of tlie eccentric porltuii of
the retina, for these symptoms indicate hut too surely a progre^ive atro-
phy of the optic nerve.
The contraciion of the field may be e<|uilateral in both eyes, e, g,^ tho
right half of each field m:iy be waiiciiij;, and the line of demarcation
between this ami the Tionual half of
the field hciitiite sharply defined, and *''8- **''•
situatcil in the axis of vision. This
U turnieil equilatend or horiionytnous
liemiopia, on account of the corre-
sponding halves (the ri^lit or left as
the case may be) being aftectcd. The
nature of this condition i^ self-evident,
when we reatentU'r the analumicul
relations of the optic nervi.-* to each
other, anil the fact that tlieir fibres
decua»«te at the optic commiasure (chiaHma') in such a manner that the
ri|ght optic nerve supjdiea (he rij^ht half of each retina (tlie teuijioral i«ide
in the right eye, the nasal in the left), and the left opdc nerve of tlio left
hnlf- A glance at Ki^. 1,57 will explain the arrangement'.
This figure represents the cumiuis4ure of the optic nerves and their
prolongation to the retina. H the n;ght optic ucrve. L the \ah optio
nerve.
[The question of the course of the tierve fibres in tho chiasm and of
tlieir relation to each othtrr to the optic centres and to the eves, is (he
all important one in matters relatiug to defects in the field of vision due
tu inlra-cranial letnioiis. i>unti<; the last five or six years iitvusti^atiuiis
have he«n undertaken by numorous ohservcrs to settle this nmcli vexed
t|ueslion. The view generally accepted, thai there was a partial decus-
sation of the fibres, as has been alreaily descrihed, has been rcjectt'd by
Bicsiadecki, MandeUtamm, and Michel, who claim, after careful expert-
inonintion and observation, iliat in man, as in the lower animals, the
ilecussation of the nerve fibres in the chiasDi n complete. AcconUng
to these authors the nerve fibres take a curvi-d course in the chiasm iit-
Atend of a straight one, and their intenveuviiig or interlacing is most
irttricftte. This view h-is been roost decidedly opposed by Oudden, and
aUo in a short clinical paper by Mohr. (nidden, by experiments on aoi-
niaU, from which he has enucleated ejes. and from clinical observations
and autopsies on patieiit^i, onviuced himself that the oM view of the
partial decussation of (he fihrctt wai^ the correct nuo. MohrV paper is
a very interesting one, ht-ing based on cliiiical ob«rvalion of an intra-
cranial tumor with the results of the auto|)ey. From his uhaervmions
he concluded that tho nerve fibres which supply the macula lutea and
tt« vicinity run along the tract and nerve of the same side, while fibres
of le«s importance for central vision pass to tlie ronculu from the opposite
tract. The im[,ortaut fibres destined for the macula lutea of the left
496
AMBLTOPIC APrECTIOHS.
e^e eonie from the left optic tract, anil with tHem come also from the left
tract Bbrci« desliueil for the external tialf of the left retina. n»i| tinallr
aoine 1ihrc!i which supply the inure int^-nial part^ of Uie relin» lionlrring
on the luacuta. Tlie lierve bmniles destine*! for the macula of tlie right
c^eunil the viciniiy, as well aa ttic fibres destined for the extemnl half
of the retina run in tlic right oi>tic tract. Mohr's case, which waa on«
of t^'pioal lieniiopia. secind to riiriush poflitlve proof of the aeitit-dccuaaft-
tion of the fibres in the chia.sni. Scliwalbc, who writer the article on
microscopic anatomy of the yptic nerve in " Gniefe und SAu-miftch'a
Haiidh. der Augenheilknnde," endorses the total decussation iilea. The
whole subject in still in an unsettled condition, but the majority of oph-
thalmologists etill hold to the partial dccuisaatioa theory as o6eriug tliu
mo8t satisfactory explanation of tbe varioua aymptoms relating to the
field and acuity of vioion. (Foi- a full discussion gee "Graefe u. Se»-
niifich's Hundb.." i. pp. H2ii~y.2ti ; "Arch. f. Opiith.," xix. 2 ; xx. 2 ; xxi.
;i; XXV. I ; XXV. 4; ami oxhauiitively in"Gracfc und Saemiftch'a Ilaiidb.,"
pp. yJW to 9.>U.)— IJ.J
If, tbertdbre, a tumor or an hemorrhagic effuaion compreMefl the right
optic nerve ou ih© central side of the commissure in such a manner aa
completely t*] destroy itaconductahiUty. the right half of each retina will
. be impaired, and coii3e<^iiently tbe left half of each field of virion be
wanting. But if the coiuprei^sioa id limited to the commiesure, alTectiug
only the crosseil fibres, and Icavinj: the lateral onea unimpaired, the ap-
3)earauce will be differcm, for then the mwal half of each retina will he
affected) and the tem^wral half of euch field be wautiug. In aucb cases,
however, the hcmio])ia is not ho sharply defined a.4 in the etftiilateral
form, for there is generally a more or less broad line of transition, in
which the defective jwrtion of the field passes over gmdunlly into the
healthy p:in. The seat of the disease may not, however, be confined
to the couimisaure, hut be aituaced principally In front of or behind the
latter. Tliis may be suspected if other ayraptoms coexist with the he-
miopia, such as paralysis of other nerves, hemiplegia, impainuent of Uie
mental functions, etc. It will he seen, hciuafter, that tbe proj^uosis is
less favora'de in ilie temporal than in the cijiiilateral hcmiopia. It in
extremely rare to uiwet with heinicipia of tbe upper or lower balvM of
tbe field, and the real uature of auch casea is »t present iiuite uaex-
pluincd.
If the cause of tbe compression is situated at the distal end of the
oplic nerve, t. p., after the crossing of the fibres in the commissure, of
course the corre-sponding eye is alone aQected.
In addition to the contraction of the field of vision, we often meet with
iuteri-u]»tions in its continuity, which appear in the form of dark irregu.
lar clouds or opots before the patient's eyes. These " scolomata" (as
ihcy are called) may be situated in or near the centre of tbe field, or at
its jH.Tiphery. On examining tJic field in ca.«C8 of Motomata, we find
tli.1t within a certain area there is a more or less considei-ahle gap, iu
which ibc object becomes indistinct, or even lost. If the scotoma i» situ.
ated in the axis of vision, it of course produces great tmpairmuDt of
sight, and llie patient often sqainia in a certain direction, in onler that
the rays from the object may fall ujwn a more sensitive (in Uiis ca44^
I
I
I
AMAUROSIS — SCOTOMATA OP PIBLD OV VISION. i^I
cocciitric) portion of the retina. Mlicrcas. if the interruption oocitra at
the iKriphcr^ of tlie field. And U only inconiiiderabte in sixe, it \» gene*
rallv altu}Eether ovi.T)o<iked by the patient.
These rt«ntoni«ui iieiiiTiilIy nuikt! their appearance very siidrtcnly :
touettmei^, bowover, a few weeki^ vhij.vM! beforu tbey become ftilly ilevel-
Oped. They are not unfret|nt'ntly met with after eshauatini; j^eiieral
Jiseases. or after grenl mental emotions, and are accompanie<l, perhapa,
by cutaneous iiiseiuibilitv to pain. The cirtiutiii)crib«d ccntrul twoto-
nwta are also aomotimes ilue to diiilurbaiice in the circulation ami impair
ment of the nutrition of the optic nerve; or, a» has been previously
stilted, to retro-ocular neuhtiif (u/i/e p. -M'.)). I have already mentioned
thftt Ijobcr haA fnund the appreciation of colors more or leu impaired in
all caaes of circnmticribed central acotoma, and his researohos upon IhU
point have led him to divide the affection into the following four cla()sea,
acconiing to the state of appreciation of colore and of the field of vieion:'
1. The central ^oti>ma is noc apparent by the usual mode of examina-
tion, bill only by testin;? the ajijuvciation of colors, the periphery of the
visual field having a noruial appreciation of colore. 'J. The scutouia 18
also recognisable nithouL toi^tin;^ Lbu appreciation of colors, the latter is,
however, oiily abnorm'il witliiu the iicototua, being unalfectod throughout
the periphery. S. The appreciation of colors id cuupletely lost, or
greatly im|)aire<l. in the scotijma, the periphery showing a greater de-
gree of impairment; but the eccentric actitone^it of vigion is perfectly
luuifTected. in euch cnscs the scotomn is generally also recognizable
by the oniinary modes of examination, but the opposite may occur. 4.
The tram^itiou into atrophy of the optic nerve is formed by thodc cases
in which, besides the symptoms enumerated sub 3, there ta iudlrtinctness
of [>cripbcnil vision. We cannot, huwever, sharply define tbe^e four
classes from each other, for one may gnulually pa.4.s over into the oliier.
The third clnsx, in which tlie periphery of tJic fiold also Ahow.'t a slight
impairment of the appreciation of colors, is, acconiing to Leber, to be
re^^nled on the whole na the more severe attd advanced form of Uie dis-
eMQf fur there often already exists partial discoloration of the disk, or,
where thi« is absent, more or less cloudiness of the retina, no that w«
but rarely obtain a negative result from an ophthalmoscopic examination.
Hence the prognosia tia to a rcdtonitiou ad iritiyrum i4 less lavor»b1e,
and homc nf Uiew cases rcsi^^t all treatm<.M)t. In amblyopia potatorum
the impftirmcnt of the sense of color, alUiough it may only reach a slight
degree, sometimes not only affects the centre of the field, but also ex-
teiuls in an irregular manner over the greater part of the |Kiriphery.
We sometimes meet with very peculiar and eharftctoriilic ca^el in whtch
the scotoma is surrounded by a circular zone, which ts perfectly or
almost |>erfeetly normal, whilst ut the periphery there is again marked
color blimlue^s.
In easci of peripheral nntcrtUiesia of the retina, we often meet with
the interesting phenomenon that the phoDplienes continue to exist in [;or-
tjons of the retina which are i)uice insensitive to light, and thiA is of
prognostic importance, as it docs not occur in amaurosis. The sight is
t "A.f. 0.,'*xv. 3,71.
St
m
AMBLYOPIC AFFECTIONS — CBBBBRAL AUAUROBIS.
generall^v verj consult^ reMv nffectixl, and nia,v finnlly become quite lost,
fto tliat the patient cnnnot ilUtiTiyiiimh l>etwc«ti lij^lit uml ilark.
In cereliral atuauru^ia, the pupil is generally tMioewliat dilated a
tltiggisl], or imiDovable and largL>, ir the eve is •(iittc blind. If the yajal
in (lilate^l t<i it« fullest extent, 6o that the uarrovr rim uf in« h hardly
diwt'niitile, we must aaauroo that there coexists nn irritation of iho »yni-
pathetic libre», causing a coiitnictioii of the ililaliitor pupillio. If oin-
cyu uuly it) afTvctjcd, we often Hntl tliaL it« puj>tl in dilated and immovahU'
undor the ftlimulun of li;;ht whtu the other eye ia clos&d, hut rhnt it at
once contracts consentaneously with the pupil of it^ fellow, when thi-
latter ia uncovered. This fact may prove of use in detecting the simula-
tion of blindnesa in one ejc hy the ililntnLion of the pupil by atropine,
vhcu of coiir^ this cousentaneoud actiun could not occur, (ireat im-
portance cannot, hnviever. be attached in cii?ptt of amaurn^ts to the
hcliavior of the pupil, for wc sometimed find that, even in complete
blindness, it retnins its activity. In spinal nmaurostis, the pupil is un-
usually (ind perhaps irregularly contracted (oval), and acta but very
Blu^I^iishly and iniperrcclly upon the ajtplicalion of atropine. The ;:reat
contraction iH due to the paraly^^is of tlie syniparhetic tibrca. [I^ee an
article on " l^e^iona of t!ie ( )plic Xervc and I'upil in certain Affection* of
the Spinal Cord," in " Amer. Journ. Med. Sciences," July, 1875. — B.]
The ophi}ialmoftCOpic symptoms of cerebral and ccrebro-spinal amaan>-
eis consist in certain chanties in the appearance of tiie optic nerve, imli*
cativti of its pro^^n't^^ive atro|ihy, i'are muet. however, be taken not H^H
nnstake sinipic aniemiii. or bhinchini; nf the diftk, for incipient atrophj^^|
Ttie »mall nutritive vessels, which are distribuied upon the ex|)anDC of
the disk, disappear, and lids partly jiroduces the white color ; whiUt the
ve!<sc[a distributed over the retina may retain their itormal calibre. «veu
when the optic nerve ia quite alniphicd. hut Generally Uiey soon become
attenuated. The symptomn of atrophy of the opiic nerve have already
been fully described (p. 481).
Accordin<; to the re^carchea of Leber, color-blindness in almost a
cotistant symptom of atrophy of the optic nerve, whether this be pri-
mary, and depeudeot ujiou cerebral or spinal leiiions. or iecnndury, and "
conscijuent uimn optic neuritis; and it mny appear at any stage and id
any ilejiitie of the dittease. In 30 cases of atrophy of the optic n- -■ ■
lie found colorMindness completely alwent in 8 caM-s, in a it was . j «
alight, but in the remainiufj; '21 cases it was very marked. Such pati«tiM|A
are at tirst generally unable to di.«tinguish red, but. as the diaeaae ai^B
vancea, the appreciation of other colors is gradually lost, blue being, as
a rule, recognlzc^l the longest. This condition cl(«ely re>«emble4 thr
color-blindness which manifeats itself in f»erfecily normal eyc<i, when
the illumination ii* diminished. He baa al.4o cdi«cn-ed eotor-UindncM in
the atrophy of the optic nene canset|uent upon jjjlnucomatoua excavatiwi.
We have now to turn our attention to tJie various caiuea which may pro-
^dtice cerebral and cerebro-spinal amaurosis. Uui this subject is far l<Ki
Bxtcnsive for the scope of tins work, and 1 must therefore confine raysplT
■ " : a mere onlline of the prinri|>n1 causes, and must refer the r«,*adcr
■r iufoimutiun to epeciul w-rks and ariicles njon Uiis subject.
AHADROSIS — MEMNGITIS.
4»9
I
tnfiMfpt ^EM I would eHpevialljr reoommeuil LUiwe of Von Oraefe,
llii^-lilingx .(ackiwn, Oji}e, Galesowski. etc.
It aiui;!, liowcver, be canilullv coiifeiuied tliat wc cannot diagnose the
epccial cerebriil cause, or localise its sent, simplv from the ophtlinliQo-
tk>o|ii<; symptoms presented by the optic nerve. In order to ai<1 ami
}jui<k- us in Arriviii;* Ht a conclusion its to the caiife and its situation,
otlicr bwiil aiM] general ajraptom* must bu searched for. But, even with
their aid, we oftvu fiiil to dctvrmiiiu tht'»e points with anytbing ajjproacli-
iug to certainty, and niiiy liiid, on pnnt'intrtem examination, tliat we
have hocn <iuii« mi-Htaken. Indcert wc »omt>time» meet with caseA of
sinijile pn>^ret)9ivti atr<jj)hy of llie optio ncrre, IvaiUnf; \*y blindness, in
which it is (|uilo intpos-'ihle lo detect any Bpocial cause, either ccnibral,
Bpinal, or cnnstitutional. On the other hami, th« trunk of the optic
iivrvc may bo seriouely implicated iu the intra-ci'anial disease, without
the si^bi beinfj in tbc least afTcclyd.'
[It should be carei'ully bume in mind tliat it U possible to have marked
intrn-iTRnial dtiteiisf without any rti;fri of litmpby of the optic nvrvo \'tai-
Ijle witli tlie r>pbthulitio.4cop<> ; and that mi tlie other haml tlicrv may be
% purely local atrophy iu the optic nerve without auv intra-cranial lesion.
-B-1
Sill) the opbthalmofloope proves of immense use to the physician in
the practice of hi>i art, and may often lead bira to the discovery of di<t-
ea-te^ which be would, without it, have passed over or miiinterpreced.
As I have already menttoneil the various aRVctiuns uf the brum which
may produce nptic ncurittH, I ^ball now oidy consider lliosu which may
Ipve rise to progressive atrophy ol" the optic nerve.
Mrniui/itis of the baac of Uie brain is a very fre()uent cnuHi> of dis*
case of the optic nerve. The symptom* of acute roenin^itia are gen-
erally flo marked and characteristic tliat tlie diaguoi'is is not difficult, but
it is didorenl with the elironic form, the course of which is often very
insidious, and it^ aynipti>m4 masked and indistinct. Bui its presence
may bo suspected, if tliurc arc febrile attacks accoui|>auied by violent
and recurrent paroxysm.') of bendnchc, scrcre vomitinj^ and retchin;;, iin-
eonsciouoiieM and sensitiveness of ibe cranium t« palpation. Moreover,
tok llie inllnnnnntion of the nicnin^s is ^Mierally Huniuwhat diffuse, wc
fintl tb.it "tlier cerebral nerves becimii; affected, bein;^ eithi^r paralysed
or in a state of irritation. TImm, we sonjetitne^i find that some ol the
muactea of the eye are pandysed, whilst others are in » state of spas-
nioalic contmclion (tM-aefe). The intlainnintion of tbo nieutn{;es may
extend from thir uiembnin<'>4 to iht- cortical substance of the brain, jwr-
baiis to a cAiuitterable deptli, reaehin;;;, according to L. Meyer,* oven to
the optic thalauii.
With reganl ui the headaches which may occur in cases of amblyopia,
we must be on our guard not to attribute tbem always to some cerebra.1
affection ; for, as Von Uracfe has pointed out, tliey are often only due
to the fiiiliug si^ht, and are produced by the intent endeavor of tbc
patient still thoruu;4hly to rcalixc tlie visual imprcKsiuns. Ou account of
' "A. f. O.." rll. 2. p. HI,
• I. KryvT, - ( ui>u«il>UU rur iiimI. WmwiuwIi.," No*. 8, 9, IR, I(W7.
500
INTBACRAKfAL TCH0R8 AND HBMtAKOPBtA.
this there occur disturbancca of scnaitilitv akin in oftturo to thoflo vrhich
An; met with in duuUle visiou, circlua of diB'usiou upon thv retina, etc.
If i\w heiulachc bo niinply due to this cnusc, ce^ation from work will
rapidly cure it ; for it can be easily understood that its intensity may tie
mtttirially increased by any cause that produces congestiuu of Uie brain
or the eye, such an stooping, etc.
Acute meniiitptis, more especially the tuhercidnr form, generally givea
rise to optic iieiiriti», and this often euanea rapidly upon the outbreak of
the Cerebral affection ; whereas, in Uic chronic form, tli« optic nerve
often remains alto<::ethcr, or for a long time, uiiaflucted. and then it un-
dcrgocfl projjre.-wivo atrophy, iw nutrition becoming im[«aired by cho
chronic congestion of th« brain and meninges.
Cfironie perioetifig of tlie base of the brain may al&o produce amau-
rosis.
Turners within the brain may cause progressive atrophv of the optic
nen-e, either by the latter becoming directly implicated in the tnorbid
process and its iiervuus elements destrtyetl. or by its bviri-,: CMoprewed,
iitri'lclied, or pui'hnt a^uh iiy tlio tumor, sn that its conductibility and iU
nutrition are greatly interfered with; but the impairment of nutrition
may also be d\ie to pressure upon the bloodvessels of the optic nerve.
Although sarconiatoiiH and carcinomatous tumors arc the most freipienC
morbid growths, wr must include other neoplasms, such as masses of
luix'rcle, syphilitic gummaljL, exostoses, etc. iSucb morbid grow^is raaj
he siiniited at tht:' VMide nf the brain or within ita substance, nicir
diagnosis is very uncertain and obscure, except other general or local
symptoms coexist, which amy aid us in determining the probable nature
and seat of the cerebral disease. Thus in e*|uil&lerHl hemiopia («ay of
tlic left half of the visual field) we should suspect tliat a tumor or hemor-
rhagic effusion ia pressing upon thr right optic nerve.
[.\troitliy of the '.vptic ner^'es from direct pressure of the tumor i» com-
imnitively uivcomnion, as only a small proportion of the intracraniftl
tumors are sitiiaU>d in this ricinity. Com])re»8ion by exostoses, cheesy
tuberculous masses or gummy neoplasms in the vicinity of the chiasm are
the most common.
Hydrocephalus iuteraus aUo causes atrophy by pressure on tlie
chiasm.
The symptom known as hemianopsia, hemiopia, or heratopaia, is of two
varieties: Ist, a permanent defect of half the visual field of both eyea
from pressure on the tract or chiasm, or from functional disturbance of
the optic centres in one cerebral hemisphere : ami, 2d, transient attacks
of half-»ide<l b1itir!nes.s without organic lesion, and called amnuroaia par*
lialij^ fngax, or Itittering scotoma. The hemiopia generally affects one
of llie lateral haU-pg of the visual field in both eyes : a superior or infe-
rior hemianopsia is very rare. The hemiopia is either laiernl, affecting
the external half of otie field and the internal half of tlic other; or il ia
temporal, affecting the tciuiH>ral halves in both fields. A nasal hemiopia
only exiala, according to I.ebcr, as a 9Viumetrica.l disea.4c of both optie
nerves. In lateral licniiopia central vision is gt^nerally verj- gwid. In
temporal hemiujiia the dividing Hue is not a sharply defined jierpendicu-
lar through the |>oint of fixation. In pure hemiopia tlie color aonse ia
:
CBREII8LI.AR TDUORB — OERBBRAL BBUORHBAQB.
501
I
P
ftonnal in the imafTectcd half of the Tisnal field. Permanent superior
or inferior hemiopia of both cyea \s very rare, and the simplest explana-
tion is that the optic iivn'OH have been couiprcKs^ nt the bade of the
tikull from abovo, or fn^iii liolon )>y Home |ialliolo;;ical proihict. Htil| it
miflhC be explained W a ^vmmctrlcal primary lesdon in both optic neri'e«.
In lateral hemiopia of centfHl origin there in for a long time a noniial
fundus, aa a descending atrofihy retpiires time to reach the optio disk.
It may be inferred from tiiidden's e;tporiracnte that central atropby of
the brain may extend peripberalty to liie optic tmcbs and nerves. If tho
lei>ion in in the chiasm, di^-oloratton of tlie optic disk will occur aooiier,
though it may bo preoedetl liy tlie aigu.s of nouriti:).
LaK'rnl hcminpia often apiK'ard suddenly with signs of cerebral apo-
plexy, and the cause ia here an apoplectic clot, or an emboliu, or a ttimor
ID the opposite hemiaphere. Tumors at the base in the region of the
chiasm are common, such as sarcoma of the sella turcica or of chiasm,
tubercle, and gummata. The locality of the ttim'tr can only he deter-
mined from all the aecompanring symptoms, and not always then. — B.]
If the temjKiral lialf of each Held iit irapaireil, the eroded faoetcult of
Uie nerrcs arc involved, awl tho seat of the discni^e i-s at the commi»-
BUN. In such cases the impairment of vision is often very rapid, the
tight being pcrhapd utterly destroyed within a few days. The contrao-
"^"T of the virtual Held begins at the periphery of the t*Mui>onil side and
ends up to or beyond ihc centre, to that hnally only a slight glimmer
of light may he left on the nasal side. If the cerebral tumor is very
slow in its development, the brnio substance and the nerves may gradu-
ally accommodate themselves to its growth, and there may only periodi-
cally arise some compression of tlie vessels at the base of the hniin,
which, s<.-uiiig lip diHlurbance in the inter-cranial circulation, will give
Hm to ejiheitienil heuiijiiugiu, ischamiia, and fainting or epileptoid fits.
Hut symptoms of paralysis of the cerebral ncr\-e.-* may suftorrcne if the
tumor })vr\adi;s, irritates, or [rre^ses u]K>n the nerve substat»c«, or if the
resseU become compressed ami the nutrition of tlie nerves impaired.'
Tumors in th- ferehrllum nearly always produce blindneas (generally
from optic neuritis) by setting up a general disturbance (tlughliugs
JacL-ioii ), whereas abscess of the cerebellum, as a rule, does not do so,
on uccuuiit of its limited extent and elTect,
(.Wt^rral hnri'irrhti/r may lie suspected if the amaurosis cornea on very
suddenly ; this sudden ei^uilateral hemio|)ia of the Icf^ aide would make
tt8 su'ipect hemorrhage in the right ht.-mit>phere. Such er^uilaleral coo-
tractioii» of the lielit often remain behind in pcrvoiis who hare been
afffctml with an apopleciio fit. Lass of the right side of the field is more
trks'itiie tlian thai nt' the left, more esix-cially iu rending, as the patient
cannot read so easily and rapidly on .lecount of his not being able to
foresee the wonls ((Vraelo). In slight ilegrees of cerebral hemorrliage,
the sight US often ipiite imaffected. Ilcmiopia may, however, be also pro*
duued by temporary ailoetious of the nerve trunk, e.;t., syphilis.
Henili' aitfteninij of tlic bratn is not, as a rule, accompanied by ainau-
' I, but, of course, the atrophic changes in Uie brain may extend to tho
I -Ct. ItonaUbl.," 18«5, p. U3,
502
AUBLTOPIO ATTKCTIOVS — SPINAL AMAUH06IS,
Optic nerves, tbe nutrition of the latter becoming impaired on account
pLTliaps of the discaiw of tlic ve»»elA.
Epihpnji mny proclnco amnurosiit vrlien it is Hue to some ^iscane of the
brain, fbr in^tADce. mtMiingitis, for epilepsy must be looked ujraa Ed a
gympfmi and not n» a liiwase.
In 'Ufentfn of the fpittal mrd. more especially chronic royelitis and
liicDinotor Jitaxy- amaurorfis, from pro;;rL'rtsive atrophy of the optic nerves.
is not urifre<iueiitly met with. But it hanllv ever makes !td appeararwe
in locomotor ataxy until a late jicriod of Itic discatto of the apine, long
after the impairment of the mr.bility and senaiMlity of the lower limbs,
and the jianilytic afiectioiis of the muitcles of the eye, the latter often
\mni^ ammi;ist the liift syiiiiitnnii^ of the spituil di.-^i'ase. In some very
rare instancri*. the atrophy of ihe optic Tiei'ves has preceded by a long '
period (several yeiirs) the first symptoms of spinal disease (tiraefc).
i'hia late occuiTence of amanrosis is explained by the fact that the defen-
eration ascends from the vertebral canal to tbe cavity of the craiiiiim.
AmblyoplH often occurs nt the commoucemeiil of the Hptnul aflc'ciion. and
n can-fill exaroinatioii as lo tbe true nature of the impairment of vision
hhi>Hld be TUiiile, for it may only be due to a Itwwj of the jiowor of accom-
niiidaiion from pamlywis nf the ciliary musele, and be not at all depend-
ent upon any disease of the optic nerve. A want of can; in tbe cxaini*
nation as to the true cause of tfuch amblyo|jia;. bat* led (o much confusion
amongst writers upon tliis nubjoct. In caae.t in which the atrophy of tlie
optic nerve is de[>eiident upon locomotor ataxy, the former may remain
stflrionnry for a few weeks and then a^ain progress ((rracfe).
[Tlie UKHt comruon cause of ainMuro^is in »piua) diaeaae ia gray degten*
eratiun of the pirstcrior columui!. but ii uecura aldo in myelitis ol ilic lat-
eral cotiimnx. According to Von Graefc, thirty per cent, of casen of
prttpressive atrophy of the optic nwrve is due to spinal disease. An inte-
resting variety '^f optic nerve atrtiphy is dBMcribed by Charcot, accompa-
nied by atrophy of onchalf of ttie body and contraction of the extremi-
ties. {" t'oojpte Kendu df la Soc. de Biul.." iv. p. 191.)— H.]
The aflection of the optic nerve in diseases of the spine is prolmblr due
to « lesion of tbe ;;roat sympathetic, through ita communication with th«
anterior niot>! of the spinal nerves.
[On thia point ace an article by the Editor, in " Amor. Jour. Med.
Sciences," July. I8T0.— B.]
In t!iomo cnHCfl simple atrophy of the optic ncrro ejcii^trt for a long time
without any appreciable cBu.«e. or the ap|)earance of any symptoou indi-
cative of a cerebral ur Kpinul lesiun ; and, even afWr death, nothing is
perhaps found except ai-rophy of the optic nerves or atrophy of thow? pnrta
of the br»in which an; continuous with ttio Optic nerve. In some of these
casefl, however, inanity may supervene. And this brings us lo a very
important point, viz., the great use of which the ophtbalmo300]ic \a likely
to prove to the alienist in establishicg the study of insanity u)ioii a more
positive baais.' lu Kngland wc are almost entirely indebted to l>r. AlU
I Fnr ftirtlicr in form at ion I wcdld purtiritlarly r«rammn»il Dr. I^ixtMir'i vt^ry lnt»-
rcilius pniitT "*^u Ortiy I'i*(t'."""™itoii.uf llu- '>|jlio Nt-rvc." " A. t. O.." »iT. 3. 177 ;
k1»i) l>r. Wi^tphnl'M iinpnrtnnt [lapi^M in tHi< " Anililv TQr 1'itychUUii%" [AIm Die
" Weal Itiiling Iilinntii^ Aaj'lutD ll<-|n)rt)>," lirat fmir jiiitn.^II.]
ATROPHY or OPTIC HBRTE — PROOS'0318.
503
butt for our knowlcd(;c of tliU aiihject, and I woald refer the reader to
bw valuahlu and iuleri'Stiii;? i'a|M;r, entitled "■ Oil tlie state of the Optio
Ner\-C8 and Kctina; as bui-h in the Iiisaiie," H^ad before ihe lUy. Med.
Chir. Society, Fehnmry 'li>, IMH. In this, he mentions that in general
(isralvKis of the insane, atrophy of the optic nen'o is constantly fouml,
and ia i:onimoidy sccompaniod by alroptiy of tiie olfftctory nerves. It is
not illi)tinctty seen till the end of the tirst stage, as it slowly cmvvU down
from the optic centres, and it is in rclalioit with the state of the pufiil,
which id contracted in the early irtage and dilated iti the fatly atrophic
stage.
In nnnia, the on1ithBlino<>cnpo often revenis symptoniAtic changes. In
dementia organic disease ami affection of the eye generally occur together.
In i<liot.s. atro]ihy ol" the optic nerve is of fre<tiient occurrence. Out
of twelve cases, it was found of a marked character in five ; one was
changing, and two were noted as doubtful.
We hare now to consider the prtt/noata which may bo made in case*
of aniaurosia or nu)l>lyopia, as to whether tlie impainuent of visiuu will
improve, remain stationary, or the r>ight hi'<;t<init {Msrinane-itly bnt. In
framing our prognosis, we mint be 4-.<peci«lly guided by the mode of
attack, the condition of the field of virion, and the appearances pre-
sented by the optic nerve. The nature of the primary disease winch has
causoii ttic affection of the eye mint naturally also be taken into anxious
consirlu ration, i'or the prognosis will, of course, be mnterially iiitlu-
enced liy the fact, that the iutm-crnniat affection is of a kind that ]»er-
nails of resolution or amelioraiiou through the absoriition of raorlud
produeia. or hemorrhagic effusions, or the amendment of irrogularitios
in the circulation.
If atrophy of the optic nerve has alrt'atjy set in, tiie progiKMis m to
the arrest of the disoase mn^t h*^ very gnardt^d, as in such c»m>5 there is
always a groat tendency to progret'-<i'>u. ami termination in absolute
blindness. iJut this is not necessarily always the case, and it would be
committing a gmvc error to irrevocably condemn an eye, simply because
the optic nerve shows symptoms of comtneocing atrophy. The state of
ihe field of vision is our best guide In such cases.
r<iray dugenvration of the optic norre, in comicction with 8]>ina1
8ymi)l(Mnri, U hoindeHsly incnmbU*. — It.]
If the loss ol siglil ha^t oi^curred with groat suddcnneu and rapidity,
tlie prognosis need not necessarily he bad. for we occaiuuually meet with
cast's in which great improveiueut. or even complete restoratioti, of sight
lakes jilftce after it« sudden lo4s. Sudden e<)uilateral hemiopia is gener-
ally due to lieuiorrhagic etl'usion^ (itjtoplexies), which is seldom the cn^e
iu double central scotomitu. Von tlraelu' considers that the prognosis
of sudden amaurosis i^ better in cliildren than in aJult^. lie »Uo stntes
that the Iwrit prognosis is furnished by those coses in which the suddiin
los« of sight is Uiv result of mental shock ; nUo if the pbosphenos con-
tinue to exist in the blinil retina, and complete darkness proves bouefi-
ctal. This fonn of nnfcsthesia U often auociated with cutaneous iiuen.
sibility to |)uin, and is perhaps referable to vasomotor action.
t " Kl. UousUbl.," 1865, U9.
The projrnodw \» nlf«o inclined to bo favortWe if the dtscnse
luniiicil ijtutioiiiiry lor ^otnt.* len^tli of lime, fur alltioiijjh the datigeruiis
tbriiiH III' aiiiiiiiniKiit jikentHir hull in tlicir [irn^^rcsx, vel UiIh iuU'mi[iUou
iloe^ not extend hcvond a few wcekit or mon^iit, when tlicy aj^n nm-
gTvtui, The foitner eases often depend upon a c^jiuhiualion of del«tenoua
cause?, giich as alcftlinl, tohacco, dissipation of every kind, o*'erwork of
the eye« and brain, or irregularities iu the digestive org&na or the ute-
rine system.
The projiiiodiJii ift had. if (he stropliy of the optic ner>'e i« of slow
development, and manifi<»tti a persistent, thouL^h perliajis tanly pro;;rcas.
When the atrophy of the nervp cannot be traced to any paruVubir
caui^e, but appears to be a diaeaae/^rr h, the prognosis is gonendly iiUo
Yery nnfavorahle.
In tho.ic cases in which the condition of the vinnnl field i.-t i)nit£ nor-
nial (even after the uflcction hiis existed for sevt.Tiil luoiilhs), and the
acuity of vision has not aunV oonsiderably (only to one-sixth or one-ienth),
we may decidedly regard ihe disease as noi bein^ due to progresaive
atrophy. The impairment of virion may iiott however, undergo much
improvement.
With re^'anl to tlie pro;rnoflirt affonied by tlio different forma of con-
tmction and intemiptioii of the vihuhI fii-ld, we nt.'iy briefly state, that tb
ia more favorable when it in e()iiitat(Tiil. with a sharply definc<l line of
demarcutinn, than when it is concentric, or its cilgett (lit the lutcml form)
are tmdefineil and irregular. Indeed, patients effected wiili 0(|nil»teral
hcniidpia never become absolutely blind, except Ibe disease extt-iwla to
the ct'mniissure. or i^tme other cerebral afleetion supervenes.' Such
paticntA often enjoy excellent central vi->|ivii, bein;: able to read the 6l)est
print, and tlio ail'eetion fretjuently reuminA unaltered for a very Ion;;
iimo. 1 havecAse^ still under siipcrvirtion in which e>|nilaLenil hcroiopia
has e.\i;9tcd for ttoiue years, and the patients are still able to read per-
fectly, nor \u\A the cnitiliiinn of the eye chau^-d, tier have any uUior
symptom* shown theniselvcii.
The nxwt dangerous cnses are those, in which irregular contractions of
the tiehl of vision occur either tuniultancoudly in botii eyea« or in quick
succession. Also those, in which the condition of the one eye being
already very bad (the degree nf its central virion being jwrlmpseven Icsa
than the eccentric), the second eve iKtcome* atfected in an exactly simi-
lar manner, the coutniction of itH visusil liehi commencing ttt a pmut
gyuui)etni:al to tliai nt whicli it began iti the tirst eve.
Central scotomata never indicate progres.»ive atmphy, if the periphery
the visual field is normal, lint if they have existed unaltered for
I'eral weeks, and the optic nerve beginti to sliow symptoms of oooi-
' Ton Or«ef«f s«7S : " TqIa] tilitHltiMH iu cmum ot untlKl«nl Wain dbcoM oxn ontjr
Miiu't (1), wlivik tli<^ oilier bouilKpliiTti )lkuwis« Ukuows ili<f BiMt of >lts«a>« ;
{'1), wli>Ti IreAh t'ffiiAioQii in tin' )i<-inUj>h<-rM ftrigiiially jifTecti-^l ocvk-iKiu dilfuitw ocrw-
brnl ill«ftuii', hn|ilv llir'iii|;ti niuvmin iTr^-bri ; (3). wlii*n a luiatliir AlTtH-iiiin finiwr-
T«n(^, <lirr-i!(]y jilli'oting tlii'tniiilcKof (li<- nptio nt^rv<-K ; <4). vihta ^ttnv fTU-Toiii-hiiWftil
nn till' Kpniv i>f lln! ci'n'lirn) ivivilv rtiitiili* in i-iiinprmnioii of the aiaus CACcrtiusn*
with i.->m»<.-^u«iil vfiiuiifc lncar(.-<'rn(k>n of lln- |>n|Mll« ; (5), »rh<^ pmiMtcitiwi en-
OBphiiln-oKTiiin^ili* Ii-a<Ii« in nouriliit tlfitc<Tuiliiiitt," (" Kl. UuiiiUeU.," lt)i£&, 33u;
•■Opiilh. K«Ti««," ii. 35ft.)
I
I
I
.._ „ ., ^ , a reslitiitioD .. ., _ ^_. ._ _.
If tlie central |Mirtioii of the retina maintjiins iu t^uperinrity of viition
ovur tliv outljfin;; part^ ( iio that the patient csin sec tJiroii);<i Ute scotoma),
the prognosis is alwnjru butter than wh«ii the revowe oUtains. If the
prnphi>r»l portion of ihc lieM of virion Ix^youd the- sL-ottpnm \i im[>iiirci|,
pri.>i;rv!:i-<iv«; nirupby \« to be feared, which is not the ca-'^e when thi!< part
of the tiehl is normal, lor tliis show.-i that the power of coiultK-tibility in
the part of the retina affected witli the iKOtoma ia perfectly retained
(^Von (>raefe).
Wo cannot form our projinosisof the case simply from the appcaranoe-t
E resented by the opiic nerve, for, aa Von liraefe rvinark;'. it is itnpoui-
le to tell from tlM;}«e atoiir. wltether tlic ain)phy 1h- prof^resutive or sta-
Itonnry. In conjunction witli tlie nppcamncc of the optic nerve, we man
Uierofore be guided by the condition of the 6eld of vision, and the mode
in which the attack occunred. Even the absence of atrophic symptonn
in the nerve does not exclude the most nnfax-orable rcftiilt. In cases of
Ruihlropia tluo Co diaturbanceii in the circuhition, or to alcohol, or in
that form which U .loraetimes met with in vi-ry ner^'Olls fomnles and in
ehihlren, the presence of synifitomK of atnipliy of Uu- optic nerve arc
always of material consequence, as they grentJy chmd thu pro;i;iiosia.
TrtMtm^Ht. — Tliia rnuAt of course be Afiecinlly directed A}i;ainst tlic
primary cauac uf the affection of the eye. In Ibo^e caseit of simple
progrea-sive atrophy, in tthich vie fail to detect any appreciable organic
or functional cau^e, we nniat t»e extremely upon our guard not to submit
the ]jatient to a very active course of treatment, more ospecially of a
lowering or depressing kind. For great mischief is thus often produced,
and llie progreHs of the diaeaHe hastened, instead of being arrested or
ntanlcd. The Ivcst trcntmrnt for such cases consists in the administration
of t<}Qi€», especially the tincture nf the muriate of iron, or a combination
of steel wit}) ((uininu or strychnine. 'Die lactate or siilphatoof sitic
may alw be given in gradnally increasing doses, commencing with i or
S grains daily, and augmenting this grudually until the patient takes 8
or 10 grains a day. The diet should be nutritions but light, and the
offect of stimulants be closely Wfttc)ied. The iMitient's conntc of life
should III* carefully regulated, a sullicieney of Hleep be iusi.'ttcd on, and
all lUIlu-^i■^lents and (■mphtymeni, that may prove injurious to his eyes
or geiienil licalcli, be stnctly tbrhiddeu. The use of tobacco must also
be alkiMdutely given up.
If there ia any evidence of the e-tist^.'-nce of chronic meningitis, irregu-
larities in the circulation (.more especially the cerebral), or a suppression
of ciutomnry discharges, such as the meur^trual or the exhalntions from
ibe skin, more particularly the feet, a derivative course of treatment
nniAt he employed. Lctx'lies Hlioutd be applied behind the oart*, or the
artitieial leech to the temple, and a seton may be interted at the nape of
the neck, which often affonli* great and s[ieedy relief to the severe and
persistent headache. The bi-chloridc of mercnry should he given in
small do^es, in combittation perha[.<« with the itKlide and bromide of
potiLSsiiim, more es|)ecially if any (^yphililic taint is 5Us{H>cted. The
sudden suppression of the norrruil eohalatious from the skin is not an
uufrequent cauM* of amblyopic aflectious, more osiwcially aft«r long
i^JHOI
506
ATBOPUY 0? OPTIC ITBRVE — TRBATMBNt.
nxpTMure to cold anil wet. Thnti persons who have ntooil for miiny
hoiir^i ill rlic wnter (sportAmtin, fiAlierrncti, etc.), arit »nnictim<:*4 uffcvU-d
with umblyo|>iit, on aocuunt of Lhe suppretiiiioii of tliu ex})»laiioii:i fruni
the feet. In such eases hot stimulating pediluvia, togetJicr witli <ltiipho-
retice ami diuretk-s, iihi>uhl be prescribed. C>i-aefc also advocalea tJie
Roman or Turkidii bath, na especially cxcitinj; the action of the .-tkin.
nliich will hUo prove of benebt in itie difT^redt fomid of congestive
nmlilyo|>ia.'
If the affection of the eye U dne to Aomc •tulilcti fright or shock Co
the nervous system, tonics ahouhl also be prescribed.
In the amuiirusis due to hwomotor ataxy, innumerahle remediea hav«
been ti-icd. Itr. Allliaiis' states that he lifts lU-rivcd much henvfit in
eases of I'je4>aiotor ataxy t'rora the admiiiistiwticin of small dosf* of
niirnle of ailver. He gives it to^jeilier with the liypophosphiut of s«ida,
an><l he never goeg beyond the dose of half a grain of the nitrate of nilver.
li should be employed for from four to six weeks conaecutirely. Bod
then discontinued for a fonni^ht or three week*, ft sliglit aperient mineral
water Iwing ^iven in the meanwhile. Then the uau of th« rfuii-dy may
he a^^ain cnmnii-nced ami continued for n month or so. Thp ^uin-t should
be examined from time to lime, as the pecidiar dusky dinct^ In ration of
the i<kin, which the long-continued use of nitrate of silver produces, first
appears in the mucous membranes.
[If there is any reason for supposing that ayphitis i« the caowt s
prompt and long-continued iii!e of mercuriald and pomsttium ir»didi> i.-t
indicated. The u«o of the cou-ttant current has l>een higldy recommended
by many oltf^crvors, hut no roles have been laid down for iL« npplicntion,
and the mnjoriry of ophtlialmic surgeons have Httlc faith in its effic4icy.
[The iiiteriinl administration of strychnia has seemed to do good in »ome
cnses, hilt the manner in which it acts has never been satiefactonly ex-
plained.— IJ.]
The treatment of antaurosis by subcutAneous iujcctionf of strychnitie
is described at p. .'ilti.
[f central scotomata have been develojted during a protracted eti>
feeblirig general illness, such aa typhonl t»r scarlet fever, diphlherit,
childbi'd, oie.. tonica and genemus diet, with stimulants, arc the beat
ri'nTfdios; ami, subsi^iuently. when the sight is bi-ginning to improve,
much benefit ts often derived from metliodic.-illy practicing the sight < even
the eccentric) with ittrong citnvex lenses, as is done in cwe« of anittlyttpia
from tiouusc. An improvement upon Lhe ordinary sioglfl convex leiuU
* An lBi|Minniit atiit Int^n^ttng f«ct In rtmniriinn yi'.th llils vntijivf hut bivn notlfwd
)i\' Dr. Lnariil. Ilnviii;; fotinil llnl ix-rnxiii ndcotnl wllb (iilii>'i» aiul tuiigivtt'iu l^t
tt'i. Ilx^iI wr.i iiTi.-ii miioh U>ii>-ilt«>l liy ilii- Tiirkiiili tMlli, livib-uitflii ilikt ilir r>tailir.t
i:< -iatntiif; t)ii ■•tr<^*l ot llir Uller ufHvn the drri-lirn) clrfiulailnn wixiM W hr
III- > liidui-iicr ii|H>ti lb« l>lunilv[«>pl* of lliti iviitia. Mr. Wurdaworllt ilivin-
fMfv nkaiiioiM I'r. L<Mirri)'« »>yn> wltii tlir (•jihtbalni'«<.'»|>i* Jiiil |>rtnr in hi* Miit»rto(
llii" i^Mlh, itixl acain ntXt't Iin tiai) n-mniiii^l in tlio hntlivt rhnmlxf (MtW^ K.) For a
'I tioiir, Biul thru fiiiiiid a •Ivitln) and uuirkvl }>al<<ur9'^ of thf <i|itir uervr,
xitiiiD in lb» *ix<' i>f till- ivtlitnl Vi^ki-Ia. Tlx' nitiuf i-ltiwl »«» »<>tkvd m
t' - ••tii[ihi,ri-*) in llifi liittli (« nr>uTi>, an Kant Itidtan, an Ktif^hvlimaii, >t»l ■
•\ft a Iru|i4rature of llfOO y,, wIm w^n* •txaiiiinid at llttr MWti lluw hj
...,..,-. -nil.
lircliiTr* >M Ejiilfpvjr, ll^itflria, and Atox/, 1966.
AMnLYOriA AN£H1C AUBLTOPIA.
507
rrcommeDdeil by Von (iraefe, viz., a combiiiattoD of two lii convex lenwjs
(the one « inches tlie oilier 4) set in a tube or ring at a liiHtJiiice of one
hid) frvin eaoli otber. We thus gain a relatively corididemblc magni-
(y'wji power witlt onljf sli^^ht fi|ihericHl abcrntunn. The eye should at
first be only i'raeti8e<l for a v^vy short time (about two or throe minutes).
ait'J wilii print ihat can he prt-tty easily deuiphercfj.
If there is any rlisturbance in the fnnetinnn of die liver or digestive
organs, loild aperient mineral waters should be prescribed, such as the
Fullna. Karlsbad, or Kissingen.
l_AMBLYOPIA.
This affection ik often due to passive congestion of the brain, the eye,
or other orgnn^^. such as the liver, uterus, etc., or to disturbances of the
noi*vou8 function*.
We mnst admit thnt the Icrm piissive congestion is very vagiic, and
that we do not know with any ocrtainty ihu rooilo in which the sight bc-
ihwn »frectc<l. and wliethvr thin is due to a retardation of the hlwHl nnp-
ly and a cotiwfjuciii insufficiency of its aiiratioii, or whether it is loaded
witli noxious ingredienta, such »* alcohol, nicotine, lead, eto-, wbioh
exert a toxic influence and thus impair the functions of ttio nervous sys-
tem.
For practical purposes, we must, however, draw a line of demarcation
between the amhlyopiie which are duo to simple irregularities in tlie
circulation or nervous function, and those which depend upon some blood-
poisoning, if this term nay he accepted.
The itwnfficicncy of blood-supply which f^vcs n^e to the aturmie am-
Mynjint may l>e due to souie excessive discharge from the uterus, to the
debility con.-ietiuent upon very mevcrc illnesse-*, to » prolonged and very
cxhaiwtit.g confinement, or to over-suckling. Copious hemorrhages (>. *;.,
after confiuement) may likewise produce it. Oases are also reconted
ill which vomiting of hluod (probably dejicndent u|ion an ulcer of the
stomach) ba« produced amaurosis.' In the^e cnses, the U>»s of sight had
come on rajiidly (lea<ling to complete blindness in the course of a few
days), ftffecied both eyo^, and was incurable. The ophihalmo^copic ap-
pearanccH were eilliur negative, or were those of aiuvuna of the optic
nerve anrl retina, IrndJoi; subae<]uen(ly to atrophy. When the Inns of
blood is very considerable, the function of the optic nerve is probably
impaired by the aniemia of the brain and the insufficient excitation of ihe
retina. Hut it is remnrlcnhle (as Von ISniefe has painted out) that the
flight does out necessarily return with a rest'iraiion of the blootl-supply
A a restitution of the other fnuctions. This is probably owing to iJic
L't, that the temporary deficiency in the hlood-supply has caused ]>cr-
tuanent cliHnges in Che nutrition of tho more delicate iier^'c structures. '
[The amnurorti.<) docs not usually occur at the time of the loss of blood,
but several d:iy8 afterwards, and the cause cannot )« found sololy in the
resulting anwniia, for tlie patients have often recovered from Lho loss of
■ O'BriUjr, •• Uiicet," lSft;t ; Voii Uraefs, >•-&. L U.," vit. 2, 143.
610
AMBLYOPIC APPBCTIOHS.
Tlie amblyopia met witli in drunkards faiablyopia potatitrotn) gon-
crfllly coiTiiiience8 with the appeariincc of a mist or cloud Vieforf the
cytis, wliicb moi-e or le^ 8tii-i-ouiid3 and shrouds the oliji^ct, rendering it
huty anil indistinct. In auiiie ca^eR tlic iiuiiainucut of viciinn becomes
very oiuxldcrablc, »o that only the largest prim can he docipbcrcd, but
if pru;*rcdsiv8 atrojihy of the optic nerve tiet6 in, the tiij^ht may fte com-
pletely lost. The visual field may remain normal, or become more or
less contracted. The affection may exist for a very long time irithnut
causing any organic changes in the optic nerve or retina, excepting tho?e
of hypersemia.and a certain loss, of transparency of the disk. In other
cases, if the dtsiease progresses or the cause persists, atrophy of the
optic nerve supervenes, and this ulwayrf materially clouds the prognosis ;
for ttlthough we may, even in «Hch caxes, suinetinies succeed in securing
a great iuipntveinunt of siglit antl an nrrest of the atro{)htv degerieraliuTi,
yet the vi,tion is hut seldom restored it'l int^i/rum. In caiics of simple
aniblyupia, viithout any central scotoma or cuntractioii of the field ofi
vi<)ion, Lelier has found that tlic appreciation of colors la not at all, on
only very slightly, impaired.
[In the few cases of this kind hitherto examined microscopictlly, the
nerve fibres were the seat of futiy dcgeneralion. and the connective-tis-
sue framework was liy|)ertropliied. The amblyopia may be acute or
chronic, the Intter being the more fre>|uent. h occurs unioli nftener in
men tlian in women. Scotomata arc not always demonstrable in thii
disease, but lu some casus central color scotomuta are very prouuuaced.
With repeated attacks of alfohf)lic amblyopia, the tendency lo aimpby
becomes mure certain. Tlie diseaiie is always bilateral, and in severe
cases tlie patients often complain of persistent colored afterimages. —
B-]
in many of these cases, we cannot detect any abnormal appearanoea
witJi the ophthalmoscope, and must therefore regard the impairmeut of |
sight as due to a functional, and not to an organic, lesion. In other
cases there is some hypera;niia of the retina ami optic ner^'e, with, per-
haps, a certain degree of jms^ive cong.-stion, together with a dimiiimiwn
in the tnmsparency of the disk, and subje-ioently symptvmi of atrophy
of the optic nerve may make their appearance. Hut 1 must here again
wam the «;ader against too readily assuming the existence of liyporw-
mia and congestion of the optic ncrwc an^l retina, simply because Uie
disk may seem to him to be ^Hglitly too red, or the veins somewhat
large. It lias been already i^ljitcij tiiat the upnearuticea of the optic dulc
anil of the rctinnl ciix-ulation vary very greatly within a perfectly phys-
iological standard, and that it often re>|Uire;« an expcrieiwcd and careful
observer to deteruiiue whether or not »oiue marked peculiarity iu the
apjiearance of tliese structures is physiological or pathological. In
judging of these conditions, vtc mtist take into special cou.iidc ration the
age. the habits, the complexion, etc., of the fsitient.
The progiiosl'* will dejiend cliiefly uiK»n the condition of the optic
iiorvc, the leuglh of Lime which the diHcase lioa ejiistcd, and the fact
whether or not the patietit U willing entirely to giro up any hubitd which
mar have caused it.
'i'ljfl effect of tobacco in producing amblyopia auU amaurosts wae origin-
AHAOROStS FROM BLOOD-POIBOHIKQ.
509
tloct«il 10 tlie IbiM nerve ami it« ciliary branches. Whoroaa if the
)Hi|fil rcuiitins nctivv, it sliovrs tliat the cniitk* of the lilindiie.^? is not
tiituat«(l within thi^ chnin or circle of conilnctihility, hut Wtween
the corpora iiiiadrijfemina and thai portion of the brain in whicli the
jierccption of li;iht is locnliaeii. In fact, as Von <tniefe says, •' the
nejialive r<'*mlt of the opbthalinoacopic examination exculpates the retina
and the intra-ouuhir eml of the opiic uervu from hcin-^ the CAwe 'tf bliiul-
ncM ; and the preservation of the activitv of the pupil not onlj exciil-
pntc« these, but also the whole optic nerve and the cnrporu quadri-
ppmiiin." Ilviioe, if the action nf the pupil mi the atimulua of li^ht re-
niiiin!« intact in CA-^es of suddvn blindness, the prognosis a^ to Uie restora-
tion "if sijibt 19 favorable.
The atiihlyopia which u met with in diabetcti is aumetimesdue to pani'
lysis of the acconmtodation, or to retinitis, somewhat akin in ita nauire
to Uiat met with in Brij^htV disease, and oidy rarely to ana:R)ia. In
fh-'h-ra we mi^ht expect that there would be great amblyopia on account
of the [wvurty of tlie bluud, but thin w not 80.
[Ucal diahl'tic nfl'cctions of the optic nerve aro of three kinda : 1 . Sim*
plf nmblyopia with a fnre field; *2. Atrophy; 8. Ilemiopia. The
retina is generally affected also in these coses. (See Graefe u. Sae-
miicli, V. pp. 8fl4-«I»0.)— B.]
C"Hiie$tivf amhli/of>i(t may be due to over-fulnesa of the system and
congestion of the eve. bruin, or other orf^and. It is not unfrtNiuenily
met with in cases of suppression of customary discharf»i'3, deficiency or
alwcnce of tin' catanu-nia, and itwnfficienl action of tJie skin or kidneya.
Mr. Ijiwson' narrates a case in which »upprc<ision of the mcnKcs pro*
duced. within a few days, complete amaurosis in one eye, and |£reat iio*
fiairniLMit of vision in the other. Under the use of iodide of pota&sium,
and with the reap|>eftrance of tlie catamenia, the si;;;bt was restored.
A very interesting and extraordinary case is also reported bv Mr.
I.Bwson.' in which amauroiia repeatedly occurrci during the period of
gestation.
Tliu real nature of amblyopia which is observed in certain cases of
M*cnlled blood- f)ni>ionin^ is at pretMint quite obscure. It is generally
Buppoiied to be due to some disturbance in tlie circulation, prolucing
what is termeil passive congestion of the brain. But this explanation is
indefinite and unsatisfactory, for, as Von Oraefe says,* ** Whether there
is a real inundation of the nervous centre with venous hlowl, wbotlicr
the current and chan;;e of the blood is only too alow, or whether the
visual function is affected from the blood being overloaded with alcoholic
and narcotic sul>slaiieL'3, are m many i{ue»tions suggested by the term
• paaaire cerebral congelation.' This lerm, therefore, only &en*efl to
dt'dignato a condition where, failing all evidence of active congestion, the
functional, or, aa the case may be. also the nutritional excitation of the
c«rcbrat centre of the optic nerve ia interfered with by circulatory
influences of the aforesaid order."
This toxic influence may be especially produced by alcohol, tobacco,
lead, and quinine.
■ ■■ MmI. TlniM And GufAlto," lt>J3.
■ **U|ilill>. It^vip«," II. p. 340.
< "B. L. 0. II. Rfp.." It. 83.
610
AUBLTOPIC AFFECTIONS.
Tlie amblyopia tnpl with in drunkarfis (ainlil^-opia pouitonim) geii-
emlly coinmence$ with the a]>pear»r>ce of a mist or cloini liefore Xhv
eyes, whiuh more or les^ surroimU sn'l elirouda the olijrci, rouilcrifij* il
hazy and indistinct. In somo cases the impairment of vii^ioa bccomcii
very cviuaiderable, so that only the largest print can bo deciphered, but
if prn^n.>(!aive atrophy of the optic nerve sots In, the iiiicht rnav he com-
iilclely lost. The visual H«Id may rvmajn iionnal, or become more or
leHt* contracted. The aflViclimi may exist for a very ion^ tiiim wtthoat
caii»ing any orj];anic chnn^rOlt in tin' optic nerve or retina, oxccptiti}; ihoxc
of hypeneraia, and a certain loss of iranspareucy of the diijk. In otiier
casus, if the disease pro;p%sse3 or the cause persists, iLtrophy of the
optic ner\'e supervenes, and this always materially clouds the projniosi* :
for iilthough we may, even in such cases, sometimes succeed lu securiu;:
a ^roat improvemeni of sight and an nrrest of the atrophic de;{enc ration,
yet the vision is but seldom rcsturvd uj inUijr»m. lu ca*e» of simple
amblyopia, without any central Hcnioma or cnntmctlnii of the field nf
viition, Leber has found that the ajipreciation of colora i« not at all, (»r
only very sti-^htly, impaired.
[Ill the tew ca-ses of this kind hilhiTtu examinrd mlcn>!icopicTiny. the
nerve tibrca were the seat uf fatty defeneration, and tlie counfc(i»e-liii-
t>ue frutiieuork was ltypertn)phied. The amblyopia may be acute or
chronic, the latter being the more frtHiUfitt. It oc4,'urs much nfteit'^r in
men llian in women, ticotomata are not always demonstrable tn tlib
di:9caae, hut in some casca central color scotomata are very pronoancetl.
With refu-ated attacks of alcoholic amblyopia, the tendency to atmjijiy
"beiiomcs umrf certain. Tin,' disease is always hilaleral, and in fevero
caoes tlic pftticntt* often complain of persistent colni-ed after-iioa»e«.—
In many of these cades, we cunnol detect any abnormal appearvtcea
with the ophthalmoscope, lunl must therefore regard the imi^irnient of
piglit as due to a functtona'l, and not to an organic, h-sinn. In other
Iries tln're is some hyperwmiu of the retina aiwl optic iien'e, with, per-
liAp?), a certaiti ilc-jree of passive cnn;:c'»tion, to;iotbvr with a diminulion
in tlie trans|Mireiicy of the disk, and suhicptently syuijuomi of atrophy
of the optic Qorve may make their apjicarance. Hue I must hc're ngniu
wani the reader against too readily assuming the existeuoe of hypi^rv-
lala and congelation uf the optic nerve a^id retina, simply liec&iL-se tln-
"■-" fuav scent to him to be slightly t«»«> red, or the veins t
I It has been already stated tiint the nppcaniivces of Uie o|
id of the reliijil circulation vary very j^ptatly wittiin a perfcctiy phy*-
^logical standurd. and thut it ofteu re^[uires an experienced and careful
frvcr to iletemiinc whether or not i^nmr marked peculiarity in the
■■• of these structui-e» in phy«iol<ij.'icttl or pathcdo|ricat. In
■'< these oonditiMtis, wu must take into speeial consideration the
-. the couiph-xion, etc., of the patient.
-'.-^-tM wilt depend clitetly u|Min the coudiiion uf the uptio
Iwrvu, tiie length of time which the disease has exiattnl, aitd the tn<:t
Mttrther xr not (tiu patient is willing entirely to give up any habiti which
|Efty have caused it.
'rii" effect of tobacco in jiroduoing nmblyopia and amaurMifl wa< ori^iv-
TDUACCO AMBLTOPIA.
fill
nlly pointed out by Mackenzie ; more lately Crilchett, Wdi-Jh worth.
Untrhinsrm, km) Sictiel have, amonynt others, pnid niiicli nttenticm to tliis
subject, ami Uelifve that it i^tve* rise lo a (M;ciitiar ami <liMtiiictive forni
of \o»» of sight, which thejr liave therefore tcrniL>() '*tol>acco amaunKtis."
It is SDpporte^i to proHuco a peculiar form of atrophy of the optic nen*e,
Uiq isvmptoms of which are im> special as to he coii!tiilcrc<l characlerintic
of trthaeco amaurosis (vhir article on "Atrophv «f the Optic Xervc," p.
4^1). One arguiuetit which lius heeii Imnj^ht forwaril lu lem) 8|iecial
weight to the theory that tohacco uiay proftiice niuaurosls it), that simple
progretwivo atrophy of the optic nerve occurs far more frequently nmonj^t
men than women. Whilst readily conceding thi'*. I must also call at(eu-
tion to the fact that tlie caut^ca which may produce aniauro!>id uhtaiii far
more among men than women. Thus the former are, »s » nile, cxpi>^e<l
to far greater cor]Htreitl and mental labor, to greater vicii'situdes, nn<l to
a greater indnlgcTicc in free li\*ing of every kind. Moreover, in all
probability, the uuiauroaia i» far more due to a combination of such dele-
teriuna influenceii than to the pn.>valence of one Apecial one, e. //., tobacco.
At leaat, in by far the greater numtter of ca^es of amauro.iii) which I
have tnct with in heavy smokers, the paUenM readily admitted their free
iTiihil^ence in otlier excesses, I fully admit the fact, that the excr^aivc
iiae of tobacco (hut niO(*t frequently together with other canies ) may
produce cnnBiderabte impairment of vittion, awl ttnally, if the habits of
the patient be not entirely changed, and the use of tobacco, stimulants,
etc.. given up. even ntn^phy of the optic nene.i. But 1 cannot, from
my own experience, acceilir to the diK'trine that there is anything |)ecu-
liar in the form of atrophy of the optic nerve, which would at once enable
one U) diagnose the nature of the digcaae, as depending upon exceasivc
smoking. For the three peculiarities particularly insisted on, via., the
premonitory hyperajmia of tlio diak, the blanching of the latter first at
tlie outer side, and the diminution in sixe or even diaappearance of the
nulntive vessels of the optic nerve. whiUt Uic retinal vessels for a very
long time retain their normal calibre, are met with in other formj of
atropiiy of the optic nerve, and ai-e therefoi-c not at all distinctive of
tobacco amaurosia. In-leed it is impos'»ihle to understand why tobacco
alone olioiild produce these peculiar ciiangeit. I believe that in the com-
mencement of the ambl^'opin of smokers and dnnikarda the disturbance
of ^i^lit is Bt first onlv functional, the rct<na being, bo to say. ^'blunted."
and its sensihilitv impaired, so that it docs not react with normal acute-
nc»s. Thi» impairment of it4 function is probably cliicHy due to some
irregularity tn the circulation of Uic nerroua contre^a, attliough it is also
pnihabic ttiat in many ca^es (cspcciiilly of tobacco amaurosis) tltere is
some ilepressiug inHuenee exerterl directly upon tJie nervous system.
The truth of thi.-i hypothesis i« proved by the fact that at first tiie optic
nerve and the retina are «piite healthy or only somewhat liy|icrjeinic, and
tliat great and rapid improvement takes pince frheii the |)atieut reliu
.jniahes smoking, drinking, etc., and is submitted to a tonic coari^e of
treaimcut. together, perhaps, with local depletion. But if the cause
]}crsists. if the patient coutinno.-< bi.-t indulgence in tiimoking, drinkin;:,
etc.. combined, perhapei. with severe mental or corporeal exertion, then
the disease does not remain confined to mere functional deraugcmcnt.
512
AHBLTOPIA FROU LEAD.
Iiiit. generally passes over into an organic lesion. Tlie optic duk licgiitft
to show svmjitnraii of atropine dcjieneration, athI tlie latter m»y [ira<liii»lly
Itut Ktvudity utlvatice uutil the fiiglit is greatly impaired or cv«ii <|ui(e
liMt (GrU4;lo).
[Tlic vimiAl rtistiirbance ami ophttiftlmoacopic result, central ncotomata,
ami tliscoloration of the optic diinlc are all like those in alcoholic ambly-
opia. It« coui-BO is olowty jiro;ires^ivo. With these symptoms \g very
api to he united a chronic cuiijunclival irrimiiiiu with scarcely aity secre-
tion, occurring eajwicially in lliojie who work iti tohucco. — B.]
Ttic absorption of fmJ 111(0 the system will produce amaurosis. I
have only met with one cane iu which the Iobs of sight could be dis-
tinctly traced to lead-poiRoning. Thi.t wtui in h youn^z woman, who mme
time ago came under my care at Moorfielda. She had been a worker in
lead, and had suffered frum severe lead-poiaoning. She was completely
blind, and both optic nerve-s showed marked symptoms of atrophy con-
secutive upon optic ncuriiia. Mr. lIutchiii*on' lins observeil similar
instances, in which lead-poisonin;; had piven rise to optic neuritis, fol-
lowed by atrophy of tlie optic nerves. [In these ca«es the amaurosis is
goiierallr very complete, but transient, but in rare tu>ttiincei4 the amau.
rosis lajitA (ar week*, and even month*. (^Seo '* Archives of Ophtlialniol-
o^'."' viii. 4, and ix. 1.) — H.J ^'ery {reiierHlIyT however, the only
symptoms revealed by the nphthalmoacope are congoBlJon and hyper-
emia of tho 0]>tic rierN'e and retina, the veins especially being somewhat
dilated and tortuoHB, The siijbt and field of vision arc even in such
cases often con.4iderably impaired. It muiit be mentioned that albnmi-
nuria is sometimes met wiiLi in lead-|Kii50iniiu, and that conae«)UCDtly nlbu-
minurtc rettnitirt may occur ((HHvier, Desmarrert),
[The amaurosis is almost always bilateral, though it may b« in dif.
ferent degrees. Tt mny be sudden and complete, coming on at the end
of an attack of colic, and this form can be cured. But the most coiomon
variety is the slowly progressive, with central scotoma, and wicb other
defects in the field. There niuy be no other signs of lead-poisuniti^
present. — B.]
t^uinine in large doses bos been in rare instances observed to produce
amaurosia, probably' by causing great congestion of the cerebral circula-
tion, aa much benefit was derived from tho use of the artificial leech.
Cr^Btnir itmfilifofiui. In the article upon retinitis albuminurica.it was
nientioned that very sudden and complete hIindnoiA sometime* occurs in
Ilright's disease, and is due to unemic bluoil-[K?i»oning. The sight may
be lost within a very few hour$, together with the appearaiice of symptoms
of uniemic blood-{>oi soiling, such as great pain in the head, epileptoiii tits.
Rte.' Then, on the subsidence of these symptomi, the sight is also
restored. This impairment of vision must be carefully distinguisbed from
that dependent upon retinitis alhuuiinurica.
[Tneiiiic nmnuronis occur)> in scarlatina, variola, and measleN. in preg-
nancy, and in the lying-in woman. It may not be complete, and is
" *'B. L.O. II. R«iJ.." ri. 1. sii<) ffii. 1.
■ ,\ i-kM of ihU unrtnir- ninniinwif followt'd ftficrwards b/ retinlUs altMmiBariea it
rooord-ii by t>r«rfi<, '■ A. f. t>.," v>. 2, '277-
AMBLYOPIA.
613
I
I
I
kliniys tntosicm. It may caropUcntc a retinitis alhuminuricn in tbo
preguiiut woroau. The rwactiou of tlif pupil is r ftivorable sigu — if tbi*
18 alt^iic or very 8lu;;gisl], the proj;tiosii) is unfavoratilc— B.]
Amblyopia 10 sometime* due to reflex irritAtion tirigiiiatin;{ in one of
the bratiche8 of tlie tlftli nerve, or in oUier ]mrU of thu nervous «yi«tem.
Tliua «evcre anil prolonged dental neuralgia may produce impjunnent of
\-iifioi», whioli mostly disappears with tlie removal of ihc carious teetli.
The opiitlialmoscopic examiuatiou generally oidy aft'onls negative reaulta,'
Id a ca«o of abiice^ of tlte antrum from a carioui tooth, narrated by Dr.
Jam«8 Salter, Ibc eye was considerably protruded and blind—the opL-
ihalmoscope revealing extreme ansemia of the optic nerve (alropby If).
The Btgbi vra* not improved by the removal of the tooth. In a ca« uf
her|>ei4 fnutalis, accoinpauiL'd by great pain, reconted by Mr. Bowman,
the optic nerve wai atrophied.'
[LJmlcr this head may also be considered sympathetic neurous in one
eye from irritation of ciliary nerves in the other eye, accompanied by
Umitattou of accommodation, luclirvmatiou, and retiunl hypeimithesia.
Alw Uie Binauroaid occurring after uijury w the frontal nerve. Moat of
the easejt of hysterical aniaui-osii! and of the blindness occurrinf; in byii-
t«r<j-epik'[«y belong iu this category. It is probable uUo tbiit the cases
of bliudneiid occurring wItJi ttie pre.>*em:o of intestinal worms, so often
reported, are examples of rctlex amaurosis. — B.J
When one eye ia excluded for any length uf lime from binocular
vUion. ita sight generally begins to fail from non-u»e of the eye. Tliis
condition u termed aml^yiiia ex uHopgia, and in cdjiecially met with in
cases in which, on aeoomit of the prc^cnoe of some opacity of the cornea
or lenst or of strabidiiius acconii>anied with diplopia, the acutenoM of
vision of one oyo u. coiwiderably greater than that of Che otlier. so that
the diflcrcnce in the tliittincCnciut of the two retinal images proves very
coufuaiiig to the p»tient, and. in order %o remeily this, he unconsciously
" ippri'SM'o the recognitiun of the less distinct image. This iirtivf 8U[»-
ssiun of the one image by the mind must be di»tiugaished from its fHi»-
give jujipression, caused by a dense opacity of the cornea or lens, tbo
presence of which prevenia any image being formed U|)on the retina.
The active suppression of the retinal image is far more injurious to the
flight than the {tas;^ivc. Hut both arc eti|>ecially s*^ in children, for in
them we often (iud thai after a strabliimmi has exi-tted for some time (itix
or twelve month»>, the siglit uf thu »i(uinting eye may be so much im-
paired that one large print can he deciphered niili it, untl yet it appeara
in all other respects perfectly normal. Moreover, if the »>{iiint is oper-
ftlcd npOD, and the eye then practised separately nilh strong convex
glaasva, the sight may be rapidly restored, if the impuimieut of vision
bad not reached too higli a degree. This proves that the defect of sight
is not congenital, a^ hns bi;en sometimes supposed, but m due to tlio
exclusion of the eye from bincMrular vision, and consequent dixuac of the
retitui. Besides, if the squint is alteniating, so that each eye i« used in
> Cams uf «itil>l/D|>ta, ncc»<n[isn;hig di-nUI iu<urnl!;lii, hnvv Inaen ri-Mmleil by Mr.
Hntrlilnx.n, --K. L. O. II. K»i>.," vol. Ir. 3S1 , aliu l>' t>i- UV<.k<T, " Aim. rl'Ouiitl*
' "R. L. 0. U. Rin>., " V. 1, p. 7.
3a
fiU
AMBLTOnC AFPECTtOSS.
turn, the siglit of liotli rrmniTis perfectly jood. Tlie mre cjiaca of non-
allerriatingsiruliisnnis, iu wliirli tliesij^litof the Sijuintiuf^ oye still retnini
its uormd ocuteiiess, arc probably due U} the alfsvnce of binocular vii»ii>m
in coni)er|Ufnce of wliich there is no diplopia, and of course no ttviiv*
8nppr«s9ioti of the double imafre. This subject, Lowevvr. in more fully
explained in the article upon Strabittmiis. in chililren. even the pasmre
exclusion of the eve (e. y.. fr"m cataract) leaiU to amblyopia far soom^r
than in adults, in whom complete catanict may exist for very many yeari
(\'nn (iraoie has recorded such a caac in which a cataract had existed
for sixty years), and yet, when it ha* b«eu snecewfuHy removed by
operaiiou, the patient can see perfectly. In children, however. tbi» is
no: the ease, and the senftihility of the retina is apt permanently tn coffer:
hence tlie rule, tliat in chiblren cataract, as well as strahismus, sboubl be
operated up'Ui snon afler its appearance.
Sudden ainl severe blows upon tlie eye may produce compIeK aod
instantauooua hliudneas, apparently from paraly^s of the retina (^rvm-
motio rrfin/p). [Traumatic anieftthe«ia of the retina U perhaps a bctier
name. — B.] The saiue has been ubserved after a stniUe of li^btninj;.'
The ophtlinlmoMTope ^renerally reveals no rtympuuus at all conimensunue
wirh (he dcj;rec of hlindneB!* ; pt^rliaps there is only some hy|>cnemia it(
the retina and optic nerve, or a few scattered blood exinivasatioiis. In
other catieit nothing abnormal is obsen'ed, and the hirt8 of ei^ht i^ prob-
ably due to some disturbance or derangement in the retinal elements,
wbich are, however. Invisible with the npbthalmoacope.' But De Wecker
mentions a ca^e in which atrophy of the optic nerve anbsft|ueutly ftU]wr-
veneii. The si^bt in ihcse cases of paralysis of the retina often become*
perfectly restored, even although all perception of light may at tirst have
been lost. [Welbuiarked cases of amblyopia due to poisoninj; by opium
and morjihiiie hare been rejiortcd.as well as mienf osmic acid atnauroEi;
by N'ltyps. One case has Iteen reported of t/)tiil amaurosis from a snake-
bile ('* Aimales irOculislinue," 187.5. p. !tO).— U.]
The treatment of the different forms of amblyopia must varr with the
cau.<e of the affection. Thus, in cases where the latter is evidently due
to great debility, conseipient, porliaja, upon severe illness. hyiwrlacLitiou,
etc., tonics, a generous diet, plenty of exercise in the opt^n air. sea
bathing, etc., must constitute the chief remedial agents. Whereas m
the congestive auddyopia, gresl attention muHl be futid to the free actiou
of the rarious eliminalive orj:an9, more especially the liver, akin, and
kidneys. For this puqwae saline mineral waters, diuretics, hot stimu-
lating jicdihivia, ami the hot air or Turkish bath, will prove of s|iecifll
advantage. In LJermany the prolongeil use of the decoction of Zitmann
U a favorite remedy, but tliis mode of treatment is accompanied by so
Duieli inconvenience, that but few Knglish pntionta will submit to it. In
tlie congestive Bmblyopin, 1 have often derived the greatest benefit from
the repeateii use of the artificial leech. In some cases, even its first
application wa« followed by the most marked and surprising improvement
in the sight. Hence. I would particularly insist upon tlie necessity of
' vide BiM SAMniMlt, " Kl HunntsU.," UM, p. iS.
■ Via* nlM SeliirmffT, IhU., IWV, tti.
AMBLYOPIA— TBBAT»BXI.
515
dlvrajs ^ii'iDS Uie itrtifivifil leoch a trini in ca9«» nf .imblropm or nmsu*
nuis, in which Uiere U evi'lenue or suspicion of cuni;v.stioii, nr of irruj^il-
b»riti«s in the circalaiiDn ; for tltia rLMiieily is at present far ujo much
iie(;lecte<l in Ent^lmiil. Tliu hlootl xlionlU \ni drawit mpidl^, so ttiat tti«
glft-is e^linrler hocomeg filled in ihree or four minutes. One or two
c^vliiKlcrs full Troni each temple (if both are iifrocioO ) will gvtierally
RiifficB. Thv ojieratiou mii^' he rcjieatwl at inU'rvnU of five nr six ilaj^n,
but if ihcro la no improveroonl of nigdt after it has liccn pcrformr^ two
•jr three timos, it abould not bo repented. After enuh application of the
artificial leech, the patient shoulil he kept in a darkeneii room for about
24 hoiira, as the operation is j^eiierally followed hy a gowl dent of
reaction in the Inlrn-ocular circnliilion.
We must also insist u|ion the i-atient leading a moat regular life and
abitntninf; from cxcemca of every kind, and in tlie Amblyopia |>otatorum
the allowanci! of o[iiricui)us lii|iinr>i muH \*o cut down to a mlmmuiu. If
the nervous Ky-ttotu ia enfcchle'l, tonlcii must be administered in cottnider*
able diJM!S. more especially Bleei, either alone or in cmubinaiion with
ijuinine or atrychniiie. 'l"he tinct. ferri. niuriat. (from giw. xv to 5-w or
nrorv, two or tliree (imea daily) nftfii proves of much benefit. In the
amblyopia of Urunkarda. Galezowttki rccommendB large iloscs of bromide
of potassium, and a coHyrium of calaharine, [In amblyopia potatorum,
the artificial leech ia ^mctimea very useful and should always be em-
phiycd. — R.]
In on^^r to allcvinte ibo extreme rcstlewncM and nervous irritnhility
of nuch |atifnt-t, di;;italia or hyoscyauiiiB uliuuld he prescribed, and
nKifpiiia should he a<1 ministered at night to relio%'o the j^reat and very
trying »leeplea5ne»s, or the subcutaneous injection of morphia may be
employed with ndianlnge.
In tobaccvi amanrowis the ^rcalest streig must be laid upon the ah»-itutt^
Hfesnttif of the j»atienl's entirely jliviii;; up Ihe use of tobacco. Only
ill this way can we boj* to cure or arrest the disease. Moreover, it is
generally more easy fur a great itmoker lo break himself at once and
altogether of the habit, tlian to limit iiiraitelf to one or two cigars or
pipe* a day, for then the temptation of excecdinj; thiti amonnt ia con*
aUnlly presented bo him. At tlie same time tonics (particularly the
tincture of ateel, alone or in combination with strychnia) should be
prcWribed. Jty pun»uing this course of treatment, we may jfem-rally
succeed in rapidly curing the amblyopia if it be !<till only functional, nr
of arre«ing it and perhaps greatly improving the sight, if the optic
nerve is only slightly atrophied.
lu the tmjiairmeiit of vision from Iend-T>oi'<oning, many remedies have
been rccommeDded, of which the moat rc-hablo ia probably opium. Thiit
ha» been found to shorten the course of the coiiatitulional diaea^e, to
diminish tlie frequency of paralytic affections, and t^i prevent r lapses.
The subcutaneous injection of morphia baa been employed with much
benefit in amhivupia aatuniina by Dr. Hnasc.' As a rule, aucb caaes
affonl a fav.irable prognosis, if symptonw of neuritis or atrophy of the
K optic iiorvc have not BU|H;rvcnud. The patient tnust, however, bo wanied
I
> " Klin. Hoiwulil.," ISfiT, 229.
516
AMBLYOPrC AFPBOTEONS.
not again to expose himself to tlic risk of renevccl lea<l-poi30Tiiii<;;. othui
wise a relate may occur. [The first tliitifr is to remove tlie fsiticu
from the influeiicc of the lead, and to ;*ive such metlicines a^* will dimt
nnce the poison from the system through the Iwwel* and feidncy. lArgc
doKf^ of |Kita»^. iodid. and hypwlunnic injections of strychnia are m\s^\
advi.iahlc. — B.]
The aml'lyopia due to disuse of th« eye is best treated by meihoiii.
cally rxercit*iiig the sight in reading, etc., with tlie aid of a Rtrong coiu
V6X lens, or still better, Von Graefe » combination of two lensm «ot U
a small tube. The eye Bhould be practised frccjaently durin;; the day,l
hut only for the space of two or three minutes at a time. [If the am- 1
blyf'pia is due to tlie Siiuinl, this ahouhl \>e correct<.*d. — B.]
In the Uf'M of »i<:;lit uepcndetat u]>ou [i:jralysis (commotio) of thr re-
tinn, the artifieial leech, and hli^ter^, shouhl he applied, anti the siibcii-|
Uiiicoii!! injection of Blrychiiiue tried.
I must now refer to two modes of treatment of aniauroiiiia and ambly-
opia which have more recenllr come in vogue, .'^nd attracted much atl«-n-
tion, viz., ihe suhcuiancimti injection of 5trychnine and galvaniMn lijrj
menus of the constant (continnons) cnrrtMit.
Strychnine injections have recently ae«ume»l ranch prominence in the]
treatment of ainauro-tJA and amblyopia, which is chiefly owin;; to ihe abloj
and extensive researches of Nagel,' who has tried their effect in vcryJ
nuuiL-rouB cases. They have sotnetimcs proved beneficial, even iu ca»«
of progressive white atrophy of the optic nerve, frenufntly, howiivcr,]
only UMuporarily arreatinj; the progre** of the disease ; they have aUi>'
been useful in cases of atraphy following optic neuritis, hut the
greatest benefit has been derived in cases of amaurosis and amblyopia,
without organic ophthalmodcopic changes, euch cases as occur fronrj
antemia, copiou-i hemorrhagcii (hscmatcraesis, bleeding after oonflnemenlTl
ele.), severe blowe on the eyv, or from flashes of UgliUiing; al»o inj
anic^tlic»ia of the retina, lieinenitiipi»,iinil amblyopia dependent u|)4>n au
e.Tce^«ve uho of tobacco or stimnlant-i. 1 have trieii llii-i dmhIo of treaU
nient pretty largely, and have occasionally derived much betiefit froinj
ilB use in these forma of amblyopia. I have someiimcti even seen soraaj
benefit accruing from it in cases of atrophy of the optic ncrvo. It aM
pears but of littlo if anv good in discaset; accompanied by changes ia.i
the retina and choroid. \Voino»' states, moreorer, that it prove* use
less if there is a loss of the perception of colors. If Itie treatment is]
likely to prove benufiei.il, the improvement in sight generally manifr't
itself early, after the first two or three injections. At first ^^ of a grain]
should be injoctwl once daily in the temple or arm, the dose being
gradnally increased to j'^, or f'j. Acconling to Na;^e!, it in someitrai*!* !
!iilvftntJigeon» to interrujit the irijections for a day or twn, 0R[>ecially if I
any .sign.s of a cnnstitutional elTcct show themselve.s, such as twitching iu
the limbs, formication, pain in the head, dizzinesa, etc. Woinow gener-
ally injects ^^ of a grain every 2-i days, and daily gives -j^g of a gmja
' "nifl B<>1iiuiillun$ di^r Amnarogton nnrt AmWyopKn luil Htrvcliiiin," twi DrJ
Altircrlil Nn^i-I. Tftliiiiit^n, 1S7|, Vidi* alsn an nrtii-I" nti liiin mltJKirt \ij I'ref.
Bornxr In the " CorrwugHiU-m-Blatl fUr Scliwt^iUT Ai-rltf," Sei»i. 1, 1872.
USMBHALOPIA.
517
of extract of mix vomica interiijilly as a pill. [Tlie iise of strychnia,
botti livpriilerruicfilly and intcrnallv, ]t»» become vt-rjr exicusivo in tlic
Uuitctl Stat«tt for iimost all kiixU of ainlilyopia and amaurusis. It ucr-
(ainly doee good in a great variety of ctises, but it U not possible to lay
duwn any rules wtiicli mav indicate ttic limiut of its usefulness. Though
beneficial in some ca^es of nmblyopia potatorum and uicotiana, it proves
uwleM in others. Some cases of chronic d«;;enera(ion of retina and
cburoid impruYc markedly uiuU-r itK uh*. nhilo others show no cliange.
]Ui cflVot mav not be demonstrated until after srvcral weeks in some
led, and thi» ia contrary to the idea formerly held. It iii well to begin
Itli a diiily dntte of ;;r. ^'^ or ,*4, and rafiidty increase it to toleration;
then hold it at this point tor some time before diniinisbing tlie dose. It
i.« udvi.sabte to employ it in all cases uf amhlyopia, but not as a spe-
cific—B.]
^ As to the trentuient of these diseuses by the conHtnnt current, it uinat
conl'ei^ged that thiit \g tiot at present pliiced u]ion a firm ba^is, ami I
think that it bo-t not received that attention frotn ooulietls which it dc>
serves. At alt events it is most iidvii^Hble liiat more extensive exp«ri.
nients nhonld lie made with it, if only for the pur|)03e of testing the
curative |>oHero claimed for this a>;ent by some obMrvcrs, especially
Itcncdikt,' Krb,' and Driver.' In eases of atrophy of the optic non-e,
the i>o3itive polo of the conatanl battery should be applied lo the back of
the neck, ami the negative to th« closed evolids, being moved gently
over ami around them; e.^vh sitting should not last more than 1-3
tninutes; the number of cells employed may range from i to 10 or H,
according to the nature of the eaae and eensitiveiiesht of the eye and of
ihc patient. The operation shonM not produce dizniness at tlie time, or
heudaclie afterwards. It is belter to have a short sitting every day
than a prolonged one at longer iuiervid*. I have found Foveaux'd
(Weiss' a) coi;stant battery one of the most couveuient.
2.— HEMKUAl.OriA [MOHT-BMNDNESS].
This (Ksfaae is especially chflractertzed by the fact tliat, although the
patient may be able to see very well during Ihe bright daylight, his
Mght rapidly deteriorates towards dnsk, ami still more so at nightfall;
hence the term nigh I* blindness. When the illumimition is insufficient, a
more or letu! dense grav or purple cloud surrounds and renders all ob-
jects indict invl and haxy, and aUu impairs tlie p<i«er uf disiinguir;hiiig
colors. Tliua, according to F6.-*ter,* certain colors, C9p(cinl1y wliitc,
yellow, and green, can be more readily distingutcshed thiui blue, violet,
or red. The pupil is wide and sluggish on the admission of light, hut
reacts normally on irritation of llie branches of the fifth,*!. </., on the
instillation of the tincture of opium. In retinitis pigmentosa, the pujiil
is, on tlie contrary, contracted. In severe cases Ihc inip-tirment of
sight may be so great, that even large <>bjuct«t cannot be distinguished
iaeelralh«ra|M«, b;r IkutNlikl.
lit it 2.
< K»s]tp'» Aivhlv.'' it. I.
* " rtipr II«>in«>rali>piu," Bf»»Ua, 16&7.
Ms
AMBLVVPIC AFFBRTIOSS.
nbeii tlie H^lit is much itiminishetl. It is, however, nn error to suppn
tliBt the ilimne.is of ^^i'^ht is due to the scctin;; of the snti, nn<1 that it
tliiis linked to a ccrtsiii time of the da^. Ideiittcallv the same svnipt >n^
apjienr if ihe illuinirmtion la :iriifictally ditiiiiiished. hy [ihiciii;: llie ]•■•
tient ill a darkened room. TIii-» fact was most satisfactorily provod l»r
FOreier. vitli his iii;;reni<in9 pliutonidler. The dimness of vision is mily
due to an impairment of the sensibility ("torpor) of the retinn, so that
the patient requires tlie full stimuloii of brigbt daylight, or artificial
light, in order to see diatinctiy. Tui^ iinpainneiit of the sett^itiility of
the retina m.iy eithir be rUie to nn in.^ulficicncy of Wood supply, to the
imjjoverifehed condition of the hlood, or to tlie nerve elemonU of the
rt^iinn haWug been over-stimulated by prolonged expoiiure to extremely
bright light. Very rrequemly, the hemeralopia u a result of a frontb^—
nation of these cauA«it. [Tnc functional dit^turlMinee does not alwaj^f
involve all parts of tlic retina alike, but there may be a number of Ko-
tomata. Both eyes are always aflccted, and the pntients are ofteii
annoyed by after.imagrs. The color perception is mnrkclly dull
low illumination, and phospbeoes can with diDiculty be excit«il. C<
jnnclivicis is a not uncomtoon complication. — B.]
It appears, however, to be true that in the early miming, after a aom
and rufreahiiig sleep, the !iou8':btlitv of the retina 'u greater than at
flub3e<{itonl porio>] of tlie day. m that the patient in then able to see evi
by a somewhat diminished illumination.
It is of great coii»e()ucnoe U> disttinguish between the flimj'le hcmural
ina, ftiid that condition of night btindneM which accompanies fr-tintt
pitfme.nt"W. The former is simply fiuicCioual and curable, the latter d
pendu uf>on urgniiic changes in the reiinn. and at a later period in th*
Optic nerve, and i» iitcumble. Inattention to, or ignorance of, these facta
has leil to great confusion in the writings of some author*.
Uemcralopia may be caused by prolonged expo*urc to extrcrocly brigl
light, Bucb a» the rays of tb« aun in tropical climates, or the glare of
o«t expanse of brightly i;1iKteiung finow. The ill effects of such cxpoeui
Bake theitkielves enpecially felt, if the individual \» in a condition of ,
4elMlity or exlmustion. a? after severe illness or long deprivation of fo
T^w, wenot unfreiincnily find hem.'ra|npiaexi^*ting among sailors reiur
mt. fnvm the ti'Opics, who have been kept for a length of time withcM
a^tetent food, and have, perhapiv. been auOering from acurvy. I bn
a(«wml times had four or tive sailors from one vessel nndcr my care
lliwrfeUn, for liemeralopia. Their story wa^ always the s;iiiie. Tliei
^ ttst lamleil from their vessel, after a long exposure to a tn>pic:il »t
mil » aeabtV allowance of food, and they had generally Iwen rtuffcriiijjj
ll^ pMl debility, or from scurry. The bemeralopia had dinitiii^K<^lj
«^B^as (Ml their reac'iing n mure Eempenilo zone, and rapidly dis*|
«^iHii «■ their arrival in England, under the adminUtration of toniei
eiit of a geueroiw diet. In none of tlicse cases was I aMe
iTd&ing I'ecnliar with the ophtlialmnsco|»o : the retinal reiiB
w^MW. alif^tly dilated, but I could not trace any diininHti<w in
■i 1^ arteries. Indueil, in almost all cases of tbia form nf
TTiHi^t« ofihtlialinoscopic examination yields a negative result,
wtmi> <i 1»— {Mtticnts there were distinctly noticed thotte peculiar,
nSHKRALOriA.
510
eilvcrjr grav, scaly piitabos of thickciietl epitlielium at Uie out«r portiou
of Ihe octilnr cunjnnctivn near tlie comen, to wliicli pArticular atcencion
tills lipcii cnllvrl hy UtUil,' tie conaitlors tlicM pacchest patliu'^omunio
of heme rail) [lia, tind ataicK thai they disappear catuteiitaiicnr-ily uitli tlid
iii*«|>|R'arance of night Minrlnesg. I have, however, fouiul thorn absent
iu at'it-nil caacH of hemcralupia, ami tlii-y arc evidently tpiict' uriL-otiiiected
with this di'ieaie, and nnly due to a thickcnin;; and doiiccation of ilit
conjunctivat epithelium from expn^urc tu intcuM* hoat, which sets up a
slau' of chronic ooiigcstton or infiainmatioD of thu conjunctiva. Thv ap-
pearance of these patches al Ihe outer i>nri of the cornea, is due lo tlua
jHtrtiiKi uf thu uciilnr conjunctiva liuiti^; most exposed, ou account of the
palpehral aperture at tliiii point.
HcnivralofMa )ui« also Wen ohserred to hr*alt out epidemically in gaoU,
cauipA, clo. I need hardly point nut that in siiuli cases, a careful exnuii*
luttioii <tliould always he iimtituted, in order to jctuanl aifainst " malingcN
iug." According to Alfred Graefe, the accotnnioilative power of ttie eye
U often somewhat impaired, there Iteing also a certain degi'ee of iosuffi-
WBDcy of tlie iiilenial recti ruitscliis.
ITje treniment rausi be chiefly directed to stren^^thenins the general
.1th hy lonica auJ a f^ncroua diet. Amon*5i(l the former, .juinino,
eteel, a[wl cod liver oil are the best ; indeed codditer oil ie cousidered by
Oct<|Htnts H)i a ft|H'uific for henieralopia. At the same lime the patient
mu9t he carefnlly ;taarded a^^aiii-tt bri^^ht Yif^tl. Iliit room should be
darkened, and he should only be allowed to go out when there \a no 5\in,
and even then wear dark eye protecfu's. If the altac'l^ of hemcralopia
in Bevvixs it may be even necessary to iiuiat ufwu keeping: bim in perfect
darkness for :<everal daya, and he should then he gradually accustomed
to a srcatt-r and y:i-eftU>r amount of light. Blistcri and local depletion
havr tteun ittn>ii^ly reeotnntcnded liy some aut'ions, hut tliey am generally
dutra-iiidicnced by ttie debility and feeble eonditlou of tliu patient. But
if there are raarkud symptoiiw of coiigcition and liy(K.'r«!mia of the retina
and optic nerve, the eflect of the artiticial leech Hhould be tried.
In «ni>i£' i>li»dm-»» the impairment of vitiion ia a1-4o chiefly due to dimi-
nution of the Bensibility of the retina from the great and prolon;^ed glare,
but it may likcui:<e ;ierha]>s be owing to the effect of [he greiit rarefaction
of the utiuoKplieiv in high mountain ranges, uhich may not only proluce
inHammatioii of the conjuitctiva, nith exiravariatjons of bbKMi into ita tie*
sue, but al^o perhaps hemorrhagic dfusions into the choroid and retina.
CIosfIt allied to the above form of am'ilyopia, ij the anicilhesia of the
retina which oecnra in cniwequencc of prolonged exp^isure to extremely
bright light (rHberbletidung der [{t>tinu). Instances of this kind arc
met willi rintongst penmn» v\m have l>een lung expired to strong sunlight,
or have givatly irieil their eyes by excessive use of tlie niientsoope, etc.,
more enpfctallv by artificial light. They are often aeised with a sudden
dimnestti of .'iight, and notice (more esgiecially if the illumination is but
luudemte) a more or leM deiue dark cloud or di«k, which appears sus-
{•ended l>elurti their eyes, and veils the central portion of an ubjecl or of
tiie 6eld of vision, leaving the periphery, perhaps, quite clear. 'Phe
I "Uuette Uebdonu^alru," 1^63.
AMBLYOPIC ArPEOTrONS.
iiam^ ami «3tMt ftf th* cloud, ami the consequent de^rree of aiDbl^ofM
■• wim in dviiNB. Are subject to cnnsidemble vanaiiou. Thus, ^w
Ami aiT aaif he nhserred for a few minutes after the exposure, or it
Mv latt fcr 4bt( atkJ weeks, or e%-oii longer. The treatment sliouM prin-
C^MtycBMH in ;ipardio>; the pntii'ut n<;riiiist all use of the eyes iiiia ex.
^MWfei Wigfct tizbt. Iii'.leed, if the qiw h severe, it m:ty l>e nece^sarv
»■■■> lyaa hb bein^ kept in the liiirk for some leii^^th of timp. The
afOKoal k«di is a\w often of much benefit. Ood-Uvcr ml and steel
abHM W fmcribed interaalljr.
iSvttmkmm or DaT-ltlindneas is thnt condition in which thp viBJon is
aaxkc^ dMiflMhe<l during; ordinary dnylijjtht. Init \* •jiiite normal in •
Ab^^iL II i^ "tily a |>nrticu1ar form of retinal liypenvxthesia. Tlilfl
mK W fistiftgotshe*] from the niodifieil dav-blimlncA^ uccnrrtn^ in alhi*
■UMLnMaan iridic. iDTdriasii«, and partial cataract. It is ntkiiX to be
ifiMBMil hy kag exposure to >;liAteuing Hurfiices. brilliantly illnminutvd
W ik» sagki httiet mo«-b1indneM \* a variety of nyctalopia. — D-l
Ir «il tbe abore form^ uf amblyopia the subcutaneous injection of
«boald be tried.
J^CONGKXITAI.] COLOR-BMXDNKSS [ACIIIIOMATOPSIA—
DYSCHRO-MATOl'SIAj (DALTONISM).
fCiiBj[eni;aI color-blindiiegs is that defect which consisto in the inability
l» A^n^i'ih color* without any disturlnnci* in the other function? of
Iha eye.. The dr;;ree and kind of tins defect may vary considerably.
Ymmhm awihivl') have been reeoinmeuded for discovering this defect, all
%iml «pon the ability of the patient to discriminate between various
Mlsfeit te*Ts. Maxwell's crtloR-d di.^k^, which were formerly u«e<I. were
•vatoMatic. but the testing was tedious and len^lhy. Meihoils have
k«<w rwoRoaeDdctl br l^nndolt, llenichel and Rohc, aud by Stilling, the
ImM^'* wmIumI consisting in testing by succeistiive or by Himultaneuus
VMMmkMtt of c<dor». Very excellent re^tulM have been obtained with
IJW ■WiiUnifinpf and the employment of sunlight. The most uaeful and
M^tw»l WMot all u thnt propr^ed by Iiulm<^en, and which hivi been
M> yWMnwtfhIv practised and admirably explained by l>r. JclTries. of
Angina it coiwi«t*j in throwing down upon a white cloth Wfore the
H^M a large number of colored worstedtn of the moiSt different tints,
Mvt rMuiring him to pick out and lay a«ide together in separate heaps,
nil ^ «ar4te<U of the snino color, or of different tinbt of the sAine color.
\s was 1bmi<.'rlv i4up[»o<K<<l that the examination of color-blind pAiieni4
««»hM fUnii-ih a 5i>un>i baii'* for the theory of culor-blimlucsM advanci*d
Nt A^I^m YtMing and endorsetl by Ildmholtz. But the recent investiga.
IwM i»f lltfciug (•' Stttungsbcr. d. Wicn. Akal.," lil. Ixix., 1H74>
Hiv^ ilnHMiiiWuiril ibat this ia not always po«^ible. As is well known*
^^ifcfft-i^mjmim i»ay be partial or total, the tii*At being much the more
||M^tM> The c«)mmoiie!'i form is that in which green ia confounded with
xaniHH AwIm of gray aud of red, and is called grcendilindness. or n-'d.
uoMU-hKudlUM. The blitiilne:>i.4 may not be ah^iolule for these two
Vufon^ IW the perception of red may be merely weakened, and bright
CONUBNITAI. COLOR BLTNDKBSS.
S31
tint4 of red may be reco^xiiizi'd ; but it mnj be total for sll shades of red.
Uc'l-greoii Itliinlm-SK is known as aiierviliropsia or Daltoiiism, Green-
Mi luliicsit is ilititiii^ulalicd from rfd-blintUiesa bj Lhc fncc Uiat die pntienl
cMifounfU pure green ind in complimeni, rcd-purple, with white or pniy.
Tltiiitlncsri for tiliic i\iii| yvUnw i.<* r»ru. In tbe citrteH rf|(tirtu(l by Stillin^f
wbiob were cxaininod by tbi> 9]»ei'troscope. the ciitiiv seprnont of tho
sjieutruiu for blue-grevti. i:reei) and violett wm wanUiig. Yellow was
enlliMi n.'<l ami blue wa» eallud t^revii.
Total colnr-blindness i* an exceedingly rare anomaly. Very few cases
have been reported, and in these rpil appeared as black and orange as
;rray. The sjwcinini was markedly shortened at both ends, (b'ora com-
j)leU.' aecDunt of ihe theory of color-blindness, the reader is referred to
the exhaufttive nr(icte» of Ilolin^reti, in the '^Nordii^kt. Med. Arkiv./'
ifi., Ileft it, nnd in the "I'psalrt la'<aref. fiirhandl.," 1874, Heft 2 and
Ay and of J. Stillin;;, in the *H\Iin. Monatsbl. AuMaerordentl. Beil&|;re/'
heft i. ami ii., LhTa. See aUo Dr. JeiTries'H Mouogmph on Color-
BliiidiieM.) Coiijreiiilal color-blindneins h fre^piently heredilary, affecting
several f^cnerntioiitt of the same inmily. The herediuiry comes oftuMur
fi-om the mother's side than the father's. Tbe male sex ia much oftencr
affected than the female., tbouj;li in some fauiilie^ oulv tbe latter were
found color-blind. Kccent resenrchcfl place the jiroporlionof from three
to five per cent, of tbe maloii of all countricii as color-blind in a greater
or luM degree.
It irt ainwwt without exception bilateral. an<l there id reason for believing
that it \i commoner in the lower cla^sei; than amon;; the better cducateil.
The importance can scarcely be overestimated, of carefully testing all
[*er»ou« employed in occupations wliich render a good jierception of color
uidiKi>emAhie, aa in sailors and the cmploydj on railroada. Tliis whole
Kubjccl has been most thoroujthly inrcsti^ated and ndniirably di*cu««od
bv I'r. It. .Ipv Jeffries in bis book on " The Detection of Color-Jtlind-
ne5*."-it.J '
I'rofessor Maxwell' mcntiooa the interesting fact that if a color-blind
person look« at red or green tlirough a red glass, the green will ap|)ear
darker, but the red be nearly as bright as before, wherens if he uses a
green glaM the red will appear darker, bnt the green hardly altered.
He has thus been able t4i make color-blind i>eoplc di>4Un<;uisb the colore
of a Turkey caq^t, and 9u;.'Ke!»ts that if such a patient wore a pair of
fipeutack't) witli one eye red and the other green, be might in time be
able intuitively to form a judgmenl of rod and green tl)ing<i.
It 18 generally held that tbe inability to distinguish » certain color
r. //.. red) is due to an insensibility of those nerve fibres of the retina
which are sensitive to red. This view bas, however, been lately stron;.'ly
opposed by Max Schult:LO, who con^i'lers that, in sncb ca!<^s, it probHbly
depends upon an excesnivc development of the yellow j>i;rment in tlic
region of the macula Imca, which has the effect of diminishing the liw
tensity of the red rays.* In connection with this subject it is of interest
that, during Santonin intoxication, everything acjuire* a yellow or
» '• Phllr^'i'Iiiral TransMtloiw," IBTO.
> Via» Mux Sohaltsi*'! l>r4)flmri>*-Ci>tM>r (Inu O.Olwn Flock, ite.," WOi; aUo bU
wnrk, "/.iir Anaimnic itud PbvsiolugitMlHr Iti<l)iia," lh6l\.
mk
ArrBCTIONS.
.'ru.^tble* jBii ni become iudiatinct; for furttier
«mM reftT tJie reailer to Articles by
. -u. fT^, and xiii. '2. Niemetc)i«k, ou tli«
■ dnc 1^ seat of npprt>ciauon of color to-
■mm,tarthey may ho dodtmyed and yet it
am aftie Dcrve.' lit.- Iia^ otmerved t)i.ii tti
'f OMCCciiLtion of color is very pmnoancrd,
tMOttveeu the orbits is greatly dereloped,
1 ^wr in whom this sensu is deficient. lie
t aewe is h cerebral function, and eapectally
of tlie anterior loli^s. In Daltoii.
IB be very little develojted. Tliis bvpo.
hy the fad that sul.ji'Ctive apiwaniiicc*
. if morbid processes occur in this region
K^maaHj iBehrowK virion*) in. an a rulo, congenital,
'1 fh*tfc* ialerriiuiig and i[n[Kirtaiit fad. ha» Iwen
SibAfa^clc., that it i^ met wii]i in atrophy of
^mBa^ V Iralezowski,* in variouii other diseases.
mm •««• it in a cose of spinnt diftcoBc, in which
^ Dr. CI)i0olnt. of Bultituora* (U. S.)< has
mm m a cue of optic nciiritii!. Rut the raottt
t9 iftiMir, tn which I liave alrendy rcfcm-<l. jnst
.w has vxamiued a ;;ruat number of p»tieiit« »uf-
aJbelMM, as to the pn'^vtico of color<b1indik>-->5.
.jHiM aa almost condtant symptom in atrophy of
tfifeif «as primary or secondary upon optic neu-
aJi CUM of circumscribed central scotoma. I
■ fully into these aflVctionK, and the roaults of
*b 4AK '4'*^. In syiibilitic rotinitii eolor-blindncas
•I 01 0<lier ca»cd not ; the name ift the case in
' ^ Uw latter ata);c3 of clioroido- retinitis, ac-
' rrtitui and optic nerve, color^blindncM not
,^ ^.aot-bbadDCsa may also be acjuired without,
L4f a^t. TliUH it lias been obstTved durin;;
K BB cwse^uence of some cfrebrul diMurbanue^-
^ n«htcii it was produced by over-use of the
: different colors for tbc pnr{>o8e of sorting;
v« a svmptoiu of certain fuuctioiukl (hysleiical)
r«.-U.]
. olVaTIOX of AMAI'KOSIS.
'■v» of simulated liliodness, more eape-
il femalej, or pcr^ns who wtJh to shirk
tr. 234.
• " E'Un. MM. Junriial, Fvb. ne9.
• "A. r. o.,' XT. 3.
SIMULATION OP AUAHKOStS.
623
thvir diitieft, as soMiera, jirUoiiers, etc. In slmrp and clever indivitluala
it U eAmeUme« ver^ diHictilt to convict tJiem of (li*ct>it. Absoluto bliml-
ncflft of boOi eyc« is but Hcldnm ftiiiiiiluietl, rxcoftt, p^rliafM, in tiuitte
case's in wliich so cousidcratite a denrce M' hin\>\y<i\<\ii rosily cxi»tj«, tlmt
tiiP patient h uiialile to L'Biii liiw livclili<MMl. :iii<l tliorefore pretemls lo be
alisolntcly Mind, in order to excite tlie commiii'mtion and nssiatanCL* of
the chnriiuble. Id such caftcs, tite behavior of the pupil tinder the stiuiu-
liis of light is the best fiiiide. Kor if i patient declares that he is 80
Ijliiid that he cannot distin(rui:»h between light and (lurk, and tJie pupils
vet contract under the «tiinu]u» of li;;ht, we umy generally iuRi»i u|h)u
Its bcin<; a ca^e of <iimulAtion. Such pnticnt^. however, wmetimcs dilate
the piipilit Hrliliciidly with atropine, and this may be suspected if tliey
are dilated aU marivwm, tor in the mydriusig due tu aniaurodis (ejccept
tlie bmnches of the 6fth nerve supplyin-; the dilatator pupillw are irri-
tated >. tlie pupil \A hut mo'lerately itihitcd. If the action of atropine
id su3|>«'ct«d, but a conviction appears impoi^ible, parnccnteaia sliould, if
practiiil'le, be |>erfornied, and the aiiueuus liuinor ii[>idio<l to some "tber
eye lo see if it will iimduee dilatation of the pnpil. Wiierc the «lri>-
pinc has only been apjilicd to one eye, tJie detection iti far more tiraple,
tor not only will tlie pupil be dilated uti mox/ritMrn, hut it will not act
eonacntancourtly witli that of the other eye, vriih the movements of the
eycK, or during the act of occommiMiaiion {I'tdt the article Mydriasis,
p. 21:^). But there are sovcml other methods of detecting! the simula-
tion of monocular amanro^is. One of the heat of thcao is Vou Graefc's
test »itli prtftmuiic ^lassc:§. Tlma, if a fiaticnt complaina Uiat he ia ab-
solutely blind In one eye, and the oxaiuination of thi!; ere i» concluded,
that of the iilhcr (b<>th v\vs, however, being open t should be proceede*l
with, and a priiim of 10" or liV bo held witli its Iwise upwanU or down-
vanU before the healthy eye. The patient shouhl then be casually
aoked (>o as not to arouse his su«piciou tliat we 8upi>o&c him to )« de-
ceiving;), whether this improves the siglit or not. If he says that it
canoes diplopia, the ttimulatton is proved, for if he was absolutely blind
in one eye diplopia could not be produced, whcreaa thin would not ex-
clude a cousiiliirnble degree of amblyopia. The pri*ni ihould be turned
iu dilforent directions, in ui-der that we may ascertain if the duubld
image)^ correqpond to the [insicifm of the pri-tm.
Dr. Von Welz' places before one eye a prism of 10° op 15°, with it*
base wmcd horiznntnlly outwards or inwards. If a correotiTe anuiot
Drisej.or if. on removal of the prism, there ia any chaQ!;e iu the position
of the optic a.Ke«. it proves at once that the patient enjoys biuocular
vision.
Mr. Zachariah Ijiurenct' employed the stereoscope for the purpose of
detecting simulation of monocular amaurosis. The elide used fur this
pvirpoM ha.'} two different wonis or fignrCH (c. //., a circle and i[uadrant)
u\t(n\ it, so arranged as to undergo an optical trausposition when seen
thnnigh a stereo'^cope. Mr. Laurence says, " Where blindneiw of one
eye is simulated, the test is certain, if care is taken not to let tlic patient
' "C«nart» i>|>Iitli»liiii>I»(tiqii»," IS<;6; Coinptw-rvitdn.
■ ■• lUadjr-lkxrk of Ophllialinto Surgery." 17.
i
■^ -rot itionoctt^ft^."'* „^.«cunfl
^,rt.»«»-
52B
DiaiASKS OF TOE CBOBOID.
chapter on GlniK'omA : the other U more simple in its course, and ia
volvfH lliP tisstit's to a far less extent. In tlie latter form, ttiere are'
geiiei-allv Iianllji" any svin|jtoiiii of irritaliou, tliv L'vvbiitl Ncing peHiai>«
only vcrjf sli;^liily iiiji-cleil, nitlioiit miy plioloplioliin, lichryiiiatioii, or
spontaneous pain. But the itighl i.t often greatly itu|iairb<l, on nccouuk
of the diffuse cloudinriis of the vitreous humor, in which inaj also ba
noficpil, here and there, a fpw ilelicale, filiform opacitiei, or thewi mif
assume a tinner and niorv membranous character. The vitreous opaoi-
tiee) moreover da not tll^appear with auch mpidity or complctcnc-^ as
in the acute inflammatory fjlaucoraa, but implicate the ;<trueture of the
vitreous humor (produciug synchysid) to a more considerable extent,
HeMroying its septa, and causing relaxation, or even diiiolutii>n, of tba
xonula of Zinn, which i« followi^d by h more or ieu considerublc dis-
placement of the leiw ((rracrL*). «^ymplomi of serous iriti.'i ot'tun liupcr-
\*enc in the course nT the di.tcnse : iJie iri.< become? 9U;5htly dljwolored,
the pupil somewhat diluted and perhaps slightly adhcreut^ the a<|iieou9
humor is secreted in larger i|nautity and becomes clouded, having small
particles of lymph suspended io it, or deposited on the posterior surfacd
of the cornea, ami generally assuming a pyramidal an'au;;eroent. Tho
stiitr of the intra-ocular tension varies considerably; in iotne casoj it
remainti iioniial, or may -^radu^illy diniini^^h. the eye liccoming Mfter aii4
softer, and tiiially atrophic. In other iiiHianccs we find tluM, together
wilJi an increase iu the cloudiness of the vitreous and aqueous humors,
the eye-tension augmeuta, or undergoes marked flucUiation«. If this
increaiic becomes pemt8tent,gliincomatoii9 complications may soon super-
vene. Viui liraefe' thinks that this de|>end!t |>artly upon the ago of Uie
patient, and i>artly on the fact whellier the lens is somewhat displaced or ^j
noL in simple serous choroiditis or chonii do-iritis, wo find that when ^H
the vitreous and a<|iieous humors have again become transparent, hanlly ^^
any (it any) changes in tho choroid are to be detected with tho ophclial-
mnscope ; and even in the severe formi they are but slight and genernily
Uaaiien to the equatorial region. Dut there is often noticed a punctated
opacity of thu p"sterior pole of the lens.'
The trfniinrnt of the simpler forms of serous choroiditis moat coosiit
ehicfly in the application of atropine, of a blister behind the ear. or thoj
^rtifttial leech to the temple ; and the eye should be kept perfectly abj
BriUaad guanled against exposure to com or bright light. Derivatives <
MttKoa the skin and kidneys often prove useful, as aUo the adminis^i
«^^«f the ioilide of pot4Usiu[u. which hastens the absorption of tli4
IB I HI opacities. If cue eye-tension is increased, paracentesis is to ba|
. .V »». 3. UC.
.^ I A «aUi »u<fnilnn to the Tnet (1. c, p. 169) that pjrra aff<>c(wt witli )M«t«-
^^-^^^CVML bat which do not bIiow the sliglitost Iractft ot An^ ^Sf^'tUm uf thai
.^^g,^ «»9Ma wA«i)wntlr itltJickeil hy vatMailary );lnuM>iiia. Dp Iw-lipVi-tt ttiAt inj
^^^ .^^B J^Mi ^tl«aUr pjiaoili>-N aru tlie rwi^lue of ft (oriniT olwrciiitilis which]
3 *nrr lliii Apptri-nt lerTuinatioii ot thrr original <liB«ui>, T«ryJ
> Ulenl fnTin of fnll&minatktu of ilii* I'liorojil ; wliicit. If oppnrlil-
I ilBvlf and givt-a ria>- to .i^cuinl.trj' ({Inuooma. Thc> pwiiliar rtU-
m in *yf» affr-clivl vritti |H,T<(>-ri'ii |xiUr entariu^t (.iinl wliiHi
tj ia the gri^m .iti'l cvi^pfiiixn-il r>-aclinn afi>-f »ny <tjH-raiioi)|
■u to a pfreiBiitut sutt^ of irrltatioo at thu dwroid.
HAPT BR
DISEASES OF THE CHOROID.
FIYPERXMIA OF THE CHOROID.
A llVTKK.F.MiccfimIiuoii oP tlie clioniiti ia 1)V no inpan;* so cssy to diag-
nose witti the ophthalmoscope a» is often asserted ; indeed it is fi'C'iiicntly
quite impossible to do so. On the other hand, the efuthelial layer of the
choroid may bo so dense as completely to hide the choroidal vessels : on
the oilier, the diven»ittcd, both in the niuouut and distribution of (he |>ig-
invnt in the stroma of the cliomid^ are so various, as often to renilcr it
i|uite impojwihlc to decide whether or not there is any hyperflD.nia. It is
especially difficult, if both eyes present the same apjwaraoces, for we
then Intie the opportunity of cotiiparing the aflfecterl with the hcaltliy nre.
nypericmia of the choroid may be suspected, if wc notice at one |>oruoQ
of the fundus, that the siKc and redness of tlie choroidal vessels, more
especially of Uie smaller branches, seem to be increiweil. so that the
iutra-vaftoular spaces appear encroached upon and somewhat crowded
together ; and more particularly if these symptoms have come on rather
rapidly. The disk may also look somewhat flushed and hypcnomtc.
The cxtenial symptoms {e, i/.. ciliary ii\)uction, tUlatcd and tortuous
ciliary veins, etc.) which have often been tjuntcd es being indicative of
byporwmia of the choroid, are quit« unreliable.
[CHOROIDITIS.
It is hy no means easy to separate the pathological processes in the cho-
roid from those in the retina, because of the close relation of the two mem-
branes. Hence it is often necessary to employ the term chorio retinitis
Or retino^boroiditts to describe tlie process ]^>ing on in the posterior seg-
ment of the evchall. It i^. [>erha[>s, well to distinguish the varieties of
inflammation in the choroid, as has been done with the iris, viz. : 1st.
Serous choroiditis ; 2it. Plastic choroiditis ; >jd. rarenchymatooe or sup-
purative choniiditts. Various suhdivisions of tlicsc three main varieties
of inflammation are in common use, which will be considered under the
proper beads. — B.]
!_ SEROfS CHOROIDITIS.
We may distinguish two principal forms of serous choroiditis, the one
conatitnting acute inflammatory glaucoma, which ta described in the
T)^
DISHASBS OP T&B CllOftOIO.
white BpoU, Burrouiided by uncliaiigeil epUlieliiiai, t«i th« laat statf^ of
glistening white, atrophic patches, embraced by a deep black circlet of
pi^ent.
in other cages the disease coramcnces in the region of the ireltow spot,
aometimea in its very centre. One or more small Kfiecks are noticed, the
centre of which is of a pater red than the eurrouDding choroid ; or the
patch may he of a grayish- white or creamy color, with perhaps a fsint.
pnl»--red areola round it. The choroid in tlie region of tiie yellow 8|»ot
i» generally in such cases of a somewhat deeper tint. The white dpot«
aoou increase in number and size, are arranged perhaps in groapa, and
gradually extend towards their cireumfercnce. The |>eriphery of the
choroid may remain nnaffectcd, or nhow only a few iwatterod groupA of
exudation.
Although we cannot wltJi certainty diagnose the syphilitic character
of the discaae simply by the ophthalmoscopic symptoms, as fte find tliat
sometimes the most varied forma of this affection are due to syphilis, yet
some autliors consider that certain appearances are more especially
symptomatic of the specific disseminated choroiditis. Thus Liebreich
thinks that the Utter is distingtiiehed by the fact tliat the little mauei
of exudation are smnll, eircumacribed, isolated, and do not show any
tendency to conlcace. even when they arc grouped closely together.
The tissue chauijfs extend deeply into the stroma of the choroid. TheM
appearances are well illu-itrtit*'d in the ophthalmoscopic plate (I'late II.,
Mji;. 4). Von Gracfe thiukit tliat syphilitic disseminated choroiditiv
sbowa itself most fre<]uently in the form of numerous circuoiscribe^l
white patches, with a |>ate red xonc round them, and occurrinp; at the
posterior pole of the eye ; and which but rarely pass over into any
other form of choroiditis. I have also found this form of choroiditis
more frequently associated with syphilis than any other. lint yet it
must be admitted that the disease may a^ume most varvin<; ftp|)onraiices.
Thus I have seen cases of sypldlitio choroiditis in which n lar;^e bluish-
gray exudation has occupied the region of the yellow spot, and around
tdis were scattered to a cnnsidcrable ilistauue immi*nmd smaller exuda-
tions and atrophic patches, the peripiicry of ihc fumlus being almost
free from any exudations. These appearances (ra«.ire especially the
gray, nebulous effusion) at the yellow spot were almost identical in both
eyes.
[In syphilitic choroiditis there is said to Ikj a ptrculiar dust-like
punctate opacity of the vitreous, which at fir^^t is movable, but later llic
liarticlca bcconte a'^j^regaled into masses of irregular 8lia[>e and some-
times having thread-like processes. These opacities are sometimes so
dense as lo completely conceal llic fundus, and generally last for a long
period. Where the retina can bo seen, it is seen to he cloudy along
the courao of the ve.'isels. There are no coarse changes in the choroiul
in this form of inflnmmotion, accor<lin>; to Forstcr, unleM the diseaac
assume the form of eiinpU* choroiditis dii^emiiiala. It is usually a late
manifostation of syphili.t, though it may accompany an early iritis, and
it often affects only one eye. It is probable that this is merely one
stage of the cliorio-reliuitis disseminata with marked changes in tlie
PLA9TI0 OnOROtDITIS.
5ST
perfnrDiedt and repeated, perliapit several tinies, at interraln of tliree or
fnurdays. VrtiiilrRcfe ivciiminciida that tlie needle fliiould be oxtrrniely
line, BDil that tin- puncture slioiilil not be made in tlie sclero-comunl junc-
tion, but in tKc cornea, nboat one line Trfm its margin, in order to avoid
Uic rUk v\' an udhcsioii of tlie in^ to tlie inner wound. Kven if secondary
glancotna eu|M-'rvenfs. repeated paraconteiiis may be tried, but if it proves
of no avail. iri<l«;to(i)y »liould be perfonued. In tbose very obstinate
case^i, iu which the IvnsioTi becomes a^in incrcaficil in itpilc of the iridve'
loinr. and repeated paracento.tis doc.* not permnnenily diminish it, a
second iridecioiny, in au opposite dinctioo to tbv tirtit, will be indicated.
S_PLA.STIC CHOUOIDITIS (Plate 11., Fig. 4).
[Most modem autboHtie? speak of three varictioft of plastic choroiditis,
vis.: l»t. Choroidiiid diMemiiiata simplex: "id. Choroiditis areolaris ;
M. Ohorio rptiiiitis circutnacripta or centralis ; and a fourth — cborio-
rotinitift diascminata syphilitica — i^ sometimes added.— B.]
When thi» disease is at all advanced, it prenenta most characteristic
and 8trikiii<; ophthalmoscopic npjwaraiKus, which cannot fail to arrest
thi,< iittentiou of the most snperficiul observer. But in the earliest i^tages
it may easily be overlooked, more especially if ii commencea, as iit very
freiiucntly the case, in the foi-m of small circumscribed exudation*,
situated quite at the jieriphery of the fuudus. 'lliese little, rouml,
j;rayish-ivhi(e ^[ioli of e.vudation vary much in Ktze and sha|>e. In some
ca^s Ibey may not be larger than A millet seed, in others they attain a
coii;*ideralile mn^uilude. The lar^^er ones ai-e, however, genentlly met
with in the centre of the fundus. The exudations occur both on the
inner surface of the choroid and in its stroma. They arc of a dull,
whiiiab-ycllow, or creamy tint : the epithelium aroand them being cither
itornial, or but sligblly thinned. At a Uier stage the exudations bccottM
abtortied, and ihc choroid porlia|is uiidergi.H'ii some ntruphic changes,
becitmin;; thinned and jwrmitting the whit« sclerotic to shine throii-^b,
which gives a peculiarly white and glictenuig appearance to the ['atch.
Vn the expant^e of tbe latter, we may al^o sometimes be able to trace
the outlines of the faint choroidal vessel* which traverse it. Around
these atrophic patches the epithelium does noc retain its normal iippear-
nnci.', but its celU [iroliferato, increase in size, and contiiin a great iiiian-
tity of pigment, which lieeomes collected around the luargiii of the white
figure, in the form of a more or less broad, irregular, black ginlle. The
individual exiidationit often increaM; in size and coalesce one with another,
thus giving; rise to larger patches, which finally attain, perhaps, a con-
siderable magnitude. From the periphery of the fundus, the disease
extends more and more towar<]s the posterior pole of the eye, so that at
last the whole background of the eye may be thickly studded with
innumeriihie white or ycllowish-whito patches of varying siie and shape
surrounded by a dee]) black fringe, ana perhaps divitled from each other
by Atrips of healthy choroid. In such cases we often have an excellent
opportunity of watching aide by aide the various changes which the
exudations undergo ; from their 6rst appearance, as opat|ue, creamy
fl2K
DISBASItS OF TBB CUOBOED.
white spot*, BurrouiKle<l hy uiicliango<l epiUieliuin, to the ls»t stuj;* of
^liHtoning wtiite, atrophic [labches, ciabracod by a deop black circlet uf
pigment.
In odiLT cascij the diaoatte coitimL'ncvs in the region of the vcUow spot,
BoiDctimes in its rery centre. One or more smnll specks are noticed, the
ceutre of which is of a pnler red than the surrouading choroid : or the
patch may he of a grnyiBh-white or creamy color, with perhaps a faint.
pale-red areola round it. The choroid in the region of the yellow spot
is generally in rtuch cni^eR of a fiomowhal th-Hper lint. The white epottf
soon iocrcndo in nnniher and ttizo, are arranged perhaps in groups, and
gradually extend towards their circumference. The [»eripliery of tbe
choroid may reniain unaflected, or show only a few ricattered groupa of
exudation.
Although we cannot with certainty diagnodc the syphilitic character
of the disease simply by the ophthalmoscopic symptoms, as wo find that
gonielinies the moot varied form* of tliis afTectioii are due tn ayphilia, yet
some authoiii consider tliut ecrtiiin iipiiearancea are more ospccialW
symptomatic of the spcciBc disscminate<l choroiditis. Thus Laehreich
thinks that the latter is dibUnguished by the fact that the little masae«
of exudation are aniall, circum^crihed, isolated, and do not show aoj
tendency to coalesce, even when they arc grouped cIo»cly logeiher.
The tissue changes extend deeply into the stroma of the chtiroid. These
appearances are well illustrated in the ophthalmoscopic [ilate (IMate II.,
Fig. 4). Von (Jraefe thinks that syphilitic diaseintnated choroiditis
shows itself most frequently in the form of numerous circumscribed
white patches, with a pale red zone roun<l them, and occurring at the
pOEtcrior pole of the eye ; and which but rarely pass over into aoy
other form of choroiditis. I hare also found tliis form of chnmiditi:i
more fre".jueutly associated with syphilis than any other. Hut yet it
must be admitted that the disease may assitmc most varying appearances.
'Jlius I have seen cases of syphilitic choroiditis in which a large bluish-
gi'iy exudutiun has occupied the region of the yellow sjwt, and around
this were scattered tu a considerable distance tiumenpus smaller exnda*
tions and atrophic patches, tlic periph<-ry of the fundus being almost
froc from any exudations. These appearances (more especially the
gray, nebulous effusion) at the yellow spot were almost identical in both
eyes.
[Tn syphilitic choroiditis there is said tn be a peculiar dust-like
punctate opacity of the vitreous, which at first is movable, bnt later the
jmrticlcs become aggregated into maaaea of irregular shape and some-
times having tliread-likc processes. These opacities are riomeiimes so
dense as to completely conceal the fundus, and genornlly last for a loo^
period. Where the retina can be seen, it is seen to lie cloudy along
the course of the vessels. There are no coarse change-i in tlie choroid
in this form of inflammation, accoriling to F{>r8ter, unless the disease
assume the form of simple choroiditis disseminata. It is usually a late
manifests lioD of syphilis, though it may accompany an early iritis, and
it often affects only one eye. It is pi-ul>ahte that this is merely ouo
stage of the chorio<retimtis disseminata with marked changes in the
PLASTIC OnOROTDtTIS.
5-29
pirl AM pkiehM of NWTf ad *mk»J nirnphy In oikur
I
clmroH. (8ce"Aroh. f. tlphtli.." t>'i(t- »".
XX. 1* p. 33; "(Jrnefe uimI Sae-
mlxhr V. p. «W to tJSl.)— «.}
Till' ftrftlar ehortnditia of
Kowtcr' 19 distingniahed by cer-
tiiin peculiar ft'»t«rcs, wliieii
eliow iitt'ter wKat diflVrent foriti!!
Uie disaemiuAted cltoroiditi» may
presotit itoclf. 1 wouM, there-
lore, r»th«r coiwi'ler it as a aub-
diviwion of tliiw affvotioii, limn m^
a »[>ecial diwfiso. [The ainrtiiig-
point in this form of clioniiditii^
sectDfi to lie the rcf^ion of the
niaculii and pApiUa. The patclien
firat appi'ar jwmninscsnr pi-rmei.t,
wliicli grow thinntT at the centre;
the C'xtidatiun makea its appear-
aTi<:c: and tin- more tliut extenfli!,
th« mor« tlie pi^iucnt \a reduced in
extent, till it fornix a narrow border aroand tlie yellow exudation. In this
dinease comparatively giHyl central vision may exini for a long perimi, until
suddenly it diniinishe* very rapidly and marke.lly without there being
ojrfjthnlmoacopically any R[»ccial cause for it. — II.] The spots arc lftrj»e,
oral, or circular, sliarply defined, aii'l of a white or yellowiflh-wluto
color, having trnccfi of faintly marked choroidal vc<taeU in itieir area.
They arc acpnratcil from each other here and there hv strips of normal
ohornid. Thev are ehiefly gronped around the yellow 6pot, but are
divided from it by a portion of healthy choroid, so (hat they do noi
reach tip to it. Their size varies considerably, some b<^iiig nearly as
large na the optic disk, ullicrs alKiut the »ize of a pes: tiiey alwava
itiRiinii<h, however, lowanU the periphery. The patches are ^urnmndcd
by A dark zone of pi<pment, winch is the more broad and marked the
xmaller thi^ central white iipot i<>. Quite at the perij^ery of the ^n>up
of white patches are noticed dark black spots, having no white centre.
[One form of chcrijiditi? di»ieminatu, which, though not so f^(^{uent
as thone hiilii'rut ik't*rilie<l, is by nn mrans rare, consists in sinjjle or
conglomerate exudations fi-ora the vitrrotis lamina of the choroid. Tliese
nodules grow towards the retina, pree^ it and push it aside, and occasion-
ally become detached from the choroid, and are met with in the inner
modt layers of the retina. These are not met with near tlie macula or
iHak. Though in tJie lieginning isolateil, they may coalesce with each
oth«r and form " pla<|ues." Clinically this variety is of no im[K)rtai>ce.
'l*he diagmtais of disitcminaied chnroiditJa is not difGcuU, and it could
not vt-rv easily W misliikeii for any other disease. The fact that the
little white e\mlation» are sitnate<l in the choroid, and not in the retiua,
nnit«r, "OphthaltuoloKls«h« Brntrln." Bttrlia, 1M2, p. 99.
34
a^^
DI8BASE8 OF THE CHOROID.
may be easily ascertained by uttention to the foHowinjj points, \it.,
retiital vessels cati be traci^H di.stinctty over them, an<l are not the le
interrupted or rendereil indistinct in their conrse: there arc no ap
auce« of blood effusions into the retina, which generally occur togeth
vith exndatjon» into the latter; the retinu is al.so traitspnrent, oimI
norninl apjicxraiice around the exiidationx, and the retinal veins are
dilnted or tiirLumiH. When the cxmlatiinm are »b»orhed .iikI the choroid
undorgooa atrophy, the patches becoine.-t frinjjed witli pigment nwl upon
their expanse can he noticed rvmains of the chomidal tii^siie and uf tie
vessels. Care ahouUl he taken to dislJnf^ish this forin of pi;^uu:atatiou,
from the deposits ol' pigment in the retina irhich may occur in irariooi
focnu of choroido-rctinitis, as also in the diseeminated choroiditU. ia
-which the external layer of the retina becomes niore or Icsa glued uj^ainit
the choroid, and destroyed or atrophied, or the pijiment of the epithelial
layer of llit> choroid becouH'K infiltrated into the retina. In auuh
the rods and cones arc ettpecinlly apt to snffcr, but the changes ma!
extend deeper, lunl evvn involvu the ki*"K''"" cells.
A pain, the retina may snffer by liorominp compressed by the ex
tions and aggregations of the pigment celU, ami if llii« lasts for
length of time, the retina generally becomes thinned and atrojihi
hcitig changed into a kind of fibrillar tissue, and its normal olementi
rendered tjnile indistinguiahable. Thus con«eciitive atrophy of the retii
and optic nerve not unlVcqueutly ensue upon dilute miimted choroidi ~
In riato II., Fig. 4, these ayipenrances are illustJaled. The optic di»'
is seen to be perfectly atrophied, uf a blui!>h-gray tint, and utterly
devoid of hi tiod vessels, excepting the two little twiga which can jmt be
discerned running over it« edge. Not a aiugic retinal v«9sq) can
distinguished over the whole fundus, it ie but very sehlom that we nii
with so extreme a caiie of atinphy, and Liebrcich supposes that in
probability a syphilitic retinitis had coexisted with Uic diiwemiita
choroiditis.
The vitreous humor also rre<|Qently becomes affected during tht
grcss of the diseaae : indeed floating or 5xed o|kacities in it are
times tlic first, or even the only, premonitory jtymptomd, which call
patient's attention to his eye. I have loet with several caaes. in whii
a few small floating opacities in the vitreous humor formed the fi
symptom, there being at tliat time no tracts of disseminated choroidi
to be detected by the mnst careful ophthalmoscopic examination, fi
some time afterwards, small circular patches made their appearanee
the choroid. Sometimes, however, the vitreous does not become afivc
till a late stage of the disease, and it may then be eo diffuM-ly cloud
as to render the details of the fundus •|uitc indi:(tinct, or he trnve
by large, dark, floating or fixed niemhrauoud lilaracnt«. tiubfe^^nently
■ poiiterior jtolnr cataract is often formed.
The irid sometimes becomes inHame'l, but hardly ever to a coni^iilcrnble
degree, there being only a few delicate adhesions, and very liitU- altera,
tioa in the structure of the iris. The inflammation often at^ume* a
serous character, and small opacities arc noticed on the poetcrior wall uf
the cornea. The external appcamucc of the eye ia generally qutK
PLASTtO CHOROIDITIS.
531
; thorc is hanlly iiiiv conjunctivn) or Hubconjimctival iuiectioa,
phoinphobia, or 1achrj.-iiiatinn, atiit liule or no pain: the pupil being
often of a normal she, or but little dilated ; ana yoi tho night may be
grvatiT inipHtred ; and it is only with the opbthalmoscopc Chat wt> detect
the ^reat and striking ohango^ in the fundus.
Tlitf 3ij;ht is often very consiilcniMy affected, the pationt complaining
of a dark cloud, or of black, GxeiL and floating objects before his cye«.
These scotomata arc either due to ditfuse and tioating opacities in the
vitrcons humor, or to injuricn wbicb the retina \hm sustained hy com-
preii<(ion or destruction of some of itt dements. The impairment of
viriion will, of counte, be proportionately greater, if the disease is situ-
ated at the j)OHterinr pole of tho eye, dinn if it he contined to the
periphery of thri fundus. In the former situation, a very small and
circumscribed group of exudations may suffice to destroy central naiou;
in the latter, even considerable dc(>ositei may not materially affect the
sight, except in the outline of tlie Beld. Not onlv does the central
vision suffer as re^^inU dirttinctiieas, when the exudations occur in the
region of the yellow f\iOl, but the obji-cfc* appear distorttd and crooked
(ineUiuiorpliupsia), on account of the compression and altuTalion in the
arrangement of the retinal elements. We sometimes notice a markiid
improvement in the sight, when the exudations are absorbed and the
pressure diminished, but of course this can only occur if the retinal
elementa have itot suffered too much, or for too long a period.
The field of vision is frequently cousiderably contracted, and shows
more or less extensive interruptions (iicotQmata) within its area. [With
tbe appearance of the scotomaia, may be noticed in many cases hemura-
lopia, tliut is, the [latieut's vision fails when the light fails. Micro|»iiia
is another common sympt<>ra which may be explained by the metamor-
pbofwiia ab'ive alluded to. According to Forster the rauge of accommo-
dation is also limited ; though it would be dilUcult to ascertain this fact
owing to the disturbance of vision. Glittering ecotomiita are also
complained of by jiatiente, who describe them as bluish-yellow or reddish-
jeltuu Bpftts, which dance about like the particlejt of the atmn^jihere
over a hot surface. These scotoimita are a species of photopt»ia. — B.]
The iiroifHogtM of the disease must alvtays he extremely guarded, more
specially if the exuilalions appear in the region of the yellow spot.
Ol theae, the little spots surraunded by a pale-red rim, whicli are so ctiar-
actoristic of syphilis, afford comparatively the liest prognosis.
In the most favorable cases the exudations may become absorbed,
leaving behind them only faint traces of a change in the epithelial layer,
in the form of light-red patches, in which tlic choroidal vessels can be
distinctly traced ; or Ihey may give rise to somewhat dfej»er cicatrices.
More fmipiently, however, they produce extensive atrophy of the stroma
of the choroid, which is especially apt to be injurious to the sight if the
exudations are large, situated in die region uf the yellow spot, and
coalesce together so as to furro extensive atrophic patches. Moreover,
in forming our prognosis, we must always bear in mind that tho retina
is very prone to suffer, both from diri'-ot compression of its 4<lemcnls and
1 from their destruction (more especially the r«)ds and bulbs^ by their
H becoming glued to the choroid, and pigment being inliltratcd thence into
L^ ^
I
»*1
w
; Cntf '■^'
^ rtir^« "'*'
*^ • « of '^'-
'^^''^^^
(*:»«:y
0<3.
-c s:*
SCLBRBCTASfA POSTBRtOR.
538
in^ of teiuton ami fulness of llio c^vcball, as if tlie Initfir were too larjie
fur tlio .4oi>ket, an<I Uierc nmy also be pain in aiitt nrouml tlie eye.
Tlie opIitlmlmoscufHc sji'iiiptotus an- >:viivrullv very marked aiiti iintiiitf-
labaMe. The cliaracu-rialic synipiom ia h lirilliant wliiui nr jwlo yellow
cre«ceDt at the edge of the optic disk, generRll v at the outer side Thi the
nrersu image it will of course apjiear towards the nasal side). This
creweiit may %'ary inucb in «ize, from a »niall w}iit« arc to a large zone,
and extciidii ]ii>r]ia|m ull round tlic disk and emlmieeit even tlie rc<;ton
of the yellow spot, itrf jjrcatent extent Uein^ always in the dirt'i'tioii of
the Utter.' lU edf^es ni«y be either sharply and distinclly de6iied, or
may b« irregular, and f^nulually hmi in tlie snrniunding heiitihy struc-
tures ; irre)?iilar pntchcs of pigment are strewn about ita margin, and al&o,
iwriiajis, 01) it<5 surface, so that little dark islets of varying size and form
appear in its expanse. The crescent it&elf 18 of a hrilliant white, so much
indeed, that the disk, by contrasl. sp[ieari to l»e abnoniially pink, On
^'iccouut of ilic white bai-kground, the ^inall retinnl voxtielA can bu traced
more distinctly, and their minatc branches he more easily followed, over
this patch than in the nci;;hburiii;£ fundus. This white crescent is due to
a thinning atHl atrophy of tJie strotna of the choroid, indeed the latter
ha* occaaionally been found i)uit« wanting in this situation. The pigment
ovIIb are not necevsiirily destroyed, but (here is an absence of pigment
molt'culog. for the irregular hiack patches mentioned alwve arc patho-
logical agglouieratioiw of pigment. On account of the hjss of pigment
aiul the atrophy or thinning of the stroma of the choroid, the glistening
Mk'rolic shines through the tatter, and lends the brilliant white appear-
ance to the figure. Tliin want of pigment also gives rise to the kchho of
glare, which the patient experiences in a hrighr light. Tlie amhiyopia
which fre'pieutly exists in thi;* tlitiease, is also undoubtedly jmrtly due to
Uiiti fact, for we find that the sight of such patients is often remarkably
benefited by blue spectacles. The amblyopia, however, as a rule, drjtendg
ohicfly upon the disturbance in the intraocular circulation, produced by
the state of chronic congestion of the renous system of the eye. Hence
we find that vision is generally greatly improved by dcpleUon, aiwl more
ea|tccially by the artifivini leech.
The ivtina generally snffcr^i only in so far from this loss of pigment in
the choL'uid, that a sUght diraiimtiou in the distinctness of perception is
produced. The " blind spot" (answering to the optic entrance) is some-
what enlarged, but this increase does not correspond at all to the sive of
the crrseent, nnrl vision is only impaired, not destroyed, in thi^ extra por-
tion of the blind .^pot. But sometimes there arises n state of great irri-
tability of the retina, prmlncing considerable amblyopia and di-«turhance
of virion, together with photopsia and a feeling of jioin and tension within
tbe eye on the slightoat exertion in reeling, etc.
■ W« nuri, hmruvvr, tw Rftrerul aat lo call ovory IfiUo whilo rim at tk« r4«* of th»
disk "MlrrpclAala |Mwli'ri>>r,'* fnr tills may hv cnatinA sliitflv by tli<< cliotoiil r>-«iyliitj
•nai««li*t from the npliv n-tvi; biiH p«rmilliiig ll>i< liy;)il I'l (all nt iliti' *|>i>l Itin-iigh
lh» retina upon tli<*<1i>nu<ltsl at-lxrvlk, lliiu (UTDnl int: tti>'np|>«%nii».'v<if uvrlilt*^ ^li^fn-
lug riiu. But (LiU uc Is nnrrxw. Ila xifgM un «har|ili- ilrflnprl. kuiI ibvri' or*.- no Biro-
|>bic t'hniiKv* "I l)ie chnmiil KmnDd it. This condition inkjr oi-cur iii mjropic, einin*^
tmplr. stui kyperawtrupic vyw&.
«34
DIBBASE8 OF TUB CUOROID.
Tha (lij^rase may remain stationtry or proji^sa. [Tiie first Tariety or
the completely alnlionary siaphyloma, cftllod by Bome nuthor* the
*'coiius," U t<) bo rcgank'il Ait a lunltoiumtioiir wliiuti may occur in ctntDc^-
Ufjiic <ir amvlnifiic cyos. Tlic siuroiitl or progrvAsivn rnrtii U aocimipa-
tiicJ by a progressive elongation of the optic axis, aod lience is especially
noticeable in myopic eyes. The staliotiary tbrin occurs pre-eminently in
myopic eyes, aUbougli it has been seen in emmetropic and bypermelro-
pic eyes. It is as a rule cresceutic, of varying width, and its stationary
character is marked by its clearly defined ouilltie towards the macula.
The proirrtdsive posterior staplivloma haa a defective ami irrc^^ular out-
line'.— It.] In ttic former case tlie myopia does not iitcrt-asc, llie circum-
orVital and Intra-ocuLnr pains dicoinish or ccaitc, and with the oplithal-
mo!$cope vre fitid tliat there In no augmentation in the size of the creweoL,
anil that. perha|i.^, a rc^'ular deposit of pigment again takes place.
Kar different is it if the diflcasc prngresses, and especially if in6amma-
tory BVmptoms anpervene. which is generally the case when the atrophy _
is at all advanced, llie niyiipia is then found to increase more or leal ^H
rapidly, vigiuu becomes dimmed or greatly impaired, Ui« patients arv ^4
often continually haunted by " blacks" floating before their eyes, which
may aitsumc all kinds of fantastic shflpea, and arc due to npacictcA in the
vitreous humur. At ottier times, they are greatly disturbed bv showers
of bright stare and flsHhes of liglit, which are due to a titato of irritalion
of the optic tiorvo and retina : and they become more and moro ilitzxled
by the light, on account of the incwased atrophy of the choroid and the
lo»s of piigmcnt. Itut the progress of the alToction is best watcheil wiUt
the ophthalmoscope. The edges of the creacent show symptoms of by-
penvmia, and become irregular and ill-defined. Small while pntches
appear arowml it ( syinjiUimatic of the progrc^ive atrophy of the cho-
roid), and these, gradually increasing in size, coalesce wttli each other
and with the original crt'sceiit, so that the latter may in time extend
completely round the disk, which thus becomes imbedded in a more or
less broad, white, glistening ring, which extends chiefly in the diroctioD^H
of the yellow spot. In i^ui^i cases, a nuperhcial obHCrrcr might supp4S9^^|
that the optic disk was greatly enlarged, or even that the opiic nerve ^
(from the while appearance) was atrophied. On closer examination,
howerer, the distinction between the disk and the whit« xone is ea^iy, for
tlie entrance of the optic nerve looka abnormally pink, on account of ihe
contrast with the bright white of the surrounding ring, and lUt Tciwels arc
more easily truceable over tlie latter than on the disk.
A similar |rroces8 may also occur in the region of the yellow spot,
Ijitlle white patches appear, which increase in siz« and coalesce, giving
the whole an appearance of alternate whit« and dark reticulated apacM,
the white spots being due to the t^clcrolic shining through the atrophied
Stroma and pigment layer of the choroid- Von Graefe tltinks that the
n^tina may in tlirs^ situation participate more rapidly in the <liseasc than
otborwisc, on account of its being thinner at tins spot. If the atn>phy
of the choroid in ttie region of the macula lutea, aa well as that aniund
the oplic entrance, progress, ihc two separute processes may gradually
extend towards each other (leaving less and ka healthy structure betwev'n
^1^
a
then), until tliey finally paau into each other, and form one largo white
figuro.
'ilie oucurrciice of iiiHanmuLtory clmnijes in the ciioroiil an'l rvtinti
in tiie region of the yellow n|Mit. goncrally causcii great imjuurriient of
vision, antl tlie imtivnt then alito conijilains of tlie cooMtanl appearance of
one or more central, tixed, dark dpotit (ticotomata) in the fielil of vision.
It shonld be mentioned that thej may be apparent to tlie patveut long
before we arc able to detect with the ophthalmoscope any changen in the
fCffion of the macula lutca.
Von Graefr' long ago called attention to the important fact that
secondary glaucoma nmy supervene upon Bclerectadia pot^terior, and lead
to great impairment of visiun, or even bliudncaa, if the true character of
the camplicatiou is not recognized sufficiently early and a timely iridec-
lomy |)tirfonncd. It always attacks both eyea sooner or later He
states that thi^ secondary jilaucoina may uither ajtsumu the chanicter of
g1ancnni» ttittiplcx, or that uf tliu inllamniatory form, (ilaueoina simplex
occurs chiefly in tlio-ie cKne.* of sclerectasia posterior in which iuHamma-
tory symptoms are absent, and all the tissues are normal, excepting, of
connie, as regards the changes produced by the eUmgation of the optic
axis, and the attenuation of the »clerot4C and choroid at the jiotiterior
hemisphere of the pycball. If in ftuch eyes ;:luueoma simplex super-
venea, we find that the tension of the eyeball increases, ihe optie disk
becomes excavated, the visual field impaired, and the sight deterionitud,
but generally only after the field huA aln^aily become greatly con-
tntcted : the refracting media, as a rule, remain transparent. Accurd-
ing to Von Urael'e, the ghiuconia simplex would appear, in^uch caDOii, to
be pnrlly due to the advancing age of the patient, for then the sclerotic
becdiue]! Grmer and less elastic, tiius offering a greater resistance to the
prtKesa of bulging (ectasia ), which causes a tendency to retapdati-in in
the venond circulation, and also compreasea and irritates the ciliary
uerves which [mm through it here. Fhis tendency to glaucoma may
also he hereditary, showing itself in several mcmbursof the same family.
In such inatance^, the myopia has generally reached a con-^iderable de-
gree in childliuod. and then, hetwecn the ages of 12 and IH. glaucoma
airaplex supervenes. When the latter altack>«, in middle age, eyei* which
are only moderately myopic, Von Uraefe thinks that the combinatioa is
accidental .
Freifueutly, however, secondary glaucoma does tiot manifest itself iu
aclerectiisia posterior until symptoms nf sclerolico-choroiditia pomerior
have sup«.*rvencd, and tlien it mostly assumes the character of iridrniho*
roidttis serosa, with [wriodic ctoudineas of the atjuoous humor, and eflu-
siona into tlio vitreons.
With regard to the excavation of the op^c nerve which in met with in
the cases of glaucoma complicating sclerectaxia ])OSteri<ir, it must be ol»-
aerved that it cloos not always present the very mai-ketl fe.-itures of the
lucomatous or pressure cup. This is especially tlie case if the atrophy
" A. f. 0.," ir. i, l&i : tttUl., viii. i, 304. Tim rraair HhmiM mpf^JAllr Linutult
liii Iwt nlRMrralioim tipiin litis puint iu the atticlu n-ci'iitlj jMihlUhitl (" A. t. O.,"
XV. 3, 173.)
A88 DI8BA8B8 Of TUB CHOROID — COHPLtOATtOHS.
of tlic choroirl oncirclcs ilie dink, for the steepness of the excavation will
then be Iciii^ cndciit, m aUo the bending of the vexstcls. Hence, u Vol
Gruefu points out, we mu^t ooti«i(ler ever^extiuvation in sclerectasia
tenor is Itein^ ^lnucotniituii.s in chunicier, if Oie etl-'e of tlte <li«li ii
tolerably ilistiuclly cupj/cJ, if tlif larger veins show a tliffereitcu in tlivirj
fuioeu at its inargin, ntvi if, together wilti [Iiese svmptoms, the •'Vi.'-j
tension \a incroattcd, ami lliero are corrc«pMn(tinj£ fuiictional lUftturhancvi
in the o}'o {e. //., coutraclioa of tiio field). In aonio of tiwuc cu
the !ii};ht rcrnaiiL4 wonderfully j^ood, considenn>; the great rotitractioQ of I
the Held, am! we may tiud that when the contraction has gnvjunllv i>x-'
tendril from the inner side tilt il ha-^ nearly rcachejl tJie centre, it patuiea^j
upwards and downwanls, leavin;; the centml |>art uniropairod. to luee
again on the other side, aod thus a eoiall iilei of the field laay be left inj
the centre of tlie blank.
Sometimes the excavation ts, so to speak, double, tlie marji^n of
diflk iHrin^ cupped, and u iifcond (perhaps steeper) excavation oxialini
in the acU-rotiu at a dislODce of from i to ^ mm. from the edge of tbii^
difik. In other cases the exoavatiou is extremely steep, presenting all'
the fcatnres of a very market! glancoumions or pre«wiiri- cup ; one pecu-
liarity Iwiiig that the si){ht romftiiui relatively rotiiarkably ^m1.
Iridectomy mui^t be performed as early as fiossihle, for jMiracentcaia
proves of no peniiauent relief. It must be mentioned, however, that in
some inatanccfl, where tlie contraction of the Geld alre*iy encroache*.
closely on the centre, the opcratton sometimes causes a dotorioration of j
the sight (Uraef<).
Compiieati&HJi. — When inflammatory nymptomg have supervened and
the disease has ajuunied the character of scloi-otico-choroiditi^ poaterior,
the vitn^ous humor ufu-n beeomes clouded, and ita posterior portion oren
iteriiHpa fluid or detached. Tlic vitreous (■[>acitit.<» may be dark fixed
specks, or lloating membninou^ films of varyin;^ si^ and shaiie, and are
often a source of great anxiety to Uie jtalient, for even the phyaiolo;{ical
motes are rendered very distinct in short-sighted eyes, wi account of tlie
circles of dtflfusion upon the return <t'/(/r Hi-ttcte on Oimuities of tha.
Vitreomi Humor, p. AMY). The most dangerous form of opacity of thft'
vitreous ia that which cumes on very suddenly, is eonGned to the postfix I
rior segtuent of the vitreous humor, uniform in character, and iduirply
defined against the transparent vitreous. It, moreover, sliows a sli^lj
tendency to ogoillate or tremble, and affonis a faint gray reflex, which
may ca^iily cause it to be mistaken for detachment of the retina, until a
close cxuminutioii of its margins shows tiial the retiim i» iu perfect appo-
sition vritii the rhortiid. Tnis form of opacity is giMierally the prc-our»or
of detachment of the retina, and Von dracfu" tiiinks that tlie following
rcaaons speak for its being, in all probability, a detachment of tiM^
Titreous. 1. Its sudilen apjK!arauce, whereas the majority of optoiliei
of the vitreous, with the exception of tlie hemorrluigio. are iu<'>ru gradual
in their ilevidopment. i. Its sharply detined limilaUon, in spito of its
considerable extent ; whereas we find that infiltrations of the vitreoiu of i
< "Rl. MonaUU.," ie««, p. 501.
SOLBHBCTAHIA POSTBRfOR — 0A08BB.
537
like inagnituile senerall^ pads over gradually into the hvaUhj porttpa of
vitreous. S. Ihc almost oontjtant supervention of (letaclimetii of tlie
Ktina.
When speaking of (ietacliment of the vitrooaa (p. 40H), I mentioned
that Ivanoff had ohscrvetl it ^oineiime^ in Bclcrectnjila posterior, and he
thinks ttial in f-wU caH<.f8 it ii« produced in tlie fullawii)<; luanncr;' " Tlic
vitreoni* humor docii not grow in proportion to the gradually incrua^iiiig
size of the eye, and the serous exudation is not at the sauie lime con-
verted into the tJMiie constituting the vitreous humor, nor does it dis-
folve it, hoth remainiiif; inHift'ercnt to each other ; the connection he-
tween tlie vitreous and ivtina bocomint^, liowever, lcM>8ened, according to
Uie amount of efi'usion. ^ow in tlie space which is thus formed hetwecn
tlie vitreous and retina we find that, in proportion to the development of
the staplivloma, more and more serous elTusion is collected, detaching;
the vitreous more and more from the retina."
I/etachmeHt of the retina is unfortunately another not uofrequent
comjtlication of the more considerable degrees of 8clerotico^hon»ditis
posterior. Its extent may be at first hut slight, and he pro«luced hy a
serous or hemorrha<oc efliision betwoon the choroid and retina ; or it
may be caused by tlie contraction of some of the exudations in the
vitreous bunior exerting traction ujwu the retina, and tlius detaching ii'
(vitifi article on Detachment of Retina, p. 440).
Ofttcittf at the fioHteriar pole of thr ieH$ sometimes occurs In the later
stages "f the disease. The opiicity is K''""'^™".V situated very close to
the tuniiiig point of the eye. ami hence remains immovable when liie
eye is turned in a different direction. Cataracta accreta, irido-cboroi-
ditis, and atrophy of the ;^Iobe may close the seeoe.
C'tHuea. — The origin of the allection is still a matter of controversy.
[In certain eyes the insertion of the choroid around tlie optic nerve en-
urnnce U of such a nature that the capaliility of resistance of the choroid^
in cases of increasing extension of the growing eye, and in the varying
L tension of the coubs of the eye in the develo|>ed organ, is less than ic
should he. In these eyes also the attachment of the sheath of the
optH Dcrre deviates from the nonnal, and this influences the power of
the resistance of the sclera. In such an eye the posterior staphyloma
must be regarded either s.-i the complete development of a congenital
uialfnrmation. or as tlie result of a |tathological process engrafted on a
congenitnlly weak spot. A second factor which enters into the amsa-
lion of a posterior staphyloma is an abnormal action of the external
piuscles of the eyeball. The insufficiency of tlie internal rtwti muscles,
so often seen in progrc-tsive myopia witli posterior staphyloma, jnostu.
latea a previous straining of the.ne muscles. — B.] Without doubt, Uiera
generally exists a c-ongenita! (and nl'ten hereditary) tendency to elonga-
tion of the eyeball in the optic axis ; and this must necessarily cause a
stretching aad thinning of the sclerotic and choroid in this direction,
I which is generally soon followed by consecutive atrophy of the latter,
llie dcvelopincnt of this prolongation of Uie optic axis is greatly fav<)red
by the strong convergence of the visual lines and the state of congestion
L.
-A. f. 0.,"aT. 8,67.
» ll.'inrioh Uflller. "A. f. 0.," wi. 1. 872.
r>88
DtSBABES OP THB CUOHOID.
of the eye irhich oconr ilurin}; accomnuxliition Tor near objects, more par-
ticularly if these arc amall and insiiflicientty iUumtuatcil. For dii]*in^
such BCfommoilatioTi, a certain presaiire upon the eye alvraya occurn, ac-
coinpanieil hy increase*] intra-ocular tension ; in consequoncc of which, the
venoutt circulatioit within tlic oye becomes retarded, and a more or less
coimidemhie stiiw itf rneclianical conKostion h produced, tnntances of
sncli intra-ocniar conjjestion arc fumishcil l»y cases of amblyopta due to
opacities of the cvruea or lens, in which the myopia is caused by the
flatten t*s brinpring small objeuts very near to the eye, in order to gain
ar;'er retinal images. A similar thing may nocur if the patient, wIiiNt
usin;; coni-'ave spectacles for reading, f^mdually appi-oachcH the book too
near to his eyes. We occasionally find that vitreous opacities, and ereu
deLicbruent of the retina, occur in such cases soon after long-coiitinued
reading or workiiii^ with H}»eetaele8.
Thi.4 iitate of con;;c<itton and increaaed pressure of the intra-ocular fluids
leada to doftening and extension of the tunics of the eyeball. As the
latter receives no support at the posterior pole from the mnscles, the pro-
lon;!atioii oc^-urs cbieSy at this {wint, the choroid being stix-lcbed and
f;ener:illy undergoing consecutive atrophy. At a laicr stage symptoms
of iiifiammation may arise, and the disease aasurao tlie character of scle-
rotjco-chorotditis posterior. The cliaii<.;(>y 'm the choroid are then no longer
ainiply due to extension of the eyeball, but to inflammaliuri. Small e!r-
cum!W!ribcd patches of choroiditis ap)>«;&r at the marpn of the original
Tfhite fi^'ire, or show themselves in the form of choroido-retioiti- in the
region of the yi-'lldw .sjxit, and the vitreous humor bwonurs clouded; so
that we hare in fact more or less pronounced symptoms of choroitlitis.
This choroiilnl atrophy may, however, exist without any posterior sta*
pbyloma. Imieed, Schwcigger states tltat a real stapliytoina poaticiim,
I. «., a more or less sharply defined local ectasia uf the nails of the eye-
ball, docs not take place in llio majurity of cases of myopia. The pres-
ence of a posterior staphyloma may be diagnosed by means of the oph-
thalmoscope, particularly with the binocular, for we tiien see that ihe
whit<*, shining portion of the sclerotic exposed through the thinning of
the choroid is uot of normal curvatui'e, but is peculiarly cupped back-
wanls, giving rise at this part to a slanting position of the optic disk.
Scliweigger, moreover, thinks that the acuteness of vision is diminished to
an nnudual degree in those caaes of myopia in which posterior slaptiyloma
exists beside the optic nerve. This is ehc more likely to happen, as he ba«
observed that in cases in which the existence of a posterior staphyloma
was proved anatomically, the retina in the expanse of tiie bulging portion
was generally found to be more or less changed in structure, and eveu
atrophied and adherent to the remains of the choroid and sclerotic. ['Vhe
visible gaping of the intervaginal space of the optic nerve is a constant
accompaniment of the development of a posterior staphyloma, and in-
creascB with the growth of the latter. This separation of the sheaUi,
together with the necessary displacement of the posterior ciliary vvtuicla,
causes disturbances in the circulation in this region of the eyet>Hll, and
may ex]>lain why, in advanced posterior staphyloma, the optic Qorre U
BO "ften partiiilly atropine. — B.]
When the sclerectasia and atrophy of the choroid are coiu<nde rabbi and
:
«MMM
BCLSRBCTAStA POSTBBtOR — THKATNBNT.
539
I
I
the mjopia high in degree, symptoms or tmtotion ami inflammaliim aU
most ftlwavs supcrvoDC. Danacrn' tliinks, •' that iilino^t wiiliout exception,
tlie iire'lispusltion to tiie <i«velo|)«ieiit «1' slaplivloma posticiim exists at
birtli ; tli;u it \n lievelopeil w'ltJi nviniiUmis of irrilatitni. whicii. in itM«ier-
at« degrees of stRphylotna. <lo not attain any great clinical imjiortance ;
but Uiat in the higher tiej^rees an inttainmatory ^tate ulinost always occurs,
at least at a somewhat more advanced time of life, as a result, and m a
co-operative cause of the develoiHnent of the diatcit.siun and of the atro-
Jaijiet' considers that this crescent or posterior !*tapIiyloma. as he tenna
it, ia alnmst always congenital and ofton hereditary, li nwy, indeed,
exist for many years, or even throughout life, wichoni increasing in siM,
or without the occurrence of any choroidal changes in its vicinity, its mar-
gin remaining distinctly ami i^lmrply defined. But we moru tre(|uently
find, if the eyes are nm^-h useil and the myopia iiicreases at all coii/ider-
ahlv in <legree, llmt the edge of the orescent hecomen somewhat irrugular
and broken, and gratlually inercaiie^ in sixe ; this being evidently due to
iuflammatory changes m the choroid.
Proi/iuma. — This ehould be always very gnanlcd when the disease is
At all advaitced, when tlie myopia is pPOgre*sive, ami when the 0[>acitie«
in the vitreous humor arc considcnible. It becomes still more <|uontion-
fthle if the vitreous opacities are diffase, or large and numeroua, if the
upper or lower portion of the visual field becomes clouded, which is pre-
monitory or symptomatic of detJichuient of the retina ; and, lastly, if the
chopjidal changes make their nppeaniuce in the region of the mncula
lutcn. Thoy hIiow t)ioni4elves in the form of itmall, i.-^iilatod whitish 8]K>t(},
around the edges of which there are little accumulations of pigment ;
these ttmall wliitish spotti increase in size, and coalesce, and then the atro-
phy of the chunud bwomea very apparent. During this pnweira, the
retina is more or less irritated, and this produces dimness of vision, which,
however, diaappeara again when the retinal irritation subsides. These
atmphio changes in the rc^on of the yellow spot give rise to fixed black
sptyU in the visual field, which, if considenible, may render working at
amall ohjoctri impossible. The ultcrutioiiK in the macula lutea generally
commence liret in one eye, and may for a time be confined to it, but sooner
or later they mostly extend also to the other eye.
Trrntmrnt. — Patients sufiering from sclerottctMshoroiditiji posterior
should ha particularly warned against working for any length of time at
near objects, or with their head bent forwanl, for intra-oinilur venous con-
gestion is thus easily pro«iuced. It is also very injurious to read in a
recumbent position. The Imit jw^lure for reading is, to sit with the head
thrown back, and to have tlie Hghi falling on the book from l>ebind, ao
that the page may be well itluminated, but the eye not exposed to the
direct glare of the light. In writing, it h ailvaiitageous to use a sloping
desk, »o that the peraon need not stoop. If such persona are permitted
the use of spcciuclcs for reading and writing, we must particularly point
out tJie danger of bringing the object too near wheu the eye becomes
I "AnoninJimi Af R^fniAtiAn and AMoramndBllcM),** p. 3M.
*'*V«bvrdi<* tiiiisi'iUuii)! <!•« ilt»(ilrl»f)i«n ApiwraUj*." Vl«nn>, IMl.
^m
584
DISBAEES OP TUB OUOROID.
The digcBBC may remain stationary or progress. [The first variety or
tho completely stationary staphyloma, called by Bome aiithont the
"conua," is to ht regarded as a niairoimation, which may occur inemme-
trfipic or ami'lropic cyp». The second or prn^^ressive form is accouipa-
Died by a progressive elongation of the optic axid, and henco i» especially
noticeable in myopic eyos. The stationary I'urm f»ccun) pre-cmincatly in
myopic eyes, slthongh it has been Keen in emmetropic nni hy[ienDetro-
pio eyes. It is as a rule cresceutic, of varyiu}! width, and it^ stationai
character is marked by its clearly ileBned oiilliiie lowarcU tlie nucuL
The projircssive posterior staphyloma has a defective and irrepnilar niit-
lino. — IS.] In the former case thv myopia does not increase, the circum-
orbital and intra-ocular pains diminish or cease, and with the ophthal-
moscope we lind that there is no augmentation in the sixc of the crescent,
and that, }icrha})S, a regular dc])Ot;it of pigment again takes place.
Far dift'ercnt is it if the disease progreftsos, and especially if inflar
tory symptoms supenvne. which is generally the caae when the atropt
is at all advanced. The mytipia is then IVmnd to increase more or le
rapidly, vision becomes dimmed or greatly impaired, the patieiitji are
often continually haunted by " hlacks" floating before their eyes, which
may assume all Vinds of fantastic shapes, and are due to opacities in the
vitreous humor. At other limes, thev are greatly disturbed by showcra
nf bright ttlar^ and Hashes cf light, which are due to a »!tate of irritation
of the optic nerve and retina ; and they become more and more dazxied
by the light, oti account of the increased atropliy of the choi-oid and the
loss of pigment. Tint the progress of the atfeciion is best watched with
tho ophthalmoscope. The edges of the orescent show symptoms of hy-
peremia, and become irregular and ill-detined. Small white patebes
appear around it (Bvmptomatic of the progi-essive atrojihy of the cho-
roid), and these, gnwtually increaaiug iu size, coalesce with each other
and with the original crescent, so that the latter may in time extend
completeW round the disk, which thus becomes imheddeil in a more or
less broiki^, white, glistening ring, which extendi chiotly in tlie direction
of the yellow ppot. In su^ cases, a superficial observer might .iupf>OM
that the optic disk was greatly enlarged, or even that the optic nerve
(from the white appearance) was atrophied. On doner examination,
however, the distinction between the disk and the white zone is easy, for
tlio cntrsTice of the optic nerve looks abnormally pink, on account of the
contrast with tho bright white of the surrounding ring, and Its rcsaob ar*
more easily traceable over the latter than ou the disk.
A similar prnccsa may also occur in the region of tJie yellow spot.
Little white patches appear, which increase in size and coalesce, giving
tho whole an uppeurauce of alternate white and dark reticulated spaces,
the white apots being duo to the sclerotic shining through the Atrophied
stroma and pigment layer of the choroid. Von Graefe thinks tliat the
retina may in tliin i<ituatioiL participate more rapidly in the disease than
otherwise, on account of its being thinner at this spot. If the atrophy
of the choroid in the region of the macula lutca, as well as that around
the optic entrance, progress, the two separate prooesaos may gradually
extend towards each other (leaving less and less healthy structure between
I
them), until tlioj finally pass into each other, and torm one large white
6gure.
'Ilie 'jccurrcnce of iiitlammiilory chnn^cs in ihe choroid and retina
in the region of the yollow spot, generally caiiaea great impairment of
I'ision, and tbe (latiuiit then n\no u(>iii]}]aitt>; of the constant appi-arance of
ODO or more central, Hxcd, dark i\K)U (iicotomrtta) in thi) fisLd of vision.
It should be mentioned that they may be apptirout to the patient long
licfure we aro uhle to ilotevt ivtth tlie ophthahnoacope any changes in the
region of the maciilii Ititca.
Von Graefe' long ago cnlleil attention to the important fact that
secondary glaucoma may supcrvonc upon sclerectasia posterior, and lead
to great impairment of viaiuu. or even bliudnew, if the true character of
the complication is not recognized siifficicuily early ami a timely tridoc-
lomy performed. It always alcaclcrf both oyea nooncr or later. He
states thai this secondary ;[laucoma may either assume the character of
■;laucoma simplex, or tliat of ilie intlamnuLtory form, (jiaucoma simplex
occurs chiefly in tho-sc cases of sclerectasia posterior in which inflninma-
tory symptoms are absent, and alt the uesties are normal, excepTJn;;. of
couree, ati regard,-) the changen produced by the elongation of the optic
axis, and the attenuation of the wteroti^c and choroid at the posterior
iicmispht-re of the eyeball. If in such eyes glaucoma simplex surier-
venca. we 6ntl that the tension of the eyeball increases, the optic disk
becomes excavated, the visual held impaired, and the ifight deteriorated,
but generally only after ibo fiehi hm already become greatly con-
tracted; the refracting media, as a rule, remain transparent. Accord-
ing to Von Graefe, tlio glaucoma simplex vronld appear, in such cases, to
1* partly doe to the advancing age of tbe patient, for then the sclerotic
becomes firmer and less elastic, thus offering a greater resistance to the
process of bulging (ectasia), wliich causes a tendency to retardatirm in
the venous ciixulation, and also compreMea and irritates the ciliary
ncrree wbich pass tiicough it hero. Tbla tendency to glaucoma may
also be hereditary, showing iiaelf in several members of the sam« fjimily.
Ill such instances, the myopia ba» gonerLilly reached a con.'<ideni.ble de-
gree in cbildhooil, and tlicn, beLworn tint agen of 1^ and 1H, glaucoma
simplex supcn-cncs. When tbe latter attacks, in middle age, eyes wlach
arv only modemtely myopic^ Von Uraefe thinks that the combination is
accidental.
Frenuuntly, however, secondary glaucoma does not manifest itself in
sclerectasia posterior until symptoms of acterolico-choroidilis pojtterior
have supervened, and then it mostly assumes tlie character of Irido-cbo-
ruiditis serosa, wiib periodic cloudiness of the a<|ueous humor, and eftit-
:§ions into the vitreous.
With regard to the cxcaration of the optic nerve which is mot with in
caws of slauooma com]ilicatLUg sclerectasia posterior, it must he ob-
_ T©d that It does not ulway.s prcnent the very marked features of the
glaucomatoaa or pressure cup. This is especially tbe case if tlic atrophy
> «A. f. 0.," iv, 2,1S3: Ibid., viii. S. 304. Thi>rena<»r shouU (•upHcUllr oontult
liis lual ahMTT&tiotiB up<iii tliia |>oiut tu lh« axtklu rcH^entl/ publialiud 1" A. f. 0.,"
ST. 3, in.>
J
544
ntSBASES 0? TUB CUOBOrD.
After perforation of the come* or scleroUc has taken placet, the in-
tense psin aiui inflammatory symptoms «eiicrally at once siihM«ic to a
very ctuwitlerablu <lejtn;c. The vyv UimiiiUhi-s in size, ami gra>)iially
be<;onu'4 tthrivrlteil up and chniigeil inui n Aiiiall coiitmcitiil litiunp, whidi,
08 a rule, does not remain painful, and itt not pi-onc to give n»e to vym-
pAthetic ophthalmia, excupt iixleed it conlaina a foreign body, wliicfa
kvf\» u|) a considerable degree of irritation, and ia always a »ourC* of
daii>;er lo tlio other eye. Sometimes, however, the eye retains a certain
sifc and consisiciicc, not becoming more completely atrophied, and on
the at[ueou« and vttreovta humor becoming inore transparent, we raav be
able to examine them with the ojiiithalmoKcopc, and Bud that ireab
inaAnes of cxndntion arc effused ; the Icnit flut)scc{iiently becoming opaline.
The treatmrnt must in the Brst place W directed to saring. it' pouibl«,
some reiiiiiaiit of liiglit, iind then, if this be out of the (laei^tidii. to miti-
gatinj^ the great eiifferings of the patient. Thus, if it be pro<lueed by a
foreign body which it in possible to seize and extract, this should Ixi
done without lo&a of time, even although it may be neceaaary to pnsii tJie
instrument into the vitreous humor (pt<jl<! article u|>ou The I'rcvence of
Foreign Bodies in tlie Vitreous Humor). If the letiH ia injured and
•wollon, it should be at once removed, together with a coiusidenible poN
tion of the iris, if symptoms of severe inilauunation supervene.
If there is a perforating ulcer of tlic cornea with hypopyon, either
paracentesis (perhaps frequently repeated) or iridectomy should b«
performed.
If u foreign body has entered the vitreous humor and lies borond our
read), and if it be small and has not injured the lens or enmmiltc<) any
considerable miiichicf in its course, we must endeavor by the strictent
aniiphlogiatic treatment to siibdne the iiiltamnuitory complications, and
if poKHiliie to prevent suppurative choroiditis. Indued in some of thear
OL-^es, the foreign bo<ly iM^come* encapsuhttcd and remains innocuotis, U
e.\cellent degree of vision being jterbaps reftoreil. But when a fon*iga
Irtidy remains in the eye, we must always keep in mind the great danger
of i^yinpatheiic opluhalmia. If the eye is hctjK-lessly destroyed by Ui*
accident, it will be far the wisest and safest cour*e to reDHii'c it at unce,
so as not only to avoid all danger of sympatttetie ophthalmia, but alio
(he occurrence of auppuralive choroiditU. For when symptoms of pan*
nphthalraitis have supervened, it will be no longer safe lo do ao. b«cauM
tliore i^ imminent risk of the jtuppuration ext<-ndiiig to the brain and
pi-<>duciug futal suppurative meningitiK. (.'iu»es, in which this baa oc-
rurrcd after excision of tlie eyebnll during acme punophthalmikia^ hare
been recorded by Von Graefe, Knapp, Manhardt, etc.'
If the inflaromatory symptoms are very aevore, and of a atlicnie ch*'
racter, coM compretvies (iced) should lie eonstantly applied OA long aa
lliey prove agreeable to the palieul, Irfeclies ehoxdd be placed on thu
temple, and if the f>atienl is atiYing. and ilie suppuration has nut already
become too extensive, so as to allord little or no chance of arresting it,
rapid aativation should be iinluced. tn the hojiea of checking tltc inttam-
motion and preserving seme degree of sight. Generally, however, ibia
■ "Kl. MAiuUabl.," ]S63, p. 4&e.
SDPPUKATIVB CnOROIDITTS.
546
I
I
firovps futile. The severe pain in and around the eye \s often most re-
ievi-d hy liot fpcy fomenlatioii? yr poulticou, and bv the eubcutaneoua
iiyectioo of niorphia at the temple. If there is hvpopyon, or Uie tcnaion
of the eye is mooh increasfd. paracentesis of the anterior chamber should
bo performed, and ri'iK-ated at intervals of a day or two, or oven less.
If the eye is very distended, and causes fireat suffering to the patient,
tlie paracetitem may be mule into the vitreous humor instead, which
often aflbnla j^reiit reVicr.
The parieni'A <)trf>n;;th imtitt be suitiained by a very nourishing diet,
the free use of ^timulunts. and by the administration of tonics.
If the pjtin utid ind^immation are very 9evere and protracted, and so
greatly enfeeble the patient aa even to cndan;;cr life, it wttl be bi^t to
remove the eye at all hazards, even at the risk of an extcn»on of the
disease to the hrain, in order nt once to ren)ove atl source nf pain, and
thus enable the patient to rojiain his ittren^tli.
[This proceiluru h Htill rej^anled by many aa questionable nursery.
There are too many cnseit on recon.1 of a fatal termination by the extcii-
«ioQ bac'kwanis of the inflammation to the menin^eu. In most of the
severe cases there is more or less inflamniation of tlie orbital cellular
tiMne, and relief may sometimes be obtained by inciung the orbital
tisBue u well as the eyeball, for the purpose of lessening the tcn-
aion. — K.]
Knapp' h%A latelv de>tcribed two very iutereitting caiM^A of umboltsra of
the choroidal Tessef». In each patient there existed well-marked cardiac
disease (in the one endo-carditis. in the other insufficiency and stenosis
of tlie aortic valvea with hyiwrtrophy of the left ventricle). The iift'ec-
tton of the sight vn* rfuitc sudden, the patients iioUcing a dark cloud
before the eye. wbtoh at first pervaded the whole visual field, hut then
became concentrated in the central |>ortiou. The imiiairment of vision
does not twcur with snob great sndilennus^ a» in embolism of the centra!
artery of the retina, nor t« such an extent, for in the one case V := y'j,,
in the other the patient could read the finest print, and only noticed a
large scotoma lying near Uie axis of vision. There were marked chro-
mopsy and photopsy. The ophthalmoscope revealed a cireum^ribed
clomf or veil in the central portion of the fundus (and corresponding to
the scotoma), which was due to a serous effusion into the retina which
extended to the clisk. The veAseU were also hypenemic in this vloudcd
portion of ihc retina. Thrse conditions were evidently those of collate-
ral effusion and hy|K'P.cmia,and due t/» embolism of some of the choroidal
vessels at this point. These phenomena are (.-asity ex])lainod nhen wv
rememher tJie anastomosis between the central artery of the retina, and
those ciliary arteries which perforate the sclerotic in the vicinity of Uie
dieli. The patients snbseipienlly tpilte n>gained their sight, and tlie
fundus resmued its normal uppearaucc.
"A.f.O.."«iT. I.
546
DISBiLSBS OF TUB CUOROID.
3 [WAHTY OITGROWTIIS OF THE CHOROIDL-a]—
COLLOID DISEASE OF THE CHOROID.
This aflV'ction was firet deacriboii tty Well,' and cansiBts in Uie forma-
tion nf peculiar, transimrent, bead-like globule* on tJic inner surface of
the choroid. Donders' supposed them to be due to flenile changes, de-
pendent upon tt colloid metamorphosis of the nuclei of the hexagonal
pipni-iit cells, vrheread H. MUlloi' thought that tbcic little bodies tic
borixoiiiiilly hfliind the pi<;meut cells, and arc due to an adventiliuua
thiokitiiiiif; of the elastic lamina. From the rcscarchca fif Mr. lliiike,
the latter viuw appeare to b« the true one ;* he moreover found that the
capillary vesticls of the choroid do nut appear to he primarily aflected,
an the hlood coi7>u.scle5 cohUI b« distinctly seen gliding along the capil*
lary ve:!Ml8 in mibroken column bcHeatk ttic globulea, t. e., to the outer
side of them.
Tiic colloid globules are highly refracting, and are arranged singly,
or ill little grouj)^ or clusters. Tliry assuun' varioiw fihafves. being globu-
lar, oval, or club-shaped. They arc but aliglitly, if at oil, affected by
reagents, llieir »ixe v.irie» from xa'jo *o , Jo of an inch (llulke). They
are very apt to undergo chalky and tatty degoncriition, and then prcaont
a finely granular a];|>earance. [They often prc»etit a concentric lajueU
lar Btructure. The retinal epithelium is not directly involved in their
growth.— B.]
Oa account of the colloid atas£cs puithiug aaidc, or even destroying,
the hexagonal pigment cells, the latter arc crowded togotlicr, so as to
form a narrow, dark rim or fringe around the single or aggregateil
globules. Ueuce, the ehomidal ['pithulium presents here atid there a
somewhat variegated, patchy appearance. Indeed tliia is about the only
«ign by which Uie presence of colhjid disease of the choroid can be rec-
ognized with the ophtli»lmoscope. We noiice*^ small, faintly piginenbcd
|«le patchoa, Kurronndcd by a dark fringe of pigment cells, the choroidal
vciisels being hidden by the chalky deposits. These patches may be
strcn n about at nniall intervals over a considerable portion of the choroid,
more especially towards the equator of the liiiidus.
It v!3,A supposed tliut these colloid formations wore due to some senile
changes, aa they are most frcjuently ntet with in old persons. But
Uulkc* has seen tbem also occur in quite young individuals, and consid-
ers that inflammation is thi> cmim of these adventitious thickenings of the
o1a.4tic lamina, as he has frei[ueiitly found colloid ili^easo an.socialed with
inHauimittory changes. He states that it is almoi^t alwayti prenent in
shrunken globois which have been repeatedly inflamed, antl be baa also
seen it several times in acute traumatic intlaiuuiation.
On account of the atrophy of the choroidal epithelium, and oonsequent
injury to the nnls and bulbs of the retina, the sight is often much im-
paired at an advanced stage of the disease, aud if the latter bus invuled
' "Orun-liUgedn- Rlaldog tr. " I8&4.
• md.. ii. 2, 1.
• l.l<-hrvtch, "A f. O.," ir., i. »0.
» "A.f.O.," 1.8,107.
> " R. L. O. II. K«>p./' i. p|>. 7U ud ISO.
* •• R. L. O. H. Brj..." i. m.
TUBBKCLBS OV TItS CHOROID.
547
the prwtcrior pole of the eye. Fortunately, howcvor, it frequently rc-
niaiiw confincn to the periphery »f IIk' fiiiiii»i» (the viciuUy of the ora
8crrata>, imii then of course only the oiitlirre of the viaual lielil will be
affeoteil.
6 TIBKUCI-KS or THK CHOIiOID— [CMIOHOIDITIS
TUBEUCLUA^SA— B.].
It wns rornierly mipptujt^fl by somp anr;^L'ori8 that a peculiar form of
pliuitic choroiilitis was somctimea met with in the later stages of chronic
tuberculosis, and was congequently ' termed "tubercular cboroiiliti«."
The extensive and very careful researches of Cohitheim have shown,
however, that Ibis la rwjt the ca«e, for he hn.i faileii to delect the prea-
cncc of tuheirular depoHits in the choroid in any cil-w of Iiic4ilixivl liiher-
culosis of the Imi^pt or intestines.' Maiw * however, discovered anat-
omicalty, iu three instances, the important and intercHtiug fact of the
presence of ttilreivle» in the choroid in acute miliary tuberculonis.
Biuiol.^ «uh8e<{iiently narrated another case. On account of the paucity
of these instances, it was generally supposed that the coexistence of
tubercleei in tho choroid with acute miliary tuberculosis was very rare
and exceptional. The ^'reat error of this euppot^iuon has, however, been
shown by Uohnhcim, who found in IX cases of miliary tuberculosis
(^ which underwent po4t>n)ortcm examination tn tJie Iterlin Palholo/^ical
lustitn(ion> tubercles in the choroid of one or both eyes i'h everif tn-
»(iimf. Whilst their presence wts thus proved anatornicftlly. it waa
reserved for Vou (traefe* to make the Srat ophthalotoscopic diaguosis of
tJie disease.
[According to Von Wccker, tlie fir^t opbthalmoscopic description of
cboroidnl tuberclea waj^ piiblinhed liv VA. von .)a«^r in 185.^. (See
"Oestcr. '/citsch. f. prakt. lleilkunJe," No. 2, Jan. 2tJ, l«n.i.)— B.]
With the oplitluilniwcMpc, tuberclew in the ohoroifl appear in the form
uf smull circular, circuni.'^cribeil sputa of a pale rose-color, or ^ravigfi.
white tint, and vary in <ixe from \ to '2.0 mm. They are chiefly situ-
ated iu the vicinity of the optic disk, but may extend occasionally to a
considerable distance from it. Althou^ the smaller tubercles only pro-
lUcc a atretchin;; or viideniiij;-up of the cboruidal epithelium, without
_iiy loas of Ihc jpi^menl niolecuk-s. ami beiice only ;^vc rise to a moderate
cliacolomtion of the choroid at this >*p'>t (llraefc), yet they should not
eeokpe the detuctiou of a ciiret'ul and dextenms njiliilialmuscopist, more
esjiecinlly if they are situated near the centre of the fundus. If ihey
occur near the equator it may W different, more especially as Uiese
|>atientt) are often difficult to examine on account of tlieir restless or
comatose condition. The lar^fer nodules give rise to more marked
changes, and are distinctly elevated above the level of the choroid, as is
endcDced by tlie |Mim1lax which can he noticed if a retinal vessel is
fotiiid to pa«9 over one of (hene nodules. The choroid around the Utter
' "A. f.O.."»t<r. 1. ie«. flMf.
• rirohdw'A ■•Arrlitv," vol. 3K, p. 448.
■ Il>.. W. 3. 12(1. untl U. 3, 133.
• "A. r. I>.," J(iv. 1, IM.
548
DISBASBB OP THB OUOOLOtD.
ia qoito nt>rmal» ami there is, except in vpry few caBea, no collection of
pigment around them, kUliougli ot ^eir mnr^i) there in a Taint red muc,
by which the paler red or gmviith eenird portion grailuallT pas»e» uver
into the nurcnully tinted chorunl. Together with tlieae chungrit in the
churoii), there may exist more or less marked hyperiemia of the retina,
hut there is not the least trace of any lose of transparency nf the latter,
even in the vicinity of the dilated voxels. The number of the tubercles
may vary from 1 to 52 (CohnUeim).'
[(ti-ncrnlly the discnse affects hoth eye«. It haa been proven by
Toiicet' tliat there may be a real tuberculouv choroiditis, llie entiiv
thicknesH of the cornea may \w involved by the cellular elements of the
tuWrcUx, most of them beinj; crowded lovfards the sclera, and the retinal
epithelium may remain intact, lliis is diatioct from the isolated tubor-
cutoim nodules.
Tubercules of the choroid may not be the result of chrome or acate
general tuberculosis, for they have been recognized in the choroid muuihs
before the gencml conatitutional liyniptoraB manifeated ihcnL-telvei*.
Virion 18 generally afleeted, though sometiiue:) Uuh is not Uie ca«e.
For a more tuil accnunt of the subject, aee **(iracre und ^at-miaeh'a
Ilandb.," iv. j.p. t;42-ti48. "Arch. Ibr Ophth.," xxv. 4, pp. iaa-2«t».
-11.]
Although there is no doubt that the tubercles are funned in the atronui
of tlie choroid, their t-xact nn^de of development is yet uncerlain. Thm
Mane auppoeed that thev ori|;iiinted primarily in Uie tunica adventitia of
the choroidal vessels ; liuach thought that they were formed from the
culorlesti cells of the stroma of tlic cboruiil ; whereas Cohnbcim cotk
flidon that they are deve)o|>cd from peculiar migratory celU ( Wander-
zcllen) re»embling lymph corpuscles, which lie strewn about in the
choroid.
Soon after the publication of Colmhcim's paper, I was fortunate
enough to diagnose, with the ophthalmoi^cope, the presence nf tu1>cR:le«
in the choroid, and oubmitted the preparation to the Pihthrdogioil
Society.
A« Ibia 18 the firBt case in which tubercle* of the choroid have beea
met with in England, and as h illustrated well their ophthalmosoo^v
characteristics, 1 give U in tj:ie>tfj.
M. J. P., a lilUe girl tei. H, waw a<lmitted on November h, 18fi7, into
King'a College Hoapititl under the care of Dr. Garrod,with e^tuptoow of
acute tuberculosis. She had become rapidly emaciated during ttic last
month, and ha<l during that time suffered from dyapnisa and dry oongh
On admission there wa* great febrile dii-turViance, pulae 132, rc«pirnti"ii«
t(li, temiH-'taiure 101". .Slight dulness of left aide of cheat, and crepita-
tion about the second intercostal space. November *ftb. 'I'eniperatun--
lOti'^, ptiUe 148, respii-ation Uti. Trine acid, no albumen. Puerile
respiration on right side, slightly tubular on lef^. I examined the eye*
with the ophtiialmoscope. and diagnosed the preseoua of tubercles in
> Pr. Priink*'! Iioh alNO lately r«'[H>ri0it iwn c»»v» nt titlll«f7 tulim-iiWU in vkiMrm,
in vhkl) ti)l)rri.-lfe wf di^giicmed tn Hit* diorold rluriu|| lifa. " Bi<rl. Kiln. Wvcbftt-
I* Oftuttf Mr<l., Nw. 7 uid 6, IS'S.]
TDBBBCLBS OF THE OHOKOIJ).
549
tb« clioroiil. November lltli. The patient grew rapullj worse and
died on this <l»y.
PoMt-tnortcm examiimtion Hy Dr. Kelly.
The brain 8ul>8Uiti<:« wat< appareatly nonnal, but on the superior aspect
of the left hemisphere were sct'ii two or Uiree smnll opacitteg In the pin
m&ter. Both )ung<« were fiDcil witli miliary tuburclo. Liver ami heart
bekltbr, kiihieys coiimlncd tubercles in their cortical suhstaiicvs and
were tliroughout conjiuMtc^I. Capsule of spleen ha'i some tubercular (';)
deposjtrt, tlie organ i(»elf being healthy. The ue«eiitonc fclainU were
Mmewhat increased in nize aiiil number, and Aome solitary ;;lAti(U of the
KOiaU intestines were eiilargeii. The surface of the peritoueiuu was
healthy.
Kxamination of the cyc« during life.
I found that the eyea appeared extcnmlly i|uite normal. Tlie sij^hl
waa perfect (No. 1 Jaeger). The field of vi.-tion normal. The rcfnicting
luedta perfectly traiupareut. With tbe ophthalniusciipe. it wua found
tbiit the optic nerve and roiina were healtliv, the retinal veins slightly
dilated; the outline of the disk perfect, fn the choroid — which was
otherwiiw jwrfecily nonual — were noticed numerous small, circular,
prominent, grayisb-wbitc mKluIes, which were chieHy stluatfd in the
vicinity of the optic disk, more especially in the region of the yellow
spot. Towards the peiipliery of Uie fundus they were more spur^ely
Kcattered. The epithelium of the choroid around the nodules was only
very slightly altered in appearance, the celU bein^ evi'lendy opened up
or pushed aside by the norluleii, and there woh no aj^^lomeration of pig-
ment around the latter, tut tbe thinned portion of the epitlielluin jASsed
iaaeiii«ibly over into the unmuil cnmliiion. Al anme jioints, a nodulo
could be seen lying beneath a retinal vowel which passed distinctly over
it. The nodules were prominent, but whether or not the retinal vessel
was arched forwanl by the tubercle could not be accurately detennined,
it was <|uite impossible, on account of tbe restleas mnvcmenta of tbe
ktiout's eye. to distinguish with certainty as to the presouce of a paral-
lax. The condition was very similar in both eyes.
The dia;{iiosis of tulx^rcular deposits in the choroid wad verified by a
careful ilissectiun made by Mr. Ihiwiiter Vunion, the eumtor of tbe
^tiwrliirldit Hospital, an account of which will be found in tlie *' R. L. 0.
II. Ite|wrt»." \\. 2, lt>8.
Other Interesting facta in connection with Uiis subject are, Uiat Cohn-
heim found that the tliyroid gland, which wa.4 supposed M enjny a ape*
cial immunity from tubercular doposita, was in most cases implicated.
He has, luureovtif, succeeded, iu Ouineo-pigs, in producing tubercles in
the choroid by inticulation. The matter waA taken from a lulwrvulous
lymphatic gland, and the animal died five weeks after tbe inoculation,
when, besides those in the oboruid, miliary tubercles were met witli in
all the organs, vix., in tbe lungs, liver, kidneys, spleen, serous metik
brancs, etc."'
• " A. f. 0.," xlr. 1, 3US.
550
PIllAtlS OF THE CHOROID.
7_TUM0US OF THE CHOROID-
[The choroid la very often the seat of tumors, moat of which beloni; to
the clas!i of melano-Mrcoma. Much more rare are tli« DitptgnMFDted
fihro-»arcomata, and the rarest of sH arc the myonma. or fibromata. — B.]
But in tuuTiy iiiHtaoces the ttiinor ]ire»cntd a mixed charsc-tcr, Wing
partly savcniiiatoiiH ami |)arily caruinoumtous. Aoctinliiig to Vun
Graet'e,' the great tnnjority of choroida) tunxini nro of a sarcomntotw
OBtur« ; » much sm»l1er proportioo arc of a niixiNl character; atid only
in exceptional instances aru tlicy carcinomatous. I'liese iliflirri.'nco« in
the nnfnrp of the tumor arc, however, onlv pccogniitfthK* v»ith the micro-
scojie, ai« tlie eye doea not present any Hpecial symptuiiM uhioh Mould
cnaMc u» to decide whether or not a /;iven oaae of intraocular tumor lA
of a aarcomatuu^ or carciuuumtoua nature.
SThe melaiiouc saruonm \a tJio most common of all choroiil&l tumon,
ia generally situated in the ei|uatonal or ciliary regionA. tttou};ik it is
occasionally oivt with in the [«o«terior part of the eye iu the uci^bbor-
hood of the optic nerve.
The unpigmente-d or leuko-sarcoma is much Icsg common than ihr pig-
mented, and is genemlly cDni|>uded of round oelKs, though oocofliooally
there arc found large numlvrs of very largest fu.'^iform celU. According
to Knapp, the ftarcomata which are composed to a large oxtenl of tbese
elnn^alcd celU |)robahly prncecd from the external layi-ra of llie choroid,
while the j^maU round-cell tumor arifteft from the clinrio<a pill aria. The
former variety, rcKvmhIiug tiliroMircoma, have a much t^lower eour^, and
are not so much inclined to pruducc meL&staiic deposits as the «tuall-ccll
variety.
The term <^rrerit<?»r utrcoma is need to dcitcribe a form of growtti in
which there is an enormous development of vesM-ls.
Id rare cases a sarcoma may undergo partial OMiRcation, and ibew
tumont are known liiatologicnlly as ogteo-«arcoma.
Among the more rare mixed forms of tumor may be mentioned the mr^
coma-carciuomatosum, the glio-sarcoma, and Uie niyxo-&arcoiaa.~lt.]
(I.)— SAKCOMA OF THE CIIOKOID.
The disease preaento itself at the outeet, as a small nodule in the
[anterior] or lateral portion of the choroid, )>etng developed fmni ihf
pigmented connective tiwuc of the latter. Ihiring the earliest Atagf,
tlie clion>id»l epithelium and the retina may remain mialTected. ftacfiing
intact over the little nwiulc. Hut, as tin- hitter incrcaacs in si»e, the
retina genemllv lK!Ci>ine9 more or leu d<?tii')icd hv tJie eflu'^ion of a
Berooa or hemorrhagic reddi;>h-lirotvn fluid, which causes tlie drtaclicd
portion of tlie retina to fluctuate and treuble ob every movemetit of the
< "A. r. ».," xlv, 2, U.*'. Tlin n>s>K-T will Rml In IliU itrllolv a vvrv lnt«f»Uat
anrf vklnaltU- aivniitit nr llii; otilor tllRm-iir^-ti U-tw.t-n Hits ajiu|»taiM, daVcla|HBcM,
«iul (-nurwi? »( ■■nxHiui of the chutuid aikI |;hti«un tvUiuc
m
m
8AR00UA OF TUB CHOROID.
651
vye. According to IwanolT,' detachment of the vitreoiiti precedes that
of the retina in tiimors of the choroid. Snbdequeiitly the retina mostlj
becomes completely detached (the vitreous humor undergoing correspond-
ing diminution in rohime). giving rise to the well-known funnel-aliDpt^il do-
tflohment, the apex of whicli is situftted nt the optic itcrve, the ha«e at the
ora serrata ; the space external tr> tlie detaclied rctiiiti Itciug oecujiiud by
the tumor, and more or less fluid. The lens now soonhccomeK cfttarncloua,
if this has not alrendy occurred, more especially at its posterior pole.
The vitroouA h»mi)r may loae ita transpareucr at an earlier stage of tJie
discflAo, whiUt the iletachment ia still but partial, ao that the details of
the fundus are, perhaps, obscured by a diffuse haziness of the vitreous,
intermixed with more itr less filiform or membranous opacities. If the
rflina retaina it^ tnin.'^jiarpncy and lies in close contact with the lunKtr,
it may be possible, in some cases, to reeognine the latter with the oph-
thalmoscope, as it presents the appearance of a distinct, smooth, or
slightly nodulated swelling, the color of vrhich may vary from a pale-
hr'>wn to a dark coffcf-cohircd tint, according to the amount nf pigment
which it contains. If the rletached rrtina ishould undergo itiHanimatory
or fatty changes ami become thickened, a yellow r^-flex Tnay take the
place of tlie brown color of the tumor. But this reflex diflcrs from thnC
met with in glioma, bj not being of so brilliantly whit« or whitish-yel-
low a tint, or so brightly opalescent (Von (traefe).' As a rule, the
early stag** of the disease is accompanied by a serous detachment of the
retina, Mliicli will completely hide the presence of the tumor; anit it ia
only when the latter increases in size and roaches up cloiie to the tie-
tached retina, that small, dark, knob-like pnitnberanct^t! may appear
beneath the latter, side by side^ {wrliaps. with portions of detached re-
tina, which show a di.»tinct tremulon!»nes8 when the eye is moved. I
have already (,p. -1-4.5) called special attention to the fact that the degree
of the intra-ocular tension is of great diagno-«tic imjioriance in cases of
detachment of the retina : for whilst it is, as a rule, diminished in cssca
of simple detachment. It citber remains normal or is more or less in-
creased when tbe latter is due to the preseitco of an intra-ocular tumor.
Indeed, in the more ailrimced stages of sarcoma, tlie di»eaite often
assumes marked glancnmatou^ symptoms. Tlio tension of the eye is
grvatly incri'a.'W^d, the coriu^a ptTJiaps steamy, n>ughen«d. and an:v»tllietie,
the anterior chamber very shallow, the iri.s pushed forward and its tig»ue
atropbteil, the pupil dilated (of^en irregularly), the lens perhaps opa<|ue,
the sight lost. The patient complains of great ciliary nenraigia, extend-
ing, may bo, to the corresponding side of the head and face. The snf-
ferings are especiallv acute and ■sudden if intra-ocnlnr hemorrhage has
occurrcil. At u later date stnphylomatoua bulgings may appear in the
ciliary region, and tnight he mistaken for masses of tumor; their trans-
parency, when a strong light is thrown upon them, will, however, guard
us against such an error ((.trafife). AfU'r tlie increased t<;nsiun has
existed for some length of time, a severe attack of acute glaucomatous
inflammation may supervene. A'on Graefe calls attention to tJie fact
that he has several times noticed this occurrence afWr atropine had been
» "A. r. 0./' XT.
« "A. f. O.," lir. 2, 109.
552
DISBASBS OP TUB OUOKOID.
atiplied for Ibe puriioee of racilitatiug the opliltialnioitcojtie exaittinntioti
Now, if wo ilo noL know ttic timtnry of die cxhc (tlie prior tletiiciiufiii of
tl)« retina, etc.) and llic meiiia arc too cloiidc-d to permit of an oplithal
nwjscopic cxuminatioii, it tnav be vary difficult to recoguix« the trui
nature of tlio ditieasc. and it will be perhajA considered a simple ca.4e o'
glaucoioa. An iridectomy is made, uiid tlie ftain temporarily relier«d
by the diminution of the tension. But it soon recurs with all its former
violence, the eye again becomes bard, our aui^piciong arc arouse! an M
tlie presence of an iiitra-ocular tumor, tbe cyctwll h enucleated, and our
coujoctures are reri&cd. Thia fact bos led eotne Burgconii to tlie belief
that DJelaiiolic sarcoma is very prone to become developed in glaucomi^
tuus eyca. But tbis does not appear to be tbe caue, the glaucomntmu
condition being dimply one pbaitc of the diAease. Such cases uf su\>-
potted glaucoma in wbicb iiitru-uuulnr tuinortii were !>ul>^e<|Uent]y found,
have bet'ii obseiTed by Ihiwinaii,' Graefe,* Hutchinson,' Dor,* etc.
Sometimes, however, the presence of the tumor se(6 up great irrita-
tion, and finally gires riae to a plastic form of irido-chnroiditia, which
leads to a more or less considerable temporary atrophy of iho eyeball.
Tbe sbruiikfu globe becomes tbe seat of intense, perKisteut pain, fur the
relief of which enucleation is performed, and then the tumor, tbe real
source of the mitichicf, h i'li.4ca%'ercd. It must be mentioned, however,
that whilst temporary atrophy of tbe globe is not unfrei|ueiitly observed
in the cnurne of glioma ix'tina;, this is only exceptionally ibc caao in
sarcoma of tbe choroid ; as tbe choroidal inllAmmfttion generally tMuoMW
a secretory or serous-bemorrbagic character, indeed tbe glnucomatous
condition may even continue after tbe extra-ocular developrnuot i>f tb«
diseaae. The atrophy genemlly depends ufwn sloughing of the cornea
from paralysis of the corneal nerved, which is followed by more or 1
severe suppurative panophthalmitis (Von Oraefe).* Att'.-ntion hasi bee:
called by Von Graefe' to jtevcral {K>ints which may enable us to di^ti
guish between simple atrophy of the eyeball, and that which la defienrl-
ent upon intrn-wular sarcoma. lu the latter case, very severe spou-
taueoua piiroxysnu of pain occur, whilst the ciliar}' region is bardly, if
kt all, sensitive to tbe touch ; whereas, in the atrojiby euituing u[xm iridn-
cyelitis, the reverse obtains, there being but little, if any, spontaneous
pain, but the eye remaining for a long time sensitive to the touch. More-
over, if a sarcoma is present in tlie atrophied globe, tbe diminution in
size, or ttuttcning of the eyeball, occurK in tbe antero-posterior mxia, Um
eijuau^nnl region not contracting to the same extent. The depreaoioiu
caused by the four recti uiuttctea are, therefore, unuttually apparent upon
tlie anterior surface of the glnlio. Agnin, on account of tlie subst^jue
contraction of tlie connective tissue elements, which have Ifeen fo
within tbe eye in the course of the [tanopbthnlmitis, a barrier is, to a
certain extent, placed against tbe development uf the tumor in front.
Hence, ulthuugh the hitler increuses iu use, the collapsed eyeball doet
nut fill out and become plumper, but remains Hattened, and a rotro-oeo*
nea
• "R. L.O. H. Il"p.." ir. 81.
• "B. L.O. H. R-iJ.."». M.
» "A. f. 0.,"xl». 2, la).
» '• A. r. O.,*' ji. 1, ITl.
• "A. (.0.,"»1.J,»*4.
■ Ibid.
att
3
SARCOMA or THE CHOROID.
553
lar fxt«iuidn of the morbid f^wth oecuni, pufthinf; the eyohall forward,
and ittus cau^in^ a certatu degrev of Dxophthaltnos. In e«tiiuatiiig ibe
HL'grrf of Uie latter, we must not forj^et that tlie e^vcball ia ilitninUhod
in Hize, othenft'ue we may eauitj undervalue the extent of tJie protrusion.
The progreiis of Eancoma of the cKoroid is genorally slow as Ion;; as it in
confined bjr the 6rni sclerotic witbin ibe c«rit,y of the eye, and it majr
reniiiiti stationar^v for u considerable lenj^tli of ttuic ; but if it bas ouce
perforated the coate of the eyeball, lU progress is very rapid. Ita ex-
posed 8urfac« bocomea ulcerated, and covered by a dark red cnut of
blood, anri ichorous iliMbarjce, U[Nm the IiicerJiliou of which it bleeda
freely, often very profusely. Perforation nuiy take plac« tbrou;(h the cor-
nea (generally at or near the sclero-comeal juncliou), at tiie front part of
the sclerotic, or at it« p'>Ht«nor portion, close tu the ojitic nerve. The
diwaae tnay also extend into tbc optic nerve; ginull. dark, stringy
patchefl bein^ found to pass backwarde from the lamina cribro^a between
the nerve tubules, and thus causing an cxten^tion of ihe disease into the
orbit, or towanls the braiu. With regard to Uto implication of the opdc
nerve, Von (iraefe i« of opinion time the dirteatie at the outlet extends
from Ihr lamina cribrosa along the inner surface of the ner»'C-sheath, or
along the aepta of the [wrineunum. Wherea«i io glioma, the whole
thickness of tiie nerve in simultaneously affected. Or again, small, cir*
cumscril)ed, black patches make tbeir appearance on tlie sclerotic, hcinji;
apparently independent of the disease, and their presence is generally
pro;;nostic of a rapid extension of the tumor. According to Virchow,
tliu microiwojte, as a rule, reveaU a pn>;;ressive implication of the scle-
rotic.
The appearance which the tumor presents on section, varies with the
nmuiint of pigment which it contairu. It ia generally marbled or spec-
Ided, some pt»rtions being pale, others of a more or lew deep brown tint.
These tncUootic-sarcouintous tumora may, however, be of a uniform.
black, iuky color. Itut according to Virchow' eiarcoma of the choroid
may, in very exceptional cases, be quire colorless. It haa hence been
termed '' tcucosarcoma :" and this is pi-obably due to some local cause, it
licing pcrbajH primarily developed from the lesA pigmented iuner portion
of tiie choroid.
[Tlieiie teleungiectJitic form) of sarcoma are not very uncomtnon, and
generally occur in uupigraooiod tumor*. — B.]
i?arcoma is characterised, imcn>scopicallv, by tlie ]ireaenoe of cells of
varying size and 9lia]>e. Tlicy may be stellate, .Hpiiulte'Sbapecl, oval, or
round, h-iving, piirhaps, well-marked prolongations. , They contain nuclei
and nucleoli. Sometiuies the cells arc of an extremely large sixc Cgiant
celU of Virchow), and contain a great number of nuclei. Between tbc
celU lA observed a variable <^uuntily of scanty, fibrilluted, intercellular
'&SUO. But there is a complete abionco of an areolar mode of arrange-
ud in the pure fonu of sarcoma the oelU are not collected into
Kips or nost3 witliin large meshes of connectiru tissue. Whore tiio
latter nmingeraent prevails in a [»ortion of the tumor, it proves that it is
• " KrankliKftK flMchwlltitv," II. 284; rlfl« »Im llutke, "R. L. 0. H. B«p.," ti.
tSi, and Iv. I^S, aut Kua|>p, " lotraouuUrw Q<iMliwalet«, " p. 12ft.
A54
SI8BASK8 OP tan CnOROTD.
lint ft simple sarcoma, but of a mixed nature, ru., carrinomstons snr-
cDuiii. The cells ol'tvii c<jiiUitii a conaitlerable amount of pi;:im-iit, and
tlie disease is ch«n termetl mclatwtic sarcoma. This is very frot|uenily
the structure of intra-ocular tumors. [The mode of ori)i;in of the variotw
forms of sarcoma is not entirely known. It is etiti nnilecidcd whether
they arise from [irolifcrating cells wlitch have exuded from the vessels,
or wheihur thev originate iu tiie stroma of the adveolitta o( the vesseb.
With regard to the procitoais of simple sarcomatotts tumors, ther« ii
mi douhl that ilicy are decnledly iiiiili>i:imiit, and mauifest a ;:reat tend-
ency to metnstasis. According lo Virchow, the dcj^rce of ranli(^naucy
vanes with tlieir structure. Thus he states' thsit those sarcomata which
contain small celU (ijuite irreBpeciive of the shajke of the cell) arc far
Tfiore dangerous than those in which the cells are large. On account of
the small size and vast i|uantity of the cells, such tumors are generally
soft, and should he viewed with very (jreat suspicion, whereas the gunt-
cell (myeloid) saruotwata afturd a relatively favorable prognosis.
There can he no doulii of the fact that tiie intra-ncular growth is the
primary affection, and that the melastAiic tumors arc secondary, I'hej
owur chiefiy ill the livur. lunjis, brain, and kidney. A fH-culisrity of
llio sarcomatous tumors, which distinj^ui^hcs them from the carciiinmaioua,
is, lh.it thoy show little or no tendency to affect the lymphatic glands,
»nd Iteitce it is more than probable thai the infection of distant organs is
caused through the hlnod, and not through the lymphatic system.
The causes of intra-ocular sarcoma are yet uncertain, hut there is do
doubt that it not uiifro.|uenily become.* developed after injuriea of tbc
eye. It may also be formed in eyes which h»ve undergone atrophy
after irido-choruiditis, etc. Here, however, we iiiunt be iijion our ;>uaTtl
not to raiawkc cause and effect- Rut if the eye has been for many years
lost from irido-choroiditis, before syraptnms of an tntra-i»cuUr growth
reveal thenit«elves. it may, I think, he fairly assumed tlmt the latti?r is a
Mcondary aftection. Thus, Mr IJowman removed an eye affected with
melanotic sarcoma, which bad been lost from acute inflammation twenty
years previously.'
Sarcoma of the choroid occurs roost fre<jucntly after the age of 30,
being hut very mrely seen undt^r the age of 15 ;* Hirsehlu'rg, however,
rccoriis a case in which a colork'Ss sarcoma of the choroid, with scoondarv
nodules iu tlie retina, occurn'd in a girl aged 1-.* Von Itrncfe has
never observed a sitiglo iuHtanre in which choMidal sarcoma affected Imlh
eyes, although he hiw met with ca«g i \ which the second eye became
amiturotic : Ute ophthalmiwcopic examination yielding at first a pcrfertty
iK'gTitivc result, hut at a l^ter period, atrophy of the optir nr'rve act in.
In two of these cases, melamitic nodules wtjre found at the base of the
bruin, reacting on the chia.^ma and tlie optic nerve of the other side.
[ C^tt'iid formationt are mentioned by Alt. They are situatetl in the
equatorial region and ha%'c an endothelial Itntiig. Alt saw them iu only
one cose.
> ••Kr>i)khxn.>l}<McliwSUl«," H. OKI.
< "A. (. O.." xir. 2, K'6.
« "R.L.a II. Rflp.," HI. 27*.
* IbM.. Jcvi. 302.
OARCINOUA OP THB CllOaOID.
5fi5
Granuhma of the choroid i^ someiimcs met with nfler injuries. Tbi«
tnmor never attain? any ^resl sine, and seenn eventually in He chan;L^rl
into cicatricial ti»«ue. There is a ca^e reported by 1<eber of a grnnu*
loma of ihe clioroid from a patient wtio hn<l Buffered from tmchoma.
KuehifuHmnw of the choroid ha< been re|K>rtc() by Knapp. It wm
prolrahly in the be;;;irinin*£ a Hnrcoinu which ha<l KulKc<|uetitly iiiidcrf^oc
car(ila;rinoa<i dogoncration. Alt thinks that tht^ hyaline cnrtilajje is de-
veloped from the remains of the ritreous inclosed in tlie tumor. ($e«
Oomp. der Histolo^e des Alices.)
The treatment consists in enucleation of the ball as soon aa possible,
and iKfon.- the glaucomatous symptoms liucc set in. or the intra-ocuiar
growth has become also exUra-ocular. — B.]
S'lrnoma of the friliarif ffodi/* ia aUo someliracB met with, and when it
haa ac<|iiired aome sixe, it can be diAtinctly obiterved prntrudiiti; into tlie
anteriyr chamber. The iris ia.at this point, pushed a^ide from ita ciliary
in.t(Tiinn by a dark-lmtwn tumor, wbicb more or Icwt filln up the anterior
chamber, its a|wx pfphap.^ lying in contact with the cornea; tlie pnpil i«
at the same time irregularly distorted. On examining tlie position of
ilie morbid {;;rowth behind the iiis, with the oblique ilUimi nation, we mny
iierhaps observe it encroaching upon the area of the pupil, and extondin;;
laeliwardu into the vitreous humor, the lens being generally displaced
to a corresponding degree backwards or upwards. The surface presonw
a dark brown appearance, being either iiuite smooth or aonieuhat lobu-
lated.
[Tlie case of Wecker's reporte<l a^ myoma of the choroid, probably
began in the ciliary Ijody. Primary sarcoma of the ciliary bi>dy i» cer-
tftinly very rare, the growths involving this region usually 8|>reading
froni tbc choroid. — B.j
(2.)— CARCINOMA OF TlIK CJIOUOIU.
Wp may distinguish two forms of cancer of the choroid, vix., the
iDcdullarT and the melanotic. I have, howevor, alreoiiy stated tliat we
cannot with any degree of certainty Hingnose the true nature of these
liimorn, except by an examination of their mtuute rttructure. We may,
ln)wever, hiid some a.ssi8tance in framing our dlagnoais, by rememlM-riug
that ciinccroHs tumors nhow a more rapid jirogress than simple itnrcoma,
lca<liii^ at an earlier |*eriod to mctjitaiitic aflectiona, nud mimifestiiig a
great tendency to implicate the lym[iliatic ^laml^.
On a micpiACopie examination of meihilUrit rarrinoma, we notice lai^
ireolar b|micu3. formed by Uhrillic of connective tissue ; and within theae
^pacet4 arc contained hvaIa of variously sha|wd cancer-cells. The latter
may bo stellate, fusiform, ovoid, or round, and closely resemble epithe-
lial and ganglion cells. Thoy oontain a largo nucleus, and wilhiu thia
there are nuuterous nucleoli.
The mtlatiotic eareinoma is only distinguished from the moilullary by
■ VMr V. OrtMl^n eiuies. " A. f. O.," xil. 2, 233: aim atw ri>|K>rlvd by tlw author
In •' IjaiMwt," JiuiuMjr H, Itt70.
sfte
I»t8BA8BS or TBE CHOROID.
the more or Ies3 considerable ninoiint of pigment contkined in the cells
au<l the traliecu^us t'onuiii;: the ureolie. It nia^T be »o threat a« to <£We h
iliirk inky color to tiie lumor. In the melanotic cancer there ore also
larjie nrcoln inclosing neata of pigmente<l cancer celU.
'I'he iiiulaiiolic caiic«r i« nxtreiuely dftn<;eniiis, and is %'Cry prone tn
rocur at An enrlj dat^. Von (imefe AtateA that he doeA not rt-tnrmber
any ca«e id which ttiv apparent cure exceeded four years, lu the
nuijurity of o&ne^ the disease recurred locally or in other orgin^ witiiio
three, six, or twelve months. *
Sometimes the tumor presents a mixed character, heinK in part aarco-
matoiH, in part carcinomacous, and tJie relative predominance of the one
over the other nitty iiiHuence the rapidity of the pro^reM and of the
r«;urronce. Mure, proh&hly, however, the Harcoiiia may have exi.'tled
for some time, when the cancer elements become developed and greatly
hapten the gronth. Virchow doen not beheve that the Barcomatoiis ele-
ments pans over into thone of cancer, m that the latter is developed from
the sarcoma, hut that the two condition:* exist si<le by side, arisin;; out of
the same primary structure, and ;5n)wiug together like two hranches from
one stem.'
The treatment to be adopted for these tumors (both the sarcomatous
and carcinomatous) is the same, vix., the extirpation of the eye as soon
as the diaj^oiiis can he established with anything like certainty. The
early removal of tlie eye is indicated, not only because we miiy thus
perhaps be in time to prevent the infection of other organs, hut mUo in
pi'event the extcniiion of the disease to the optic nerve. In removing the
eyeball, the optic nerve should be cut very far hack, so that we may, if
possible, get beyond the seat of the dtsea»e.
If, on removal of the eye, the cut end of the optic nerve looks awollea
and dark, it should be pulled out as far as jiossihle with a pair of forceps,
and divided close lo the orhil. This is often very difficult if we endeavor
to look for the nerve, and hencu it ia host, as >Ir. Hulohiusnn' .■4u;4;:ei3ts,
to feel for its trunk with our forefinger, und, when it is thus ftiiind, lo
seize ittc extremity with a pair of strongly 'toothed forceps, and drawiug
it forth, divide it.
When the optic nerve is found to be diseased, or the tumor has ex-
tended into the orbit, the ciilorlde of sine paste should always bo em-
ployed (vide Tumors of Orbit).
I)e \Veekei* describes a unitjue case of my^Mrt of the choroid which
occurred in his practice. The |iatient's left eye was hard, the anterior
ciliary ve&sels dilated and tortuous, and he sulfered from severe paroxysms
of ]inin. \early the whole of (lie internal half of the iris wb« pressed
forwani l<)war<l!* the cornea by a rcddi.tli-hrown tumor, which also occu-
pied the greater portion of the pupil. Tlie vitreous humor was clear, th6
optic di.sk somewhat hypeneiuic. The eye was enuclented, and tlie micro-
swpic examination of the lumor was uuule hy Lwnnoif, who found that it
was a myo-sarcoma, there being in it distinct unsthped muscular fibres.
Leber,* again, describes a very interesting and peculiar ca-w? in which
the sarcoma of the choroid assumed a distinctly cavernous character.
J *• KriiiiktiBfl.* (iMMtiKQUto." il. 182.
> " Maladies iltfi Yuuz' (2d nlltiutt), 1, 5-13.
» "R. LO. H. Rcp.."v. 1. 92.
* " A. r. O.," xiv. a, 231.
I
I
A fomiatioD uf true bone in tmt mifre'iuently met wiUi' on tlie inner
surface of the choroid, in cyct which liavfr iin(icr;;i)iie atrophy and become
shrunken. True o«su<iu» tiiwue occurs, sKcordinj^ to Kiiajip,^ in tJie eye
only in conoeiiuoiici- nf pUsttiv intlnmmation of ihu capillnry layer of tho
choroid ; wKereuH cretiRcation ninv occur in nil the ti-tAue.-! of tho eye.
The nature of the process of o»silicatiou i» identical with tJie formation
of bone iu perio5t«nm. The@e osseous depo5itt<> may appear in the form
of sDull circuniscrihed spots or plates, or they may bo sa extcnaive aa to
form a complete hollow cup. reaching from the ciliary processes to the
optic nerve, and being perrornt4.'d by the Intter. In close appo««ition to
this formation of Iwne m»y often be miticed carli!ft;;inou8 tia^ue.
Tlie mhruuken eyebdll in which a de|)OHil of bono baii taken [dace, is
not unfrc<iucntly very painful, both to the touch and sponC&neoualy, and
may give rinu to syuputhetic intlanimiition.
9^COLOB0MA OF THE CIIOKOID.
The nphthalmiflcopic aymptoms preaentcd by this condition are very
striking and characteristic, and show a remarkable siiuilnrity iu all ca^ea,
allhou;;b, of course, the extitnt of the cotolioma ami of the bulgin<; hack-
wardii uf the ■wlorotio greatly influence tlic«c ap)ioarances. Liebreich
gives an admirablf illusiration of this condition in Wn Atlas.'
With the opbtliftlmoAcope there is oliaervcd a mo« peculiar, large, white
figure at the lower part of the fundus, extending perhaps nearly up to
the disk, or even embracing tbia in its expanse. A nt4>riorly it may reach
more or less closely up to the ciliary pi-occsses, or even »juite up to the
corre«|wnding coloboiua of the iritt. In some rare instances, however,
the coloboma of the choroid exists without there being any cleft in (he
iris. I bad lately under my care at Mowfields » patient iu whose risthl
eyu thcro was a colobijma of the iris ami choroid, whereas in the l«ft eye
there was only a coloboma of the choroid. It is also very rare to meet
with a coloboma of the choroid conBned to the region of the yellow spot.*
Together with the coloboma of the choroid, ttiere always exists a staphy'
lomatouB hulgin;; Iwckwarda of the sclerotic. Tliis may be nearly of the
same depth througiioutT or sud<lenly and abruptly increai^c in depth, which
can be distinctly observed witli the ophtbalnwscopc, aa it produces a pe-
culiar apfwarance in the course of the reUiial vessels, whicli will be seen
suddeidy to dip round this e<igo and bealightly interrupted in their course,
tltoa giving rise to a markerl parallax. These appearances can be well
studied iu Liebreicb's illustratiou.
On the while exjwnae are noticed the retinal vcsscla. which do not,
however, pursue tbeir regular course, but, undergo ]ieculiar windings,
• TMo Wp>1)'s " Atlaa Avt Paihnlo^sohen HlntolofU' dn AUfM."
' Kiin|i|>'i ■■ ArotilT.,"' 2, 1.
< \1%U> xH. Kift. A. [S,^ aleo Schi«(>BOmu»ui. " A. r. 0." xix. 1, p. Sl«.— B.1
* Vid« P« Wrckrr, •' Trsiti d^ Uitlulio du VonA dt r<£ll. " p. 9u7 ; aU« ■* KJ.
Uoualsb].," Un, p. M.
i>5S
DC8BA8BS OF THB CHOBOID.
Bome twisting; and curling round over the edge »f Uie cololiomA. Tlie
prescucc of the retiTin, or at least of some attenuated, t-iciirionit iik'iii*
itrane, is )irov«d hy tlio appearance of the retinal veaeelii on the Hurface
of tlie cololtnma. The retiiin may either lie in apposition with tiie aelv-j
rotic, or be stretched acroas tlie bulge in the latter^ and in tliia case it it
often ^H^htljr fohted, no that braiivlics of its vessels may a]i|>ear to spritigi
directly from the aclcrotic, on account of their continuity with the other
retinal vessels being hidden by the folds. Traces of choroidal vewela'
way also be noticed upon tliEi white figure. The margin of the latter is
very sharply defined, of a dark reddiah-brown or coft'ce-colored lint, and
stronjity pigmeuied. If the cleft stops short of the disk, it will t>e ditided
from the latter by a sharp line of demarcation, and a more or less normal
portion of fundus ; wliorcae, if the disk is included in the cololionta, its <
Kppenranee is remarkably changed, for it can hardly lie dii^linguiabeil
from the rest of the white fi^^urc except by it« more rany-jp^y lint ; ita
I'unu being ellijitic, with its Ion;;; diameter placed horiiEontally.
If tbf^ anterior extremity of the colohoma does not reach up to the cleft
in the iris, there are noticed small rudimentary ciliary proceMcs, and
h divided from the coloboma Of the iris by a more or less extensive por-
tion of perhaps darkly pt;^mented fundus, traversed by a kind of raphe,]
or white stripe' (soni'elimea Uiere are two or three). Where the culobout4^
of the choroid touches tliai of the iris, the ciliary processes may W oomh
pletely wanting, tiaemiscb* nnrraics a very intereiiiinf; caae of colo1>oina
of the iris and choroid, in which the former wan divided from the {•upil
by a narrow band, which wam pnibably a remnant nf the pupdlary mem-
brane. Baumtei' baa alao noticed such little bands traversing tlie area
of the pupil in cases of colobouia.
If the region of the yellow gpot is not involved, the sight may l>«
tolerably good, hut there is always an interruption in the Held of vision'
(scotoma >t corresponding in size and situation to the coloboma of tbc
choroid.
Liebreich has also observed and figured (Atlas, 1*1. xii. Pig. 4) the very!
rare and curious condition of a colohoma of the sheath of the optic norvtt.j
10_m-pTrRE OF THE CUOHOID.*
Severe blows upon, or cnntuaioua of, the eye by the fist or some
body, as, for instance, a piece of wood, may produce rapture of the
choroid by sifn|ik- concussion of the eve without any injury or niptnre n€4
Uie acleroiic or retina, being here evidently due to a contrc-coup. TIibI
aecidem is generally followed by extensive bemon-bage from the ohoroidf,]
uid more or less sewre inflammatory symptoms. The vitreous humoi
ofkcn brcomea diffutH-ly clouded autl traversed by membranous 0|)acitii
I VM* Aril, •' Knii)k)irlt«ii rin AagM," U. 138 ; also SMmbcli, ■ Kl. UonatoU.,*
fffl, p. HT.
• I. c. p. 87.
'■Wntd.urirrr M."I, Z-ltaol.Hft,- 111. M.
% K>>r i>t) lilt' r'>itiii; n "iiul of ru]ituri- of thr chomlil, and a Uliilnr ArrAn|^Mn#t
Af 111* i.-tutf li[lli<-iUi ivcurdod, I would rcter tlir rokilrr loft |in[wr hjr Dr. Kluk|>|i<i<
b^ti tubjv^t in bU •■ Arthlvn,*' 1. 1, t-W.
Rt7PT0&l DV TUB CHOHOID.
55fl
«hicli iDflv be du9 to iiiSamaaatory exu'lationg or h«morrtiagic eBusinrts.
ir tlio vitrenua liiiinor h Buflitiiuiitly clear to permit of the cxaminalinn
of the fuDtlud, wc notice the [>reK«ncc of one or more pale linear atripcA
in the r«};iou of tli« vellow spot. Tliis appearance is produced hy the
rupture of tlie choroia, which la generally somewhat irregular in outline,
and diviited, perhaps, into one or more otTshoots. Ita edges are smooth,
or sli;:htly notched and irrcgulnr, and fringed or studded with deposits
of piginrnt. or little heniorrliagic effusions. [Tlic ni]>turc i^ gaid to in-
volve cliieliy the inner layere of tlie choroid, and iJic outer layere of tho
retina are prubably involved in the injury. — B.] Aii the blood Iwcoroea
absorbed, the efluntoim may either entirely disappear or leave behind snuitl
]>ale patcliei4 in the choroid, and the linear rupture asuiuuies a bright, gliB-
leniag. tendinourt appearance, which \ii due to tho sclerotic being *piito
exported, on account of the alworption ot* the blood. Within the expanse
of (he white figure a choroidal vessel may, f>erlm|is, be observed. The
fundus around the rupture {«xc«pt perhaps in its immediate vicinity) is
generally quite ROTuiaJ. 'ilie retina is aUo fre^iuently uninjured and free
from any rupture, for its vessels either pa^s r(uit« unaltered over the scar
in tlie choroid, or present only a very faint interruption. Rupture* in the
choniid geiienilly oeuur iu the regloh of tho yellow spot, and run in a ver-
tical direction: they are aometirae* straight, in other cases arched or
crosceutic, the concavity of the arch being turned towanU the disk, lu
some caHus thure is only one rupture, in others two or three, of nearly
miual or varying mxc, and tlic one eml of the rent may split up and ho
divided into Lwu ur three little branuldetA.' Dr. Aub' reporla a unique
cft8e> in which there existed a rupture of tJie choroid at the periphery and
another at the yellow spot.
The sight is nt first often greatly impaired, on account of tlio hemor-
rhagic cffusious into the choroid and vitreous humor, or the iuBammatory
coniplioatiotut. As the former becume absorbed and the vitreoun liumor
regains its transparency, the M^ht may become greatly improved, and
even quite restored ; but this is exceptional, for mostly it remains more
or less considerably impaired. The imprtivemenl in the sight is. as a
nile, only temporary, as ^nsion generally deteriorates agaiti at a Inter
period, owiug to injury of the bacillar layer of the retina, produced by
the choroidal rtcar, or to a cireumscribed detachment of the retina caused
t>y the Coutnurtiuu of the cicatrix. Accortiing to Kniipp, su)>se<jaent im-
pairment of hii^ht is tho nile in tlioiie ca&es. 'Vhe field of vision is some-
time« coittracted at the |ieriphery, and there mny also be interruptions
[fCoUiinata) iu it, corresponding in situation to the rupture in the ehoniid.
Although, in favorable catws, the cicauiiaUon of the rupture in the
choroid is not followed by any aul^eiinent affection of the retina or optic
norve. yet the former may afterwards become detached.* Dr. Frank*
also narrates a case in which rupture of the choroid was followed by
the atrophy of the optic nerve.
■ .^uuiDf^i Athrr intorr.otiiij t-Mim of nipliirr at thv rhomU, I n-onM espMislljr <<nU
Uiv n-ailvr'a aHitJItoii (o llif fiilloMiR);, itmcrilipil hy Von Dmnfp, " A. f. ()■," i. 1,
V*i. Von AtumuD. ibhl., i. 2, IM ; I'ruil:, " R. L. O. U. Ett'|).." lit. H : S>HutM4i.
'•Kl. .MnuaUl>l.." iH«. Ill, ana 1S<;;. 31 ; IIjuuc. " KI. MrtnnuM.," l^M, ±U.
• Knajiit'it " .\roliir," il. I. r.«. • " Rl. JIuiiauM.," IWU, |'. III.
• -- R. t. 0. U. Ki-purli." IN. H.
560
PtSKASeS OV TUB OnOBOIO.
Tlic trcatnient roiiet principaily consist iti hn^^tening tlie absorption of
thd heniorrliB<;ic cfTuiiions into the choroid ami vitrecni't hutnnr, and for
this purpCHC the compress liaiiilflge nud tite repeated application of the '
artiliciiil K-«ch will he found moitt serviceaMe.
Jncined u>ounJ» of the sclerotic aud choroid arv not generall/ ttc«om>]
panied by a protnisioti (hemia) of the choroid, but the edgo of &«]
wounded choroid may he forced out between the Iip« of tbp jclrmtic in-
cision b^ the exuding vitreous humor. In woundi of the choroid, thvrc
is often a considerable effur^ion of blood into the choroid and ritrciKU
humor.
11— IIKMORUILAGE FKOM THE CIIOKOID.
Kxtrarasationx of blotKl from the choroid nia,v be produced by an acd-
dent, such as s blow upon the eye, or a woniid implicating the »c!protic]
ami choroid. Hut it nlito occurs iu diseases of tlie e^> which itidueuoaj
the intro-oeular circulation— as for instance glaucoma, sclcrotico^hc
roiditia posterior, etc. — and produce a cougesUon of the choroidal re«-'
sell*, more c-ipecinlly it' the latter should bo diseased. [Occiktionally
wetl-marked si;^naof penvHacuIilischoi-oidcofi have lieenob»en'ed in tbcM
cajWB. — B.J in sucli casea. any rtuddtn atrain, *iuch as violent vomiting
or retching, or the sudden relief of the intrn-ocnlar tenttiun by paraevi
tedis or iridectomy, may caofic a mpUirc of Home of the smaller cl
roidal vesiicls, and perhaps oonaidemble hemorrhage, it may kIso dcoi
e[i(ttii«ricoiwly, or after severe and protrai'ted cuerlion of the eye, lu it
enfxruvin;;. Bcwint^, pTOlon;^ed use of the niivrodcope. etc.
i'he blood may be effused between Ihe choroid and nclorotic, into thi
tiMue of the choroid, or between the latter and the retina. If Ihe he-J
morrhage ts but Bli;;ht, it will simply produce small circumtwribefl ecohy<^
roo<iO!i in the choroid, but if it is coujuderable in <|uantityi tt may oaii
dcuichment of the retina, or perforate the latter, and escape into thi
vilrc<tu» humor. This, as hata been already Htatvd Jn Ihe article upoi
heraorrhftgc into the vitreous hiimr»r, p. :i;iH, will chiefly depentl ufwti
the situBiJOD of the hemorrhage, for if the latter lakes place near ihi
ora Krrafa, it h more likely to perforate the retina (on neconnt of tbfl^
UiinDiMi of the latter at tliia point), and to escape into the vitreooa
buttior. VTherea.'*, if the extravmialion ncx-nri) near the posterior [tole o|
the eye, it t* mm-e apt to produce iletaohnicnt of the retinn. E«marvh'
I 1 very interesting ciis*' 'if extravaiintion of bbjod from ibm\
perroraiion of the retina in tliu re<rion of the yellow si
I' of the blood into the vitreous hua^or, where it gnulualh
' -'sorption, until nothing remained but n small dark sped
if a pin's head, tlie perforatjou in the retina liavinf^ healc
y irM*- \>i-\i'\:A it. tiometime^, however, the \t>yn
\ in»y rt'in;tiu recDjj;niiahle a-t a smiiU Uaok pi;
1 between (be sclerotic and choroid may pnxli
• "A. f. o., iv. 1, aw.
PSTACBWSNT OV OflOSOIP FROH SOLGROTrO- 5G1
With the opIithalmoscDpe, effusions of blood into the choroid may he
recognized liv their presenting the appearance of uuirorm, dark, ctierry-
ilored paichcfl, of varying sixc and shofie, boiuj: irre>;iilar. circiitar,
ral. etc. Their edjica may be sharply defined, or somcwiiat indistinct
atwl irre;rutiir. The uolur nf the Hpnplexy is imiroriiily rvd, and not
strintrd, nor arc its e<l;{es aermted or ** feathery," as i» the ease when
blood ia efhised into the inner layers of the retina, and follows the course
of the oplio nerve fibres. Again, the retinal vessels can be distinctly
»een to pa^ straight over the efl'usion, without bein^ interrupted or
hidden by it. If no retinal vessels should W situaied over, or in very
eluse pruximity to, the licmorrha^e, the situation of t)ic latter, upon a
plnne deeper llian tliat of the retina, '%» best rccogniKe'l by means of the
binocular i>|>htliKliuosoopo. If the diseuo has laitted Mime little time,
■ouio of the iicixhbori[if;extravajiationa have probably undcrj^ne partial
alworplinn. and given riiie to peculiar appearances in the choroid, which
will aid U9 in our di«;;nopi9 of the exact Hituiition of any special ecchy-
mosefl. iMiriny the pr<iLes* '>f Hhjtnrption, the ettu'^ion gradually sRSumt-H
n paler and more yellonish-whilo tint, and becomes rriu<;ed by a circlet
of pigment. The smaller ecchymoses may leave do trace behind them,
or only a small pi>;uient spot.
If the hemorrhafic is but alij*ht, and in situated at the periphery of the
fundus, it may prfkliico no ini|>nirnieht of virion, or only a smalt scotoma ;
but it is very diflert-nt when it is situated at or nirar the yellow spot, for
then it may very ^^roatly afi'oci the sight, and rentier the [natieuL unable
to reail even large type; a more or lees dense cloud or spot covering
tlie letters and rendering them indistinct.
The treatment must bo the same ns that which ia adopted for hypcr-
icniaof the choioid an<i reiian.und hemorrhagic eSuitioiu into the latter.
[ Knibolusof one of the ciliary artcrie;( or of one or more of the choroidal
vvfeeU ha^ been found in eyes, but there is 00 special ophtJiftluioscopic
ngo of its presence. — B.]
li— DETACIIMEiNT OF TIIK CHOKOID FROM THE
SCLKKOTIC.
A few casea of this very rare affection have been ile»cribod, more cs-
pQuially by Vou Uracfe and Liebreieh.' and a very beautiful illutttration
of this condition wilt be found in tlio lalter's Atlas.' Iwonofl' has also
given a wry careful dejtcripliou of the dissection of an eye affected with
deiHchmi^nt of tii« chnrfiid.
The r>phihaltn<i)tcopic symptoms of tliis disease are very marked and
characteristic. A more or less considerable globular proti-usion is oli-
»rved in the vitreous humor. lt« outline is sharply defined, its surface
le and smooth. an<l devoid of all wrinkleri or f[ddin;{s, and npoo it the
"retinal vessels can he distinctly traced as they paH.-! over it from the
normal fundus. .But the moat characteristic symptom of all, is the ap-
' "A-t 0.." iv. 3, 22lt ; Li«liMloh. ibid., v. 2, 239.
■ PI. TU. 1^. 4. » " A. f. 0.," xi. I, l»l.
91
£62
DISSA8ES OP TAB CHOROID.
pearance of the choroidal vessels tnd intra- vascular spaces Ijing c1om^
beneath the retina. At the angle where the nrotrueion springe I'mtn the
normfll funduB, the retinn is not unfrequenlly somewhat tleuiched, be-
coming still more no ai a later date. The color of ibo protrusion rarics
from » jiale yellowishgrav (int to a ilarl:«r red, atTonling as tlie fluid
caiisii);^ the dt-tachmpnt is f>f a serous or hemorrhagic nature. Tt« fiiir-
face is not unfrcqaently studded with small ecchj^mows. On account of
the protrusion being situated so far tn front of the focal length of the
e^e, it can be dtstinctlv seen in the erect imujse at some diiitancc fmi
the eye. afiordinp a faint rellow reflex in place of the bright red i;Iow of
the normnl fundus. The retinal ve^seU enn aUo l>c di:^tincllv obsened
to traverae it-t surface. It may bo espccittUy distinguished from simple
dotaclimcnt of tlic retina, by tlie fact that it docK not oscillate, tremhle.
or fall into stnal) wavy foldrt when the eyo ii4 moved in different direo>
tionft, but retains its tense, smooth, bladder-like appearance.
It may be difficult, or indeed t|nite imjiossible, to determine whether
the (letachmetit of the clioroid is due to a serous or hemorrliHK''^ effusion,
or to some morbid ;;rowth pressiuj; it forward. And only a^ the diaease^
progreascs shall we he able to decide this question with certainty, for
simple detachment of the choroid by fluid always ends in irido-vhorni-
ditifl, and sortenin^ and atrophy of tlie eyeball. Whcreaft, in intra-oeular
turonn, symptom-s of increased tension and i;l&ucomatou3 )iillammati(^n
generally «ui»ervene as the tlisease progresses.
[Ueiachment of the choroid liaH been known to follow cataract extrar*
tioD. (Archiv f. Augen- und Ohrenheilkunde, t. i. p. WJ.)
That part of the choroid next the ciliary body is most apt to Iw de-
tachcd, and here it is mo<it likely to be mistiilien for a sarcoma. Itut la
the latter the tension is Increased, while in detuchmeut of the choroid
Ibc tension is diminished.
The subject of treatment has not received any attention, probably on
account of the extreme rarity of the diKea^c. \\ hether the scleral punc-
ture or the method by drainage, o^ puntucd in detachment of the retina,
would prove of any use, can only be determined by trial. — B.J
Ch APTEB XII.
GLAUCOMA.
Wb liave now to tiim out attention to one of the moat impoTtant and
daogorous discifles of the vye, riz., glaucoma; a iii*ease whose timely
treatment by iridectomy wilt yield the mo^t fdvorabte rcjuli^. but vrhich,
if allowed to run its coarse unchecked, except perhaps by inefficient
nimi'dies, snomir or later dooms the eye to irrcraediahle blindness. Il
it4, therefore, of the utmost consequence that all Siirj^cons should he tlior*
oughly conversant with the different symjilora^ which it may preeent in
its vnrions form:*, so that they may be able at once to reco;;nixo tbia
dangerous and innidiouji affection, and to combat and subdue it before it
is too late.
Hie term glaucoma was applied hy Hippocrates to all opacities situ-
ated Itohimi the pupil. After a lime, it was confined to those which
presented a j^rcen njijicaranee, Oic nature of which was not, however,
understood, aUli^mgh the fact wa.4 recngnixed that »nch green opacities
were not curable hy o|ivration.' By s«mc, the wat of the aitoction was
<uppo»od to be in the vitreous humor, hy others in the retina and optic
nerve. At a liter period, it was thought that glancomn was due to a
peculiar inflauunation of the choroid, which occurred most fretjuenlly in
gouty per,*oiia, hence it was termed ** nrthritic ophthalmia," a name still
retained by some writers. Lawrence considered that the syrapioms of
glaucoma were cnmted hy an affection of the retina and choroid. Wcller
ft m«»t eiceUeiH an.! graphic description of the symptoms of glau-
includiTii^ in it many of the pnnciitnl and m<Ml iin|Hir[ant |iointa,
f. If., the intermitting course of the discftMO, the sluggujbnCM and dilata-
tion of the pujiil, the circnni orbital pain, the niinlwws round a caudle, etc.
He also made mention of the tcntieness of the eyeball, hut Mackenzie firat
pointed out (in isyit) the importance of the latter symptom.
In lM.51. ilelmhollz discovered the ophthalmoscope, which has proved
of snch inealculnhle value in dif*cnscs of the eve, and has so completely
revolutionized ophthulmulogy. The lirst rcKult« of the ofjlitlialiuoscopic
examination of casca of glaucoma were negative ; soon, however, it was
iiacertaineri that there always exist* a peculiar alteration in the optic
disk in all cases of well-marked glancntna. In IHoi, Kdward Jfi^er
gave an excellent illustration of the ophthalmoscoinc appearances of the
' F"r an fnti>rn«<in)t liifii>rrii-«1 rftum^ of KlaiicomJt, I wnold tfUr llip tyaAcr to Dr.
UaflUuino'* Hzoiill''Ui \\^yr on OUuMxns, " A. f. I).,*' x\\\. IL With ngiuA to IIih
lilt-rslurn nt iLis oiilijcct, I wniilil ilinM-t liia altontittn <w[in-tallr tn Von Un«fv'a
pnyvt*, "A. (. 0." Hi. 2; i*. 2; «iiL 2, aud xv. 3.
£64
OLACCOUA.
Optic nerre entrance in a case of glaucoma, allowing Uie peculiar ili^-
pincement of the vessels at the edge of the disk, the alight rim surround-
ing the latter, etc. It was, however, reserved for the great genius of
Von Gracfe ta unite these various and disjointed links of the chain of
Bjmptonia pr«denled hj gisuooina, and, weUing them into one counected
whole, not onlv found the modem doctrine of glaucoma, but, at the
same time, to bless liumanity with a cure for this liitliertfl irremediable
disease. Soon after 3&^ct» delineation of the ophtbalmoscopic appear-
ances of the optic disk. Von (jraeic described these peculiar appe&F-J
ances atill more aceurutelv. and at the same time [H>intcd out a most
important fact, viz., that an arterial pnlriailou exiutfi in the optic nerve
in (ilaucoma, being either spontan1-'o^_^, nr producible by a verj' slight
pressure upon the eyebail, a pressure far les« cliuii is necessary for ita
production in the normal eye. Within a short time aflensards, he aim]
discovered that the peculiar appearance of the optic disk, wiiich had
been supposed hy him and other observers to be caused by an arching
forward of the optic nerve entrance, was in reality doe to its being ex-
cavate^l or cupped, lie at ouce recogiiiise'l the connection of tlie^o two
symptoms (the excavalton and the sponiaucou^, or easily producible,
arterial pulsation) with the increased hardness of the globe, and his
clinical observations soon showed him that all the other symptoms were
also closely connected with this augmented tension. The next pniblem
WM. to solve bow this tension might be permanently dimintsbed. All
the usual remedies, such as mercurials, antiphlogi^tics, diuretic<>, diupho-
relics, liad proved as inaufficicnt in his hainls. as in those of other prac-
titioners. Mydriatics, which had been fonud to dimiuish intra-ooular
tension, were next had recourse to, but they also proved of no avail,
lie then tried tapping the anterior chamber, but this was only folIowe<l
by a ti'inpiirnry liviieRt, whiiiti soon {lassed away again, Tne di»Mse
gradu.^lly progrc-wd, nor coiihl the relapses be stayed by a methodical
repetition of the paracentesis, for he found that it^^ therapeutical effect
became each time less, anil Gniilly null, as far as the si^it was con-
cemed. In only two cases, out of a great number thus treated, did it
prove of lasting benefit.
Paracentesis having been of no avail in permanently reducing the in*
tra-ocular tension, be next had recourse to iridectomy, having found that
it proved of great benefit in ulcerations and intiliratious of the cornea, liy
diminishing the tension ; and that in cases of partial staphyloma of the
cornea, anil in staphyloma of the sclerotic, the protruding part often ns
ccdeil completely after this operation.
He firet tried iridectomy in glaucoma in 1856, and soon foun<l ihat it
not only pernuincntly diininislied the intra-oculnr tension, hut that it
might indeed be regarded as a true curative treatment of the glaucoma-
tous prucestff having, however, like every other therapeutic agent, its
natural limits. Since that time, irulectoniy has been rccogniEed by moat
of the eminent oculists in Europe as the only cure known, at present, for
glaucoma : but although it has achieved ino^l brilliant n^sults in the bauib*
of many of fmr most (iistingnishod Kti<|;Iirth oplilbalmic surgeons — among«t
whom 1 would more particularly instance .Nle^srs. Bowman and fritchett.
who bare from the commencement been ita alaunch and warm supporteiv
0LA0COMA.
565
— there are t«1 some Kn-flish ociilUu of re|nito whu eitlier condemn the
opemtion completelv, or ujilioM it in so luke^tarma mauner at) in rualitj
to " damn it with fnint praise."
Mjr" fwn wiilc exfwrienco of the beneficial ufFecta of iriilectomy in glau-
coma enables nie, not only to recotnmenH the operation most strongly,
bat oven to urge upon the profession to trust to no other remedies, as
they have nil prove<i insufficient, ami as we shouhl thus permit the most
raluablo time, when an iridectomy might still save the eye, to pas* irre-
vocahly awny. Wu shall see. hereafter, that an aecurate profrii'nis of
the Iteiiefiu to be e-Tpectcrl from iridectomy may he made iit the majority
of caited. »n<] it will be shown why the operation iniy have proved «n-
succeM^tj'iil iti the hands of some practitionore. Hut too freniiently im-
poitsiltilitics were expected of it ; it n-an tried, for the firnt and only time
[*erbaps, in chronic cases of glaucoma, which were beyond all help: it
proved, as might have been foretold, unsuccesisful, and waa then at otwe
di«cardfd as useless.
The commencement of the disease, the development of the different
symptoms, and the course which glaucoma may run, present numerouH
variatiouK. and for thisreaaon a precipe cla^siBeation is somewhat difficult.
Rut on closer obrtervaiinn, it will he found that llic aeveral varieties also
show a great ieu«1ency to pass over into each other. The family re»em-
blance of these different forms is verv marked, for thevaro distin^iuishod
from the eommencemetit by certain clmnicteristic symptoms, and although
they will vary somewhat i» their course, they all, but too surely, lead,
sooner or Inter, to that la^t ho|»less condition in which the eyeball is
stony hard, the pupil widely dilated and fixed, the refractive media
cloudetl, tlic optic disk cupped, and the Night eilhifr entirely, iir nearly
entirely, lost ; that condition, in short, to which our forefathers confined
the term glaucoma. The modern school of ophthalmology, however, no
longer limits the name glaucoma Ut this last hopeless condition, hut em-
braces in it all the varieties of the disease from their commencement,
which lead to this la^t stage. In regarding the different varieties of
glaucoma from a clinical point of view, we are particularly struck by the
fact, that one clajis of cases i-t distinguished from the commencement by
more or lean marked intlannnaeory symptoms ; whilst another appears to
be f^ee from inriammatinn. altliough in its coume inHammatory symptoms,
cvtn of an acut« kind, ot'teu make their appearance. We may, therefore,
divide cjwes of glaucoma into two princii>af classes: —
I. Ct%*e* atten«lt'd with inflammatory symptoms.
H. ('ases in which there are apparently/ no inflammatory symptoms
present.
Olaucoma may, moreover, exist as a primary disease, or may se«ond-
ily complicate a previously existing affection. We must, thereforo,
cognixe a primary and a secondary form.
We find that the different varieties of glaucoma show certain common
characteristics, and we may generally recognize the four following
stages : —
1. A prem-^nibory stage (glaucoma imminens, iDctpiens, of Von
tiraefeV
566
OLAOCDIIA.
2. A Bta^c in wliicli irliiucoina is fully developed (glftuconia evolu-
ttUtt, confiriUHliim, Voii (jraefe).
S. A Htagv ill wliicli (juaiitttative peroepUon of light lias )>««□ coni-
p1otx>lv lodt for snmp tiind (glaucoma alMolutum, cousuitiniatuui. Von
Onele).
4. A stage Id vhicb the tyc nndorgpes glbtMOtniktous degeneration
(VoD Gniefe).
Wo ilistiiigutsh two principal forms of in6»nimatory glaucoma, the
aciitu and the chronic.
I^ACfTE INFLAMMATORY GLAICOMA.
Prtmomtortf Statfe. — In the great mnjority of case« (75 p. c.) there
is a premonitory tilage, wtiioh 'm churactorized by the preMtwc of surersl
or all the following symploma, which are, however, of perioitir oocur-
ronce, there heing in the Interval a perftft inimnittitn. When thw
cvaaoft to be the uasc. when there are no longer perfect int^nnisi^iiHis,
but only remissions of the symptoms, we can no longer desi-piate it the
premonitory stage, but must regani it as conflnnod glaucoina.
1. Inrream^il Tentiim of tkf KtftltaU} — This is generally not very
considerable, and never reaches tlie highest dogreo. [It is remarkable
that viilli a very cun^idorahlt; ik-gree of increased tension, Uie vieiuu nv
mains iii>nnal. — B.] In lamilica in which glaucoma is herc<lit.iry, a
marked increase of tetuiou is vftcn met with, even in early life, although
the disease may not break out till a much later pcrioil, or oven not at
all. In such ca«e8 there van ba no objection to look upon this abnonnal
tension as a predisjiosing element of ghiucoma, more pailicnlarty if it be
accompanied by hy|ven»etPO]>ia. and a disproportionate diminution of the
range nf xccommodation. It bus been vupposed by some, tiiat the in-
crcuftotl ilcgree of It- iLsion alwayrt precedes, for it longer or shorter {Nrnod,
the other rtympUims of glaucoma ; Von Gracfe has, however, met with
aeveral marked exceptions to tliis rule. In some cases iu which be ope-
rated for glaucoma in the one eye, the other was found to be of a per-
fectly nDniial tension at the time of operation, but was soon after attacked
by glaucoma, in one case even by glauconia fulmiaaus. Hut nit increase
in the t«iL4ion of the eyeball should always excite our susfdcioits, and
ahould at once lead us to examine as to the presence of other syiDptom
of glaacouiA : if we Bud none, we should still watch the eye with cwv,
and warn the patient carefully to obscn'e whether any other sympbocM
twgin to show themselves, r. <;., rainbows roond a candle, rapidly in-
erouing prcshynpia, periodic dimnes? of vision, etc. Wc must be «pM
our guanl ag:tiiiat thf )>iu t<»:> rre<)ueui error, Uiat a senw of fttlDeas or
teitsion witliin the eye ex|rerienced hy the patient, ts onj proof of the
itM'n>Hm^ hariliK-ss in llie eyeball. For this feeling nf fulness ony cxbt
without the slightest iucrv&so of tension. Another fre<{uent error U, to
■ Tba aMlluiil ot Uiwrlaining and soliag tlie Aegtve Dt inln-ocalar toBiU« I* fmOj
axplatB*4 In tht [ntradoetlos, p. 36.
ACDTB INFLAUMATORV OLAHCOUA.
567
I
I
I
suppose that all acute inflammations of tbe eye are avcoropanied by an
incrvsuite in the intra-oculHr pressure. A careful exarniiuitioii of ordinary
cases of acute inflamniatioD of the conjunctiva, cornea, iris, etc., will at
once prove the fallacy of ibU opinion, for tlic tension will be found normal.
If tlie tle;;rt'e of tc-iisiun U incrca.'ted. we miut raiipinl it an a d»ii};eroud
compHcAtimi, which is to he carefully walciied, Icdt it be the precursor
of other glaucomatous Hrmptoma.
2. fiajmi Ini'reitge of anif jire'exi$tinff Pre»htfojna. — [A better ex-
prcwion ig *' rece«sion of tlic rcar-poini" and diminution of tlie ran<;o of
accoramodation : or the refraction may be diminished; the latter is not a
common anomaly, and Uaqueur even denies it. Ilelmliolu explains it by
the eyeball having become more nearly » sphere under the intlueoce of
Uic incruatici] iiitra-ocular tension, and this has been pro^'cu by measure-
mentd of the corneal radius. — B.] Kt. the |»erAonx attacked by ;;laueon)a
•re mostly beyond 4i> or 50 years of a;?e, some degree of presbyopia i«
jtenerally ulreajly present, but it i.-< found that tbin often increases in a
very rapid and marked manner duriii<j; tbe premonitory 8tA^e of glaucoma ;
so that the patient may be oli|i<:ed, in the course of a few montlts, fre-
(picmly to change his reading ^tlasses fur stronger and stronger ones,
'i'bii* i-apid increase in the presbyopia appears to be Dot so much due to a
flattening of the coniea through an increase in ihe intra-ocular u-usion,
w to the action of this presiture upon tbe nerves supplying the ciliary
muscle, thus cauKtn*: [laralysisof the latter. I laBiuanu has called par-
ticular attention to tlie fact that hypermetropia very fret)nently occurs
together with glaucoma. It appears probable that hypermetropic eyes
are more prone to ;;laucoma than others ; but hypermutropia may also bo
devcloj«ed in the course of iiic disease. The cauic of this ii, however,
•till i|nite uncertain, it is probably to bo sought for in some chanses in the
crysdlline Ittns (rapidly progrcsdivo senile involution), by which the re-
fractive power of the latter is c<»raiderably diminished,
11. Vrmnnn J/ifprriPmia. — The eongeiition of tlic ciliary vciiLi is ;:enc-
rally slijLjht during the premoikilory sla)(e, and they nt^vcr present that
[>eculiar tortuoui, dilated appeanince, so eharacteri;»tic of chronic i^lau-
coiua. Generally, only a few scattered, dilated veins are seen ninuin»
over the sclerotic. On examination with the ophthalmoscope, tbe retinal
veins arc also found lo be dilau-d and tortuous, there may be Hkeuiso
spODtaucous venous pulsation, or this may be produced by slight pressure
upon the ercball. [it sliuuld not be forgotten that spontaneous venous
pulsation also occurs in j»crfectJy normal eyes. The tiarrowing of the
vein* begins at tlie poruH opticus and the dilatation follows from tbo
puriphury towanls the centre, immediately sucoeedini;; the radial pulse.
4. ArUriaf J'uttuiti-in. — This is first seen on the liisk, and is always
pathological. It can be produced in tbe normal eye by (irm pressure
witii the Knger, and can be incroutied in the gUucomatous eye in tbo
same way. The arterial branches on the disk, one or all, contract oim]
dilate, but tlie pulsation is not notJced iteyomi tlio tnargin of the disk.
Thisspontancouspulsaiionirt of j»reat diagnostic importotico. Von Graofe
saw it twice in orbital tumors, and once in desoendiug neuritis, in neither
of which cases was there any glaucoma. — ii.]
sas
aLAtJOOMA.
a. Ctou<ii»et» of tie Aourout) and Vitrfong ffumrtrn. — The aqv
liumor IK oftoti foiiiid alislilly buluuiforinl_y Iia8_v, reuJerifig; Uie structure
of the iri:i somewhat imlistitict, aiirt causing a iili;;ht chan<;o in iia color.
']*he vitreous humor aho becomos a little cloudetl, but uniforoilj so, for^
on O) ill thai tnoacci [lie exaiiiliiation, wu dn not llml d&rk m&saee BiNitin);
about in the viirt-oiis humor, but onlv a difFuMd chmdine-M, which rendem
tlitf titftailii of the fiinilu!« murt; or Ivas indidtiiict. Tliii* haxinviM of tlie
humor) in very vanatilo in its dogree ami dunttion : wtnit'iinies it is ho
slight AS to be hardljr perceptible, at others it ii* so cnnsidprable aa to
prevent nay ophthalmoscopic exsminaiioD. In the majonty of cases,
however, it is but niodcmtc in the premonitory gt.-i;*e. It may come oaj
sercrsl tiioes n day, 1nitin<£ but for a few minutes at tt time, or it oar
be IcDS fre<|Uout, or of Ioniser duration. [The cause of the cloudiness tt<
an csiniation, which ia cither inflnminatory in its character or the con-j
setjuence of venous stasis. In '^ome cases the cornea is aUo difTu»c1;
cloudy in it4 parenchyma. OhIi<]ue illuniinatinn will aUn in some case
reuder visible a punctate, gray precipitate upon the membrane of Do!^1
cemet — -B.]
Ck lUtatation and Slui/(fithneia nf the Pupil. — On comparing the
pupil of tlie eye affected with premonitory M-mptome of glaucoma, with
that of the other (aupjiosin" this to be healthy), the former will be foai ~
somewhat dilated and slujigish, reacting but sli<;htJy on the stimnln
of ti^lit. The ilil»tation i» never so considerable as iu the advancei:
stages of glaucoma, when we often fiitil the pupil widely <li)ated and
t|uite immovable: its sluggi^liness is. however, generally well marked.'
[This condition of the pupil is pmh»lily not due to diminution of func*
tion iu the retina, but to an iridoplegia caiwcd by paralyrtis of the ciliary,
nerves stoi'ig to ilie iris, the direct result of the increased tension. — Ti.']
1. Ptnodiir I>imfut» of >Sii/ht.—The patient is troubled by ocl-j
sional intermittent dimness of sight. At such times, surrounilutg o\
jectA appear veiled nud indiiitinct, as if they were slirou>led in a grfty|
fog or smoko. The degree of dimnea* varies considerably, as doca also]
Uie duration of these attacks ; sometimes they may last for several houra^
at otiierd, only for a few minutes. At sucli a time, there may oulj
cxint A slight contmcrion of the field of vision ; generally, however, thcr
is oTily indistinctness of eccentric impressions in certain directions.'
Although thejip ohscurations may be duf to traiL-titory chnnlinesA of the
■i|ueoMS tLiid vitreous humors, they are goncrally eaufted hy di^tiirbancei
in the clruidation of the eye. The character of these obscurations maji
he imitated by pressure upon the healthy eye, and iMmlers has found
that the dimne^ of vision shows itself as soon as retinal arterial pul
lion is produced by this pressure upon the eyeball. 1 have expeii!
uiviitetl a good deal upon this point, an<l have arrived at the sai
rosulw. I have also fuuud, by experiments upon myself, that by regt
Uting the amount of pressure, I have been able to produce any kind
obsuuration, from the slightest, in wliich only the objects lying (|uite at
Xhv periphery of the field of vision appeared somewhat clouded, to that
e^ceystve dimness in which the light of a hri<!;ht lamp was rendered •|utt~'
uutt|tparviit. 'fhc increased intra-ocular pressure, acting directly upof
the rttina* does not, therefore, appear to be so much the cause of the
ACUTB IJtFLAHMATORT QLADOOMA.
5t>9
nliecanitiom ; but we must seek for it rather in the iiit}>aini]e[]i of the cir-
eulation, the sta^ntion and fulness of the veins, am), perliapn, the nropty-
iog of the artericB (ischaeiuia retinse). The increased prt'jwur© produces
the ehaiiges in Ujc cirLMilation. and the latter CRUse the obscunitions.
The truth of this as-seriinn is aUo proved by the fact that these atucks
of dituues^ are >:r>iier»11v i>n)u;^ht on liy aiij^thiiii; that caimes con<;cstion
of the bloodveasieU of the eye — lor instance, a full meal, great excite-
ment, lung-continued stoopiuft, violent exercise, etc.
8. The ajii'airitH^e •!/ a Hat/) nr litiinbuw rmimi a faaiW^.^Thia is
also a very constant aymptoni of the premonitory Rtage. On lookini^ at
a candle, tlie patient sees a colorcrl halo, or ntinljow, round the light.
The outer side of the ring is red. the iimer bluish-frreeii. This has heen
fupposed by aome to be a mere physical phenomenon, due to a Hiffrac-
tjoii (interference) of the rayft nf light, owing to some change in th«
refractive media, especially the periplier*! p-irlion of the lens.
It is seen when the pupil '\» dilated, hut di.-fappCHrs wheu the nattent
is directed to look through a ^mall opening. It may, however, ne also
due to congestion of the vesaeU, for I have seen it sometimes brought on
by stooping.
9. Ciliary yeurali/tn, i.e., pntna. more or leas iicute, in the forehea/l
and temples and passing down the side uf the no^u, occur occasionally at
an early period, hut sometime only at a latnr |mrt of the premonitory
stage, at the name time with tlie intermittent obscurations. In aome
instances they are, however, iiuite absent. [The siidden increase of
tension will in some caiea explain this neuralgia by pressure upon the
ciliary nerves in the sclera. When the neuralgia involve* several
Hranchca of nerves, we mmt aasume aomo irritation of the trigeminus. —
B.l
ID. The fii'fd iij virion is iiecasjonally flomewhat contracted: gene-
rally, however, there is only some imiistinctneas of eccentric improaaiona
in eeriaiu directions, more particulurly if the illumiuatiou is but mode-
rate. In glauconm, the cimtraction of tJie fiehl, a*t a ride, commences at
the inner (tia*al ) side, and extends thonce towardn the centre, as well as
above and below, until, at a lat<*r »tage of the tliseuse perhaps, only a
small slit-ahiippd held ia left at the outer side.
The intensity of these symptom* varies with the severity of the attack.
Tlipy may be ro filigbt iia to escape all observation, or they may be very
inarke<l if the attack i« aevere, and then there are often aildpd to the
symptoms almve enumerated diminution in the size of the anterior cham-
ber, arttfrial pulttatinn, and indistinctness of eccentric vision. The lntt«r
svniptom may be aWnt if the illumination is very bright, but becomes
evident if it be moderated.
At the cnmtnencement, ihef*e premonitory rtymptoma only show them-
selves at long intervals, of perhaps several month.s, hut gradually they
become more freipiont. At first, months may elapue between each at-
tack, then weeks, then days, and when they occur at intervals of a few
day?, the second stage, the glaucoma evolutura, may be expected, although
this mav even r«cur when a long interval exists. This stage may al(*o
be suspected as cIohc at hand, if the premonitory symptoms do not dis-
appear af^r sleeji, even of short duration (dracfe). If the periodic
570
OLAUCOMA.
atUcks no longer leave behind tbcm a nunual pupil, and a norni»l ftCiittf-
UC8S of viHinii. Ktill nioru, if tliB optic nnrvo is already cupped, we miut
no lonj^cr dciti^nfttt- it as tlio preiunititorv stage, [>ut a« a cMe of glao*
coma evoliitura, with perioiliu increase of the symptoms.
The premonitory atige may la^t for an indefinite perio<l ; years may
even elapse before it leads to confirmed jflaucoma ; but in Uie majority
of cases it does not extend beyond a few months, or it may poas orer
into glaucoma even after tlie second nr third attack, there boin;; only
rcmisdioiia. and not clear and wellHlt^fincd intervals between the attacks.
SomctinicH, as han been nicntione<l nborc, the premonitory symptoms &rs
BO tlij^ht a« >]uite to escape the notice of the patient, particularly if tba
other eye is still perfectly healthy. It is different, however, when oo«
eye has already been lost by •:l«ucoma, for then tiie patient's nltcntion
and anxiety are at once aroused by any of the premonitory symptoms,
and he early consults bis medical attenduDt, fearful le^l be should alsQ
lose the sight of the second eye.
In the great majority of cases, as already slated, acute inflamuMoi
glaucoma is precede!! by a more ur less marked premonitory stable of"
varyioi!; duration. The intervals between the premonitory attacks be- '
coinc Vss and less frequent, until the Utter recur [lerhaps every two or'
three days, or even every day. The patient is then suddenly seiied,
fretjuently at m;;ht time and after having passed perhaps aevoral slcepleaa
nights, by a severe, often excruciating, pain in and around the ere, which
extends M the forehead, temple^ and down the corres|Hindiiig &u\t; of the'
nose. Hi far as the extremity of the bone. Sometimes this luiiu rvacb«»1
also to the curres ponding half of the lieud, ami even to the occiput, whichjJ
causes it often to be mistaken foran aiiack of rheumatism. At tlic sane 1
time there may be considerable constitutional disturbance, febrile excite-'
ment, and severe nau^a and vomiting, and these symptoms may be of*
auch prominence that the fAtient is ituppowd to be frnfTering from a so*
vere bilious attack, and the affection of the eye is either overloi>kud, or
is thought to be dcpenilent upon tiiis. But the eye shows marked symp>
toniB of acute internal intlamination. The evelids may be nmcb swollen,
red and pufly. The conjunctival and suliconiunctival vessels arc injected,
the veins in particular being dilated and gorged. There may also be
very considerable serous chemosis, which completely hides the deeper'
fluhconjunctirni v.i,wnlimly nntl the rony zone round the cornea. There
are alH> much pliotophobia and Ischrymation, hut lliey are accompatiicd!
hy very little mucous disctiargc, an 1 this chiefly of a thin frotliy cbar<j
tcter. The cornea is clouded on its posterior surface, being iierhapej
atudd'>d with minute opacities, deposited from the a<{ueotis humor, f Phcrt'
may be loss of epithelium of its anterior surface and cirouniBcriheil <ipaci-
tics. — n.] The sensibility of the comon may bo also somowhat dimiiw
isheil, but this aniestbesia never attains the si\me degree as in cUn»aia-j
glaucoma, where it is of^en so great, that the cornea may be tonched or
even rubbed with a roll of paper or the brush of a (|uiU pen, without ila
being felt. Occasionally, tbo ansesthosia is only partial, lieiug confined,
t4i a certain jtortion of the cornea. This loss or diminution in Oie senH*'
biliiy is due to the couiprcssiou of the nen'cs supplying the conm by
ACUTE INFLAMMATORY OLAtCOMA.
671
the iTtcrD>Ai>(lintrH<oct)Urtcnftion. aa is provfid in cnMfl of Aoutc;:1iiucorofti
where tlie ftoniiibilit^' at once returns after diinumtion of the tiMiaiun hy
iriilectomy or paractfntesia. The sensibility of llie cornea ia best. Hasted
by touching it delicately with a finely-roUm apill of sillc paper, care Wing
tnken to keep the eyelids well apart, so thnt the coiijiinctiia is not touched.
In healthy eyen, the cornea ia so cx({Utflitely sensitiix that tlie sligbleat
cnueli of a foreipi body will Ite fell and resented.
The anterior chnmher ia t'unnd to be iwniewhat more shallow, the fleiu
an<t] iris being pressed fonrard. and even, perhaps, in contact with the
cornea, the a<|ueou8 humor is clouded, the iris fiomewbat discolurcil and
of a dirty hue — in aorne cases there may even be acul4> iritis, with do-
[>o«ils of lyin|>h at the ed<;o of tlic pupil — the pupil is dilated and slug-
psh, am) in cidertv people a peculiar ^reeo retlex ia often seen, coming
appfirently from the buck of the eye,
ItbasatreAdv Wen siateil that this;;roen reflex was formerly considered
&9 the princi|>al aa<l patKoicnomonic aymptom of f^laucoma. It U due t«
the loilowing cause : ITie lens iinderjioes certain physiolou'ical channeB
afti;r the ajje of forty, amons:*! <tthers assuuiin;^ a yellowish tint. Nnw,
if tlie eye of an ehlerly person (and they are the most prone Ui tlic ili*-
ea«e) is attacked hy glaucoma, the a(|ueous humor becomea turbid and of
a dirty, bluish-gray color, and thU blnish-^ny tint, mixing with the yel-
low of the lens, gives ri^O to this peculiar green reflex. The latter i* the
more miirked on aircnuut of the dilatation of the pupil which exists in
c;taucoma. a* more light is tbns reflected from the lens, more pftrrienl.irly
its periphery, tlian when the pupil is of the normal size. Tin- jjniyish
haxiiK-ss of the vitreous humor, moreover, also tends to increase the inten*
siLy of the reflect«d li^ht. Two facts prove that this is the true explanb'
tion of this green reBex. 1st. If the anterior chamber is tflp|>ed, and
the ft<|iieons humor flows off. the green rellex at once disapjiears; *2d. If
a youthful eye is attacked by glaucoma, this reflex is not viaibto, for at
this period of life tlie lens has not yet ac(|uired a yellow tint, and in
fluch a case the pupil looks, therefore, only of a dirty, bluish-gray color.
The eyeball will W found abnormally hanl. The refractive media ara
generally tto clouded at to render an ophthalmoscopic examination impos.
aible. If tbey are. however, sudiciently clear to permit of the details of
[Jfcfi fundus being seen, we find the retinal veins dilated, tortuous, and
ptrbaj^Ms pnUating; the optic diak may be slightly reddened or of a dirty-
yellow appearance, and there is either spontaneous arterial pulsation, or
this may he readily produced by slight pressure on the eyeball. In the
6rsl attjick of acute glaucoraii. no cupping of the optic ner^'e is fnund,
for thiA oidy occurs when the incn'a.'^ed tension has laated for <(iune time.
After iridectomy we gcnemlly tind more or lefis extensive lu-morrhagic
tfl^isions into the relimi andch<»ruiJ. It was furtULTly supposKd tliat they
often exist prior to the o|MTUtinn. but. according to tiraefe, this is not
the case, except the glaucoma is secondary to some bemorrbagic affcctioa
of the retina {f. g., retinitis apoplectica).
Vision may W either greatly imjAired, so that the patient is only able
to diiitinguish letters of the ljirg«.;.st ty]* or to count fingers, or it may he
lost completely and suddenly, as at one stroke, being diminished to a
mere quantitative perception of light, i. e., to a mere distinutJoD between
h-2
ULAUCOMA.
tight and dark, not an appreciation of colors and olijects. In sonio ver^
serere caaea even t1ii3 i^ tost. Tlie field of virion ii generally somewhat
contracted, often concenlricallv. Tlie patient is in moot ciu«9 alia
iroulded with subjective appearances of light, balls of hre, showers of
bright star?, etc.
The iiiif^iHirmeiil of Ki>;lit ifi eviiteiitly not so much duo to direct eOB-
pression ol' tlie ncrve.filire« of the n^tinft hy the incrvnscd tension, aa to
the impediiut'nt of the arterial blood supply (^ist'Iiicniia retime) which id
produced by the latter. Moreover. Von Uraeff* thinks il pnjtiable that
wlien the im|tainnent of vision ia very yreat, a^ in cases of acute intlam-
matory glaucoma, in which of course there ia no excavation of the optic
nerve, the tia^ue of the retina ix niao -ipcclnlly affected. This supposi-
tion ia, moreover, aupported by tlie fact thai retinal liemorrha;;C9 art- of
cormtant tn;currence after the iridectomy, if there liaH been, to;!i'Llier with
considerable increnrie of tension, marked clomlincna of the refracting
media. Von (irnefe formerly explained the occurrence of these ecchy-
mnites as being due to the aiidilen diminution of the morbidly increased
tension ; but tbi!* explanation, as he now [loiuU^ out, appears to be iimuf-
(ieient, more eapecially when we remember tliat in caaes of glnucomft
simplex the:ie retinal lii^morrbagex do xwl occur after iridectitmy, even
hitbough the tension bud been greatly iiicreatied. Hence he tliinks it
probable tliat the iiiu^rniptud, and therefore defective, supply of arterial
blood (which ia evidenced by the fl]K)ntanQou<i arterial pul^tation which
is but seldom ahiient during tlie gbiucomatnua att.ack). the im|N>diment
of tlie vctiouH circulation, and, finally, the inundation of the retinal ti»-
sue by the floida effused from the uveal tract, lead to a atate of fran-
gibiliry (softening) of the retinal tissue, which favors the occurrence
of these hemorrhages.
The inflammatory symptoms may gradually autieido, but the blindness
continue : tlii« is, however, very excoptinniil. In most cases, the intlam-
matnry attack pauses off after a few ilays or week?, having. perliap»«,
undurgfMieiliiring this time Heveral remifuiion!?, and vision may be entirely
restored.* Such a b'mporary recovery may occur spontaneously, or after
the use of antiphlogistics, mercury, opium, lecehes, etc. Itut the cy«
does not return to its nornml cottdition ; the anterior chamber toostly re-
mains somewhat sballow, the iris dincoloreil, the pupil dilated ami altig-
gisli, itie lielil of vi«iori somewbui contracted, and the tension of ilie eye-
ball more or lesa augmented. But the disease ia not arrested. The
acute ititlammalory attacks may recur again and again, leaving the vision
each time in a worito condition, ami the visual field more contracted^
until the sight is finally completely destroyed. In other ca.scs, no fur-
ther acute inflammatory attacks occur, but chronic inflammatory exacer-
' " A.f. O.." XT. a, 109 : tHo alBo Ryiiel. ib., xrili. 1. 1.
' Mr. Fridgin Toalr- li»» inrorinrvl mi' of tlio inli.-raiiltn'; fsct Ihal Jnrr»ii<>>-il elatiMV.
maloiu letuion may Ikti'IIi-vM liy nii>r|>Uia, Hi' waa oallMlo ai>aticnt !<utri-ri)t|: trnn
aetile Klftucoina •:>( a tvw hotirh' riiiralion. »n't Inrint; itnablo to iiidrvtomiit.' tut tonve
lioiiiD la<<>r. III.' luJ«ct«Hl o!)<^-oi);btli of a K'*'!! ■■' iDorphla rni'lcr 111* Bk)n In i<r<l<>f lo
rflii-v« tlie ]>alti. [n half nil liuur ihe jiniii had jcotii*. Iho <litnnrasor aicht altnual
ninittitilitif; to liliiiJtii'Ait had di3ap[>L-iT<-d, and nu lils wn-iiif; iIil' imtiriil fnur houn
Rn<Tii,'ar<l«, IIh' IfUfiU-n i+1i) hail iMri-ndH- noruial. Hu «t uncvdvferrH the >fiM>fa(li>n
unit) glauooina tu|wrr<<iii!d a rortnigUt later.
ACDTB INFLAMMATORY QLAUOOHA.
57S
iMtioits l&ke place. Or the disease niav pro^Tcm iti^idioiDily, without
ftTtj apiMtrcnl recurroncu of the inflmiiinamry 8ym|itomd. Trie eyeball
btxoiuoA more ajid more tense, tlic field of vi«ion more contracted, often
to a slit i$h&pe, the sijat ^radimlly Inst, the tixatiou perhupd eccentric,'
the comea ntn;;heiied and stijc^tlu'lic, the atiteriop ehainhfir very tmiill,
the ptipil ];;reatly (lii»te<l and fi^ced, the iris disco1oi-ed, atrophied, and
shrivelled up to a nnrrow rim, the siibeunjnnL'lival vein^ turbid and tor*
tuouit, fonninj; loops round the cornen. If tlie refractive media are siif-
ficiently clear to [>ermit of an ophtliahuoitcopic examination, we then find
that there i.-* a projircMivc excAvniion of the optic nerve, thai the retinal
vein!) are dilated and tortuoiix, and that there iii either a spontaneous or
cauly pDdiicihIe arti-rial puUation. We not mifreijuenlly hud, even after
the diseaiie haft ihiu inttiilio^iflly run \t,R cnur-io wittiimt any intlammatory
exaueriiation since the first acute attack, that at a later Ptajie these intlain-
matory attacks, ei-en of a very ncnte kind, may a;ntin occur. When the
disease ha^ ruu its course, and all. even tfuantilative, perception of It^ht
u lofit. Von firaefe cjillii it " jjhuicomn eiHwiinnuntum," or '• ahaolutiim."
Sometime* we meet with a fuhitfutf form ot" jjlaucoma, in which all the
taflamauitory pyinptoiiiii are much dtiuinisLed in intensity ; the [lain is
abo lesa, nor is Uic aifiht so miieh impaire<l us in the acute ea»CA.
The very dan<;eron.'t disease which ha» often been termed " liemor*
rlia;ne •:laueoma" is really a secondary ^laiicoiua Hnpervt'nin>; on rtoiitc of
the ht niorrha;;ic affections of the retina, especially retinitis a[K»plecti«i,
and will therefore be described in the section on S-'Condary i.Jlaiicorna.
\' ou (rraeft* lia.<i called attenlinn to a class uf cases in wliich the course
of acute glaucoma nf taoft rapii], 90 that the si^fht, even all •{uantitative
rceplton of light, of a previously perfect healthy eye, may ho entirely
It within a few honm. or rveu within half an hour, of the outbreak of
tbe disease, lie ha'« termed this t]l(iu'roma t'ulmhians. It is, however,
a very rare form indeed, in comparirioi) with the common acute gluu-
(»ma.
He has found that cases of glaucoma fulminans are also oeoBsionally
distinguished by a very rapid development of the other symptoms of in.
creas^^il intraotMilar pressure ; vix., iulen-te ciliary neuralgia, rapid dil:»-
tatiou of the [lupil. t^non reachin<{ it^ maxiniuin extent, rapid dimiimtidii
the tixe of the nntcrinr chaniber, an^-^tliesin of the eonu-a, and stony
iiirdneaH of the eyehall. Sometimes, however, these symptoms are nut
lOre pronounced than in the common form of acute j^laucoina, and yet
c siy;ht may be completely destroyed within an hour or two. The
phctwmena of vascular excitement may appear simultaneously with the
loss of sight, but they occasionallr lag behind in a peculiar maimer.
'On ujicro5Co|)ic examination, the a<|ueuus and vitreous will he found to
iho diffusely clouded, hut if they are sufficiiMilly clear to permit the de-
twls of the fundus to he seen, a considerable overfulness of the retinal
' Bj-the lijrm" central lli(a1ton"lB meant, that a lint'(irawBfroiniIi"obj(?ctlhr<i«gli
Ihn rrnlttt i)( (lie ci>rrita of tlio iilj^crvi't wnulil sTrib*- lii« vr!i<"'w spul ; hi» visual liiin
bring III f:ii-l Qxrvl iijxfti ttii- i>l)Ji.<«t. Koivutrii.' flxJtlii'iii, th(-rvri>r>', lufxno tli»t kiuiw
pvrtmu tliaa tbt- ^t^llnw Hpol te dlreutifd to tli«! obj^i, bariug rataiovd nprw
itnliUlt/ tlian thv luAcula lut«a.
A. r.O.,"rlH. 2.
674
(ILAUCOXA.
veins will be observed. Diminution iu the sixe of the arteries sml «x-
cavntinii of tho optic nerve afipoar, cotuiMirntivcly, very rapidly. Vol
(Jraefe iiaa id one caiio noticed tbe latter in a very deep form, evi
within a few weeks ufter the outbreak of the di5ea«e. lie thiuka ni
nnist aKsume that, in this fonn, the increase in the tension ta either mot
considernMo or more sudden than in the ordinary cases. On account of
tho t^rent stagnation in the renous circiiiation of the eye iu theac c&mi,
iridectomy is often followed by extensive heiuorritage into the retiua
choroid.
a^CHHONIC IXKLAMMAroUY GLALCO.UA.
This disease may be insidiously do%'eIopcd from the premonitory
The premonitory symptoms beeonie more rretjueiit, and continue tor fti
longer period ; the intcrraiititionit are of less duniuon, untJl there are no
lun}!er any lUiitinet intennisKJons, but only retDtsaions, and the diseaie
grailually and almost iinprrcoi)tibly paMSea over into chronic glatiooma ;
the eye ji.4:«umin^ the same condition aj it did in the acute form, after]
the eouclnsion of t)ie intlammalory proces:^. It beeomeii more atid mortl
tense, until it mjiy at lattt .isdiime a Btony hardneiw (-fT. 8), so that it can-l
not he dimpled by even a tirra pressure of our fiuger. The subconjuMi-r
tivnl veins become dilated and tortuous. Che sclerotic assuming iu the tat* I
stages of the disease a peculiar waxy hue, which is due to atrophy of I
Uie Buhcoiijiinutival tissue, and to a diminution iu the calibre of Uie aul
conjniwtivHl arteries. The cornea Kradimlly lo:*es its sensibility morol
and more, rre<)uently, however, only in certain portions. It also be-1
comeii flatter. The anterior chamber becuincfl shallow, the Bf|ueoi
humor clouded, and this turbidity may chanj^e witli great rapidity, oc
onrring, perhaps, several times a day. It mar be produced by any si-.l
citemenl or fatigue, often cumingon after a fnll meal, excessive exercine,
etc. The iris is pushed forwanl, wt as to be perhaps almost in contact
with the cornea. U iH <lull and discolored, its fibrilla; being tnore or lesa^
obliterated, aikd not .showing a clear and distinct outline. The pupil isj
widely ililated. and either immovable or extremely slugi^sh to tfaeattnia-|
hi!i of ligiit. The field of vision becomes greatly contracted, a--
pi'flKifti^, a slit ii)m|>e. As has been before pointed out, the coi
of the tii'td in glaucoma be;^in!4. ni^ n rule, at the inner side, exti'nding
from tlir'iii.-e upwards and downward^!, so that the outer portion is th<?
hiAl (o become affected. Vision progressively deteriorates, tbe Htatianj
ofltrn becomes eccentric, and finally tJie sight may be complrtcly de>
atniycil, so that not even a remnant of i(Uanutative perception of light is I
I, even ultlumgh the light hn inten^iiivd by means of a powerful bicon.'
tx letLt. (In ophthalmoscopic examination, we find that the fnndttt
nlaays ftppi-ar^ more or less clouded, often to such an txlent a^ to pre-
»nt our didiinguishing the details of the background of the eye. Thiaj
^ncu is due to opacity of the a<|ueous and vitreous huinora, ami \a\
w cases also of tbe cornea and lens. But if the media remain fuffi.
tly -'Ivar to permit of an examination, we find tlte retiiul veiiu widely
I tortuuua, the arteries dimioishcd in calihre, and pr«seutiug
CHROHIO INPLAUUATORY QLAIIOOUA.
675
I
either a spontaneous or easily producible puliation ; the optic nerve mora
or lestt deeply capped, and (he veMcta displaced at ita peripherj. The
chief and cbaracteriatic difference between the ooiitc and the chronic in-
flummatitrv gluiicomn i», that the latter may lead to even complete de>
Structiod of iii;;lit, without iiiiy nyniptonin of severe tiiflaiuiniition or ^reaC
pain. There may only he instdioin utlaclta of chronic, freijUKnlly recur-
ring iiillainiimtioii, leading graduallv to l«>»^ of sight'. At firjt these in-
flammatory attacks may he intermittent, occurring at considerable iliter-
vftU, wherea.1 lat«^r they may only show remiHsiong. In other eases
a)^in, nfU-r the eye has been suflferin;; for some time rrom thette insidtotia
cliniiiic indammatiiins, it may be smhlenly attacked by a tiierere acute
cxncrrhation, causing very great pain and anflering. These acute ex-
aoerbatioas may recur again and ajiain^ and the pain may he so severe
that recourse must be had to an iridectomy for its relief, even although
there is no chai»ce of restoring utiy sight. In such instances, tlie patient
and \m fricndi^ must he warned l»erorehani] that ttie o|K!ration h tint per-
fortoed for the sake ol" privinj; any Hijjht. hut only in order, if [Kwsihlo, to
relieve the pain. In nuiny fiiM'S. particularly if the iridectomy be made
aufficiently large, the relief may he permanent : in others, it is only
temporary. When speaking of acute glaucoma, it wns mentioned that
alter the first acute attack, the di^caete might gradually pass over into
chronic inflammatory glaucoma, riofre.-th acute attack occurring, but only
chronic, latent, inHannnatory exacerlKitioiis.
When the iliseBsc has run its course, and all sight is lost, VontJraefo
terms it "glaucoma abaolutum." Then any chance of benefiting the
eight by an operation ia past. [Bluisli-retf vessela run over tlie den^e
wltitr scl^^ra, the limbns a^^nmes a hinish tint, the cornea becomes
clondy in spots, and if the lens is transparent the optic disk is seen to be
dense white. — H.] The tens frequently becomes opntpie, assuming the
peculiar greenish hue so characteristic of glaucomatous cataract. The
glaucoma absolutum may exist for a length of time without the eye
undergoing any changes, except that atrophy of the iris, choroid, and
optic nerve hecomc more and more apparent. In other cases, fretpient—
often very acute ami violent — inKammatory s;, mptomn show ihcmselveSt
accompanied hy intonite ciliary neuralgia and headache. In the last
stagei* of the disease other changes occur ; the iris becomes reduced to a
narrow streak, the cornea opa<(ue and sofienod, more particularly in ita
central portion, and hemorrhagic efTusiona take place into the anterior
ebambor, the vitreous humor, and the inner tissues of the eyeball. Sc\e-
rotic fltaphylomnia are formed, and suppurative intlammntion may even
occur, leading to atn^phy of the globe. Von Graefe calls this the stage
^of glaucdmaliaw ilegeneraiion. In it, iridectomy no longer proves a
^^Bprc remedy for the inflammatory complications. GcncmUy the sight
^^^w completely lost. Sometimes tiie one eye may be lost from chronic in-
W flammatnry glaucoma, or from the apparently non.inflammalnry form
I (glaucoma simplex), and the other be attacked by acute glaucoma.
570
aLAOCOMA.
3.— GLAUCOMA SIMPLEX (DONDKRS).'
This disease wfts for a long time considered a* Jiatinctivc from ploii-
coma. witli which it uas BU)t|Ki<e(l to ii&vv iiotliln^ in common but tlie
excavation of the optic iicrve, and was originally dpscribo-d hy Von
Uraefe under the title of '^Amauro^ia with excavatiou of the optic
nerve."
Tlie course of the tlis<?ase i* often excecflin;;ly insidious, so that it may
be considerably advanced before the ]iatieui8 pay any particular atteu-
tion to it, suppoaiug, but too frcfjuently. that the increasing weakneaa af
w^ht i« simpiy owinj; to old nj^in. Though thi« impairment of vision may
be noticed alao for distance, it uiakett ttdvtf |iurtiuularly felt in reading,
writing, sewing, etc., and convt-x jiIumch ai-e fonnd but of sli^fht auint-
ance. There i? generally no premuiiitory Bta^e, for ilic intermittent ob-
Kcurationi), niinbow.-t rnund a candle, etc., are mo.-itly due to Home flli{E;ht
inHammatory attack, accompanied by cloudiness of tlie refractive inedia.
The cAtcmut appearance of the eye may be perfectly bealtfay. Tbt
refractive media may be ijuite clear, the cornea sensitive, the anterior
chamber of the norm:il aire, the iri» healtljy and imt discolore<l, or but
very sliglitly so, this bcin-; only nppurent on coraparieon with the iria of
the other, healthy eye ; the pupil perhaps alighily dilated and a little
8lii;;gi;«h. But the eyL-tmU is generally found to be abnorumlty t«nK«,
and with the ophiJialmm;copc we obAcrvc that the optic ncr\'e shows a
glaucomatous excavntion. Sometimeii thi-4 incronsc in ten^iiou vaHc^
greatly, bein^ very marlieil at one time, and hanlly. if ut all, apparent
at another ; it la of ^reat con9e»iuence, tlierefoi-o, to examine fuich eyes
freijuentty, aud at different periods of the day. There i$ atill ft (pwd
deal of discrepancy of opinion as to the Invariable presence of increased
tension of tlie eyeball in this form of glauconm. Some aa^ert that ten-
sion is always increased in all caMca of glaucoma aimplex ; othcra. a^aiu,
tliink that alchou^'li this undoiibtediv docs occur in the majority of caMM,
yet that in otiiera it is absent. Von Gracfc, in particular, maiDtainfl
ibat Uie intni>oeular tenxion ia imt in a\\ cases incrcaaEnl in a marked
manner. lie thinka that the occurrence of glaucomatous excavation of
tbe optic nerve, without any marked increatie in the tension of the eye-
ball, may be explained tliii'}: That perhaps the renisting power of tlio
Optic pnpilla varies in dillVrent individu»U, perhaps iiIm> at ditferent
a;^es. Just as iritis and indo-cyclitis serosa may occasionally be ob-
served, particularly in young individuals, to exist for aome lengOi of Umo
with au unmistakable increase of tciit«iou, without any excavation; may
nou on the other haml, the power of resistnnco nf the optic papilla ho
absolutely (?) or relatively so diminished that an exceedingly alight itv-
crcase of lenjtion, not excciliuK tbtj iionnal range of variaUon nf ten-
sion, may already caitite an excavation? l!ut every, even the mu«t con-
siderable increase of tension, requires to act wme time before it leads
Co cupping. The truth of thiti is shown in caics of acute glaucoma,
wbere there is no cup directly af^er the first acute attack, although tliis
I lUnuann, "ArchtT," rilt. 2.
HLAUCOMA SIMPLEX.
67T
ntnr bare lasted Tor some weeks, (hiring wliicli the intrn-nciilar tenstnn
wa^ ^i-eatly iiK!r4>aseil. In ftlaiicoroa rulminans it is i^omewhac difTeront,
for llicre it ayipetrR to supervene early. Bat a loiig-continiieii, tJioujili
slijfht. increase of tension will lead ^railually to nil excHvatiftn of the
optic nerve, which increasc-s mure and more in depth ; th*i vessels then
Ifcconic inlernipted at its cd'^t;, and tliem is siioiiiuneoiis or easily }tro-
duciKli.* artt-rial pulstiiion, Tii« veins appear dilateil, and perhaps some-
wli»t tortuous. If the tension continues, the optic nerve gradually
utrtiphieSf the arteries hecome diminished in calibre, and complete blind-
new may supervene. It is found ibul if the increase in tension 13 very
slow and gradual, the e.'tcavatioii of the n|itie nerve may become very
conaiilerable 10 depth, without the -tight or field of vision being mark*
edly im[>aired. Increaj*«d intra-ocuhir tension i«, therefore, generally
the Brst ^rmptora of glaucoma KimjileXf being accompanied perhaps by a
Tclatit'cly rapid incrcniie of presbTopia, anri some hypermetropia ; grad-
ually, however, the optic nwrve becnmc-j ('uppcd, and these symptoms
may Inst for a consiilerable time without others supervening. In some
casen, however, the augmenlofl tension may exist for a long period with-
out the presence of other glaucomaiOiLs svmptoms.
Occasionally glaucoma simple:; may run its couMO, even to complete
blindness, without the appearance of any inflammatory symptoms. The
di-sease alowly hut .surely pmgreBws, the eyeball becomes more and more
Lnr»l, the cornea anitstlietic, the anterior chamber narrower, the vessels
more tnrgiil iiu'l congested, the jiiipil <lilnted and sliig,:;ish, the retinal
veins engorged, the arteries diminislied in calibre, and perhaps puNating,
the optic ner\-e deeply cupped and whitish in color, the visual field more
and more contracted, and the siglit finally destroyed. [Beginning glan.
comalous cupping mav be diagiiositicateil when a vesse! luiikt-x a distinct
bend at the margin of the di»k, and when it^ pa])i11:irv eml lies ileuper
than its retinal end. As the excavation iiuTeasc^ in (fepth and the wall
becomes steeper, the apparent di!<plafemi,'nt of the vessels becomes more
marked, until finally they appear interrupn.'(i. the (xtrtion between the
margin of the cnp and its bottom being lost to sight. — B.]
In stich instances, the course of the discHfc may he so insidious that
the sight of the eye (if the other is pt-rfect) may be completely lost,
without the patient being aware tliat there is anything the matter with
it. Perchance he closes the good eye, and then be discovers the bliml-
ness of the otlicr. and thus often snppo_spa that the viitton has Keen aud-
deuly lost. On being i|ueBtiotie(i, he may perhaps remember that he
occaatonally exju'rienced flight pain in ami aroiinil the eve, which was
supjtO'ied to Ik- rbenmatic; that it sometimes becamtr a litlV flushed and
watery, which was attributed to a cold ; but otherwine he noticed nothing
peculiar. This may not only occur amon'Mt the humbler classes, follow-
ing pursuita which re<piire hut little employment of tlie sight in reading,
sewing, etc., aa amongst laborers ; hut it may even occur amongst men
of literary habits and avocations, employed for many hours daily in
reading and writing.
But, in the majority of cases, inflammatory symptoms show themselves
during the progress of the disease, and these may assume an acute, s
clironic. or an intermittent type. Thoy present the same character as
37
578
oLAuaoMA.
in acute or chronic iDflnmmator^ glaucoma ; rapid diniinution of Tision,
obscurations, rainbovrs round a candle, augmentation of tension, duloeM
of tlie aqueoua and vitreous bumora, etc. Sometiiu«8, bowerer, tbcM,
iiiHamniatory symptouia may not appear until the disease has long
its course, and the sight has been completely lost. In other caws, thcj
may )« so tranftitory as to escape our olmervntion, and tlieir pri-viuti
exintencc may not he ascertained, except hy a very close examii
into the history of the case. Wher* manifejtt Byniptonis of inflami
are apparently wantin;^ in a case of glaucoma simplex, the condition of
the other eye, if healthy, should be aftcertained ; and tlien, on a com-
parison of the two, we may often detect slight changes in the color and
structure of the irit^, and slight haiiiness of the aqucoua bomor of the
affected eye, ivbich, but for this comparison, would l>ave eaoaped ot
attention. Von Gracfe also iwint*! out tlie necessity of examining suob^
patients at a period of the day raoat favorable for the obser\'auce of Uiy-J
inflsmmatory symptoms, and points out the fact tJiat whilst Uie inflac
matory nymptoma ni iritis, etc., particularly the doe|Kir injection, heeoot
commonly more apparent soon after sleep, the reverae obtain* in gUt
coma, for here tliey become Uie more prominent the lon^^er tlie
keeps awake, more particularly if he remains up hcyoml his custoi
time for retiring to bed. lie mentions an interesting case, illustrative
of the pecniinr transitory character which the inflammatory symptama
may occasionally assume. 'Hie right eye of the patient in question ordi.
uarily presents a perfectly healthy ap]»earance, hut for aevenl year»
past It assumes a well marked gluucomatous condition when he haa bMti
playing canls for some length of time, and only then. On snch ocoi-
aions, Uie anterior chamber becomes shallower, the aipieoua humor dif-
fusely olonded, the pupil somewhat dilated and slug>^h, tbo retiQal
veins dilated, particularty towards the edge of the optic disk, and arte-
rial pulsation may be pn>uuce(l by the faintest pressure upon the eyeball;
together witli these symptoms, there is indistinctness of vision, = ■
inp objects appearing to be cot-ercd by a veil or cloud. No;
following morning have all theae symptoms disappeared, then the aij^iit
is again nonnal (No. 1 of .lair's types at 1*^ inches), and the increM*
in the tension of the eyeball, which was very manifest daring the attack,
is no longer appreciable.
Ulaucoma simplex as a rule attacks both eyes, almost syminetricallyf
but at a more or \v/^n ronfliderahle interval.
[With the failure in central vution is connected also Kimo indUtiiv
nrss in eccentric vision, and even a pntnounced defect in the 6eid. la
fact, the latter may precede the former, begins at the periphery, and
exieniU on the nasal side towards tlie centre, the temporal aide being
the li^rijreal preserved. — B.]
llfkHDiimn considers that glaucoma simplex is identical with the pre*_
fiDonitory stage of glaucoma of Vou Graefc, and maiiitauis that all th
-•yinntoms ennmerabod aa existing in the premonitory stage are preaei
in glaucoma simplex ; but 1 thina. it of the greiitest praottc&l importUKa]
maintain the existcnoe of a premonitory stage, for we find, af
its course Is generally I'cry different from tliat of glaucoma ail
premonitory stage may exist even for many years without prodt
BBCOSDABY OR OOffSBCDTIVB GLAUCOMA.
579
ui\y glaiicomatmtfl cliaTig<>ti in the eje, the symptoms may odIj Bhow
llicm!»eK'e»t at long intervals, and in tlieir intermiiwions the eye may W
lierl'ectiy htialthy ; or they may recur ftl more freiiuent intervals, and
pass over into acute or chronic glaucoma. In other caaea, they may
paaa orer into developed j^laitcoma afler only a few premoiult>ry atiaukn.
Besides this, ire find that the most brilliant results of irulectoniy are to
b« expected in the prctiiotuUtry itia^ : but tUia is by m.) mvaiis the oaae
iu glaucoma ttiiupK'X, for here (he reeulta of indcctomy differ in a very
peculiar and imporunt manner.
4 SECONDARY OR CONSFXUTIVE GLAUCOMA.
We fltnl that certain diaeasea of the eye may in their progreaA become
complicated with glaucoma, the eye then prc^^cnting glaucomatous aymp-
lODis superadded to those of the original disease. Indeed, acoorling to
VuQ Graefe, there la hardly any infiammatory disease of the eye which
may not in itn course give rise to secoiulary glaucoma. This is, however,
far more apt to occur in those diseaacB whicli, whilst running their typical
course, are prone to cause fluctuations in the eye tension, than in those
iu which the latter la not aUccted. Thus diifuse corueitis becomes more
freipienily complicated will) socomtary glaucoma Ltian Uie circura<(crihed
infiltration of the cornea; and the c()uatorial charoiditis accompanied
with vitreuua o|iacitieA, than the diasemiimted choroiditis.' AmoogK
the dineaaen in which secondary glaucoma moot frequently uuperrenea
ore, 1. Diffuse corneitis, and anterior ^taphyluma of the cornea, 2.
Iritis oeroaa, and iritis complicated witli conaiderohle poatenor synechiffi.
8. Traumatic cataract. 4. Dislocation of tlie lens. 5. Serous choroid*
itis. I>. Sclerectasia posterior. 7. Intra-ocular tmnors. 8. Hemor-
rhagic affections of the retina.
A fuller account of this subject will, however, be fumul in the sections
iu which lliese different diaeaaos are treated. [Cicatricial ectasia of the
cornea i^ probably the most frcipicnt cause of secondary glaucoma, ettpe-
cinlly if there are extensive adhesions of the iris to the cornea. Whether
the secondary increase of tension in these cases is in consequence of an
increase of secretion within the eye due to a stretching of the ciliary
nerves, or to the collection of Huid behind the iris causing venous staais
in the ciliary body, is atill a moot point. — B.] With regard to the sec-
ondarr glaucoma supervening upon rulinitis apuplectica, I must, how-
ever, uriefly call the attention of the reader to some of the most im-
}rtant point*. This complication is particularly met with in persons
lyond middle age, of a very full habit, and affected with uiore or less
extensive sclerosis of the coats of the arteries. The disease commences
a^ retinitis apoplectica, and afler this has vxiatcd for from one to six
moniha (Uraefe), secondary glaucoma supervenes, which may aaaume a
very pronounced ami acutely inflammatory character, in which case it is
often acconifianied by the most intense ciliary neuralgia. The Geld of
vision ia but slightly, or not at all, contracted, and bhero is no glauco-
' "A. r. 0.," IT. 3, 121.
dLAITOONA.
mntouB oxcxvtition, nor, as a nilc, artrrinl piil^ntion. Pr. Hermann
PageustecUvr' has ri>iiii(l on microscopiciil oxiitniitaticin [hat in the*c
ca^cfl Ut« walU of the retinnl ve8si>U nK greativ thickuncMl (st'IerosiA^,
and dhow coTist>1erab1c varicoaitici^. This sclerosis of the walls of the
vemels ami their coni^eiiueut hfi of elaaticit)' must. &» be jioinia out,
have an importimt cffpct m disturliiuj* the oirculatiou of ihw |«rt of the
eye. llu inentionif one curious case of he:uorrha};ic' ;:laucoti)a which nan
evMenilv of symjwithetic origin, as it im|irovcil vcrv «;reail.v ami ra|»i(lljf
after excision of the nthor eye. Or it may fipprar in the form of jtlaii- ,
coiua simplex, the increase in the tension being rery gradual, acatc
inflammatory esacerhaliuim occurring only at a later stage. The diaease
is often accompanied hy licniorrhagic efftiaions into the vitreous and \
afpioou8 huinnrs : an<l during an acute jiaroxysiti the sight may he 8ud-'
rtcnly lost, this hein^ pmhably due to a hemorrhagic detachment of the
retina. Von Gracfe points out the fact, that in such cases the ai)pUca-
tion of atropine may accelerate the ouibn*ak of the glaoeoma.' Me also
states that m twO'third>i of the caAes of glaucoma ^u intervening on hemor-
rhagic retinitih, tiie imtbrtHk occurred between tlie fourth and the tenth
week after the first fimctional diaturhsince of the eye. ilence, tho
longer tlie tenth week ha* paased, the less chance is there of secondary j
glaucoma.
But glaucoma mav also complicate diseases which stand in no oaiml I
relation W it. Thus it mav aujiervene upon senile cjitarai-t or upon oerc-;
bral amaurosis. In the tornicr case, the cataract should never be re-'
tnoveil at the HSine time that the iridectomy is mmle for the relir'f nf the
glaucoma, for in case any vitreous humor should be lorit during die ex*
traction of the lens, it might very easily give rise to severe intra-tKulari
hemorrhage. Some months should elapse between the two operations,
in order that the improvement in the circulation, teiwiou, and nutrition ftf j
ihc eye may become thoroughly ci^lablished.*
' "A. f. O.," xTll. 2,n.
* Ttint KtnipiiK' irill ram-Mmt* eiiue sn anl>irMtk of gUncona in omm nf fntni*
vcqIbt tuuior, anal ncuu- vxawrhalious ill uhruiiiu gLaut-viiia, was i)i>int«it out It/ Von I
Clri»-fc, In " A.r. 0.," xiv. i, 117. Dr. IVrtty. of Diwttm. Ims alto n-lHi"il ivm <'jum^
in frhirh thn iimtillAlloii nf almpinn wkh dirirtlf fullnwM hr an nuttircnk "f utita
(^ftnvcraa (" Tnuii'itciuinti at Amorinan i*)ilithnluiol(igicAl .SorioLy," l^ift*)* ' tiK*«|
likcwiiii* UK-t trilli .t U-v mnli irist>ui»7it. In vnv ca^*. llii- ^uirK-iit batl Inat lli«< l#n
«yi< fruni rhfinii: )il:iiirv>iiia, iikI, n>iiip1iiiiiin|( of slight preii(<»iitory Njai]>t'>iii* in th* {
ri|;)it. niropiiK" wa:> niij^i^-il to tin- latur. I hrifiljr fxaiumwi tho pvf with ibi' 0|>li-
l1iaitn<if>i^i|uT, anil wilhlii 'JA lioiini a sfircrp attack of »i!ut>< Klauroma oiyTiirrqil. Th^a j
fBctN ohoiil'I trarn iix imt to muplay atropine UDDVCV&iiarilv, lo bi> c«ro(ul aa l«> iUj
pxlrcmt? piiritj, nml to nuikr an; ojthlhalmoacoitla ezamlniilii)a u hrlof antl oa lIlUi
tf/inj! t*) th.' tye a* i«BniMf .
• It i" mi inl«rf«lirii: fart llinl Klauooma may also, in rare imrtanrp*. Immuiv d**]
Tclo|>pd in an oy<t In which thn Ima it, ahoi-ni, aiHl Ihi.i, a# hai^ tnim iH.iutitl 'Wt bv |
Bjftli-l (" lleri<'hl iih'-r >li.> Wii-ct.ir Au^^rnklinik," p. 15J)- '* »n iinpurlaiit poiiii wilU
rfgard to the thwry that On' tn-ii-.-ni^ial eBi>t.-t of thu iri<l<-4>loiny in ^Inuoonui i^ due Xni
itfl rplivif of Ihp irrtt.ilion anil tfa*iii); nf ilif iris, which "tvttr wh<Mi llic latter, trv
K^thiff with thi* tpiiK, in pr>«»H<l (■■rwanlH uwini; In lliir ini.-n>as«<l intra.<.H.iulai ti-ntiiou. f
Nov. in (wocacoH of^Lauwima in ••/» wtLbont a h'rui, thu antiin()rchamlM.T was drcpj
and the irlt l/ing in ith m^rmal plam-, w> tbjit lh<<ri> muUi >w ni> >)n«!itinu of its Mnf I
~twai«d or irritated hy presaore. Ileyiuann »l|iu r«|iwrt» •■mw i:a*e« of j(Ia«">in» h^J
comiug developed in eyta in wbioh thu Inns waa »ba«int t" Kl. Monala.." 18t7).
NATURE ASD CAVSBB OF THB OLADOOM ATOUS TROOBSS. 5^1
[In ft few rare caset* Hecondarj' glaucoma lia^t been known to cumpli-
caLO detnctiuicnt of lUe rodiuL, iu wtiicli llierc U usually diminution of
iutra-uciilar tcnsiuti ; and in ouc cnsc ro|K>rted hy JJusiuarreft it appeared
in a tvpiual cnsw of reliiiitia pi;^nK'iiU>hft. Finally several oWrvew,
nmong them Qunglino, iiAve ob^ened glaucoma supcrveno in eyes trith
cuugeuital colokoma iridid and total irideretnia. — B.]
5._OPHTHALMOSCOPIC SYMPTOMS OF GLAUCOMA.
Thv characteristio ophthalmoscopic symptoms of glaucoma uro — pulsa-
tion of the central reti»eLi of tJie retina, and ejcoavation of the optic uorve
(ei(te p. 485.)
Tb<> stusiii in the venous circulation of the retina is often very con-
sideralilc, the vcitu are dilated and tortuoiu, the smaller veinletii a^uum*
ing a corkscrew appeanince ; if (lie .stasis he very great, the hirger
venous hrnnelie? miiy i-veii nhow pcciiliur heiid-like swelliti;;!). Tliis ij<,
however, vcrv rare. I Imve iieeii otie CA.ie In which there was a distinct
tendency to these swelliug^, hut I Jehretch hgures a case, in his ** Atlas
d*0[)hthalrnr)3copie," in which it exi:ited in the most marked manner.
After diniiuiitiui) uf the pathulngical inorcHso in the inira-ocutar tension,
the scigiuition in the venous circtilation ceases, the calibre of tlic veins
dimiiiisht'p* in siia, ami they lose ihcir tortuosity. For inslanco, after
the {wrfurmance of iridectomy and the con0''t)iicut dimiuutioii iu the ten-
sion of the eyeball, we fre({uently have an opjioriunity of observing the
change in the venous circulation. Thus, extensive retinal ecehymoses
aro perhnjis met witli, antl the vidntu, which, before the operation, were
very ililated and swollen, are now much diminished in sixe and [tfiler.
The retinal arteries in glaucoma appear very thin and small, and much
puler tlmn in the normal eye.
Whilst spontaneous venous puliation (ride p. 31)1) may occur in nor*
mal eye:!, Kpunlancouit iirteriHl puUalion is only ot)8erve*l if the intra-
ocular tension is nuirkudly iiicrea.se'i, or in cased of insufficiency of the
aortic valves. The arterial pulsation is syncbronous with the radial
]>uUe. but slightly later than the carotid pulsation. It is ctinBiieil In the
ili«k, and presents a rapid to-and.fro movement, and a rhylbmical tilling
and emptviug of the artciies. The arterial diastole takes le^stime tlian
the sTstofe, and is characterised by a rapid, jerky entrance of a column
uf blood into a pi-oviously empty vessel.
0 ON TIIK NATLRE AND CAUSKS OF THE GLAUCO-
MATOUS I'KOCESS.
The true nature and cause of the gUucomatoas process are sdll in-
volved in some obscurity and doiilft. In the great maiority of cades of
glancomu there arc marked inHamnmtory symptoms, but it must he freely
a<ldiittcd that wc do sometimes, although far more rarely, meet with
vtuttm of glnucoma simplex, in which no inflammatory symjitoms can be
tletfotcil. Indt-ed \i 'm the latter fact which causes all the difficulty, for
m
£82
at&trcoMA.
wo cfin eaoily eT|^lftin the incre&Aed tension, nnd all the sTTaptonis which
follow ill it» trsiii. as <lue to an iiiHanuuatory orij^iii; but w« cannot aa
satisfactorily explain wliat conf^titiiti-ft iln? primnry ejiiiHt,i of th« incrca«eil
tension in glaucomii simplex, which leads t.) the gnidiial lo*» of sight
from excavation and de<;eneration of the optic nerve without any ap-
pearance of in^ammation. In the inflammatory forms of glaiicomn, lK«
seat of the iiillaniaiattnn is chiefly in the uvea) tract, the choroid, ciliary
bfMiy, and the iris. But other strncturea, such tu* the cornea, wlerotic,
and retina may »ubset[u<?ntly K-coine inrolvod. Tliis irido-choroiditia
causes an increase of eernsity, more CHi'ecially in the vitreous humor,
and an aagmontation of the inira-ocnlnr tension ; the latter giving rise lo
all the glaucomatous symptoms ilescribed abov«. Together with tliis
incrraHB in tlic vohimc of the vitreous humor, there exists in glaucoDia a
diminution in the power of fthsorjition, and this may explain why these
serous effusions are not removed, as in other forma of choroiditis, by an
increased activity of the absorbents. Attention has been called by sonw
writers to the fact, that the sclerotic appears peculiarly rigid and un-
yielding in glaucoma, and it has been 8vipi>osod that this ia not unfre-
qnently congenital or hereditary, and may form a predisposing clement
to glaucoma. Now, if e>uch an abnoniial rij^iditv of the sclerotic exists,
we can canily nnden^tanil how any rapid, thf>ii*;h nlight augmentation in
robime of the contonbt of the eyeball, must, not only give rise to a dis-
proportionate increase in the intra-ocular tension, Vnt must also augment
the tendency to stagnation in the bloodvessels. Coccius has found in a
case of glaucoma, that the sclerotic bad undergone fatty metamorpbosi*,
and he thinks that the affection of the sclerotic may perhaps have been
tlie cause of the increased intra-ocular tension. There can bo no doubt
that the rigidity of the sclerotic plays a very important jiart in glauct<ma.
For we find that in youthful indlviduaU, in whom the sclerotic i* more
elastic and yielding, an increase of the intra-ocular tension, dependent
u|ioii some intl a initiation of the uveal tract, may exist for some time with-
out exerting any delcteri(%n« effect upon the optic ner%'e or retina. The
Klerotic perhaps yields a little, as a whole, before this increased tension
and adaptj^ itself to it, or it may become slightly bulged at a certain
point ; whereas, in older persons, in whom the sclerotic is more firm,
rigid, and unyielding, the existence of an increase in the intra-ocular
tension ia much more dangerous, for it soon causes the least resistant ti».
sue (\n this case the optic uen'e) to yield before it, wid become exca-
vated. Vnii Gracfe attaches very great imjtortancB to tlio part played
by the sclerotic in the pathogenesis of glaucoma, espccinlly glaucoma
aimplex. With reference to (his [>uint he says :' *' The very fact that in
glaucoma simplex inflammatory processus do not supervene, harmouixes
with the supiMsition that the primary cause of the disease is furnished
by some tissue, in whicli the interchange of material is slow, and a cer-
tain degree of vascular torpidity exists." .... "Just as in other di*-
turbancos of innervation, our at(ention ia being more and more directed to
those of the course of the nerves, in which their free action is threatened
by an osseous or tendinous point of transit (as we now attribute numerous
» "A. to.," XT. 3, 210.
HATtiRB 4nD CAUSBfl OF lU B GLAUCOMATOUS ?ftOCS68. 683
fornu of neuralgia ami paralygU to periosteal trriution at these pomt«):
it a)ij)eani! to me that, with regard to the ciliary oerves. it ia jiut their
passage through the sclerotic which deiuatid:) the most careful study. I
should not be inclined to au8p«ct seuile n;4idity or patliolojjical contrac-
tion of the sclerotic (whctlicr thifl be diffuse or limited to cerutio points)
as cantting glaucoma, from its giving rise to a direct comprcfi^ion of tJic
coatentA of the eyeball, or to narrowiug or occlusion of the veikou^ emis-
Rftrica ; but rather bccaunc the nerv^, containing the flccrctory 61amcntSt
which pans through it, thus suffer a certain impediment in their function,
which mnat weigh in the scale."
When considering the different forma of glaucoma, we had fretjnent
occasion to point out the great variations in the intensity of the inflam-
matory syniptunkt. We saw Uiat in acute glaucoma, tlie inflammation
might be very severe during the first attack, but that after its subsidence,
the inflammatory exacerbations might assuuie an insidious, chronic char*
actor, and the (tiscafle gra4lu»lly paiiit over into glaucoma absolatum, with*
out the recurrence of any acute attack. Again, tliat iu the chronic form
the inflammatory symptoms might, at the outlet, be hut little niarke<l, but
that in tbo course of the disea^ie acute exacerbations, even of a very
severe character, might show themselves. In the third form (i^lauooma
simplex), it was stated that the disease might occasionally run its course
without the apparent occurrence of any inflammatory symptoiaa — tlie
eyeball becoming stony banl, the optic nerve deeply excavated, the sight
destroyed — but the refractive media remaining perfectly clear. But in
the vast majority of caj^es of glaucoma simplex, iullannnacury svnipLoms,
of varying severity, do show themselves during the pnigrcM of the dis-
ease. Now, on account of the fact that glaucoma simplex may occasion-
ally run its course without the apparent presence of any innammatury
symptoms, and on account of the increased tension being sometimes tlie
6nt manifest symptom of the disease, it has been supposed by Uonders
that the intlammation is not the iniegral part of the glaucomatous pro-
cess, but only a complication, wliicli, tliough occurring in the majority of
cases, need not necossarily be always present. Ilo considers the increase
in the intra-ocular tension as the cssciko of the diiiea^o, and therefore,
the glaucoma simplex, which runs its course without any inflammatory
Bymptoniit, as the [trimonlial type of the disease ; and he think;? that the
acute or chronic inflammation which «liows itself in tlic majority of cases
of glaucoma is but a cnm plication, which is of secondary imporUincCf and
not necessary to the glaucomatous process, lie, therefore, speaks of
gtaiKoma simplex, and glaucoma cum ophthalniiS. The anomaly in the
secretion of the fluids of the eye he thiiiks due to an abnormal irritation
of tlio nerves regulating the intra-ocular secretion. Now from some very
interesting and ingenious experiments m«de by Dr. Weguer (."A. f. 0.,"
xii. 2, 1), it appears certain that the vaso-motor nerves of the iris, atid
in all probability those of the choroid aUo, arc funtished by the sympa-
ihetio. Ho foiuid in experiments u(>on rabbits that a division of the
sympathetic in the neck leads to a dilatation of tJic vessels of the iris
and choroid, and a dimiinition of the intra-ocular pressure. It may con-
sequently be nsiiumed that irritation of tlie vaso-motor nerves would pro-
duce an increase iu the tntra.ocular pressure. But, as Wegner stales,
686
QLACCOHA.
I 0'
ror tlio ophihalmowope constantly reveals to us the pre8«nce of even
considerftble inflaimuatioti of the chnroM ftnd rotina, without tlic exist-
ence of any increased vascularity of the external tunic* of the eyehnll.
The l)axinfiti.s nf tlio ai)ueou8 nud vttreoas humors, which mar arise dur-
iog such an ephemeral exacerhttion, may likewisa be so nHjrht and deli,
cate as to escape deteciiou with the opIithaJmoscopt*, for we kuuw chut
fine diffuse opacities of the at^^ueous humor are ofWn quite invisihlo b^
nsuitted light.'
[During t'le pnst three or four yeans, the nature and cuufiation ofglao-
ran liftvo oceiipied very lar>;cly the attention of opbthalmic surgeons,
especially in Ouruiitiiy, and a number of obsen'ershave published exten-
Bive pa[)er8 &s the results of tlicir ex))vrimenid Mud oliscrvatioiis upon the
subject. Though some light hnA hern thrown upon the nature of the
disease by these studies, the pathology, and to a certaiu extent the caa-
satioTi also of glaucoma, is still obscure. The two great theories now as
heretofore, are the inBaiumatory and the neurotic or irritadve. In 187<j
Knies published an article upon glaucoma, followed by a second one in
1877, baaed upon a careful examination of twenty-two glaucomatous eyes,
which had been enucleated for various reasoii<t. (See "Arch. f. <)|«bth.,"
xxii. 3, and xxiii. 2.) The mo»t fre<|uent, ami, as be thinks, the most
important pathological change found in thctc eyes waii the oblilerv
lion of Fontana's space, for he reasona that the obliteration of ttits spacei
niuBt cause an increase of the intra-ocular tension. Fiirtliormorc he dooAl
not think that the flattening of the anterior chamher from advance of the
iris and lens, must necessnrilv he rogttnicd as a sign of increased tension.
Jn every eye exi^mined, indubitable signs of inflammation or its conse-
quenccs were found in the neighborhood of Sehlomm'a canal ; and this
held good as well for casen of secondary glaucoma as for the jirimary
Ibrm. His investigalioiw led him to the following conclusions : —
1. The moat important ctiange in rcnl glaucoma, is the nmniUir adhe-
sion of the periphery of the iris with the cornea or the obliteration of
Fontana's space ; the excavation of the optic nerve is a secondary matter.
2. Tbo same relation exists also in secondary glaucoma.
8. Iridectomy cantwt be replaced by the use of eserine, nor by the
other methods of operaung proposed.
4, Sclerotomy is an exception to the preceding, as the excision of a
piece of iris is unimportant ; it may therefore be Kub»tituted for an iri-
dectomy.
0. The relationship between miiny staph ylomatouB processes andglaii-
coma, is proven by pathological examinations.
About the same [leriod Ad. Weber nulilished the results of his own in-
vestigations upon glaucoma. (J^cc the "Arch. f. 0|4ith.," xxiii. 1.)
He came ut the conclusion that a pure theoretical analysis of the phy.si-
val features of glaucoma leads to the conviction that the cause can oidy
be a purely meulmtiical one, that of a gradual narrowing of the filtratioD
channels of the fluids contained within the eye. In all forms of glau-
coma, in the inflammatory as well as the non-inflammatory, the primary'
. ' Pop rorther lufominlion anon thii*jnt«r««titi(t *nd lni|iort«nt aublMt, I nasi wftr'
lis TtmA^t lo TOO Qrwrfv's mad Dr. Uiffnui'i juper OQ OlMieoma, '• A. 1. 0.,'* VUi. t.
KATCRB AND CAU8B3 OP THK GLAUCOMATODS PHUCF.8S. 587
t\\ M the seeondarv, thf^se chnnneU arv narrowed Knd linallv obltter*
ated. Weber hesitates to accept the view that the BwelHnj; of the ciliary
processes is the c&iLte of glaucoma. It in tnie that the ^pviup orsjrm|>-
iomt known a« glaticoiim appear when thid mechanical oblitvratiou has
taken place, anil that the exciting caiwe of the sto^alleil primary glau-
coma i» the swelling of the ciliary processes. But this pathological con-
ditiou 19 not contined to glancocna, but i» tnct with in ot-her diseases;
neither is it, even in connection with a certain rlf^idity of the sclera, the
only cause for the development of the giaucoraatous condition. Weher's
paper ia a very long and interesting discu^ion of the subjeot, but does
not easily admit of a satisfactory ahslract being made.
Next in order of importance appeared* lengthy paper by Schnabel. en-
titled "Contributions to the Knowledge of Glaucoma." (Sec "Archive*
of Ophthalmology,*' vii, 1, 2, 3. and 4.) In a previous pAper published
in vol. V. 1, of the same journal, he pntnnuncea the opinion that it had
not yet been proven that the clinical picture of inflAmcnatory glaucoma
wa!4 the coi)5et|uence of a choroidal inflammation. In this second paper
he iliscnttscs and coinbats Knies' interpretutiona of the pathological
changes found in tlie aoterior chamber. The »an>e changes he found
himself in glaocomatoua eyes, but he does not accept Knies' views.
His own conclusions are hosed upon an examination of thirty-nine eyes
examined by Imnself. He holds that the pathological changes in the
fwriptiery of the anterior chamher, do not neee.^sarilv present the t»ecu-
liar clinical picture of the glaucomatous process. What functional dis.
lurbanceH of the eve are caused by the obliteration of tJie angle of the
anterior chamber, W is not sure of, hut thi« obliteration do(-« frequently
exist without being clinically obsf^rvcd. lie docs not consider that tho
existence nf corneal cicatrices with incarceraU'd iris endanger tlio eye.
The peril of increase of tension and of consecutive excavation <if the optic
nerve occurs only when the cicatrix begins to Imlge. The obliteration of
the angle of the anterior chamber alone is hamileas ; the traction on the
Origin of the iris and the stretching of th« sctero-conieal margin cause the
im^rease of tcniitim. He thinks it erroneous to suppose that iridwtomy
in glaucoma arts hy establishing the oomnumication hctwfcn the anterior
chamtfer hu<I Fmitana's spaces, and denies that the scleral cicatrix pos-
aeflses any peculiarity of structure by which its impuh'd function as a
filtration titwue coidd be accounted for. He calls spi?cial attention to
Bailey's discovery of the atrophy of the ciliary musole iu glaucomatoaa
eyes. He rcgaMs it as the only anomaly dcmonsti-atcd hitherto by the
anatomical exunuuHtion. which has undoubteitly a relation to the gluuco*
raatoiia process, and is not merely a con-«e<|uenue of it. It cxista before
die glaucoma can be clinically demonstrated, as he proves by a c&ac.
The highest degree of atrophy is certainly only found in eyes in which
the glaucoma had exi<tted for a long time ; but the increase of tJie atrophy
doci not stand in a direct proportion to the duration and degree of the
iDcreaBcd tension.
The latest observations of importance are contained in a most admira-
ble paper by Mauthnor, entitled "Glaucoma Aphorisms" (see "Archiros
of OjAihalmoIogy," vii. 2, S, and 4, and viii. l). His riews arc very
different from those of Schnabel and others, in th&l ho sccepta uno<|uivo-
5bS
OLAUCOHA.
callr the inflanimatorr theory of the disease. He fint considcn the
cu|>|jiii<t of the optic dUk. Kuiuiuiiif; up tbe evidence deriv-vd from tb«4
observatioiiii of NlUller, Mi>oi*!n, Bailey, and Sclinnbel, with 8i>cciill
reference co the condition of the optic ncire fiUrcs. Theae b»v« sliown
that all unatomical exntiiinations of glaucoinatotie eyes in wliich tite layer
of nerve filircs lia.^ bepn preserved, never (jivc, in sjjite. of the yii'lditi;^,
of the iHOiiiia cribrosa, any otlivr picture tliiui tliat of a partial fuiiurt-j
sliaped excavBiioD ; a picture from uhich it is possible to explain, acconi*
ing to our present viewa, the ophtlmlmoscopic appearance of a " prewufe'*
excavation cxtendin;;; to the margin of the dink. Mautlmcr boldj
the total excavation is not a pres^nra excavation ao loiij; as the rnnction
uf Ihc iii'rve i» preserved ; in thii« Hf^reeiug with von Jae;^«.'r aitd Kiciu,
and differing from Sclitmhvl. From tlie sum totftl of facts prBsenliHl by
himself and other autlioritiea, he believes that glaucoma in a cboroidiiisi
complicated with inflammnt-ory symptoms also in tbe anterior eci^meot oP
tbe eyeball, which as a rule Uegintu with increase of tension bnl also pro>
presses withont Uus, and is acc'iajpanied by the developmenl of an aflV-c-
lion of the oplic nerve, which is ilopendeiit on the process in tho ehoroiil,'
hilt is not alivay* pre-(ont. The functional disturbance in ;?lauconia caa-
nut )k- explained by a jiriiuary uBccti'^n of the li;;lit-conductiu;;; iipp-iratuji ;
it doiwniU upon Aoine injury done by the choroiditis to the fuuciioD of
the lif!;ht-perceivinp; apparatus. Increase of tension and <rt»iiconiat<iaB
ulTection of the optic nene Hre neither the cauiiie nor the be^innin;^ ot
blindness. There are real glaueoniatnns pnicei«:*e-t which lend to hliml-
mm without increase of pressure and Hitliout exuavaiiou. 'J^he nature
of the choroidal process which lies at the boliom of gluiennu is still hut |
little understood. Ha prmlucta are fioor in new<fonn«l elements, but ili
may be, and tljat uut remoiely, connected with choroiditis aerosa. It
lie;^nN in the anterior He^rmont of the eyeball as atrophic chomiditti.
In the bcxinniug, the piguit^nt epithelium in tho erect intake shows some
delicate alt«^'nitions, and slight ii8 these arc, tbe process which lies at Uieir
foundRtion i» threatening to destroy tlie layer of rods ami conca. Mnulh-
uer also diders from ilailcy and Scbuabel in regarding tbe atr»idiy of
tbe ciliary muscle, not as the cause, but as the result of tlie glxucona-
tOua pr«>cea». Ho leaves entirely untouched, however, the aulijcet of the
cauxe:4 <if i^l.iiii'oma, and tuiy.s nothing of the theory of t)ie inipAdod outlet
at thi- irit-ittij^le, which has occ't-stoned so much iliscussion. — B.]
(ilauconia It a diseaae of old age, being moKt fre(|ueDt1y mci wiili be-
tween tliu ages of 50 and i>M, but it may ocuur even at a tnucb later
period; it ia but seldom observed in early life or bel'ure the a>>e of IfU.
[It has Ijeen known, however, to occur in young persons, Stell .^
niiT «een a caste in n girl of lii. Schirmer in a boy of 12, and >
''ty uf l\l, (jlauvoma occurs in nhoul one p<;r cent, of all eve du-
L -. atitl with about the same fre<|uency in thu two aexca, tliougli Uic
lln iuHatumatory form is met with ofU'ner in women, tuui tho simple
■' " liimatory in men. In a certain proportion of ca-tes ll.i '
trv. — B,l Von (Jraefe believes that the predis[KMiti"
U) ^L.kU(joma is chiefly due to two causes:' 1. Tbe saiue decree u
I "A. f.O.," x«.T"^-
590
OLaDCOMA.
7— PHOGNOSIS A>D THEATMENT OF GLAL'COMA, ETC.
If the disease be left to itself, or be treated by iiipfficieiit remodiea,
tliv prv^iio»i» ia most unfavorable, na Jt lenrU sooner or later to deetruc-
tjon of »ight. The obi treatment, wliich consisted in leeching, capping,
mercurj, opium, etc., faiU, and is sure to fail, in atayin;; the progresa of
the ilii<ea&c. The acute itifiainniatory attack oui}' subside untler ilie use
of these remedies, or even without any treatmcns whatever; the inf)arD>
matory symptoms may diminish, the refractive media again become
tnuisparent, the Bight restored, aiid the patient and bia medical attend*
anl may deceive themselves with the fond hope that the dangeroiu di.4-
oaao baa passed away aud is cured. But this is not so. Sooner or later
the eye again becomes attacked, perbaps by acute exacerbations, per-
haps by insidious chronic iutlauiinalioud, which gradually lead to total
and irremediahle blimlnci^A.
[It Hluuild be especially remembered that all mydriases, particularly
atropia, are to be avuidud : for ati acute attack of glaoeoroa liaa been
repeatedly known to occur after itialillatinn ofatropia. — B.]
The chief and most important indication tn the treatment is the dimi-
nution of the abnormally increased intra-ocular tension, for as long aa
this exists we cannot hofic to arrest the progress of the disease. Pars*
centesU of the coniea baa long a^o beeit tried in the treatment of gUu-
coma, and has lately been H;;ain Htron;;lv recommended as a cure for this
disease ; but wc know that its efioct is Vut transient, that it relieves the
iiiti-a-oculnr tension for a short time, but that this relief is not perma-
nent, for the latter (as well as other glaiicomatoiis symptomit) soon mani>
feeta itself again. [Sperino has advocated paracenteciis of Uie cornea
most strongly, but has come to the conclusion that in tJte advanced
stages of glaucoma it cannot rival iridectomy. — B.] Division of the
ciliary muscle (as it has been termed) has also been much vaunted sa a
cure for glaucoma. That it may tem|)orftrily relieve tension by causing
the escape of the aifueous and [>erhapa of some of the vitreous humor,
cannot bo denied ; hut ta[>ping tbe anterior chamber will do the same
thing. If a considerable amount of vitreous humor tlowji off, the tension
may eveu be purmanentty diminished. But the escape uf vitreous in
glaucoma ia a thing to be avoided, if possible, and not to be desired or
courted ; for wo find that the loss of vjtreous (for instance, in tbo o|>era-
tion of extraction of cataract) generally renders tlie eye more prone to
chronic inHammatory affections of the choroid, accompanied by opacities
of the vitreous humor, etc. At present no evidence has been brought
forward by the supporters of Una operation that would permit of oar
placing it side by side with iridectomy in the treatment of glaucoma.
[Hancock first proposed intra-ocutar myotomy, Ibiuking tliat glaucoma
was caused by a spasm of the ciliary muscle. Ho iutroducml a Beer's
cataract knife in the sclero-conieal margin between rectus exteruus and
inferior, and eut tiirough sclera and ciliar}* muscle for about one-cighih of
an inch in a direction from above and forwards, outwards and backwanU.
Various modifications of this operation bare been proposed by tiolumou.
PROaNOSia AMD TRBATUENT OF OLAUCOMA.
591
Ilciberg, and Prichard. It ia aaid to be without danger, and to give
Uie best resulu in ikcut« glaucoma. --B.]
More recently ibe incision of the sclerotic (sclerotomy) has been
brought forward as a aubs^tute for iridectomy iu some cases of glau-
coma, and ha^ been chiefly rocommended hy Dc Wcckcr' and Qiiaf*ltno.'
The fonner now performs the operation a« IbUowd : With a narrow
Graefe's knife he makes (he pwncture and cuiinter-jjniicture exactly
as in his operation for extraction of cataract; hnt in -withdrawing the
knife he leaves the central pan of the flap standing, which diminishes
the tendem;y to prolapse of the iris, lie has tried it seven times in
eases of ahsohite glaucoma accompanied by intense pain ; the latter
was stopped and the eye tension diminished. QuagHno makes the in-
cision in the sclerotic (about 2 millimetres from the cornea) with a very
wide iridectomy knife, and in withdrawing tt very slowly he presses the
back of the blade somewhat against the iris, m an to prevent prolapse of
the Utter. Tf a portion of iris should protrude, it must be gently re*
placed ; bat if it should protrude again, I think it wuuld be better to
excise it than to irritate the iris by repeated attempts to replace it. I
think that the operation must he tried much more extensively before we
can arrive at any just conclusion as to its relative value. [For a Full
and complete history of the operation of sclerotomy, the reader is re-
ferred to Mauthner B paper on Glaucoma Aphorisms, already (|Uoted.
(dee "Archives of Ophth.," vii. 2, 3, and 4.) Both Weckcr and Quag-
lino think it offers better results in acute glaucoma than in any other
form of the disease, but Schmidt thinks it is to be preferred U> iridec-
tomy only in those cases where the iris is so atrophied that it« excision
u reodered very difficult. Mauthner belieres that even simple and
chronic glaucoma, as well as the acute inflammiitory form, oaD be cured
by sclerotomy ; but the scleral wound must be made in the proper way,
and must not be too small. He lays down the following rules for the
technique of the operation: 1st. A one percent, solution of eserine
sulphate must he dropf>ed into the eye before the operation. Sd. The
operation should, if [Kissible, bo performed without narcosis, ifd. The
StfCtiou, if possible, should be made upwards. 4ih. Ivitor with Oraefe's
narrow knife at 1 mm. from the edge of the cornea, as if about to make
a scleral flap. 5th. When the knife had made the counter-puncture, it
is to he piistied slowly forward, and the operation is to be ended in the
{ilowcst possible manner, and with a sawing motion of the knife, tith.
The flap is not to be completed, hut the apex is to be left as Weckcr
advised. 7th. The sum of the length of the two incisiona should exceed
the length of the tnetsion in simple iridectomy. Kth. 11ie knife is not
to be removed from the eye until the aqueous has entirely escaped. 9th.
I'lserine is again to be instilled, and a tight biindnge applied. Mauthner
thinks that sclerotomy should unconditionally repluce iridectomy in the
following cases: 1st. In the so-called prodromal stages of glaucoma.
Sd. In glaucoma simplex, where central and peripheral vision are still
' " Kl. MonataW.," 1871, p. 305 : and " Annalos d'Ocaltsllqufl." M&re-AvrtI,
1572.
* " Annali dl OttalmologU." p. 200. 3871 ; vid« also a paper read U tlw Ophthal-
moluKirxl Caii|[m3 held in l<undan, 1673i •
m
•tACCftXA.
•Imnrt rtAnut. M. Tn afcraiwc glji»ewa. wbea ck« defect in the 6fM
iMMtlniwn sxtrMDpIv amr te ihc amaimi fisatH*. -Mi. la eoajmiitol
},i'<1r'-<nhttiBlaua, llw operaim^lHWfrwr. hw «m t«c been done with
' rrec)iii!ncj O illow of ito tJtiBiM« nine to be &u4. Glancoutft
ii> T Fx- i iiitpd Srates U a nre HjjeMe, ani ilttmg^ atiermumy has been
(l«ie B ontnlwr of tjovte, tbe rtrtiiOca us toe ^nll to be of bo^
rali'-
I ' ,00 the Other haatt, bao bvea pr«*a4 to &Miiiah (arwl m
thi' ri^ of caM» penaaaenilj) ibe ■boar— Py hiereaeed iotra-
.,..■(). The aHminiMe reenlu ef ibb apefa&m m A« treatment
<iim hnvr lotii; atfaiiitrrl of t*o AonUt, itttfi atvl efi>k>ne<l aj tliej
>i&i . iDMt of the dHORgaHbed oeafaitfa of Ewppa.
i4#>^n of t}ie ofMratiMi bare, mppmnady^ tbfl^rt Cliat iu
CTififinri 1 for it the f<«wer of retoruig ngbt in all caae* of
I'UiiAini.. .,!'"<-r ihmr suj^ or oatore angb^ be. Bai nooe of its
* tntve ever done thi« : thejr have oaljr apbtld ita curativ«
^nw cams in which irremnUe rhaaffle m tbe Btmctiirea of
»>t yet taken place. Tbe exseat of cba beaefic which nut;
"< iri'lecloniv will, therefore, 'iepead opoo the BUkj^c an>l
^I'tr. in which it is had regoorae to. Il oiajr Im* laid
>taOTT «• an »jn<im, timt the •ooner the rtptration in performcJ wbea
,.Ar^ .i-TT>|.,„ni« hare bocotae marked aod frenuent, or after
u timriue. the better; ao that tbe alection ha^ not yH
tnaterinl changea in tbe Mnieturee of tbe organ.
iittsidcr what progawig may genmlW be given of
eioKiB of iridectomy in the various staj;es wl forms of
ry Stuffe. — A* lonjf %i the ftremonitorr «Tmptom9<
• ■''rr«l» and the intermivHioiu are complete, tlie
il eonditirt'i duriii;; itie tntervalSf we may (Kwlf
■•afptr. Wc hIiouM, however, warn the |>ati#r
I'ati^e or exertion of the even, and iheir cxjiosai
•r rapid chan;;oH of temperature : a^ioitt every.
■■, ^r jinnliice h_yj»crwniia and irritation of the organ,
hwcen the oiithrealc of tbe disease. He muAtaUo
rf every kind. But the ayatem of lowering atiij
from (itaiicnmii is not advisaljle, indeed oflea
J,,,,, aiwnUrly il" ilicy arc elderly, and hnro been vpr
.tzrnt* rihould ho pla^od u|ion an family ■li;{<^4tiM'
..»ps generoua diet, and should l}c pumiitteil
=f,,. , -^m^mm-- •taflalanls, tlir i|(iniitity being regulated by tbei|
fition of their t^cncritl henlth.
aid I
JlllUT
fllnno.
wa» can
caiiirnct ■
lerior,!!
inch in .
arious iu<
OD loiiRcr fjiimpU'te. hut there ore only remiM
F the periodic •ilt^^iinitiona, the ciliary nonnil-J
r U »Uort intervftli* of ft day or two; if Id*
^■^ireil ar rl :ho fitdd conti-itc-ied, tlie vessel
■rM, it would he dnn^craui* to delay thai
attack \e then probably imminent, aulj
cy niny he, anil whether ic may not
even tliai of glnuooma fulminans, ooj
PROONOStS AND TREATMENT OP QLADCOUA.
593
jiidly lead to such serious lesions of the structures as great!)' lo im-
p«ril, or even to spoil, the inie{;rity of the orgnn, before operatire aid
can be ohtained. But there i» another renson why we should not wait
for the acute outbreak of the disease, fur we cannot be certain that it
will occur, as the alfcriion may gradually, and pcrhHps alnin^t imper-
ceptibly, pass oYcr into the chronic glaucoma with excavation of the optic
nerve accimii>anied by sncii a d<?teri(>ralion of tlu- retina and other tittttiies
that the operation may then prove of but little avail. If iridectomy is
performed during the premonitory stage, when the symptoms become
* and the attacks fre.(uent, but hcfopo any structural changes have
place, the proj^nosis a tuwi fjivorable, fur the progress of the dis-
ease is arrested, ami the si^ht of \Uv eye saved.
In atnite iiitftimmatory (fhiu-'tniut tlic prognosis is also favorable, if &e
operatiou ia only performed sufficiently early. If the impairment of
vision increases very rapidly, if the sight is already diminished to a
more quantitative perception of liglit, or if the visual tivid is much con-
tracted, the delay of the ojwration would he mo^b dangerous, and it
sIjouIiI be performed at ouce. We may generally expee't a nearly per-
fect result if indectomy be had recourse to within a foplnigbt after the
outhroak of acute glaucoma; alvravs remembering, however, that at least
good quantitative perception of light roust still be present, fiut we
should never voluntarily wait so long.a.-) there is always a risk that dur-
ing the ilelay the ti«sni'H may undergo aerioua clmngos. Von Orac-fo
lays particular sliv*,-* upon the fact, that the immediate nrces-tity for tlic
0|>c*nition dependii le^^s upon the intensity nf the inflammatory symptoms,
the acutcness of pain, or the amount of increased tendon, than upon tJie
•Ute of the vision, if this be not greatly impaired, if the [lalicut is
Btiil able to read large type, the operation may be jwatponed, if it be
■ necessary, for a day or two. But in the inl^trim, tlio [tatieiit must be
dosely and anxiously watched, and if rapid diniinutitm of vision rNjcurs,
no funher delay must he permitted. SmnrtiniL-s tJu- nue.ilion may arise,
Lwhetlier a patient suffering from an atLick of acute glaucoma may be
permitted, if neoeBsary, to undertake a juuniey in order to have Uie
operation p^-rformert, or whether he may he safely allowed to wait nntil
the inHammation baa subsided, and the eye lias agnin become *' (juiet.**
Here I must siTongly urge the necesnity of not delaying, for if the jour-
ney be |>08tponed until the intiammation is allayed, the eye may he found
^ be irretrievably lost. The joumcv would have proved far leas dan-
gerous than the delay. But even it tiie most favorable event should
occur, if the inllummatiun should subside, and the eye npjiareutly regain
its fonner condition, we know but too well that the disciise is not cured,
that it will sooner or lator recur, citbcr in tlie acute form or as chninic
gtaucuma. In the latter case, the progress may he so intnidious that
serious and irreparable changes in the optic nerve, the retinu, and the
coats of the vessels may ha^e occurred, l>efore tlie patient's atteutiou is
attracted to the state of hts eye.
In tflmia>ma J'uhuiiutini thf optrntion mutt be performed at 90m a$
-p'irsifite. The structure.-' undergo hucIi great and rajiul changes thut the
eflcct of the operation mav not bo |)crfect even when it is performed
S94
OLAUCOHA.
within thrtc lUrs after the outbreak of the dueiue, ai wm shown
CBBo ui" Vou CintelV's.
Ill llitMo oawrt uf acute glaucoma in which the pain is rery intense,
anti tliere is much incHuKlion to vomit, but th« imjiairment of iruion la
Quly moderate, Von (iraefe thinka it may he bt'tler to vfait a day or tw
before performing iridcctoinv. Here he employs the auhciitatieoua '
jection of mori>hia, p*- ^ to J, in the region of the temple, in order
procure a jjood ni^lit** rest, and to «|iiict the nen-ou« system before n
rating. But if we give chloroform the iperaiion nee<l not, I thiuk,
pOdt[>uneil ou thii^ account. In fact, iridectomy proves the hv»i iitiU)>li
gistic, and it4 beneficial cfTrcte in acute glaucomn are moot marked a
brilliant if it be performed sufficiently earlv. The teneion is general
greatly dimitiiahed directly after the operation. In the next few ilavs f^
may increase aj^in a Hide, but then it subsijes »pontHncoii«ly to
norma) standard. Tlie anterior chamber is either re-foriiKnl very ^Ito
after the irideclnniy. or in the first few days. The relief of the ofiena
Qtziug pain is gencnilly immediate ; paiiente soon full into a tran<|uil a.
rcfi-CMhing «Icep, after having perhaps passed several sleepless, miiwrah!
iitfEhtri : the intlainm»tory gymptoma rapidly subside ; the ^ight is greaU
imprnved, imrtly from tlie dimiuiuion in the intra-ocular loiisiou, toi
partly from the escape of the turbid aipicous humor. This impr»vfiiit'iii
rapidly increases during the lirai fortnight, and is generally due (o the
absorption of the rotiiial ecchymoses which occurred during thu ojwt*''
tion. The improverocnt of sight reaches its maximum extent ahoui two
months after the operation. If the latter has been performed «ulIicicDtlf
early, vision is generally perfectly restored, the patient being able to
read the very finest print (with, of course, the pn»pcr ghts^s, if li« i*
presbyopic), and this improvement is, in the vast majority of cases, pw-
manent. Such a result may even be expected up to within a fortaigbV
after the outbreak, if, at the time of the operation, there was still gP«i
perception of light and no considerable contraction of the ficM.
In tlie late stages of acute glaucoma the results of the operation vary.
In such cases, the prognosis will dcfieiid u|>ou the extent to which the,
degenerative alierntions in the tissue have alreiuly advanced. Tlic- proa
Qosis may he favorable if the visual field is only moderately contract*:'
more jtartieularly if the contraction is not slit-shaped but concentric, '
fixation central, and vision not very greatly impaired, especially if
impairment de[H;nil« upon cloudiness of the refractive media and li
creased intra-wular teiisiun. The operation will generally not oi
restore au excellent and useful amount of vision, but this improvemi
will mostly be permanent. It is diflerent. however, if the field is greail,
contracted, especially if it bo alit-ahaped, if "the fixation is eccm
vision much impaired, and the latter due, not to opacity of the refracti
media, but to an already considerable excavation »i the optic Dcrve
deterioration of the retina. Here the prognosin must bo guarded
although the operation may do tnucli even in such coses, the good rmtll
mkx sometimes not bo pcnDtnent. but ttie sight Ih* gradually lost ag«*
vit&tr Uuvugh n.'curreuce of inflammatory attacks, or through pro,
tin Mcavmtiou and atrophy of the opiic nerve.
Til* prognoaia of the c'tfcct of iridectomy is extremely bod in
4
I
wconilftry glaucoma supcrvonin^ u|H>ri hemorrhagic aflfections of the
retina (Uie ito-callcd hcmorrtiaf(ic glmicoma). Oulj in very rare in-
staiicea is tlivrc iitiy pcrtoauent iinpravement, generally the operaUon
gires rise Ui a great iiicmBk-se in hemnrrlinj^ic offusinns, which may burat
Uirniifrh itito tiie vitreous, rapidly deatroy the l«<t sjlinirocr of si-^iit, and
pro<luc« Buch cxcruciatinj^ paiu, tliai the eyehal! 1ms tfl lin excised as the
only mode of rcllcviiij^ the patient from his agony. Von Graefe has
i]ittl<.- abandoned the operation in LhiK Ibrm of gliiimoiua. It may ho a
question, however, whether, in those cai^es in which the patient has
already lost llie other eye, vre mar not afford him the last chance and
operate, warning liira well, however, of tliu but l^io probable uiifortuiutto
renull.
In chronic inflammatory ijlaueoma the prognosis must also he guarded.
The progreaa of the discatto is but too often so insidious, tliat tbo paticnta
do not tipply for medical aid until very cunetiderabte chansca have taken
place in tlie tiiwucs, more particularly the optic tierve ami retina. Iri-
dectomy will, liowcver, generally ftrn.':<t the disease, and preserve the
existing amount of vision, or even improve it. This is particularly the
case if the fixation is still central, tlie sight not too much impaired, the
optic nerve not deeply excavated, and the field of vision not slit-shaped,
but contracted laterally or concentrically. In such cases, the progress
of the diseikse and of the stniutnral changes is generally stayed, and the
exi)<ting amouiit of viaiuii permaneiilly preserveil. Tlie heuetieial effects
of the operation arc, however, far more slowly developed titan in acute
glaucoma. Months elap«ie before the improvement ha^ reached it$ uian-
mum deforce, or before we can be certain that the effect will W {»enoa-
nent. But even when the field is greatly contracted and the fixation
Tery eccentric, we may yet occasionally be able permanently to preserve
a certain nmount of sight, enough perhaps to enable the patient to find
his way about. Ami eveu this little must Iw looked Ujiou as a great
boon in com[>arison with total hliudncAs. But in such cases, die elVcct of
die operation is sometimes only temporary, the tension of the eye again
iDcreases, the virion slowly but steadily deteriorates, leading at last to
lOniplete loss of sijrbt. This is far inort' lre<|uently due to prugrensive
rophy of the optic nerve, than to a recurrence of the glaucomatous
symptoms.
8houhl a recurrence of the glaucomatous inflammatory symptoms witlt
increased tension, take place after an iriilectomy, the 0[>eration may b«
repeated with Itciiefit ; before doing so the efl'cei of repeated paracen-
tesis should however be tried. This U jiarticuUrly the case when the
original iridectomy has not been sufliciently largo, or tlie iris has not
been removed ijutte up to its ciliary in'^^rtion. The second iridectomy
should he made diametrically opposite the first, 80 as to cut off ttic two
halves of the iris from each oiher ; I have often performed this second
operation with much advantage in obstinate chscs of glaucoma, and it
appears to have more effect ihati if the second iridect'Muy is made beside
the first. In those casen nf glnncoma where it seemn likely that the first
iridectomy will not suflice to diminish the tension permanently, and that
a second one will probably be required, the two opposite iridoctmuics
may be made simultaneously with Mr. Bowman's stop knives, as described
^mmmiK ^Stl increases ngut:
— ^m/'1 be ayaiu rtpeate*
-d. tftiiier fmin ;:;Uiicf>[nfz
^Bpa B» tnflnmmatory attAe '
.^■■Mb U> reniovL* it, an tliL*
Btic irritation eanae*
t^cfar fiKt, that a wtiidsh diaeo
't rrtnptom of progresairo
increases lu iQienntr f<
' in cases of some stnnainj
»-&>«t«>ntioa progresses up to a
»•■, It Is only (iangerons when t-
bj a simultJiDcous deteriorai
~ :3Hi^i^ vkieh are not acuompnniet) hy
^ Amtaat nimfitcx), we find that rC
^ B«Tv. as ill chronic glaucoma, thfl*
mirrmt >iues not apply limit the iliseaac fal
V a4«ctei]. t)ii8 may be nearly lost k
■^ s^ aaftbing is the matter with it, and!
HC (&* disease has nearly, if not com^i*
■IT such serious <.'haD;;ea in the stru
i»tat of little if any avail. It is other
fac%i>l witli iJie ttanic form of iliseafte; fu:
^"■fk'al ai<l, and wilt consent to a timol
■ _rit may still bo gowt. Id order to
, !ae 4|wnition iniist be performed oarly,
■ tivMM have been producod. <rraefe r
.^■IM^ould be perfunneil in time, und i^ho
.•^■hbimpairment of vision or inHaramatory
Here also tiie beneficial effects of the
.,v..t It and graditully. If Uio utropliv of tii
r^ iLtj i»r. a Btcftdy, tlmu^li alow, improrcme
i-ajtes in which, during a r>crio<i varving
• . ttv field of vision and tne sij-ht had
-.»niled, and where after iridectomy (dii
_-~^ , ^uudiM); from one to three years), either
^««tfiaudenihle improvement occurred. 8uch im
, m nw eases in whieh, together with a i^erfevtly
.^•fffwaable increase of tension was absent. lU
^lannMnt is the more likely if the impairment of
^pM ite condition of the optic nerve, but is aU
■iippduKnt in the conducting power of tlie retina
• ivodoBcd that tlio renntts of iridectomy vary gi
ffauHtHBtt itimplex. In the great majority of ct
■<• s nonnal standard, and the offtrct of the
I , jther* tlic tension still remains somewhat to<
ii«» u|)*r*tion. and may ;(radually increase mon
oMW npefttod paracentesis, at intervals of two or
h&8
OLADCOHA.
ft regard for the different facts whiuh ahonlil influence oar pl^pifia of
the effect of iridectomy in ginucoma, has been one of the cliief reasons
whv this operatioD has proved unsuvcesaful in the bands of some practi-
tioners.
1 Smv iridectomy dimiaiBhes the abnormally increased intra-ocular pres-
irc in {glaucoma has not yet been decided. That it does in the vast
inujority of cases permanently relieve the tension w, however, an an-
douhtcuanii imwnirovertible fact. Various theories have been advauced
in onlcr to explain tho tnotlug operandi. Amongst other hypotlieses,
some have thoii|j;lit that tho tension was dimiiiisbcd by the excision of ft
considenhli! [Hirtion »f the secreliiiy (i"*) surface ; others, tlint iJie re-
moval of the iris fpiitc up to its ciliary insertion, and the conse.|iiont
exposure of the zonula Zinnii, facilitates the interchange of tluid )wtw«vn
the vitreous and ac|ueoiis humors, and thus diminishes the difference in
the degree of tension between these humors. We must a/lmit, however,
that this prohlera has not at present been satisfactorily solved. [A
recent statement of Kxucr's, hasdl on anatomical inrcsti;^lioits, is of
some iiti|>oi'tiMice liere. Assuming Chat, with tlie increase or decrease
of Iho intra-vascutar tension is cocuiected a corrcsftondin;; chan-^ in the
intra-ocular tension, he found that iridectomy lessened tlio incra-rascular
tension as follows. Tho excised iris contains the smaller branches of the
arteries and veins witli the connecting capillaries: there remain behind
in tho eye only the larger arterial ami vt'nous trunks. Between these
are formed direct anastomoses, as injected preparations show, by which
the arterial blood pa?«es directly into the veins. Thus a lessening of
tension is brought about in the arteries of the iris, and indirectly in the
choroidal arteries. — li.] Now some opponents of tho ojicration appa-
rently reject it, because the solution of the m>>du» ovtrandi has not yet
been found. They wcuild rather deprive their liapless patients of ihc
benefits of iridectmny, which would, in nil prflh:ibility, cither restore or
preserve vision; they would rather permit them to lose their sight, than
ficrform an operation, the effect of which in diminishing tension, though
ully proved, they cannot at present satisfactorily explain.
Some writers have i^tatcd that the operation of iridectomy, as it is to
he performed in <jlaucomn. is just the same as the old operation for nrti-
fieinl pupil. Xotliiiig couM be uioro erroneous. Tue prineiide of the
two ojicrations is entirely diil'oreni. Tn the old operatmn, an openinj5
was made in the cornea, and a small portion of iris, in proportion to the
desired size of the pupil, excised. In the modem operation of iridec-
tomy for glaucoma, tJic chief point is to make the incision in the stTlcroUc,
or at the nclero^ornoal junction, and of a sufhcient extent to p«<rn)it the
removal of a targe segment (if tim iris (a))oui one-lifth) ipiitc up to ita
ciliary attachment.. The more intense the symptoms, the more cotisider-
ftble the increase in the intra-ocular tension, the larger should the iridec*
tomy be. Many of the negative, or only partially successful, results
which have followed the employment of iridectomy in glaucoma, were
undoubtedly often due to some fault in the performance of the operation.
Either too small a portion of the iris was excised, or it wa« not removed
quite up to its ciliary attacbtucm ; or, again, a pan of it may have
become involved in the secUon and tended to the formation of a cystoid
PB0ON0SI3 AND TREATMBXT OF OLAUCOMA.
599
cicalrix. which proves a fresh source of seoretorj irritation. We some-
times tind that if only a smftU portion ia reinove<), and this not up to the
ciliary insertion, the symptona do not completely yield, and more or lesa
increase of tension remains. If, in Aiich n case, a second and a lar;;cc
iriiU*ot<nny is ins'le, more crtpcuiully in iin opposite direction, and the
iris removed quite up to iM eiliiiry attachment, the hcncficia) effect'* at
once bworne apf/arent, the tension diminishes, the infiammattnn subsides,
and the vistjon improves. The iridectomy should be nmde upwanls, for
^e upper lid generally covers the greater ponion of the artificial pupil,
and thus not oidy hides the alight deformity, hut alao cula off much of
the irre^fularly refracted lif^ht. But this operation ia somewhat more
difficult than that in the liorizoiital direction, «tid consoi|iiL-ntly the he-
j^iiiner will do well, at liret, lo peribrm tlie operation uulward-i or inwai-ds.
For a full dcacription of the mode of pcrforminj^ iridectomy, I must
refer the reader to p. '^29.
In tliose Glides of fully-rleveloped gUneoma, in which iridectomy haa
only been aMe to preserve a ct- rtain »tii'tunt of Hi'^lit. considerable hime-
fit is often e.\perieneed from the application of the urtihciaL leech to the
temple some months afterwards.
I roust in couclu«iou cull attention to certain disadvantages which may
sac upon iridectomy, but tliorte are <di<*ht indeed when compared with
the inMtimahlc boon which the operation aflfonU in this disease.
[Whvn an iridectomy hm been dune on an eye during iin acute attack
glaueonm, if the eye i^ eKnmined dome days lat^'r when the media
kftve become clearer, retinal hemorrliages may as a rule be seen, t^en-
enUly in the vicinity of the di^k and m:icula, though they may reach to
tJie ei(uator. Ilcmorrliajjes into the vitreous have also been met with.
The vascular walls are here probably very fra^^ile. and when the tension
relieved by the operaiion, ilicy are not strong enough to resist the
rascular pressure. — B.J
There cannot be any doubt that (be perfonnance of iridectomy during
the period of irritation of primary inHammatory glaucoma of the one
eye predi»p'j«» to, or accelerates, the outbreak of the diseame in the
t>tber. Thi-s, according; to Von tfniet'e,' is probably duo to the triiu-
matic Irritation profluced by the operation in the one eye, being reflected
to the other and there awnkenin<; a pre-cxistin;; disporiition to i^liiucoina.
This predisposition of the second eye to glaucoma cbiefiy manifests itself
during the first four days. Von Graefe, however, never observed thia
tendency in ;;1ancoma simplex or secondary glaucoma. It is esjiecially
fro'iueui if the second eye bus already shown premonitory aympioms, for
he haji in such cases found (lint a marki-d glaucomatous attack occurred
within a fortni^^ht after thf npcnitiim in '!■'> per cent, and in the \aat two
rears in -Ui p>ei'cent. .\ll patients rtbonld therefore be warned of the
chance of such an eventuality, but it should not cause us to jto.npone or
shrink from the operation, as we know bow dangerous any delay is in
acute glaucoma.
Again, some surgeons have thought that iridectomy may cause a rapid
development of cataract. But Lhi^ la not so, for wherever aliortly after
I "A.f.O.,"iv. 3, 117.
600
GLAUCOMA.
«
irideotomi/ a cataract i» Fonncd in a previously healthy Iciu, thu imut
be miiiihlered as due to a soUition of continuUj of the capsule i^orr-
ally hy tiie poiui of a kiiiftf ). Aa the (interior chambtir ia very ilinltu"
iu glaucomn, and the pupil often widely dilated, the extract nf CnUlnr
bean should be applied shortly before the operation, in order that ihf
pupil may hecome gri'atly contnu!tcd,aiid the lens be covered. Or.VoB
Graefc's narrow cataract Iciiifr iniiy he used in.4tea<l of the laiico-ahaped
iridectomy ktiife, for with it we can skirt the margin of the anteriw
ohaffiber. and yet obtain a very larjje and peripheral incision. Wg caa-
nftt, however, regulate the encape of the a'jiieou» humor so well with thia
instrumeDt as with the iridectouiy kiiifu ; Htnl a Huildcn, forcible diEchari;e
of the a<|Ueotw may not only give rise to severe intra-oenlar hemorrliajp,
but also to a (tpontant-ous rupture of the cajouie and a (mh!K*.|ui'iit cati'
ract. Mt)n'uver, on aceourit of the very peripheral pwditiuii of the section,
vitreous hmnor may easily be lost if the patient presaea much, or a little
prolapse of the iri» may occur.
Although the section as a rule heals perfectly, without learing any or
but the sli;^littwt trace hetiiud, we occasionally meet with instances in
which thiM }fi not the cntne, the lipn of tJie incision beiii;; wpuraled by t
web of cicatricial tibres, which show a tendency tc bulge out, nwinj; to
the intra-ocular pressure, in the form of small vesicular or l*addike
eleviiiioiis. Indeed the cicatrix may even give way repeatedly, and tb«,
afjucotis humor escape under the conjunctiva. Von Graefe terms thii
peculiar mode of union of the incision " etfntoid eiratrix.^* It occv
chiefly in those cases in which there has been considerable and narked'
increase of tension for souie time before the operation, also where glaii*
comatoua excavation ha*i flopen-cned upon sclerectasia posterior ; and
finally, according to Bowman, if the tension remains soiaewliat in cxoesa
after the iridectt)my. Von Gracfe, on the conuary, has found the teoj^
aion of eyes with the cystoid cicatrix rather leis than normal. ^|
If a tendency to this form of cicatrization shows ilself, a compressive
bandage sbould be at once applied, and continued for several days or
even longer, being afterwards, if necessary, j«riodically repeated.' If
the bulge is considerable, it ahould be pricked witli the point of the nar-
row knife, or a broad needle, so as to allow the aijueoiis liumor to escape,
and the collapneil membrane is then to be 8»ip|B;d off with a pair of scis-
sors. Mr. llnwniJin advises that it should be re|K.'«t«dly pricked with a
broad needli*. It is not safe to touch it with caustic, aa tliis might set
up serious irritation.
[t'or tlie ladC three years, a treatment of glaucoma by the iustillation
of eserine has come aooiewhat into vo^^uc, the most satisfactory reaults
having been published by Iji.|ueur, of Ijtrassburg, and Knjipp, of New
York. (See " Archiv fUr Ophthalmologic," xxiii. 3, and •' Archives of
Opbthalmologv," vii. 1.) I«n|ueor found that a neutral sulphate of cse-
rine reduced the tension in a cose of acute intlammatury gluucoina and
' Hut if thp t*>tuiian mmnins loo liigb ftrt<>r llie 0[i«rftliAn, und thn AHlofior i>liftmlMv
is not U>nu'-l, niiil t^tvcitdlv If sytriptoius of irriuiion nrv nl lli« aunc tiiui* tn'sMi.
nlu^ Iu rDKiiif(-»i thoiiLM-lVM, Von Crncri- Strang)/ objiwu to tho appUcation uT tliM
KiniprMis, as it greatly incroMei tliv danger.
IlKC
tb«^
tlti^
GUI^H
kedV
d
PEOOXOfltS AKD TKEATMBNT OF GLAUCOUA.
601
iimrke<lly Icascnvil the jMiin. witli improi'emeiit in all tli« sjmpboma wliicb
laaicd for fifiecn luotitlid. Ho then triotl it in a coiifl of sccontlnry ^lauuomn
dire to luxatioti of the Ictw, with ci|ually good rcitults. The dni;» wrtrkej
wfll ill cases of recurriiis j^laucoma al'Ur irifiectomy, aiul in iwme casea
of j^Uiiconia simplex. Mi- Awn not, howpver, advise o-scrine aa a siihsti-
tutc for glaucoma, but thinks it bnit<;d the eye into a more favorable con-
illtioii for tjie Buccca^ful |)erforniiitioe of the operalion. The cst'rine pro-
batilv act^ as an irritant to the muscular tissue of the vesscU a^ well as
upon the iris and ciliary muscle ; contractiag tlio calibre of Uie veMcIs
and thus reducing the intra-ocular prosHuro.
Knapp 8lftt«a Uiat he ban U!t«d eitcnne methodically in the majority of
CAWH of ;;laucomH, Htid ^ivor^ sdiiio Htrikiii^ rci^ulUt. In one cafto of acute
glniiconia c-icrine wn.t instilled from the second day of tJie diitcane, and
the pittient vftis permniieDtly cured. In another uasjc of acute glaucoma,
which »et in seventeeu days^ after an iridectomy for chronic glaucoma on
tliC other eye, eserine produced a temporary improvement only, and an
iridectomy had to be done. In chronit: glaucoma the results were eitJier
negative or unfavorable, and in no case did he see anv benefit from
eserine. He etidorwes Weckcr'a pn>|K»ition of the pp-'piiyhutic use of
escrine in the licaltliy eye after an iridcciomy for glaucoma in the ollicr.
H«, however, rccognize-s that the indiscriminate use of oiterinc is to be
avoided, owing to its lunduncy tu produce congention and iiiflamiDation
of tlie iriK ; for it may caua« an acute attack in n case of chronic glau-
coma. Knapp thinks that if the pupil fully contmcti and the attack is
completely cured, an operation may perhaps never be necessary ; hut if
the rcmeily produces incomplete myopia and incomplete re<luc(ioti of
tension, or if rclapees occur, iridectomy ahould not be delayed.' — B.]
f Fpr A rrttu^itliTdtloi) of t lie fVy-^jt* of o«prf ttf on the frt. rniH iu oiM'? n{ luHinn rm'
a 1>4|«T hy .M'llii in iti« " A. f. d.," rxiii. 2 ; bv W.s-k.-r tti llm " ll,'fic)it<l*'r llvjdvl*
tM»»vr Ojilillial. Own'lUyli.," I*t75. Wober. "i. f. O.,'* xxiii. 1.]
Chapteu XTII.
THE ANOMALIES OF REFRACTION AND
ACCOMMODATIOJS" OF TUB EYE.
l._TnE UEKRACTION AND ACCOMMODATION OP THE
EYE.
The afTectionH uf tlic refraction ami acooimnodaticiD of tbe eje are
daily aa.Huniing rnnre importance, aitil are engaging more and more tbe
attention <>f some of our most able ami Mientific opIitiialnmlogMts. For
it h DOW known that certain forms of a^tthenopia and »rabl}*opia, which
had in former times »et all remedies at defiuiice, arc not due. as wma
geuerallv 8U|»|»o»ed, to serious leaiou:* of the inner tunics of the eyeball,
but are in reality dependent u|ioii i^omc anomaly of the refraction of the
eye, or a peculiar asymmetry of the organ (astif;mnti^m). Since the
discovery of these imjwrtajit facts, a consideralile Kroup of cases haa
hi^en found to be amenable to treatment ; eases whieh liad formerly suirely
puzzled the oculist, and were by him but too often deemed incurable.
The greater the strides which have been made in the inresligntion of
the aflections of the refraction and accommodation, the more evident baa
it become how esseiltiaUy neceasary it is that they should be thoroughly
and carefully studied, and scientitically treated. I would tbcrcforc im-
presit uiion the student the fact that, after ha has made himself conver-
sant with the Iheorctieal portion of the subject, it is only by a practical
and oft-rt'pcatcd exarnlnaiion of a cnnsiderable number of cases, that be
can ucijiiire the re<|ui6ite facility in the examiwttion of the state of re<
fraction and of the rangcof accommodation, or in the choice of spectacles.
To those wbo may consider these subjects as somewhat abstmae and
difficult, I would reply, that the difEculue»i lie only on the surface, and
that a little piTseverance and practice will soon enable tbcm to unravel
tlie knotty points.
Before wo enter upon the subject of tlie refraction and accommodation
of the eye, we must very briefly consider tlic properties of optical leuMMH.
For Biwetacles, tho spherical biconvex and biconcave lenses are almoat
solely used, and 1 shall therefore conHne m^Mtlf tot)it.-ir demrription. In
the article upon aatigntati^m, the properties of cylindrical lenses wlU be
explained.
The biconvex lena is formed by the apposition of a segment of two
spheres, the radii of curvature of the two surfaces bein;; equal. Such
lenses are often also termed convertfimj lenses, as they poisscaa the power
RBPRACTIOIf AND AOCOMHODATIOK OP TOE BVB.
COS
axU, dniwn Frooi A throuj^h the conipi! e of the lens ; a is coiuorfuentlT
tlic lauif^iv of A ; in tho same roaniic r <• is the image of <?, mid tiic niys
from fi, wtiiated uu the principal axis of the lens, arc tinitcil at A, like-
wise placed on this axis, hence A is the image of B. A reverse and
Pis- 163.
^.
ginaller imago of the object A B Cia therefore formed behind the lena
at a h e. The rv,y» which pasa through tho centre <■ of tho lens arc not
deflected; and abe are the conjugste foci of A B C. The distance
C B and c h is also conjugate, for. if the object tie placed at a 0 v, its
tnvencd iin<l enlarged iinngti wouhl he formed at .'1 n C
Now the sixe of tlic imago formed hy the Icn^^ will depend npon the
distiiDce at which the object is tsituated. (1) If the latter is placed at
an infinito distance, the smallest inverted image will be formed behind
tJie lens at \t^ principal focus. ('2) If the object bo appri>xinmtod ho as
to lie at double tlio focal length of the lens, its inverted imaj;e will be
,^tuated at double the foml length bcliind the leii«, and be the ?iame sixe
the object. (A) If the object be brought still closer, but yet further
san tlio anterior focus, tho inverted image will move further away from
the lend »nd be larger than the object. (^4) If the tatter be placed at
the auieri(tr focus no real image will be fnnju^l, for the rays will issue
from the lens in a pamllcl direction. (■'») If the object is* placed inside
the focal length, the rays will still is«fuc in a di%'ergeut direction from
the lens, and the latter will act as a magnifying glass, the image will
not be inverted and sitimtcd behind the lens, but will be erect, magnified,
and ailnnied tn front of the lens, {.<■., on the same side us the object.
Fig. I))4 will explain this. If -.1 B be au object situated closer to the
lens t than its anterior focus /*, ilie rays from .4 will still diverge after
their pa^uuige through the leii', and in such a direction as if tliey came
from a, and the rays from B will diverge as if thej came from A. If
60€ ANOMALIES OS UBPRAOTtOH AHD ACOOH»UDATtON.
tlie Bye E is placoit on the otiicr side of ttie lens, it will sec, instcsd of
tlie object A It, \\A magnifiod, crc^t, imajrc, n A.
Tliii* magniCyiug power ul' thu lens will be greater according lo the
shortnoss of \\s fociu length, i\\\\i a 4-iiich lens nia^^nifies more titan a
6-iuch, and the latter more than a li-incU lens. In order tliercfore to
(^r« t\n- correct magnifying powur, aixl Co tieuionstrace at otvce tliat a
ti-incli leiB loagnifies les* than a 5-inch, we designate the inagrtifying
puwor of a k'lis by fractions, the immeratora of whicli are one, ibe de-
nominators, the focal lenglli of the lens. Thus ono-fourth is siron^'er
than one-fifth, the latter Traction being less than the fortner. Moreover,
thi9 way of expruAtiing the strength of the lens is also correct, as indi-
cating \u power of refraction, for a lens of one-fifth will deflect rays of
light i(U|>ingiug ^pon it tuorc than u leiij vf ono-tenth.
If parallel rays fall upon a biconvex lens, they are united into a real
focus hohind the lens. U is different, however, with a biconcave or
"diverging" lens, for this does not unite parallel rays. but renders them
divergent. Thua (1), if parallel raya (l^ig. l^^S, r t) fall upou a cod-
cave lens, they will be rendered divergent, assuming a rlireclion a.^ if
tiiey had proceeded from./', in which the prolongation backwanU of the
divGrg«iit rays / r* would cut out? another, hence this point ia called
the negative virtual focu* of the len?, and is an imaginary one, being
situated upon the mine fiiiic as tho object. The distance of thi^ point
for parallel rays from the len* gi%'c8 the focal distance of the latter.
Tims a concave lens of lO inches focus renders parallel rays ao divergent,
as if thcr came fn)m a distance of 10 inches in front of the leiia. (2)
If the object is brought closer to the lens, so that the rays emanating
from it will diverge, they will be rendered still more divergent by the
concavf loiiii, and their focus will lie closer to the lens than its principal
imaginary i'ocu<«.
We have now to consider the manner in which the eye receives upon
Uie retina a clear and sharplv defined image of an object placed in front
of it.
We may regard the eye as a camcrarobscum, upon the screen (retina)
of which iH formed a dimini!<lied and inverted image of the object. The
impression of the object will be formed upon the bacillar layer (nyls and
cooes) of the retina, bo conveyed thence through tho fibres of the optic
nerve to the bmin. Iw there received, and then projected hack again in
an inverted direction outwanis to the object, ilie mo«t sensitive |H>r-
tioD of tlic retina being situated at the yellow spot, tliia point is always
RUPRACTtON AND ACCOM MOD ATION OP TBB BTB.
flOT
dirotitcd towards any object at wliich we are looltin;;. T)ie Bcnstbilitj
of the retina, which diminishes rapidlv from the yellow spol towanU the
peripUvry, tuny be excilvd by tin.' unJuIatioiu of raya of ligltt, ur by
iiiocfianicul iiieaiii}. Tlie farmer (■xcitatinu occiim when rnyH, omanatinj;
from » luminonM ohjtict, impinge upon th<^ rotina ; the latter, when the
eyeball U 9li<;htly prusKed by the point of the finger, which will pmiluce
^th* appearance of luminrm? rings (phosphencs) situated apparontlv in a
Edirectioii oi.posite to that of the pressure. Thus, if the oui«r portion of
the Bclerotte he prosned upon, the luminous ring^ will appear at the nasal
aide, and vice verrd.
The refractive powor of the normal, emmetropic eye is such, thnt rays
which emanate fmm a di.<«tant object and impinge in a )iarel1el tlircction
upon the cornea are brought to an exact focus upon the retina, ami the
eye receivey a distinct imajre of such an object. [In Ibis state there is
total relaxation of the accomm^Klfttion, the eye being aJjusl^^d for far-
distant objecta. — B.] Tiie dioptric Bystvui of the eye whicli causes this
refraction of the roya of light, coosii^ts of certain media, which, taken
conjointly, act a^ a bicunvux luna. These refractive media are the cor-
nea, aiiueoiiit humor, crystalliite lentt, and vitruoutt humor. On account
of the ili^bt tbiekness of tlie cornea, the pamllcHsm of its two surfaces,
and (lie fact tliat the refracting power of the corn«a and *(uuuub liumor
arc nearly eijual. we may a-wimie that the two form only one rrfraeting
surface. The index of the refraction of the vitreous humor i^ (dmoi^t
_tho same as that of the aqueous. But the refraction of the cornea and
)f the aqueous and vitreous humors would not itullice to bring parallel
lys to a fwus u|kui the retina in mi euimetroiHc eye, for the fi^ua
rould lie considerably behind it, and the lens is required to render the
rays sufficiuntiy conrcrgent. The axis of the dioptric syateui is called
Jtho optic lurig, the anterior extremity of which uorrcspunds to the cuntro
)r apex of the cornea, and the posterior extremity to a point sttnated
KJtweeu the yellow spot and the entrance of the optic nerve. By the
term vifiual line, is meant the line of direction drawn straight from the
object (through the nodal i»oint) to its image formed at the yellow
awi. It was formerly supposed that the optic axis ond vlstml Hue wore
iilentical, but this is not so, for according to Helmhohz,* the visual lino
l^<iut«ide tJie eye liea somewhat above and to the inner nide of the optic
Mia^ and its posterior extremity on the retina consequnntly liei^ a little
to Uie outer and lower side of the axis. Tliis fact will be found of
practical importance with regard to the ijueauoD of reul and apparent
strnbiitmus.
If we now apply to the eye the principles laid down above as to the
propertied of biconvex lenses, wc can cattily understand the raodc in
which the reverse image of an object is form';d upon tlic retina. Thus,
if A B C(l''ig. ItJiJ) be an object placed at the proper distance from
the eye, a distinct inverted image of it will bo formed upon the retina
at «i 6 c. Let B b be the axial ray passing through the nodal jwint to
the retina. Through thia nodal point draw a straight line froin ^ to d.
This line A a will be a secondary optic axis, and all the rays cmaoating
■ H<>liuhuUi' " PIiyMoloffsdMi Opllk," p. 70.
ItSFSAOTIOIf ASD ACCOMMOlfATloy.
A win be focDsed upon the retica nt a. The str»i«)it line
pawing through tiie nodal puiiil, will )>« anollivr Ktooudurv i)|)tic
wmd all the rajtt from /'will Ih! tmiu-d u|>fiii the mtjnu at c. Uvnce
win b« the iuTcrtcd diminiAhod iauigt; ol A B (J.
unt,'
Now the quosiion^ whether or not the ray* from the object will be
)troiisht 10 a focus iifion tiie retina, and the* latter thus receive b clearlft
deSued iimi;:e. will (h'pcnd ii[>on the slliiiitidn of the object, and the dt
tatkoe for wliioh the dioptric system of the eyv is accomnHMlatcd. The
nnw principles ae were laid down with respect to biconvex lenaes ai'i'ly^
lo this ease. Thus, if an eye i? adjnstod for parallel rays, these will I
brought to a fociu upon the rctinu. If the object i^ now brooglit near
ti» the eye, so that ibi raya become dirergent, Uicy will no lunger
united ni>nn tlio retina, hut behind It. The eye will consetpiently noi
receive a clearly-defined image, but the latter will bo blurred and India*
tinot, on account of the " circles of diffusion'* formi-d ujwn the retina.
A* th« focus of the rays lie-s bcliind the retina, each luniinoua point front
Uip object is no longer presented by a point u|Hin llic reUua, hut by a
oln-ilt' ((he fteetion of each conical pencil of rnyji), and as these circle*
overlap each other, the image ii* rendered indistinct. These are called
" cireh'S of diffu-iion,'* and take Ihir form of the pupil, cousequenUy their
ftilc dinitnishcs with that of the pupil, and mW tY-rxd.
For tlie more exact c;ilculaUon of the pasj<age of rays of light through
tht) eye, LittUng couatructed a diagrammatio eye (Fig. It3i ) having aix
i
canlinal poiiica. corresponding to those of optical Icnseii and situated on
the optic axis. 1. The foeiw ^' (t'ig- 1''m) situated upon the retina, in
viliirh rava falling parallel upon the cornea would be united; 2. The
aulerior loetut f^ at which rays coming from Uie retina, and whu.se
BEFRACTION AND ACCOMUODATIOX OP THB BYS.
609
counw is pnrallel in tlic vitreous humor, wmiLl he brought to a fociw ;
8. 'ilu! two " priiK-ipal points" // //', wliitih lie on the optic axiii iu tUo
interior chainU'r close I>eliin<l llie cornea (in Fij». 1*J7 thcae two ^(oitita
lie lioinewhat t«o far from tlie cornea); 4. The two "nodal iwiut«"
A' A'', ju which tho lines of direction cut caoli other, itnd which lie near
Uic pOKlt'rior surface of ttie lens.
On Bctimnt of the extreiiu-ly xmnll (lictHncc (loi^s than j^ of a milli-
metre) heturcen the two principiil points and the two nodal jiojnt^, thia
disgramniatic eye maj be simplified, and these four canlinit] |iointjt be
reduced to two. viz., a principal ]ioiiit situated in tKe nnterinr cliauiber,
and a nodal point, eituat^'d somowliat in front of the posterior surfaee of
the tens. *Flie two focal points remain the sume. i'or the method of
calculating the course of the ni_v3 nf li;;ht, accordinj; to tJie cardinal
points, I must refer the reader to Ilclniholti!, '' Plivsiologtsche Optilc,"
and Dondcrs'ft work nn the ^' Anomalies of Refraction and Accooima-
dation.*'
A j-lanee at Fig. Iti" will alsti explain the relative ijositioiia of tlio
Optic axiTi (/'/"J and of the vi,'<ual line ( I' f). Tlif latter in an imagi-
nary line drawn from the yellow spot to llie object [M»int. They were
formerly supposed to be identical, hut llelmhoitx hu^ found that tills is
not the case, but that in front of the eye the visual line lies inwards and
generally somewhat upwards of tlie optic axis, ila [>0!*terior (retinal)
exlremilv coti»c'<tueiitly lyiu;^ to the outer aide of tlie optic axis and
alightly below it. Thus in Fig. U\' (which repri'senta a horizontal 3(!C-
tioii of the diasraninijitic eye, the upper «id« of the 1i<;ure beinj; the
temporal, the lower the naaal side) f I'' is the visual line, and F f
the optic axis. At tlie cornea, the former Ilea to the inner side, at the
retina, to tJie outer side of the optic axis. At the nodal point K tliejT
croisa each otlier.
In the normal or emmetropic eye the visual line impinges upon the
oomea &U;»hlly to tlic inner nidc of the optic axis, forming with it aa
aujjle of alwut 6'^. Hut iHtuders has shown that in the bypenuctropic
ojo it lies still more to the inner siile, so a** to form an angle of M** or 0",
-whereas in mjopin the vittual line may correspond to the optic axiii, or
even lie to the outer side of it. These differences in the relntion be-
tween the optic axis and visual line often give rbe to an apparent stra-
bismus.
The Viftuai Angle. — The apparent aizo of an object depends upon the
size of its retinal image. If, for instance, the eye U adjusted for the
object A B (Fig. hW) and the lines of direction, A A' and B B', are
drawn throu<!:h the noilal point i\ the angle A k !i will be the vii^ual
■n{;le under wbicb the object i^ seen, and this au;^Ie Mill ei|ual tbe an^^lo
A' k B'. The visual angle sian<ls in direct relation to tliu sixe of the
object, for the larger the latter is, the greater will be the visual angle
and consequently tlic image, and vi^x vertd. Moreover, the vlaua! angle
will also increase in size according to the proximity of the object, and
diminish as the latter is further i-cmoved from the eye. If, liowever, tlie
size of tbe object increases in due prniHirtion with \Ui ili^tance, it will be
seen under the same visual angle, riius A fi (Fig. liiKj and a A are
e«cn under tbe same visual angle, although the former is considerably
610 AMOMALtBS OF BBPRACTION ADD ACCOMMODATIOS.
further from the eye than ab. From this it will be easily understooil,
that the mere fact of a patient heing ahle to read the smallest print doeg
not exulutle n certain degree of amblyopia. In deciding upon thi« point,
ve must always take into conttiilcration ihc distance at which he can read
it, and thti state of refraction and ftccommodatioo.
rig. isa.
The Bmalle«t visual angle under which an ohjcct can he distinctly seen
hy iho eye is one of.)'. lU'iice thi.-^ ba» been ta.keii as the staudartl fur
determining the ncuteneas of vision, and the test types of Snellen and
Girsud Teuton have been deviled upon thiti principle, as has been already
staled (p. HT), each ty[ie being aeen under an angle of 5' at the di^tAnce
in feet correftponding to it« number. Thua No. 1 is seen at an angle of
.") uiiuutcB at 1 loot. No. 2 at 2 f"^et, etc.
We have now to turn our attention to the consideretion of the subject
of rvfraction aiitl aecomniodation.
By tlie term '* accommodation" is meant the power which every nor-
mal eye possesses of adjusting itself almost imperceptibly and uncon-
Bctonsly for differetit distances: at one moment, looking at something
but a few inches from the eye, at the next, regarding ^ome far distant
object, or taking in at a glance the vajit expanse of miles of scenery.
[Tlie limits of iKc accoramodalion are the far and the near points. The
far |>uint depends for its position on the refraction of the eye, and the
near ]>oint depends upon the accomniotlation. — B.]
In n normal eye the whole apparattu of accommodation is so beauti-
fidly balanced, and its functiontu ure jwrl'ormed with such ease and accu-
racy, tliitt, Jillhongh in n-ality u volnntJiry .tct, its duties arc from early
childliitod fultilli'd intuitivelv, uneoiisciouslv. No wonder, then, that
this power of adjustment of the eye to dificrcnt distances has been a
favorite study with some of the most eminent physiologists and natural
philosophers.
That such a power is essentially necessary wilt become at once appa*
rent by a consideration of ihc following fact, and a glance at Fig. ItSll.
It has been alri'iidy stat«d Uiat the euim«tro]nc eye in a titute uf rest
is adjusted for jKiralle) rays a a (Fig. 161*), so tbat tliese are brought to
a focus upon the retina f>, wittiout any eflfort of the accommodation. But
if the object is now brought to c (12"' from Uic eye), the rays will be
1 I nuijr remind tb<- r«adpr of ttie aignilleittiou of Ike fbllovriiig ftjmlmla : A, nittun
rmi>gi< o^ acooniDodatinn ; r, tut point i f, n*ar point ; <c ( = 0), liiflnllv dbisiwv ;
f, foot ; ", iMuh ; '". lin*.
tm
BEFHAOTtON AND ACCOUMODATIOH OF TUB EVE.
611
very flirergent, and will be focused heliinil the retina at rf, uiiIpm the eye
can increme its |»owcr a( rcrrnetion suSioiently to unite them upon the
rotiiia. If n^'t, circles of (Uffuaidn will be formctl upon the Intter, nnd
the object conseiiucntly appear bliirruii and imiistitict. If the accommo-
Fig. i«g.
tlationof tlie eye is paraTyaed,ray* from tlie ohfect tf, 12'' in front nf Iho
eye, would l»e liroa^jht to a focus uixtn the retina by the nid of ft bicon-
vex len^ of U inches focus, which would render the rays parallel and
thiw ennhlc the eye to focus them upon the- retina.
It is very nccewary carefully to distinguish between the nieaning of
the ternis refraction and accommtxlation, as they sif^iiify two jwrfcetly
different thtnjiA. By refraction is understood, the passive power which
every eye |K)5PeMe», when in a state of rest — i.e., adjusted for its far
point — of brining certain rays to » focus U(i4)n tlie retina without any
active effort or itarticipation of the mu!w:ular apparatus of accommoda-
tion. This power of refraction is due to the fomi of the eye and to ibi
different refracting media.
We have just seen (Fig. Iti9) tlmt the state of rcfniction of the nor-
mal eye is iinch that, when it t-; in a state of rest, parallel rays are
brought to a fociw upon the retina without any cflort of the accommoda-
tion, lu furthest point of distinct virion IJef at an infinite ilisc&nce.
l>onder3 terms thtji condition emmetropia. He says,' " the rcfniction of
llie media of the eye at rest can he called normal in reference to the
nitualion of the retina, only when the parallel incident rayi^ unite on the
layer of rods and bvilbs. Then, iii fact, tbo limit lies precisely at the
measure ; then there e^cists emnietropia (from ififiitp^n, modum tenena, and
a^, ocnliia). Stich an eye we lenn emmetropic.
" I'hia name expresses perfectly what we mean, Tlie eye cannot be
ealled a normal eye, for it may very easily be aboonnal or morlnd, and
nevertholess ii may be emmetrojiic. Neither is the expression H-vrmaUtf
amttruKted eye tpiile correct, lor tlie structure of an emmetropic eye
may, in many respects, be nhnormal.and emmctropia may vx'wi with dif-
ference of structure. Here the Mord emmctropia api>ears alone to
cxnreM with precision and accuracy the cjudition alluded to."
riie state of refraction may ilcvinte in two ways from the emmetropiu
I'oiidition.
1. The principal fomiR nf the eye. when adjnstetl for its far point, lies
in front of the retina (,Fig. 1 1'*). ."u that parallel rays arc not brought
' I)Dii4«n "On tho Aunnnlioe of A<:<>niiu>o>liilii.>n uiJ Kcrraction of tha Bji>," p.
U. Kow 8.rdeiihAu Bocietjr, IHtH.
612 ANOMALIES OP RBF8ACTT0H AMD ACOOMMODATIOIt.
to a focus upon the latter, but in front of it at/, and circles of i1tnu<iiifQ.
h h, will be formed, only sufficiently divcr^ienl rayg hein;: unitc-it ii[x>n the
retiiift. This comlitlon is tornicd luyopia ; also hraclivmetrojiia (^(«2tf
tirevirt, furiioi-. modus, Ji^, ocultu, the limit lico within the tDeasture), ami
depends upon the eyeball being t<Ki Umfj, or the wale of rofnurlioii too
high. A siiitahlc concave lcii» will be required to unite the parallel rays
jijiou the retina (.Kig. 170).
Fig. 170.
2. The principal focus oiay lie behind the retina, 90 that when tlte ere
is in n state n( rest, parallel rays are brought tn a focus behiml the redna
(»■, Fig. 171) at tlic point/. Circles of lUffusion, i/i, are formed, and
fig. 171.
the objects look in<li«tinct. This condition is termed hy{>criuetnipia
(iffip, super, ^triKw, uiikIub, i^, oculns, thu liniit lies b4.-y«)iid the mea«iurt).
To remedy this iinllttinctnciw of the image, the eye nndcrgoea a chanj^
in it« scconinindation, so as to increase its power of refraction, ami ren*
der the jiamllel rays sufficiently convergent to be united upon the retioa.
Tlie saint' etlect may be produced by placing a suitable oodtvx leua
before the eye.
In order to ciprcss that the eye is not emmetropic, Douders |>ropatM
^tlic terui ametfjpia (fnna i^t*^i, extra motlum, and j^. oculus) ; mwt Im*
^" servos that myopia and bypfrroelropia are both, therefore, rcfomblt*
^o it. Fonnerly presbyopia and myopia were supposed to b« upponic
conditions. This is, however, ernnieous. In myopia there is on moiwr-
niflt position of the fiir point, whereas in presbyopia the position of the
fur t"^iiil L8 normul. but llint of the near [oinl i^ changed, being reioorn]
furihrr from the eye. Indeeil presbyopia and myn|ii» inav ooexiat.
l*n.'«byopiu in nut, therefore, an anomaly uf refniclivn, but a diminatioQ
in thn ran;£e of necoiuuimiation.
Il ' been a keenly dehAii.'d <|ue5tion id what tlie changes of
ceoiii: :i of the eye consist, and various opiuious have been ad-
tiired. :!-<>iiiv have thought that the cornea undergoes some altcmiion
REITRACTION ASD A0003IUOD ATION OP TUB BYI.
613
liiirin;; nccoinitioiJation for near ohjects, so tKat ita power of refrsction ia
tiicr<>]i:»tnl, nn<\ the eve enabU'il to ailjnst itnelf for reaiiiiig, writing, obc. ;
but a|inrt fi»ni other reasons against this theory, Uchaholtz ha^ ttliown,
with iiit) ojilithalmotneter, that there is no alteration in the curvature of
the cornea clurinj: accomiuodn.tioii. Oltiers have supj'oaeti that the mus-
cles of the ejehttU phiv aii important part in bringing ahoiit. in conjunc-
tiuo viith the cili&rv nin^clo, thv itiljiiittiiiont for near otijectct. But that
Uiia is not so, has h**cn incmtrovortihl/ [iroveil by a case of voii Gracfc's,
in which all the recti and ohlitjtii munclcfi of both cycit were paralyzed,
»o that the eycballa wore completely immovable, aud yet the poirer of
accommodation was perfect.
It has nt ieiijilh, however, been (leBnitely settled, chiefly by the ex-
{>eriuit-iits of Cramer and Helinholtz (conducled independently of each
other), that the necosaary chanj;c in the refraction of the eye diiriii" ac-
commtKlation ia due to an alteration in the form of the cryalalline lens.
Hehnhohx fonnd, hy means of hh onhthalmomotor. that t)ic Inna did nut
change \H [>Oi)itioii during accominonation for near oigect^;, but tins was
brought about by a change in the curvature of tJie anterior and {m^turior
surfaces of the lens, which become more convex (the lens itself thicker
from before backwardi«), so that the lena aci|iiire3 a higher power nf re-
fraction, and oon8c(|ijently a less focal diritanoo, by which means rays
from even very near object* are brought to a focua u]K>n the retina. He
found, viith tlie o ph thai mom cter, that the eye underj^oea the following
changes duriii'^ accommodation for near ohjucti* :—
1. The pupil dimini:)hed in !<ize. 2. The pupillary edge of the iris
moves forwards. Ji. The peripheral iwrliori of the iris moves backwards.
4. The anterior surface of the ien^ becomes more convex (arched), and
ite vertex moves forwards. 5. The posterior surface of the lens also be-
comes slightly more arched, hut does not perceptibly change its position.
The lens, therefore, becomes thicker in the centre.'
As the volume of the lens must renutin the same, he tliinks that we
■ froU-aietr Itri-krr tijw fniind tlitvl fn nIMnotir fjf* Xhf «pn>-r twtireon tlin t-fliiry
firiiivu*'* nnil the v^lyi" <>f llif> Iwna iHTnnirw iiirri'Aiu'il in HUr ilurin^ imvMnm'irlAliiHi
ur i»«of t>lij*^'t»i. Ilv thiiikit it pnibaMif llial tlm vchjon- of tin: oilinry priK-i^uK:*
VArit.-* in ihiMlirrvrciit ixinctiliouAof Ihv nooomruolktion, kihI iinp]>niM's thai l)ii« ix dii*
to ilin iiitr>'i-pri<-<- in thf hUvii Kiip|tlf to tlir iris, nliinh be tbiulU vnriM with tho diU-
lAltixi aitd mtilrftclion )>f the papil.
C^KH-iiin tiiM niiwi>; iiiiiiiKrflti> ••x|>criinMil« and olim-nrBlioai U to Iho nfiooiiintivla-
ticiii. (.'X HID ill ill): for ll)ii> ]iiirpi«>> ilin ryos of pwrsoDK U|>"n whoni irttJiTtdiny )ia<J linrit
I>«rr»fmtxt. Ill' fiiiinit tliut IliM i-iliiry [iniCReMM move f<>rHn^U and tH-ruiiir Boturwliat
twi'lli^ii durin;: HitomniiHlatinti for rx-nr utiji-oU : and tlinl nUvr tli" iu^lilUti'iii uriiirii-
pini> thay appvar rvmarkaldy r«>tri»rl"nt, whrreiw after tlio uapnf tli»><'nlalwr hi>xn thnjr
may forwardu (vide liis " )J(i.:hAiiii)iiiua d>*r Avrotniuodalion dns in"ii»rliliL'l>fn .InKfot,"
■.eipjijj. 1 86?). I7i tlicv'Xpi.-riitK'Tit^ n* (■) llif- iiiocltnniKni irf lliiM<>i<>iiini<Hlal>"n, wlnttL
H«r« insdi* liy lleiiai-n and VnU-lcrti n^unt digs, ll was found that during thi' nrtinn
nT tlic '■itlary luoscte. tho <;tiimiid nnd ri'ltna an< iilitftmi riirwurd. Tliitt fK<'t would
pxplniti llii>>Hri:urri>ni.'v of the flL-i-iiiiiiMi>'la(ivi<plii.>splii>itt-H •ifl'ii'minh. Iiiid iiiiri<>rt»)rifr,
lui Uitry iiojiit ijiii, of i;rt)at piaciicul liiti-ri-jit Jiiid iin[>'>rtajic<<< in di«i-n9f^ uf tlicnc tia-
Htif*. Fur if IUi!> bi- Hit, it uiknnnl In' liiinialprial in ull'ii^tiouB nf l)ii''-)i»r<>ii| jind rutiUA,
Hln'ttiT till' ni-'i»Hiw«liili"ii id fiiiplnycd or imt, and Hip l-oncfliinl i-ffi-it "f nlropiiie
in *ii>;)i iliM!a:b-ji inny ]in>hal>ly Im> due b> itj* pAralyxIn^ the iNiirrr of atwoinuixUiiun,
and (tin* nbriatinK tti>' luoreuiiHUt of llie oliorx^d and rHina. Tlt« <-xpcriin«nta nf
thy»e ulwrrvfrr l-ml tltriu, on tin* whoI«, to aKfi*" nilh Ilvlniboltx' lliiv>ry of acooni-
ino>lnti(in. ( Hfuitfit iiud Vot'l-frt •• RxiM^nM.>uUl-riiU>niiohuii]{«n Hhvr ilvn Uiwhiuil^
Fiius dur AlHiitiiuuKljtiun. " Kiel, IHciH.)
61-1 ASOMALIBS OF RBPRACTIOS ANT> ACCOUHODATJOX.
may, niorcorer^ assume that the traoBVcrsfi diameter of the lenn becoratft |
dirainUhdi. He fiiicls, from culciilivtion, that these changes in the leua
aiv (juite duiUcieuL for all uccuiuiuuilaUvc jmrjiOttCd.'
Fig. 172.
\
Fig. 172 illustrates llie changes which the eye iiii'1cr;ti>cs during
com mud n tit m. Tlio anteriur [loi-tion of the eye is divided iuto two equal
parti*. Tlie one half, f, bUows the position of the pnrti* wlien the eye is
adjusted for distAiice, the other, N, when it is accommodHtetl for near
objectti. When the eye im in a state of rcHt^ the iris fonns a curve (n)
in the vicinity of Sclilemni's eimal (S) ; but wlicii aKeommodaled for near
objects, the fibres of the iris suffer contraction, tlie [K;ri[ihery of Uie iri«
hcoomes stmiglitened (f'). and thp anterior ch;imlw--r leiij^thened, so that
its dinunnlioD in depth i^ eooipeu^ated for by the adiancv of the anterior
surface of the lens.
The (|ueMion now arises, in what manner is this change in the form of
the lens produced ? There ean be no doubt now that it is entirelv due
to the action of the ciliary raunclo. Cmmer, Dondera, Heluiholu, ^f^ille^^
u« well a* many olhi-r observera, considered tliat whilst tlic ciliary muscle
played the m<mt iiu[)ortaiil part iti the mechanism of the accommodntiuD,
it was materially assisted hy the iris. Indewi it was imposaiblc to deter-
mine with uctiunicy, even after the moat careful dissections and most
elaborate investigations, the relative amount of iniportnnco of the iris and
ciliary mnscde. This quei<tinn has noir, however, Ipeen definitely sot at
rest by a case which oceurred in von (jraefe's eliniiiue, in which, to-
f^etlior with a total absence of the irid (the latter whk removed after an
accident) the power of accommodation remained jwrfcct. Moreover, on
the applicatiou of a strong solution of atropino it became completely
jtaralyacd.
■ II WM Touitd, with Oip n)>li(ltkliiioaivtOT, tliat l)if pmltlon of llif raflwlion )mac<9t
of a duikIIc. producMi by ihi' oiirn<'a kdiI tlir (k»lrri<ir and (ninutrior mirrAmA ttt th"
lent, nndrri;)^ a chinij(f ■luriun; nnxmiiiwidnliiin tor ii««r oltjii-tn. Whili' tli« rt-llfi
imiig)> rrdiii tUc ox-rica rouiKiti* iiiioliiiii^;<<l, ttiitl rroiti Iho ■iit''n»r anrtnei^ uf llir t>-iu
i|>pn)ac|]is ihi! rarneal iiiiaj|:<- jhhI dimiiiinlii<# iii «iip ; t)io nuK^'>- n-«iii titn |Hi«trrinr
inrfitM of llie Ipii9 ftitu dimiuutliwi wry Hlighlljr in miev, bat aiwIrrgCHV no a]i]>rt?cia>>l«
diniige of pMllioD.
THB &ANOB 01 ACCCMHODATIOM.
QXl
[The proecM of ftccoromodation is u follows : Tlie lens, Wing elastic,
tcnilH Ui approach a spburical vhape. Tlio zonula or Buii)>eii!^orv li;*a-
iiietit, wliich iH attAched to the ciliary pnKesse^t aixl to the e<iuator of the
lens, is also elastic, an*! when the ciliary rotiscle is at rest, it is kept on
the stretch ami the lens is thus flattened. When the ciliary muscle con-
tracts, the zonula is at once relaxed, the lens is released and assumes a
j^ealcr convexity by reason of its owti elascieity. It is pmhahlv that
both the radifttiri); and circular fibres of ilie ciliary muscle act simulu*
neously to relax the zonula. — B.]
S^NEGATIVE ACCOMMODATION.
Some ophthalraolo^jista of eminence, more especially von Graefe and
Weber, havt- tlioiight iliat when the emuielrojtic eye i* in a state of rest,
it is not quite ailjusted for its furthest ]>oitit of di»<litict vision, hitt can
liMomc so by a !tlif;ht alteration in ita accommodation, which may te
called the negative acci>mtiiedation, in cuntmdititinctiun to the po»itiee
which enahlein it to adjust ittielf for near objects, von draefe has
thoiij^lit that, by (he aid chiefly of the exterruil muscles of the eyeball
whieli exert a sli|;ht pressure upon the eye, and thus somewhat flatten
ihe cornea, the refraction of the eye is slightly diminished, aud the far
point removed still further from the eye, than when the eye is in a state of
abaoluto rest. Coccius likewise believes that tlie action of the exu^mal
muscles of the eye, as well as the iocroascd iutra>ocuIar tension, may
somewhat flatten the lens, and thus produce a certain amount of negative
accommodation. Ilcnke,' however, thinks that both the positive and the
negative accommodation are produced by the action of the ciliary muscle.
The former being due to the action of its circular fibres, the latter to
tliat of iU radial fibres.
The chief argument against the theory that the eye accommoilatea
itself actively for distinct objects is furnished hy the action of a strong
solution of atropine, which completely paralyxes the power of accommo-
dation, hut docs not interfere wiih Uie distant vision of an emmi^troptc
eye, aiul docs not change tlic position of its far point.
[This is not, strictly siteakiug, correct, for, according to more recent
and accumie investigations, atronia will produce a dimiimtion of refrac-
tion varying from ,'(, to ,',. — B.J
3.— THE RANGE OF ACCOMMODATION.
When the eye has assumed its highest state of refraction, it is accoin>
modatod for its nearest point of distinct vision ; when its state of refrac-
tion is, on the other band, relaxed to the utmost, it is adjusted for ita
furthest point.
itut as the |M)vrer of the ciliary muscle is limited, the accommodation
for near objects must also be limited, aud the near [xfint coimot be ap-
I "A. I. O.," Ti. 2, S3.
616 ASOMALIEB or RSrRACTIOX AMD ACOOMMUD ATIo:( .
proximaUd closer thmi a ccrtnin distance to Uie e^e. In tho irDutlifuI
emnirtmpit cvf il licrt atalmul XJ or 4 inclips from tliP ey«, t'nt rfceiie.-i
fnrtlior ami furilicr with a<lvaiK'ing age. The furthest jwint ufdisiinct
virion in ilie emmetropic eye lies at an iiitinite di»Canc«. The funhetn
point of distinct vision U expressed by the letttr r (punctum rcmotissU
miini), the nearest point bj p (punctum proximiiro. [Tticrc is an ^Ueo-
lute and a binocular nearpoint. The latter h tho ncare«t point iipoti
whicli tlic HCcomtnWation with Itinocuhir viEfion t*aii hv directed. The
alis'>Iiitc neiirpoint iiTrrH Ut one eve alone, wifhnnt rt'gard to conver-
gi-nec, that is nilli motiocnhir vision. — li.] Tlie distance between Ibcw;
two is called the ran^te of accommodation. 'J'lie extent of this nutf;e
\'ariefl, of cour^. according to the strength and efficieticj of the ciliary
muscle, the elasticity of the lens, and the age of the ftnticnt. The dU-
tancc of p from tlic eye (measured from the nodal jioiiii ( in i>)cpre9»4>d by
i', tlie distance of r from the eye by H. Now the raiij^ of accommo-
dalioii can be easily foniiJ, if we assume it to ecjual the focal lens^th of
a leiw which would give to the rayH emanating from an object placed at
the nearest point (p) a direction as if tliey came fn>m the furthest tolut
(r). Let us suppose that the eye is emmetropic and accomaiodab*d for
an object placed at its far point (parallel niys), if the objt-ct Li now
nmvt'd up to i>" from tlie eye, and the latter does not exert ita power of
accommodation, tlie rays from thu object will be brought to a focits be-
hind (be retina. In order to unite them npon tho latter, a bicoinvx leiw
iQu«t be placed before the eye, which shall render the rays coming from
the object (pinned at ft") parallel, i. ft., give them the same directinn as
tbey )i»<I y>\ieu the object was situated at »u inlinit« distance. A 5-inch
leiw Would he required for this purpose, for the ray.s from an object sita-
ated at its anterior focal length would isaue parallel from the lens. If
we now suppose this auxiliary lens placed within the eye, it reprvscnis
the accommodation of tho eye, and iia power the range of accomruuditinn,
tJie latter would, therefore, in this case ~ -. The range of accmunod*-
o
tion - may be found by tlie formula — «■ _ ^ _,
A -^ ^ A ? R
I.et us illustrate thi» by a few examples : —
1. If the furthest point lic« at an infinite distaDoe, B m oc, the
nearest point at 6", P * H", the range of accommodation will be -, for
- — — w — The range of accommoclatiou U here represented Ly mi
u X b
auxiliary lens of tj inches focus.
2. If, in a myopic eye, the far point life<i at S" and Iha n«ar point at
4" from the eye, the range of accommodation will be „^ for - - ^ .
H 4 fct o
S. If a presbyopic eye has its far point at an infinite dUtanc^. and
its near ]toint at 10", the range of accommiMlaUoD wit! b« s-,for
1 I 1
10
10
m
TUB BAHnS OF ACOOUHOOATrOIf .
017
Tlie rollovinf; iit also a very ^ood method for testing the rnngo of ac-
Cfimmnilaiion, ami for ijiiicklv discovering whetlier the eye \a cmmctropio,
myopic, or byperawtropitj: —
A convex lenrt of ti" or H." focus is placed before the eye.' With
thi^ leiiD the patient then rcnd^ No. 1 of Snellen, uiid bis far and near
point are noted. The far iV) and nenr point ( jj' } thus found, stand in
8ucli ndiklion to his real far(r) und neiir point (/'). that the rays coming
from r' arc refmcte-l hy (he lens iis if tliey cuine frnin r, those from
P' tteing also refracted as if they enianotcd from /i. With convex l», r'
(in the cmineirypic eye) lies at *\" from the eye, for niys from an object
at (!" distance falling on i\nf* lens, woul<] \m rendered |inmllel )iy it, and
vronhl, eonse*picntlv, impini^e upon the eye as if they eunie from an infi-
nite distanvv (the uormal far point). The near point ( f-' ) would lie at
ahout "l^". This varies, however, with the age of the patient.
The range of accommwlation is, therefore, easily found by the formnlft
— _ -^ -^ . The lend and its distance fruiu the eye (about I" ) are
omitted in the ealcnlalion.
If (with convex ti) the far point (r') lies at &', the near point (//)
I.et ua illustnitc this proceeding by the follow examples: —
I. .l/y.//>i'f fi/f.—Vt'c find thai with convex tJ, r' = .^", // =3". The
eye is eonseqnonlly myopic, for it is not adjusted for the normal far
point {<[")» hut for a nearer one, the rays from which impinge in a di-
vergent direction iijwn tlie eye : — — ^ - „» =-r-
A S • > 7 5
Now, what glasses will this jintient require for infinit*^ distatwo ? By
means of our strong convex lens we have changed this eye into a very
myopic one, in fact, into a myopia of |, for we should have to place a
concave glass of 5" focus helbre convex rt, in order to enable it to «e
at a distance; for tlii.a concave glass would render parallel rnya as «li-
vergcnl as if they came from h" distance. In order to BimI the pn»j>or
concave gloss for distance, wc deduct concave 5 from convex ti. lloncft
the proper glass will be concave 30, for - - « ...
II. ITypn-metTvjnf eyt. — With convex U. r* — 8, /'' « IJ". The i-ye
is, therefore, hyjiermctrojiic, for it^ far |>oiut lies Iwyoinl the nonual far
point (»>").
Its range of aecnrnmodation w _, for — _ - _ — .
Above we have only sjioken of the nhfthilr nince of accommodation
which exists whuu each eye is tried separately. l>onderh* has, however,
> Tltc \-l\* Tnii»t In^ Btranir, in otHit lIiaL Ihn [mUoiiI tnaj- ri^ll,T rmnniitiHl ItiH far
|ir>iiit, ntii] tliiit till* laUvr diii>' ■■? nitpniKiiiiatiil tu utui^li tlifit lli<.< iiiinitiiiim "f Itiv
Ulltl<^*>r (llftUDt^non no Inngtr i>x»ris any Uitliii'nre, nint luuhlyopia In tlifiyif»rt- cx-
* 0|>. dt. p. 110. Poll Rxplanatiotia, wlUi «xpljiiisiorj' iliagrHnH uf Uiis »DbJ«ct,
will Im round In Donrf«»'« work.
C18 lyOMALIBB or RKPRACTIOir itND ACCOHMODATIOX.
pointerl oat tKat vif most rlistingtiish two other kinils of ranges, vis., tfac
hinoeutar Biid reltUice. The hhwHhtr ci>m|m»e» the accoaiitMd*tioa froa
the fiirthen point r, to the ncarcKt [Mtiit yi, when Ixtth cym are tried to-
aether. Tlie formula U ^ — — -—.
A, i', K,
Although a certain connection exisM between the acconimo<lation kod
the convergence of the visual lines, yvi this connection is not Ebtolutc
and definite, for we tin<l that the position of ihv. visrial lines nuj bt
chnn;^(Hl, yet the accommodation remain the same : for if a itri^m of
luoderate strength be placed with its base outwards before one eye, dw
convergence of the visual lines vitl be f^atl^* increased to overcome tb«
diplopia, and yd the object can bo diiiincttv seen at the same diittaiie«
with both eyo8. A;^in, the accommodation may be altered, and jr«t tlw
Btntc of converf;cucc remain the same, for if we place weak conesYe or
convex lenses before the e^es, an object can still be distinctly aeen at %
delinite distance. Thiit provea tlial the accommoilation may be modified
withoat any cliaof^e of the convergence of the visual lines. The«« ex-
periments shovr that there exists ti certain independettce between tbe i
convergence and the accimimodntion, ami the range of accommodatuia
over which we have control at a given convergence of the visual lineg .
is termed the relative range, and is found by tlie formula — ^ . ^|
It consials, moreover, of two parts, the poiititv and the ««</«'«r^. the
poi^itive being the part which is disposable for a distance eWer than ihs^H
point of convergence, whereas the negative is the portion which 'u re-^^
ipiired to see an abject lying beyond Ihu ]H>int of convergence of tha
vi.<<unl line». Now the relation hctwecn tJiciic two jtarts of the relative
range of accommodation i^ of much practical tm|M>rtance, for it is fouud
that, in ortler tliat the eyes may be employed comfortably for some length^^
of time at near objects (reading etc.), it ifl absolutely necessary tlist tba^^
positire part of the .iccommoilation tihuuld l>ear a certain proportion to '
the negative (it should at the very least l>e e(|ual to ^).
The best objects for testing tlie range of accoratBodation are Snellen**
test types or von (tracfe's wire optometer. But as tlio latter requirea
some exactitude and inietligenco on the part of the patient, I find it more
pmctical, especially with hospital [latients, to use the tcct type^. If,
whilril they are reading Xo. 1, we mnve the type a few time-* iiltematelj
neart>r to anti furtlior from the vye, the nearest and furtlie.^i |>oint of
didtiuct virion can be readily uiwertained. Von Oraefe^a optometer eon-
aism of a pmall Ai|uare steel frame, acrou-ia which a number of delicat«
Tiarallcl, vertical w)ret>> are stretched. This frame mav tie alt«c)>e<) to a
brans roil (graduated in inches and feet^ upon which it u> movable ; or
it may be fastened to a graduated tape. <_hie end of the rod. or the
bobbin of tiiu ta|K-, i» placi-d against the forehead of the patient, and tbe
frame moved to the nearest point at which the individnal wire« still Inait
clearly and sharjily deBned ; the distance of thia point from the ey« is
read olf fn)m the graduated scale, and put down as the itear {Mint (^)*
The frame i.^ tlicii removi-d to thi* gri'iitost diAtancc at which the- in»ii-
vidual wires still appear sharply <lt<tined, and tliis is noted ne the far
point (r). The distance between p and r gives the range of aooainaa>
I
MYOPIA.
619
dalion. The wires only ap[iear sharplj (lefiiicil when the eye acoomncio-
dalca iucif |ierfcctly tor tliem, itirtrclly thoro is the alij^hlcat dcviaiioii
from ihis perfect ftcconiiuodatifin (the framo being too far from or too
near to the eve), the wires seem iii4i»tiiict. Uiickened. or ati if ftur-
roiimted by a haln ; or colored double imaf^eti of tliem may oven appear
in the tninapareut iDtervals, With Che test types the examinatioD is still
easier, the uearest point at which No. 1 (Snctlon) can be di»(inclly and
comfortably rcaii is m«a)iiirvd and noted a« tlic near {>oiiit, and then the
furthest point (in an t'liinietrupic eye No. 1 of Snellen should bo read
up to 1', No. XX up to 'Ht') in mearttircd and noted.
4_MYOPIA.
It baa been alroa<)y shown that in myopia parallel r&ya (emanating
from an object at an iiifiniti- <Ustance) are brought to a fociu in front of
the retina, and that only oufficiently divergent rays are united upon the
latter. This is either due to the antiTO-pOHt^rior axiH of the eyeball
being loo long, or to the refracting power of the eye being too bi^^h. In
order somewhat to im|irove their sight for distant nbjects, short-siglited
persona nip their eyelids slipbtly together. They in thin wny diminish
the «te of the circles of diii'usion by narrowing Ibe palpebral aperture,
and also render the eye slightly less myopic by the pressure which ia
thua exerted upon the eyeball.
The anterior chamber is generally somewhat deeper, and the pupil
somewhat larger in the myopic than in the emmetropic eye. If the
myopia is considerable in degree, the eyeball appears abnormally large
and prominent, the lids are widely apart, and the lutenil niovenientd of
tlie eye somewhat curtailed. The increase in the length of the cyclmll,
and the sub^ovoid shape of it« posterior portion can be easily recognized
when the eye is turned far inward^) towanls the nose, the litlle holluw
which exidLs in the emmetropic eye between the outer canthus and the
globe having diHappeared.
Myopia bt frL'<(ueutIy congenital, and often horedilary. and ita exist
ence may aUo be Bometinies traced bxck through several geueracioc
incroatfing iierhajis somewhat in decree in each successive gonoraiion.'
It may also occur in several members of the same family.
The most fre<|Uent cause of myopia \» an abnormal increase in the
length of the eyeball in its antcro-posterior axis, 'iliis exteiu^ion otcum
chiefly at tlie posterior jjorlion of the globe, and may give rise to a more
or less conaiderable ovoid bulging ([loaterior staphyloma), which ia ac-
companied by thinning and ntrophy of the choroid and sclerotic (nu/f the
article on Sclerectasia I'osterior, p. 5!J'2). But even if this sIkkiM not
be pre-tcnt, the ophthHlmoscopc of^en rovealH a bvi>ei-n:mic »nd eongt'i^ted
condition of the optic nen'e and retina, especially if tlio eyes have been
much overworked hy ariiBcial light.
It iii aUo supposed by some, that long- continued work at near objects
may produce myopia. For persons tbua employed, continually accom-
modate for a very near point, their crystalline lens has, therefore, con-
Btantly to assume a more convex form, and, after a time, it may not be
b
620 ANOMALISS OF RBFRAUTION AMD AOCOMMODATIOS .
ablo quite to regain iw original form, even wtien the ncccBsitj for adjusl-
ing itsplf for near olyects no longer exisw. The eye has in fact become
someulijii myopic.
The pro<!(n:tion ami increase of myopia hy contimioiia U8c of the eyes
at near objecb*, ap|>ear to fin<l their explaiialion chiefly in the fact that
the inner tunies of tlie eyehall hccome congeittcd. The near a|iproach
of tlie object nece5«itate!< a stnui;: conrersence of llie visual liiiet*, which
can-«i;>i iiti aeeiimiihiunn of hliMrd in, aii'<l (;oii;!(>Ktinn of, the inner tUDics
of the eyehfill, these eonditions hf'iiig inen'asnl still more by the stoop-
ing position generally induige«l in during such employment. We cau
easily undei-stand thiit this congestion and uiignieiitatioii in the prewure
of the ocular flnids mnst, if long continued, neceswrily lead to an rxteu-
ftion of the tunics at the posterior pole, and thiu give ri^e to Bclvrecta«ia'
posterior.
[If the distension of the sclera is once eatabliiihod, it is ennily intel-
ligihli' how thii) may he iucreasotl by intra-neular hypenemia aint a state
of irritation.
Though in the majority of chscs the primary cause of the myopia liet]
iti n congenital weakness of the |M)3terior juirt (»f the sclera, yet h amy
certainly he acrpiired. Myopia is often 'leveloped in children after
nientjleit or scariet fever. — U.]
The seeds of ahort-siglitedness are frequently sown in childhoo^l, either'
through a premature over-exertion of the eyes at near objects, or throagb
some afTccLitin of the refractive meiUa (the cornea or Icn?). The cornea
niay, for instance, be clouded, and then the patient often brings the
object very close to the eye, in order to ithtain larger an«l more ilintinct
retinal images, and thus myopia may bo soon induced. The same thing-
(nay occur when the lens is somewhat opHque ; thus it is well known tfa*t
lamellar cataract frcijuently becomes complicated with short siglit.
There can be no douht that the degree of myopia is oft«n greatly in-j
creiwed durinu ehijilliood hy lonir-coutintied study, more especially by]
insufficient illumination and a faulty construction of the tables or desk»|
at which tlie pupiU read and write. An insufficient illumination neces-
gilatCK H close apprnxiniaiion of the object, wliich gives rise Co fltmiiuug;
of the accommodation and congestion of the eyes. A faulty constnwvj
tion of the tables, or of the distance between the latter and the seata, \»^
also injurious by forcing the children to stoop. An interesting and
valuable monfigrsph has been written hy Dr. Cohn' upon this >tuKjrct.
lie examined the eyes of 10.000 school children, and could di.^linctly
trace the incrense in the proportion of tlie myopia acconiing to the con-j
tftructiou of the de»ks and the lighting of the school-rooms. But tb<
valuable and itilcrculing rescarchea nf Dobrowolakj' have abown tfafti
the rapid increase of myopia is often due to spasm of the ciliary muscleJ
which gives rise to uiarkeil symptoiiLs of asthenopia. Aiuongsl the moit]
prominent symptoms are : difficulty to contiinie work at near objects
any length of time, photophobia, lachryttuittoo, pain in and around th(
■ Dr. Cohn, " rni«naobiinr d«r Anfcvn von 10.060 Schnlklndum." Lrfpaie, IWt^
Vide *tM A pKlwr by Dr. Brlmoaun, "A. f. O.." xrii. i. I.
* " Kt. MonsUM.," 186^ ; vli)** *li><> more rewut papvra nti tlip ■■«•■ ■at^nrt hy Dr».!
I]oiu>li, Bwitl, IS7I, and rrof««iior SolilvAd-Qvamstjas, BM«d, 1872.,
UrOPTA.
621
ert>, fliwluii^ of the eyeball, a contracteil |vupil, hyp9ne>>)>» of the optic
4uk aiol fii1nei*4 of tlio retitial ve»!te)!). Aittl t>!t|>cciiill_v niArkird fliioMiationa
in the state of refraction at (iiffereiit titiies iif examitmtiuti. Tliut »iia.sm
of the ciliary muscle occurt) much more frequently in the lower and
medium degrees of oiyo|iia than in the higher, and more ««peciiilly lu
young persons muc!i enK'»ge<i in reading, sewing, or other fine work.
We mu»l niii. however, coiifriiiii.t thiw condilinn willi the a|i|)an-iit mv^pia
occasionally uh&crved in iiyiiermtttropic iiidividtiiilij which in entirely due
to apasm of the ciliary tuuiwle. T>ie tn-atmcnt muAt contti^t chicHy id
paralyzing the ciliary muscle hy the inethodical use of atropine, either
applied in suhstatice or in a strong solution (;;r. iv ad Sj) '2-^ times
daily, to he continued until the ace nmmoi latin n h <juite relaxed and the
muscle completely paralyzed, or eveu iwniewhat longer. SJometiuiv!* the
spaam yields in a few hours, in other cbbcb not for several flays. If the
symptonid of hypcrtemia of tlic fundus do not yield, and the myojua
does not diminittli after the airnpinc has Wen employed Tor several daya,
the artificial leech should be employed. The rehixalion of the ciliary
muscle generally produccj< a marked diminution in tlie degrcu of myopia.
It was formerly 8up|iosi.'il that increased t-nnvrxity of the cornea wa^j
thctause of myopia, hut tliis is erroneoiM, for Dcnulers has found that
the cornea is. as a rule, les.^ convex in myopic por^ons than the emme-
tropic. Increase of the curvature of the cornea (as in conical cornea)
may, however give rise to myopia. We sometimes al*i> find that persona
Biifering from incipient cataract hccomt- itonn^whiit myopic, and ^e twlter
at a distance with concave gla^^es. The real explanation of this fact la
8lill uncertain, hut it may perhaps he due to a flight swelling (V) of the
lens, and a conse<{ncnt increase in its power of rL-fractton.
The diagnosis of myopia is generally a matter of uo cUfliculty. The
far point of distinct vision is more ur le^ts approximated to the eve, in
con«e<'|nence of which distant ohject'* cannot be clearly disiingiiiahed, and
a suitahlu concave lens is rei|uired to render them distinclly pereeptiblc.
We must bo on our guard, however, not at once to pronounce a perjun
shoi't'dighted because be hoVU tttuatt ohjuctA (^uch m small print) very
cloAC to the eyu, or because he cannot ^ee wvtl at a distance, for wo shall
hereaficr point out that this may aUo occur in hypermetro|iia, in which
case convex and not eoncavp glasses are re'jnired to ri'medy this defect.
Together with the myopia there is freijuently present more or less
amblyopia or weakness of sight. This is especially the ca^je if there
18 a considerable degree of sclerotica^ hoi-oidicis posterior, and apiiears
to be chiefly due to the stretching of the inner tunica of the eye, more
especially of the light conducting clementit of the retina. The impair-
ment of Hight may aUo he due to opacitic!^ in die vitreou-' humor or the
lens. Myopic eyes are oft4Mi very irriiaUc, M that prolonged use in
reading ur writing causes them to bt;come red, but, and very painful.
Thia may be partly due to irriutbility and congestion of the inner tunics,
or it may be cauacd by a weakness of the internal reed muscles, which
are not sufficiently strong to maintain the rc<|uisitc degree of convergetioe.
If this insufficiency is developed to a considerable degree, it gives ri«s to
marked gymptoins of aatheuouia and fatigue of the cyea ( vide the articlu
on Mnscular Asthenopia). Wc may easily distingmsb simple myopia
623 ANOMALIBS OV RBPRACTION &VV ACOOUMODATIOX.
from Uiftt complicalod with aroblyopia, by the fact tliat the former can be
completely correctctl by suitable concave glua^es. The le*a the concan
g{i.Me» currect tli« myopiit, tUe greater t* tlie degree of the eoexuti
nmblynpiA, ami vice vertA.
[If the myopia id of a high dcgwe, there U such a marked elongati
of the eyeball that its movement** in the orbit are irapotleii and thid it
the secret of the relirnjuishmentrtf binocular ciiigle virion for iiPttrohjwts.
'Ithis may be regiirdtnl as an advantage, for all strain on the accommo<la>
tion Hiul Rtroiig convergence of the visual axe.i are svotiled. The pa-
tient nsos the beat eye for near work, while 1 he other diverge* to 4
greater or lo3a degree. Diplopia 18 rarely complained of, for tho rvtiiud
ima;:eti of distant objectii, being very indistinct, are readily suppreaaed.
Very often a dt-gree of amblyopia amoutitin* to one-half or even on*-
thinl for the distance may exiitt, and yet the patient is able i/t rend Gn
type easily, owing to the object being held nearer the eye, and thui
being seen under a larger visual angle. In many coses of myopia of i
higli degree, especially if pmgresiaive. the jialieut*i complain of n diwigrce-
ftble pliotopsia, and of " mouchrs volante.*,'* the latter being ulimut
always caused by the projecttim outward of the shadows of small bodies
in the vltreoiij. Thia myodesopia ia the rule in high degrees of myopia
with wiile-spi'ead choroidal changes.
In high degrees of myopia there occur in advanced life changes in the
e<(uatoria1 region and at tho posterior polo, of an inBammatory natore,
conaiating of spot^ which are ^omctimea red, sometiiues white with blac
margiiw. In the region of the |H>*ifrior jwile, the choroidal atrophy I
comes very marked, spreading mainly on the temporal side of the dii'
Ii-ohiled Hpota of atrophy appear and coalejice, vrith hUek maascH of ch
roidal epithelium in and around the white atrophic spots. When th«
region of the macula 18 afl'ected by these changes, vision is serioiuly div
turbcd. There are seen collections of pigment varying in siie, and min-
gled with bright reil or white ajvotj*. often aecompaiiied by heni' ■.
into the retina in the vicinity. f^ometiracK a small aclero-choroii
terior develop^) in thi* region, independent of the atrophy surrounding
the optic disk.
Tho dinturbances of vision accompanying these depend friirtly apon
t' "ling of tlie retina caused by the choroidal changes and [Artly
> Mt' of the retina itself. The patients complain of a trembling
H'i ti'w. of the linc« being curved, ami of pmall ccntnil scotomalA.
It -■■ tia^t oxplaiued tlie trembling of the letters by the presence lu the
aula of these ncnTomala., white the shape of the letters is changed l
ifiiarnce M' the displacement of the rods and cones. In the elon
of die axiit of ibe eye, the sclera is stretched and thinned throo_
"mat V • T! tlie ti*mpornl more than on ilie median side, and
i.ii of the posterior pcde. These changes exert a
tiui:ii<'v upon the o|itic nerve entrance, s" that it is puahcd tuwanU
'< ''■•■■' The distension of the sclera also causes a traction apon
■ of the nerve which is continuous with it, which draws
' ..th and increases the space between the two,
.ire greatest near the disk, and as an ult«ri<
iid diiviuhiiig process, the ciliary body and trts no
the
gb-l
HVOPtA.
&2S
baL-kwnrd, which accounta for the deep anterior chnmhor in manymyopie
(.•yes. (See " Schweigger'a llaudbook of Opbtiial.,'* 1878, pp. 32-85.)
-B-l
Ojfhthalmntrofne DiaffnoiU of Myopia. — We may also recognize tlie
AXistence of myopia, hikI HKccrtiin iIa approxinmte tle^^reu, hy means of
the op)ithft1mo!i«op4'. and thin will oftoii ho fonnd very vi*ctw\ in practice,
pftrticdlHrly when the patient's siatemerits are not very trustworthy. We
oan iliagtmse the esistetice of myopia hy the following appearances : —
I. If we examine a hi;ilily myopic eye in the erect image (that is
merely with the mirror, without any convex lens before it), we are at
once struck by the fnct, that wc can aee the dctaiU of the fundus at some
distance from the (^yt. If we re;5ftr.l one of tJie retinal vessels or the
optic ili^k, and imive our head ttU^htly to one side, wo notice that the
in)B;*e mrtvoa in thf rontrftry direilion; if wc roox'c M the rij;ht it moves
to the left, and vire vertdy so that we obtuu a reverse image of the back>
groami of the eye.
Fig. 173 will at onco explnin the reason of thiii. T4et n be a very
short-sightefl eye (ffr= |), and ft the eye of tlie ohserver : « being in a
state of rent ii* adjiisieil for itn far ])oint (■-■) which lies 4'' in front of tlie
eye. The rays iVom the fundus, therefore, jjasa out of the eye in a
Btrongly convergent direction, and meet at c, and cros.>ting there, fall in a
divergent direction upon the eye of the observer. If tljc latter be myopic
(accommodated for divergent rays when his eye is in a state of rest),
they may he united u[Hm hi.t retina (ft) without the aid of any corr<.M!ting
lens Uliiiid the ophthalmoscope. But if \\\i eye Is ecatiKtropJc ho will.
If ailjii^ted for htt< far point, reipiire a suitable convex lens behind the
mirror, in onler to render the divergent rays parallel. If he, however,
accommo<lates himself for a sufKciently near point, he will be able to
unite the divergent rays »[>on his retina without any correcting lens. The
reversed image of the eye represented in Fig. ITil (.the myopia of which
Fig. 173.
vJ
!>1*
— J) will ho seen at a distance of about T"-8", because »h the rays
from it cross at c, the upper ray, f, becomes the lov-er ray after they
have crnased. atMl the lower ray, </, becomes the upper.
II. In order to examine a myopic eye in the erect image, it will bo
Ueoeasary to place a suitable concave lens behind the ntirror, so as to
obtain a distinct Image of the fundus ; the greater the myopia the
atroiiger must this concave glass be, and the nearer must the observer
>roach to the eye. The strength of this correcting concave lent* will
ftfilib enable us approximately to estimate tlie degree of the myopia,'
' Kt s vt-ry Trill aiid vnlunblf* cr.ilanniinn of lli« ilolpmilnatfcin of lh» tihU of
n-fiat-linti )>.t llir «iil »! Itir i>i)litlia uioa*xi|«.', I iiiU:tt refrr lltr r<-iult>r lu Mnuililivr'a
fi24 ANOMALIBS OF bkphaotion axd accommodatioh.
whicli will be always somenrliat ledd than tJie 8trongt1i of the corrvotiiig
lens. Fi>r iiiatant-«, let ua supjioae tlmt the eye of the observer is ••mrrw^
tropic, and not using \i» jioircr of iLCL>omino<lntiou, nml the jiauirut'i
myopia = ^ (i. «., the rajii omanatin;; frorn a lumiuniift point in the
fundud will be brought to a fucuH 0 iin,-he» in front of it^ niidal point).
Now if the examining eye is f-laccd 11" in front of the optic centre of the I
patient's eye, tbe rayn from the latter would impinge in so divergent a
direction upon the eye of the observer, thtit they would he brought to a
fociiA A" behind it, and a concave gltv^ of 4 inches' focus wouM unite
them u[K>n hia retina. IIciicc, if we add Uie diatance between tlie optio
oentre^ of the observer's and patient's eyea (2") to iJie focal length of
the correcting len* (4"), we obtain the degree of myojaa, viz., ^.
["- If the observer in a inyojie with reliixeil accommoiLatiou, Kin royapia
must be corrected by a conciive gla^i before he can soo the f(indu.<t of an
emmetropic eye dictiuctly. If he cannot relax liis accoiumoiiation, he il
so Diuch the more myopic for near vision, and tbit? mu^l aliM be acoouoted
for in determining the result. If the eye examined ie myojnc. the degree
of hiii own myopia mu»t he Bubtmcted from the gloss which renders the]
fundus of the examined eye distinct, and the distance of the nodal point
must also be taken into conKideratiou." ( Ix»riiig's " Tlie l>etenniriatioa
of the llefraction of the Kye with the (>i>hthalnioscope," lH7t>. — B.]
The field of vision will appear j<mallcr, and the image nearer the
of the ubitenrer tliau iu the emmetropic oy«. The image i« altfo
bright in color and leita ilhiminated, hut apparently larger, for we cannnl,.!
as in the emmetropic eye (thtr sixe of the pupil being e<|uar), ov^Houk'
tlie whole ex|«nse of the optic di^k at a glance, but only a pnrtiira of it.
In the indirect mode of examination, the image of the di^k will he le««,
(than that of the emmetropio eye, ou account of its being formed neuci
to the object lens.
[" For an emmetropic observer whose eye is at rest, Uic myopia in t
given case will e(|uat the weakest concave glass thr»u;:h which the.
fundus iit .-teen distinctly, plus the diAUncc of the ghn.^ from the nodal {
point of the observe*! eye.*' (Loring, loc. cit., p. 2-i.)— IJ.]
M'yopia may run a very variable coun^e. In some eaticd ita prognMS
is marked and mpid, in others slow and insidious ; in the most favorablv
caaes it remains stationary at the adult age. U is generally, however,
aomewliat progressive, especially between the ages of l.i and i'i, mkI
often remarkably so in hereditary myopia, or if the patients employ ,
their eyes a great deal in reading, sewing, etc. A moderate degree of
stationary or but slowly progressive myopia causes hut little annoyance
to the patient; but it is very different if its degree is very considerable
and it^ progress marked and rapid, for in the tatter casv il is almosij
always accompanied by symptoma of irritadon and inflammation of
inner tunics of the eyebnil. giving rise to reduosst beat, nnd ciliary net
ralgitt during prolonged work at near objects.
" L«lirbu('li "It 0(>liil>nlnirm:iipi«>," [Aiwl U> nn nrtU-lo hy Pr. RlwnnI U, I,nr[n( lo^
tbH"Am. Journ. M>>>i. ^i.," A]irll, IK711, ^..1-^:1— I), j l-Sv al»»tiii--lUB uid LACflalt'i
Krlirlii *'(l|>hlli'ltniaHvi|ii<'," in llrii»ri> and Ssprniiii'li'* IMti. i)i>r AuicKiibf'ilk., tbi. p|h.
D^ITS. ktid |]i« tnmtl A(liiilr«bly clritr mni ('••iiciv nu)uivra)>li of Dr. E. U. I^^ia^,]
"The DflttriolDBliou of Um Kefrutlon of Uh> Kyo wJUi Uu Oi<btbalBii»o»»«," 3(«*J
Ynrit, IftTB.— B.]
UYOPI&.
It is of coDsoquence, both in the prognoaia and treatment of myoftift,
carefully to watch ita progress, and acciirntoly to aactrtnin and note
thv drgree of myopia at the commt'iicemeiit, eo that wu uiav liercaflcr Im
able to (Icborminc whctiier the di^-teaac has remained stationary or pro*
greased, and. in the latter caw;, to know the extent and rate of such progeas.
1'lic fHipnlar jiluu t!iat myopia diminiiithea with old a^e is not iiuite
corn'Ot, ttltlioiigh it is tnie that distnnt vision i? Aomcwhnt iniprovca by
thv diminution in the size of the pupil. Moreover the aenile changes
(ack'rosis') in thu lens may slightly diminish the myopia.
With regard to the proj/nogit of «ihort eiglit, it m»y be 9l&t«d that
there it nothing to be feared from n alight stationary myopia ; but it is
very difTt'rent when the latter is high in degree, progressive, and asso-
ciate-l with coiisiderahlo sclerotico-choroitlitirt iwttfriur, for then it is
aUvnyii a tsource of danger to the eye. There is a {Kipntar fallacy that
short.aiglitcd cyca arc particularly «rong, and even some medical men
participate in it. But thiM is r^uite erroneous, indeed a myopio eye
must be looked upon aa unaound, more especially if the disease is ex-
tensive and progressire. In such casea care roust, tliervfore, be taken
that tlie patient avoids all employment or amusement thai mayhn?tenthe
progress of the myopia, or give riae to irritation and straining of the eye.
It is of much,consoi|ui-uce in myopia that tlie epectiicles slioutd be se-
lected with Bcciiraoy and care, fnr if they arc unsuitable, more especially
if they are too strong, they may prove very injurious to tlic eye.
The proper strength is rapidly and easily fouud in tjie following
manner: —
Tlic degree of the myopia must in the first place be ascertained with
exaciilude hy trying the furthest distance at which tho patient can read
No. 1. If lie can do so up to 10" from the eye, his far point (r) Ues at
10", and hi» myopia = y'j, : for a concave lens of 10" focus would enable
him to see at nn infinite distance, as it would give to parallel rays a di-
vergence as if they came from u |)oint 1*'" in fn^nt of ttif leiw (the pa-
tient's far jMjjnt). Tlie position of r. therefore, always ntfordfl us a clue
to the numl^r of the concave l«ii.i rerjuired ; imt iilthough No. 10 would
be theoretically the proper glass, we find practically that it would be
somewhat too strong. The reason of tliis is. iliat the convergence of the
visual linea at 10" prevents the eye from exactly necommo*latiiig itself
for ili^ far point, the latter being only atlainablc when we look at dis-
tant objects with parallel vUnal lines, ilence concave 11 or 12 would
be the glass really suitable. Whether a given lens is accurately suited
to the patient's sight, can be easily ilctonnined in thu following manner:
I>et H8 return to the case above referred to of a myopia = ^. With
concave 10 the patient is able to read No. xx of Snellen at ztj'^ hence
hia V = 1. In order to determine whether Xo. 10 is exactly the right
glass, we alternately place l»efore it weak concave and convex glasses
and try their effect. If weak concave glaasea improve the siglit, tho
original lens (No. 10} is too weak : if. on the other hand, weak con-
vex glasses improve it, it i» loo strong. If neither concave nor convex
glasses render any iniprovem^int, the original lens suit* exactly. The
proper glass can be easily found by a very simple cukuhitiou ; for if tJie
B myopia a .■g, and convex aO iinprores the sight still more, oonrcK 40
L :
626 ANOMALIES OP EBFBACTtOS AMD ACO0UU0DATI09.
making it worse, the original glass is soroewhat too strong, and we mnxt
deduct jV *'">™ i** '^^ proper glass will be — , for, _ — -^ --
We trj concave Ift and find that oeitbcr concave nor convex glaatei ren-
der any improvcmeni.
If tho sight with the original lens (^o) was most improved by the addi-
tion of oonuivc 50, it was too weuk, and a concave lens of about V inchei
focus will be required, for — + ^— » —
A« a general rule, the weakest glass nbicli neutraliz«>s tbo myopia
may be given.
If a myope desires to have spectacles to enable hira lo see at a diAtanoe
of about two feet (for reading miisic. etc.), tlie pro|K!r glassea can be
easily found by the following cttlcuUtion: If liis myopia •• |', and he
wishes to see aistinctly at 24", tho formula will be — ^^ + J^ ■■ — |'|,
and concave 24 will bo tlio proper glass.
The degree of the patient's range of accommodation materially influ-
ences the choice of spectaclett, and the queeiion ba U) whether or not he
may be allowed their use for reading, writing, etc.
I'hc range of accommodation may bo tested in the manner already
described, by finding the nearest and furthest point at which No. 1 can
be read with ease, and then deducting the latter from tho former acoor
to the formula _-
A
1 1
The following plan, recommended by Dondors, is, however, sUll betCerf
as it allows tlic patient really to accommorlato for his far point. The
myopia having been neutralized by the pro]>er concave g1a»»es, so th)
tho piitient CHn read No. XX at 1^0', the position of his near })oint (wit
thcDC glasses) is now found ; if it lies at i>", his range of accommodatic
« VI for as r « x, and p 6". — ^ y ■■ ?•
-.a A 5 OD o
In determining the degree of myopia, each eye should alwaja lie xcMi
separately, for tlic degree generally varies somewhat (oiten considerably)
in the two eyes, llie 'luestiim as to what glas^s nhuuld be givt-ti when
there is any marked difference in the two eyea, either in tho degree of
myopia, or In the refraction itself (tho one eye being perhaps nyapk,
the other hypermo tropic), will bo considered hereafter.
There is no harm in |wnnitting myopic )K!nions to wear aucb glftaat*
for dij^tunce as jtist neutralize thrir myopia, especially if the degree of
jihort sight is but nio<ieratc. If the patient is young, the myopia slight,
and his range of accommodation good, he mar even be permitted to we«r
iht-'Se ghiases in reading and writing, as in such cases tlie myopia abowa
but little tendency to increase. But if the myopia is cou*idcrablc, th*
range of accommodation diminished, and the ncuiencsg of rision impaij
the myopia jfiliniild not be quite neutralized. The patient may.bowoi
use a hinocular concave eye-glaib* boforo hi« spbctacles when he
(o sec distant objects very distinctly.'
I In Very high f1>f;rw« of inj(i|i|«, I h«r« fnunil WvinliBlI'" gtkM-nme twrr oi
iprtllnUtnt vt>Jwu, u it acu Uk« kflalileui lel«sco)w. It consiiuof a ataall sonx
UYOPtA.
627
Fnr i^^e piirpMe of rending mnsio, I thiDk it best to give patients spec-
tacles suited tor a diatatice of 2'-3', for if the myopiH ia considerable,
and tticv tue glaMCK wbiufa completely neutralixe it for dtittftiice, tti«
size of the music is inconveiuenlly dioiiiiished, ami thus hecontua some*
what indistinct and difficult to decipher.
We now come to the iiuestiuii whether myopic persons ^ould wear
glasses in reading, sewing, writinj;, etc., and the answer to this must
depend upon several circum'^tances.
Where the myopia ia but slight in degree (less than y'|). thcr may he
diitpeiised with — or, if the employment is not conUnued lor any length of
time, the diiiianee ^rlasses may even hn worn, but the ty|)0 mun-t \hs held
at A gn^Ater distance, otherwise the eye bocomcs fatigued, and the ac-
comroo<iution strained. Indeed, I lind that it is le^s trying and more
comfortjkble for Buch patients to read without their glasses.
If the myopia is considcrnUle in deprec, so that the print has to he
held very cloi^e to the eye, glatues should lie prescribed which will re-
move the far point to abimt 14"-16", for this will prevent the Decesiity
of stooping, which causes an increased How of blood to the eye, and an
increaite in the tension of the intra-ocnlar fluidit. This ci)n;:;ei«ion of the
eye greatly temU to promote the devclopraont of Aclcrotic4>-cboroiditi)
posterior, intra-ocular hemorrhage, and detachment uf the ri'tina, which
are (w apt to occur in very short-sighted pernons. For theAi; reasons we
shouhl direct myopen t^> read with tboir heads well tJirown back, and to
write at 0 sloping desk. Strict injunction must also be given against
the habit of reading in the recnmbont position, either in bod or on a
conch, as this produces great congestion of the eyes.
Rut the strong convergetwe of the visual linc.t which takes place when
Ihw object has t^.' be lield close to ilie eye, is also u source of great danger,
for it IS alwHv? aecnnipanied by an inorea(<cd tension of the eyeball anti
of the ncconimodation. The latter is nn associated action, not arising
from the mechanism of tlie convergence, but existing within (ho eye
itself, and may, conse<|uently. easily give rise to an increase of the
myopia. But besides this, the pressure of the muscles u[M>n tiio eyeball
is greater when tlic visual lines arv convergent tlian when thoy are
pamllel, and this increase of pressure must tend to give rise to the de-
velopment of posterior stiipbylunia, and to hasten ita progress, llie in-
crease in the tension of the eyeball in particularly marked when the in-
ternal recti muscles arc weak, and thus render the convergence of the
visual lines more difficult.
Now if we sfFonl such very short-sighted persons the use of glasscA
which enable them to read and writ^ at a distance of 14 or lit inches
from the eye, we do away with the necessity of a considerable conver-
gence of tlic visual lines, the sf>oping position, and the evils to which
these give rise.
But the {Mtient must ho warned not to bring the type close to him
when the eyes become & little tired, for this would strain and fatigue
the accommodation : but the book should then he laid aside for a few
minutes, and Uie eyes rested.
till itUs*, ttw hut of wlilcli i« (.iinvMx, siitl llu> oiPixnhp ^nrfkc* OMUava.
H onv tnoh In l«B|^h, sad cad be rvsdlly carried lu tliv w»iat«M( imfeet.
It ii
rita
626 ANOMALIES OP REFRACTION AXD ACOOMUOD ATtOH.
Spectacles may also be used for near objects in tlioae ensm in which
tlie myopift is accorapanie'l W muMulap astlienopU (il^pemling upon an
ini^tiffiuieticy or weakness of the internal recti intHcle«)r which mauifeflta
itself as soon a^ the patient has worked at near objects Tor a short lime.
Whilst the use of 8|iecticlea for near objects may be (lermiited with
ailvsiita^^e in tlie above forma of myopin, it must bo forbidden if the range
of aocommodatioH la very limited, and if the patient* aiifiiT from such a
degrvo of amblyitpia (generally dvpeiidin;^ upon sclerotico-ehoroidiliB pos-
terior), that they are tinahte to read No. '2 or :) of Snellen's typcit. The
glasses will diminish the size of the letters, and, in order to see thena
utKler n larger visual angle, the patient will bring the object very ctoM
to the eye, which will cause the ftccommndation lo l»e K'eatly sitniioed,
the intra-ocular tension to he increased, and SMirious mischief will but too
sorely ensue. Spectacles bHouM not, therefore, be permitted for near
objects wheu nmrkod amblyopia exists.
If the myopia is very considerable, wo j*enorally find that only oite
eye is employed for near objecta ; the eonver^tcnee of the visual lines
being therefore annulled. l)ondens aayet, with n-fercnce to thia jioiot,
*• Thin apjieant to nie (o be often » desirable condition : in Htrong inyo]iil
binocular vision lot^es its value, and the tension which would be rp»|uir<
for it cannot he othorwiac than injurious. Now. in auch coses, for read-
ing no spectacles are given ; in the tirst place, because the acntcness
vieioii has ui$ually aomewhat decreusefl, and the diminution of concav
glasjiert i« now trouhlctome : in tlie second place, because, with the
lroce*.Vion of r, injurions effort* at convergence and at binocular vision'
■night he exerted. In any case the spucuictcs ahoiitd be so weak oa to
avoid these results."
[Id the case of myopes who have strained their eyes for a Long time,
rest and the use of atropia relieve the spai^m of accomuindation by caus-
ing the recession of the tar-point, liut our best eflbrt? should be directed
towards avoiding the development of myopia. All near work inhould bt
forbidilen during twilight or by any dmi light. An erect position of tb«,
head must be insured while reading, aitd in writing by the use of a d«
with a high atid steeply inclined surface. If a high degree of myoj
appear in early youth, it should influence the chnice of an occupationj
All school -rooms should be properly lighted and furnished, aud
work should, if necessary, be fre<|uently interrupted. — B.j
fi PRESllYOPIA.
The first symptom of presbyopia is that small objects (small type, fine
needlework, etc.) cannot be seen with such ease or at so shun a di-ftancoJ
as before. In order to set: minute objects more distinctly, the patieull
Is obliged to remove them further from the eye, or even Lo seek a bright
light, so as (0 diminish the circles of diffusion upon the retina by narrow-
ing the size of the pupil. But as the retinal images of these fine nbjecta
arc very small, on account of the distance at which they are held, he will
Boon v-xperivnce a commensurate difficulty in clearly distinguishiug them :
the print, for instance, will got indistinct aud confused, and the eyes
become fatigued and painful.
PRESBYOPIA.
629
«
In simple presli jopia , the far point is at a nomuil distance from the
ejre. parallel ra^va are united upon tlic rotiiiu, and nciclior concave nor con-
vex glasses (oven After the iustillatinn of atropine) at all improve diittaiil
vision. The eye is neither myopic nor hypemietrojiic. There i», in fact,
DO anomaly 'if refnwtiou, but only a niirrnwinj: of the range of nccotn-
mcxlation; the near point is remflvecl too far from tlie eye, and hence tlie
difficulty of uccurntely disungui:§hin^ ^mall oltjeets.
Amhlyopia tuonietimes coexists viih presbyopia, and may even ho mis-
taken for it. as the amblyopic patient liVewUe cannot see very small
objects distinctly, and convex j^lat^es a,]m improve bis si}{ht. Itut in
nmple pro^tbyopia (uncomplicated with amblyopia] we should be able to
restore the norm»l acuity <>l' vinimi and raii^e of accommodation by the
proper convex (j;1:ihs. With iu aid the patient should bo able to rvad
No. 1 at X" : hence if he can only deci|ihor No. 2 or No. 4, or is obliged
to hold the print closer, he is also amblyopic.
L>onilerH has found that in the emmetropic eye the near point gradu-
ally rcceiles, even from au early age, further and further from the eye.
This recession coramenees about the age of H(. iiml iirogreRsea rc^idarly
with increasing year*. At 4ft it lies at about i^ , at oO at 11 "-12",
dauon. In the emmetropic eye.no inconvenience is generally ex-
rienccil from the reocMion till alioiit the age of 40 or 45. This change
the po:<ition of the near point is met with in all eyes, the emmetrt>pic,
by |H,*nne tropic, iind myopiu.
lint the far point also begins in the nomial eye to recede somewhat
about the age uf ,*tO, so that the eye then becomes dlightly hypermetropic
(distant vision being improved by convex glasitcs). Ai 7t) or Hil years
of age, the liypermetropia may ■■ ,',, t", e.,ihe patient can see distinctly
at a distanco with a convex glatu* of 24" focus. This hypernictropia,
which is at first only ftc^uircd, may afterwards become abfioiute; so that
die patient is not oidy unable to accommodate for divergent, bat oveD
for parallel rays.
1 he recession of the near point from the eye, and the consequent nar-
rowing of the range of accooimoilatioo, arc far more due to a change in
those parts within the eye which are jiassively changed during the act of
accoiuniodation, than to an alteration in tliosv wliich, through their
activity, bring about th*t Utter. For the ciliary nui.-tcle, the active agent
of accommodation is generally normal, altliough it may, Inter in life,
undurgo senile changes ; whereas the pikssirely changed <>rgan of nccom-
minhntton, the crystalline Icntt, gra^liially becomes more am! mure firm
with advancing years, and in consequence of this increased firmness, the
same amount of muscular action cannot produce llie same change in the
form nf the lens as heretofore.
[This harduiiiiig begins at a very early age. aU'ectiug 6r8t the nucleus
of tiu' lens an<l spreading to the pi-'ripbery. letter in life t\m hardening
may be recognized by the stronger cetlection of light from tJic lens when
fucuijed upon by oblique illuniinalion. True presbyopia is therefuro a
senile change and is accom|iJinied by other acnllc changes, such as loss of
transpareitcy in tbt* media of the eye, slinllowneaa of the auiurior chaio-
ber, alniphy of the muscle of accommodation, eie. I'rcmalure presby-
opia may occur uich marasmus, after prostrating diaeaso, with incipient
cataract, and also vrith the development of glaucoma. (Sco " Schweig-
sr," I.e. pp. 2o-28.)— B.]
At linft, ul' course, no iucouvenienco li experienecd from this gradual
recession of the near [lolnt ; we do nut, in fact, noLice it until the di»-
tance is »o considerable Lli&l we cannot easily distinguish ftti»\] ohjecta.
When are we, then, to cousider an eye presbyopic ? bonders thinks tht^
shotdd be done as soon as the near point has receded further thnti 8"
from the eye ; for aa soon aa this is ihe case. pAticuts generally begin to
complain that conuniicil work nt small objects lios become irksome and
fatij^uiiifi. We, however, sumetimes meet with peraoiw with very strong ^i
sight, who can read and wi-ito for hours without experiencing any incon-^H
remence, even although their near point may be 1 !"-12" from the eye. ^^
But these cases are exceptional. Let us. therefore, with Donders, con-
eidiT presbyopia to begin when the near poiui is removed further than
8" from the eye.
The degree of presbyopia ( Pr) may be easily found if we decide njmii
a definite distance (e. g., H") aa the commencement of presbyopia, for
we have tlien simply to deduct the iiresbyopic near poiut (p')'t'rotu this, i
Thus if |>' lies at 10" the iireshyopiRa^ig, for ^ — i^ ~ Vs* 'f'-'nce
convex lt> will neutralize the prcshv'opia and bring the near |ioint again
to &".
It will perhaps have already struck the reailer, that if presbyopia Ihi
assumed to commence when the near point has receded further than H"
from tho eye, not only the emmetropic, but also the myopic and hyper-
metropic, eye may suffer from presbyopia : for if a person has a myopia
v^g. and his near point lies at 1^", he is alsD presbyopic. This cannot,
of course, occur when the myopia is higher in de;;ree tliati J. In hyper-
metropia the «iine thing may take place, for if, witli the convex glaas
which nciitndizcs tlie hy)ii:rmelro]ii)t, the near point lies at V2", there
is also presbyopia.
The range of accommodatioa is found by the formula — b . If]
A 1 K J
p = 10", and r " * 1 i-- 1 1 1
■».
1 1 f«. 1 1
10
There can be no queBtion as to the advisability and necessity of per- '
mitting old-aigbttd persons the use of spectacles, lliey sh'juld !« fur-
nished with them as soon as tliey arc in the itlii^htost degree aniioyrd or
inconvenienced hy Uie presbyopia. Some tnedicai men tlunk thnt pres-
byopic jffltients should do without spectacles as long ss possible, for fear
that the eye should, even at an early period, got so used to them as to
find them indispensable.
This is, however, an error, for if such persons are permitted to work
wiilioul ginssei*, we ob3cr%T thai tho presbyopia soon rapidly increases.
The proper strength of the glasses may be readily c»lculat*)d. If p
(the near point) lies IH" from the eye, i*r « | — Vi ■" i^s- ^ convexl
glass of W focns will bring the near point back again t<i ^" from tlie
eye. We must generally, however, give somuwiiat weaker glasries. be-
cause, on account of the greater convergenco of the risnal liiio't. the
near jwint will through these glasses (^convex Iti) be in reality brought
UVPEKMBTBOPIA. 681
nearer tfaaa 8'^. Late in life, when there is some dimiaation in the
a«iitennsH of vision, the near point may sometimes be brought even to
il" or 7", And it should be approximated the cloaer, the greater the
nui^e of acoommodatioD.
If no hypennetropia exists, the weakest glasses with which No. 1 of
Snellen can be difitinccly and ciiitily read ac about \'2" dixtAiice, may
generally be given. But [ have often found that if the peisott in much
employed in reading ami writing, and has always been accustomed
to hold his book at a coiiHiderable distance, he will be at titNt much
inconvenieneed if his near point is brought to 10" or t'2". We shall,
therefore, bare to give bim glasses which will bring it only to about 16".
With tbesw he will he able to work with ease for a considenible length of
time. They may afterwards be gradually changed for rather stronger
opes.
In choosing spectacles for old-sighted persons, we must also be par-
ticularly guided by tlie range of their power of accommodation. If this
is good, we may give them glasses which bring their near pmnt to S",
but if it i* much diminished weaker k'i^^s sKonld be chosen, so that it
may lie at 10"-12" fmm the eye. [The choice of glasses should never
he left to die patient, as he is almost certain to choose those which are
too str<mg, for the sake of Uieir great magnifying power.— B.]
$.— HYl'KRMETKOFIA.
Tl has already been stated (p. fil2) that in hypcrmetn^pia the refrac-
tive power of the eye is so low, or its optic axis so short, that when the
eye is in a state of rest parallel rays are not united upon tbc retina, but
behind it, and only convergent rayd are brought tc a focus upon the lat-
ter. Wc must therefore give to parallel rays emanating from distant
objecit*, a convi^rgent direction by means of a convex gla«<(, and the reader
will now comprehend how it is that a hypermetropic eye requires convex
glasstis for seeing distant objects. The patient may rei|uire t>erlia|>a
even a stronger pair for near objects. Tlie consequence of this low re-
fractive power of the eye is, that whereas the ttormal eye unites parallel
rmya upon its retina, without any accommodative effort, the hypermetro-
pic eye has .-ilready, in order to do so, to exert its accommodation more
or loss coimidemhly, acconling to the amount of hy]>ermctropia. This
exertion incrcast-rt, of course, in direct ratio witli the proximity of the
object. If the degree of hypennetropia is moderate, and the power of
^^MOomraodatioQ good, no jKirticulnr annoyance ia perbajis expcriuticed^
~ »n in reading or writing. Rut in abtot^tU hypermetropia tlie pntient
will not bo able to aec well at any point.
It will be found that hy|>onnp tropin generally depends upon a peculiar
construction of the eye. It is smaller and Qatter than the t^mmetropio
eye, and nlthough all its dimensiotu are loss than in tlio latter, this is
more particularly and markedly the case in the ante n>. posterior axis.
The eye does not appear to fill out the (wilpebnil aperture piiiperly. but
a little space may be observed between the outer canthus and the eycl)ftll.
Upon directing the eye to be turned very much Inwards, it will also be
632 AHouALms of repkactios and accouhodatiok.
seen tliat the pwlerior portion of the Gychall 14 ftntUir &ii<1 moK
preaacd than in the cnimetro|ii(.' eve. Doiidtrs cons'ultfrs tlial the livjwr-
mctropic is generally an impeHV-cUy (levelo|>f<l eye, that the expaiLtinc
of the retina is loss, and that tliere is a smaller optic nerve with a leu^
nuDiher of fihrea. lie thinks, moreover, that in hyperrociropin theraj
often exists a typical form of face, chiefly depc-mleot upoo tbir ahallow/
ness of thu orliit, which leiitU a puciiliar llatnesa to the pliyaio^inoniy^
The hypciinctropi'C construction of the eyeball is congenital, and »ftei
hereditary.
[In the liypcrmetrupic eve, tlie line of vision deviates inwanl from th«'
corneal centre mure than in erametropia. It may develop durini; tke
growth of the body, hut it is ac<|uired compamttvely seldom; mphakia
being the most fretjuent cause of acquinHl hypcrmotropia. Hyiwrme-
tropia may also he caused hy the retina being pu-iied forward by exwla*
tioQs beoeath it, or by a fiattcnin^ of tlie eyeball |>u8icriorly by orbital
tumors. (" Sobwei(»;(or," I.e. — B.)]
The oplithaiuKJdcope also enables lu to lUaj^ose a hypermetropic 03
hut in this case just the reverse obtains to what was seen in tlie mvopM
eye (p. fi^>.
I. The fundus may also in this case be aoen in the erect image at
con-tide ra hie distunce. but we obtain an erect imn^ of it (and not as ii
mynpia a reverse image), for if we regard the optic nen'o vr one of lb4
retina) vesscli', and move our liead to one hiHc, «c find that tJie inAgMj
moeek !n the mmr- direction. For an explanation of thin let tu glanra^
at Fig. 174.
Fig. n4.
T^t a he tlie byfteniietropic eye, h the eye of the oh-tcnpr; a U
justed for itd far |wint (convergent rays), and the rays reflected from i|
back'grouud vriU, conflei|uentty, emanate from it in a divergent dirttcttoi
as if they came from a point behind the retina, and they mu^t, tbereforej
also fitU in a diverj^ent direction upon the eye of tlie ohser^-or. If th\
latter is myopic (adjusted for divergent ray*), the rays will he unite
upon his retina without the aid of any correctin<: lens behind the opbt
moscope. Bntifhia oye ia ommctropic (adjusted, when in a «tal«
reitt, fur parallel mys), be will either have to place a convex lens behti
the mirror, or have to aocommodnte for a nearer iwint. Tlie stronj
convex leno with which the details of the fimdiw can still be oeeii in th<
erect imiii^e, aflori? uh a relative estimate of the degree of existiug hvpei
mctroj^iia. Thna if the hypennetropia — i, the rays euuinatiiig from 1
lumiuouii point on the retina will diverge as if they cnmc from a poini
6" behind the nodal point, ajipearing to the c3'o of the obA«rrer (plaerdl
1' in (rout of that of the patient) aa if ttiey oame from b" boUiod thi
HTFBRHKTBOPIA.
638
I
I
nQdnl point of the aye under examination, and he wiU henoe ivquire a
convex glass of 8" focus to see the details of tlie fundus distinctly. The
di8(anc« of the two eyes (2") from each other mumt be $ubtracte<l from
the re(|uired lens (S"), in order to find ihc dej>roe of hypcrmetropia
6" : and the latter will always be greater than the focal distance of tbfl
lens.
The image of the observed eye will he erect, for c and d retain their
relative positions.
IJ. On going ctoaer. but still examining in the erect image, the 6cld
of rision appears much enlarged, and the imago removed further from
the eye, its size is considerably diminished, whereas the inu'iisicy of its
light and color is much increased. If the hypcrmetropia is high in de-
gree, we can overlook at u glance uot only the whole optic untrance, but
also a couaiderahic portion of Uie fumlus around it. In the indirect
mwlft of examination, the sixe of the optic disk will appear much larger
tlian in the emmetropic eye, which is <lue to ita imago being formed fur-
ther from the object lens. If our eye is emmetropic, wo mu^t, in order
to gain a distinct image, either place a strong convex leu* behind the
mirror, or else we must accommodate for a nearer point.
The ophthalmoscopic diagnosis of hypermctropia is frequently of much
service, especially id young chitdruu aflectcd with atrahismus, the stale
of whose refraction we wish to n^ertaiu, but who arc too young to n^ad.
Again, in w»pasm of the ciliary muscle depi^ndcnt u]>on hypermctropia,
the Inttor may be s" completely masked that the patient can only see
at a diKtance with .sliglitly comrave gla-sscii, and not at all with convex
ones. We hence, perhaps, believe it to he a case of myopia, but on
ophthalmoscopic examination we Und that the refraction is markedly
hypermetropic. In such cases the patient should, how«ver, look at
some distant object, or into vacant siiace. mo that liit accomniorlation may
be quite relaxed. Wc nmy notice m such patients how the ophtlialmo-
Bcopic appearances vary when the accommodation is relaxed, and when
it is called into action by their rogarding some near object. [In gen-
eral terms the hypermctropia in an observed eye is always cijual to the
glass used in the ophthulmoscope, minus the dielnnco from the nodal
point of the eye examined. *up[xjsiiig that the observer [a emmetropic.
If he is not, his own em<r of refraction must be taken into account or
corrected by the proper glass. — B.]
We must distinguish various forms of hyjiermctropia, and in our clas-
sification of these we shall I'olluw Dondcrs's sysstem, which \& the must
praciiciil.
"V may, in the first place, divide bypermetropia into two primarj
DCS, the itriginal uimI the ac4]uircd.
Owing to the senile changes in the lens which apfiear with advancing
age, the far point begins to recede somewhat from the eye at the age of
40 or 45. At tiO, the eye is generally already bo hypcrmctmpic that
dist;tnt vidion is markedly improved by convex gtaoavs. At TO or 80
yearn the hype run- tropia often = ,'i. This is termed ae<|iiired hyper-
mctropia. The latter will, of course, ho very considerable when the
crystalline lens is absent (as after extraction of cataract).
634
AK0UALIB8 or RBFRACTIOM AIfJ> ACOOMMOO ATIOX.
Original hvpcrcaetropia niaj be divided into the mtimfeet (Um) Ami
latent (HI) form.
In order bo determine the presence of hypcnnetropia. the patient a'
dirtrcted to read No. xx (Snellen) at 20'. I^t us suppose that he can
do 30 with enac ; we tlien find the strongest convex glass witit whioh be
can still see the same number clearly and distinctly, and this gives as Uw
dej^ree of manifest hy|>ermetropia. If oonvei 20 is the lens (convex 18
making Uic sight worse) Hm = ^'g. Each eye should he tried sepa-
raielv, as the de<^rec of hy]>enaetro|iia may vary. The range of accom-
modation with this glass is then tried.
But although convex 20 may he the strongest glass with which be can
see at a distance, the degroe of bypermetTO]iia may in reality be very
much higher than ,'g. Tlio fact htnng, that the patient ha~>t been m ac*
oustomed to exert his accointnodution (wen when regarding distant
objects), that he cannot relax it all at once, even when there is no occa-
sion for it, the malconstrnction of the eye being compensated for by a
convex lens. To find the real degree of hypermetropin, we most, tbere-^J
fore, poralyze his accommodation hy a stront; solution of atropine CJ^-^^|
iv ad JSj).' This slitfuld be allowed to act for two or tbree hours. Ab^H
the end of this time we nj^ain examine the patient, and now, perhaps«^H
find that he cannot sec No. xx at all at 20' without glasses, or oven vith
convex 2U. To do so distinctly he, perhaps, requires convex tf ; and
this difference in the power of the glassi-s reipiirci^ before and after the
taralysis of the ciliary mnscle, shows us to what an extent he exert«d
bis accommmtatioii before the application of the atropine. But this
great dilference only exists in young persons with & good range rif ac*
commodation. The atropine should bo only applied to one eye at a
time ; its effect goes off in about six or seven days. Hut as its effieet
proves very disagreeable and confusing to tlie sight it should only be ap-
]>Ued in ihoee cases in whicli it is of imfionnnce to know precisely the
degree of latent bypcrmctropia. Its action may, if neceiwiry, be neu>
traliied by the extract of Calabar lean, which will however bavo to be
repeated severat times, as its effect is much more transitory.
A slight degree of bypcrmetropin is often unnoticed until lh<* ag« o
25 or .30, when symptoms of asthenopia show themselves if tlie patieo
is obliged to work much at near objects. If we try the sight for d
tance, we find that be can road No. xx at 20', tiv\ also witli a we-ak
convex glass (SO or 40). Or, perhaps, if only momentarily held before
the eye it makea tlie sight worse, as the patient cnnnot at nnce relax hts
accommodation, but after looking throu^^h it for a few minutes be sM*
belter. To make sure of the degree of 111, the accommodation miut be
paralyzed with atropine, [.\fter complete paralysis of accommodstiotk
from atropia, tlio latent hypermetropia returns, even when the [>alient
wears continuously the proper correcting omvex glasses. — B.]
' Dr. Bwlin a^lTiviM thnt In th»w> nftum of h)rp#rmi*tf«iiii» I" ->"■»' k •- 'ii>h1i
tn riniilu^r almpiiRS llie il>>iir*-i' of lA[4frit li,rpi>rtii<>lri>)>in idh; ^ mqI
lug two aluluotjiij; |irtiun4 (i?^ In-fo**- riM,t|i ryn), tc tlittt llic |' ■ i*d
bv p*r8ll«l, sikI bta wjoomiBodiilton ranMqmintljr r«lut«d. (" Kl. MaiuUbt,"
Jauo
UTPBRMSTROPtA.
6S5
P
Dondvra ilivMes manifest hypermetropia iuto three clnsses, the /at*u/-
tatite, the rrhtitffy an<l the ahrolute.
In /ai-uU<ttive hypcrmetropia the patient can see well (with parnllcl
optic axua) at- an iiifinitv diiitttiico, with or without convex )^)aiMes. He
can nl-no nee to retui small print with ease witliont ^laiues, ho that he
experiences no fatigue during work. iVcsbjopia. however, setfi in ud-
ustially early, ami then symptoms of asthenopia supervene.
In rehttite hypcrmetropia. tlie eye may aUo \>e able to accommodate
icaelf either for parallel or tor divergent raya, and see well both at a
distance and near at Imnd, but it can only do ao by convor^ng the \iBuat
linCM for a nearer [>oint than that at which tJie object is situated ; by ac-
tjuirin};, in fact, a periodic convor^^cnt 8i|uiiit. Tt ia imt of very fret)uent
occurrence in childhnod, hut is more often met with after the aj?o of
puberty and iu early manhood. The sight is always more or \es« affected,
and the patient has a difficulty in finding the exact distance at which he
can see best.
In uhmluU h-tfiimnetvpia rision is indiiitinct, both for infinite distance
and for near objecta ; for the patient cannot unite the raya npon the re-
tina eviMi » ith the stron^ent eRort of acconiniodaliou, or with the !ttroii<^st
oonver|;unce of the visual lincK. The focut; of both divcrj^eutand [)anitlo1
raya remains aitnated behind the retina. It it not ofien mot with in
youthful individuals, as they gcnerallv poitsess a sufliciuntly tstmiig power
of accommodation to overcome it. In a Bnperficial examination, nnch a
patient mij^ht be mistaken for a person sufTering from myopia with am-
blyopia, for he will not be able to see diatinctly at a distance without
glares, which may be crroneouslv attributed to myopia, nor will he
be able to read very fine print, am! thin may be aupposod to bo due to
amblyopia.
If the hypernietropia is considerable in degree, the psttienti often see
bettor when the print is held very close to the eye, than when it is 10"
or 1*2" off. This it* partly (iue to diminution in the sixc of the circles of
diflfuaioQ, OD account of the con;raction of the pupil. Moreover, tJie cir-
cles of difiusion increase comparatively less in ma^itude than ttte siae
of the retinal ima^^e, as the object is approximated (Oraefe).
A hyperroetmpic eye may at a certain a<^ become presbyopic. If
with the gla)*«c3 which neutmlize the hypermetropia, the near point lies
at \1" to 14", presbyopia coexist*, and a stronger pair of glasses will
be re(|uireil fur reading.
The range of accommodation is best found by neutralizing the patient's
bypennetropia by means of the proper convex lens, and then finding
where his near point lies with this glass.
In high d<.'i;:i-ees of hypermetropia tlie acuteness of vision la generally
somewhat diminished. This, acconling to Donders, is [lartly due to the
structure of the eye, for as the nodal |)oint lies far hack, the retinal
images will be correspondingly i^mall ; hence convex giassei^ improve the
sight, by advancing the nodal point, and increaiiing the size nf the retinal
image. It may also be due to astigmatism, or to the !!iiialler number of
nerve fibres in the o{>tic nerve and retina.
Hypermetropia is a very freipn-ut can.** of asthenopia (sea hcheludo
visus, impaired vision, etc.) ; this condition being distinguished by the
83ti AKOHAtEBS OF REFRACTION AND AOOOUilODATION .
following symptonia : llie patient cammtlook at nearol)ject« (in reailing^H
wriliniT, sowiiif!;, etc.,) for any li.'n;;tli nl' tiiii*' witlmut tlic ryi-s bfcoinini;
fatijiacd. The print becomes tniiistinct, the 1ett«n^ run nnc into auoiltor,
there Is jrain in and around the eye, and tlie latter may become rud nai
watery, ami feci hot and uncomfortable ; yet the eye looks quite healthy!
the refractinf^ media are clear, vision is good, the couvcrp.'nce of
visual lines perfect, and the niohilitv of the eye unimpaired. Nt*ith(
does the ophtliiihnr>!tco]»c rfveal anytbin;^ ahnurmal, except pcrha}
sliglil liypera.'n:iia of the uptic nerve and retina. The symptums of asthi
nopia ((uiekly vanish when the vork h laid aside, to r«ap]M>'ar honevc
when it is resumed. It was indeed a great boon when Donders dutcover
rimt most of the-e cades of asthenopia depended upon hypt^mn-tropia,'"
and could he fured liy the pniper use of spectaclea. If we wish pcrma-
Dently to cure auch ciuee we mu^t aflfonl the patient the aid of glaMMi
and thus prevent all unilue straining of the accommodation.
This Accuuimodativv form of asthenopia must be dietinguielied from
the miint^uhir, whirh de|)eiHig ufMin wcakne>ui of tlio internal recti miuolea|
and from th<> retinal asthenopia. The latter is generally doe to hypei
Bsthesia and irritability of iliL- retina, accompamtnl by hy[K.'ra;uua of the'
opiic ncn-e and retina. Tt iwwtly (K'^nr« in feeble, nervous, and excilabie
persons, especially females.
Let us now consider how hypermetropic persons are to be auit«d vil
glasses.
Theoretically, it would appear right to neutralise the liypennetro|
hy a convex lens, and thus change the eye into an emmetropic one;
lens forming, so to speak, an integral part of the eye. Uut in pracUc
we Hnd that this duui? nut anawer.
In i'ocidtotive hypormetropia, there will be no occasion to prescribe
glasses for distance, as the patient can see well without them. Mor
over, there ia the disadvuntage. that after convex s|>ectaclea have bee
worn for aome time for distance, the power of seeing distinctly withot
them is logi. which is of course very inconvenient, for this reason
should never he ordered, except in cases of absolute or relative hyj
metropia of a considerable degree. If there are symptoms of
DOpia, glatses should bo given for rca<ling, etc., which are somewbl
stronger than tlio^e which correct the manifest hypermetropia. If ihea
are found too strong and tryiug to the eve, they must be exchanged
weaker ones, and the strength be gradimlly increased until the astheno}
has disappeared.
In relative and absolute hyfwrmotropia spectacles should also be woi
for distance, as we find that in such instances distant vision is not
tinct. In such cases. I generally commence with the glares which
traliiie the maiiife.sl hypermctpopia, and in young persons order them
be worn lif)th for near and distant objects. If they prove too strong
distance, a weaker pair must be prescribed, and their strengtii gnidtukl
increased. If they do not relieve tho asthenopia, or if prcsbyo|
coexist, a stronger pair must be given for rea<ling, writing, and s«wiik|
In using the s]>ectacle3 for rea^ling, sewing, etc., it is always advia
ble to interrupt the work for a few minutes at the end of half an hour a
au hour. This reatjt the eye, which is thea able to resume tho vmploj
BTPCRMKTROPIA.
687
ment with ronewef) vigor acd ease. If the asthenopia does not quite
tli4a{tl)ear under the use of glaadea, we must exainiue the puwer of eoti-
vorfTuiico, for logcthcr with the hypcrQietro|iia there may CKist inBuffi-
<»ency of the internal recti muscles, and the ftiithcnopiii be partly due to
thii<. If the acc<>miiiu<lBtiiiii hutt hceii greatly fatigued hy proluiij^ed
work at near nhjecta without the aid <if }:la<»e!s, or if there in a ^imitm of
the ciliary tniL&cle, the aecomnnj'lation should he placed iti a comlition of
complete rest, hy hein<!; paralysed hy a strong solution ofatrupiiie ; and
this f>aralysis should he maintained For several weeks.
bonders has shown that convoi-gent strahi&mus very freqncntly depends
upon hypermetropia. A person suffering from the latt-er is always
obliged to accommodate more or less, in order to see with distinctaess.
Even Ht a distance, he uiual already actioiumodatc in order U< neutralize
the hyp(;rmi'tropia, and the nearer the ohject is approximated, the more
will this tension of the accommodation increase. There uxiatM, however,
B certain ndution hetwcen the accommodation and the convergence of the
visual lines, for with an incnrasw of the latter there is alw an increase
in the power of acconimodntion. This assertion is proved hy the fact,
tha-t if we place a prism with its base turned onlward before a hyper-
metropic eye, the latter will fiipiint inwanU, in order to avoid diplopia tn
looking at distant objects, and this convergence will enable the eye to
accommodate for parallel rays (distant objects) ; whereas, with i>aratlel
visual lines, it before rwjuired convergent rays, (. «., the rays from a dis-
tant object had to be rendered convergent hy inean» of a convex glass,
in order to be brought to a focus upon the retina. Again, if we place
a concave glass before a normal ere, wu uhange it into a hy[>ermotrfjpic
one ; parallel rays arc united hentHil the retina, and it either requires
an effort of accommodation or a convex glass to bring them to a focus nit
tiie retina. If the concave lens is but of sli^t power, an iitcreased
effort of accommodation — an increase in tlic convexity of the cystalline
\ei\A — wilt neutralize i)ic effect of the concave leibt. and overcome this
artificial hypermetropta. But if the concave glass is too stmng for this
the eye o'lten overcomes its effect by 9<|uinting inwanU. anil thus con-
siderably increasing itd power of accommiHlatton. Xow the same thing
fr«<^ucncly occurs in hypermetropta ; for the eye squints inwarils in order
to increase its power of accommodation. This has been called periodic
Btpiinting. In the beginning, no deviation of the visual lines is observ-
able as long as the person is not looking sharply at anything ; but as
soon as he looks intently at any ohject, near or distant, convergent sipiint
shows itself. Sometimes, this only occurs when the patient is looking at
near objects, the et^itiut disappearing assoonati he rcgarda distant objects.
After H lime the jMpiint hcconies permanent, particnfsrly in Ihtwe pormiw
will! work much at near objecu, whetlior in rejuling, writing, or sowing.
Wu meet with it very fre<{uently in elitldren about the third or fourth
year, when they first look attentively at things, or begin to use their
eyes for any length of timo for near objects. When this tendency to
squint first shows itself, it may be corrected by neutralising the hy|wr-
metropia by means of convex glasses, but will generally require an o|X'ra-
tion.
Moreover, the patient should always bo warned beforehand that after
03B ANOMALTKS OF REFRACTION ASD ACOOHUODATIOIT.
the operation for strabismus it may he necessary to wear ^sses in order
to prevent the recurrence of the *|uiut.
The cause of the apparfnt divergent atrabismus, which is often noticed
in markctl case* of hypcrmetropia, ha« alrcatly been explflined to he dne
to the cotiaiderable angle formed hy the visual line and optic axis on Ihv
comea of hypermetropic eyes : for, as the visual line in the latter liea
much to the inner «ide of the optic axis on the cornea, it will be ut once
evident that if the lisual Hdrb are parallel (fixed npon some distant ob-
ject) the optic nxea will diverge, often to a marke.1 degree. In lii^h
degrees of myopia the reverse obtains, for, as the vieual line then often
lies to the outer aide of the opcio axis, an apparent conrcrgent aquiot
will arise when the visual lines are parallel.
['* It \» ali«o |>os»ihle to determine the refraction of an eye by the
mirror alone. In examining a myopic eye with the mirror, we aee an
inverted aerial image of the fundus, situated in Front of the eye at its
far point. In a liy|>ermetropic eye we itee a virtual, erect ittiago behind
the eye at a distance equal to the degree of the hypermotropia. In a
myopic eye the tmage and the field are both larger tnan in bypcrmetrD-
pia. In myopia the image move3 in a direction contrary to that of the
observer' 14 head ; while in liyiwrmecropia it moves in the same diree-
lion." (Loring, 1. c, p. 47.)
The refraction of an eye may also be made out by means of the in-
verted image. In a myopic eye the inverted image uiuHt be smaller
tljan in an emmetropic eye, since the nearer an image i» formed behind
a lens the itnuillcr it will be ; prcivided the same lens is used with each,
and is held at or within its focal length from the eye. In a hyiwnnu-
impic eye the image will be larger than in an emnietmpic eye. In a
myopic eye the size of tiie image incraases as the lens is removed from
the eye, while in hvpcrmetropia it decreases as the lens recedes. (Loring.
I. c, p. 60 and dl')— B,]
7— ASTIGMATISM.
We have aeen that the anomalies of refraction resolve themselves into
(vo, viz., myopia and hypermetropia. But tlie state of refraction may
ry in the diHercut meridians of the some eye ; tjuis, it inav lie emme-
Iropic in the vertical meridian, but myopic or hypermetropic in the hori-
zontal, or vii'e vergd. Or diflereuces in the degree or even in tlie form
of emmetropia may exist in the variouii meridians. This n.symnietry hn»
been termed aKtigmatiDm (a, privative, and anr^a, a point), wliicb «iglii-
fies that rays emanating from a point are not reunited at a point. This
peculiar defect' was first observed by Thomas Young (179^), who con-
sidered it due to some inequality in the structure of the lens, whereas
Wharton Jones thought its seat was in the cornea. Donders has shown
that it is of frequent occurrence, and that many cases of congenital am-
blyopia are due to it, and may b« cured by proper cylindrical glasses.
' For a man inti^rMthu histoHual socoont ot tbtt labirrt, sm iJonders's work,
p. &39.
ASTiaUATISM.
6Sd
Bat even m the normal ere, the coniea does not refract oqually m
all ila meridiniia, for the focal distanco of the dioptnc s^vatem m (generally
shorter in the vertical meririian than in the horizontal. On this account,
6oe vertical Hne» can h« seen up to a further dietanoe than borizoalal
lines, but the latter can be Aeen closer than the %'prtical linca. For tliia
«;x|>eriin<;iit horizontal and vertical lines m»y be drawn upon a page, or
von Vrraefe"-'' win- o[>toraeter may he u»ed.
If the Ptripes or Hnct arc arranged crosswise, we are imahic to dis-
tinguish both tht! horizontal and vertical lines with equal clearness and
diatinctness at one and the aamc distance ; thus, if we can see the vertical
lice cleftrlj and sharply defined, we mn^t approach the horizontal line
nearer to the eye, in order to gain an ctjualty distinct ima^e of it, and
mee vertd. These facta prove that the vertical meridian has a shorter
focal 'Uatance than the horizontal, and for thia reason horizontal lines
are »eeii diatiucily at a shorter di«anee than vertical ones. Fur, aa the
rays which are refracted in the vertical meridian are united in a point
HOoner than those in the horizontal plane, these latter ^ve rine to circles
of diffusion upon the retina in the form of small horizontjil lines which
do not eonfase the images of horizontal lines, but interfere with those
of vertical lines.
As it is of much consequence in the study of astijimatism that the
reader should tlioroughlv uuderslaud theao preliminary facts, 1 give the
following extract and explanatory wooil-cuta from Domlera'a work. After
speaking of the fact that a vt^rtical stripe can be aeen further oflT, and a
horizontal ntripe at a closer distaucu, he continues : " Theae experiments
prove that the points of the refracting meridians arc not symmetrically
arranged around one axis. Tne asymmetry is of such a nature that the
focal distance Is shorter in the vertical meridian than in the horizontal.
In order, namely, to see a vertical stripe acutely, the rays, which in a
horizontal plane diverge from each point of the linc^ iDiist be brought
to a foca-t up4)n the retina : it i-4 not necessary that thoAe divcrj^ng in a
vertical plane should also previuusly converge into one point, as the
diflneionimages still existing in a vertical ilirection cover one another ou
the vertical stripe. On the other hand, in onler to see a horizontal stripe
acutely, it is necessary only Uiat the rays of light diverging in a vertical
plane iliould unite in one point upon the retina. Now horizontal lines
are acutely seen, ns I have remarked, at a shorter distance than vertical
ones ; eoodeqiiently rays ctituated in a vertical plane, which are refracted
in the vortical meridian of the eye, are more syioodily brought to a focus
than those of equal divergence situated in a horizontal plane, and the
vertical meridian, therefore, has a Sorter focal distance than the hori-
zontal.
*' ITie corn'ctness of this view appears further from the form of the
difftision-i mages of a point of light. In accurate accommwlation the
diffusion -spot is very small, and nearly round, while a nearer point appears
extended m breadth, and a more remote one sccnu to he extended in
height. Tlie aigi)i6cation of this phenomenon must be clearly under-
stood, and appears, therefore, to demand more particular explanation.
" T-et na suppose the total deviation of light in the eye to be produced
by a single convex refracting surface, with the shortest radius of curva-
640 ANDMAI.IBS OP RBPItACTION AND ACCOMMODATION.
Fig. 175.
ture in the rorticsl, nnJ the lonjrest in the horizontal, meridian. Thei
two are then the principal tnendians. Tliroii^rh acf^ntral round opeiiit
(Fig. 17o, V V h h) let a cone of rays [•ri>cec'ilit
frnm a point situated in the prolon^tion ot' tht
axis of vision, fall uipon lliis Burfacc ; of this
cone let us consider only the rajs situated in the
vertical plane v v, and tlic rays situated in thi
horizontal plane A /*, whereof resfioctivcly tl:
point* r V and A A are the most estcmal. Adi
the refraction, l>oth approach the risual axl
(which perpendicular to the plane of the drawing
passes tlirough a)yV v dues so. however, inor
rapidly than A A. Before union thcj therefore
lie in the ellipse A, as in Fig. lTt>, and where r r meet in mte |*oii^H
B, h ft have not yet come to a focus. Thenntpon wo now Hml in flueced^|
aioii r V already intersected, A A approached to one another, C, />. Si
further, h h united in one |>oiut, and r v after intersection more wiitclj
Ftj. 17«.
^— ^ — ' T ^
F
T
O
hh
M>
rii
rval
Bcpanited, F ; finally, hoth intersected, (?. The focus of r p thoi
U«9 most nnteriorly. that of A A most posteriorly in the axis. The
between the two points, where rays of different meridians intersect, may
he calletl the f<»cal interval (intfrvatU f<><-at, or I{n>nnstrccke of yturmj
From the ahovc fi;5iires, it is now endcnt what successive forme the m
tion of the cone of light will exhihit. In the middle of tlie focal inlorvaT
jP, it will he nearly ntund. and anteriorly throu^li oLIate olIiiKnei, '.',
with increasing eccentricity, it will pass into a horixuntal line B : pos-
teriorly through prolate ellipses, A', it will come lo fnnn a vertical Uwe
F, whde before the focal interval a larger oblate ellipse, j4, and bchiml
it a larf^er prolate elliiwe, tf , will be fouiitl." ^^
The poaition of lliese figun-a with reganl to the focal interval is show^H
iu Fijj- 177. In the cone of light emanating from L are depicted the
Fig. 177.
AfMT S«liltiMr.
ravs which impinge upon the vertical meridinn V I 'and upon the
zontul meridian H H. The former are united in o, ilie latter iu m, «o_
that 0 m is the focal interval.
ASTIOMATISM.
an
I
In Fig. 177, the letters A, B^ C, i). /?, f, ami Cf correspond to the
same letters in Fig. 170. The myn which lie in tlie plane of the verti-
cal roerirlian K I' (in Kig. 177) are broupht to a focus at o, where the
rnya which lie in the plane of the horizontal meridian fl It, arc not yet
utiitod, hill fuim the horizontal Hue h h (the nHteri-fr fucal line). The
rays // // arc united further back at m, where the **ertical rayjt form
the vertical line v v (the j*"ttrrhr local line). The distance between
these two focal lines fumi-) the focal interval. The anterior focal line
A h corrcBponds to the position of the meridian of the lowest refractive
power, whereas the posterior focal line v v. to that of the meriiliau of
highest refraction. Generally the astigmatic patient endeavont uncon-
sciotmlj so to rcfiulate his accommodation that the middle portjou of the
focal interval tails upon the retina; in this way only a small round cir-
cle of diffusion f> (Fi;;. 17li) is formed, and the object is more distinctly
seen than it would b« at the anterior or posterior extremity of the fociu
interval. In cajie the anterior extremity of the focal interval falla upon
tlic retina, ami if this should he the focus of the vertical meridian, a cir-
cular Bame appears of a horiiontiil luminous line. The revcreMi will of
courwe occur if the posterior extremity of the focal line (if this corre-
sponda U> the focus of the horixontat meridian) falls upon the retina, for
tficn the flame will appear as a vertieal. luminous line. Hence, horimn-
t-al and vertical atrlpca will be shaqily and distinctly seen when the dif-
fiision-imai,'e8 of all the [winta of the stripe form rcRpeetively horiaontal
atiil vertical lines, which cover one another in the strijw ; and thii4 will
be the caM when the beginuiiig and tlie end of the focal interval corre-
apoiiil respectively to the percipient surface of the retina (Ltoiuiers).
Although we have hitherto assumed that the principal axes of curva-
ture correspond with the vertical and horizontal meridians, it must be
nicntioiied that they nuiy deriatc considerably from these. AUo, that
ilidt'end of the minimum of curvature corresjimdiug with the honKonlal
meridian, and the maximum with ihe vertical, the reveme may oven ob-
tain, and the maximum cur\'atnre coincide with the horiiiontal meridian.
The alturration which is duo to a diHerence in the focal distance of the
two principal meridians, is called re-inhir astigmatism, and depemls upon
tbe curvature of the cornea. Whereas the aberration which is due to a
difTerence in tlie roi'raciion in one and the same meridian, ia called
irretjulnr aatigmatiam, arwl is generally caa8e<l by a peculiarity in the
BtriLCture of the crvsttalline lens, and cannot Iw corrected by cylindrical
glasses. It often gives ritte to monocular polyopia. The two fonu^
soineiiroea coexist. The degree of regular astigmatism met with in nor-
nial eyes ta generally too slight to caui>e any impairment of virion ; but
when it in more considerable, the siglit is indisiiuct. ThJ^ amblyopia is
duo to circles of diffusion being formed upon tiie retina, winch croi^s and
overlap each other. The greater the dinerence in the refraction of the
princi|ial meridians, the more coni^iderable will be the circles of diffusion
aad coii^ei|uent indistinctness of vision. If tlie nAtagmatism is at all high
in degree, the acuteneas of vision is much impaired, l>otli for mtar and
distant objects, if the eye is myopic or hypermetropic, we find that wo
cannot with any spherical letis produce a very ilccided impruveraent, or
raise the acutcuew of rision to the normal standard.
41
MJ
64*2 ANOUALtKS or RBFBACTIOH AVD ACCOHMODATtOX .
The diBgnoais of utigmatism maj generallv be made without mucb
dillictiltv : biit it in iiccc!^<tnrv to follow a Hcttled line of examuiatioiu
oUienrisc the toginiter will fflll into great confuAion, and wa^tiO a Ur^
Bmount of time, ^'timorous modes of discvTenog the preseuce of a»ti|;>
mati^m, and of esCimatii^ its de^e aro in use ; but the following an
the fciraplest and most pracUcnl.
In t^ie first place, we must carefiillv examine the acutene^ of vifioo.
anJ ajitcertaiti which number <if Snellen's types the patient can Me at a
diftttince of 2tK. If tlio acuteness of vision is below the uoruuU ataudnrl
(if he cannot read No. xx), wc maat try whether it can be raised to
this bjf concave or convex spherical lonsea. If we fail in doing; »o, we
nin.''t susjH^ct tlie preiM^nce of aeti;i;iii»tisni. ami next proceed to detennitte
tltc fiituation of the two principal ni(-ri<lian.i ii.f.,, the maximum and
miuiinuin of curvature). Tliis may be doue hy dii-ecting the patlfpt
to Inok at a small, distant point of H;;ht (varyin<; from two to four
millimetres in diameter, and seen tlirough a small opening in a lar^^e
hlaok screen). The patient should bo placed at a distance of from
\'2 to Itj foct, and directed to look at the luminous point. The laiur
will uot aiipear round if ihe eye is astiguuvtic, hut will be elongatiMl in a
certain itircciion, according to the fact whether the li^hl is nearer "f
further off than the point for which the eye is accoromodiitod. Thoa. if
the maximum uf curvature coincides with Uio vertical meridian, tlie lumi-
Doutt line will be horizontal if the eye U aucommodaied for a funhcr
point, and vertical if it i« acljusted for a nearer poinL Weak concave
ami convex leases are then placdl alternately before the eye (the latter
being thus cb,nn;;o«l into a myopic or hypormetropic one), and the ante-
rior and posterior focal line hrou^^ht alternately upon the retina. Tt>c
direction of this line will depend of course upon die direotioa of Ui«
principal meridian.
A better test object is, however, formed by a series of atraight lines,
which croas each other in the centre of a circle. For this purp-TiK*. I
have found Dr. Green's' test objects the best, and use Lhura in prvtVr-
ciree to any others. He employs three figures, which can he arranpwl
in such ft manner as to amplify and check tlic results obtained. I have,
howeter, found that one of Uie diagmma (Fig. ITS) )s Buffiuieot. It con*
ahu of a circle, traversed by a set of twelve triple lines, corr-j-
iv Ihe fi;^ure4 cm a watch dial ; the figures bein^ placed at tlie ^
of the sei» of lines, as In .Iiival'it optometer ( Fi^- 1~'<' )• Hacik Ituu u
ei|iial in thickncM to the lines employed by bttelleu in tlie construedoa
of No. XX of his t«»t ty|res. and is designed to be diAtinrtly seen at a
distance of aliout :2m'. The circle is about 12^" in diameter. Snellc
\jut* a srmioirck' of straight lines.
Thi<< tei^t circle in to be placed at the dietnnce of 20', and if the patic
can SCO nil the lines distinctly and sharply defined (any oxisung myo[
' Tit- Hi, flrwii*!! naiK'r ini "Tli- P-1«tJiin ftinl Ufaaiinueutfif AallcmAttim.*
'. 7. itorv Tr
I ■■-■\, n» «i-r
HAIUV |>ilil>'<M> (Vt'lf ' TI -.<-lb1'|>b-
• /. lHfl»"). [I>r. lirwu r. i»iii *ii««
1 :,~>i>> riir aalirnutllnn, witkh will bv |t<v>»l n\ tHr " Irarn*. Anirr. (ta«lilbaL
■.-».]
A8TI(JMATISM.
643
or hypermetropia being corrected hy suitable apticncal IcMuea), he is not
ucigniatio. But if ou]y tlie line in one meridian appears cl«ar auj
ahnqily dcBnctI, whilst tlie others arc indistinct, the presence of aatig-
roati^m ii proved, and the direction of the distinct lino corrcflponda to
the meridian of tlie highest refraction. If wo uow Trish to discover the
Fig. 17R.
degree and nature of the astigmatiiini, and are only supplied with spheri*
eal lent«eH, wo try the weakest concave or tlie strongeat convex tens
which, placed in a stcnfijMiic apparatus,' enables the patient to see all
the railiaiiug lines with e<|u;il diaiinctuess. If a cottcare lens is ret(uired,
it 19 a ca,se of myopic asii;;matirtni, whoroas it 18 hypermetropic if a con-
vex leu8 is required. l>r. Pray has demed some very useful test letters,
which are composed of stripes runniii;^ at different angles, by which the
presence of astigroatbm may be readily dieoorered.' (Knapp't *' A rchiv,"
i. p. 17.)
If we portsees a trial ease of cylindrical lenses, the weakest concave or
»tronp;o8t convex cylindrieal glass should he found which renilcrs all the
radiating lines ipiitc distinct and clearly deliued. When we have found
the lens which citrrects the astigmatism, the |«itient's i^i^ht should next
he tried with Snellen's teat typ*9, in order tliat we may accurately as-
' T1i« atfitopAlc ftppnmlus orapl'-ywi for this |iurpo<i« oonaJBta of a small A^rltnder
ii|u-r) at (i»c i-iiil, no 09 Id Hi vIu»l<1j' to tlir vro, ihr otltcr «nd beiii); rurnUlml irilli a
Bmsll ilit, wliitrli cAii IfV r«ft<lll.'r iinrrovi^l aiwI wMviimI. Tbu uflvcl »t ttiit »lit (wliirli
*houlil ho net to » wlrltli »f 3l><>iit H -Jr 2 inUlltn«trea) Is of oauno to AilmU onl.r mr*
tti > crliiin tlini-ticiii, i-xt-lii<liTi]t nU itii- iii)ii-ni. Thv Imx of tliu (^jrliiitlur ihoahl 1m>
mvlv Iv uiiK'.Tuw, ill vtiliT tli^t !i|i)icr(o.iI Il<i>!«<« iiuir W i>Imv>I in It.
• Mr. Htnili'in-U ('ArWr hiw hml I*r. Prav'ii oHxIiint shrt-t ('htilnitriiphically rMti(v<l
In oiM-fourtli nf iU ■■■». It is miUI li^* llii^ Aulut/)>u Fiuu Arl C<iw|)Anjr, 3(1 KalliboDti
PUw, W.
Mm
644 ANOMALIES 07 KE7RACTC0N AND ACCOHMODATtOS .
certain the degree of improreinent of sight prwlnced by it. In ciws of
hypermetropa, the effort of accommodaUoii often conceals a consiJeraMe
portion of tJie astigmatism, and may tbua greatly mialead us us to its
actual degree. The examination i» therefore greatly facilitated if the
acoommodat-ion is Qral pnralvzed by atroiiine. It in only tbiu tliat we
can arrive at the true state of refrnction. for spasmwlic contraction of the
ciliary iiiuifcle may nut uniy more or less correct the aatigmatism but
may iucrcasc it. Indited spasm of the ciliary muscle may change a hy-
ptrniotropic into a myopic astigmatism which is owing to an irrcgnlar
oontractioD of the fibres of the ciliary mu»cle.^ In the abovo otodea of
examination each eye is to be tried aeparately.
Javal has de%'i3ed the following itigenioiu instrument for the rapid dc>
tvrminatioQ and correction of a^itigmatism.' It la in tlie form of a ftervo-
scopu mounted upim a stand, and is 8up[)licd with convex spherical Icntcs
of about o" focua. In high degrees of hypcnnetropia a leia of '6" ^boQ]d
he employed, whereas, in high degrees of myopia we may omit the con-
vex lcnsc3, or substitute concavo ones. Two circles are drawn siile hy
aide upon a piece uf cardhuard, Just as in a stereoscopic plate, butng at
such a distance from each other, that the centre of each circle corre-
aponds to the distance between tlie two eyes. In the one figure C^'g*
179) are drawn a seiiea of radiating lines, and at their extreuutT am
Pig. 179.
.^
placed the 6gur«9 I to XII, arranged like the figures on a vatch dial.
If the visual Wwia are parallel, the two circles are fused into oite im.'Lge.
in th(^ centre of which lie the radiating stripes and at the circumference
ttie figures. On account of the parallelism of the cyos, the latter arc
acc'omtnodaCed for their far point. By means of a screw, the circle* an
now remored further and further from the eyes, until all the rn'tinfin*
liot-M, except one, become utdistiuct. The direction of tbU one -
idi-ntifii'd by the figures, anil its dinrctiim corresponds to the di;ii
the highest refraction. Behind the ocular lens of the one eye i* amngctl.
poo a pirot, a aeries of concave oyhudrical lenses, so that ihcy can be
n
>'rln. VkTis.
■ ihr AcLi-uKiiiilMion,'* '■ A. t. O.," air, X
\H&, 33«. Tills QpUHocur ot Jafal'i la Rwit hy !Ca»hfl. 17
m
ASTIUUATISU,
6ti
r
nipiiHy rotitod in front of the eye aotil the lens is found which corrects
tlie astigiimtii^ni and. indicAted iu degree. Thcae Iens4>9 are irran^ed in
such a manner that thev can be used singly or together, tints Allowing
of most varied comhinationB. After the degree of aatigmaliam has been
determined, the 3tat« of the refraction of the eye must be a*certained,
and the aanie apparatus may be used for this pur[H>ric. Alter the ex-
Boiination of the one eye ha:^ been Rniithcd, that of the other jthonUl
be proceeded with, the serieu of cylindrical lenses being turned over to
the other side. The principal objection to this instrument is. thai on
account of the patient heinj» conscious of the doi*e proximity of the oH-
ject, he may not relax liis accora modal ion completely, and is hence not
in reality sooommodatcd for hia far point, and we may tliereforc fall into
error a« to the degree of liis astigmatism. Thi» error is to a gn'at extent
avoided if wo te^t him with the radiating linos at a dintanee, and com-
pletely so if in a caiie of hyjiermctropia the accommodation \% paralyzed.
Dr. Thomson* has devised a practical teat for ametropia which will be
aldo found very useful in detcc'inc; astigmatism ; it is ba^ed u{M>n tlie
experiment of Scheiner. He has shown that whenever the vidual axis
is too lonj; (myopia), or too short
(hypermetropia), a point of light [Pig. 180.)
used as a tuat object wilt appear
double to the eye of tlio observer
when it is examined throof^h two
small perforations in an o[)a<iue
screen. To myopia the double ima-
ges are homonymous, in hypennetro-
pia crossed. The patient is placed
n metres from a small point of light,
having before his eye an opaque
screen with two perforations in it,
each .5 mm. in diameter, and placed
-4 mm. afnrt. A piece of ruby
glass is [tlaced over one of the
holes. 80 that he can readily diBtio-
guish between the two imagos.
[Dr. ThouiBon's optometer, which may readily be made with a visiting
cani and a pin, consists of four screeos of thin metal or cardboard jier
foraced as follows : —
Nn. 1. On<> bole. 1 mlUlmutn dtanMtt^r.
•• 2. Nine holrti, \ ••
" 3. Twu liulm, 3 millimutms npnrl, i nUllimotr* diainetw.
ti ^ " "4 t " "
The patient should be placed in a darkened room, at not less than ItJ
feet from a lighted caudle, and should look through Ha. I, and, at the
same time, move the screen quickly before his eye. If the lengtli of the
axis of the eye be normal, and the refraction hence emmetropic, the point
of light will remain atationary ; should the eye he ametroptc Uie light
will move with each movement of tho screen. With 2io. 2, the light
> Tfanaaetions or Iha Ani>!ric«Q OphLhalmoloKtcnl Sociiiiy, IS'O, p. 33 [and Am.
Jfittru. of Meit. &I.. JaTt. I6TU, p. 70, tad Oct. ibH*, p. 414. Al«o Urow's Surg. &Ui
i-l Tol. ii. 1). 237.-11.].
rik
I&
J
646 ANOUALIBS 09 RBFRACTTOK AND ACCOMMODITIOK.
vritl appear sinjilc to an etnmctro|iic eye, multiplied to an ametropie.
Witlj No, 3, the V\g\xt whicli enter* the two perforations will appeur ut
the obeterver, when placetl near bis eye, to come from tvo lar^e ciitl««,
at Uie screen, which overlap each other at their inner borders. In this
overlapping space only will the Utsl li^ht appear iloulile to an ametroptc
eye ; and care must he cxorcisod that iho patient uses both ftporturw,
and thiit his attention is fixed upon the overlapping space. This screen
ia provided with a elide of ruby colored gl&ss which can be poshed over
either perforation and thus color red the light which passes through it.
To an ametropic eye the li^hc point in the overlapping space will appear
us two tight?. On sliding the red ^laa^ over the perforation on tlie nght
side, the li^bt on the riglit appeara crimson, and thus indicnlea that the
axis of iliu eye is too louf^. lo an hypermetropic eye the left hand ligbt
would become colored, indicating the axU to be too short.
With No. -4, we can determine, without test glasses, the degree of
optical defect, by estimating the apparent distance apart of tlie two lights
as they appear to an ametropic eye. There is a measured and fixed
()imntity, 4 millimetres, in ilie screen, and the j)iktient should be place<l
at a fixed disuince, 1G feet, from a small point of light, when the decree
of the defect, and tlie proper glas8e« for itit correction, can be ascertaioed
by the measurement of ihe disiAnoo botwoon the two lights. Where tlie
single point of light npftears double, approach to it a second Hght, until uf
the lour points) wliich the piitient then perceives, the right hand one of the
fixed, and the left hand on'.* of the moving lights, are superimposed, ami
he then sees but three. Hy measuring the distance between tlictwolishis
wo are able to ascertain the optical defect by reference to the table Icloir.
IMaOnc* vt t.l«ht* Xymli. Offtvn u( Auiolni|'l& ObUacr at LWhki Ap«rl, I>v«TC« of Amttr<»l4
I
I
i incli
=
<'<
A
iiu-liwt
=
1
• •
] "
=
sS
ti
t>
=
1
U"
=
.\,
7
•t
=
1
S "
=
A
8
It
»
t
3 •'
=
I'o
9
u
=
1
1 "
-=
i
10
••
=
1
II
A blackened disk, ten inches in diameter, having white lines one inch
apart painted on its face, attflchod to a spring candlestick by a pivot,
liaving in ils centre an opeuing i inch in diaioeter.
Pig. isi. through which tlie light of a candle may be tnns-
milted, affords a very useful instrument. Let the
patient regard this point of light, and when it ap-
pcara double, he can determine the nuiuberof white
tines between the lights, nnd bonce the distance,
rince Uie lines are one inch apart. By rotating
the dink and chani^ing the position of tlio scrwjn, in
cusee of astigmatism, any meridian of tlie eye can
be cxnmtned.
The following diagmm (Hg. 182) of an emme-
tropio eyo indicates the path of tUe light admitted
ttirough encli oncuing, and tlio position of each
image wbicb is tlnw formed. When the eye is oto-
raetropic, the two im.ngea are superimposed and ap-
i
A8T[0MATrSM.
047
p«ar na one ; when byi>enn«tropic or ui,vopic, two ima^s are formed
upon the retina. 'Hie <|ii[ied line represenw the path iti* tbe reJ ray
whicK fi\\h ii\K\n one aide of the retina iu h^'pcrmotropia, aud upou the
Fig, Itti.
VlAcnu* •bvwtiir BTI>*niMU«pU •! a, Xyftplk kl fr.
other in mvopia ; a fact which enaUea these defects to be instantly dia-
tiii^nisiieil. — H.]
[In is~>i, Dr. Thomson, of Philadelphia, presented to the American
Uphthnlmologica) Soeioty an instrument, cnltcd an ametromoter, for the
rapid diagnosis of errors of refraction, a full description of which will bo
found ill the Trniisactiona for that year, pages 45a to 4(>1. It consinttf
of a thinihle which van he actnchctl to a common ;>a8-burMer, to which
is attached a cnidtiated half-circle. Connected vith this is a horizontal
bar, the end of which is » [lointer, which can he placed ut any part of
Ao ji;raduated half-circle by elevatin;; or depressing the other end of
the bar. Upon this bar slides a small box which is connected with a
»i9-jetf and at the upper end of the thimble and at right ati^Ic^ is a
nxed gas-jet, the two jets being connected by a flexible rubber tube.
These two jets may be placed in contilct or at any distance from each
other up to 30 cm., the len<^th of the bar, and at any possible an^^le
with the bar by the pivotal action of the latter. The descripliou of tiie
nicthwl or using is too long to tranwribef but die iualrument u applicable
for the determination of the kind and degree of simple amctrnpia, and
also for that of astigmatism. The bar is ditided into spiicos of ^.n cm.
with .1 half space between on one stile, and into KngliHli inches and half
inches on the other. Each space of 2.5 cm. will indicate an ametropia
of one dioptric, and each inch j'^th of the old system. Dr. Thom-
son has since added a fifth di^k of thin brass, t^ inch in diameter,
having in its centre ten perforations, ^ ram. each iu diameter aud h mm.
apart, arranged in the form of a cro.4s. A scratch aero-^s the face of the
diA)i. in a Hue with the ^(cm, enables it to be placed nt any angle iu tho
trijil fi-ame!i. Thu tent object should be a amall bright puint uf li^ht at
a distnnco of not less than 1<i feet from die patient, whose aoconimutla.
tion should be entirely paralyzed, i'or the cliniual corroctiou of aslig-
matism. the meridiaiu of greatest and least ametropia must be carofnlly
ascertained by the circuKir opening advised by D<»udcr8 and Dr. fJrcen's
mdiiitiiig lines. Tlie tlis^k nmy then be placed in the trial rrames, with
the Atcm of the cni*i corresponding lo one of these, and by parsing a
cud iu frout of each part of the cross, the refractjou of each meridian
648
ANOMALIES Or REFRACTION AKD ACOOHUODATION.
may be separately ascertained (" Trans. Amer. Ophthal. Soc.," 1873.
]>oiuIcra hns iliBtinguished tliroe forniB of a»tigiQatmm, viz. : I. Simple
&(iti<;mati9ra ; II. Compouud ascigmatiim ; III. Mixed aiStigmatism.
I. Simple Asli^uiutitim.^ — The aUte of refraction uf the one [>nuci|Al
meridian is emmetropic, wherena that of the other 1.4 either mynpic or
hvjtemietrDpic. If we, in such a case, turn the slit of the stoDopaic ap-
paratus ill the diruction of the nornifJ nieridian, the acuteneas of virion ^
will Ijo perfect, whereas a certain concave or convex BphericsUptw wiIlb«^H
rctfiiired if the slit h turned in the direction of the other meridian. ^H
Simple astigmatism ia divided into: 1. Simple myopic aaticmatism
(Am), in which myopia exists in the one principal meridian, and eramv-
tropia ill tlic other. 2. Simple lly[ierrocU'opic At^it>;mHiism (-Ah). In
thii* there is hj'permotropia in the one principal meridian, and emta^
tropia in the other.
II. Compound AstigmatiBra. — In this form, myopia or hypermetropi*
exists in l>oth principal meridians, hut it varies in degree. If the »I«U'
paie alit bo used in such cases, it will be found that a different concav
or convex lens will be required in each of the principal mcridiam, in
order to render (he acuteuesa of vision normal.
Wc raiiat here also distinguish two forms: 1. Compound Mycipic A
tigmatiam (M + Am). Myopia exists id both principal meriilians.
Cumpomid Uypermetropio Astigmatism (H + Ah). Hypenuetropia
exists in both principal meridians.
ITT. Mixed Asugmatisin. — This is a rare form, in which Uie OM
priiK4pal mi-ridian is myopic, the other hypemietropic. We must
also di^tingnisb : t . Mixed astigmatism, with prcdooiinant m'
(Amh). 2. Mixed astigmatism, with {tredominant b^iwrmetropin (Alimy
Knapp and Schwcigger have pointed out that the ophtlialmoiscope alw
furnishes ua with a valuable and easy diaguostio symptom of regular
astigmaliBui. On examining in^he diri>ct meUiiKt an eye aflected with
astigmatism, it will he foHn<l that the optic disk, instt'ad of being rotmd,
appears elongated in one direction, and that the latter corrcspoiuls ex-
actly to the meridian of greate>8t currature. For aa the focal dtii
is shorter in this meridian than in the other, the Image must also
more magnified in this direction. If we now examine the aame eye
the inverted tnuige, the optic disk will appear elongated in the opjx^
din*ction ; thus, if in the erect imugc the disk appears oval in the ve
direction, in the inverted it will ap]tenr oval in the horizoniul direction,
this at once proves the existence of regular astigmatism, and showaalso
that the vertical meridian ia of greater cun'attire, and, cDnse<|uently. baa
a less focal distance than the hori;tontal. The comparative examination
in the erect and inverted image, therefoi-e, furnishes us with a OKist tbI*
uabte aid to diagnosis, which will ofccn spare us the uecosaity uf a ing
and intricate subjective examination,
[''In the inverted imago of an asUgmatic eye the reoemon of the
lens causes a variation in the size and shape of the optic disk. If lb*
long diameter of the oval contracts when the leas is moved from the eve
90 as to become equal to the short, and thus make a circle, tben lite
astl;zmatism is hypermetropic. If. on the contrary, the short dtaiDeter
e.\j)«ud8 so as to become equal, at the focal dtsiaiice of the lens, to ih«
ABTlOUATtSyt.
649
lon^, and tbus CDake acircle, the a^tigcaatism is iii;ropic." (Loring, I.e.,
p. r>5.)— B.]
Tn cxRmimn;;, in the erect imaf^e, an cje nffecteH with hvpcrnicl-ropic
asti;niiutism, it will also be fouud that in ordur to see with e\|uat distiiiut-
tiesjj the vessels running in tlifFerent iUn.*cti<iii«, the state of accommoila-
tton of the observer's eye haa to mi<ier*5o a chaujie.
Mr. liowtnan " hatt heen sometime^) led to the discovery of regular
astigmatism of the cornea, ami tlic direction of the chief meridians, by
iiain)£ the mirror of the op)ithalmoseo{>c much in tbo Kanto way as for
slijiiit de^jrees of conical cornea. The observation is more easy if the
o[)tic disk ia in thv line of sight and the pupil large. The mirror is
to b*- hold at two feet liiMUinco, and its inclination rapidly Viirii-d, 90 as
to throw the light on the eye at small angles to the perpendicular, and
from opposite sides in sucoetsion. in suocesnve meridians. The area of
the pupil then exhibits a somewhat linear shadow in some meridiana
rather than in others."'
Mr. C'oupcr haa lately shown' tbflt cases of mixed asii^matism may be
readily diajjnosed with the oplithalmAscopic mirror alone; an inverted
or an erect imagtV becoming altenialelv visible accunling as the observer
views tho fundus tJirough the meridian of the greatest or of the least
curvature. Mr. Coupcr has kindly furnished me with a brief outline of
Boue of his observ'ations ; and I can, from my own experience, recooi*
mend his mode of examination as very practical and atucful. For ihia
examination he employs a concave rairr«>r of silvered glass of about thirty
inches focus, which enables him to illumiimto the fundu.^ at a maximum
distance of about five feet. A concave mirror of t»" or 8" focus scalten
the mya too much to jicrmit of an ade«|uate illumination at oven half
this distance. A twotold object ifl served by commencin;; the examina-
tion from an extreme distance of 5'. 1. Very small degrees of myopia
can t>e recognized by tho inverted aerial image, which ie tbvi8 phu^ed be-
yond the observer's near point. 2. The meridian planes of maximum
and minimum curvature are sometimes cleariy revealed by the distortion
which tho image undergoes when viewed from a distaiwc. It is best to
have the accommodatinn paralysed with atropine, and tlie surgeon should
then recede to a sufhciont diiitance to make sure of gaining an inverted
image, and next direct the i«*ticnt to follow with the eye under observa-
tion gentle movumentA of the forefinger, in a horixontul and vertical di-
rection, and then notice in which direction and at wbat distance he gains
the inverted or the erect image.
Mr. Couper lays apocial stress upon the fnct, that in this mode of ex-
amination tho owerver may — by taking strict account of tbo adjustment
of his own eye — gain a much moro definite rwiult tbuu the mere exist-
ence of aHymmotry of tlic media. For instance, if the observer, with
his eye adjusted for parallel rays, obtains at a minimum distance a clear
image of the linear detaiU uf the fundus in one particular direction, and
if, bring emmetropic, he cannot, by any adjustment of which his eye 19
capable, obtaiu a clear iouige of those details running at a right angle
to the former, he knows that he has before him a case of simple myopio
> Dondvn, p. 490.
■ " Hnl. Tinwi uid Ouotlo," Jan. 30, 1869.
ASTTOMATTflM.
6ii8
t
- , to be
80
vritten as M w
niToma™ - and Am « -t. — -
aO lo 8
Am i .
30
In such a case, a spheric o-cylindrical lens la required, the one eurfaco
of nhich has a spherical, the rjther a cylindrical vunatnre, and its action
u that of a plano-cyliiidricfll Ions combined with u pUuo-sphericwl ii-ns,
and it ma_v be expressed b_v tho foriuula for each of the refractiug sur-
fttCBs, uiiiled by a sign of comhi nation.
The caso wIiioK we have suppoaed would therefore be corrected by
— - »C — i c.
80 ^ ao
For the spherical and cylindrical surface would rcipiire to have a nega-
tive focal distance of :lil", niid the axis of the cylimlrical Burfauc would
have to be pinccd horizontally.
2. Comp'juml }tiff>ernirtri>pic Axtitjmaiism (II + Ah).^ — Hypcnue-
tropiu exists in both principal tneridtans, but more io the oivi than in the
other.
In the vertical meridian let II m ^<g. In the horitontal meridian lot
H * }-. We haYC then II m ^- , and moreover Ah •• '._ 2.— 1,
12 1« 13 IB 86'
and we write H_
18
3rt
Hence a positive spherico-cylindrical
I
lens win be required, and it will be corrected by —a
lo
the axis
of the cylindrical surfaco being placed vertically.
111. iUixeii Antii/niiitinn. — In this foim, in which myopia exists in
the one princiiial meridian, and Kypermetropia in the oihcr, we most
make use of hi cylindrical glasses. These consist of two cylindrical sur-
faces of cur\*ature, the axes of which are perpendicular u> one another;
the one surface is concave, the otlier convex. In consequence of this, the
effect of such lenses is to render parallel incident rays divergent in the
plane of one axis, and convergent in that of the other. The axis of the
concave surface must be placer! iu the direction of the hypermetropic
meridian, and the axis of the convex surface in the direction of the myo-
pic meridian, llieir action may be expressed by the formula for each of
Uie two planes, united by a sign of a right angle ) .
1 . Mijfii Astiifutatifin, with jired/iminaHt myopia (Amh).
In the vertical meridian let NJ = y^. In the horizontal meridian let
— . Thoreforo Amh ^ M - + H — — — , and is corrected by
20 I lO**'
The axis of the convex surface lo be placed vertically, that of the con-
cave horixontally.
2. Mixed Attiifmattfm with predominant kypermetropia (Ahm).
In the vertical meridian let M
I's-
In tliv borixoutal meridian let
AN0UAUB8 OF REFRACTION AHD ACOOUMODATtOX.
1
12
H — ,4. Therefore Alim
1
1
^r2+^<f8
— , and in corredetl br
12^ I - rs"=-
The axis of the convex aiirfnce to be placed vertically, that of the eoo-
C«ve surface horizontally.
These examjikt} illufitrate the method to be adopted in fiiidiugglaeses
to convct the astigmatism and the ameiropia. But in many c'atie» it ts
not advisable completely to neutralize the aiiocnuly of rf.-fr»ction, both
on account of the differonce in the size of tlie retinal inia^eii whtuh irilt
occur if the lenses arc ittrang, and al^io on account of the disturbance in
the combined action of the ciliary muscle and the internal recti musclei
It \» often desirable that the aatigmntiam should be wholly corrected, ha'
that only a certain portion of the myopia or hypermctropia should
neutral ixcd.
After the operation of extraction of cataract, the sight is often mate-
rially improvea by cvliudrical lenses, even alihouj;h before the opacit;
of the lena the siglit had been perfectly normal. Such caneri can only
explained on the supposition that a certain degree of corneal astigmatU
ha<L been neutralized (compensated for) by some lenticular astigmatic
so that when the lens is absent, the itUefiects frotti the corneal astigm.
ttsni make themselves felt. This condition muatof couree be didtiuguUhed
from the acqaired asti^atism due to a faulty cicatrization of the seo-^
tion. In all cases of extraction, in which the sight U not as good
might be expected from the general appearance of tiio eye, the fiivfieno
of astigmatism sliould he lucked for, aud the effcot of cyliiidriciit Il-uscI
tried.
It is of great consequence, that the axes of the surfaces of curvatnre
of the cylindrical glasses should be sit\tatcd in tlic principal meriilians of
the eye, for even a very slight deviation will give rise to coosiderahle
iudisuiictness of vision. In order to insure the exact adaptation of the
glasses to tlio eye, tlic lenses should be set in round frames, whicli per-
mit of their being readily rotated iu any direction. When Uie proper
positiuti uf llie axis is founds the screw should be tightened, and the
lens thus Bnnly fixed iu the dcsin9<l positiuu. The clumsy and awk*
wanl appearance of tlio circular frames may be greatly diminished b
making them of a smaller diameter, or by having the glasses groui
down into oval ones, and tiivu reset into oval frames. But this retjuire*^
jreat exactitude and nicety.
Jm-yular mtiymatUm way be divided into two clashes, the normal or
physiological, aud the abnormal or pathological,
A'THia/ irre</ular untit/iHtUttm is due to irregularities in the stmctorB
and density of the crjatalline lena, w that an aberration of the rays
occurs as they traverse the different 8ect<ir8, in conseijueaco of whio"
there is an imperfect coincidence, even after acwmmodatJou, of th
muiges of the dirt'orent aoctore ; and tliure is also the astigmatism prone
to the imago of each sector iu itself. The normal irregular nsugmausc
is of course wanting in eyes in which the lens liaa been removed. The-J
chief symptom of this form of irregular astigmatism ts polyopia, but the
•
APUAKri. 655
acutenes9 of vision u not affected. Wbenever the latter is dlnuDished,
wc must rc^anl it as abnominl irregular ai^iigiiintism.
Af-tMrmiil irreyular attigmatiam ma_v depend upon gorae dofoct in the
curratiire ot" the cornea, or some in-egularitj in the atnivture or position
of the IciLH. Thu irn!|<^I»rity in the curvature of the cornea nuj be due
to thinning of the latter after conieitis. to conical cornea, or to a faulty
anion of the section in extraction of cataract. The defect of the lens
may be owing to changes in its structure, e. tf., commencing cataract, or
to diaplacement of Cho lens, ao that ita edge hes partially in the area of
the pupil ; which may also give rise to thia tonn of aatigraaiiflm. On
account of theiw irregularities in the cornea or lcn», the refraction of
luminous rays is much distorted : for not only tlo the rays in a certain
diann'tcr undcrj»o irregnlar refraction, hut oven perhaps individual rays
in the same diameter. The retina, therefore, receives a very confused
and lihiiTed image, and hence there is always a considerable degree of
impairment of vision, the objects, moreover, looking more or less crooked
and distorted (metamorphopeia). Munocular iliphipin or [)o]yopia is often
also present. Araongac the objective symptoms of irregular ik^ttgrantiitm
m&y be mentioned irregularity of the corneal retlectioiiit, the surfuce of
the iria appearing perhaps nho somewhat wavy. Willi lint obliiiue illu*
mination changes in the curvature of the cornea or of tlie position of the
lens are eaaily recognized. Ou ctamining Uie fundus witJi the ophlhal-
mowojio, the optic liisk and retinal vcrisels will app'car liistorted and
irregular, and Uiere will be a more nr less wclhinarked parallax.
\Vhilst the irregular astigmauam cannot be corrected by cylindrical
glasses, it is ofken susceptible of improvement by stenopaic spectacles,
wtuch render the image less distorted and confused, by excluding a large
portion of the irregularly refracted rays. If regular astigmatism co*
exist with the irregular, it will generally be adraotageous tu correct this
by proj)cr cylindrical leiisea.
8._Al'nAKIA (ABSENCE OK THE CKYSTAI-LINE LENS).
This conditiott may be du« to an operation for cataract, to absorptioa
of the li'us after traumatic cataract, or dislocation of the lens into the
vitreous liumor ; it miiy nUo bo congenital. The state of refraction is of
course greatly altered by the absence of the lens. Thus, an emmetro-
pic eye becomes strongly hypermetropic ; a hypermetropic eye still more
&o ; whereas a myopic eye will become less ehor^s)ght«d, or, if the degree
of myopia was very great, it may oven become emmetropic. The power
of accommodation is eomj)Iotcly abaont in aphakia. This has hocn now
iuconii-uvurtibly proved by liouderi' numerous and most exact experi-
ments.
The acutcnc^s of vUion, even after the most successful operations for
catariict, and with the aid of the most suiuible glasses, does not usually
reach the normal standard. In old ]>ersoo8, this is fretjucntly due to
certain senile chuiiges which take | lace in all eyes, aud of\cn consider-
ably deteriorate the sight, fiuc wc must not forget that the insuificieut
LCTION A!tD ACCOMMODATIOX.
sea maj be due tn nstigmattsin, and «e
Wtj t^ cft'oct of cvliiidric:tl ^Ia3!tes in «iicl|J
cause 15 to he found in tbo ])rcdt;m*e
th« vrrinkliiig of the transparent capsnte,
l»le distorlioD and coiitWiou of the rvtiul
i«pant«d u[ion for caUmct ref^uire very Fti
tibe acquired hy|n;riiietro|iia. Tlie fltrengd
. mBi mew aceonlmg to the degree of the hypcrrot-tropii
*^^^ iT iSm apcio axis ; for the shorter the latter is, tb
- '«t{aire Co be. Two sett) oF glasses will be wauu
r-irr Hrjv«.-«»^aBJo(»e for reading, sewing, etc. For the fonot
«• iiHMBv^ cncrallT ranges from -I" to 5" focus ; for the
•'•Jicus. But aa this varies considorably, diffcrci
vi until the best i» found, and it muitt he rvniri
■m Immm of high power, a slight difference nmy extrt i
.»..A...w «ttrct upon the sight, fa onlcr to reuiedy Uic grcl
Mui •ihtoiaM.ac aberration of light which is prwlucett in the
* -'■Qi.-v in the thickticsH at the centre and at the pel?
- «re gem-rally sec in a broad horn or tortolsc-sheU
•-:\x the more central portion of the glaea exposed.
.-■.igtuatic, he will require a sphero-cylindrical gla*^J
I Uw ordinary manner, will be very heavy aud eluiosj^H
1 fivt. Dr. Loring' has had the lensefi made in Uie fo^^
■ V aitnple cylindric glass of the required strength a
■-T-tacIe frame iu the u:^ual way, the axis of the glass
the required direction. A thin plano-convex gI»M
sing advantage of the fact that leiuJCB can be
[saiii, this id lirmly fixed by its plane surface to
of the cylindric glass." The weight of the i*
i«uaieb viicQ Dicely made is only oue-fourtb of ttio onliaar
vltVLTSIS, SPASM. AND ATONY OF THE CILIARY
HUbCLE.
>:«J|mi
,•■ > .twnwai
or hm of accommodation from paralysis or atony of the
:Ns U occasionally met with after serere illnesses, the wbol
'•ciug greatly debilitated. In such ca«efl, it is not
»v*n for amblyopia dependent upon general debility.
m»i <*itli after diphtheria, and appears to depend Icm u
-imrtitittT*''*' weakncas, than upon some special and peculiar
i« 4XiHt iMture of which is undetermined. [A cold in often re-
:^iM\ tad often no cause can bo found. .Many oasee are
^ - ..._.. JMmM. — B.]
IW tjwyliriiH of fAralysis of the accommodation are very marked
ofUieOplithBlmolDgtccI Sodetj," 18T1, p. 1(W.
the '
lol^l
4
liar^
PARALT&IS OP TBB CILrART UDSCLB.
657
I
I
emmetropic cvea. The patienta find ttiat tlioy cannot accuratelj^ dtatin>
gaiifh near objects, so tliat thej are r^mte uniibte to reail. write, or sew ;
but iLt a diatauce thvy can sou difttinctly. Tlio far point lias undergoue
no clianfio in {Hisition, but the near point has recodfli) further from the
eyo. It we te« the siijlil with a convex lens of 0" focua, we fiml, per-
haps, that the near pclnt has rccuded to h" or ^l" from the oye, and
that the far point lies at 0" (the foci*! distanco of the Icus), heuce that
the power of accommodation is almost entirely loai. The poiiition of the
near point will of course vary with the degree of parnlyAiA ; if thia is
but slight (paresis), the near point may be but little removed from the
eyo, ami the dit^turhatice of virion but inconsiderablt). If tliero is uompleto
paraly^s, the patients cannot generally diatinatiish any print smnllor
than So. 14 or 16 of Jii^er, but can easily read the 6ne3t type with
Strong convex leiiacs. The si^^ht \» much \l'as aifeck-<I in 9hr>rt--j)iglited
persons, for if the myopia = y^ or ^\, they are atilt able to read al their
tar point (12^' or 14"), as only the near [toint underj^es a change, and
the far point lies sufficiently close ta the eye to permit of small objects
being seen distinctly. lu hypermetropic patients it io, however, ijuite
dtfterent, for in them both the near and distant sight h impaired, juat as
after the instiUntion of atropine. In incomplete paralysis, the symptoms
often rescmhio thone of asthenopia, and the true nature of the affeotioD
mav be easily overlooked, if the range of the accommodation is not ex-
amined. Together with the paralysis of the accommodation, there is
almost always paralysis of the constrictor pupillm, and consc<|Ucnt dila-
tation of the pupil, as both muwle^ are supplied by the third nerve ; and
fretpicnlly other iiinscleij of the eye, muppliiMl by this nerve, are also
affected. In tryin>i; the .^ight, attention should be paid to this dilatation
of the pupil, and the consequent presence of circles of diSusion upon the
retina, and lite patient should be directed U> read through a small ateno>
paic opening. [Paralysis of accommodation also occurs without paitici-
pation of the spnincter of the iris, and here the annoyance to vision is
not BO groat, because the circles of dtspemion arc not so great. Microp-
sia id often complained of in these cases. — B.]
The treatment of cases of paralysis of tJic ciliary muscle must depend
npon the cause. If the patient has been suiforing from diphthoria or
any debilitatiug disease, tonics must be our chief remedy. In Uic rheu-
matic form (due to exposure to cold or draught) or the nypliiliiitf, iodide
and bromide of pola^^siuni are of much use, as also a suppurating blister
behind the correaponding ear. I have often found the most marked and
speedy benefit from the latter remedy, so that a patient, who before
conid only decipher letters of 14 or |ij J&gor^ was able, within 24 or 48
hours after t)ic application of the blister, to read the tinest print. I
have also used the ludution of tlie extract of (^Vlabar bean with excellent
results. 1 emplor it of a strength suthcieut to cause considerable con-
traction of tlie ciliary muscle and constrictor pupillte, without, however,
over-straining, and thus fatiguing, these muscles. I then allow the
effect to pass off entirely, nnd after a few days' rest, the extract is re-
applied, 80 that the muwle^ may he iteriodically stimulated. The action
01 the Calabar beau, and its peculiar ulfect upon the pupil, were fully
■I
658 AXOMALtBS OP RBVBAOTION AND ACCOMUODATION.
inTCitigated in 1862 by I)r. Fraecr,' in hiiivalnnble j^raituation thpei»ror*
tlie Uuivereity of Kil'mburgh, on the " Cltaractcrs, Action, nnd Thorn-
Kiutic Vav^ of the Ordful Heaii of Calabar." And in I tfti^, l>r. Ar^U
oborumi discovered its effect upon the accommodation.'
On tlie a[>pIicatioa of a minute (|uanuty of a strong solution (1 drop
B 4 j^rains of the bean) to the inaidc of the lower eyelid, a little irrita-
tion atid rednew are produced, but lliese pa*» off very rapidly . Willi;
five or ten Tiiiiiutes the pupil begins to contract, and at nearly the sat
time the spaflm of tbc ciliary muscle commences. The contraction of it
pupil reaches its maximum degree (aWut 1'" in diameter) in fn>m SO
4o minuti's. After two or tlirc« houra it gnuluuUy dilat«s again, bi
doea not regain its normal siJto till after the lapse of two or ibn-e dan
vrhen it may even become larger than before. Even during its great*
contraction, the pupil is still under the inltuence of light. [A bet
pi-e|>aration of the Calabar bean is the sulphate of e«erine, solutions
2 and 4 grains to the ounce of distilled vater being used. It is via «i
however, to use this drag for any lengthy period or very frcqnenily,
it is apt to produce conjunctivitis and even iriUa, besides occasit
considerable patn by the spasm of the muacle. — B.]
The spasm of the accommodation commences abont the samft dme
the contraction of tlie [>u]iil, and both tbc near and far point I>ecoE
greatly appmximatod to the eye, which becomes, in faet, strongly myof
The far pomt in the emmetropic eye may be brought to 6" or <i"
the eye. and the near point to 'A" or ii\". The effect u|K)n Uie aococ
dalion patMcs off much sooner than that upon the pupiK for i.bree or fn
hours generally suffice to restore tlio state of refraction and accommodt-
tion to its normal condition.
That the spasm of accomntodatton is due to the action of tbe
upon the muscle of accomiotHtatiou, and not upon Oie iris, was inci
vertibly proved by Von tJracfo,* who tried its effects in a caiw of
plete al>s«nce of the iris, and found that the action upon the aocoouii^
dation took place at abont tbe iiamc time, and in exactly the aamo tnuuwrr
as io eyes in which the iris was present. This action of Ute Calahor
bean is. therefore, exerted upon the ciliary muscle, and is completely
de[)«ndeot of its etfecta upon the iris.
The effect of the Calabar beau in counteracting the action of atropfi
hftii ftlno been proved by many experiment.''. The weaker wolntitinsi
lUropine arc easily overcome by a strong solution of t 'ahiliAr. But
complete paralysis of the accomniodutiun by a .itnmg solution of M
1(4 grains lo the ounce), is only tem]>orarjly overcome even by a re
strong solution of Calabar, I drop ^ 4 grains : the pupil becomes sinaTt
and tlie stale of n.'fraction increased, but the action of atropine re- _
litMlf in the course of a few hours. In sncb cases, vo must repeat tfat
ItiT iiivMUf^nliotit mi ilii^ lihralolivit^ftl nnliriuiif tb« rAlahu- Imaa u* iva-
.1 n:(ir« r<!«vDt |>tt|>iir l>/ Ur. Kiuvr, ill the " TrsiMartlnu* of tbe tUtjrtl
■iirgli," »«l. 24.
■■•r ililB ilUnivrry of Dr. -Argyll llol»«n«OB, I had lli« f»M"**w»h«
iho i^lTi^i u( lli« I'aUl'iir Itvai) iiiHin • MM uf (nu .
ill Ncixitiut or whtcli « ill Iw (blind In tba "BIml. Ti<-
.... ,-,. I -a.
f.O.,"I».3. 113.
SPASM OF TUB CILTIRV MUSOLB.
■ppllcAtion of the Calabar when necosaary, until Uie effect of the atropine
upon tlifl accommodation has disappeared.' ['Plie hopes placed on Cala-
bar bean ha%'e not been realized. The prognosis is generally t&vorabtc,
but wc should rely mainly upon a tonic course of treatment. In £ome
ease« the ^nlvanic current and tlic faradic current hare prorod utieful in
rostorins; tlic muscle to its pniper tone.— li.]
Great fatij^e of the ciliary mu»cle through over-exertion at near ob-
jecta, niay j;ivu rise to very severe symptoms of asthenopia, and this is
neitC tri>atC'<l by the me of strong convex ^Iamo! (ti to ]0 inches focus),
for readin;^, etc. After they havt; been used for some lime, the MODin-
modation should be gradually exercised by employing weaker glasaes,
the distance of the object remainin;; the same. The accommodation may
also he rested by the applicaiiou of a stronjj solution of atropine contiuued
for some little time.
tSpa4m of the ciliary munclc (apparent myopia) ia not of such unfre-
tjuent occurrence as is often supposed. We have ali'eady seen that it
may accompany myopia and astigmatism ; but it is most frequently ob-
served in youthful hypcrmctropes who have strained their eyes much in
reading, sewing, etc., without using convex glasses : tliis continued ten-
sion of the accommodatim producing a spasmotlic contraction of the cilinry
muscle, or apparent myopia. Siicli palienta comj.lain chie0y of two sotj
of sym]>boms, vix., tb'J«e of marked asthenopia during reading and Sue
work, and alsti that they am Hhort-aighted. l>obrowolsky' statett that the
following are the principal symptoms of apparent myopts : The pupil is
generally small, the shape of the eye is often deoidediy hypermetropic,
the anterior chamber shallow, and the iris arched forwnnU from t]ie in-
orMsed curvature of the Icn^, the optic disk and retina arj hypericmic,
and there is uot unfrcquoiitly a posterior staphyloma. There may be
nl^o a convergent 8i|uint, and there are marked variations in the state of
retraction, the patient sometimes preferring one g)aaa,sometimca another.
On exjimining the sight of such pittiontt, I have often found a great dif<
ferenco between the position of the far point in reatiing small print, and
the degree of apimrent myopia. Thus for instance the [latient may not
be able ti» read \o. I furtlicr off than 8" from the eye, and we suspect
a myopia =* I ; but on trying him for distance, we discover our mistake ;
he can only read, perhaps, Snellen 50 at '2<j\ but a very weak concave
lens (60 or 40) enables him to read No. 20 (. V » Jj; ). This fact ahouU
at once arou.sc our suspicions that wo hare to deal in reality with a case
of apparent myopia duo to spasm of llic ciliary muscle. If wc now ex-
amine him with the o])hthaluio(h:opc, we find, v, hen he is looking vaoautlj
into tlu> far distance, tliat the refraction is highly hypermetropic.
Licbreich^ confident that spasm of the ciliary muscle is sometimes due
to insufficiency of the internal recti, the excessive etfort therefore re-
cjuircd to maintain the necessary degree of convergence for reading, etc.,
I Iimtcnd of lh« «>lra«t tlii< iriur* cl«Kaut pniMiratlon of Ihv Ki>lst[n« <lu(k> m»y im
ffmjtloyod. But tliont! <lti iiol Aiun-cr lui woll wbun nv wish to atUnnlKte ttiv jiuttidl/
ftaralvKHl iimsirlc, Ha it>- raniio) r>'i;uli>tt< tiif nlmii-lli no <uuolljr AS In tlia mIuUuU.
* *■ Kl. Mwuftubl.," lbi)6 ([tuiUicvlu-lt), t>. 1-*1-
» "A. f. U.,"THI. I. 2i».
660 AHOMALTBS of RUVRACTION AKD ACCOHMODATIOy.
being accompanied liy excessive contraction of the ciliary muscle : in siicJi
CtMs li« recommetiiU tlie u«e of aWuctmg |>ne<ii8. Tb« treatment of
n)ipnrent mynpin muflt cntitttat chiefly in elic methodical and prolong
use of a strong solution of atropine (gr. iv nd sj) S— I times daily : some-^
times it must be continued for several weeks before Uie spasio is over-
come, ami thir ciltfiry imiscli? cfimph-telv p:iriiiyi(i^(l. The cfl'ect of the
atropine is often marke'IIy accelerated liy the application of tlie artificial
leeeh. which al^o proves very usefid in diminishing the symptoms of hy-
peremia, or irritation of the optic nen-e and retina. When the ciliary
muscle is completely paralyxcd, ve can aAccrtaiu tho exact degree of
hyperaictropia. and it is bc^tto j»ivfl the patient the proper convex {tlasses
at once, so that he may wear tlieni and get accuMtomL'd to tbera diirinj^
the time tlio niiiBcle is recovcrinj; from the effect of the atropine. For if
wc do not do thi?(, we shall find that the spasm is apt to recur af^r the
atropine lia« been left off for eome time. If patients will not submit
the prolonged application of atropine, 1 generall}* give tliein Mronj^ c(
vex gldsdes for reading, and try to {.tersuade them to wear weak eonvf
glasses {e.t/.y + 40) for distAUce. 'llie effect of the latter is gradual'
to diminish the spasm of the muscle, so tlint after they have been wr
for some time, a patient, wlio before coidd not [lerliaps decipher No,
of Snellen at 20 feet witliout a weak concave lens, may be able to
Mo. 20 without any glasflea. Rut m they render distant objects india-
tinct for a length ol time, but few patients will submit to this lucouvq.
nience. Where the ]iatient will neither sidimit lo the use of atropine
Or of weak convex glasses for distance, I prescribe sti-ong convex glauea
for reailing, ami permit him the occDsioual and short use of the weakest
concave glasses wliich make V >=i go, l^ doing this we roust warn hicD
strictly, that the concave glasses should only he used for a short tioic
occasionally, as at the theatre, etc. Nngel has found benefit from the
snbciitaneous injection of utrychntni.' in !*pasm of tlie ciliary inii*cle.' If
the internal recti arc weak, wt> nmy combine the use of convex gla&aes
for reading, with the u.4o of a prism (base inwards).
Ifl._SPF,CTACLES.
The spectacles which are generally iiseil for the |mrpose of cor
some optical defect in the eye arc either ftpherical or cylindrical len
Or a combination of both. The properties of such leuaos have
already sufficiently explained, and I shall, tlierefore. now only add a
remarks as to the different kinds of spectacles and their constntetion
From the perusal of the different anomalies of refraction and occO
modaiion, tlie reader will have been sufficiently impressed with the .
imporiiinco of tlie proper and wiienttfic selection of spectacle?- I IiahH
DO hesitation in saying that the empirical, haphazard plan of seleotjofl^
generally emjjoyed by updcians, is out too frcfjuently attended by the
worst conse({uenoes : and tlmt eyes are often permanently injured, which
might, hy skilful ircattnent, have been preserved for years. For thii ^
' -SLHoiiftUbl.," 1871,991.
8PBCTACLS8.
661
reason, I tnufit strongly urge upon medical men the ncceHitj of not only
examiiiiag the state of t-he e^e, autl attcortaiiiiiig the exact nature o( the
afleciifiii of rcfractiiiii oraromimwdatioii, biitof Koin« even a step further
thnn thia, (uid dctemiiniii;; wUli cAi*e ftnii accuracy the number of the re-
c|uirc(l lent). For thta purj^Kise thuy must poaseaa a caae of trial-glasMM,*
«ont.iining a camplete as-sortment of concave and convex lenses, glasses
orcorrea|>omUng number Win;; kept by the optician. Written iliractions
as to the focal distance of tliu required glass, and Trlictlicr it is for di<^
tance or for reading, aro to be sent to thu optician.
The stronglh of any given convex lens may be eaaily ascertained by
finding the distance at which the inmgi- of a distant object (a candle, Uie
))ars of a window frame, etc.), ia distinctly formed on a shoct of wiiite
paper or the wall. The ditttancc uf tliis distinct image from the lens,
gives the focal length of tlie latter. Hut if we have a act of trial glasses
at hand, a more sim{de and ready mode is to Gnd the concave Ions which
completely ncuLralizcs the convex one, and this at once f^vea us tlic niim>
~ ir of the latter.
Tlie complete nciiiralizatinn of the convex lens hy the concave is
known by the fact that if the two are placed in cloite appo<«itJon, we can
read as well throu^^li theia as without any jilasa before the eye. Another
test is, that if we regard a vertical line (f.y., the vertical bar of a win-
dow) through them, it remaiuit perfectly immovable when the glasses are
moved to and fro before the eye. Whereas the line will diBtinclly move,
if the two glasses do not ncutmlize one another, the more so, the greater
the difference between them. If the uUjuct moves in the contrary direc-
tion to that in which the lenses arc moved, it proves that the convex
lena is the stronger of the two ; whereas, if it moves in the same direc-
tion, the concave ia the stronger. The strength of concave lensci may
he tried in tlie same way.
Care should be taken that the spectacles fit accurately ; that th«
gltuses are on the Bame level, so that ono is not higher than the other;
that they are suificienlly close to the eyes ; and that the centre of «ach
flaaa is exactly opposite the centre of the puiiil. The last point should
e |Mirticiilarly observed in the selection of glasses whicli fit on ttic ttose
by meaiu) of a spring (pince^ncx). for we find Uiat. on account of tJieir
oval shape, these generally are not accurately centred. If thej do not
1 Sncb Irikl oM»s «r« toule h/ M«Mn. Parti anil Plohr. nf Barlln, aod CQDUin
4Mnu|>lcto «><ti of ouDoaTff »ii<l L<oiivex l«as«e, prUiiutlu aad tlulvd gluiM, and « clip
ftpi^tack rram# for hoMing the lenfitw. Thesa U-nsas arc dcllni'il m Pnnsian ini'litia,
wliiuti are alniiist iilentk-al wild llio RngUsli ; whereas tli» Prandi are ooriBlitnratily
more, h» ilie ariauttt-iiu^ut of ih<! K^dms in thme trial cms la, however, made with-
oat anj s^atiini, so that whiUt tb<>r« am r^rj nunr and bnl slight grailatlon-s In lh«
wi«kiT f-liiiseii, thu*i' in th<< *(r'>iif,'i^r ant nut auScioDtly tiiiUM^tu«, lh« diff«niiHW iu
(lie rrfra'-tion of tlio lilxtxrr imtnl>i.T8 \» very ifreat. Thus. wUIUl the differmoe tn
the refraction Ix'lwei^n the convex tHJ and iO In only |||,. that bi>1iPt-i^a 3jaad 3 h ^.
Tu Teiii-.'>ly ilifM- d<'f-!cla, u well M to iiiiiiiilirr Ihn trttl caxiv, and Kr***'!/ dimiuun
the ntmibt't nf lon^it*. ZfAw-nAt-r haa p^nJ>oN(^d a new c<wi hi nation srair of glnitoaii
(vide "Klin. Monata.," ISltll). At Ibw mA-Linj^ of ihn li)tiTnntt<inal r)|dilhaniu>ln|p>al
OtDifrt-SM, li'^ld lam year tn iMivlmt, a larm- nuiuWr of ni'-mlK-m aure'-^l t" ouUlitale
the ai(^ of tlif mi^rr inoaanri' for that of ioohm tn the dctiTiuliiation of 1h» iitr^n)Cth
of letiMiM, In iirdnr llial ilivir uuiuImt luajr be lliw aamu in all onitiitciiM, and ri>r uUivr
prwlical reuoiu.
6')2 ANOMALIES OF BBPRAOTtOS AND ACCOMMODATION.
fit propcriy, ao that tbeir centre correaponda to the centre of the puful
Uit\v aot as prisms, aiui give lise to diplopia or a correapoiuHiijr «iiui
and itte latter may even liecomc pemiaoent, if their use is persisted
Concave rIrsacs dhouH be quite close to the eye, otherwise they wi!
diminish the sixe ami diBtiiictness of the retinal inia<;e. As the rayi
which impinjie npon a concfivf' lens are rendered divorj^ent by it. it fol-
lows that the further the glass is removed from the eve. the fewer peri-
1
^
them more con**ergcnl. a greater niimher of penpheral rays will enter,
the further (up to a certain point, of courve) the convex glftM h removed
from it, the retinal image becumitig at the same time larger ind
brij^htcr.
Single eyeglasHes ahould not, as a rule, he permitted, as tbey ofldi
lead to weakness of the other eye from non-use.
Besides tlie gplierical and cyliudnca! spectacles we most also conai
the foilowin;; kinds : —
The pari ii^pi^ glasses consiat of concavo-convex, and convexo-concafe
lenses (so-called positive and rmgative Txienisci), and consftniently ha?
only a very fi1i;;;ht splicrical aherration. On this account, when the
cave surface is turned towards the eye, there is less irregular rcfraeti'
at the edge of the glass, so that the rc;:ularity of the imaj^ei) is mQ<
le*w impaired, hi consequence of this, the observer can look more
liijufly through them, as was first shown by WolUstou, who od iht
aooount termed thera periscopic. Their chief disadvantages are tliat
they rcBect the light more, and are also more heavy and expensive th;
spherical lenses.
Spectacle ;;lasscs arc sometimes required to have a difl*crent foen
the up|)er and lower part (pant^tcvpie $pf«'ta'-fet'). This is more
cially llic case if preshyupia coexists with myopia or liy|)ermrtropl
'j'hus Franklin, who was presbyopic and also slightly myopic, i-mploy
glaases, the lower half of which was convex, to neutralize the presby
pia, and the upper half concave, to neutralize the myopia. In Parii
such glasses are termed rerrcs d double fi'tftr , and are constructed b?
grinding in the upper part of the a|)cctaele-glaas, the surface which ts
turned from ihe eye, with another radius. Such spectacles muat be
placed at a proper height before the eyes, so that in looking at near
objcctB the rays only fall upon Ihe eye through the lower jiart, when
those from distant objects must only fall upon the upper part.
form of Hpectjicle is found very useful by ininoture painters, Icoturvra,
etc.
Prigrnatic spectacles are sometimes employed either for the purpose
of exert'iaing and thus Btreiigthening certain of the muscles of the cjfr;^
bell, or to relieve them. The action of prisma has been already ^^^M
plained in the introduction (p. 4C), and iho u!ie of prismatic spectacle^^
■ ll hfis alr^ndy hi>Mi Htattyl tlinl mncAV? ^Inmm diminish U)<> rfOrinl Imnicf'
itinTiii^ till* niiHiil piiint fiir11i<-r hark, tliim dimitiMhing ttn' nn;;li' (•( virion , »l
fK-iivt.iit (flaMM vnUrgr ttii- rclntnl ititit^", ah (hcj* uura tliu uwliU jiviiit funriud*, n
Uitu [Dcre<AM Ui« six« of tho *aglv of visiuD.
tf^
SPECTACLES.
66d
will be founil described in the article upon muscular astheDopia. llie
prittoN are generally tunictj with tlieir hma luwanld (to relieve the in-
tcmal recti mu&ctc«), and may either be lUtcd alone or in combination
with eonrcx or concave Icuaca. In the latter ca«c, they are ground in
suub a luaiiniT as to euinbitie the efluci of a pmm with tbat of a splieri-
cal lens. Bv tiimin;; tin> Imisc of the prism inwards, the rays will be
deflected Romewhat to the inner side of the jciiovr spot, tlie eye will
eonsei|uently move slightly outwards so as Co brin;; the Tuys again upon
the yellow spot ; there will con»e<|ueutly be a lew convergence of the
visual lines, the effect being the same as if the object were placed some-
what further off, but it is seen under the same visual an;;lc, and the
divergence of the rays i^ al!<o Ibo same.
CloHvly allitid to tlic prinmatic gla-saes, are the decentrod lensoa of
(iiraud Tculon. They are constructed in such a manner, that the eccen-
tric portions of two convex lenses are used instead of the centre, so that
they mn^t thus ac(|uire a slightly prismatic action. Thus in convex
lenses the centre should lie a little to the inner side of the visual lines,
whereas in concave {glasses the rcvorno obtains, and the centre should lie
a little to the outer side of the visual lines.
I>r. Scheffler proposes to substitute for tJie coniniou spherical lenses,
glattses which are cut out from the periphery of a large lens, in such a
manner as to act as decentred lenses. The advantage which he claims
for them is, that with them the convergence of the visual lines undergoes
an alteration in Imnnony witli the change in the accommodation, which
is not the case when the coninion spherical lenses are used. His work
" Die Thcotne dor Augenfehler und dcr Urillc," in which this subject is
fully created, has been translated into Rnglisb by Mr. R. B. Carter.
[StcnopsDic glasses ofton improve vision luarkcdly in cases of cloudy
cornea or lens, and thoy arc most applicable for near objects. They
have been recommended in cases of high degrees of myopia combined
with loss of (lie<tiitct vision, where, in connection with weak concave
glasses, they improve the vision by lessening the size of tlie circles of
dispersion without affecting that of the retinal iunges.^B.]
kye-protectora are found of much service to guard tJic eye against
ry bright ligbt, dust, or cold winds. The test are the medium blue
curved oye-pm tee tors. They are curved somewhat like a watvli glass,
BO as to Hi closely, except at the teni|M)nil side, wlioiv they permit a suf>
ficient amount of air to enter and come in contact with tlie eye, to main-
tain the evaporation of the conjnnctival moisture. Tliey art* greatly to
be preferred to the goggles with wire or silk sides, or the glass spec-
tacles with large glass side-pieces, for these keep the eye much too hot
and close. The goggles are useful if the patient is exposed to the at-
mosphere very soou after a severe operation, when the eye is still
inflamed uthI very aitsccptible of cold, but for all other |Hirposes the
curved glasses arc to be preferred. Messrs. Salom (of 137 Regent
Street) have lately introduced an excellent modifioalion of the goggles,
by ndfiing thin g.iii/.e side-pieces to the curved blue eye-protectors, which
vnders them i^uite as efficient as the goggles, and much lighter, as welt
less unsightly and conspicuous.
The seu$e of daxzling of which many (more e5f>ecia11y myopic) patienta
It 11^
6G( ANOMALIES OP ESFRACTTON A»D ACCOMUODATIOK.
Cfttoplain wlion thoy are cxpowd to bright ann or gaslight, is most effecto.
ally rt'lii've^ by cobalt bhio glasses. It wan fortaerty Bupposed that t~
re<l rays of the solar 8|M>ctrum were the most trying to the eye, and c<
sequcntly fprccn jtliiMca ( which exclude the red rays) were much in rogU'
Bwt it is now a wt-ll-kiiown 1*ac-t, that it is not the red but the orange ra
•which are irritating tn tlie rptina, and as bine excludes the orange ni
tJiiB 18 the proper color for 8uch 3j»ectacles. Moreover, the Mue color,
on account of its more eccentric position in the solnr 8j>ectruui, makes a
less impreaaion upon the retina. Smoke-glassea are not so good, a« they
more or less subdue and dimiuiiih tlie whole volume of lignt and color,
and thus render the image nomewhat indistinct.
It is often very tlesirable to combine the blue tint with the uae of
Tcx or ciiiieave npherical lenses ; in the weaker glasHCS this can be ve
eft'ectiially done, but in the higher numbers it la difficult, for the va
ing thickness of the glass causes a conaiderable difference in the tint
the centre and at the edges of the lens. In such cases it will be well to
adopt Mr. Laurence's suggestion, viz., to join a very thin piece of plain
tinted glass with (Canada Wlsam, to the hack of a colorless gpherical lens.
Besides the colored eye- protectors, which are used in orflcr to diminish
the tpri;;ht glare of light, or to keep i)ff the cold wind, dust, etc., the
are iJirne which arc emjiloyed by workmen in order to ])rotfict the e
during their work against injury from pieces of ntone^ chips of steel, c
The best are tliofle maile of thick plate gla»^, with wire or gauxe eid
for they are sufficiently strong to resist the force of miy , cxcejiring » ve
large projectile. The chief objections to these are their cx|>en8e a
their weight. To obriatc these defocta, Dr. Colin' has recommended
use of 8i>ectaclcs made of mica instead of glass. If the mica is of
quality, it is tiuito as tniiLiipHrent. as glass, but lends a faint gray tint
objects, which docs not, however, in tho least diminish the acuity
vision, but rather tempers the light. Ttiey are made in the shape of ti
large curved eye prol*irl4)rs, and should fit close to the eye. leavini; onl^
the temporal side somewhat o|jen. They are much lighter and ch'
than the glass spectacles, and do not break on falling down.
II.— DIFFERE^'CE IN TlIK REFRACTION OF THE TWO
EYES.
Differcncca in the refraction of the two eye* arc not of unfrcqner
occurrence, and generally consist iu ditfercnces in the ilegree of the
myopia or hvpermctro[)in in the two eyes : or, again, one eye may bj^H
>xiM
emmetropic, the other myopic or hypermetropic; or myopia may o
in one eye, and hy|)ennetmpia in the other. [I'nilateral aatigmattsm
may also occur, but usually with myopic astigmatism in one eye Uiere
myopia in the other, or with liy|)erme tropic astigmatism in one eye the
is hypermetrnpia in the other. — B.] Absence of the lens (aphakia)
one eye, gives rise of course to a very great difference in the state of
fraction of the two eyes. In the majority of cases, the refracUou of ^
■ Brrliuer Ellniscbe Worbonwrhrin, F«b. S4, IMS.
I
BIPFBRBNCB IH RBPRACTIOlt OF TBB TWO BVBS.
665
two ejcs is very nearlj alilce. Somcttmos, however, tre fiiiil ooiiKidtTa-
ble differences in the degree of myopia or hypermetro]tia. The |jnwti-
cal (jucittion i», what k'lud of gla«;4e9 aie we to give to such patients ''! It
might appear proper to furnish each eye with the glosa suitable to ita
own state of refraction, but in pmctjcc we find that this doc^ not gene-
rally answer, for the |MitieiitA, as a nitu, complain that Kuuli H|>eetaulea
render their vision confused and indi-itinct, on account nf the difference in
the sixe of the two retinal images. U is best, therefore, to funii^h both
eyes with the glai>.s which suits the least ametropia (hypennetropic or my-
opic) eye. If ilia very desirable that the patientshould enjoy the greatest
po«Hhlc acuteuess of vision, we may give two different glasses, so as com-
pletely to neutralize the difference in the state of refraction, and the
patient must try whetlicr he ii able to aec distinctly and comfortably
with them. Sooietimes a little prnclice will enable hitn to do so, and
then their use may be allowed. If this la not the case, wc may par-
tiatlj neutmlize the difference, and thus diminish the siiw of the circles
of diffusion. Tfan» if the myopia of the one eye » ^'^ , and that of the
other |, we may prescribe concave lo for the former, and concave 9 or
lOfur the latter, ll has alito been adviacd that when tlic si-ilit of the two
eyea (which differ con-siderahly in the degree of their myopia) i^ eijually
good, the gla«!) which Ilea midway hetwucu the two degrees of ni^'Opiu
should bo given for botli. If, for inatanco, the one eye nN|uirCH concave
4 and the other concave 8, it would he advisahle to prcacrihe concave
6 for both eyes. But i^uch ghtsses prove unsuitable, as they suit neither
eye, being too strong for the one, and too weak for the other.
If there is a difference in the refraction of the two eyes — the one
being myopic, the other hypermetropic — it is also often difficult to suit
Ihem with glasses which shall neutralize each anomjily. This is owin;;
to the difference in the size of the retinal imtiges which wilt be produced,
for the convex lens will enlarge, the concnvc lens dimini^th, tne Atxo of
the retinal image, and this may prove asource of cmmideralde confusion.
In all ca^eH of difference in the refraction of tlie two eyes, the pationta
should try the glajMcs for some little time, so as, if jKissihle to become
accustomed to tlicm, before we decide dehoitely as to the kind of glasses
which we shall prescribe.
[In nearly all caaes of difTerence of refraction with g«Mid vision in both
eyes, it can be deuionfttrntiHl that onlv thnt eye is uited for near vision,
which receives distinct retinal imafEcs with the least effoi t of accommoila-
tjon. Still a normal binocular vision maj/ exist in s]>ite of the dissimi-
larity of the retinal images, the circles of dispersion in one eye being
overlooked. If one eye be hypermetropic and the otlier emmetropic or
myopic, the former is usually nmhlyopic.
If there is a difference of refraction, and at the same time there ortisks
the mutual visual act and binocular nxatJun, the first thing to determine
is which eye possesses the Itottcr vision and also the leani error of refrac-
tion, 'riic proper lens is then chosen for tliis eye, and generally the
same Ions may he prescribtMl for the other eye. Sometimes, however,
the best results arc gained by providing each eye with its best correcting
lens. If the eye with the beet vision lias abo the greatest error of re-
fraction, it is better to give the other eye a proportionately weak lena.
(*' Scbweigger," loc. eit., pp. 74-70.)— B.]
Chapter XIV.
AFFECTIONS OF THE MUSCLES OF THE EYfi.^
1 ACTIONS OF THE MUSCLES OF TIIE EYE.
Tn order properly to utiderstand the pliyitiolo^cal action of the di
f«rt'nt muscles of llie t■TO^aIl, we must coiwider the eye as a sphere, tbe
centre of wliicli heing fixctl, itt> raovementa can only ^o rotations around
a fixed axis, and hence there can be no change of locality.' But for
p irpose or accurately determining these rotations, it does not isuffice td
ascertain the change of position which one point upon the surface of the
sphere may undergo, hut we must take iutti couside ration the position of
a tefiiiil point, which must noi, liowpver, stand in the ri'lation of a pole
to the first. If we take the centre of the cornea for the one point, and
the vortical meridian (the greatCKt circle Ktandlng i>erpendicu1ar to tbe
e(p!ali»r of the eye) a« the second, we shall he camly a\>\c to determine
the rotations which the eye undergoes, by watching in which direction^H
the centre of the coniea moves, and what kind of inclination the verttcal^H
meridian undergoes. '
For the purpose of discovering the inclination of the vertical meridian
in the different positions of the eye, Uondcrs devised the following in-
genious experiment. Having vertically suspended a colored thread, h»
looked at it until its image was impresi^cd ti]>on hia retina (tliit< image
was of course in the vertical meridian of the eye), he next moved hia
head in the different directions in which he desired to ascertain the incli-
I Porfnrthor informnlioa upon the ilisciuee of Ili« nniseles of thv <7«. I mast iv/cr j
Ihcrt'iulir to Vondrat-fuM Krtirli-n in tlir "A. f. U.," voU. 1. Aod iii.. And tti liiit wnrt
(•ntitli-d " itymptniiicitli-lin! ilvr Atig<-ninii9ko!i*)iiuungen ;" to Alt- Omufc's " MotlH
liilji-»Uiran^<'n Hm Augtit;'' and &lsn lo m^ nrticJea in the '* II. 1* '>. II. Itiii.." Tot<b]
ii. itRit iii. : anil in the "Med. Titnrfl kod tiaiflte," 186S. [Or&<-fe uitd SAxcuiscti'l
" Hnndtruch dft AagvahviWt.," vi. 1.— It.]
■ tt iri, liowcTfT, not quite corrocl to consider tho «jr* ** ^ aphure (glotw) and it
criilri-M ntntinti a.'xitaftU-d in lli<- conlrv of lli<< visoal axii, |i>ril i* in r>-^! '
»(>nii<nh.il hitliiri'l il, tm w*» ihuwn hr niimiToiit tnMuurvnivnts ini(d>^ )>v !>'
l*uyer. Tliry found, moraurvr. that tfao cxaut position of the c^ntroof inoi.
Ing point) vari» with th<- ilalu of refraction nt the vye. On thii snbjerl l)«
naj-n : " 1. In the <Hniii«l Topic ejc. the wntrv of iwlion is »itUAl*->l at a ooutldt
diclaiuv^ (1.77 mm.) Wttiitd lh<> middle of th» Tistial axis. 2. In oiTflpit? iudlrldni
tbi> oonlre of motion in iiitunl>>d room dcwpt^ in lh» i>yt; but aUo furilivr from lli>.< pu
tvrior surfacQ, and indn-d bu that in lh«! t^y^e <rf «u<'li pvnoos thv Mntioti biitwwi
Ihi^ paH« of the viaiinl ax)» tiituatt-d bi'toir and U-liiud lite cculrv of nnutiuu ia neait
th"" *ami> n* in th" pmni«>tr»pip .-vi*, H, In the tiyjiiirnit-lroplc fiyv iho ti-nlriiuf iiKflia
IH Kitiiiii<>'l not «(« diN|ily, liui rilativulj closer to the [iftucrlor Burfaci' of tho vy*,"-
" AiiouialitTti of IklriM-tion and AcromuiodaUou." p. 102.
ACTIOSS OF TUB MUSCLES OP TUB BTi:.
687
naiioiiA nr tlie vertical mcridiAn, and tlion meawured Uie aiif^le which the
inia)j;c- ujion hi^ rctiiift fnrmei) with a lint; Ih-M vorlically befnrc his cvA.
As tlie (wsition uf the retinal image of course agrevl with thnt of the
vertical meriilian, he was enabled in this way readily to ascertain the
dir«ctiou of the vertical inendiau in every movemenl of the eyeball.
I must here |»oint out that from habit wc sec ohjects veitical and not
elaiitiiij:, even althoii;;h the vertical nifridiau tthoiild be inclined.
Bu^d u|Hiii thuric experiuK'ntt). Doiiders laid down the fuUowiOf; rules
B8 to tho position of the vertical meridian io the different moveiDents of
the eye : —
1. It) lixjkiiig in the horixontal meridian plane, etrai;;htfor«arda, to
the rij^ht or to the left, the vertical meridian suSera no inclination, hat
remains vertical.
'J. In looking in the vertical meridian-plane, Btraightforwardd, upwards
or downwards, the vertical meridian aUo remains vertical.
A. In lookinj; dia^^onnlly iipwanU U) the left, th« vertical meridians of
both eyes are iitcHned' to the left nnd parallel (that of ilie left eje alant.-
tug tmlwaol. that of the rif^lit inwards).
-1. In liHikinj; diagonally downwanU to the left, the vertical tneridiaiia
oflvoth rycji are inclined to the right and parallel (that of the left eye
inwardti. that of the right outwards).
5. In looking diagonally upwards to the right, the vortical meridians
of both eyea are iuclined to the right and parallel (tliat of the right eye
OutwarU. that of the left itiwanlc).
IJ. Iti looking diagonally downwards to the right, the vertical mcriilianii
of both eyes are inciiuud to the left and parallel (that of the right eye
inwardji, that of tlio left eye outwards).*
For the »ake of simplicity, we may consider the muscles which move
the eyeiiall as consiHting of three {HLira. The two muscles of eadi pur
act in an antagonistic way to each other, hut each ]^>air has a common
traction-plane, and hence abo a common axia of turning, around which
the one muscle dest-ribes a positive, the other a negative, rotation. Now,
although these three pairsofmiwclcs would be cajiable of placing the eye-
ball in every kind of (loniiion, wo find ihatonly a t^mall ]Hjr(ion of all the
poasihle positions really occurs. For Dondcrs has rlcmonstratod, that as
every poititiuu of the eye is given by tlie direction of the v\^\m\ line with
regani to the lieail, ami by the nimiilt»neouB rotation (inclination of the
meridian plane-i to tlie vistual plane), ^) a given direction of the visual
line is always associated with a dcGnite degree of rotation (Uunder^'s
law). This of ooune consideribly curtails the number of the positions
of the eye, and substitutes a physiological certainty for the uulimited
raechanical posaihitity ( (iraefe).*
In onlor to ascertain the direction in which a muscle act«, we must
draw tlirough it a straight line which shall unite the middle of itti origin
with the middle of its insertion. A plane laid through this line and die
turning-point of the eye, is termed tbo plane of the muacle {muacle-
' Tlip u/rper cnil of llie ct-rtirol nirri-litD Una is the on* oIwuvh df«>^ilMvl.
* Tlii'Hcriil.-'t Iinctt 1m-.*ii Irnii^UCiil fnini AIOliI tJrAifln'ii i-xcwlli-nt «r<rrk, " Klinitclio
Ai)al/Kif il<ir Mu(ilittllH-«t&riiiiK<.-ii tU-« .t (!;;•■«,"
' " Syii)|itaineiil<KbTfl dvr .tngonmnskitllUhmuiifni)," p. 81,
668
ArPBCTCONS OF TlIB UUSCLGS OP THB BTB.
plane')f and a line stanilini; perpendicularly upon this plane in Uie tarni
point is called tlie axi* of turning. Now we shall find it of tho jrivalc
iDiportaiice iu the paralysea of the different mHscles of the eyeball,
know in which pisitions of the eye certain muscles act most upoti
height of the comca, and in which poaitiona mo«t upon the vertical meri?
dinu. We shiill timl that the effect upon the hcij^ht of the conioa is the
greater, the more the musclo-plaue coincides with the vertical EneridiaB*
plane, and the more the axit* of turning appro^choa the liortKonUil diame-
ler. On the other hand, the power over the vertical nieridiau will be
Irnst in this position, but will incrcnM! in proportion n.4 the oye i« tunu-d
iu tlie opposite direction, for the axis of turning then approaohe*
anil more the position of the optic axis.
1 . The axis of turning of the first pair (rect. ext. and int.) •* vc
ftud coincides with the vertical diameter of the eyeball.
2. The axis of turning of the second pair (rect. aup. and infer.) Um
aUo in the hori/,ontaL meridian, aud is directed from before and inwardi
to behind and outwanU, iu such a maiinur that it forms with thv opuc
axis an angle of about 70°.
3. The axis of tuminj; of the third pair ( ohlin. pup. and infer.) lie*
al^jo in the borizoiktal meridian, ami is directed from before and oiitwardi
to behind and inwards, in such a manner tliat it forou an angle of about
85^ with the optic axis.
Let US now consider the action of the different muKles upon tiie pcwi-
Uon of the eyuball aud the direction of the vertical meridian.
tPfg. 183.
ninu-d I
I mon^
rtioil^^
.A
I'^-i
^
rL» ">.•■•«»»"'
'"'-'■■
I
^/;
Ariocarar--»,j
The superior rcctiw rou»clc arises from tlie portion of bone y.
front of the optic fonimen, and runs obli'^nely over tlie globe to be
sorted into the sclerotic, about three lines from the cornea. But
course \% so obliipic, that the internal portion of its insertion lies ali
one line nearer the comca than its external portion. Ita action in
ACTIONS OP TUB MOSCLBS OF THE BTB.
669
move the eye upvrnrda and sUj^htly inwards, indming the vortical me-
ridian inwarda. [h'ij*. 18:1. — H.]
The iiifcrtor rectus altHi amus tr»m the optic foramen, and ita tendon
is inaortcii iihout three lines from the lower edge of tlie cornea, but ftoroo-
what (about half a line) to the inner side of a supposed vertical line
dniwii tlinmgh the centre of the coniea. It mores tlie eye dowtiwank
and inwarrlin. »nd inclines the vertical mcridinn oiitwanl;i.
The superior ami inferior recti exert mosc iullueiicc ujion the height
of the oomea, when the eje is iiimed outwards, as the muscle-plane tlien
coincides more and more witli the wrticul meridian-plane, and the axis of
tumiiijE appronclieA the linnzontal diumoter. TlieHC niuxelc^ act most upon
the inclination of the vertical meridian, when the eye \* turned inwards^
as the axis of turning then approaches more und raon> the optic axis.
The exteniul recius arises from tlie common tendon, and ruiw alonj^
the outer side of the eyeball to be inserted about three lines from the
external edge of the cornea. It moves the eve directly outwards, with-
out producing any inclination of the vortical meridian.
The internal rectus is the strongest of the ocular muscles, and nearly
four linc'i in width ; it arises from the common tendon, and is inserted
into the sfllerotic about two and a half lint-ii from the inner edge of the
cornea. It moves the eye directly inwards, and does not incline the
vertical roeridiau.
The Huperior obli^pie arises just in front of the inner portion of Uic
optic fontmen, and ntn^ along towards the inner an;:le of the eye, where
iu tendnn passes throu;^h the trochlea, and then, bonding outwards and
backwards, it spreadi; out like a fan to lie inserted into llic upper, outer,
and posterior quadrant of the eyeball, by a tendon three linei! in length,
the convexity of which looks backwanls. The action of the superior
obliipir h to roll the eye downwards and oatwarda, and to incline the
verticnl meridian inwards.
The inferior oblitjue arises from a depression in the orbital edge of
the superior maxillary bone, slightly towanls the outer Hide ot the
lachrymal sac, and passes alonj; the floor of the orbit in an outward,
downward, and backward direction, until it has pa^ed beneath the infe-
rior rcclua (to which it is connected by fibrocellular tissue'), when it
curves upwards and backwards, and pasifcs to the inner side of the ex-
ternal rectus, to be insert«{l by a short tendon close to the insertion of
the siipt^rior obli<{Ue. The inferior oblique rolls the eye upward.4 and
outwariLs, and inclines the vertical meridian outwards. The two oblique
muscles act most upon the height of the cornea when the eye is moved
inwsnia, as their muscle-plane then coincides more and more with the
vertical mcridian-plnne ; whereas, they act most upon inclination of the
vertical meridian when the eye ia turned oulwarda, for then the axis of
luniiii;^ approaches more and more the optic axis.
Having deftcrilted the action of the individual muwlcs, wo must now
pass on to the consideration of the movements of the eye which are pro*
duced by the combined action of several muscles. In so doing, we bavo
to consider the following eight diflfercnt movements of the eye :'—
I In <>T()«r In ramprchiHid tW various eomliiiHxl i»oviik'iiI» of tliv tye, w« mutt
u«utD« a, " primarjr pMition" of Uu vye, startlDg flrooi wfaicU IL« tUo&I IUm (Dlick-
GTO
AFPBCTIOMS or THE MU6CLE8 OP TBB BTB.
1. The movement Tcrtically apwawl*, in wliich the rcrtical meri«iiwi
remnitis vltuchI, is brouglit jibnut by the avtioa of the sujwrior rvctn*
and inferior oblique. The superior rectus ftlmie drawti tlie c<^>niea up-
wards and inwards, and inclinei the vertical meridian inward«, hrucr
some other muscle (inferior ohlinue), whose action 'm to draw tbe cornea
upward;} and outwardx and iiiclinu the vertical mvridian outwarfU, intwt
associate iteoll' with the eupertor rectus, in onlor to counterbalance Us
action.
2. In moving the eye diftgonally upwards and inward*, the vertical
meridian being inwards, the superior nxtus is chiefly SBSOciaicd with ibp
inl«rnn1 rectus. But as the latt^^r has no effect upon the vertical merid-
ian, the superior rectus would incline it too much inwards, and Ucu»r
disturb it8 pamltelism with the vertical meridian of the other eyo {which
is inclined outwards). Some other muscle, wliose action is to iudir
the vcrticiU meridian outwards, must, therefore, be called into play, 'a
order to check the action of the superior rectus. We shall a^^ain (tml
in the inferior oblique the muscle re<|nirt*d : moreover, on account of it«
having least influence on tlie vertical meridian when the eye i» tnmftl
upwards and inwards, it will not over-correct the action of ih» superid
rectus, but only limit it.
3. In moving the eye diagonally upirarda and outwards, the verttc
meridiun being incliued outwards, the superior rectus acta in conjuncti<
with tlic external rectus. But as the latter has no influence ou the
tion of tbe vertical meridian, and as the superior rectus turns it inwai
we mu!«t call into re<|ui8itiou some other muscle, wbivb ahall twt oolj
counterbalance the effect of the superior rectus upon the rertical meritf
ian, but shall even more than correct il, and incline the latter ouiwap1«.1
The inferior oblique will be able to do this, for tbe eye is tww in the
position (upwards and outwards) in which the inferior oblique acts mon
U|ron the vertical meridian.
4. The movement vertically downwards, the vortical meridian rfmniii-
ing vertical, in produced by tlie civmbioed action of the iufcrinr nvtiw
and superior oblique. Tlie action of the inferior rectus alone, would be
to draw the eye downwards and inwanls, and to incline itio vertical
meridian outwards, hence it must be associated with tbe superior oblitiwe.
whose action 'a lu move the eye downwards and outwards, and to indit
tht' vertical meridian inwaiils, and tlius to counterbalance tlie inferit
rectus.
5. In the movement diagonally downwards and inwards, the rertit
MDeridian l>eing inclined outwards, tbv iuferiur rectus is associaltKl with
lie iutcmal rectus, and the superior oblitiuo is requtriMl to limit Uie ef
. tir ntovM iJlreclly iipwunl* nr downwaH*. nr ilirrctly tA the rljehl
itliiMit tli*> uci'iirrniiiw uf nny ri>tjib>rv tiiriiiii)[ <ir imit.'riit'iii, i. «., «ft
■■ ■ ' *'■ ■■ -'ic*l ini-ri-liMn low»nli iht- t- ■ Tliif pritn&r/
ly to ttiiit of tlw eJTM Wl i v-t IwlMg rfrt.-!; tl.i-
, ' L on the lioritpD lying in ' at |>lui<' r^ lh«
't, lh<- Iaw rf)(iil«Liut; Die tuowmrtiUi ct itii> iMinnftl ey*a
^n' PXpFMiwi »i tnWrnn : " If ilt« rhual line piii»'-i
'thvr iKicillmt, th<> rotniorj^ m>iT,>nftit <jf \\-
i.'h a kitid M 1( it (lltc cj^i-balt) liwl bmii
[•■.r[»-|i<ll''nlu to th« Hral anil iwcoihI itlrfocfon of Iti* <'ttuil IL
■' PbjrftlolafiMbv Optlk. " |>. -Utf.
ACTIONS OF TUB MC8CLES OF TUB BtB.
671
of the inferior rectus upou the vertical meridian, and to prcfterre the
parallelism of tlic meridians.
ti. In the movement diagonally downwardB and outwards, the vertical
meridian being inclined inwards, the inferior rectuii is asttociated with
the cxtenint nctns, ami the nujierior nhlii^ne iit uallod into piny, not otilj
to coiinterkilance the effect of the inferior rectus upon the vertical
meridian, hut to over-correct this, and incline the latter inwards.
7. The movement directly outwards is produced by the action of the
external rectus.
8. The movement directly inwards ia pradDced hy the action of the
internal rectus.
The folluwinj; tahular Hrran^iemcnt will eiuihlo tho reader to remero-
hcr more cA-*ily the manner in which the different movements of the
eye are produced : —
Hor(>iDent
Upwards .
Downwards
Inwarflfl
Ouiwanla .
Upwanb and inwards .
Upwards and outwards
Downwards and inwards
Downwards and outwards
III {irndnnMl by tbo actlnn of iho
Superior rectus and inferior oMiijue.
Inferior reciun and Huperior ohii'iue.
Internal rectui*.
Kxtcmal rectus.
Superior rectua, internal rectus, and inferior
obliiiue.
Superior rectos, external rectus, and infe-
rior oblique.
Inferior roctuR, internal roctus, and superior
oblique.
Inferior rectus, external rectus, and supe<
rior oblique.
The effect of the recti muscles is to draw the eye into the orbit, that
of tlie oblique muscles is to draw it out.
TIic nerves supplying the muscles of the eye are the third, fourth,
and sixth.
The third nerve supplies the snperior, inferior, and internal rectus,
the inferior ohiiiiue. ttio levator palpebiie superiuris, the constrictor
pupillw, and till" ciliary muscle.
Tlio foiirtli nerve supplies the superior oblique.
The sixth nerve supplies the external rectus.
There are two different kinds of binocular movements, viz., the asso-
ciated and the accomnK>dative [or convurging. — B.]. In the former, the
visual lines remain parallel, whereas in die accommodative movements
thoy converge towards each other, ond moot in the object. When the
muscles of both eyes are quite at rest, tJie angle formed by the visual
linos of the two eyes is called the muscular me4oro]iter ; and the con-
vcrgcncc of the visual lines is such, that their prolongation would meet
a point varj'ing from S' to l:i' in front of the eyes. 1 most here
sntion the fact, that in looking downwards there is always an increased
"tendency to convergence, whereas in looking upwards, there is a greater
tendency to divergence. llcncc a convergent st^uint becomes more
G72 AFFECTIONS OP THB UUSCLBS OF THE SVB.
marked when the })AtieDt looks downwards, and divergent squint «bca<
he \ooVs upwards.
We have now brieHy to consider the 8)'in[>toms, diaguosis, *nd trett-^
meut of the paralytic afTfctiund of the diflcrent muDCles of the eye, u
I ghnll commence with the simplest and eAsie^t form of pAralysu,
thai of the cxtenml rectus muscle.
To prevent nccilless repetition, and to avoid the chance of any fytnptoo*
being overlooked, it \» alnavs hesl to follow a certain routine in examin-
ing patients BUppoeed tu he aH'ected with strnbismua. or paralysis of one
or more of tin- muscles of r.hc eye. Such an exaraiimtioti is Wst begus
by directing ttie patient (who should hold his head (|uite straight and ii
movahle) to follow with his eyes some object, snch as a pen or ruler,'
held at a distance of a few fuct, and moved in all directions. Any ab*
ii'jnuality in llic movomcnc of either eye wilt thn^ become at mwv n)
parent. We next cover one eye (^say the right) with our hand, tlif
patient the while keeping hts eyes steadily fixed upon the object,
we then observe whether the left eye remains immovable, or makcdii
movement in or<ler to bring its visual line to bear upon the object.
the latter case, we know at once thai this eye had before deviated frm
the object ; thus, if it moves downwards, it before stood too hi^t, and
vice vend.
2.— FARALYSIS OF THK EXTKRNAL ttECTCS MUSCLE
(OF THE LKKT KYK).
If the object (a lighted candle) ts held in the horizontal meridian-pl
about four or five feet in front of the jiatient, we find Uiat l»oth visual
lines are steadily fixed upon it, for upon the closure of either eye
otiier makes no movement, 'llie obj«t is then successively moved to i
right of the patient, then upwards and downwards, and still Imth eyes
"tllow it accnrately. But when it is moved somewhat to tlie left sido of
the median line, we find that the left eye lags behind, thus ginng rise
to a convergent squint, which increases in proportion aa the objeci u
ivv^l further to the left. As the paralysis of a muscle only sliovs
elfwiien the eye is moved in a direction which calls into action tha
fie in MucAtion, the paralysis of the left externa) rectus docs not be-
-I until the eye has to be oiuvcd in a direction to the left
1 line.
In a receni case of complete paralysiit of the external rectus, it will be
found that when the tiealtliy eye is closed, and the object moved sUgl>tl
iiihr tht' left half of the field nf vision, the lefl eye wlTl attempt to folia
n"' >>-r, in a straight, horixonial direction, hut by a tigxag. n
.1, lirought about by the action of the tiu[Krior and infen
be
il
noi^H
1 is by no means always so, for in many cases of recent paralysis,
I ' lutely no motion beyond the median line. Id tlie «aMS
..^'lUaiory motion or zigaaK action is observed in the aicefaed
ixtcnial rectus is not completely paralywd, bol only putiaUj
PARALTStS or TRC SXTBRXAL R8CTU9 UUSCLC.
I
I
I
I
I
There ctn be no rootion where there is complete paralysia of a motor
nerve.— B.]
A third symptom is that the gceondary deriation is considerahW grrater
than the primary.' This is a Bjmptoni of great importnncc in diatin-
fTuidhing the paralytic from tho oommoa concomitant squint. The deria-
tion nf tho aqviintinj; oyo is termed the primary deviation. Now if the
healthy eye is covere«i. the otJjor will more in a cortaiti direotioa to ad-
just itt> visual line ii[h>u ilic otiji'ct. which movement will be aocompamed
by an ssMciated movement of the healthy, covered eye, which tbas he*
comes the squinting eye, aud this movomeDtof the healthy eye is tonued
the se'-'ytidarif dovintioD.
To render ihi^ more intelligible, let us presume that in our supposed
cue of paralygis of the left external rectus, the object is moved somewhat
to the left side of tlie patient. At a certain point, a slij^ht degree (say
one line) of convergent wiuint of the left eye will appear, owing to the
inability of this eye t« follow Uie object. It" we now cover the right eye
with our hand, the l«ft will make ao outward movement of one line in
order to direct its riaunl tine upon tho abject, but the ri^ht eye will
sinuillaneoii^ly make an a^ociatcd movement inwards of {x'rhKps two
a:id a half or tlirec Hnes. This secondary deviation <,two and a half or
three lines) is therefore con-tiderably greater tlian Uie primary (one lino).
Tho reason of this is easily explained. As tho external rectus of the
lefl eye is insufbcientlr innervated, it demands a greater impulse of the
will to l)ring about thiH movement of one line, than if the innervation
were normal. But this increased impulse also affects the associated,
healthy internal rectus of tho right eye. and thus produoes n greater
amount of movement in this eye. lience, it is an invariable rule in all
oasee of paralysis, that the sceondary deviation considerably exceeds
the primary, whereas in the common conoomitaut squint, the two are
exactly e-iual.
The linear measurement of asquint may be made as follows: We note
a spot upon the lower eyelid, which wouhl corrcHi-ond to an imaginary
vertical line drawn through the centre of the jjupil of the squinting eye,
when tlio other eye is 6xed upon an object licid ai from 8" tu I'J" dis-
tance. The normal eye is then closed, and the squinting eye directed
upon tho object, and tho sjiot on the lower lid which now oorroaponds to
a vortical tini: drawn through the ooniro of the pupil is agun noted, and
the distance between the first and second spot
gives Uio linear bi^ of (he sijuinc. Tlieeo
splits may be at Brst marked with a dot of
ink upon the lower lid, but a lictle practice
will aoon enable us quickly and nccuratelv to
estimate the diijt;tncc between them. 'Vhts
proceeilin^; is illustrated in Fig. 1S4. i4 re-
presentA the mark corrrcsponding to the ocn-
Iro of tho pupil when the eye is squinting,
Fl«. IM.
• To waU'h tli>
aclipnf Kliglitly f
' •■ ill*- cru nxoliKlpd from pArtitipatiou in the A«t fif vltlon,
-liDulil Imi plnreal li«fofH tilt, onwvyo, IriKloadofcOTwIitg
It witli till likD-l : «<? " iiiii-i iha ^Ikhh pr«vvDUi iJt« |*«llttni (nHn SMhtg, it doM not
prevent our Dbserviug tba puallion of Ihe ejre.
43
074
AFFSOTIOSS or TBB UUSCLlS OF TUB BTB.
B the mark corrosponiling to the centre of die pupil wtiea Uie ejre 4
fixed u[>oi\ the objeet. The dUtaoce betwccu A and B gives the sir'
of the squint.
It U, liuwevcr, still mure convenient to employ Mr. Lauroiict-'s sir
birtuiOHieter (Fig. 1H5), which consiata of an ivory plate (/') mouUed
the confortDAtion of the lower eyelid. Its bonier is gradaatvd in suet
a manner, tbat while the centre i« desifinated 0, Paris lines ami haH
linea are marked ofl' on each side of 0. The handle (J7) it atlaohod to
die plate. The plate Im applied to the border of the tower eyelid of
the gqniutinj;; eye, and the aixc of the ^({iiint can be read off with gre»t
ease and accuracy.'
[Dr. tiulezowekiV btnooular strabismoroeler coiisista of a graduate
horizontal bar, upon which filide. in the Rulct
Fig. 1S6. Qf n screw, two needles ; these, when placed
positc the centre of each com^gpondins comcaj
indicate, by means of the ecale on the bar, thi
degree of deviation. The transverse bar
held on a level with the eyelids, the handle
the instrument upwanht, and the fork of the IntI
against the root of tho imse. Hv tnniin>^ lli«
little buttons at the extn-miiies of tht- bar, tli(
needles arc moved until eacli is found oppusit
Che centre of the cornea, as is shown in Fi<sJ
ItiG. The graduation of tlie transverae
enables us to dcu^rmine the degree of deviattoa!
with ease and precision. Thust. with this ini^c-
nioiis and simple little instruiuent, wv can mea-
sure with exactitude the degree of deviation aj
well as the precise result obtained by teuotomv.
-"■1
Another symptom which is at once char
teristic of a [mralytic affection, is the ern>n<
oils projection of the visual field. For iualancej
if we close llie right ovc »nd tell Die patient to
strike quickly with bin finj-cr (if be does ''
slowly he will have time to correct his mil
take) at an iibjeot held soioewhat Luwanis tht
left of the median line, ho wilt mi^s hitti»|^
it by going too much to the left side of it. The reason of this lU
that tho insufnciendy innervated external rectus requires to make a coi
traction far exceeding the extent of the roiinired movement, and fa
greater than would be necessary if the innervation were norma). Il
consequence of this, the [latienl overctttimatcs the amount of movcmer
and believes the object to lie further to the side of the affected mu3cl<
than it really d<>eti. and cousequentiy striken too much to the k-ft. If
tile paralytic affection is not too complicated, the patients in time learn
to correct diese errora of projection. The disziness which they oft«n
* Movorand Ifnlfxovralcl ltavrii>ort'lat*-l,r<li<rWH Itlniwulftrslrsl'ieuiQOK'lun, wlitek
srv, hnwfvnr. marc pxpviiHivc, aud leM liaiitljr.
> [•'Jlrdical Timcn nixl Ua*.," 1)«6I>. [. 401.— H.]
PARALYSIS or TtIK EXTERNAL RBCTU8 M080LB.
675
jilaio of is Dol Dec«»Mirily due to a ocrvdral )u»uti, but is generally
owin<; to tltc ooiifiittinii which arises from the diplopia, And tbe orronoouA
projection of the visual Bold.
[Pis. Ut}.]
¥^.
[(iraefo'a method is more complicated bnt somewhat more etact. By
its iu«an3 tie is enabled to determine the degree of the 8<|uiut and Uic
relatione of tlic »iiiintin;; e;e to its collective motii?ii in the horisontal
plane, and he also makes the measurements directly upon tlie Mslornl
curvature, all starting from the external commiasure of Uie lids. (See
Oraofo u. Saeraiaeh's " Handh. d. Aug.," VI. 1. p. JtH,)— B.]-
The manner of cxamininj; the position of douWo images, and tlio action
and usi's i>r prismatic ;^lii(««iji, haw Imjoii explaiiicd in the introductory
chapter, p. 4.5.
In a case of paralysis of the external rectus, the diplopia will appi^ar
vrhen the ohject is moved into tlie left haJf of the visual field, hut will be
absent in the right half. Tlie distance between tlie double images will
increai^e the further the olrject i^ mored to the left. The double images
ftliow only lateral differencea, being pnrallel, of the same hei;;ht, and
iiomonymoua. It is, however, an interesting fact, that although the cx-
terual rectus baa no direct intluenco upon Uie vertical meridian, it yet,
aseisting in the external diagonal positrons of the cycKill, help* in
BBCrving the iianilleltsm of the vertical meridians of the two eyes. For
!, if the patient be directed to Inok at an object held diagonaliv
Is to the left, the right eye will bo moved intf» the oeceanary posi-
tion, by the combined action of the su|M;rior rectus, inferior fiblii|uc, uud
the internal rectus, its vertical mcritlian being inclined to the left. The
left eye reiiuircs, in onler to lie moved upwards and outwanls. the com-
aetion of tho superior rectus, tbe inferior obli(|ue, and tlie external
:tus. But as the bitter is paralyeed. the left eye will remain alntoet
straight, and its vertical meridian vorticul (instead of being inclined to-
wardrt the left) : the paralbdism of the vertical meridians i^ therefore de-
stroyed, and tlicy converge at the top, whilst liic double imagvs apt>ear
to the patient to diverge at the top. But as in conformity with the iaw^
of normal Tision, the image which falls in the slanting meridian of the
lienllhv right eye fl{)[)i>iii-K straight to the patient, the image of the affecteil
eye wdl nt.>cussnrily appear slanting.
ILeuce, in the diagonal positions to tlte loft, vis., upwards and out-
676
APFBCTtOItS OF TOE MU8CLB8 OF THE 8TB.
TrarilH, and downwards and niitwards, the doable images will show not
onlr a difference in incliniitioii, but also in height. As the extcnul
rectus is engaged, together with the superior rectus and iuferior ubUi|ij
in bringing about tho movement of the eve diagonally upwards and 01
wards, it« paralysis must impair this, and' aUo affect the position of
rertical meridian, which^ instead uf being |>iLra11el with tliat of the rif^
cyo, and inclined to t!ic left, will be nearly x'crtical, and consefjueotly"
tiie two vertical meridi&nii will converge at the top, the double images
appearing tu the patient to dirergo. A glance at Fig. 187 will reatUly
explain this.
Ib Fig. 187, 1 represents the healthy right eye, whose venical m«-
ridion A Bib vertical, and whose honKontal meridian CJ) is horitantal.
Fig. 187.
the imao:o a h falls in tho vertical meridian. II is the left rye KAvtad
with paralysis of the external rectus, in the position upwards and 'nW
wards the vertical meridian A' li' is not pmllel to tiial of tJie rigbt
eye, hut converges towards \t {A" li"). The imago «' A' will coi>m>
4uently not fall in the vertical meridian, but in Uiu upjier and outer
(yl"/i"), and the inner and lower ((.'" ^") quadratits of tbe rwuna.
llic double image will, therefore, appear to the patient to b« tunicd
towanls tbe left, and to diverge at tbe top from that of tbo tiAi rjc
(III and IV,uAan<lrt'^/).
I must here again call attention to the fact that the inclinatioos of ik«
vertical meriilians are merely relative, so that, although in re»Ii:v tbv
image of the healthy eye may be the one which is inclined, it _
appears to the patient to be straight, and the image of the af!.
is the one which seems to be slanting, although it« vertical mcr.
remain vertical.
We altto meet with a curious phenomenon in thia morenwnt (upwardi
and outwards), viz., a difference in the height of Uie double images.
PAKALYlflfl or THE EXTERNAL RECTUS UUtiOLS.
677
without any diffcreti«e in the lifeij;hl of the comoa. This appannt
anoiuftly ts eaaily t;xi>l»ine(i hy a glance at Fig. IS8. In I Uie raya
from iho object will fall on the yellow Bpot a, hut in the left eye (Tl),
on account of the convergence of the eyes and the inclination inwardu of
Fig. 188.
le vertical meridian {A' B*)^ the raya will not fail upon a', but on «",
a |>oint in ihe inner and upper ijuadrant of the retina, and henco the
double image will lie to the left side, and below the object. Whereas,
in tlio dia^^nal po^ution downwards and outwardB, the double ioiagc will
lie to the left and above the object, and bo inclined towards tli« right.
The poiiitiou of tlic head is alao characteristic, for the patient carriM
it turned slightly to the left, in onter to avoid the diplopia, by bringing
all olijects Hd much as poiisiblti into the ri;{Kt half of the fiold of viition.
The j>roipi')gis is generally favorable if the paralysis of the external
rectus muscle ia acute, not coo considerable in extent, and not dependent
upon a cerebral lesion. Hwih cases are often completely cured, or very
greatly relieved. Sometimes, however, secondary contraction of the
internal rectus of the same eye supervenes, on account of the diminished
force opposed to the action of the latter muscle. In tins nay, a perma-
nent convergent atjuint of this eye may bo produced. But if the aflectod
eye enjoys the better sight of the two, and ia only suffering from a ])artial
paralysis of tlie external rectua, tlie patient may use ii^ in sfkie of the
eft'ort ro<iuirod. in preference to the other, which wilj sqnint considerably
inwards, and perhaps permanently so.
In paralysis of the external rectus, a prism would have to be applied
with its base to the temple, »o that the rays may be refracted outward«;
for, on account of the convergence of the visual line, the rays from the
object will fall on the inner side of the yellow spot. Prismatic glasses
may bo used for two purposes: 1, simply to free the |Kitieut from the
anuoyanco of diplopia; 2, for the purpo^ta of slightly exercising the par-
alyzed muxcle, and ho gradually strengthening it. In the former case,
we prescribe tliat number of prism which completuly neutralixeii the
diplopia at a certain distance. Whereas, if we desire to exorcise the
affected muscle, we order a prism which only approxitnates tlie double
images ; this proves very confusing to the patient, and he endeavors, if
possible, to fudc them into one by a voluntary exertion of the paralyzed
muscle. In doing this, care must be lakcn that the pri»m is not too
weak ; at drat one should be selected which nearly fuses the double images,
PABALYStS OF tNTBRNAL RBCTU8 OF LBPT BYB.
671)
of general paralysis of the third nerve. Upon the application of atro-
pine, the pupil dilates to its fullest extetit. Finallv, as the ciliarj muwie
is paralyzed, tlie eye will have lustiu power of accommodatiou.
If the healtliy eve is closed, and the |wiuent directed to walk straight
up to a certain object, he becomes giddj and faint, and reels in lii^ gait;
which is owin;r to the illusion which exists in his mind hetwoen the real
and imaginary position of the ohject. There is j^cntTnlly some protro.
sioii or the eyeball, on account of the paraljiiis of the three recti uius-
cle8, whose office it is to pull the eye into the orhitJ There is also
marked ptosis, but the latter is not so e:iccssii'c as when the orbicalaris
pal[)ebraruai is aUo pciralyzcd. By rolaziu;; the orbicularis and con-
tracting the frontaliB, the upper eyelid can still be somewhat lifted. Al-
tttou^h we but seldom meet with a coniplele, isolated paralrsis of the
individual muscU's supplied by the thinl nerve, it will be well briefly to
consider the symptoms wliich paralysis of these tUflcrcnt muscles would
present.
4^PARALYSIS OF THE INTERNAL RECTUS OF
THK I.KFT KYK.
When an object is moved from the left to the right side, both eyes will
he fixed u|)on it nearly up to tite middle line, but when it is carried over
to the rif^lit, the left eye will iafu^ more and more behind, thna ^^iving rise
to a divcriicnt wiuint. If the paralysis is complete, and the patient en-
deavors to move his left eye inwanls, a vicarious, rotatory, xi^a<; move-
ment inwards will be produced by the action of the superior anri inferior
reotua. As the stpiint is divergent, the diplopia is crossed, and the lateral
distance between the double images will increase in proportion as the
ohject is carried over to the n;;ht, but there will be no difference in the
liei^ht and Ktrai;,'htncas of the images iu lookin;i vertically upwards or
downwanls. liut in the diagonal positions inwarch, there M'ill not only
he a difference iu the height of the double images, hut the one wilt slant
comddemhly. In the oblujuo position of the ohject upwards and inwards,
the double ima;:^^ will diverge at the top, that of the lcl\ eye being in*
clined to the right. Whereas^ in the diagonal position downwards and
inwanls. the double images appear to converge at the top, that of the
left eye being inclined towards the left.
In the diagonal positions inwanls, there will also be a difference in
the heig(»t of the images, even although there is no difference in the
height of the cornea. The reason of this has been already explained in
tlio description of paralysis of the external rectus muscle.
iThe line which divides the portion of the field in which the patient
double from that iu which aiii^le vision exists, does not run vertj-
' H, Mllllor Hbrrtv*rH In Ih* Inferior whitnl flsenrA a rixfdMlt-^ity t«'.»a ^.r,Bi.iit,p
of ImiikIU'3 of iiii.scri|><il luiifruular nbr<> kUIi ••LitAtii! IpiuIhim, niinL ii aI
rofUibrnud of tlio □i.iuiiiinlia. Hi> aiii>po%rt] tliat iu notioti ii to |>r ' '' ili ;
i1 tH 9iip)ili-il bv lllireg (ttMii thi* n^tiijMilhetJc, it»it irHtalioii nf Die iallor >ti Iiil- neck
}iM Ih^cii futiud to csu»v pi(4riuiou ot tbv vym, \mth%pa llirvu^h tbi; AcUon ot lliU
ArrECTIOSB OF TBB UCECLBB OF THE ETB.
kreot
tnis
callT froco ibore doimwaKlfl, but obtlauelr left to right : iTittf; to Uic
left side of the Tcitical line above the noru-'ittuil line, aod io the ri
side of it below the honzonul lias. This is vxf>laii»«<i bjr ibe fftct
the dirergeoce is mocb gnaicr wbeo the eyes look npwusls, th&o wbcD
tbej look down.
The [>atieat'8 beftd U tamed towgrtla (be n^t, so is to ftvoid diplo[ni,
bj bringiiig objects u ranch u powble ttuo the left half of the vitnud
field.
S^PARALTSIS OF THE SUPERIOR BECTCS OF
THK LEFT EYE.
This DTOScle moves tbe eje apwords and inwarda, and inclioea
Ttrtical meridiim inwards.
The iiiefficieocy of the par&Wzed saperior rectus will not be apparent
ID the morenents of the eve b«low the horizontal diameter, but unljr ift
those above the latter. The diplopia will contse'juentl^- be alao obI
apparent in tbe upper half of the fifld. When the object is moved abo
tbe horizontAl line, the left eye will lag behind, and Uiis doviatioa
iocreatte in proportion the higher the object is mored. At the saaw
time tliere will aUo be a direr^ent squint, for on acconnt of the paratnis
of the superior recttu, the inferior oblique will move llie eye eoraewhit
outwards. If the ri;;;ht eye is covered, and the patient directed to look
with tbe Left at an object held Bli;zht1y in the upper half of the visual
field, the lefi eye will move upw»nU and inwards (tbe ile^rec dcpei»iin|.
upon the nmount of paralyAin), Hhowiiig that it hud before deviau^;
downwards and outwards. The covered eye will at the saoie time naka
a oonsiderably greater associated u>ovement upwards and outwards^,
The patient, in ondcavoring to strike an object, will aim too high. Ha
viU carry his head thrown hack, so as to bring all objecta, as much »
poesiblc, into ihe lower half of the field.
Ttw diplopia manifests itself in the upper half of the ritual ficM-
Tlw double images show lateral ditfercuces, are crossed, different in
^{cicht, and not parallel.
A» the cornea deviates downwards and outwards, the riy« from an
ottJM^ held above the borizoncal meridian line fall upon the outer and
la««r portion of the retiiuj, and will cons&piently lic projected upwards
Mil iowardi; the double image of the aBected eye {fiftHJ»-iwiyf} lying^,
■Jbtfvtt aiul to the right of the image of the right eye. .^H
At *he action of tiie superior rectus upon the height of the eye ii^^
IHMJIM as tlie Utter is moved outwards (to the left), the inefficiency of
1^ waniywd muscle in raiHing the cornea, will alan l* most evident in
^b wnvtMK* The diflercnce in the hcij^ht of the double imagea, there-
flte*h, tMMMM aa the eye is turned outwards, and diminishes &B it IS
ruFii^J mwM^. On the other haml, the inclination of tlie vertical
. ;! be most apparent when the eye is turw'd inwards, and
•• is tiimcJ outwanls (to the left). On account of the
*(iperior rectus, the vertical roendians arc not p*niUel
. -jx uw left eye b turned outwards by the unopposed
PARALYSta or SUPBHIOB OBLIQCI OT t.BPT SYB,
I}«1
tiie inferior oblique. Hence the pseudo-image would appear to converge
lonardd liie image oC the right eye, but the double images are crossed,
and hence thev divcrj^o at the top, the pseudo-image being inctiiicd
toffai-da the ngKt.'
6— PARALYSIS OF THE INFEUIOH RECTUS OF
THE LEFT EVK.
The symptoma arising in a pralysis of iIub muscle are just the reverse
of tho«e in paralysis of the superior rectus. The waiu of moTement and
consoi^uem diplopia are ooIt apparent when the object is bold below
the horizontal meridian tine. The pseudo-ima^e lii^a Mow tltat of tbc
rijjbt eve, and towards ita right. The double ima^^es increase in height
when the eyes are moved to the left, aiul in ineUnation when tbe,v arc
moved to the right. The double images are croaeed and the ]U)cui)o<
iniHge inclined Ufwards tliat of the right eye (t. f., inclined towards the
left).
7— PARALYSIS OF THE TXFEUIOU OBMQl'E OF
THE LEFT EYE.
it is exlremetj doubtful whether an isolated paralysis of this muscle
over oiTCunt, I shall not describe the STniptnuis whicli would he prt-Aentcd
bv such an aftectiou , but simply stale that they would be just the reverse
of those met with in piiralytiis of the superior obliijuu, and from a
knowledge of which these symptoms could easily be constructed. [Dr.
Noyes, of Uew Vork. has described a well-authenticated instance of
traumatic paralysis of the ri^ht inferior obliipie muscle in his own per-
son. It differs somewhat from the dv»eription of the symptonts of
fiaralyfiis of this muscle as given by Alf. Omefe. in that tite iumges were
crossed. The cause of the parulysLs was a fracture through the malar
bone across the origin of the inferior oli1i<jue muscle, and Noyes thinks
it possible that only those fibres going to tlie outer side of it's insertion
were impaired, and that in this way the adductive power was impaired.
'bee "Trans. Amer. Uph. Soc," 1879.)— II.]
8^1'ARALYSIS OF TIIE SUPERIOR OBLIQUE OF
THE LEFr EVE, ETC.
le paralysis of the superior oblirjuc illustrates, better than that of
any other of the ocular muscles, tlie correctness of the rules laid down
OS to the action of the different muscles, and the nature of the diplopia
pre'tentcd by their paralysis. Indewi, the deviation of the visual line U
80 extremely sligbt in cases of fwralysis of tiie superior oblique, that it
* A»|tfttifiBlsofli-n Atid it difflcnlt tA «tiiuA(«Meurjrict)r tile ubliqDJtjr of ft small
pt(jm-|, auiTli M t)i» fliimi> or M tighteit (-nitilli-, it is tMtt«r to ose H ao objod a wkit«
slair, or « ruU of paper about 12 tiicLoe iu loujjth.
68S
AVFBOTtOJfS OF THE MOSCLBS OP TUB BTB.
ini;;)it e&itily ewftpe deteeUon, aiwl we mu-^t, therefore pinoc our ehi«F
reliance upon the position of the double imaj^s to assist us la dotenmn-
ing the itia^noaitt.
A person aftected with panilysis of the left superior ohlinuc woulj
complain that objects (the floor, Hteps, etc.) in the lower halF of the field
ftpl>ear double anil irregular iQ outline. Above the liorixontal median
Hue, the vt>;ual lines arc iixcd upon the nbjectand do diplopia cxixts. If
the ohjecl U held in tlic horizoutal median lino or a very Utile below it,
a very 8li;^ht deviation of the left eye in an upwanl and inward direc-
tion is noticed, whiuh become more and more marked the furiher the ob^J
ject ia moved into the Inwcr half of the field, more especially towardii th^H
right. If the right eye is clo!»ed, the lef^ makes a well-marked move^^
ment downwards and outwimis, and there will be an erroneous projec-
tion of the visual field in the name direction. Upon clo^in-j; the healthy
right eye, and teatiiif; the mobility of the left, we might at finit euppoee
it to be unimpaired in all directions, but on closer examination w© find
that downward^ au<l inwaixU (towards the nose) tJiere is a distinct want
of mobility. InKti'nd of foIlowin<; the circular sweep of tho object from
below to the inner side, tlie visual line make^ a diaji^nal aprin;; upwards
and inwanU. 'Itie double imaj^es are huuiouymoua, and show a differ- ]
enee hotii in height and latertUy, and the one tdanta. The diplopia tl^M
confined to the lower half of tho visual field, and i« absent in the upper.^^
On account of the convergent squint which arises below the horizoutal
line, the diplopia is homonymous, and as the left eye remains at the saiDe
time too hij;h, it^ image will Sfjpear beneath that of the right eye. The
lateral dift'erencc between tlie double images increases the more, the fur-
ther the object is moved downwanU, as the converj^nce of the viauai
lines then liccomett greater, on account of the unopjiosod action of thi
inferior reutua. The diffort-nco in tho height of tlie double images i
creases the more, the further the object is moved over to the right, an
diminUben m it is moved over to the left. Tiii:4 is owing to the fact, tha
the superior oblif|Uo exerts the grenteat influence upon the heighl .>r
eyeball when the eye is moved downwards and inwards, and liencu it*
Josh of power upon the height of the cornea will aUo be felt Uie mcut ia
this direction. On the other band, the inclination of the double ima^
will be greatest when Uie object is moved over to the left, anil least w
it i« carried over to the right. For the superior oblii|ue exert* miMt i
fluenco ou tlie position of the vertical meridian, when the eye is moved
downwards and outwards. Ou account of the paraly.<<ia of the superior
oblique, the inferior rectus will exercise unopj>oscd away over the verti-
cal meridiau iu all the moveraeutd of the eye IhjIdw the horizontal mcdi
line, and iiwdinc it outwards. The parallelism of the veriical mcridi
will, therefore, be destroyed, and they will diverge at the top, the doub
images appearing to converge. For, on account of the slanting ouiwiirda
of the vertical meridian of the loft eye, the imago of the object will not
fall in tlie vertical meridian, but u)iou the upi)er atid iimcr and lower an'
outer qnadranls of the retina, and tlu^ pseudo-image will, tbrreforo, a
pear to the patient to be inclined towards the right, and to converge
towards tho imago of the right eye. A glance at Kig. 187, p. tiT'i, will
reuder this intelligible, it being remembered, however, that the verticil
th*|
rheu
ItaoJ
m
OAtrsse OP paraltsts.
G88
meridiftn is ttimed oiitwnnlg in pamlj^ia of the supcnor oblique, aud in-
wnnla in thkt of thi* extvnial ructus.
When the object is carried very far down into Ibe lower half (>f the field,
a curious phenomenon ia ol>«erved, viz., tttat the p(i«udo>iiuaj^ apjicars
above ibai of the rixht evo, even althoiijfh the left cornea still remains
hi)£h^r than the right. This i-t due U> the extreme inclination of the ver-
tical meridian, which hecnmes so great when the eye in moved far down-
wards that a dislocation of the qnodranu of the retina UikeA place, the
raya from the object falliiig no longer upon the inner find upper quad-
rant of the retina, but upon the inner sad lower, and thoy are hence
projected upwards and (o the left.
The double ininpea in paralysis of the stiperior oblique arc not at the
same difliance from the patient, but that of the affected eye is contider-
ably nearer to him. Tliii waa I believe firut noticed by Or. Michaelis.
U wnidd appear to be due to tlie projection of tho imai^e iifHin a horizon-
taJ surface below the eye (e. i).^ the floor of tJie room), for tliia ?ymirtom
disappears with an alteration of the tturface of projection.'
The line which divides the field of single from that of double Wsdon
do«a not run horizontally, but obliquely dovrnwanU from the ri^ht to the
left. The patient carries hia head turned downwards nod to the n;;ht,
io &J to bring the objects as much aa pouible into the upper and left
portion of the field, ae the diplopia arises sooner in tlie ^i^hl half.
PnHtn.4 roust be turned with ibcir bane downwanlti and ontwanU.
After a pjiralyni* of the superior oblique hart existed for «oroe time,
secondary contraction of the inferior oblique often supervenes. The
diplopia then extends into the upper half of the visual field, but here be-
ootDea crossed, the pseudo-image, however, bein;; still beneath that of the
right eye. This ia due to tJje cornea being moved abnormally upwanU
and ontwarfls, on account of the contraction of the iiiU«rior obrripie. The
increaflt! in thu height of the double itna^^es will »u;:n)onl towards the
right, and diminiith towanU the left ; th« reverse obtaining with n'gard
to the inclination of the double imagea.
Having considered the varions aymptoma presented by the paralytic
aflectioas of the difl'erent muHclca of the eye, we must now turn our
atteotion to the causes, pr>j(»iiOiiiis, and treatment.
We mar distiiiguisli peripheral and cerebral causes. Amongst tho
former, cold and rhounuti»ro arc the motit frequent. In nuch caAes tlie
affection ia rapidly developed, and is j^encrally accompanied by more or
loss severe rhuumatiu pains in tlie corresp<mdin^; side of the face and
*\. Very freqmuitly there ia no difficnlly in tnicinj; the cau3e to a
]d which the patient bos caught from a umldon ex|H>siire to a great
change in temperature, or to a draught of cold wind. This is goon fol-
lowed by pain in and around the orbit, accompanied by a slight degree
of diplopia. The pathological changes in auoh caMB generHlly coiijiist in
a rhcumntic inflummiition of the nerve sheath.
The c4iU6es may be situated in the orbit. Amongst theac we mu»t
Vi(l» rou Unvfe'B " SympionMnlttbre dn AagnunDsktllUunungen." p. 140.
C>64
APPBOTIONS trn THE MUSCLBS OP THE BTB.
enumerate eETusions of liWd, all Oio diflcrent forma of orbital tomnf
abecefts of tKc orbit, exoplitlmlniio goitre, etc.
The mosi frequent cause is, tiowever, s^'philis. Acconiing to Von
Gracfe about oue-thinl of the paraljtic affections of the muscles of the
eyv are due to it. In many cases tt id, however^ impossible to deter-
mine with nny degree nf accuracy the exact seat of the cause ; we tmist
hv s&tislied with the fact that the patient has eufTered from 8yphiH», attd
TTc fi-ei|uently find tliut a rapid recovery ensues under proper outi-sypbi-
lilic treatment.
Syphilitic nodes or exostoses may W situated in Uie orbit, or at tli«
base of the brain, and oatit;e the paralysis by direct pressure u{)on the
nerve. Syphilitic neuromata may also produce it.
Pamlyais of the ocular muscles is often due to some cause utualed at
the base of the skull, and this must be CBpecially suspected if Bevenl
muaclcs of one or both eyes are afft'ctcd, or if some other nerves (sudk
fts the facial or some branches of the tiftb) arc also iiDjilicated. We fit
that the cnuAes situated at the base of the brain, generally prodii
paralysis by a direct compression of Uic nerves which lie at this sitt
tiori. Amongst such causes wo must especially nnuni«rau> syphilitic
rheumatic ostitis and periostitis, exostoses, syphilitic tophi, tuberci
deposits, effusions of blood, and tumors of various kinds. In coses of
tumor or anenrism, the progress of the paralysis is generally bIcW|
whereas the reverse is the case in inflammatory exudations.
[Pa^en^iccher says tluit in epidemics of diphilieria, paralyses of
exirinsic muactcs of the eyes are not uucommon, and are noticeable
till- rapidity with wliich they appear ami diaappcar, and for U>e
they only occur in the staj;o of convalescence. They are also
occur in the course of and after febrile infectious diseases. — B.]
The cause may, however, be situated in the brain itself, and we thi
generally find that the patient shows some deran^mcnt of the intelU
tual runctious. ilis memory fails him, and ho ex[)cncDccs a difBc
arranj^inj^ his ideas, or in f^lving oxpressiou to them. ThcM
meiils arr often very transitory, and may vary ;^reatly in cxlenl^ frOfll'
ili^ht impuirmeiit of memory to a Btaic bonleriu^; on idiocy. P
not unfrequently a symptom of a cerebral affection, wherca.4 lag^|i
nios is only exceptionally so. Amongst the various lesions wit
brain whiuli may produce paralysis of the muscles of the eye, most
mti-ntiouf-d si>l'tening of the brain, effusions of blood, turbercular deposits,'
nneuriema, imjw.-rraoability of some of the corehral bloodTosseU. tnmor^
situated within the br:iin, hydrocephalus, oto. The nature of the dip
fiia aidd us to a certain extent in localiziTig the cause of tbo uanilya
iir in piiralysis due to a cerebral lesion we ol«prve tiiat there u a
difficulty in the fuMOn of the doable imaj^es. It is found very diffiooll,'
or almost impossible, to uuitc thum, even with the more carefully si-lectcd
pri.^ni, the patient bcin^ unable to fuse tliom by a voluntary effort, erM
nlthuug)) they are brought very clwe togetlier. [A liiagnocia of
^future and seat of the cause of paralysis of central origin can only
oade from an accurate knowledge of tlie origin and course of the
jtor nenes going to the ocuJar muscles. It should be
It the third, fourdi, and sixth nerves all rise in the vicinity of th« '
PRnaVOStS AND TREATMBHT OF PARALYSIS.
of the fourth ventricle and aqueduct of Sylvius, the nucleus of oripn of
the thin! bcinp the most anterior, close hohind it that of tho fourtli, aad
ID the I'v^ioti of the pojiterior third of tJie poud Uea that of tho aixth.
Forthennorc there is a complete decussation of the fihrcs of the fourth
nerves, and probabi/ n partial decusdatioti of the fibres of the thinl
uervL's: while the sixth nerves are not crossitd. Iletveo un^v abnormal
growth or diseased process in tho re;non of orifiin of t\w fourth or
sixth would cau«e homonymou^j paraWsiii of tho sixth and crossed [mral-
yeii of the fourth ncrvc-i.
A moos; the causes not mentioned above must be mentioned hjjienemift
of the brain and its menihmnefl, on tho autliority of Niumeycr; disftemi-
nate s^'lentttiM of the brain, and degeneration of tho posterior oolummi of
tb« cord. — B.j
The prtigncit^of the different kinds of pnnilynii varies vith the cause,
the degree, and length of duration of the paralysis.
With regard to the ffenerai prognosis of paralytic affectiotu of the
muscles of the eye, it may be laid dowa aa a rulv that it is the more
favorable, the more recent the affection. Again, a partiitl paraly»id
affords a more favorable prognoaia tJian if it is complete, even althou>;h
the latter may be of much »bortcr duration. The character of the diplo-
pia id nUo prognoittically of importance, for Uio double imaii^An which
only show a lateral difference and none in height arc far more easily
united when there is a difference in height. Sli<;htcaaes of paraly^iii of
the internal or external ret-tns may be sponianeoualy cured by the effort
of the act of viaion, which causes the fusion of the images.
The progDOBia ia generally very favorable in tho rhounutic pomlysia,
especially if tho patient applies soon after the outbreak of the diwMe.
If the cause ia situated within the orbit, the prognosis will principally
depend upon tho fact whether the caiutc can be removed or dispelled.
In the syphilitic form of paralysis, the prognoeia leans towards tho
favorable mdc of the scale, but in greatly intlueuced by the scat and ex-
tent of the cause. If the paralysis is due to some cerebral lesion, it is,
however, much more unfavorable, although a complete cure may arise if
tlie primary affection is i-emoved (as in absorption of exudations, otc.).
The treatment must also vary with tho nature of tlie cause. In rheu-
matic paralyiii^, a free purge should he administered, and diaphoretics
be prescribed, together witli a good-sised blister behind tlie ear. I have
found tlie greatest benefit from tlie latter remedy, as also from the use
of iodide of potassium internally. When the inflammatory symptotos
have subsided, and the ner\'ea are regnining some power, raradization
or gaWaniKation should be applied. In syphilitic cases, the iodide and
bromide of potassium arc found of tho greatest scn-ieo ; or mercurial
inunction may be emplovcd, if necessary. Zittmann's decoction is nliM
very sorvicoable, as it acts not only as an anti-Hyphilitic, but also as a
diaphoretic. Its uso, bovover, entaiU a good deal of inconveniencu and
discomfort.
To relieve the patient from the annoyance and confusion produced hy
the diplopia, the affected eye should be excluded from the visual act by
ft Hfaade or a piece of froateil glass (if spectacles ftre used). TkU cxcla-
siou also obviates the tendoncjr of llie patioiit to carry bia bead turned
to one side.
Pritiinatic ^liusps mav likewise be employed for tlie pnrpow of fmig
the double images, and their strength, ms well &b the direction in m%iA
Ibeir Lwe is to bo tumod, will de|K*ud upon tliu muscle affected, and Htm
degree of deviation. In piiraWfliit of tlie internal rectus, (he liadc tbiraU
be turned inwanU, in that of the external reclu!>, outwmnU. If tl»
double iina;;ei4 slion iKith a difTerenco sideways and in )it;i|,;lii, wc oiay
divide the prism.^, placing one with itR base laterally, and tite other with
its base turned upwards or downwards as the ca«e way ho. Or we aay
divide these two prisms between the two eyes. In avuordance with the
fact, that the eye can readily overcome lateral differencea in the dooUe
images, whereas it canuot correct any but the very slightest diifereaoe in
height, we often find that if we con-ect tlie latter by a prism, Uw lalenl
diffcrenceit are at once corrected by an effort of one of the boritootal
muAcles of tJie eye. This fact is of much importance in those cases in
which we operate for the sake of curing diplopia. I have alrea^ly ttated,
when speaking of panilysiK of ttie external rectus, tliat when wc deain
to 1186 prisniH tlieraiK'uti<:aiIy,thi' dmihle inia;:cs nhoidd not Iw fused into
one, hut only Mpproxttoatoi), in oidcr that tlio paralyzed moscle tnaj be
atiunilated to au effort to unite them.
Ivlcctricity (both faradization and galvanisation) is often found of
great nervico in the treatment of paralysis of the muscles of the eye,
especially if the cause is peripheral. The negative pole of the iniiru-
iDvnt is applied to the cloocd eyelid in a situation corre»])ondin]E to the
affected muMcle, the )K)»<itivc being placed nn tlie temple or ilio back of
the neck ; the sitting should not extend beyond two or three minatas.
In galvanixution from 0 to 14 cells shouM be employed according to the
point of application and the degree of cfl'oct we desire. Mitlierto, it has
generally bt?en snpp^iseil that elcclncity acls beneficially by a dirtvt ei-
citatioii of the panilyxed motor nerves, but acconlitig to Beiiedikt' Ihli
iti not tm, for he state--^ that ibf effect is due to u reflex exi-iuiioii of th«
fiftli nerve, lie found, moreover, that in most cases a curative actioo
was only produced when the excitation was relatively weak, and wbeo
no trace of muscular contraction was produced by the electricity. Tbe
prujwr measure for the strength of Uic current is the sensitiveness of the
fifth nervo. If the latter is extremely sensitive, the luiiti-r- . 'arc
to he reduced to throe or four cclhi; if, on the otiier btiitd. : ^j i«
very inscnnible, it may have to be raised to 12 or 15. The cunnrt
should he bUtficiently intense to produce a slight seuution in the partt
excited^ but iho excitation should «nly continue for nlMiut half a miiiulv
at each aittiug. In paralysis of the external rectus Uencdikt applies the
positive twlr to the forehead, and the n(.'gAtive over the neighborhood of
tlie cheek bone. In ntydriasi^, the latter should be applied to th« same
lilnce, hut the positive to the closed eyelid. In ptosis, the poeitive may
either on the forehead, or may be applied by means of a abort
I
I
* V[Ar a ri'ry Intrrmliiiff |>ii|kt ti> [>r. Uoriu BontHltkl, " On Rlwetro-TlMtaimrti-
il util rbr»lologtott KfieArJiPfl nn l>nrA]v«ti of tJi« Oular HumIm." " A. (. '~ "
«. 1, (raiwl
>0|ibth»lmlc Kvrlnw,*' rob fi. p. 143.
TREATMENT OF PARALTSIB.
m
I
cathcicr-liko reophore to the mucoDS membrane of the cheek, while the
u«gsUv« \i Urawii over thu till. For all ttiu other brattchcs of thv tbinl
nerve, the fiositivo pole U applied aa above. In onlur to act upon the
internal rcctud or inferior obliijue, the negative |)olc shoulii lie dmwn
over the »k\u of the side of the nose^ near the inner aii<i\v of the eye,
and in order to act upon the inferior rectus, over the lower marjijin of
the orbit, ilcuedikt foumt that in tlie greater number of case* the ira-
provemeiit takes place instantaneously, as ahovfn by increaseil mobility
of the eye, and a dimiaution of the field in which diplopia arises; and
vhon this is not the caDC, a longer continuanco and increased atrenjfth
of the excitation are not indicated. When the paralysis haa been iin-
aft'ecled by fourteen days of treatment, he has not seen any benefit arise
from its longer coiitimianee. Nut unfreiiuently, liovrever, ftiradization
BQCcecds afu^r gal»-aniwition haa failed, and vice VfttA. Dr. Alliiaus"
therefore recommends tliat if the one haa not produced any efiect after
some time (<*. </., 10-14 days) the other shonid be tried. Mr. Knidenell
Carter* adviaea the combliiatlon of faradization of the parntyxed muscle
with tenotomy of the contracted opponent. The liiU are to be held
apart by a speculum and the current applied to that part of the con-
junctiva which corres|H)ndH to the paralyzed muscle. Bui tUia ia very
painful, and should only be trie<l I tJiink in very obstinate caaea.
Paralytic aflecUons of the Timi«cle.4 of the eye may run the following
difierent courses: 1. Tlie paralysis may be coui|iletvly cured, which is
most likely to occur when the affection is recent, atui duo to aome
peripheral cause. 2. The cure may bo iitcomplete. the muscle being
only partially restored to its former power. 'A. The paraly^ia may re-
iDftiu complete; but this condition generally soon leads to tJie next
(4) state, viz., to a secondary contraction of the opponent muscle. Thus
in paralysis of the loft cxtemnl rectus, tlie diplopia ma\' extend more
and more into the rij^ht half of the viHual field, and a decided convergent
i}i)uint of tlic left eye Iw apparent, even when the object \6 held in the
ri^bt half of the field. Jne opponent muaclo may in time contract so
much aa to drag thv eye almost immovably to its own side.
Wlien all other remedied Itavu failed to effect a cure, it may be neces-
sary to have recourse to operative interference, and the nature of thi*
will depend upon (he de;;rce of paralysis which remains behind. Thus,
if only a slij'ht degree of paralysis of the external rectus remains, ao
that the wHnt of mobility outwards amouuts to about 1 or 1^ line,
dirisiou of the op|)onont muscle (internal rectus) will be iudicated. Bin
when the mobility exceeds this degree, and amounts to two or three
linetj, this tiperatiou will not suflice, and we must combine with it the
operation of bringing Ibrward the Innertioii of the pimilyzed niutwle (the
Utter operation is genenilly termed that of *' re-a-ijustminit"), so at to
incrca^ its [Htwer over the mobility of the eyeball. '["Um operation
should not be deferred too long, for after a time tlie [taralvKed muscle
may under^ fatty degeneration, which renders it unfit for the ret]uisito
degree of contraction, oven if it8 innervation were completely, or iu
' Vidn Dr. AltKnoa'* »(!4>11f>nl " TrattiM nn Mudiual Kl«Ktricitf ," p. 40S.
■ '■ LancQt," Dvci-mbcr, littS.
688 APPECTIONS OP T1T8 UDSCt.BS OP TUE ETB.
grcnt part, restorud ; ami it also fsvore seooiidary eoirtntction of
opponent. 'Vhe method nf pt>rforniiii^ tlie operattOD of re-«^iutioenl will
be coueidereil together witli that of tttrabismiis.
fin oxtr<?mc cases of secondary oontntcdon of the antagonistic miucle,
tt Qocit not iiuffice to divide the latter and advnnce tlie |Aralv]UNl mu^e ;
but it bucoinea necessnr}' to divide the co-oplinnting muscle of the nUlier
eye : the intcnial rectus if ihe paralvted mu<tclc ia the external rectiUf
and the external rectud if the paralvzed muscle is the Ltttemal recttu.
The defect ia a much more difficult one to renioly when the nujieric
or inferior rectus is ihe miucle flffi:N:teil, owing to the rihlir|nf dircctimr^
of their inaertioiu, and the difficulty of producing the exitcUy denmt
effect, without overdoing or underdoing it. — It.].
9.— SPASMODIC AFFECTIONS OF TIIE MUSCLES OF THE
KYE. NYSTAGMUS, ETC.
The eymptonis of njBtagmua consist in a peculiar, restless movement
or owjiUation of ttie cjclmlU. ' nils oacillation is genenitly h'>rii:ont*l,
but occaRionally rotatory, the CTeballs o-scitlatin;; roun<i the axis of ihe
obli<|Uv rauttclua. In rery rare iiuftauccs tlic nvtilagmue may be verticiL
1 have seen two such cases. In one, tJio eye was affect*"! with convr-r.
gent w^juint, and made a constant upward and downward movement, whic
was not arrested or even improved by tenotomy of the intenm'
The other (rt;currcd in a man affected with cboroido-retinitts. ■
both eyes ghowc<l a well-iuarked vertical ny«tagraua. Zeheii'li-r' :<
met with one case. I lately saw a very curious form of nystajiu^u-* lu i
Eatietit of Mr. James Adams, where the oscillations only occurreil when
e looked below the horisoiital meridian, tlie eyes being ijuite ate&tlj
exactly in the horizontal meridian and in all the movrmentu aI>ove '
The oscillation may be perio<lical, and its degree is often very vnriahU
at dilfcn-nt times, being markedly increased by any nerrou--^ excitement
and by the effort. of accommodation. To remedy the indi«tinctueM o|
vision producetl by the unsteadiness of the eyes, the patients often malct]
a contrary movement of the head ; or they hold the print in a sUnting or
vertical, instead of a horizontal position, so that tlie lines nm vertictillyj
instead of horizitntallv. The reason of this is easily iniel)i';ilile, for they I
can then see the individual lines chiefly by the aid of the ^ui'crior
inferior recti, and the circles of difltuion caused by the oscillation of tbi
eye will then extend die letters vertically, instead of horitontally ; tbi
length of the letters will conse^piently b© considerably more incna
than their bruadth, which is less confusing to the siglkt, as their Utef
eeparatriiii will be preferred. Wherens^ when they are extended hori-
aoiitally, one letter runs into the other, its outline is blurred aud eoo-
fused, and the power of distiuguifthing them much imjiaired.
Althon;;h there may be cotisidtTable oscilluliou of the eycbvJU, tb<
movements of tlic eyes are unafl'ected and perfect in oil directioiw, and
the two eyes may act perfectly together, but binocular vision is oft«o di*»J
' "El. MqdiOsU.." 1670, 113.
SPASUODtC ArFBCTtOKS OF MUSCLES OF GTK.
f>89
I
I
turl>P<I, and the sight of the two eyes frequently very differeni. The
ow;illation sometimes <^iminiRhe!i greatly, or U ev(>n arresterl vhen the
eyes tre moved very fnr outwards nr iawards, or ia one of the diagonal
positions downwards ( liohm. )
Xysta;,'rau8 j^'encrally appears In early infancy, and is capeeJalty met
with in caat's in whicli a eonsideniMc acf^e of exertion of the ocular
mu8cle» is reijuired for distinct rision ; the object having, perhaps, to be
hehl VHry close to the eye, either on aocount of some anomaly of the
refraction, or some opacity in the refractinfH media. Thua the affection
is often met with in infants together with opacities of the cornea or of
the lens, in cases of strabismus, in alViiiO;), etc.
[Nysta^^mus is almni«t always hilatoral, and the roovemonts associated
ones. The deprrec of the nyAtaj^mus with rcs[)ect to the rapidity and
amplitude of tlio oxcuriive movements is not always constant, and hero a
psychk: causation is of undeniable influence. In certain oases of hori-
xontal nysta];;miis, the innvementa may be caused to cease by strongly
conver;j;inj|; the eye*. In the majority of cases the nystagmus occurs at
a periu'l in early life when, in addition to the cnuacs above enumerated,
there is an abnormal disposition of the muscle in addition. Although
DTStagmus is apt to bo connected with various forms of congenital am-
blyopia, it does not, by any means, occur in all ; and thou;;h its hered-
itary propagation is well rccof^izcd, the occorretioe of an actual con-
genital nystagmus hatt not yet Iieen proven. There is a peculiar variety
of nystagmus, ivccumng in minenj, which is still hut impi^rfectly nntler>
stood. It is aciiuired in adult or declining years by men who have
worked for a long time in conl mines. Oimiuution of the acuity of vision
is, as a nde, not present. Tlie nystagmus is of a periodic character,
the paro.xysras being favored hy a dim illumination. It appears espe-
cially when the eyes are turned in a certain direction. Darkness plays
an im{>ortant rolu in the development of this anomsly, iu rendering the
vision and fixation very difficult, for there is an almost constant effort lo
recognisto distinctly certain objects in the darkness. It was formerly
supposed that tho position of the miners, lying down, kneeling, or crouch-
ing, with the eyes elevated, had some inHueiKe in produuing the nys-
tagmus, but this ia now doubted. The form and direction of the move-
ments are less variable in this variety of nystagmus than iu the former
variety.
Another kind of nystagmus is due (o disease of tho central nervous
aystem. Though a jjeriodic owillntory motion of the eyes occurs in a
variety of brain disfase,'), the constant typical nystagmus is a very com*
mon symptom of insular sclerosis of the centml nervous system. A
similar trembling motion is also seen in the arms and legs in this dis-
ease. The nystagmus is usually bilateral. (.See "Arch. f. OphlJi.,"
xxiii. 3, p. 2tl-2iVI ; "tJrncfe u. Sacraiach, llandb./' vi. 1, p. 223-
241.)-n.]
Tlie disease may diminish, or even disapiwar, as the patient grows
older, but it goncrally r<>main9 pcrmanrtit. varying pfrhafii, somewhat
with the state of health ; any debility or nervous excitement iocreasing
t Biiltm, Dtir Nytitagiiins.
44
OttO
AFFECTI0K6 OP TDE HtSCLES OP THC ETK.
iU intensitj. If ntmbifttnuii coexiste, thU shooM ht cured hy an opci
tion, nnd in gome ca^tt the nystagmiui is also constdvralily (liniintsliirdbj
Uic tenotomy. In others it roust, however, be coiifensed, that either
benefit, or ouly a very temporary one, re^iults. Hence I do Dot cviiaidi
it adviaahlo to perform tenotomy of any of the ocular muscles for
chnnceof curirif; the iiysta^uA, except therein aleo strabismus. Alt
unomaty of n.>rrncti»n shoulil be corrccietl by suitable lenses, anti WncE
\» sometimes oxpi'Hoiiceil from tbo use of blue cyc-pr<> tec tors, ti> ilimhiig
tbe intensitT ami ^lure of Uie lijj;ht.
Spafimodiu a^ectiutis of tJie ocular rouacles are extremely rare. Clot
BjiAams are sometimes met with in children affected wiUi chorea or banli
oiciiin^itiH ; also in cases of lead-poisoning . and in some of the afiectioB
of t)io brain and spinal cord. Tonic spasms of the ocular muaclos
occaf«ioTialIv obacrvcd in cpilepitv.
[The abnormal deviation of the eyes in certain cerebral diseaKoa call
by Prcvoat ^^ ci>ni\igate deviation," nnd the obaorvationa of ]»nget upiM
the Slime subject look to the existence of a cpucial centre for ossMnal
movemenii!! ; and as the associated relation nf the mm^di's is a cei
form of coiinlination, these cases may be reganlM as spasm of ct>drdiiia'
tiou. (tSee >' (jraufe iind ii^aemisch, Hnndb.," vi. 1. p. ^21.) — U.]
SpAMD of die orbiculuria paljtebrarum is described in the article n\
tJi9 diseasea of the eyelids.
10— STRAUISMfS.
We have now to turn our attention to the consideration of tb* x-m
formti of t<()uint and their treatment. The surgeon should tlmroufridj
nuuiter the theoretical portion of this subject before he attero)>CA to ot
rate for the cure of this affection : for although the operation for •40111
ia ni)i|wr « a difficult one, wo yet meei with many canes wbit-b
very groat exactitude and nicety, not only in the preliminary exi
tion, but also in the mode of operation, i:^till more ditbcidt and iutricat
are those oases, in which we opemte leas for the cure of the defomuty.
wbicb is, pcrhaj-s, hardly observable, than for tlie purpose of freeing tb«
])3iirnt from tlie great and constant annoyance of diplopia. Tbw«
itt:iii<) a Uiorouj^^b IcnowltMlge of the individual actions of the muteleti
' lit, an inliiiiKle ncpiaint/iuct.'' with the various forms of dii
II . icrable maiiual iloxtcrity in the performance of the opcl
Uic extent and character of wLicb should be accurately detonuiiu^l ufi
beforehand. Such cases, imleed, often form some of the m4>st dit&eal
pfMblrms in ophtltalmio surj^ery, and can be only succeS'^fuDy treated brj
tl -o who hax'c m-tiiivred the theory of Uiis and kindred subject*. A
u.iut of such knowledge brou>;bt the operation for muint into almosl
Oumulote disrepntc. and wc arc chiefly indebted to Von i.raofe for haring
extricated it from the ublofjuy vriih tvhich it had, not unduserTi-dly, '
^ i^itid, and for having rendered it one of tlie most 6ucc««sfal o|
hi ^^ir\tstj. He has achieved this suooou not M touch by imptoni
III -Ir o( Operation, us by his eUborato nwearehoa into the phjsi
STBABISUnS.
691
and avmfitomfttologj of the Tariouit fomiA of squint, wtiich hare enablol
liim tv lay Jowu exact data for tliuir successful treaUiieiit.
Sjrniptomaticany vrc menu hy the ti-nii " Aipiintt" an inability to bring
both visual lines to be»r itimiiltAiicou4]y upon one point, the one alwaya
ileviitting in a certain direction from tliu object. If the squinting eye
deviates inwards, it is called convergent squint, if oulvrards, divergent
»i|uint ; if it squint upwards, strabismus eursumvcrgeiis, if downwards,
sirnbiaraua dcoreuravergcns.
Tbe name strabismus was formerly indtBcriminatcly applied to all ab-
normal deriationtt of ibo viHual liues. wliatever their eatiKC ; wbotbor they
were due to paralvflii or npfLttn of one or more of the mu*clefl of tlic I'ye-
ball, or w|i(!ttier some tumor, etc.. of tbe orbit prevented tbe free move-
nifiit of the eye in CLM'tain directi<piis.
We now, however, limit the term strahiAmus (or strabismus concomi-
tAni! of von Gracfe, a name we shall adop;) to that eroup of cases which
preseutti the following welt defined and constant symptoms: —
1. The viauul line of ouc eye being fixed upon one object, tbat of tlie
otiicr always deviates from tlio latter at a certain angle, and in a certain
direction. In conver^jcnt squint itile^'iatca to the inner, iu divergent
aquint to the outer side of the object. In order to detvrtiiine which is
tlie squinting eye, the parent should he directed to look steadily ut an
ohjeet (a lighted candle or our uplifted 6ngcr) hold in the horizontal
median line, at the distance of a few feet. Then, alternately covering
,ch eye with our hand, we note whether the uncovered eye remains
adily fixed upon the object, or lias to change its position before it can
bring ita visual lino to bear ujion it. In the former case, it is the one
generally used for fixation, in the latter, it deviates from Uie object. We
may, however, fail to detect tlie deviation in thia manner, if it la so very
slight as to he nlmost objectively inappreciable, in which case we must
citll the diplopia to our aid, as it enables us to delect the most minute
dfviati'Mid of tJie visual lines. But the concomitant wjuiut ia generally
very evident.
U we cover the hcaUby eye with one hand, the other will move in a
certain direction in onier to fix the object (in convergent squint it will
move outwards, in divergent inwards), the hcaltliy, covered eye making
at the saniu time an ami'triatftl movcraont (which lias hcen det^ignatcd tbe
»fc^»ditrif deviatiiin), beeoniiiig now. In fact, the squinting eye.
I have slrea<ly (p. ()74) explained tlie method of meaauring tlie linear
extent of the delation with LaureiMie'a stmbismometer. I need otdy
add that the degree of strabismus should be tested both for near ami dis-
tant objects, as it is often far more considerable during a strong effort of
accommodation, as in reading small type, than when the eye is looking
at » distant object.
We sometimes find that there is not only a lateral deviation, hut alw
a slight dirt'crenco in the height of the two eyes. It is important in such
a case, to determine whether ( in a case of convergent Btpiuit) this is due
to the upper fibres of the internal rectus being more contracted than the
niidiUe it lower fibres, or whether it is owing to the superior rectus being
also affected, for upon this will hiuge the queatiou of operating upon mum
titan one muscle.
692
AFFECTIONS 0? TQB MUSCLBS OP TUS BYE.
The associateil morement, which the lioalthy eye roaVea whf^ ii
covered and the sijuinUng eye fixes the oSj(;<^t. will enable a* la <.\eu>t
mine this, for if the internal rectus is alone at fault, the aH«ociatetl move
nicnt of the healthy eye will he only lateral, withi)ut any tleviatioa
height: whereas, if Uie Ruperior rectus is also lm|ilicatcd, the healiLj
eye will make tint only nil inwarij, hm also a downward movement, cor
reMpjndin^ lo the outward and downward raovtmeiit of the other eywj
In ilie fonner chsv, we shall almost always succeed in curtu|: the inwar
and slightly upward dnviatinn by a tenotomy of the internal rectus alontJ
more particularly if we freely divide the upper portion of the lendooj
In tiie latter case^ we shall have not only lo operate niion tlie ioti'ma'
but also upon the superior rectus.
2. The primary and secondary deviations are quite equal iu extent.
The meaning of these terms has been already fully explained at pai^e
tiT2. Let us suppose that the left eye squintit inwards to the extent of,
two lilies. Now, tf tlie ri;:^it is covered, the left will have to move ouH
wanls to the extent of two lines in order to fix the object, and tlie eor>
ered eye will make at the same time an associated movement inwanls <^f
two lines, thiti secondary deviation being, tlierefore, exactly equal to ihi
primary-
3. The extent of movement of the two eyes isfjuite normal and eqnal.
the arc of mohtlity being exncdy of the same extent in both eyes, ami
only a little shifted towards the side of the shortened muecle. Thus, Ui
a convergent sipiint it is shifted sli;|:htly inwnnls. hut what i^ gained in
this direction is lost in the movement outward)}. Thi?) increase in (he
mobility towtinla the side of the shortened muwle, ts, however, u-rv
sHght when compared with the degree of the »quint. On account of itits
complete accompaniment of the ».|uiDtiQg eye in all the movenieiito of tlie
healthy one, it has been called etrabiemtis concomitans. If Wf 1 ' '
object in the horizorital median line, and then move it to tJie i ,
left, the visual line of the Sl|uintin^ eve will exactly aecom)<aii> iluit i-f
the healthy eye in all ita movements, deviating from it, however. alwaya_
at the same angle, except, indeed, at the extreme portioua of the field
vision.
In order to note accurately, and to keep an easy and diagramimtio
recon.l of the e.\trcnie lateral movements of each eye inwards and
wards, Mr. Itowman ha:^ for some time adopted the following simple
practical method; He notes the extreme range inwards, by ii>arkii
positiou of the pupil on extreme inversion, eom])ared with Umt
lower punctum ; and the extreme range outwards, by mnrlcioi; the
tiou of the outer edge of the cornea, ou extreme evvTBiou, compared wit
that of the external ennthuit.
Tho following figures illustrate this method, thepaticut being tttppoW
to face the observer: —
Fi^. 1H!t showtt /* the right outer cantlius, and L the \eh outer oi
thus, crossed by a vertical lino a, or b, or e, which indicates by its
tion the extent to which the outer edge of the comeA ftpproacfaes
(Sinlhns, or even goes beyond it, on extreme rfrrman of the eye.
Fig. l!'0, in like manner, exhibits for It (he right eye, and for J.
left eye, tbc position which tho pupil, O, takes with regard to the pvnc-
Hdi
STRABISMUS.
ad»
Ttiin. . , when the eye is moved intrardt to the extreme degree. It may
fail to reach it, w ut a a, or be over it, tu at A A, or }jass more or less
iiiwnnis beyond it, aa at r c.
Fig. 199.
e 1" ft
a ti o
>
VXg. l&l).
H 000 —1^ 666 1-
% h »
In tnking the relation of the pupil to the punettim tf the eyo is much
invortetl, the oWrver ahouU, a$ it were, face the pupil in its iuverted
position, (itherwise Ute Interral between it and the punctum is not8ooor>
rrctly cstimatt'd. Or the parts miiy he riewed from above, the surgeon
raidiug the upper lid, and standing behind tlie patient, who sita on a
ch:iir. But a littk' practice soon renders thi;! unneceisary.
If the oul<.T ed^e of the cornea, iu extreme evcrnion, passes under
cover of the canthua, its actual [>usition can bo readily enou^jh marked
by noting how much of the ina U hidden from view.
A diagrammatic record should be kept of the range of mobility, in
orc|«r that we may horeafler W able to estimate the effect of tlie opera-
tion upon tVic lateral movements of the eye.
The accommodative movements of the eye ahould also be aocurabely
tested, for they are extremely important, as will be shown hcrcafWr, in
determining the nio>le and extent of the operation. On briuj'ing tlie
object ncanir and nearer to the eyes, the visual line of titc lieaTthy eye
will remain fixed upon it, converging the more the nearer the object is
approximitted: the pn-titiou of the &(|uinting eye (convergent atrabiismus)
may, at the same time, undergo the foUowing changes: —
1. It may ret&in itsonginal position, stutuining only afewoKilbittDg,
irregular, lateral movementa.
2. It may remain completely stationary, so that the angle of Si)ninting
will diminish the more, the nearer the ohject is brougltt, until, at a cer-
tain point (if the dipiint he not excessive), iu visual line will aliio be
fixed upon the object, and there will no longer be any !k|uint. If, how-
ever, the ohject is appniximated atill closer, a divergent sipiint will arise;
for. whilst the healthy eye cnnverges still more^ the otLer retaiiu itd
poaitiou, and now deviates (passively) outwards.
m\
AFFBCTIOifS 07 TllE MD9CI.B8 07 THE BTB.
3. It retains its position np to a certain point, and tlien, u the health?
eve moves tiiwariU to follow the object, it makes an atvteiaUd movemf m
outwanla.
4. It deviates aodrlenly and apasmodically inwards, when the object
h approximatuil v«r^ closely.
[Alfrni Grn/'fi- dciKimiiintcii concomilant Birabiflmns as muscular «
m^opatliic sijiiiut, and aisserts tiiat the excess of contraction which givcsJ
rieu to tlie abnormal position, when the sijuint is )>ernianeiit, is only |)a<i
ive. In atrabiemus, the sijuinting position is that of rc^t, and the ence^
of tenaioD ftf the rectus iiiteniua is a purely physical condition of th<
muiKrlo, independent of any iunervntion. f^" Oraefe u. Saeroisuh, llandh.*'
vi. 1.^
T'. Jfatmer holds somewhat similar views, and looks upon strabiswuf^
aa an abnormality in the priraary binocular position, laying great streaa
on the anatomical equilibrium. ('' Beitia^e tar Fhys. u. Path, dea,
A uses.")
HuHten, of Copenhagen, differs from both Oraefe and Hasner. Thi
real cimse of sfjuintin^, he thinks, is the abnormal situation of tiie ran^^
of accommodation. When strabismus docs not appear in a person wl
is hypermetropic, this is due among other things to the range of the rcl
tire accommodation being sufficiently great to make it independent
convergence. He regards it as established that id strabismua the innei
vation to convergence is uiiually strong in botli eyes, and that tbe cor
ditionrt in s-iuinting are fnllv explained by "considering ihcra to coufii
of an active sihortcning of the muscle, brought about by iucrenscd inm-i
Tution to convergence." In the normal eye tJie convergence for a fist
point " fulfils the demands of binocular vision,*' while in tbe S(|iuntin^
eye " the convergence satisfies the want of accommodation and puts ttiM
the demands of binocular vision." As the result of hia cousideratioo '
upi.in the subject, he states the following: " Every hypermetropic s<iili!)t
depends upon tbe reUliim bctwcou aecnnunod&iion and convcrgeuce.
Convergence is partly an immediate cxprf-ssion for the accommodaiion
used in the moment of fixation, partly an expression for tbe unconscioii
innervation to convtrgence arising from accommodation, and lasting]
during its .-itate of rest." (See a very interesting paper by Hansen ii
"Trans. Kifth Internal. Ophthal. Congress, New York, 1876."). — B.J
CoiKomitunt squint may be either monolabcral or alternating. In the
former case, tbe squint is always confined (when both eyes are open) M
one and tbe same eye. If the healthy eye be covered, the other wif
move in order to fix tlic object, but directly the former is again uncov^
ered, it will at once resume its $>{uintiug position. In alteruat4ug 8>|uii
it is different, for somctimci^ tbu one eye deviates, Kometimea the other.
If w^o, in this case, cover the healthy eye, the other will ui.'kke a mov{
ment in order to adjust its vit^ual line upon the object, and will retain it
position when we uncover the sound eye. The latter haa now, in fart
become the stjiiinting one. If we then cover the other, the stiuint will
alternate again. It appears almost, or quite, immatorial to tbe patient
which eye he ums. In such cases, there is grncniUy no diff'TciK^*- it
the si^jht of tbe two cyea \ whereas, in monolatcral litrubismus cite \u
STRABISUUS.
6D5
of the sqamrinjt eye is almoat always affected, on sccount of tlie suppres-
biuu uf tlie ilouble imii.<^e, sometimes, iude<>d, very con^^idcrably.
'Hie a<r(ivo negation of the double image by the brain soon leads to a
more or less coiwideralile deterioration ia the aigbt of this eye. We
occasioiinlly find, however, that tlie vi3ton of the ih|miitin)f eyo remaiiw
good, allhough th^ strabihrniw is not ahemating. indeed 1 have seen
caaes (exceptional. I grant) in which the patients could reatl the very
fiocit print with it, never having, a« far as they could remember, suf-
fen-d from diplopia. Here binocular vision had moat likoly never ex-
ited, »ttd hiMice the ahaeuce of diplopia and tho call for the aupprcasion
of the double image.
It was at one cimo proposed U> cure &(|uint by cloiiin^ the healthy eye,
and tlius neceasitating the fixation of the othur upon the object. Tho
error of such treatment is, however, self-evident, as the squint is merely
transferred to the exohuled eye ; for just the same thing occurd, as
when we place our hand over the healtliy eyo in order to eslimat* the
primary and secondary deviation. Tlie vision of the squinting eye is
exiTciscd, bat the di?ea*e reranina uncured. But this proceeding often
prove)* very valualile iu practice, for by it we may render a monolateral
squint alternating, and pretHsrvo the sight of botJi eyes. If, for iusuuice,
a child si^ntnta (seeing perfectly vritli both eyes), and the operation haa
to be postponed for some reason, we may presun'e the sight of tlio
Hqiiinting eye by the periodical excluiion of the other. In this way, wo
may not only maintain the alternating character of the stral'ismus, and
tlie sight of both eyes, but we may even change a monolateral into an
alk- mating squint.
The question as to whether binocular vision exists or not in a case of
strabismus, is of much importance in the prognosis. For if it docs not
exist, wc cannot expect a perfect, bnt only an approximative, cure, for
there will not be any iliplopia. and the perfect cure uf squint depends
upon the fn<tion of tlie double images. Ilence the presence of binot-'ulur
vision should always be ascertained before the prognosis of a strabismus
0}>eratiMn is made. Its presence is of course proved at once by the ex-
istence of binocular diplopia. The sight of each eye may be good, and
there may be no deviation of tiie visual lines when both are open, and
TPt both may not be used at the iiftrac time. The existence of binocular
visiun is easily pruvcd by the aid of jirisms. Kach eye should, how-
ever, he Brit examineil separately, and its acuity of vision, range of
accommodation, and state of refraction be accurately ascertaineil ; notice
being also takon as to whether the visual line is adjusted upon the
object, or whether the eye " fixes" the latter with an eccentric portion of
the retina, and ntd with the yellow spot. In the former ca^e it is termed
*' central," in the latter *' eccentric fixation, " The patient is next di-
rected to look with both eyes at a lightM candle situated at a distance
of four or six feet, and a prism, with it« base outwards, is then placed
before one eye (let its suppoae the left). One of the following iliroe
things will then occur : 1 . diplopia ; tf, a corrective tqnint if the prism is
not loo airong, for the left eye will endeavor to overcome tJie annoyance nf
tlie diplopia by 8<jiiintiiig inwarxU, and llnis fuslug tlie double images ;
8^ tiie pnsm may have no eBect^ producing neither diplopia nor a cor-
096
APFBCTIOHS OF THB UUSCLBS OP THE BXC.
rectire st^uint. This proves the abeence of binocular vision, ftaJ thai
tlic prism lias been belJ before [he eye whicli ia not used. For if «
placo it (still -with its base outwards) before the other eye, this wiU
move iuwanU in order to brio^ tlie dvlIvcteU ra^'s aguiii upou tJie ye\U
S|ii)t, which is, of course, acRompiiuicd by nil assuciatcd movemeDt oui
wards of the eye which u excluded from biuocular vision.
Binocular vision id frettuently only lost in certain portions of th
retina, inoro eepeciallj in those which, though not identical with. ar<
constantly excited simultaueously with the central portion of tho retina
of the other eye.
Thus in convergent squint we find that, in the e<'iuinling eye, the por-
tion of the retina which lies internal to the yellow 8]K}t is the fini
nulTor a Iosb of binocular vision, for it i* directed tAwarila the objcci
and is therefi.>re (thui^b iiut identical with it) constantly excited e>in)ul
taiu'uusly ivilh the central portion of the retina of the other eye, which
is fixed upon the object. The reverse occurs in divergent «<juint, foi
there the external portion of the retina is the first to fail. At first, t
loss of binocular Waion only extends horizoutallv, so that if we turn a
prism with it^ bnse upwards or downwards (or place it even iu a diag-
onal position), we at onoe produce double imaf;cs, which sliow not only
a difference in height, but also, if there is any S4uiiit, a lateral difter-
ence. We may thus dctenniue, with the greateat nicety, which pan «t^i
the retina has lost the power of binocular vision. Soinetimea it cxtend^^J
over the whole retina, so that we fail to produce diplopia even with U*^^
strongest prisms turned in any direction ; in other cases, this loss of bin-
ocular vision is tolerably ciiTumscribcd, beiii;; confined to a very small
portion of the retina. In conver<i:etit strahisniUD, for instance, only a
sinitll portion of the retina inlenml to the yellow spot tnay have suffcrod ;
so that ou placing a prism, with its base towards the nose, before tbis^J
eye. and dctjectiuf; the rays still more inwards, ih)uble images are ftt^f
once produced, although the deflected rays now impinj^e upon a more^^
eccentric, and naturally less sensitive portion of the retina. Occadioa*
ally, we may in such a case also [irmluce dijilopia, if we, by means of a
prism, bring the rays nearer to the macula lutea. Thus, a Kuddcn ali^era*
tion of tho position of tlie visual line of the affected eye, may at once
give rise to diplopia ; as, for instance, after the operation for sijuint, oc
iu cases of paralysia or spasm of tho other muscles of tho eyvhali.
Von Graefe baa found that btnoctdar vision is absent in about !)0 pv
cent, of cases of concomitant srjuint ; that wc can produce diplopia b
pnsms in about 2o per cent. ; and that after tho operation, binocular
vision is found to exist in about 50 per cent. Tho reason why binocular:
vision is so fre<^uenUy absent in concomitant squint is, that on account o\
the annoyance and confusion produced by the diplopia, tbc patient soon'
aci|uire3 the habit of mentally suppressing tho retinal image of tha
fiijuinting eye. This active suppression of the pseudo-image is mostly
accomp.inicd by considerable amblyopia, and the latter is especiallj apt
to iucrease very rapidly iu children, so tliat, perhaps, within a few
mcmtJis afler tlie first ap|iuarance of tho s<iuiut, the child may hanlly
able to decipher large letters (No. lt» or ■}» of Jii-jer) with the squln
ing eye. This beiug so, the operation should never be uonoceuari
bt.
Blioiua W operated upon lor w^mn
U not better Co poacpone the operation until it is much older. Mj; opinion
19 very strongly opposed to the Utter practice, and is urgently in favor
of tbe offeration being performed a» soon a* \tomh\o, whilst binocular
vision Blill exiftts, an*! the nij^bt of the Ki(uinUBf; eye la j^ood. If it is,
however, abaolut«ly nocuMary to j)0!ft|.H>nti thw operation, the vision of
tlib At|uiiiLing eyt; shoiilil he very fn>(]ueiitly practiced, aiid each uye
iihomatcly used for reading, etc.
Tlie amblyopia due to the suppresaion of the retinal image is often
greatly improved by the operation, and especially by practising the sight
an«rwar(U with a strong convex lens, or by Von Gracfe's arnini;ement
of iviO lenses placed in a ithort tube. The improvement produced by
the operation varies with the dcj;rco of amblyopia, and is preoto?it when
U)« patient can still read moderate sixed print (from No. 4 to 14 Jii'^er),
irben tlie sight is improved by convex glasHUii, and when tlie lixation is
central and the visual field good.
The sudden and very marked improvement of sight vhiuh occasionally
takes place directly after the division of the tendon, is probably due to
tlie relief of the compression exerciseil by the contracted muscle upon
the sclorotie, and through it upon the retina. It is difficult otherwise to
explain this very sudden and striking improvement of vision.
\W roust now brielly consider the dificreut forms of strabismus, and
the various causes that may give rise to tliem. Before doing so, I must,
however, again call atteuuon to the fact that wo occasionally meet with
cases of npfiarent Btrabi^tnus. In such there is an undoubted and well-
marked deviation (either convergent or divergent) of the optic axes, and
yet both eyes are stea<lily fixed u]ion the object, and neither moves in
tbe slightest degree when the other is cloM^d. Iletico the 8<^)uint \n not
real, hut only iipparent. l>ou<lers has called particular attention to this
:t, and has funiiHhcd us with the explanattun.
I have already mentioneil (p. HOii) that, according to TIelmholtz, the
optic axis and the visual line (an imaginary line drawn from the yellow
8pot to tlie object point) do not correspond, but thai the latter impinges
apon the cornea slightly to the inner side of the optic axis, forming with
it an angle of about n'^. It will, tlierofore, be at once apparent, that
if the visual lines are parallel, tlio optic axes must necessarily be sligliily
divergent, and such is. indeed, the case in the normal eye, but tins di-
vergence is so very slight, and wo are so accustomed to it, that It encapes
our obecrvation. In some cases, the visual tine may change it« position
with respect to the optic axis, and if this deviation be at all considerable,
an appan.>nt squint will ari^e. In myopia, for instance, the \'isual lino,
instead of lying to tiie inner side of the optic axis, may corresp«jnd to
the lattt^r, or even lie to tlie outer side of it ; and, in the latter ease,
there will, consequently, 1>e an apparent convergent s<{uint: for whilst
the visual lines meet in the ohjcet-)>oint, the ojiiic axes must necessarily
cross on this side of it. In hy[)cmie tropic eyes the reverse may obtain :
the visual line may lie more than normally to the inner side of the optic
Axis, forniiiig with it. ]ierliHpiii, if tlie hypermetrupia be execHsive, an
angle of »'^ or even it^, insteatl of oue of 5*. If such eyes look at a
SftS
AFFBCTIONB Or TUB UUSCLBS OF TDK BTI.
distant object, thev will Appear to be aflTectcd with a direrKent squint,
for whilst the visual line* are 6xed upon tlie object, the optic »\e« will
(iiver;re froni it. Tlii« explatiniion of bonders is not oaljr «xcee<litiglj Id'
teresting. but is alao of much use to 09 it) practice, for it will fiiara i»
a-iainst an erroncoiut rli.i;^no3i.<( and trcatraent of iuch cases.' borne of
the cn.s4?.-< of so-callcil iiteotij^rucnce of tlic retiiia; vcre probably re*!!]
ciue» uf appareut strabtsmua.'
(1) CONVERGENT STRABISMUS.
Conver^jent a'piint is in the vast mnjority of cases due to hjperm#t
pia. Accordin;; to Oomlerfl * ttio latter is [ir«?!»e»t id abt^ut 75 (kt cim*U<
of the caMS ot^ convergent stmbismu^i. t)c Wecker places it oreo ataj
higher figure (85 per cent.). The presence of hypermeiropia iit oftrai
overlooked, because it is either latent, or because the patients are verrj
Tounv and do not know how to read. The ophthalmoscope would^.,
however, tn such cases, at oace enable us to detect the true state of r»-]
frucuoi).
It will be remerahcrod that we understand by the term " hypermetnwj
pia,'' that condition of the eye iu which its refracting power is too low,,
or the opiic axis (Antero-ixMterior axis) too short, so that rays which im-
giujTo parallel upon the eye (enuumtiufi; from diitant objects) are not
brotigUt to a focus upon the retina, wlien the eye is iu a state uf rest, a* ,
occurs in the normal eye, but more or Itws Itehind it, accnrdin;^ uj the
amount of hypormetropia present. The eifect of this low refractivu cou-
dition is. that, whilst the normal eye unites mys from distant objects u|ioii
the retina witliout any accommodative effort, the hrpermetropic «ye has
already, in order so to do, to exert its power of accotnmodation toorv «
less coiutideraltly. This exertion must increase, of coarse, in direct ratio
with the ap|>r')xiiiifttion of the object to lliu eye ; for if the accomi
tiiui \mfi atri'iidy to be brought into play to unite |iarallcl rayn upoal
retina, bow much more miiAt this bo the case when the object 14 ctf
appntximated, and the rays from it impinge in a very divergeat din^
tion upon the eye ? Now, in order to increase Uic i>ower of acoomno*
datioD, ooe eye often squints iQwards,for the followiagreaaoa: BecMso,
' Pruta xhtta fnnu th« reaJcr will ma Itow iKwosury ll h ihal the tfrm* "1
axis" Bii'l " riftunl lliio" shoiil'l no Uu^cr Uo n»i>d as U>iiig i<1i'0tieiil In •IftuDr
for litis ia not out; iucorrnot, but ntusl ]imA tu connluit roiifuniou vtid n>ia«|ipr
sioii.
* Wo oomAlnnaily mtyt wltti nui^ in whtt-h the dnuhle Inagia do not at ■)■ s^rat
in iikorkctDf wIlU llic [■Miliuii iiT (li» rbtiAl liix^. Thtu adcr Ui o|Kirattnn Lt imiO'
T»rpini atraliUiniifi wc luay Uml lli;tl, I'veu aUliuui;1i s constdv rattle it> ■•'..< ..r
vrr};.'iit mitihil U ictt, tin' flipioitlA ts nol h'^monymoiu liut mwivd,
wtic4T of tlifl retina itcc^ura, atiiKnl williuut vsocptiDU, unly iu ciuo* in
tiirKtniin in the |jim>oulnr vi»lou ilsivs (two vtrly rliililhoncl (iMfi^rc th« •-if;hUi y4r)<
whirli li>nHa in all {irolialiilitjr to a fautlj <l(ivi-lcipni>tni of tbu Ajiprr^Utinn "f *h»
i'lirntltj "f till! twti r<rtiiial luiprir»«ii>n* i n fauuhv wtiirh ai)|K'art tn ''
olii'Mtl nixl chii-Hy •InvclopiHl in cliildhcirid. (Vhiii Von (lra><r<-'t " .'■
dur A 1 " ' " ''mnnftxii," p. llO ; iiUo ^agt'l, " l>aa Btihoii Hit *.m i-i .iii^ni
l'>'l . f«. -A. f. O.," xi. 2.
• V'.i 1 iioh-o»-'Th« I'stlH.«.'nyrtf .Snitlnl."-A.f. O.,"!'*. 1, 9» : t^
■n atil» tntnalotton of tbu liy Or. Wrighl, ei Uobltit.
OONVBROBITT STRABISMUS.
699
together with the increase in the convergence of ihe visiml Hno«, there is
also ftii tncr«a«e in the power of accommtKlatJon. We can ta^iily jirove
the truth of this statement, br placing a prism (with its base oiitwanU)
liefnre a hypcrnirtropic eye ; for the lattrrr, in looking at distant objects,
will tlien iniuiiit iiiwarls. in order to avriiii diplopia, autl tlii^ converyence
of (he visual Hncs will now enable it to unite parallel rays (frrun ilialant
objects) upon the retina, whercod, when it« visual lines wore parallel, it
coutil only unite convcrj^ont rays. Again, an placing a conenve lens be-
fore a normal eye, we change it into a hypermetropic one, for parallel
rays are now aniteil hehiiid tiie retina, and it will re'|uire either a convex
ffla»<{4)ran eflbrtof the iicconnnoilation, to bring thei<e rays once more to a
focus on the retina. If this c^ncavt; glass he but weak, an incroasod effort
of the nccomiDodation will neutralise its effect, and overcome this artilicial
hypermetropia. If, however, the concave lens be too strong for this,
the eye often overcomes it« effect by scjuinting inwards, and thus increas-
ing its power of accommodation. ThiK !<hnw«, thorc-fnn?, a]iart from
otlior conscftucnces, the danger of giving a ahort-siglited person too
stnnig a glass, for we mtty thus induce n convergent 5i)uiiit. ^t'ow, the
same thing often occurs in hypormetnjpia— the one eye S(|iiint4 inwartla
in order to incrca«e the power of accommodation. At first thin ft(|nint
is but periodic, appearing only when the patient is intently regamtng
some object. As soon as he looks at any object, near or di.-^tant. tlie
one eye may move inwards. Frei[uently, however, the gqaint only occurs
when lie is looking at near objccis. aa in reading, writing, etc. This
p([uint has, therefore, been termed periodic 9<iuini ; and hypermetropia is
by far the most frequent cause of it. It is even aurpriHing that Ki{uint ia
not more common amongst the hypermetropic. This form of periodic
strabismus is often met with in young children, frequently showing itself
first about the fourth or fifth year, when they are learning to spell, etc.
In atich cases wc may fail (on only cursorily glancing at the eyes) to
detect the slightest squint : if we, however, direct the patient to look
fixedly, at iwmctliing — aa in reading, etc. — one eye directly s<|uiut« in-
wards, this deviation, however, disappearing again aa soon as the object
ia raniovcd. Sninetimes tliiD periodic si|uint shows itself whenever the
person is looking intently at any object, ho it near or distant; in other
eases, however, it only occurs when the eyes are looking at near objects,
the squint disappearing assoon as they regard distant objects. The stra-
bismu amy, aUo, be fre(|uently corrected by placing suitable convex
fflaases before the cyea, so aa to neutraliKC the hypermetropia. If the
Btber U not neutralized by the constant use of convex lenses, the squint
will genenilly soon become permanent, ac<)uiriiig then all the symptoms
of concomitant squint. As byi*rm(!tropia is often hereditary, and fre-
quently exists in several members of the some family, and as it often
also causes strabismus, the popular idea that u squint may be produced
by imitation, has gained considerable credence, even in the professioi].
I have olten had occasion to examine such eases of 84|uint occurring in
diflercnt members of the same family, and have almost invariably found
that Itotli [latientd, the supposed imitator and the imitated, have been
bypermetropic ; a common oauso had produced tlie same alfecdon.
The reason why the majority of hy|<ermetropic persons do not squint,
AFFECTIONS OP THB MU8CLB8 OP TUB STK.
is eridenti y due to the fnct, as pointed out by Douders, tliat they {irrftr'
Co sftcritice a certain degree of distinctness and ghnrpnei:* of rt^too in
order to avoid diplopia. Tliia is often proved by the fact, that if n*
cover the one eye of a hypermetropic patient witti our hand, it will soon
deviate iuward» when the other h used for reading, etc. But it i« other*
wine when the images of the two eyes are very different as r^ganb di*-!
tinctness, as, for instance. If the degree of bypcrmetropia Is much gre«t«r I
in otio eye than in the other, or if tliere is some opacity in ti)« re-
fntctin;; media of one eye. In i^iich caiteii a convergent adjoint cosily
becomes developed. The vame occunt if the iuiemal recti muAcles an
very stron^. A great difference between the poution of the vtaual line]
ami the opiic axis (the two forming a coniiiderable anjcle] scecns alao m
hypermetropic eyes to predispose to strabismus (Uonders).
Convergent S()umt is most frequently met with in themixlemte degrrea
of hypermctropia (from :i'ij to ■^), being generally absent in the btjib
degreea. Thi» iit evidently due to Uie faet, that irhen the bypermetr«ipa
ift very considerable in degree, the accomroodatina is insufficient (ereu
when the visual lines are ahnomudly converged) to produce a perfect
retinal image, and the patient tWrcfure uccnatoiiw hiiUHcIf to gain correct
ideas from imperfect representatiyii, rather than iui|irove tlicsc by a
maximum of effort (Donders).
Impaired vision of the one eye is a freqnent cause of strabismus, is we
can often notice in cases of opacity of the com«a or of the lens, or of
some affection of the deeper structures of the eye ; the distinctnesa of Aa
retinal image of the affected eye being consequently impaired. Thii
difference In the clearness and IntcnHity of the retinal ima;!es fif the twn
eyes Is often very confusing and nnnoying to the palienl, and, in order J
to escape from this annoyance, he involuntarily S'quints with the affected]
eye, m that the rays from the object may impinge upon a mure pcnph«<
ral (»nd, therefore, less sensitive) portion of the retina ; and t)ie iQUgQl
of this eye be consequently so much weakened lu inlcusliy ait m»: twi
prove any longer of annoyance. The direction In whicli this dL-viation
may take place, is gcuc*rally determined by the relative sirengUi of lh«<
diflerent muscles. If one proves pre-eminently strong, the eye «iU'
ft[mnt in the direction of tius muscle. The laltor will contraet mons
and more, and the S(|uint will soon assume all the charact«n» of concont-
tant atrnbismus. The image of the oquinting eye will be gradually sup*
pressetl. ami (hen amblyopia from non-use of the eye will be »ii))eniddrd
to the weakness of slight caus<>d by the original affection (opacities in ihc
refracting media, etc. ). It must, however, he admitted, as has bcco
pointed out by I'agenstecber, that In yery many of these cases of iat>
paired vision Lypermetropia coexists, and must, therefore, he regarded |
as the true cause of the squint. Uondcrs thinks that tlie iuflainmai
which uausve the corneal opacity, niav extuud to s<jme of Ihe niiucU
antl ai hr^t bring on a apa.iinoilic and then an organic coutrmctton of dn
muscular t)!>due4. Convergent s<)uint may ali^o arise as a seouadary i
affL'ction, after paralysis, or wounds and injuries of Llie npixmeut muitcla.|
Marked instances of this secondary form of sf^uint are but too oAen for*
tiirtlicd by oxco&flive operations for strabismus ; the extent of the opera-
tion having either been too great for the requircmcDts of the case, or the
MVERORNT STRABISMUS.
701
I
ntiscle liAving been diridcd instead of the tendon. Spasmodic contnic-
tiot) nf the inteniul rectiLS ma,v also produce couvergeni SL{aiiit, but tWii
does nol, fltricily rtjipftkiii];;, ln-Ioiijr tn iiiir present suhji-ct.
Von flraefe' lias piiiiited out. tlmt in rare liwtaiiceH nivopia niay be tbe
caHseofcoiiverfientwuiint. This occurs only in cascsin which the myopia
i« moderate in extent, and in which the eyes are mnch used for very near
worls. After a time, the iutenial recti become contracted from this con-
stant and excessive use, and cannot be relaxed when tlie patient looks nt
a distftnt object, tlic external recti being too weak to overcome the action
of tlie iiiterual recti. CotiKe<]uei)tly a convergent fi'piint arittex, which is
at first periodic, but may in time become |>ermnnent. and nppoar as Hoon
as the patient looks at any object which is not very close to him.
Thift 9i|uint is not met with in cases of very coiisiderablu myopia, be*
cftiwe in these the necewary convergence of the risnnl linea can gene-
rally not he maintninetl on acconnt of the close jiroximity of the object,
and therefore the patient only uset* one eye. This form of strabismus
mostly becomes developed in early manhood, more especially araongrt
Btudeiila or literary men who arc not in the habit of wearing glasses.
(2) DIVERGENT STRABISMUS. ETC.
Just as hypermetropia is hy far the most frequent cause of convergent
BTjuint, myopia is the int>dt fre-pient cause of divergent airahismus. The
latter may be constant or absolute, the one visual line always diverging
from the object, and tills divergence existing for all distances, so tliat lioth
eyes cannot he brought to converge upon the object at any distance. The
divergence, however, sometimes diminishes aonieMhut when near objects
are rcgiinled. AliS"liit*i divergence in CHpecially met with in capes in
which the .«iglit of one eye is greatly impaired (amiiuroMS, mature cata-
ract, etc.), in paralysis of the intenml rectus muscle, or in cases in which
llie latter has been too freely divided in an operation for con»ergeut
srjiiint.
Tlie principal cause why myopic eyes are so subject to divergent stra-
biatnas is to be sought in the elongation of the Biitero.po.<iterii.ir axis of
tlie eyeball in myopia. On account of the ellipsoidal shajR' of the globe,
ix» range of mobility is diminished, and it caiiuol be moved so freely in-
wards or outwartifl. The outward limitation of mobility does not matter
much, as it only comes into aucount in the extreme lateral movements of
the eye, and the inconvenience arising from it can eajity bo remetlied by
a turn of tlie bead.
We find, however, that it is very different if there is a considerable
curtailment of the inward movement, as the necessary dcjjree of converg-
ence fur a very near point can then only be maintained with great diffi-
culty and exertion. The internal recti muitctcs arc much strained and
fatigued, symptoms of asthenopia appear, and then, to relieve these and
the strong muscular effort, one eye is allowed to deviate outwaids ; when
the work can be continued without difficulty. Thisie one form of periodic
< "A. f. 0.,"«. 1, IIW.
702
AFF80TI0X8 OF TUK MU8CL£8 OF THB EVE.
or relative divorgent strabieiQus, anil the same thing occurs, as Di^mlcn
has jioinied out, wlienever the degree of myo|iia is bo exlrenic tlmt 'tir
object has to be approximated so closely to the eye, that the viitual huvt
cannot posaihlj b« brought to couvcrge upuu it. Kvlativo divergence
jany be due Biraply to the elongation of tlie eyeball, together with great
myopia, the intenial recti being healthy ; or to vreakness of the iDtemal
recti, witliout tho presence of myopia; but in most inscances "
causes coexist. The tendency to divergent squint is also iiici ^
the itnall angle which the visual line forms with the optic axis in cases
of myopia. We likewise find that divergent S(|uiut may only appotr
when the myopic patient is looking at any object beyond his far i"')!)!.
aiul Khich he docs not sec distinctly : or tiial it nccui-R when be is look-
ing vacantly hcibre him witliout fixedly regarding any object. <'>n
account of the indistinctn^M of the olyect. Ihero is u« effort at biwwnlar
virion, and the one eye will follow its natural muscular impuli^e, and de-
viate outwania, if the external rectus is relatively stronger than the inter-
nal. But if the patient is furnished with suitable concave gla&ws for
distance, so that he can see the objecta clearly and distinctly, the desire
to miiintaiu binocular vision will overcame the divergence; the saioe
occurring if he is looking nt any object within liis range of accommoda-
tion. When one eye is blind, or there is a great difference in the refrac-
tion of the two eves, divergent stnibismus fre<|ueuUy occurs. For as
there is no impulse to maintain binocular vision, the internal rectra
gradually dimintsKes in strength, and the cxtenial rectus perhai- ' i-
goes secondary contraction. The relative form of divergent &■>■■
pendent upon insufficiency of the internal recti, is a subject of such grvat
importance, and one which demands such careful and special ex.
tjon and treatment, that I shall treat of it separately, uniler the uame
"muscular asibeDOpia.^'
annni^^J
ame ^H
tnrr Of'
We mnst now pass on to the treatment of strabismu*. Tlie nat
coucoiuituut s«|uint is totally different from that of the paralytic. In
the latter, the innervation of one or more of the muscles of the cveliall
19 impaired; whereas, concomitant stfoint is due to a change — an in-
creased degree of tension — in the muscle in tlic direction uf wliich the
a(|uint occurs. But its innervation is normal, a.t is at once prov<-<) 1 1
the perfect niohility of the vyelKill in this direction, and by the face, i .i~
the secondary deviation exactly etjuats the primary, and does not eseeed
it as in cases of paralysis. Practically, we may regard tbe aSeotvJ
luuscie as shortened. We often meet nitli fixed forma of fii|uini, for
paralytic and HjiaAmmlic affections of the muscles of the eye may giva
rise to concomitant A^uint, leaving behiitd them but very slight tracei af
the uriginal affection. But just as pnralysis may he the cause of ««t>
oomitant fhpiint, so may the latter, if it be excessive in degree Ukd ef
lou^ standing, produce changes In the opponent muscle. Let tis, f»r
instance, suppose that there is an exces.4ivo convergent squint of tli« «t>f
eye: if the latter is not frequently exercised, and made to fix i(a visual
tine u{Kjn the object either by an nnilicial or natural alteration, the non-
Ujie t>f the external recttis will gradually induce atrophy of this miucle.
The intenial rectus will at the same time become somewhat bypenn-
TaKATMBIIT OP 5TR A DTSMOfl.
708
phied, and tKe mobility of the eye oatwarda will be more or Icsg cur-
uilc'd. TLeae clinnges lu tbe structure of tlic imisctes are bedl pre-
vciitctl l>y ibc frtN|iieDl separate exercising of tlio a<]uintin^ eye.
In slij^ht coses of strabismus, it may be ndvantogeous to exercise the
weaker uiiijtcle tty rrot|iuMit nitd pystomatic " ortlici|>wtlic" exercise; so
ttmt it mny bo gnulimlly Atrcnj^theitcd, and enabU'il to overcome the ex-
c«s!iive action of its opponent in the direction in ^'hich the eve is
deviated. Such exerciaes are, however, only indicated when tiie tu^uint-
ing eye jiosscsses a fair degree of sight: when binocular vision exists;
ftud when there is intolerance of diplopia, so that when the double
intagea are brought sufficiently close togeilier, they are fused into one
by a vfdunlary muscular effort. These exercises may bo performe<l by
the aid of priauis, ttie double imaj^ea being approximated i^o closely to
each other, that they can bo readily united. Aa the strength of the
muscle increases, that of the pnsm must be diininished, for thu;* the dis-
tance tictwccnthb iuingrswill be increased, and tlie muscle more exerted.
Jaral* has introduced a very ingenious stereoscopic arrangement for
these orthopedic exercises. The latter consist in the fusion of two
large dots (one in each half of the stereoscope), and aubscnuently of
lettei'S and words, gradually diniiuiiihing in sine, ^ut both the pris-
matic and storcoiicopic exercises demand very great patience and exacti-
ttidc, and hence moat patients infinitely prefer the more speedy cure by
operation. These exercises, however, often prove very useful in per-
fecting the rusultri of an oiwration. The sij^it of the squinting oye
should also be often practised by itself.
Absolute concomitant squint can be cured only hy an operation.
De Weckcr* is, however, of opinion that hypermetropic convergent
strabismus not uufrequently undergoes a spontaneous cure later in life.
ITie object of the operation is to weaken the muscle in whose direction
the Sqiiiiit occurs, so that its inHuence upon the movements and position
of the eyeball may bo diminished. Thi!* is eflected by carefully dividing
tlie tendon as closely as possible to its insertion; tlie mu.-)clo will then
recede stigbtly, and acquire a new iiuwrtion somewhat further back.
This recetksiou is. however, accompanied by a certain diminution of
power, for the fuither back the insertion lies, the leas power can the
muscle exercise upon the movements of the eyeball. As we wish lo
weaken the muscle, but at the same time to preserve as much of the
lateral mobility as i>ossible, we must carefully regulate and adapt the
amount and nature of the oporatian to the requirements of each indi-
vidual case, and we shall see hercaflor how its effects may always be
estimated to a nicety. The success depends less upon manual dexterity
than n[ion a thonmgh knowle<lgti of t.hc theoretical ]Art of the subject.
After the tenotomy and retrocession of the muscle, the eyebnil will
incline passively to the side of the opponent to about thu same extent as
the muscle receded on the sclorotio. The diminution in the lateral mo-
bility towards tlm side of the operated muscle, will, however, exceed the
extent of tliis retrocession. If, for instance, the muscle has receded two
I "Anp«I««l'OcolUr!fnii.," IW3. p 7« ; also 18«7, p. fr.
< " KI. Uunatsbl.," l6;i. 453.
704
APFKCTrOItS 07 TRB UtJSCLSS 07 THS STB.
lines, the lews of mobility will be from two to three lines, and tfaiswnold
iuipuir tli(^ r08u1t8 o( tlie operation cousiderablj (partJculartv witli rv;:i
M ttic nccominixlativc mnvomciitA) if it was not for llic fact, tliai ihi
mobility of llic »piiiitinK eyo %n pntltologic&tly increased towanU ilie
aide itf tlie shnrteued miiwK'. Hvnuo the mobiliLy will be in renlity b«t
«lij,'li(ly fiiniiniahi'd by tlic operation, or it may even remain (!.j».il ti» iliai
of tlic other eye.
The rpieation, whether one or Iwth eyes are to be operated on, dc
not bingo upon the fact wbetber both eyes »>|uint or not, but depet
solely ujwn tlic extent of tbo atrabiiifmuR. It la quite crrooeoua to
fine the o]wracion to one eye, merely hccanse the W|iiint is monolttt
atid to perform the double operation only in cwea of alternating frtra-
bisnm^.
If the flrpiint meflsnres from *2"' t^ 2J"' we may j^encrally corre<l it]
by a single operation; by incising the subconjunctival tissue aumrwbat
freely, and by using a larger hook, we may even obtain an effect of
2J"' or S'". This i» particularly the case in children. If the dciiaitvo
exceeds 25'" or S'" we inuat always divide the operation between tbo
two eves.
Let us suppose, for instance, that a natient is afi*ect«d with a conrd
gent snuintnfthe right eye ofahoni 41'". To correct thia by one oper-
ation, we should have to divide the tendon of the internal rectux miL'«.*le
of tliis eye to such an extent tliat the muscle might recede 4^'". Tliia
would he. however, nccomianied by a diminution in the mobility inwardi
of about .'>J"'; and even aupiKiaing that the pathological incivase in the
mobility in ihis direction had been previously about one line, we sbonM
Still buve a deficiency of about 4^'" Hfter the o|»eration. The asHociated
movements townnls the left side of the patient would, therefore, to
greatly impodtMl : and thift want of mobility inwards wonld make itself
particularly felt during the accommodntive luovementif, for it would pc^
Tent the proper convergence of the visual lines during reading, etc.. as
the visual litio of the right eye would devinte slightly ontwanls from
object, and this divergent squint would soon increase in extent and
come permanent. In onler to obviate this, we must divide tlie oponiti.1
between the two eyes. Let us ^up[>03e that the tenotomy of tlie rigli
internal n-ctua has corrected 2J"' of the deviation, liiere will.
(fui-ntly, still remain an inward i^tuint of this eye of about t!'". <.>Ui
rring the left eye with our hand, and tcltiug the |>atieut to look
object with the right, the latter will have to nuike an outward moi
of 2'", and this wdl Ire accompanied by an inward, associate*! omi
of tlie left eyo of Uie same extent. We must now calculate the vi
the operation which will be necessary to correct the secondary aqaMi
the left eye. just as if the latter was nrimurilv atfccted with a couver^cst
S4iulnt of ii"'. Un us now assume that the felt internal rectus baa,"
divided, and that we have obtained an effect of 2.'": iht ryo will,
qnently. inoline oaiwards to this extent, a div^Tgrnt squint of tt'" '
in fact proiUicrd ; iind it will, therefore, re^juire an extra exertion
iutenuil n'Clu» to bring the ^ isnal line of the left eye to bear
the obji-ct. Now. this inwani movement of -'" will l«e ac
at) aS40ciated outward movement of the right eye to the saow
TRBATMBNT OP STRABISMUS.
70fi
bfince. the convergent si|uint which had remained after tJie finit opera-
tion will he completely corrected. If hinocular vmon exists, tho douhle
images will now be »ct very closely approxiniatcd, that a very Rltght
iDQScuIar eOTort will he abb to tinito tliem permanently, and the cure of
the s'luint will be perfect.
Tlie (ipvniliuii is lilwuya to bo pcrfonncd in such a manner, that the
greater amotint of correction U apportioned to the aqiiinting oyo, as the
mobility u pathologically increased in the direction of the shortened
IDUBCle.
I ahall confine my description to three operations, vix., von Graefe'a,
the sulfconjuuctival opcmtion of Mr. Critohctt, antl Liebreich's modifica-
tion of (iracfe's operation.
I may mention, however, that the old operation, in which the conjunc-
tiva ana subconjunctival titisuu wi<re wiilely inciseil, the captmle of Tenoa
lacerated, and the mu<it:Io itself, and not its tendon, divideii. should never
be performed. Its effect is gcnernlly most unhappy, and it brought the
operation for strabismus into great disrepute.
The principle of von tiraefe's operation consista iu a very careful
division of the tendon clo&c to ittt mi«ertion, with the smnllest possible
amount of laceration of the aubconjunctival tissue, and the tendinoua
processes of the capsule of Tenon. We diminish the power of the muscle
by giving it a more backward in.sonion : hut vc, at the same time, pru-
aerve its length intact. Our object is only to weaken the muscle, and
not to render it more or less impotent. Before proceeding to consider
this method of operating, I would, however, dwell for a moment upon
the anatomical relations of tjie muscles of tlio eye with the ocular aheath.
Commencing at the optic foramen and loosely embracing the optic nerve,
the sheath expands, and {>asses on to the <^Teball, which it incloses like h
capsule. It is lootiely connecCcd with the sclerotic hy coiincciivc li«uiue
— 80 loosely, indeed, a» to allow of the free rotations of the globe within
it. At the enualor of the eyeball, it is pierced by the tendons of the
obliipie muscles, and, more anteriorly, by tlie tendons of the four recti
muscles, with which it becomes blended; being finally lost on, rather
than inserted into, the sclerotic, close to the cornea. The posterior por-
tion of the iihcath, up tn the passage of the tendons, haa been called the
rapsule of Bonnet : the anterior portion, from the paisagc of the teudons
to its insertion in the >)clerr)tic, having been designnted the cajisulc of
Tenon. On piercing the capsule, the tendons of the recti muscles become
connected with it by slight cellular proceaaes, sent forth from the capsule.
These processes prevent the too great retraction of the muscle after the
division of iu tendon, which would be followed by a great loss of power.
It is, therefore, of much coiwe-juence tliat these connecting prooesaea
should not be severed by the tendon being divided too far back, or be
lacerated by rude and careless manipulations with the strabismus hook.
Von (Jraefe has, moreover, pointed ont that the result may be unfavorable,
even although the tendon has Iwcii divided anterior to these hhrcs, a«
the alieath of the tendon becomes thickened from tJie point at which it
paAses through the eupttule, and this thickening extend? no.ivly up to ita
insertion. If the tendon is, therefore, not divided sufhciently clo^e to
ita insertion, it is apt to retract within thia thickened sheatli, and this
4&
706
AFFBCTC0S8 OF TBB NOSCLBS OP TIIR KYR.
r«traction will in mitny cases prevent its reunion with the sclerotic. Is'
the old opei-atirm, t!i« miiscle was divider! far hack, fro^uently even ^oa-
terior to its passage through the capaule, nn<l it wa^ conso^uctitly often
reitdered so powerless that the ei^ehall could not be moved in this direc-
tion ; its 0|)ponent acfjuircd a corrc-^ponding pre jmnde ranee of power,
giving but too frf(iucntl_v rise to u secondary Sijuint in the op{K>sitc 'lirec-
tion. Hence the (xipular dread of the i){>i-rati<ui. •' lost the ere shonid go
the other way.'* Hut such an unfnrtunatc result is not to be feared if
the surgeon performs the operation with care aud circumspection, and is
thoruugiily cmiversant with the theoretical part of the subject. It is an
important rutct never to do too much, for nothing is so difficult as to
retrace oue^s steps and to patch up a fault which has been committed.
It is far easier aubaeqoenlly to increase the effect of the operatioit than
to diminish it. I Vdow of no surgical operation which is so safe and so
sure in itA cure as that for fltrabismus when pm|>crly pcrfonDeil. I<et
us now pass on to tlic description of Von (Jraefe's 0|>eration.
As it is sometimes very pninf\d. the patient should he placed underj
chloroform or nu-thelyno. [In the I'niicd Slates, sulphuric ether is th
anesthetic generally employed, and very recently tiie bromide of ethylj
has been recomnieuded. — B.] The eyelids are to he kept apart by tlic
spring speculum, or, if this proves not sufficiently strong, by the broad
silver elevators. An assistant should evert the eye with a pair of
cufxK ( I am supposing that the internal rectus of the right eye is to 1>
operated on), taking care to do sn in the horizontal direction, withouB]
rotating the eyeball on its a.\is ; oiherwise Uie horlKontal position of tliftf
internal rectus will he changed. The operator should then seize, with «j
pair of finely -pointed forceps [Fig. 191], a small hut deep fold of the'
[Fig. m.]
conjunctiva and suhconiunctival tissue close to the edge of the cornea, amll
about midway between the centre and lowur edfjo of the insertion of iticj
internal rectus, lie next sni|>s lliis fold with tTie scissors (which
be bent on the flat, and blunt-pointed [Fig. lOii]), and, burrowing
neath the subconjunctival tissue in n downward and inward dir«ctioi
makes a funnel -shaped opening Wneath the sul>conjunetlval tiasne,
being, however, done, very carefully, so as not to divide it to ton great
an e:ctcnt. If the ^ul conjunctival tissue is thick and strong, it will b4
bettor tirst to take up a small fold of the coujunctiva only, to open thiSfj
TItBATMBEtT OP SlRABI6Mr
707
Pig. Wi.
and tlien, netzing the subconjunctival tisnue, to ilividc the Intter. The
«tj|uint-hook, which should be bent at a nght-anfcte. and have u slightly
hnlbona point (t-trf/ Ki<». T.til>. ia then to be paused through ihe ofwning
to the lower edge of tlie tendon. It* fto'mt being jjrcvssed some-
what firmly against the Bclcrotic, the hook is to he turned on
ibo [:oini and »lid iipwarrla beneath tlie tendon, is close to it^
iiwertion aa posKitlu, »nd the whole expanse of tlie tendon
caught up. The operator must he careful not to. direct the
point of tiie hook iipwan.!;? and outwards, yther«ise it may per-
forate the fit)res of the tendon, and only a porlion of the lall^r
He caiicht np ; the direction of the point sliould, therefore, be
rather upwards and inwnrda. When the tendon baa been se-
cured on the hook, the conjunctiva which covers ilfl upper por-
tion may be gently pushed off with the points of the ecissorit,
so as to ex)iot;o the tendon, which in then to lie carefully
snipped tliroii^h with the itcissors an cloiiely as |K>Mib1e to ila
iiwertion. When it bn!<> been completely cut through, tlie con-
junctiva is to be slightly elevated on the point of the honk, and
a snuillci* book passed upwArda and downwnnls to ascertain
whether the lateral cxpniLsiona of the tendon have been dirided. Should
a few fibres remain, thev man he divided, and the surgeon jthould again
nmrertain whether any otlient arc atill present. He ahoaUl never omit lo
Miti^fy hinuteir u|>on tbiii }Hiiiic^ for ttfiiuctimeH Uie lateral expnn.sions are
oonsiacrnble, the tendon Apreidin;; out like a fan. and although a few
fibres only might remain undivided, they would suflico to spoil the effect
of the operation.
I hove lately adopted n slight modification of von Oraefe'a operation,
and perform it more snbconjunctivftlly. 1 uao a pair of straight blunt-
pointed scisson* [Fig. 1".M], and, inotvad of pushing off tlie
conjunctiva from the houK fto as to expofte the tendon
caiigbt up by the latter, 1 divide the tendon aiiheonjunc-
tivally, quite close to ita insertion. In this wuy, th« ad-
vantages of iiracfe'a and the suhconjuiictival operation are
combined. On account of the smaller size of the hook, and
Ibc iiitualion of the incision (which ia lietwecn the centre
and lower edge of the tendon), the subconjunctival tissae ia
tftreiched am) incised to a much leas extent tliaii in the aub-
conjunctival operation. Again, the position and direction
of the conjunctival wound are such that a Htiture can be at
ence applied, if nece^ary ; whereas in the aubconjuuctival
operation the incision woold have to be oonsidorably en-
larged Hpwardfl, iH-ff.re any effect could he produced hy a
luturo upon the two cut edges of the tendon. But where
tHie degree of »trBbiamu<i is ao considerable that it is certain
no «utiirc will hi* rci|uirtid, tlie subconjunctival o{>cnition
may he employed : and aUo if we have no ait^int^nt nt hand
ti> roll the eye in the opposite direction.
If it ia found, on the first introduction of the hook, that this slides op
to tlio edge of the cornea without having caught up the tendon, it is cer-
tain that we have either not divided the nubconjunctival tissue at all, or
[Fig. IM.J
708
APPBCTIONS OP THB HUSCLB8 OF TUB BVS.
Uuit the hook has been pas8e4 between it and the conjunctiva. If
former is the case, we nmst open the suWmJunctjval tia.^ue, ami then,
reiDtroduciiif; the hook, we shall hare no difficulty in finding the t<'ndn
The opening in lh« ennji)iii;tiva and siibcrvnjiim'tival tift-six:! nhonlil he I:
small, and the excursions with the hook limited, othiTwi^e the su^co
Junctival t\s»ne and the lateral procci<>se:i of the capsult; of Tenon will I
extensively lacerated, which may be followed by too great a recAaaion
the muscle.
The after- treatment is very simple. The eye, after having been well
washed and cleansed of any blood coagtda. is to be kept confttaiitly
moist with void-water dretuiiij^; ilitrin^ the d»v of o]>eratio[i, so as to piw-
vent any extennivc cffu<ttr>ii of Ktond under the cDnjunctiva. No bucum
of grauulations will form on the 9tump of the tendon, if the latter hu
been divided close to ita insertion, and if the opening in the coojunettTa
has been made near the upper or tower edj^e of the tendon, ao oa aot lo
leave the latter exposed.
The effect upon the mjuiiit which follows immediately upon the operv
tion will not be the peranineut one. Wu may, indeed, distinsuiab three
sta^OA in the eflect produced by the operation: Int. The period imouv
diately following the operation ; 2d. .\fter three or four day* have
elapsed ; 8d. After the interval of a few month!^— this bein<; Hw perma-
nenc effect. During the first siajje, the effect will be considerable,
die eye can now only be moved in the direction of the divided m
by the indirect connection of the latter with the sclerotic by iJie late
proccsijei of the capsule of Tenon. As soon a^ the divided end of
tendon becomes rc-unit«d with the sclerotic, which j;eucrally
within three or four days, the effect will diminish, for the muftde
again exerts a direct influence upon the eyeball, This is the n
stage. liut we find that a further alteration in the p<.):ii(ioTi <;en'
shows itself n few weeks or months after the operation, the effect
then ajrnin somewhat increased. This is due to ttie action of the
nent muscle, which, on account of its antagonist havinf; been wcakc
can now exert a greater tntlucnce upon the ]>08ition of the eyeball.
A clue lo the pcrmnncut result of the operation is funiiithed by Am
position of the operated eye during the accommodative movement* of iha ^
eyed, wht-'U they an: directeil ufM>n i>ome near object. It is, tberefnrsflf
of threat consetpieuce always to test the position of the eyes during a(9^
comn)o<Ut)on immediately af\er the operation, as soon as the fStvt of tb* i
L'hlorofiTm tioa Ronc off. We have already aoon that tlie position of the j
Apiiiitiii'; ere f convergent strabismua) may rary when the object u >p
V U) the eyes: for whiUt the visual line of the bejiltby
I u|M>u ihc ohjoci. converjjiiif* the more ihi* nearer ih*
nUir i* hroui'lit. the position of (he snuintinK eye may un'lerjto lite M-
inyi'in- .'<.'.•. jfg: loi. |t may retain its original position. «Q.ttaiuing oall
'c ::rit;, irregidar, Intttnil movements. 2d- It mar rcoiahi
lary, ««) that the anj^b* of s<|uinlitij; will dimini*b the
cihjecl is broufihi, until, at a ccrlatTi point < if the
-ive), lU visual lino wdl also bo fixe.1 u|ioii tlio object, and
- longer he any stjuiul. If, faowovpr. the object ia appni
lA
TRBATM8NT Of STHABISUUS.
mnted Btilt closer, a diverj;ent squint will arise : for vhiUt tho hosltliv
eye converges still more, the other reuios its position, and now deviatea
(pasftivelj.) ouiwards. ^1. It retains iU posittDn up to a certain \io\i\t,
anii tben, aa the healthy eye moves inwards to follow the ohjcct, it mnketi
AD Associated movement outwards. 4th. It deviates suddcoly and spas-
nKHlically inwards when the object is very closely appn>xiinaled.
We .Hhrkidd, therefore, soon nflcr the opcmtioii, when the effoct of the
chlorofurm hait paired oil*,' a!>c-ert.iiri wiietber both visual lines can be
ateadily iixed upon tlie objetit, when it 18 hroughi bo a dii>tance of from
four to «ix inches from the eyes (tlieir slnte of refraction being normal).
If the eyei are very short-8i<;hted, the disUince ehould bo still less. The
final result of the operation may be predicted from the position which
the 0[>enited eye now a:<'4uniie«. If it remains intatiotiary when the object
is brought up to within eit^ht incheH fnmi the eves, sn that a paiwive di.
vergcnce will arise on its bcinj; approximated still closer, we must expect
a certain amount of divergeu'ce in the course of a few months. Hut this
will be still more the caw. if the eye, instead of umply remaininj* sta-
Uonary, makes an a^aociated movement outwards. It is nvccsiiary to
test this at short distanceii (four or 8ix inches), for tlie eye miL^ht be able
momentarily to'fix its visual line upon the object, altliou;;!] imit^^ incapA-
ble of maitilaiuiug this jwsition for any length of time. In both tbe
above ciwes, ibe cffeet of tlie operation in to be diminished by a conjonc-
tival suture, and particularly so in the latter instance. The eflect of Uie
suture will vary with its petition, and with the amount of the conjunctiva
embraced in it. Its effects will be considerable if it be inserted in a
diagonal direction from downwards and inwanlH to upwards and out-
wards, so that the inner and outer lips of the wound are united. Ity
giving it this direction, wo also prevent any sinking of tbe caruncle.
The suture diminishes tlie eRV'ct of the of>eration by re-advancin;; the
tendon, which is closely connected with the conjunctiva and subconjunc-
tival tissue : the divided cuds will conseijnendy be more closely approxi-
mateil, and tlie retraction of the muscle diminished. The suinre may
remain in for from *J4 to 30 hours. Sutures should not be applied iu
all cases, aa is recommended by some authors ; for this is t|uitB errone-
ous, they being only indicated if the effect of tlie tenotomy is too
eonside ruble.
The fourth position which the operated eye may assume during accom-
modation, viz., making a sudden sjMismodic movement inwards, must make
us fear that there will be a relapse— that in the course of a few mouths
tbe inward squint will again show itself; for this convergent squiot,
which ut tintt only showed itself durin-i accommodation for near objects,
will gnulnallv extenil also to greater rliHtance>>. In ttuch ca^e^, the ope-
ration is said to h»ve been only of teni{Mir.iry benefit; but on oxamina-
tioo we modily find that the patient is liyperme tropic , and chat suitable
glasses generally correct the si|uint.
' For HOtnp liinr pad I havo otKva •nnpluved inolholjiio in |>lnc« of rblororornt fu
■trahismiiK o|>iTaiioiut. iriititrtomici, vXc. : it.-* nliicf adr4ntafi>H ovrr dilnrofarm arc
thkt itM nfln't )« im! iitilv iuiii-!i i(iii> ki-r, liiil alsii |iuiitr« <ilT ngKin mucb sounor. If U
)m woU given, 1 like it vrcu fgr cxlractifu vf citarM't.
710
APKKCTtONa or TUB HUflCLBS OF TUB BYB.
The oxt«nt of the operation must be regnlated according to the de;
of the siiniiit.
In very flight dep-oea of strahiBrous (V" to 1|"') a partial teootom^
waa formerly often practised, the tendon not bein;; completely divid
but a few of the upper vt lower UbreB (as Iho cas« oiifiht hv) being le
standing;. Itiit thi^ does not answer, as the power of tiie muscle in h
ttlifthtly, if at all, impaired. In such cases we nhould, therefore. iiuik«'
a eomplt-te tenotomy, and. il' nece-H^Jiry, insert a suture. Tiic conjuno-
tivfti opening shonUi he amnll and the book but of m»»ilcraty *ixe. Tl
acconmiodative uKivemeuts mu^t he accurately tested iminedtalely afl
iho operation : for if there is the sliglitest tendency to divergence wh
the object is brought up to 8 or G inches from the eye, a autare aho
be inserted. In a si]uint of ^ or 2J lines, the cellular tissue mar
somewhat more freely inciHttl, and n larger hook cinplovcd. \n cliihlren
we find that the vffcet is generally moro considerable, fur the miucle it
not hy|)C'rtPophie<l and the surrounding cellidar tissue is very elastic ; we
may. therefore, in iheni easily attain an cHeot of 1:^ or 3 liued by a single
operation.
If the aquint exceels *2i or 3 lines, we must always ojierato upo«^H
both eye*. We shouhi peiiorm a free tenotomy in the wiuiiiting rve^^
and a very caivful one in the other, limiting the effect in the latter by a
:4uturc. In thU we inu:4t be guidL-d by tlie amount of »|uiut left after
the affectcii eye has been operated upon. As a general rule, I do not
tliink it udviitiible to oiierate upon Imth eyes at the same time, except the
».|uint is very considerable, exceeding 4^ or 5 lines. For if both musclea
have been divided »t the same time, we cannot accurately te^t the acooifr
modative movements directly after the operation, and we tlius lone Um
only duo to the permanent efi'oct. It it, tlicrufure, far safer to opermle
first upon the affected eye. atul then, after a few days have elapsed, and?
the divided tendon ha^ again reunittnl with tlie sclerotic, to osccrtaia ho
much uf the stjuint is xtill left. The amount still rem:iiiiinL:wil| guide
an to tlio extent of the operation necessary npon the lu-altliy eye.
afler having operated upon the latter, we hnd that the effect Homcwhat
eieeeds our widhej^. we can always diminish it by a suture. It certain
id far more brilliant to operate upon both eya at the same time, and ih
rid the [latioitt at once of llic »|nint. but tlicn we run the risk of the
iiloasant contiiigcticy of the eye sub»c«]uently ** going the oUier way.
Il should alwiiys hv remembered that the cure is to bo permanent, i
not temporary. In Home exceptional casos, howevor, the rij^k mutt
run — if. for instiince, the time of the patient is liuiited. or a h^coihI tm
ipottsible. If Uieaf|uintexceeilafive lines, we may, particularly ir i '■■'•^
^r«t« safely upon both eyes at the same time. It may bo oec.
U> o|HTate not oidy u|>on botli eyes, but oven to repuoi tha
im . . u|Hiii ilic Ki)iiinting eye, before we can cure tlie alTeckkMU
Thin gciK-rally oecura only in case^i of excoit'iive ai|uint, or if tliv strabw*
mu* iiixi existed for a long tinu;. and the nni^*le has bet^umc hype
phird. Thiii second operation upon the aflbcied eye rci^uiret
.' ' ■. for the effect of the corroctioo will exceed llic f ."
. OH the induencc of tJic muscle upon the eyeball ■.'. ..
>cUvu (u the backward position of its iiiaertion.
THBATMSItT Of STBABISHUB.
711
Itat io severe cases, tt is still better to operate first upon the squint-
inv eye^ and to increase tbe uB'ect M ranch sis pns^Jhlf by making the
patient look over to tlie opposite side for some days after tlie opemtion,
fm that the citt ett^ea of the tendon may be Btretohed apart and widely
Acparatcd. The effect of this will be that the union will take place fur-
ther back than wouKl liHt'O nccurrud if the eye had maintained a median
poiiition. If the internal recMw of the rijtlit eye has breu divided, and
we (let«ire to increase llie elfect of the operation, the patient lihould be
directed to look, a^ far tn possilile, towards his right side. The easiest
way of attaining this is, by making; the patient wear speotacles, the lefl
half of each ^laaa being covered with a piece of court- plaster, for ho will
in this way bo obliged to look to the right. They should be worn dur-
ing the first three or four days after the operation. Or two pieces of
card may bo fixed over the loft half of the eyes^ by mean^t of a tape
passing over the forehead. By this means, we shall obtain a very cou-
aiderablooflTect by the operation, and the amount of 8ciuint»till remaininjg
nniat then be treated by an operation up«m the other eye.'
Von Itraefe points out the fact tliat, occa-sinnally, though rarely, we
meet with cases iu which the operation is followed by no eficet, either
upon the position or mobility of the eyehnll, and yet uo lateral fibre* of
the tendon have remained undivided. In such c!)!<es, there is a second
connection of the niuwlc with the sclerotic furtlier hack, near the equa-
tor of the eye ; in one instance, indeed, ho found it even posterior to tlie
eipiator.
If the operation for stjuint he carefully performed, there is no fear of
any hut tiie sUghtest thinking of the caruncle. A little ginkiug will occa-
sionally occur, whatever mode of operation be employed ; indeed, I
know of no method which can guarantee a per/eti immunity from it.
YoD Graefe thinks tliat the sinking docs nut depend so much upon the
gaping of the conjunctival wound and retraction of itA inner lip, a.4 upon
the cicatrization of the connective tis.^iie situated between the mucKle and
conjunctiva, by which the movalde caruncle is retracted. The furilier
back this cicatrixittion extends, the more will the caruncle sink. Hence
the danger of incising the tendon too freely, and of any considerable
sweeping about with the hook, ami consequent extensive laceration of the
eubcoujunctival tissue.
> [b cuimi of T"iy ooiiitldfTAbU' squint (bolh iDt«m«l and extornsl) von Ora«fe »d-
viioi lliAt l)i>- flTi'iit i>r lli« iirMTAtloii ahoulil be iDcreiUMt by ihci iDdc^rtioii of a saturc
■Ni that *nin nf Win <-y« nliiiU in upiNitiilvi llio tenolinni;. Tluia, If tli« iiitemnl r-xidm
lioa btnin iliTiilnd. a inrvitl uokOIm. artnml nlih « Btrone illk 1hr«ft>l, ii to be tiiscrtwl
ill lliii iXmlAr rriHiitnilivA, ni'Jir Itic outiT cADthua, and pushi-il loviiiritH tin' rH>i-n«K,
iMmvalb lilt' iir»ijun<itivn, (u mi oxt»iit v( 4'"— &'", atid then r.-iiM>irii|. In tlii(> war »
brawt fiil<l(ir<xiiijuiicilv» will Wlncltubjil within Ihv loojiof Hilk, vrlik-h Lh to l>u liBbll.v
tirnwn (Of:i-llt<T Ami flrmljr LrxillrKl. Thia wUl cnnae tlit> t-yi' In roll AuiwiiriU, and
uoiwidr'riililv' limit the niovcnionl iuwanU. Th« tuluri? ia Io T«uiaiii iu Tor 2^-3 ii»j%.
I hnvo tf-nli-l inaiiy caa*-* iu ibi* way wltb inarkcJ (huvm.'b*. Iu »wne »i?vi-re c««»
fw{>i<rin1l]r uf ilirHrgi-iil ■•|iiiiit) I liKvn iuai-rtiil n >t.r(>t>^ milurc (iahsivI fur 2-3 liRM
iMtHAth tlio coiijunclirn. clwv tu tli» ■»l)(v of tin- wrm-a, •i|tpi.i»ilti Ui iho lauti^ki which
totn Im> iliviiJMl, ftiidllicn, ofli^r ttid tenotomy, rolliDg tli<> cyr to thtoppnttitn sitlt-, and
kwt>])iii]{ il tix'^l in Lliiti iMMilion liy mnntio of tli^ ■iilurn, »>> Dial Ihi' liiriiltwl ■•ndii of
tho tAndiU) ar« widely ilTDtcbcsl apnrt. Tbis BUtarc ia to Ik rciaititMl (vr i-3 dayi.
712
ATPBOTIONS OP TRB MUBCLRS OP THB BT8.
Mr. Cntchett's subconjunctival operation is to be performed as foltovs :
The patient liaviug been placed uiuler tlie iuflucnce of chlo-
Fif. Ids. rnrorm, and tUo o_>'eU(ii kept ajtart hy the slop apeculum, he
suizea a amall fold of the conjunctiva and auWonjniKitiv*!
tieiaue at the luwvr vd;^e of tliu insertion uf the rectus tniis-
cle, and vith a pair of binnt-pointed straight scissors, makM
ft aniall incisioo at this point through these structures. Thv
Lover edge of thu tendon, close to its insertion, ia now ex-
posed. \ blunt hook ( Fig. lOo > t^ next to be puwd
throuf^h the ojicning in the subconjuncuval itnsuc beneath
the tendon, so as to catch up the latUrr, and render it tense.
The points of ilie ttci^ont (but ftlightl^ opencdj are tbeit to
be ititroduced into Uie aperture, and one point paaso' _'
the hook behind the tendon, the other in front of the t«iMloal
between it and the conjunctiva, and the tendon is then to ba
divided close to its in.seriion by successive snips of the scis-
sors. A small coiiiuer.puiicture avty be matle al the upper
edge of the tendon, to periuit of tlie escape of any cfTuaed blood, and
thus prevent its diffusion beneath the conjunctiva (Bowman).
[In this operation tlie tendon, owing to tlie cuttinj; action of the scia-
gors, is apt to slip off the hook beforo it hait Iwcn vompleti-ly divided.
To remedy ihU, br. Theobald' has devised the "crochet h'>ok" (Fig.
190). With the exception of the crochet point it is similar to von
P
Pig. 1»6.
«. Crodbdt li«ok, MMuial ti*i-. t. MtKnlS*'! *l«v o! (ro«b*l potnt.
Oraefe's strahigmus hook. The tendon being twciired by it, it is
necessary to force the point up against the conjunctiva, as is ordinariW
done, so as to throw the tendon inio the an^lc of the hook, while it IB
being divided, but simply to hold the handle at right angles to the mas-
cle.— II.]
Mr. Licbrrich' bos lately introduced a modification of the operation
strabismus, babied upon a different view of the anatomical relations of tlid
coQJanctiva, sultcunjunctival tissue, and the capsule of Tenon to th<rj
muscles of the eye. He considerri the cafMulo »i Tenon as divided intaf
two portion:^ — an anterior and a posterior — the divi-iiou bein^ f<irmed at]
the ["Hoint where the recti inuscles pierce it from without inwards; the'
capsule being at this point so closely connected with the muscles as to
n'nder any displacement between the two impossible. The posterior
half of the capsule, with its smooth, firm, inner surface, forms a cup, io
> ("Atp». Jonrn. or Hod. 8d.," April. 1R7S, p.406.~ll.]
■ "A.f.O.," xii. S.29fi: slw -' British K«dU»l Jvurunl," D«c 15, 180«.
TRBATUBST OF STRABieUUS.
713
wliioli the eyeball moves freely as tbe head ot a joint in the socket. The
olofle counoclion between the miucles and tlic posterior half of the cap-
Bulo ts incrcaiwU by sheatb-like proccs&es, which intn backwards from
cbe outer siirTaco of the capsule towanls the orbit, and which arc, for a
certain distance, closely connected with the miucles. But there nre no
fiheiith-IIke proeet^^s between the innur portion of the pivtorior capsule
und the sclerotic. The anterior half of the capsule of Tenon adhere* to
the upper surface of ttie muscle, and is intimately eonneeted with it.
But Liebreich denies the presence of sbeath-like proceases derived from
die capsule, where they pierce the latter, and accompanying the nius.
oles as far att their Insenion. Ho states, moreover, tliat " the caruncle,
together with tbe semilunar fold, rcsta ujion a hand-like ligament, which
paasM from tbe capsule i>f Tenon towanls the edge of the orbit. Now,
when the internal rectus i» oontractetl, am) the eye rolled inwards, tliia
band Ia rendered cense ; and the caruncle, which ts lixed to it, i$ const*
quently drawn in towards the inner edge of tbe orbit. But the outer
edge of the caruncle, together with the semilunar fold, and an luljaining
portion of coiijuijctiva are drawn backwards into a furrow.*' This inti-
mate connection Wtwcen the muAcle, capsule, and caruncle, is the rcaiion
ot tbe sinking of the caninclo and ttcmilunar fold, which U occasionally
observed after an extensive division of the internal rectus. To obviate
these ditiadvantagen, and yrt to obtain a considerable effect, Liebreich
operates in the following manner: —
*' If the internal rectus is to be divided, 1 raise with a pair of forceps
a fold of conjunctivii at the lower edge of the insertion of the mnscte ;
and. inclining this with scinhors, enter the jwiikts of the latter at the
opening between the conjunctiva and the capsule of Tenon. I then care,
fully separate these two ti»!)ues from each other a^ far as the semilunar
fold, also sejHirating tbe latter, as well as tlie caruncle, from tlie {urta
lying behind. When this |>ortion of the capsule, which is of such im-
portance in the tenotomy, has been completely separated from tbe coo-
janoUva, [ divide the insertion of the tendon from tbe sclerotic in the
usual manner, and extend tbe vertical cut, which is made simultaneously
with the tenotomy, upwards and downwards — tbe more so if a very con-
siderable efi'ect is desired. The wound in the conjunctiva is then closed
with a suture.
'' The ttame mode of operating is to lie pursued in dividing the oxtental
rcctu$i ; and the {Reparation of the conjunctiva is to be continued an far as
that portion of the eitemal angle which is drawn aharply back when tbe
eye is tame<l outwards.
*' The following are the advantages of my proceeding; —
** 1. It fltTord;) the operator a greater scojie in ap[Rirtioniug and divid-
ing the effect of the operation between the two eyes.
'* '2. The linking buck of the caruncle is avoided, as well aa every
trace of a cicatrix, which not unfre<|uently nccura in tbe common
toDotomy.
*' 3. There is no need for more than two operations on the aaroe indi-
vidual, ami therefore of tnwre than one on the *ame eye."
I have performed Ijiehreicli's o[>craiion in numerous instaticea vlth
ocss, and should prefer it to any other in those cases in which it is
714 APPUcTtosa OP tub uusclrs op thb itk.
ileairnUe to |j;ain a rery onmiderablo efTect, and vel confine the opeta.
tiop to one eye. Kor T have not found tliAt we are able by any otbcr
operation to obtain so considerable un effect with so sli^it ■ loss of ne-
bilitv, and so verr little {if any) sinking of the caniticlc; ret the iiuul*
misstbility of chloroform and the iri^rtion of tlie eutures liare praranted
my practising tbi& operation cxteiuively. If chloroform ift given, v«
cannot estiruute wilh cxaclitudo the dt-grw of effect which we arc pn»-
ducinj^ hy the free inciMioiiA in the oaiiHiile ; and hut few patients m_
w*illin;r to Riihtnit to a leo;;thenefl ana very painful operation, tmU
cblorofonu is udioiniAtered. The removal of the sutures a *)ajr or h
after the operation is frei|uently attended with a good deal of difficnilt
in children and nervous hysterical women, for although the pmcvedit
is tfuite painless, yet it k often regarded by llie patient and hi« friec
iM a second operation. Where it is absolutely necofisary for the sue
of tlie o|>eration to insert a suture, I never hesitate to do »o, hat
Graefc's operation this i^ tlio exce[>tioa, whereas, in Liebreich'a it is
rule.
[Dr. Nojea, of Detroit, operates for the cure of squint hj making tin
tenotomy on the antagonistic, or^ what he calls the elongated, iciidoa..
Tiie shortening tiece«i»ary to correct the !t<(uinl is made hy lappiug tb4
en<la of the divided tendon, »nd maintaining Lhem in position bv two
sutures passed through the conjunctiva and lapped ends of the tendon,
above and below, and tied lightly. Uc cousiders the operation appli-
cable in all cfli^es. It is practically an advancement of one muHcle witb-j
out the tciiotomv of the antagonist. (** Trans. Amcr. t>phth. Soc.," 167-1
p. 278.)— BJ '
I must now describe the method in which certain special fonns of stra-
bismus shouhl he treated. The (jucsiion sometimes arises, whether the
perio<lic si|uint which is caused by hy|>ennetropta tdiould be operated ^m.
or whether it is to be corrected by Uio use of auitahio convi-x glasses.
If it ift hut ftlighi in extent, glasses may suffice, but if it is cnni^iderabV.
and the intenial rtctiw t« very strong, tt?ii'jtomy should be performed;
for by dividing the internal rectits, wu dimint.ih its power, and a greater^
exertion of this muscle will conse(]uently be demanded, in order to brif
the vifiiml line in hear again upon the object. This extra exertion wil
l* accompanied hy an increase*! power of accommoilation, as wa* the case
before, when the eye dijuiiiCed. But we eliall now have nn incrvMed
[K>wur of acconiniodalioit with a normal position of the visual linos.
(In examining much cases of periodic a.{uint with prunu, we geuerallj
find that the internal recti muMtos are abnormally strong, this pre|
ilerancc in ntrengcli extending throughout the whole field of vision, aal
that the correct ("idition of the visual lines, which may occur whrn cos^
vex gUitaca are iutoi7»8ed, is fnxjnontly forced. A carefally [xrrformed
tennt<>mv of the internal rectus muscle is, consequently, pnvluclive of
verv favorable results. By advising an opernttou fur ihtd furm of
periodic iU|uint, 1 do not propose to set aside the use of convex gUiM*
for the treatment of the hypermetropin ; I only think it Iwneficial t»i
balance the strength of the mascles of the oyeball, and to restore iheii
normal equilibrium, for thi^ will be accompanied bjr increu*d faciitt]
TKBATUEHT OF BTKABtSUL'B.
71ft
and comfort iu the use of the eyes, partiuularly for prolonged work at
near olijects. Wheilier or nai botli eyes will require to ho operated on,
will defH-'nd upon the amount of the tiquint, and the relative strength of
the inteniat recti muscles.
I helieve that the Iwst treatment fur tliis form of periodic W|uint con-
BJsU iti a (.'arefiil tenotomy of the internal rectus, wiih sulwt'nuciit ucu-
trahsation of tlie hypennetn)pia by nieanH of convex jilait-iC's. In gotne
cases, tlio question may, however, arise, whether, hy operating upon the
]>eriodic squint, wo may not only free the paUcnt from the deformity, but
also obviate the necessity for spectaclea ; for, after the operation, the
incr«a«e<l exertion of the accommoilation in reading, etc.. will be unac-
oompanii'd bv a »<|uint. This i|iiOHUon ari^a rliii'lly with ladies, who
doiiro not only to be freed from the squint, but also from the necessity
of wearing spectacles.
Dr. John Uretin' stronorly recommends, in the periodic convergent
hypermetropic strabismus in young children, the pcriudic instillation of
iitnqiinc until the accommodation is completely- paralysed, which leudtt
to tlio fti>ecdy ahandonment of the habit of ftquinting, and then giving
them Ruitable convex ^la«(ses.
The periodic nquint which occurs in the short-sighted generally only
flbowg itself when the object u removed beyond the range of accommoda-
tion. As thiii gquint disappears us soon as the myopia is neutralized by
the proper concave gla3^ea. it mi';ht appear uiinece«ftry to have recourse
to an operation, but ne yet fiud that this greatly facilitates the continued
UM of the eyes for near object;*. On excluding tJie aflecled eye from
(he act of vision hy shading it with our haml, we oljoerve that it then
moves inwards, even although the ohjecc is held within itf range of ac-
commodation ; itjs fixation wa«, therefore, forced. On le«iing such caoea
with prismatic glasses, the internal rectus muscle is generally found to
be abnormally strong. It is, therefore, necessary to weaken it, and thus
restore the «4|uilibrium, so that the strength of the ililTfri-ot tnimcles of
the eyeball may be evenly iMtlanccd. But great care oiu^t ho tjLkun that
wo do not produce too great an effcot, and render convergence of the
visual tines for near ohject^ imimssihle. Hence the power of conver-
gence for a very near point (iV to 4") must always l»e carefidly and
;>gficurately tested, and if it is found (hat it is only pro<1uced with ditfi-
' telty, the effect of tlie operation must be at once diminished hy a con-
junctiva) snturc. In onler that we may not l>e misled hy the tem[iorary
insufficiency uf the divided muscle, which afterwards partly diaappeara
again. Von Graefc recommends that the point of fixation (imth for near
and distant ohjecto) should not lie in (be median line, but towards the
temporal side of the o]ierated eye. For in thia poefition, the temporary
insufficiency of the intenml rectus will come leas into play, and the tem^
porary result will corre«[>ond more closely to the permanent.
In slight caaes of this form of perimlic squint, it may auffice to give the
patient concave glaases, so that he may be able to hold the object {hook,
etc.) at n greater dittcaiice. Or, again, we may combine tho cuncavs
glasses with abducting prisms.
TranM«tioDS of tbe Amfticun Ophth»lntol<igjcal Soawtjr," 1870 and 1B7I.
tu
APFECIIOKli OP TAB MUSOLBS OF THE RYR.
Operation for the mre «/ Diplopia, — We are stimctirnes called afno
to operate lor tlie cure of ilipl<>|<ia, the tlevjvtion of tlie visual lino being,
at tliu same time, ju'rliajis, iutrUl}' |>ercc|)tllilc. TlleiK^ form the iiio»t
difficHlt and intricate cnHen, for liere le^s Jepend^ upfm mere nuuioal
dexterity than upon a cuinplete miustery of the theoretical |iortioii of the
subject, anil a thorough knowleilge of tJie actions of the roaiaclcfl of the
cvehiill, and their effect upon tlie position of tJie vertical meridian, etc.
Iinviiig already explained thpae subjects, 1 shall only mention the chief
pointd to be conHi<len.'d in the treatnienl. We must, in the first place, %*•
certain tn what directions prlsuis have to be turned in order to i\iiv the
double iraaji^cs, and whether an^* active tendency exists to unite Ihr
images if Ibey are cloiiely approximated. We tiud that certain kinds of
double imageii arc far more difficult Xa* unite than otiienji. It is i|Uttc
impossible to fuse images which arc of a different height, except, indeol,
this difference be of the very slightest, ei|ualling a piism of 1^-1°.
Crossed double images, again, arc more diflicnlt to unite than homonr-
mous. If the double images show a difference in height, we must first
endeavor to remedy tliid by an opcrniion, and then, when this is cared,
the patient nmy be able to fuse tli^m if they arc sufficiontly clo-tc to each
other. 8huuld they be crossed, we inuat cliange them iulo homonyoiuaa,
and approximate tlium close to each other, ho that they may be easily
united.
Stcondarg Utraltiwmus nfter Paralgait of Ou Opponent Afii$ei€.~~
Our treatment must vary with the amount of immobility in the direction
of the paralyueil muscle. Let us ai>«un)e tliat, after a paralysis of the
abductor, the immobility outwanl:t amounts) to from 1 to H line, but that
there i« no deviation inwanls, ao that the diplopia only cxtt-iida up to Ute
middle line, or but slightly into the np]>o.-iite half of the field uf risim.
lu such eases, a simple tenotomy of the internal roctns will genernUjr
SufKce. If the immubility exceeds 1 or 1^ line, ranging between thii
am] 2 or 'JJ line^t, a simple t4.>nolomy will not suffice, and we inuM then
bring forwanl the insertion of the paralyzed muscle (operation of " re-
adjustment"), and combine with litis a tenotomy of the opjHMif nt and a
suture^ If tlic want of mobility in the direction of the paralyzed nuwcle
exceeds 2^ lines, we must bring forward the paralysed muscle, and. at
the name time, divide it*« opponent. Our object in bringing forwarl tl.i'
insertion of the )>Aralyzed muscle is to afford it an iitcreaned aoiiiiii4 »i
power over the eyeball ; for the more anterior its insertion the greater
it-) power. This operation of re adjustment, as tt is called, is also !• be
perforrued in Uiose cases of secondary strabismus which sotnctiiQca follow
(onotomy of the op{ionent mui«clc. I also do it in cases of coiiniderabU
divet^enl fitrabiitmus, where tenotomy of the two external recti «o«U
prove insntScieut.
I now generally perfonn tlie operation of re-adjimtment in the follnw*
g manner : l^t an suppn.'^e that tlie insertion of the internal revtos is
be brought forwani accompanied by tenotomy of the external r«>ctos.
commence by making, with the binnt'poinled strabismus scisaore, a
»rtical incision in the conjunctiva about 1^-2 lines from the inner ed^
^ the coniea and extending somewhat bevond its upper and luwcr mu-
10 r this incision must not be made too close to the cornea, othcrwiM
TRBATMENT OF STRABtSMUS.
717
the portion of con)unetivA tcft ^landing next tho corner vtll not he nufli-
cicntly wiiie to a'luiit of fltn)ng firm siitureH being passeil tliroutth it. In
the next place, all the parw covering the inner side of the globe (con-
junctiva, snbconjtinctivRl tissue, capsule of Tenon, and the internal roctuit
miwclf) are to be dissected off with the scissors (jiiite close to the sclerotic.
This di.*?ection should reach to the e(|uatAr of the eyeball, and wlien the
Hap thus fonncd, contniiiinj; the muscle and |H>rtioii of capsule appertain-
ing to it, has been rendered freely movable, it is to he pulled well for-
wanl with a pair of forcepm. and if there appears to be rather too much
conjunctiva, a portion of this Is to be snipped off, but cure mast be taken
not in cnt away too much or any portion of the miucle. I next paas r>
curved needles through the Hap of conjunctiva left standing at the edge
of the cornea ; the i^ central needles are very small and carry 6ne silk,
the 2 lateral ones are larger and nrmod with very strong silk. 'I*ho central
sature is to bo opposite the centre of the cornea, and the next two nearer
the upper and lower margin of the cornea, and the two strong lateral ones
are to lie above and below the cornea, and embrace a good sized piece of
conjunctiva. For tbeao two auturea bpo of special imporuncc, an the
chief pull upon the mnsele, etc., ts to be made by them, and they thus
take oft' most of the strain from the smaller central sutures, which are
otherwise very apt to give iray. The sutunis are then to he p-istcd
(very far back) through the flap raised at the inner side of the eye and
at points exactly n[)po^itL■ to tlnwe in the corneal Hap, and firmly tied. 1
tied the lateral first, and then the central ones, for in this way we greatly
diminisli the strain npmi the lattrr, and thertt is \vsa cliance of tlieir
breaking. 1 next proceed to the divi;4ion of the external rectus, but be-
fore doing «o. I pass a curved needie.earryinga strong silk thread, beneath
a broad porUon of tlie conjunctiva, midway between the insertion of the
external rcctnn and the cornea, hut I do not tie the suture until the ten-
don has been divided, otlierwise it puckers up the conjunctiva and renders
tlic tenotomy more dtfTicult. The eyeball is finally rolled far inwards
by means of this suture, the ends of which are to be firmly fixed by strips
of plaster to the bridge of the now. [Various modifications of this
operation have been propoited, all diffennc; merely in the quantity of
tissue inclndc'l in the sutures and the points at which the needles arc in*
troduei'd through the mmcle to be advanced. In Agnew's operation the
lateral sutures are pa**ed beneath the conjunctiva a-s far as the vertical
meridian of the cornea and then brought out and tied. The conjunctiva
is dissected up from the mujicle a-4 far as the caruncle, and made to cover
it after it is advanced. — U.J
In bringing forwnnl tho internal rectus, some operator!* dmw forth
the musele sofnewliat and pa.s^ the stitches through it. Sehwcigger rec-
ommends a flat tenotomy hook to be passed benealh the iiL-^ertion of tlie
mnscle, and then behind the hook a suture, with a needle at each end ;
the tendon ts next divided, ami the muKcle can then be easily drawn for-
wani by the sntnro. As there is generally considerable reaction after
this operation, cold compreseea should be applied for the first day or
two. The suture by which the eyebaU is pulled in hIiouU be removed
at the end of 4ft or 72 hours, but those which keep the internal rectus
in position should be allowed to remain for 8-10 days, if possible.
'TIS
APKECTtOHft or TDB UD8CLBS OF THE EYE.
U MCSCULAR ASTIIKNOPIA (INSUFI'lt'lKNCy OK THK
INTERNAL ItECTI Ml SCI.KS)' -^ [LATKNT DIVERUKNT
SQL'INT— B.J-
This affection u of common occurrence, itnd is charactcrizoyl by Terr]
luarhcil symptoinii of astlieno[)iti, which sometimes prove 90 irksome an^
liarassin^ to the patient as to incapaciinte liim from rcailing, etc. Sudi^
]wtieiiti eomplairi tlial after tlie>- liave been working or reading for a
curtain leiigUi of tiiue, tlie cveit become liot and uncomfortalile, the print '
fijxtm dim, the Icttent liecome cmifused and run into, or orerlap^ each
other. Thia is generally preceded by a feeling of tension and weight in
tJie eyes and over the brow, and some pittiuntc ilistiticlly feci how the i
one eye hocnmpg iinAt«ady and wavering in it.^ fixation, and then moTM
gradually outwards. They often aUo anticipate these symptoms bj
oloatng one eye. After resting for a short time, reading may be re- 1
siimeil, to be, however, again iaternipted by the same train of symptoms.
On examinin*; the eyes, we lind tliat they look normal, that the acuity
of vision and range of accommodation are good, but tliat there is, u a
rule, a considerable degree of myopia. If we direct the j^atienl to look '
Bti'adily with botli eyes at an objnct {11 pencil, or our fin>!;er), and grad-
ually approximate tlii:i to the eye, we tind that when the object is brought ^^
to about t)" from the patient, the one eye becomes unsteady and wavepi^H
ing in its fixation, and then either gradually and slowly, or suddenly and^^
spi^inodicuUy, deviates outwards. The same deviation occurs (even per-
haps If the object is some feet distant) when we cover one eyo wirh oar '
hand or a slip of ground glass, so as to exclude it frum parlicipation in ,
binocular vision. Such a deviation will likewise manilertt itself, if a
ftrism is held with it.i bajie upwards or downwards so as to proiluce dip-
opia, for the double images cannot Ife fused into one, as the eyes are
unable to unite double images which show any, but the very ^lightest^H
difference in height. This is a much more delicate tCAt than that of cor^^H
ering one eye with our hand, for it will enable us to detect degrees of '
deviation of the visual lines which are too slight to be appreciated hy^
the eye. But in mauv iuBtanccs of muscular astlienopia we fiod
althou^ a pri^m with xU haac tumc<l upwards or downwards docfl
pi-oducc divergence at a distance, yet that the external rcctujt i« abl«
overcome a prism of 10", 14^. IS", for distance. This power (faculta-
tive tliver;'(;ri(.'c), as von (iraefe points out, is much increased if the^
patient is ordci-ed to wear an abducting prism for a day or two bcfo
the final triid is made.
We tind that the normal eye is generally able to overcome a prism of
from 'li}^ to ;J0- with iu baae tunieil outwards, ami "no of ti*^ or ti'-' wit
its base turned inwards. Thirt is owing to the fact that the inienml
tus is much ttrouger and more excrcisi;d than the exterual. But
few persons can overcome more than a prism of 1" or '!'•' with itd ha
turned upwards or downward;;. In coiuieijueDce of Ihia, diplopia wll
ea 01
a nos^H
t>l« to ■
^■ilta- ~
the I
fortj
I For fuller lurornuiiion n]M>ii tltl« •ul-ject I wnuld ntvr llir ruwlir to Von ItraMU't
anictei, "a. r. 0.," rtll. % Jiml " Kl. Uuiii.ubl.," UiSi, p. 22&.
UOBCULAR ASTUBNOPIA,
719
Hi
i
titerefore, bp produced, llie risual impnlao wilt 1i« annulled, and the eye
y'lvUi lo the pre pond era ling iiiHuencc of the fiti'on*;eiit muecle. In Uie
iiQmml eye ihc luiujctect aru equally bBl;inced, and the double iniH<i;es will
only show a difference in height, standing straight one above the other.
But if either the iuterim) or external rectus coneideraUy exceeds the
nortonl ntandnrd of 9trciip:t]i, the double iningea wHI not only show i dif-
' fereiice in hvigbt, bnt iiIho a lateral difiijreuoe. If llie internal rectus is
jineuffifii'tit, the eve will nwvc outwards when a jirinni iti held vrith its
>a0C npwnrds or downwanU, ind there will, consetjiicntly, be not only a
TdiBereiice in the height of the double images, but tliey will niso be croesed,
UD account of the divergent squint. We may then easily express the de-
gree of iii«nfficicncy by the degree of the prism (base turned in*ards)which
18 required to brin;; tlic double images one above tlie other. In judjiing
of the presence of iiiRufficioucy of the internal recti muscles, we must
not be guided by the poRttion of the binocular near |)oint, for yoiitliful
myopes nay be able tn converge for even 2| inclie.4. and yet there may
be a considerable dirtlurbanee in the lateral c<milibriunD of the eyes.
Hence Von Urnefe' insisltn upon the iiuporlance of carefully estimating
the lateral equilibrium of the miit«elps at the diHtance at wliicii the patient
generally reads or writes, this being best done in tbe following manner:
A dot is drawn on a piece of paper, and is bisected by a very
fine vertical line (Fig. 197). This paper is placed at the usual Fig. I»7.
distance of reading or writing, and the patient is directed to
regard the dot with both eyes. A prism of 14- (with ita base
upwards) is then to be placerl in front of one eye. Thiit will
at once pmduce diplopia, and the iiuagv of the eye ta^fore
which the prism is held will be beneath that of the other eye.
If tlic eyes are normal, the double imageti will only show a
idifferenco in height, but not any lateral diflerencc ; they will
lie straight aWve one another. But if the internal rectus is
^QfluSicient, the eyes moves outwards, and consojnenily the
' double images will not only show a difference in height, hut
laUo a liiteral difference, and tliey will be cn«3<d. We next
try what pri.^tn (wiili its base inwarde?) is requiivd to neutralize
the effect of this deviation, and bring the images straight above
Each other. In or<ler to ascertain whether the images arc
sroascd or homonymous, we place a slip of red glass before
the other eye, and this will enable us at once lo distinguish
which image lielonjiR lo the right and which to Uie left eye.
I Von (iraofc points out that if the line is not very thin and the
dot 5Ut1iciently large, the patient may bring the linear double ininges into
line, which of course entirely deceives us ha in tlie dynamic equilihriutn
nf the muscles. We may know, however, that this endi-avor at fur^ion
of the double images has occurred, if the slightest latcrnl turn of the
vertical priem does not at once produce a corresf.onding horizontal devin-
tion of the double imageM. We uiui^t next test the degree of the di)^-
Itnrhance in the lateral ei|uilibrium a little furtJicr off, nnd finally at »
"(Umce, a lighted candle forming the best object. Von Orncfe, how.
• '•KI.Mon»libl.."Ui}9. II.-J47.
720
AFPBCTrONS or TIIR MPSOLBS OF THS EYE.
or,
Ik*
ever, strongly inaiste npon the fact that the absence of flynnniic i\-\
verf»CHce for distance (or even the presence of a certain di-gree of
dynamic convergence) docs not contra^indicate tho necessity for in
op«ratiou.*
We must next aacertnin the jiowor nf ahduction (facultative divergenee)^^
for distance, i'. e.^ we must find the strongest prism (with ita base torned^B
inwanU't which the patient can rwercorae by a volmitJiry exertion of the '
cxU-rnal rectus, when the oVyect is placed at a diataiiceof H-Io feet. In
testing ibis, the object mast not be held w the horizontal visual planr.
but about 20^ below it. A prism of 18^ (TritU its bose turne<] inwanla)
ghoiitd be placed before one eye, and ttie candle be tlien gradttally
moved from tho eye, until Iiomonymoun dnublo ima^ies appear; the fur-
iheat point at whicli sinjilo vision can be maintained for a few minutca
bein<; noted, for a mero momentary fusion should not suffice. If the
jiower of abduction w very elij^lit coin|)ared with the diftlurbnuce of the
lateral equilibrium at a short distance, an abducting prism (the strength
divide<t between the two oyoa) should be worn in spectacles for a few
daytt. which will soon greatly increase the power of abduction. In tfaeea
ex]M-nnn;*nt» great care must be taken that the prisms are held <[wit«
horizontal, for any difference in hei<;ht render* tlieir voluntiiry fu^iua
extremely difficult, or even impossible. Von <!raefe points out the im.
portance of detecting and correcting the Utile diflerences in the liei;;lit
of tho double images which sometimes exiitt in these cases, and which
should always he suspected if the power of abduction is very sioall, for it
will be found that when these differences in Itfighl are eiiualized by a
auitiible prijim, the power of abfluction is generally often very greatly
increased. W'c must also be upon our guard that the patient docs
8ijppr<?9ti (exclude) the one image, for in ibis way he may appareotlji
overcome excessively strong prisms, and his single vision may altogctlie
mislead us as to the nceossity and extent of an o|rcratioD. Ilcucc it ~
of much importance to ascertain in all cases whether or not the patieni
excludes. If the one eye is not excluded, we find that each re
a:eadily fixer! upon the object when the other is covuped.
Having ascertained the strength of the external recti muncles of each
eye, we may next te«t that of the internal recti, by finding the strongest
prism which they can overcome by voluntary convergence.
Insufficiency of the internal recti is moat fre-tuenliy met with in oaaM
of considerable myopia. The reason of ihLs can be readily umlerslood,
if we remember that a penMin with a myopia of \ would have to hold
any small object (a book, etc.) at a distance of about 5". This, ho
ever, necessitates a considerable degree of convergence of tlio visa
lines, and great excrtien of tho internal recti muscle*. After ft xi
tho latter Iwcome fiitigned, symptoms of asthenopia arisi<, and if
work is persisted in, our eye deviates outwanU. Hut a temponiry i
ficiency of the internal recti may also be produced by severe constit
ttoniil diseases, which greatly weaken the sysuim (such as feve
di|>litbena, etc.). but it disappears when the patient has reg-,iitied h
strength. U may also cotsxtst with hyponnutropia, and itj4 preset
> "Kl. NonaUltl ," l^fi», 250.
UUSCULAH ASTUBNOPEA.
721
Bbould always be suspected if the sjmptoma of asthenopia persist in spite
or t^e use of convex lengea.
[According to Ilauaen (1. c, p. 121 et set],), latent divergence is not
dependent upon a muscnlftr Anomaly, bm npon lUfferenl kind* of anoma^
lii's of inucrvation. lie considers timt convergtMicc in tlic act of viriiou
is regidatcd l>y, 1, the consciousness of the approximate (listaiice of the
object: 3, by accommodation; and, -i. by thi; tendency of fusion, or of
bnngiiicr tim macula lutea of both eyes to bear upi>n the i^ame object.
A purely latent divergence is dependent on some disturbance in tlie
central apparatus. lielativc insutSciency h the most freiiuent form, iiiid
U oidy found in myopes. Next in frotpiency, and .(uitc differcut from
the relative form, u the latent divergence wliicli occur* in eminetinpia,
or iu hypermetropia and minor dcjirrccg of myopia. The thinl and leasst
frer^iient form is the divergence depending on tko want of fusion, and
betrays itsell' by diplopia, wliicli occurs at the ordinary working dis-
tance.— It.]
The iliseaae may be treated iu various ways, according as our pnrp-igo
IB merely to alleviate ihe n^llicnopia,or to cure it. It may bo alleviated
l^ the use of concave glasses for rea/ling and working, so that the
patient can hold tlie objoci at a distance of 12" or 14", and thus require
& much less deforce of convergence. Moreover, the use of prlsnw with
tbeir base torned inwards will relieve the interufll recti, but the fear is
tlutt, from want of sufficient exercise, those muscles should, after a time,
Iwcooie still weukor. This mode of usiuj^ jirit^ms \n only inilicated in
tlie eligbter cases of insufficiency, or if there is only a very limited
power of abduction for diMance, ^o that there is a risk of producing
conver;;ent *i|uiiit by a tenotomy of the external rectus. These prisma
may often be 3dvautaj;cously combined with concave glasses.
Again, the internal recti may be strengthened by fre'|ucnt exorcises
with prismi (whoae base is turned uutwards). The object (a lightwd
candle, while wand, etc.) is to be placed at a distance of 0 or 8 feet, and
a prism witli its base outwiirds should be held before one eye. Crossed
diplupiu will bo produced, ancl iu order to overcome this the patient will
voluntarily snulnt inwards. The strength of the prisms will be gradually
increased, but elioidd not be too strong at first, otherwise the internal
rectus will be weakened by over- exertion. If the patient is short-sighted,
be should wear concave glasses when he is looking at the object. This
pUu of treatment, however, requires mucli patience and accuracy, and
generally soon proves irktiomc lo the patient. Galvani:iation of the
iniem.'vl rectus may also be tried.
The best mode of treatuiunt consists in the divt^luu of the external
rectus, for we tims iiulirecily i^tn-ngtheu the internal rectus, which will
have a leas resistance to nvercomu. In a myopia of if, our chief object
must be to enable the patient to converge vasily, and for some time, for
a distance of about 4J", as he will hold the print or his work at about
TiJ" or *)". But besides this, the operation, has the great and import-
ant advantage of materially arresting the progress of the tnynpla
(Graefe), For ihin progress is much accelerated by the continued eRbrt
of convergence which a patient affected with insutliuiuncy of tiiu internal
ti is obliged to make.
46
722
AFFBOTIOSa OP TUB UUBCtES OF THE ITB.
[According to Alfred Graefe, the queslioo of an opcnttou ahovld he
eonsiderc^l nnly under the followini; circuiu^tAtKes : ** 1. When the bu»
cular trouble ia uitiioahte<lly the source of thn Asthcnoptc iiTmptoini and
their conscquooccs, nnd whun the pathologicnt couditions cannot be oror-
come hy the onlinnry menns at our command, i. When the itxmjAom
diiuippear with the change from latent to manifest diverf^enc**, but at the
exi»enae of binocular single vision ; while the fitonsa of both eye* «*-efM
to iniUcato the mabit«uaiico of the latter as importaat Mid practicablr.
jj. When there i& roason for believing that forced a»e of tlie interail
tnuAclei) pi-oduces an involantary increase of the aceommodatjon, a cer-
tain rariety of spa»m of accoinmodatiun, which canses the degree of
myopin connected with the iiiDufliL'iency to appear greater ttian it ntDj
is. ' ("Graefe ond Saemiwh." I. c. Vi. 1, p. lOO!)— li.] ^m
But great care and circumspection are rciiuired in accurately i^ppo^^l
tioning the extent of the operation to tho degree of the distur^nce n^^
the lateral equilihriuin. For if the effect of the tcDotomy is exct.>«sive. a
cmvergent anuint — with moat annoyintr di]tlopi» — will be prfnliK-cl Tir
distance, which will he very awkwaril, for if the internal ri'Ctus be Mit u
divided to rciueily this convergence, the former itisiifliirii'iicy for rea-linj.
etc., will bo reproilneod. To guarr) Bg:iii)st snch anfortunate rcaulu. tbc
preliminary examination aa to tho power of abduction for dii^taovc uinst
be very carefully made, and the extent of the operation be en^ '
portioned to thin, and the after-treatment roust also be >
attended to. Thus von Gi-aefe lays it down aa a general rult-. tl.aL il' a
prism of from l.'i'-'-18^ can bo overcome for diatance by facultatire di-
vergence, a simple tenotomy ithouM be performed. If the atrength of
the pri»m is Icsn than 14"^, the effect of the operation mual be uorr nr
IcRH diminti^hcd by the application of a conjnnctival Autare; thel:>i'<T
iDoIutling the m'>re oonjuiiotiva, and Ix'ing tied the tighter, the greater
the effiict that we desire. As a rule, the operation iii not to be recoa<
mended if only a weaker prism than S^ can be overcome. Hut if, in a
case where one of 12"' or 14° can be overconw, it is very doairablc
divide live operation between the two eyes in order to gain a very
tnetncnl effect, a very broad piece (*2J"'-J("') of conjunctiva (nwards'tl
outer canthuj must be included in the suture, and tlie latter wry 6
tied. If tho abdnctive power cxceeiU a priuro of IS*, tlif- 0|»ei
should, an a rule, be dividwl between the two eyes: but if fnim
rea-Hiin this is not deaimhle, tho effect of tiio tenoiiimy may be increaied
by applying a subconjunctival suture at tJie opposite (inner) fd<ie of tb«
eyeball as rocoiiunendv<l for severe oa<ies of convergent squint (p. 711,
note), and thus rolling the eye inwanla.
As soon a« tho piitii-nt has rocovcivfl fi-ora the cliloroform tumTvutt.w*
mu^t carol'ully teat tliu effect of the ojieratiau, ani a.scertain w'
tiot we have obtained perfect Utcral e.|uilibrium for distance, i..
however, to avoid being misled by a temporary iusufticienoy of Uk
ratcd muMlc, we must not hold the object Cwhich is to be abtrnt \n' >^if)
in the median line, but about l^" to the side of the healtliy ey**. nn't a«
mneb belon* the horizontal meridian. A pri^in nithita haae ' ' iwii-
warda is to bo held before one eye, and the double images ahoii '^ligiit
re one another if there is perfect lateral equilibrium, wUicb shnoU
UCSCIIL&R ASTUBMOPIA.
723
rist directly afwr the operation. Only "i certain instances (according
to vou Oruefi*) may we iillow slight exceptioiis to this rule. Thus, if
tlie case Is just on the vergw of being suitablo for an operation (i. e., if
the fthfluction power — a prism of 8° or it '), a very slight divergciMje
of a prism of 1° or U** may be pcrmittcil. Dynamic eonvertjenf:^ of 8"
DDuat 1)0 considered cxc^ssivo, and must be corrected by a sutui'e. If the
effect of the operation i» to be increased, the suture mjiy be released or
"Bmoved ; if it is to be diminished, the suture must be applied, or made
include more conjuncUra, or drawn tigliter.
Now although a proper examination in this position will pi-event any
)nvcrgcnt strabismus and diplopia in the median line, it doca not guard
against tlie occurrence of diplopia towards the temporal side. Heoce
must also test ilie defect of the absolute mobility of the cyo towards
|e side of the dinded muscle, and such a defect should not exceed
y"~^"\ if the jiower of abduction equalled a prism of 14" ; or \\"' if
ic latter wan but sllgiit (Gracfe).
Six or eight hours after tlie ojwration tliere is generally some increase
the effect, so that there may be in the median line a dynamic converg-
ence equallin;^ at 1')' a prism of 8**-l(i**, the homonymous diplopia com-
mencing beyond S'— 1'. But this need not alarm na if wo have accu-
rately tested the lateral equilibrium and the extent of the want of
mobility directly after the operaliou. Tbiu iucroaso iu the eScot is
chictly duo to the tension of the conjunctiva by the blood cffu.sion. If
the increase is, however, too considerable, the effect of the tenotomy
3t he limited by a fresh suture.
The suture should remain in for about two days. If, at the end of
~t!ic first week, the effect of the operation is found to be considerably too
real, tlie wound in the conjunctiva must be reopened, the slight adhe-
fonned by the tendon gently separated with the sqiunt-liook and a
Uiirc applied. If, on the other hand, some increase of the olfeot is de-
sired, the patient should bt.^ supplied with a pair of straVismuA flpecta*
|ea. whicli are so constructed that the half of each gla*8 wliich corre-
jnds to the oiiorated eye is covered with court-plaatcr or paper, so
tRftt he is obliged to look considerably to the other didc, which of course
puts the divided muscle more on the stretch, and thus incrcuseii the effect
of the tenotomy. Von Oraofe, on the other hand, does not deem it ad-
visable that the patient should be directed to look towards the affoct«d
side during the first few days, for the purpose of diminishing the effect;
this is only imlicatcd at the end of the second or third week.
If it it! suhseipiently, at the expiration of a few weeks, found desirable
to increase tliu effect, the patient should be furnished for distance with
the proper concave glasses, combined with addueting prisnu (the base
turned outwards) so as to practise and streugthon the internal recti
muAclea.
Iu settling the question aa to which eye should be selected for opera-
tion, we must he chiefly guided by tho fact whether or not one ami tJio
same eye always deviates outwards when the object is approximated,
'whicit will become especially apparent if the object is held aWvo tlie
srixontal meridian. If so, this shoiUd be selected. If tho deviation
[bei-natesy we must try the power of abduction for distance, and ojieruto
724
APFBCTIONS OF TUB MUSCLES OF THE KTE.
upon the eye which has tlie greatest power of facultalire divor
Tf hero, iif^in, the power is ei|ual1y hnloiiccd. tiie eye shoalA he sefected
irhwic acuity of vision is the worat ((jraere). If the facultative <ii-
Torgence is so great that a stronger prism than IS'^ or liO^ can bv over-
come, it will ho necciisary to divide the oporalion boiwecD the two ejet.
liut this demands the j^reatci^t care, and Hhuuld never he done nt the one
silling. First the one eye nmat be oporalod upon, and tlien, after twc
or ihree weeks, when the liiial result of the tenotomy ia apparent,
operation must be performod upon tlio other ; special rare and aLtentic
hoing paid to the preliminary and 8ubsc<iuent examinatinnti as to
power uf abduction, etc.
When the irisufliciiMicy ie» but inconsidemhle, and the power of ib<W-
(ion very slight, we most give the patient (if myopic) coi)oaTe spt^ctadei
for reading, combined with the proper abdiicling pnsms (baao turned id
wanb); adductiug priamB being woi-n for distance, ao as to exerrise
atrengthen the internal recti musclea.
[For a moat carel'iil and clalmrate consideration of this wh'de sidy'ecl
tlic reader ia referred to the {>aper, by Alfred (^racfc, in flrnefc iiad
Saemisch's " Uaudbuch der gesaminten Augeuhcilkunde," Bd. vi.Rirt
i. pp. 188-207— B.]
Chapter XV.
ISEASES OF THE LACHRYMAL ArrAKATUS.
l.^DISEASKS OF THE LACIIKVMAL GLAXI).
^vntiitiTial anonuti{e$ iu tlic lachrvmnt ^Innd constat in au abnormally
jptuKliiMl or inorcascil fit-crotion. Tlic forinor U CHpcctatly nolici-n)>lo
SuroplitliAlmia, And h not duo to a closure of tlic excrctinft ducts of
tbe gtand, but to a npread of Uic dUease from the conjunctivn to tbe
gl&nd, an(l on actual lessening of tlie secretion with eventnal atropby of
the gland.
An iDcrcasod aecrction is met witli in almost all inflammatory affec-
tions of the eye, especially when blo]iliarospasm la present: also iu
cases of neuralgia of the trigeiuiuus, wbeu the firat and sccuud branched
re involved. — B.]
Inflainmaiivn of the tachrtfmal gland (Zfacrjfo^deniiie) u generally
chronic in character, and ^ivcs rise to a more or less considerable, firm,
nodulated, immornblc swelling .it the iipprr nnd outer margin of tlie orVit.
Tbe upper portion of the tumor disappears beneath tbe edge of the orbit,
hut can be readily followed if the tip of the little finger is inserted W.
neatb the upper and outer orbital ridge. The skin is movable over th*
tumor, and the upper eyelid is somewhat reddened and puffy, sometimes,
indeed, ihe redness and swelling may be very considerable, so that tbe
ipper eyelid bangs down in a thick, niasiiive fold over the lower. Tha
mjuiK'tiva is womL-whut injected and swullcn, especially at the retro-tar-
lal fold, and there may also be considerable cbemoais. As a nde, tbe
iwelling is but sligbUy painful, either spoutaneonsly, or to the touch ;
but if the inflammation is very acute, the pain may be severe, and ex-
'tend to tbe corresponding side of the face and head. If the swelling
aaiuires any conaidcniblc size, the eyeball will be displncwl downwards
id inwards, and its movements be impaired in the opposite direction.
le iutlammation generally runs a very chronic and protracted course,
le swelling citlicr gradually undergoing ubi^orptjon, or chronic suppurti*
ion oceurrin;;. But if the tumor is to Urge m to displace the eyeliall,
or tu impair its mobility, it will he necessary to remove it. Sometimes
both lacbrymnl gknda' become simultaneously inflamed, giving ri*e to a
Bymmctrical snelliag at the upper and outer edge of each orbit, hi
< Vitlo KiT-iiM Walton. "Uej. Timw aiid OamIU," lf>M, p. 311; ai>'I rioni.r.
"XU UotuLibl.," 1806, p 257.
726
DISBABBS OP TUB LACHRYMAL APPAaATUS.
mror instances, the ttiflainraanon as8iiniet» no acute ami ftlhemc cbancter,
there Win;; jj;reat heat, rodncas, ani dwelling of the part, with pcrhap*
n rapiil fortnation of pus, su that the diseiiisv a^^siuuus all tbo Bpp«
of an acatt! abscess. The latter poiols, the skin gives viay, and there
au escape of pu^, which tuAy coutinue to ooze out for some l«iiglh
time : suhsenuemly the opcuinK closes, the itiflatnmatory prodocls '
come aboorhed, anil the swelttng ^njilually <li9»|>penr8. Sometineft
however, thv ai>erture remains patent, and n minute htttulous opeiuug Is
establisherl, through which the tears ooze ford). The fiittula maj lUo
occur in chronic suppuration of the glaud, being 5itu;iteil either on
external ^ktii or on the cunjutietivul surface. Such Hstulie prove
tremcly ohstinate and inlmctfihle in the treatment, and if the npertn
should become accideutally stopped up, severe iuBaiumaiorj syinjiUj
may supervene.
Inflammatlou of the lachrymal gland may be due to coM, or to a
matic origin. It may alao tiupervenc upon chronic inflammauon of
conjunctiva or cornea. Von Gracfc mentions cases in which cb
swelling auU congestion of the gland were produced by the protrac _
use of a compress bandage, the retention of the tears in Uie gland pnb-
ftbhr exciting irritation.
In chronic ducryo-adeniiis we may endeavor to produce abaorpiion
the inflammatory producta by the hicul application of ointments con
ing iodide of potassium, iodine, or mercury ; or hy painting tincturo
iodine over the part. In the acute form, hot cataplasms and leecl
should be applied, and if suppuration threatens, a free incision sboiJd
made into the swelling. The same Is lo be done if pus is formed
chronic cases.
lUo
Simjile htfpertrojihy of the lachrymal gland is a rare affection, a
may occasionally be somewhat difficult t-o diagnose with certainty. It
may ensue upon repeated inHaminiitory atiacks, or occur 6|K»ntaHeoii*l
and is most fre<|ucntly met with in children ; indeed it may oven
congenital. This condiUon is jiarticularly characterized by the extrei
slowness with which the swetHii'! increases in size, and the absence
all redness, pnin. or other inHammatory symptoms. The tumor is cir
cumacribed, more or less firm, clui^tic, and nodulsted. and mar, iu time.
ncr|uire s<i coiiBiilenibIc a sixc as to displace the eyeball snd curtail iu
movements. Attempts should be made to dis]»er8e it by the applicati'
of iodine, mercurial ointment, etc. : but these remedies genemlty pro
unavailing, and recourse must be had to opemtivc interference.
i
Cysts of the lachrymal gland' (Dacryops) are of rery rwo oocn
and present the appearance of a little tumor, varying in size from a wm
and extending back beneath the edge of the orbit. If at nil con.4
bean to a huzel-nut, in the upper and outur portion of the upiier eyekdi
the edge of the orbit. If at all
able in sixe, it is at once obser%'able to the eye, and readily so to
touch. On everting the lid there is noticed, close beneath the conjaoc
I VIdo a very intorcsllng iwpcr on this sulriMl liv Hr. nnUce, " R. L. 0. II.
], 2SS.
flat, I
dcfM
th«^
DI8IA8BS OF TDE LACURYHAL QLAND.
727
tira, a bluish-pink, spiDi-tniiw|iArcnt, clastic, and somewhat lluchinLiiig
awclline, conai«ting. perliafMi, of sevenil wxlulatcd ficgmenta of varying
siao. it springs still more into view, if tlie \vi is rvlractvd and prtMud
in n downward direction. The swelling, moreover, increasps suddenly
and mnrkedly in stjce if tlie pntieiil crtes, or the secretion of teara is stim-
ulate'l I'y llic appUcaliou of some irritant to the conjunctiva.
Tlie Cyst is generally due to the stoppage of one or more of the excre-
tory dueta of tlio gland, so llint tho teara arc retained, and distend the
portion of the duct and gland ahnvc the point at which tlio obstruction is
situated. The duct is sonjeiimes. however, patent, bo tliat tJie tears may
slowly oozo out, and the cyst he emptied hy pressure.' Aceonling to
Schmidt,' the disease is sometimes congenital. Tho hest mode of treat-
ment ia to establish an artitieial opening on the inside of the conjuuctiva,
80 that a free exit may be affonied for the escape of the tears. For if
an attempt \i made to remove the cyst entire, we shall generally fail, as
iis wall ia very delicate, and the uuiinr is very apt to recur. Jloreover,
there is much fenr of leaving; a small, fiatulous npeninj;, which may prove
Mtreiitely obstinate and intractaMe in the treatment. De Wecker has.
howerer, lately reconlcd a sucressfnl ciuo of removal of a dacryops.'
An arti6cial opening of sufficient size may be gained by simply roalcinj*
a linear incision of from 1^'" to 2'" in extent, and keeping it patent by
passing a probe every day along its ctlgea, until the Inticr have become
cicatrized. Or agaiu. von Uraele's* plan may be adopted, of passing a
fine, threaded, curved needle through tlio aperture of the duct (if this is
patent) and carrying it along the anterior wall of the cyst to a distance
of almut '2'", at which {H)int it is agaiu to be brought out, ao that a
bridge of the anterior cyst wall of about i'" in extent is inclnded within
tho thread, which is to be tied in a loose loop. The intermediate bridge
may eitlicr he nllowed to slough through, or mav be divided at the end
of a few days, and thus an artificial opening will be established, through
which the lachrymal secretion can (low off.
J-'itiitihi of the lachrymal gland ia occasionally observed, and may ensue
upon dacryops or an acute or chi-onic ab«ice»s, or be due to a traumatic
origin, i«u|M;rvoiiing u|ion some injury of tlio gland or some operation, aa
for iniiiancc the o|jcning or removal of a cyst- The fi*tuloiL'< opening «
geneniUy extremely minute, only ailmitting perhaps the iK>iut of a very
nne bri'^ilc. Through this little aperture the tears ooze slowly forth, and
their quantity Increases with the augmentation of the secretion of tho
lachrymal gland during any mental excitement, or irritation of the eye
from dutit or wind, astringent applications, etc. Tho affection often proves
eomewbut obstinate and intracluhle. The edge of the hstiilouv opening
may he touched witti a Bne imita of nitrate of silver, after the edges
have perhaps been first }Mirea; or the obliteration may be attempted by
the galvauo-caustic apparatus. Again, we may succeed in occluding it
by freshening the edges of the aperture, and then closing it witli a line
suture. Isometimcs, however, severe inflammatory symptoms, followed
" Vta* Von Onfte. " A. f. 0..'' vH. Z. I.
* " Li-hru von ilnn Aug>>nkr:inklu-ileu,'' 1S17.
■ "Kl. UvDaUbl.." ]««7, p. 34.
• " A. f. O.," vH. 2, a.
«■ «M« LAO
cs.
mftm (lie liealing.or tilooking ap of tbe
and again witli grvHt severity. Airrc<[
kitid, ill which he was linAHy ohUj;eil to
« order to cure the diseue nnd relieve the
tnd ftnnoynnce. Mr. Bownun* vob-
ami long-eetuMished extenuU Ostuta of the
_ an artificial oiiiming on the conjimcUTa]
t&CD cIoEiag the external aperture.
to give good resulta. The two ends of i
i ^itk % itcedtc, are passed through the exterul
» BftDDer that one needle penetrates the con-
* the other. Itotli ends of the Hj^ture in
;ft« •M^oDctival cul (le-s»c. and hcinj; drawn ti^t
«f the upper lid in their gm^p, tlie apex (if
aal ibe buo in the conjunctira. The end* nrv
fooa beal«.— B.]
are met with in Die taclirymal gland, Imt br
of a sarcomatout nature. Cancer i«o(
i> probably always eecondary, extending fmcw
ite gland. Knapp,' however, reporte a eoae ^.
Ihnhijiml glaitd with cnrciuoma.
A« bchrrnml gland are rare occurrences. Mv
have been described by various autbiir%
m mmcpXe bypertropb^r, adenoma, adenoid. cqIV»^
Bedttllaris, encepbnlnid t-ancer, sclrrlias ^^^
Ian. however, rendered it probable tbat w^
£flen:ut stages of development of the
wbcrdie Aiigcnklinik der Wiener Utv\
of Biixcd cnchondroma and byjiertrophv-
■ Tcporicd by Itusch. Hchirmer ig i
I ftr vario'19 growtlis under the comn\^s^
■ been dewribed as a greenish, boin^-'^
.^and cauBing death by attackinrr
iTo also been reported of angionniy
(Sec *'(traefe unrt r!:icniisc\\** ^
am tiie aamo for all these gr«iVf v?
with more or lew pain in tVx^,^^
tioQ will always lead to a ^^i,^
ffcwslive rerooral of the tumor and c»-\ ^^
tpi'miMt in order, if poaeible, to prev^a-^^- ^^
«Mi efde fterre— B.] ^
of the gland may undergo ^^^i^^A^^
Wflhtw*)* ffhis tendency t« i^o'»t^x-,^ -
\x rare. The concri'lion.-i **^»<:i-x-"\ \
ta tbey occasion conjunct! ^r-^ ^^
^ ^ hAiTwJ gland may have to V^
Qf
• "B. L. 0. H.
^V-1
8TILLTCIDIDM LACtlR Y M ARH M.
729
hypertrophy or chronic inflnmmation of this organ, if it prnducoa much
distignremetit or displacement of the oycball. It has, however, been
lately strongly recommended as a euro for very oUlinat^ ami sovero
cases nf lachrymal dtHcaiw. Tliis operation hn8 been particularly prac-
tised hy Mr. Zachnrtah Lnnrcnco for the latter class of diseases, and a
full description of the niude of operating will bo found in his jiaper u[>on
the suhject.' The patient havinj; hocn piswed nnder the influence of
chlorofonii, the siu-^<;on is to divide with a i^culpel the skin, masclu, and
fascia over the upper and outer third of the orhit, to the extent ofahont
an inch, so a« froely to enter the orbit at tlie situation of the lachrymal
gland. The latter mav easily bo felt with the tip of the little finger as
a small, hard body. If there ia any difficulty in finding the gland, Mr.
Laurence recommends that the external c'omun»giiro of the lids should
be at once divided by n horizuiital inciitiun, nliieli should meet the outer
extrvmity of the first. Thus a trianpilar flap will be formed with its
apex outwards, and the gland can be more readily reached. The latter
is then to he firmlv seizeil with a sharp hook, drawn forth, and carefully
exclstil. Tolerably free liemorrbago generally ensues, but this can be
readily arrested by the application of a stream of cold water. Hie
wonnd is to be closed with tine silver wire sutures: this should not,
however, be done until all bleeding has ceased, otlierwise there may
ho extensive extravasation of blood into the cellular tissue of iho
upper lid.
8.— [IMPKDIMENT TO TIIK FLOW OF TEAKS.— B.]
STIU.ICIDIL'M LACltYSIARUM.
A)thon;zh the terra epiphora is generally applied to every kind of
** watery eye," this is, strictly speaking, erroneous, and hence tt should
only be used in those cases in which there is an undue secretion of tears,
and of the mucus secreted by the conjunctiva ; so that the canaliculi
cannot carry the tears ofl', but they flow over the lids and check. The
epiphora may be due to some Irritation conveyed to the luehrymal nerves
from the conjunctiva or cornea. Thus, if n foreign body is lodged on
the cimmnctiva ur cornea, a cousiderable degree of lachrymation at once
takes place. Ttio same occurs in miiiiy t<f the inflamniHtioii!) nf the ej^e,
more Cttjiecially [ddyctennlnr ophlbalnna, the diflurent fonus of comettis,
and also in some of the morbid ciiangea of the deeper tissues of the eye-
ball. Mental emotion will also produce ii. The degree of lachrymaiion
will of course vary with the nature and intensity of the morbid process,
and also according to individual circuras lances. From this condition we
must distinguish thnt in which there is no hypersecretion of tears, hut
the lachrvuuition is due to an impediment or ohstructiun to their efllux
through the lachrymal passages. 'V\i'm is termed " ttif/iridium lavhry-
ptarvm.^* In such cases the tears collect at the comer of the eye, cans-
ing the ftuticnt frefjuently to wipe bis eyes ; or else tliuy slowly How
drop by drop over the edge of the lower lid, which gradually becomes
I "Ophtlialmlc B«Ti«w," No. 12, 3fll.
730
DISBaSES OF TOE XACHRTMAt. APPABAT0B.
SATc, red, and swollen, from conatAnt moistening. TJiia initalikcoDdi-
tion of tho litis th«u tontU still wore to increase the laclirvtiiAiioa, nudj
to a\t<^T the position and the titructurc of the |iuncta ami caiiulit'ull. TL<|
«yes ofl«n become vcr}* irritalile, the patients complaining much of ih*
constant pricking, lie:it, and itching in them, which is much aggravatej'
by reading, writing, etc.» and hy an exposure to hrighi light, wiud, i
dust. If the true nature of this irritability of the eye and of the Uelirj
mation is overlooked, very ohatinat? and intractable inttaiuiuatton nf
edge of the lid and of the conjonctiva may on§iie, which sets dcfionce
every form of collyrinm or I0]iical ajfplication, but readily yields If thl
jmpcdinipnt in the lachrymal ajiparatua ia removed, und the stilliciiliM
cured. The obstruction to the efHux of the tears may be situated at au]
point of the lachrymal canal, in the puiieta, the canaliculi, the no,'
tlie nasal duct.
We sometimes notice in elderly penons, or after a severe illneu, till
the orbicnlans palpchrarom i.s so much relaxed, that the tears are no
longer pro|H>IIed hy it into the puncta, but that they collect in the c«n»
tral portion of the lower lid, which is sunk down and somewhat ever
in the form of a little pouch or hollow. In such cases, the fluid
not R'adily pass into the puncta, even altliough tliese may be |Kit«nt
This re.laration of the orlicidaria ia, in elderly persons, often liue
atrophy of the orbital cellular tisaue, and perhaps of the orhiculai
muscle.
[The fdffe of tht lids may be ahnormcUit/ ntunt^d, being tnnteil
far in towards the eye from cicatricial contraction of the conjancHva.
too far out by contraction of the skin. In either case, there will be
overflow of tears. Tlie same occurs from almiiruuit ttze or jwition
the Citrttnrle, and hero the latLer must be removed. — B.]
The puncUt laffymaVui niiiy undergo certain i'hanijt» of poaitinn
form, or even become ohUu-ntU-d. In their normal ]K)sitiun, they nt
turned directly inwards towards the eyeball, so Uiat the tearn whiou en
loot in the Incus Inerymarum near the caruncle may be readdy guideJ
into the puiicta and canaliculi, thence to make their way through thi
hichrymal sac and naf^al duct. Now when the posiuon of the punctui
is changed, so that instead of being just sufficiently inverted, it suntl
erect or ia everted, tlie tears can no longer enter it, hut must collect
the conker of tlio eye and oTcrHow the lid, and a very slight, porhai
almost imperceptible, displacement will suffice for this. It has atrea
been stated that this conaiuni moistening of the lids soon maki.'^ thei
Tory irritable, swollen, and inflamed, which will tend still moiv to evel
the pimctnm. The malj^osilion of the punctum is must frequently
with after diseases which cause a shrinking of the external ukin of ihi
eyelid, as, for instance, eczema, or inflammation of tlie edge of tliu li^
ectropium, etc. Also, if the conjunctiva or caruncle aru much swoll«
or hypertrophicd, so that the edge of the lid is somewhat pushotl awa]
from the eye. Small tumors or cysts, situated close to the punctuoii''^
may also prmlucc it. On the other hand, the malpositioD of the punctum
may not consist in its being everted, but in the edge of the lid ani^y
punctum beiug tamed in, which may uccur when the eye is much suuk«^|
in the orbit. This faulty position of the punctum is very frcqucntl^^
STILLICIDnJU LACnRTHARVH.
731
tne II
^Mrect
OTcrlooked. The puiictum, and a portion of the can&liciilua may niso
ilateil auii have \mt itd coatractilily, appcnriug in the form of a jiromi-
leut ui|i[)lc, &o thiit the eittrauco of the tenrs U reijilcred diflicuh. Or
, the punctuDi rony be grc&tlv contracted in aiEC, or oven quite
literated, having btfuome corered by a layer uf epithoUum. TUia is
apt to he the caso in very chronic inflannmatlon of the conjunctiva and
edgv of the eyelid, in nhich the seerctiong an) altered and diaiiniiflied,
and a thin layer of desiet:ated epithelium id formed orer the free edge of
the lid fltid the punctuiu.
The beat mode of treating mal-posilton of the )>unctun) — whether it bo
ct, everted, or turned in — is bjr Mr. Itovrnan's operation of slitting up
punctual and the can;diculu:«, and thus clmngiog the doted into an
channel, into whiuh Uie tears uan gain roady entrance. This little
operation may l>c porformed in various vrav3, imd a1Uinuj(li it appears
simple auil easy eiiuugli, yet it Boiiietiuies re<|uires a uertuiu de;:ree of
nicety and care to perform it quickly and witli success, mon^ eHpecially
if tlie patient is timid and re&tless. Let us aupjHWc that the lower puuc*
^ ra ol the right eve is to bo divided. The patient should bo seated with
head supported against the back of nn nrmn-hair, or the
it of the sur>;eon. 'Jlie latter should then, utaiuling heliiud '''«• ^^S-
the patient, intrmluce a very Bne sharp^poinbed grooved direc-
tor (Fig. lf»rt) vertically into the punctum, and then, turning
St horizontally, ho should run it (with the groove upwardo)
along the canaliculna as far t\s the inner edge of the lachrymal
lac. Whilst the director is passing along the canaliculus, the
skin of ihe lower eyelid sliould he put tightly on the stretch,
by Wing drawn outwunis and somewhat downwards with the
forefinger of the left haii<l. Otherwise, if iJie lining ineiuhrune
of the canaliculus iii .4wolIen or lax, it may become tucked up
in front of the director, and thus somewhat impede its progress.
When the |wint uf the directiir has reached the further end of
the canaliculus, the instrument i^ to ho t.ikcn into the left hand,
between the forefinger and thumb, the lower lid iM-ing at the
Bonic time put upon the stretch by the ring finger of tlic same
band. The patient being then directed to look upwards, the
point of a cataract knife (lield between the forefinger and thumb
of the riglit hand, the i-ing finger of which is at the same time
to rai^e the upper lid) i» inserted into tlie punctum and its edge
nin al<)ng the groove of the director to the inner wait of tlic
«ac, 80 Uiat tlie lower canaliculus may be slit up to its whole
extent. If the patient is very timid and restless, and nips his
eyelids very firmly together, the aid of an assisunt is gene-
rally ret|iiired. To ohviute this, some surgeons employ a very
fine pair of straight, blunt-pointed scissors, tlie one blade of
which is to be inserted into the punctum and run along to the
extremity of the canaliculus, which should be at the t<ame time
put upon the stretch and then divided at one sharp cut. I my-
aeif prefer liowman's narrow probe-pointed canaliculus knife
to any other instrument. It should, however, be made very
tf^a
732
PISEASSS OP ins LACnRYWAL APPARATUe.
narrow, and its prob*-point W very Bmnll, otherwise it may be difficiil
to Ciller it if the piiiii'tuni i« very inimite. In such a caj>e, the lurei
should tirst he Mmewhftt dilated with the point of t!ie director, nnd thi*j
will ^'iit'rallv suilke for the read^v admission of the point of the knit
vhich nhonld then he nin alon^, with it^s sharp edge upwanb, nnita np*
to the extremity of the ranulicnlns, iind the latter be dirided aionx ibi
whole courfi! hy lifting iho knifi! somewhat fmm heel t" [".tint. Car
should be t:^kon that the canaticnlii<i U dinded to lU fiitl cxtf-nl. Foi
elittiug the upper punctnta ami canaliculus ttiiti knife, or the groovcjil
director and cataract knife, may aUo be employed, although I geueniltjrf
prefer Weber's beak-pointed knife for this purpMC. In selecting tlitfj
inainnnont, we must be particular that the nodular point, as well u thi
cutting portion of the blade, is not made too largo, else a difficulty willj
he experienced in inserting it iuto the upper punctum. and pa-'in;; i||
along the canaliculus. Tlic bcnk point fihimld be passed nell (lown tnt«,
the ftnc, »o that the upper canaliculus mnv be divided to iti whole ext«tii
The bleeding which follows the slitting up of the uauahculus in gi^nrntll
but very slight, and when it has ceased, tlie fdm of bhiod-coaguluin shivnli
be reni.jveil with u small pair of forceps, from the whole length >'f :h'
wound, and a little otive-oil he* applied to the latter, ko as to pn-'veiit i
cloaing. Moreover, it is ailvisahle to pn^s a director along the tDCi^ioo
every day for a few days, so as to keep this patent.
But the CAualiculi may also be contracted, or partially or wholly oV
litenited, their poaaage being narrowed by a swollen and iaflamed cundi-
tion of Uie lining membrane, or from cicatricial changes which the lalli-r
has undergone, in con-tf<jUirnce, pcrhnps, of preceding inflammation. Snrh
cicatrices are most freijuentty met with after a granular condition of the
lining iiii'mbrane, for the granular inflammation may extend from the cod*
junetiva into the canil, and even iuto the lachrymal sac. Tiie cicatrice!
may, however, be of traumatic origin, having been perhaps produced by
wdundi^ or hums, or by the bnii*ing and ti-aring of the caiml r ■
a clumsy and rude passage of tin* probes. The swollen and (m _ ,
Utiou of tliH canaliculus ii» due either to an inflammation exten<lirig to it
>ni the coDjuQctival or tlie laclirytnal sao^ or may be caused hy the pre-
acuce of some foreign body within it, auch as an eyelasli, a dacryolitb,
r- . M fungus. .Although the stricture may exist atany point of the
n- . . it is mo«t freipiently situated at the spot where tho latter open g
\i le. [Small tumors like horiclamay compress the canalicutot^H
rate i(« calibre, or the canal nuiy be blocked by ooncretioti« of^fl
I'olypi have also been fi.tund in ilio canal. The presoncc of all
-T-iM-ufltions is easily recognized by a fine probe, and the treatmcnc
>ip the canaliculus and remove them at once. — B.]
ii'ii ! the lower punctum be obliterated (atresia) and qaite inraiUe
r nifist catfful search (aided hy a magnifying lens), mn ingpnioos
of >I. Streatfeild' may be performed: riit., aft«>r i
i"'f canaliculus have V»een divided, a fine dtrector >.
imssed by this a]»erture into ihc inferior canalicuhn. a
'^, i-tirough (Ue lower paitctum ; if ttot,the lowor cuialicultts
• "R. I,. O.Tt. R-v.,"iii.4.
1
ISFLAUMATION 09 THE LAOUItTUAL SAO.
733
81
k
1)0 laid open aponit. This operation will also be found verj service-
ilite in tlio»e ca8e» iu wliicU tlte lower puiictum autl a portion of the
lower canal are obliterated. The convcntc nu^ nUo be clone, Uic ilircvtor
lay l« introduced by Oie lower punctutn, and brought out by the upj>er.
bene o[>enition8, however, ofWu rcfpiire considerable dexteriiy and
tience.
\f the canaliculus ia onir narrowed, it should be well laid (>]<« n in tbe
manner alio ve directed. K the stricture exists at the neck ot iht- eac,
nd iH firm and contracted, it should be freely divided with a canula
ife, which is to be introduced sheathed, and then, when it has arrived
|oppo«ite the point of atricturc. the shoftih is drawn back, and the blade
ncovcred. Tins initnunciit is best introduced by the upper canaliculna,
rhieh tnhuuld have buen pix'vioujtly divided ; or ttio slncturc may be iii-
liscd with WeWr's Itnifc. After tlie division, the stricture must to
rcatvd by the use of probes. 1 sliali retuni to this subject aud to these
istruirientJ:; in treating of stricture of the lachrymal passages. If the
ower canaliculus (mviug to a swollen ami tbicken^d coiulilion of the lid)
mains everted, even at^cr bavin;^ been divided, Mr. Critchett' iulviseg
I a portion of the posterior wall of the canzil should )>e seir-id and
tpped out witli scissors, " thus effecting the treble objects of drawing
ilio canal more inwanls towards the caruncle, of forming a reservoir into
which the toani may run, and of provontiuj; any reunion of the parta."
[Wheu there ia any ovoraioii of the lid, it is better to incise the canali-
eu1u:4 in a ilirection Itackwanls tonnrds the eyetmll, and not directly
upwards, as is usually done. If this docd not succeed in curing the
ovorllow. then Critchctt'a methml can be resorted to. — IJ.j Hut if the
whole or tlie greater portion of tbe lower canaliculus is obliterated, it
will be different. In such eases, if the patient is troubled with epiphora,
tlic up[H.'r canaliculug shoidd be freely slit open along itd whole extent,
80 that ibe tearn rituy ^lin an easy entrance. But if this should not
Hulfioc, and the lower canal be only |»artially obliterated, we should en>
.dcavor to pans back a very fine gnwivcd direetttr from the oi>ening iu
he upper caualictilua into the lower one, ai»d lay tins open uj)on tJie
"i rector.
iPllKKCiMONOtJSl INFLAM.MATK)N OF L.\CnUY.MAI. SAC.
ACUYOCYSTITIS [PUHULKNTA-ltLENXOKUIliEA.— 11.]
Tliia disease is fre*inently very acute in character, and is then acconi-
Dnnied by intense pain, which extends to the corrcspondin;; side of
bead and face, and there is, moreover, often marked constitutioDal
turbance or feverishuess. The skin over the region of the lachrymi
Bne and its vicinity ticvomes )i>tollcn, red, and <:listoning, and an ovi
iwelling of varying sixe appears at tins spot. The inflttmmntory sweU!i_
|iig often aleo extends to the eyelids and face. The former become very"
puiiy and (edematous, so that they are only opened with difficulty, and
' limlunn on the Dltrut* of tliu Lsclirj^nuil A|»i>u«1u>, " Laomt," lS(f3, rol. U.
rz*
atiXAtms or tbx LAOSKr«AL appabatos.
3«dbiiB aolHed Aat Ibe en^aaedra is injwied and stroU
\ <ertam <!agTec of dtenooi. From thU great xwrl
luw wtai &er, lb« CAM MmaiM eiMWwhat tlie api<eamiee ol
r vf tfca fam.far wtueb it nj^ tadeetl be mL'tiaken I) y a sum
Bng soAn Kfjtensitire, tlie patient iiumIuii-'
KBrnraaemc ut tdoch it. If t\n- inflaininaior
ifae weamdnutm w moch Icau marlccil, ai
4ifn« irf* pf<eam«, v« bmt be ablo to prcu out
af l«i Ihniq^ the pvaeti, or it mav pass ilown the nonll
g«ad IIUBh—iag of Ibe Bmog membrane of tht |iu>
r^ W ■> aaadnaUe, w to prevent tbe exit i«f an^
Am opaoing tofio tbe sac mix have bcc^ro^ vtne-
, «B aceoont «f tbe twelliD^ of tbe lining membnitii.' am]
«f cb« cavitT of the one, ami ihos offer anotlior obstacle
of ibe eooBfote.
m tbe sBdbaiBatMT sveffin^ baa somewbat mbsitled, nrnJ tb^
wteii Aaa JBCHfcuil, tbe todtargo maj on«>n he very freel/
■a <^tt» pineta^ wdfine up at tbo Eooer angle of tbe eye m\4
K-tba lidL IWetber with tbe pain, tbe patient experiences i
m^mm v*i we^l^ m cbas siie of the noM : and if the dis-
■B pweoifai bv Meaorchcea of tbe sac. or a stricture in tbe
ibefv b alwaya a diadaet history of the pre-exist-
beaeoMNderable ami obetioftte epiplwra. To the acute
l»aK, tbe onset off tbe £aemse u generally rcry rapid
loNC iv >c">e in the coarse of a few davs. It nuT,
t procneted and chronic in its eoaree, and all the in-
be le38 marlced and severe. If the disraae i> left
: lb* svelliog gains in site, the dkiu orer it becnmei
.■^Btiact feeling of fluctuation 13 ext)crt<.-nccd. «ud
: a spoatancooa opening; throu;:h the skin, and a
«f ptu escapes. The perforation is rapidly fol-
io the intensity of the inflammati>ry symiK
nutter will continue to ooiccont throu^ the ope:
mr aHiy clonic and cicatrize brmly. and tbe diseast
»tmj remain » chronic inflammation of the saci
obflinate and inlractable. Fresh inilanmuitonf
», pas be again collected, and thus a rrlap^
tbe inflammation is so lererc as to de-l
■■ gf tbe 8ac, and the latter may thus becotod
tba aperture in the skin may scab over, pui
■se sac. and force its way once more thri>ag"
«carnug a<^:iiu and again, until 'flnnlly a fi
.•Jit wbicii a thin muco-punilent dl'^harge sad
. In yet other cases, the ^ac may ui»«l«r]*o
<^ mntlor escape into the neighboring eel*
10 a secondary sac or pooch, perforation
I fistulous opiMiing be estabUsbcd. lending
■» tb)^ divLTticuIiitn. Jn some in^-ttanees,
K burrowing beneath the skin id dificreoG
l<
ol-
EMFLAMMATION OF TDK LACBRTMAL SAO.
735
livctionit. Thoy are, howe%-er, generally, only met with in Llie cliroulo
form of dacryocystitia.
Inflammation of the laohrrmal sac is orten due to an cxK^nsion of the
inflammation of tbe mucous lining of the nostril lo the naiial duct and
Ltiie sac. or downwanls from the conjunctiva rmd cnnaliculas. ilcnce,
may 9Hpcn-euB upon nasal catarrh, or conjunctivitis (morv t;s|.'eci:illy
tlic },!;ranular form). [This is a miicli im>re fre<iiient cause than \a •^en*
rally supposed. Ft ia the editor's opinion that the majority of case*
>th of catarrhal and purulent dacryocystitis are caused by a primary
bflammation iti the lining of the no:3c, he it catarrhal or svpliilitic.
Periostitis of the duct ami nose is a very common complication. — H.J It
lay jilso follow ljlcnorHi(i:a of tlio sac. PenoBtitis and caries of the
s.il l)ono3, more especially in poraona nf n scrofulous or syphilitic dia-
»c«ii, may likewise produce it. It sometimes occurs as a primary alfec-
toii, hfiiig tiu'u gi'iierally due to exposure to cold and wot. ll in often
Btatoil that eryjiipclaa is a fre<|uent cause, Luc it would rather appear
lat the tatter diaeaiie is the effect, and not the cause.
Our chief effort in treating; these cases miwt be directed towards the
stahlislimont of a free and ready e.xit for the discharge. This i» best
mv hy dividing the punctura and canalicnlui^ tjuite into the sac. If the
opening into the latter is somowbat contracted, I am in the habit of
iihvidin^ the upper canaliculus with Weber's knife, and then pasdin;; the
Uu?r into the sac, and fively inciflin^ iti neck. In this way a very free
^ninf{ i» obtaimd, throu;;h which the contents of the sac can he readily
iplied, for a slight prt-i^siirc upon the latter will siifiice to cauM! the
cape of the pus. A probe may then be parsed, so as to dilale t)ir neck
the sac and the nasal duct. Agiiew' sometimes opens the sac between
\c commissure of the lids and the lower punctum ; this la easily done as
le swollen lachrymal "sc forms a pmraiuence here. If the mucous
liii;: is much inflamed aud Hwollen. it it; irist^r to alistain from loo much
sddlin^ and prohinj;. as this only tends to irritato. .ind excite fresh in-
immation. A free exit having been obtained for the discharge, the
liu and inllammatury sym]itonta soon subside, and, moreover, all dauffer
p<>rfnration is prevented. Indeed, by at once emplnyin* this mode of
reatment, wc may often avert this dan<^cr, even when the skin over the
telling has already 1-ccomo very thin. To aid in allaying the inflam-
ition, warm poppy fomentalious or a leech or two may be applied.
But if the diitoa^e has adranerd so far that fiorforation is imminent, Oic
ic should he freely laid open with a scalpel, and tlie pus evacuated.
The incision should run in a downward and outward direction, and be
ifficiently lar^e to fH-rmit of the ready escape of the dischar;;e. A
rrow strip of lint sliould bo inserted into tiio sac, so as to keop the
round open fur a few days, and allow uf the draining off of llic matter,
warm poultice is Vt he applied after the operation, and frefjuently
)an<:;ed for the first day or two. When tlie iiiHammation has coDsider*
sly abated, the canaliculus should be divided and a proho passed into
lie uasal duct, so that a free pa-^Aajjie may be made for tike discharge
the tears. The opening into the sac will then soon close firmly,
' "MMieal B^oord/' Ort, IS, 1670.
736
DTSBASB8 OT THX LACURTUaL APPARATOS.
leaving bat a very slight cicatrix l)clund. To hasten tlie cicatrization,!
the Cflf^e of the opening wsiy be lij^htly toitehetl with snlpbate of i."p]«r.|
If pcrt"i>rJilioii has alreadv taken [ilaco before the surgeon is coiitiilieil,]
the canal icultLS ami neck of the sac should he divided, atul a prot
IwssL'd. In such cast-s, the edgen of the [wrforation are often rpr
Mirjed and granular; imlecd, there may even be an ulcerated opcnioj
of a considerable sixe. Thii^ should be touched with sulphate of co{)pcr,1
a probe be pas^d daily through the duct, and then the tistuloit'^ opening^
will aoou bo found rapidly to he.al. If any fiatnlous opemnjj;;^ exbt 'm\
coimcction with dirc-rticula, tlicy should be laid open, and caused to
from the bottom.
Shonld a condition of chronic inBnmmation of Uio sac, accompAniedll
by a uuieo-purnlcnt diKcIiargo, pftrsial fur some time after the |H:rfiM'atn>ih|
is closed, and the more acute inflammatory rtynipl'iras have di.-Mtpiii'art\l,1
the j^ac should be syringed ont with an astringent lotion. Befoni- t-mploy-
ing thin, it 13 well to inject the aac with water do aa to fiiish out all thv]
discharge, and then a weak astringent injeciion (zltw. sulpli. gr. ij-iv,or|
alum gr. ij. arj. dest. 5j) should be employed. This wUl dimiuibb the]
inflainraatory swelling and secretion of the lachrymal pasaagea. Thin
injcctiun should bo used every day, or every other day, accor*Iinjr W'
circunLstanccs, and will frenerally soon proilncc very con^iderablr ioi-
provement. Its strcnijcb should gradually be increased. Varimw kin-ls
of gyringeji have beeu devisuil for this purpose, but th* best is u suiILl
graduated glass syrtii;(e hnlding about half an ounce. I am in the habiti
of em]>loying one made for me by Mcs.sra. Weiss, which di0er» somewbiti
from that in ordinary use. The iustrutuent consists of two separate
fiort«, the canula and ihc syringe.
The silver canula is of the size of Bowman's No. C probe, and it abo«
three inches in length. At the top is a cross bar, by which it can bal
easily held and directed, and bevond this bar is a i>ortion of lo>tta>|
rubber tubing about 1} inch in length, ending in a silver mount Inlai
which tlie nozzle of the syringe fits firmly. The advantage of die lndia»(
rubber tubiEig is, that when the canula itt pa«!fed •juite down into Ui4
nasal duct, the patient can lean forward with hia face over a ha«in, aodj
the surgeon, standing in front of the patient, can bend the Iniliiv.rubb«i
tube forward to the necessary extent, and readily insert the nozzle ut
the syringe, and thus inject the fluiil without any difficulty. Whereail
with the ordinary silver canula it is often difficult to do so, on accmnt of|
the proiuincDce of the brow. The fitting of the nozzle into the caauli
by a plain mount is much better than by a screw, because, if the scror'
sticks a little, or the patient is restless, tlie lining nieuibrune of tht^
lachrymal passages may easily be bruised in tbt* endeavor to acrcw
nozzle on. The instrument is to bo used in the following mi*nncr : Tlie
cannia is to be passed down, by the upper or tower cunaliculus. throa^jh
the sac into the na«il duct, and allowed to remain there for five or ita^
minutes, so as to dilate the passage. The patient being then directed
to lean his face well forwarvl over a basin, the nozzle of the syringe ti]
fently inserted into the canula, and the fluid slowly injected, which wiV
on out through the nostnl into the basin. Whilst injecting, liie sur
geou should, with his leit hand, soiste the canula by the crou bar, anJ
CATARRIJAL IN PLAMMATIOH OF THK SAO.
737
slawlv withdraw It, so thkt Uie fluid may come in contact witli ever_^
^tun of ttio <iiict ai)<] hac. Thtt first injection f^tioiiM cnnsist of wator, iu
onler to h(w!i ftway the discharjje; tlio cnimla j<liouIJ then be rc-intro-
diiceil, and the iu)triti;,;ent injection bo lucd. Mr. Bnn-inaii emijloyd a
small I niiia-rnltber hall syringe, hut the streann from iU'ia h ntten too
weak to force its way thi'ouj^i, if the lining mvnibranp of the sac and
duct is greatly awolkni, or the stricture very firm. If the oaae proves
very ohstinale, and the patient cannot possibly submit to a lengtbened
course of treatuicrit, itnu is yet aiixiously deiiirou» to be relieved of the
coni[ilaint, tt tnav be necessary to destroy the sac, but such a counw
ahould only h« followwl in very rare and exceptional instances. I ahall,
liowever, retnrii to thia vubject when treating of bleuorrhica, and of ob-
stinate strictures of tlie duct and sac.
4.— tCATARKIlAL INFLAMMATION] OF THE SAC
tMCCOCKLE).
9Chu disease is often developed very slowly and insidiously, coming
*ea atimst without the patient being aware ibat there is anything the
matter, except ]'erha{M a little epiphora, and a alight and occassional
swelling in the rc;{inii of the lachrymal sac, uocoiniMiuicd, tf the latter is
pressed, by a little ooziii];; out of turbid, viitcid di-tcliarge, whiob, pasiiog
rer the cornea, dims the sight. The swelling of the sac rariett con-
lerably in dixe and hardness. It in generally ela.stie and finn, and the
skin somewhat red; on Bijueczing out the discharge, the tip of the finger
ainlcs a little into the skin. The disbeusiuu of the sac nndergoci coo-
aidcrablc alterations, varying with th« changes in the temjierature, and
the exposure to which the patient subjects himself. As toug as the
weather is wann and dry, the patient may be rpiiie free from any troo-
ble, but as soon as he exiwaes liim-<elf to a cold bU-ak wind or a damp
atmosphere, the sac becomes intlame<l and swollen, the eye is watery,
aitd on pressure upon the sac, a copious discharge welU np through the
fiuneta. The frequent recurreucc or long existence of this conditioa
eads to a tliickencd and villous state of the lining membrane of the sac
and ducts, and the secretion becomes more thick and muco-puruleut in
character. If it eonsmntly regurgitates through the puncta, these and
the canaliculi may become somewhat dilated. Stricture of some part of
the nasal duct, or of Uiu canaliculus near its opening into the sac, if it
has not already occurred, will generally stwin supervene.
In some ca<»c«, the (lac, iastead of being thickened and hypcrtrophicd,
becomes thinned anil greatly distended: being tilled with a thai, gtalry,
viscid fluid which flows down the »asal duct, or oozes up through the
puncta.
[('atarrh] of the lachrymal sac is almost always met with as a second-
ary afl'cction, being often consecutive H[K)n an inflammation of the
SchDeiderian membrane, which, ascending along the nas.'tl duct, has
reached the sac. Mence nasal catarrh, and periostitis or cirit*A of the
nasal bones, are not unfrei^uent causes of the disease. Or it may super-
vene upon inflammation of tlie eoninnctiva (more especially granular
4if
78B
PtSBASXS OF TUB LACURVMAL APPARATUS.
M
ophthalmis), or of the edge of the liil. Malposition or omttmctiryn of
th« ^tiiicta, or a nnrrowing or stricture of the laclirvmal canal, aUo often
pnnlucc it. Imlced oWtiuciions in tlie Iftclirynial |wwsa;:up, either above
or below tKo »ac, are very fruitful sources of blenorrha-a. This dbeue
u, therefore, often met with iu cases iu which there id a narrowia^, ob-
literation, or cvcrsion of the puncta ; or a iontraction or strictaro of tho
catuiliciilas or of the ua^ul ^uct, vrhich niny be due to inflammatoij
swelling of the lining membrane, or to tlie presence of cicatrices. Polypi
or other growths, which by compression narrow or obstruct the d
may also give rise to it. Persons in whom the root of the nose is v
flat and broad, and the eyes far a|>art, are very subject to diseases
the lachrymal ap]*aratus, on account of the diminution of the antero-
jtosterior diameter of the duct. Hut the snme tiling may occur, as Arlt
and de Wecker point out, if the iiosc is very prominent and narrow, so
that tlie passage id much narrowed latonilly. Itlonorrhuea of the a&c
oft«n supen'oncs npon acute inflammation of tho hitt«r, wliich. after
having perhaps caused repcatc-d perforation and escape of the discharge,
pas.ses over into a etat« of chronic iitflammation, accorapatiied by a
thin muco-purulcnt discharge. Acute inflammatory exaeerbntinnd recur
every now and then, and a more or Ic^ exteni^ive and finn stricture of
the luciirymal or uiisal duct 'i» almost nhv.iyg present.
Only in very rare instances do we find that the disease, if left
itself, undergoes any considerable or permanent improvetoent, tnui
IcBS a cure. For oven in spile of tho best and moat patient treatment, i
often proves very obstinate and intractable. The lining membrane
tlie sac and duct becoiuea by[>i>rtni]thii'd and snollen, and often unde
goes extensive cicatricial chau^rs, bring transformed into a fihro-tendinoi
tissue, and the discharge becoming thin, glairy, and viscid, or ia
cases of a thick gluey cliuracter (f^tellwag).
Stru-turfti of tht favhryinal patxttffg vary very considerably in «xt«i
firmness, and t>ituation. Tlieir most fretjuent scat is the [Kjiut whore
caimliculi ojien into the sac, or where the latter passes into the
duct; but thoy may also be situated at a lower |Mtrt uf the duct, ar
hence the necessity of always {Missing the probe llirougli the whole lengt
of the latter, in order that wo may ascertain whether any stricture cxij
at its lower jKirtion. If the stricture he duo to a thickened swollen con-'
dition of thf lining nuunhnine, and if it be considerable in extent, it will
oppose a certain dc;(rcc of obstruction to the passage of the probe, am
will emtirucu i\w hitter firmly and closely, but will yield to the gentle ye|
sleiidy jires^ure iif tlie instrument. Tho dense cicatricial stricture affor '
a more obstinate rcsigtance, and it may be «lifficuU to puss even a vccy^
saiall probe, witliout employing a considerable degree of forco. Tlie
symptoms to which a stricture gives ri^e are epiphora, hk-nnrrhoca or
inflammation of the sac, and a glairy, viscid, or muco-purulent ih5-
ohargo.
The first and fundatnental ]>rinciple in the treatment of blt'imrrlnrji
of Uio sac auid stricture of the hichrynial passages is, to dtviiL
both puncta and canaliculi, and to ]>asi« a probe down through Uh-
duct. The mode of dividing the nuneta and the canaliculi
already described. The probes which are best adapted for
CATAft»nAL INFtAMMATrOH OF TUG SAC.
, did
1 tr»
lion, are iliMo of Ntr. Bowmnn,' wliicli arc roadc of Btlvor, [Fig- IW-]
and of oix iJillertMit sizc^. Ni*. 1 i^ vvvy small, like ft fiiic
hair probo ; No (> is about ^, of nn inch in rliametor [ntut n
npreMnted of it* actual ei*e in Fiji.T-'l*. — H.]. Mr. Pridgin
TaJcf of J>?crt8, rccomim^mls a bullet probe, irliich is also
preferred by Mr. Critchctt,* who tliinks that it pa»*tejj more
readily, and w losa Hpt t'> lact*raie tlic miicou?) liiitn>;, or to
make a falne pasfuif(c. [[>r. VVilliamit,' of Hfkiiton, advocates
the use of Bexible probes with bulbous cxtreDiitii.*8, of the
sise of Bowman'^ seriett, hut slender for ono-thiril of Ihe di».
tatice from the bulb to the flat disk in the middle. Thev are
of alloyed silver, and have an elastic flexibility' without being
able to l>cnd upon tlipm^elves in cnconntering ohstniction?.
Dr. Williama has louiid iu practice that these probea adapt
theiu8elvo« to the Kiniiosilii-H of the pasjiagea, nnd can be in-
troduced with more facility and Icm pain, and are \ei» likely
to laki; a wroiij: pnssage than Uowman'a probes, which, if
not hent tw as precisely to corrertpond with the direction of •
the duct in each particular individual, nften laeerate the
mncoua lining of ihe jmasages, giving rise to pain and hemorrhage,
and retartlingcnre by causing local inflammation.— II.] l.as a nile,ui(c
Mr. U<^u-nian's probes, but frei|uently employ a considerably larger si»e
than No. *!. The instrument i& to be introduced in tlie follon-ing man-
ner: 'ITie end of the ]»rohe having been slightly bent, no that it may
pass more readily forwanl into the tia.'^nl duot, \tA point should Ik) innorted
vertically into the lower pnnctnm, Ihr ^kin being at the .s.ime time put on
the stretch, and then passed borimontally along the opened canaliculus
until it8 extremity reaches the inner wall of the sac, which is easily rec-
ogniKed by its prescnling a hard, bony obslniclion to the probe. The
latter is then to l)e turned vertically, the convexity of the bend looking
bnokwardtt. and stoa-ly and gently passed into the sac ; when llie latter
ia gained, the direction of the instrument must he slightly altered, the
point being directed somcwlmt outwanls and forwsnis, so that it may
readily pa.<w into the natiu] duct, through which it in to he pushed until
it reaches the Hoor of the nose. When the lining membrane of the sac
atHl of the duct is much swollen and bypertrophied,it \s sometimes rather
difficult to tiiid this entrance, as it may be somewhat displaced or cou-
traetcd, or more or lens covered by a small fold of the mucous membrane,
bich thus formii a little valve over it. If, afWr some careful searching,
do not succeed in tinding the opening into the nasal duct, it is better
withdraw the pndie himI Ut wait for a day or two until the inflamma-
tory swelling bji^ sulwidcil, than to att4'mpt to force the pa,«age of the
probe ; for this niny not only produce severe laceratiou of the womhrane,
but lead to the formation of a false passage; or the probe should be
withdrawn, ita curvature somewhat altered, and then 1h> again inserted,
in the hopes of finding the aperture. The first probe that is passed
ahould only be of medium «ize (Xo. 3 or 4 of Bowman), but if the stric-
" E. t. 0. H. Rep.." i. 10. • " r^nwft," l«frl, vol. !. 147.
tare is very coust(ler«l)le,^No. 2, or even No. 1, may liare to b« iriBl
before it can be pasficd. The instrunipiil sliouM l.e aflowed to rumntnm
the duct lor five or ten luinutei^, ami he then gently witbiirawn. and tiiM
catheteriiation should be repeated evcnr iUy or every other Hav, acconiine
to llie exigencies of tlie Ca»e. The niiie of the probe ahould be increanwl
until we arrive at No. 6, or it may be nrccMary to go oven beyond ibis.
[It is better to increase the she ot tfte probes rajiiiily up to No. 10. tiuj
allow them to remain in the duct for from tvfciity niinutts to half an hour.
— B.] If the probe is arrested at tho pnint whore the eanalieul! join the
anc, the skin near the tcndo-oculi will be moved witli the movement nf the
f>robe, and an elastic obstruction be felt ; whereas, when the ioainink'nt
ia« eiiteruJ the eac, tlic skin dye» not wrinklp or move.
If from the displactment of the pimcta or stricture of the canaticuli
the sac lias been emptie<i for a Ion/ period, it may become conaiiicrahlv
dioiiiiislicd in size and it* walls mucli ihintied. We then find gniat diffi-
culty in introducing tlic probe into the «ac, aw it repeatedly slipi om
again. In many cases, it suffices to open the lower canaliculus and lo
pass the probe through it; in others, it may Iw necessary alao to divide
the upper one. This is more especially the axse if we desire to get a
very free opening into the sac, to pass an extra sized probe, or if ibere ^j
exists any stricture at the entrance nf th« sac, where tlie fl|
Ftj. 200. caiialiculi" open into it. If tlie latl*r !;« the case, I prefer to ^^
X open the upper punctum and canaliculus wiili Weber'a beak-
pointed knife (i-i^. iidO), the point of which should then be
passed (juile down into the »ac,and tbo interual pal|(ebnd li"».
mem freely divided aubcutaneoiLslv. In doing so, the Hli>^ily
convex-cutting edge of the blade should be turned forwanli
and outward:^, find the internal palpebral ligament divided
fiuljcutancously, with a iilightly sawing movement. It will
be felt to grate a little, and it4 division is futlowcd br mqrv
or less copious bleeding. This having been done, a* probe
I
I
I
should be passed down lo ascertain the exact situation, nature i
and extent of an)' existing ^triciuro.' Weber uses for this ^H
Q purpose a fcraduated biconical sound (Fig. 2M1), which in*
creases very rapidly in sixe from the point upwards. This is
10 be forced through tlie stricture, if the latter rea<lilv vivlds :
if this \ii not tJie case, but the liuiu<^ membrane is inuc'b swolk-u
and intlamed, it is better to postpone the probing for a few days, uiiol th«
i'ig. 201.
inflamnintury swelling has sulwiiled. tn haaton which end, injections of
wattT and fif astringent lotions are to be employed. The intenial palpfr-l
I VM-^ W'iWb ariklMoii l>ii>..MMi>f thp Uchr/mal Ai>Mratui, "A. f. O.." rUL
1, 107 : «'»■* •*'■ MorwuW.." isa.
CATARRHAL IN FLAUMATEUN OF THE 8AC.
741
lira] ligamonl nm^v also he dWUletl vitli Bovrnmn's caniita ktitfo ; the
upper cnQftlicalua in to he frcoly tilit up, ami then th« point of the knife
U to be patwed, alieaUied, into the sac, the shcalh withdrawn, aud the
lij^ment rlivitled Ht)hciitaneoii.-tly ; or the director and cataract knife may
be used. Weber's koife will, however, be found more convenient for this
purpose. The openin;^ into the sac may aUo he widened with Uonraan's
dilator, the blunt bhideri of which, in separating like thoite of scissors,
dilate the openitij; into the sac.
[In casca of utrieture of the lachrymal paasagoji, division of the puno>
luiu And canalicuhut la generally unnecessary, for considerable improve*
mcnt may onlinarily be eileuted by the careful and repeated introduction
of a succession of probes of gradually increasin*; «liameter. Mr. Benja-
min Travcrs, as long ajro as 1S24, reoommcnded the practice of dilating
an obstructed lachrymal canal, ami observed' ihat "it can hardly be re-
quired that I should occupy the time of the reader in showing that the
practice of restoring a pa.4itago particularly cloMd * * * * coiamauds
a decided superiority over the practice of making an artificial opening,"
and modern surgery has ii<jt disproved this observation of tliui eminent
stiiveon.
The instruments which Mr. Travera oaed were silver probes of about
6ve inches tn length, flattened at one end and slightly bulboua at the
point. Dr. H«y&' has slightly modified and improved those
probes by making them small at the end, and wolhrounded ^Ut* 303.
(Fig. 202), and of sizes varying from ihnt of the thtcknosB
of wire No. I" down to that of wire No, 21.
The probe.'} uro passed tlirongh the entire longtli of the
iachrymfll passages from the punctum lachrymale to the
floor of the nostril. Tlic probe is prcrerably introduced
into the lower punctum, and in the following manner: —
The lower lid i» drawn tense with tlu- thumb of the left
hand, the patient \a diriKted to look upwarl--^, and the pnilH;,
held vertiealiy wiLli the convexity of the licnd looking back-
wards, is introduced into the pmictum ; it« direction is then
almost immediately changoil to the honsontal, and by a
f^ntle pressure is pushed inwards until it reaches tlie inner
wall of the lachrymal sac. which is recogniaod by the bony
obstruction to its progress. The direction of the probe is
then again changed to the vertical, and with moderate pres-
sure it is gently pushed onwiirdi^ until the Ktriuture is passed and the
point of the instrument rests upon the floor of the nostril. Folds of
tnucoutu membrane sometimes interfere with its passage, and to avoid
tearing ihem rerinires (wrsevemnce and delicacy of manipulation. On
no acuoimt should violence be used, for injury would then unduuhtedly
result. By the aid of continued moderate pressure a paitsage c&u of\un
he effected through a stricture which at firjt was impermeable.
Tlie prolw should he allowed to remain in the passage aboat ten
minutes, and its intPoductif>n should he repeated every few days, as soon
as the irritation caused by the previous operation haa subsided. The siso
[* " ernopsls of Iho DteeMtaarilt- Rrran-l tlieirTn>.ilni.'Ht." M •sL.p. 3T1I.— Q-l
[( " Lnwrwiioe aa tli« Kjt," ediud b/ Imuu lUy*, Pluln., W^M^y y. *^'1».— Vk..\
TtrSBASBS OP TBS tACURYMAt APPARAtng.
of the probe M«*d nbouW be gra<liuilly incrcaaeil until the tul* ii fully
•iilflted. Should these raenns pruve uu»uoces»fuI. the caiiiilicultu nwjr
be »lit up, ae rccnnimentletl liy Mr. Jlownutii. — II.] [It n imt nlvitta-
blc to introduce a probe iuto the sac wtUiout first »ltttiiig up tlie canali-
culus.—Ii.]
for some ycarji past, boufpes of laniinaria diiritnta have been nsod br
several diirgeoiitf of eminence. 'Vhvy wuru first ititroiluced fur tbl» pur-
itoac by Mr. Coupcr. and have been cxtcnuirply proployt-d by him and
Mr. Critchett. 1 bnvc also ofi<?n used tbem with marked success in casn
of very obstinate stricture. 'Hieir peculiar advantajre coiiaiftts in their
imbibing: the fiuid in the lachrip'fnftt [■assa^^es, and swellinfi; up to double
and treble their ori^^inal size. But there is the dan<;er thai they may
swell up to such an extent het/ontl the point of atricture, that the dilateil
bulbous part can only be drawn back througli tlie stricture at the expense
of miicli contuition or e%'en laceration of the lining membrane at thiN |>oint,
or, wliftt is still worse, that in the {jreat effort to extract the prril)e it may
break short, and bave to be excised. The Wet mode of obvintin^; tlies«
diftic 111 ties, and yet at the same time to produce a slow and gradual <1ila-
tation, is to draw back the probe a very little at intervals of a minute or
two, in order that it may not Imve time to swell up considerably below
the stricture. By tliis gradual retraction, the latter will, moreover, be
gently dilatLMl by the enlarging probe. By pursuing ihid method. an<l
by always boiii;! cxtrtimcly careful to u«e these pr<ilHfR with <leUcaoy and
gentleness, I have found great benefit from their empluyineiii. Their
lue, however, requires so much supervision, that it Is somewhat diffiaolt
to find sufficient time in hospital practice, where the patients are so
nuinorous, that one may e«ily forget to withdraw the probe • little at
short intervals, and let it swell up too much. In onler to limit the dila-
t.ition to the point of stricture, tlie rest vf the bougie may l»e covered
with copal varnish.
If the blctiorrhrca proveti ob{«tinatc, and the discharge as welt as the
swelling of the sac and duct continue, great benefit is found from the
systematic Ui^e of aetriiigent injfvtions, of sulphate of xinc, alum, or
acetate of lead. Their strength must xitry according to the amount and
nature of the discharge and the dej;ree of swelling of tlie lining mem-
brane. JJeforo their use, the sac must be washed out with an injection
cf water. The patient sliould also be directed fre^iucDtty to press out
the discharge, for if it is allowed tn accumulate in the f*ac. and to become
decom])Ose4l, it proves a source of considerable irritation, and may eren
set up an acute intlnniniation of the sac.
l)r. Stilliu;^, of Oassi'I, has devised a cure for strictures of the lachry-
mal passage* by internal incision.' The punctum liaring been divided
be passes down a probe and tiiids the exact seat of the stricture, then
withdraws the probe and passes down his knife' (Kig. 20^) tn the
» VWp Dr. SUIIIng*)! I»n*liiir«, " tT^ilwr <!{«• Rwiliintt ilvr Vnn>nRf ninRim Avr Thr*-
n«nw>-gi' mUixUt it)t linicni IituitiMi." Cnx*i-I, IdilS, A Minuwbal stiuiUr procevdiBc
)»'! ■■'.•■•n r--tiiiiiiiHiii-l-.lI I15 Jai-iiiiH< in ".K. 1. 'i..*' ic. 2, lUfi.
* Tli« liltt^i'- of HiiB knife ii 13 mm. I"iii;. -1 nim. l>f(M-l n>'nr'"it IIh- liiin-Il-. *n.l
grvtiinlly ilimini>lir-« to J mm. *■ X\if imitit. wlih-ti 1» Homr-irhnt muiiilit-l l-iit i-hIiIti^,
TIti- l-ln'lv )>Msi.-a oVL-r into a d&l vlcio, uliicb U uluitt tlx- ■iii' itf IbiKnikii'a litr);r>i
CATARnUAL INFLAMMATION OF TRB SAC.
743
BtrictuTo, and ttiviiles it in three or four diKwriona. This hav- Fig- StO.
iiig beoii doue, lie withilrnwij the ktiU'e, r«-introducc!t tliu probe,
and ir minther atrietiirn i* found further down alxn divides thU.
Ur. Warlomont, in on article in tlic "Annalcs d'0i:ulifiti«|uc,"'
8p«akit ill the waniH'Mt turm^ of his grcnt and itnmc<liate sue-
ceas wttlt thiit nppration, nnd narrnten ncveral civsct. He ope-
rates in the fDllowiiig niaiUKT: The upper puQctum having
Wen dividinl with Weher'a knife, he next peases Weber's bi-
coiiical sound down into the ita^al dnct, and leavea it thore for
a few uiiuutcK. On its rcoioval. he inimediatclv passes Slil-
lin^'s knife couipleioly duwn into the na^ii duct, so that its
wbule b1a<le ditiappeari*. and then inciw(> the duct in three or
four direction.-^, until the kiiifo van \w ttiniud ituitu freely in all
dircrctions. N'o diliitor or probe is intro-hicod alVr the opera-
tion : and, according to Stilling and Warloniont, even severe
and obstinate ctnes are thiu immediatelr and permanetitly
cured. The favorable action of thia operation apjyeard to be
tfhiefljr due to its affording a very free uxit to the contents of the Bao.
Aa the operation is very painful, chloroform or tlie nitrous oxide gas
sliould be given, 1 have tried the operation in uuuierous iniitanccs, with
varying flucceAa. In milj.' a few caKcs did I obtain a complete aod per-
manent cure ; in most of the othent con-tidcrahlc benefit vra.4 derived, l>iit
tlie operation hatt aubsei|aeutly to be tiup]deaiented by the occasional
UHG of probes or Weber's sound, and of injections, which subsequently
led to favorable rei>ult8. In a few ln«taitcea I have found that after a
time the nasal duct was greatly contracted, almoot as if the poriosteiim
had become swollen, so that the prol>c was very finuly grasjiod, and
couhl only be passed with difficulty at lirrit. On the wholCf 1 have fouttd
iDO!<t benefit from Stilling'a o|kcration in cases of oikftinntc chronic blen-
orrhoca of the nac. accotDpauied by a copious secretion of tuuco-puruleut
discharge, and but a slight stricture. In 8uch. it6 favorable action ap-
pears to be principally due to its affording a permanent and very free
exit for the contents of the sac.
l>r. lierzeiiateiii proposes the forcible dilatation of the stricture, ou
the principle of Mr. Uarnfird IIoU*» dilatation of stricture of the urethra.
[Dr. Theobald lia.^ rcociidy advised the treatment of stncturos of tlie iia^ml
duct by the introduction of very large probes, the canalicuttia having
first been slit up. He employs a series of sixteen probes, made of sil-
ver. No. 1 measuring \ mm., and No. l(i moaituring -I mm. Tlie pain
caused by the large probes is not especially severe, nor has he seen any
ill conge<|ncnces result from the great distension of the divided canali-
culus. The endn of these probe* are olive-shaped. (See "Archives of
Opbtlial.," vi., and "Trans. Amer. Upbtbal. S.K.," lyTi*.)— B.J
Wu sometimes find that the atterutions in the lining membrane of the
sac arc bo great, that they persist even after the passage of the tears is
pmlw, and is atlitohi-d lo thi> liaiidli-. Tliv back of th« tilailo Bliould ba mado Btroog
umI ralh«r wi-dgr-nlmpM. And it nftonld tint h^ tM> liiglil)' ttfn)p«r«d. attxTWiM-, it
Di*; (mRitr hntjtk, (ir a |H>itiiui of it i-lii|i "11, iii r«m:i^ il Utrougb, or iu indsiiig tli«
Btrioture. This knifv luajr lie vl>tatiit>d >t( Mi-sire. WviKa,
* "Anoalcs d'Ooulialiiiue," ixt. l»M.
744
bISBASEfl OF THE LACORYMAL APPARATDe.
unoljstnicted ; and th«n it may be ncce.*ftary to hav« recourse to «ofMj
direct ireutiutnt of the sac. Thus, if the Initer is Dot only much iHtatvu
but also thickened and secreting much mnco-punilcnt discharget MrJ
Bowmau hus dissected out the auterior half of tlie tliickened mu. MrJ
Critcht>tt hn8 treated such cases succcsafullv by laying open the sno, ac
deatroyiiig a portion of the interior with potawa emu calce. As thil
condition of the liiiinj; nieniliriuie of the Bao, as widl as titf coiwiderablfr'
dilntatinn of the latter, arc to a great exlvnt maintiiinod and tncn^ait^
by the constant Qow of the tears into Uie s&e, Weber' has remedied tbi*
by producing an ever»ion of the puitctuiu, so tiiat the tears caiiuut flov,
into the canaliculus ; thus caiiain); them to collect in the little rpservol
fomcd by tUe lower lid being slightly turned away from the eyeballv^
Ho ;;ain8 this end, by pn«.sing a needle, armed willi a stout tin
^)rou^b tlte skin and mui^cle clo^ to the punclum, and bringing
again a little further inwnrd», so as to embrace the pmtctum and ■
fold of the akin witbin the anturc, vrbich iti to be tigbtly knottod. Hii
will readily produce a t<light ectropiiim, and the beneficial effect of
ventinj; the entrance of the tears into the lachrymal sac will j;encrallj
already evident withitL '24 hours afterwards. I have sometimoa
great benefti in such cases from the application of a firm compn^BS
age over the sac, wbich prevents the entrance of the teara. Thia mat
of treatment k also of great use iu tliose cases in whiclt the aac i« mud
thinned and dilated, and secretes a lar;^ i|uantity of thin >;liury
cbarjie. Mr. Critchctt' has devised an ingcnioua little truu, so as
keep up a gentle and continuous pressure.
It" the stricture is very firm and dense, and there U mnch tendency
to close after the removal of the probe, a stylo may be passed into the
duct by the slit canaliculus, and left iu for a few days. The upper jiortiM
ia to be very thin and bent at a very acute angle, so us to be bent o«
Uie tower lid, tbuii keeping the jwrtion in situ. Tbo bent portion oiaj
al^o bo made an tbtn and small, that it will lie along the of^H-: \f. ji
the lower punctuni, and thus be invisible. Mr. I3<mman hr- 1'Mm4"
this mode of trcntment, and it in often atteiHleil with suecens, bat in smmt
cases the style sets up a considerable dogret of irritation, and cnay cv'Hj
give rise to ulceration if it is left iu too long. The sixe of the »tyU
sliould be grHdiialty increased as tlie stricture vields, until it bas atuitii
diuentiidiis CMn^id^rably larger than Bow man's probe No. li. D(
Green* rerommen'U leaden sivlen for Una purjtosc, a^ (hey readily aibf
themselves to any irreguhinliea in the dircciion and curve of tiic
luct. The »malk-r sixes are made tubular, and contain a ateel-wire stJl
ibich renders tbem sufficiently rigid for inirotluction. Jae«clt«hai
riae employed leaden styles for fievcral years.* Tlic olil>faahion«d
'ivhieh used to be inserted into the nasal duct lliroiigh an external
ing in tlie sac, has fallen into welbim-ritiHl and almr>st entire dtrawj
[Attempts have freifucntly been made to tr«at the stricture froia
"Kl. Mnntut>).," l^«fl. !'>«.
l..-.ir.rr9on Db«ftsr«or Iju-lirvmal App&raliu. "Luieet." 18U. 1. 14B.
< tkiM of AnMriuui 0|>blb&liiio1(igWa] Sacicly, •wooimI AsDiud XmUbc,
t:i. UouubL." Any. IMO, p. :tM.
i^
CATARKHAt. IN FL AUU ATTO!? OF THB SAC.
745
liy the introduction of cnrved hollow sounds throii};h the n&aal opcnin}; of
the fluct, and after (tilatiiif; the strictuix-, to inject vanous cniutic and
nfllriiij^eni fluiiU: these methodg have, however, ail betn pveii up as
impracticHhle. Sometimes, however, wliere there in a tiglit strictufQ
at the iiiuinl <)[i<fiiin[: vf tlio diicit it is poNtiblc to dilate this through tlio
nasnl mpntiia, and tinw aid in making; tho duct patent.
It has long Iwen recognized that women are more subject to diseases
of the lachrymal lippnralus tlian men. but why this i« so has nercr been
discovered- This ia e8peci»l1y true of stricture of the duct. It has nl»o
been noticed that the left nii^al duct is more frciiuently diseased thun the
right.
The prognosis of these cases is good so far as a marked improrement
is concerned. Hut the physician should reDK>nit>er and the putient
sliould he toM that the course of treatment re<|uired is a long one and
must be systemntically persevered in to the end. — B.]
In very severe and ob.'itinate cases of chronic inBammation of the sac,
BCcumpHuicd |KThapa by ulceration and periostitis, and a severe stric-
turi' or even closure of the duct, case;! which rejiist every mode of treat-
ment and prove a great and constant source of annoyance and trouble
to the patient, it may be necessary to obliterate the sac. This is also
indicated if the patient, cannot remain undor medical care for a sufficient
Ienj;th of time to lead to *ny rcanonahle hope of licnetit by the uiual
mudc of treatment, atid i9 yet very anxious to be reliercd from tins very
troublcsunie affection. Hut this oj)eration should, I think, be only
adopted in very exceptional ca^es, which have resisted every other mrans
of treatment. For it is surprising what a degree of improvement may
often be attained by treating these coses with ]>attence and care, although
it roust be confetMed tJiat a very long time is but Um frequently rG4|uired
lieforc much improvement takes place. Obliteration of the sac is, more-
over, only indicated if the natural secretion of the tears is not consider-
ahle, so that they are nearly ciitin.'ly carried off by evaporation, othoiv
Wise, great and annoying epiphora rcmnins after the operation.
Various methods of destroyiitg the sac have been devised and recoro>
mended. At one time, the actual cautery was extensively employed
for this purpose, hut lately the galvano-cauatJc apparatus has been largely
substituted for it. The sac is to be openeil by a free incisian, which ia
to extend likewise tKroiii^h the tendo-oculi into the uppt^r jfortion of the
sac, which fomu a cuhdc-sac above the tendon, and thoroughly cleansed.
When the hcmorrliagc has ceased, the lips of the wound arc to be kupt
apart hy Maufredi'a speculum [Kig. 204], which is, moreover^ ^tosvAsA,
746
DTSBAgBS OP TUB LACBltVMAL APPARATL'B.
with siilc platea to prevent the eheelc from hcw^ burnt, and the actual
cautery, or the galvano-caiistic apparalus, can W applied. Inatcad
«r these, varitius CHUs<tic» are often employed, f. ff., nitrate of ail- i
vor. butter of antimonr, pota»3A c. cnlce, perchlorido of iron. etc. f^|
myself prefer the nitrate of silver, which 1 first saw employed for thil^fl
purpose with great success by Von l.lmofc. It is easily manftj^sbU,
very safe, ami leaves the smoothest ami least unsightly cicatrix of any
caustic. Befnru atu-mptin;r to «lu3tn>v the 9»c. the pniicta uml canab-
culi mii<tt aln'ny;^ be 6rst oMitnrnted, ao as to etop the entrance of tcan
to the sac, otiierwise their atlmissiou will prevent, or at least greatly r^^
tarrl tlie adhet^ive inflammation and oblitemtion of the sao. Tlie be
method of closing the puncta and canaliculi is to pass into them a v«f
fine probe, coated with nitrate of KiKer or a thin hot wire, which will
up adhesive iriHammation. thus ohUieratinjr the pnnnta, and cUxin;: the"
canaliculi. Wlicn ttiiit end U\i9 beeu nbUiined, the sac must be laid opeD
to ita whole extent by a free incitnion, thorou<;hlj cleansed nut, and when
the bleeding has entirety ceased, the walla of (he sac should be touched
with nitrate of silver. Cold compresses should be applied to dimimab
the intlammatory symptoms. The nitrate of silver should be n^'d seve-
ral limes, at intervals of alx»ut two days, before the epitlielimu is formed.
Or at the en<l of forty -oijihi hours tli<^ thick eschar sliould l»c complet*Hi"
removed, and a small firm compre^ be applied to the ^ac, so as to lirii
tie raw surfaces together, u linu bandage being placed over the compr
in order to keep it tn titu.
[A betu^r plan in to open the outer wall of the lachrymal sac throii|
the oonjunclival eul-de-t^ac, by a vertical incision either in front of
behind the caruncle, first incising both canaliculi. Then pull the li|
of the wound apart^ by a sharp hook, and apply cither nitric acid ou
cotton probe, or the galvano-cautcry directly to the wall of the
This effectually destroys the sac, and at the same time leaves uo exte^
tuil pcar. — B.]
Dr. I^ijjrenstecher strongly rccitmmcnds the chloride of sine pMt*
part Jtinc. clil'>rid. to y parts of starch), which he uses extensively for
the ubliteration of the sac. llu divides both cmialiculi (with a \vxi
knife made for this purpose by Weiss), in such a maimer that the
cisionii meet in front of the canmcle. When all bleedinj; has ceased
inscrt<( into the sac a smiill portion of the paste (about the size of a split
{)ua. this varying, however, acconiiug to the dimensions of the sooj^l
wntpiK-d ill a tliin layer of charpie or cottoti-wool ; a thii-k layer J^m
charpie V»eing pushed in after it in order to prevent any escape of the
cscharotic on to the conjunctiva. Thtt past« is to remain m for 2^
hours. At the end of two or ilirec weeks the sac will i^enemlly
found to be obliternied by adhesive inHnmmation. Dr. l^ageiMtccl
has been latterly luduceil to perform obliteration of the sac more
quently than in former yearj*. not only on :icc(uintof the relapcs whi
sometimes occur after the treatment by probing, but more especially
the fact that he considers that eyes affected with chronic blenorrhoca
the sac are exposed to the greatest dangers, being cxceptioiudly
to suppuration of the coniea if tliey should become |>erchaiice affect
with comcitis profunda, suppurative comeitia with hypopyon, etc.
ou a
* A
y for
:uli4^_
IV i^H
;d. h^
fr
■AC
riETDLA 07 TIIR LaOlIRYMAL SAC, BTC.
ri7
I
states tb&t when the itraospihere is dry and rory hot, the secrotiona
of the lachrymal sac become very readily decompoaocl, and if an eyo
afTected witli chroiiic bleaorrliwa of the i^c should thuu mt;et with an
injury, protlucio*; perhapn only a alight ahraitinn of Uie conical epithe*
Hum, it is almost uLways followed by n very d&ugerous and dclctcrtoua
form of comeitis.
At the ()pliihftlmolo;iica] Congress, held at Heidelberg in 1818, Pr.
Bvrliu narnitod several ca^ed of very obutinute and severe disease of tlie
sac, in which \\v ohbiiiied a aueeet^aful result by extirpation of the latter.
In severe and intractalde cnses of epiphora, intlanxmation of the «ao,
eto., the extirpation of the laohrynial }{Iand ha^ been strongly urf^d by
severnl surgeons, more esiwcialiy by Sir. Zftchariah Lnurcnee,' who haa
pracliscd it extensively ; it haai ulsu been employed by Mr. Carter, l)r.
Taylor, Mr. Windsor, and othura.
I
5 FISTtl.A OF THK LACMKYMAL SAC, ETC.
"By this term ia undenstuod a communicaliou between the Uchrynial
aac or passaj^s and the e\tern!il intfj^uinent. I have already mentioned,
when fipcakinj:; of the inflauimation of the hac, that after A|>i)ntaneou9
perfuration of the latter, a m<;re or lesa extettsive ti&tulous opening may
D« left, which iiuiy prove very obtslinate and intractable if there is a very
firm or iropAHSable stricture, or consirierable disease of the hone. Caric4
and neerosis of the bony nnlls of the sac are a very frequent cau^e uf
fistula. The latter, on the other haiul, i» but rarely produced by direct
iujury,Dr a wound of the sac. 'J'lie fiiitula may either o|>en directly
iota the aac, or there may exist n Rslulou^ track of varying len;;th. The
edges of til© fistula may be at Brit swollen, irregular, and somewhat
ulcerated, Uie uluemtion [icrhaps extending; (u snme dititaitce from tho
aperture, liuc after a time it contracts in sisc, its mnrjjin becomes
smoother, and finally only a very minute opening, which hardly admita
the Bnest probe, may be left ; tliis is sutnetinies termed capillary fistula.
If the orifice is retracted, and its edges covered with bealthylooking
skin, the miuute aperture may be easUy overlooked, but on prcMing tlio
aac, a small tear-drop will be seen to exude. [Con}^niial lachrymal
fistula has been observed by Agnew. (£Jeu " Traiis. Awer. Ophth.
Soc.," 1K74.)--Ii.]
The beitt treatment for lachrymal fistula ia that of slitting up tbo
puncta. dividing the internal palpebral ligament, and passing a probe
ilowtk frH<|uently. If the ]»asRage is free, this will generally cause the
fistula to heal in the course of a few days. But if the passage U imper-
meable, or the disease of the bone extensive, it may bo neccMary to
obliicmte the sac, or to foive the passage. The latter is to bo done
with one of Bowman's probes or Weber's dilator. But extreme care
muHt be taken to do tins with delicacy, for if rude force be ust^d, much
mischief is sure to accrue. In the capillary fi?(tula, tbo edges of which
' VWp Mr. Lnnrencc'e btUcIp. *' On Removal ci lli» Livbrrnuil Oluai w i radioal
u-nr" fur Lfti-liryuuil Uiuue," "Opltlhaliuia Rwinw," No. 1^
T«
DtBBASBS OP THS LACflRTMAL APPARATUS,
are coveriHl by gmnnth skin, it ia someiimes adrisalrle to pare Uie edfrei,
80 aa to mslcc them raw, nnJ then to close thti minute B|ierMire with »
future, wliich vrill uauue tlic o|ii'uiii^ to lieal hy tirst intention.
Piilypi «)f tlio ft.i« arfi of raro rHicurrtMiCC*. Thoy closely roHotoMe o&ail
(loljr'pi ill stmctitre, unA nmy attain the sixc of a amall nnc. Thcv j^ve
rise to n ]u-ciiliar feeling of resiUeiice nnd elasticity to the fin;;er, and
aUhftu-ih itn presjuire a certain qHantity of glairy or miico-puruli-'nt tlnul
may be evacuated, yet we carnot empty the eac completely. On incu-
in;^ it, aoiue fluid escapes, and the polypus (like a pelatinoas maw)
springs into the wound,' If the sac is extensively diseased, or ther** !»
A very firm stricture of the iiaKul duut, it may bu iieccuary to oblitcrat*
the fine after the removal of the polypus.
Cases of hemorrhage into the aac, producing thus an im{>eniicabilitT
of the latter, nre of nire occniTencc. Two ini*tance9 of this kind ha»«
been reeordeil by Von Graefe.' The prrsence of chalky concrciitMW
(<lacryoliths) la the ducte or in tlie lachrymal toe is alao but nir«ly
observed.
In some rare instances a peculiar fungus (leptothrix) is met witti m
the lower canaliculus, resemblin;,; very eloaely the leptothrix buocdia,
which h&A been ob'tervcd by Ijchcr and Roltcusteii.' in carioua te«dL
Several cases of lept"thrix have been described by Von Gracfe.* and
one by Korpt(!r.' Aci^oiMliiig to tlie former, the affection commenc«
with a certain degree of epiphora, which is followed hj redn««s of th«
cnmticle and neighboring portion of the rctro-tar»al fold, as veil ai vf
the conjunctiva and margin of the lid in the vicinity of the lower canal*
iculufl. The palientj* at tlie same time complain of a sensation of b«tt
and itchiii;; at the inner angle of the eye, at which nltm small crosti of
di,ichargi' are noticed, especially in the morniDg on waking. On clw'
examination, we now fttid that the shape and appearance of the tnarjciu
of the lid along the lower canaliculus are aomcwbat changed, |j»vifi;E
become (liickened and rounded, so tliat the e<lge of tbe lid does not lie
in apposition with tlie eyelinll ; thu^ producing n tendency to ectropium,
which i« eapecinlly noticeiible when the patient looks up. But tbe
change in tiic lid \d still more appreciable to the touch, for with the
finger vo can trace a marked cylindrical Hwelling along the eourec of the
canaliculus. The lower punetum is dilated, and at a later atagv its aper-
ture becomes filled with a drop of a creamy substance, when the tumi>r a
pressed ; the aixe of tlie latter is, however, not diroiniabcd by Uie exit «f
this discharge, (rradiially, or perhaps suddenly after a cold, the thipl
stage aupervones, which is characterized by a more considemble M
rhoea of the canaltculus, accompanied by a more marked irritative »-^^l.
ing of the surrounding partM. The lower punctum becomes still nwn
dilated, and Its a|terturc is now constantly filled with a yellow tiib-whtte
flnid. which, on preiu^urt.*, exudes in a thick tlrop, or welU out rpontt*
iMonsly at intervals. The affected part of the lid ia now aUo verr t«b-
I Vide • ■:*•« of Von Gra«fo*«, "A. f. O," 1. 283.
» •• A. (. o.," III. i, aa;. • Bwiln. l
' " A. r. O.," i. ii. and xr. 1. 324 ; »1«) " Borl. Mwl. W.vlionschrm," 18«K, p.
^ -A. r. O.," xr. 1,3U. [Abo. ■' K1. U«u. f. Aug.," viji. p.l^. Ik. p. MA.
•• Anhirw or Ofiiaii. Kod Otoi.,' lii. i.— U.j
FISTULA OF THE LACHRYMAL SAC, BTC. 749
(ler, especially to the touch. The treatment of Icptothrix consists in
slittiog up the canaliculus as far as the commencement of the lachrymal
sac, and then carefully emptying it of the masses of fungus, which are
sorootimes found to be mixed with chalky particles. On microscopical
examination, the leptothrix masses have been found by Leber to consist
of extremely fine, closely-aggregated granules of a round, or somewhat
rod-like shape, and interspersed with very delicate filaments. The fun-
goid mass is firm, of a cheesy consistence, but its external layers are
softer, and often contain pus-cells. According to the same authority the
leptothrix elements are smaller than those of the leptothrix buccalis, but
are especially distinguished from the latter by the fact that they are not
tinned violet by the addition of iodine.
Whilst in some instances, there is an absence of the punctum in either
lid, which is generally due to its obliteration by inflammation, it may
also occur that there is more than one punctum. These supplementary
pancta are generally met with in the lower lid, and are situated quite
close to the punctum proper.'
' Vide CMes of Supplementary Puncta recorded amonf^at otIit>r9 by V. Graefe, "A.
f. O.," i. 1, 288; Wober, il.., viii. i. 1, 352; aud Zeheiider, " Kl. Mouatsbl.,'' 8C3,
p. 394.
Chapter XVI.
DISEASES OF THE ORBIT.
I._INFI.AMMATI()N OK TIIK CELLl'LAK TISSIE 01
OUUIT (CKLLILITJS OKUIT-K).
TuR sjmptonw and course of this difieMe are generally of a very »ent
and Bcveri' intlnmniatorT uliaracter. 'I*be eyelids liectunv rapi-ily swotlc
red, and liot, the palpebral and ocular conjunctiva tnuch iniit!t(:-d, tod
tliery is nioslly great serous chenionis, surrounding tlie cornea la tbt
form of a thick liusky-red mound, the edges of which may even oviTlit|i
and partially bide ihe cornea, Tlic patient complains of int«iue, iii'-^r.
mittvnt pain in and araimd the eye, aud extending over the correspond u:
side of iho forehead. There in alHo, generally, marbed febrili* con^iit'i
tional disturhance ; and if the inflammation should eittcnd from the -•rt.it
to tlio hrain, severe cerebral symptoms will suptrveno. The cyeladl
•oon becomes protruded. At the outset of tlie disease, this prot
is not very marked, and may only become evident when tbo two ?t1
are compared. But when the inflammatory swelling of the orbital oc^li
lar tissue increases, and still more when pus is formed, the exoptitt
rapidly augmeuta. perliaps even to (4uch a degree, that the dusky swr
lida can im longer ho closed over the eyeball, but tJie latter project* i
or less helweeri them. If the pus collects cliieHy at the tnittvm nf th*
orbit, the pi-otrutiion is uniform and straigbtforward lu iho axis uf the eyt
bait, and not jn one particular direction, m is generally tlte case in
exophtbulmoa accompanying periostitis of the orbit. The moTcmenti
tlio eyeball are also uniformly impaired, and not mpeeially ao in
direction. If the patient attempts to loove the eye, or it is tn«cbetl,
more especially if it is slightly puithed hack into the orbit, intense pain ii
protluced. But this is not the case if the point of the little fin^r
gently passed along and somewhat beneath the rdgenf the nrbit, nAd
do not Hnd a siiectui jHiint, where itt touch excite? great pnin, ma u
o:i:>»' in periostitis. The formation of
wv'il marked rigenj.
piu is generally aceom(>auieU
From the expoanre of tlie protruded eyeball to the atniospbepe,
secretions on the surface of the conjunctiva and tbo chetnoltc swcllii
become dried in the form of hard, dark crusts. The surface of tbc come
may alAo lieeome hm^hencd and clouded, from desiccation of ita et^t
Hum and its ex)M>9ure to ineuhanieat irritants. The sight is oflpn nrc
impaired by the stretching of, or pressure exerted upon, the 0["
i Uie retinal veins are generally more or less engorged and v..
INrLAMMATION Of CELLULAR TlfiaOB OF ORSIT.
751
tliere heixta, poriiaps, at the same time a serous iiifiltratioD of the dink
and t)uf retina in itn viciiiitji'. The ftold of vi.iimi h nlso uomewliat con*
tractei), often con^iiierably so. If the exophthalmos l:iKt3 for anj length
iA time, optic neuhtiti may aupervene npon the congestion and engorge^
merit of the optic nerve, fallowed, perhaps, hy consecutive atrophy of
the latter. [Sometimes the nutritioit of the eyeball i^ so interfered with
by the compression of the infittrntcd orbital tiA.-*nej!, that the cornea hc-
I coinei> Ofm'jne, sloughs, and then the suppurative process extontU to tlie
■bycball.— B.]
^Hr If the pus bo formed in stiflictent quantity, it makes its way forward
^Bon the bottom of the orbit, and may cause distinct fluctuation behind
^The coiijiinetiva or the lids: and it perforates either through the lid or
I tlirough the conjiinctiva, and in the latter case, it will appear (o come
from within the eye. But the inflaaimation and snppuralion may also
vade the oyetukli, and panophthalmitis be set up : pus will appear iii
e anterior chamber, the pain wilt b« still more increaseil ia severity,
id will only be amoHoratcd when the eoniea j;ives way, and tlie lens
and the humors of the eye are evacuated. Sometimes, the swelling of
the eyelids is so teiwe and gix-at. that all sense of fluctuation is lost.
Althnii;;h the si-veriiv of the inflammatory symptoms met with in
orbital cellulitis varies considerably in degree, the disease generally runs
H more or les«i acute course. But, nccording to Mackenzie,' the latter
may in very rare instances be extremely chronic. Not until a very long
I.', jicrhajis many months, has elapsed, does matter accumulate in the
bit, and tlien the eye gradually protrudrs, the lids Itccome somewhat
oltcTi and re<l, the pus iiiitkvs it-f wav tu the surface, the skin gives
y, and a sinus may be let't, often pniving extremely obstinate in the
tmcnt. [Sometimes, although all the itiflnmmniory symptoms may bQ
11 marked, no jnis is formed, in spite of hot applications and free in*
ons. 'llie liri'^uy cut* like brawn, and there ia very little hemorrhage.
ie>*e arc the most unfavorable eases, for the process of resolution is
slow, and the great pressure fretjuently destroys the eye. — B.]
Jn framing our prognosis, we must always rt-'mcmber that cellulitis
t unfrc<{uciitly becomes complicated witli periostitis, leading subse-
entiy to cartes or necrosis. That, moreover, tlie inflammation may
tend l>ackward>) along the periosteum to the tnerabranea of tho brain,
rorluein^' meningitis or alwcess of the brain, if caries or necrosis of
e walls o{ tlie nrbit has taken place, the pus may make its way through
is iiptTture into the cninium or antrum of llighiuore, etc. Moreover,
e pntient's general health, already perhaps undermined by a long and
ry serious illness, may give way Wncath the acute and protracted
.fferings produced by the disease, if tht* latter is iatpro[>erly allowed to
ran its course, and is not arrested and relieved by a timely evacuation
of the pus.
[The pragDosis in most cases must he reganled as barl, as far as the
Itcgrity of the eye is concerned, and rapid suppuration is to be fa-
ired.— B.]
Amongab the moat frci)ucnt causes of inHanmation of the ocUular iis-
" biMUM of thtt Eyv," p. 2&».
752
DISEASftS OF TBB ORBIT.
Bue of ill© orhit, are oonlii<ier1 or incised wounds of. and the lodgment of
forci;:ii hndio^ in, the orbit. Tue diaease mav also he cau^f^d bvond'It
uhmiges of temperatiirt.', and exposure to cold and vrvt; and it luaj
occur secondarily in severe constitutional diacasea, hucK lut [>yn:nii
puerperal fever, etc. It may also be due to the extension of the iofli
Bullion from neigh bo rin;; parH, aa in crjsipelaa of the bead and fat
severe inflaiuiuMtion of tlio lachrvmal »«c, or operations performed uj
the hitter, mure especially ita destruction by tuo galvauo-caoatic apf
ratu.* or very stron;; caustics; or it may ensue upon pane ph thai raitis,
ojjeratiuns upon the eye or eyelids.
[It has been known to be caused by an iridectomy, the iuflatntnatic
Iwfiinning in the capsule of Tenon. clo«ie to the wound, and rapiillr ii
volving the orbital tissue, (riee "Amer. Joura. Med. Sciences," Juli
1878.)— B.]
The treatment iihould b« chiefly dirocte<l to subduing and arnvtii
the inflamniittory aymptoms. If the diseaac ta due to ati injury, tlv
treatment ituitriblo to it4 special character {viii^ Injuricii of the Orbit]
must be adopted, and cold compresses and leeches should be applit
But if auppuration has already set in, these iipplicatious should
changed for hot poj)py fonieiitaciona or hot poultices, and a free inei«*
with u bistoury should be made at an early period, In order that the pti
may be evacuated. If much doubt exists as to tho true nature of th|
dtaeaae, a small exploratory iucisiuu should be made, and if put 19 fout
to oose out, the incision should be sufficiently ciitar<;ed to permit of
free and ready escape. If powiblc, the opening should be made throi
the coiijuuuttva, and not thntugh the eyeliiiH : hut if the nlxioess poiu
directly beneath the latter, tlie incision must be made nt this spot.
In makiug tbe incision through the conjunctiva, the upper Ud should
be raised witli the finger, and a scalpel, or the point of a cataract kutfq
paascd through the conjunctiva above tlie upper edge of the eyehnll iu|
tbe orbit. Care should be taken that tho globe is not injured, and
avoid this, the e«lge of the knife should Iw directed somewhat upwanls.
Warm poultices are then to be applied, and the edges of tho wounil are
to he kept open by daily possiii-; a prube between them. If the track
of the wound is deep and long, nnd fear is entertained that it may not
bent from the bottom, a smull dnssil of lint should be inserted a^ a tent,
and changed every day. The sinus should also be syringwl out ntu-c or
twice a day with a mild astringent lotion (zinc, sulph. gr. iv, a*}, deitt.
Sij). If the healing of the sinus prove ob-^tinate and protracted, a care^-
ful examination must be made as to the presence of carious or noorodwl
portions of bone. In the latter case, time should be allowed for (bt
loosening or detachment of the spicula of hone, and the ineision ahonl^l
then be sufficiently enlarged, and the fragments of bone removed witli a
pair of forceps.
If pauophtluilmiiis coexist with tbe abscess in the orbit, and there 11
pus in the anterior chamber, paracentesis should be performed, aud
pus evacimted.
The patient's health should be sustained by a gencronadiet and tonic
care being at the same lime tiikeu that the bowtds arc kept well opei
PBRIOSTlTia OP THE ORBIT.
7S8
and febrile syniptom.'; nllcviated Ky niaintaininf; a free action at the kid-
nevfl and tlic itkin.
Wlien the pus has been evucuatcd. the protrusion of the tye will
gradually diminisli, and tli<! latlcr reai*siinn? its iionnal [wwitioii. If tlic
eve has otherwise OMiped all injury, and the impairment of vision was
Biniply due to stretching of the optic nerve and stasis in the retinal cir-
culation, tlie sight will rapiiUy improve. Sometimes, however, a curtail-
ment of tlic movemontj) of the oye iu certain directions may remain
behind.
I
I
2— PERIOSTITIS OF THE ORBIT.
We meet with two forms of periostitis of the orhit, the acute and the
chronic.
In acute: periostitis, the Inflammatory syraj^toma are often very severe
and pronounced. The patient complain-s of great pain in and around the
eye, and the constitutional symptoius may also be vury severe. The
eyelids, more especially tlie upji^^r one, become bwoIUmi, ri-d, hi>t, and
jAiiiful, but the swelling and redness are, as a rnle, not m extreme, and
do not advance with such rapidity as in cellulitis of the orljit; moreover,
in periostitis, the swelling of the two lids is not alike in degree, but one
ia generally more swollen than the other. The ocidar conjunctiva and
aubcoiijuneiival tissue are injected, and there is more or less seroug che-
moais. The eyeball become* somewhat protru'lcdftven perhaps to such
a degree (if iinicli pus is fdrrneil) that the evelids cainiot tic clor^cd. The
protruaion is not, however, straif^ht forward, aa is generally the case in
abacesd of the orbit, but towards one side : the movements of the eyeball
are therefore not curtaile<t eiiutilly in ivll directions, but more in certain
directions than in others. This is due to the fact that the periostitis is
chietiy and specially coiitiued to one wall or one portion of the orbit.
Thus, if the inner and upper wall of the orbit arc afTccled, the eyeball
would protrude downwards and outwards, and the moveraetits would l>e
especially curtailed in the upward and inwanl direction. If the ta\) of
the little finger is passed along the upper or lower edge of the orbit, and
pusheil snmewhat back into the cavity, we are often able to detect a
point where its pressure causes severe pain, and where there is distinct
swelling, thns indicating tlie seal of the disease. Someliraes, the pa-
tients can themselves h>caliKC the situation of the jicriostiits with much
e:(actitiide. In the course of acute periostitis, the cellular tissue get**
erally also becomes extensively inflamed, a great amount of pus may be
formed, llie eye be very considerably protruded, jmhI its movements
■ greatly, or even uompletely, inipaireJ. The ili.se.ise then assumes a
mi.\ed type of periostitis and nbi^cess of the orbit. The perioslitia ia
generally accompanied from the outset by a certain degree of inflamma-
tion of the bone itself.
In chronic periosiitis, the inflammatory symptoms are far less pro-
nounced, and the disease is more protracted and insidious in it« coiirae.
The swelling anil redness of the eyeliils, the injection of tlic conjunc-
tiva, tlic chemosis, and the protrusion of tlie eyej arc generally far lesa
4&
752
DISBASBa 0? THE OKBTT.
sue of tlic nrbii, are contiucii nr incUed vronnds of, and the lod^toetit
forc-i;^! boflies in, the orliic. Ttic disease may "lao ^p caustMl 1
changes of teuipeniture. and ex|>OBure lo odd and wet; an > .
occur secondanly in severe cDuntitiitioiinl disea^ea, Hucb aa pja'oiia.
puerperal fever, etc. It may aUo ho due to the cxtenaion of the ioflain*
■nation IVom neighboring paru. as m erysipelas of the head and face,
severe inflamniation of the lachrymal sac, or operation.'* performed npoo
the latter, more capccially it« destruction by the galvano-cauatic Bppt*
ralutii or very atron;; caustics ; or it may enaue upon panopbthalmitUt or
operation* upon the eye or eyelids.
[[t had been known to be caused by an iridectomy, the inflaminatioB
beginning in the cnpsulo of Tenon, cIom to tlic wound, ami rapiilly ii
volving the orbita] tissue. (See "■ Amer. Jouni. Med. Scienecs," Jul
1S78.)— B.]
The treatment should be chiefly directed to auMutng and arresd
the intlammntory fiymptoms. If the disease is due lu au injury, the
treatment snttable to its special character (t't'/«t [njuriea of the Orltitj
must be adopted, and cuhL compresses and leeches should bo apiih<-<l.
But if suppuration Iiils already set in, these applioations should t:«
changed for hot poppy fomentations or hot poultices, and a free inciuoo
with a bistoury »lioukl be made at an early period, in order that tlie pu
may be evacuated. If much doubt exista as to the true nnuire of the
dtsea.H'', a small exploratory incision should bo made, and if pus is fuuud
to ooze out, the incision should be sufficiently enlarged to permit of ibf
free and ready escape. If possible, the opening should be made tbroo^
the conjunctiva, and not ilirouj^h the eyelids : but if the ah(!ce<*s |Kii
directly beneath the latter, tlic itici:4)on must be ma^le at this spot.
In makin;; the incision through the cunjnuctiva, the upper 1i<l ah'
be raised with the fiiigor, and a scaljwl, or llie point of a eauiraet kni
pBSBod through the conjunctiva above the upper edge of tlio eyeball '
tlie orbit. Care should be tiiken that the globe is not injured, and
avoid this. Uie edge of the knife should he directed suiucwliat upwa^:
Warm poultices arc tlien Ut be applied, and llie edges of the w<.und
to be kepi open by dnily passing a probe between ihem. If the ti
of the vouud is deep and long, and fear is entertained that it mar
heal from the bottom, a siuall dossil of lint should be inserted as a tc
and changed every ilay. The sinus fihould also be syringed out once
twice a day with a mild astringent lotion (xinc. sulph. gr. iv, m^. 4
Jtj). If the healing of the sinus prove obstinate and protracted, a
ful exnniination most be made as to the presence of carious or necroMJ
portions of bone. In the latter case, time should he allovrmi for
looseutng or detachment of the spicula of huue, and the inei»ivn ah
tliun be sufficiently enlarged, and the fragments of hone removed wi
pair of forceps.
If paiiophthalmitin coexist with the abacoas in the orbit, and then
pus in tlie anterior cliamber, paracentesis sbould be iwrformcti, and
pus evacuated.
Tlie juitient'a health should be sustained hy a generous diet wnd
care bcinjj at the same time taken tliat the bowels are kept well
I
PBRI08T1TI8 OP TUB ORBIT.
768
nnd febrile RympUima alleviated hy maintninin^ a free action of the kid-
nevji and tlic -iVm.
Wlieii the [Hw lia» been evncuated* the protrusion of tlie eve will
gnulimll; (litnitiiaii, am) tlii> latter reassiime its normal jxisitinn. If Uie
eve lins otherwise escaped lill injury, and tlie impairment of vision wm
Bimply due to atretchinj^ of the opiic nerve and atosia in tlie retinal cir-
culnliou, the aiglil will rapidly iujiittvc. Soroctimes, however, a curtail-
iDt of the niovomiMits of the eye in certain directions nuiy reuiaiu
liiod.
2 T'KRIOSTITIS (IF THK OIIRIT.
We meet with two forms of periostitis of the orbit, the anite atid the
chronic.
In aaite periostitis, the inflammatory Bvmptoms are often very sorere
" prononnced. The patient complains of (^roat pain in and around the
J, and the conatitutioiial aytniiioiiis may also be very severe. The
eyelids, more especially the upper one, become Bwollen. red, hot, and
painful, but the swelHui; and n-dncjij are, an a rule, itot 90 extreme, and
do not advance with Huch rapidity as in cellulitis of the orbit : moreover,
in periostitis, the swelling i>( the two lids is not alike in degn-e. but one
is generally more swollen than iJie other. The ocular conjunctiva and
Bubconjunctival tissue are injected, and there 13 more or less serous che-
modi^. The eyclinll becomes somewhat protruded, even perhaps to such
a dej^rec (if much jiu^ i^ funned) that the eyelids cannot be cla-^ed. The
protrusion is not, however, straightforward, as is generally the case in
ab»ceM of the orbit, hut towards one aide : the movementa of the eyeball
are therefore not curtailed etpially in nil directions, hut more in certain
directions than in others. This is due 10 the fact that the periostitis is
chieHy and s|)ecially eoniiiiod to one wall or one portion of the orbit.
Thus, if the inner and uii|>er wall of the orbit are aflbcted, the eyeball
would protrude duwuwanis ami outwanls, and the movementji would Im
rspi'eially curtiuletl in the upwanl atid inwani direction. If the Up o(
the little finger is passed along the upper or lower edge of the orbit, am)
pushed somewhat back into the cavity, we are often able to detect a
point where its pressure causes severe pain, and where there is distinct
swelling, thus indicating the seat of the disease. Sometimes, the pa-
tients can themselves localize the situation of the [>crifl6tiiis with much
exactitude. In the course of acute periostitis, the cellular tissne gen-
erally also becomva vxtensivtdy inflamed, a great amoimt of pus may !»
formed, the eye he very confiiderahly pnjtrudeil, and itf: movements
Bitly, or even completely, im[wiired. The disease then nftsumes A
ixed type of periostitis and al>secMt of the orbit. TIk- j-erioMitis is
generally aoconiftanied from the outset by a certain degree of inflamma-
tion of the bone itself.
In chr'ruic [wrioslitis, the inflammatory symptoms arc far less pro-
nounced, and the disease is more protracted and insidious in its course.
The swelling and redness of the eyelids, the injection of the conjunc-
tiva, the chetDosis, and the protrusion of the eje, are generally far less
48
754
UISBASRS OF TUB ORBIT.
seven- than in the ucutc fonti. Pain is expvrienceil in and amnnd the
e^e, whicti mostly increase* in sevurity towiinl.i inghi, ami ia markedljr
migmenlod by pressure upon the edge of the orliil, or hy pretwing the
vye liaoknarils in n certain direction. SometiiiiL's. ducitU'd swelling of
tlie orhit cHii be detected at <ini- point. A certain amount of ituppnra-
tion );oncral1j inkc^i place, and if piiit is formed in considerable quantity,
it will, of counc, cause j^reat protrufiion of the eye. As a rule, hoT-
«ver. the suppuration is limited, and the pus 14 apt to accuinuUte between
the periosteum and the bone, ami lift up the fi)rtiu*r. The pcrioeteuu
often becomes greatly swollen and thickened, giving; rise pcrhajptt to little
nodules or tuberonities. These may *ub8ei|uently agaiiniiiiiitiish in .liie,
and finally only leave a somewhat thickened condition of the jwrioeteuni,
or they may undergo osjiificatjon, and thus give rise to exostoses. If llie
b<me boconios involved, caneit and often nccroutis will result, and the in>
flainmation or the pus may extend thron;j;h the aperture in the orbit to
the cavity of the cranium, or inl« the frontal aiiius. Indeed, the great
danger of the disease is, that the inflammation should eslend from the
orbit back to the membranes of the brain, and set up fatal meuiu^na, or
that ail abaecss should be formed in the brain.
Periostitis is sometimes met with in infants, and is indeed far mnrr
conimuu amongst young persons than in adults. The most frequent
CAuseK of acute perioalicis are [leneti-atiiij* wounds of the orbit with ^hirp
cuttinp; iiwtrumcata ; or severe contusion nf its edge from blows, or
blunt itistrumeutit ; and the todguiunt of foreign bodies within the orbit.
It may al.*o he secondary, the inflammation extending from the perios-
teum of some of the ueighboring cavities, e.g., frontal sintitf, maxillarv
Bpaee, etc. Exposure to damp and cohl and to sudden changct? of tem-
perature may ai-*o give rise to it. As already staled, it may Iikewi.*e
appear lu the course of iuHammiiuon of (lie cellular tissue of the orbit.
Chntnic jieriustitis is moat frcijuently due to syphilia.
[Feriostitii may also be caused by the presence of intra-orbical
tumors. — B.]
The general plan of treatment resembles very closely that rocom-
mended lor inflammation of the celhdar tissue of tlie orbit, and if Ihf
iirosence of putt in rtusiwcted, it should he evat^uated as early a« |»OMi)iIr.
Where the diAciute is due to ayphllia, the iodide and bromide of pota»-
fliuin, in combination with some preparation of mercury, should be wi-
iHiniatercd, or the mercurial bath should be employed. Care should he
taken not to eufeeblo the patient's health, but to fortify it u much »•
jtuKiiilde by touicjt and a generous diet.
3^CARIES AND XKCUOSrS OF TIIR ORBIT.
At the commencement of a carioun aflfeetion nf the bone« of tlie orbit,
there is generntly a certain degree of ncdi-matouit swelling of the «-*y«'-
lids, which are at^n soibewhat red and perhaps jininful. The conjuucti>a
and aulwonjunctival (issue are injected, and the eye i« irritable and
watery- The cudeina of the eyelids i.« often very coiudderable, particu-
larly III childten of & wrofaluua diathesis. Soon, a a|M)l is noticed where
CAR[BS AND NBOROBIS OF TOB ORBIT.
756
I
I
I
[Kig. 2110.
tlie cyolid assumea a more diiiiky rod Unt; here the alMtc(<eB points, the
skia giveii waj, aiii) through this urnii]! perforation a thin, scant/, muco-
purulent or '* 5trinj{y" discharf^ oozes o ut. On pnsaing n probe through
tht5 aperture, we Hml that it leadi to a portion of bare roiigbfncd bone.
The edf^es of the opciiinj; generally become somcwhiil cvcrte<l. swollen,
and ulcerated, and covered pcrlmp» with HcAhy j^ranulntioiui. A portion
of the hone, as a rule, becomes ctecrosed,
and Kinall fra»nientj< are cxt'otiated. After
thit) condition liait lasted for a more or le.s.4
considerable length of time, the sinus closeti
up, and the aperture heals ; hut ilitring the
process of cicatrisalion, the integuments be-
come adherent to the perioatcum, and thus
an eversion of the lid, perhaps of very con-
diderabte extent, may be produced, causlni;
H great expoHure of the eyeball (lagophilial-
luoit) with all its deleterious couscquencci.
[Fig. 2U5.1
The course of the disease is often mns\
protracted, especially in person* of feeble
health, and of a tieroiulnus or syphilitic dia-
thesis, in whom relapiies arc very apt to occur. The di«>caso improrea,
the siniid and e.\terual ajierture appear to he healitif^ kindly, when a
relapee takes jilace, frerili M'mptoms of iiiflnuimation supervene, tlie dis^
chark^G again inureiue« in quantity, aitd fre^h portions of boite are perhaps
exfoliated.
Carie* and necrmia may occur in different portions of the orbit : thn«,
(he bottom of the latter may be the seat of the disease, a» is often the
case after penoatitia of this portjoa of the cavity. In rarer instances.
Affair H«rheiillii.|
(Wg. aiifl.
Fig. 207.
Atur Mii(li««il«.
Aftet lUek«u)i.)
lit may supervene upon inHammation of the cellular tituue of the orbit,
accompami'd by periostitis. Sometimes the caries \» confined to the
margin of the orbit, or it occurs ju)«t within the cavity near the edge.
In audi ca:?pa. the upper or lower lid, according; to circumstances, may
become extensively involved in the cicatrix, and a very considerable
<;clropium result [Kig<i. 2ii4) and 1207]. 'Iliese ca-tes of caries and oeortMia
;<r D1SBASB5 OP TUB ORlllT.
«f A* ■upD of the orbit are generally the result of o blow or fall u{H>n
1fta»|BR,uKl are freiinentlj met with in children, more pftrticularW ihrw
if • Krofalooi diRthesiB. Srphilie is a fre'iuent cause of caru'd ot the
■■til, ami the disease of the honn may in such cases be due tn an cxteu-
«■■■ $i the aflection from the nasal h^nx.
1W pnociples of trcntuicnt shouM re^eaihle those recommended for
■erintitis. The pus tihoiild he erncuated as CArljr as poAsihle, the luui*
iMtailitu he waahetl out fretiuentlj,- with warm water or mibi astrili^vtit
i^iefitiDCie, and a small tent of lint shouM he introilnced, in onler to cause
0»» Mitns to heal from the bottom. If n louse »pocuium of bone i* <te-
lifibcd with tlie probe, the external opening: should l»e »oiae(vhat enlarged.
awl the treatment he carefully removerl with forceps. The treatmeiit of
tb« iagobhibalmod and cctropiuin con^e^uctit upon the caries, is fully
descriU'd in the articles upon theiw nubjects.
[I'tccasinnally a carious process U dereloped In the lnchrrm.iI or eth-
moid bones, which gives rise to an uncommon pathological condition, a
prelichrrmal ab^cea?. A swelling slowly dertdnp:!! at the inner canthtu,
abore the internal canthal li(;ament, lying iii the hollow of the lachrrnial
heme and side of the nose, immediately beneath the upper margin of the
orbit, and invoU-ing the inner end of the upper lid. When the skin h
cut throiij^h here, there id «een a distinct cyst-wall which bulges, but an
attempt to dissect out the cyttt faiU, for it is found closelv uniceil with the
|»eriosteiim of the lachrymal or ethmoid botieo. After being oponed. it!
cavity is fouud smooth and comrouEiicating at the bottom with a hole m
ihv bones. A probo pasicd through this enters the ethmoidal cells, and
dead bone isdisco%'ered. This prelachrymal abscess resembles somewhat
abaoem of the lachrymal sac, but has no connection with the Inchryniat
pAsaages, and causes no epiphora. The cariei> does not admit of opera>
tive inU'rftTciice, on account of its proximity to important cavities, and
the most tliat can he hoped for is that a careful syringing of some aatnn-
geot or some caustic, like a weak solution of arjientic nitrate, for a pro-
tracted |}eriod : or the introduction nf a drainaf^e tube of flexible silver
through the hole into the superior nanal mcatU'*, may cventimlly put an
end to the caries, and admit of the cavity filling by granul»tii>ns from \U<-
bottom. niOTte casca are usually the result of a blow nt the inner aiij^lr
of the orbit. a» from a foil in fencing. (rSee a paper by the editor, in
" Amer. Joum. Med. Sci.," July, 18»U.)— U.]
4.— IXFI.AMM.VTION OF THE CAPSILK OF TEXOX.
The fibrous capsule which envelops the eyeball (capsule oF Tenon) w
occasionally i«iihject t« inflammation. This disease is particularly disiin-
guished hv the apiwai-anco of a more or less marked cheinosis round ti**
eontea, there being at the same time considerable coojuitciival and eub-
cniuiietival injection. On closer examination, we find that there is mi
op|)iireiit cause for this chcmosis, for the cornea, iris, and deeper tunic
of tlie eve are unalfectcd, and the ^^ight and the held of vision are atsa
tfOO<l. Tiie eyelitts are likewise aomewhal red and swollen, 'ilie eye-
tMill u, ninrenver, sUjhtlif \irotruded, although perhaps to so inconsitlvr-
KXOPUTHAI.HIC OOTTRK.
757
»blc a degree that it nii;:ht escape obacrvfttion unless tl)c»tat« of the two
vyv* ia coiupiirud. Tliere la, at the Muie lime, a cvrtaiu impHlroieiit of
ihe movement) of the cjioliall. which is es|>ecially cvi<lcnl in the extreme
movement:* in (liffercnt iHrectton^, when diplopia will aI.4o ariiie. Tlie
pain in an'l anxind tlie eye nuiy Iw somewlmt sovem, but it iiovtir readies
the same interwitj as in celliiUtiA or perio.stitis of the orbit. The prog-
ress of the disease is geuerally slow, eight or ten weeks perhaps elapsiu};
before it ia cured.
It is generallv of rheumatic origin, being due to a draugbt of cold air,
as. for iiij4tanee. iu railway travelling;, et«:., or u> sudden changes of t«m-
pcmture. It i8 also seen in oa.sea of irido-dioroiditis riuper^enio;; upon
oiwraiions, especially thosw for cataract. According to de Wecker, it
may aIho follow the o|iemiiou for 8irabi><ii]ud, if the Bclerotic Uaa been
mmih exposed, or the capsule of Tenon too freely incised.
If the inQnmmaiory symptoms are severe, a few leecbca should be
applied to the temple, and wHrra poppy fomenifttions be prescribed,
together witb the compound belladonna oiiituieut. If the iutlammation
U due u> a traumatic origin, an, fur insiancc, lu the operattou for tHrabia*
uiu, ice coinpreasc<i should be applied.
a — EXOPHTHALMIC GOIXnE (GUAVES'S DISEASE,
MORBi:.S HASKDOWII. ETC.).
11ii.s is a very interesting and pecaliur disease, tlie true nature and
cause of which are at present unknown. Amongst the fir^t symptoms
are, ):enc rally, great palpitation and acceleration of tlic action of Uie heart,
the puliio perliH[M reaching 120 or 1<S0 beats in tbe minute. There is at
the same time much nervous excitement and dyi^pnuett. SoinvUmes there
are, moreover, Rvrnpinms of gn^tric dt-gmngoment, huch an fre^^iient aiHt
oliAtinatc retching and vomiting, or diarrlm-a. It U now p(>rlm[M also
noticed that the eyed have a peculiar and somewliat staring look, whioli
ia partly due to a retraction of tbe upper eyelid, leaving the eyeball
much uncovered, and giving an expreDnion of astonishment to the patient.
Moreover, as von (iraefo haa pointed out, tbe upper lid doea not tiuite
follow the movements of the eyeball when the person looks upuard-'i or
downwai-di(, but remains somewhat too elevated. This is ijuitv indv|)en<
dent of the exophthalmos, and generally appears during tbe stage of pro-
gre«t(ion, and may diiiap|kear witliout any diminution in Uio protrusion of
tbe eye. This retraction is prohubty due to irritation of the unstripod
miiMCular fibres of the upper lid which are supplied by the sympathetic,
atid is relieved by the subcutarteou.'* injection of luorpliia. Stellwag' has
lately called attention to the fact, that the norrmd, involuntary nictitation
takes place very imperl'ectly. and at unusually long intervals. The lid*
f^an, however, be easily and perfectly closed by a voluntiiry eflorb. 'ilie
cardiac symptoms may have lasted perhapa some little time before those
of bronchocele and exophtbalmoa present themselves. The latter symp-
toms generally apjiear alMut the same time, hut do not necessarily bear
■ " Wi«DBr medexintiche JAl>r««hrift," xvii. 1S69.
7S8
D188A8BS or TUB ORBIT.
anjr absolute relation to each other, and need uot coexist; for, nccordiii;
to Praijl,^ in exceptional instances, the bronchocele may be alisfni
There is, moreover, notbiiij; peculiar in thia form of bronchocele, exce|il
iiig that tlie veins are j^eiieniHv much dilated, even peHiape to ouoh
decree that the disease mi^lit lie termed " bronchocele aticiirysmntica
and uften a di:>tiuct diaiftolic muiinur can be heard in them. Ac(-onliD|
to Virehow,' there is. at the connnencemetit. only a siniple awtdling of iW
thyroid jJiUnd, the disease becoiniiig gi-adtially developed into a tru
bronchocele. Degoncracire clian^es, of a ;:^latinou« or cystoid oatur
may then occur, or nodulated, fibroid indurations be formed. As all
these changes occur aUo in commott bronchocele. Viroliow thinks it pr
babic that thu affection of the Lhymid is of a ne'^/ndnrif nature.
At the commencemonc, the canlinc affection Acems dimply to consist in
(he greatly increased action and violent palpitation? of the heart, bi
after a time dilatation and hypertmphy. more especially of the left
tricle, en^ue. There is often u marked bellows murmur, witltout fierlu
any valvular »ffcctioii, and the murmur may extend into the anrta auil
carotid. The puliation in the cnrotid is sometimes (jiiitc evident at a
little diiitance from tlie jiatient. The aorta and lar-^er arteries have
casionally been t'onnd to havo undergone ailiuromau^us changes.
The cxopbtbalmoji may become ho con Aide rahtc, that the eyelids can-
not be cloBcd over the cornea, but the latter, and a more or Icm consider-
able portion of the sclerotic, protrude between them. The protninion of
the eye is not j^enerally Btrai',xlitforward. in tlie direction of the optic axi#.
but towanis one side, t're<.|Uently the natnal. On account of the constaui
exposure of the nncovercd cornea to the influence of external initants,
its epithelial coveiin^ becomes rouj^hened and thick, ulcers are formed,
•which, extending in circumference and depth, may lead to extensive per-
foration of the cornea, and even to sulwe^i'ient iitrophy of the eyeball.
The eyelids at ttte came time become inHjimed, the ocular conjunctiva
injt^eted, and perhaps tedematon.o, and of a dusky-red color from oonstaoi
exposure to the atmosphere and irritants. The suppuration which maj
occur in this diitoaae is not, however, of neuro-paralytic ori<;iii, bat Vna
tjraefe thinks it i* due to a paralysis of the " trophic'' fibres of tlie fifti
nerve, as was shown in Meissner's experiments.
Cases of suppuration of the cornea are not, however, of frerjuent oc-"
eurroDce, uud 1 have only miH with a 8inj;le instance of ttic kind. wher>
a young woman affected with exoplithalmic goitre had lost both cyi
from suppuration of the cornea, and the eyebalU, although shrunkenj'
were still very prominent. According to von liraefe, it occurs more
frequently amongst men than women ; thus out tif 14 cases in which snn-
puration took place, it occurred ten times in men and four limes ID
Yfomen.*
The exopbthalnios is due to hypertrophy of the adipose cellular tLnsue
of the orbit, and to a hy{)encmic swelling of this tissue, which may
6rBt be diminished by prci^turc, and rapidly disappears after death.* [Thi
has been proven by Snellen, who, while examining such an eye with \l
• •> A. r. 0.." til. S. S09. ■ •• Erankhtfto OtMbwfilst*," 111. 1, 71.
' BerUni-r " Klin. WochiiMchr.,*' 16(i7, MB.
• VirL'li4iw, I.e., W.
■ XOPUTHALUIC (lOITKB.
76»
tttetlioficope, heard a distinct vaiwular murmur. Such murmurs occur
onlv in places where the blwxi channels dilate, and in contiecticm with
tlie exopli thill mO!i, tliey prohnMy indieatu a dixtcnition of th« orhitnl
veMftU.— n.] Rccl(lii);;liiiu3en has also observed fatty dpgeneration ot
the muscles of the eyeball. L>r. Wright' found, bolides stnm^ dilatation
of the veins, a small ([uantity of half coagulated blood extraraaaled over
the cTeball.
The true cause of the diacnsc and the nature of the connection between
the affection of the heart, the thyroid gland, and tlic eye are at present
unknown. It waa aupjiuKed by i^unie authont, that the pressure of the
enlarf^d ihvroid upon the cervical hloodvewcls caused the protrusion of
the eye. In opposition to thi^ view it may. however, be urged that we
often meet with very lar^^e broiichocelea without any exojilithalmos; and,
on the other liantl, aa has been eliown by I'raol, the lalt<?r may exitft
without any enlargement of the thyroid ^flaud. Others liavc supposed
that the symptoma are due to annemia, and Mackenzie speaks of the dis-
ease as " Aniemic Kxopbthahnos." But it is imposnible that aniemia
oould be the direct cause of ituch a condition, and it could, therefore, as
Virchow poinLs ont, only act in ao far, thai the morbid condition of the
blood cxertti a deleturinu» influence upon the nerves.
It is, however, far more probable that the affection is due to an irri-
tation or ■neuro«i« of the syrajHithetic nerve, producing hypertrophy of
the adiposo tiesuc of the orbit and dilatation of the veins. Tliere ie,
moreover, another fact which would ar>pje in favor of this view of irritA-
tion of the ttymnathulic, viis., the retraction of the upper lid ; for H.
MUllcrdiACovert'rtnnntripedmu.'tcular fibres in the upper lid, which arr sup-
plied by branches of (be n'lnpathetic. Any irritation of these nervelets
would cause an elevation of the lid, wliereas, if this irritability were
allayed, the retraction would disappear. Now the latter, as has already
beeit mentioned, may be observed to occur after the snbcutaneous injection
of morphia. The anatomical coiulilions of the sympathetic have, how-
ei/cr, been found to vary considerably. Thus jtouie observers (Wright,
Moore, TrousKcan, etc.) found the cervical jranj^tia uf the Kvnipathetic
enlarged, hard, and firm: and on microiicopical examination they were
seen to be filled with a granular substance, like a lymphatic gland in th«
i^T8t stage of tnbcrculortiti. Tbo trunk of the sympathetic, as well as the
branches going to Uie inferior thyroid and vertebral arteries, were found
to bo enlar;:;c(l. Whereas Kocklinghausen,' on the conti-ary. observed
th&t ^e tniiik and the ganglia of the sympathetic were diminished in
8ize,a<t if ulrophic, without, however, presenting any hisl'dogical changes.
One fact, which argues rather ngiiinsc die asaumfition that tbo disease la
diic to irritation of the sympathetic, is the condition of the pupil ; for the
latter was only in some casus diluted.
Virchow in speaking of the functional disturbances, also calls attention
to the fact, that together with the diuappearance of the bronchocele in
ennsetpiencc of small doses of iodine, marked acceleration of the pulae,
ami palpitation of the heart may be observed. Now as Uie same thing
has been occasionally noticed when ftpontanoous diminution of tho brou-
' •• Hod. TImn and OaMtt«,'' llffiS, Kov.
• Virrhow, 1. dt., p. MX
HI
760
DtSEASBS OP TBB ORBIT.
cliQcele lias taken place, the (juegtinn artnes whether tJieAo ftvinptomi nuj
not be due to an iidmixtiirc of soluble goitre- mat vrial with tht* blood.
The disease occurs most fpetpiently in women, (■3|«;cittlly during thi
limetif [jubiTLy, or Juriiig con fine iiitful. It is also observed to l»e paired!
with disturbances of tJie iitcnnu fiinctioru, particularly cbloroab, 8ii{
preettion of tlie catamenia, etc. ; it may al^ «upen-ene upon aerere cot
atitutioiial disease*. Aeconliiif^ to von Graofe. it is not oidy more mi
amongst men, but in them it occurs at a later period, and with grcatet
severity. It has been caused by severe bodily labor, or mental ahock*,'
fri;tht, great depreaslon, etc.
The course of the disease tn mostly very alow and protracte*!, and n*-
la{]9H>;t are very apt to occur, more especially if there still exists great
disturbance in the action of the heart. Amon;;«t men, the prognosis
should be very ^uanled. as the di»ea!Hf iwsuraea a much more seven-
cliunicfcer. and is more frtHjuently wjuipliciited witJi wirions afl'ections fif
the cornea. On account of the im|)edinieitt prodiicol in tlie intra-oouUr
circulation by the esophthalmoa, the retinal veins are sometimes dilated
and tortuous, but otherwise there are no changes in the fundus, and th«
function of the retina la generallv unimpaired. Hyi>ermetro]na mar
ariito on account of the flattening of the eye.
[Dealli nmy follow ny)on an increase of all the aymptoma, aomcrime*
speedily with ;!;reat cerebral disturbance, or it may ensue tlowly frHDi
gradual failure of all the powers. Somoiimesa complete recovery talcn
place rapidly, though tbo progress in either direction is uaually alov.— ^j
B.l
\\ith regard to treatment, the most benefit geema to be derived frookl
the adiuitiiscration of tonics;, more es|K'oially the preparations of i|uii)iiw^
together with a generou.-! diet, plenty of npen-air exercise, aud, if necea-
aary, a change of air and a prolonged residence in the country. Both
Ton Gracfe and Troussuan' comsiiler that prepamtiuiis of atcef arc con-
tra-indicated, more especially when there i^ much excitAtion of the vaA-j
cular Bytftem. Trous^au strongly recommends the U!w of digitalis,
which is to be Ireely given until tlie pulse sinks to 70 or tjO beats
minute, when the dose h to be considerably iliminishcd or the reroedi
suspended. He also advocates bleeding to diminish tl\e dai^r of
aspliyxia from the prcs^iurc of the congested thyroid, and to altonaie the
violent palpitations of the heart. Ho ban likewise found beuetit (mm
hydrnpailiy, anrl ihe continuouA application of cold comprcMcs on llie
thyroid and over the region of ihe heart. On the other hand, ho ik r>p>
posed to the use of iodine in cases of exophthalmic goitre, although Ih?
admits that, in rare and exceptional instances, it may temporarily pmvo
beneficial. I have ori«n derived much benefit from the administru^
of <|uintne and steel, combined witli largo doses of digitalis, if Uiere ts
great acceleration of the heart's action. Should the steel ho not well
bonie, I only give (|uiuiue aud
digitalis.
Dr. Cbeadte,* in his recent
paper on Exophthalmic (!oitro, ^iitate.i that he ha^ employed iodine with
advantage both internally and topically to the throat, and bcUevea thai
• ••CUniqaoU«dical(;,-'3<lMlt.. vol.11. &02.
■ "St. Uoorge'R UoapUnl R«|>urta," 1609, «ul. Iv. 192.
KXOPIlTUALMtC UOITBB.
781
I
I
it ts probahly most useful in those cases in which tho ;;oitre is Inr^e and
(xerts daii(;;erou]} invs^nrt?. A tirm compress haiiila|;e «itl often cauko
the exophthalmos to diminiBh couitidernhljr. rTinrt. reratri vin<tis Iim
proven beneficial in some cases, beginning with cIobcs of one drop and
l^radiialtji' iiicrHagiu;^ ; Itiil thiit iii»v iritti^u diarrhtva ait't iihouKl be com-
bined with opium. Bcllndnnna hnii also hccii given in rutwc caites vith
benefit. U niisesthi>Hia vr inliUration of the cornea occur, atropine and
the pressure l)aiidaj;e aliouhi be employed. — 11.]
Galvanixation of the sympathetic nerve has lately been slroncly rocom-
mended, amonRst others by Chvoatck,' and Moriw Meyer.' Tlio latter
has found it very Bucceasful in curing the exoplithalrooa nmJ the Roitro,
ae well as in improvio;; the •^i.-dcral health; but on the other hand, it
does not npitear to exert any iiiQiienue on the acceleration of llic pulse ur
tJtc palpitation of the heart. I have laU-ty tried it, and in one ca<to with
marKed bencht, as to the diminution of the exophthulmo:;. I generally
Apply the positive pole to the auriculo<maxillary fo>sda, and the other I move
jCently over the eloped eyelids, and after^itrda over the goitre. I em-
phiy about ti-IO cells for the eye, and S-14 for the K^itre, applying tho
eleclrifity for about ! J to :i minnto to each part. We may besides this
galvanlxo the cerviual ganglia of lliu sympathetic, applyinj; one electrode
to the a uriculo- maxillary fns&a, tho other to the titii or Tth cervical ver-
t«bra, or manubrium stcmi. It may take about iit-^'.fl aittinjja before
any very marked improvement i« noticed in tlie exnplitJialmos or ^roitre ;
and ronsiderinj; the little effect that other treatment lia^ n|K>n the dis^^ade,
I think that ^alvaniziiuon should always have an extended trial.
The peculiar retraction of the upper eyelid may be. if necessary, alle-
TtatCil by an operation upon the levator palpebrje, as has been advised
by von frracfe. lie was formerly in the bnbit of rceommeudin;^ turso-
raphta for this elevation of the upper lid, but now prefers a partial
tenotomy of the levator palpebne superioris. The latter opi-rali'm is to
be |)erformed as follows:^ The bom spatula having l>een introtlnced
beneath the upper lid, so as to put it well on the stretch, be makes a
borizoulal incision throu-ih \hv skin of the upper lid, extending nearly the
whole len;;th of the latter, and situated about 1'" above the upjwr edj^
of the tarsal cartilage. Ho then divides the orbicolaris, or still better,
excises a small hurixoiital portion of it, in order to '^m a Iwtter view of
the subjacent parts. A careful exposure of tbc tar>>o-orbital fascia will
bring into view the vertical or i>blit|ue ^tnatiou which indicates the tendon
of the levator {lalpebra*, w hicb here [tosses over into, and heciimes bleiwled
with, the cartilage. With a very narrow knife, the point where they
are blended is then to be inci<«ed at each side, so that only a narrow
central bridge (of almut 1'" in width) remains standing. Care must
of cuurse be tjikeu n<jl to perforate the conjunctiva. The result of the
Operation is an ineomplete ptosis, wliieh diminishes con.^derably during
the fir«t few weeks, the remainder just neutralizing the rctractuHi of the
upper lid which before existed.
■ " Wriiirr M«1. Pfrtiin"," IP69.
» H.Tliii.T " Kllii. Woi-li,.iiHohrift." S*pt. 2.1, I?72.
* Vlfitt Cumpltf-Routlu <lu Cvnitiei tl'UbUlli&lniidocle, 1M~ : alio "Kl. Monatsbl./'
UQT, p. 272.
762
DISBASEB OF THE OBBIT.
6,— TCMORS OF I'HK OUBl'I'.
It rroiilfl he quite Wyond the plan and scope of thi^ work to enter xi
Icuj^ih into nil th? variuuee of tumor that may be met with in ihc orbtt,
as well M the ])oint8 of difference in tbeir structure, di»;;i)Odi«, and tnode
of dcvelo|iinunt: I Ahnll. therefore, confine mvtielf to a brand and prac-
tical division nf this suhject, and nhall endeavor brietiy tn give the mn^t
chanictt'rititic and fading featurvs presented by the principal varietiei
•if liiiiior, AS well !\6 the different modes of treatment whiuh are mure
especially indiCHted.
Tutnora of the orbit may be developed primarily in the latter, or may
commence within clie eye or one of the neigbboriug cRvitica, an*!, grado-
ally increaaiiij; in size, finally make their way into llie orbit. .*V^ loii;t
08 the tumor it, confined wittiin tlio eve, it« proj^ross may tie slow aod
protracted; but when it h.i* once perforated tJie ocular tnnicsi.its growth,
bein;r no longer rehtrained by the firm sclerutic, is riftvn very rapid, fo
that it may, within n Hhort time, attain a very conttidorable sixe.
Tumora may be developed from any part of the orbit ; they may B]iring
from the bottom of the cavity, from ittt walls, or from its moat iiDlcrior
|>nrt close to the cd»e. As the morbid growth increases in siio, the eye-
ball wilt be more and more protruded, and the dirvetiuii of thi* prolr\idii)Q
Trill de]>end iifion the prit)ci|iii.| Riiiiation of the tumor. The exopbthalmcw
may finally become ro great, tliat the eyeball is ijuitc putihcd nut of the
orbit U|»u the ctieek. Together witli the protrusion, the movements of
the };tobe will be more or less impaired. The cyelid-i are genoratlT
a«'ollen and ce temitou*, and the uedema may be s» great thai it is impm-
eible to jud^e of thu true nature of the tumor, or it may even obsteurr
the presence of the latter. If the tumor is chietlir' *«itualed at tbo upper
part of the orhit, a certain degree nf ptoeia is frci|ueiilly prosoni. Tbr
eyelids arc. in other cftsos. grcatlv everted, their exposed conjunotiral
surface being dwollun and Kc-ciliy in appearance. There is often also a
very conaidfrahle de^rree of clietnosis of a dirty, dnsky-red lint. Tht
sight may suffer from the optic nerve being stretched or prcfisod upon br
tlie tumor, or from the impediment to the iotra-ocular circulation. Tbr
efflux from the retinal veins is retarded, symptoms of inilammation of
the optic nerve may supervene, and if the tumor be not removed, tlir
optic nerve may undergo cont^ecutive atrophy. Hut tlic sisht may alM
be greatly impaired or even lost from inflammation or extensive ulcenition
of die cornea, dependent u|)on it!^ coit^tint ex|M)sure to the action nf
external irriuiiiCtt, wlicn the eye is much protruded. Perforation or
ftloughing nf tlic cornea may ensue, and, the conleota of the globe encapioj,
the eye may gradually undergo atrophy.
lit attempting the removal nf any tumor of Uie orbit by ojieralion, ««
xhoiiid aUayx take into anxious coikMideralion its size, rate of pro^reM.
su!tpocted nature, and situation ; us well m t)ie cnnititioiiof the eye, and thi'
general health of the patient. If there is still sight, we should alwa^*
endeavor to rciimve the murliid growth, if {wsaiblu, witJioutsaerilicing tliv
eye. But in some caries, more cRpecially of malignant tumors, it is qniti'
imjKJssible to remove tho whole of the morbid growth without the removal
PIBROUS TUN0R8. t*>9
of tbft eye ; and in «ijch inAlanccs, it is far vfiser to sacrifice the latter,
iban to ruD the riak of Ivavjng purtions of tumor betiiiii), to prove the
ready source of a nH^iirrftnce of the ilisease. Wo fllirmld, if [m-isible,
remove tlu- tumor tliri>U[;!i the coiijiinctiva, hut il' this i* not jnnctionMc,
the incision must be carried throiij^h the skio of iho lids. The incision
ahonld.in such a c«!ie,l>e nlways hoi-izontal. and perhaps slightly curved.
so 08 to corre«ponil witli the natural wrinkles of the skio, and thus avoid
the formation of uiisi;;htly cicatricca.
In order to gain more room to work in, it may aUo be necessary to
d'rvide iht- outer caiithitH. We should always endcttvor to extirfMtc the
tumor without any inj'in" to the neij;hhorin^ parta, and fnrthis reason the
kuifc must not Ik- too freely used, but the attachment of the tiiuior uhouM
rather be loosened with the tip of the finder, the handle of a siialpel, or
with Ae pnint of a silver knife. In some tumors, it is nece9:»ry to
gouge out the different portions, or to snip them off the walls of the peri-
osteum with a pair of blnnl-priintcd, curved wiioora. The u*e of the
chloride uf xiiw pattte in case;) nf reuiovel of lualigriiaiit tumors. Tin well as
those who-te recurrence may he feared, will he cun^idert^d when itpeaking
of these tumors in detail.
b
(I) FIBROUS TUMORS.
The fibrous tumor itt oiipeeinlly characterized by the fact that ita
structure closely reeoml'les ihat of the radiating fibrillar connective
tisaue, the fibrillte being closely packed together. On a suction, auch a
tumor presents a firm and perhaps somewhat rflUijh surface, traversed by
buDiUes of parallel fibres. Its color is of a grayi»b-wbite or grayish'
yellow tint. The tumor is always surrounded by a distinct sheath of
thickened connective tissue, and is peiieiratcd by a small number of
veueh. These tumors may iiiiderj^o secondary changes, and cysts may
be formed, and in such n ca^c their firmne^ is diminished, and a certain
degree of fluctuation may he jjerccptible ; and if tbiJ la considerable,
Uiey may be easily misiakt-n for cyKt«. Or a^^ain, they may undergo
ofueous or calcareous changes, the bone being gencnilly met with in the
form of Bmall spicula.
Theee tumors grow from the periosteum either by abroad base, or by
one or more pedicles. They are generally formed near the edge of the
orbit, and if they are stalked, they may be felt in the form of small,
firm, circumscribed, movable growths. The consistence of the tumor
may vary very considerably. It ia generally firm and hard, from the
thickening and condensation of the radiating connccwvc tipsuc elements.
!n 4ilhcr cajies, however, it is softiidi and perhaps lobulatcd, or the aur-
face luay be euft, and Uie central portion, or that nearest to the point of
origin from the perio>ttcuui, may he firm and hanl. Tlie progress of the
tumor is generally very slow, and the firmer varieties du not. as a rule,
aciiuire a very considerable size. It U difforenl. however, with the
softer kinds, as they may attain a gi'cat magnitude. Thus Mooreti'
• Howrvn, "Ophthaliui&trUc1i« Bwiluicbtuiige'n," p. 41.
IrtSEA8E8 or TUB ORBIT.
(J TIMORS OF THE ORBIT.
It would W f^iiilc bc_v<>n<i the [dftii and ucopc of ihi* work in cntor
length into all the variviiefi of tumor tbut may be met vrith iii the nrbi
as well as the j>oint« of itifTerence in their atmcture, diagnoais, fitt<1 mi
uf tievelopraent ; I shall, therefore, coii6no myself to a broa<l iint] pn
ticitl division of thiit ■tiiliject. and .-ihiill cndcnvor briefly Co gire tlie mi
characteristic and leading fuaturcs presented hy the princijml ^-urictiei
of tiiniur, &n \\v]\ M tiio difleront modes of trciitmciiL wliich arc mo
esfMicially imlicatcd.
Tumors of the orbit ma; be developed primarily in tlie latt«r, or ma;^
vnmrat'iice within the eye or one of the neighboring cavitios, and. gradu-
ally increasin;); in siee, (inally make their way into the orhit. Afi lon^
as the tumor la confined within the eye, ita progress may he alow and
protracted: but when it has once perforated the ocular tunica, it* growth.
Win;; no lonjjer restrained by Uie firm ack'rutic, is often very rapid, «^^
tliat it may, within a dliort tiniv. Attain a very conniderahlc site. ^^M
Tumors may be dfveIoi»ed from any part of the orbit ; they may Bprinjf^*
from the bottum of the cavity, from itt> walls, or from its luottt iintenor
part (jIohp to the edge. As the morbid growth increases in nize, the eye-
ball will be more and more protruded, and the direction of this protriu-ion
will depend upon tlie principal situation of the tumor. The exophtfaaloHM
may finally become go great, that the eyeball U r|uito pushed out of the
orbit upon tlie cheek. Together with the protrusion, the inovemente of
the globe will be more or lew impaired. The eyelidj are j(enerally
dAollen and <e:lem:itou4, and the oidema msy be tto great that it U irapo*-
aibic Ui judge of tJie true nature of the tumor, or it may even obwurt
the prraencc of the latter. If the tumor is chiefly situated at the upper
part of the orbit, a certain degree of ptosis ia frequently present. The
oyelida are, in otlier caaes, greatly everted, tbeir ex|>osed conjunctival
aurOice I>cing awoHeu and fleshy in appeanmce. There ia often also a
very couiiidumblti de-^ree of uhemosis of n dirty, dusky-red tint. The
sight may fiutler from the optic nerve being fltretched or pressed upon by
the tumor, or fnmi the impediment to the intnk-ocular circuliitinu. The
elltux fmm tlie retinal veina is retartled, aymptoms of iuHanumitiou of
the uptic nerve may supervene, and if the tumor be not removed, tlie
optic nerve may undergo consecutive atrophy. Hut tlic si^ht may
be greatly impaired or even lost from inflammation or exlen^ivp ulceratl
of the coniea, dependent u|»ou its constant exposure to tlie action of
external irritantji, when the eye is much protrude<l. Perforation or.
sloughing of the cornea may ensue, and, the contents of the globe oaoa
the eye may gradually undergo atrophy.
In attempting the rtimoval of any tumor of the orbit by operation, w
slionid always take into anxious connidcration ita size, rat« of pro,
suspected nature, and tfiluation: as well as the condition of Uie eye, and
general health of the patient. If there is still sight, we should alwa
endeavor to remove the morbid growth, if possible, without sacrificing
eye. But in some ca«es, more especially of malignant tumors, it is qtui
imjx}9sible to remove the whole of tU« morbid growtii without the remo
riUROUS TUU0R8.
768
of ihti eye : ami tn siich instAnces, it is far wiser to aacrilice the latter,
than to run the riak of leaving portioM of tumor behind, to prove ih«
romly sourco of a recnrronce of the liiscaBB. We should, if poasible,
ri'inovc the tumor throii;;h the conjunctiva, but if this in not pfBCticflhlc,
the incision inuHt be curried tliron;;li the skin of tlii^ lids. The incision
should, in such a case, he slway" horizontal, aTid pcrtiji|»?i slightly curved,
80 as to correspond with the natural wrinkles of the skin, and thus avoid
tiie formatioD of uiii«i;;htlj cicatrices.
In order to gain more room to work in, it ntay also be necessary to
divide ihe outer caiithus. We should alwajifi endeavor to extirpate the
tumor without any injury to the neighl)orin<; parl^, and for thin reason the
knife must not 1m? tou freely used, hut the attacliinentii of the tumor should
rather be looitvued with the lip of the Bu;^r, the handle of a sralfnd, or
with ttic point of a silver knife. In some tumors, it \n necesiiary to
gouge out the difTorotit portion!^, or to snip them off the walln of the peri-
oateum with a pair of blunt-pointed, curved scissors. The uw of the
chloride of ittnc )>a8te in cases of removcl of ni»li;j;naut tumnn*. a-* well as
those whose recurrence may be feared, will be coiuidcrcd when sj>eakin};
of these tumors in detail.
(I) FIBROUS TUMORS.
The fihrouH tumor is especially charnclerized by the fact that it*
structure closelv resembles that of the radiating fibrillar connective
tiMue, the Ghrilla} being closely packed together. On a section, such a
tumor presents a firm and perhaps somewhat rough surface, traversed by
bundles of [Amllel fibre^j. ltd color i» of a grayish-white or gra^i^h*
yellow lint. The tumor is alway;; aurroundiid Ity a distinct ><healli of
thickened conoeetiTc tissue, and is pcnetratcil by a small number of
vessels. Tliesu tumors nuiy undergo secondary changes, and cyst* may
be formed, atKl in such a cu^e their finane^s is diminished, and a certain
degree of fluctuation may he perceptible : and if thiJ is considerable,
they may bo ea«ly mistaken for cysts. Or again, they may undergo
osseous or calcareous changes, the bone being generally met with in the
form of small spicula.
Thfttc tumors grow from tlio f>erioateum either by abroad base, or hy
one or more pedicles. Tbey are generally forincd near the edge of the
orbit, ami if they are stalked, they may be felt in the form of small,
firm, circumscribeil, movable gntwths. The consistence of the tuimtr
may vary very cnnsidi-rahly. It is generally firm and banl. from Uie
thii;keuing and condeofiation of the radiating coiuxHitive tii^sue elcmeut«.
In other cases, however, it is softish and |>erha|>3 lobulated, or the sur-
face may be sufl, and the central (K>rtion, or that nearest to the point of
origin from the periosteum, may he firm and hard. The progress of the
tumor is generally very slow, and the tirmer varieties do not, as a rule,
acquire a very conaiderable size. U U ditl'erent, Imwever, with tlie
solter kinds, as they may attain a gt-eat magnitude. Thus Mooron'
> Mwren, " Oplilhftlniintrtschu Deobiichtungvn," p. 41.
7tll
UtSKAdBS or IU£ ORUIT.
naeiitionii a 61)rou« tumor of the orKit wliicti, »fUr a former opontm,
Itlnined the i\zv of a cliilirs heud, ami invnlvnl dm booes of tb« &flt
ind head. Mr. Criichott* narrate! a remnrkablc case of fibroai tamot
of the orlfit removed at two sittiogs. Kehendei* han also recorded
caAe, in which he snccemruIlT removed a larji^o fibrouH tumor (pr' -
tlio eve), and applied Uie chloride of xitic pocte on a tflrip >. '
to the bottom of the orbit, the Hiirfacf of the loatlier on whict
caustic finatc was spread b*in:» tnrnt-d outwanlK aafty from tht* cyt
the latter protected bj tlie iuterposition of a thick layer of cl
This, Imwevcr, only just sufficed to save the eyehall from the actitMT
the paste, ns the outer surface of Ute gloV>o was covered bj a
layer of eiKhar, the sclerotic remaining, however, uninjured.
If the fihrou.4 tumors are small in size, and situated near the fdfje of
the orbit, ttiey can ^teniTally be removed without anv dauger; btM if
they are lar;(e, extend deeply inUi the orbit, and are widely itttAchei) to
tJie perioMteura, either by a broad base or by aeveral pedicle*, 0|M*nuiT«
interference must be extensive, and may set up very cotuiderablc ia8a»
mation, extendin;; perhaps to the periosteum of the orbit^ and (na
thvncc to the brain. Or the operation may be followed by fatml
(2) SAHCfJMATOl'S (FIBRO-PLASTIC) Tl'MOHS.
Sarcomatous tumors arc particularly dletingubheil in their cniu
stnieture by the fact that they arc eompodcd of rariou<t1y -ihapcd. clotelij
packed cells, and a scanty intercellular substance. These cells vaiy
much in size an<l form, bein^ Htellate, circular, oldon;;, ^pindle-^hapet:
etc. If the cclU contnin jiigment, it i-i tcrmc«l mcLinolic sarcoma. Tli
filinf-plji-xtic variety shows marked spiudle-sliapcd celU with a larj^t oiri:
nucleus and long, perlin|»s subdivided, Glatncntous extremities. On
count of this poouliar shaiie of the cell and these long terminal pnii
tions, it was iormprly sup[>o-*ed tliat the oonneotive tiasiie was formod
a division of these cell--t. liui this, as Virchow* points out, is errffneoi
for it is the rt|)ecial clmnH-tcrintic of these tumors that their cell*
as crlln, ami do not iM^nvdie develo|>pd into connective tissue: for il
develiipment t*iok placo, and a considenihle formation of fibrillar int*i
cellular substance really occurred, and if the ceIN were Lraosfonneil i
fibres, the tumor would simply be a fibroma and not sarcomatous,
fact, the fibr0-[>liistic tmnor is nolhiuj; but a spiniile-shapvd cell »r
eimia. 'I'lii! mali;^nant fibrous and recuiTenl fibroid tumors of l'n;;ol are
al«4i varieties i.f siircoma. The amiiunt of the fibrillar interrcllul«r »u
stance ("aries oousiderably iit ']uaiitity. In ttouie cases, it is Qrm
dense, in others, on nccnuni of the |i;reai devehi{>tucnt of tlte oella, it may
have nearly disappeared; In the latter case, the tumor is very soft aiH
become'4 meilullary. In rare instances (he tumor also contxins cyalst
and is then termed "cysto-sarcoma."*
• "A. f. O..- W. 2. 63.
• " KTWikhafti- li«k)iwaUl4f," H. 1, ISO.
• ViJ« " Kl. «oii«i»W.," 1WH>, M^roh. 11. 1
* Vi4» MwkenslB. p. 357.
SAROONATODS (PrBItO-PLASTtc') TUMORS.
l65
8arooiiiaU>iiH tumors are not benign in character, but show a great
t«fi(l<Micy l<) inft'ction of Mety;hboring orghiis, conimencitig tirwt m UiO
bomolugous tissues, and ttivn pastsiti'* on W tlie heteralo;;ous. Jliit tlivv
affect rlistnnt organs, ami as the lymphatic glands fre<ineutl7 remain iiii-
affetrtt^d, it lias been giippoaeil that the infection is carried n»ore liv the
blood thnii by the lynijiliatic vesstU.
Accorilinji to Via'tiMw. the sarooioatoua tumors of ilio orbit " are gen-
erally <ievfln|)uil from tin; adipose cellular tisane behind the eyo. alter a
time pnshing tbe eyehnll nut of the orbit, and appearing beneath the
conjunctiva in the Ibrm of round, firm protrusions, finallj aiisuming a
fungoid eharncter. Their (.'ommencemcnt may often be traced U} distinct
traumatic caiises. If no operation is performed, the eye is in llic end
dentroyetl by pressure or inflammatiou, and at tbe best becomes atro-
phied. Or again, ilie fuufpis may grow iiiwania, reach the dura mater,
invade the cranium, and generally ends in mstasUiiwa, amongst which
Ihone of the honen of the skull are the rooeiL reinnrknble. Mn^t of tlie
orbital Mrcomnla have n ftoftiith conmalcnce. and belong to the melamv,
myxo-, or gliosarcomata. They aru generally multi-cwllular. But even
those cnnsiiiting of amaller cells may bo oiH'rau-d upon with suceesa."'
Freipiently the sarcomatous tumors, especially mt-lanotic sarcoma, origi-
nate in the eyeball, ami subse<iuently make their way into the orbit.
In some cases the sight n<maina perfect for a long time, in others tt be-
comes greatly impaired or entirely lost from optic neuritis, atrupbv of
the optii! nerve, detachment of tbe retina, extension of the tumor into
tbe optic nerve, etc.
The great danger of the disease is itJ> extension into Uie neighboring
cavities, the \nmy walls, which separate these from the orbit, Wing de-
stroyed by caries or necrosis, or worn through by the pressure of the
tumor. In sueh a case, the extension of the growth in an outward direc-
tion may !«■ slow and protracted. The operator, thinking that he has
only to deal with a moderate, Bliarf)ly defined tumor, ie surjirised to find
it cxtemting far into neighboring caviiies, in which it baa perhaps
reached a very considerable sixc (Stellwag).
[In not a few instances the sarcomatous gnmth starts from the perios-
teum of tbe orbit, and grows very rapidly. It i* not uncommon to find
that these grow from both the orbital and intracranial sides of the roof
of the orbit. Somt authors have advocated the removal of the orbital
plate of tbe frontal bone in these ca.se.ii. and it has been done with suc-
cess ; but the risk of injury to the dura mater is ceruinlv great, anil
seems a very serious thing to do. Still a radical and complete extirpa-
tion may in this way be powibte. — B ]
Kuc the tumor may he originally developed in some other cavity, as,
for instance, the misJil ftrtsa,* or antrum of lliglimore.'and extend llicnce
into the orbit, f lirowtbs originating in this way are very serious ca.sc:*.
They are generally of very rapid gniwih, have widely -extended ramifi.
catioits, and are almost always complex in character, such as combi-
nations of sarcoma with myxoma, adenoma, osteoma, enchondroma, or
• "KrAnkhftni>nr«chwaUt>!," p. 349.
■Grw'ff. ".A. r.O.." t. 1.4Ifl.
* fagonntMher, *■ Kllnlsclic BcobaolilUB|«n," 1.
TA. uei.
m
DtSGASGS OF TII8 ORBIT.
cArcitioma. It is scBrcclj pflsatble to remore these f^wtha eoiii|]lelelT
without an excision of tlie superior mnxillft alone nr of jMtrf'
tioiies of (lie face ; anil tliv (lisvasutl proceed has frt.-i|ueutl_^ ■
far til all itirvcuoiiti, Uiat even Huch a t^everc onr^ii-iil procodun.- a^ IM
above prove« un9ucce»]irnL (Sec " IVans. Fifth lulei'uat. U|iltUi. Co<&*
gresa, 187ti," p. 58-fi2.)^B.j
These tumors are verr apt to rccuFt and may have to ho opentdA
upon several times. Tliua in a case narratod by Mr. ^uain he openlad
three limca.' If the ni^ht is uimfFccloii, wc slumhl endeavor to remoTf
the tumor without sacrilicing the eyeball, and in order that all remain
of the niorbii) ;(rowtli may be removed, the chloride of sine ^la^U!, sprad
upon strips of lint, ithould ho inacrtcd into the tround, care hcin^ takes
that (he dry ^ide of the lint i^ tunied tgwanh the eye, and the latter
should be still further protected by the iiiter[io»iiion of layen* of cliarfiir.
That the caustic may be applied without injury (o the eyeball •►r tt*
mu;4c]es, waa already shown in Zchender'a case: Mr. Iluike' hiu more
lately published a similar instance. The eyeball may generally ^>e save^j
as ton;; as the disease has not extended into the conical space (Mui>kell
richicr) inclosed by the four recti miisclea (finiefe).'
But where the disea.'W is exicnnive, tlie eyeball lost, or there it na
doubt HH to the maliguunl nature of the disea'te. the ^Mm must b« ex-
cised witl) the tumor, and the latter (thnuhl be M thoroughly removed aA
poxnible. Hub the excision of the morbid growth with tbu knife aixl
bhint-pointcd curved ecissors alone, will not suffice in cases where th*
tumor is of a sarcninalous or carcinomatous nature, and infilirutea more
or less the uci};hl)orinj; structures ; for then it cannot nith certainty bel
eom[>!etely removed, niiil remimnta of tumor are tture to bo left boKind.l
The eurgi'iju sliouhl endeavor to remove as much o^ possible of the oiof'
bid (^rovrth by uliippinx it uway from the walls of the orbit, uxplorin;!
tieforchand with the En;;^r the ma.«ii which he tit about to excise. If ibt
Willis of the orbit are ^iso aftected. the periosteum, or even portiotia of
the diseased huiie, may lie reailily n'lnoved with the elevator. In onier
to chock tlic hemorrhage, and to destroy any remaining porti«>n* of th»
morbid j^rowth which cannot be readied with tite scissors, the hut irofi
should bo applied to the wounded surface, and then, when all bleodiB^
hwf ceased, the ciduride of nine paate, spread upon strips of Hut, ta to he
npplieil to the wound. The chloride of xinc [lasie hait U'cn used extrn-
tivcly, and most successfully, at the Middlesex Hospital, wIicT'
lowing formula is generally employed: One |"iirt by weight 0}
nf zinc is rubbed up with four parts of tlour, to which i^tithcicni ciociun
Opii is aibled to make a paste of the cousistviKC of Imuey.
To many surgeons the use of the hot iron and of an escharotic bo ibe
orbit will appear a most dangerous proceeding, on account of the thiu-
ness of the roiil' of the orbit, which divides it from the brain. Hut
exfiericiice proves ihat this proceeding, if carefully and exjiertly [*r-
foniied, 14 nut fraught with any particular risk, lor Ihc action of the but
iron is au|)erficial, and that of the chloride of xiue can aUo be venr well
• "Mwl. TiiOM," IW4, No. '_4I4.
••■A. f. 0.,- X. 1, lUT.
1 ■' U. L. 0. U, iUr," t, 4, 34&
^^
O8SB0TT8 AKD OARTfLAQ fHOira TUMORS.
7fi7
rogiilalnl. Moreover, it produces little or do constituUonal disturb-
aitue, mihI only excites tili^^lit inflammation of ttic liviu<; tissues bcjontl
the aloiijih. The tnith of these statemente ia sufficiently prcved by the
very i-eitiurkable cuHes in which this line of tn.'atjnviit bais he«n pur-
sued by Mr. de Mnr^^ii, Mr. M<iore, Mr. Hulltc, and Mr. Lnwiioii, iind
which have been brought before the notice of the profession at different
periiHlt}.
Mr. Ilulke' reports a very interesting case of large fungating mela-
notic sarcoma which had become developed from a ahrunkeu eyeball,
filled the cavity of the orbit, and protruded between the eyelids, which
wa« succes?ifully extirpated with the aid of the actual cautery and chlo-
ride of tine [Mixto.
A very intcrcsling and important case of recurrent fibroid tumor,
which liBM been operated up<.>ii several times by Mr. LawAoii, is reconled
ill tJio " K. I.. U. H. Keports," vi. H, :i«tj. [tfee also *■ Trana. frlfih
Inteniftt. OphUial. Congretw, HJ"tj." pp. 258 to 2(>a ; " Traus. Aroer.
Ophlh. Soc.," Ils7».— B.]
(3) KArrV TUMORS OF THE OnHIT. [LI TOM ATA— B.]
Tlic fatty tumors arc developed in the adipose cellular tissne of the
urliit, either in its cavity ur between the recti miLtcle;*. juxt beneath tlie
ConjniK-tiva. They generally occur in early life, aitd are somelimc!* per-
haps congeuilal. They increase alowly in growtli, are not accouijwnied
by any aymptoms of pain or intlammatJon, and vary much in aiice and
coiiaistencc. The latter will de]iend upon the relative amount of the
fatty material, aixl tlie tirmnc^s and i|iianiit<y of Uic flbru-cellular tissue.
Tbey are often very cindtic tn the touch, and give rii40 to a setvse of flue-
tualion, which may deceive u» aa Ui their true nature, and cau»e them, per-
haps, to be mifitak«Mi for a cyst. Utt fliiRcidty ia generally experienced
in their removal, which ehonld, if possible, he rlonc from withio the eye-
lid. [They do not retura. — B.]
(4) OSSEOUS AND CARTILAGINOUS TUMORS.
.Vccorditig to Mackenzie,* w«* may distinguish throe form^ of exostosis
uf the orbit: 1, the cellular; 2, the oi'a;;gy, or semi-cartilaginous; 8,
the ivory. The cellular exostotd^ is chamcterisceil by its being composed
of an Oisaeoua cruat, which surrt>un<h» a softinb enbatance. ti-aversed by
numerous delicate l)ony itarliiioiix. Sometimes, it may coniain byda*
tida. Thia form of exontosis springs fn:>ra ihe periosteum, does not
j|enorally acquire a coniiiderable »iiie, and may remain >(uiic statiouary.
The craggy or semi-cartilaginiHia e,xo«toai» generally consist* in the cen-
tre of osaeoun laminw, whicli are surrounded by cartilage, over which
the perioatoum may be imperfectly traced, but it has no complete shell.
t ■•&. L.O. H. B»p.."T. 8. 1$1.
■ " DiavMfVtff Ih* Kr«," 4tb nlftlon, |>. 41.
168
DtSBABBS OF TKB ORBIT,
It tDay ^row from the cnncclii or from th* periosteum. The ivory ein*.
tosia b the form mont fre<|nently met witli in the orbit ; it is exce»»i»TlT
ImnI, and consist! of perfectly (Jerel
[I'lg. 208.] oped, dense, nnd very firm l»one tis»oeJ
Avcordiitj; to Maekfiixie. it origiuat«4'
in t}ie diploe, pre$.tc.i the compact tiwua
of the bone before it. and I'onnrf a round,
amootli, or somewhat nodulated tumor.
[Kig. 208.] It, moreover, itbow« a dia-
KjiliZ^vOMkfl^^Jr position to extend into the cranium.
Kxoatoaid fre*|ueiitly supervenes apon
periostitis an.l ostitis, and m»y bf 'in
to a Kcrofutou? or syphilitie diathesi
or be produced by injuries, aiich ns fal
or blowH upon the orbit, or by fractu
of the latter.
These 08*eous tumors »re innre or less bard to the touch, «low in theil
pro;;re88 and ;;ro«th, and (generally accompanied by litUe or no pain
inflammalory avrnjitonis. Somclimeg, the pain may, however, he severe.
more especially itflymptoiu* of [n-riostitis eoperveiie in the coiir*e of Oie
disease. The de;;rec of exophthalmoii and imfjiinnent of the moveoien
of the eye will vary with the extent and sitnaiion of the exostoais. It i
often (|uite impossible to dclcmiine the exact nature of the di»ewc Iwfg
operation, more e--ipet'iiilly whi-n the tmnor is "ituatud deep in the (irtii
Ivory exostosis is frcquvntly developed from the frontal or ethmoid boti
[According to Knapp. these bimy luraors gn>w on the peripherv onlyj
converting the connective tissue over them into bone. Their bulk ma;
spread out beyond the base, and their adhesion to the underlying bone
Komeiimes less firm than their consi-ilencc. Tlieir periosteal coverii
may contain cy^ts. and thus render the diagnosis very difficult. Knap
HdviBes. when tbey grow from ttie rofif of tiie orbit, that they aliould ti«'
removed with their ha«c by cbisel and mallet, and by traction in varioi
directions, thus leavin}» the dnra mater exposed. ^Sec "Trans. Fi
Intemnt. Ophtb. Congwia, IHT'J," p. .'>4.) — B.]
In the early stage, the treatment should be directed to promote th
absorption of the tumor, by the administration of the iodide nf potasai
internally, the appliciitioii of mercurial oiiiimcnt over the bniw. etc. Thf^
SHitietit's general henllb imist be attended to, and kept up by a generviM
liei and tonics, residence in the country or at the sea side, etc.
If the exostosis is small and remains stationary, it shunM not be inter
fen-d with by operation. But if it is increasing in site and in prodncing
exophllmlmofi, etc., the aurj^con should endeavor to remove it.
The tumor should be freely eK]W)scd by one or more incisions, carried
through the integunit-iiti and Iwiween the fibres of the orbicularis, or. if
necessary, by directing iMick the lidtj. In order lo jjain plenty nf r<joro.
it may also be necessary to divide the commissure of the lids. 1'he
tumor, having been thus exposed, is to be stripped of its periosteum and
carelidiv excised with a schIik-I. uii^iKted by cutting pliers and •nfti*
bone forceps, lireat care mu*i be taken not to injure liie up|R-r and
inner wall of the orbit by a rough and ihuughilcds use of the itutnimm
J
0T8TI0 TUMORS Or THE ORBIT.
769
The irory exoetoses are fre"|»ently so Brm »ml liard, and m intimnt«l/
And widely tioQni>cH.'d with tlie bono, tlmt it is only possible to remove a
oenain portion of the murbid growth. Mr. Ilattiea Walton narrates a case
in which he succesafulW removed a large ivory exostosis.* Two siintUr
insiancca are recorded by Mnisonneiivo. [Kor theao very dense tumors,
the cbidel and mallet are belter than die miw, but a ttill better instniinent
is the dental hithv with drilU of variotut size;}, the rapid revolution of
which niakcrt it po^siblo to use lateral pressure. — B.]
Sometimes, however, the tumor is so exceasirely liarJ, and its attach-
ment so extuujiiiive. that it resists all the efforts made with the saw, oDC-
ting pliers, or mntlct ; Utile splinters of bone may be chipped off, but tho
great ma^s of the growth is impre finable, and the o]ierntion hii? to be
abandoned. Snch instances have been recorded by Mackenzit:* and
Knapj).* In Kna]>p'8 case, seven weeks after the operation, the first five
having tieeii |)as3cd very i)iiicllv and fuvorahly^ the patient was attacked
with symptoms at meiiiii;;itiH, of which she died. On post-mortem cxamU
nation, a general tiitckening of tho uraoium waa disoovered, together with
a larj^ui cxoatodis, about the sise of & gooao'a egg, springing from tho
frontal bone. In a subge(|iient case of ivory exostosis, Knapp succeeded
in removing the tumor.*
[A rery interesting case of large osteoma of the maxillary sinus and
floor of the orbit Is reported by Mans. The tumor was entirely removed,
and the patient recovered wllii fair vision. (''Archives of Oph.," viii.
3, p. ;iii(»-a2K. )_I1.]
The trnv cartihiginoiw tumors (enohondroma) am only very rarely
met with in the orbit. Many of the case* which have Wn recorded
under tins name, were in reality instances of osteo-stetitoma or osteo-
sarcoma. This mistake is the mure easily mai.le, as some of these tumora
in the course of their development undergo cartilaginous changes before
becoming ossified.
Altliougli these cartilaginous tumora, as a rule, spring from the bone,
they may also become developed from the softer tunics of the orbit.
'Vhcy arc most frci|acnlly met with in youthful individuab. In a case
" von (tracfeV it occnrrod in a child only Mven months old, it being
tted that the tumor had existed since the first mouth after birth.
(6) CYSTIC TL'MORS OF THE ORBIT.
Cysts may occur at various purla of the orbit, either dcen in itrt cavity
behind the eyelnill, or near it.^ upper or lower mar;;;in. \^hilst some of
tliesi.- cysts contain hydatids, others are dcvt-lopt-il from tiie follicles of
th« liiU. At first, tiieir true nature may bo reatlily recognizable, but
when tliey attain a couiiiilcrablc size, the conneclioa between tlie cyst
and the follicle may become so attenuated, stretched, or even torn
through, tlmt their real mode of orighi is otten overlookwl. Tho con-
sistence and contents of thexc follicular cysta are subject to considerable
■ " Rar^csl IMowwm of tho Bye," 28tf.
• "A. f. O.," vUi. 1.239.
> "A.f. U.," 1.1,415.
4»
■ L. c. 46.
« --Kl. Mcoaubl.," 18«5, 37C.
70
PIS8A8B8 OF TEB OBBIT.
rarintioiw. Thaa in the athcrorruLtoiu form, Ibe conienia un of % fnaUe,
cbee^jr, or curdj nature ; whereu, in Uie •UaUnmaUMM U)«/ r»ili«' n-
Bcmble 6Uei.
Other cysu sprinf; from the glantlular stroctaros of the oenjoBCtiTs.
Aiifl uiiLV contaiD a jellovi. gerouj^. or rattier vimad and *"*—"■*"* Bnd.
like whit« of egg (the latter kind of c^st ii teriDed lijgroan). Tbef
mar he shout the size of a pea or bean, and situated near the avriaee ii
tlic* conjutictiva. Hut tliey sometimoa extend back into the orini, uaii
A rerj conKiderable size, and then gire ri«e to great eTophthal»oa. b
rare iofltances, the cyats contain a browo hemorrhagic 6ai<I.
iwme orbilul cvstH have been found to have hairs, etc., growii^ (nm
their internal walla. [See "Report of Fourth Intcmat- Ophthal. C<i»-
grens." London, 1872, article on Intra-orliital Uermoid Cjata. — B.]
Two kinds of hjdatidB are met with in the orbit, the echtDoooociu, aad
the c^attccrcu8. The former is much larger, and occurs in grvater
niiinticra than ibo cyxticercufl. Thus echinocoocus maT accjuire (be 5tsa
of a filbert, and be pr^4i;nt in great <|uantitieii, cauaing an exeeuire pr»>
tnision of the eye. In a case of Lawrence 't;, quoted bj Maekemie.*
half a teacuiiftil of echinococd, varying in site from a pea to a filbert,
were emptiea from an orbital cyst. Sir. Bowman* operated opon •
Bomewhnr similar caiic, in which Uirec hydatids tramc away a few days
after the operation. Two were as big as large marblea, the third about
half the aizo. In a catte of Waldhaner's,' some of the hydatid*, of
wbit'li there waK » i^eat ciuantity, had ac<|uired the exte of a liazel-nnt.
Tlic by^latid li inclosed lu a capsule of thickened connective tiane,
besides the proper cjst wall. T^t
[Fig. 20|>. cysticcrci are much fmalter in
sixe than the echinocooci, an4
their eyat wall much slitter ud
thinner.
CyiitJc turaora of the orbit arc
generally slow in their progre«.
and may renuoin but small in •'■
if they however grow r
bly, the eyeball will gr^
protruded. Ilie devcloitauriii. i>
generally tmaccompanie^i by a&y
pain, but when tliey are very large,
and have cauaed great exo)*^'i>-i-
moa, the sufferings of the y •
are ol^en must intense, the jam
cxtendini;; |M>rha|w over the con«-
9]>0Qdiii^ Mi fif the head anl
Afur iiMk*iui«.) ^'"^^' '^^'*' tumur is not, bowerrr,
lender to the touch. If the eyil
is situated near the front of the orbit, so that it can be seen n-; ' '" '■ - - '
present a round or ovoid appearance [Hg. lioit] of varying -
UlArkriutii, 10^7.
- Kl. Muuitatil.," IMS, p. 381.
■ lb., 10«i9.
CrSTIO TDMORS OP TUB •tUUIT.
771
aerreil to b« quite unconnected with the c^reball. When the cvst w»ll is
thin Biwl Boft, the tumor wiU be verj? elaBtic to ^e touch, and distinctly
flucumting. [f (irm pressure is applied, it miiy pi>rhiipabc tn*de lo rccedo
iiiti> the orbit, reapp<;ariiig, however, when the iMXSsure is reUxeil. If
the cyst wall is thick, or the in teguments over the tumor are swollen,
the Utter wilt, on a guperlicial examination, feel somewhat liria, the
fluctuation Iwiug only discovered on deeper pressure. When any doubt
cxiiitt as to the nature of the tumor, an explnratory puncture or incision
should he made, and then, if the cyst is found to he only moderate in
extent, and not reaching very far back, and if iH contents are dense, it
ehoiild he excised, wliich in beat done by directing it out with the aid of
a apatula, or the end of tlic handle of a scalpel, a^Diatod by the linger.
If the content* oi*c duid, and the cyiit i« large, it will be bettor to empty
it (if neCGMary, repeated several time») by an inciition, and then to per*
rait it to close hy adhtf^jive intliiniuiatton. SometimeA strips of lint are
!nt)ertc<L,thu.s ^ttin;{ up Auppuracivc inflammation; hut thix is dan;{erou«
if the cyst extends deeply into the orbit, as the iiiHummation might ex-
tend to the lining menibrani-s of the bniin. Injections of iodine have
been recommended, but they are also accompanied hy considerable risk.
I may state that at the commenceowDt of the disease it is often ex-
tremely difficult, or even impossible, to diagnose with anything like
corUiintv. whetlier the nature of the orbital tumor is benigu or malig-
nant. There are, however, certain pointii, wliich may atuiiit us in our
diagnosis. Thus, in maltgnauE aflections the general health of the patient
mostly suffers considerably even at an eai-Iy stage: whereiks, in the
benign tnmoiit this is not the case, the patient retaining good, and even
blooming health, excepting indeed the tumor has attained a very consid-
erable s'lZQ. and prorluees great pain by pressing upon the eyeball or
stretching the iierven.
The progrett!4 gf a malignant tumor ts also, M • rule, much more rapid
than when it is benign. The rapidity of its growth will, however, vary
acconling to circumstances. Thus, as long as it is conHned to the pos-
terior {Hirtion of the orbit, the pressure of the eyeball ntlers a certain
dr-groe of check to its development, and somewhat restrains its rapid
growth. The same is the case in intra-ocnlar nmllgnant tumors, whose
pnjgresa may be comparatively very alow as long as they are confined
by the external coatt of the eye; but nheu tliese have once given way,
ami the tumor sprouta forth, its increase in sixo ia always moat marked
and rapid. The pain U aUo much mure inteiiite and continuous tu mnlig<
nant tumors, but this symptom is not very reliable, for even in benign
tumnrs it may l>e very severe, if llie eye iu much protriideii.
Von Graeff' lays great importance upon the degree to which the mua-
cles of the eye and their nerves nro implicated, as a point of lUagnosis
between benign and malignant tumors of the orbit. Nlalignunt growths,
according lo him, always cause a much greater ami earlier in>|minnent
of ihc mnvements nf the eye, bo that the latter may be already almost
immovable, whilst the exophthalmos is yet but slight in degree. In esti-
innting the amount of immobility, we must, of course, take into con^d-
* "A.r.O.."a. 1. IM.
77«
DISEASES OF TUB ORBIT.
eratton Uie raechanical effect of Uie tumors and the cbange of positioa of,
ihc eycliall.
The skin and neighhoring parts are more frcrincntly affected in imlif
Dfint tutuors. so tltat the bQuiiilarie.'< of the latter caunot be so cxactlj
made out, uml the skin U not so movable over them. Miili;jiiant j;n)wlh»|
of the orbit are also of more common occurrence in children than ia]
adults. Thus Leher has found tliat in one-thi«l of the caaes of ouicer i
the eye and orhit, the patients were under ten years of age.
Whether or not the uimor sjirings from the eye or is eonttnuotu with
it, may be estimated hy cho nature of the movements* of the eye^Mill. Ifj
the movements take place rounrl the tuniln;^ point of the protruded eye,f
it proves that tlic nonnul layer of conneuiive tisisne between the po*.^
terior hemiaphpro of the eyehall and the tumor still exiot^. Whereas if ^
the tumor and the glohe nre continuous, the movementtf wtU not be TQimd
the turning point of the eye ((iraefe).
Canceroua turaora of the orbit may be developed from the walls of iIk
latter, fi"om the adipose celhilar tissue, or may extend into the orbit from '
neiahhoriuj: cavities or from the eyeball.
The modulUry and inelanodc cancer are far more fretjueutly met wiUi
id the orhit than scirrlius.
(R) SCinRHFS.
Scirrhas of the orbit is generally due to some injnry, or to prior in
fiammation. It mav show itself in the form of one large scirrlutud hm-
imjilicmiiij; the whole of tlie orbit, or iu the fonn of small, circnmhcribt-lJ
hanl tumnrs, which closely resemble exostoses in their appearance. Ital
growth is i;enerally slow, and not accom|Minied by much or severe pain.
The following cn^o of scirrhous tumor of the orbit ia of ran* im])ort-
ance and interoAt, a^ tllit^tratinji; the j^renc benoRt to be derived from
extirpation, followed by the application of the hot iron and chloride of
sine paste.
A woman. a$^d 4A, upon her Admission into the Atiddle^ex no«pital
under Mr. Lawson, January .^0, IStiii, had her left eye protruded a full
inch beyond its fellow by a hard solid growth, which could be distinctly^
felt with the finger to be filing the orbit. The surface of the come
was ulcerated, and tlie eye had only jwrcoption of H;;ht. Tlie uii[t4-r li^
could not close over Uio globe. About four month.* before her admi.<«lv:
n hard ecirrhoiw tubercle wa(* noticed in front of the ear, it waa no»
about the t^ixe of n bean. Mr. Lawson excised the eyeball und tin
whole of the caneer down to the orbital walls, and then applied the aetui
cautery to arrest the bleeding. Strips of lint, covered niih chlori<le m
zinc paste, were then applied to the bottom of the orhit and around it
via\\». lie next excised the tubercle on the face, and also applit--d Ml
this, after all bleeding had ceased, the chloride of zinc paste. IjirKO-f
superticial aloughs were at Gr^t detached, and in about three nK^utbs
aftcrwHrds the whole bony orbit became completely detached, and Mr.
Lawson pulled it away in one piece (Fig. 210).*
1 "Trniiuctioat of the PatholoKte«l SoctKj." 18S7. p. Z83.
MBDULLAHV CANCBB.
778
The exact me and niipttaraace of tlic orbit after its renwvnl are hero
very correctly represented. It is tiDw in the mascmu of the ^fi^ldlosex
lioHjiital. The |Miticnt had a gowl deal of pain in tlie bead and ftiukre.t^
during Ibe se|Hiration of the bono from the lie i^HiIk) ring tissues, but sit
these sjmptonw at once cmwod after ibc orbit bad come away.
I^g. 310.
Pis. 211.
/i
TTp to this date, June. 187^1, nearly 7| ycara after tbc aperation, she
IS Atill perfectly well, and hait had no rt-L'urrencc of the disease. Her
present appearance ia well illuittnLted to Fig. 211,*
(7) MEDULLARY CANCEtt,
This is cspocinlly diatinguished by ita soft con^iateuce, vrbicb greatly
nwmbles tlmt ot rice, by tlic peculiar cauliflower excre^ceitcve. or the
rr^I, Beshy, fun;;nug appeaxuncc (fuiigux hanimtodcA) which h prettentA
when protrudinft from the orbit. Tlie fomi of tbc tumor may be toler-
ably oircutmicribed, and it otay not be very adherent to the puriostoum ;
or it may he closely connected wiili the latter, al?o invading and destroy,
ioy the nmscles of the i^ye, Uie periosteum, ami, fiimliy, the bones of the
orbit, and then extending into the neighboring cavities. U may like-
wise extend along the optic nerve to the bruin.
The tumor may grow with considerable rapidity, and attain an enor-
mous size, and this is especially the caAo when it recurs, after tlie eye-
ball and the primary tumor have been extirpated.
The fdlbmiing ca«e of Mr. de Morgan's grHphically illurtiraiea the ap-
pearanoen prraontcd by such a tumor, an well as the mode of treatment
wbicb should bo adopted, and which proved successful for a period of 14
' Thiwi- woodcatH (vrlilcb Tei« klodl/ lent bj Ur. Lvaoaa to tbo author) Are ■'ram
jili«t<>gr«pli3 hjr Mr. Uviscb.
776
DISEASES OF TBS OttBTT.
F'K. 213. rernly from the orbital for*.
men aud ^plieuoiilal Qhutp,
the or>uc ncrvo as far as iho
comtnigfiHre beinjc involveil in,
and undtftiii^ruistiaMp fmtnit.
Cancerous de|K>*iW wrt. iit«
found in the glands aruund
the aona,and wlhering to the
norvc tnitiks of the cauda
o(|utna. Tho orhU naa eniptr,
and froo from auy cancerous
The rottini of the disraae,
and itfl fatiil tcnnination, vtre
coDSoqut^ntly oaly duo to the
fact tbat the optic norre ni
involved in the cancerooi
afTi'tition. Mr. dn Morgan
therefore thinks that these
faubi jut^tily Uiv Wlief, that
had tho operation hccn done in tho snmo manner at an earlier periodi
the patient might have remained well.
(8) MELANOTIC CAXCER.
Mclonotio tumors of the orhit are, like those viihin the eye, oflea
either of a sarcomatous or a mixed character, one portion of the morhiJ
gru»thhotn^of a sarcomatons nature, another carcinomatous. The char-
aetor and proj'resjj of melanotic cancer have alrt-'ady been given in th«
articles upon tumors of the choroid (p. oo5) and need not be entered
upon here, as the disease does not differ e8t>«ntiallT in its ooarae asd
nature (exceptin;; its color) from other cancerous affactiona of the orhU.
(9) EPITHELIAL CANCEK.
Kpithelial cancer of the orhit ia also oocasionnllv rai't with, nr
in tlie skin of tlic teuiplc.clioek, or nos«, and extoniiing from iU-.
the orhit. Mr. llulke' narrates a most intercstin<{ case of opitlielial ciu>
cer of the orhit caused hy a severe hlow upim the cheek, in which tht
sirmptom? presented h^ the disease closeljy- resembled those of carhuues^
lar celluUuB.
[(10) Among the rare tumors of the orhit mav he mentioned the ryJi
droma. These tumors arc usually mixed, containing KctteralW a larL-
number of sarcomatous elements, but also more or \vm of tlif cvlindrotA
arrangement of epithelial cells, wliich is the eharactcristtc feature of tbeie
1 "B. L.O. H. K*p.,'*T.33e.
VABCU1.AK lUUORS OF THE ORBIT.
777
growths. An lnteTC3tinp[ cmo of this ViJiA i* reportcfl liy Sattlcr. (See
the ** Vicrteljahnieli. f. prakt. Jleilk." lid. 1.) Tiiey are maliguaiit and
tend to recur after removal.
There are a few cases on record of conysmtai tacephaheeU, which
grow to an enormoua size. One such caae is rcponcd by Haab. (See
I the " Weiu. Med. Wocheiwch.," May 11, 1870.)— B.j
fOnl;
7._VASCL'LAR Tl'-MORS OF THE ORB!T.
(1) Caversocs Tttmor.
Only four instanci's of This very rare form of orbital turarir have been
recordeil, by Lcbert,' de Iticci,' von Oraefc,' and de Wccker.*
These tuoaora do not present any specially charateristic features in
their external appearance, excepting that they are prone to undergo
marked fpuntanevus cLiatij;es iu vizv, which arc d<.'puudent upou mechan-
ical hypcneuiia of the morbid groM'tli. TKui!, any straining or vii)leut
exertion, or stooping position of the head, maj' be followed by a striking
increase iti the fiize of iht tmnor. In voii Graefe's case, the mere pres-
snre of the pillow in bod upon thiu side of tho head and fai:« ;;ave rise to
a temporary protrusion of tlie eye, accompanied by great congestion of
the conjuiictivul and subconjunctival vessids.
The growth of these tumors is generally slow, more egpecially if they
are situated deeply in the orbit, for then the pre»8iire of the eyeball
restrains their rapid development.
The cavenious tumor' is surrounded by a capsule of dense cellular
tissue, which is only very luuci-ly connected to the adi[K)se tissue of the
orbit, so that the tumor can he very readily and completely removed,
with but a very elight amount of hemorrhage. On a section, it Is seen
to be of a spongy nature, and to be traversed by dehcate meshes of
fibrillar connective tissue, dividing it into a vast nmnber of little com-
partinenta. Tliesc Ititerspaces contain blood, which can be readily
aqucezed out by a little pressure, and tbia causes a con:*idernhlt' dimi-
nutioii in the bidk uf the tumor, which at the aarae time becomes of a
pale gmytb^h tint.
The erectiU tumors (telangiectimis) which arc met with in the orbit,
almost invariably take their origin from the eyelids, and then, increasing
in size, extend thence into the orbit. Tlify are described in the article
on Tumors of the Kyelids.
[rulaating tumors of the orbit with exophthalmos may be due to one
or more of several causes: Ist. Thoy may be due to true aneurism of
the onbthulmic artery or one of ita branches, thoiigli this Is |)erbaps tlie
most iiifr4;<]uent cause of all. 2d. The caii^e may be a false aneurism
from rupture of an artery, the result of injury to the bead or orbit. Sd.
> " Abhondluugen bub dun CkblohP dvr (iriiktboh(.>ii Cliirurglu." Berlin, 1646,
p. B8.
• " Halj1fn Uiiarlrrl^ .roiim*!," 18fJS, Norinnbot, p. 338.
» "A. f. O.," vii. 2. p. 12.
• Ue Wecktr, " MalAilii* dM Y^iix.'' 2a rdit., t. 7!>«.
> Vlrclivvr, "Krankhaftu [iM>i.-liwQIi*t«," iii. 1, 3&6.
778
DtSBASEB OP THB OSBIT.
There ma^ be no dii^ease of any Brtcrjr, but simply Bome caii&c oT no^
|(rc8si()(i of the ophthnlmic vein at ita exit from the canty, as by an
aiicuriiiQ of the ititeroitl carotid, or plilehitis of the caveruoud «i>m». — B.J
(2) Ankcrishr op Tns OBnrr.
Aneuriam bi/ (inant'tnu-nU is of far less frciiucnt occurrence tn thei
orbit than was at one time siipiiose<i, and many of the ca^es which hava]
been iloiicnbed ini<lt>r tUh uninv, were eviticntly iiktt:iiicf-i of ilitfu:«,e|
anenrism. Aneurism hy anastomoais is met with ])rincJpaUy in yoicij]
children, ond is mostly congcmtal. The tumor commences in or near,
tJio skin, is cotinected with the subcutancoua tissuu, and presents thoj
a]>pGarance of an irregular nodulated growth, consisting of convi»hitioM|
of dilated arteries ; the vesiitilH of the neighborhood parliciiratiii;; in
the increased action. [Fig. 'Mi.] The origin of the tumor u neither^
(Pig. 214. J
A
sudden nor prodiicod by direct violence, bat >8 alow, and its inareado inj
size i^ tardy and gradual. Ttie aizo of the swelling is much increase'
by any position or exertion which cauMii eongeslrou of the head, i.g^i
atoopin^, straining, cnughin};, etc. Althou;:h the tuninr presenfcs distiiwt!
signs of puliation ami thrilling, no efiV-ct (or only a very tardy one) hi
produced upon tliese symptoms, or up«.in the swelling, by cuiupreosion of
the carotid artery. Moreover, aa was strongly insisted ajmn by Mr. John
Bell, aneurism by anaatomoDiB is not curable by ligature of veMels. Ttie
best treatment is that of sulx-'utuueous ligature of the tumor, the ligature
boitt^ either applied tn a circular manner, ^ as to include the baoe of
Uie tumor within a single loop, or else the figuro-of-S ligature should be
employed. If tlie growth ia of conaiderabtc sixe, and is divided
VASCOLAH TnMOKS DP THE ORUIT.
77»
%8sKQt nodutateO imrtions, these mar be operateil upon euccessivet^
bv tlie ligature ; or tlireatls satiiraieil with a mIuiioii of the ])erchlonde
of iron mav b« drawn Uiroiigh the lumor, bo that thej cro^ and n>-cro88
eaoli other in varioiiH directions. These niixlcs of operating are far more
safe than, and much to he preforri'd to, the injection of the perchloride
of iron or oilier aj^eiiw for ilio purpose of proiluciiis coagulation . Dr.
Althaiw's treatment by elcctrolvsia might also be tried.
True arifiirisms of the orbit are of rare occurrence, anil do not attain
any considerable bulk, on acconnt of the small sir* of both the opbthal-
mie artery and the centnd artery of the retina. In a case recorded by
Mr. (tuttirie.' an ancuriBoi ot the ophthalmic artery of each side, about
the ftir.e of a large nut, was discovered after death. The opbtlialmic
vein wiu; ;^reutly eiiliir;;ed. and ohKinic-tvJ near itd passage thrnu^^h the
sphenoidal tissiirc by the j;^reM increa^w in sixc of the recti muscles,
which had aUo acfjuired an almost cartilaginous hardness. Altbongh
the eyns were greatly protruded, the sight was hardly affected, and the
exoplitliiiliiios was evidently ah much due to tlie state of the iuu»ele$ as
to tlie dilatation of the vesseU. There was an audible hii>siitg noise tn
the head, which was attrihiited Co aneurism. As the disease existed on
botii sideit, Mr. (iutiirie did not pp)po«e ligature of tlie carotid.
Cases of aneurism of the central artery of the retina have been ob-
BCrved by (iraefc (senior), Schraidlcr, and A. Cooper. In Graofe'3
ca^c the central artery of the retina was dilated to the nizu of a stalk of
gn^. But Souo' was in one caw able to dingnnxe the affection with
the ophtbalmoscopc. lie observed, in a woman of "J-1. a red ovoid tumt^r
on the left optic disk, extending somewhat beyond its margin, and, after
becoming suddenly narrower, fiassing over into one of the retinal arte-
riei^. It presented evident signs of pulsation, the dilatation being syn-
chronous with the sy«ole of the heart. The other retinal arteries were
very tuirrow and threadlike, the veins somewhat dilated.
Ttifuitf or fahe anmrhm nf the orbit is of far more frequent occur-
rence. It may be either primary and traumatic, or consecutive in its
origin. In the former ease, the walls of the artery are torn or ruptured
by n sudden blow or wound of the head or orbit, or a fall upon the head,
and the effect is imnwdtate, blood is effuse<l into the orhiuil cellular ua-
sue, and a certain degree of exophthalmos may be produced. As the
exophthalmos jucreasei*, the eyelids become swollen, red, and wdematoufi,
the conjunctival and tiul>conjiinctivat vcatels congested, tbu movements of
the eyeball diminished, and the sight perhaps more or less impftire<l.
The bloodvessels aronud the eye are also somciimea dilated and tortu-
ous. A bluifth, elastic, soft tumor now makes its appearance at some
point of the edge of the orbit, nnd &hows distinct pulsations, which are
evident both to the eye and touch, are nynclironous witli tlie systole of
the heart, and accom[^«nied by an audible thrill. If tlie ear is applied,
a iieculiar huimiiing or whirring sound is heard, like the action of a steam-
etigino. threshing* machine, or humming-top, and this prove* a source of
' " I>^tnr*i» nn Op^rntir* Snrir«y," p. 1.1?.
• "Aitiiali.« U'OculisiitiUf," ISUS.
780
DISEASR8 OP THK ORBtT.
tho greatest diitrosa and anxiety to the patient. TItis may extend over
a considerable portion of the liea*!. lu a case narrated hy Dr. Joseph
Boll,' ttii* whirrin;^ snnml was audible lo a bystander at the distance of
a yard. Tltcrc i* often also intense pain in and aronnd the orWt and
over the cor res pond in <i side of the head. (_'oinprej*sion of the carotid
artery at once stof>3 the pulsation, an<l pressure np<^in the tumor gca-
Uly causes it diiistiQctlr to diminish in size. In some ca»es, the ap|war-
incea of an aneunsmal tumor do not come on till some length of time
al^r the accident, and it» increase is slov anU gradual; tu other ituj
stances, the symptoms supervene iiuutediatcly, or very rafudty npon tb«
injury.
The consecutive diffuse aneurism of the orhit is freiim-ntly preceded'
by a true iiniMirisHi, aet^oinpanied by a fatty or athi'n)matoua de^renera-
tion of Uie walls of the veswl, which thus become weakened. Hut the
disease of the walls of the bloodvessels may also be alone present. Any
sudden 3train or exertion on the part of the patient cau^s the vessel to
give wav, and tliis is accoiupaiuetl b^ a very marked and sudden }<iia
throufih tho head and eye. :w if a iiistol had been shot nff, or something
had given way within the head. 'I lie blood flows throiij^h tlie rent in i
the artery, and, becoming inhltrated in the surroumling cellular tissue, ,
a cavity, communicating directly with the vessel, ia formed. 8ymptom»|
of exophthalmos, together with pulsation and a bruit in the tumor, and
otiier signs of aneurism supervene, the patient at the same ttme expe-
riencing intense pain, ^^ometi[nes the disease may appear spontaneously,
witliuul the slightest apparent cause, and without any accident or violeut
exertion, it has been !rc(|uently met with in women during the lirao of
pregnancy or childbirth. Compression of the caroiid causes a consider-
able diminution or arregt of the pulsation and bruit, hut is cuometimca
accompnntt'd hy severe pain and distrcusing symptomjt of fulne»s in the
head (l.iioppi). Or tliese may be produced lo a very marked degree
hy sudden ndaxution of the pressure, whereas a gradual removal pro-
duces no pain.'
But all the symptoms of orbital aneurism may exist without the pres-
ence of any sucli affecliou wiiliin the orhit; tho pulsating orbital tunwr
being simply due to some com])ressionof the ophthalmic vein, which pre-
vent^ (ho efliux of tho hlooil from the orhii. 'Die cause of tliis compres-
sion is freijuently the presence of a[i aneurism of tho ophthalmic artery
near its origin, or of the iulenml carotid artery. Thus Mr. NuuncIey,iD
his valuable and interesting pajwr on ** Vascular Protrusion of the Kye-
ball,"' narrates, amongi^t other cases, that of a patient in whom he sat-
cessfully tied the carotid, in lHol>, for a puhiuting tumor of the orbit.
In 1S(14 she died, and on post-mortem examination the presence of %
circum.scril>ed aneurism of the ophthalmic artery was discovered, just at
its origin, of the size of a hnxel-nut. The trunk and branches of the
ophihalinic aricry, continue*! forwards into the orbit, being of small »Ue.
The following caw of Mr. ItowmiLuV is also of much iuier&at, as aboir<
' " KrtinhHrsh MMicnl Jftarnul," 1861, p. 1064.
* Dr. .i<i-.<)>h it.'ii, I.O., p. im:,.
* ">li^l. Cliir. TiKD*.." vol. 49, 1SD5. p. 29.
* "B. L. 0.11. llop.,"U. p. 0.
VASCDLAR TOMOBS OF TBB ORBIT.
781
ing how all the syraptoms of orbital ancurUm may be simulsteil mthnnt
the existence of any such affection. The patient, n woman aHed 40,
Dftticed severe paJii in the Ifft temple, very »liortly after a blow from a
&fH 01) the left Ride of the head and temple. A fDrtni^lit aft<'rH'ard!t, she
felt a constant rushing sensntion on the Aamc side of the head, like the
beat of a Kt«aiii-eii>!;inef which increased with acceleration of the hearths
action. On her admission into King's Co|lc;;e Hospital, iinrler Mr. Bow-
maD. the eye waa prominent and congeated, the pupil dilateil but active,
distant aisht waa perfect, but she wna unable to rejid. There was a
loud sibilant hniit over the left side of the head, being synclirouous with
the beating of the heart ; aliio distinct pulxation of the Icll eye, appa-
rent to the touch, and n loud bruit cniild be hoard when the Btethoscope
waa placed on the closed eyelids. Mr. Bywnian tied the common caro-
tid, and the pul.'nation ami bniit, hitherto ftdtand heard over the front of
the eye, at once ceased. Hut, the patient died 18 days after tlie opera-
tion trom phagedenic ulccmiion and hemorrhage from the wound. Ua
post-mortem examination, no appearance of an aneuriam could be discor-
ored,and it is difficult, as Mr. Hulke says, in reiK)rtinj^ the ca.se, " to
exj'lftin the ancuripmal aymptoniB by the patholn;^ical apjiearanoea, which
were those of phlebitis of the cavernous, transverse, circular, and petro-
sal Binusea. The intenial carotid may have been partially compressed
hy the swollen walU nf the cavcnious »inui> against the side of the body
of the sphenoid bone, giving rise lo the bruit, which would have a good
condacting medium in the cranial bones. The plugging of the tnmk of
the ophthalmic vein, where it joins the cavernous sinus, by obstructing
the return of blood fiotu the orbit, accounts for tlic protrusion of the eye-
ball, and perhajw aUo for the pulsation whicli waa felt when the finger
was laid on it, because each diaxlule of the nptilhulmic artury mii^l have
been attended by a general nioiiienui.ry increase of the wliole i|uaiitity
of blood in the orbit, because itt exit thrniij^h the ophthalmic vein waa
cut off. ami the resisting bony walls of the orbit could permit a distttiision
in front only."
Tlie ojieration of ligature of the common carotid has proved very suc-
cessful in coses of aiicunsm or supposed aneurism of the orbit. l>r.
Uoyes,' of Kew York, has given a tabulated account of all cases of liga-
ture of the carotid for puUatins^ tumors of the orbit, which had occurred
up to 18fil'. He haj* collected Ut caws, of whicli 82 were cured, H par-
tiatly successful, 4 unsucces-sful. and 7 died.
Digital compression of the carotid has (^been tried in nine cases and]
proved suceessfiil in three easen, viz., in those of Gioppi.' Vanzetti.'
and Freeman.* In a case of SzokaUky's.' digital compression was con-
tinued for fiftyshx hours, together with ice-cold compresses and small
doses of digitalis, but proved t|uite unavailing. Ligature of the common
carotid vraa then performed with jierfect success. Digital compreaaion
■ "New York Uodicsl Journal,'' Mareli, IBSD. Vfdo niso Dr. Morton's p¶ In
" .^infi. Joiirtinl of M.-<1. Scwiiwn," April, ISUS, and July, 1870; Hm 2«lieiidef'>
•rliclfl. "Kl. M.,"1S69, i*V.
* " Annalt« rl'Urnllfitiii|n«," NoTcmtwr uid DuortmbiT, li^AS.
■ " Aniinli I'nivcn.," ie!>8. p. 14$; viA*i kIho "LAUcet," March Ifi, lt>a2.
' "Ainvricui Jourunl of Mud. 9closou«," July, lS6t).
• "Kl. MonatBbi.," ttJti4, 4-JT,
782
DISEASBS OP TUB ORBIT.
may \ie applied tn such a mntiner m to preu thecomniou carot'iJ direcUy
back a<^iiist the vertehral coluinn ; but ni thift mode llie jiif(u1ar vrju u
very apt to be also comprcs-sed, wliicli pro^iuccs grettt congestion of th«
head. It is, therut'ore, better to raiife the carotid eomuwhat, and oni-
prc5s it between the fingers. Kelays ut' assistaiitti should ht> ready to
altcniate iu this duty. Sometimes, hovrever,it cauuot be boniu forlon^r
than lour or five minutea at a time. The siicoess of these ciisf^ itbnuM
encourajte us to give this method of treatment by digital coiiipresiiiUi «
fair trial, before having recounic to ligature of Uio carotid, for UttA oyt-
ration uaii always be {icrforroed if coinpresaion fails.
Two cases have been succeMrolly treated by styptics ;' and Dr. Ilolmefef
mentiom an inatance of traumatic aneurism currd by the adiaiiiiatratiott
of the extract of ergot, and tincture of green hellebore, to;»etber whii
complete rest and low diet.' Two cases in which el octroi ysis and iojoj
tioii of the pi^rchloridc of iron were tried, are narrated in Zander him\
tjeitislor.* The latter remedy is, however, excessively dangerous, tar
iiiatautaneous death has Iwcn caused by it more than once.
[The difficulty of diaf^oaia in cadtea of orbital pulsatios tumors it
rery great. In examiiiinj; a case we muint notu the effect of; (1) coin-
preasioii of the common ciirutld on the Miune Hide ; < -) ritevly pr(*<uarc
on the cyelmll throu;;;h tlie clo.'ied lids, whether on reraoviti;^ tbt-
the former wtat« is sl'-wlt/ or tfuickly reproduced; (3) the seal oi _
pulsation, whettmr the puUation is strong or weak, tlie effect of |HMtaK.
the presence of a bruit heard by tJie stethoscope orat a di«tanc« tbrou-j;h
the air, and the character of any sound heard by the patient in ht& own
head ; (4) paiu and tntlammHtory iiymptoma an<l history of injury ; pai:
is of^en severe incases uf traumatic aneurism with exlravaaation :
urbital inflammation. (Ncttlcship.)
Hariau has reported two cases of vascular disease of the orbit, in '
of which the cause was supposed to be aneurism by anastomosis io tte
orbit, which was probably congenital, or at least came on in early child-
hood, la the second ca^e. which was of traumatic origin and was at first
supposed to ho orbital aneurism, Harlan seem-* later to have been sonr-
what doublful of the diaguosia, and to have adopted Nunnel<'y's idea of
vascular protrusion. At the present day most ophthalmic surgeoiia seem
inotined to agree with Nunncley, thai in tlie great majority of soch ca«e4
of protrusion of the eyeball, there is tio disease whatever in the orbit,
but liiat the symptoms deiicnd on obstruction to the return of blood
through the ophthalmic vein. Orbital aneurism is certainly a vorv rarv
di.-'VHse, and it^ symptoms are oft^n imitated by coses iu which on'tjr th«
veins are tiffectcd. (See "Trans. Amer. Ophthal. Soc.," l5"ri.)
(iruening has reported au interesting case of vascular protrusion of both
eyes of traumatic origin, which he thought was probably doe to an anc-
rio-venouB communication in the cavenious sinus.
There was double choked disk and total blindness, OompreseioQ
the left common carotid outtrely stopped the bruit ami headache.
[I Dr. XojrM Um ooUwt^ (" N»w York M«d. Jcinnial." Mftreb, 1S4«) «lx
lrvA(t-'J b.r itijMtiuu or Btyptics, and iu »ll with « •aoMVtfal rwult. — H.)
< " Anirr. ionr. of MmI, Sci.," SvXy, ISM.
» " \>rlcUunKeii dim Anget," 433.
EFFUSION OF BLOOD IJilO THB ORBTT.
788
tion of the WU coraiDoti carotnl fire days after complete amaurosis set in,
restore«I the vision completely in oiie eye, anil very markedly improved
it in tbe other. The entire absence of all cerebial symptoms is afjaiiist
the |jossibiliiy of a true or ilifFuse aneuriam of the left intcnial camtiii
within the skull, and all the symptoms pointed to an iiitra-crantal arterio-
venous coauuunication. (See *' Arch, of Opth. and Otology," v. i. p.
40-47.)
In the " Archives of Ophthalmology," vjii. 8. pp. 32« to 344. Nieden
reports three cat^es of piiUattng vascular tumor of the orbit cureil by
ligation of the common carotid. The first case he diagsnosed as rupture
of ihe ophthalmic artery, fi'ee comraanication of tbe blood in the rctro-
orbitn) cellular tissue with the arterial current, and a cure ciglitcon
months later by the fonuatiou of a thrombus. The second case was
Iirohably due to au inipodimont to the return of the blooit by phUdiiiis
)chind the orbit. The third cose he considered to be an ancuri?mal dila-
tation of the intcnial carotid, or a rupture of the artery in the cavernous
sinus with a direct communication between arterial and venous blood.
In the "Med.-Chirurjj. Tmns.," Iviii. pp. 1W4--H'*, Hivington lias pub-
lialicil an interestin<( paper on pulsating; tumor of the orbit, iiic!udin;»
autopsies on twelve cases, which contains most of the literature on the
subject.
One of the latest communications on the suhjoct is by Schlnefko, who
reports a case of suppoAod trauaiatic rupture of the left internal carotid
artery iu the cavenioui^ sinus, with the fonoalion of an arte no- venous
aneurism. Tht^ bruit and puliation ceased iromciliately after lij^alion nf
the common carotid. The patient recovered but died three months later
from empyema and purulent pericarditis. At the autopsy the loft optic
nerve was found atrophietl,and the IctY cavei-nous sinus widened, and ita
walls very much thickened. All the orbital veins were etiannously di-
lated ami their wall« thickencil. Tlic left internal carotid in the cavern-
ous fuius was dilalvd and connected by three openings. There was no
chan;;o in the ophthalmic artery. NuiiieroTis thn)mbi in the orbital
reins. The paper is a long iiml interesting one, but contains nothing
new. (See " Arcbiv ftir Ophthalmologic," xxv. 4, pp. 1I2-1G2.)— U.]
8.— EFFUSION OF BLOOD INTO THE ORBIT.
Tlie effusion of hlood into the orbit is generally rapid, and can mostly
he traced to some direct cause, !>uch as a blow or fall upon the oye or
bend, incised or punctured wounds of the orbit, or the lodgment of a
foreign body within the latter. In rarer instances, the hemorrhage may
Xte due to violent exertion or straining, or may even he spontaneous in iLs
origin. The eye gencndly becomes rapidly jirotruded, and its mobility
curtailed. Fre(|ueiitly the protrusion, as well as the impairment of the
mobility of the eyeball, occur chietly in certain directions. The sight is
tnorc or less affected, and this is chietly duo to direct pressure upon the
optic nerve by the effusion, but in cases of injuries to the head, it must
be remembered that the affection of the sight may be depeudent ujKin
Kouie cca-brol lesion. Thus consecutive ncuro-retiniUs may become do-
784
DISEASES OV TBB ORBTT.
velopwd, being iliie to the inflnminntion of the meninges.' On Account of
the impairtnent of tlie mobility of the eye, there i» nl^o diplopia. Th«|
cyelidiii are often aiunhi^wollen, contused, tUacolorcd, and perhnpn' sluddcij
with ccch_vnio303, which may iiUo occur in thw conjunctiva nnd suK
junctival tissue, ^[oreover, altJiuu^h the Ittood amy be at firat coaSned^
to the posterior portion of the orbit, it may press forward and become
diffused beneath ttie conjunctiva, and thua produce considerable chemo
8ts. Ill canen of orlnlal heuiorrliage dependent u[>on fracture of the bouG
of the orbit, it hfts been supposed that the presence of cccbjmosofl in tb(
eyelid;* IS a guide to tlie diagnosis oi the seat of the fracture. X'etpvai
especially insisted on the importance of this ayroptorn. When ecchyJ
mo^i^'of tiie lids exisu alone or precedes tbc aubcoujunctiiral cftii&ioo, it
watt supposed to be indicative of a fracture of the margin of tlio orl»t
Whereas subconjunctival eff'uaion existing with other ayroptoms of fr
tore of the orbit, in which there wa« no ecchymo«is of the eycliils, or ihit]
only came on ttuiirinpiently, wa« guppot^od to.be jMtthogiinmoniu itf tb«1
injury beinp; aituated deeper in, or at the bottom of, the orbit. But abr]
aolute reliance cannot be ]i1aced upon these syuptoms, for the boues of
the orhit may be fractured, and yet there may not be the sliglilcrt effu
flion of blood either under the conjunctiva, or into tlie eyelids, [f ihei
is a fniL'ture of the inner or lower wall of the orbit, omphyseaa of the
latter may also bo produced, and then the protrusion of the oje will h«
iucreaded when the node h blown.
The treatment niuai be chiefly directed to hbitcninj; the absorption
the blood. Cold compressoii and a firm banda<ce will be found most
viccftble. Only in those case* in wliich the ettiiHion of the Wood is very
great, and causea extreme exophthalmos with very severe suffering to the
patieut. is it advisable to make incii^ions. in order to permit of the eecap
of the blood. In the majority of cases, it u wiser to allow il to^
absorbed.
9_KMPHVSEMA OF THE OKBIT.
Emphysema of the orbit is generally accompanied by a similar L-i>n-|
dilitm of the eyelids. The affection may be produced bj a nipture t>f
the ethmoidal cells, by fracture of tbe frontal sinus, in wliieh oaae the
swelling may extend to the forehead and temple, or aa is most frei"[uently
the case, by a rupture of the lachrymal aac. The air ia admitted iiil«
the cellular ttasue of the orhit and eyelid,-«, caiinin;; great protnmion oCJ
the eye and swelling of the lids, both subsiding considerably when gentle'
pressure is ai>plied to the eyeball and lids. If the afleetion is due to I
rupture uf the lachrvmal sac, the swelling may be immediately produerd
by the patient's forcibly blowiug his nose. The euiphyaematous swelling
i» ver}' elastic to tlie touch, and Uicrc are marked symptonu of crepitation.
[It may occur from fracture of the lachrvuial bone. (See " Amer. .lourn.J
Med. bci.," July, 1880, Aru IX. Lesion of Bonea of Orbit.)—]!.}
' VldoMam, "At. 0.,"aU. 1,1.
PBEfiSDRB UPON TBS ORBIT.
78S
rio._RTPEROSlX>SIS AM) PKRIOSTOSIS OF THE BONKS
OF TIIK ORlllT.
Iionca of the orWt occaflionally undergo hypertrophy, and the
proIifvratioQ niay affect cither the bone Bubsttaoco itself or the perioo-
teuni. The two comnMjnly coexist in the bonca of tlie face. 'ITie exoes-
aivp development of one or more of the bones of the orbit would of course
pTO<luce the most sin^uhu* ehan-^ca ui the shape of this cavity. Accord-
ing to Wagner, hypcrostosiii may affect only the cxt«mal compact tissue
or the mcdullii-y substance alone, or it may be met with in both at the
same lime. It seems^ hoirerer, to involve mKinly the extcnial lablo of
the bones. It is a mistake to suppose that iutlnmniatory action i-s at the
bottom of this pmliferalion in all caaes, for cases have been known to
occur in which a facial bone has continued to increase in size without any
srmptoms except those produced by ita increase in bulk. As a result of
the change in size and shape of the bones of one orbit, the two orbits do
not occupy a corresponding position, but one of them is found to be on a
bi^^her plane than the other. I'criostosis may result from long-continued
suhticiibe periostitis of traumatic origin. (See *' Trans. Amer. OphtJiul.
Society," 187il, pp. 5UM102.)— B.]
1I_PRESSURE UPON THE ORBIT FROM KEIGHBORIXG
CAVITIES.
Dilatation of the cavities in the vicinity of the orbit will cause a con-
traction and malfomialiou of the latter, accompanied by more or leas
considerable exophthalmos, curtailment of tho mobility of tho cyoballf
and iinpiiirment of rision.
i>i«rvws qf the frontal n'nus' may produce considerable dilatation of
this cavity, which then encroaches upon the orbit, giving rise to a con-
traction and malformation of the latter, and consequent protrusion of the
eyeball. Amongst such affections of the frontal sinus, must be enume-
rated acute uad chronic intltimioatiou of its lining membrane, giving rise
to the fonuation of a purulent or muco-ptirulcnt d i charge ; in rarer
instances, f»olypi, cystic tumors, and entozoa arc met with; also, per-
haps, exostosis. Tlio latter la, however, according to Mackenzie, ao
extremely rare, Uiat he is not aware of a single reconlcd case of cxoa*
tosis of the frontal sinus, although ho happens to have two specimens in
his own collection.' Of these diseases of the frontal sinus, acute and
chronic inflammation, terminating in abscess, arc the roost common.
Tlie symptoms presented by abscess of the froutul sinus are often some-
what obscure, and may mislead even an experienced surgeon, for they
limy BO closely simulate those presented by an iutra-orbital tumor, tliab
the true nature of the disease is not recognixed until an exploratory
> Vide Ur. Hulke's arilolss on DtocuM of the Frontal Binua, " B. L. 0. H. B«p.,"
111. 147.
* MauknuJe'B *' IMscoms of tba Bye," 4tU «dlt.. I. p. flU.
60
786
DISEASES OF THE ORBIT.
incUioQ has been ma«lc, or die abscess hai pcrbaps burst thrangb the
upjicr lid, &iid a listiiloua oponiiig id roaiid* leading into the frontal nnns.
Again, if the swelling extends somewhat lower donrn, so that it \s crowed
hy the tendo oculi, it may be mistaken for distenni'^n of the lachrvmal
BEW. But wi> ehould be guarded against such a mii^take, hy the ubftvtui-
of epiphora and sjmptoma of intiammation, &s well aa bj the liardncs* of
the swelling, if it he duo bo distension of the wall of the atnus.
The iliseasc generally present* the following symptoms : llie f>aticnt
ex{>erionces a fut-Iing of fulness and unea»iiie!$7! over the vyebrow, accom-
panieil by a dull auliing pain, wliich is sometirm;s iiicrcaaed by pressure
upon thist spt>t, or hy any exertion or posture which cinfws an aocelem-
tiou of the circulation. Id the acute abscess, the utuco-jiuruleut di4
charge generally perforates the roof of the orbit, or makes ita way iul
die noac at an early stage, before there has been time for the sinu*
become much dilated. If the discharge has made its way into the orbit,
the eyelids become red and swollen, the upper lid perhaps dropping
Utile, and a itmall elastic tumor appears at the inner and upfwr aii;:l(
the orbit. As tlie abscess incrcaaes in eize, ilie eyeball ia di:<placed in a
downward and outward direction, becomes more and more protruded, at "
its mobility impaired, in con»e<|uence of which, diplopia mauifedt^ it^e
when the patient looks npwanls. if the abscess is not opened, ii wil
point and burst through the gkin of the upper eyelid, generally near iu
inner angle, or perhaps lower down, just above the tendon of the urhica-
Uris, when the fistulous opening which remains may bo mistaken To
inflammation of the lachrymal sac. ]3ut if a probe be passed tolo
opening, the ainus will he found to extend in an upward and backwii
direction, perhaps to a very considerable distance. Sometimes there ni
several fistulous openings. In a chronic abscess, Uie frontal sinn^ ohci
becomes very considerably distended by the collection of mucus, am) thi^
produces great exophthalmos, and gives lise to a marked pr^imincuc
over the eyebrow. The progress of the chronic abscess is oft«u exi
tremely stow and protracted, and accompanied by hut little pain and di*-
Gomfort, until symptoms of cxoplithalmos and diplopia supervene. ln<
flammation and abscess of the frontal sinus are, in the majunty of casef,
caused by blows or falls upon this part of the face, hut they may ariso
spontaneously.
As the symptoms arc generally at the outMt very obscure, tKe treat-
ment can then be only directed to llie alleviation of the pain or iuflaiu-
matioD, by the application of warm popjiy fumentatioitn. Hut when the
prcscnco of matter is ascertained, a free incision sliould be made inW
the swelling just beneath the supra-orbital arch, and the pus he thorougUiy
evacuated, the finger or small piece of sponge being introduced into the
cavity of the frontal sinus for this purpose. The |»int of tlie fonifiuger
should then be inserted into the dilated ainus in order to ascertain its
relation with the neighboring cavities, and aUo the condition of its liniD|
membrane. The point of the little finger should next bo introduced a|
the corresponding nostril as high as the floor of the dilated .^inus, and
bistoury or trocar should be passed tlirough tlie opening in the front
sinus, and the lower wall of the latter, just over the tip of the fingq
iutrodnccd by the nostril, should be iuoised, so that a free comrounicaur
PESSSDItB OPOH TBB ORBtT.
787
*
\
oiAj be ostnblished botwacn the diniis and tho nasal cavity. A stout
geloii, c(vmp«->se(l of several tliicV silk tlirea«U, is then to be passed
through the aperture in the skirt iiitu the sinasi and thence through the
Doatril; tlie free end, projecting through the latter, being tied to that
which projects from (he inci^iou in the skin, so that a Xargfi and easily
movable loop is formeil, which should be frcclj moved by the patient
two or three times a daj, so as to keep tJic openin;; between the nasal
cavity and the sinus permanently patent. It is, however, mueh butter
to employ an India-rubber drainage-tube, having holes cut at short iD>
ter^'i)ls. Thiii is to be tasitteDed to a director, and the Inttcr passed ia
the SAiue manner as the seton,and the tube be then drawn through. Or
it may be passed up the nostril into the sinus, and thence into the orbit
and out by the extenial wound, the one end being fastened to the fore-
head by a strip of plaster, the other being left to project a little from
the nostril. The cavity of the ainua should be washed out several times
daily with water or an astringent lotion (/Jnc. sulph. gr. j, Alumin.
gr. lij, A(\. dcst. 5j), this being injected through the tu))e; the latter is
also to be moved a little unce or twice daily. The patit-ut is to be kept
in bed for some days and einsely watcbe I. The seton should be worn
for several weeks, or even lonj^er, but sbnuld be rentoved if it gives rise
to muoh irritation or to cerebral symptoms. When tjie communication
with the nosD has been permanently establiahed, the seton or tube should
be removet^K and the opening in the skin will tliou granulate and heal.
1 have seen several cases very anccessfully treated in this way by Mr.
Bowman and Mr. Lawson. The following case of my own also iUu»-
tmies well the symptoms of the di»ea<?e : —
K. S., aged 40, baker, perceived, about twelve years ago, that the
right upper lid was swollen, and hung down over the eye. This swelling
disappeared smntaneously in tlie
course of a week, but recurred aliout Wg. %M.
every two years ; and six months
ago bo noticed that, hc)>ide tbo tu-
mefaction of tbo lid, there was a
small swelling at the inner angle of
the upper Hd close to the root of tbo
uoso; and as it gradually iuorensed
in size, he applicil for advice at
King's College Hospital, on June 4,
IHGtf. lie tben presented the fol-
lowing appearance : The right eye
protrudes coni^iderably, and is so
mucli displaced downwards and out-
wards, that the upper edge of the ^^iS
cornea is below the level of the left
lower lid {vide Fig. 21^). The
movements yf the eyeball arc greatly
curtailed both upwards and inwar>U. The upper lid is cofisiderabtv
swollen, aiul at itd inner angle is no;iccd an oral tolerably <lotined swell-
iog. about the aiie of a lai-ge baisel-nut, which extends vipwards to the
eyebrow. Uut thd nasal prominenoe on tliis side is ouly very slightly
OUIT.
IDCl-
Im
isul
m
i krwcr mar^n of th« orbit cut
iand to be sbarply deBned ud
IT mmnr. Tlie ov&l swelling,
- » 'li»tiiict flense of Suctiution,
■ paiieut Also experiences lome
-wr of the eye outvanit orer iht
7s *iMi becomes irritable and wtter;
ja befat. But tbo sight and visul
9 'luite riornifil, nor has th? cxo
dsaw ■')' ilie u|iuu nenx*, produced by
^ c optic nerve. I considered the
aak«^b liad burst through the wall
-« aa opemiiui). which was performed aa
- if orer ilic most proiiiinent part of th*
_;« orbicularis muMjle were sotneitbit
MB rf' the knife was tlien plunged into the
i.^ii to Uie sine of the external wound. A
oefa pus escajMid. the eyeball jEnulually
^ Milion. On jiajtniiig the liitle Hn^tr
>mmsinn of the frontul !>inud, a large irp-iru-
••no^ into [lie hitter and readily adtniltin^
zAtber haviii;; been removed from the cavity
-jc fiuger of Uie other liand vras paaMd ap
A<«U be touched by tliat of the finger in
amw intervening. Tltis wa«tben carefully
^ viih a trocar. An India-nibber drainagfr
^Mrt iniervuls, was fustetied to a probe, ami
md iutii the sioiifi, ami thence out thrnui:b
tJie orbit by the external incision ;
tlie tube was then easily pullt'd
through in the Bfiine direction, and
its Olio extremity fastened to tfce
furvbesd by a strip or two of plwier.
tlie other being left to prujerl a
little from the nostril. In thiit «ay
a free comniunieiLtion was maintained
between the sinuii and the noM. m
that the Foruier cuuld be fiu»bed '»ul
with water nnd nstrin^ent injections,
and the di»chargo How off tbroa](h
the iiustril. Tbe operation vaa fi^-
lowcd by a certain degree uf inflniO'
matory reaction, swelling of tlie lidi
and cheek, etc., but tbese symptom*
tioon yietdeil to hot poppy fonienta*
tiona and poultices. The iuci^iiaa
^ 10 (lemiit tlie free exit of the discharpe, and the
^ rftinpcdoul with lukewann water several times aday,
^M^Hutt being aUo eligbtly moved up and down twice
nowvrad rapidly, and was made an outpatient on
WUIINUS AND INJURIES OP TUB ORUIT.
789
»
July 3. tho tulie still reinaininj? tii. TKe swelling lia<l now nlmost en-
tiri>I_7 ilL-ui [ipt'arcH , tlie (•yeliall ti:i'l rr-iiiiupd io naturat piiiiliaii, aii>l tta
range of mftbility npwanU an<l iuwunU vran very grcally nicreased, Th*
tubo waa altuwed to ri'intiin in till September ^'{, wlieii it was removed,
&s there \w\ been no return of tlie awelliiig, and all discbarge had
censed. The external wumid now i|uickty clo>ie<.l: the eye haviog by
tins time rej^nined its nopiuiil appearance (^vide Fig. 21(>), nnd ics mo-
bility was perfect in all ilircccious. Ui> witd ?>een last in tlie beginning
of February, ISTO, aud was Miill purfectly well.
Knluri/inn^tit of the inarillanf /tiiiu*, tho tuL-tal cavity, and the cavity
of tbe craiiiuiu may also caiue procure upon, and a contraction of, tho
cavity of tlie orbit, aeconii>auied by protrusion of tbe eye ami limitation
of itA movements. For intcreAting cafteit illustrative of these diflbront
ooDditions, I must refer the reader to Muckenzic'i) '* Trcadne on Dtseiues
of tho Eye." [See also an article by Knapp, in the " Trans. Fifth
luternat. Ophtbal. Comjresa," IHTO, pp. &o and 50. — B.]
i
12-_W0UNDS AND INJCKIKS OF THE ORBIT.
Incised and pnnctured wonnds of the orbit should always he watobed
with care, for flerioiis symptoms do not always arise Jiroctly after tbe
injury, and may not manifest themselves till some time afterwanla. The
instrutDent which has inflicted the injury should be examined, in order
tbat we may a.<icertain whether a portion of it has not been broken off,
and perhaps remains loib^ed within the orbit. Even if the eyeball itself
and the Imneit of tlie orbit haw v^aped direct injury, inflammatioti of
tbe uelluliir tinHin- <if the orbit and a more or leiis extensive formation of
pus arc \*ery likely to occur.
Foreign bodies, more eapeciully if they are small in sixe, such as shot,
Bpliubers of {ilttsa, Bteel, etc.. may remain for a long time umletected
within tbe orbit. The lod;;mcnt of a foreign body in the orbit may prove
daujieroiis by direct injury to ibe eyeball itself, the optie nerve, or the
orbital Willis, which may he fractured. Ur it may produce iuflammatiun
of tlie coltular tistsuo of the orbit, or of tbe {>erio8teum, etc.
Sometimes, very lar;!c forei;^n botlios have been lodged in the orhit
without the patient being awaro of their presence. Very extraordinary
cases of this kind have been rcconled, amongst otherc> by N^ton,'
and Mr. llrnil^ntdl Cartei' [Ki;:. 217]. In Uic tati**r indianci*, a por-
tion of hat-pejr ii^i^ inohe.i in Icn^fth bad rcnmined impACt«'<l in tbe orbit
for from ten to twenty days without tho putient's being aware of it. It
was so aucccssfully removed by Mr. Clarice, tbat the patient recovered
without a single unfavorable symptom, tbe vision and movementd of the
oyi- being miimjiaired.
Fractures of the walls of the orbit are extremely darifjerous, more
especially when tho niof or iipjier [K>rtion of tbe inner wall is fractured,
for the foreign body (frequently the stem of a |>fdntcd infltrnment, as
the ferrule of an umbrella, etc.) may penetrate tbe cranium, or tbe splin-
> Ziadar aut Qeleslflr, loe. ctt., 223.
" " Ophth. E«v.," Ko. 4. p. 337.
m
DISEiSIS OF THK OBDIT.
IFig. 217.]
tors of the fra«.>tare<1 bone tnhy net up great irritation and infUmmadon
of the braiu and lueuiugts. Thf sevvru character of the injury BO'i Uw
prc8fjice of cerebral sym[>«tiiw, may n**
sliow tlienwclves for & d^y or two after
the accident.
If tlie fracture exteocU from the orltt
into the othmoidal or frontal celU, there h
generally cmithyscma of the orbit and
eyelifU.
[Injariee to tbe ftupcrior orbital
or ltd vicinity, irbicb do nnt inrolvtf
roof of the orbit, are often bomt' ttTj
veil, even vrbcn caries is the resnlt ; aad
this 19 true of fMstol-shot wounds tj of
other injuries. The carioos procc» ii
here very slow, and the sinus or firtiia
leading dowu to it. is generally visry
tuons and Ifiiig. Tbc removal of tha
rioua bone in the roont thorough manner u,
of course, at once iiidicatcU. I'istot balls
have been found imbedded in the orbital
edge of the frontal bono without caa«iaf{
any jrrave symptoms. (See a paper bjr
the Kditor,in "Amer. Joiim. of Si<m1. Sa-
C1ICCS,'" .luly, l!$80. on Traumatic LeueM
of the Bonos of the Orbit.)— B.]
The treatment of injuriee of tlie otM
must vary wiili Uicir iMtara. Ineasnvf
incised and pniicturcd ftonud^, we
endeavor to Kubdue the inBanunatory
tiun by oold coni[irettse8, leeehM^cto., aad
an early evacuation of tl>e pus. Foreign
bodies ghonld he remored aa ao<Hi a* pD*>
Bible, unless they arc of so >)man a u
thiit they would bo found with difficulty,
ami their rcninval mt;*ht cauM more dtt-
lurbauce thiin their prcset>ce.
Before an operation ts attempted fortlw
removal of a foreii!;n body, the size, na-
ture, and p(>8itioii of tlie latter abould W
asoeriained aa nct>untely ts possible by a
careful oTitmiuaiiun. If the forci^ boily
be considerable in sixe, aiKl sittiatcd deeply
in the orbit, so that it mui>c be cut dmn
upon, the outer canthus may have to be divided, in order that th« appfff
or lower lid (us the case may be) can be turned un or down. The cH^
junctiva K-tween the eyeball and the lid photild be divided over tlia
point whrri' it is auppoecd that the foreign body is situated, and a praW
or Uic til) of tlie little Einj^er bo introduced to nocertain iu exact pd«tt)Mt
ao that il may be grasped and extracted witb a pair of fupc«|ii. Tba
7
EXCiaiOS OP TBB BVEBALL.
791
incision sbould never be made through the skin of ttie evcUd, for the
contraction consequent upon the cicatrization of tlio wound niij*lit give
rise to a subsequent ectropium. The lip» of the incision at the outer
cauttiua are then to be united hy two or three fmu sutured, or Uic Iwistod
wire suttire.
In fractures of the orbit the most absolute rest must be enforced, tbo
patient should be placed upon lovr diet, and the use of aljmulnnls should
be forbidden. Cold compreaaea, and, if nooeas&ry, leeches, should be
applied.
The ovehnU may be dislocated and pushed out of the orbit by a for-
ei;fii Iwdy, e. */.,a piece uf iron, (he fwrrule of an umbrella or stick, etc.,
bein<; tlinist into tlio !i;ockct. In such caAeft, the eye lies ujioii tlie check,
protruding far beyond the lids, which cannot be closed over it. The
Optic nerve is, of course, greatly stretched, and vision more or less com-
pletely lost, but on the removal of the foreign body, and replacement of
the eye, the sight may be perfectly restored. The foreign body should
bo immediately extracted, and the eye replaced. The latter ia to bo
done by gently, yet firmly and steadily, pressing the eychal] back, which
will cause it suddenly to spriug back into the orbit, the sight being then
genumlly at once rcsLored. The oyo should bo retained iii its poditioQ
by a firm compress bandage.
IS^EXCISION OF THE EYEBALL.
The modem method of removing tlic eye waa first deriscd by Bonnet
and U'Ferral in ltS41, independently of each other. Stoeber practised
it in \H42t and Critchett tirst iiitrmUiccd it in London in 18ol.
The pvincip.'il advantages of this operation over the old one are, that
the eye is removed from the ocular capsule without any injury to, or
iiiterference with, the cellular tissue of tlie orbit, or a division of the
outer couiraiasurc of the eyelids ; that the miiMles are divided quite
oloae to their insertion into the sclerotic, that nearly the whole of the
conjunctiva is pre-wrved, and that only a few bloodvessels arc divided.
Thu!4 there it> hut a moderate amount of hemorrhage, and an excellout
degree of mobility is preserved for the insertion of an artificial eye.
The operation la bent performed in the following manner: The pA<
tient should lie on a couch, and a large sponge should bo placed beneath
the temple and cheek of the side corresponding to the eve about to be
removed, so that the blooil may not flow down his neck or over his
clothes. An assi.'itaiU should be ren<ly witb several cnuiller sponges, to
wipe away the blood from the eye during the different steps of the ope-
ration. 'Hie pntient having been brought thoroughly under the iullu-
euce of chloroform, and the eyeltda held apart by the stop speculum, Uio
operator places himself behiud the patieut, and, fixiug the eyeball
steadily with a pair of forceps, divides the conjunctiva all nmnd the
COnica and quit« clottc to llie latter, with a pair of strong blunt-|>oiiit«d
ScistKtrH curved ou the Qat [Kig. 218]. He next incises the subconjunc-
tival tissue at one jwint, and, passing a strabismus hook through this
aperture, catches up one of the recti mu«:lcs, and divides it i^uitc cloM
792
DI8BA8B8 OF tflS OBBIT.
to its insertion. The four rcoti niascleii sre to bo thwi divided in fK-
ccMion. When tKia has been done, the operauir preftitcii )»ack the upf«r
and lower 05«Ud. so as to uaku tUe e^ettull ii|)hng forth through Uia
small opening in the conjunctiva And protrude between the e^'clids. lie
cut cud of the teiHloD of the cxtcmil or internal reciux muscle htiu^
eeixod with the foroeps. und the eyeball rolled to thp f^tsm>
[Pig. 216-1 siwnding aide, the scissor* (ch'sud) are to l* p' ~
ilie poiiierior surface of ihe glolic until the opt <
reached, when the blatles arc to he opened and tlio ocm
divideit quite close to tlic «;lerotic. The eyeball i«liould Mw
be lifted rnrward l»y the fingiffs, and anj portions of coo-
junctiva or Hiihconjunelivnt tiit-sne which may adjierc to tbe
globe, as well as \Uv inserti'ju of the oblique Diascles, ar« W
be divide<l close to the sclerotic. T)ii8 fiiiisiieci Uie opera-
tion, and the ©ye will have been removed quite free froo
conjunctival or mu&cular tissue, and pr««eat a perfccily
smooth and polished appearance.
As tbe operator stands behind tbe patient, it will be fooni
most easy to divide the opiio nerve of the right eyv froB
the temporal aide, the eye being at the Mime time rotat«4
inwards ; the Icfi optic uerre, ou the coutrarrt is best ifiri*
dod fmin the nattal side. Ry so doing, the nght hand caa
be used for either eye, and the operator is not obliged la
alter bis position.
The hemorrhage which ensues upon the division of the optic Denrrand
ophthalmic artery, is gcucralty soon stopped by making a stream of eoU
water from a simngc (or, for want of this, from the narrow spoat of a
small jug) play u]k>u the bottom of the orbit, and it will not b« ueceHtry
to lij^aturo any vessel. Wheu the hemorrhage has stop]fedf tbe lips at
the conjititctivul aperture, through which the eye has been remoTed, may
bu brought togutlivr by a fine duturc, pomcd through the four Httls la^
nets left in the interval of the rt^cti nniaclvM. The tiuUire, which is bcMl
inserted with tlie long needle with a linndlo dcvi.<ied for this puntuse by
Mr. llulke, may tlieu be tied or twiated, so that the lips of tbe luciuoa
may Ih> accurately brouglit together. It is still better, however, to wait
with Uie (yiug of the suture for an liour or two, until all lirmnrrtinji
hail cca.-«ed. Although (ho in&crtiou of the suture brings the edg«a «if
thv conjunctival wound very nicely together, it ahoul.l not bo c»ploy«d
in those cases iu which the excised i-yc is acutely iuQamed, as it pre-
vents the exit orintlanimatnry exndatious. When the oi>oration in 6nt^t«d,
a thick plo«lgct of folded lint or n sfionge should be pnM*«d finaly- for a
few minuter a^UKt the liils, in order to stop the blevdiag. Sfaoold tkit
not nrn^st tho homorrhsge, a compress of lint soikcd in *:o\t\ [ or ttti)
wat<jr is lo be tied very tightly over the eye. This is far lend lauam
than keeping tiie liils oiien with a wire sf>eculiUD for an hour or two, ani
packing the orbit witli lint and small pif>rtioiis of opongc.
The after-treatment of caecit of excision of the eye is geucrallj TCfj
simple. A ' ' <i|>roas should U* apjdttNl during the first few ilan,
and tlie orl' ..il out with a Utile lukewarm «at«r, toelewtfe away
the dtschargu. It the latter should ooutiuue for longer titan a wvfc m
liSb
tnS JlPPLICATIOH OF AltTlFIOtAL EYBS. 793
t«n days, and the conjunctiva louks r«d and swollen, a mild Astringent
injection of gulfilinto of m\c or alum should lie ujwd two or lliree times
dailv- If the H^mptomA of iuflnmniation of \ht^ coUuUr li-ijiue of tlic orbit
flhould Buiierveiie, vrarro bread-and- water |)Oidticfs or warm poppy fomcu-
tatiiiiis should bo applied, anil the exit of pns be facilitated by a free in-
cision into the conjunctiva ; tliis should never be neglected if the lips of
the wound have been cloeed by a suture. Should small gmnulationa
make their appearance on the conjunctival cicatrix, these should be at
once Kuipped off with a {Miir of scisi«ors.
When the eye is cxciiwd on account of the presence of an intra-ocular
tumor, th(j optic nerve, instead of beni;? dividdl cioji? t^j the globe, must
be cut as far back as we can reach, in onlur iliat all tlic dis9eaH0<l [Kirtion
may, if possible, be removed. Or Von (inicfc's preliminary division of
the optic nerv« may be performed, a de»:nption of which will be found
in tho article on (jlioma of the Retina (p. 4(>t!). The extirpation of tlie eye
together with the soft parts of the orbit, as in orbital tumors, is a more
severe and protracted operation than the simple excision. Tho outer
commissure of the lids must generally be divided, in order to give more
room for the extripatiun of tlto eye and the morbid coutcuta of the orbit.
U^THE APPLICATION OF ARTIFICIAL EYES
(PltOniKSIS OCULl).
The use of an artiBeial eye should not be allowed until five or six
weeks after tho excision, when the cicatrix has become firmly uuited, and
lixiy pnrtH are •juict and free from all irritation. If tho eye has been
reMK'Vc'd oil account of sytiiiwithctic irritation of the other, special care
mui^t Ik* taken that no artthcial eye Is worn uutil all the sympathetic
aymptoms have penuftnently disappeared for some months, and the eye
must be carefully watcheil tor some time ufterwards, lest the artificial
eye might re-;Lwukeu Uiem. Imleed, tho wenrin]; of an artificial eye for
too lon}( a time, so that it sctn up great irritation, may even give rise to
sympathetic disease.'
At 6r»t, a small eye should be worn for a short time each day, and
then, wlien the part;:* have become accustomed to it an'l tliere is a com-
plete absence of all symptoms of irritation, a. larger one may be adopted
and worn for a longer period, and at last the whole day, but it should
atwatft bt reiiuived at niyht. After tho lapse of some mouths, the in-
ternal t^urfiicv of tho eye becomes rough, luid as this is a ready source
of irritation and discomfort a new one is required.
Aa the insertion and removal of the artihcial eye re^iuire some lilUd
knack and practice, I subjoin the following concitte and plain rules,
which are given to the patients at the Hoyal London Ophthaluuc Hos-
pital.
Tiivtru'-tvuiifor Per$"n$ tvMrhtif an Artijirial Etft. — It should be
taken out every night, and replaced in the morning.
■ Vidru) iotorMtiDgCMeofUiiakltutnoorded bjrUr. Lftwson, "11. 1., n. )!■ (!")».."
vl.3,123.
794
DISEASES OF THB ORBIT.
To put the Ei/f: in. — I'laoc tbe left hand flat apon the forebead, mtb^y
tlio fingers ilownvrarHs, and with the tvo middle -fingers raise the oppep^f
eyelid towards the eyebrow ; Uien with tJie rijrht hand, punh the upper^^
edge of the artificial eye beneath the upper eyelid, which may hv allowa]
to drop upon the eye. Tlio eye must now be supported with the middle
fingers of tlio left band, whilifil the lower eyelid is raised over its lower
edge with the right hand.
To take the Eye out. — The lower eyelids roust be drawn downwardi
with the middle Htigor of the lefl band, and then witli die right huiHl the
Cfhl of a small bodkin must be put beneath the lower e<igc of tbe arti-
licial eye, whicb mun be raised gently forward over the lower eyelid,
when it will reii'lily drop out ; at thi» time care must be taken that the
eye does not fall on the ground or other hai-d place, as it is very brittle
Bud might easily be broken hy a fall.'
Aftor it has been worn daily for six mondis, the polished surface
tbe artificial eye becomes rough; when this hapjiena, it should be
placeil by a now one; for unless this is done, uneasiness and intlai
tion may result.
[It is sometimes necessary to perform certain plastic operations u
tlie orbit, before an artificial eye can he introduced and worn. W
the eye, orbit, and lids have been injured by extensive bumi
whether by hot metats or fluids, the cnls-tlc-sac become so contrac
that an operation ha^ to be done to make a place for the insertion of the
ere. This aUo sometimes becomes necessary after severe orbital cellu*
liiis.— B.]
I 111 ordor tn ftvniil tliiii ncridrnL, Itin psiiont •huuU sloop ovnr ■ multbtn orhAUd;.
kvK'liiof pUcvd «u « tnUw, or ovvr « bud.
Chapter XYTI.
DISEASES OF THE EVKLI0S.
1.— (EDKUA OF THE EYELIDS, ETC.
(Et>KMA af the IliJt Terr freqiicntly nccompnnics (lu we have won)
the severer forms of inHuniniatiou Qf tlie cuniuiiotiva. cornea, aiul iris.
It may. however^ be also (icpcmlt'iit u|khi some ilisturbain-'e of the gene-
ral health, more especially in iVeble and delicate persons. It is often
due to an affection of iho heart or kidneya, and shonhl, therefore, alwayg
arouse oor su^piciona. and lead iia to examine as to the presence of
geueral dropay, and of atbumen in (be uriiiv. The degree of usdeiumtflus
awellin;; of the \vU is siibjwit to niucli variatinn. If it be due to consti-
tutional causes, it u often but incoiwidemUc In dc<5rcft, n"'">S '^"'* *^"'y
lo a little pufliness and fuliioss of the li<ls, which is m'uenilly >!;reate8t iu
the mominjj:. and diminishes during the day. Soraetiroca, the puffine*9
18 pnuvipaliy confined to the lower lid, forming a little pouch or sac,
which is very unsightly if it be considerable in size and if tlie subcuta-
neous veinji are dilated, &» the awclUng then aaaumos a dui^Vy, bluish
tint. The swelling pnxluced by trdcma is emooth, jmle, soft, an<i tienii-
transparent, and it is cosily pitted with tbo point of the finger, the mark
remaining for a little time.
If the wdema is due to constitutional causes, the trcatmont must bo
chiefly directed to their ntlcviation, when the swelling of the lid will
soon subside. Where the puffiuevs of the lids occurs spoutam'ously in
peraons of a feeble, delicate babit. tonics should be administered, and
the general health attcudedto, A corapre»9 bandage should be applied,
and i hnvc also found beuefit from the use of warm aromatic bags <^cou-
taining chamomile Bowers, camphor, etc.') tied firmly orer the eye. If
the wdema is very obstinate and unsightly, a small horizontal fold of
skin may he excised. Whore this condition ia deimudont upon some
other di.4ea.so of the eye, thist must bo treated, and when it is allcviatod,
the pufhiiess will t^oon diHapiwur.
IJnififiiftirtna of the lui» is ilue to the admission of air into the areolar
tissue, and is generally cau-ied by a fracture of the na».tl bones or of
the frontal or ethmoidal celts, and rupture of the mucous membraoo;
lliou^U generally produced by severe blows or falls, it may arise afler
blowing tlic nose very forcibly. The swelling of the lid ix tcuse and
eliwtic, and there i.t distinct crepitation on jires.-turo; tlic color of tbo
skin is, however, unchanged. The treutim-nt con^isKi in the application
of a compress bandage, with the use of a mildly ^tinuilaLing lotion.
798
DISEASES OF IltE EYELIDS.
In erythema {hyperoemia) of the tyelida, the sVm U very much r*i-
denod, aiid prescute a brtj^ht scarlet fluith, nhicli temponirily (lifta|i|>can
upon preftsure. There is, however, but very little, if any, nw^'Hinji of
the lid, and no pain, iiltliuugh tliu piitivnt comptaius of & scnsatii>n ■■(
great heat. The reilm-sii lienerallv exu-mls .-inniewhiit on to 'I" ■ ''..
ami tlie palpebral and ocular conjuneliva inav likewise be iujet' ■ .if
veins at the ^kin are aUo somctiiuea dilated. Tbia aficction is Dot uo-
fre.|uently due to prolonged exposure to very bright sunlight or inWttt*
beat, and is aUo mot with in persons suffering from K>me irregularity of
tJie general circulation. Comprcssea, Boalcod in cold water or in fiou-
lard lotion, should be frei|ueDt!y applied ; and a flolutioii of nitrate «»C
Bilrer (gr. iv ad %}) may be paintod over the outaide of the lid&. If
there is much vAKCularity of the conjunctirft, and n alight niijct»-purulcnt
diacharge, a weak cullyrium uf aulphate of xinc or alum should be prs-
scribed. •
A jieculiar bluish di«:oloration of the eyelids (mors eapeciallv th«
lower one) is occasionally obsen-ed in jwrjous of feeble b*"aUb, and of a
very transparent and delicate complexion. This liark tint is especially
conspicuous beiteaiU the lower lid, producing a dark-blue, aemicimlir
ring. This appcamitce is due to a dilatation of the subcutaneou veiMi
which are more conapicuouii on account of the delicflcy of tho skin. Ic
u often difficult to cure tbi^ discoloration, more esjHreially if a oertali
degree of usdema of tbr lid coexists. 1 have found tlie most henefil
from the use of a solution of lAnnin (gr. iv-riii, to Sj of water), wbi
ia to be puiuteil frequently over the outside of ibe eyelids. WUeii
has been employed for some little lime, a solution of acetato of leatl or
of nitrate of silver should l>c substituted. Care must, however l>e taken
that the nitrate of silver docn not di^olor the skin, which iii especially
apt to hapi>eu at the jH^inls where ibe latter is a liitle wrinkli-d. The
general henlth should, nt the liame time, be nttettded to, irragularitie^ m
the circuluiion or the digt.-stivc' functions W rectiBed, and absUiMM*
from every form of dissipation strictly enforced.
[Hemorrhages beneatli the akin and in the tissues of the lid ooettr a*
the rexult of rupture of Uie palpebral veau-ls, or from tlie cxt^Dsioa of
an orbital or iutra-cmnial hemorrhage into (he lids. Any Mow or 5kU
n]K>n the eyelids may cause a hcmorrliage, and likewiM any o[.<cratioa-
Tbe ptilpebml vesseU may also be ruptured by auy undue stratohin.? of
their walls, as during riolrnt vomiting, or snoceing, or coughing. >
t^matic hemorrhages by diKpcdesis, without any rupture of the tl-»v»,
also occur in acurvy and purpura. — B.J
2.— KVFLA3IMATI0:s OF THE EYELIDS, ETC.
Jfi thf nctttt phJe^monout injiamm^tion (absocss) of the eyclida, then
is gr«at rcdiiesti, beat, and swelling of tlic lids, wbicb are also acatrly
Hniitiro to tlie touch. The skin h greatly reddened, and. ju the dti-
Mse advances, it iissumes a darker and itxire du^ky hue. '~ njuoe-
tiva is aUo injected, and ihere is often u considerable degr. < laiMii.
iTho swelling is finn and hard, and not liedematous ; it oTteu oxteoda gnt
INFLAMMATION OF THB EYELIDS.
7PT
tlie cjrebrow and cheek, and may become so considerable tliat Uie upper
lid IB swollen up to the siw? ol* B pigeon's eg;^, or even larger, fhia
hardness is at first espfcinlly conapicunua at one point, which feels like
a little^ firm, circuniscribud nodulo : this increases tooro and wore ia
eisc, tlien tiic harduoaa gmiiiially jichU. the swelltn^ becomes softer,
more douf^hy, and there is u distinct sense of fluctaation. The skin be-
comes thinned and ,vellow at one point, gives way, and a large i|uantily
of thick oreamy pu4 escapes. In mrcr instances, the perforation oocnrs
tbrough the conjuiwtiva. When tbo abmess forms at the inner angle of
the eye, near the lachrymal snc, it has been termed anrhylopa, and may
then be mistaken for acute inflammation of ttio sac. If it |>erforates at
the inner catithua, it ia called trijiljp*. It generally, however, occurs
in the upper lid, wliich, on account of tlio swelling, hani^s immovably
down, so that tlic pal|H.*bral ajierture is iiuite closed. The pain is mostly
very great, and of i» violently tlirohUing character, extendinf; over the
corresponding side of the head and face. There is often aK«> much con-
stitutional disturbance and fevcrishnet§8. The course of the disease
may, however, be more chronic, and till the intiiimmatory symptoms be
sulmcutv in character. Abscess of the eyelid ii> almost always of Iran-
matic origin, l>eing produced bv wounds or hlovr^ ujioa the eye. It may,
however, occur spontaneously, or aujiervene npon severe inflaunnation of
the conjunctiva, or erysipelas of tbo eyelicl^.
If the disease is seen at the very ontsct, wc should endeavor to pro-
duce the reaolulion of the inflammatory swelling by the applicntion of
cold (iced) comprestiCft, leeches, etc. Jlut if we caiuiot succeed in tJds,
hot poultices or sedative fomentations should he applied, in order to
accelerate the formniiou of pus, and as soon as tluctuation is felt, a freo
incision should he made into the awclllng pamDcl to the edge of the lid,
•0 as to give ready exit to the discbarge. For if this is not done, but
the abscess is allowed to {wrforatc 8|iontancously, tlic auflerings of the
padunt are not only greatly aggravated and prolonged, hut tlie ojienlng
will be ragged and insuflicienl, ami by the contraction of the cavily of
tlie abscess, will tenil to pmdnee ectropium. If perforation hua alreaily
occurred, the opening should he enlarged if it is insuflictGnt for tbc free
discharge of matter ; and if several apertures exist close together, they
should be laid open into one large wound. After the escape of the pus,
warm poidtices should be applied, and subset(ueiiLly warm water dresi>ing
and a compress bandage, so as to keep the lid in [loeiuon an<l the walls
of tbc abscess in contact, and tbus hasten the union. A generous diet
and tonics should be prescribed. Any evcrsion or malposition of tlio
eyelid or puncta must be ire»te<l at a subsequent periml.
In J-'ri/Kififta* of the lids the swelling is not Bmi, hard, and of n
dusky.red tint, bat 'edematous, softer, ami uf a muru rosy, s^'uii-lrans-
pan-nt" hue, the blush disappearing on pressure. The cuticle is fre-
qucntly elevated in the form of small blisters by an effusion of serum.
The swelling of the lid is often very considerable, and extends over tlie
eyebrow and down the cheek ; the conJunctiTa is injected, and there ia
more or less chemodis. There is likewise much constitutional diiturb-
ance ; the j>atient is feverish, bis tongue foul and loaded, ottd he is often
extremely weak and feeble. The paiu is generally not very great, nor
708
NUABBs OF TUB BVELIDS.
of a throIiVmg or pulsating character. If pus is foraoed. the swelLin*
ft9Auiii^3 grL'ittcr finiiiit;3s, tlie akin lioconiea more teoae and of a Itnil.
dasky-rvd lint, aitJ Uie pain, heat, and throbbing increaae in •creri:v.
Xhn swellin;; bccooies softer, there is a distinct feeling of flnetntiiK.
aiiil thon, if left to itself, the abscess points and perforates. Tbc mattrr
Diay extend freoljr into the connective tiwue, and gire rue to rx(ctL>;.(-
stough«. Itut crv-iipclaji may prodoco much more scriooi oocnplicatioi*,
for the iaBaiDmation mny extend to the CL-ltidnr tiMue of tbc orbit, ginng
rise to al»9ce9t) within thu hitiur and grc'Ht exoplithaltona, folUnrcd ^t
bajia bj sloiighin;; of the comea or suppurative trido-choroiditu ; cr, the
the iuflammation maj extend backwanls from the orbit, alooK the opiie
nerro to the brain, and set up meningitis : or, again, the eryaipelaloM
iiiltAmmatjon may also become diffuse, and extend to the face. The
t;ight may likewise be much impaired or lost by the infiammatioa •xtcttd*
iug to the nourilemom of the optic nerve and setting up optic nenritia,
which may termiuate tn atrophy of the nerve. Or the latter tuj
be produced by the great pressure upon, or stretching of. itie o|><ir
nerve. The purulent matter, as Mackenzie points out, may likr«i>if
make its tvay into the luchrynuil sac, which bucomes filled whfa pm
from without; iu the pruductiott of nhich, its lining membrane baa no
share-
Krysipelas of the eyelids may be spontaneous in origin, being eiTtsnl
by exposure to cold and wet, more especially if the patient is already is
feeble and delicate health fi\>m want or dissipation. It is oft«*n. bow-
ever, of traumatic origin, being due to injuries, wounds, etc., of the Ii<li.
Our first object in the treatment must be to strengthen the patient. If
the btomach is much deranged, the tongue loaded, the breath fetid, a
brisk ])urgativc nr an emetic ahonld l>e at once administered. Then
tonics should be given^ more especially the tincture of steel, or prcHni-
lions of steel and (|uiniiie. The diet roust be generous, and sttmtiUDls,
particularly port wine and brandy, shoold be freely admiiustered. Warm
poppy or laudanum fomentations should be applied to the lida, or t>iej
may be painted with culludiuii. If pug is forming, a free inciiiion wut
be made at once, in onler lo j)cnnit of its ready escape. If the cbem^
sis is very considerable aud firm, so that it pressed ujion the veaeeb wbkfa
supply the cornea, and thus endangers the nutrition of the latter, the
chemotic swclUug should be incised at diRurvnt points; but if the pre*
eure of the swollen lids is threatening this danger, the ■<< iho*
should l>e divided. When the crysijielatous inHammatton . . ..It-i
to the orbital cvllulitr tisane, and the eye is protruded from a oolleeooa
of pun or an effusion into the orbit, a free and deep inmnoa ahonld bt
QUide so as to evacuate tt.
Caeca of anthrax (carbuncle) of the lids generally ooenr in elderly
persons of feeble health. The iuflommatorj- swelling i* of a du»kT,
livid red, and firm and circumscribed, and there is a great teodeaey to
alougbing. Vciticlos form on tlic lid and bunt, diMrharging aaniooa mat*
t«r ; ibc skin and areolar tituue become black and gangrenoua, and.
sJoughing out, leave a more or less deep cavity, which then gr"'-;!-*--'
anrl cicatrixoa. A crucial incision should be made into the «>• >
early stage, so as to allow the escape of matter and facilitate tiic sepa-
sypniLITIC AKD KXANTnCMATOUS AFFBCTtOSS.
ration of tKe sIou;^h, and warm poultices should then Itc ftppHcd. Hie
pntioiit'ii streu^tl] muiit bu sustaiiwd hy a libenil U(liuiiiUlniU<m of hrnmlj,
v/\w-, touiom, and n ^ooA diet. If the {mui i<i ;;reAt, opium must bu
g^voit, either internally or by the subcutaneous injection.
Mnti}/mt7it vuttuie of the lid* is said to b« somewhat common in cer-
tain parts of Franco and of the continent, but 1 have never heard of it«
bftviug been met with in England in its true type. According to MftC-
kcnuie. it in chiiracterized by the fonmilion of a vesicle filled with bloody
serum, which is accompanietl by great and firm swelling of the lids, the
skin of which is dusky and red. The base of the pustule is hard and
nodular, and soon sloughs, the gangrene spreading with great rapidity.
There is severe constitutional disturbance, mucli fevur, and intense [min.
Tilt- diKoasu is alm(Rit always producm] by contact with decomposing car*
cosses of cattle, or with animnl.i sufTt^ring from farcy ; hence it is most
frequently met with amongst tannurs, butclienj, drovers, etc. It is so
extremely dangerous that it may prove fatal within 24 hours of the out-
set, the inllanimation extending to tlie head and neck, and tlie eye being
either destroyed at the timo, or 8ubge(|uently from exposure. Mackenzie
states that the best treatment is a deep crucial incision of the swelling,
tolluwvd hy the immediate application of the actual cautery. Toiucs
and slimulauU should bo very freely administered.
S.— SYPHILITIC AND EXAXTHEMATOITS AFFECTIONS
OF THE EYELIDS.
[Syphilitic lesions of the lids are of three kinds : Ist. Chancre or the
iniiial sclerosis; i2d. Exanthemata; 3d. tiumroata. The oxanthcma-
tous variety is merely a local symptom of the constitutional diseaae, and
the gumma is a late manifcsLatiou of tlio disease.
Tho exantliematous lesions of the Uds are usually of the papular or
tubercular variety. Tlie result Is frequently an ulcer, the centre of a
papuk- or tubercle breaking down and sloughin^r on the sunace. It may
be confined to the skin or involve the entire thickness of the lid. The
tubercular sypUilide presents the same oharacteristics as the gununa, and
microscopically they are one. The tubercle may be cutaneous or sub-
cutaneoutf, and the latter ia apt to be very painful. The papular syphi-
lide, tliiMigh goncmlly of rapid growth and often extending over the en-
tire lid, dues rmt extend very deeply into the tissues, and the dostmciivo
proOMfl is consut{uently superheial. — B.]
Syphilitic ulceration of the eyelid genenilly commonces at it^ free
edge, along which it rapidly aprea4ls, more e«{>ocially towards the akin,
showing a greater tendency to extend in this direction than inwards
towarU the conjunctiva. .The cj'olid is much intlamod and swollen in
the vicinity of the ulcvr, and of u dusky, livid hue. The swelling is
firm and hard, and feels no^lulatcd. The ulcer has a har<l, cartilaginous
base, its oilges are iiTegular, and ita bottom presents a peculiar dirty ami
lttnlacL-r>n5 appearance. The whole surface of the lid is often swollen
and indunited, ami of a du-sk;--rcd tint, the inflammation extending gen-
erally to the conjunctiva, and being accompanied by a muco-parulent
8O0
SISEASBS OP TU> BYKLIDS.
discharge. If the disease is not recognistoJ »iul properly tTc»t«*i, the
ulcer will rapidl^v aprciKl, beuixne deeply notclie'l, jiihI pcrliapa nonn oat.
iu wny through the whole Hubstancc of the lid, dcstroyltijj «kiii, car-
tiht;j;L>, and conjunctiva. lnd<.>t.>d iUi nivnj;t>s tniiy he so great, t-haV th«
whole of the eyelid may become destroyed, and the disease even extend,
to the other lid. In rarer instauces, the ulcer may occupy the iutemalj
surface of the eyelid, and apread over a considerable portion of Uio pal-
I>ebral conjunctiva without appearing extenially. Ff the ulcer it* f^itiuttMl
at tlie inner eanthuA, or tlie inner edge of the lower lid in the viciuitv of]
the lachrymal nac, it inay lie mistaken for n fistula of the latter ; indeed}
it may penetrate into the sac. It h often somewhat difScult to deter
mine with certainty the true nature of the disease, or to make the dif
ferential diapio^is hotween the syphilitic nicer and the difleront formii
lupus and epithelioma. The syphilitic character of the nlccrauon mostf]
however, be suapecled, if it proves very obatinnte. and instca'l of yield-
ing to the usual ix'niedies, gets v.-one and spreads more and more. W<
must then carefully and searchingly tni|uirc into the history of the ca
and aKccrtaio whether any other symptoms of syphilia arc present, m
as cmptions of the skin, ulceration of the throat, ete., or whHher tbfr
has been any chance of direct conta^on. For although these ulcers
are almost always secondary, a priraary hard chancre of the lid may b«
iDCt with. [Tlie chancre may occur on the edge of the lid, and the ia*
duration extendi upward some distance upon the tarsus. It i» usually
very slow in its course, and resists treatment obstinately. The indura-
tion occurs very rapidly in the margin of the lid. Hoth maoroscopically
and microscopically the chancre bears a close resemblance to the gummy
infiUriiiion which lias undergone ulceraUon. — B.J The softer variety
appears, however, to be of rare occurrence. The ulceration may tU
extend to the eyelids from the neighboring parts, such as the nose, etc
[The condition of the glands nearest the lesion should always be ascc!
Uined. It may happen that induration of the soreisabsentor hut slightly
marked, but it very rarely, if ever, happens that glandular induratir>n und
induration of the ulcer are both absent. Out of iG4l* cases of indumteil
chftDcrc tabulated by Sturgis,' the lesion was situat^^l on the eyelid in bnt
six. — H.] [The gumma of the lid may Iw circmnraribed or difluse. The
former appears as a nodulo near the ciliary margin. The latter may ia>
Tolve the whole iid, and is then known as Tarsitis syphilitica. Thv cir-
cum^ribcd gumma when isolated is a tubercular syphilide ; it may
acute or chronic. Chronic infiltration of the entire lid is rare, though
number of coses have been recently reported. In these coses the skia
is not inrolred. The isolated gumma sometimes follows hard after ih*
iuilisl sclerosis, though it is usually regarded as a late symptom. (^
apA|>er on Syphilis of the Kyelids, in the '*N. Y. Med. Joum.," Marehr
18"S, and one on Tarsitia Syphilitica, in " Trans. Amer. t»phtji. Soc.,"
IbTN, by the Editor. — U.] Tiie treatment must consist in brin;;iTig tlw
patient as rapi<lly as |«ssible under the inHucncc of mercury, eitiicr by
inunction, or mercurial baths; and Che system should be kept slighily
under its action for some time, otherwise a relapse may occur, or Uie
C> •■Amn. Joorn. U«d. Boi.," Jan. 1873, p. lOS.)
ir-
iia^H
SVPntLITIC AHD ESAXTIIEMATOnS APFKOTIOXS. SOI
nicer return. The latter shouM be freclr touched with oauetic, aiid
when it U begiimiri;^ to hcnl, the n-d jirccipitate oimrneiit. or the hiack
vash ahouid bo nppticd, in ortlcr ti^ acccloi-atc the cio&trization. If tho
ulceration prove very ohatiiiate, ami resiuLs the action of mt;ix'ury, much
advantage ia oftpn experienced from a course of Zittmnnn's decoction, na
this is accompanied by a very free action of the skin, If this be inap-
plicable, warm hatha should he prouriKeil for the same purpose.
In infants, the existence of con^enitid sypliilifl generally niamfeftts
itMif by the ap[)enrance of papular or niistiilar eruptions on the face*
haadSf and around the aniu*. The eyeiidit arc inflamed and swollen,
there is A purulent discharge, and. in very weak aii<J feeble children,
Uiere in nineh ilnn^er of sloughing of tlu' cornea and hym of Uiu eye.
Small (lost^s of cnlotnol nnd opium sliould he adinini<)tcrrd, and an astrin*
gvni collyrinin, or the red precipitate ointtueut should be applied.
[ liave alruudy mentioned, when treating of the exanthematous affec-
tions of the conjunctiva, Umt the eyelids are alao very prone to suffering
daring the exanthemata, more especially in smallpox. [This is also the
case in scarlet fever aud meoitlc^, though to a lesa degree. Among cho
non-C'Hita;;ious fkiii diseases, lichen and pemphigus are met ivitb not
infret|uoiiily upon the eyclid'4. I'i^onaAitt, pityriaHitt, and urticaria are
nUo occa«io]valty found upon the lid:». — B.] tlcxema of the lids occun
very fre(]uently in conjunciion with eczema of the face. It in also due
to severe and protracted inflammation of the conjunctiva or coniea,inore
e*]M>ciiilly phlyctenular ophthalmia, and is caused by the irritation of the
constant discharge, and of the hot ticalrling tcar^ flowing over the eilge of
the lid And down the cheek. The proper mode of treatment is deacnWd
at p. 188.
}ftrye% lotter frontalia tcH ophtfialmicuft is not unfrequently accompo-
nieil by inflammation of the eye, ami is hence of [veculiar interest to Uie
[»phthAlmologist. Mr. HutchiiiHon lios called sjiecial attention to this
Kt, and has also shown that it is of far more common wcurrence than
U generally supposed, being hut too often mistaken for erysipelas. To
him and to Mr. Itowman,' we are chiefly indebted for some admirable
papers upon ihix diseafte. The affection is generally ushorcd in by more
Mesa severe pain ami tcndcmesia in the brow and head, which lasts for
rerul days, then tlie skin becomes red and swollen, anil numerous small
Xtic vesicles make their appearance, being arranged in groups (,gen.
^' of an oval shape). The individual vesicles become conriucnt, their
contents dry up into scabs, which afterwards drop off, and leave deep
and characteristic scars, which are very diagnostic of the pre-existence
of zoster. The eruption extends only along that |iortiou of tlie skin
which is supplied by the nplithalmic dlvisiun of the liftb nerve, and is
therefore confined to tiie foreln^ad, the anterior portion of the scalp, the
upper eyelid, aud the side of the nose ; the neck and lower lid are oflou
swollen, hut arc quite free from vesicles. It may, however, affect only
certain branches of Uie ophthalmic, £.(/., llic frontal, the trochlear and
• " It. L. 0. R. Roiwtrta," r. and ri. ; vide alM a cue of BuOTan's In •' Q. Uo-
natflM.," 1866, 3M.
61
802
DISBASSS or THB ETBLtDS.
nual brancli escaping. But Bonictimcs the miclille division of
mny also be afl«ct*!<l.jw well as t!ie first (lU'Iira). ami then tlie i
apiwan* likewise on thi* chefk. 'Ihv tliseasf i« nrohshly moatlv ilne to
CoM, vrhicli cau^CA Bti inHammntinn of Uie superficial portion of th«* trunk
of these nvrves iiiid their cuUneous ramificaUons, nliicli is aoocueded U
the erdption of vesicles.
According to Ilutcliinfion' the eye hardly ever suffere mueli in Iiei
frontalis, iinlcsa tiio oculo-nasal hrench !■( alTeotc'l, and ilio veAiclcfl appci
on the Elide of the no-te, and itt* tip. the severitv of the enij>tion twiu
usually in direct relation with the sevtrrity of tlie ocuUr inBamiuation^
The eye doeo not inflame till the eruption is at ita height, or bejnnnit
to decline ; it is n)o«t commonly obicened in old persons, in whom iodc
hiTpfa KOBter frontalis is alsfl tnost apt. to occur. The pans of tho ej
oftcctcd are chietly the corn*'*, upon which small, fn^-^iirntly mar;;irt«lJ
ulcer* form, and the iris, wliieh may become inflamed. The irilis la gm
erally only alight in character, bnt if the corneal ulcer is large anil ]vt
fomt«8, and the trills in severe, serious complications may ensue, ami th4
sight be even lost. There is often great awulling of the lidn, t«geih(
with A varying degree of photo phohi.i, lachrymaiion, and conjmiciivi
redness. The ttMnperature of the affoel^^d psirt h markedly iiicrea-ioJ,]
but itrt sensibiliiy i^ dimtTushed. Accoi-rliiig to Honifi' the carlit
Hymjitom observed in the eye ie the appearance of tramiparent ve»ict
on the cornea ; tbcy aro generally situated at or near the man^n at
arranged in groups, or they may appear in single file like the beads of i
rosary. They are accompanied by slight clomline^s of the epithvliiir
Thc3c vesicle* soon hursl and leave behind them small excoriatioiw, jii
&$ if the conica had Iteen scnitchcl by a linger nuil, and the conioA
becomes o|iu<|ue and unie^ihciic. This amcsthenia is not, however, cun-
fined to the portion deprived of its epithelium, but extends nearly ovie'i
the whole cornea. There is, moreover, marked diminution of the intr
ocular t*'n»iim. A form of herjielic conieilis, very elosely r'
this, iii aUo met with, as Homer has shown, in the cnuriw of . . dj
affections of the respiratory organs. Herpes froutnlia only atiauks
patient once in bis life, and is exactly localized according to the dist
buiiou of the nerves, never overstepping the ml^Uan line. There is
most intense and persistent (utin after the dir;caac has suWnled, retuliTr-^
ing the patient's existence miserable. The eye may tjiwh uji at times,
and become irriLable. hut the skin and the eyeball are more or les^ aiuB»-
ihetie. ()i:oasiona11y there may iilsn he piiralysi.-t of the motor nerve.
Herpes zo*ter frontalis i.< very fi-eipieudy mistaken forcryrupelas cv*
by praclitiouersof eminence, hut there are certain well-marked and easil]
recognizable differences, which should prevent such an error in dingnosiii]
Tliese distinguishing features are well pointed out by Mr. HuteiiiiisoflT
who says, " lleiiMis frontalis is always limited to one side, nover trans'^
grosses the median line of the forehead and iiose : it never affects th«
cheek, although there may be »ouie sympathetic icdema of ihtA |r
(oedema of contiguity). There is lese general swelling of the akin
in «ryst|>e)as, and in some cases very little. The resiclea of herpes
' " R. L. 0. B. BoporU," rf. 3, 182.
■ "CI. )iCoDaUbL,"1S71. 321.
MABOINAL BLGPUAaiTia.
803
ler. more defined, more numerous, ntiil altngctlicr more consptcnous
aii<1 pnHiouncol iLau are the bullae of ervsijieUs. There i? much more
paiu and niucli less coiistitutioiml disturbance iii herpes tlinii in erysipelas.
The strictly unilateral clinracter of the one, contrasted with the irregulur
aitiiatiuii of the other, iit, however, the mo«C reliable feature for the [iiir-
po.te of rcadj diapiosis."
With regiini to tlie frm(ni»rHf. unfortunatelj nothing very satisfactory
can Iw stated. Tonicti, esitocially preiHirsttons of <|uinine, should be
administered, atropine flhouM ho prescribed, and some simple Intion,
such as Icml with opiiiTn, may be applied to the skin. For the relief of
the after-iwins chloral or the subcutaneuua injeetion of morphia should
bo tried. If lhv:ff fail to nlK'vintc it, the subcutaneous division of the
fronuil or uat>al nerve ^Iiould l>u performed, as recommeiuU-d by >fr.
BowniAii. In (wmc instances it, however, only proves of tcmfjomry
benefit. The intense neuralgic pains are sometimes tustautaueously cured
by the application of galvanism.*
4 INFLAMMATION OF THK KDGKS OK THK KVKLinS
(TINKA lAKSl, 01»H'IHAI.M1A TAUSI, liLKl'UAKJTIS
MAIMIINALIS [SEU CILIARISJ), ETC.
In the mildest form of the disease, we notice only n hyperscmic con-
dition of the ed^cs ef the lids, which look angry, red, and sore. There
is ttt tlie same time a feeling of heat and itching in the eyes, which
becomes aj^j^ravated by ex|HMure to a very bright light, a smoky atmo-
sphere, or by long^ontinued use of tho eyos at fine work. On awaking
in the morning, tlie patient notices tbut ilio Hds are somewhat glued
together, and (liHt xmnll eni^Ui form u[k)ii and clog the lashes, which are
perhajis stuck together int^i little binidlos by the hnrdcmng and ilrying
of the discharge. The edges of the lids now Iwcome somewhat thickened
and hyperlrupbieil. and ap[H-ar red, glared, and shining. Tlie discharge
11 also more copious and thicker, and the crusts more firm and consistent.
If tho diseaso advances, small white pustules are formed here and thero
at the roots of the lashes, which project through the pustules, or the
latter may be situiited between the cilia. These little piistulci) become
excoriated, and exude a yellowt^^b muco-purulenl dii«chargo, and readily
bleed if tho edge of the lid is rubbed, or the crusu arc roughly removed.
Tbc margin of the lid becomes more and more inflamed, swollun, and
irregularly notched, and the pvistules may invade its whule extent, so
that it looks quite raw and ulcerated when Uie crusts have been removed.
When the whule substance of the lid along the margin is thickened and
banlened. it is tenncd tt/l:»i». The conjunctiva generally participate*
more or less in the inflammation, and this together with tlie intlamed
condition and altered Si^cnHinn of the Meibomian glands, causes a sen-
sation of sand aud grit in the eyes, which I'cel, moreover, hot, dry, and
very itchy. This itchiness is especially marked if the lid and cheeks
become excoriated and inflamed. If conjunctivitis supervenes, there is
» Vlie Na8*». 'Kl. MonattM.," 1871. p. 331.
804
SISEASBS OP TUB ErBUDS.
of conrsc an increase m the dUcliftrge, which now aMomcR a roaco-parn-^
lent chanictCT. lu the severer cases of l)|y|)haritiB inar^finulis. sup|iur
tion of the hiiir follieles Lakcti placo, and the pustules which form at thi
base of the cilia may attain a conVidcraMe site, and, on givinji way
being pressed, they exude a thin niuco-punilent discharge, which dri<
Hjion the edge of the Hd in tlie form of thick firm crust*, beneath whicfc
tlic mtirgin of tlie lid n ulcerated, and perhaps decpU' notched and
dented. Ilie lashes hecouie loose, and are shed; either falling out,
remaining glued to the crust*. For «ome time, new lasho* are forme
but they are not of normal Birength or growth, hut are weak, crooked
and ?iimtcd ; hut if the disease runs a very protracted cour«c, and
severe iti character, the lashes cense to grow, and a more or less con
eiderjihle portion of the lid in ct'mpletely deprived of them (madaronii)!
or, at best, a few, thin, atraggliiig cilia are Mattered sparaely along it
margin. The position of the lashes often undergoes a considerable chang*,"'
BO that they become inverted, crooked, and stunted (trichiasis), or a
douhle row of cilia (diritichiaids') may be formed, either along the grvat«
portion of ihc lid, or chielty at one point. There is also much dfln;;gi
that the cieatriKalion of the ulcers should lead to a closure and obUteri
tion of the .Meibomian apertures, so that these become skinned over;
secretion from the glands is thus blocked up, and on pressing the ed;
of the lid no diijcharge exudes. This condition, and the inflamroatioti^
of the MeihoniiuD glands which often supervenes, aggravates still more
the intensity and obi^tinacy of the disease. Indeed, when the af>ertnre4|
of the greater number of the Meibomian follicles are obliterated, tltl
case may he considered incurable, and only cn[)Ahle of alleviatioi
Whereas, if these ducto are still open, a cure may with porseverat
and care he looked upon as certain, although many iiiontlis naj eUi
before it can be attained. On account of the thickening and hy pert
of the edge of the lid, this graduallv shows a tendency W become
what everted, and then the lachrymal punctum, instead of being tumc
in towards the eyeball, becomes erect or ev«u everted, and the teat
which can no longer enter it, flow over the edgo of the lid. and thus t«
still more to maintain or aggravate its inflammation. Moreover,
latter may extend to the puucta and canuliculi, and cause their obUl«t
tlon. The inner edge of the lid loses \U angidarity. Itecomi's roiimlw
off", smooth, hardened, and cuticular in character. The contraction
the skin which ensues upon the cicatrization of the excoriated lids and
check, moreover, increases this tendency to eclropiura, bo that even a
considerable degree of lagophthalmos may be produced.
BlepliKritis marginalia is fre<|uently produced by llie various forms of
conjunctivitis or corncitis. more c!»pecinlly if the latter are accompanied
by a great diecliarge of hot scalding teara, which constantly moisten
excoriate the edges of the lids. Hut it occurs also as a pnmarv di«eas9i
ftod is then generally duo to prolonged exposure to wind, cold, brigt
glare, or to an impure smoky atmosphere. Its intensity ia much nggr
rated by dirt and want, and it is, therefore, most frciiuently met nit
amongst the jtoorer classes, and especially amongst those nationaUt
which habits of cleanliness do not prevail. It occurs most frequi
amongst children, but it ia also met with in adults, and ii es|>ec!allj
MAItaiKAL BLBPllARITIS. 805
prone to attack persons of a delicate, feeble, anJ scrofulous constitution,
or wlio dufTer from impairment of ttie ili>;edtiou ; iti such, it proves espe-
cially obstinate ami apt Co recur. Dr. MuCall Amlersou conxidcrs that
tbis diMa^e is neitlier more uor less than a pustular ecxcma (impetigo)
attackiiiK the e<ij;os ijf the liiU.'
In the trmtrnfut of this tli^casc, tlie groatC!)t attoiition must he paiil to
the most scrupulous cteanliiie^s. In miM ca<^c9, the uye should be fre-
quently wanheJ with i^pid nater, ur warm milk ami water, so at) to re-
move the cruHts from the laches, and when this has been done, a little
of the yivak nitrate of mercury ointment should be applied to the roots
of the lashes with a fine camel's hair brush. [A better application i« a
soluUoii of aodic hicarliounte in the pro|>ortion of gra. xv-xx to the ouuce
of hot water, to anfteu thecru.Htfi. — K.J If tliit prove too irritetin;^, we
should dimini«b the Atrcnf;th of this oiiitniont by an admixture of one or
two parts of lard. If the crusts are thick and firm, and the edges of the
lids very swollen and red, mere ablution with warm water will not suf-
fice, but compresses, steeped in hot water, should be applied for ten or
twenty tDinules,and rrei|iieiit]y clian>;ed during this period, This should
be repeated three or four times a day, or hot bread and water or linseed-
meal poultices may be applied instead of the compresses. Tliia will
greatly alleviate the irittammaiion, and the crtistii will bo so ilioroughljr
soaked and softened, tliat they will cither become detached spontaneously,
or can be removed without ilifficulty or injury to the lid. The hot com-
proHseit or |H>ulticc!4 will he found es|K'i-ially usuful in the morning, when
the crusts ar< thick, and the lids 6rmly glued together by Uio nocturnal
di^harge. After the removal of tite crusts, the lids may be bathed with
tepid water, and then some astringent ointment or lotion should be ap-
plied. Before doinj; «o, any diitcased or attinled eyelashes sliould bo
extmcted with the cilia forcej«(, as this favors the growth of the new
ones, and renders the applictktion of the topical remedy more easy. In-
deed, if tlie di^eatiC is Kcveru and imjilicates the gr(?atcr portion uf the
lid, it will )>e well to remove the greater part of the likslie^, or, as sug-
fKsted by Mr. Streatfeild, to cut them down 4uite close to the margin.
j]al[N>3itiun or a faulty shedding of the hiahed is a not uufruquent cause
of a very obstinate, tbongh perliaps mild, form of bleptiaritis. In auch
cages we find that on passing the lasher lightly through our finger and
thumb, many of them come out nC once, their root being often black.
Great benefit is derived from careful and repeated epilation of the affected
laahe^. A great number of ointmentj^ and lotions have been recommended
for tliis disease, and in very chronic and ohi^tinate cases it is advisable
occasionally tc change the remedy.
In the milder foniw, the iipplicatinn, night and morning, of the weak
nitrate of mercury, or thi? red or white precipitate ointment will lufSce.
[An ointment of yellow or red precipitate of mercury, from It to 10 grains
to tlie drachm of vaseline, is an excellent preparation.^ — It.]
If the edge of the Ud is much excoriated, a solution of nitrate of silver
(gr. v-x ad sj) should be lightly painted overit every day : or jdcdgets
m lint, dipped in a weaker aolutiun of nitrate of silver or of sulphate of
* **A PrMUcal Trualiao upon Ecwmg," bjr Dr. MvCalL Anctwrsoa, p. 197.
PIJBASU or TBI
MM. ikadd W pRMiatiT >n6ed. If
(mned, dkoe Avoid be tnoched wilt a
of CMMT or lb* tpiupoed Htnit of
p«*t WMit fnm die aw of Hebrm's
mru of (JUrmm Vm and KiMfjItHnM narilK.nft
JVrv. tuit M ipraM OD s plrai^ct of bM mm lyHM
tmr, beiaj; kept cm aXl ta^t. On its nwval i» Ae
an to be well tpmgei whli warm water. Dr. 3kC«il
nooaoMndi the vie of » tolstioB of potMM fwa fao
M nofwe of wKier), a rtrr IltUe of wUch it la W foi
tiie edge* of tbe ImI^ wiOi'a fine broih br tta laifttiB
brarit.MwkeditiD - - iboaklbeni fcafiaaviDil
mt\niiih»m
»*«b«»acldl<
■>i»V*eevf9
F MS gruM to
ncrr dar oa
Kir. 'Airjt
itaanwwhfla
iMred. If »AV ^ ^1 vitM noexMta,a4i«f artw«~«raeoOTTiaiB
tnlpbaxe of fiac or of alnm sttool'l ti« applied iw« or tbrce linr* a
The erei ibovld aUo tie protected a^atMt bn^ E|^ aad eold
bj a pair of Uae evti-prrHvcton. To^etbcr wilb dib loe^ tn
great atteatioa taast be paid to tbe patient*! ceaeral beahi. If
a eenifiiloiu babit, or in delicate bealth, cod-Bnr oil wiA iMvl
niBa ihoald be adminiiitprc'l. IVn diet tboiid ha ■atritioaa boi
(Bigeatihle, and all exctu, more espeeiatir ia drirftii^, AewM be a<
Indeed, even the moderate use of stinmUbU cvuiot be borne bj
ikaM patientii. cauBtn" an aj^^nvstion or a relapse of (be Jiw aef .
dbiBMle ea«e<, I have almj 'icrited moch benefit from Ac pwlaueeJ
OS azaeno.
durJ
Jroc nJiariB ifl not unfreijucntij met with*, we tlten notice one
aorrr — " nndulcs, which ■«• due to so inflamaiatioo of Uie wl
vrh-- ' ■*, and wtiiaM clone in tlio eilgc of Uie lid, which is nw»l
or i' -u, ro4l, nud iiiltniiivd ; indeed, if die attaclt i* wren-.
■Uii' -iv Ih- verr irdemiiUiu-i. Thcue dimIuIi^^ are sitnated in tbsj
fulMuaoetjiu celliiUr tiiivue, and are loniewbat movaMr, Mid sever
mf liproui out fruni the apex of the pw* tulcfi. The latter gradt
Iiriacrcase io lize, and. after having attained a certain i-oloine, ma]
■ rcmlotion; hut thev [.'eiicrally suppurate, tlie piw e*ca|<inj
rt'tt-ch the duet of the tnlli(.'le. or makin-; its wav throii;:li iho
In othtr cMt'9, the iiotlule W-cfunc* hanlfuied aud iodi;
'tdiirala), niwl inaj tliiu oxt^t uuclian^d for a vcrv It
Tr—ttv met with in youthful individnaU. who may be
i lu^alth, (I'xcpptiiig that Ou-y sliow a diajiosition to
I U tiiiiv, liiiwfver, occur iti'!<-iK-"iidtiitIy of thts. if
eon, V.acroiKi folliclt'ii of the eyelids i* frwui ai)y cauw iiiof
bj ■: ■. fillier fn»m \tA excew in qiiajitity or Imrdiu'sa, "
exti-u.. ...^, .:■ :iie gland, and then 8et« up iuHnmrnation. On i
and ia i • anc^itixe and number of the sehnecous follicles in the upf
glare, f-i -upe fre<|m'iitly in tliln thati in the lower. Tlni eai
rated \\ -<nitj|i* thofli- of acne in jicneml, and, like the lat
amonc'-' -nns a pmtrai^tcrl rourw, and Is very apt to recurJ
which U;! ') 1 causes, I may roeiitiou irregularities in difl, iV
auMngBt cbi' irit«, or uUiur czoesBes ; and, in females, derange
GPUtDBOaiS AN'D CUROMUYDttO&IB.
SOT
ment or the uterine functions. Kxpoaure to dust, tiirt, cold winds, brij^ht
glare, etc., increases tlit* severity and obstlnncy of tlic disease, and
favors tlic tt-ridfucy tn re1a|>6tf3. If the affection has lasted for some
time and 13 accompanied hy a good deftl of iiiHaiuniation, it may become
complicated with blcphanti^ raorninalis.
[Kuuiiui'rt'rld'* lotion is lii:;idy rvc'>nimpnded a« a prGventive of recur-
riiij; attueks. It cnii.sistK of gum. cauiphone, 0.4 ; ]nc nulpliur. -J.U;
calei* iu\atc. and aq. rotic, ait 411.0; puin Arab. 0.8: aud should bo
paintC'tl ov^r the edges of the lidd at night. — B.]
<.'reiit attention Hhould be paid to tlie cleanlinesa of iho lids* irhicb
sliouhl I>r frenuently washed, so that any diiwhargo which clog* the
lashes, or has become eooru-ted on the lids, may Im? n.Mnoved. The loose
or alTected eyelashes should 1>e frt'i|uently plucked out. If tlie nodule
and the neighboring |>ortioii of the lid arc red, intlAmed, and painful,
eold compresses sliould be applied, hut if exf^nn of auppuraciou appear,
hot poulticca or forocntationA should be snbitututed, and the putilule be
punctured, in order that the discharjje may find a ready exit. In the'
indiirHtcd form, an ointment contaitdn;; mercury nr iodide of potiiasiiira
shfiuld lie applie<i. The diet and hahits of the [lAtient i-hould be carefully
re;,ndated, and if be \s feeble aud delicato ia health, tonics should be
administered.
The presence of Vice' oA the eyelashes (phthiriasis ciliiirum) might be
mistaken for tinea, hut the crustti present a more vireum^ribeil and
beaded form. The citrine or rod preeipilatc ointment should be ajipUed
twice daily, whioti will ;j;encnLlly kill the pediculi in a iVn days. If
they are numerou.^, it may bo necessary to clip the lashes very clo«e.
I
fl_EPUIDUOSIS AND CtlROMIIYDnOSIS.
An nxccssivo secretion of the sudoriferous glnnd<! of the lids, mors
capecutlly the upper, i<t occiuiionalt r met with. The perspiration cxodes
90 freely that the surface of the lid ia (;over«<l by a thin layer or film of
Huid, reacliiiig perhaps nearly up to the e<lg;c of the orbit. This con-
dition is termed Epliidrosis [or Ilypcridrosis. — B.]. On wiping the
skin dry with n Hnc do^.-^il of linen, we can easily notice (with the aid of
a mttf^ifviiij;-^laAs) that the moisture exudes from inounu'rablc little
purcs, 60W8 together into large dropii. and finally covers the lid with a
thin layer of fluid (von Grapfc).* Soon llie conjunctiva becomes some-
what injected and inflamed, the edges of tJie lids become sore aud exco-
riated (more especially at the angles of the eve) from the constant irri-
tation of the moisturo, and an obstinate blepharitis nmr^iiudi.-i, with a
alight degree of cuitjnTH*tivitis,iHsetnp. The pationt at. tht> s;irue timeooro-
{ilaina of a jieculiar itching aud biting sensation on the outer tiurface of llie
id. The affection is very obstinate and protracted, for although astrin-
^nt lotions and collvria iicnclit the intl.immation of the conjunctiva aud
the edge of the Hd, they exert but little, if any, influence upon the aecre-
Uon of fluid. H'ecker recommends '* IIehr«*a ointment" (^p. 80t>). The
"S. L.O. n.Bep.,"il. I2i.
' " A. f. 0.," Iv. 2, SM-
806
DIBKASES OF TUB BVGLID8.
line, slioulil be periodically applied. If small piuttules or nicer*
formed, these should be touclied with a finely jnunted crayon of jiulphat
of copptT or the mitigated nitrate of nilver. I have also foiutd *ei
groat bcTiefit from the iiae of Hebra's oiiitinent, which conatstw of e<|tHLt
parts of Oleum Liiii aud Kmplastrum Pluuihi, with a little Balsarn
Peril. This in sprciul oti a pledj^et of tint and apjilit**! to the lid* at h
time, being kept '.>u sll night. On its rernoval in the rnnmins;, the cyt
are to bo well 6poii;;ed with warm water. Dr. MeCall Aiidewou stroni^lj
recommends the u»c of a ^nlntion of pota?i!Ui fiiita (usually ten f^raios
an Ounce of water), a very little of which is lo be painted every day
the edgC9 ufthe litUwich a line bru^h by the surgeon hittkwlf. A Urn
bnish, soaked in cold water, '«lioiild he in readiness to stop the action when
desired. If any conjunotivitia rocxiats, a drop or two of a collyriiim of
Bulphate of Kinc or of alum should he applied two or three times a daj
The eyes should alao he protected a;;aiiwt bright lijiht and cold wint'
hy a jiair of hUie oyc-procectorH. Toj^ether with this local treatinei
great attention must he paid to the patient'it c<^ncral health. If he i.^
a scroful'Kie liabit, or in delicate health, oddivcr oil willi st«i.d or ■pd^
nine should he administered. Mi:* iliet should hi; nutririotw hut ea^ilj
digestible, and all excess*, more especially in drinking, sliouhl he avoidet
Indeed, even the moderate ui<c of stimulants eonnot lie home by some
these pEitieiita, causing an aggravation or a relnj^e of the di-<i*ase. H
obetiiiale casuis, 1 have also derived much bvuetll froiu the prolonged i
of arsenic.
Acne eitiarit ia not niifreiiuently met with ; we then notice one
more small nodnles. which are due to an inflammation of the selaicenti
or hair follicles, and situated clo^e to tho edge of tl^ie lid. which t$ nor
or leas swollen, rod, and inflamed ; indeed, if the attack is severe, the
whole lid may be vcrv u-'dcmatons, Tliese nndules are ailiiatcil in the
Bulicutancoiu cellular tis^tue, and arc somewhat movable, and several
cilia may sprout out from the apex of the pustules. The latter grada-
ally increase in eixe, and, after having attuinetl a certain volume, naf
un<lurgo reHotutimi; but they gontirally suppurate, the pm escapiag
either through the duct of the follicle, or making tta way through Ibo
external skin. In other cases, tlie nodule hecomi's hardened atid inJo-
rated {item indiirntu), and may thus exist unchangeil for a very loi^
titoe.
This disease is mostlv met with in youthful individuals, wh" may be
otherwise in very good lioalth, excepting that they .<hnw a ditipusition tO
acne of the face. It may. however, wcur independently of this, if iha
eecretion of the Bcbaco«ii« fulliclefi of the oyelids i.s fnini any came srtr-
bidly altered ; so that, cither from its excess in quantity or Imnlnesi, it
becomes contined in tlie gland, and then set^ up inflammation. >_>« no-
count of the hirgrr siste and number of the sebaceous follicles in the upper
lid, acne occurs more fre(|uently in this than in the lower. The causea
of acne ciliaris resemble those of iicne in general, and, like the latter,
this disease generally runs a prolracled cnurse, ami is very apt to recur.
Arooiigat the principal causes, I may mention irregulariiica in diet, fret
indulgence in wine, apiriia, or other excesaoe ; and, lu feualea, derange-
BPHlDBOSIfl ASP "
TJTors tbe tendency to r i ^^^ -■
- ^ mI^Is U con»i8t6 of gum. cmmphone, 0 4 - be .
^r t" Ue^^on .1>o«ia be p.>d t. Se; J„L- rf 4. M^i
«hluW be fre.,uctaly vrfl^l^el so that any d«d«f^ .UA i««
A rcneiicbbo.\"K portion of n,,. ua ^^e ^ed, U '
*J»;
rc^uUteTl,"and if I'C >» f'-'^'tW and delicate u baiatL.3
TW presence of lice' ofi the eyelashei; (pht -™
mistrtWeu for IJ'"^"-' *"'^ ^l^^ cmmw prcwMil a ■■■
beiided form- '^^^' '=.'""""^ or r<'<l prt-eii-itale wMm
twice daily, which will j'eiwrully kill the pf^dio^
thfV are jmmcroua, it miy Ije necessary to cMy tktm
S^EPHIDROSIS AND CH]
An excessive secretion of tliu- amloriferuar
especially the upper, is occasional !y met witi .
BO freely" that the surface of the lid i« co»er.
tlmd, reaching perhai» nearly iiji to the m:
dition h termed Ephidrosis [or Ilypeiidn*.
slcin ilry willi a fine (hfSHil of linen, we •■
A iuagiufvi"g-gln»') that the moisturL
poTca, floi*'* to;;eUier into large dro(». aui
thin layer of fluid (>on Graefe)." Smwj
what ii'ijccteil and inBamed, the edge* 0f4
riated (u)orc especially at the anglm oT
totion of tlif moisture, and an obatinu
slieht degree of conjiinctivitis, i« set up.
plains of a (X'culiar ilcliiug and liitjoj;
!iil. Tlie affection la very ohaiiuait
cent lotions and collyria benefit the
the cd-je 'if the li(!,uiey exert hut b
tiou of fluid. Wecker recommend! *
"B.L.O. R.
,*• U. 125.
80»
DISBASeS OF THE EYBLtDS.
general heaUli,aiHl especially the action of the vkinand kidney, diould
be attended to.
CArwwAy Jrowt (stearrlnea nigricans of Krasmiis Wilson). Fnder titis
title has been deecnbed a verj peculiar pigmented condiiion of the eye-
lids, which is chnnictorized by ihe appearance of a dark brown or
brownish- black discoloration of the lidn, more eHpeciall^ the lower, whidi
is chietlv iioticeablf in the folds of the skin, and does not reacii up u
the lashes. It can be readily removed wirh oil or glvcerine, hut, appa>
reutljr, not wiih water. It has been ohieft^r met with iq females, mei
especially those of a nervous, hyaterictil temperament, and there cau In
but little doubt that it is artificial, being dtie to »omo picmont paint
on hy the patient in order to deceive her medical attendant, and
awaken interest or compassion. [Itnth Rothmund and Miclict are ni
willing to admit this in all cases. — li.] For a very fnll account of thi
condition, I nould refer tlic reader to the French Translation of M
Icenzie, iii. 44. and to n paper read by Dr. Warlomont, before the Hei-
delberg Ophthalmological Congress, IHHiyViJe **KI. Monatabl.," 18tl'
8M1.
Xanthehignm pnlffhrarum [Xanthoma, VitIU;roidea, Fibroma lipomafi'
todes. — U.] is the name given hy Mr. Kraamus Wilson to peculiar ycllo
8pot3 or patches, which ure sometimes met with on the eyelids of middl
aged persons, generally near Uie inner or outer canthus. Tliey vary la
Bize from a small npeck, like a pin's head, to an oval or crescentic patch,
perhaps one-third of an inch in magnitude. The spot* or potchc:* are
yellowish in lint, Hat. somewhat elevated alwve the level of thi- skin.
and their centre is genonilly marked hy a black point. Mr. Hutchinson'
has lately called special attention to this affection, and since then nu-
merous caaes have been recorded. Virobow* narrates an extraonlinary
one, in which there were 8ma1l yellow notlnles on the cornea, nnd l^^B
number of yellowish tumors all over the body (xanthelasma multiplex). ^^M
[Mr. Hutchinson thinkb' that it is not imposaiblc that theso jiAtchcs
result from derangement in the nutrition of the itkiu of the eyelids which
frec|ucntly occurs in association with hepatic and ovarian diiiturbancea.
The patches of tnie xanthelasma are always persistent, and usually tend
slowly, but steadily, to increase. — U.]
[The patches are ftfimetime« nodular, ami grow fjuite large, and not
iiifrecjurnlly occur all over the Irfidy and extremities. Icterus is very
often present in tliese caaea. A very early ttymptom of the dcvelopmei
of xanthoma is a twitching and pricking in tlte lid. Anatomically
change consists, says Waldeyer, in a hyperplasia of the connective tissue
cells and their consecutive fatty melamorj>ho8i«, especially between tJw
hair-bulbs and sebaceous glands. Anoiher view is tliat the dLseave is «
hvperpludta of the celts of the sebaceous glands, with obslritction and
dilalaiion of the glands. The tresiment comtiftta in excitung the dU*
colored skin and siibcutaneoua tissue, and dboultl only be done for cm>
motic purposes. — B.]
S!tU«^|
' "R. U O. II. Ilpp.," vi. 4. 1689.
• t"M«l.-Chir. Tram.," vol. li-r, 1871.]
" TIrchDW's *• Archiv,**
QOaOBOLUM.
e.— noRDF.OLrM (styk).
Tilts ilisease is not, as is sometimes su{)])osed, ati inflammnlory aSeC'
tion of the Mvibomtan gtaruLs, but is a riiruncMlar iiiflainumtion of the
connective ti&sue of the lids, baling ita seat ;^cnerally in the vicinity of
the hair rolliulea, and near the margin of the lid. In most cases, there
is only one boil, in oilers, there are several. At the outlet of tlie dis-
ease we notice a small circum»cribad nodule or button near the cd^e of ■
the lid, tlic skin beinj,; freely movable over It. If the dci-clopmoTit ia
very acul-e, the liil is ohvu much iDtiaiDed, v«ry red, and oideniatous;
and iiltlHmgh iheae (iymutoros are gciionilly confiiieil lo tlie portion of
tin- lid in the vicinity ot the stye, they may extend trt the whole eyelid,
and the ocular conjunctiva may also become ocdumatous. If the upper
lid ig the one aETectod, ii may hang down in a mas^^ive fold und quite
close the palpebral a]»erture, there being at the same time, [wrhaps, a
good deal of photophobia and Inchrymation. The patient generally
complains of very considerable pain, and ihe swelling in the vicinity of
the nudule is ex'piirtitvly tender to the touch; suiuvtimes, thoro is also »,
gitod deal nf fevori.'thnerta anrl constilntional di«tnrhaiice, ihu sufferitiga
of the patient being ipiile out of jiroportion to the extent of tlie di^ase.
The latter may. however, run a more subacute or chronic courtie. Tho
prominence produced by the iiodulo is generally at once evident to the
eye, a-^suniiiig Uie appeara,nce of a little circumscribed tumor, about the
size of a pea, tJic skin of tlie lid in it^t vicinity being of n du»ky, angry
red. Sometime!), several Inithes project from its apex, if it ix situated at
the margin of the liil. If it be not visible, itj* presence may be cjiaily
detected by lightly passing the tip of the finger over the surface of tho
eyelid. On eversion of the latter, the conjunctiva will generally appear
smooth and unaltered, but if the hordeolum points inwards, the circum-
acrihed no<lule nill appear on the inner surface of the lid. the conjunc-
tiva over and around it being reddened atid swollen. If suppuration has
act in and the matter '' |>nint.-t," the apox of the little button prosenta a
gniyish-yellow tint. If the disease is allowed to run its course, it may
sometimeo umlurgo resolution, but, as a rule, suppuration nets in, and
perforation takes ]t1ace, more or less thick purulent matter being dis-
charged, together with which there is often mixed some grayish-white
gelatinous substance, consisting of ill-developed or hroken-down connec*.
Uve tissue. This is discharged in little lumps. The disease s^hows a'
very great tendency to recur again and again, so that itd existence may
be prolonged for very many months, and this has led some authorities to
coitxider it dependent upon some peculiar diathcsiii. It is most frei|uently
met with in yuuthfut individnaU, more especially in those of miher deli-
CAte health, who are oftt^n subject to acne, or who are addicted to free
living or <linsipation. If the course of tlie disease is protracted, and uiore
eepecinlly if there are frcipient relapses, it is not unfrc<|uently followed by
chalazion, being due lo inllammatory changes in tho Meibomian gtauds^
and followed by fatty or chalky degeneration of their contents.
At the very outset of tlie disease, more especially if there are severe in-
I flammatory symptoms, cold comprosaett should ho applied ; hut, as a rule, I
810
DISKASBS OF TUB KYRLtOS.
prefer the vw of liot ptmliiccs, «hicli slioiild he changed very frcnucntly ;
iVir thia will grtatly accelerate the formation of pus, atnl expedite UibJ
Ero'^ret-s <if the ci)^*. When siippuraiian has sot in, ami the i<l>in hu]
ccome thinned and yellow at one point, a emnll ineUion should ha
made to pertuit of the ready escape uf the piu, with which will generallji ,
be mixed Rome af the gr»y ^elatinou:a connrcrive tiMuc. The pain in in^l
mediately and greatly relieve'l by the incision. When cicatrisation hu
taken phiee. I huve loiind mucli benefit, in preventing a recurrence of lit*
disease, from the n«e of a weak oinimetil of nitrate of silver (gr. ij-iv
ad sj). If the patient Is feeble and out of healthy tonics niust be ^v«o,
■nd the digestive functions thoroughly regulated.
[Fig. 2111.
7— Tl'MORS OF THE EYELIDS.
Chalaxion (Tarsal tumor, Tarsal cyst) \f> n tumor due to inflummatOf^j
chanjres of the Meiboniiau glands or ducts, givinji rise to an altemtjc-
and retention of the secretions. [Any di^turtmuco in the uutritioni
a Meihoiuinn <;tand excites a clironie inHammation of the conncctire tism
around the t^land.which leads to an infiltration of the latter with small nil
By a coalescence of several ;;roups of cells there results u iiOiUle. wliicli
consista of granulation tissue witli giant ecUa. The result is softerun(!,|>er
fomtiou outwards, and healing by a scar tn the tarsus. (Sec a paper bjfl
Fuchs, " L'eber das Chalazion," Archiv f. Ophih., sxiv. *2).— H.] If tlie*
inflammatioti has been acute, or if an acute inflnmrnntorr exacerhntitn lias
occurred, suppuration may take place and pus Ih* formed. In othercasei,
the contents of the eyst, instead of being purulent at muco-purulent, aro
fluid, aiMl gelatinous, fatty, or (Sebaceous and clotted. The tumor is]
Tally about the size of a little pea. but may increase to that of a
bean ; it is situated at some diaunco fimn
Uie free margin of the lid, and is geueraUj|
nvifX raimif'cst on its inner surface, lyii
close beneatli the conjiinctiva (which
often coniiiderably thinned), and formit
here a small, circumscribed, bluish or yi
lowish-wliite tumor, which springs pron
nenily into riew when the Inl is w«
everted and the conjunctira put iijk>n it
8tr»'tcli [Fig. 21'.*]. In other and rai
eases, tlic tumor points niitwanis and lief
close beneath the skin, whieli is f'rct|uculij
goraewhat redilcnetl and thinned over ai
around it. It occurs far more fre<)ueni
in the upper than in the lower lid. Son
times it may exist in both eyelids, or io
both eyes.
If the tumor is small and hanl, an<l its
^}Mkn hMi been extremely slow, we may enileavor to favor its ahsorp.
IJB» hy tbo use of red precipitate or iodide of potassium ointment, hut as
% rwli tHia pruvvs quite inetf(.'ctual,and we must generally have reoonraa
\
^i
!MMfcma«.I
CnALAZTOX — HILIDH.
811
to operative interference. If ttie tuntor presente upon tlie oonjnnctival
surface, the liii tthoiild be thoroughly Averted, ami the conjnnctiv& put
apoii tlie stretch, bo ag to render the little nodule prominent and tcnae.
A free crucial incitiion Bhoidd then W made into it with a eatamct knife
or small scalpel, so that it may he laid well open. If the contenta ara
fluid Mr raueo-piirulenl, thoj will iit oucv efcajpi*; if tliis ts, however, not
the case, and they iirc sf>mewhat coherently gelatinous, a small cnretto
should be introduced, and gentir turned round, so a^ to break down aud
eeoop out the contents. Should nmall portions of the latter adhere to
the wall of the cyst, they should be smpped off with a jinir of scissora
curved on the flat. After making a free crucial incision we may often
sncceed in more completely and rendilv emptyin;^ the contents of the cyst
by tiippin;; it fimdy between the thumb and uailn, than hy the use of the
curette. If the tumor iit deeply aeatcd and near the outer surface, Ihd
JDcifiionit must be pro]iortionate]y deep, and extend throngh the tarsuK,
it is generally Iwttcr to ojieii the tiunor. if |>usi«ible, from wilhin. for
we thus avoid the fonnntiou of a cicatrix in the skin. Special attention
must be paid to this if the chalazion is situated near the margin of the
lid. and particularly near tlio punctnm, for then the cicatrix would bo
very prone to produce a certain dej;rce of cversion of the edge of tho
lid, and diaplacemoiit of the pnnctum. But if the luuior is situated at
Bonn- distance from the tnh^G of the lid and in its central or outer jmrtion,
lyttit; close Iwineath the skin, and if tiie latter i:* lax, the inclAion may be
made from the nutitide : for the wrinkles of the loose skin will hide the
cicatrix and prevent the danger of eversion. The removal of the eoiu
tents is ijenerally accompanied by considerable bleeding, and the tumor
may. hence, appear to be hardly reduced in e'lio. JIul in the course of a
few days, the adhesive inllammalion 9ii|»erv©ning on the operation will
cauiie a contniclion of the cyst, and it, top;ther with the thickening
of the strnoturf!* in its vicinity, will rapidly ilis»pi»ear. This adhesive
inflammation may be augmented by li^litly touching ttio interior of the
cym with a finely pointed cniynn of nitrate of pilver.
If the tumor is hard and firm, I generally direct the patient to apply
hot poultices for a day or two before the incision, as this accelerates any
tendency to suppumtion. and softens the contents so Uiat they are less
tenacious and m<irtr va^ily removed. As ]>atieuts, affected with cli&laxion,
often •suffer from irre;;iilariticsof the digiviivo functions, tlice^e should be
carefully attended to.
The .Meibomian follicles sometimes become obstmcted, without there
"being any swelling or dilatation of the glands. These obstructions are
due to an accumulation of the secretion in the ducts, giving rise t(.> small
yellowish-while concretinnr^, cither Aiuddeit irregulariy alKrut the smooth
conjunctival surface, or arranged, perhaps, in single file, like little pins'
heads, along the course of the duct. If these are verv small, few in
number, and unattended with any ineonventence or irritation, we neod
not interfere ; but if they are numerous, large in siae, and productive
of irritation, they should he pricked with the point of a knife, and the
hardened contents s(|neezed out, or their removal may be facilitated by
using a grooved spud.
Milium is a minute white tumor, about tlio sixo of a millet aced, hence
812
DI6BA8B8 OP THB EYELIDS.
iU name, wbicb ie mostly situated at or near the free «dge of th« U<l. It
geiicrallv occurs iaolateil, aUlinu;ili [lerhnps in considerable nuinbeni, or
the tiiniora may be- arranged in clusters. The cilia aproat fortit from tha
ceutru of, and betwevn, tbeae little iiodulos. The latt«r should bv pricked^
and their soft, suei-tike coiitonts 8i|ueexed out.
M'AlufCum^ oralf'umittvid tumor, is of the Hhtne natore as nulium, but
attains a much nioiv considerable size, and is gunonill; situated at mme
little distance from the ei\'j^e of tlie lid, and is i|iiite painle»). Tlie ^Vin
over it i». as a rulo, Bomcwhat tluiuied. so that its yellowish- while color
and nodulated surface arc very evident. In ita centre is aoruetimea
noticed a ininut« a|ieiiirii;, tl)ruu};b which a little whit« fluid exudes, and
dryii);,;, forma a litile bnllKi cruint ii|ii)ii il. In recent cn^e!^, this matter
is con(fl;;ioua. If Ibo tumor cxUu for a very louj; titue, ita attachment to
the %\\u in.Hy be stretched and elongated, so tliat it ha4 a more or I«a>
diMiiict neck or pedicle, wbich renden^ it pcnduiuus. Mollunciun U gene-
rnlly not confined to the lids, but occurs at the same time tipon the fa«
aii<l other purta of tlic body. The crust upon ita apex should be detached
with a pair of forccp, the nodule pricked or slightly incised, and the
contents !><|uee£ed out between the thumb uiuld. If it ia not eniptte-l at
once, the pressure should he rv|K-atetl. Whet) several niollusca cxi^t oa
the eyelitis and face, it is better to operate upon them all at one idtting.
Ebert' uarmtes an extraordinary case of » girl aged 4, whow cyelttb
were so covered with mollusca (some reaching the siao of a haaol and
•walnut") that she could not open her eyes.
[Michfl describes two varieties of molluseum ; the M. contagiwium
or sebaceum, and the M. fibrosum, the first of which is described above.
Tlieir contagiousness is hotJi aJIiruicd and denied, and is aaid by thoM
who afhnn it, to be due to tlic ao^allcd molluscous bodies, which reaembb
fat, though no tru« fat globuWs are present. It occurs in both sexes
and at all ages, and no s]|ecial cauM can be assigned to it. When th«
tumors are of large size, it is better either to ligate them or to remove
them with the scissors.
The fibroma niolhi^cum is more apt to bo- peduncuhititd and to attAiii a
larger size. The molluscous bo^ltes arc wanting, and iUey consist of a
soft, fiuely-fihrillated connective tisaue with few cells. — B.]
SffMtt-ftma lutmtr$ occur most freirjuently in chiMrcn, and reaemWe
iDolluica in their iialurv, but attain a still more considerable siae, reach-
ing perhaps thai of a large filbert or even a small walnut. They occur
moat frequently at the outer and upper margin of the orbit, close to
tlie eyebrow. The skin over tJio tumor generally rctaina its uonual ap-
pearance, or may hocomc somewhat reddetiud. The conientii are in-
elodcd in a cyst wall, the posterior portion of wliich is somewhat thickctkcd
and hypertrophiud, and are suet-like and selwceoim, consisting of broken-
down cpilliidial cells, fat moU'cule.i, and hairs. In other ea.'»*.'5. the
tumor in sofurr, and its contents are more oily. If it U very snmll, and
its appcara,ncc does not annoy the patient, it may be Icfi untouched, but
otherwise it should be removed at an early stage. As, in order to pre-
vent its return, it is necessary to remove ic vhole, it is better not to
> "Kl. MonaUbi.," 1671, ji. US.
SEBACBOtlS TOMOXS — FIBROMA — CYLTXDBOMA. 813
pnnctiir« it and siiiieese ont its contcnu, bnt to <lin8ect it out, if potoible,
without te-irin;; or pricking tlie erst wall. Hence, a free incision should
bo made tliroogh the skin, with a cnt&ract knife or Email scalpel, anil
parnllol to tlic e(i{»c of the orljit. When the tnmor is of con«iiierable
size, a crucial incision nmv be luadc so ns to facilittito the disseclioii, tmt
gcnemllv one lonp incisinn will suffice. The turoor shouM then lie cV.wIj
an'l earefullv diMecte<l away, the ailhesions between the cyst-wiill and
the Hurniuii tin;; cellular tiBsne bein^ <lcliealely severed with the point of
the knife, or detached by gentle traction, awiialed, perhaps, witli the end
of the handle of the knife. An assistant should be ready with a sjwnge
to «i|K! away the blood, so that the operator may conatatilly have a good
Tiew of the outline of the tumor ami iu adhesious, otherwise the cyst-
vall may cattily he pricked, and its white pultaccoua conteuta be;:in to
escape, which j'rcntly increases the difficulty of completely removing the
tumor. If thecyst-wall has not been removed eutire, the remaining por-
tions may be lijiliily touched with nitrate of silver. In order t^i accele-
rate the unii>n, the edges of the wonnd flhouM \tc brought together with
fine sutures, andcoM water dressing be applied
[Umler the general heiul of sehaccous tumors occur the atheromatous
cy»t« and dermoid tumors. All these tumors may be congenital or ac-
quired. Tlicy are more apt to occur in the up[*er ltd and eyebrow, and
may reach an cnormou* sistc. They belong to the claw of retention
tumors and their contents may undergo marked alteration. Serouit and
colloiil cvBts are aUo met svilh in tliiti region. True dermoid evicts are
ahrayij congenital, and where they have existed for a long time, they
liave Iwen known to produce ahuorption aiul even perforation of the
underlying bone by their steady, long-continued presaiire. They occa-
aionally undergo calcareous degeneration. (See a paper on '* Kneysted
Tumors of Kvclids and Vicinity,'* by the Editor, "Amer. Joum. Med.
ScicHces," April, ISTH,)— R.]
Fihroma ia met witli in the eyelids in the form of a (>mall, hanl, cir-
cnmacribed tumor, being ^oraetimcA coiigcnital, and occasionally exqui-
mtely painful to the touch. Tliese tumors sometimes assume a cartilag-
inous chanicler. and spring ]u*onunent!y into view when the eyeli<l is
everted, looking like a second tarsal cartilage (Wecker). Von (Iracfe'
reports a tumor of this kind, occurring at tlie outer angle of the eye,
and which had attained the size of half a hazel-nut. It waa siiuated in
the submucous conueciive tissue, aud, on removal, waa found to consist
of tnio bone tisane.
Fibroma)) inerease but very slowly in size, and this forms tlie chief
distinguishing feature between them and saa-onintous tumnrit, lor they
cannot he distinguished with certainty from the latter, except with the
microscope.
Under the term c\fUndfi)ma von Gmcfo dcKribes a peculiar turaoi*
which is sarcomatous in it^ nature, and is met with in cloao vicinity to
tliu uye. f. (/., the eyelids, orbit, etc., or the hen<l. It is particularly
diatingui.tlicd by the fact that, together with its flareoniatoua structure.
It shows peculiarly club-«haped outgrowths from the capillanes and vcim
t '• Kl. Uoaatibl.," 1863, p. 23. < '• A. t. 0.," x. 1, \U.
814
DtSEASBS or TnB ET8LIDS,
;cur
wme-
(R«cltlingliau8eii'). Tbe tumor is very painful if firmly prewe*!, Iwt
gpontaiieoiifl pain only nociirs pflTlndically. It shows a ti-mieiicy to recur
after removal, a>i it is vory difliciih lo extirpate it completely.
Wartt Dccafiiounlly fonn on or iiejir ihe eilgei^ of tlie uyelidii.
BhoiiM be snipped otT with a pair of sci^^ora, or touc1ie<l witli caustic
acetic nciil. If tlic batte is narrow, a silk or fine liorse-liair ligaii
s)ioul<l be np]<lictt, so a* to .^trnitj^nlate it, yfhicli will cause tbe wart to
drop off in tilt counsc of a few days.
[Paf/iUo/n'iUt, in which the |>apiUie are iaolatcil from the begimui^,
Are altio met with od the margiuA of the litl.
L-hthjf'tsii lia^ ai^ been seen bere by Arnold in a ca«e of genenl
con;;cnit«I tchthyoaiB. — B.]
Fnttit tumora are not of frequent occurrence in the erelid* ; they nay
generally be readily reco^jnixetl by tlicir aiiKwth, ciruumscriWd, wme-
what lubulated fonn, and urc firm ami ela«)tic to the touch. 'Heir
resfl is, as a rule, extremely slow, and they can be readily removed.
In mre imtances, nif/tnemiM finrng are obMrvcd growin;* from the
The only caae of the kind wliich I have seen, occurred in a paiient
>[r. llowman at MoorfiultU, whose his-'
Pig. 220. tory (for which, as well as the -Iraw-
inj;, I am indebted to Mr. Fwrlie
Clarke) was ne follows: J, U., »^
"ii. farm Inborert applied at Moorfio
on .May 18, 1801*, oti account of
horn jjrowitig from the lower lid
the left eye. It be>^n about
niotiths a^o as a yiuall wurt^ and
gradually incroajwd in she until
ha5 now reached a length of about
inch, and ia the thJokuess of a cro
quill. It [a situated at the centre n\
the ciliary border of the ri^ht lower
lid, and han^ down in a Denduloiu
niauner {vid« Fig. '2*10), It is of i
dark color, bard and hiimy, except
junt at it!t baiic. where it in continuo
with tbe akin. By its weight it has dnrnti the eyelid slightly down a
everted it a little. On Slay 'Jldt, Mr. Bowman excised tbe **honi.'
including the base within the limits of a I' incision. The edges of th
wound were brought together wiUi a pin and secured with a figur«-of<
ligature. On May ^*8th tbe pin and ligature were removed, and t
patient waa diiwharged from tbe boapital cured.
Another n;mnrkab!o caae is reported by Dr. llenrv Shaw,' of tbe
MaH9«chusctw Eye and Ear Infirmary. The man was mi years of age,
and tlie horn, which waa situated on tbe right lower lid, attained a length
of Ij inch, its circumference at its
curved and looked Like the beak of
base being 1^ of an inch : it wai
a bird. JJr. ::haw excised it with
succoaa.
I "A. f. 0.,"T. 1, 190.
■ "BostoD U^. uaA Borg. JonrB*1," 18«9, Feb. II,
BPtTUBLtAL CANCER.
815
I
I
J^pithetiai cancer Is nlinr>gt the only malignant tiimnr wbicli occiire
prinmnly iu the ejeliils. for t)it> other form?, such a^ scirrhus, medullary
cancer, etc.. are generally only secomlarily met whh in (hia sitiintion.
K[iithelial eaiict^r shows itself most freiiueiitly iti the lower eyelid, atul
near the outer canUms. [It i« of three kiiiils: the imi»erficiai, the deep,
and the jiftpillnmatouK: an<l it id «.iid tliat these are all different stages
or the itamo diseaec. — B.J It occurs (generally in penuma above the ase
of forty, or even in thrufi much more n^^ed, hoinj; rarely met with in
yonthl'ul individuals. At the outset, the disease assumes the appearance
of a ftmall, circumscribed, nli'^litly elevnted induration, situated at, or
clone to, the edge of tho lid, and loftkinj;; like a wart or a small ttiicktriied
cruiit. It is cohered by hcaltliydooking, uninflatncil skin, and a few
varicose vesscla are perhaps seen to pasa over or near it. The suriac*
of tlie little nodule often looks rough and scaly, as if the cuticle were
thickened. It may remain in thin couililton for a very lon^ period, and
years may elajwe hefon- it incrtiase^ materially in size, or becomes nlce-
nil';d. On this account, and from its being tjuite puinle&s, it is often
entirely di.'^regarded by tlie patient, who supposes it to be simply a wart.
When the disease occurs in the skin over the lachrymal eac, it has been
mistaken for dacryocystitis. Tims Mackenzie mentions one instance, in
which tlie patient called to have a style introiluoed, and another, in winch
one hail actually been worn. But sooner or later it (gradually and almost
imperce|itibly iucrea^cR soiricwhat in mta:, crceptn;^ along iheedgo of tlie
lid and aa<tumin;{ a Icnjxthcncd, ovoid shape. Its surface becomes bn'iken
fttnl excoriated, and a thin grayish-yellow discharge exudes from it,
which hardens upon it in the form of dark rough crnsta. Then ulceration
MtR in, and the tumor slowly s]>reads in circumference and depth, the
edges of the ulcer being somewhat elevated, and sludde<l. perbajis, with
a few palii>h-re<l tuhiTcles, wliieh rapidly form a;iHin if al<sci«ed. The
skin around the tumor is hut litik- thickened, swollen, or di!^:o|ort,<d. and
thill distingutdhcji the disease from lupuK, atid aim from a syphilitic ulcer.
Moreover, the slowness of its growth and the history of the case, would
prevent its Iwing misuiken for the latter. When the ulceration set^ in,
tlie |tain increikses, hut seldom to any coiutidcrabU; degree, nor ts it of a
very acute, lancinating character ; but if any nencs are exposed by the
ulceration, the patient's suffering will, of course, be much augmented.
The discharge is of a yellowish color, healthy in nature, and free from
fetor.' Sometimes, the ulcer may become temporarily cicatriaed, either
comjiletcty or in part, and then remain apparently healed for a certain
time : but awim n breach of surface again occurs, and fre^h ulceration
seCtt in. In time, the ulcer inviides the lid more and more, spreading
along its surface and extending deeply into its structure, until it may
eat it« way completely through ita whole thickness, and appear on tbo
conjunctival surface ; thence, perhaps, extending to the orbit. If the
lids are dcHtroyed, the eyeball will be exposed, ami supjmrattou of the
cornea may ensue, accompanied perhaps by loss of the lens and a con.
liderable jtortion of the vitreous humor, and foll<.>wcd by atrophy of the
< Vldu Dr. Jacob's able Mper on this dlseas*. " Dublin H«pitalfiroorta/' vol.Jv.,
1M7.
DISBAaSB OP THE EYBLIPS.
globe. Mackoiizif' has witiiesneil the most excmoiating pain eitsuti
upon implicauoii of the eyeball, or when the ulceratimi aflecietl the
frn-orbittil iind supra-orbital nerves. The disease may also extend to '
face, fiually opening into the moatli. The vein? which pass over Ih
ulcer often give way and cause very considerable hemorrhage.
The cauae of the dittease is freiiiiciitly dubious, but soii>etiroc« we an
able distinctly to trace its orijipti to ftomc injury or blow, or the exiateacc
of some prolonged course of irritatioD.
If the disease is mudonite iti e:ctent and circumscribed, so that llier
ia hope of entirely removing it, the treatment by extirpation in, I tliiiik,'
as a rule, the best ; care being taken to carry the incisions thrr>U}!)i tW
healthy integuments, for fear of leaving any of the morbid ti*3ue hehiw' '
'Jliis incision is generally made of a V-shnpe, and suffioiently large
include all the di^asc4l fwrtion within it. The edgca of the wound eht
be brought together with fine autures ; or if the Io-ih of tubsianco i& en
siderablu, a plaatic operatiou sliould be performed, and the «kin brou*
from the temple or cheek. Maekenjiie, however, pt-efcrs ttt ninke a new
lunar tnciiiioii, and to allow tb« wound to lical hy gnunilation. It mi
be admitted, however, that even when the operation has been fotlowi
by u iirm cicatrix, and the disease has appeared to have been eure^
■l^r a time a relapse has taken place, and hence the treatment by esclia-
rotica and other agents has been strongly recommended. Potaasa fua
and the chloride of zinc paste have been especially nited as cauadn.
Mackenzie' strongly rocommfuda tlie svilphate of ssiuc for tids purj-oiM'.
The water of crystalliuation of the aulpiiate of zinc having been driven off
by heat, and the residuum reduced to a fine powder, he mixed it with i
little glycerine, so as to form a Uiick tcnaeiuufl paste, and on the point of
a bit of jitiek, applied it over tlie scab and the hard edg«s of the ulcAr;
the part being then covered with a bit of dry lint. This treatment vu
repeated two or tliree time-), and producevl a firm, healthy cicatrix. oimI
apparently an cTCcllent cure.
Dr. Broadbent^s treatment by injection of acetic acid (one part
strong acid to about four of water) may also be tried, and has provt
very succesoful in the haiidu of several di^tiugtiislied surgeons, amonv
others, Mr. Power,' Do Wecker,* etc. Dr. Altlmurt's trcatuieni by eU
trolysis may likewise he trio<l, being iiuttc free from any jiain «>r diM»l3
fort. M. Bergeron' recommends the internal and local use of chlorate
potash.
[Better results are obtained from sliding 6ap8 than by the metbodi of
trauii plantation of flaps ordinarily in use. The epiThelionm or diaesM^
tissue is to be removed bv a four-cornered or rectanirular excision. The
if ttie aliding tlup is to come from the nose, horizonCil incisions arc to
made tlirough tiic skin over the nn<ie, inclosing a flap of skin broa
enough to cover the defect in the lower lid. This i^ to be dissected up .
Toadn to slide forward until it mecta skin on the other side of tlio deft
to which it ia to be united. If the Aap is to slide from the temple, tli
■ " Dlti-aHM r.f the By»." 4lh pHit., 137-
■ Mr. Povft OD Di8«ai«s of iliv BjTff, p. 103.
* Dc WccktfT, "Ualaaiei des Venx," 2d ntltloa,
■ lb., p. SM.
• "B. L. 0. H. B»p.." ii. i.
CM,
incisions are to be marie towards the rej»ioTi, the upper one being a ppo-
longfttion of the exc«mnl cnuthus, oTiii the lower one diverging from it
floniwhat downward, tkjmetimtre both flaps are made to slide townnls
each oUitT. This mo()c of o]>eratiiij; has been practised (piito extensively
in this country by Knapp. Noyes, and others. {See "Arch. fOr <*pli-
thal.," xiii. ; " An-h. of Ophth. and Otol.," i. I and 2.) A iiioditication
of this operation has been practised by Noyes, of New Yorlt, for the pur-
pose of remedyiii" defects about the inner portion of the lower lid, and
wliich succeeds very well in some cases of epitlielioma. It consists iu
alidiii;; the wluile cheek, together with the remaining jfortion of the short-
ened lid. inward and upward. Ics adva[ila;;e over the other operation
by sliding flapH is that the neecs>iary incisions arc not so conspicuous.
Tlie Hap does not slouj;)) ; it lies in perfect coaptation and U fuily ade-
3uate to cover any defect. One of the incisions runs perpiuidicularly
ownward in tlte furrow alongside of the noM as far as the ala nasi, and
the other one ia made lionzontnlly oulivard across the temple towanU
the ear. a varying distance in different oases. It is, in short, a hucco-
teniporal dap instead of a ua&u-buccal Hap. (See "Trans. Amer. Ophtli.
Soc," 1879.)— B.]
Snreoma and carcinoma of the eyelids arc citrcmely rare affections.
Hirshberg" describea a case of small-cell Barcoma invidving the lower
lid, in which llie tumor reached the niite of an apple, anil wan rt-nioved
by him together with the eyeball. [Sarcomatfius tutiior=i which onginat©
in the orbit, however, fret^uently involve the lids in their progress. I^ri-
niary earcoma of the lids mainly occurs in childhood or youth, and begins
as an ocdematous awclling Wncath the movable skiu. It is elastic, grows
rapidly, and soon iufiltratfis the interatiiial tissue of the orbicular muscle.
A case of inelastic sarcoma of the lid has been reported by Vnbson
(** Phil. Lancet," No. 2, 1851) ; and a case of cysto-sarcoma by Dauchor
('* Allg. Wicn. Med. Zoit.," 18.i9), During the last few years several
cases have been reported, among them two by Samelson and Schirmer.
Front has reported an interesting cose of sarcoma uf the tarsus and con-
junctiva in a young girl, which involved the lower Hd. The growth was
removed without diflicuky from the conjimctival surface of the liil, and
on exaniinjition proved to be a round-cell sarcoma of the tarsus and con-
junctiva with admi.'cture uf club-shaped or cyliudroid cells. Portions of
the growth had umlergone extensive amyloid degeneration. In places
tUe epithelium of tlie conjunctiva was very much thickontrd. (See "Arch.
of Ophthalmology," viii. I, pp. 78-7S.)— B.j
Jtnthnt iMHi-erof the eyelids generally commences by a small mole or
pimple, which has existed perha|m for many years, beginning to itch and
Decoming aoraowhat tender to the touch, and tJien a breach of surface
occurs, which becomes covered with a scab. Iiradually the solid pimple
iucreases iu size and involves the healthy structures, and the central
crack assumoa the appearance of an ulcer. The margin of the latter is
indurated and broad, but is <]uite free from tubci'cleSf and there is but
very little inflammatory congestion. The solid growth slowly spreads to
the adjacent structures, advancing in depth as well m ilk cia'umference,
■ "Eoapp's Anhfv." 2, 1, S29.
»3
818
DISEASES OF TBB BYBLTD8.
atift without any regard to difTercncc iu the tissues ; althoagh there is
Constilcrahlc difference in tlie rate of progress in the various tissues, it
skin always yielding most rapidly. 'I'ho disease, as a rule, occurs ootj
after the age of uO, proiiucea no cnehexia, and hui little pnin, and
never followed bv enlarged glands or deposits in the viscera. Wil
regard to tiie prot/nons., it is favorable if the di^easo is ^ecn at an earU
stage, while complete removal hy the knife or escharotJcs in posmhl
It« progre^ is the more rapid, and the tendency to return the
marked, the younger the patient. When the disease occurs in the oyi
]id4 it is best to excise it, and to fill up the gap by transplantation of ii
skin, for iu this region the use of a very powerful cscbarntic, sucli as tl
chloride of zinc paste, is generally not advisable . I f excision ia not pra
tised, it is ttierei'ore better to employ t>ome other caustic, such as nitnit
of silver, nitric aciil, or acid nitrate of mercury. To relieve th« pain C,
the application of the latter, the part should be painted immediatel]
afterwards with collodion* (Nayler).
[A few cases of admoma of the lids have been reported. They grei
near the edge of the lid, ulcerated and developed Qshdou^ tracts. Tl
surrounding infiltration was extensive. A micmscofHcal examinat
showed a neoplastic growth of epithelial tubes with sparse am
connections. Inacasereportvdby NL>ltle8hip('' K. L. Hosp. It«p,"TU.
the tumor was w large as a raspberry, projected both from tlie oiiU'i
and inner surfaces of the Hd, wa.^ solid throughout, and its cut »tirfAce_
did not bleed. Sections shovrud it to be composed of numerous gl
follicles with secondary pouches, and an overgrowth of Uie connectii
tissue elements of gland structures.
NeitromafihriUare of the lid is mentioned by Billroih as congenital,
removed a tiuoor fr<^>m the upper lid of a boy six years old, which extendi
upon the tcmplo and wan very senBitivc to the touch. It was removed
with difficulty, and showed on examination nodular branched cylinders,
in the axis of which were the remains of small nerve branches. Bruna bai
described three such cases. ('*liraefe u. Sacmisch, Handb.," iv. p. A%\.\
Amyloid dfneneratUm of the tarsus has only been recognized of lal
years. One of the first to call attention to it was Vogel, who observ<
It in a case of enormous infiltration of the lid with great thickening of
the walls of the ves&els. Tlie application of iodine and sulphuric aci-l
proved the existence of amyloid disease. The symptoms are very char-
actcriHic; enormous thickening and elongation of the lids, which are
very hard and cannot be everted ; the absence of all signs of inflammation
in the extcnml skin, which utnuilly remains freely movable; entire ab-
sence of pain. And steady growth of the disease. Hull has repiirtcd an
interesting case of amyloid infiltration of the lid, in which the di«eaM!
began in the orbit, and eventually spread to the brain and caused deal
Both lids were involved to an extreme degree, and a piece being excii
and examined proved the case to he one of amy loid degeneration . (** Ti
Amer. OphtUal. Soc.," ISTS.) Von Uippel has an interesting ai
' For a(lmirnMi>itp«<<rlitt)oti!> of t)ii« ilkoniio vltl« Mr. Hoon'» work, *'0d BMcb)
C«n«er," fend Mr. Huti^lilDnon's "CUnlcAl Utrporl oo Bodest I71c«r," "Uwd-Tinci
and Uu«rtt«," IfibO, vol. ii.
I
I
BAVDS UAlBRHtrS. ^^^ 819
upon the subject, btsej upon tlie carofnl exftiuination of one case (sM
"Archiv fdr Oplnhnl.," xw. :i), and Mandclstnoira Ima also rciwrted
Bome observations upon the subject biisc<l upon cases (**Arelnv fUr
Ophthal.," XXV. 1). In Trout's case of earcouift, which had undergone
nrovloid degeneration, the Utter was mont extenMve in the interior of
U)« tarsus, linally crowding out entirely the sarcoma cells. In tfaia
region of pura amyloid infiltration, the ve»seb were more numerous, and
the walls of the smaller arteries and capillaries Bliowed well-marked
signs of infiltration, the internal one being the first affected. The con-
nectire tissue in the ricinity was also involved. ("Archives of Ophthal.,"
vui. 1.^
Luvut baa been met with in the eyelids as a secondary growt]i from
the neighboring parts of the face. It jiometimcfl extends with great rapid-
ity along the edge of the ]id, which leads to marked shrinking and
cicntrizatiuii of the lid with sometimes anchylohlepharon, and sometimes
octropiiim.
I^pra or £lephaniitm» Grceeorum of the eyelids has been frequently
observed as the first symptom of the disease. Bull and Hansen have
observed & large number of cases of leprfi, and among the first symp-
toms noted a loss of the eyebrows and die formation of notlules in Uie
lids with losa of the lashes. These nodules may reach the size of a
banl-nut, are brown in color, and lie in tiii< skin or just beneath it. The
cellular infiltration belongs alone to the vessels and may obliioratc them.
He nodules ulcerate on the surface or break down in the centre, bat
there is niroty any suppuration. Ectropium is the final result. These
nodules mny be extirpated early in the disease, but when ulceration has
once begun, it is useless. ("The Leprous Diseases of the Kye," 1873.)
Cifgtirerd have been found in the ccllnlar tissue of the upper and
lower lid, and even between the bnnrlles of fibres of th« orbicular muscle.
The skin is freely movable over the tumor, and Uicrc are no eigns of inflam-
matory irritation. They are to be n^nioved by excision. ('* Graefc und
Saemisch. llandb.,'' iv. p. -JiiS).— B.J
8.— [AKGIOMA— D.J—N-'EVUS MATEBNUS
(TELANGIECTASIS).
[Angiamaia occurring in the eyelidi include cavernous tnmora, a» well
as telangiectusiie. The former are rare, not coiigeuiul, but appear in
cbihlhood or youth, and may involve the entire lid, which is markedly
Bwolleu, blui»l)-re'l, and drnoping.— B.]
The telangiectatic tumor is more frequently met with on the eyelids,
and may vary considerably tn size and appearance. Its surface may be
amooth and even, or granulated, and perhaps divisible into two or thre*'
distinct portions. The color also varies from a light scarlet to a dark
bluisb-red or purple. ii«vi may b« quite superficial and confined to the
skin, or extend deeper and implicate the sulKUlaneous tissue, iwHiaps to
a considerable extent. They have also been divided into an arterial or
active, and a venous or passive form. The former are firm and di<«tinctly
pulsatile to the touch, and cannot bo emptied, except die vessels which
DtSKASES OP THE EYELIDS.
snpply them &re compreaaed (>rackeTi2i«). Tho renous are softer &i
moro clastic, aod can bo easily emptied by presaura. On the patJcu
stooping down, tbo nievug rapidt^r swclla up, and hocomcs dark and vtr;
teuw.
Tlio ntPTUii is atmnsr nlways congpnitiil, and may gradnnlly incnr
up to IL certain point, and tlien remain Rlmost stationan'. or else it luaj
Bpontaneoiiely diminish in size, and slowly disappear without leaving
trace behind.
Various modes of treatment have been rccomincnded for this diae;
Of tlu'se the best arc, I think, the application of threads soaked in per-
oliloriilo i>f iron, the various forms of lijiatiipc, and electrolysis. Injec-
tion of the pcrchloridc of iron if excei^stvcly dangerous, and sevcra] cuas
of in«tantancoua death hnvc been rccordctl. Hence it 'n far irincr to
vcnjo tlie tumor in diflerent directions wilh thrcaila dip[.>«d in perchturi
of iron, ami to allow them la remain in for a few days. The auVicn
iieous ligature, cidier in u li;j;ure-of>i, or circular, also proTcs rery
ceaaful. If the tumor is considerable in size, antt rlivisihle into
portions, one of those may l>e taken at a time, and the operation re
Stfveral times. De Wecker' transGxes the base of the little tumor by i
iH^edlt^s crossed at right angles ( + )tand then firmly gtrangulates
bast' with a thread passed beneath the needles.
The application of electrolysis to these meri, apfwars to me to be *ert
scrxicetihle. Dr. Alihaits.' to vrliom wi> »re iiulehted for the iniro<lac>
tiou of this mode of treatment, has found it very successful, and narratM
t case in which a nievusof the eyelid (in a patient of Mr. While C
was npidly cured without learing any trace behind. The great
tagee of eiectrolysis are. that it is free from all pain and danger,
that it does not leave any scar or iliBfigurement.
Galvaoo-puncturc has also been recommended. [This method any
be employed where the au<^oma is not very large, as it reduces IM
cicatriuitton to a minimum. But many of these nosvif and ei'eo tltf
ki^r angioroatn. can be extirpated by the knife, care being takco t>
■w iH'snuirres' liddamp or otlier contnvance for controlling the fahio4-
SQpplv. Generally speaking, less deformity results from the lue of tke
Vniti* than from caustics or the gaIvatH>cautery. Knapped Ud-foreefi
arv liettcr than Dcsroarres*, for they give more space for opentia^
.\flvr the tumor has been excised and the cavity washed oat, a careM
application of pins and twisted sutures will almost always arrest ths
bcworrliage, and. if ikot. it can always be controlled by the KJdaf
I'See a paper by Knapp in " Arch, of Upbthal.," iii. 3 and 4. Sm alia
• p«i<r by the Editor in the "Trans. .Vmer. Orfith. Soc.," 1880, i
- Nr'w Y.'Vk Med. Joum.," September, lS»U.)— B.]
a r rates
».— PTOSIS.
aA<ction tlie upper pjelid droope down, so that die
a fTMtlr narrowed, and the cornea more or less ootvred,
— i&le by a Tolnntarr effort to raise the lid. la the r-*-
-^ ..tts.
■ Tide Dr. Allkam'* tnttfMtiac «wk om DMO^yak.
A
k
PTOSIS. 821
ter upon the Paralytic Aftcciions of tlie Muscles of tlie Eye, it was men-
tinned tliat ptofli« U a frci^ucnt srmptom in paral^sii! of the tlurd nerve,
on account of tlie levator jiaifchfr BUfiFrifrin being supplied by this
nerve. In complete paralysis of the thini tierve, we find, besides the
ptosis, that on liftin*^ the eyelifl, the eye is immovable in all directions
except outwards, and sligbily downward* and omwanis, that the pupil is
dilated and the nccoiontodatiou paralyzed. The ptosis may be partial
or complcic ; in the former caxe, the npjjer lid can still bo somcnhat
lifted, and does not rlroop to the full extent, in tbo latter it ban;^ down
immovably, and haa to be lifted np by the assiatariye of the finger. The
pnlpehi-al aperture may, hovrever, be somewhat widened, and the upper
lid slightly elevated by the relaxation of the orbicnlarig and the onn-
traction of the frontalis muscle. The causes of paralysU of the tbird
nerve have already been mentioned at p. 084, and 1 need not hero recur
to tbem. It muat be stated, however, that in some rare instances the
branch to the levator ))al|)ebnu may be alone iu)[>licatcd, owin^ to its
direct comj)res3ion by an exostosis, turaor, etc., the other brancbcji of the
thtr<l nerve being tinafl'ected. Or, again, snnie traumatic lesiun, impli-
Cftiin^ the nerve or the nuincle itself, may be the canse. I'tosis may
aI.*o occur independently of any paralytic affection, being due to some
vrant of development or congenital inenfiiciency of the levator palpebrte,
which coexists .sometimes with epicanibus. Or It may remain afler
the great swelling of the lid and hypertrophy of the conjunctiva accom-
panying purulent or granular opbihalmia, the levator not being suffi-
ciently strong to overcome the weight. A certain degree of ptosis is
aluo flomctimea observed in aged [leople, if there is a great superabund-
ance of flaccid skin, and the levator palpebrte is at the same time somo-
wbat weak.
An interej-ting fonn of partial and slowly developed ptosis is occasion-
ally observed in adults; it is accompanied by myosis of the same eye,
and there is an entire absence of paralyais of any of the other muscles
supplied by the third nerve. Homer' records an intereating instance of
this kind, in which there waa also, duriitg any excitement, marked in-
crease in the temjwraturc and redness of the corresponding half of the
face, which stopped exactly tn the median line ; this aide of the face
beiny also cpiite free from any [lerspiration. The eye-tension was
slightly dimiiiisheil. He considers that this form of ptosis is evidently
due to paralysis of the plain muscular fibres of the upper 1id, which are
supplied by the sympathetic, thus forming the opposite condition to tho
retraction of the upper liil, w\iich is met with in exophthalmic goitre (p.
75T), and which is due to irriUilioa of these librea.
The trmtinent must be varied acconling to tbo cause of the aflcction.
If it be due to paralysis, the general line of treatment laid down lu tho
l^lapter upon the Paralytic Affections of the Muscles of the Kye (p.
68.">) nujst be followed. Klectricity often proves of considerable benefit.
But if the disease resists all these remedies, recourse must bo bad to
operative interference. In those cases in which tbo ptosis is simply duo
to an ovcr-abun«lance of hyperiropby of the skin, a horizimtiil f«d<i of
ibc lattcrr jMirallel to the edge of die lid, shuubl be pinched up niih a
> "Kl. Monaubl.," Jnlf, \H^.
822
DESGAaSS OF TUB SVBLtDS.
pur of forceps and excised, the edgas of tho wound being united hj
fine auturi?*.
The attempt hns, moreover, been made b^ Bowman and von Oraefe
to bring fon\'arfl the insorCion of the levator ]uilpebrfe,and thus augmou
itd pi^wer, i>u tlio Hanic principle u]>on wblcb tlie ini>crtiou of aome of thft
ocular ninsclcfl is sometimes bronglit forward. But the results wens M*
favorable. Von Graefe' hm more lately devised the follow in;; opera-
tion: A trans vureo inciftiou is made tlirouj^li tiie skin of the npper Ud
about *2J lines from its free mBrgiii, and extending the whole length of
the lid, the incision being made to i^»]w hy a vertical traction upOD
its edge-9, and by separating the subcutaneous cellular tissue with i
knife. When a snffictent breadth of the orbiciilaris has been thus «-
posed, it is to be seiied with the forceps, and a portion of about four or
live lines in width is to be excised, care being taken not to injure tbe
subjacent fascia. The incision ia then to be united by sutures, wbidi
arc to be carried thrfiugh tlio skin and the cut edges of tlio orbicularia.
The effect of this operation is to causc a subcutaneous Bhon«ning of the
upper lid, to weaken the action of the orbicutaiis, and thus to aaadet that
ol the lovati>r. If the length of the lid is increased, von Oraefe, after
having fiuished tbe transverse incixion, tnikkes a second, havin]^ iu ooo*
vexity upwards, so that a shortening of tho skin may be contbinod wiA
the subcutaneous shortening of tbe lid.
10— PARALYSIS OF THE ORBICULARI.S PALPEnRARUM.
In this afTeclion wc find that the eyelids cannot be completclT obMc4.
on account of the inefficient elevation of tbe lower lid, so that a chiak
of varying size exists between the two lids. By a strong effort of tbe
will, the patient may succeed (more easily ifthe other eye is closed), la
almost shutting tbe lids by the relaxatiruk of the levator palpcbna. TUt*
wide gaping of the eyelids giveg a peculiarly starinj; ap[ic«nuic« to tho
patient, and ia termed latf^phthahnot. The paralytic la^opbllmlaiiM tt
present even during sleep, and resists the action of reflex irritants applied
10 the conjunctiva. Paralysis of the nrbiculaiis is soon followril hy
other symptoms. There U marked epiphora, and Uie constant flowing
of tears over tbe cheek soon causes irritation and excoriation uf iko
«dgea of ihe lids, upon wliicli thickening qthI eversion supen'enL^. Tbe
«X|>0«urv oflhu eye to external irrilauts (such as partick-s of dost, etc.)
soon produces oonjnoetivitis and supcrficiarcorncitis, ending, perhaps, a
'pannoft and xerophthalmia.
The affliction of the orbicularis is due to paralysis of the facial tmm*
The orbicularia may be alone affected, or the iiaralvais may cxtetMl M
several, or all the branohea of the facial nerve. It is only wry rarelf
net logr.-tber with bemi|<legiB. I'he eausea of the disease may 'be f>rn-
pheml or central. Amongst tho rirroor. exposure to eold air, da«|»,
•to., ii t1i« most fre(|uenl. It may also bo caused hy direct prtasai* (m
^tntn a lumur) upon any part of the nerve, or hy injuries which tn|i&
ifi^
DLBPUASOSPASU.
823
lie the Utter. AniongBt Ute cerebral causes need only be mentioned
the presence of tnmors, svphiHtio extidations, heniorrhagic or punilerit
etfueions, etc., ami rtiflferent legions giUtated at the ha^e of the brain. If
the didDBso is clue to paral^Kts, the treatment Iniil down in the article
upon •• The Paralytic Affcctiona of the Miidcles of the Eye" should be
pursued. In orUi^r to ^uard tlic eyeball aj^iiinftt tlte cfTeut of cxteniul
irritaDta, wc may pare to a slight extent two corresponding poinw of tbo
tersal margins of the upper and lower lid, and then unite them by 2-3
Btltches ; the eycbull being thus protected uatil the orbicularis hae
regained its power.
I
I
11_BLEP1IAR0SPASM.
This affection varies iinicli in iiitenfiity. In the slighter forms, there
rony only ext.st a moderate <lef;reG of temporary twitching and contrac*
Uun of the lids, which soon passes off again. If the affeotioti is more
serere, the spasm of the orbicularis may be so great, that the eyelids
arc firmly pressed together, and that it is quite impossible for Uie patieut
or the surgeon to open them even to a slight degree. The endeavor
forcibly to open the eye is iiUensely painful, and may eren almoat throw
the patient into epileptiform convul^tioua. At the outset, the diseaac is
generally hut mmlerate, but if the cauac persists, or efficient treatment
la not aaoptc'l, it gradually increases in Kverity, and the spaam, which
was before {Htrhaps only periodical, becomes poruianenti so that the
patient cannot open his eye at all. Then the other eye may Ix^come
affected in a similar manner, and the muscles of the face, neck, and
even of the extremities, may undergo sitasmodic contractions.'
Blepharospasm ia often mot vith in the courae of inflammatory affec-
tioiui of the cornea and conjunctiva, or if a foreign body liait become
lodged within the folda of the latter. In such cases, it is evidently due
to a rellex neurosis dependent upon irritation of some of the branches of
the fifth nerve. This disease liVcwisc occurs in severe cases of hyper>
jcathesia of the retina. It is aI<to observed in connection with neuralgia
of the supra-orbital nerve, or of other branches of (he fifth ; the exact
seat of these affections being perhaps unsuspected until a certain spot is
found, where firm pressure will at once arrest tlie spasm. It must he
tnentioned, however, that in some instaooes even direct pressure upon
tlie facial nerve at its exit through the stylo-mastoid foramen will stop
tiie btirpharottpa«m (llooiberg).
Tlie treatment of the disease mast vary with tlie cause and dumtion.
Thuu the severe hlopharospoam often noticed in the course of corneal
aflectiont> dit!>appeani with them ; or. if it persists, it frequently yields to
tonics, immersion of the head in cold water, sea battling, and the subca-
taneoua injection of morphia. Indeed, the latter remedy ia often found
of great benefit in the treatment of these apastnodio affections. Krota
one-sixth to one-third of a graiti of morphia should he injecled at the
point where pressure will stop the spMm, and be occasionally reiH;aied.
' "A. f. o.,'M. l,«o.
824
BtfKASBS OF TUB BYBLIDB.
If, lioworcr, ihew remmlif^ fail to cure the McphM'n ip— ,
Ran- upon tlie HupnMirbiml oen-e iU)yf it,aDil enaUas^Ae
tarily to oj*!! hi* eye, this nerve mnsi he dirided.
fir«t performed by voii Gracfe, at llomberg'a
ifih>i»e blrpharospMrn which had supenrcned Bpoa Am
forei},;n body in th<? folds of the conjunctiva. It waa
bvperasthoaia of thu nrhicularis frooi contasion, and
Romberg t« he a retlcx .iipiism duft to n pAtliolo^^ical irrirati— rf
norr norves. lie, tlivrclore, ftdvised the dirUioa of the •
ncr^-e. fntm which recurrent (sencMrjr) branched arv prabaMy
to thv fiH/icu[ari«. The operation proved perfectly ^qcccmM.
since thou been oftcu rejK^ated with much beuefit br tom i
othrr siir^ooiifl. Tlie supra- orbital norvc should be diTtdeii
exit from tlic aupra-orbital foramvti, and in order to facilitM*
eyebrow Ahould be tlmwu well upwards, so bb to oake tlie akam
It' the nerve u not completely divided, the effect viU only ba
temporary, tud the operation slirKihl he repeated. As tlua
rofty sometimes ho doe to » reitnion of the divided ends of Ar
lome Aur^eoiis have cut f>ut n piece of the UtU'r. After tb*
there nhoiiM be a ceruiiu de<;rL-L' o( unteaihc^a juM ahora tk»
portion of the nerve, and in tlic nppi>r lid. The operaaoo «1mmU la
peribrmed under cblorofonn. more especially in cbildrao. IVinr «n m
performance, the aur;;eoa shouUl, of course, try whether Um 6rm ai»
iiruMiuii of tlic Hupra-orhital nerve alleviates tlie blepharoisp*am, for aalj
in Much t;:vw» cau we expect a favorahle rc:iuU. I'Subcutaneom diiiww
of the nrbicutar ranttclo waa recommended and practised by l>i«l«aiidk,
but nitliout much success.
br. MathowMiD, of Itrooklyn, has proposed a method of treating Ua-
pharoripMm, wliich has been sometimes employed for the reliaf of ptuM.
A nlendur ImnJ of rublier, about one line broad, half a line thick aad m
inch lonR. i»t to bi' attached by one end to the surface of the upper M
near its lower cdKo, at the middle of ils horizontal It'ii;^h : n ■trrpof
iHini;laM planter, iiinchedsu as to adapt itjtelf accurately, isa; roa
the band, ami tliu whole is covered with colloJiou ami alti^-, : .. irj
till firmly adherent. The band iei then to be stretched upwanl to aninck
and a hnlf, no oj to elovate the lid moderately, and faatened to the fiart-
hcad in the snruu Hay, and to be kept in place until the ldepharos|—
is overcome. 'Ilio sizp, lcn<;th, and tension of tin- band mar be raneJ
to suit circumsiancos. ("TraiLi. Ainer. (Iphth. Soc.,** l#T4.j — 8.]
A^Vf/rn^inn, or involuntary convulsive twitching of die eyelids, is OO'
ca^ionally met with in n varying dej!;n.'e, and i* ;renerally ofiinj* i»i ai*
flex neiintsis nruducinj^ a spasniwiic cotitraclion of tlie orbioi' . M -^
twitchin^^g lollowiii^ each other in rapid 6iicce«i*ion. Tho ri' ^aj
hi? limiU'-l U> one eye. or involve both, the upper lid b«ini4 uwitv frs-
quently iraplicaterl tliau the lower. U is always marWwWy \noreaud »»j
any ncrrouaness or agitation of mind, and i» rttt|ueuily «*ev with n fU'
sous in a weak, nervoon. or hystcrica\ cuuditu.^^. \v \m.-3 y^so b« Amis'
s'.mt- local irritation, as mi inverted laah, ■hgSaWtxfti^'^J"'*^"*^
juiwtiva, etc. It is someUroes obaerveil in „_.,a^ ^'SV
TRICHIASIS AND DtSTICIl t ABIB.
825
which glasses Are not worn, anrl will then dUnpftear with the remotral of
the canie. In nervous ami delicate pOMons, tlit? pcncral healtli shouM
be attenilcd to, nil ammutic ami ^It^htljr ^tiniulutiu); htlioti apiilicd to Uio
lidi, and the «yc-douclic be u&ed. In liyiHrrtntstnipia, tlie proporglawee
bIiouM be onlured, and tbcu tbe tnitcbing will soon disnpiMar.
12._TK1CIIIASIS AND DISTICIUASIS.
These conditions arc characterized by an irrc;?uliiritv in the growth
and direction of the eyelashes, which are more or less inverted. In Iri-
cbia:tts the Inshcs are irregular.
\
*v:
'fji
80UIC ptrliauij liaviiig a natural IP's- 321. 1
poKtiion and a|i^K>arnncc, whiUc
others arc incurved, tliin, i>a!e,
Btra;.'f;lifi;; and stunted [Ki^- 2:il].
In distichiasis. there ai*e two dis-
tinct rows of lashes, the outer
boinj; in the u^iinl position, tbe
inner being situated further back
rknd turned inwards. The double
Irnm^jemont is, however, often
only Apparent, bciuj; due to a
thickeniii}; and stretching of the
ed;;(! of the lid, and a conseiiuent
alteration in the direction of the
hair hulh-i and the cilia. Uoth
trichiasis and distichlasis may
afi'ect tbe whole leti;{tli of the lid, or be limited to a certain portion or
portiona of it; and if the malposition only involves a very few, colorless,
thin cilia, it may readily be overlooked, and maintain a prolonged and
very aunoyin;^ irriuition of the eye and lidn.
This faulty position of the cil!.-! is generally accompAnicd, or soon fol-
lowed by a certain degree of inversion of the eyelid (entropium). and
perha|)8 by a shortening and incurvation of the tarsal cartilage, jtut in
the simple and true trichiasis or distichiasis this is not the case, nn<l the
position of the lid and the condition of the cartila<;c are perfectly normal.
The most frequent cauties of these conditions arc long-«oniinued and
severe iutiammatiunt? of the conjunctiva (^purulent and (;ntuular uphtbal-
inia, etc.)* aixl of the edge of the lid ; in whicti the Iniir follicles have
undergone Inflammatory and suppurative changes, so that tliey are either
destroyed, or their functions no much impaired that the growth of tho
lashes i» Injured, aitd they Itecomo weak, stunted, and distorted. L'lcers
and small alxscesses at the roots of the cilia, or injuries (burtis, cuts, etc.)
of the edge of the lid, may aUo produce these affections.
The iri'egular growth and inversion of the lashes, eveu altliougli only
a few may be iuvulved, set up considorabln irritaltoa of the eye, which
becomes watery, rc<l, and irritable, the patient complaining of a constant
pricking and itching iu it, as if a minute forrign body, or a little sand or
grit, were lodged beueatb the Ud. If the affection is allowed to cuutiaae,
806
DT8BABE8 07 THS KTBLID8.
the ayinptning of trritAtinn nicreaM in sererity, am) iherc nay be
tideraMc laclirjmatinn ftn<l photophnbU. The coDsUmt spaunwdic co^
tractiou of Ibe i'yfli<I» cau5ei< an inversion of the edge of tim l»tter«
which may, iii time^ become permanent, so that an eniroptam ia tttftr-
tiided to the trichiasis. After a time, the conetaot fnctioo of Ch« n-
rerte<t or stunted lashes agaiiiitt the cornea seta up a superficUl coni6-
iti9, ami a more or less severe degree of i)aonu« vrifl superren*.
The treatment of distichUaia and trichiaaia must vary with the extent
and Bevericy of the disease. If only a few, Atrajrjcling cilia are mbplaceil,
their repeated evulsion may erentually core tbe
(Flf. 222.] aifection. By fr«i|oenLty extracting the laabrs, we
may, in time, succeed in caunng an atrofihy of the
hair bulbs, and thus arreat the fcrowth of Uie alia.
Indeed, many potieuts learn to do this very well for
tiienuelvea, or are satisfied to have the laahet ex-
tracted every few wcekti by their medical attenilaal.
If the trichiaKiJt is confined to a very few and aea^
tcred lashes, Uns treatment may snffice. But tke
oft-repeated evulsion occa«ionany leads, after a time,
to a certain degree of irritability of the eye, aoj
may thus become a source of annoyauce to
patient. Sometimes, the destruction of the hair I
liclu» by the application of U4{uor potaa^K ain
t proves auccc&sfut, where only a few cilia are
I |)licatcd. A horn spatula [tig- ^'2'2\ having
inserted heneatli the eyelid, anil the edge of
latter put on the stretch and somewhat everted,:
that the row of lashes is brought well into rici
point of a needle (dipped into liquor potaasie) ah<
bo run up to the roots of the distorted I&shrs, so ••
torciic]) their follicles; or1iL)ue(ied potitasa fussi
be employed for this purpose and in the «ne
ner, as has been propftscd bv Dr. Williams.'
will generally sor)n cause tlteir destruction,
surgeons also produce the latter by means ^f the *|
plication of a strong caustic solution («. r/., the sulj
hydrate of calcium). In order that it inay not
tend to the coniiiiicttva or the cheek, ami Mt up'
considerable intinmm-ition, the surrounding parte
should be smeared Mith oil, the edge of the Itfla be
well everted, and the solution very carefully applied. The calcium 15 to
he washed iLWsy with a sponge after four or five minutes. But if a eon*
ndorablc ext<>nt of the lid is trented in this manner, a very unikigbt*
haldnoss (nrnflaroBi*) will ensue. And hence it is always wi»"'r to
deavor, wlu-re ft considerable len;:th of the edge of the lid in \i\. m
perform some operation which shall prove a cure, and yet pre. .
evclfMihes. Very numerous operadons have been proposed fnr the cure
of trichiaua, more especially when combined, as ia generally tb«
"R. L. 0. H. Sop./'Ui. 219.
TRtOniASI9 AVD DISTtCHUSrS.
827
with entro[ttUiD. Some of these consist in the complete excisian of 8om«
or nil of the ejelaabeij, olbera in giving the Utter a different direction
but not iic8troyin;; [hum.
Whcu only a limited number of lashes is misplaced, the foUowiug is
the best mode of excising them.
If the upper lid is the seat of the diaeaae* Snellen's mo<li(ication of
PesmancA' clamp, Fig. 22ii, should he used. The lower bUdu should bo
Fig. 22.1.
*^
msorted beneath the upper eyelid, and tlie two blades then screwed down,
80 as to compress tlie eyelid firmly between them and contro! the bleed-
ittiE [Fig. '224J. [Mr. Laurence has slightly modified Snotleu's forceps
(Fig. 22.1), aitd adapted the same priikciiilc to the lower lid. — li.] In
the operations for slight partial trichiasis, tt is not so noccsAarr to use
this instrument, as for those which are porfumietl when a considerable
portion of the tid is implicated. An incision is then to bo made with a
small scalpel (^or with a broad iridectomy knife) at the edge of the lid,
just between the Meibomian ducts, so tliat tlic cilia arc included in tlie
anterior portion of the inciaion. The latter is to extend upwards to about
^"\ and its! length should include all the distorted l&shcs. Two incisions
are then to be made through the edge of the lid and the skin, thottc in-
cisions meeting at the centre, so as to form two sides of a triangle., the
base of which is formed by the lower incision along the margin of the lid.
This triangle, which includes the bulhs of the nii^placed lashes, should
then be removed. The lateral incisions may also be made with a pair
of curved scissors, one point of which is to be inserted at the angles of
the longitudiiisl wound. The lateral edges of the iocision are to be
brought together with fine sutures.
82rt
DISHASBS OP THE BYBLID8.
[Pig. S24. |FiE-225.]
Hcncnstein has devised the following operation for trichiasis,
appears Lu be espcciallj ajiplicable to the partliil forms, wliure
few cilia are implicated
Ti^. 226. It consisbf in the iiiserti«
of a tliread, whicli M
upconsidernhle irritation,"
Skud the accoEOpaiijriog
supparatJon causes the
destruction of the folljcl*
of the displaced cilia. D|
I Icmeiistcin performs tM
operation in the fr>lloi
iii^ inuimer : he entera
noe.lle (jV, Fiji;. 5-2i)]
carrying a fine
thread, at the edge of
lid between the cilia
the openings of the Mea|
bominn ducts, at a (t^j
S^ij), pasae^ it alon^ subcutaucoualy in a Yei*ticul direcUun, and briiijj
it out at A, !tli;;ht]y above the tuarj^in of the lid. The one thread is boT
drawn through, and the needle n^ain inserted at the same opening, t', an
passed along sultciitaneuusly atid |tanillel to the margin of the tid, to
extent of tlie distorted lashes (to •■). The thread is here again dni
^TRTCntASIS AND D18TI0HI AStS.
829
through, anil the neerlle re-inserted at the same orifice, c, anil passed
down Tertlcally to make its way out At a jwint («*) between the Iwrdera
of the margin of the lid. Tlio two ends of the thread are then firmly
tied, and permitted to cut their way out. Cold compreasea should be
niiplit'd. If iiutiiBroiifi little yellow siioU of suppuration apiwiir, the
thread AhoiiM be at once removed, tic ha^) alAo operated iniece»sfu1ly
in cases where a very considerable extent of the lid was affected.'
When a considerable number of the lashes are misplaced, we muat
remove a long narrow atrip of the edge of the lid, which Includes tliese
faulty cilia, or even "8cal[>" the whole Hd. Snellen's clamp having been
ajtplied, an incision is to he made with a scalpel or cataract knife along
the free edge of the lid between the eyeluiihua and the upening of the Mei-
bomian glands, so aa to split the tarsus into two, and sufficiently deep to
pass beyond the roots of the lashes. A second incision is then to be
made on the external surface of tlie lid, and carried along, aud parallel
to, its eil«;e, jnst hohind the row of lashes, so that tlic two incisions meet.
And the strip of skin and iiitegun)ent, containing all the faulty lashes
aud their roota, is then to be excised. This operation may be partial or
extet»d nearly to the whole length of the lid, according to the extent of
the faulty lashes. Un completing the excision, the part should be
8])ongod and the tarsus be closely examined, to discover if any of the
hoir bult>!4 (which appear like minute black spots) have eacai>cd, in which
case they should be excised, otherwise the cilia will, of coureo, grow
again. Sutures need not be employed, but u cold wet compress should
be applied.
The above operation is certainly efficacious in curing tlie trichiasis,
but it is unsijihtly, more especially in the up[>er lid, and the entire ab-
sence of the cycloslica and tiieir protective iiiEuence may give rise to a
good deal of inflammation, from exposure of t)ic eye to external irritants,
auch as dust, etc. However, in persona wlio are careless aa to their per-
sonal appearance, and are anxious to be iiuJckly and effectually cured of
the disease, this operation will be found a very suitable one. Kut in
those cases in which it is of importance to preserve the eyelashes, nod
simply to give them a different and better jiosition, so that in place of
being turned in, they are well everted, the operation of transplantatioii
is to be much preferred. Indeed, I almost invariably perform it in pref-
erence to that of scalping, even although the personal appearance vany
be of DO particular importance. The two following are, I tbtuk, the
best operations for transplantation.
1. Ark's mndificAtion of Jaesche's operation. Aa this is a tedious
and painful proceeding, the patient should be put under the influence of
chloroform. Snellen's clump having been applied, an incision is to be
carrietl along the free edge of the eyelid, between the cilia and the
openings of the Meibomian ducts, and reaching to a depth of about 2"%
care being taken to avoid the punctum. In this way, the free edge of
the lid will be split into two portioDS^ the anterior containing the intega-
niente, eyelashes, and their bulbs, etc., and the posterior the cartilage
and the efferent ducts of the Meibomian glands. When this incision u
• <• A. f. 0.," xll. 1, 78.
830
DISBASSa OF TOR STBUDS,
completed, a second is to bo carried alvng tbe outer ittrfacc of Uic lid,
about 1}"' or ^" above Uie e^relasbes, and parallel to then). Tbu ia-
cisioQ is to extend through tbt
FiR. 227. skill and the orbicularis down to
the cartilage, and be of safficipm
length to pass at eacli cxtreniiir
somewhat bcjoud the first to-
cision. In Uie next place, i
third, Bcmiciroular inctaion ta to
be mode from one cxtremitj of
the second incision to the other
(as in Fig. --7 ,|, so that a &• ^i
circular ]r>ortion of skin u m
eluded within it. This portion
of sltin \% then to be very carefully dissected away, without any injuiji
to the orbicuUris. The size of the flap must vary with the amount
flversioti which wc denire ; in mmple cases of trichtai«irt, wilhnut any en-
tropium, it need be but small. When this has been done, the ed^t.'S of
the incisions should he brought together by fine sutures. The effect of
this shortening of the akin of the eyelid wilt he to roll out the edge of
the lid and the eyelashes, which can be the more effectually done as U>»
edge of the lid has been split into two, and the extcnuil portion is tii«a
greatly liberated.
I have found this operation genemlly very successful, but it must
confessed that it docs occnsionnlly fail in two ways. l*t. The <^t
in the position of the faulty ciUa which are situated near the extremitii
of the incision may not he sufficient. 2d. The nutrition of the nar
bridge containing the eyelashes may be here and there impaired, lei _
to a partial alou^b and loss of the Inshes at this point. To obriate tbeas
ill results, and yet to preeerre all the advantages of this method of ope*
rating, von Oraefe has devised the followin;; modification:* —
2. Vou Oracfo's operation {vide V\g. 'Z'l^). We makes two vertic
incisions A'" in length, which pass upwanls from the anterior edge
the ltd through the skin and ortncularis,
from the lateral margins nf (he portion of
lid which ts to bo transplanted, llcnce,
tbe trichiasis is complete, an') eiien'is
whole length of the eyelid, Uie external T«rti-
cal incision will be at the outer coRmnasurc*
the inner at the upper lachrymal punctt
(which should be preaerred intact). In
next place, an incision ta to be carried at
tbe free edge of the lid between the cilia
Meibomian ducts, jual as in Arlt's opermtiot*
The lashes can now be well everted, and ta
! still further in maint«itiing this poettion, an oral poi
t! excised {vide Ki);. 22N), or this may b« effected b/
<iuu of two or three vertical sutures, without eicision.
FIjT. WK.
•^^^^P^
"A. r. o.,"a.a.aM.
£»^
iJ^KJ
TRICHIASES AHU DISTFOUIASIfl.
831
Fir. S39.
Fig. 230.
~^^'rY0'
Fig. 231.
>fW
In CS8C8 of partial tricliiaais of the upper liil, the following oprration
of AnagitoMtakiK' wilt be found very succeseful. He inclucleg the cilia
which are to be excised between two rerticnl
incidiuns (Kig. "J^'J), which diverge somewhat
above. The cilia having been excised, he rc-
sectB a fiortioii of the liap of skin (Fik. iiO)
Ij^ing between the incisions, draws it down
until it reachc!) about half a line beyond the
mnrgin of the lid, and then attache:) it by a
Buturo at each corner (Tig. 2^1). The suture
is reuiHved about 24 hours arterwards. By
this proceeding is avoided all shortening of the
external lip of the uiarfpu of the lid. Where
the tiiuhiasis or entropium affecta the greater
portion of the lid, be makes a long incision
tlirough the skin, parallel to the edge of tho
lid, and al>ont 3 millimetres distant from i^
and if the skin is very abundarit, he removes
a horiwpntal fold. He next excises some of
the fibrcii of the orbicuUris which cover the
U}iper segment of the tarsus, and then uuites
the incision by sutures.
In those cases in which a few cilia only have a faulty position, the fol*
linring operation of Snellen ia indicated : The two free ends of a silken
thread are to be drawn through the eye of a curved needle so that a
sling is formed on the other side. The point of the needle is to be in-
serted at the free margin of the lid, as close as possible to the misplaced
eyeluth, and the needle is then to b« brought out, in a line with the
uonual cilia, at the external portion of the lid, about 1 line from it^i
margin. Willi the aid of a pair of forcej« the faolty eyelajili in laid into
the sling, and the two drawn completely through, so tliat the lash is laid
into the tract of the needle wound, and its point should issue from the
external opening of the latter.
[When tho faulty posiUon is limitcil to a few hairs, especially if these
aro isolated, and not grouped together, the hair-bulbs may be destroyed
and a cure cfTvcted by the galvano-cautery. The needle is introduced
into each hair-bulb separately, and tlius the follicle is most surely and
effectively cauterized. No bad results follow this method of treatment.
Another simple way of treating slight cases of trichiasis, which is
flonictimes effective, is to pass three or four ligatures vertically thmugh
the lid : eutering tliem along the ciliary margin of the Hd, passing tlicm
heneoti) or behind the orbicular mudclu, and bringing them througli the
skin just l>cyond the curved border of the tarsus. They are then to he
tied tightly and the ends cut off. They may be removed on the fifth or
sixth day, or allowed to slough out. — ft.]
la severe cases of trichiasis and entropiom, Dr. Pope,' of New Or*
VMv " AnnalM d'0cDlistl4|uv," 16S7, and French tnuisUth>n «f Maokoiui«. vol.
ii. p. 80.
• '* Areh. of Opbth. and OloL," t»1. i. p. 10.
&33
DISEASES OF THB BYEtlOe.
leans, recommenils Ui6 extirpation of tbe Ursus. HAnti)!; Rrst ptr-
ror[ue<l nil the steps of AHt's operatioo, aiv.) rcmove<] n portion of tlie
orbicutarU. he noxt extirpates the tarsus, beginning hv an incision in the
posterior flap, along its free i»8rgiu, betweeu tbe Unus and conjunctiva.
The tarsus ia best removed piecemeal, nniil nothing remains but it^ Q[j|>er
ritn, Ui wliich the levator paluebnfi DUpenQriif if atMclieil ; tliis rim i* tn
lie bevelled off. The wouiiil in the outer flap is then to be united br
sutures.
1.1— ENTI«>PIi:.M.
In tliift comlition, the free edge of the eyelid is more or !e« inverted,
so that tlie c^yelushe^ arc turned in and sweep a^inst the uyebalt. Tito
cntropinm may he citlier partial or complete, ami he limited to one eye*
lid, or ulfect both. We must <liatingui.th two jiriiicipal forma of the dit-
case: 1. The spasmodic or acure entrnpinm ; and li, the chronic tmtro-
pium, which is caused bj inflammatory changes in the conjunctiva and
cartilage.
The spa.'iniodic entropium is acitte in character, and occurs chiefly in
elderly jterdona (hence it is often also trraed senile entropium). the skin
of vFho8e eyelitls h very lax, and who have perhaps had ilioir eves band-
aged up for some length of time ; thus, it 13 often obser^'od if a firm
bandage or pad has been worn, either ou account of some o]reraUon uo
the eye. or fnr nonie inflammatory afl'ectioti. Indeed the pliotopliobia
and long -continued ;iipa:«m of the lid attendant upon the latter, may give
rise to eniropiuni by the spasmodic cuutraution of the iirhicnhiris, wbidi
caUjR's the edge oi the lid to roll in, more espoeially if the skin of t]i«
lid is very abundant and lax [Fig. SS'I],
[Vlg. 233. In this form of s[»a8iiiodic entropium ve
observe that the lashes have Iteome
tucked in towards the eyeball, and are
quite hidden from view, the margin of
the lid being rolled in upon itaelf. and
presenting its smooth, rnunduil edge up-
wards. i)n gently drnwing back the
evt'lid into it« normal position, wc no-
tice that it looks, {wrhaps, quite healthy,
or Only slightly swollen and red ; bill
After MMkMiio-] tts edge is not sore or notched, and tlir
eyelashes are perfectly regidur ami well
[idevcloped^ being neither distorted nor dwarfed. The lid can he tempo-
nrilj retained in its natural position, but very soon it rolls in Again,
jesiwcinilr if the patient xhould wink. This form of entropium is par
tkularly'met with in the lower eyelid, but may aUo aiTect the upper.
in the chronic entn>piura the appearances are very diBcrent, for on
evertin;; the edge of tbe Hd, we generally find it inflamed, oxooriaied,
eoutracted, aiwl notched. The eyelashes are sparee and irregalar in
tkeir rrowth, ibowing the chamcters of distichiasis or tricbis«is. an<l
being dwarfed and stunted, lustead of the eyelid presenting folds of
,m— n^f>^mitt lax ikio, it often lodu rather shortened and tightly
rift
ium
SNTROPIUM.
838
etretched, the cartilage being coDtractoU and iDcurvod ; nnd oo versioa
of the eyelid (which ia freijuetitly p«rf<)nned witli difficulty), Uie con-
junctiva ehovrs the reoiains of innammatory, and often deeply marked
cicatriciBi changea. The length of the palpcbnil opening (from angle to
angle) is frequently cotii^idorably diminished in aiee, ao that the eye looks
snialler and sunken. The induration and contracllou of the carti]a>;c arc
often very marked, and it may be shortened horizontally nr transvcracly.
These changes In tlie cartilage are especially obaervud as a cons<Kjueoc6
of serere and long-atanding granular ophthahnia. This form of entro-
piiira ta generally caused by various iiiflammationa of the conjunctiva and
the edge of the lid, more especially if there is much photophobia, and,
in conaequence of this, severe blepharoapaam. Long persistent diatichi-
asia or trichiasis may also, as haa been already atated, give rise to a cer-
tain degree of entronium. The latter ouiy likcwtae occur when the eye-
ball ia atrophied ana .shrunken, <to that it no longer fills out ttie orbit and
Buatains the lids, which coimoquuntly show a tendency to become rolled
in. Entropium may al!io be of traumatic origin. Thus hums, scalds,
injuries from lime, or wounds of the inner surface of the eyelid, may
produce it, by causing a destruction and cicatricial contraction of the
conjunctival and subconjunctival tissue. In such cases, symblepharon
often coexists.
Tlio preiwnco of entropium generally soon seta up great irritation of
the eye, producing photophobia, hichrymntion, and hlepharoaijasra, Sub-
setjuetitly, superticlul cornvitis supervenes, and a more or less dense
pannns may be formed, leading to still graver complications if the inver-
BLOQ of the Uda is not cured. In some instances, hovrerer, even a toler-
ably severe degree of eutrapiaui may exist for some time vithout setting
up mucli irritation.
Tlie treatment of entropium must vary according to the nature and
extent of the disease. In the slight and recent cases of spasmodic or
senile entropium (esjwcially of the lower lid), it may suffice to replace
the lid in it^ nontutl position, and then to paiuC its extenial surface with
collodion.' This will dry at once, and prevent the lid from again invert-
iug. The collodion must be renewed every two or three days. But if
the entropium is too considerable in degree for this mode of treatment, a.
narrow hoiirontal fold of skin, ruumiiy parallel and close to the edge of
the lid, and a [mrtion of orbicularis should be removed. A fnld of skin
of the requisite size, having been caught up between the branches of the
entropium forceps [Kige. 2S.'J, 2!i4], is to he excised by a few rapid snips
of the scisaora, and ibou a nnrtion of the orbicularis should, if necessary,
be also removed. Before beginning the excision of the skin, we should
8«e what effect the pinching up of the fold between the force]is has iqion
the position of the lid. If it does not evert the latter sufficiently, a
larger fold must be seized ; if its eftect is too great, tlie size of Uie fold
must be diminiiihed. As a rule, no sutures will be rct|uirod, but a light
pad and bandage should be applied, when the bleeding has ceased. It
has lieeii also recommended to excise one or more small portions of integ.
ument in a vertical direction, the edges being united by fine sutures.
• Vide Mr. Boirmsn's paper, " Braithwalt*'* B«trMpM4," 1851,
63
m
A» the palpebral aperture is froqaontly ciiujuilcrabljr shortened b
iroiuc cusus of entropiiun, so that the ejre loolu very staftll, macti bi
tin ortcn ilorh'etl from slitting up the oiit«r caiithuii <'t:ahthopLutT)>
The canthiis may be divided witii a bistoury or with a |>.-tiri>r itront
Aclfuora. If the Utter be employed, one blade should be pa»«4!4l bvlnii
the outer canthiu, the ottier in front, and the cotnmUsure be (tiridad
with QUO sharp cut. An asBidtaat is theu to stretch the incUtoo im
iftical difpctioa, eo as to caiute it to gape. The conjunctiTal eurfan ef
inciaioD is to be anited at one or more poiats to the ikia b j a tM
itarc ID order to prercnt onion taking place. Oub sutara thonU
BKTROPIVM.
835
Tig. 235.
ftfijiffed at the upper angle, aootlier at the lower, STid, ir advisable, a
Ihinl may be ioaertttti at tlie outer extremity of the wound. Dr. Noyci
pushes a narrow knife between ihe conjiincLiva and skin at the outer
eanthiw, raakinu a vertical incision (IJ"' long), next a horizontal cut
(I to J" long) through the skin ami orl)icu-
laris. The cut edge of the conjunctivn h
seised with forceps, slight cuta are made into
it with scisaors above and below, so as to form
a small flap. The bands of connective tissue
which hold down the outer caiilhus to the e^Ige
of the orbit mint alan be cut acro^ig. Sulurea
are tlien to be applied to the edge of the coa-
jinicCivii and t<kin.
Von tlraefe' strongly recommenils the fol.
lowing operation for spaHint>dic entropium.
Be makes a horizontal iiici;<ion (Fig. '2lMi')
through the t»kin, |>anilk'! to Uie edge of the
lower lid and about 1 1'" from its anterior margin, the extremities of the
incision running up to within 1'" or 2"' of a vertical line passing through
each eommissurc. Ho then removes a triangular |>ortion of skin (\.4),
the two lateral flaps H and C are Bomi'what (lisaected up and united by
two or three fine bori/ontal sutures. The horizontal wound ia left to
cicatrize, lie varies the height und breadth of tlie triangle, according
to the degree of relaxation of this portion
of the lid. The height ia of little conae-
quence, hnt the breadth may have to vary
from .1'" to 6'". If we desire to gain a
still more con«iderable effect, the vortical
iuctAiima may be made of the shape repre-
sented in Fig. 2'Ii3.
If, together witli a spasmodic entnipium
of the upper lid. the cartilage is contracted,
von Gntefc, after having made the hori-
zoiUfll incision and removed a triangular
portion of skin (Fig. 2;J7), carries a hori-
zontal incision throng) the fibres of the
orbicnlariji muscle close to tlie edge of the
lid« and pushes them up so as to expose the
external tiurface of the tarsus. A triangu-
lar imrtioii of the latter (J9) is then to be
removed, the poution of the triangle being the rcvcrao of that in the
skin, 40 thnt the base of the triangle (varying in cttent from 2y" to
S"') reftcliCH close to the upiwr edge of lite tarsm.and its apex lies close
fio the margiu nf the tid- The whole thickness of the tardus should he
Bmoved. so (hat only the conjunctiva remains. The middle suture {3i)
^u>utd pass through the edges of the incision in the taritux. It h gen-
mlly nece«ary to combine canthoplasty with tliis operation, a« it may
otherwise diminish the sixe of the palpebral aperture too much.
Fig. 23it.
Fig. 237.
"A. r. 0.,"x.3,222.
BSd
i)ISBA8&S OF TBB BrBLFDa.
In ihose COM* of ontropium in which the tarsus U unaffected and luu
retained iw normal curvaliiro, the operation of truuplantatioD of Arlt or |
von Oranfe (pp. 820, Wilt)) will bo found very Bcrriceable. Kiit if thai
entroplum U considerable, a larger portiouof iheskio ahouUl be r«iQOv«d|
(together vi'ith some of tho fibres of the orbicularis) than in the case of]
simple tricliiasis.
The following operation of Pageriatecher' will aWj he fonml an m-
cceUingly good one. He commences by dividing; the eKtcrn!il commi*-
flure of the lids to such au extent that the wound in the oODJunctiv]
equals from 2'" to a'", and that in the skin from 3"' to 4'". JJy mod- 1
eratoly stretching the edgos of the incision downwards, the horizonral
wound U changed into a vortical one, and the oppoeed surfaces of hIuo
and conjunctiva are then to be united hy fliitnrea. By thi* proceeding
tlie palpebral aperture is enlarged, a slight vctropium ii produced, and
the Bcuon of tho orbicularid is diminisheil by tlte interposition of thu
conjiinetiva between its 6bre8. The lid being everted, he next iMcrta
several ligatures, more esyiccially at those points where the cilia have a
faulty position. For this purpose, the lax &kin of tho lid and the fibres
of the orbicularis are to be lifted up into a horixoutal fold with a pair of
forceps, and a curved needle (armed with a strong, waxed thrcnd) pas5«<l
-through the base of the fold, ([uitc close to the oxtcmnl surface of the
tarsus. The point of the needle is then to be brought out at tlie ed;;«
of the lid, shghtly to tjie outer side of the apertures of tho Meibomian;
duct«. The ligature is to be firmly tied and allowed to suppurate out,'
■which gouenilty occurs in from six to ten days. As a rule, two or thn."*
ligatures will suffice to produce a considerable eversion of the maririn ofj
the lid. The effect of each suture can be calculated accor*ling to the
width of tho fold of skin which is lifted up. The advantages* which
Pagenstccher claims for this operation are : 1. That the pressure which
the lid exercises upon the eyeball is diminished by the widening of thtj
palpebral aperture; 2, the prevention of tlie cilia coming into coniaci
with the cornea ; •!, the eyelashes are preserved and their normal growth
promoted. The little scurs loft hy Uie autunsa very soon disappear,
without leaving any trace behind them. Cold-wator dressing should be
employed in order to alleviate the infiaromation, which is aometiroes w-j
vere, and a bandage should he applied so as to keep tho |>art8 i|uict.
some cases tho sutures may be removed before ihcy slough out.
Snellen* recommends a lignture to be iusertod in the following manner:
Tlie lid being very much evened, he passe-s two needles (attached to eaob
end of a silken thread) from within outwanl tlirough the whole thickneai
of the lid, 9o that the one needle |:nen:es the upper margin of the tarms,
and the other passes a little above this edge. Tho needles are then re-
intr«4iuced at tlie [mints of exit, passt-'l down to the interior surftiee of
the taistis and along it, beneath the orbicularis, towards the edge of the
eyelid, being hrvught out just in front of the lashes, clo30 to each w"
at about a distance of two miUiinetres. The up|>er edge of tho larst
) "KlinlK<-l)o BHibftoblnngwn," 1641 ; also " Comitlo-Rmdn da Congrto <t 'Opklh
niologic," l««2. 1., ill.
I •> CoBipio-Rcmlu du Coa^T^ d'OphtltAlmoIogic," 18«2, p. 238.
BHTBOPtUU.
837
is thus inclosed in a sVm;;, and in tyinj; the threadii near the ciliarr border,
wc evert the edge of the lid and draw it upwards. The thread may be
removed abuut thts thini davi care being taken that no portion of it
remiiiiiit behind, otherwise slouching may oi^ur. It must he admitted,
however, that Ugatiires alone often prove but of slight or only tciniKirary
benefit.
When the entropitim is mired with contraction and incurratlon of the
tarsus, operations which sinaply act upon the position of the lid by the
removal of a portion of skin, and perhaps some of the fibres of the
orbicularis, no longer suffice ; but «o must then also remove a portion of
the tarsus, so that tlic ctcatrizailon may cause a contraction of the outer
portion of the tarsus, and thus counteract the incurvation.
Fwr this purpose Mr. Streatfeild' devised bis operation of " grooving
tlie tarsus," wliieh answers vury widl when the latter is simply incurved
without being contracled. lie uerforms the operation tlius : •' The lid is
held with l>csmarrcs' forcejis [r'ig< 2SH], the flat blade passed under the
[FIS- 238 ]
lid, and the ring fixed upon the skin, so as to make it tense and expose
the edge of the Hd. An incision with a scalpel is made of the desire4l
length, just through tlie ^kin, along the pitlpebral margin, at a distance
of a line or less, «) as to expose but not to divide the roots of tlio laches ;
and then just bcyoud them the incision is continued down to the tarsus
(the extremities of this wound are inclined towards the edge of the lid) ;
a second incision, farther from the palpebral mar^n, is made at once
down to the tarsus in a similar direction to the first ; and at a distance
of a line or more, and joining it at both extremities ; tlicsc two incieiona
are then continued deeply into the tarsus in an obliigue direction towards
each other. With a pair of forceps the strip to be excised is scizud and
detached with the scalpel."
I have succeeded in curing severe cases of entropium of the upper
lid with marked contraction and incurvation of the tarsus by a comb!*
nation of Arlt's and StreatfeiUl's metbo«l. The first Bte|;« of the operation
are identical with thoso of Arlt'a (p. 8*20); but after tlio removal of the
oval portion of skin, I make a longitudimil incision through the fibres of
the orbicularis down to the tarsus. The latter being well exposed, [
make two longitudinal incisions (inclining towards each other) in it, nearly
down to its inner surface. The incisions should slope so much that tlicjr
meet near the posterior surface of tlic tarsus, and thus include a wedge*
' "B. L. 0. U. R«p.,"t.l21.
8S8
DISEASES OF TltR EYKLIDS.
shaped Btrip of the latter, the bnae of the wedge heing turned tnwanb
the akin, and the apex tuwanU the coujuiicti^'a. Tnis strip nf (Arvtu 'ul
then to ho oxcitted with the scaljiet. Ilie sise of this tttrip will depend
upon the i]o(j;ree and extent of tlie incurvation and cfintrftction of tb« ,
iareuB. The i><lu;e8 of the inei.'iion in the ekin sboultl be ueati v brouf^bl
together by sutures, which arc to be passed aoinewhat deeplj, no afttoJ
include a poriiou of the orbicularis^ but uood not be pUMd through tW'
tarsuB.
Snellen' performs a somewhat similar operation. He CDakes nn incifliMi
throu(;h tJie »kin of the upper liil alKuit 'A millttuelroi} from tbv marpu,
parallel t^ it and cxteiuUng alnng its whole length. A correapnodinj;
portion (about 2 niillLtnetres in width) of the orbicularis is exci»e<l. uM
next a triangular wedge-shaped piece of the tarsus along the whole leojEtfa
of the lid. Three sutures arc then icuorted lo the following iiuitmer:j
A suture armed at each end with a needle \» to be |iassed tJirough the
upper edge of the incision in the taraus, and both needles are then to be
Carried thnmgh the lower margin of thi.4 groove and brought out throiigli]
the )4kln ju^t abriVL* che line of laaben, the piuiit«t of exit lying 4 miIliiQ»''
tres apart. The two oilier jtuturcD are to he inserted in the sanw iraj,
care being taken that the puints of exit are about -f milUnietres from caclkj
other. A bead is then paosed over each end of tlie duturcn (tn prerenl
their cutting the fkin), and the lat(«r carefully lied, so Uiat the t«rt'
opposite sides of the incision in the taraus are accurately approximated.
The upper edge of the skin wound is loft open.
Dr. Berlin' rcconinicnd!) Uiat a [lortion of the tarstu inclusive of thfl
conjunctiva, should be excised. An incision is mafic about » milliiuet
above the margin of the upper lid, extending along its whole U-ngth
necessary, and including skin, muscle, tari^us, and conjunctiva, theu
correaponding portion nf tarsus about '2-^S millimetres in width U i-seisodj
together with the coujanutiva. The wound Is tbea as a rule closed will
BUturca.
[Schneller'a operation ("Arch, for Opbthal.,*' lix. 2) for trichii
and entroj)ium ooiisista in making two incisions through the akin, parallf
to the edge of the lid, and uniting thorn al their ends so as to include
cllipticiil {Mrtion of skin, which id left in ]>otfttion. The skin above and
below is then dissected up, and the two free margins are united Uirouj!
out their whole extent by sutures over the eircumticribed |K>rtton, whic
ts Ihaa buried. He claims thatlJie buried elliptical piece aids in stiffei
ing the Ud. and thus opposes the tendency to inversion. After a tii
it seems to fusv with the skin covering it.
A modification of von Ammon'a taraotomia horizontalis has been pro-
posed by von Burow, The lid is everted and the point of the knife ia
pushed through the tarsus near its outer end a line or more fi'oui thv cilia,
and carried along between tarsus and muscle from the outer to the innai
end. If the tarsus is very much thickened, a wedge-shaped piece shou~
be cut from the up[>er side of the incision. A narrow strip of skin T^
then excised from the length of the Hd, and then from thre« lo 6v«
■ "B«I«re SuUitiqoe A« la Cllolqov," du Dr. D* Wi>«k«r.
• "A. f.0.,"3tvW. 2, «.
1J<73,
BNTROPIUM.
sutures are inBerted in the skin ami the external wound closed. The
inci.-iion tbrouf^h tlie tarsus niny be mide with a pair of scisHora. ThU
operation had been done bv Ureeu, of SiiJnt Louis, with good results.
^ on Hitrow clniincd success in more tliari one tlioufland caaea. (See
'* Berl. Kl. Woch.," 1873, No. 24. and "Trans. Fifth luteniat. Ouhtb.
Conj:n;M>,"N. v., 1870.)
In cntroptuin of the lower lid, Noyes, of New Yorlt, has employed &
method of operating; which is of the natnre of blephnroplasty. A hori-
zontal incision is made outward a varying diatance, usually about .V",
bcgiinnin^ at the outer cnntlais, and the canthal liganientA of botli lids
carefully severed : the conjuiicliva is nUo loo&ened from its altnchraents.
A narrow tongue of skin is then formed by making incisionii upwa«U
tAwardti tbe temple, judt WyomL tUe end of the eyebrow, constructing a
small tlap, wiiicli has itt! base below and ita apex above. 'I'hia being
loosened is turned downwards and inserted between the e«l^e« of the
wound, room being made at the palpebral angle by nicking the margins
of the lida above and behiw. In closing the wounds, the first step is to
draw together the edges of skin where the flap was removed. The apex
of the flap ia next attaelied in ita new position to the conjunctiva, and
tlicn finite a large number of sutures must be introduced t* make a close
adaptation of the parts. The eflect is, ho«pever, satisfactory. (" Trans.
Fifth Inieriiat. t'ongress of Ophth.," lH7(i.)
Another operation for cntropium has recently been recommended by
Ilutx, who diucards both the lid-clamp and the hum Hpatula. While an
assistant fixes the skin of the eyebrow firmly against the supra-orbital
margin, be seizes the centre of tbe ciliary margin of the lid and draws
it tightly downwai-<l. He then makes a horizontal incision through the
skin auil orbicularis acrosK the entire length of the lid, two millimetres
above tliQ lovel of the canthi. lie then excises a strip of mu!^:ular fibres
three millimetres wide from end to end of ihc lid. Four sutures are then
introduced through the skin of the lid two millimctreB below the border
of the incision, are passed Uirough thu a|inneiiro«is u]ion the upper third
of the tarsus, a Httle above the junction with the fascia tarMMirbitali!?,
and finally through tbe upper cutaneous border. The sutures are then
tied with a firm, deep knot. C^old-water ilrettsings are then to be ap]i1ied
fortweiiiY-four hours, and the sutures may be removed on the third day.
("Arch.'of Opbthal.," viii. 2.)
In all the various operations proposed for the severer forms of entra<
pium, especially wheru there is an incurvation of the tarsus, it is gen*
orally nenet^sary to perform some little nt>cration at ilie same time at
the external canthus. This latter operation, hitherto known aft canlho-
plasty, was first proposed by von Ammon for Uie widening or lengtlien-
mg of tbe interpalpebral aperture, 'lite operation, as gcncnilly per^
formed, ia not, strictly speaking, a plastic operation. The external can-
thus ia })rolongcd outward by a horizontal incision, which is sonietimes
extended as far as the bony margin of the orbit. A pair of scissors or
a iwalpeL is then used to dissect up the conjunctiva, and the canthal liga-
ment is then divided, either of the upper lid alone, or of both. 'Hie skin
and conjunctiva are then stitched together. (See a valuable poper by
H. Althof iir" Trans. Amer. Ophth. tioc.," 1874.)— B.]
MO
OlflEASBS or TBB ETELIDS.
I i^ECTROPirM.
Id tfaU eoivliUoD, the eyelid is more or lew erertod and its esMat-^
tiTBl nrfacfi isxpoMd. l*he ctegree of ectropium vanex ^reatlj, Msag
is some owes »■> ifligbi tbat the edge of th« Ud u bat ■ rcrj- tittle tamc<4
otii und droopitifi;, whcrcu in otlicrs, the whale ejelid w ererted mod ta
liiiiug Diuiiibraue upjAreiit [Fi^. 'ZH'Jt --^Vj.
[nc.z».
P%.M».
^
, I
;
AflM lllll«r.
iiMt xiu«v.1
Slight doercos of ectropium arc often Mea in eMerlj- people.
Cflpociall}' if tliuy are affected with a clinniic iiiflatninauon and thick
of tliv coDJiinrtiva and cdgo of the lids. Tins, together with a co
du;;ruu of atrophy' and relaxation of the orbicularis, causes the tdjre
Uit! lid (fnpocidlly the lower) to become somewhat everted and drop;
jKi lliat its margin is no longer applied to the eyeball, bat sinks a^-,.
)m it. In coti4e()ueiice of this slight eversion, the punottun laehrymale
is no longer turned in towards the eyeball, but la croct or evort«d. TV
tears, instead of being carried otf through the canaliculus, collect at the
inner comer of the eye, so that the eye appears to be always moist aud
Hxrinimiiig in t^ars ; tho latter flow over ttio edge of ttie Ud, and thud
matniaiu oiid increase any existing excoriation or inflaminaUon of its
mnrpin. S<*vt»ro inflammations of tho conjunctiva (especially panilvtit
aud granular ophthalmia) are freijaently the cause of ectropium. partica-
larly if they uru uccomiuiiiied by great swelling and hypertrophy of the
conjuiiotivft, unil by r'ncli cousiderable chemosis, tliat the latter protnido
p?rha[)A lietweiTn the lids. For if the ocdcmatous iufiUration and swell-
ing of (ho lid auhsido, hut thoae of the conjunctiva contintic, the lid is
apt to Wcotne ererterl by tlie action of the orbicularis ; beiD|c lamted is
this by tlio hypertrophy of the conjunctiva, to which the ext n ' >rtioB
of the lid can offer no oountor]x>ise, and also by the great d. : iilte<
musts. If such an evcniiuu occurs, and is not at once replaced, tiie 0(M>
preHsion of tlir carttln;^e ait<l of the upper [lortiou of the fid soon [trodaH
gn-at straitgulalion aud a serous aud hemorrhagic inSltratiou of the lid,
which greatly increase the swelling, iioncc the tumor, as Maekemia.
rt-iiinrk«, is occasioned in a great measure by straDgulalioQ, like th« sm
iug uf |iiirti)')urno)ti8. Wu not uiifrciiuciitly observe such cases of
tiiuni in children sufl'eriitg Trim purulent ophthnlmiH, in whom the lid
itcomo accideatally everted during the application of local
BCTROPIUU.
wst
etc. ; ami iustvad of hnving been at once ropiaced, some time, perhaps
several daya^ han clajMioii before metHoat aii) was sought. T)ie strangu-
Ution in greatly increased in children b_y their riolent fits of crying and
struggling. In chronic cases of purulent and granular ophthalmia, the
conjunctiva h not only swollen and liypertrophicd, but tiie cartilage be-
comes relaxed and stretched, &o that it no longer maiiiliLing the proper
curvature and position of tlic lid, but aaaisu materially in the production
of the ectropiuu). The lid becomes at the »ame time elongated ; indeed,
ectroptmn seldom exittts for any length of time without causing a certain,
often considerable, increase in the length of the lid.
Paralyi^iH of the faciiil also causes ectropium (especially of the lower
lid) and lagiiphthalmos. Intra-orbital Lumora, ubsoeas of tJie orbit, etc.,
ofYcu prodHco eversion of the lid, on account of tlie exopUlhaloios to which
tlicy give rise.
But the most frequent cause of eotropinm is found in tlie pre*ence of
cicatrices, uxcuriatiuuM, etc., iu the vicinity of the edges of the lids, for
by their contraction, diiring cicatri-
zation, the mni^n of the lid becomes ['''s* 241*
more or less everted [l>*ig. 241].
Thus, in long-continued excoriation
or eczematou8 inttammation of the
edge of the lid and its vicinity, we
find that a contraction of the skin
takes place, and the lid becomes
somewhat everted. This can often
be observed in cases of inflamma'
tion of the conjunctiva and coniea,
accompanied by severe lachrrma-
tion. The edge of the lid becomea swollen and inflamed, it« margin
rounded, the eyelashes stretched and displaced, and the punctum everted
and perhaps obliterated. Varioua injuries to the external surface of the
lids oP the integumeiita iu their vicinity, such as burns, Hcatds, wounds,
etc., which produce los* of substance, may give riac by tlieir cicatrization
to more or leas considerable ectropium.
Caries of the orbit, more es|iecialty at its outer and lower margin, is
a fruitful source of very severe and obstinate forms of ectropium ; for
the caries is frequently accompanied by the destruction of a con»derable
portion of the substance of the Hd, which may be implicated in the cica-
trix and adherent to the bone. Thus we sometimes find the smooth
<turfacc or the lid drawn at one point into a small funnel-shaped aperture,
wliiirh extends deeply down as far as the bone, to wbicli its apex is
udlierent. Abscess of the frontal sinus, which perforates by a smali
opening through the upper portion of the lid, may hu fullnweil by an ad-
hesion of the lid to the aperture in the bone, and a considerable degree
of ectropium. In cases of ectropium of tlie upper lid, due to cartes, we
may often notice (as Mackenxie pointa out) tlie vicarious action of the
lower lid, which becomes somewhat raised, so as to accommodate itself
to the deficiency of the upper.
Kctropium generally so(;n produces a chronic infiammatiou of the con-
junctiva and cornea, on account of the exposure of tlie eye Vs th& vcr^
JUlpr IdWMO.]
842
DISBASG8 OP TUB SVELIDS.
tating iniluencea of tbe atmottptiorc, ati^I of foroign substances* sqch u
dust, etc. After a time, the conjunciiva bpeon«w tliickeniM), gwallen,
and desiccate'!, il« epithelial layer hypertrophied and roughened, and at
len^^th xer ophthalmia mny be produced, the conjunctiva ami tai«na
Tindergninj atrophic chimL'es. The coniea hecnmes inflamed, piinnm
fupervt-ncrt, or deep ulecrs are formed, which may lea<J to ext^^iisiv* |»er-
foralinu and all ila dan^eroua conae* pie news, such as staphyloma, or utpo
atruphy of the eyeball. Wc often find, however, that the effect of tlic
ectropium upon the oye Is hut inconsiderable, ami ig not followed by any
markt-d inflammation of the conjunctiva or cornea. Ttiis ia due to the
fact, that the eypl>all is rolltMl upwanU, and is thus protected by the
upper lid (the wrinbliiiL; and coiitracliim of the brow often aflsistin^ m
this), which thus guards it against external irritants. Hence, we some-
times Bnd that patients apply to us for treatment of the eccropium far
leas on account of the inflammatory or other affections, than for che sake
of liavtng ibeir personal appearance improved, which i« rendered e<-
trcmely unstgbtly from tbe e?[|M>3nre of ttic red, fle-ihj' conjunctiva. In
conscipicnce of the cctropiuin and the malpo.^ition of tlie puncta, the
tears cannot enter the latter, but flow over the eheek, and from tb«
lauhrymal i^ae being in a couAiant ^taie of emptiness and non-iine, it may
in time shrink and become permanently diminished in siite (W«Her),' its
walU being thinned and atrophied.
In the eversion con»e<pient u|Mm infianimation and hypertrophy of the
conjunctiva, the lid ^lioidd l)e at "fcc replaced, if ne see tlie ca^e suflU
cienily early, and should bo retained in itw proper position tiy a compreffl
bahda;ic. IHrections sbould als<.> be given to the nttendants in cases of
purulent ophthalmia, etc., more etifiecially in chiMivn, immeflialvly to
replace the lid if it bccomea everted dnnn;; tbe application of topical
remedies. If this treatment does not suflice. and there is great hyper-
trophy and proliferation of the conjunciiva, the surface of the latter
sbould be touched with mitigatfld nitrate of silver, t]ic cfl^cct of irbich is,
however, to be at once neutrabzed with salt and water. The conjunc-
tiva ia tben to be freely scarified, which will generally cause a coniiider-
able diminution in the size of the lid. In some cases it is. however,
necessary to excise a more or less considerable imrlion of the swollen
and bypertrophicd conjunctiva. If these remedies fail, we must have
recourse to operative interfurence ; hut 1 may mention that the ojiera-
tions proposed and practiited at different time^ are far too nntnerous to
be entered upon here, and I shall com^equently confine myself to a ilc<
ecription of those which hare been found to be the moat useful and aoo-
cessful. I must state, however, that no very definite or precise rules
can be laid down as to the exact method of operating, for wo constantly
meet witli caaed of ectropium so variable in degree and extent, that we
are obliged to modify and alter ilie mode of operating, in order to adapt
it to the exigencies of each individual case.
In the above form of ecirojiium, a.s well as tn the senile, the belt
treatment is tbe diminution of the paljtebral aperture by tlie operation
of tarsoraphia, more especially if there is a certain degree of lengtlien-
I
I "A. f.O.."rUi.l, ftft.
ECTROPIUM.
843
ing of the ejelid. B«fore proceeding to operate, the mirgeon shouM
lake the outer edj^es of thu liiis between Wis fDrefin;;er ami thumb, and
draw llitmi Aumewimt out towards the cxU^idilI cuiithu^, and then approx-
imate thora towanU each otlior at tliU poinl-, in order that he tmy bo
able accurately to estimate the extent to which the |>»]pebral aperture
.should be narrowed. The effect which this narrowing has upon the edge
of the everted lid shouM likewise be noted, us also tlic fact whetJier Uio
Ud has to he a little raised or depressed, in order to brinj^ it into a proper
position. If the puncta are erect or everted, they should be slit up, so
UK to facilitate the eiilmnce of the tearfi intu the sac.
Tamorttphiti, which was first devised by Walther. is to be performed
an follows : The operator, having Inserted a horn or ivory spatula be-
twecD the lids at the cuter canthua, niakoa an incision througli the akin
and connective tissue parallel to the edge of tlie upper lid aod about
three-quarters of a line from its niar^rin. This incidioii la to he com-
menced at the outer canthus, and carried along the edge of the lid to a
distance of from U'" to 3'" ; it is thuu to be carried vertically down to,
and throu^^h the aniorior edj;c of the Ii<l. This portion of the lid. iuclud-
ing tt«( cilia, in then to ho completely excised from this point to the outer
canthus, care being takeu that the hair follicles are nut divided oblitfuely,
hut entirely removed, otherwise they will {{row again. The same pro-
ceeding is then to be repeated iu the lower lid. so that the two raw sur-
faces of the edges of ihe lida can be accurately applied to each other,
and united by two or three sutures. In order still more to facilitate the
atiion, and to give the lashes a more |ierfect and favorable incliimtion,
von Graefe' has modified the operaUon in the following manner : He
carries on horizontally the inner portion of the vertical incision (which
has been made perpendicularly through the edge of the lid) to the ex-
tent of abo'it 1'" or 1 ^'" towards the nose, along the posterior border of
the margin of the Up, and pares the latter by removing a small slip of
flonjUDcUva. This is to be done in each lid, the cilia being of course
left at the outer portion of this part of the lid. In ttiose cases in which
there is a considerable elon^atnni of the edge of the lower Ud, as well
as of ifcf cartilage, an unsightly pnckcr or fold is apt to bo produced by
the sutures at the outer canthus. To obviate this, a triangular portion
of the substance of the lower lid should be excised near the outer com-
mieture, the base of the triangle being turned towards the edge of the
Ud. The operation of tarsoraphia will also be found very useful ia
lagophttialmos due to paralysis of the portio dura aa well as io that which
is sometimes noticed after the old S()uiul operaliuu.
For tlie senile or spastic forms of ectropium, tarsoraphia will be found
greatly preferable to the operation of Adams, which consists in tlie re-
moval of a triangular, V-«haped piece from the whole Ihickuess of the
lid, the hose of the triangle being turned towards the margin of the lat-
ter, and the apex towards the cheek. [Fig. 242.] The edges of the
wound nre then to ]>e brought accurately together by sutures, one of
which should be inserted close to the margin of the tarsus, so that the
Upa of (ho wound may be brought very clo«ely together at this point.
» " A. f. O.," iv. S, 901.
644
D1BBA8B6 OF TUB EYELIDS.
[Fig. 243.] The chief disaciranUge of tliis operation is, that when it is
done nenr the cuntrnl part of tbo lirl, it shortens the edge of the tatter
without elevating it at the outer canthus, hence it la closely pressed
ajptitut Ibe eyeball, which may, moreover, be somewhat irritated hj the
puclter or fold to which the cicatrix gives rise. If this operation m^
adopted, it should, therefore, he performed close to the outer canthi
as tliis tends to elevate the edge of the lid at this jraitit.
[I^ig. 243.
Fig. MS.]
>-.
^-*
We have now to turn our attention to thote eases ia which a partial or
complete ectropiura is due t« a cicatrix, which is Biluated at a short dis-
tance fi-om the o'lgo of the Hd, and causes eversion of the latter by traction. I
Very miracrourt O|»eratton9 have been devised to remedy this defect, of j
which I shall orily mention those of Wharton Jones (ttomedtnes also
termed SaniM>n*s operation ~), Dieffenbach, and von tiraefe, for they are,
I think, the moat piencrally useful and succeasfui.
Mr. Wharton Jones's operation is to he porfomwd in the following
manner :' " The eyelid is set free by incisions made in such a way. tliat;
when the eyelid is broit;;ht back into its natural position, the gap which <
ift left may be closed by brining its edges together by sutures, and I
thus obtaining immediate union. Unlike the CeLsian operation, the nar-
rower the cicatrice the more secure the resolt. The flap of skin em-
braced by the incisions is not separated from the subjacent parts : but ;
adrantn^^e being taken of the looscnera of tite subcutaneous cellular ds-
auc, the flap is pressed downwards,' and thus the eyelid is set free. The
success of this operation depends very much on the looseness of the
cellular tissue. For some days before the operation, therefore, the skin
shouhl be moved up and down, la order to render the cellular tisso«|
more yielding."
In Figs. 244 and 24.'> the method of performing this operation upon
the lower eyelid is illustrated, A horn spatula having been inserted
beneath the lower lid 80 as to render this tense, two straiglit incisions
■ TMo Mr. WlivtoD Jones, "Treatba on Ophtliklmic Ucdlelne and Sxir%«ry," p-
* Mr. Jadca is li«roilMcril)ln£(b«raeU)ni3 iu wtiicb thAonn-stloo )■ to be pprforniMl j
nil tlifi iippor Uil ', in thif lower ltd, of cuur»i*, Itiv flap would bn |ir«M«d apwa.i<da, uiit|
lli« natural povftion ot th« iidge ot the Ud wonld br ibtia rrgfttiiL-d.
SCTROPIUM.
845
are to be made from the edge of the lid, io such a manner that they con-
verge towank each other, and meet at siicli n dUlance Mow the lid,
that the cicatrix U completely included withiu the triaiigulur flap ihua
fonui*d. The Uap is thon to be proascd upwards, so u to hriiig the edge
of the lid into iU} iioruial position, and all the opposing bridlud uf cellular
Fig. 244.
Pip. 2\i.
Alxtt tullmtg.
lft«r Btallwsit.
tiSHoc arc to V divided, without however diMecting off the flnp from the
subjacent parts, except iierbuja very nli;^htly at the periphery. The
edges of rite wound existing below the apex of the flap arc next to be
ctosely united by two common or twisted sutures (Fig. 24-*i). and then
the two edges of the flap are to tie aucarately united by sutures at each
side to the oppo»it« margin of the wound. If it be necessary somewhat
to shorten the edge of tbo lid, tarsoraphia may bo uuitod with this ope-
ration. The above method of opemting is especially indicated in those
cases of cctropium in which the shape and form of the lid are but little
changed, its margin being chiefly elongated.
Dicffenbach deviated the following operation for overaion of the lower
lid, due to a cicatn.\ situated at a short distance fruio it. The cicatrix
is to be included within a trian-
gular flap, the base of which t%- 248. V\$. 447.1
[Fig. 24G, (? c] is to he turned
towards the margin of the lid,
the apex to the cheek. This
triangtilnr portion in then to he
removed, and the iucisiim, which
rejiresettts the base of the tri-
angle, is to he prolonged hori-
zontally on each side to a short
distance [a], in order to facili-
tate the approximation of the
lateral edges [b (>] of the tri-
angle, which should be raised from the suMaccnt part« hv a few inciaioas
with tb« scalpel. The two lateral incisions of tlie Inangle are to be
DI8BASB8 OP TUB BYBLIDS.
nnit«rl hy fine sutures, and then the boriKontal itvc'iMnn, on each side of
the base of the triangle, ia aUo to be brought together by sutures [u in
represent*"'! in Kig. ^1"].
Von (Jmefc has lately introduced the following method of operating for
Uie severer cases of ectropiuni of the lower lid, more esjieciMlly those
which arc the result of chronic hlepharo-adenitia. He makes a horiaon-
tal iiieiitinn just hchiiiil the edge of the lid, in the inteni).ir;:iiial Bitace,
from the lower puuctuiii tu the uuter cauchui;. From the exireiuilitiS of
this lino ( Ki^. '248) two iucisioiift an*
Kig. W8. tlien to descend vertically down the
clieek, for a distance of from H"'tolO"'.
The ftjuare flap A is next to be di>sect«d '
up, and. if nece&ftarv, Eomcwliat raiwd
6ubcutoueoU8ly beyond the lower extre-
mities of the vertical incisious. Th«
flap iii then to l>o seized at itjt upper
edge by two pairs of broad frirce|<4, and
forcibly stretched upwards, and main- .
taincd in this poditiou by sutiircti, which
are to be applied Gretat the vertical incisions commencing at their tower
extremity. The two u]i]ieranj:;lcg, which now project considerably above
tl:c upper margin of the opposite edge of the wound, should next be auffi- ,
ciently bcvelleil off, and this i^ beat done by making a somewhat boutj
incision ( fi B) whose acute an;;le C in then to be drawn up and united
to If, The effect of tliis bent incision (li fi) ia twofold, tiz., it shortena
the edge of the lid, and elevates the flap. The closer U) the edge of the lid
the point Ch brought, the lees does it elevate the flap, but the more doea it
shorten the edge of the lid. Whereas, the closer the point C Ue» to tbe
vertical incit^tou, the more ia the Sap elevated, and the leas ia the edgo
of the lid shortened. The more exact meaaurements as to the sixe of the
iQeittinos, etc., can only be determined during the [terformance of the
operation, m<»rc eapecially the adaptation of tlie flap in its new position,
ae we tnu^it xhape and mcxlify them according to circumstancea. Indeed
this hohU good in all plat«tic operations. Finally, the horizontal wound
iR to be chvied with AUtnres, and in auch a manner that the latter include
broad portions of skin, but only narrow ones of conjunctiva ; as tins ix
more favorable for the Rubsetp)ent fnsieniiig of the Hap, for the different
threaila of the sutures are to he tolerable tightly lixcd to the forehead.
A firm compress bandage is to bo applied during the first twenty-four
hours. Von tjraefe haa found this operation much more aucccaaful than
that of DieO'eubach.'
In those instances of cctropium in which extcnaifo cicatrices involl
considerable portion, or even the whole thickness of the lid, as often
occurs in caries or nccrntda of tlio bone, or in caAce of cancer, etc.. it
may he noce^ary completely to excise the atfected portion, and to fill
up the woutul by transplauttue a flap taken from the adjacent iotegu-
tnenta. This operation of making a new eyelid U t«riaed hUjiharoplattif,
* " A. f. 0.," X. 2, 229,
BCTROPIUU.
847
and vPiT numerona mtMliBcntions of it have t>een from iltne to time de*
vised ; liieffeiibach and Frickc liaving hecn amonj»st the fii-nt tn practitw
it. The flap ia somotimcs taken fruni the teiuple and t'orfliuad, in other
cases, t'rom the check or side of the nose, accortlin°; to the size and posi-
tion of the cicatrix or growth vrbich is to be exciiieil. The flap has even
been formed from th« hack of the hand.' 1 shall, however, only describe
a few of the more important and niottt ^nerally 8iicceit;«ful niudea of ope-
ratinj;, wliich will suffice t*) illustrate Uie princinles thai shouhi ^uide us,
but the details of Vfhich mnst he modified ami alt<tred nccordin;; to the
exigencies of special cases. There are, however, a few pointa which
apply to all these caaes of Uepharoplasty, and attention to which greatly
increnaea the chance of a favorable rosnlt. Thus, the sikc of the flap
should always he Inr<;cr than the woun<] into which it is to be 6lt«d, in
ordor that t\m may be coraplctoly filled up, and its edges and those of
the llaj) be readily miited without any undue stretching ; a certain degree
of latitude being also allowetl for a little tthrinking or contraction of tlie
flap. Care must likewise be taken that the surroundrnj; skin i« not too
much stretched when the flap is fastened in its new po«itiuii ; hence, if
any undue tension exists, a few superficial inciitiaiLs should be made in
the skin near the baao of the flap so us nomewhat to liberate it. Tlie
base of the flap should alvrays he rnnde sufliciently hniad to maintain
the vitality of the transplanted portion, wiiich is otherwise prone to
tilou;:h. This vitality may, however, be also impaired by the uuhealtliy
coiidilion of iho skin from which the flajt ia tnken : by it being too Brmty
pressed against the hone by a very tight comprcsa bandage : or, on tlie
Fig. 249.
An*r 8un»M>
other hand, liy itit not being kept in suflliciently close contact. Tlio
prospect of the auecesa of tbe operation is always best, when the in*
teguments from which the flap is taken are quite healthy, and are free
from all ciciitricial or intlaramatory changes.
In Fig. 240 is illustrated the method of excising a large cicatrix of the
t Vidg Wharlou Joan, loo. dL, p. G38.
848
SIBEASEB OF THB BYBtTDS.
upper lid, which has produced ext^naivo ectropion). The cicatrix ia to
bv iuc'lmlvd wichin two borizoiiLal inciaioiu, vrhich converge towarU each
otlicrat ttic iiiiuT(ii»iiar) <iiile,l]iit dtverj^) and descend Aoraewkat at tbe
temple. The difteti.<4cd portion of the lid in then to be carcfullr diaaeeted
away from the euljJHcent tissue, ^ aa tliorou);blj to libemto the lid*
which is then to be drawn into its oormnl portion. The extent and shape
of the wound which is thus made, are to be cstimateil with as much ac-
curacy- as poaaihle, and a corresponding flap (A, Fig. 24!*) is then to be
dissected from the skin of the t*uiple. For roaaons atatod above, the
aize of this tlap tthould, howuvnr, he Homewhat larger than the wound
into which it i-t to be fitted. When the flap has been carefully diaseotcd
off, 80 that only it6 base remains standiug, it is tu be twidted somewksi
upon itadf, Btted into the wound, anil carefully fastened there by nune-
rous fine suturea ; the inciaions in the temple being closed in the bum
wav.
In Fig. 250 is shown the method of fn.st4?ning a flap which haa been
issect^d out from the temple into a wound in the lower eyelid.
Fig. 2S0.
in*rSU]twic.
Bieffenbach made three incisions, which formed an er[uilatera1 triangle,
and included the cicatrix ; the one incision being carried parallel to, nnd
somewhat below, the inar;^in of the lower lid, Fi;;. 251. lie then ex-
cised the portion included wicliin the tr)an>;le, and next dissected an ob-
long flap of skin (Fig. 251 A) from the parts immediately adjacent to
the wound, and shifted it laterally iuio the latter, retaining it in ita posi-
tion by sutures (Fig. 252).
If the margin of the Hd ut implicated in the disease, U mast also be
included in the ]>art which is excised : and the upper, horizontal incisioo
of the new fiap should then be made somewhat longer, so that this por-
tion of tlie Sap may form the edge of the lid.
Knapp has described' an ingenious modificntion of hlcphflrop1a«tr,
performed by lum in a cose in which a cancerous tumor occupied the
' "A. t 0.,"xiH. I, 18S.
ECTROPIUM.
849
inner two-thirda of iho lower lid (including its e<lge), extending gome-
wlml beyond the inner angle of tho eje, and involving the skin of the
noee to an extent of from 2"' to 'i'". As tlie flnp u apt to contract
Fig. 361.
Fig. 2»2.
X
AfWr St«nin«.
Afta? SteUnv.
when it is mado with ita base downwards, and may thus give rise to ectro-
ftium, Dr. Knapp, at the sngge^tiori of Dr. Frito Pagondl*cher, ojierated
in the followin;; manner: He included the tumor between straight iucia-
ions (which were carried well into the healthy dssue). Aflor the morbid
growth had. been thoroughly removed, he prolonged tli© internal horiion-
tal incittiotis tonanln the no&e, and thuH prepared a square, horizontal
flap at this point. He then made (in tiie prolongation of the palpebral
aperture) an incision from the outer canthus slighUj upwards into the
BKin of the temple ; and next a second incision, which was at first a
straight prolongation of the lower edge of the wound, but wa^ then some-
what arched downwards on to the cheek, the concavity loiikiii^ down-
wanls. The long flap thus formed, and which increased considcrribly In
wiilth towards its base, was then diwecteil off from the subjacent tiwue,
drawn forwards, and ita inner angles uuit*>d by twist^'d autiirea to iho
vertical edge of the naAnl tiap. Dotli flapA, though ti^^htly strotchod,
entirely covered the wound, and funned a very sui:cessfiil artiticial lid.
Tlie external fourtli of the latter, which had remained standing, now
formed the most internal portion. The edges of the wound were then
carefully united by very nuraorous sutures, and a compress bandage
>plied for 4y bom's. I'erfect union resulted, and the patient was dis-
larged 14 days afterwanla, completely cured. The |iatpebral aperture
IS slightly (about m'") diminished in li-ngth, but could be e&silv and
650
DISEASES or TBS 8YELrt>8.
perfectly opened and closed by the action nf the upper lid. Tlte Imtct
lid was closely applied to the globe, and Knapp states that tliU «»i ooe
of the RXiAt aucccasfnl caaes of belpharopluKty with whicli ho hu net.
[Knapp* haa since operated by the »ame metlnxl upon similar curs,
imd the result left nothing to he desired. But, although tiuA invlbod
produces very excellent results, it is limited in iu efficiency, and Ktuipp
has not ventured by its means to repair ilio Instt or more tlian thrce-t^oar-
tera of the lower lid. — H.] In cases in -which we unite the upponte
edges of two flaps, care must always be taken (•.■ ilIIhw a sufficient anutun^^p
of skin, so as to permit a certain degree of contraction and gaping of tb*^^
edges of tlie flapa, in ca«e they should not unite by first intention, wluch
is not unlikely to occur.
In those cases in which oicatricea or canoeroos growths implicate the
inner or outer canthos, and to a ^rnall extent the opposite edgeH of th^H
two lips, the flap which is to cover the wound muy be taken from the sU^H
of the nose or the temple, according to the situation of the disease. Id
such instances, the folluwing operation, devised by Uasner, will be foand
useful: If the morbid growth be situated at the outer canthus, and im-
plicates to a certain extent the edges of tbe upper and lower lid. tho
tumor is to be included above and below between elliptical iuci^iooj,
which should be laid well in the healtliy integument. The line of joiw- '
tioD of these two incisions should then be slightly prolonged outwa:
and a sufficiently large Sap be excised from tbe temple. The a
extremity of this flap is to be bifurcated, so as to fit easily into the wo
made iu tbe edges of tlie lid at tbe outer canthus. If the disease is a
ated at the inner eanthua, the flap should be taken from the sido of the
0060.
If the cicatricial adhesions are narmw and tiot very firm, it may saf-
fice to divide them i^nbcutaneously, and thus to lil»eratc the lid, and allow
it to assume its normal position.
[In the repair of U'sioiis about the inner halves of the lids, or in cases
where Ibere is no skin available for Haps either upon the forehead or
temple or outer portion of the cheek, Noycs, of New York, makes use
a naso<buccal flap, in which the iucieions are made down the didc of
nose and cheek, as far as the upper Hp; tlie free et>d being Velow, a
tbe attached end or hano above. The inciiiions are so made as to inchi
vessels which come from the supra-orbitat, ethmoidal, and nasal bmoch
of the orbital arteries ; and also s<jm« branches from the other aide of
median line, by laying the incision ublitiuely across tlio nose,
this flap is twisted upon its base upwards and Uid in poaition, there
left a large gap in tbe face, which is filled hv sliding the cheek iu towai
tbe median line, and unidng tbe edges by pins and tigure-of-eight sutur
The deformity resulting is sometimes, however, very coosidorab
(** Trans- Fifth Inter. Ophth. Congress, 187ii.")— B.]
Shin i/r(iCtirfj ha« lately been much advocated as a suhatituce for the
vifioui blepharoplafitic operaiiuna in cases of eciropium, injurjr of c'
«T«&b Erom bums, etc. Some operators follow Keverdin^s origti
acihnJ of ioBOTtiiig a few small isolated portions of tldn ou the granl
I [** inbiv of Opblba). aad Otol.," nl. U. p. SM.]
ECTROPinil.
851
latin gsuiface, to act as centres of new dermic cell-formation. De WeckoT,*
who has had great experience in tbe eaiptovnieut of skin-grafting in dis-
eases of the e^'clids, liowever, recoinm«nda thai the wh'tlt^ ^ramilating
wound should m covered with aomll pieces of sVlii measuring *i or H mil-
timetrefl, jnst like mosaic work. TraiisiiariMit isiii^rlaiss phistor, or gummed
gold-ljeater skin, is to he placed over it, so that the condition of the tittle
portion of skin may be watched, this being covered by a pledget of cot-
ton-wool and a 1)aiidage, aa it is of much importance to maintain the
tempcratare of the f>art. If it is foond that some of the pieces have not
taken, freah oues must be substituted for them. De Weckor oonatdcrs
skin-graftjnf; especially indicated iu the following cases : —
1. It should always be employed in bums of the eyelids or neigh-
boring partfi, which ):ivc rise to suppurating wounds, the faulty cicatri-
zation of which threatens deformity or displacement (crcrsion) of the
eyelids.
2. In partial or complete ectropinm, due to neighboring cicatricea
(from bums, caries, etc.).* In such cases the lit! is to be eo thoroughly
freed by dissection from its cicatricial adhesions that it can lie with
eaae drawn into its normal position. In order to maintain it there, two
op[>u!»ite [K>inta of the margins of the lids are to be pared, and uuited
by suturi'8. Tliis causes the wnund to be kept open and level, and
after good fleshy gr.inu].ations have sprung up ((". c, after six or eight
days) they arc tu be completely covered by a mosaic of UtlLu portions
of skin.
U. Skin-grafting may advantageously replace many of the methods of
blepliaroplasty in cases of destruction of the eyelids. In a case of com-
plete destniction of the eyelids, de Weckcr freshens the parts next to
tlie edge of tlic orbit ; lie tlicn diii«cci« oft" a strip of skin (fVom H to ^
centimetres in width) on the forehead and cheek by curved incision."},
which meet near the temple. These strips should he sufficiently freely
disBccted off to permit of their sliding easily into the proper position,
and of a very exact coaptation of tlieir freshened borders. They are to
be fastened by a series of deep and auperficial sutures, which are to be
kept in for 3-4: days.
4. In all canes iu which the eyelids have suffered, either tlirough acci-
dent or o)iemtion, a coinKidcrahle loss of substance, leaving a suppurating
' Burlace, as for instance after the removal of cancerous growths.
[[.awBOn, Sattler, and Homer have all hail good resulta from this
I method of filling in defects by the "'greffe derraiiiuc."
More recently Mr. Wolfe of Glasgow has devi.-ted a new roctliod of
ekin-grafting hy transplanting a largo piece of skin, without pedicle,
upon the surface of a fresh wound. Wolfe began his operntions m cases
I of loss of conjunctival substance, by shifting portions of conjunctiva from
one a|>ot to another, without keeping a ]>edicle. He then carried the
principle further, and supplied conjunctival deficiencies by transplanting
poriiyns of conjunctiva fmm tbe rabbit to tbe human subject. In apply-
I "AnnalM'l'Ociilistifiap." Jnillot-Aftftl, lft72, p. S4; Tlde»l9»" Ro]cv<StjitiMi<to«
t d* 1« CliiiiqaeOptithAlniologique," du Ur. do Weaker, 1873.
1 I Vtd« also cwub by iir. Lftwsvu, "Clinical Sool«ty'tTrauaftctipiu," 1S71, p. 4d.
853
DIBEASBB OF THE BTELTDS.
iiig this principle to tlie filling up of cutunooiw deficloncJM, he oune to
tlie CQiictusiou that if il is desired to make a skin-Uup adiivre ti> a m^w
surface liy first intention or by agglutination, it must In- cartTully ami
completely cleared of all nreolar tissue, aud property fixed in it« nev
place. lie reports tvio coisca of destruction of the lower Lid, in wUicli
the skiu-graft, two inches long Ly one inch wide, was t^ken from Oie
forearm. Hir dooH not cut away any cicutriciiil Ua-suo in tiie skin, hat
ninkts a hririzoiitiLl incision thr<»ii>(h tht skin paniilel to the ciliary re-
gion, and :;'" from it, and diwticts up tlie cicatricial skin all r«und. He
then jHircs away the cicatricial siihcatanoous lissue till a clean surfaoiij
is made. Then the two lid« are fastened together at their cilinrj iBar-]
gins by sntures. Next a flap of skin is removed from the forearm, orj
vhest, or from any point nhere the akin is thin, carefully prepared Tm i
of all areolar tissue, and placed accurately in the gpce that is to t>e fillejil, ■
so tlint the cicatricial skin tissue surruumU it like a frame. No suture* i
are to be nacd, but tho graft and surrounding skin are covered by a Knej
gutta percha ti&^uo or gold-beaterti' skin, next by a l^*"* *>f collodion,]
and finally by a lint compress aud a bandage. (** Med. tumes and Gaz.," ,
June 3, 187t>.)
Wadsworth, of Boston, has reported a most successful result froia'
Wolfe's metho)!. The case was complete ectropium of tlte lower lid
frvu) a burn. The flap was removed from tlie inner side of the forearm.
The case did well from the beginning, and Uio patient was discharged!
eighteen days aft^r the ojtemtion with complete union, and the ectropium
c«>uipWtcly relieved. ('* Xraus. Fifth luteruat. Ophthal. Congreis,"
IhTtJ.)
Aub, of Cincinnati, has also reported two saocessful cases, operated
on by this method. It is of great importance to make the transplanted
graft sufficiently Inrge to compensate for great shrinking, and tu clean .
the graft thoroughly of all subcutaneous tissue. (** Arch, of Ophthal.,"
viii. 1.) Noyes, of New York, has alw o|>erat«d sacccasrully by tliis
method in two cases, restoring the enure lid. — B.J
15— INJURIES, WOUNDS, ETC., OF THE EYELIDS.
Hi-i^ymoua of the eyelids is of frequent occurrence, being chiefly the
oouaeuuence of a severe blow or fall u[rt>n the eye, anil is hence often ;
■et witli in pugilistic encounters. Ii it< due to a sanguineous eflusimi I
into the areolar tissue of the eyelids, which gives rise to a dark, livtdj
dv(CoKintiou, commonly termed " black-eye." Ao a rule, it occursj
withiu a few hourt^ alt«r the accident; it may, howorer, cooie on alj
««c«, the di8Coloratii)n extending from the eyelids to the neighboring]
Murls. These facts diiitiuguish this form of occhymo^ia from Umt which i
lA due to a counier-fracture of the orbit, for then the rcvenw obtainO
tlw dtaealontiou shows itself after a much longer interval, and graduall/J
^ lis to the eyelids. Together with the effusion of blood into tbc
viwlar ttMue of the lids, titere is often much i>crous infiltration
awellwg of the Utter and of the suirounding [larts. the lid^ being per-
lUi|]« t(k swollen that the eye is firmly closed. 'J'he discoloration is at'
IXJCniBS, VOtJTtTiS, BTC, Or TUB ETHLIDS.
853
first (lark and livid, bnt gradually uDden*ocs rarions clmnges of tint,
turning bluish-red, green, yellow, etc. A black-ejo generally disap-
pcnrs in two or three weeks time, hut the aVHoqrtion of blood may bo
accelerated by various local remedies. Directly after the injury, com-
preaaes of lint dipfH^d in ice-cold water should he a])iiliod, ana very fre-
quently changed, being retained in position by a firm l^vndngo. This
aiiplicatioa of a cold compress tends greatly to limit the effusion of
blood. The abBorption of tho latter is snb^'iiuently much hastened by
tbe continuous application of a firm bandage, together with which an
evajiorating lotjon sliould bo employed. Of the two. the bandage will,
however, be found to render the greater service in accelerating the ab-
sorption. The tincture of antica has long enjoyed a great ami 8[>eci»l
re|)Utation for curing hlack eyes. It should bo cmjilyycd a« a lotimi
(tr. amicic mont. 'S\j, art an. dcst., or mist, camphor, siv). A compress
of lint h to be soaked in this, ami applied to tlie lids by a firm bandage.
The following formula, recommended by Mr. I^awson, is al-io a very
grto«l nne: R. Tr. arnic. mont. 3iv; Li'|. iramon. acet. 5i : Sp. roama-
riiii 3'^'! ^^'»t. cnmph. ad 3viij. — M. f. lotio. A poultice of black
bryony-root is likewise much in vogue amongst the public. The swollen
parts should never be pricked or punctured, as this tenda to produce
suppuration and erysipelas.
Wiiu»<h of thf ft/eftti» vary in danger according to their situation and
extent, and according to the fact whetlier they are i^iniply iiiuiiiefl, or
are punctured, and accompanied perhaps by consideniblc bniising and
contusion of the parts. If the iucision is superficial ana honzontaJ, and
has only divided the skin and a few of the fibres of the orbicularis, it
will soon heal by first intention, if the edges of the wound are brought
together by sutures anil atrtps of plaster, and little, if any, mark will he
loft behind, lint when tlie wound is cjttonairo, and haa penetrated
deeply into the upper lid, impHcating perhaps the tarsus, and dividing
tlie fibres nf tlie levator paipebne, its cousequeiicus are much more
^eriouB. For not only may it produce a conaidoraldo degree of ptosU,
but, on account of the suppuration which oiay supervene, contraction
and shrinking of the integuments may ensue, and give rise to a severe
and obstinate ectropiuin. If tiie cut is vertical, it may divide tlie tai-sal
eilgo of the lid, splitling it u[> and laying it open to a muro or less con-
siderable extent, thus giving rise to an unsightly gap or coloboma. If
the rent is situated near tiie inner angle of tlte eye, it may divide the
eanaliculurt, and tear it away from the punetnm lacrymale. In a small
punctured wound, the danger is but »liglit, if it i^ confined to the eyelid
and has not extended into the orbit or injured the eyeball, otherwi.se it
mny province more or le^s orlutal cellulitis ; or, if the globe bus been
injured, serious consetjuences may arise, and tJie eye be perhaps coni-
iitetely lo«t. If the wound or tear in the eyelid has been accompanied
by severe contusion of the parts, there is alwars much danger of 8uppu<
ration or even of sbiughing setting in. WouimIs of the cyefitls) implicat-
ing the infra-orbital nerve have heen noticed to produce amaurosis, which
was termed sympathetic. The cases of this kind which ha%'e been nar-
rated, occurred, however, before the discovery of the ophthalmoscope ,
and hence the true condition of the fundus oculi was not known.
8A^
DI8BA8EB OP TUB BYEMD8.
4w>
Wounda of the elfin of the ejcl'ub should bo brought accunLt«ljr to-
gether with fine sutures and strips of plaster, the i»an beioj; kt'pt cool
and at rest hv the ii]iplicHtioii of a moi&t compruss utid u baudage. Kveci
irboro the wound extends deeply into the tissue of tlio e^velid, ami is
■ccyiupaiiied by much bniiwuf;, it is better to umte its edgiw bj suiurei
than to leave it to heal by granulation, as this nill prtxiuce a more or
le^ considerable loss of tub-
[Vig. 253. Rtanco,ci>utracUou of thi7 iutego-
mt'nta, and very probably ec-
tropium. If the tarsal ed^ bai
hoen divided by a vertical cut
[Fig. tioS], the edj^a of the
pap should be very carefully
brought t'>gi.>thcr, and niaio-
taiued in accurate appoi^ition hy
the insertion of one or more
twisted sutures. One suture
should always be applied as
closely as poAsihle to the ed;^ of
tho lid, BO that tho margin of the latter may hecomo accurately united.
The ed^es of the gap oiuy, if neecMary, be pared: tlie needle :)h»uld
be a very 6no one, and shduh) )« innoreed tbrou<;h tho tnnuis. If the
canaliculus has been divided, it« opening shouh] be searched for, aiKl a
director (Fig. Il>y, p. Till) should be tttsortcd, and the canaliculus be
slit open into the s&c, with a cataract knife. [When the edge of the lid
is divided, thus forming a traumatic coloboma, the iirt<l stop ia t^) remove
carefully all ciciktricinl tissue. If the coloboma is extensive, the adjacent
skiu miiitt be dU^ected up so as to relieve tho resulting tension, and
aometimea Knapji's method of lateral or sliding flaps becotut-ti nocc«Aary.
It is advisable after operating on such a case to cIokb both eyes, tbu^
keeping the }>arts in absolute apposition. . If there has been a good deal
uf jiapinj; of the edgee of tho laceration owing to oontractinn of Uie fibres
of the orbicularis, vertical incisions may he made through skin and miiit
cle on one or both sides of the wound, which aid in relaxing tho narta.
(See a paper by Knapp in " Arch, of Ophth. and Otol.*'* »• 1-) — B. J
The eyelids ai*e often also injured by burns or scalds from hot seething
fluid, the flame of a candle, etc., the explosion of guniH^wder, or the
action of strong caustic fluids. If the edges of the lids are severely
injured, these may ht-couiu adherent, and a more ur less extousivu auchy-
lonlepharon Ite proituced, or synibiephiimn may ensue, if the conjunctira
has been implicated in tlie injury. Moreover, a very severe ami obsti-
nate form of eclropium often followti burns of the lids, on accuuut of the
shrinking and contraction of the akin which accompany and 9ui>ervene
upon the cicatrization. This is especially observuil m the lower lij. If
the injury is so extensive that little is left of tho eyelids except the tarsal
and the conjunctiva, the ecti-opium and conse<|ucnt lagophtli»lmo>s are w
great, that severe inflammation of the coniea and other structures of tho
aye supervenes, and the tatter is generally soon dcstroyeti.
In slight cases of scalds or burns of the eyelids in which the cutis ia
not destroyed, cold water dressing ahoultl be applied and coustanlly n-
IKJDRIB8, WOONDS, ETO.* 07 THE EVBLIDS.
865
newed for eho first 24 or 80 hour*. If a btiater f^niw, this should be
pricked and the fleruni nllowed to escape, the water dressing being then
re*&pplied. If the injury has heen so severe that the skin is destrojed,
simple cer&t« dressing should be applied and groat car« he taken that
the lid is kept upon the stretch during tho ficriod of ctcatrixation, in
order that new skin may be fonncd, and cftropium be thus avoided. A
bandage should, therefore, l>e so ni)]<lied as to keep the lid u|H)n the
stretch, and tho patient iihoiiH not be allowed to use his eyes until com*
ptet« cicatrixation has taken place.
The oyelltb) often become greatly inflamed and swollen from the stiog?
of insects, snch as bees, gnats, etc. The sting should b© rcmove<l as
800U as possible, aod cool water dresaiog or evaporating loUoos be pre-
scribed.
Amongst tbe congenital malfnrmatinnR of the eye, we sometimes meet
with cpicanthuA and coloboma of the eyelid.
£pic^nthu« coQsists in the presence of a crescentio fold of skin, which
paseea from the nose to the eyebrow, and overlaps and hides, to a gnmter
or less extent, the inner canthus. If it is considerably developed it is
very imaightly, and it may be necessary to cure it by operative inter-
ference. But we should wait with an operation until the child gets
older, for it is often found that the deformity gradually disappears as
the bones of tho nose become more devcloiicd, and the latter more promi-
nCDt. If this should not, however, occur, an elliptical fold of skin (the
size of wliicli nnist vary witli the amount uf effect wo desire to ttroduce)
is to be excised from the upper portion of the dosc [Fig. 254]. Tho
(Fig. 2S4.]
edges of the wound should be somewhat dissected up, so that tbey may
ho the more readily approximated, and the lips of the wound closed
with sutures.
t'oMrmiui or fiasure of the eyelids ia a congenital dcfonnitv. which is
bnt of rare occurrence. It is sometimes associated with cleft palate,
hare-lip, coloboma of the iris and choroid, dermoid tumor on the comesj
9 \ > »»<
^
'^i?
-»-.* ->•
n
•
SELECTIONS FROM THE TEST-TYPES
OP
PROP. EDWARD JAEGER, OF VIENNA,
AVD
DR. H. SNELLEN, OF UTRECHT.
TEST-TYPES,
CWEEBSPONDINa TO THE 8CHEIFT-SCALEN OP
EDWARD JAEOEB, OF VIENNA.
No. 1. — Diamond.
A Fh M^ flUfM l( • Bi^ wH ikt H iimiiii* k> Ui ■•* kr Iwl^ Ml Ml btUal Uai tall ■«« ■«% alnM l«k
■kanfU, kt to0> M »• ■ t^lkli t( Uh nM)iMi iMk klrfMnaM krtif ifH UihlkH M al»vl aWiil k> kii IM
nlWt Ika ■«• Mr MAat U. Bhrv, hbItMc <•■■*■ l^ ^^ •<• t^ ■■». k> alkd > BHIbi ■< lk> rw d Ita
lUH, mt n^Hit IkM an AhM MIh Ui aw*l>. -!•■ ku< ■• ttlim,~ mit ta, -^ Iki imt trnt awAH alib sbM
I ■« iim akMli ■ waU hw kw* kiUmJ M » I ki4 •« bM U BTHiri tu ndl; wkw vh •*• m mhi iv« tt. ■
Ml liH* •■ 1^, hMim«l»^ »« MIT ■>»■<»«» *«■ iWHlf wHlK b (te^Hruai.n wM )w> (■■ ■vMikliH
U^. I |ii| I ItM^i^ Bf «nk; WHkn^ IkM tw an (nit k} (k> HpirtnM IkH I tm M« >lUb| H i*H r». u4
IkUiU r^bM tkai^teivdiUiCikirk Mill.' Py IMn«»i«lki aMf^il fcm«4, mJ »M. -IiMkt Iklik.
^b. 2.— Frar/.
■r tittmi, UM TM whU aM kart kdtlHd u ta put wttb Mr UIU, IT tka* mn u; ehuo* M
noOTVHkC rnr oan.~ A Uu wbs lud b*m tlu« lif ■ Def ni (olDf iIbiu uUn( wba oonld nn
kim. Om Ihit bM Ub hM, "Blr, ir jv» wobM k« ennd. ok* k Ut of bmd ud dip llh It* blesd at
Ibl wiDDd, ud fh* It la tte dof tk*t bit jm." Jt* BU lalM, ud hU, ■' Ir I nn u IDIlaw jsar
kdrlM. I Amid M Mlun b; all (Iw daft iB Uu dtj." 8a wba proolalBi felaadt raadf la tiaj op kli
•bibUi will Bmr nnt k nppl; of Ihta. A sanalD Bum kad Iba (sod kwtiuu Id p— ■ a Oaoaa IbM
laid klB ■ Qiildan B«( anrr daf. Bal dlttatliaad ■Ith M alow aa Ibohbi. aad (hlDklni la aalit tt*
«bal* tnaaar* U (■**, b* iUlM ika Ooeaa , ajid eaXlDt bar tftu. toobd b«H>M "bat aor atbv (MM
No. i. — JUinion.
would ba ! If nob wuita mora uid loies all. A Dog made hla bed in a S{uig«r, and
U; loarllog and growling to ke«p tbe hoTMi from thoir proTender. " See," said one
or tbem, " wbat a mtferable oar! wbo nritber cao eat com bimaelf, nor will allow
thoie to eat It wbo ean." A Viper entering into a imitli'a ebop began looking aboot
for lometblng to eat. At lengtb, leeing a file, be went np to It, and oommenoed
biting at It; bat tbe Pile bade him leare bim alone, daring, "Ton are likely to get
little from me wboee botiseai it ia to bite otben." A Cat, grown feeble with age
No. 6. — Bovrgeoia.
and no longer able to hant the Mice as she wu wont to do, betbongbt
herself how she might entioe them within reach of faer paw. Thinking
that she might pass herself off for a bag, or for a dead cat at least, she
suspended herself b; tbe hind tegs from a peg, in tbe hope that the
Mice would no longer be afraid to oome near her. An old Moose, who
was wise enough to keep bis distance, whispered to a friend, " Manj a
No. &.— Small Pica.
bag have I seen in my day, but never one with a cat's
head." "Hang there, good Madam," said the other, "as
long as you please, but I would not trust myself within
reach of you though you were stuffed with straw." Old
birds are not to be caught with chaff. As a Cock vaa
jaeger's test-types. 873
So. lO.—IHea.
scratching up the straw in a farm-yard, in search of
food for the hens, he hit upon a Jewel that by some
chance had found its way there. Hot said he,
you are a very fine thing, no doubt, to those who
^0. 12.— Engluh.
prize you; but give me a barley-corn before
all the pearls in the world. The Cock was
a sensible Cock ; but there are many silly
people who despise what is precious only
No. 14. — Oreat Primer.
because they cannot understand it.
A Man who kept a Horse and
an Ass was wont in his journeys
No. 15.— SWtne EnglUh.
to spare the Horse,
and put all the bur-
den upon the Ass's
)l I
i;
nn
Snellen's Test-Types.
ZBDFHKOSUYAIO
25311.
SUYACaNPR12
;xT.
PRBDHKOIS
:£'^.
Y A C E a L
!SdS:£.
H K o e:
i.
INDEX.
ABSCESa nf oomen, 14*2
of tjtMa, im
ot froDtnl sinns. 7f*5
of lachrymul kho, 788
of orbit, 751
Abscision, operation of, 184
AbBorpifon, oun of oiitaniot bj, SS7
AocommodatioD, aotioo of atropine upon,
214
ftotion of Cftliibar benn npoo, 6&7
binoeaUr, ranfte of, 6IS
meohftnisin of, 61tl
nittiira of, 610
Dcgntife, 616
range of, 618
pftmljHis of, 666
prooew of, 616
nnge of, 616
AcbromtitopaU, 620
Aon« oiliaris, 806
AoatenesB of viaioti, model of wtlnuttng.
87
Adenoms of eyelid, 618
^gllApa, 797
AgDew'e opemtion for avoondArjp ont«rMt,
84B
Albuminuria, toaoae of nmblyopia, 426, 612
a oause of retinitis, 420
Allbol, Dr.. on the state of tb* optic Dcrve
in the inaane, 602
Altbaufl, Dr., on electrolysis, 816
on locomotor ataxy, 606
Amaurosis, 498
cerebral, 408
reflex, 618
aiaiolntlon of, 622
Amblyopia, 607
anvmio. 607
congestive, 609
ex afiopsli, 613, 600
tram blood poisoning, 608
from non-use, 618, 696
from pamtysls of retina, 614
from tobncao, 610, 61 1
potntornm, 610
■atumina, 612
tmnsitory, 608
Brteroio. 612
Ambljopio affections, 498
Ametrumeter of Tbomsoit, 647
Ametropia, 612
Amyloid degenemtion of tarsus, 818
disease of coojaoctiva, IftO
I AnairnoBlakis, Dr , on dinliohiasia, 831
I Anchylnblephnron, 118
I Anchyiops. 797
Anderson, Dr. MoCnll, on eciema of lid,
80o
Aneurism of the orbit, 777
by annsiuroosis, in orbit, 777
of eyelids, 819
of oentml artery of retina, 779
of oentml retinal artery, 418
Angioma of eyelid, 819
Aniridia, 224
Anterior chamber, changes In tbe conlenU
of, etc., 288
oytlioeroi in, 240
foreign bodips In, 288, 229
Anthrax of tbe eyrliilN, 798
Antiseptic methods in extracting eatamct,
SOI
Aphakia, 666
congenital, 282
Aqueoas bumor, core of cataract by re-
peated eraeunlion of, 846
Aqno-oapsalitis, 198
Areas seniUs, 178
Arlt, I^r, on causes of pleryi^nm. 111
I on operation forentrupinm, 829
Arterinl pnlsntion in glnoeoma. 667
ArtiftciftI eye, mode o. insenion, 793
Icpoh, 49
Asthenopiii. due to hypermctropia, 686
muscalnr, 718
retinal, 686
Astigroa(i>-m, tiS8
acquired. 6ol
compound, 048, 662
oongeiiiiiil, U60
diagnosis of. 642, 648
Irregulnr, 642, 664
niised. K48. ti58
ophtbulmoecopic diagnosis of, 649
regular, 641, 661
simple. 648, 662
trentment of. by oyllndrical lenses, 661
[ Alaiy, locomolDr. a chusc of amaurosis, 602
• Atresia of the UobrymnI putictn, 782
; Atrophy of the optic nerre, 481
of the retina, 468
Atropine, action of, on tbe accommodation,
218
on the iris, 214
anomatous etfrota of, 187 — note
idiosyncrasy sgaiust, 187-^ote
880
INDSX.
AU6fia« In Mill, 206
irritatioa of conjaBctint, 84
DMcani^ of lu bsiog pnro, 137 — tiata
polaotilnit by. 'JOT
AaNaphtltatmiwcopv i>r Oirnuil-Tealod, STT
As**. »twvi%rj. 9t loDMB, 044
Alia, •ptie, 'Xi
«f luniag, 067
B*L'
ADII, Mr.. M iBOsnlatloa, Dd
Nijr, 98— Bole
tMttiaeM of mBh»l enrMK. 177
>*• aamtia* fw eoDic*! eorncA. 177
i^ H eooaifaa in gnuinlar lids, til
h^m. Ml mil romis of, 47
MapnM hftftdtgs to oomtitit, I4£
iMnttiis. 186
Hvftu. 75T
'•> br., lyfcrtoliBMOfiyf. 27 1
r. Dr-, mm »o&ammai»tkon of llic tjc,
Ik. iwMfc. •• wcariMB of orbil,
iMt,67
1^^ « ■twiWg, «»
. ar I ilijBil MA, T4T
Bmniiiii|ii.«r»
,T«
Ui
23B
IT
1^ f^.
CI
rf*l
BoarvMi, Mr , oa eaUinvtini^ lb«
t«nilon of lb» eye tn
on eiclfion of pupil, ZSI
on kerpM iMtcr, 801
on Moop extnetioa of ousn
on BtraMsmBt, 6SU
on ituilDB f7rin|t« flir lalMiil. Mi
«B tnfttnMoi of upHrtar apMitlM ky
iwo-B*«dU opanUloa, M8
ofdvUclitilmtin, IM
of ohitniotctl daets, 7tl, 7Sli
Bovmaa'ii imntioa for ooalol
17*1
RnclijmDtroplK, 6IS
l)nl>«tia'ii mudiOoBliMtaof Or»«Ai*a
lion. 882
BnphtbfttmM, IM
Bii7», Dr., an uae nt aMUt* of l«d
gnnaUr ophthalaU, M
CALADAR bcu, mUm af, Mirii, Sli
on cilmry mam^, ttT
Cftloaliu, Uolirjiii*!. 747
MeihtHBlnn. 811
Calonwl, intafliUMi of. IM
CuAlieuU, iliTUlaa of. iH
obtimcriooa Id, 1S£
Omwvt ot cliorold, libi
of conjuncllrm. 124
opilMtaL, of ejelXla, 81ft
of orbit, 778
OHtUiopUetj'. a-14
CutoD. Mr , (in kr«ua aanilit, ITS
CkpioUr oatarnct. 204, U"!
MUrior, 3t>3
pMifTior. '290
Capaol* of Boiioat. iO(>
af TaaoA, iOi>
CapMtla. rviAara of, 29S
Cartiwula of Uo ayvllda. 799
CatriB'>w* of clMmid, &66
Btelanoiie, of cborojd, frW
of aptio nerve, 4fl9
■rtaiaij, of caojoMtit*, 136
Cteasat poi&u ia diapanniMle axe
' Cuin of ib« orbit, 7M
C«rwalu l^., p«rini«tar of, 44
Carur, Brmlfarll, Mr. oa
apbthaliaoMope, 971
m I^Joriaa of ofMt. 7e'J
M iwiruMaat far eumiaisg fiaU nf
vbiaa, 48
ObrMr'a a«« daaoaatrktiBg apktkalaa-
•Mpr.<71
ftiillagjanai ttuaor* Ht ettti. 7fi6
• rilwaii ■•urtar aapaoUr. 29&
•MbMtfa awctr; ta, Hit
XM
SM
XN
188
INDEX.
88t
Catkmct, InmeHar or lonalftr, 284
MorgngiiiftD, 2ti'i
nuolesr or bard senile. 289
poat«rior capsnlkr (pol&r), 290
pjrnimtdnl, 296
aecondary, 847
operatioDS for, 847
eenite. 289
eilicnloHB or ehalkj, 268
■jmptoma of, 283
traumatic, 292
treatment of, br diviBioa or solatlon,
339
b; flap eitraction, 802
with iridectomy, 817
by Ton Oraefe'i extrkotion, 824,
829
by Lebmn's method, 884
hy Liebreioh's method, 882, 884
by linear extraction, 818
by repeated paraoentesis oomen,
84«
by reclinatioQ orooaching, 837
by removal of lens in its oapanle,
818
by scoop eilractioD, 821
by BOotioD, 344
by Taylor's method, 833
by Weber's operation, 822
forUmelUr, 841
for traumatto. 842
Cataracts fuiirormis, 281)
Catarrhal ophthnlmta, 62
Catoptric test, 284
Cat's-eye, nmanrotio, 46S
Caustics, mitigated, on ase of, 69
on the use of, in puruleot ophthalmia,
67
Cavernous tumor of orbit, 777
Cellulitis of the orbit, IbO
Chalniion, 810
Chanore of lid, 799
Cliarpie, 48 — note
Chemosis, 64
Chlorine water, use of, 89, 97
Cholesterine in Titreous humor, 404
in optic nerve, 488
Chorio-retinitis circumscripta, 627
Choroid, carcinoma of, 666
oavernous sarcoma of, 6o6
colloid disease of, 646
coloboma of. 557
cysloid formations of, 664
detnchraent of, 661
diseases of, 626
en chondroma of, 666
formation of bone in, 667
glandulur degeneration of, 408
granuloma of, 666
hemorrhage from, 600
hypertsmia of, 626
leukosarcoma of, 060
myoma of, 666
rupture of, 668
sarcoma of, &oO
Choroid, tubercles of, 647
tumors of, 660
irarty outgrowths from the, 646
Choroidal vereele, embolus of, 66 1
Choroiditis, 526
areolar, 529
disseminat)!, 627
in relapsing fever, 648
metastatic, 640
parenchymatous, 640
plastic, 627
serous, 526
eypbilitic, 630
Bnppurative, 540
luberculosa. 647
Chrombydroai^ 807
Ciliary arteries, erabotus of, 661
body, iuflammatton of, 2K8
muscleB, affections of, 66S
atony of, 659
paralysis of. 666
spasm of, 669
nerves, division of, in Bympathstio
ophthalmia, 266
neuralgia, 65
region, injuries of, 271
sarcoma of, 665
Circles of diffusion, (i08
Clover's, Mr., chloroform ftpparatns, 317
Coccius, Prof., compound object tens of,
383
OD accommodation, 614 — not*
on glaucoma, 581
opbthalmnMcope of, 364
CoociuM's roodificiition of Qiraad-Teulon's
binooular ophthalmoscope, 876
Coho, Dr., on mica speotactss, 664
on myopia, 6'20
Cohnheim, Dr., on tubercles of choroid,
647
Colloid disease of choroid, 546
OoUyrin, mode of applying, 52 — note
Coloboma areolaris, 629
disseminiita, 627
lentis, 282
mstastatic, 640
of choroid, 567
of eyelid, 865
of iris, 226
of sheath of optio nerv«, 492
parenchymatous, 640
syphilitica, 5l^8
tuberculosa, 647
Color-blindness, 480, 498, 520
scotoma in neuritis, 480
Compression, digital, in orbital aneurism,
781
Conical cornea, 174
Itader's operation for, 177
treatment of, by iridectomy, 176
iridodesis, 176
von Oraefe's, 176
Conjunctiva, diseases of the, 61
cysts of, I2:{
cyetioerous in, 124
66
INDEX.
883
Deamniree' operation for ptcTygfuni, 113
UesiructioD of lacbrymal esc, 744
Detached retioa, cbromatopsia in, 448
Bcler&l puncture in, 448
apontsneous recovery from. 446
treatment by drainage, 448
Detachment of the choroid, &m
of the retioa, 440
Deviation, primary, of tisuaI llnea, 678
secondary, of tIbuaI lines, 678
in pnrntytic affections of ocular
musctea, 678
in Btrabismua concomitsns, 690
Diabetes, retinal dixease in, 440
Dieffenbach's operation for ectropium, 846
Digilitl pressure in orbital aneurism, 781
l>ipbtberitic conjunolivitiB, 76
Diplopia, crossed, 46
homonymous, 46
monocular, 4ft, 666
operations for. 7L6
Discission of cataract, 887
Dialocalion of the eye, 790
of the lens, 861
Distichiaaia, 625
Divergent strabismna, 701
Division of cataract, 887
Dixon, on dislocation of lens, 864
on peculiar deposits in cornea, 16B
Donders, Prof « on ametropia, 612
on aetigmattam, 687
on brachymetropia, 612
on colloid disease of choroid, 646
on emmetropia, 610
on entoptioa, 401
on glaucoma, 688
on bypermetropia, 612
on retinitis pigmentoaa, 486
on Bclerotico-choroidilia posterior, 630
on Btenopaio apectncleti, 171
on sympathetic ophthalmia, 268
on vertical meridian, 667
on visna] line, 60S
DouMe sight, vide Diplopia,
Douche, eye, 60
Duboisin ag a mydriatic, 69
in keratitia, 188
Duct, lachrymal, obstruction of, 783
Bowman's treatment of, 789
Critcheit'a treatment of, 742
Ilaya'a treatment of, 741
Stilling's treatment of, 748
Warlomont's treatment of, 748
Weber's treatment of, 740
nnani, stricture of, 738
Dyachromatopaia, 620
Dyacoria, 226
ECCHYM0818 of cotynnotivB, 127
of eyelids, 862
of re^na, 416. 482
Echinococoua in orbit, 769
Ectopia lentis, 861
Eotropinni, 840
Ectropium, Adams's operation for, 843
Dieffenbach's operation for, 846
from caries, 840
from cicatrioea, wounds, etc., 840
from Inflammatory hypertropliy of con-
janctiva, 840
Qraefe'a operation for, 846
Hnaner's operation for, 860
Wharton Jones' operation for, 844
Knnpp's operation for, A4'J
treatmentof, byblepbaroplasty (trans-
plantation), 847
by sliin grafting, 860
by tarsoraphia, 848
Eciema of the lids, 8U1
Effusion of blood, into anterior ohamber, 238
into choroid, 660
into conjuncliTa, 127
into eyelids, 862
into orbit, 782
into retina, 416, 482
into vitreous humor, 898
Rgyptian ophthalmia, 66
Electricity in atrophy of optic nerre, 617
in exophthalmic goitre, 700
in herpea loater, 803
in optic neuritis, 476
in parnlyais of ocular mnaoles, 686
in vitreous opacities, 400
Electrolysis, 788
Elephnnliaais Grtecorum of eyelid, 819
Embolism of central retinal artery, oausea
of, 468
of choroidal veeaels, 646
of retinal artery, 460
Embolus of ciliary arteries. 561
of choroidal vessels, 661
Emmetropia, 610
fimphynema of eyelids, 794
of orbit, 784
Encepbalooete, congenital, 777
Bnchondroma of choroid, 566
of orbit, 769
Encyated tumors of orbit, 769
Engorged papilla, 466
Enioioa, videCyaticercus and Ecchinoooo-
CUB,
Entropinm, 832
acute or spasmodic, 882
Arlt's operation for, 830
Author's operation for, 837
Berlin's operation for, 838
chronic, 833
Graefe's operation for, 885
Pngenstecher's operation for, 880
senile, 632
Snellen's operation for, 686
8 treatfei Id' 8 operation for, 887
Enucleation of eyeball, 792
in sympatbetio ophthalmia, 265
Ephidroais, 807
EpidiUtbus, 866
Epilepsy of the retina, 449
Epiphora, 729
Episcleritis, 102, 272
^H^ ^VF ^^^^^1
^^^1 Epithelial c«noer of eytlida. 615
Efeli'I*, nivvni of, 819 ^^^^H
^^^B Epitliclif^mA at eara*h, Wi
ndcnw of, ^^^^H
^^^^M metiiuolio, of L-ut^iiitctivK, 125
pusLqlR, nmrtKiiant, «f, t09 ^^H
^^^H Ereclile tuinon of eyeliJi, ^19
lamora of, t*\0 ^^^^^|
^^^H
ulc«n. 87pbiUtie, of, 700 |^^^H
^^^H F!rupl1aH», B}'pliilitio. of fjreUds, 800
^^^^B
^^^H £rjr!tip«1n--« AteyHtJ.i. 7V7
tronail* ^^^^B
^^^^1 KrylhriDit nf eveli'Jn, TWl
^^^^^^1
^^^H EmHm in corned (tlffuiloDt, 188
^^^^^1
^^^H In glAUiMtnft, WO
PAR point. 016 ^^^^B
r PnraiKbl«<lii«fla, ASS ^^^^|
^^^^M in psTitljrsis of ncoomninilatioB, fK8
^^^H ill purulpQt opbthtlnitn, 70
Fatty ileitviicrorion of reltam 433 ^^M
^^^H EstUoder, Dr., on ohorulJlila In retkpMlng
In reilniils ivlbuiiiiiiiirlu, 438 ^^M
^^^H fever, MS
tuoiora nf eonjunclifm, 121 ^^B
^^^H EtmuuUoii of Biiueous buinor, 149
of »)-cli.|!'. »I0 ^^
^^^H EvrrHiflti of th« upper Ikit, Si
of orbit, Tt>7 1
^^H of tbe ejreliJn, KXB
FitMwna tipoiiiato-le> palpebntrvni, $9^^^^J
^^^H Eianlbrmntou* (>i»litlinlinla, 100
3BH
^^^^^ Kxcavulon or opiUi nerve, IM
orbit, ^^^^1
^^^^^^L
f'Jbmmiita, papillnrjr, of ooi^ttncliTftT'^^^H
^^^^^B gUdcomatou*. 4M
FioU uf vitiou, eontrnction of, in datnul^^H
^^^^^^^ pby»i'ili>gic«l, -186
relioA, 440 _^^|
^^H Sx^oo of ejvbttU, I'M
in rvtiniiispigmoolow^ '^'^^B
^^H of puptt. mo
erroneou* pmJMtioa of, W<7 ^^^
^^^H Bxophtiilt'niic goitre, T-'>7
cquilnicritl or bomonjrmou* con- 1
^^^H belUiIotina in, 701
tnictioD of, 495 ^^J
^^^H Tsralriim viridt in, 7fll
HAmiDttlion of, 88 ^^H
^^^H Bxo»to«i!i of orbit,
Aoilior'i nrtbod, 19 ^^H
^^^H £xtirpncion of fyvbitll, 791
Cartcr'a noihod, 4S ^^B
^^^1 of Incbrymnl gluid, 729
F<irst«r'a tnnbod, 42 ^H
^^^^1 oflKchrjtmal bao, 747
»r. To'ik'i. ^H
^^^^^ Extnotion of lena bj Hap openiioD, 802
d« ^Mker'ft, 4i ^^M
^^^^^^_ by von Qmcfc'a ap«r»lion, 1)24
ia itiiil>l^u|ii« ktfectioDA. 4m ^^M
^^^^^B b;r Lcbrtjii'a tnvtlMMl, 3M
ill heuiiopia, 40Ci ^^B
^^^^^H br I.iel)reiab'« metkod. &82
FllDrln melinemla In tbe tyw, 241 ^^fl
^^^^^^H bj linear inoiblfMi, BIS
■pirMta in viireona, 4(H ^^H
^^^^^^H hy »ouop vporation, 824
PiMatn of oonica. IRQ ^^^H
^^^^^^H by
of iMtbrymftl glmd, 718 ^^^^H
^^^^^B bj Tajrlor'a nelbod, 342
^^^^^1
^^^^^ b; VTeber's up^miioa, 922
Flap exiriMilon of ntanul, 302 ^^^^H
^^^1 In iu c«psu)e, 11|8
Poeni ti40 ^^^^H
^^^^H Eje, 'Itagmminitlic, of Liating, 608
^^^^^H
^^^^B Juuctiv,
^^^^^H
^^^H grncr.ll inftnmniiktioil of, 640
Fo«i, flonjagnre, of lennM, 804 ^^^^^M
^^H B^cbdl, dinlocnlicn of, 789
Foeuii iif Irnsfti, WU{
^^^H BzcinioD of, 701
FoiBcaUiliims, warm. In sappanttT* eor-
^^^1 E]ril«»bo«. inveraion of, 825
ndii*. MS {
^^^B Itni on th*, 807
pDrDiga bodies Id anterior ebambcr, 23& J
^^^H trasflpUnutiopor, 821)
in ciMijflticliTn, 110 ^^M
^^^H E7*n>1s. >li*«iiKea of, 7114
coriim, IS'i ^^^^
^^^^^ »b»«M of, 7I>4
la Iria, HO ,^^^B
^^^^^B uaarUn at.
In ^^^H
^^^^H vilhrsx
vilrcona, 404 ^^^^H
^^^^^H «»lobonA of, 866
removal uf, 40(t ^^B
^^^^^H DMItllSlttDSof, 853
F«nn»lion (if hone inrbamtd, 6A? ^^B
^^^^^^H ec«bjtiii<Mi* of.
PSritrr, Dr.. on areoUr cboruidilia, 6S0^^B
^^^^^H onphy»em» of, T V4
on bemeratnpia, fil7 ^^M
^^^^^^B etityaiei tumor of, filO
pertinrier of, 42 ^^
^^^^^^B epitbrtini o«iicer uf, 816
P6raler, Crof., pboionvltr or lislrurnvQl
^^^^^H
for nenitariDK tbe Moalblliiy to licVt,
^^^^^H erylbemft of, ''M
89
^^^^^^B
FrMtnrea of walla of orbit, 789
^^^^^^B bora
Frank, Dr.. on graiiuUr uphlhalmia, 89
^^^^^^H inHitumatioo ofMlgoi of, 808
on nipruro of tha cboroid, iVlO ^^i
^^^^^^1 ot^ 9i2
~"~"i
IMDBX.
8S5
PreemAn, Dr., on digital oompreision of
orbital Kneuriem, 781
Frootal Binue, diseases of, 785
absoess of, 785
Fundus oouli, ophlbftlmoscopio appear-
ances of faeallby, 885
Fungus htemntodea of eyeball, 467
Furnari, Dr., on Byndectonij, 98
Fusiform cataract, 286
GALVANO-CAUSTIC appsratus for de-
Btruotlon oriHchrymBl saoi 746
Gelatinous iritis, 202
Qerontoson (nrcus seoiliB), 178
Gomese, 1*8
lentifl, 291
Gibson's operation for cataract, 820
Oioppi, Dr., on dimital comprefsion of or-
bital aneurism, 781
Qioppi's operation for extracting lens and
capsule, 819
Oiraud-Teulou's, Dr., aut-opbtlialmoBCope,
877
binocular ophthalmoscope. 878
Gland, lachrymal, diseases of, 72d
extirpation of, 728
Glaucoma, ^63
acuts inflammatory, 5(16
arterial pulsation in, 6K7
chronic inflammatory, 674
fulminans, 678
bemorrbflgic form of, 672
iridectomy in, 692
nature and causes of, 581, 686
ophthalmoscopic symptoms of, 681
premonitory stAge of, Otifi
prognosis of. &W
eelerotomy in, 691
secondary, 679
simplex, 670
subacute, 678
treatment by eserine, 600
with congenital coloboma iridis, 681
with retinitis pigmentosa, 681
with total irideremia, 68t
Glioma of retina, 4<>5
histo]o|iy of, 455
Ollosarcoma retinn, 466
Goggles, 6<>8
Goitre, exophthalmic, 757
Oonorrhoeal ophthalmia, 71
iritis, 208
Gouty iritis, 203
Oraeffl, Alfred, Dr., on isohtemia retinse,
449
on the muscles of the eye, 664 — note
Oraefe, *on. Prof., oq amblyopic affections,
493
OD bandages for the eye, 47
OD central recurrent retinitis, 481
on coDical cornea, 176
on cysticercus ia titreons, 406
on detachment of retina, 445
on diatichiasis, 825
Graefe, Ton, Prof., on eclrnpinm, 846
on embolism of central artery of retins,
460
on entropiam, 884
on exophthalmic goitre, 767
on fomentations (warm), 94, 147
' un glaucoma, 664, 682
on glioma retince, 460
on hypersesthesia of retina, 465
on irido-ohoroiditis, 249
on muscular asthenopia, 718
on operation for staph y torn a, 187
on operation for strabismus, 706
on optio neuritis, 467
on ptosis, 820
on retro-ocular optic neuritis, 479
on sarcoma of choroid, 650
on sclerotioo-choroiditls posts ri or, 636
on strabismus, 606
on sympathetic choroid o- retinitis, 265
on sympathetic ophthalmia, 264
on transitory amaurosis, 609
on treatment of cataract by linear ex-
traction, 820
on trioblasis, 880
OD tubercles of the choroid, 647
on tumors of optic nerre, 488
00 use of caustic in ophthalmia, 68
operation of. for cataract, 224
Granular lids, 89
tirannlatioDS, chronic, 89
vesicular, 82
Granuloma of choroid, 655
of iris, 228
Oraies's disease, 767
Green's, Dr., test olgecis for astigmatism,
642
Green, Dr. John, test- types of, 88
Griinhagen, Dr., on iutra-ocular tension,
684
Qummata of eyelids, BOO
of iris, 201
ophthalmia, 81
Oathrie, Mr., on aneurism of orbit, 779
HAFPMAN, Dr., on glaucoma, 578
Hairion, Dr.. on granulations, 95
Halo round the macula, 886
Hasner, Dr., on ectropium, 850
on pterygium. III
Hays, knire-oeedte, 839
treatment of obstruction of lachrymal
duct, 742
Helmboltx, Prof., on accommodation of eye,
61S
on the Tlsnal line, 007
ophthalmoscope of, 859
Hematemesis, a cause of amaurosis, 507
Hemeralopia, 517
in retinitis pigmentosa, 487
Hemianopsia, 600
Hemiopia. 496, 500
equilateral or homonymous, 496
temporal, 496
^^H ^^^^^^^^H
^^^H^ U<murrhii)ti!. cerel^rnl, KOftUMef natqroriB,
Bjpem^ircpia. <t1l,ffil| ^^H
^^^K
abttolute, 4M6 ^^H
^^^^1 tram ehotoid, MO
ii«quir«il, C84 ^^^H
^^^^H tiit^ iiaicrior «hitiRber, 23B
fHCiiIutUe. US5 ^^H
^^^^H intn nnnjiirtt^tiva, IS7
^^M
^^r i„to liij,. ;(ja
manirBiit. 4t!I4 .J^H
imo opilo nerw. <RS
ophihftlmAs«>pte tllKgaooU of, 'M^^H
iiito nrhit, |K3
originitl, IVti ^^^M
Intv rvlinn, 4ia. 4-13
rafalivv, (}3J>
into vilKous hani»r, 808
a frcqaont euiw of uUiaiiapU. AM
■iitbtinnjuiiclivnl, 4'JH
• frgquont eaaao of ooavvrgvat •qHi»t
Ilcusrii nnJ V&tckvr*. rt|>«HiD<BU DU lO-
U3«
ciiiii(ni><1iili<ui. ftl:-! — nolo
ITypcrofllMia of boiiM of artiit, 785
lltrpr* of Iha eDtijiinohva, lUI
Vjpvpyoa, ilifforoat origin* of, 142, \M
oriti« ciriitn, 1^4
tiMtcr rroiil«li!>, B"U
ltan«n'*l»iii. mi ■irioturo of luhrjmal pu*
TCHTIiroSIS pftlpabrkrnni, 814
X lllnmlTitilon, (t)OI()a«, S4 ^^|
f«icu*, 7W
on Irmtinchl at triohUsia. 828
vlnunl. uf fuD>lfl4 o«tili. 8^ ^^H
ll«uTii?loiip, [Urnn, RrttOalnl leech at, 49
Imag*. »«tual, of fnnlu* ncull, -iSl ■
llourtclaup'a l«e«b, Lcriiig'a ntMlkAfiklioa
Intulu (liilKudf. inp*nliiK 'if l*rtii, I'M I
of, »0
InflunmaLiiin uf oap>ule itf Tvn-m. iM 1
Uippvl, von, Dr.| oa eoinpuund intrft-oeulftr
of DvtlnUr iiK!(ie uf orbit, 7fil 1
tcn'ton, A»t4
of oboroiil. &'Ju ^^J
Tlippua. 210
ofcllUrj ho<}y. 2tlS ^^H
HlrMbherr, Dr., «n illomn rallnw. 4XS
of oonJnnclivn. 6'i ^^^|
llati«cr«ii'a li*nis for c«l«r-bHitiliieaa, -14
ofooraca, ^^H
TTonleolnni, Rllli
of v(l|[« of tb« v^lida, 808 ^^^|
Horn of «r«li'l. 91^
of vjt (raiiiTallf, MO ^^^|
llororr, I'rof.. on diors. 168 — ooto
of fvcli.U, TVU ^^1
Du Kl«uc«mB, 684
oflHi, 1V4 ^H
ou liariwB canen. 188
of irii nni oboroid, 'Jll ^^H
on harjios lowtvr, W>'J
of Uelir^mal gUnJ. 7S& ^^H
Ifoli'i nperittion for aulro|iii)m, HSft
oflnrbrjrinat aao, Hi ^^H
Ilulko, Mr. J. W., on •■enrlAm of orbll,
of rrllun, 418 ^^M
TBI
■if rtin^iiiitt liuiBor, )tn| V
on colloid <lifi»s« of choroid, S44
Inflnvnon of nMi« III sntiitiNr IMi (4 1
i>n c/sti iu tl)« Iria. Til
Inj<>clio<i of lM«lirj'ian1 : . MH 1
OB iliteiiiev iif froniAl ninui, 'Hfi
BiboM>jttii<iiiT«>, oatar Ih
vtt eplihelliil ounoer of nrblt, 776
eorn«ttl oy • • ■
on xUnuiu mlinM). V^l
Injariaaof lb« 1". ,971 1
wi upiioDvuriii*. 4T5
of ibv cviijum-i-'i. 1 11^ ^^^
on Miwomfi of orKii. 7<1fi
ofthocornM. }99 ^^H
[lulebiimm, Ur. JDu«lh*i>, on gUuoant,
ihn 'JI8 ^^^H
6K4
of thelvot. 3^2 ^^1
on lierp«i &n«trr fronUlio, 802
OflbelHU, S52 ^^1
mi Qptia n<iaHtU. 4HJ
of lb« oibtl, 71*0 ^^M
on pjrnrBtilAl c*tnrn«l, 2M
of ibe aolorotir. ?7T ^H
<M vjrpliilitio coraciliK, H13
Inocnlalluii, at It. < r panntt*, M
ott i<«b«c©o •ni*i)m>U, 4M
loMflieivna; of ii :■ mnMlc*. 7)7
^^^H on Kiinlk«lB«iiw pAlpobrariun, 808
iDlerBlitial ksratiii', I'u
^^^B
Inlernl, fvoal. «VIO
^^^H Uynlitii, purulntt. 997
lotnt-otrvlar tcoaioo, m»i» «f wtfaaibl
^^^^^
drtETM of, S&
^^^^H H/nloi'l arlvrr. p«r«it(«nl, 409
Inoraaw af. In flwieoMa, &S>
^^^H llyiUtiil* «f ott>ii. TttO
Tntnt-orbiul dermoid oj»u< 770
^^^^H iljrilr.ijin ufufiriO IMTfe, 4<Ul
InnnlMi of lid. t*-V2
^^^^ II)<lrop)<ibi>imlft. ISO
IrldMlncnj, NioJa of parfomiKi, 2X7
^^^H Hyptcniia. 2i»
diametric. 84(>
^^^^^B HjpwftitinU iirolinroid, 535
inilirslt'>ui> for p*rfi»rm*n«« «t, SKt
^^^^^^ of oooiniKlira, 61
in Umrll^r r«(«r«Bt. ;t4l
^^^^^^ I'M
in cotiioal aome», 1 71
^^^^^K^^
in coriMal 6pMitit», 171
^^^^^^^^^^HjpirnalliMk ntiat.
inoamitia, 149
^^^^^^■^rtdnitt.
In gUtteoBu, GM ^^H
ZDDKX.
887
Iridectomy id irido-oboroiditis, 247
in iritis, 210
in pftnnas, 101
Irideremia, 234
Irido-ehoroiditia, 241
Irido-ohoroiditiB gummoaa or i/phiUtioa,
248
pUstioa, 242
purulflDta, 248
HeroBB, 243
Iriiio-CfolitU, 106, 2fi8
Iriilo-ojolo-cboroidttis tranmiitioft, 271
Iridodesis, mode of performing, 282
in corneal oornen, 1 76
in corneftl opaaities, 171
in lamellar cataract, 841
Iridodiatjsia, 23tt
Iridodonesis, 217
Iridotomy, 284
and irideotomj in ophthalmia neonati,
76
Iris, cancer of, 228
coloboma of, 226
oongeuilal absence of, 224
c;ste of, 220
ToreigD bodies in, 220
hyperiomia of, 194
inflammation of, 194
injuricH of, 218
prolapse of, 153
tremulous, 217
tumors, etc., of, 220
wounds of, 218
Iritis, 194
chronic, 204
gonorrlioeal, 208
goaty, 202
idiopathic, airople. 108
pareiicbytDnlous, 200
eeroas, 198
sj'mpnthetio, 208
sjpbililic, 201
traumiiiic, 202
Ischnmia of (be retina, 44fl
Iwanoff, on detachment of vitreous, 403,
637
on glioma of the retina, 468
on <sdema of retina, 4 1 4'— note
on peri*ascuUr retinitis, 418
on retinitis, 410
JACKSON, Dr. Hnghlings, on epilepsy of
retina, 449
on optic neuritis, 4C8
Jaoobson's operation for extracting lens
and capsule, 319
Jaoobson, I'rof., oo cataract, 817
on tumor of optic nerve, 4'^
Jaeger's cataract extraction with concave
knife, 318
Jaeger, Prof., on staphyloma postionm,
532
(est-types of, 87
Jugo, Dr., ou entopiics, 401
Java), Dr., on simnlation of amaaroais,
524
on treatment of strabismus, 708
optometer of, 644
Jones, on operation for eotropinm, 844
KERATITIS, see Coraeitis.
band-shaped, 168
interstitial, lUl
parenchymatons, 161
Keratoconns, 174
Keraloglobns, 160
Kei^tonyxis, see Division of cataract, 887
Knapp, Dr., on astigmatism, 648
on eotropinm, 849
on embolism of choroidal vessels, 64&
on exostosis of orbit, 767
on glioma of the retina, 467
operation for pterygium, 118
for staphyloma, 186
Knapp's operation for corneal staphyloma,
186
operation for pterygium, 117
opblbalmoscope, 698
Kflchlpr'B operation for extracting lens and
capsule, 819
Kammerfielil's loUon for acne, 807
LACHRYMAL apparatus, diseases of, 726
oalculns, 747
canal, obstructions of, 787 -
stricture of, 788
fistula, congenital, 747
gland, functional anomalies ofv 726
diseases of, 725
catarrhal inflammation of, 787
cysts of, 72(i
extirpation of, 728
fistula of, 727
hypertrophy of, 726
inflitmmation of, 726
neoplasias of, 728
pnnclA. eversion of, 729
malponitiou of, 730
obliteration of, 730
■ac, abscess of, 788
blenorrlxEa of, 733
catarrhal inflammation of, 737
extirpation of, 747
fiolula of, 747
hemorrhage into, 748
inflammation of, 7l<3
oblitentliun of, 748
polypus of, 748
Lagopbthalmos. 822
Laminaria boogies, 742
Landott, perimeter of, 44
tonometer of, 36
Lapis divinus, 52 — note
Lardaceous disease of coi\)tinoti«a, 130
Laurence, Mr. Zachariah, binocular oph-
thalmoscope of, 374
on extirpation of lachrymal gland, 728
INDEX.
889
Meyer, Dr., on dWisioa of oiliar; nerrea Id
sympatbetio ophthtlmia, ^65
Mioa spectaotes, 664
Mioropeia, 420
Militar; ephtbalml^ 68
Milium, 812
Mobility of eye, range of, 692
Motlnecum oontagioeam sea aebaoenm, 812
fibrosum, 812
of eyelids, 812
Monocular diplopia, 46
Mooren, Dr., on cataract, SI 7
on dipb(h«ritio ooDJunDttTiiii), 79
on bjpersesthesia of retina, 464
on syropathetio ophthnlmiA. 25S
on telangieotaais of iria, 122
Morpbia. subcDtaneooe injection of, in
poisoning bj atropine, 208
MSser on perimeter, 42
Mucocele, 787
MQUer, Prof. Hei&riob, on capsular cata-
ract, 294
on colloid disease of choroid, 646
on orbital unatriped maacular fibres,
679— note
on retinitis albumtnnrloa, 424
on retinitis pigmentoSl^ 486
Mnson TolitsDtes, 401
Muscles of the eje, nffeotions of, 666
action of, 667
paralysis of, 672
spasm of, 688
Hnsole>plane, 667
Masoalar asthenopia, 718
Mydriasis, 212
Myocepbalon, 62
Myodeeopsia, 807, 400
Myoma of choroid, 656
Myopin, 612, 619
ophthalmoBoopio diagnosia of, 621
Myosis, 216
Myosis spastica, 217
N^VDS matemna of eyelids, 819
of iris, 222
Nagel, Dr., on retinitis, 418
on subcntaneoas iiyection of strych-
nine, 616
Nasal duot, exploration of, 788
stricture of, 738
treatment of stricture of, 738
Nature and etiology of sympathcUo oph-
thalmia, 260
Near point, 616
Nearsightedness, 612, 619
Nebuln of cornea, 1B7
Necrosis of orbit, 764
Negation, actJTe, of retinal image in stra-
bismus, 618, 697
passive, of retinal image in ottaract,
299
Negative accommodation, 616
Neonatorum, ophthalmia, 7^
Nephritic retinitis, 420
Nearnlgia, ciliary. 66
Neuritis, color scotoma in, 480
optic, 466
retro- bulbar, 479
retro- ocular, 479
Neuroma flbrillare of lid, 818
Neuro-paralytio affection of cornea, 146
Neuro-retinitis, 467
Neurosis, sympathetic, 268
Nictitation, 824
Niemeichek. on color-blindness, 620
Night-blindness, 617
Nitrate uf silver, action of, on oonjunotiva,
68
Nodal points, 609
Noyes, Dr., on operation for secondary
cataract, 849
Noyes's naso -buccal flap operation, 860
operation for capsular cataract, 849
for entropinm of lower lid, 889
for squint, 714
Nunneley. Mr., on vascular protrusion of
eyeball, 780
Nyctalopia, 520
Nystagmus, 688
of miners, 689
OBLIQOB illumination, 84
musole, origin of, 669
functions of, 670
Obliteration of laohrymol aac, 748
Ocular sheath, 705
inflammation of, 766
(Edema of conjunotiva, 127
of eyelids, 796
of retina, 414
Ointment, belladonna, 67
Hebra's, 806
red precipitate, 108
yelloir precipitate, 104
Oldham's ophthalmoscope, 869
Onyi, 142
Opacities of cornea, 167
of lens, 280
of vitreous, 307
Ophthalmia, catarrhal, 52
diphtheritic, 76
Egyptian, 58
exanthematous, 106
gonorrbceiil, 71
granular, 81
membranous, 60
military, 68
neonatorum, 78
neuro- paralytic, 146
phlyctenular, 101
purulent, 58
aympathetlc, 252
tarsi, 808
Ophthalmoscope, mode of using, 878
aut, 377
binocular of Giraud-Teulon, 873
of Laurence and lleiscb, 874
Carter's new demonstrating, 371
■ I N DKX ^^^^^H
^L OphUiklmownpe, fliNi, «f Boale, 371
Orbit, euetr of, vetrrbooa, 773 ^^M
^^^ of C«rlrr, ST 1
MriN of, 754 ^^
^^H o( Liebrcld), 3T0
oellutiiiii of, 7A0
^^^H of Snilh ana Kwk, S71
ejtticcreus in, 77U
^^^H nMtio, of LorinK. 8<j9
entpbyaeiiiK, 7M
^^H »r C'occitw. 8n4
•xosioRid of, 7<i7
^^H of IlvltnbolU. iiu8
fraeinrM of, 7K9
^^H of KiMp|i. Si:8
hvmortbaKV into, 7M
^^H of UebreUih. Ui
liydBtJda in, 770
^^^^H Ijoring, SKii
bjrperostosia and peHiMlMis ftf, ItH
^^H 9f (.»I<JhnTO. U9
lofloniBialloa of oallular tiMno, 7(0
^^H of
IiiJdHm of, 7&VI
^^^^*^ of !£eli«nilrr, 8«i5
oecrosiB of. "M
^f (>phtbntiiioKO{i«« for tvo obicrfers, 8TT
pcrloxiii* of. 'M
^^^ OphthklnioMopie ftppMnuiMt of bi>allli7
pbuUe aperittiaoa M, 794
^^K «je». AiHb
pKMure upon, fnxu DelgbbdriKg CkVt*
^^^H opioineiry, 379
li«s.785
^^H Optie aiiii. W7
tuDutri of, 762
^^^^1 dink, nomuil. apbthiilmoMopic appear-
«iirtilii|[lQnu«. 707
^^H anew* t>r, 8^
Hvemottii. 777
^^^^ oertc. Jiwun »r, 4A&
eyttie. TH'J
^^^^^^ Rtrnnhj
^^^^^H cnrcinonm
arvclilo, 777
falty. 767
^^^^^^1 eolohoiBit of nlicath 4D2
fibroM*, yni
^^^^^^H oondttion of, io t«bM«i> umaaroaia,
QMBOUO, 767
^^^^H 4dl
Mrcovikloui (fibn-pUtUe). 764
^^^^^^H eong«nilal «xcn«ittiiHi of, 4t<6
lumon of. 4H9
^^^^^^H coiiMMUli** nlropb; of, is3
raacular, iTT
^^^^^^^B decuMalton of AbrcH of, i9&
wotinds of, 789
^^^^^^H dinbrtie iilTvuUuas of, 509
OrUUI ejriiadroina, 776
^^^^^^H dUgaloraiittn of, -lA:;— boIQ
liponatn. Ti'J
^^^^^^B txCAvation or cupping of. K&
pulsAilog tumon, 777
^^^^^^H of, from utropby, 4^
diflioiiUjr of diflfttoain in, T92
^^^^^^H flbna.
OrtliMoapio spcciaolea of Dr. (khtdUr, M>
^^^^^^H glaucouialoua eic&tnilwi of, 486
OMillftUen of «7eb>IU. 668
^^^^^^^H hcnirirrbiige 489
OstMina of orbit, UH of dmtkl litb* la*
^^^^^^^L Id «erul)ritl ainauroiks, 4Dfl
769
^^^^^^^^^^H inlluniKwlion
sdlxioqjaDClIrBl, I2C
^^^^^^^P bOurlea
^^^^^^^^^ pigmtBtntlon
^^^^^^V rupture of, 41*0
l)AOBNSTErilER, Dr.. on extraction of
L teas In itf c»p«ule. 3)8
^^^^^^H sircooia
^^^^^^m almpU procruaite atropby of,
on oblllcnilon of lAchrjmal aae. 740
^^^^r
on oparalioii fur entroptum, 636
^ tuiDoni vt, 489
oo pterygium. 112
^^^K Dcurlrls, 4tlA
OD ^elloiT oiul« of nerear; oUtlnKntt
^^^^^^^^ as«eiidtn|i.
11)4
^^^^^^H
Pagcniteeber, Dr. Herawn. m rapiurt of
^^^^^^^ retra-oealAr. 479
nptin nrrro, 4Kt
^^^H^ Opti«o-«iliitr)- nvuroiomy, 'HO
on «itrv»a« baoior, K^M*
^^^K Optomotitr of Von Orntle, (ll8
P«]p«bral bvDiorrfaagt, 790
^^H of Jft*al.
>;pbi1idci, 7WW
^^^H of Tbomion, B45
I'anaiii^ 133
^^^H Optomolr;', ophthaltnoMopie, ST!)
from mmUlioaa. 91, 18S
^^^H Orbi«ulatia p'llprbntruut, paUjr of, tU2
harpetMQS, )<i-j. )g»
^^^^1 spitaiB of, l!l'.'2
tranmatic. i:)^
^^^1 Orbit, diMftKs at, 7&4>
PanophlbBlQiliii), diO
^^^^H abMVM of, 7iiU
I'luitoiicopic ■protaulci), CA'J
^^^H ADBuriiimi of. 778
fapillilis, A'M
^^^B diffuse or falM, 779
['■ptIh'inalA of Fjr«lida. 814
^^^H
['arHi]«ul»ai» pifurw, 141', lAO
^^^^^^^ eanwr of, 773
ParnljfliB of ciliary nusclv, <}54
^^^^^
of fourth aertp, H&i
^^^^^^H Birilulliirj',
of legator |>«l|>*bno Rupvrivria, 810
^^^^^^1
of muMlu uf tbo i/ft S72
INDEX.
891
Paraljr§is of obliqnns inhrior, 681
superior, 681
of orbicularis palpebrnruin, 622
of portio dura of BCTeiith nerre, 822
of rectus esternuB, Gti
inferior, 681
in tern US, 679
Stiperior, 6H0
of ntina, 614
of sixth aerTe, C72
of tbird oerte, 678
ParenohjmatouB Iteratitis, 161
pBSBKTftnt, Dr., on corelj'His, '^36
PasanTant's operation for anterior eyne-
chise, 160
Pedragita, Dr. on leprosj of cornea, 198
Pemphigus of conjunctiva, 126
DO eyelids, 8U1
Perfuralion of cornea, 163
Perimeter (Forsier's), 42
Carter's, 43
of Landolt. 44
of Soberli, 44
Perineuritis, Hu
Periostosis of bones of orbit, 7S5
Periostitis of orbit, 7o3
Peripheral ojstutomy, 329
Periscopio spectncles, 662
Peritomj, 98
PeriTBsoular retinitis, 418
Pbakitis, 29;>
Phlegmonous inflnromation of eyelids, 769
Piilyctenular ophlhHtmia, 101
PhtycteaulsB of cornea, 134
Phosphenes, 607
Photophobia, 102
Photometer of Forsler, 89
Phthiriasia of the eyelnnhes, $07
Pilocarpine in onrnenl nifections, 136
in plastic irido-choroidiiis, 261
In vitreous opacities, 400
loonll; in phlyctenular eonjunctivitis,
106
of CarmHlt, 44
Fingueoula, 121
Piringer, on contagiousness of oonjunotiTal
discharge, 64
Plastic operations on orbit, 794
Polycoria, 226
Polyopia, monocular, 642
Polypi of lachrymal 800,748
Pope, Dr., on retinitis pigmentosa, 437
on trichiasis, SM
Position, primary, of eye, 6C9 — note
seconUury, Ii70 — note
Power, Mr., on transplantation of cornea,
172
Pray, Dr., test letters for astigmatism, 648
Prelncbrymal abscess, 756
Presbyopia, 628
Pressure, intra-ocular, 86, 688
bandage, 47
Primary position of eye, 6ti9 — note
Prisms, action of, 4tl
in muBOulnr asthenopia, 721
Prisms in paralysis of ocular muscles, 666
in simnlated amblyopia, 47
in slrabismus, 702
Prismntio apeclnoles, 662
Probes, iHchrymal. 788
laminaria, 742
Prolapse of iris, 168
Prothesis oouli, 798
Protrusion of k'o^' 767
Prout on sarcomii of eyelid, 617
Psoriasis of conjunctiva, 181
Pterygium, 109
Knapp's opernlion for, 117
operation for, 112
Ptosis, 620
fulsntion, arterial retinal, 891
venous, 390
Panota loohrymatia, 780
eversion of, 780
fungus of (leptothrix), 748
malposition of, 780
obliteration of, 782
obstruction of, 732
supemumerarj, 749
Punctum proximum, 616
remotissimum. 616
Pupil, action of atropine on, 218
of Calabar bean on, 214
adliesioDB of, 198
artificial, operations for, 226
by incision, 284
by iridectomy, 227
by irido>!fl!>is 282
by iridndialysis, 286
contraction of, 216
dilatation of, 212
exolnsion of, 197
occlusion of, 197
Pupillary membrane, persistence of, 226
Pupillometer, Mr. Laurence's, 212
Purulent ophthalmia, •'i8
Pustular ophthalmia, 101
Pustule, malignant, of eyelid, 799
Q
UININE, amplyopia from exoessivfl use
of, 612
locally in granular lids, 97
RANGE of accommodation, 616
absolute, 617
binocular, 618
negative, 618
positive, 618
relative, 618
of mobility of eye, 692
Re- adjustment, opemtion of, 716
K«alination of cataract, 887
Kecti muscles, functions of, 667
insufficiency of internal, 718
origin of, 667
Iteotns muscle, paralysis of external, 672
of inferiiir, (»ftl
of internal, 679
IHDBZ.
898
Slitting up of the pnactnin, 780
SmMlpox, ophthalmia in, 107
Smith and Back's ophthalmoMop«, 871
Snetlen, Dr., on distiohitiais, 831
on eDtropium, 886
on nearo-pnralytio ophthalmia,
lib
teBt-tjpei of, 87
tonometer of, 8S
SDOW-blinilDeHa, 619
Solution of cntnrAot, 887
Souk, l>r., on aneurism of central artcr; of
retJDtt. 779
Spasm of ciliary masole, 659
of eyelids. 828
of ocular mnscles, 690
8pecl(a of coroea, 167
Speolaoles. <>60
curved bine, 663
deoentred, 668
of Girand-TenloD, 668
in different refraotion of the two eyes,
6G5
mien. Dr. Cohn's. 664
OTthoscopio, of Scheffier, 668
paotoscopio, 662
periscopic, 662
prismalio, 6ti2
stenopaio, in corneal opacities, 171,
6<)3
Sperino, Dr., on paracentesis of ooroea as
a oure for eatiiract. etc., 846
Spinal cord, diseases of, a cause of aman-
rosia. 501
Spongy iritifl, 202
Spot, blind, 42 -note
Squint, Noyes's operation for (he care of,
714, see Strnl>iBrous
Staphyloma, 161
anterior sclerotic, 274
Doretli's operation for, 187
Criichett's operation for, 184
de Weolcer's operation for, 188
Oraefa'a opernlion for, 187
Knapp'a operation for, ltJ6
latent ditergent, 718
of cornea and iris, 182
operation by excision, 183
posterior, 682
rocemosam, 1G4
treatment of, 181, 188
Stanung's pnpille, 46ii
Steinheil's glass cone, 026 — note
Stellwoft Ton Carion, on granulations, 82
Stenopnic spectacles, 171, 068
Siillicidium tachrymaram, 7:^9
Stilling, Dr., operation of. for stricture of
laclirymal passages, 742
Strabismometer of Mr. Laurence, 674
Strabismus, 600
active negation of retinal Image in,
ftllernans, 698
apparent, 687, 697
ooncomitane, 698
Strabismos, convergent, 698
in hypermeiropia, 6S6, 608
in myopia, 701
Critchett's operation for, 712
divergent, 701
in myopia, 701
Javal's orthopaedic treatment of, 708
Liebreich's operation for, 712
linenr meaHurement of, 678
monolalenil, 604
orthopeedic treatment of, 708
paralytic, 671
operation for, 716
periodic, ti09
operation for, 714
primary deviation in, 678
secondary deviation in, 678
secondary, operation for, 716
treatment of, 702
by operation, 708
▼on Qraefe's operation for, 708
Streatfeild, .Mr., on corelysis, 286
on entropium, 887
on operation for obliterated paneta,
783
operation for oapsatnr cntaraot, 850
Stricture of lachrymal passages, 788
of nasal duct, 788
Stromeyer, Dr., on granular ophthalmia,
85
Stye on the lids, 808
Stylo, Inohrymol, 744
leaden, 744
Subconjunctival cysts, 123
osteoma, 126
Suction instrument, Mr. Teale's, 814
of soft cataract, 844
syringe for cataract, use of, '-iH
Mr. Uowman's. 845
Bnpra-orbital nerve, division of, in ble-
pharospasm, 828
Suture, GonjunciiTal, in etrabismus opera-
tion, 709, 711 — note
Sylvester, Trof , on leprosy of cornea, 192
Symblepharon, 114
operations for, 114
Arlt's. 115
Teale's, 116, 117
Sympatheiic choroido-reiinitis, 256
irido cycliti--, 258
keratitis, 256
neuro-retinitis, 266
neurosis, 258
opbthalmin, 252
enucleation in, 265
nature ami etiology of, 260
serous irilis, 256
Synohyais, 402
sparkling, 408
Syndeclomy, 98
Synectiia, 1117
annular, 197
anterior, 154
posterior, 1?7
Syphilides of lids, 799
H ^1 ^^^^^H
H SirvMla «r w^vwtfn, 138
TabenlH of ntina. 403 ^^|
■ STfWltic timrm^MM, htS
ra(i«reuli»i* <>r «i>iijiiiKii*a, 180 ■
^M MnMlH*. Ifil
Tatnor*. oervbntl, a. csagv vT aiDBUratlf, J
^^_^ iritla.30t
4{)a ^J
^^■1 t«Mlu,«SI
dcnuoWl. 122 ^^1
^^^B •iMnvFcM^jaMtiM, 128
of ebarol'l, MA ^^^^|
V af cTctiil*. ;m}
ooc^unotiTk, 131 ^^^^H
■ 67TiBp ■or Uehrjw*] •fjwntnii, TSQ
of cnm**, lUl ^^^^^H
or ejtW'in. »|0 ^H
K^ flnkKlskr am •rUuI AMttrlui. 781
^^1
^^^^ •■ pt«v7ip«B, iia
of Uehrjraial Rload, TSB ^^H
of opilc arrrc. 483 ^^|
^H
■ 1 a^liltelaU. 0W
nf reilii*. 4&& ^^H
Tarpentlnp, uw of, In IHUg, 214 ^^H
■ TftniHt mtltmticB, MM
TMllotiii>K of rjreUdo, 321 ^H
^1 T%Uo<>iBc Ike conwA. 171
^^H
^H Tftjiar, lir . <<n e«Lkr»ct, SS^
^^H
^1 Tt»)«, Mr. i>n4ciM, «a cr*t<H'*iu ^ ■»'
rTLCERS ofeoRiM. ISO. |&» ^H
U r<Kli-nl, of cjellil<i. Kit ^^H
^K terior clitaibsr. Ulu
^^^^1 oa ■aroarj ui4 atr«|iiiia In IrlUi, SOS
ayphtlltli!, af«7«ll<lB, 128 ^^H
^^^^1 «« mtlkod af tsvaialog tfcft IMd of
Daguia. ^H
^^H ihioa. 4i
Dieria* disease la eyaiill*. 260 ^^H
^^^^1 «• af«r«iiMt hir ^^bUpbaroa, 110,
^H
ITANZitTTI, Dr., oa orblul anrari*», 1
1 ;si 1
^1 T«a1«'i op*t«iiua to *an MiarMi, M6
■ t»hfh>i»«i irf artUd*, HIS
Vnriolona aphilioliaia, 107 ^^1
VnKiiIar Krnirtliti ol r«ilaa, 462 ^^|
^^^B *r nrtilt, TT7
Vvmtaa |<ul»ii(Mi of eauinil *««m>U of iba ^^
^^^H «r ntinhl vMwt", 41S
rrltna. H.tO 1
^^^ Tmw, «.]Mik> af, 70&
Vrrnnn, Mr., on tulirmlp of aborvtd, 64V 1
■ U>«amiloa of, ;M
fe^iculftr )Er«iiul ■linns. B2 1
■ TMMitb. ;u
Vcsoel*. coiijunclital, 63— iiula ^^fl
^H T*«ai>mj fur MralihniM, 7tX
•c1eroi>c, bS ^^H
^ft^ Tkmwi, tBtr«-vcal«r, nod* at flatiHistlng,
guhoonj unfit it ■], AS ^^H
^^K
Vlrabow, l>ror.. on exopblbalmle icaiire, 1
^^^^V Id (t*uoani«, UR
76H J
^^^^ la inirvoetiUr lunara, 447, Ul
o« gtioma lit Uie retla«. 4M ^^1
^H TMl-ljrpos of Dr. John Urecn. 38
oo oAreotun of ehoraid, 663 ^^|
^H ThttotwM'a Wrjgt tachrYintl |>rnbe*, 748
of orbir, TiW ^^B
^M Tklrl sMtVi par«1v-i9 irf. nTM
Vision, biuocalar, made afesamiBatioa of, 1
^^^^ Ttefluui'B aaMir><iii«icr. ttii
(>H6 ^J
^^^H opiwoifivr.
Id BirablBiniift, n!)6 ^^M
^^^1 TbranilkMM af r«Ua«l vesMls, 413
fleld of. Btmle of exAffliDatioB of. Sft ^^H
^^H TVmm uni, 803
Vliual angla. flOtl ^H
^^^1 TvbaoM KmarMlf, Al 1
1lB«. (HI7 ^H
^^^H MKl>ljr»|i|i*. 61
VillUgoldM ptlprbmram, Wff ^^H
^^^^1 «o(iJit«i«tivlUB, AS
Vlireoaa bumnr, iliMaw* of, Sl)8 ^^H
^^^B ToavnrNr. W — not*
afaoloilniof oryiiali ia, 403 ^^H
^^^H at Ki<«llcu uhI Laadolt^Sft
ejroticcreuB la. lUfl ^^H
^^^^H T*w4ii>iu«,
ftliirt* -plraK* in, 403 ^H
^^^B TniivpluiiktiMi of ciUft. SiQ
flai'l eooJirioo of, 402 ^^H
^^^H a|<«rftilMi »f, tM r«atomlloa of e/elld,
forHigii in, 4U4 ^^H
^^H
b«tnorrliiig« Into, SftS ^^H
^^H Tniunaiid oMuut, 303, S43
JnflBmaiAiieD of. SU6 ^^|
^^^H Tr*iDiilouilri«,
bc»-|<Uilio furanlloaoEa, 409
^^^H Tr«t>lilne, Mr Boiriaati'a, ITS
ti«w )>1oo4reiM»U \m, lOd
^^^B 4* W«eher'9, lift— oaU, 697
epa«itie« of, SIiJ
^^H TrtskiMrfh (*»4
afoctriuiljr In, 400
^^^H tiMted t<j (TttTanu-canlcrjr, Mt
renaval of foreign bn'ittt fron, 106
^^^^B bj liKKture >if UJ, SSL
VitscuUr ncn giuWIbo in. 4IH
^^^^K T«bcrtl» uf ahi/ruitl, &4i
Von U'lrow'i oprratioo for inobmaiB aBil
^^M af irk, :iu
■
INDEX.
895
WAQNER, Dr., od intm-ooniRr tension,
663
Walton, Mr, Haynes, on exoBtoiis of orbit,
760
Wu-lomont, Dr., on ofaromhjrlrosis, 808
on Stilling's operation, 742
Warts on oonjunotivK, 122
on eyelids, 813
Wartj outgrowths from the choroid, 646
Watery eye, 7:;8
Watson, Mr. Spencer, on eetons In comei-
tis, 158 — note
WenlmesH of night (nsthenopin), 636
Weber, Dr., Cftnnlicuiua linifeof, 740
grndunletl Inohrymnl sound of, 740
on abscess of cornea, 148
on oorelysis, 236
on persistence of pupillary membrane,
226
operation for cataract, R22
Weber's operation for capsular oataraot,
851
Wecker, de. Dr., on cyets in iris, 221
on delachgd retiua, 448
OD fistula of coinea, 161
on foreign bodies in anterior chamber,
230
on linear extraction of cataract, 331
on method of examining visual field,
42
on myoma of choroid, 556
on operation for optic neuritis, 477
on operation for staphyloma, 188
on remoTiDg lens in its capsule, 819
on sclerotomy, 690
on secondary cataract, S47, 860
on skin grafting. 851
on tattooing the cornea, 170
on trephine, 178 — note, 51)7
on trephine in glaucoma, &U7
"pince-cystotome," 828
Weeker's operation for corneal atophyloma,
188
ophthalmoscope, 86R
peripheral extraction, S31
pince-cystotome for lacerating the cap-
sule, 828
Wedl, Prof., on colloid disease of choroid,
646
Well, von, Dr., on simulation of amauro-
sis, 628
Williams, Dr., on trichiasis. 826
Wolfe's eorneal transplantation, 172
Operation by grafting for pterygium,
118
Operation or grarting large pieces of
skin without pnlicle, 8->l
Wordsworth, Mr., on glase shields in sym-
blepbaron, 116
on gonorrheal iritis, 2U3
on tobacco amaurosis, 511
Wonnds of cornea, 100
of eyelids, 858
of iris, 218
of lens. H'M
of orbit, 780
of solerotic, 277
XANTHELASMA palpebrarum. 808
Xanthoma pnlpfbrarum, 808
Xerophthalmia, \W
Xerosis oonjunciiTic, 108
ZEHENDEB, Prof., on fistula of cornea,
181
on orbital tumors. 7*i4
ophlhftlmoKCope of, 365
Zinc, chloride of, paste, in orbital tumors,
764
I
HENRY C. LEA^S SON & CO;S
(I.ATI HBHRT O. tU)
or-
MEDICAL AHD SUEQICAL PUBLICATIONS.
In asking the >nontton of the jirofi-^MD to the work* «ilv(!rl inrtl in the fnllonrinj;
pBg«-s. llw [Hitilishent would (Ule (IihI no puii» nn- 4]i«r^ lu «fiifii! ■ vuDiimiuiK-v of
ttif tvnilitltiicr ixtniod Tor ihi' [NilrlifaliiMM of ilii.' h<nu<r hy thrir cMTvfal nt-lKi-UDn xnd
■wurary nod finish of extMrutkm.
'i'/f ''T'/' nuiwA^r "/ inquirifa rtC4ireit /ritn ikt pra/ettiiA /or a finer eta$t of hinit'
irtffi lArin i'k unnnU^ flavM »n mciitftl IkuiI:* km inilttctd w( In put e^rtai,, of nur
itamiaril jmhlicatiun* in hiilf Rutnin, amt that tkf ijrtnciug taste mug hr tnctturmjril,
Ikf /iruvB hnt^ kttn fixed at to gmall an aJtvnet over the entt nf ifufp, an to jtlart it
vi'tAin iMt tufOnM 'if att to ;>o«««a« a librnrg that thatl hane altracliona a» w*lt /'or the
eyr n* for Ike miW of (Ac rmiliug prneiilfm^r.
Thi' imuifii prk-cs •r'.* lliusi; Ht which liMtLs c*fi |i>^iMrrKllT hp »u|)|ihVii by book-
(rllim ihroiinlnMiI iIk- l.lnit»-<I SiaU'a, who can roiHity proriitt; V«t ihiir cuiUtmcni aiiy
worki' inH k»'I'i in Mock. When? hi^cph to tmokMorvs is not <.-onvi-tiii-ni. hooks will be
«rn( 111 iiihII iionUpeiic) on rr-<H-i|tl v4 iht: pmi.', Htxl w thr liinif ai muiUlilr w^i^lit haa
lieen n-iiiovL'il, uu tliflit'ully will hv vxperiotMviJ iu obiniiiin; throujfh iIm- |jo«t'Olhri-
nny work in lhi» cululugur. No ri»k«, huwevnr. are wNumol .^'ilbr.f on llui luunvy or
on thr b(K>k«, sml no [iDhlirniionv hui our own nn* »uji|il)i-il, «<> tlmt ^<_-iitlcmcii will in
moBl ca»c» (inil it tnom: cuDveoient to dtui with thi- iwiitTit l>ou)(«<fHiT.
IIKNUV C. LEA'S SON ft CO.
No«. 7ua Md 7W Samwui 9t., PatkAi>UPflu. S<>pU-iabrf, 1BH1.
INCRBASEIi rXDUCBMBNT FOR SCDSCRtBBRS TO
THE AMERICAN JOUUNALJ)F^TUli MEDICAL SCIENCES,
TWO HBOIOAL JOUKNALS, ooaUiaing nevl; 2000 LAfiGC PAGES,
Tree of Poatege, for FIVE DOLLARS Per Annum.
TSBMS FOB ISBL
MRRICAN Joi-KXAI. OF TIIK M^KICAt SviKKUBB, puhluhcd 1 YlvO Diilbira
(jiinrli-rly (1 150 iiugi-a \wr aiiniim), with \ xkt annum,
TiiK MUTUAL NxnB A>u Aii»ruAi.i. mouthly (TfiH pp. pi>r unnnm), ) in aclvsocv.
SKeAHATB SVh»CXIt*TtOtt» TO
TiiK AuKHiCAX Jouk.NAL. vf Tiut AIkpical SciKMOXB, whfin not paid for is
mlram'd, K!vh iJolUn.
TuK MEt>ic.\L NKWtt AM' AusTKACT, frou of poMiige, in advance. Two lloll^n
iind n Hull'.
%* AlUiiticv paying nibecribcre i-an obuin at the doxr of thn rcjir rloih i-ovrnt,
gilt.letlLTi'd, for ffii-b volnmv nf the Jounml (two annually), ami t^ tliv Ncwi aiu] •
Alstnrt (one annually), ln>« by mail, ^ reniiuing tvu cend lor each vovrr.
L
Jt will thns bo Men that For thn inodundtf aam of Five Doujiitft in odvatkce, th»>-
■tibxiTilMT will rrtvive, frfc of postik^p, tki' ninivalt-nt of four large or|«v»> volume,
Mtortrd with tlu; dioicrst inutt«r, original nixl M-K-ctvd. that cuil bo ftiriiiahtHj by llw
medical Itiirmturt of both iM-mi^phnrw. Thu« taki^n logvthcr, tht " J<>i'rxai," luid .
the " Nkws akd Abstiiact" (.■ogibiuo (he advautagef of (be chiI>onit4! prvparation
that can be <](>TOCtH] to the Quarterly wilh the protnpt fonvcyaoK of iatclIig«no«.by
thtf Mnnltdy; whilu, tlir whole brin^ tinder a aiagUs aditorial tti|HWwisiun. lh« *ub.
Bmbvr IB Btxurvd ii(:uiut tlia dupliiTiition of nuthv iaevitable whuu pcriodicaia frvtn
difr<!reu( sout^ci are token toi^lhtT.
The ponodickla thua offcniJ at thk naprvcedettted nta in uiutvmXk^ V'brn*^ l«
2 Henrt C. Lea'b Sow & Co.'« Pt'iiiiCATirt5»g-^(j4m. Joum. HM. Set.).
tlicif bigb profcuiooal rtsnding.
1.
THE AMEKICAIJ JOURNAL OF TBE MEIUCAL SCIEKCES,
EpitbpbtI. MINES HAYS, M.D..
for morr than hilf a ccntor}* bar mntntiiineil iu pmttinn in t>ir (Vont nnk of ilia
■pedkal liti-ralur* of tW world. ConlinUy »uij[wrtc<i l>v ihc profeMioD ol' Ammra. it
cinmUtvi wht-nv^r tlie Inugwi^ !• rpail, mmI m unitcmillv TvponliHl ar tb« luitiotial
fX|>onent of Arnwiwin imslicinr — » prwirinn to wIik'U il w ciiliUi-il l<y Un- (1i»linpui»li*"3
iiiimcs from (>Tei7 BVclion of ikc ITnion wlik-li aro lo l<€ fuuiid jitnnn); it^ rotUliuniion.*
Il is ■■m<-<) ([luirt^l)', in ilaiuinry, ApHl, July, »ni| Ih-rolirr, r««'li iiumbfr L-ODtaimng
aliuQt tliroe huitdrcd octavo pti^v*, nppinpriiiU'ly )lliisiniii''l whviwer nvr-cvMiry. A
liu^ ]>nnion of tbis Epacu in (Ii>to1«1 to Oripnul C»nifutinirflti[)n!>. embracing japm
Iroin t|i(> mcMt omiiu-tit mvmberx of Ihc profMiioa Ilirotij;liout tbc i-ouniry.
Following tim it the Kevikw I>KrAitTUKST, conuiniiig cxtriitlvil rvvkwy by nxm-
pvtfiit writi'n of proiuinrnt nt'v works and to|iics ot tlif rlny. lo^-ihrr witb euB»«tMH
tflnV-uraii' Anslyticnl and liiMio»Tkphtcal Noiica, giving a fairly co rap U'te sarwT cf
niciliml litiTAtare.
TllVU foUtmB Ihi' QvARTEBLT SUMMAnr or Illl-BOVIUirNTS AKD BlACOYKBltS
JK TtiK UKDiCAL SctENCKs, flUuified and arranged atidiM- diUWiitl head*, ami Aim-
i»l)in(C n (niiwt df niv4li<-al jn-n^'ss, nhroad kim) at lionwf.
ThusdiinD^ thv ynir lt(Hi> thf "•Ioi'iinal" rontaiavd £7 Original Commnniratiocii',
InoeUy t'bUoriitc in <.')iumct(.-r. 170 K«virwBiin<l Uibltiyrnpliical NoticM, and 147 wticlM
in tli« Qiiiirtvrl) Sunitnariex, iUgmral^ witb 47 wwmI vngraviitpi,
Itat the efl'orta ihna taade to inainl«i» the kijrh rvfxitalinn of* the "JocuxAL" »n
nt'cvMltil, i* showii f>Y (ho poMtion auconlvd to it in Viotit Aim*rica and Europe a* ib«
leading organ of ini>dic-ul progress: —
■nit t* tinlr'nAllr ■«knDWlo4R<4 m tko t««aiBt Th- rkllmlilphla Mtiifal tf« rhT-|r»l J-^nittl
Jktiiokwii Ifeuiaal. kinI k»» 1-mm ntujnolad t>j Dt. I»>>d \:t. attt uuMrlri ]r l(^>, ••iI, afui > lirt'it*Kl
Vaja »talM Dhlll 1^*. KbBIl hkn Mk «>■• nxctinirJ (Mr4*r, Uiu tin <:' 'ill 1 Ir l-J. iv lli> Ani>ilia«
L«|lt>Illni W« QBIIa UK!** Wllfe ill* < : II- J»ui<lll 111 it' ' - ,- ,if
[ JuDruil ImaftaitJ lonoaitlBib* tauKu <- v.t.U-irlil* rt. ' ' itit
I fall* troaril la II ill* fltal plMv, fill i| ,.i<t«*i (wI'^ith i i hM
Wr tuil uivic kklP kud ■•»!• Impailtiil :.! ■■ uudtnirJ iB»M<l.— Irrw«# * ifwJ^y h/ rf
^utf Id*' ■Dcb a i«p*rtuf f ol abl* ur\ J^mJ ^tf#pqf>M* t^TA-
■I IhK "~
Itxlpril, lr4« tliH
■BrltUh nna I -
Tb* >>(ti u>*<l)«ftl J'-ar*«t»*#T p«l>II(h04 IB l«Mt»
(h.rnrKlMl H»vl-wr h., I,.,.l.,.tr,l li. ....... liw o( »,ii»i,r. _1 « W^ Jr..»M(v, W.j. liT».
A"t*ileaK Juutaiil tUailf vtifcuvl a ri*«l.— Z>ini4li>« . , , ....
»«*. Ttmtanim«ttllt,X«t ftl, IftTT. Il |. eDlMr-allr t.f .v.l...,*4 ■• !.• th* laa4la|
. ..... _ Anvrifau ttrji - iu<l. la uMt tfalaisa. u
•rkaliMi MdliAlJoarii*! » Uia w»iliia«n.-«M- .„.„d ,„ „„„, .f..-ii*.l*.Of-i. -•<
,(o# JM- ""J »•"*. /<«™oi. A|w't. 1ST» . ij,,^ /...ruai , ■ ■
Tin |OT«al i.«ml». of Iha AuiTl<^a>> J'orMi I. . Tfcl, U ift. ■^...1 J.,a..ul «f»or«„at«l»wM*ll
*n.-3^\iotly |[*.l «ii-.»»J K »« r^,,)f ir«o.l., ,k, ji,„„,„» pt,,i„,, .b„o.a»lll ralol *li|i U*
*l ..l»l..a<ii« la- w^n-rn^l r.roU.U« o(«h. ^n-a.-.l ...Ull*1l«a. a. «<-...«« Ih- Mai, nf .-.I.
t«*Uv. llnr.aar.aH. ^ . . h.. .>uth»i „i,„i,„„., hi. .-uaKi T,...*«al m,mr jwtt
«Mb«a.wd (r- ran ...ir . fc, ,., that H ,, ,,„ t.„ ,„, ,„4,a». n^«,.i, w».i»k .-.ir .bl«i
Arid tliaJ it was fpecUicjiIly tncludn] tn tlie award of a mrUal ol' ncril to Uie Pkl^
lialMra in the Vienita Kiliiliition in 1|I73.
Tbe wtnoiptian price of the "Aubeicak Jouakal ov tuk Mhmicai. ScituiCKa"
has iwver hivn raiw^ daring itA iong CArt^vr. It is siill KtVK l>oiJ.AiLa |>t-r annum ;
and when paid for in advHncv, the sabwribcr ri-vviToa in addltioo A* **Mkuicai>
Kkws A.tit Abstkact," making in all tiLiarty 3000 large oouvopagiwiieraiitMim, frea
.of postage.
THE MEDICAL KEWS AND ABSTRACT.
Thirly-Wicht years ago ibe *'&lviiicAL NKvr»" was comm^ncrd as a monlbly to
eonvex ^ ^^^ njlncriben of tlo "Ameiudaii Jouekal" thi) clinical instrurtion End
■ CftinaimBkanasi an I>*1>«1 tnm iratlajaBB !■ all ni
IliM u* Ubt nUr paid for hr tks rakltskm.
UIIM
u uf Ika tauaUj. AttltlM laaarMd tj Um
enrrent itifortnKdoa wbrrh t-tniM uot bv An.-ooinioilut««] in the QoNrleriy. It rouMHwl
of oixtreD ptkfce* of fluoli iHJiltEr, to^tli^r witb «ixU>4Mi mofv known u the Library
PfparlRii'til >nil ilrrotttl lo ilic [lubliiiKmir of books. >^'i(b the incTvurd ]>rc^r'^-w of
!«ioi)oi-, linivnvfr, tliis w»s Toiind iiuufficicnt, wid somo yvnn nince Mioltii-r jicnodirjil,
kiiiitwn KK tliv " &k>NtHLV AhMTkACT," WD! DtATtiHl, and wu luniialied at & modfriilo
prirc (o subecrib*'r<< (o (he "Amkhican Jocit>'AL." Thv»e two niontlilie* tiHVii bi-po
voniuliilnwd, uutlvr llie title of "The ACkdiCai. Nkws akd Ahxtkact," knd ar«
furnWird /^ee e/chartfe in roiin«ciion with the "Ahkhicak JovKHAt.."
Tlie ■' Nkwb AM" AuTiiACT" (.■aiwwt* of 64 ]in)^9i iniiiithtv, tn n pwit cover- 1(
coaiutiosa Climcal l>B[>AaTMKNT til wtm'h will hv voiitiiiu(.-d lli« u-nve ffOuiuiNAL
AMkiitnA;^ Clinical hKcrriirs, b^ gt^'ntlcmt.-n of l)i<.' lii}|[liest rcputatiou throii](li.
out lltu Uuitct] £)UiW9, toKvlbvr with it vLoive Klvi-lioo of foreign Lmtunv and
lln^itnl Nolo Mid (rWitniitgM. Tbrn follovra (hv Monthly AR.<tTiiACT, nj-jK-niuii.
cuUv iHTaiitit*<l and rlusificrt, and prcsciilii^ five or vix bninlrvd biIwIm yeiirly ; and
each nutidKT roni-liideft wiUi im KnrmntAi. and a Ntiw^i I}r.rAi<'nii:.\T, iiiving cur-
rriit iiriift'^sinriAl iiitvlli^-in'f, ilouii-ilit ami fotiA^a, tbi; wboli- fully inilcxt-d nt tbv cIom
of ciM^b voliiinu, n-ndcrinj; it of |M-Tnam*ot value for rcforcnur.
A.i HtaifH nboTi', tbo si(bM-ri|ilion |tricc to the "Nkiuft axd AjmtkaCt" i> Two
Doibirti nnd a Hidf pur annum, inviuiably in adranve, al wliich nt« it nuikd u uiw
of tbr obMipt'.it moflirul fM-riodirnh in the rountri'. Rut it i» nUo furni:tbi;'il, frtv ot
all cbuJ^o, in i-niutiiiiLitian wilb Hut " AukiiiL'A.v Jouknai. ur the Mhoicam.
8cii::ncu>," to nil wbon>mit Ftvit Dom^ds inadvoncc, tbiis pvin^tolbc MilncriliL-r,
for that ycTj moili-niti> lum, a complete rvcord of medtcit) pragrvaa tluxmiibout the
worl^l. in tbe coiii]iaM of about two ibou^and lar|^! oetaro papv.
In thi* fflort to fiimi«b »n \uTfif an amount of prartica] infornuition at a price *o uii>
prvcedi'niediv low, aii'l ibus jilacc it within tbv rvnch of vvvry DWuber vt tbv iirufvx-
cinii, thv piitilis|u-n cO)itidi-nlly iiiitiri{nil(r llit^ friciiill}' aid of iiU wliu fct-l nn inttri.'-jt in
tbe tlusEvminatioD of itt<uii<i uii*dical lia-ruturc. Tltry tnift, vspvciall;, tfant tltv nib>
•criber^ to tbe '•AVKHICAK Ukpicai. Juubkal," will call the attention of their
aciiuaintancc* to tbe advw)ta([«s thus otfered, and that tbe,v will be sunuinvd iu iIhi
(.-ndt^'.tvor to permimently vAUtblioh medical {MiriodicAl litvraturc on a footing of i::b«ii|»
nesB never beretofon* atltnipled.
PBEKniM rOK OBTAIKIHO HEW SUBSCRIBERS TO THE "JOURHAL."
Any guntk'iniin who will n*niil thv amount for two iiibscriptians for IbAI, oih- of
whicb Hi li'-iut niuitt bi! Iiw » ■■• >r tuhtrriftrr, will n-cvivv as ■ J^JUCMIUM, frw br niaij.
a copy of any ono of thu following rwcni works :—
"Srii.KK ON TiiK Tm(nAT'" (lee p. 19),
" lUitNKs'B Maxital t>f MiDWirKUY" (bod p. S4),
*' llllUlVMt UN THK V»K VV THK Ot-HTHAt-MOM.OfK" («Ct> p. 3fl),
'•'Fust's EftBAve OS fVisBKuvATivK MmiiciNK" (bc« p, \&],
•'Sti'kukk'b Clijuicai, JIei>ici»k" (»vc p- li),
"Tasnkr'b Clisioai. Manual" (wv p. 5),
" WkST V> NEltVULI! l>lflUltM:iUI OV C'UILt'KKX" (KO p. 21).
*„* fiendi-mL-D desiring to avail tbcmnelvca of tbi- advantaged ibus olIervt\ wil]1d»
m\\ 10 forwiinl tlicir iiubw^Ti|itioii« at an ■Nirly day, in ord«r to tmun: the n)G«(l)bof
eompb-tn setii fov the year ll4til.
tf^ Th« safest inoilc of rcmittancw is by bank cbwk or pDftal moiwy onlrr, drvwa
to the oritpT of thi! uwlcr^iifm-il. IVbrr* tbi-M- jirr nnc iu-ci-M<il>I«, n'uiltancvii foTJliv
'*J(>i-itRAL'* maybe nude ai the risk oi'the jnibltahen, by fonrardiog in RKOtUKiixt^
ktlere. Addmnt,
Ukhht C. Lba's Su» & Co., Not. 706 and 108 Saiuon 8l, PbiU.. P«.
nsNRT C. Lea's Son II Oo.'b PuBLiCATions~<( ilanaaW).
CKSTURV f^F AMERICAS MUniCISE. UTIUIST* By Uuelom K. 11,
Clkrk*. H J. Btpelcw, S. I>. OmiH.T. O. Thoni-* »nil J. 8. Billing*. Inoiia •'•rykaail-
fOna ISnc thIdib* ofabnut 3>D ps|pl : Klotb. t) I».
■hJRtLh {JOHN), M.D., and OMITR {FRASCtS O.). M.D., ,
AN ANALYTICAL COMPENDIUM OF THE VAIITOUS
B&ANOUlfS OP MBDlCAt SCIENCB^ for tba U«* and Kiamlnatioo of St4ia»DU. A
OOMlltica, r«Tb«d Mni lnpT(>T*<l. tiii>ii« v«r]rlar(«Mi4b«iiil««in*4;priiiU<l rojkl IIilu.
roluma, o( ab«Bt »lt« thouanU itagM, wtib SI* wond-eutt, el«tk, ti i (ironglj bound ia
. Ualhei, wllb raiMd bMxb, $4 U.
■
■
fABTSHORtVElBENRD.MD.,
A CONSPKCTUS OF THE MKDIOAL SCIENCES; rontnining
BaD'IWgk* oa AnaUinj. Phjiiiulogjr. Chaiautr;. ilatrrU MpiIio. Practtral Medk'ta*,
Snriifrr >a<l 0b«uiuw«. tie«ond KiJiUun, thor^agbly ra*l»«<lanil inpro'xl In ■>&« lar(r«
r«y>l ISoiD. vvlvtn* of wor* ilma I0«» oloi^l; |>/lni«<l pag«> with 477 llluiiratloni ««
wood. C:olb.«4lS; Uaibvr, <fr 00.
Wit van •>; mill iii* ■rilct**) tiuih ihar li t* ih« worib;. If MDibDit ninat i*T* ■ auai|i(nna,ife*T
bad auikur 111* hind «itti wkieb «' *r> Miianiaud vlll ba <rua i*> prMata iliai a\ tit Hmiabofaa —
ll •rakadU'laaC'iud'a*^ furimtl inraaKHUtillia- Oariril Rn-itf Mail «■■( ^A>tp« , ««« I«T4
tlaaXu piaKlral >a>ili<l>i«, aO'l l> lliartkro HMfal Tk* «mi
!•■ aTMj b*'j pnetUi-ian l'*ti'^K^-ni out riiaaltjr, ^ ii«,m«»J t.y
baaMaa Wla* ■•ImltaMr >dirl*-l >" !■>« ■•' ut *<<•- .^u n, ii>ii.<
daal*«r maJlelD*. T>,. !...« ^' Mlhl.lly aad ably *"'
aaacatad — MiTW*>t<n> Had. Jiturn. , AVtll. U71
Tha WMk la laiaBila4 aa aa aldiuilia oiadUat
•in taal, anil a* 'BKh ■!■(«*(■ !• ad alrabi)' fat! I lu
«b|ECI l>7 ili'Kti-llrul «iraa««iu*u(.iaa futK-iMr''
l*lt^l• or rati*, I ha f^i'iilriiXlf lud •.•■(•aaaa of Ian
Tk* mtrll bafar* n* k*« manj rvdarmlai halaiva
'I- ika bail ■• bar*
■ iBii')! •kill In f>oa>
■taBaailnn. ll 1- ' , .1 ),. iJi* rliTnlrUti la
bdlTa t>racll«fl. irnri <(,, 11 ■« iiBlllnillad ifii>a in ika
flmillarUiaKsf hiiaaaKwIth lb* Inp-iriaei (faaaa<«
wblrli karit b«*a nmi* tttfr hr •Xanif.d toriritnt.
Tba uatDAl uf plir*li>t'
• ad rIim lb* atuai cciui
fu*(r, and ib'a <laai aad la*IIilftlTe lllknliktinB* adTanraala tb*Ml*at'
ta I'm* r»"* •>' "i" *"* — ^"•"■'""•» /■•"■ a/
/•barauiV, PbllaAalplU, Jalj. 1STI.
Tba aulunia will ba fuuad aaafnt. But uolf t'l ala-
Jaaia ba oaairuikaf t wk-Uiay daai't laialraib
IImU ni«ia>irl*i aillb Iliaaiii4ll*at ptiulbUaxpaadl
larai^ilma— .V T. Mfl. Jtnmtt.BtH. 1S'»
Tliaatudaat Will And Ihlilhr moalenuTealaal »a4
aaafal bixiK af tb* kl«d on wbKk ba (an Uf bl
4
%
tu Iba tuhjarl. TIik ■xuIumI'iI niM-ir.ii, vi" Iba
btf&k Uaraa KDlblai lu 1w «Mi>(4 tat, — /Vainanlar
Aflar (ar«faUr lovktag [br«it«li tila aoMpariat.
wa an oanatralaad lu aajr Uiat 11 la ifca hiimi «4i«.
flat* w<rk. af^alalljla itatll<ul(aitmia,i>rtuk)B4
ibal wa baaa awn — ilnHnmait i^n/m. SapL Iftlt.
Tba haor witk wblah Iha BtiI t JTtI la ■..' IhU
Cnmiwadtain waa naaiaad. wa> au - t i|«
b»B4 — Pia<;(o JTirf uw>< .Ixri; ^owrs., Aa« Ifl'l
Tbt* la Ika baal b'iak<irili> klvl <)iat wa fcara am rail'ia* aieallaae^a Tfe* (irvuBl ' ' ■!.
ax* ml Dad 1 1 *• aa koa«*l. a< cataia. and eoaclMi dMiea '-T t r>ri''3t tai tfei>r«i>(1i ra'i- iia.
ait»paad "f ■"dt«at«i*««a. a. faifly aapiMMIiia ki'i>- ' * of •eiili» jjnu iba
taptaaaallaa Iiiair pr>-autCi>adii!iB. Tha»h»a(*a (all' 1 u4 nfiiraaa^itvc IhfU,
and tba addlllaaa baia bnra aa iBJIeloaaaad lb*- , In a . '"aa Maaost — Lmvsb-
(«aikaatiinadarll,aofaraali|«ai,*Btlialjiraat-| warf/i Jf'-f /f^r1IlJ, oci. l^:(
r DDLOW(J.L.), MB.
^A MANUAL OF EXAMINATIONS apon Anatom.v, Physiology,
Sargary, Prxitiaa nf MaJirlea. Ob>t«lrlca. Mal«ria Hailles, CbanUtcj. Pbaraacj- «d<I
TbvrapBuiiM To wbU-b U addad a MeillealPnrBialarjr. Tbirdadillon, (boroagbl; rctmd
tadgntaily ailendcl «b4 anlargad. WUb ITO flluttradont la »iia baadiOBi* rttjrfti
lamo. volunaor^lSUrgapic**- C(«lti. ta Si i laalhar, %» T».
TbearraDgameBlof tbliToianalnihaformariaaatlna aodanawar riad«rt UeapMUII^ mU-
ftblar«i tb« ofieaaxaminaUoB of itndaatj, aad for tbi>«« prapanngforfrMiaaUaa.
fTANNER {THOMAS 11 A WKRS), MM.. Irf.
^ A MANUAL OF CLIXICAL MEDICINK AXD PHVSICAL DIAO-
NOSIB- Tbitd Aoi«rl«aB Troni tb« goooiid Losdoi Xdltlan. Havljtd and Knlarged by
TiLBtntr Fov. M. D., Pb^iielBii to iba StllB Dopartstent in U«iT»r>iiT CoUe** HMpliai.
L>nd«n. A«. In oor neat rolutnt. (nail IXiBo.,»ralioat2Ti |Mge«, clulb, SI 44.
««« Oe paga J, It will W *a«ii Ihat ibU work it offered aa a preatlun Cor yroourlag arw
, inbBoribera ht tba "A«BaiCa.]l JoonilAi. ^r XU% MtDlcjiL SciBXcaa."
Hesrt C. Lea's Soi? &. Co.'b Pcbucationb — (Anatomy).
I
I
A LLEy laAKRISOS). M.D.
'^ ^rmfrttiT nf Ph^tlrititgyi tn tht Cmt* of Fit
ASYSTKM OF HfMAN ANATOMY: INCLTTPINO ITS MKDICAL
ftnd Surgk^ H*lBti«ni. Forth* U»«r Pnetllloiit»RBd Starftcttrf U«dt«iBf With in
Icir^rfliicinryChRptrroB llUloloejr By K. O. SniKKiiritAHB, M L> .OphllialaoloKlHtn Iba
PLila. Ilxap. In ime larce uml h»ntl«Ana qoAriu tcl«n#, wiib (^leral bnttdrcd AriKiiutl
llladrntioKr on tlthograpblo filntf*, and nitKatani WDi>iI<cal' in lb« last. \iik«rtlf.)
In ihlavUborktAWork, abtch b** baan inBotW* prcparnLion foriaveral jfwi, ifceaalbot haa
toughl togl*ii. not only Ihadaialla i\tA»t«tiy\\T» anatomy in ■ cl*>riiB<l eimdeniwd foMu, butal*«
Ibtprocllrnlaptilkatlon* ortli«t«i*na«lo ni*dl»ln»an>l*DrK«r«. Tbrwurhthnabaralalna spvn
iba ntl'nllon uf llingvnvrat praclHionvr, «■ «*ll a««l lb««iadrnl, anablin|t b)in itat onir lo r*-
frtth hi* r*i:oll««[|(>ua o(lb« dirtaollng rnum. but atau lo r«>«"cniia thaalxniftcanroor allraria-
tlnni from nornal eonditlon*. Tb* natkrd uiiliij of tb» objart ibna loiiahi by tba author li
telf-atldaKl, and bli lonjt aiporUiioa and aMidannt d«Toiian to ii* tborooghdavelvpaivni u« ■
«nn«UnlpiiiraBl«*of ifaa maoatr in nbish hb aloa ha*« baancairinlovl. Nopalai bar* b«aa
•parail with ib« lliuttrallon* Tboi* ofnornial aDnloniT arafrooi vriKiaal *li#»««lioBa, druwn n%
aina» b;r Ur. lUrnaao f ab«r. with tb« nan* of cTrrr paH cltkrlj- oaitravad apr>D ilie fi^vra,
aner lb« manner of" Iloldco" and "Qt^y," aad In errry lypcfrnplikal dalaU U trinba tba
elTnrl of ib» jiublifber* lo r*i>der ib*««lai»* votthj ojlb»rarjdlitlDgai>b«d pAiftUk wbicb la
BBiiei|«l*d for ll.
LV.U^ (UKOKfJE VISEK)
J--' Kwfrilvm /V/mnr r/iludliiKty fn F»iB0Vtt|i tMUgv, C4sd*a.
DEMONSTKATIONS 01' AXATOMY; Ik-ins a Onirk' to llie Know-
Icdfa (if tbe Human Budjr bj Dlateclion. By Oboboi Vinkb Kllm. Kaiariliu PiufMior
of Anatbinj- tn Untvornitjr Collrfo, London. From Ihe Klflilh arid ll'Titad Lnndoo
Bdlti-in. In ona Terj haudann* o«U*» vduiBa of at«r TUO |>asai. wilb IM tlloatrnUona.
Clotb. 94 2S . taatbar. t6 a&. {Latiif lt4-t.i.)
Th(a work baa lonji Iweit known in Kngland a« tb* leading Buibmilj' on praellcBl Boatonj,
and (h« fitruril* i^titdo in the diMortln^'roOBi, aait all«vl(d by llic naui«T0u» adiliont tbtou)[l|
which il ha« paaied. In the laal tvniaton. wbteb baa Jnat appaarrd in IjondwB, Iba arooiHaplifbad
author bafioiigbt to bring it an a laial wUb lb* uti>it raconl advanera nf a(<i*n«* b; nftklag (b*
■ooaaaarj ebaiiK*! fn hli uceoonl of lb* niioriMcopIo alrnoturo of Uta lilffvroBt urgBoa, u davtl-
op«il bf Iha lalaal r*aaar«b»a In t*il«ral BBalouj'.
Bllla'* DaniuaiirBiLun* t> Iba la*(iflfa ■•■t-bMib III laadanblp 0>af tbo Ragllali naaoala apva dia*
Of tb* Kat-lNh ilaJcal ol aoalouiy. la paa^ls^ ■kiidc — i'Mlit. Mtd- T'm'*, Mtj t*. t8it.
Iht*ajib alibi adliloa ' - ■
_ It ha> ba*a wo (a«i*ad aad
adaplad lo'lkn oaadi «r lb* aiodaat Ibai ti iroBid
aaaai tliat U bad bIiikmi t«i(ibad parfocttoa la tbli
■pMlal ll««. Tba d4««r1^iait* are rii^r, aiiil ibe
loalboda of panoini aaalalBhal In > - i - •'■
HlvM wlih aacb d>i«ll tbal Iba L- i[»
aatlllad (o Ll> oaai* — «r. irOVA < '< ' <r.i,
J DO*, an,
Tha lacoaan af tbUuti loaanat aaaiDi (a baa* wall
A* a dliafwIoT, or a work l« baia la haed aad
■laillHl whila naa U (ii|>(M la dlatHnyi, «■ r*'
card U a* lb« Tntj b«al wiirh ailaal, wi^'rl '■ mr-
I4ltilf (iirlBga rarf graat d«al. A'a:<
hn ilDdtpd la Iba dUM<:lBfTi)«Di, It It
• «* <i(lb* wvrka npOB aBttniuT, — On i . i
,VltFr>, Utj 21. 18»
Wa lunii noraaarfadlp raaotanand It to OVvrf
detarrad la iba praaaai •( la fba pa^t ToioBiaa. i fracilliaaar af nadMa* «bo aaa poaitblvaai il ~
Tba book aaaa* daailaad to ualHtata jai (or laara i yn. Mad- JTatalAly, Jaao, tvn.
VTILSOX iERASAtUS), F.S.8.
' ASYSTEMOFUUMAiN ANATOMY, OeneriiUnd Special. EdUed
b/W. R-HoBBErnT. JJ.l) .Prufeaioraf Oanaralaad Surjtiral AnaloiiijiB tba Mtdieal Col.
Ivga »f Ohio Mlu'tratad wiib Ihrnefaundrad und ninely-totan anirsnagr oo wood. In
on* larc* Bad bondMua oaiavo ««laiB«, of «*«r 61)0 pagat i ololli, (4 . ImUict, ti.
OMfTH (ffA'.Vif r tf.), M.D.. andffORS'ER ( WILLIAM E.). M./i.,
AN ANATOMICAL ATLA8 ; Illustrative of tlie Strncture of ibe
BaniBn Body lo on* Totntoa, l*rg« imparlal oetBTo, «Iotb, «rlUi sbasi lUc bvndrod and
flflj beauiilvlftgnrai. %* 50.
^CHAFER ( ED WA UD A LltER T). ,V. D..
A COURSE OF PRACTICAL IIISTOLOOY: Beirift an Ititroduction to
tbe tl*e of the Ulenn«opo. In one butdson* r«r*l lino* volun* o( lt( pagoa, wiih
nanoroBt tUulrDUona: elotb, fS «D. jl^tig i4»md.\
aORHKHSflPICIil. AKATOMT AilD BISTOt
n<iJ R.fhth ■dltl'ta. astaBaiaa'y raT|t«d aad
■odiiad la S rvia. Hva . of u*«i 1000 pB(aa,
WttB SM wond'flola.- alath. •<< ilO.
■ llAKri' A»r> QC*1K-« HrUAIf avatomt.
S«*)*«di ^J iottrp l.Bl»T, H U., Fm it AbbI
lu Uut*. ol faaa Is two Miavo vnl*. «f a«*Bt
]«X>paKaB, wUh All llladratloaa Ololb.M Ml
BKLLANT-S iTORSitTS ODIUB TO BOROICaL
AJI*T<>*IV 1 A Tall-h«ak far ■ladaBIa prapa(lB(
tarlhalt PaaatnailBatisB. wiihvnfradac* «b
wui>d. la oaa baaduaa ro/al llwa atilua*.
Ctvib.fSSf.
CLBLAXR'8 DIRECTDHT FOH TDK til^SCCTloX
or THE HtTHAM BOOT. la •>a* •a.dl toUib*.
royal ISnu. of IB9 pafoa; aldth #1 U
nAKTSI10KBK'SBASD8OOK.Cl« k.<lLWtuWt *.'»%
I'HT8IOLOtt\, fc*<t>B» »4\\\a» . t^'^'vB** ■ ^*- "*
rotal lln«. »oV., wW"*. lOd it»*>*-t»«. a.'iu'i*.
HENttT C. Li\'B Sorr & Co-'h PoBLioAtiOKa — i 0h4ini$try).
I
A TTPIEI.n {JOHN). PkD..
CHEMISTRY, OKNERAL. MEDICAL AND PH AKMACEOTICAL;
lncl«<llnr ilifCh^nitMrfnf thcll. t). i'hAri&»'^r«l>- A Menn>.lar ihcOenrral l*rin4'lt>lci
of tbeKctenfr.ftnd tbrir Ai>nliriiti<intft Mrdielnr And fhuMt^j. Ki|hlti*ilill<iii,rcti*ed
hy tk* author. In nne k>n<i*oiB* royal 12ra«. *»lnuc of 706 p«fN. villi illuitrktioaa.
Cloth, fl ifl ; l»lkor, t3 00. iftou' RMu/y.)
W* b»v* r«p*aU41f •vTir«>**<l unr i»9-'i%\f}t ft Phdmltirr Is all Ik* nvJlMl ^lrir*i <■ Ik*
«p(ai<>a of tkt* work. ■■•! oo Ikn afpfsriarfl 'f > rnii*4 4fai*> Tb< praaait Mliluu «oii«ibi inpb
SBW ■•lUloB ct II. hill* r«tD>la> r»r n> !•• •■▼, »%■ allsntUai ant addtllnaa a' (aattird ■■•Dnaatr for
g«4 4bM «« «sp««l Ihli «l|blb (dlUot 10 V* a* I Ik* 4*oi''D>iraM<>B at Ikt lk»*t df'rlnpataia vf
1n4U|Hfaa>t>l* Id •■ » iha aavvDlb sail prsrloni | nkaaliil pflaTl|>lM. asJ Iha lalaai applloalln** «f
•dllloK* biT* k*«a. Will* tk4 caoanl rUo 104 i ika«ifeirr in rharmaav ll I* aratTviy BM^«ar7
■rraBgauaDI kara haaa ulkarad r», aaw maliar foT ■• ta (ar ■•al It ■ililhlt* (bamlMij la It* yia*
baa bMa *4da4 (•Tariaf ika •bairvailnai- noJi itaal aJraadH iUi*.— <7iacf>f>«li JTMllfdJ gn»».
■ - ■ April. lkT».
Ttaa popvlarllT vblfk IbU wr-rb hu lajuyai U
ovlai la ihn i>rlirl|jitl *Bd tiatr dl>piialllt>B ol lb*
Tar In oTiko K'l'ira. Ihf artoraCT 0( tl^rJHalti.aal
f ha nmUal'ta n1 rav^b «hl'h^r>ilff*ii" mivjfanilkaa
tifarlljr vliboDi brln(la(«iirTi<aK'«illn(l«ii|>««ttOB
It <ha rf>«4*r Dr Miiflatil wdtM f<<r ■)i>)i<al*, aid
pMtnarL]ffnrlBa4^ral •litil'-ol>i b« alwajftiaaaa
a1a«* Ik* (oraiar •dtll'iii. Tka praaaal >llir*t* feat
lb* AraOBdliR no* clilHIr la tlii<*« allafaliuo* and
la abnui l*B piR» -I awrnl li>>l*i biIiIvA ta IBB ,
appae4ls —Am /.■•■rn, ■</ I'K^rmttft. War- '^'*'
K aiaailard wntk Ilka AIIII*I4'* r*h««lalry aaad i
o«ly ba aaaBttnBBd br II* oafna, wlibonl fa rib nr I
DnmnMBta Tba ar«aBt aJI'lis pnaUIS* 4it(h at- i
larKit'>aa aoit aJdlllna* a> hkih*.! axif'Hry r.3r i .
■«• 4a mnwiratloa tf lb* Ulul 4n«itji«»n'» •>( ' af ■ lo Iha pba't^i^opn-la «b4 Ha nllelBal pr*[>m-
cbaMlral ^rlne^plaa, aad tha lit'a-l ar-itlfcallaaa of ' Moaa; 114 hg !• rMnM«aall|r polOa^ Iba aatlar la
cbaalMtj Is pbarmany Tb*Baib'>f baab*>tnw»4 ' ib« i*!! *aib«t It (ai;>oa<l* li Iba qva-il'iBa irlib
ardnoKa Ubar .id iha ravtalflii. led Iba ailael at , wbltb imth •«<'iliin la pr'Uldad Tlin* tW aiB4«*1
IhalDfoflaalliiB tha- lalrudiwtj mar ba avllniala^ ; laara- raiilf aud *aa ■Iwaji- r*'''<'*ti acd t'<i bla
from tbaTaft ihat lb* Ivdav -nnlalaa tara4 bun- I(Be«li>4||a —ilii.it^dHnrif. RipaHfr, April T'/tl*.
4ra<l •«« raAtfaaraa •*UliB( <a addli'anal nilot- W# of^ticad .->«!* ahiBi l<r,i Taart aal a baJf ac«
« (tr*""'*' '■'"■'"''" "■* t'**"**-^ 0««lla. ,h, oiibl.c..i~n «f Iba frrKaJlai a.l|i>»B. aad ra-
May. IfTU mBflrpiI bI'.'B It— raci-rik-.Balljr laliubla aba'UiBT
Ttia *>rf papnUr aB4 niartlnrin** vark baa ' >>f ilia wnrh. Tka wnrt anir la*lad'> lb* wli'<>a nf
B*w rM4bpd lla dghlli bJIIIoo, wblrb farl apaaka i)i> cliM«l*lir nf Iba pb*>Bia««rsla aflba Tallad
la Ibahljkaal l«rm> la «alaa»An4Altna «f (la *l*al- i MlaiH, Iraai HrUata, «a4 ta4lB. — JTMp KimtAttt,
laaoa, Ii baa m» bacvna tha principal if si-booh I Hajr, inn
flliKKXB {WIU.IAM H). IIP.,
A MANUAL OF MKDICAL CHEMISTIlV. Porthe U«eof8tudent».
Bni»d HiMin Howniiri'i Modlonl CbvmittTy. In one rajal ISwo. voluna of lit pagoa
With lll«*U*lion«. CIolK f I 75. <A'<m* ffcWy.)
|> l> wall wTillao.aad alT** lb* UI'>t *!•«• *a Tha ' '- ira whieb *■ Iblak
Vllal el<ainUirr- a •at'J"*' wilh wbtcb n>a! pkrid- will I- -si p(->lll Tlia da-
Vlaaa itn am *iia<l>flilf UwllUt To lb*** who •'Mnl " >', aad Ib wmt (aaa«
■ajr slab la l>n|<T-it« ibvir aanirl>d«8 la ihal 4I»*- •iilDilaDI ht i' u |-iii 1 <><" T'll* k^k wHI, IB aaafljr
IIOB, wa (aa haailll; r'B>iraKianJ il.li noibaa^alnc all (aaaa, «■■! iviii-iil apptufiiL — J M. /imrit. A^
wafib7<.raaan'falp>rH>«l ^fhil.i Mfl "mi 9mrf I'hnrmtU^, Afnt, IMO
Jlcpvf^cr, Apillll. I«W.
rfLAFSRy [ALFXASDKfTi.
ELKMEXTAttV QUAXTITATIVK AXALYRI8. Tfsnslfited with
antH an-1 aj>lilii>0( \iy RnoAit p .Smith. PhD , AialitaDC Prof nt Cb*aiialT)r in iba
Town* ERianiille Sahnol. Univ. nt Pans*. Is one kandaona royal ll<io. rolima, of S24
PBC«>. wtk iiliuirftltotiit elotk. |3 vo.
[l la priibablji Ifcii bail miaaal oi ao tiNinaalUy
■ atar*«iianl,IOMB>wrbiulla i»*llt>M*aiv IBf< bn<i
I) t«i<«>>aa yj Biainplaa, anmiBantlBf Wl'h alDfla
diiariDlBaUiiiiB. fiilluWDil br anparallusa, aad thai
ibaaBalpal* at «itsai>U ati4 aacb ft*'
ii-l wilh i.i . -.Itiir Ilia
1 1* b~ik r«' 'Haaitatrr.—
, a/ l%tmUi . .
L
/lALLOWAV [HODKRT). F.f.S..
^-^ rrnf •>r 4ppllta V^nnmtry In Iht H'-ytt ntl'*i/» -f 9rtin>f* fnr trtlint4,tH.
A MANUAL OP QUALITATirR AXALVSrS. From the Pifth Lon-
dun E'lllton. In one aant royal ISoio- ««(iiB*, vt^llluairattoaai alotk, $3 Ii.
pEMSKyilltA). MD.. Ph.D..
PRINOIPLESOFTnEORETICALOIIKMrsrrtY. Willi «i»en«lri.riirGnr8
In (be 0«nittlai<'>ii of Ckomlcal O'lMpniratla. In out k»ii<]ioia* rojal lino. t«I. of ov*r
}93t>«Ctt; olotb.ttiO.
BOWMAX'B iSTRoprrriPR TO PBAonrALI wfiiitri: ixr pnTTn'firim.miiaop rtRiiAiitc
CHf;ill«TKT, IKCI.I [ilXi AflALTHI{< flS'b ' < l : ),,
A Met .(an. fri-in ih« ^d h asd (oilkod UnoJiia adi- ' - tl t- .
Il-ia W|ib BnmarAv> <ii>i<irAiiva(. la «m BMI '. " ' - i i . '.^ .liana
»oI.,ro7BntM».,«l»Ui, Ml*. I C.il««-. JU.I. lauaaT^lkHta.tuiaJllMii. Of »M
I pip.aJoUi.tl.
C.l.U.'aSa> & Co.'s FiBUMrioKfl — (Chemiairy).
A MATTaL op elementary CHEMISTRY; Theoreti.-al and
t>f>^iam4 imtmtml hy □■»*! W>m. B A . V tL.8 ,uilliarnr' A Dietiqa-
««. V1lkft«^ni4f4«t*, sad o«* h«ii4r*4 aailMifriilj'MT'iilIlm*'
A avw A««riM«, Cn* Ik* Tw*llU aaJ *Dlarg*d IruttUQi «<lltioD K4iIMl by
H-P b *a«tMf« r«T«i !<■«. t«)vb«, sf ever IMC mmi
■ La ah^ lbnBi4a.bU dMit: - '- -">• - -r,-rrm i^« %
, H Iba«>««d •■^■< b>* * '•>' •■•»-
•■•••itoa *lib*mULt; eixiu Tfe*
lr**^ia>Dbal(*tT <"•. .^^ .^. ■.. ....B.a»>Bf]r
:««Mi;4mnc»4 i* (*(iiiutc •■■■ir tad rtr«r»«i«
Mtt ^ tMl h«rf la M- lml»A
JtW asJ Smtg. Srfi-rt-r. » an
Tla avtk l« loo w«ll tsi" ..
to •*•< aaf •sia»da4 ■<•»( '
IB«f>*n.la«|if IktEirill'L'
4-M. aa4 (kw r>.l'-
faaM ca^Unjr Tii-
■Mtia Is ihU n«* I), i.il U
«/ Ck«MUfry. lg( |j<;s.
Il wiU haaatlivlj •uiBaa**i>t]rfn( t» l> ikakaaif
ra«Bf«*r*lallfe| Irlk* ((aTraJ rharHlatuf tiivata'
■•■••1 r •"' i>>alj ^••r>ll ba> Bal4lk*lara-
kaal t>> Ik— ik. ■■! 'ha al>k«tal> aa<
»h««aai'- ' ''Kk k*T* )>«aa b(4« frua ti»*
kallBMI'i- .;iDafur anjwldaaaahailasl T*
• lar ^^***<''— •^"■Mloa i'kniv J'aur . l«f Un
A> a »aaaaJ at ttrailairt li I* allkval a lapattar
la (•• laacMfa,— JM, JfaJ. /aar. . A«g, UT|.
OLOXAM (C / >
CHEMISTRY.. -.'.kMC AND ORGANIC. From thp SecDod Loa-
It iM TM7 fca^wa «rU*a »)m*, o( TM pagaa, wiih •haul 3H lilac
Cla«k: t* M , laalkar. tS 19
'1 vmU ba Aiacoll fuf a rruUca) «li«ala| aad
' i(44« (4 lail a«^ aiMatui tail) *iib thi* »«ai i4-
BinMa irraitaa Thi aaiaor baa Kivaa n* aJnHxi k
, «yifc|ialU «liUa Ikx llBttl><>'ae->a<>al>Bt >uiaB>.
a«4 kaa 4*Ba ••> »l*«iil l-aaalaK ' *■* *u*'"* pan-
■rapfea tmaaraaal; nakiaa ap ■ araai pai- aT ika
i^lA 0l mumf mm>nt.* trvik* rka ripiraatfta
a>taa«M t* sat tlmvr^ni^i whrn U iLnk* Ur iba
rmmtat aawaM r>: l ,l 4Waaa(-
•H, vMlaibaaaMlau- - auiiia'iia
faaai »aa«fBa»< b- • .uA afata'
Ik'Uaa. A pafatUi pu cr i>i aioLi-n'* i> ■■■■ •t.y *.
lAlltwJ *»ia of ajfu-aalni la «k it ^t*bI iialki a/>
^tfrrt'-^ in T*tf •\:nri f«ra|r>f M« ••■aUiary 111*4
ii>4t<' aa laif •rtaai lufla. ■■!
I • r**'* laai llM'a. ifauf
*lli)«a4tiai, tl taaa'dao ja«
•aa m ird i'.*..i •- naarlj raaiiJaM.~ OMMmMfl
fta^tf. Xa*. IHd.
t<aat>aa-aa«a«»aili.»l4t.
t fa aaaaa^ ^-Aaataa Jfcrf- a«« ^ara
t^iah— aka iha cjBla af aw* «Ua« vaaa »aa>
•MaMNMaa^r w— aal U«t»4>ala ml abawla-
ttX. litl MMaj-aaa wana*<ka^>tr*«w*iri M
■iS>^a*rta«fca*tt^aifcMlipia»aat*» 'at! >■<• aii
•Ttkak^iMaa *a U «** .taa** >* - l • a
ar (&••«•« a* a4«W«Mra««pa4 ' ■ -^f
Wtaaia^M >aiai.. >.». .a-_r.J .. .-.-
■••aa af f^m^^-■ tt'itw i*a>t
^■■■■Mi^. ^ ka •■ -t ikni m0»o-
Maa •• aar fM<a> ..... .. a v<-*A. ii l> •
Wmi> •« ka Fial ky all *Ba vial la haaai vhai
Uaakaa*irr aria* yra^aiAay — ^aartaia Pt,.
A>' KLKMENTARY TRKATI.SE ON PRACriC 4 L CHEMISTRY
AND griLirsriVK IKOR^kKIC AXALVatB- Apa^ially a<1«pt«d for DaaIh ika
LatafalatWa of Sfks'la aa4 CoIUf^f aa4 k; BaKtnnera Sm«b<1 A>i<riCk>i Intta Uia
Tlii>< »Bi lUauaJ KnxlUk Ultlnv. In Aka *a(7 bai^>*iiia fOjal ISna. vuluina «I
Tkh la ■ •alaaWa VMk tw lh«* a^^l la
^aaaa akvvi.i-* ii^ n.^r* «« «■ at [i* ■•« »h4
I «f ««««laa:
*faJaafc^*#u
<-- i Mali.
'. ,-« )|
1. - _...., 4 .,_.__ v-.:-. ,.- ;m jilaai
aa4 *• a>a;»— «J A»«W JIaA. >Ml ^ra. y««rM.,
maf IV91
TVi* wstk !• Bol >at* vail aJaplad far aia a> •
t*K> ko-.-k la aaj'/aj Mllacaa, kal i> al<d oa* 'if It '
ba-t ikat a praciltlaaH aaa kafa Hr aaavaalaat r'
K>*rr*9TICH9OL0aT:arOliaialaliaApi>U*4 la
\%* Ana t%i !•■ Viaalkaivta* Witt Axrtaaa
»«liloai \t Pnt- Wa^ti* K. Jaaaaani. ta iw«
' <kn>a«a laJ latirwilaa la hli Mirvrf. Al a tal*.
.,,,1. ...I,, ... ■ . . '-. i^- III aaA abilraai tnt
■■ aiil. Iial (ha ralaaia
.B.I.IB. aai win ^af
,,,.....,..-, -* > rfMIIIIak-
■ ra— X. r. Ja> itsi.
Tka labia* |-* . i -- r<K ihaV
ara B4iamM7 r<.'i:ii>'! '-iii r.r •:. a-.rutrmf af t9-
fkraac* and <■!*•»> a( tarrnualiaa. la •l><irt, wa
iln net rrmamkir ii liar* n>*l triik a Viok «hUb
I' r ••fra Ika ■laj-al aa a aaUa to lb* tj^
' :d» af lg..r«nlr *l>«»Ulrr.— CmiUMU
-. MU<h 13 IVI.
»arj kaB<l»aa tcuto T«la»aa, «11hAMv»«d
a«|ra*lagt,cloit>, |B <M,
HctntT C. LxA*s'Soit Ms CCa PcBUCATioim— C FA or., Jfitf. MM^efe.^. II
I
I
pARRlsa {EDWARD).
A TKEATISE ON PHARMACY. DeMgiici iw a Teit-Book f-.r llie
StadMil, uiduo Oald«f«T tb« Ph<rilal>n >ad Pfavn ictvtlst. Witb mftnj PomtlaknJ
PrMcripUoM. FaNMh KdlUoD, (li«r«iiglil}r r»riaDd. b7 lucmtA S. Wiiie«!in. tn »■•
baaAtnmg ucuvo viklniD* uf BIT pAf m. «Ub >r)0 >llunr»U<iQi ; elbth. tb 10 i l«Mk*r, f S tO;
hair BvMb, IT
or Dr. Panl-b'>V'v>'' irarb oa pb*rm«or II oaly |lb* work, aol oalj-lo pbannarUla. bat aha to (ha
tawaiaala Va^ald ihi'ilia ••lllurbaia««aiBp)t*b*d| ■■tl1ia4« of madlcal p(aFililaB4r» wbaar* «t'IU»4
ht* Viirk ■» wall ■■ lo Mslolatn. la Ikla Toartb w)l- lo F->inpiieBil i li'.r own oadlclUH Ii nlllaVH tiutd
lloB, iba hl«k rUn^KFi or •xcfll'o<4 wkkh It bail aa h<'B>'r<-d pUm nft itir ern ^<>•.k•b•1r•• — XtaUl*
allalB*dlB pri>*l<>u->illiioa>-aB't<rlbaa4ttaT*hlpur jr*rf. J>Va/«aHrf fXrtrvinr. Aaf. II, IM«.
Il* B(o»a>p1UliaJiiailivr TbI* b«> Bt)! hMu aMan , ._ . . , * ■ ^i.>. ,
pil.h.d«lib«'™"bUb.».a>Jw.or*d.llil<.B.«»a' W--"P'™f ■■<>;<'P""i««'»'B(«r».P«lttl«n la
rnpr«r.naau. l«r.,lT„, .ka.x*. la lb. atfaac- ' f*™' "'"'*"/,.'? ^"'■"' "* V '" " '? "*"*
■iaal*rib« M"n«l B*ri.D(ih- w«rlt. and ih. ,«i. '"dBi'/M "•>•■ '»•* "Maloa la r.l-r-ae* t« ib. «••
lloa »r muth aaw ..Itai. Wl.h lb« »"dL8t»Hoaa ■«»! «lltl«n. th. pta«».ll..B »f wl.lrh 1,.. fnlLoial*
lbaaaf.<t«liUaB..maia>>.a. o«» »r..-ai..l . . .«n. - «; wr-'** b*»Jh Itl.a boakirlih •Licb norbarma.
. - . ,,_. 1 , .^^ ^^ J ^^^^ which Ba f bjilcliiii <>■
uch lafMinatUB «l *bIb« te him !■
0 JTad AMiffarf ^iMira,. Jnn*,'T4-
Intaair vUh Ibn iihartnun-ullral |it<par«ll*(i »tlh*|
lbaiaf*<tediUaBtlllaia>,a> o«» »r«*i>Bi*<l , a >»bi - e'-wt^'** »«nii.
p.B<lui«-.fib-Mlao<.*ndarllBJl.|M-.i.bi.loihB f' can -l l"P-n.-.
pharnarUI. Bad sf !t>< ntmo.l Tallt f (rtry (all |,. atrl^ r..«
p'atllitnDvr -1 .o«dl<lB»H(.i.lti.«« of f«»BUIa»l>lng r'ai-lltr — f^»«^o
tnlcl»> wtilrh ba r*'**"""* '-'T blifaltaala.^Obl'
enfro Jf'd- /»ur«.. Jnljr. im.
faTtaapa viif,lfB«llb« »Dit iHpartaal book iip»B
' pliBima<r wblrh ba> appaarad lu Iba Kagtltb taa*
(ttiip hm vMiKiatrd fri-M Ik* iraiiaallaallr pieaa.
Tb« w*rblB«wln«ai>r pra-ilfal. a^J baa ibararBi "PairUli ■ Pi>aiMiiT)F'*ii>a wiiikanwawnrbaB iblf
rhlUllprB- ililn af Iba vaiar and ll'n faviali no-
naitti/ b*1sira*4labl0aa<l li>l*r*«<lB(. <
*arrc>a<l(lc'1)r .il»ntia(chiir»«i*r Fli' »Ln!» w^rli g^a'a) wifh a**arbf«4iB4-
ralarl'Iha n'oaiMi i^rndli db HUt hot. •alitor and pnh Thanli* In ih> |n-<l<tnaa •■lltii
>i ■ taally
!'• (a ID*,
tad, tba
ttihar ll •ll10"a*rjT-i(ii-Ha*«flb»IK>"rall'"f wM'h i>.-i'liiiin-<ii*<-ti|l<'n vf "Parfl-' 'ii*»4 (•
haakaa«l»<l'»i>d apoa ttapfodartlan •baa wanea- Iba pa bile wlib all tba aiatut* rximiWst* at It* aB-
lUalbaltbaraaraunlaaalhaaUOaaralallTaKMalrd lb<». aat p««hnpa aaaoiha vnna tm a-laah oraa*
lllilKtrallna*. lB(OBrl«t1ail,Bab«*T<ll7'ariiiii<naB>l hliml — t."wf. jitam Ja*ritml,OM li,lt7i,
QKIFFITR {ROBERT E.), M.D.
A rXIVRRKAL FORMULARY, Cnntaining the Melhods ofPn-pur-
[nit Bft'i AJminiftarlojtOBI'Inal and olhar Maillrirtaa. Tb«-wlinlt n'lkplfdtit Pbyilclniiitiid
PbmrtJUMUtirt* ThinJ sjilion.thoroqglily rerlii^l. atUb nnmcrniix n'littllnni.b; JoiiN M.
MAinrti, PrefrafOTofMalertiMt'll'Btnib* PhiU>lfr1fMaCnl[p||r<if Phaimui-y. tnoAeUrg*
■d4 hanitfonia dcIbto volamv of alioni 800 [a|;*** Clolb, f 4 tC -, l«at)ivr. $1 W
T*l(M4r«ut-i aia»4fnrnilar9l* aiapljlndl*. A nora eonvlaia rArnalarrifcia IllaUlia ppaa-
p««Hbto, aaf pa<h ipaau f'lrmatarT'haa baaa mnt* ani tvrm th* pharmatial m jihiralrtaa rniild bantlf
• Kiaa<>T>lvn*Fd Ihaa thr vcit-kaowa wort bnfor* ilttira T» iha Aral Hnma ta<h work I* ladlipaara-
«■ Nanv |>l)ir>:rlKu- haci- t>in4rr>aia, at*o. aa d>ai hl>. uni) II lahirjif iHiaaaatlU) ii|h> vrHrlnlL'^ar
('ala. Tbii la fa* a<p>clalir "' Ikaeaoolry phfal- Who rompnun^a hUnira Mrdlrlaaa. Mncb nrwbal
•la*, aad ■ viirk vMcit ah-tii i*a*b hiis taa maaaa i !• eonlaiaad la lb« lBlf«daail*k i»a«bl ta ba f>M-
b« wblcblAa-dinLal^la'oaTimblBB kt> raaaedia* la «iU(a4 ■•> namorr lijr araif (tudaal of isadletBa.
tha nn>l aflaefUn* a nit pla^oaal maaaar. will hi \ Aa abf-laia phtnieUaalt will hr foaarf laTalaablt,
waya hold IT* |>Ur* Bfinii hia •h'lf A fioiaBlalf "f ' aaJ dnaioU** <alll laake lia way I nl" llhr^ilaa «ai
IhloklnJ la ofbaBrni »'•*■ \f Ih* cllf i>h7-l«laB la'alrea-lr •■rpl'*4 wlih aalaadard « rJ< nrihi< h Ib4.
lanaai fpaedM.— C[<tP4a4a«<7'la(«. ffb 11, !»»< ^Tkn AinfrtranPrar*tHonrr,y,o»\-*»\:l%\y,'^t,
F
fA RQarr A I7S0?/ {ROBERT). M.D..
r.fflHr>ran itM*rV> K'-Ur.tnt St. Il*ri,'» ll-ttpUtt M'lllr^l S'klml.
A OriPK TOTHERAPKIITICS AND MATIUUA MKIIICA- So-
e-ni Am«ri-an edition, rtritui by Iba AtilhAr. Knlarjcfd aid 0da)>t«d tb Iha U. 8.
Phiirtnac'ip'vU. By Tn-tt WoonapK*, U.D. In one naat rojal 13mo. *olum* «f 408
pa|M; ali'ih, 13 35. (/^jir/y TuumI.J
Tba appaaraaa- nf a b» adlllaB of lb la mbtb- ca^Ioiu aolaa bavabaaalalrodaaad, BBbadvtai lb*
alanl and haadjr h„fi\ In Uaa Ihao Iwe jaar* na* Uiaii radaUtb i>f Iba I'liarBarwlHBla, 'n^aibar vt'b
taplalalf M lakan aa aa lod'oaiiua adia a**f'il- tba aalld'ilaa la Iha vara pruatlaaal i-i.ii^aa, tad
aaaa. Tia nnaaialanl atranfainaa', aail 11a l*fh»- ' ausli af Ilia aaarar laMadlal ai:aal>Ba aaxoad a*raa>
da»», a«1, al tht •4Bia lima, «pinr'l*'i*B*aa of Iha aatr fi Iba <iFinplalataH iif ilia irurh, Tablu ot
Infornallna ilran. coaka It a haadj hunh 'it rafat- «>UhU a ad isBa*iiraa, and a (n'-d alpkibaitol la-
TbI* writ aODlalna la nodarala AAlnpaaa assb
ir«|1-dl|a*i(>d U<t> 'iBsaralai iba pb^-b' )•<«<» I
»<! tbata^Bllfa) artloa '>f (aN-fsllaa a* ara raaaoB'
ably a*tBbll(liad UP t"iha pra*anl llMia Ky aaoa-
Tfiilaol ■rraai'iaaBl Ih* rniiaapnndiaa afaita nf
4»» ani Iba aiivBa.— /^u^f (j(i' Vtr^itlar anil
Ciumivtt Ountl: Jaaa. h't.
ll la a pinaaara In Iblnh ibai Iba rapildtir wtlh
whiafc a Hmsd adlllan <a danaadad may ba lakaa
aaaa >Ddlrallaa Iballbaaaaaaof appiacUtlo* of tha
aalna ■•' ral labia la''nniiailsa rafardiai Iba aaa af
aach arllcia In ^aalih aad <IU*>t* ara pinHBt'd Is taaardlaal- •i'laall>«lruva>arb')in*d i a fbraalliaB-
parallal eolanna, b"! "air r«t')>>riB« rafataoaa ■!"» I'f i-aibuliMitfalMadiM.fliatafi'rlanfodka pr*-
aaaiar bat alui lapmHisf ibp facia Mora aliaaily aaal da jr. Thia wiitk rt>rlalDl]r marliaiba aneaaaa U
Bi-aalba tnlad «( ibe raadar TK« bouk kaa b«i« ; bua0i|alaU7 Mblavad.— J>^ JtmandlM, Jotf, 'Tf.
•dapl«d la iba VBBta of iba ABarUaa alBdaat, and i
CSRINTIflOX'!! DIRrBilRATORT. Wlibcnptnaaad-
diilaaa. aad III lircs waod aaimrla|> Dy B.
E>i>.aa*iBi-o i^Bivrita. M.D. Oaa avL gaoti, pp.
I»00,elotb,l4 00.
ObltPXXTIIt-R PStZK BfflAT OK TBK V9t Of
ALOoaoMi: Llaixilu la Hbaitb ark I>i>iuai. J(««
•dlllnB, vliha Prartr* 1>7 1> F CoittiR X tl .aad
alplaBallaaaaf ■(l«Billrwa(d«. V% a«»%<M.^^^I^^~
aoUna, n. Ub.eNMV.^'A «a«va.
I
I
HsNaT O. Lba's Ron A Co.'s PtrBUCAnoN»— (Jfa£.ir'tf^TII)^ap.,«fe.}. IS
A MANUAL OP ORflANfO MATERIA MEPICA. Brine n O.ii.le
lo M*l*rin MmImb of ths V»|i«talil« ■■id Anlmkl Kln^lninit Pi.r th( uia "f Ftu Irtiti,
l>r*fn(t«t*. PkomaFiiU and Phj*loi »if. In on* bandtunt ISoio. volau*, «hb nuBiaf
»■)■ 111 lUl nit I on* vm wood- tPr^pn rim^.}
1Vh#n in lOM th* ii<jlh'>T «n# ?:iltr<t to <hp «bni* »r Mit'orla H«<li«>> in tba io^iU'iLioii namvl
(Ihr I'hilnilFlf htn Cii1l«)(* nf PI|Brn)<iD*i. be *rri-<ii><_v f#1i ih« r>M>i| nf « •nlliilitn ipii t>iH>k
nhlah mmld he il-rtl in e^vn««tio<i *itli bl> Irviurei iind tan'U pr»pMrfttt'>n< for tlis |>iihlirai<i»i
itr^iwti a work »i fin wi'ty J«U T" ■Ubn'ttr ■ Fjrttrm i>[ntii>>>nf>rit.|nii, which fVr>Dl>l he m-xh-
0«t diffl«ull)^ c-'tn^rf hvnlad aod *«iiilll.v a|i|>Jlr'l bj- tlioia l«r whoia >( *af in<tn'l*d. witf by nt
nena* an tn*y (Mh. an>l the author (oinl aNifloa, nimi**l »*«ry <*«at. i<- «iihc( rcnndtl (liai
jiroTK'fl'lT 'elcctMl nr ii tnnkt wb it In hit opinion aaenod Ia b* il«>trnt>t> Imp'onrnvnU. Tba
pwLlinaLlon urtb« " Natlno^l DmeD'Ainr} " iti a iuta««r*«iipvtlMl ih« waai fell, al liart v far
■a a work «l ttlrtvne* i> <'<in rr'ri but ntrioK t« tu l«eal atranit*mfnl, ili> noi a'lapiad tn
ajatautatio in^lfuotinii llnvrrvar. i:t piiMiea.iaa raitdcred a uin'liiiiiatlna t.{ Ihi urii^iiul plan
fni a traatb* on NaUrU U*4i<* dprimhla. nrd it i* rioir prf rrnlri) in a rorm ttriOf an ent'inr
of Ihr (ubrlancenf ihr l«i>larr«anil ■mtirariiijc irbal arti coaKi-lBrrd tbn ••ornliitl phjrticiil, hulo
I(>i;ica1. iiTi'l (hrm'eal rli^tiaclrr* -if the utjcAiilc tltoR, tt, a> l< * Ui- w<.ik ■!*•> » tt'cful and
rcliklitp f-uiilr in baBinoi I'anwii-iai, ll«K*rdiiic >J>" '-' ' ' <^<- Kalb"' i* fixt'rt-u*
of it* ini|wrr»:liijn', Imt. ba heliFtti il l<i hf oiiBveuUnl aoil . f j>Tnrtie»l af pliFalloD
Id rafaraat^* lo iha kpopv aftia W'>rk. Ill* mala nlii bni btmn l« «ia)ira'-> all tbo draj;i laOHi;-
Biiad hj the I'- <^. Pb'>rina«npnt1.i, tof^lhcr Willi Ilia old. hot now Nnofli'ltntl nnva, and tnali
uihar*, iha e» nf wtti.'k )ui* b*an rM*eil,( ra>ircil or sui-icrilad, and wliifh ir*ni lo drifrra
KTlvntlon. Tha luadH'^l |>ra|»>rii-f an<l itti*a* of lbi> (atiiton druj^ nrp mnt\j liri*!)^ (lata' m
nl>j*4tf af lanaral iinp<it(<iol Infuruialti'n ; Uim prpa*i|t nink i* luii iniii.dxl fat K'*'"!! luatruD'
Uon In lb« ibarapautU applioailui of delist-
OTILLE [ALFRED). M.D.,
■^ Fr,.ft*iM'if r^tttrvand PT*<ttc«/ M'^M^ttnth* P»*W tHlf »f .fraw.
• TIIKKAPKUTUVS ANHMATKKIA MEDICA; HSysUjiimtuTrcatiFc
nn tba Action and Ilia* of Moli«lDkl Ag«aU, iD^lurling tbvir D^tcrlptiun and HItlnr*
FoartbadUlxn.raTlaadasdaDtant^ Id twolaric* aod hBDdromaSva.toU of abvdlSOuQ
p>Kt*. Otolh.tlP: laalhrr.tlS; balf Ittxxia. |1.1.
af ih* r'v°'*dl>lra a waal-ffdopa-IU *r (kar»-
paoilci— rtfa«jr« Jft>llc'il /'.winflj, Fab I<ta
TharBpid»ha*>ituao'iaf«**diiiua* s^d th* aar
«»>•»! rat->r wlih whkh iha w^'rlt b>> t:i>*n i*ri>l«(4
I
II Ih aB«*«***aif tv d>t iM'Ifl] fli"'4 iliaa in aa*
tiM<>*a<liaapimt*uce ■•f lli* runilh oiltilnu nf ilila
wall kauwB av4 aat'llaa' W4rk ~UfU. and Fur.
Jti4-f^lnr S*t(fia.Ucl IkT.1
far all wiuiilailta aaainfUtavark oa Ibarapaa-
Ilea «a1 ■--'-,•-■ -r lien fur ralaranrs, la «■<■* la-
ViilrlBn )ac-U4«i, >* WtU •> furin
ftitrnaiii I
Ly llir lapJItal proFM-l.-a, •'* •i«cl»nl in....l .il |(>
I « II* 11a HI • ■* ■ Fii|iMi<>ry kF I'lutiCaf aad np^lul Ib-
r'>T-Biiil-<B f«> ia> I'hT'iciaa. The *<ll!l> n li-f ' r* a«
ii'tun.lui Kill- alt. Ur HfillA'aU , fuMr ■"**■'"• ll<lkT*>illri,\aili> vaik k** !»•' narw-
" wir ■<'■ '.•>!:• lit* «i»a ll*iD«.tni af pflat.hy i fall f '■■)•< J sad la ■una riirlliiai r> " r ' * ; iia-
lhaaakaU'Kun vrr'>r<uai*-l|i|<ia*.ibaa>itbi>r hatlalil nni'tl ap i« lb* pta-aal ilsa ^f \'-. »r
tba BtitaiBleB un4*i nwwr-^ "Mita'l ni. I>t ih* -ililnrd aad ciolnu shli'tal altriia <
laraiaL laital-iD.liaparU*
laattJaf a w<krk not anat^
Oiarr la tb« Ka(li>)i lati' .
Tlia inaahaairal nxHaili>» h irni-. tii>I' • .i-i- <i> ; ii«
wall kiK'WiKklll a»tli(>i<'4 i.<i«.>r >l.^ f'MUbrr —
SI. E-'il" Jf'' "ad Aorff yii-'PH-il. Pac I>.1|
fcilB Ibr IxiMjMlli.aar Ua Br*! aJIIMU ' ^lli^'a
rlda uf IBalb«l*a«, Oiaibvlle Mba>, iiM>i>rii f. «■
l>a>iind«, i(al»iniuoDi. aaJ fl'faar ralsedlaa.— Jm
;»ar« V W'l'-mrt.T/, Pth l«T.l.
Wa fac I -' ■ •. haa m tiTal la Iba
(HallltAda ' iKa fnlan** at lt> ra-
•aarrb ml" >■ il «■ nan a>*i|ra It
Maea !■ tb- i>li;>itU" • Ii>-i8t^ . a»l. I»<t»<l. a*
Tliaiai<aa(l<a" ha* a*«a uar o' ib« «l»ial<t: Ita at' | Itillr ••■D'a-aaDnt <!'• |>iw«»i •■''• of 1iB"W<*dfr la
aaotfl ff'iDi aai hhrailaa wiialrf craaia a TB4iaM | a*iar'aaDi>d]raaiBliia. I>u< ta Itjfat lbs mA>t rfluptata
Vbtflb ana'd >>« lll'vd Vj a^ 4|hcr wnrk la lb» lia-i lr«atl-* upiia ib* n'a'ial aai piadtaki ilda *t tba
gaB(B. aad tla rraaMaaaappllaa.la Ibaiuro valnMaa '^aaailaa— B-u(uN Mtt nttd ffarff. ./>Mr«oJ,ll««. t,
I teT4
rtonxiij ( r.). a sd t>a .v rrKn ( /..v
MANTAI. OF PATKOLnniCAL niSTOI.OOV. TranfiUtwI. witli
Nntaaonrl A'idltinaa. bv R. O, AaikKai^rK ARK, M I> . I' ■ ' ■ ' aadOphlb'' " " ■■-<%
ti> PbilnilB ll'>*)>tiiil, l.arlurar nti K*rr*rliii»i anil Oi- 'na1lnt<i ^D' <'
of Prntia , and b; llatiav C. ^^laaa 31 P., UaiDor." I'.MbnliiicUal i „; m
Ida rnW nf Pa, [* nna very banitannia MlaTP *'<tiil(i« ul over i<*(> |Mi«rii. wilb atai
Cli-Ui. 96 Wi Irulhar. fS M ; half Kaaala, fT Uom ^M^y.)
310 IIIUilraLlaM
It ■'fonuiasdlai
V lUadai'i "Pa.
"otk ti Iba klad
. If! Ila taadafi a
I lll'-ad iB I ai'l'd
- /rarllcat hu'lBfi
J4u ^uara. ^f Mtd.
1)1
lu au:^
IfMitW -
Wti* r< I I
at palliv' .<(l:al iual^iifc>.
Sr<>nr>«, A rll luM
Tklt tiap-'riaat waih.lall- Anaflaaa draa*. laa
waltuna itSaiiait e<> afl •(«■)••«'( hF Iha ■■hj»«li
wblah II Iraaia. Tha Kr>al inaia ot ptiir-ilai la
a*r>a(>4 aalntally and ('Mnpfaboaalral; Tba
aUaalPaAMain aTiaaofa It alaaraad full, loibtat
r . and Ihl" i.«"fV«p-
'n. a T%m 1l|n»ta-
, >•<» Wl'>i<i«i Iba
' . • h->a>sl
^1 Iba
■ ' r Tii^r.
lb* -"».)*»1 idlfc-
lai la Wrilh l^a ■
Una* ara Li>tiWiU
• tltfKiaal baiparHJL.ci'r itm
DjaRba far plar>af Ihia laill
t>ia4> -r ittn.riaaa •ludaaK
April U. m-O
Tata •iitaaia a« in id la Up la waait la IVaavar
alaa. II Will prr-T- -.->■,-
■itdlrldia iQ Iba •< I
pi ra'''.aBa.8a&
FKtfWlCK {SAMVBL), M.D..
THE STUDKXT'S (RUDE TO MKDICAI. mA«X0SI8.
Tblrd R»ri»<) ■nd Knianteil Eogliib K'lition With elKlitf-four 1II«*1mI|»u i
Id one rery hnndtuia* Tnlaraa, tojtl llmo. ,nlotlt, tl ii. t /-dfn/y lumrd.}
/yRERS [T. HESRr),U.D..
PATHOr.OOY AXn MOUBin ANATOMY. Fmirth Am^ririn
ih* Flfih Enlnrft^d bdiI K"<it*<i Ei>itli>h R'lliinn. In ovtvery b*ii<)fAiDe Ml***
of BbouiSftll p»gM. wtth 138 1ln« *n|T:t*lDet> clmh. S) 3&. XJtut Km^ip.)
RxTKArr fHirn tii*> At^nni'* PnvrAcR.
Tn pT«iMriBK lb* dflh tdttUiQ of my TBi(b~"k on P>t)iKln^ tail Mnr^l 1 ' \
■caln Kildsd tnimh b«" niKllcr. wl'h th* objfci of niiklni; Iha wnrk rt matr . i|
Ikr aiH'lfnl. All th« dbiipttrt h«r« been c*r«r'tll]r rerlpri]. i6ib> uluralion*
th<> «rranr*<nenl nrih* work. bs'I nti klilllUB ba* Wen mad* t« Iba nmuber nf vnxd~«tt{
nrw <nM4 euU. »* in prtrloni adliioiu, bavt )M«a draira by H.', Colling* froa my o
(oopi«itl |i(«|>*tali»ni.
Wi> b«*« Inil «AB>t4arf4 Ihia th* had r*!''* r*< >■■*« rfenmubly n»1>H. »••! MllCb I
p-asBOMil ■•! iha •liid«Bl r-it llr« <il*«tiB<Bll-ia »f •>• b^ bran "ddad. T» tb« |ikf>t(iaa a* k
tl>>n* Murbld tiKoa* W* b*'> fo'tad it nti-ni •«<••- dUcBoaii, ira ••«-*Bn*f>4 IbU valBva — $
Ikelor/ Ihaa any otbac. Tha praaaal a4lil«D ba* aui Bar^ratt, Ha^. I>*1
TiRifiTo wE(Jons srsft). ju d . prcp..
A
TREATI3E ON THE PRACTICE OP MEHICIXR.
Aiii»Tif«ii v'lllioii, reTi>«<l by (lis Anihor. (MlFeil. wiib Addiiion*, b; Jimb* II
ISHOM, U !>., Pliyalcinn to Ibr Pantta. Hutpltnl. In nna hnn4>ame nolarn «i
naiirly ItM p*g» With illualralluti*. Clolb, |fi «) j laatbar, t* BO: bktl
$« a« (A'mv jRaai^r)
TbaaacoaJ •■lin-tu t>fltiUrK«ellaBl W'>rk. llbc lh« Tlka rlawaafibaaalbar ata ■l^r•■Hd
»fH. h«« rM««»ail lb* haoalt nf Rr, HDii<l.la>..a'* tl»B •-< -n-.'i n . „,,,.,.....,..„,_.. ..J
■aaoUtlnai. I17 vbieb tlia pbase* .rf dlanaaa wlilrb wtili ',J
•n poCBilar l-f 'hit conaiij ira ladiooil, aail iba* u-NI
• lraa*)*a wlilcb «*• liit>ad*d (i>r llil'lih ptact
(lAB«r* and •tit't*<ita 1* mctr mnr* prmfrallj it
oa IhU (Ida uf tlia valar Wa bm> an rruiie
B'idl'r III* bleb iiHalaa pravtoaal^ eipre»rd w
fftri m IJ, nriKl^w.-. 1..KI1 axapl hf artatox ,..\.'ZJiir^\,Z\h^l'^^,\7'/.< '.
««f.|.pre.l..|:.»..l.b-n.rrfolUb-;f.i.JlMa,>jtl.n, ^,.,,.,, „ , .,,1- ,1 „,*, -|«, i
!• MUwfM Iha l»(a«l ^«»tb»riiiadl(.l .ri.a.a. ,,., T*. .,m„. „. « „t. t, (.. >|
-n^1«n]ttdi<vtanHSHT9itmU«vrn'>l,V*Vnu7. „,,„„„,,,„ „,i ,„.etl«.l. aad *r.a.ly
IMO ti»lali...i.>Ai.i.rlM.t ><>.4>n -tr*/^fu
What wa >aM of lb* Ural adillao, *• MB, wirb
lB«r»*a«l (iBplxila, rpprBf caBPi-ralBf iJil>r * Baarj
»M* la abi radar rid bjr th* aliaranca<<>( a t>i.iB(hi-
fUl ai*B VTbal baa li»a uN. baa baaa «a|{ aalrf.
and lb* bonk ta a fiilr raflai at all Lbal I* 'iHalnty
t^'tf-i vB (h« aiih aeu euaalBarad."— Mlo Jr*d
Mfatdiir, Jbb. T, Ii6iX
■ ha* u-NI. • '
taitl- trlB. _.--.. ,.^- i -u..... ..,,.;;,. L.,^
••rul hi' tll»alOI%tt PVOaX^aulUMtaB.— JI.O. il
a in ' jar;, /..a.ra . Pab ISM. 1
""^ Tl>. ra.d-r •rlll lad ar.fy ■ ' ' *]
«>rv, /"Hn , Uarcb. IbM,
U** t*ca>d t( ***a (Ira I ten) Wciik hi •till
fi^r prarlltl.iii-. ll l> (landr *'
; .lylf (aa li La i--
' BXHil ' I'll alfHKI
aad CI .-' - ', i - ?*<ait4 tjf dW'j
, SxArd, fab. IMU.
fJABEBSnOS (.?. O.) i/./).
-^ ' Nru<>ir PSyitrt-^n ta, M4 lata la^tMrir a* U* trtmelitttt *tA fVncKM it/ Jr«4t«fB« 1
OX THE PKSEASKS OP THE AliOOMKN. COMI'tU.srNO Tl
of (.ha 9tniiiBrU, and oihar part* of the Aliueatarji Cnnal. Q{i"[>h«Kaa. C««ui
lint* Bixl Parilonann. Sarond Ani*rloBli. frnn ifa* Tfai'd atilaniad and ra*i|
)lih BdliliB. With [llB>trnllaa«. In oaa baBilxiBia nrtavu tnlnu* si orat SI'
Clulb. i.1 Ml. {I.Mfit fffuni.)
Thia TBlitabla traaHa* •» dl*aa>*> "f ib> rlnmaab <
Bad abd'tVI'B bHabaen nalorprioi fDraafarnl JfavH.
aad la ibarafni* bM <•• «•'> kai)wa I" lb* rr'jA>a-L<n
B' II d*a«rT*« to ba ti will ba I^BBd B ercl«ri*flla
«r lafonOBilaa. ara^aiiialU-iHy m 'aiii*.!, ob all dla-
a»a* ar lli«BllB*DtBr7 inri < 'lb tnlh*
raelnia A (Blr)wnpatl[aaui a itaiSMd
aaadad Vr (^ aqlbnr. Bararal BaVibBI
'ba*a Klr)r.<, >.rlr,i<Bjtib* wxrH (>t'lj'>|-l
■ b4 F"- I'lTii^ii 11/ l>
t|,.«-r I I.T najl«l,i.
•ratir 1 . ■ ■» •"■ma '--r: ■•_•
ili-ati.'^ ■■" tkTi 10 oil'
1 1; til ikai c*a ""> xMalao <
If •yniptAiM. >Blhala(y, n:i ii'i«b, Tbe tt'""'')- ^^ Ili^artli
prcaaiit adltlon l> rnllat lkB» laiaut iiaa |a MBO* praMKlaaat ah >Bld r8a4 acJ •
patllcaUr*. aod bt« bMB (harw«tfeir rartaad aad ' y. r lr*i Jturn , kptll. Ihn.
• abPOt'H atlaBof p»THOLoair»i, msToutaT
rrana^alrd, irtlli Hitla* aa^ AdilLiluaa. hj i<i*tn
lillpt, M. I>. la as a (nliiae, tarj largalnpaiUI ,
^naiia. vllb SID onrP*r-plaU listaa, plalB and
BAlnrad.tlaih (4 IM '
i-aVT'B TBKiTIKl nH TOB
OCHriON; II* l>i>o'd*ra a<
Prniw ■ ha lbai)Ei4 Load-'a ad
•"IB* Tulnn* a^nll A«B««, (I'><1>. Him.
aOLLtVD'8 ■KDIOAl. SOTAS AND
TIOAS 1 *i>" ^Tfl.pp Wrt, (>li.ib l.»
HBitmT 0. LiA'8 Son A Co.'8 PuBLiOATiotfs — (ProfHcfo/ Medicine), 15
JPLIST \A USTl.V). M.D.,
A TREATISE ON THE PRINCIPLES AM» PRACTICE OP
HRDICINR : (I«i|tiieil for tha utc of SlodvBU and Pr>otltioDar* of McdicioB Fiflh
• illllon, pnllftly ranrlliin nnd nioi-b lmprnr»<l. !■ on* Iftrf* nnd eloitlj prlntad fMtavo
Tol'inivof liy^ pp Clotli, ti M| Ualk»r. |* Mj vwj bftadMn* baJf ftawl*, ralMd
ban<)i. iT. (/w« tUnJv )
ThU o^rli bub*#a ■» li>B j iii<l 't«n(iilil7 Vniiva, ]ra*r> >wfi>r« It yUIJa )h* ^Im* la sthari — JTifh-
• ■il hid iihMli*>l -n blfli ■ p.HltiiiA onuninl mm).
■ rK l<#4tl*>* -JQ Pl*4lc^D*» thai 11 '• htrilljr 4«F«B
i^rjr <» iln mot* lliaD ■•ii-'i x* llii> ("'■HratUri -if
Ul* tttlli •din-ia All wh- p"'!-* II aiii*i >•• •Irntk
h« ibn •iiaiiirK rxH'rIi vklBh lis* Wall a*4>r-
Uk«« If ■ ■ r«l>l"*<llt'>Hi,e*ntl>l<i«4 "11 h
*' FIIDl'n frailln" la nwoiinlml lA b* ■ ■(«Bil(r4
IrnailM uf l>l<h not ufHtn lb* pflu>li>li)< **i Iha
r inn Ira iT martldBir wbi>r*<*r il>* Ratllali liii|«*^
• rrt'l Till- i.plBlani ■(■r][ wlirfv r**"<l 'be ai4k
«( viianilv* ■ipstloar*, iIiIimii •toil^. caJin Ja4(>
'-_ ''!'^!r '* '•■""'' ■ •■'N'^f' mm. mo4 ai>i>U»«l rriikura. tt- niirk ibt.aM
Which il I I'fit'b Itln-trattnii «n<l lUinii
■Ifia. «|Hia'u« Of iixw (Iota tit Inf^alry vMrb b*') oiil
IxM lh«u«hl->( <>k«Bil>*pr«*l'-n-><ll1t'<l ••■t<*4f<'l.
Wacssaui ci^acliida till* aoil<a wlibiul •X|»aulaf
om ■ilmlrnnoa or ili'i T->1aiit>, Wl>'e« !■ f«rialnlir
oaa lit rtia irinilun) I >ll-1>''-'ki »• mclWiaa, an-l ira
»ty >*NlriiflMiill»I.Uk<:a uKufilx'!. Ii <iihl>H[i l-aain« p»lll..a *m « icTI-b <.>k (« tl
■ (nlltraal wli^r •«|««ii.|jn€- will. f<-al (Hlbo- ■#«o*l •»h>'l», *n4 lha kl(4 pn.l-l
lafKal lo-|«l'r l''*« ■"? -irallaf "-'^ Mlh wbl.b " '■ •'•• !•«■» '• ■ (""•la" ■-■* • W'
w«ar*iir<r»>uia<l, whilnl ai ih*>a"i«ll»a II •huw> '•"'• M^o'tiim ifc"l">.'»: iii^ri- ••
III ■hlk'i !■• ^a p<.>inua4 »' tlH f»ra raftnilM of '>ia_i>»««i»_l (Ul* of Ik. <. ic
fltr i<Xr"<'1l>B. Iti>'a«lil.r«l JlicriniiiitlL «, kad
Miad JiiJcnrol — feoaiti- ^ni-ct, Jalf S. Ihtl,
^ Id tha fcii^* of avary prwiUUvaaf — iVa« furA
«>■(. K«cvr>l. I>1. 14. IMt.
Tha •(; l< aa'l iliaracar of iMa w«rii *>• ton wall
kanvii In llir rr'>r»»lv* !•• (ainlraau latrtidscll*'!!.
Par ■ Dnmlkar "F y*«ti Ihl' •'luma ha* vnaf''^ •
j|
» I«'i1d*itlf
11 nil Mfllettt
Pn«llfallf, lb>« 4-|lll0t I' a B4<r wnik ; tat •»
mimf adilllloa* aR<l rli«t|*< batn Wan wiid* thai
»<M "til •«']ialDI«4 irlih |>ra*l<iii> a4itl"aa «n«l4
aajardo >^ aoJ UMf M
Ka4 pfa«rtitABar4 ot maHl
/•firwiJ. Mknb I, lUt
Tb* aaihor baa. la (bla •Jlllaa, raa)**! aai r*-
irrlttaa ■ ci-mi darl aad a*vt« It aocor^ wllk (ha
h.td'v r«..iul^il.1 "1.1 rria.J Tfc..ii-..r "*"• adfaoe-J T.la.. wlil.h ^»a baMi daTalop«l
IL-..|i<u«l>>u«««>»M.er.,..J. A« •«'lr« a*' »1IL1« He p..l fu- r*^r.. Ho l» ifc* »•« ail** !•
aa.>ll..n.Dri.nT.n1 nni. «l.ji.t-r. h..« b.-e .drl-J. d" -. •• h. I. .eilralj ..ffagad la hi. frBha.lita
II I- Bii»»r««IIj'e«(i*«l.4'1i.t a'.t.^iboi* ap-a *•■" «•■ a-l"* d..l»<.Ua« 1.0.1 (r«a Iha »erk o(
Ihl* xihjaal. wa- «-( paMl.bad la ihu c a •^''•'•. <"' ''•'» >■'• •"" l.bor.. il 1. a l-.Ua,
Ibal t-u .1 all ea»p«r, wuft II U lia. I-** b*.B "H'h "-rr Ao.ar!..a pl.y.lUa ahaald ba>a a|.»a
•I il.a r.r, lian.1 ..f Aia.fU-Blan li-.i.k llr.,.iar., M' labia. 4it« wki-h 1 .ml4 eaatnU oa OMa^ona
aad tu«a«.. b« a« J.4tit bu. Ibal li wl-l t« aiaar *''" ''j I«'""a I-""i" '''« '.'•^.',"~*'- ^•"
nr rifa «d>fK aothou.
CUNICAI. MKPICINE; a Sy*tomalic Troatiw on the Diftennsia
and Trcalaifnl of Diteu**. Denixtied for tittidanu nixl Pni<;lU>vn«n of Mt'lloln*. 1 ■
on* Iniyo and handimac Ofiaro tftlaou of 7V& f^*H Dlolfa, $4 &D 1 lUlbM, $A Wi
half EluHla. %t. ^Nov Rnniy )
Til* aktlaoai '••«bat who ha* «rlu*a tb* volaia* \ la Iblaoqt ' ii«lbar of i>a worka
Ondrr (4d>I Itraltaa b* raaognliad 1 ha nvada nf nf faal K'" ». and af avnari'iu
Iba OnaflviB t>r«f>**l')a.and lb* rt-ili i* ali ibkl pai-«r<. ■> '^'L'T aad ■■i«g.|*«
I
(a Amu Id wlab. Xhu a'jita In wlilch l< 1> vrjl an l>
pnailarlr iMaiilb.x'ai iiltfl'ar abd rortlbU.aad
Marka4 by Ibuaa obaraciarlailaa vblvl' Laaa (■>•
dvrfd lilia una vf lb* li**i trdim aa<l i*u:b«f> Ikl-
«oaDi ry bat arai prudacad W* baa* mil apufa f.ii
B* (all t (i)oiId*rall"u Af t>i<< ttinnriaMr «»rk a*
wa iTuiiIri H*ilra.— M. fjood OfiB J)(minJ,(t*r. UT«
taa> aMb — t'
<■>'■/. Daa. IST>
Tliara la •*•()• raaaao m ballaaa |hal Ibla ba«k
will ba wait iMVIvad. Th« >«ll«a ptaMlllgBat la
TraqBaailf IB B*M of •^ma work ibat will anahtii
lilni la ablalD lafiitBallas la lb* AUfanal* aad
iroainaal o( «a**a wlib 'ompafalirtlp lliiU lal«r.
6r. PiIdI daa iha tunX't -if aipTnaalDK blmt^f
Il )■ li*rc lb*! ih* 'kill aad I«>arDtp|nf ina(*Hl I dtarlj, atil al Iba aaia* lima to Auadulj
•llnlrUe ara illipUjRl Ha ba- |l«aa at a -Xotv. I ■laVla ilia •■t>(il>ar to maart* ih« anllM (rpaad
bao-B-l aadlMj kBijwIaitca. niral^aiil fat Ilia ila af bla •mnh, aad al Iba aaaiK lliaa iililala all ibal
daal.fi'Biauiaai for iiia i>ra<i|H>ii<>T, tka iiault r>r ■ I li aaaaall tl, axliviil plrtO^lBi (broeah an lal*rlal*
liiBK llf'' >''flbo CI.*] Ktiilifil cIIbIuI «atk. cnHaol- . aab'a apaca— ff. T. JffJ Jaur.. Hut. IhTB
•d l.r au 'iii'RXBtacll.ar ■ ,» .r.laa^iK a. aa- TUa , f-,l .ibj.«< I- !• pia«. bafn™ (h> raaiar tb*
llrl..« aad w,..(bad b, . Ja '(n.ai a.> Iwm «'.ar i.,„, „i«„..| J ,«p.rlaa,« l« ril.fo^.l* aad
tbbo bl. cWraBllua la »lo».- Jr<A<M« ^ J(«l^ ,„„ „„ s„h . w.fk I. a-pwlaliy aalaaM. to
Mn<, Uac. 1h7« alodaaia II la euatplala la ll> apaclsl 4a>1(n. aad
To |i*a aa ad*|«*la aad a-oral eoa*ra«ia« «f Ik* J9\ •« «aa4*o**4, ihai ba *ao 1-7 11* aid, ta>p ap
OKlaaaHa aald«r •nJaracllalrjl MadUlaolaa taak wiih ilia lariarav •>d praftiea wltbiiit BBclacllag
*r B» "NtBarjr 4-a#aii)r : bni in *«aA«pllab il>l* o'har hraael.aa. It wtii b'I a<«<pa ih« DMiiaaif ib*
Oi>B>Uf«Btlir wlikbrxUj II n J f laaroaat.tba Jif >r*ai iifanlitoDar ■ liai aafh a «»ik !■ mual aalaabla la
■<i'' t 'IjMr >a ratal |>arl> ta«ltlo| lb* kill' a- ml Ua pjicl* ID dlaiauaU aad (raaluiaai la (ba IB*
Iralr ^'> Ebplr iiup<k|iaara^ madlc'^l
Ul' - I'lt lliaiu.l* allil BvradllfCHll Tbti ,
lata W.I ^■>4i t^HjiaJ lu mty liat baaa avacai^i vl*li
BO to 'baa paillal aiMcp" li)' I>i I'liai «liu>a aati>r
la aliaadrfaalllBf I0alu4«nl*<if «d*aa«odB*ditlu* 1
mil ■■•'waaa Iba 4a|l)r roUDda of lUlla tli
raa la * taw aiu«im nroah bla noibrtrf . vr Iwat*
Ibaliiaaiadaaacola Ibairaaimaal af tf)>aa>aa oLKb
dninaad bU'laataal ataatloa.— tnarfaaisJI I.d»«at
'lad ifMnfa, On. U, IfT*
D r THH samk Ji nreaM.
ESSAYS ON CONSERVATIVE MRDICINR AND KINPRKD
TOPICS. Xa ew vtry butJione ror^ IXibq- roiiimi. 0)«lk, tl IS. tJmn /Ma«rf.|
DAVIii'S CUSirAL MinTRBS OT VARI'lHII »Tril'»B>;'»( 1 UTRf^ITCTIOX TO THB HTrDT «r
IMI'oltrA:)'' l>l'iKA><K<; t.«IB( a enllMH -n -^f ih«
Clloleal L-rtB»>.|allT«a<^l In Iba Urhlkil Wardi
Of N-raP llMpI al.rkl««. MIM %J Paaac H
b^vi*. H l>. Hfo-ted adlttaa, oalamd la aa*
kaadaMB* (oral iSao. *«laai«. CMh, II li.
CI.ISK'aL lIF.l•ll't^e.
T*a1)fall>.a ilf i>laa4*».
talatta.ilaa,«lU.
Ualaia Onldalolb* ■•-
ta »oa l.aiidaixfla tjata.
|g ngtsT G. Lka** Soji k Co.'» VvmcATwnH—iPraehce of MMicim).
O/rff .^ff/is-/) vfpp.V/ WX ill).. y.R.S.. M,A.. LLP.. F.S.A..
rr.
I'JCl.NH. iDuneoelavovtitumcorabODt 500!
■ li. >
,(.!
i
aARTSROH.VE (RBSRD. M.n..
BSSEXTIALS OF THE PRfNCrPLES AND PRACTICE OF VFT-T.
CCTB. A kudj W*k fxr SlndcfcU luid PtaeliUoocr* tiiWt (illitun, li
Tk« »»«y CP*M l*r«<t« likkfc ^a» r-xhsDttr4 fnur tiVPir» rdlliin* of IkW ftrtfti •!>»>•? tkfti
MttarkH raMM4*4 in «p^i> . li^n af ili* >
«a«hMhtelB*MC«»iia r«< I l.tf t:lin. ■.
»DB •awvwtkf *r iw (at".- ^ -„ .. i,„ rd. Th» j-i.:-.. i. .... ..^_
pt^Stmt «Ua»l>*« ■! iW b«i><li M lb* tdtbnr li> lirins il ia ircry Da; uo ■ IxbI •lihi Uia oi
•**MM«4 n*41UMi Bt tliK tah/Mk Bad n< ■ITorl biu Itnoa •p*t*>l lit ntnh* lb* voluai* «i<iibj |
VMMmab** Df U« v*r} (Teat Utor atUi «b.<b il bu bitltMlo baao r*eaif*d.
t/poonttrpy [FRjyK). M.n.
A V -noK OF TnR PRIXriPLES AND PRACTrrE 01
> • tb* u* •( JiiailaBto uiJ l>ruUUi>iitrc. In ont D«al «oIau*, r(ijr»l IXaa.^
, P4>tadi/p»(n,rdU C«V-'*^'* '" y^.ClitiU,Sif
• tiA iii«<iT.ktiau- l/a iViMl.)
F°
TRRRGiLL iJ. UJt.S'KR).M.n. Kdin.. X.R.C.P. LnnH..
Jwt r^r' ('«%• tTMlCriiaJ tf-f^ ; Hut ^t«< ''•'*• ^r> •?'&'•«''- "luii ,tir
THK PRACTITIONKn'8 lUNOBOOK OF TRK.AT.MEXT; Or.lli
MMlfh* at Th»rap«iii^ St«««4 *diii«t, r**l**it aati vnla'CT'l In nnr rarr
•aan ?it«at «f Bbusi t5« l«fw. Cloth, t1 V«; lar; hiUHliom* btir Kuoia, t> M
iBiba llMnihl'al raaaat all Ikw ck^rM> a*d
.1.. -f . «■.-■■ *>>: ... ,:,.T»|. Ka pi-. -J. .-- ..»
Tka Jaak«t
-natlbaprfftrnM vtllladlB
>..,I4 ..,1 .-I. I_ ..K,! L,.t ..••
tfc" »rtT([, wk|l« fnom
!• U foJ CaaJ -U'W jr.>t, Xcotril, Oct \X liB.
TW A fall Ibh
(\« uiMbmi af ilh -
iMMa* bT a BMM
tfc«fa#Hj iMiBllti <
fytiVLArsos (JAMR.'?). ifP,
X n*iMHa« ■■ it CH<*rv >■ t1i«(ri|l V«ir(>riu(*lkr 4>it*puM ITutan rB))HBir*y.aa<>.
CLINICAL PlAUNOi^lS; A Uiimll.<N>k fur Slu<lriiu aim! Pn^
titiB««t* •! ll««ll(«Ma. [b ona fcanibaaia lliu«. (olnus, uf iU paga*. allh Si lll«Hr«
■ H>I.|t*««ttBl II H :
U4«* Ik* (MiaBl a—:'
*<>•■ ft^ iwtakaaalri <
aaJ il"aa mrl Im> la lafutBainB ibM *il atvai
B-BBM 'f ur*r>raf«4 ak^ alda* «B».— /^Il>i« >
niMB, Jaa I 1*T». . . . J .. . n
nMH«MB(U«MaU7MBfall»«a. hlaaWi— 1— A W"*"'''*^-»^««-lW».
lltrATSOV tT/tOMAS). M.D., $7.
LECTURES ON THE PRTVOIPLKS AND PRACTICE Of
PHTSIR Ik>ll..r*Jar K - .I'loH. A naw Aianriflou. frani ib« PirU r«
vtcJ lai-nUrr- I Knj;)i' < <rilh<4411toaa, Md-rfBral hundrMl IIUiii*
llMkf.br Oia*> llABTtii';*-!. j>i L/ I .-' icoaor u( llvrirar in ib( UilTeMhy ol PaBK<
tylVMln. U tvo lM*B nod bMilaoina f4T« rali. Clstfa. |tf Rfli Iralbar, tM It.
m
4a>>it- iL
la
ablaut OS orrMTiiii
a>>*t. villi aa - '
TaJaani la **n'
^I'laa. l»BbBki*i
■ l».
Uail jiU)ii lullalna ul atuui
" --< Traak
<>..»>, elalh.i
bMITH '
««\«'<
'UKTkJri
F:^kliaa. n
iTiua ; in i*KLTA.m ts
k I wal.BvA .ftf lA* ta
' ' THk Lrvnii AKV
t», mr>i*al [M
' PfOB th
'>>, la aaa l)a»4a«i
TTiNRT C. IiBa'b San A Co.'8 V OBtio ATioss^-iPractiee of Medicine). IT
I
TfEYNOLDS iJ. nnssEUA. M.n., *
J** Ppn/ ft/ fft( prfiiWftbi nniJ fV4#Mm o/ J(Hffr(«a4s Data. Ovliayi. toiufiHt.
A SYSTKM OF UKIlIUNK with Nnrv* ■>!(. AoDt* k.m* bt INmnt IUvta-
Hi?lil>M, M D-. I*L« Pfofvnor of RjniUnr in l1i# t'iilt«r>lly or P*nii>. Id ihrnr Ut|ta>«<l
))aiiiUuni« veiAi'i (nlitmvt, onnlwlBlOK 3i)i'>2 cIosvIt pflnivd dn<ikla.«otNmn*l |Mtg*t with
DumeriH' illurtratloni. &i/i^ vir/^ Jv "■^"''■Tdon. Prlc« p«r <al., la «loth. t^ 01^ , is
•b«t|>. t*M: hnlf RvMin, ni*rdb«Ddft. tt,b«. Par Mt iu oliilb, IIA; ibM|i, tlB; half
BumIu, SI9.A0
VoLttHi I [JHU ttadu'i fnnUin* Qhrkdii. T>i5B*s>ii mnd Di^stfirK i>i- Tun KtBri.r* SriTSM.
ToLuwi II. IJHii rt^ilf] rc.nlnlnF l>i«ii*iiK« or RKariH«tOBV Diiil Ciii'-iM.At'inT Smrtiia
VoLnHi til. Ijmt rfTJ^i toutitxM DibBAias t>r tui Hiobaiivk dd<1 BL'•o^ Oi.*MnitLiiB
PrkTsai. or tnx Uniatmr OiiaAM. or TKC PsHkLc BcriipnvCTi rx BriTsti, imI or rai
CCTASKUO SrOTKH.
IU}Do1(l»'« Sthtsm or MHMCl.-ti, ivrvnlly exnplalri). ha* afiiuiftd. «lBfF ihp Ar#i ap|kr«rBite*
or the (Int valanie, lfa« wall -ilef^r* nil refMlillinq ftf h«tD|; the wnrh tn Khirh mni-rn br<ti«k
lu'-li''ini> t> rrp^rnlnl in il* fnllmt aii'l aioat prarli«al form Tbia rniiM •■-kri-i> i:-- ■ ' la
rirw i>f ihv r«f t IhJl it ii 'h« rranit of Ihr cottatxiralioB t>r Ihc Issitini; iiiindi <i( '■ rL,
«uoh auhJAel biini; tivniad bi Mina xeiiiirman who i* rrgpirdol ■■ iu lil|;h«*l aulli Uit
{B(lan««, Dii*aa«f of th« UUtliirt h^ Sir Ukphx TnoHrauir. Miilpt'dHnna n( Itie |,iafua 1^
GaAii.r ItaviTT. Inaaniif hj ItRnay M«ItD*LKr. CBmnaifilioB bv J. IJuima* Baaxti. DU-
•am '.rtha .S|>ln* b* rH*Bi,a» lit ^vn itii'iti tr. PariPirclliii hjr ra«?iriK Siasoa. AipnhnlUn
bv riit<ii!|o R. A^itTiK, Rirtial Air*<itinB> hj Wii.i.i\ii ftoHKiirii. A'thma lijr IItiis f>jLTHK,
Crivliral ASrettopa l>y 11 CitAftl.TON )<<taTlAi<. fiam nod Rb*uaiall*iii by ALmEn Rubiiio Uaiu
HOP. C'lni'UuUaniil SypblMa by Jo^atham ilrrcBipiani*, I>iMSi*ii if thn SlomiMrb by Wti.wX
Ifos. DiwntMef lb* Ski« by Bilmavmo l>QeiHR, Aff*cii"nt of lb* Larynx by M"k«i.i. Mao*
VEffXil. Direu'f of Ilia Br^taifl Ky BuH «nii CuHtiHO. Diakaiei by Ljtueii BHfNTuR. IniM-
tlfl l>la«i»>of by .TrjHii ftvitK )lnt»i<.>'ni, Citialrpry anil SnrnDnmbDtlum by Tiii>«a> Ki»u Cm >■-
BKM. ApoplasybyJ. llvnyLiar.n Jack^un, Ancln* PfS'oria by Pr^faMor dAiHvnKa, Ewpbj-
f«BB of Iht Lonin by Sir WiLi.um itnuwK. ale «ie. All iba Iradlnx HbtaU tn (Ira^l Brli«l«
bav« ecnirt kill All tbpfr b*»t mrn In Ktntioiti' ri*«lry, t« build up ibia Manirmi'tit of mvdiMl •£!■
•noe. Si. Itiirthtil'iutav'a. Oiiy'f. t^t Tbc>iua«'». llniTirfily Cnll'st. Kl. Mary's, t* LM<don, whila
lll« K limb II rich, Ulorgoir, and MitnchMlar >eliiKil>aTcr<|u.illy wxll rF|irrrrnte>4. Ilie Arwy HrJIml
£«bi>nl at ,*(*llFy. tbe uiililaiy inJ naval 9«fvlc«ii, und th« |>«b)lB bralib bfiaida. Thai ■ <r<.rk
Cnn^rivBii in luch • >|>i(i*, and cirri^ out undrr auoh ••*|>l<'«t ■hould tirnia un iMlitii-n-ablt
IrraiUry of facia ami rl]i*>irnpr, auilet) lu Ibn daily vual* of Ike plmetiUi.arr. Oai iDati'alila, and
Ikr aiteeraa ivbirh II lua enjoyed in Rn|t)Aa4. and the ra|iuUtir>ii vbii'lt il hna aniiiirril i.n (bU
•idpiidho AlUnliOk bi>iBi«Hl*il il *ilhlb«i>t>Mtibiilir>af>f thalwii |i(a*THitnFiitJy piapikonl nationa.
Il> Ut|C' (Ii« anil btgh jitie^ hovlnir ka(>l it bajmul Ihr taarb i>f ninny prni-lllinnrrp In Ihll
eonntry <abn da^lra In piMarn il. 9 drieariil h»< arlaan fnr an rilitibr) at n |<')<t nbleh thnll rvfl-
dar it aiv>a*tibta to all Ta tnaai lhl> itviaani) iha frt'tnt *ilitii>ii baa bran ur-drrlBhi-a Tha
|va T'llnni'ii and Bv* lliunaaid faH(*ior tfaa urijiinal bare bj id* uaa of arainllfr lypa an > dcuMa
«nlnma>, barn ennipr««>«d into Itiraa rnturatu i>f nret (hraa ibpaaand pairn?, olaarly and hind-
foinaly iiiiiiiad. and I'tlrttd nL a jxtoa wbieb i«iid«ri il unauf tha eb*a|/«u worka avar |ii*^«nlad
10 tkv Anarlcan prol*ff ivt.
Hul nat only la tha 4iiif rleati adlllan inera cnnrvnlanl nnd iMraf fr)<'«d Ihx* lk» Snell'li ;
11 (■ alia.batlar and aaora o.inp>«l«. i"m* jmn having alap*ed eincr Iba aiiprriritn-e uT «
porlloa of tba work, addllloni an rnitiirail to bring up tbe anbjai-ta to Ibf nuifnjt fx-Ddltlnn
sfaolanaa. S(>ata diaaiwaa. b1>o, nbick ara a<>nparaUfT)y aiilHiporlnQl in Rn^laiid, rntuiir roura
alaborala trantmaat >■> ikdaoi Iba arltclM daviviad l« tb*ta to Iba wanta or the Amcriran f>)iyaU
ela* I and Ikarc ara paitnU on «hiab tba racAlrad pr*^ira in thia nnuulry diflara froiD lliat
• daplad itbraad. Tha tupptyinic nf Ibaaa drfl^itnairf b-ia been unJdrUliaD by HatUT Uaktfl-
aunaa. M.D..IhI« Prnlraanr af Hyicinna in Iha liDtraralty of Pann*ylrnnka. who ha* andi<a*«ra4
|i> ranilar Ihr laork fully up lo iba day. and aa uaafnl tu tha AiarH»«n jihraician iia il bsjt jirova^
to ba tc bia liD^iib bratbruu. Tba nttnibar vf iltualrnttuUB baa iiUo bean Urf{a!y iaucriiaaj, and
au affort iipiuad la tanJar Iba lypi'f[Taphlaul es»nutl»n unasrapiinnabla in aiaiy ra«pao(..
Kaally tao lunab pmlH* can lurrrty %t al*aa ta { aah)aala «llb wlitek ha ilrfinM ba Ikmtltar.— ?dff*
Ihli B'-bla Ira-nk. It ta • rfal'ip**!* af Madtataa i /nail'a M>rf /i>*>-«,, Pali. t8m
V(t<lan t>y tvina «f tha b>*l uaa -tf Kar-<tw- II >■
full ot iiiafal la(na»atl«s aaah a* na* ami* fr^gaaal
■•ad ftfta >><in'a dully •itk A* a tii-'k ul r*^a>riira
Il la Itiralaahla, Il la uf vilh tliv tinaa, Il i* rl**r
aail laaraiiiialail la iiyla.and M- ''<rni )• vnitli^
or lia (ainuiK pnbllalipr. — Lva(*al<(a Mt'i >'a«aa.
Jan .il, lUa.
"RayaoMa' Myaaaia af H-dlalaa" N fa'tlf ao*-
at4arr4 ll<a mnml p»HiIaf *-rh •■■ tha prlBi'l|>taa aai
yniattca <•( laailiriaa In Ilia RBiliah t>is|ii>^ Tua
maldbiiinK tt <liU wnrk ara (aallaaaa nf Vall-
kn-'OU rai>nlat<'>a du ImI^ ciila* 'if Iha A'laBII'..
Kaah (aailaiiKB I>aa a >)**■ la mtkr h<- pari af Iba
V'>||| (• riaelloal aa pii* llila, aail lb* la'iif »■'>■■■
»>ala>a*a i* marb ■> l> Dcdail I17 ilia liaay c .
U laai- - St Luula W'lf. ifM'I Aiirif. ■fuurii .J*'.
Itr Rarlahaina baa inada aianla adJIIloai an,;
ravi'Ma-, all nf vhloh ^laa laar«A*ait *al<i* In iha
TulniHa. BUil landat II faora •u/ul I" >ka Aniwl-
e-a l<r*«iiil'iaaT Thar* It B" *<>i«nia la bn(ll*b
naadlnl l>'a Binia »»(* olnat-la and ararjt par-
• haw will, an I<a4 iBilai '■mil df lallb II. loaa**!-
nlaip ifi<">*><r^" Iha |H<«A»«ai«i* '«/ th^a va*l Binr*-
basaa 0/ laAtrMatiaa. la rairafd I* *• naay at Iba \ Jan. VtMO.
Tfaaaa la aa Biad'aal anirli whiek ara kava )• titaaa
|M*t mnra (ra^aaalt; *m4 fallj aooaoltad vhaa par*
|r1*a*d bf dottbia a* l« ItaatntaBi. ut I'f l>a>)Bf an-
naiiaj at apparaailf iB'KpEiaabla af »p'i~<Di* pva^
••aU4 \v ua rkan " K*Tu<>'Ja' b^aiaiB -A Madl'-lua."
.Vincec lia aoulttboiufa ara laatlamaa <aku ai* aa
trail Haeirii hy rapalalloa Bp«a Ihia 114* nf Iba
Ailaii'ta a- la r>ia«i IIiIibIii, bbJ irb'iB* tijlil la
ayaak wilb aiiibiirlir uiHra Ika autiixla abani
vBlch Ihay haia «niiBu. la tatcialn-l Iba ■Mid
n>n> Tba^ ■•<* a>><laflIlT aliltaa In Mala ibatt
: aaJ Wlilla Ibaka ata
p't^i LEI it-a S'taa uf
ilaol .
shtetah" Laia1t>(ac\.ia\<.-— Aita. Ji-U*' Av>.
I
I
Bbnbv C. Lba'j Sox & Ca'a Pubuoattohb^Z)**. o^<Ae5<tifi,i^.).
AfORRfS iitALCOLM). M.D..
^R[N DISEASKS. Including their T)eflniUonB. Hyaiptoms. Oin^ngis,
PruKDiwIt. Morbiil Anntnoir anil TirAtoiBnl, A Maimal for SlnHaata noil Prnotll lunar*.
lBon»ltioo.TuluiiiP«f ararSaOiHijt**. Wtlh tllnatralioDi. Clulli. f I T(. (iVim- itnaJw)
Tt> phf tidu* vko Wonl-i hkt lo kaaw t<^ifi*Ihliii) I tm(lBn«f -^L iWiiIa OiitrCt* tif M'llleiitt, Apdl,
B-huut altls dlMiiin*, «'• ikiil *(»a ■ paiUoi piasaao | liiiC.
».litt-.lffi.r .fllU(i!i-yfUM »>k- > t..n«i .I.4.b<..i. Tha inlh*r of ibU Maiiil fcM«»M.n'l» « full m4
ABtfpfa»»Hl'fl»t.lli.i»Ur»»'ineiii.w.au!i«j^lilia«tJ .Bl.i»«(a «-i<t*lau»i>» wHli ika !U»t»i'.t...r Ji.t««.
rMc<»<a.<d .h . ll.lU h„ak nf n, Un.Tl. Tb- .«.«■ ,^,„,, ,,j ,„^ ,b, ^„, ,„„ 4„^„i,„.e,. ,oJ
lloB* af ih- •lilD .r* <l**tin*l U k Mr... I< cU ««■- ,p,.,„o„. of .uuaMU* M-lKli*. H- i"-. t,-.l',t*4
nar. aodltt-lr urani oij.f««i-tt-.lo. .« pUl.ly «. , ,,,„ p„(,te^ fc^.fc. bi aid of whl^B. «li" ao
f»rlhlb>( .l'»t«».U will 1» «i.y. Tlv. Ir.tliaiol ,iino^, ^„- „,,, (,« av« t* tb« f^r^.^.l-lPO uf
U «»h o..a M .o»* •■ Ih- •<(-Maar...('l.. ™...i „ h, hoi .l,p>ll»nl ^if.r.B<.>.. T»i» rf "" i p. loao
■«»..ol 4.-m.M "|«^.la a4Tl.*-0t«<(»««l( Jf.ift ,,, oaiiha. too va.aa nor uVtrraBttad . Iba 41'afr
(Hi) A'fliN, Arrll, IMO.
Till* I' •mpb><K«ltr»lMr*tr'* took; r»rir*m
■■biy iBf, w fWr ■■ enr lud^inaai (o*>. ifaai lo ika
vk#a raDii* »f »Mk«l liimiar* df it t)k* m-iihi
itiar* 1» B» IbMk vlitak fur claarBaa* »f •■(ira"t»*
aud naifca4le*l ■r'aaicokakl la baiur klKiidd r-*
lluBi tai iramoivij: ■(• alaar >«d aaoclaei-— IVh^'ik
Brif ■., April. IfSO
TIm aulhnr'a I«*k hu baaa «al| Avuaaa^ b» f'o*
ilOAM on* »l tha )>«■* rr*«al »4rl**|>'>B (ti* dlBrotl
■MlifiiM nf (rhlth II) oai'. larfaUf.n irdik r'«l''<*l>a4
wtalth (I'a* ■ baJlar Tlaw if Iht ultmtt^ttf 'MU
CfoBiiiO B ralliioal e«»(*pliaB »! flaiinaUilog;. k ■■•! iirl'iciiil** af d*tiaiUulufy.— >.V(iu ii. Ihiim ifwM-
rBB*b aunhMill? ilfteull aad parp'aKiim lu lb* eoJ a«d tforjiiaai /vumu/, Arrtl. 1*60.
JPOX {Tlt.BnnD. i( D..F R.C.pJiuPF7c. FOX. B.A,.M.R.C^.,
EPITOME OPSK[V DISKASEJt. WITFI FORMtTL.E. Foa firu-
»B*Tii AHv PHArTiTioHHSS &*cvfi4 ailiiion.itiarniiskly Taatawl KMil BrMllyvnlaTcad. In
OKt wry b«Bdioia« Itno. Tallin* of 319 pftjcon- Oloib, It ii,
r^lNT lAUSTLV). M dJ
A MANUAL OP PRUCaSSION' ASP AUSCUl.TATrON ; of the
Phjfkal Dlii|CBii>ff of Dlffntry of tb* [.nnf* and Uaart, i>n<l cf Tbnneie ADaurUm-
fit^oD't cftlUoa. It nne kAn<liou« rojkl Itno. Tfltdmt: tteib. tl <IS' (JuU ttmJy.t
Tha lliila •ork Vtfura ni ha* al'aa^r bMnina ■ I
alabdifil oaai, aad ka* bc^uai* rx' *■•■•* I* ti"fttt \ ,-, n-fna^ i»iiin ■■uu ■• ■■— ■■ixi.-u »<■ i.i.«.>r-<i»,
aa ■ laKi.bnok. Th-ra !■ Mrialnljr auaa twiiar. It i lo t^rlvaia atiuaaa.runipoM^ at laadttm! ■ii:d*Bi> aM
onaialBt itM i>mh«iBO<a ,,4 iba Iwmb* >hi(!i lb* | p aallllaBrra - (.'InclitaAtl Mtd, JAmm, reb, UR.
antbar ha> fat ■>•«; l*ar>ffl*an,lo «na>*v<l»« irllh
riartlrat laMrMllao la ■■■'UMAIlAa Md I-*l<4flO«,
J5
or rwir HAMK AVTIlnK
PHTHISIS: ITH MOKBrO AXATOMY. KTI0I,0(3Y, SYMPTOM-
ATIC BVENTS AND COMPFJCATIOSS. FATAMTY ANl> PROllSDSIS. TR8AT-
MKNT AND PlirSICAI, DIAOSOSIR; In » aatUa •>! Clii>k<<al Niuau. Bj Al-rtiii
FtiNT, M D , Priif nf iha Priiiriplaa ntid Prac<«'««f MailUtNa in Ballavns ll(.*))ilat Mad.
Colltg*. !l«<r Tork. In una buixlroiiia arl>T« *oUia*: $JI 69.
jay nf* sauf afthhs
A PUACTICALTKEAT!8EOXTHEnrAOXOSIS,PATnOI>00T,
AND TKBATMKKT Or DISBAKRS OF TIIR HBART Si^otxl r«.rl«*<l *n4 «iilar(o4
edkloo. In oan ootavA Talmne otii* r>|^*s. 'lib • ptale. elolh, {4.
i»r rat SAUK APTitoK. '
A PRACTICAL TKKATISE OS THE PHYSICAL EXPLORA-
TION OF TOR OnRST AND TIIK DIAONOSIR OF DISEA.SKS AFFKCTISO TUB
RESPIRATORY ORdANS Se«on<l»<l rtrlMilsdiltuii. ta on* budwinavotATu *<)l«m«
af i»S paged, ololh. t4 kt.
ROiv/f [r,f-:\'.\'0X). frv^.s. Ed..
Srwtlnr HnrgmnlaHa f}tnlritl LnajMn T^rvwtf tn-l Ri«r //na|t(ri«J, «(B.
THE THROAT A\D ITS DUSKASES. Sccoiii Amprlpan, from ilie
Safun4 EnKli'h Kdlliun, lhor"<i|cblj roisr-t. Wiifa nna bnn'lra4 Tjpteil ria«tr*tiOD» In
tnlor*. and flfly ww'-l rnirai'lnsi'i 'l*»fiir<l Mnd *s<GUia<l by iha naltior. lB«n«TarT
baiid-itm* lin|>«rltil uotaToToIaiaa af orar AM pBCaa< i, Prffo^ttf. >
CfFll./iH (CAHK). ,V./>..
Xj L-i'fur^^n l^rnttg./t^rv at Ik4 CmU. 9/ Pn(n«., C'AI</ n^ (A« rhrodl JHtpttuam al IA«
HANIinooK or MAdNOSTS ANI> TREATMENT OP PISEASKS OF
TIIK THROAT AND NAStL CAVITIRS. In nna han.NoiD* royat ISmo. roluna,
of IJ«|):i|[fi, with .1^ Uluatralli>D>; Rlotb. fl. I f^fit Ifini.}
Wn nH»i kxurillf eiwinasil ihl> bunk »• •hawlH( AtABTraltioi llill* hiadbosk, cUar. cobcIm. aa'
Hxiad liKlamaallkpr^cile*. aa* ra'f'** (*«iilaH«r **«eraia lo ii> iBaOrtrd. bb<I tdMlrahji raJlilliilia
wtlli Iba Itlafsiara al Iba ipaa allr H ■» ablf aft- I yanatB of biiaiia* tda •ab)«(l of wllrh II lta»la
leulaa* — rA(;«4a. J<>it riaua, Jalf «, Ull. wltbla 'ba a(.si>iaWa<laa »t IK* taaaMl pfa«t1-
\ lUB<t. — jr 0. Af.r* ynar . Jaaa. IHT*
OL'XirAL OBHRRVkTlOKH OR Pt;?irTloMAI. I KIL|.IKK-| 11 AXDtOfkK OF HKtX tirnSk&CA.nn
XBRVfinSDlS'iHUKKS B>i: H*«i.riKi.i<;oKi< SlqJaal* aB4 rrh*l^v^utt*.Kk ^m*»««. V« tti. "^^^
H tl , Pbr»BU* in 81 Hair'* H'l'Mtal. »« M« I *»» l»T»V\*»».»'>\-o*«» W- ''^^'^'*-'^***'*'*'***
UBril Amailon HdldOB Ib .laalKBilBoa* MMVc I OImVi Mtb.
■.alolt.fSU. \
raltmrttt)iitp»t»g,'
■
Hemrt C. Lka'6 Soh & Cow's FoauoATioira— {i7u. </ lfMi«n>
rpsOMAS iT,OArLLARD),tl.D..
PRACTICAL TRBATI8K0STHBT>[SKASF,S0KW0MB». Ffffc
SdUin. tk»ra«eliPj revlMd nod Kwriit*«. In one rar^a anH huO^uai* MUth hIvm
TWaaU«r bat iaImb AilraaUi;* af (be oppoManUf ■Kor^cil hj ih* ckll ftr « nrw t4IU»*J
l¥W vi'ik \n rf»4*i ii «--r>bt' • (-(iDttBii*ii0« *t Ilie ler; rrdi'^rkiihU fitrivr will) wbl^rh Ik bo
ba«B r*r*>i«cl. Grvri (■ttlinii of lh« work h&* t>«an n.iinfall j rarii*'), Tvrf RiUii]l nf 11 k<*
bM» r*»rtll*Ii. a>il ■j-litlnr* ami nllarilloH* i>l«i>]<it>p() whar«<*T lbs BJroni)* oT r«t«IM« u4
I (•■r«a*nl cxpMlvite* of lb* aalhor liitTv ■hnwn <b*in df>«fral>l*. At lb* *ktn» tiuta •|w>l«|
*«r« haa b«»« ■■•r«iH4 1b aroid wnila* iaet*«iv la Uic »!» nf Ui* vsUin*- To an-Bicra'J't
tba •«■•»)■• ■d4lli<Hwa nan eovdawvd b«t r'tjetaar laU«t b*> Irri-n u«p(l. aoivtthttiui>Ut>(1
vbieh, ifc» n«ab«ff ef VH!** fc** '•wn iB«raa»»>i liy n»»r» ib«K flfly. Th« "»i»» mt iliaiirvi'daa
ha* bWa •lUBatvalr naafa4 ; m\*j vbl«b w*m«<l la ba taparltavar hi'* b*«a omiiud, Mi't
larga nanbar af %rm and laparia' dniwin|^ b«T« h«*n taatrtad In t<i ImpTDTvl form, t)
f«ra, IL U bopa4 tb>t tk* relan* will nalDtaiii ibt clitrMtar It Im* ac^uUad af a tusd«r
■ylbaflu on avarjr deuil of iU i«>|>arUBt )ubJF«t.
ka aBaKlaaltoa af ik* vMk bI'I ■■''.•/j ih«l <■ )• li* ■■iL<ii'*|Arf**iparl*«>«, liai T»lla«li kUi
aaaaf fT«U ■*rtl. It I* aat ■ nat* MaatUllaB tal ua-lr •oi'tDc rHii>T aaibarlilr* la ii'i-v >
fFMa Mbar v^rfcv. bal ^» iha tr«>i af la* tlt» h-iili «i Ii>miv nail ihriitJ Pr. Thim :
IbaaabLMsad Jaripaaat aad cnilnl oWer*a<liw> ib-I cmacl'iilUui lfiarli«r HI* mi.
«( a ItiMH. »tf«ail«e aiaa li '• ■ •~.-n.. ..r
b»o*l>>J<B ot lb* 4«partBa«l sf ix-
U k «>fDiW la It* prwHQl T*T!-
lalal/ bol4< ■ ft>t<iBii>l po*lilaB •• . 1 , u -.
V>tk. laJ wtll tOBllBua l« Iw raoM'tl <•' • *'*"-
d>rl aatfconij — Ola«Hi*«ti J^kI .V.v>. bw IbnV
m* w>i«t •••J' n-i lBlr»4aell*a !■• air ^ lb*
«lrllii*>l aaltouul ili> irutid Tba adkloa ImAm*
«a adi* (It lb* (Ir* D( b "f CniBtr rnlftM**. W!ib
tka VMdn« sf a niaaiar ravWr W* k*n fira* iha
raMM*lbai,lB kit ]ad(8Ma>,Bra ibimi liBtiw jrth;
al iba ft«wgi Una* :a ll> ■«« |>'*«a li k*i an
Itfvt. bMkata Ibi ■Hikiii U ih* )>■•■ i*b(Aa( na Ilil*
■ab^aat <a ih>ni*kM*>ir ih* ptvFant"a A* btlbarln
thU varh liill Ih- i a* i*(t.lh»it .<• il>aa>» •>! vo-
*■■ Wa aalT *ltb ■•>■< i-i <'tli*r brfta<b«B of m,**i-
rlaa a* capiatila laafban e>iaM l«fi)«Bl lu«rtlati«r
Uai-ba-^B.— Jfrad t*tnKl. Ua iwi.
SiU'S It* am apjiaaritaoa tvalia yaara ■■n, aa'tl
Ua M*-*al 4aT. II ba- bilJ a ffsatitaa »l bUli r#-
faM - -I ■ •'■• - —I '" ■- ■'«• nf ma
■ ' ■ - J»- pfa
iai . r,. il.pKI.
MCHi '. !• ->< <<<<i.. ..,.•..•..> 1'* aat Miir I
- *o>l *• t I
■ luUa ibaa • .
aa« laoxl* i« lhn*« aifaadf waa. — Xd
Ir ka* haaa aaUrgad aii'~ i
aalhat ha* kfiitflil M '%V
and •• ■' • »"t ■ "' ijiffi ■ •■
1(1*1 ti'
aa* tf*i] ' I
ll^■l^'^•l-• -i-m ii'. .■ ■ rli.f h
ajcU-pvtl* -f iT*** iliwIrAl ■i*41 IBf. Thai
arranrETiral. [''n miiiril j nini,*! :ii
•ablari -
rlTi-J 'r tinra
la that . ■ ■ . --'1*111
C'MiiW'Ul II In ill? ti.*-i':'i iniH- ' ■ iiup i-ii.!tir»»»«f.
— irftMvKIa y»»ri>. •/ "•' aaJ Jfary*. Ju- UU.
wht.
I>ARSE!ZiROBEKT\ M.D.. F.RCP..
ACI.IXrCAl, EXPOSITION OK THB MKHrCAI. AND aURfll
CALDISRASRS op WOMKIt BM-Aitil Ainarlpaa, fmm IhaS^oon-l RnramiM aa<l Ra*!'
Bn|;lM)l K-llli'>n, Innna b^nilmnna Aalaro vnlava, of Tri4 paaa*. >llh Hi klliutratinU.
Clatk, «•(}«: Ualhar, ti M ; half Kanla. $11. < T^lr/f ItwutJ.)
Ar Baiaa* 'iBaJ* tt iba h<^d of bU pr<rfaH*sa Is taaaItT, la ibovn Hr iba Baeoad adlHt^ IMIwIag
•a t*ua aaaa Iba irM.— J» ft««ai*a», lac.
Dr. B4rB*«'« vn'b t* naa ar a pnttlnl aba
la>xal]rilliu«talrJ 'r.iw n 'aat la htni» a a«f arta
ba> bf aaM*aa>eaaM)fdl« •acb, ai will balaw
frn«a Iba ^(r ihii b* i|iiDia> fraia i" ■■'• thaa
ainllt»l aalbar* la aBikarwaa ''
*rnai as'li an lailini. II U aol a<-<
Ih* vnrb <• ■ T*Ii*Ma ■a'.anJ
C'la-allrii <i; iha |>r"r**alna — Ja* l~]f i>*-(f.
y.»rK fif flHfofi* a»d fnlmif. I>(1. 1 Al
ifdarbat (Tu •enlKflfii [ wvrk h»ld* a falfha*
Iba aI4 «--
1 II >~...|rr> bal t«aBI Miaitaj
er bla no .
.• ka'a ikatFliad lif a
Biaalar
«-ini'i4»>a taa^a; *faatr*
•arv ■•—■
■-■'- , l> -Ml-
aaB
- 1 lllral IB-
•all
lo
- . . -. .. .i.d lulba
•anna* upimi'iia* r<>Baan«ii wiin iti<e biiarh il
taadldaa. lail Vlll ia Harh tu mBiUhIi (lia tag^il
^tli al iIm *'HU( a;B««-'t icI*! aa'l tBll»alh* T1*-
blaatir of Iba ivaa "f nulit* jaan. — OiBwIfaa
>«i - - -
Wa ^IV Iba daflar WbO, baalaf *IJ Me4ldM- I
abia prMtlea Ib dlinaiw «( wnBaa, ba* an *r>pf of
■' Bataaa" tar daJI* Ma*Blla<k>a *bJ la>(rii*llna. Il
la al owaa « baiih af rtaal Inmiiif. tnnafrH, aail
ladlrldnal alparUata. aaJ ■! i<» «aui> (lina <'eil-
aaallr atvMlMl Tr«i ii b>a b'*a •pt'rf«Ui*4 by '
tba ^ofMalna, hnib la iliaal Ddlalu a»l ja (hU '
ll»a. ba*1u< l>-c»fnt
dliaaia* nf wnniaB
fiitlT abl>«<l i>r x-tf
<)<ja-r if iaa.1 ■ ■
ur Ml llbrxr
IMt-b**!!— 11
• aibariiy avarjvbaM U
riia ••r«i b>* baaa braa^
ui Iianirlnlf* K*«rr |iaaatl-
iiaan II upoa Ik* tlialia*
'"1,1 *t11 lladtlaauratUU
ffODOK (RCOH L.\. M.D..
JwapttM iWau»i- It/ 0*«Mrt». ««< I* f^r ITalairHty •(/ FrMHlrfwiaM.
ONDISRASES PRCrUARTO WOMEN ^InrloillnR Piflpl/uv
of tba Vt^nt- Wiih orirlnal lllnslrationf S^ctid rdlilnD, rttUtd anil »ul.rfad.
oaa btaillifRlI; primed actaro TBlnaia ot HI p*ita*. clulb. $1 }0,
U
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I
OM/TR [J. LEWI.% M.D..
A COMri-KTK PRACTICAL TKEATIHKOX THE DISEASKS OP
OIIILUHKN. Firih BilUtoK, tbornunhly favimil and r^orlllrn. Id ooe bandioiii* m-
Utn volumr of a linn t MDU f'S^. w\ih itluilratloM. (/■ />'*> }
Tb* T«r J miirkfil fainr wilti wlllnb thW wnrk bn* b«*n r*e»irrd wharvTrr lt>v Rtis't'b l«n-
f(|ftf!« i* KF^ikaii, V** 4I>ibiiIbI«<I lh« inihfr. [q lb* pieiaraMoB nf Ui* Fifth Gillili.n, la f^ire
BO pain* lo lb* euiliBTor tii t*iiiitt U wi>ribT lu *vcrr r»r|>cri ul ■ c-Ditnuaut* iif |Tur*»loBB|
fAottiUni't. Many puttMin* t>t the valiiini tut* brcb r««rltl>n. apd in«i>h nr« matter Intro*
4need, bat bjr kb lArnMl •fnri ftt 4«n<l*iuaU«ft. Ik* bIm of tb* ttsril «il( Bat ba aiMtrliilly
JTEATfyO iJOlI.V .v.), M.IK.
THK MOTIIKC'S OITIPK I\ TUB M.\NA(»KMKNr A\P FRED.
INO op ISVASIS. Id om bNi>4muf lino t*I, of 116 pt«*^ Cloth, |l U4. uVow
Tn >b* pT*pi'*il*B of thU volaia*. it bnf bt*n tb* «bj*«t «f th* »*ihi»ri4 frovid* awark ibai
p1i;f4f !&□( onii isff ty plug* In ibc banJ* nf lb«lr pallf nii for ili* p**'!'"'* ^' iDtilrvoiInx tb*<a
•* to lh4 *Br* ■1(1 nanovciacnl ol' ih*(r ohllilran lhr<>w)^h««t ih« trii (h'*« yrtrt of tk»lr lir*.
Whit* lh*re klftMly nisi 4 ■nolrtr of f«ch luiinuaU. Ihf'r* it yrl Inekln^ ont i>( tiklU* nrl-
;la. •■f««Ully n4a|it«(l in lb* pMulUrill** af Amirioao diaitln. uimlri ol litinf noil 'fcc vnrl.
on* minor oirrnnkalkiirri in vrhivh tb« cutt^iu* of oat anaulrj •litat rr«iu Ihiu* of lbs ntd tiurltl.
Tb* pOBiltoa s«iKipie(l by Llis aulbur a> leoLuraf aa Diaaxpi of Childrti* ■! ibv UnW. ot Pmmlkm.,
\a « gUMonlva uf tlie •■li«fiw>tofy iBiuniiar in ohkb bi) Ukur bu b*ati pitfiitiaed.
IT^fiST {CHARLES). M.D..
LECTCTRES ON THE DISEASES OF IXFANCT AND CniLD-
H<N>D. rtdh Aner1»DfiomlbFHiithrpvt>rdii)>lpnlaf-ired Kncli«h cdiilnn. iBo&elBrs*
and huidiOBtt octavo ftlaut* of (t;!i pa ft. Clotb. %A id . Itvtbir, IS 50.
n^ TMB SAMB AOTHOR ' £dl<lv '*'«'« <
ON SOMRDISORPERS OK THE NERVOUS SYSTEM I Nrnn.D.
BOOD; bciDS th« Lnfflt«bD t^cnrtp dtllvrrpH »l tb« Eoyal f^nll'-Kt ftf Pbylolktir ■(
LonitoB. in Uatcb. ISTl. la OB* vvlnne |b«11 13mB.. olftlb, SI QD.
LECTURES ON THE DISEASES OF WOMEN. Third Americmi.
from tb« Tbird Li'Sdon •diLkuo. In oDvnaBt oeUvo vsluuter abMil bbd pj^u.aUlb,
t3 Ti; ■■ttlb*t. %* 76.
an'Ay.vf-: {joskph qhiffithh), m.o..
"^ Pka'<'t'">-Avr'imi:Knrti'thw BritltS Imtral Hnrptmt. it.
OBSTETRIC AIMIORISMS FORTHE U8K OF STrpRNTS COM.
MKNCtJCO MlbWtrKKY PKACTICR. Sftcad Imtrkan, ft'ini ih* fifth and K«*t»«d
London KtlUias nitk Aa.lUioni by K. fi. fluiuaUB, M.A, With lilii»lrAlian«. iB oji«
n>al ISmo. vulan* Cloth, f 1 SS.
OBrRCHILL ON TRKrrKRFSkJiLrKVEE IX b
aTHBRI)ISBA)tBliPE<n'I.IAKT<l W01lb5. I tul,
■*« , pp IJo.elftlh %t ■'<>
OHWEKAlTRKATtSE ONTHEDISSASRS or rt'
JtALIS. WUbl!t*>ii»ii»n>'. l[l«*«iiilr EdtilM
vlia lb* ^ alb or'* Uklln)pr«*aBi*u'* »ad n'trtf
lloBt i ■ an* o'Ikftf *«luiBa <t( £>M v*a^; «llb
pUlH. clalb. 1:1 CO.
.UklOH ON TRR VATnuK. HIQttlt *III>TV1aT-
HKST or rHii.uiiKn rivkH 1 *i>i **», p*.
tnt.rlBih. f.- Id.
i.-iKWII.L-l^ |>R*>-TirAl. TMKATIliKollTHIIBlft*
KAtlK»PBCtILIAItT<> W<)<tl,V Tblr* iniatlMB,
Itoni IhaTMrd aBilrvdiiail Lu>4oa*d)l}»a. 1 r*l^
S*ii., p* &S». •■■lb W SB.
\V!SCKKL (p.).
A COMPLETE TREATISE ON THE PATHOLOGY ANDTREAT-
HENTOF ClIILDBRD. for iillg.UnU nnl Pn»ttllnn«rn. Tmailalad. «Ub lb* onvavat
of lb* BUlhor, fron ib* Svtrand llorman BdUloB. by Jahm Rhap Cuadwiri.N !>■ In
OB* patBTo rolum*. Cloth. |1 W.
■OirTOOltKRT'8 IXPOSITKIH Of TBt MOVS' RiaST'b BTSTW OF BIDWIPIRT With aMM
t:iD STMPT0H9 OF PHEOXtriry witb two | and UdlUtiaiilliiiraUoa* KMMd kmartoa
■ ■■|fi<Bti>ri>lDf(ilputM (ii'Dainiirofli wii-i4«aia -^liloi. Oaa valnM* oalava.tlotk, «SI (*<•■,
la I i*l.k**..*lBaftrty«0Opp.,«l*lh,UI*. > WM.
«4 HssBY C. Lba's Son & Co,'8 P dbuoatioh a— (Jfufm/cry).
TBlSHMAif ( WIUjIAM). MD.. •
A SYSTEM OF MIDWIFKUV. INCLUDING THE DISBAS1
PREaNAKCT AND THK PfgRPKRAL STATE Third Am.finx) rdlitnn. ri
th* Auitiur, nHb nddiliun* by Jvks S. PAititt. H t>.. Obfivirkian i« i.h* PbUi
Hii«|iItii1, Jt«. Ib one lari;« anil vcrv tundt'in* oOkvn Tnlvin*. of 133 p«itp«.
l«o hufidrad II I ml rail vor. Cinib, S4 >l»; l»lfa«r, SS &0 ; fastf Rufsta. f S. {Jmtt .
Tvv iriirli* lift (b1* ftul'Jtci hAT« mft wliti a* frail . *■««■ la rm\aif*, ^*A w* cAntiAt b«i
■ ilviaiiiitt B> Ifaia lion apTxiat* lo hiT*. ToJadK*
fcj th" ft"iii««c7 wiLfc nil III I)* taihrr'* *\rwt arc
Q4'*l«i1, fea-l lEBa'atfiUfftiti tat*rr*'i loin «btf lineal
lii'iiiar*, o»# «naM |q<'ir' ll>i>' tbri* >r* Wt^J-
■1ri«B4 ilmting iKorti •ti«iiik><n i<i rtbtfatrlfs vbn
■ r« ■rlihunlll. Tbs kulkiir l> ■rttlrnllr > niiB 4l
rip* ■■I'aikaaM and *OB>#(rKl1r* il*«>, ■att la •»
br^ark ut Vinlloiifl uta 'Iikt bui* vaUabUlbaa Is
l^U—HnP Rrm*dU;Jti, ISM)
W* (ladlir vslnorn* III* •«« t^liloo adhU »s^l-
l*ni InK'bniik iif riilitirirar|. Tli« tuim»t ■dlllna
tia» b««a mft'i hiTiiralily rfultod b]r Ike pnxp*' ' f>':i la Vi k
*i<Mi iiD linlli •-il*a nr lb* idUaitr la ika pmpara- 1(4 mrill T :
l'>ia rif III* pr*>*Bl ailKlna il>a anlhcif ha< Bado ancb l*C"nllallf i>"
■llanllDHa >• ik* pr^r*** of obaiMrlatl »fl*ae* /Mara , Ma»U, l»<i.
ablltljr vllta whitl. Iba raak baa •>■■■
Vr. (uattdat II ■■ ad*triil4ii i^mt b-f-'H hf (
4^.i„.. .(-1, 1 . — aima laciBCaa,
I iidl«(lt Ataal
'■■•I da* ll baal
(l-.r in Ki- i-nji.-i. laii ^aait*.— Ma*«^a i
l«»l
T-'li» liT'niki >*if«a> ib» wvrk h*P
CdMIilMa lu all
•Kbiafa aai
::-*i a«J prvnlila
. II a <r<trk
I lo Im pHf
pLAFFAtR ( »r S). .VO . F.R.C.P..
ATKKATISK4»NTHK.SCIKN(;K ANIH'K\(TirK OPMIPWTI
Tbtr-I Amvrl^DD •ditioa, rertaad by Iba aalbur. B<lfl«d. wllfa a4<llllai>t. by Bol
HtKKia. M U. In on« banilinia* nria*" vnlnnt* of abAot ^t^n papva. lalih va
tllntlniUona. Cloth, %i ; laalbar. %&; half Kouia, fi AO. 'iJhM ffHu/y |
Tb* niaillfBl ptoriM'loe liiu •<•• ItMioppaitaully i
gl wddlat tn ilifir •l-wit vf .•■n4«i4 nadlrai wnfb>
naanf il» haal (nia ■«■•••» nldoi'rr; i-var |i«lili ibril
Tb» •ab|»Pt U «ak>a ar "I'l" " »"'»r hand Tb»
pait d<-r<M«4 la Uli«rlu all II* *a(U>u> |'nu>olall-iaa.
tba iaaa*rVM*ai aud »>Bli*, 1* aduilriblf iiraon'-l.
■ ail lb" t1-»» ni'iHtainad lalll Im rmbil a-walUdT '
PI*-!- ■ .ipial.-i.. >iii|>r<>avu| tra>IWArtl.v
Tlw " •• ■ii)> I'la'at. Illuuratlia rn!..
«fc.(« B-; th>r «r- a-lnilrahly •loi..-
aad a^K' I «'-" 4«>l>i ' ' ' •iad*«t'>~. '.'
JTaJ. iKi^ Sard J-nv
U laialml iif hjr a i^. u i trhai wntk na
obdnlr'n wa ahniilil ic< mijiiiiuiI f>r h>ia. »• t><tr
• •-•"'■-a «• wuali! a doabiwllf a-iil" hlu I"
cliiii-» I'l.ii'i !■*. Im- dF^ib *■»!<•& I tli'.lml wbai
u '.' ' '• iraaiiaaai •! 'b* »»i(*<i«
• all' I'ala. VblU Ilia dlacnaiiou-
au4
<ia4laallyaUbarauiof«ad«T , lu^
• rarf lula1li(»al tt-» or Ibata. ^al all d4
■#j»**ar7 trtv I fall aa«1»ralaaaiii r ' "
amlllnl — /UmelwrnnH MM. ^xn
Tli> taplillly «lib •bkb itn* • '
rolliiv* an'ilbaf la |.r'->>r allta ■■I )• r
iTf 111* aalliDal* >lia> ll» pt•<t•'■^■'U lTa>
1l In ' N 1r- 1 • I IT- II '• u..ir» • u<: •<• 1-
M'-lu-'iiJ i-.r.."I. JIuj, I-?-
ll ourlalnly 1* aa adiaiiaM* «||>«>I|I'
B<i"n«- ae<1 I'lMiIca •■! Uii-"...
■ ilitiiina* aiaiir b| ib* A-
HarriB. lalbii a#r*r aliaf"
• la>ll«a> tt>-ai((lifa la >>u>.- ».-
ii:iftia4r*ra ai* *'< wfll kqi'«a ^a iba |»>ti
■•' (laal (liar.— iTfci Ja«tri0i« Pr-multii
T>AHyfiS iFANCOUHT). M.D..
•'-' Ph^tleMt In r** Qnirai Lvt^et" Jiat^Hnl. £a<Htm_
A MANUAI, OF MIDWIKKKY FOR MIPWIVES AXD MKf>
fiTt:i>KNT4. Wilk &0 illaalraUou. In Mta naat royal ISma. ri>)a«t »r IM
ehilh. »l U, (No^ K«»^9.)
pAli y/.V {TSIEOPH ILL'S], 'MJK.
A TIIKATISK ON MIPWIFKHV. In oiic very liniwIiOTBe <
veUnf ol «bi>«i MS pfa*, «1U) naBAroiu UliutnaUoiu. (/"ripdruv-)
JJODOK {HUOff L.). M.D..
TUR PRINCIPLES ANIi PUACTICE OF OBSTETItlCS.
tr«ta4witb Unt* HibQffTBpbM plau* ecDtaialiic ob* bun<lra4 Mtd Bny-ntBa tftnl
arl^litt phatoirraphf. kiid with namaroai w<h>-I «atii. Ib uia tar|[a and tMallfDlly
quarta «Aliiinr nt fihlt ■l<tnKtr-oaliiniB«4 X'*t**- tntnK\y b^nnd in elalb. 1 14.
Tba viik nt t>i U»d«* la lAiaalbiDa Uvf* I baa I *«"lf la a <la<l* tuinnii (b* WliiU aaUa««
K aliafi* pt '• ■ " '■■ ■ ■■' ■ ■- — ■ 3l»' 'tawa la Iba I ilhu-lfl** i « al4l.>rii> laai la *i»nMa>d
daiaiiB'" -<>iDrl)la( Mi-ca *aial* anl >*il-<l |ilr4->r<a1 lU«-lr*Ll
Ibaa aa r ' -ry : !■ la.ia Ami, I (ii-^i <ii (<Ttnti|il« a l*li •taatald nr do*
aay«le(»a'a -t nii<iwi>aiT ■■■ i.aa aiB*l lo am I— 4aa Writ Tliaaa, 4a|>t » I CM
^a, 8pMl«tBi of Ibfl itlnlM kBd lati«f-praii will b«forwBrda4 to noy B4dr«H. fra*
an ra^flfT of »ix -aBU til patXhgt lUlnpt.
ftUAO WICK {JAMF..^ R.), A-MZmTo.
A M\NVAli OFTKK DISKASKS PRPHLlAn TO WOMEX.
»aat tuUftt, tosbl Itnu.. «Ub UliutrkUoiU. iPrtfarituf.)
Hbnht C. Lca's Son & Co.'b ruBuoATionB— (Pm.o/ Women).
ET {THOMAS A 00 IS). M.D.,
SttffifMt lo tkr W'lmnu't U^pUat, AVm York. itf.
THE PRISCIPt.KS AND PKACTICE OFOYN^OOI.OOY, for ilie
ut* of gtuflf^nu HO*) Praeilitoner* of Medieln*. Stcond Edltitin. Tliomuc'T B**'**!!.
In (>n« inrite nnit **rv bnnitaomt ociavo rolun* of kTA pAf*'. w'lb 133 itlii«lralioiit.
Chtlb, t»i luktkvr, C4 j luif RbmU, rMe»d bsixli. t<i M. [^mm itmd^.)
PNKriCS TO THR StWND BdIIIOII.
Tha unuRunlly KpM •ihsnitlluD of ■ Urte edilion of ibi> work, «hlU fluirrlift to tti« ftHlboF
u ttn i-Ti4*ncn itiAi bU lHh>.r« h>v« proved MeeriiUblc, bii* in a grrfti iiinitiir* hfighirned ht*
trntv uf iriiivitt>iliililf . Ilv bM Ibrrvfiire «liileft*iira4 i» Uh* roll aJvanlJif;e ut 111* op|>«rt«ikit7
airoTilfl I'l htn lar lt< re*uion Krcry pn|« ha* r<-cfiT*<i lii« ratnrft leialinf: Iks crilUltnil
of kii review*ra hav* b««ii rartfuMy ■rp)|clu>'li «Ril itbil* do luathrd iacrcaw btt b«*B ruaJe ill
Iba aia* of th« rolunia. MTsritl |»>rtliinf hav* Wvti renrillen, anil uiurb n»w malirr h** t»«lk
kddail. In Iblf iBinule an<l iborauj^b rprltlon. tbp Ikbor inrolva'l ha* liven nuph grvnlar tb*n
la p«rha|M kppuraot in ibr fi^iilt*. bul il bui liven ^hrrrtaUy ^xprnnAtA in th« hofie ol rvbd«riB(
111* itiirb mora wurltaj urtbs hror (ibicb hn* been aCfortUd to il b; lb* profMaion.
1b ua cvasity u[ Ih* woflil hua K)ra*«''lutJ rr- aalMcUoii-iiilDf kal f rol»»< ilailT. lU vilHt
B*l*a-I iiiCiiaftllrattoD ib>B la Auai [• Il u. > 1i*b. *> ■ gj*iilliBil«a " Kt*'"'"-"Vf **■ p»'>>al»ili ■■•'■'
•PLh ■ r«rllu or ftaaa«tr llikl v* Wiilroni* k vnf i (ban Ihal »l all |irati»u> Ili-mlure !■» \h* •abj*«t
on (I I -<•«••• of wunaa tram ■•■ ■•"luan' a (jeM'mIk «»aihlii«il ~-t^frvif. Jfd (Jni , Af re '. I WA
|l*4 (t Dr. Bramei. aod rh,. w,fk l.t..BotUll7 cllal- , ^ ^^, re^oUlU.. at l>«>nlk«r BatM Mt pa«>.
ril.aBd ♦.••.« 4ip.B»ii»p«..M lb* »oili..f .lo. ii„,([.„.„ „,„, u ,1,, „.,n«i.,,i„i ...r)J ; .»!
dUlrtn.llljr To rritlHt. -l.fi .h. ..-• Il w.rtt-. | ,,,,,„ ,i,„„i, ,„ ».,« .h,„. a *affc
tt»l"".kih"afli'<ui. w'oH J-iii-i,4 Uf m.vf«.p^t- „ i,, uo'tUJ ■■ili ra«.. . II max ilwar* >»••
Ikan In ■! oar couh&bb'I.
Ibat
vala*)>
UIIOD
dali HolMa>^— JBrff. 3t*4. Jiurii. Fah SI. lUO.
Xa ■jrawtiil'vlnl IrrallH ba* appMta^ which
aOBialoa an •^aal aBBnai «f ''rliiBal ■n4 «ui«1
luBitur: ii'ir 4uaa iba b»JImI aod -Bfcloal b^^l•ltf
ol Aniaiica iBClod* * ■•<><>< niur* a«r*l ah* a»(iit
Tbe raliiiiar aD4 4iiiiliiieal l»r><rniii|iuB wIikIi 11
doutaiBi It Mtrr.licrtB, k<-<b la ■iftagilij **'i «(«D'
l.al «or F.nom.B'!. Ib fNt'lliif. wa en »? ,„,^ ,„ ^^ ,.„rn|lT .in<tM aail rr.'|H«BllT M*.
ite •oik t-jm. itlib *rUi»al iiloa^. Ii.-b >n4 ,„,|,^ ,,. ,^„„ ^^n prKilM thl' ht%mfh ••{ yvr Tn>.
•hi. watbxta "f Pi.rtlM, an-l u .t.ir.n In a f,,.|„„ _t„,i Jf,.( TiW^^-J l-ii , l»m 10. ISa
' aail •lasiBI •'*!«. w-<rlbT III lbs lllxiry f*pB- . _
DorihBKiialrVBf U9^r.ll4«BBdO>it.>«r»B-i T»-»h.Mel-» -f II.. trnfk ,. i«.. «.ll ke..iri I*
fRIillif aiKsuJixl a<ill(it^*Bana II lu •a]' thai ao
rarvui «ntk Bp->D nay 'abjaci bal Btiati^il ■■<«
(>*Bi ^>rnlariif •> mnldljr A* • wurk ■•' (aBDIal
rataraaa* opAe ih' MihJ-n 'if i>iMa>a' ot Vfomaa It
'■ iBdInibl* A> a r(*->r4 «r Ih* taitaitl (llnUal
•Xi'>r<*BD* aad •^(•.••i at In a II b*f »« fiiiial. i<a
l-hXt'olaa irbii p>Hi«Dt> tn kaap np wtia iba Bd-
TBa<«<o( ihUdrpaflaaal nf nvawta^caB «('>?4 <a
maji, aBd caaaoi ha oibarinlBa Ibas iDialnahla i<f tw vlibuoi li.->.V.iajka<Ua Juum. ^ Mttlirttm ami
fnlsr* laft«i)^t*n>. fl la a woik whUfa ilrmiiad. dor^rv, Hair. I'M.
nCSCAS'iJ. MATTlJP:\\\'i)7M.I).. LLD^.F.R.S.R.,ete.
CLINICAL LECTUUES ON THE PISEASKi
I)«liTvrr<l In SnInI Barlbolonrw'* Haapilal.
, piigaa. Utoth. tl W. (JirM RtaJf.)
Tbar tf* in t^ttj w>j voiib; "f i<i*lr Baili*r :
lBd.*n *B Itxili niHia (ban ■■ aai-icg lea moat Talu>
S OF WOMEN,
In «(>« car; btat ooIbta roUtD* of til
Tha lollKT t* a tanatkablr i^Itar la'latar, Bvd
bf ptaoilllsaar* aa vail
Nl. «i«d <Hr«. MtptrUr.
bla dlaeaialae uf tfuiiiioiiii iBd iifamaBl !■ fait
and laaceiilrA. li vill ha
tara uf cesl liiaotl !•• Iha («B«iat Draailiiiiaaf fait ia ba taad wllh baoaUt
Si'ina iirih'iH dsal wl li 'aM":!* >bai a« uul, aa a a< fcjr aiuilaalf. — /"MJa. JTNir
' rnla, ailninaif t ■ tiiBil.a.l iu IJ>* lail-b lulK, iiiliafe Vrtt, J, IMn,
aflbnn. Willi* WadBM Ufiu t<.i'l«a'>iala»B.n>Il7 w» hat« Ttad ibia hnak «|ib • crea< daal ol
|r«al'<l -I «' l«n<lih la ■mb vofka, «ai knt .arh ■ pl„,Br«. Il !• full fl i-vd ll>l(|t T>« l.'al" 6*
Btaiiip ..r lu4l<l>li>Blll7 that. If wWaly raad, a> (h.y fatnal-kT »nJ I"**' »aoi wallaf-* ibf>«(b lb> b-fffc
Mil.lalr*!**"* "■■-'•»•/ '*'"^" ''*""* *^*" * Bfa a*nnd, iiB««-oMb)t, and "f afrai ralaa A
wb<la«'>nata.lralBtt>r<>»llia3Bdi»aa«aM»i«l<l< b.^llhy •«aplln«B.. « Ut(f vkptilaBM. *Bd • elai^r
Wbleb*l«ar jraaniphyacl.na ••«■! baui ap»n Tit. ja^^n.ai ,„ .T.r>aibara uaalhal lB>laa4 of
l.>vlRg(ha wild iBBthlnr' labirh •ulBlW.i ita«tr<t»- li,i,|iio, .uk a.ltUa or dnabtfol •alna aid Ot-
aalutr uf lb* praMul day.-Jf T. Jfail. /«■»•., .,.■.,.! (hancivr, irta nonk l> lu aTM* raapaM a ■•Ih
l(B>*ii,l»«0. auaa.-na L-oJtiA L««Mr. iaB 31, Kut.
AMSBOTHAM [FRANCIS H). H.t).
THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI-
01 NK AND STROKRY, [n rarfr«n«t to tha Prooea* of PartarilloD A u*b ■nd«nlBrKa4
•dltion, tboroiigbtf mTiaxd b; tb> lulbur With addlllona kj V. V KKari«a, M. D.,
Pr«faMnr of ObstairUif, A«., la (b* Jvlfacnn Mrdlfal Cnllaita, fililln^lpliU Ib ds* 1 rira
and btadxHua linp«ri*l«icta«ii nil'iBit of '50 pat;a4. ttronitl; IhibbiI Ir UBihar. «lih rBl>»4
fcandi ; iriik ^^x^^-l1Ht bvaaifful pUta>, and nanrroua •ro(i4-<Bl* la tha i*Bt, ecstalMLni I*
all iBUlT HO larfc Mid baavtiriil Bjiiiraj %1 n
■ pARRT [Jorry A), m.d.,
■ EXTKA-UTEHINK I'KKWNANCY: ITS CLINICAL HIS'IOKV,
■ DIAQKOSIfi, I'BOUSOSIS ASD TaKATHEKT. In oaa budnuaa mUv» vulMiaa.
■ cioih. t3 ao.
Mr,
mASSKH { THOMAS H.). M.D.
ON TIIKSKJNS AVD r>lSKASF««OP PRKflNANCV
Fir»f AmoriciB
from Ihn Saiioti'i ind Bnlarsa-l 1Cnell*h R>llllni> ITIib f-inr r»liir«d ^lu.!** «u^\S\m'vnr
HcMiT C. LiA'B SoK k Ca'a PiiBUMTicwfl — (.Bvrgery).
9fi
TjAMILTOSiFRASK H.) M.D.. LI.D.,
A PRACTICAL TUKATISK <».\ KRAOTURES ANO PISLOCA-
TIONS Siiilh KilUlon. tborcaftliljr ri«U*(l, nml utu'li linpiuird. In oit> vvrj huiilMiMa
0«t«in vnlaoM nf orvr 900 ftaRH, wllb 3)3 lllRitrBlivsi. Clolb, |A >0; Ualkar, SA SO,
hair RiimIa. niMd b^niU, f T M. (Jiut Ktai/f i
ha mmj klD<l oKpieHluai >u nalcuAi- ki re toin
•hvwaivl a|» II lui k imii:***!** till I'm nl ilii* (hI-
■liiMa (T*iM-a, lUil miMlr B^ribluj ta'nilaa 'ai
a* la L a l.al luia aad IbainalaH^ty (ufiltal ir*rt
tof. Il 10 Iba only ouaain*:* «^fk na Ik* anlijati
u( Piairloiaa la lb* lii)(ii*b imigatca Wa c*'n
gtkiaUia lb* *c«>n>pli-bail tvlhar «• iii« tt»a*'>4
»at<«-* vl bii <*o>ll. iMt4 bi'|ia lb* b* viY i>t« ir
bftT*n*ar ■'i(«a'4ieg«4lil<>iii )■'• m<l*r bWablli-
«J aBIKfTlaioa —;'*«&■ (Ja/i. iin*l trrfa Sfr-rt^rf
So* li. ISM.
tlalnrnal i«r4lcl bu pr«aii«a(ad ll, banBalT
■paiklBf •• pariail li«al a>> npsa Ihia ■fib]aai. !•
ll U III* 'ibIt tuairlal ■•'■ IIUt(rBt*>l w.>ih In nk^
!«<)£'•■(* Ira- llaR ul fr->ciur«- lO'l 'iMIirMiuaa, t<
!• aaTa lo -Olrin Ibal araty vMvaw'ke nar^-a abd
ft««ral prMilll«i*r wlli r*(t>M li k> iiUMpai'abi*
ta tha ta/a uil pl«&*aai ciioAati of lli<4r ptolia-
blOBal work — J>MP(ilt Zfinr*', Ku*. IK, l>M.
I)r HanlUoa h»d«nii*Jf>a«i l«bor alb«>lttdy
lit i|i*i* aibjatl*. HIa laftv *K|"''l***f, r<l*B4r4
raa^APib *arl fiatlaai lavaatift^Oi^a i*aff" oiaiia biM
■si>«r ifta bl<ka-l BDEhixM •■naiiaa iltUc wilitr*
!• I hi* lkr'n<a vl aaif I rf T)i'> woi \ la ijikhkiIc
■ uil |ita- liial la Ha ■rraEfmral aau piswal* t'a
aabjaei ■■••<)" •^*'tif lan [ r(ib<; ('■ <b« twii4t
ui *iu4(al.— Jhry/aKtf J^wflrnl^uwrwi. K*t.l6,
Tb«u«l)r fuurlaUwuik <>«lla aabjpclla IbalUt
■ lab (au^ua, .lail, lailrad. aay sow <« "M lo ba
III* oaljr WDtk lit !<• kla>l la ^%j 'I'Bcua. Ii voalj
r*^a>la «■ •liM*4lB( 7 tnliiiai 'Uiiuivaituu iv d**
taci la It BB7r>"lB>>>a>< 111 wLlcb I IBl(bl ba tui'
rrvTBd, rb< woik l> K n»uda«ai ID Aavrlcaa
■ «>t*rf. Bad olll tnag Bfif* Id kai']> ||i>Bti ib«
uiaiavrir Of ita Taaai«bM •aibut.- JTJMIffMi JTatf.
Ansa, Hub. I<i, 1»s1.
SHHORST {JOHS. Jr.). M.D.,
pro/ ■'/ainvtH Surgery. ttilV •/ ^4.. Sw^mi r«tJtt SpWAVa f ffMFO«^ /'*((aAJ>U«.
THE PRIXClPLKa AND PRACTICE OF STJROERY. Second
KiMtlon, •olarjEBi) bdiI ravlaai). In on« *«r)r Urn* ■«<! b»tii|i«ni« velaro yoIbib* vf ««ar
lOAO p*gB(, «ltb 543 llluaii^lou*. Cloth, tt , Uaihar, S7 ; lialC KiMiiB, f> W. {Jutt
noaaclaotlauasBiBBBil t^rnnshoaaa an I«r» vary 1 Ib«b«b«« all Ibal la ■atBBBBFf lob* I«arva4 by lb«
narkaJ inlu of cbBnciar In iha «nlb«r of IbU I •(•dral al *»m.fj iihtlM U Mia<id*u« •!•»» Ia«.
baok. Oai it tbsa* Irslu tarfaljr Iibb (riiva ika | laraa, «« tb* («aBt*l ptarii|iaaat la lila dallf roatlaa
Ba«4««s df bit nastal rrnli Ib lb* pfl>i. aatl ll>* pra- 1 piactlc* — JTil iTAt JimrKnt. Jaa I^Ts,
aatl alfar aaami In an «l»a an •«<Bpiino lo what h«a ...
fuM Mar*. Tb* l*B4ral Brr*u-nBBI *l it* T>|. I "''• '»« ""' IbHrntk hai taMbad a HOaBl oil.
ain*l*lln«amaB*lBlhallrat*.l[it'>B, bal •larjpaM ' tl'>B aA iTT >>>■'« afitT l»* pBbltCBIIaii i)( iLa dill
baa »Baii BarerBllT raTHad. aad UUtb aov matlBt , •■■•. 'paak* "-"a Ll|hl)t rf il* moUa Ibau Ba^tklBg
•d4*<.-i^ll<l. Jfrf. r«»«M*, f*b. 1, ii,79 , "• ""'('ll BBT iB Ike laBj of cniDmeB^BIIoa. It
__ . t.1 _ .1 r ■>. ■ "«(■• !■> bB»* lnii»*4lsi?lT f llBfll lb« (k»af of tlL-
naraaiaauf lb«pi>pkUrlirot miaiiliil'ia, wMcb ll '^ '
tmU ffiJDi ill* •ttUur'* ^aBJ■ wklh laaii; bdIo^b
m*it-and improTWDanif, TIk BvibBrtt Iku work
J« ili..»rf»01)( piipnlai •• bb iiilllur -luil wtliar. bu4
Ja dmiirlLiiiUBi to lb* llltraiora o( tntft ksr*
Blunl fill liIiB alila rvpmatloB. Tka «Bl«iks &•■»
riJ iii« pii^aaaUk «lll b44 ■<<« Uatilaiu ibaM
•llaaill v»B bf pfBBkuaa cuulrikulliHia Wh raa
aaly B«J IbBI llM«o«bU irall arraUB' J, kllaJ ullb 1 ilatiharai ha* bd •■M<1.ir ■~iuaD(lbB Mtrdiai >tU«r*
pMDIkal BiBllat, BBd coslalaa U brUf aad tlaai > !■ AnflnBS.— Jm. /Va^KKutur, JaB. liff.
TIMSON (LB Wis A.), A.M.. MM.,
A. MANUAL 01' Ol'KRATIVE
tftjiA ISino. rntniiic of abAiit S4* P*K*>- '
TbBWarfc harm* at la a ««ll prlataJ, pcvfutaly
lllBdlral<4 tDBDUBl of oTitlvur tiiBdrad bb< M'ani*
na,(Bi- TDb noilaa.bf B pnriual »f Ika ■■■rb, «lll
gala B I'lw) ld«B of iki faaatal daoisii ot AC^raiifa
f arMTf, vblla iha pnMlical aaifvoo haa praHBlBd
to Dim kIIIiIb b tbtj faatla* aad iai4iiuibic furm
■ ht taiaal »at nuit approiad aalH-llriut ■..ruparailra
proCBilnr*' Tkapraavilna asd eoBciHBoa vith wbieb
Iha dllTvraai oparaliuiti an d»af11iad aiubL* iha
KBlbM I" taotpt*** >■ imoiaana aiuuufll ul pfBalleal
|BfuriB*l>o0 Ua rarjraniall euui|iau.— .V Y. JTail.'iil
JlMWnl. kvt 3. U'i-
TkU Talunt la dovolad aallralr lo oparaclra <nT^
Hff. <IB4 U iBlaadad to (amlllBrlta ibadadaal »lta
th«d«iUlBo(«p*rBilsiiiBB<l lb* Jlferaui nadBB«r
I
s
Wa ba>8 prarUtanljr •ix>k>a of t>r Aabkam'i
««rV IB \*tta» ut pralar W*«iib t^ rsilatBia Ibnaa
latma bara. BBd 10 add lliBf Do iBrira aaiutaaiarjr
ri>pt***BlatlBk ol maJriB (aiMO; liu Jt\ fallan
rtuin Ihs prna*. la p.ilai of Jndiflal rilreiM, of
puirnr at eiadaoMllfn, oX acruia'7 Bad rHBCi>«a*aa
III nKpnii-lita »nt lkotwn([iiif c-oit Kaiilbb, Ttvt
SUROKRV. In oiiu very hanilaotiie
lUb Mr illamUatloD* ; cloth, $3 M.
parf-irulBf Ibati' Tka «i>fk la kacidBanaij IIIb^
iralad, and ik*a«t«npil<in* arrflaiiraadVBll drawB.
II ll B <latar Bail uaafnl •uliiin*; B*arf aiBOaai
•ballld !>->«•■•• UBB Til* prTfitailuB cf iIiU Vitrk
dwaa Bwaf vtlb Iba Bacaaallj <■( {'■'Blailag >it«r
UrgBT wnrk* '^n tnrprr fir d»*rr|(iUB* d( u^^'b-
llf>Dii. a* 1 1 proMBi* la a aut-akiilljiul sbaila vanird
by Iba >urt>>->B wlibaai an alBbDrala acarck la Bod
It —IT't. U-t Jnmrttal. Aog UTt
Tb* aaibvt'i taaol*«Ba>a aad Ika raptaUBaai *r
tba work wllb lalaatila Ulailnulaaa aallllali IB ba
tUaBBd Vllk III* 1*BI-b«0ki I'M ItBitBBI* jl iipantlaa
lunary, aad aa oa* of iwfaiaaoa la ib* pf aMllkvait.
. —mmtimm*ti Lamettam4 CIUU, JbJj «, IMb.
SKIT'* OPSSATIVB NCROBBI. la 1 tbI. &■«.
«l.,atd«0pB«a«:>'llbab«alllK)woed-Bala.«3 3«
OOOPHtt'SLKTORUOSTBIPBINCIPLISBUD
PBACTICBOrSVBllBBT. IbI V«l.l*a tl'b.TMp fS
dlBSOXeiltSTITCTUAIlP PBAIiTl'IXUI kCB- 1
.t(Kt lllKkib*4lt'n.liupi->TadBad BiiBrad Vlik ^
Iblrlj-fimt plala* I a i«i> haBdagasauo'aap Tiil-
• maa.abnni lAiW pp laall'ar raUail Haad'. •* W. '
TMlPHIHf^IPLSSAHD PHArTICSaPaUROKIIT.
07 Wit^iBHl'iBBit.P K b L.Fr'>r**'iD[k«mTT
iBlAfl'Bl'BraK/Br AbBrdBBB. RillBiby JoBK
Hail,!.. H D., PrafaaaarutSiirforlB ibaPnaa*.
H«dl(a1CQlI«(>,HBrg amiBi CiUBijItaBia Oa*.
rllal.Ae. In nil' '••" ll • ^iln"i!ia ixlatu »»| oi
»►»««.""■ ' Mnlh.MJk
MllXKH'^fXlN 11 >»uiltiAn».
rt«a, fvata U>> iti,-.i 'ui iM:rio hdlt>oB. In nB«
lat^a *>)«. tid. at TM) tMi>>, ^*^ **" 'I'ttilnilau,
aiotk. |:i :A.
MIIXKII'll PRACTICK orAUkAIIIlT T
rina, rn>Bllwl«akUW>WlA>V'V.'0»:^>
ikakanWiatiB'UVM \nw<i%Va.tl.»'>^'' ^
1 1«ly»^a«,«Vttik*\\\.\«««WS«*»-'''\«^^A^ ■^-
Rksbt C Lea's Soit h Co/a Pubuoatioms— (Surt/tfry).
DRTA ST {THOMAS). PM.CM,,
THE PRACTICE OF SUROERT. ThlrH Amoriran, fmin ItieSc
«»d»a4 B»>tii4 8tt(U*h Iditloa. Thotovjchlj ra*i»<1 ■nil laueh liBfcor*4. Vy /xb*
ftv^MM, H U- I» ••• l«r(« and ovry kaa<l*i>m> iinporlnl om«mi *■!■«•«( a^tr )'
^■CM. BbJi 473 illMCrMlM*. Oaib, fl M . iMiliir. tr 10 ; *«r7 liiBdMai« Utf
nM*4 U>4s, |!* M. iJ-M KM^ri
«r Bir***'*«''t !•■ "..*! ^.i . f..,.ft'* IB* lb* »tir.t« »oHl hM It— c«r*fatly f»Tt«»<, »«
«ukMi«Mm>. .. Mwriiwa, |«pArt*kt aMiUiMtU
r-tMy |n«ti' < . atiii m\ •Tarf ckafUr — Ot««i«q
tMmI 1* n-i J»B. i«^r ^
U»v«>i ■■■ ■ .,™ .. . .(-Tn- ,j,) n.t j_^^ fc,,.,,,,!, ..ilTini., rron •■
Cf M.
.rj',!.
.,>l— I... t-r
ll I* ■ *»r(
Ma4a»u aa4 i
,(r ■■■■ ■-- -- ■
<•-
B-
bll -1 ' .. -
•atC*'r.
Ib»* It
r.H - ■
*"-'' »''"' '*«» ka> liiir«liiiKl mii»7 i— ■> 11 r
■ •■"f""— ^ ' ' «•« laal.tlat UMl l-^0%\ lu I I
' «• tM ■rrliia* to* wii't -■-•■
^■1 i*d III I ha Vkat* at ' 1* ■ riki* tIi laa la bd Am'
^»<la a--l r'^III, II h*«rk. t' ooa *iirtld pi
". I ■ — .'.xal dflati r«r a roll a a- aalt'if . -M* vulaa> «i]ii „ ..,,_, u. ^ i.. .. i..i.
-arficat pnaclflaa aa4 th* irtat- 1 ir n« j■■l^<M i<t'>, Cdtti *•'• itaraiirir «>aU
I Jtui— II aahrac*- in lU aaiif* iJitoil, Bail ir ha lalihaJ a ihlid, iiniaa'a aufi
jJvlm^FbLiaiurttuijr
viiiar> hi-vrrat ill*
la* II la ihta ^itlav \ Bim* — dif*- iit:
TQE SCIENCK AND ART OF8CK<JERV;beiDga TreatlseonSa
^«al loJnriM. DiiM«a« anJ OpeniioBf. C*r*r«lly rrrlted b^ th« Aaib«r fraa i
g**«KthaM cDlatjr«d Enfllrfa Kdllion. Illn^tnitd bjcigbt bnadro^ atat drly i>a<
framgi «b wood. Ie (ita larg* and bcanitfal oetaro v«1ubi*« of ncarlj SAM *>u)
ololk.St>» >lMllier.SIViO. balf Komi*, SU ». (JVm.A«i^«.|
Tkioraath ^dillea la t>*r»ra tha vnrlil uikali,^
<ror4 »laars>cal kI* ava Tbar* waj !■■ ai.*»^-(t||
*hlt& axtal U iip'>a stilala r^lati^ bat a> a m
•paMoa apuB tm^eal pdatilpii
aariTkllnl- II »ill w«>i raw
raail II, fur ll L» li*ak a |wf r;
KiitbHa i« 4iBLa>itiiia itr uti. ...
tur^ of aiaklWftJ asd HarfUal bvI^l
•caioalT add. la nia<la*ti<a. Ihii *•
■naad Ifea «ntt l>> aiailaaia ikat . . _ _. .
frauaJnl It a avHad tallli.sad In pCBeililoaaf*)
aa laralualili Bai4* ai (ba t>»4>l(la. — Jm
■ifHHT, Aprlt. I^TB.
r>'>Hap«>ll**a(]i raaral{rli!ha«a>aS«rs*Ty ta<
nialatalaajlla|rtacaaalli«l«a4lD« lasvku. ~
lalliUe-iaalf]', bai [a •.ir4al BniAJa
tX Iba HaM mHUiM o« p^tyvrj wfaKb i; bai tad.
•or twk inatiBly.aVvur (ilaaiw ra bi m** titwaia n»n>
>iad>lrallMaWha<*atl>bnliu>*<i(ll w<lk>ekMt<
traal)*' of KilctHvn. Ht- - ->-> ■» - • i,(t«.
rfvn Cnm pr^ UiUf* at 1 ' ^ai|
««M< ■i>lil<n,and Tui . ii4ai
■ilHlraWr lOKhliiaiu ... ..<>i<lk
M lb* loaal fOtl Dflilu. i ■ in^ic Ir
tu'^tj, aa torn, hj | tK Ii la *
jh^ra, lli»rt(>»»». «-'• — ..-; ..-.,.,-.. i.il'.o ..ti| U
■■uagal. tail lia* 1*0 ui lii*a|ipK4raB-'p''f anoibn adi
U«a.— IM. •»•< -*wy A'ryirur. frK 1. laTS.
:<nlBlUMb»ill«( Ihr lb«r>a*T tun
■M«U •■i-l mttat ba« ti^a (tntiljii
ha> hMB IbiifBUtfblT vnitra a^ab.! .
«tt bf a Aiv •« I ra rhafUn Afraaiinj.- v-ci.*!.: I •■ . ._ . .
W<a «a4* 111 ilMlliWtrattMi*. <)■>■ bunJinl aiHl nttj is hulJ il> (r.'aail. U aiiaailasiir |>(ti:
«■« a«aa ftat* baao aiMml, aM) taavf <4 Uii <'J<1 'iK- > .iiitn*«> villi «Iiltb ib< rtataal ri
h«(a Ikpq mtraaa The avlliiv til|hljap|<»rU<r ■ ; asd b^ Iba U-c« aisiiiitl pr f*l(al.U i
ra««r«lifc ablFbhliinirtlMabanrtOTliadbr Ai .f ha< b«*iaJd*<l. A*14>rt»ia lbla,<Ba
can aanc*i(i* *'■■' *'*> i-Dtraiiinil letradat fal* : -. i . uri ati; :>. >■ Ml<. -i^a ^> •'. vhc '■«
•dittm K": I'l '^(li*lraH-n>*al. tl«\ iui'IujU« -i-.
ia ba* ■.. nbat, ww (hlnk, ba Iba 4aFra '■( pan
M*««nl.<i< ' ncoBiMbil tkabu>k ll I ibaofar'ii 111
both (tiali-ui aaJ I'nu'liil'xier— A'. J'.JTarf. JtmrmmL «iba*bllr«ir na' .ic* —Mil. litt~>rJ, ttb.' tl'u
Ftfc. 1X71. I
.'I I a..: .»IJ
i
(• I
.ff
OLMBS (TiMornr). n.d.,
^•.rgtitn la ai •ifirpim H'lrfiital, ^omtlom
SURGERY, ITS PRINCIPLFS AND PRACTICE. In one han
•i>Bi»(i.-l«»o»ot«maofnaarlylM«p«||M. wilh*IHllnrtr«lloii». Oluth, <«t iMifcar. |
UifnrcaaBd dlMlMiB*M.-jr. T. JM Samrd. A]
ll vill bato«a4 a na*! axoairabl atiltiima vr _
tttf bylba ir^nTa' T.T.L-i-.'.:B.t *bt> baa aul (
-' «l«ai*'u 'iBBia aoJaaias
hair BuMia. tT M
ThU I* A work wblcb ftaabaan lookadror aa hn<b
aHMartttaAilaatlcwllbnacbiel^rau Mi, Halan
ti a laf (ana ollamaaaa Tarla4 aijMitttac*, and da*
at Iba baft toa<>a. aad |/*rtia|.a tba uual billllaal
wM'at np'iB taiglcai luhjacia la Kailaad. Ii |t a
b*ib Tor il'iilauli— lad au ailultatila noa— aaJ /i>r
Iha b«aj'»»a.<jir""iiii.Bft ll *ni«)*tbiiu4(ai
all Uia >■■ ■-'■ I •' I"! '■-
tl«a. n- '
ibai irai"
' bouk.— (.ImriBaaii jr«| JVnat, jiprll.
•arts, BDil I
>- 1 11 rut. *aB.
aul .ir aatli ■Br|.
Iba iraaiikaal -
BiirBY C. LiA's Son ft Cc's PoBUOAriOKs— (iSuryery).
21
I
jd^VES { TIMO TIf r). if ^ :
■*-* AuriKua uixf ttrttrtr ira fforiitry of 5f, fh^rgt'i ttntptt-\t, £r>«itoi.
A SYSTKM 0FSrU'3KRY; Til KOHKTICAL AND PRAOTfCAL.
to TmATimK ST VAsrovt Anrii'mt. Amrrr'aw Bditior, Tnoii(ii'uiii.t nvriaBii afb
KBttHitTKH b* JoH B fACKititn, H.D.,Sinv*ot to tbt EpUe«|>*1 DtHl Si- J«t«phi llu*p)-
Ul*, Pkiladdpkiti. Miuiid by & larir* 9orpt orth« nort ttmincni ABariean nritiHit)^. In
IbrMlargv ud Ttr;bkn<lMiiia ImparUl muto voliimeiof«b«il lOOOpti^f Mch, *iili nv«r
touo lilMiiatUiii* OS woMi and Iblnecn liibiignphte fX*t%*, bMallfvlly ooImmI. {.nm^
•h/jt Ay MiiMrt>>rM>i*.1 frira per vnlumv. im ciDlh. #0 flV; to kolhrr. 8T DO; \m faaJf
RuMla, fT &0. P*r ••!, Id cloth, >li M ; in iMthar, SSI «D ; in half hmt»\». tS3 W.
VoLCm I. (woa- TVd^'y) ooBLaltts OinrNAi. pAruoi^vr, Moi>»tv PBOcmaa, Iwumm in
flanavAL, Ca>ri.irAifusM up I^iuKiKs *>■> laiomsii or HiaionH
VoLGMK II {titanly) i^oDlaini Diibaii:!! or OiiaA«a or SrctiiL t)aa*a. CucULAtuMr Brs*
T«», DioBinvK Tii«'-r .*«iii Uamto-PKiJum 0»!u»s»,
Voi.(j<iK ill- {tkortff) ronUIn* l.)titaA«t:« iif TDK HaaPnuroK* Uroam*. Joi9>«, Buaxa, >»it
MiTicLaa, Orai(«TirM inn Mimuh Sukoaiir, Ovjuhot Wocans, IfoanrAiia axd Hiiruu.*
t.AKKoiia ScBJaorH.
Tbi* grtal Wftrk, i»u»d lone j-anr* tinea la Bngland. ban irun aueh unkv*r>«l eon1tiIva«a
vbararit lb* iBncuiift" ■* ■p>>l(«i>, ibnt lU TPt>ublic>tifli> bars, in a foTcn ttiotn iboroBfihljr
adiipt**! to tba oaDla u( lbs AiuarioQ pfaatiliunar, ku lacniad to b* a ilDtjr ovthg (u Iba yaa-
To aoaoBiplIali Ihl*. Ih* ali) bat baan InrilaJ of tblrly'thrM «r Iba nto*! illitlnguUhrtl ganll*-
n«D. In ai^rjr part nt Uia oonnirf . ai)4 lor luof* than a jaar thaj b;tra b««n MiMagaalji «BKii|:a<l
ia)Kiii lb* i»b. Tbougb ilia vnglDal wurh prt(«ni« iha Mnblsad lab«r of tb« boN aiBiiiakt
rormbnri uf all iluf m»i( pruiulnaat •eliiKiI* uf Kn|{lafli), yel lb« UpM of tlm* iIdm tba apjiaar-
r>B«« c( lb* i«*t eiliitoD. tba proc^*** o' *«<cbc«, and ita paeuliarliiaf af Aaicrioan priKlke,
bava r«nd«ra4 nee*>«ary a iBo*t enrafiil, iborongb, and MBtchlnr r>*l<ioa. Eaeh nriicle bM
b«*n plB«Eil In lb* band* -if a Kenilauiaa fpMlaJly eonpaiaal to trtki lu itibjrcl, aad nu Ubi>r
baa bean tpartd to biinic «a«b ona ap to Iba CoracoMt Urtt of Iba linaa, anil l« adapt II ibnt
obkIiI]' t« tba ptaotts* of Iba rouatry. Ib carUkin casta, IbU ha« fandaNd naCMaary tba ««!»•
■lilHllcn of an anUralj iiav at/ay for the nrlflnal.aj In tba eaM o( lk« artlclrt Ob Skin DiMMaa,
and OB Ulvacuat of tba A b«orbaiil {(yiita n, irli«ra Iku rUira o[ (b* sNtken Intra baab snparaadail
byibaadraDcaof Riedioal«el*n««, and new aritclMbaialb^rarorr b««npTP[iar«il b,v I'm AartiKa
Vas lUaklxaaa anil 8 C. Iti.-aitt. ttafiMilTaly. &«al>tt ia tbeMje of AuKitbdio^, in Iha ii*a
of Hhicb Anaruati praetiM dillM* IrMu ibat «f Bngland, Iba original b»* bcvn auppJciuaaud
wltb a nan ouaj by J, 0- HBari. U. U., traaling ttnA only <>f iba amployinvnt af vtbir and
Ohioiofbtm. bat of tha othar ■atatlbalic acanU of tsora racanl dUacxacj- Tba «an* earoful
and ponpoiantiuua ravUloo haa baan pnr*i>aa tbr(ia«buat, laadlng to an ianraaaa of naattj una,
fourtb id uiAlUr, wliUa Iha aariea of llluatraltoof baa bevn mor* ihaii doiibUd, and lh» vbola
i* ptaraiitnl a* a noB|>lal* axponanl of Brltlib and American SurgsTy. a(iiipt*il to iha daily
n«*di> •'t' ihp irorklDD pnelitlunef
In udtrr lo bring It wilbin iba reach af avary maKbar of Iha profraiinn, iba fiva roluin** of
tba oiiglDul ha*a baan cooiprafaad inlw ibiva, by ainiiloying a <loBtiI«-colaiiin«l ImparUI iK)ta*u
iwga, aiid in ifaU imptrovad foria It i* ofarrd al Ivm tban oaa half tba prto* of tba orljliDnl It
)■ brniiiifulty pHiiC«>l on bandi'xiia lal-J pupar and furiai a avrlhy coinpanlvu U) BBT:<'>t.l>B'H
"Stuteh or >Uiiicii>iF,*' wbi?b ha> mat with ao mucb faror in avary Hctloa of Iba cuuntiy.
Tba Kurk nlll ba itvid by aabiivri|>ti'in only, and In dua ilma arary lutnbar of tba preteMioo
will ba «ali*d upan aid olfarad an op^dunlly lu aabaortb*.
Tba ffwii»Uc*>BpT«ndadtalil nrva tolndiuaia itaa btatty kppraf al anordad to Iba urcTlaad
adltlon on Ita appaaratet aooia janra ilBca : —
Thar* t> lo tnncli Ukui l> lixiriiriiia, n*ea lo Iha j Hbraiy *t tb* BnrpM.~J(dll»taJvA JfadfaBJ/war-
nil/
lit* ■ ar«lBp«dlaor*nrgarir ol Ua noil Niniptait
Bad aitautTa sbaiadar; ke4 «•> laay JaMly tiua
Ihat ludaalia aad aaaeqllandn (rvat hnU'irli ihiwa
euiicataart, aad that iha larf* nu'iibm aai) klib
*taB4la|t of Iba ■oil'ista aalvrtW (or ih* 'Rikiu*
iniii'>ifi«[>b* r#B4]vr ihlp "ltf>rBra"vbiJ ;liKifloal»|
*■• mtsndrit Is In. i<i|<r4*iEUIli« Afika miMtl 4tala
oi (arr^oal aclauca ani art la tka aooauy.— ImiwIvk
In ««atlaal*a. *a vlll add Ibal «a eaa «aBt mb>
*<la»pl"«*>r (M^unMBd Iba iHiob to aaarr nadiattl
pracllhpii*! ti Frri'inmaiidlof Iba *' tty^ti*^ &H**
ffw/' 10 »Br iTlaudi «B« h4<ra )• 4<«1 in aargical
Ga*»>. wa h| ■■• nw«Bi »Uh t* (ubRb* i>«r faauai-
niwBdallvii lu ibaui alvu*. 8*«rr piartttloHl of
niMtlalaa aiaj rati •onialblBf w\nt\ij e4 nola rraia a
pataaaluf tl>i*i»luiua - Tht BrttUh If*^ Jvmuul.
Tha faar urisKiaa lanBio ■ U'lBUiaaBi lo V-r •or-
ileal t**\»* vf cur diy. I'bfi iiaal naluiiiy uf mr-
Ir^t'^Liiaa Kiirfaouavf *niiB*iu« astl jitovad ability
*'■ ra|>tT>aiiItd in lliam. aad fui ia»k)l jaaii la
ivB*, •hu**«T ■l<)iH III bsow lb* (Bimi aaihuK-
iBilla Word* at KailUk hudiieal milnsia ..» iiiu4|
■ abja*'!* In (badninalu i)t tnnnj louM Iuib I'.< ib«*«
IMca* III raid *bal Itita !• ol f itth Hal lahaa u
a wliBia lilt Iha nb.i>l liupurtkBI ■ar|lul wmk nlii- '"
bu arel laaiiad fruM Ika Kua^VkV ^vit^—\*rrA -•■
i^nc-tl.
•XI'Bltciitcd prattUI uBiif, Ib tWi I'raulUal aad all*
«rllBtii>lliif uaoiifr <it ii*jtlt»j villt mnutad qn»'
tlnai, nulla lF whtrh ••bib lo h* BCHlMlad; ibalt
•tai'Uiii tUaiinilorii. 4rB«u al o«*a ff'^ni •■ bb
llnKKil drl 1 ul h<ii|>'1>l «XF«rl*aca. »u<i llirti (aad Id
aad «rra>ij1i tn<>d« al tmadHBI Iha ahal* iBl-]**!,
thai ibH* varllcuUi tO'tlvaa (if (bo wmb pixMxa B
••Ina wulvti pluB> iti<» ru abota an:* pavllaailoa
■HI laa •anil ingilci jui laaaod la tha lBa|na|«> — J«i
•^oH'b. Jfid. dlci(n<«<.
Tba naiinarallaa *r Iha Iraalltaa, aad Iba aaiaaa
0' Iha •niciaai wiliaia iraM wh»t« p>ni ibay jiiu-
rnad, naOloalaaba* thai IbU la ao I'tdlaar; U»ih,
aBd IhBi IB lbBlhi>a*ao4 pajaol ihnguodlf voIbmb
Ufa a aliita of lfl(li» laallipa ao(b aa bj aih^r (uiiiBal
wiiklBlhaUacBdcaaaB praiaaa laufer Thwvtio
BTB aniBaialad viih ilia a|w*iai laatanhaa and pub>
lleallx.a •■{ Iba irifcUit ■■il.^d «UI But Ull to
Bflllaa [hat 1-f a }ndiii<uBi vi,«iDi-a ct aJLioilai dU'
MatluB. ra<Ii (ubjaM hu baab aiii(B>la-l. a> tkt ai
poaMbla. ID a •ii'f*fln n( ilia buapiiaU wtiu )■ haiivB
10 barf lira* aapacUl atuallua 1^ ll. aud \-i |waw*a
JheUtilaafot •«MM1D|opn:tibBBibuiii]>iIi*aaF«^4d
opiatuaa of tba dsf. aad uldlBf vrliiaal laaiU* lO
Tba worb aiiat ba c-<a-idnrad a »a'r r^aplfta aa-
QUUril «if ctrijifalaf cfiEiavClad wllh Iba latanra and
ptaclM* «r •Drpary. la ciibc^mIub w«<aa «u*4tnlir
laautuolaBd Ibu nvik aa a aalaabla addlltoa lo Iba
S8
n«NRT C. Lra's Son & 0o.*9 Pitbuoattons — (Surpwry).
pi«
DRV AST (.THOMAS), F.R.C.S.,
THE PRACTICE OF SURGERY. Thirrl ArooHwin, Fmrn ibe
qad and RvTUad Enffliih B[|lti(>a. Tbiirowi^lily ravl^ad Biid uivi-b tuptnTad, hj JiA
BftMrta. M 1) In '>na large and *ei]r hBudn^m* lin|Hrnil n«i«iQ mtunvof ■>«■
■pun't, wicli (172 illuRtTBlionr. Clotb, |B 59, laaiLvt, (T M , rmty lidtiiltam* k«lf
Ur UijHoVi sork ^■■ Inag h'lta • fafitrl'* A»*
Wllh •ar|*»n*. At lla natn* ladltuc. U t* Of i til*'
rnilfMir |i(*f(li'il rhaiau*!. 1l U JuilBCIlf In4l>
■Iriii.l Ib ikal It (ira* 'in r«<«ltt if th* aii'b-r'*
IbTI* ••* •••I'"' '"'V*'"'"'"* •" " ''I™'"''" •■'' '""
otnl (t*'lj*i*. •• d u as iLnI aMiiiaal pfiXed 4*->(r'
Ksrtlx roiiilvnHd. Ill a il'*cr1|il1'ia> ul tai ii''>l •l'>'
«H-«> iriaf aad |u Hi* imliii. Th« iilo'iiiliark at*
wall ehou-a. ka4 Ifca ly plial u-na uf I hi* aDIhur'i
*il|>«flfa«* ar« riil<o( lulmii. «ii4 •'••■f mar* tti«
Uidiual/ Taluv IM >)<•■ Wurlila( •BllfOB. — /T. F.
It U a wurli fa|.netall)' xJaf Iril t» Iba ««ala i>f ' !• a tal« tirliir la aa A
•lli'^aaia and iiraciiiii'B'O. M liila B'iI yrsIlK, It ^«nrk. If aB«T^iil4 |>
alT'td* loMliKllaik la atiBclrDl i(«lall (<■■ a fall im- aiir|rrf . 'hla TaluBa
dcr-laniltiij <if iiirg'.ral |irlnol|>li<a aud Ika iri-ii
mi-Bi of •Df f leal Jl>"-M>4 II »uilir>rr> la >!• aC'ir*
at) iBcdla^iiai ihai arc rri>i||DrM4 ■■ i»t .n.c. .
BUfM'T. ■'■<) *ll "aunnltT lujailaa. Ii
tbt^« <i tu< •«*atJ !<■ b# tb« iini «t '
nithar i» pra-anl iha ainiaar with piaciu .. .-
inailiis.ai A llial alctr, (hau l«l'Ui4*c hit lotUi'iy
Willi Ilia Tiava at ■llifixax rrilara. hnafcfat Jia
lliijolakcil titj aatuht bar* teaa. la iblawlUltta
Ib* vbau vark kaa k*a* 4%t%tw.Ur r*fftea4.
<i[ i| lira liapa rtoitllaa. Iniutrtafi aHirlrl
|i»i uiaiU ti> aliu «I ararf ctianiof —^
l/"t .V-41*, Jaa I''^'
Thr Eii(li*h *Jlt>i-«. frou vhtek Ibia •*
kaibraa MPBraiiy r*fia»t aa'i lewfiiiaa
ararj fibB|ilav hta i*faiVBil ml-i
•■(i« hua-lrad ■•(»«'lli Isl l-J ,
iba Aaaattiaii ailliiii, bi J<.i.
r» f aj<b in<r*4*a4 lb« rai'
hi* Iuii'i4a>*d aaa( n><a ii i
Bin' Balmal nul ritflttil lu il
Ha La* ariuoa too aaiiU •■•- .
aJIt
[r ha 4a->'ni iv». KfUh ae
>idd»l, aad Vt ka iriahad • i'-
Tonid la«ilT W "■■ - ■- ■■■
■r.>ra "T Oiaaa la
»•» ai)r(»aa, II' .
ab<tva all 11^ i.->-
UV'TaJ -al .
JU*I ••Blalli'
MtnU-— alVk — ■-.. «. " .-. ^
pRICanEy {JOBS R.).
THE SCIKXCK AM) ART OK SURiJERY; being a TreatiMon
fical Iikjuriaa, Diuaaaa and Onaraifoki. Carafnll; rrrlard uj th« Aulhot tr^Wtl
ev«illh anil •QtBrf«d Bniflliili Kdition. IHuitrai'd ttj aigUt bumlraxl akd *tttf lw«]
■troTtnss OB food. It [wo >'rK« bed bcaiillriil oouro r«liinpa of avarlj J«t§
<ilBtb.|S»OiUather, tiu »0; hall RoMto, tU •'>«. l/Vov AauiT*.)
rkaaaaaaik «iI'U»b i> Il.'^<f. iI,. -m-r..: t ..
Orib«IBiaT iraatlMvxn r-'irtrtj whkh it ^a> t.''i
aar taak in atiiiT, uruur |ilmaurx tumail, lb«-rvt* n<>n<
wbUaiBTall rolDUbBaaBiiBnmaa>Aw>|l**lb>i!lB>-l
tnatltaaf >!ri(h>cn. Ilia ju-lljJiaLrlaar *(• " >.>■■-..
tloa Hmu pt^utUto and bobMaa. kMun>ii r
(ifbla •u^afi,anil rati rllnlml aipaitaiK"
•dmiraWr towrtu • m^M tn:ii-hMk. V\. .,
ai tha laaal mat orilmo. li> l*BTB lb* mr-^tot a u^ilvtr aac* of ataallrai aa<l
aair^cr;, <*• turn, by p(v4--r«inv. la hia «arK It I* a i aaa^aaly a>li. la «na<l
(rlaaauia, Itvrafon. (<> i*> tliat ih* B|i^n«kl|ixi uf It b aiaad Iba worb ■••
wdfJ [.raairieat ■'
• hlch alfal II Ml
•IHoiaa a|><ia aara.!... ,
<lDrl>ailB<), II »iil •■->
raad U, fat II Laa baaii
Kitaliaab in^aiXBH'*!-
lt*H«nii.aiid baa lad to tb*a|<r*am><«<»r aua^hot adl
tl«H.— ■lAat. swf Saig. Rffurtr. ifr\ V, tK».
Non>lUwUOill<l|Clkaln«rr«aalii •li-i.a>
■•obuU naltai tiat tvrn uniiurd I'L--
kaa haaa tbem*Bl>7 «riit*B ui'. 4b4 n>i n
ad hf a (ru •(tiarualitrra A in'rai tiu|<r
kaMi utadaia tli*ll>ttflr>tlOBf 'Ju* buD'..
KBv auH bat* baaa a-Uad, and ataii* lU
hata >b-rn miraan Tb* aulhoi bl^lily aiiin- ii!-> iti>
Cavvr wlib wblKhhla vcrk baa b**n rarni rail U; Amrrl-
Rau •iirgisfiia. aiaJ tuw eajt«tand lu tvailar lil* lalrii
etljtbxi ni"'* tt»ii piat nirilty nf Uiaii' apBttiaaJ. Tlid
bs bat ■arxvilnl aJuiiiaM) I uilul. «« llilnk, Im lb*
naaral'>|>lni'<ii. Hr livAdilj rr««nB«Dd tb* book l>
WOi aliMlanI »i>4 pmetUloaar.— JV, TilM, AwnuM.
f •». IBTB.
'•"T
(lauoiad la a buub4 lalili, aa4 la ft
■ a loralaabla amd* a( iba I>r4tl<la — .
•t-»tr. Aiitll.ltCb
Vorifcaptit IwaBt^ y*ara tiUbaaa'a :
[itaialalba4lt>r<kaaaaikalaadlsj>BZi-k,>.
■ mnnirj. I'ai (a ilraat Mil
I Lir (fuuaJ, la aliaaJar. I
. nari vlib atii;!. iL. | ti-.
t»Ti.-<l and bj It . ■ ji -J i.;*a*la"i
rial !>>«'>■■• I>MB ' 'flan tUB,<
lif-a Mt'l 'fiy >:■ ' ■ litabaatj
4*aaaBilni]r ««*'<!• -Mtit. XmmO, Vafc.:
^
OLME.^ {TIMOTHY). Ml)..
Sttrffmntr iit Ot'^g-t Mr,r^ifnJ, Haiaiilo*,
SURUKRV, IXa i'RIXCIFLES AND mACTICB- In »ne hi
wmaw'Wva v<.lont.«ri)«arl7 >"" (•»«"• »l(h «l I illiMTblioiH CIttU. ■' luuai
half R«mU. %% fid ' ■ ««aa
TfclBiaa wdrk wfcicb bsa Uaa iMkadfut sa iMlb ilUl^tMaaldlatiMI
•tlaaonliaklUaUf wllbMBiklalaraai. Jlr. UulMaa | U IM4
It a aargs-iB al lariaand ranad aiparlaaca.aBilaaa
«f tb< UatI kaaWD, bb4 poba^a iLa nual billlUal
Wtliar apDB •aii<:ai<al>ia<.'aialr. .^:sa4. It la a
bo-ik tor aial- a— aad Tit
lb" ti«B7<»»" ' paMuiaal
aliibaitBLiwlr-- - ...:.. ,., ■ --
|U«. Tba l>.<i>k lallif iu.linaaili.
ihal VBiafiliBad >ril Itaal/lal-
«r«abilllUki at (!■■•*, aa<l ib« a...,,.. »-.. .....r i
l4bllQ|ll*\lhlaltaTta(*r\\«\uV»ta<A\»tkVi«l
•«.!■ JM ■,, ,<|.i
U«lllliarB«a4 « aott •Vdallaalapl
fnj t>t ;h' rasara' pT.rii '-iB.r aj, . ,,-
iia> -
arot I ■
t-'u ii Bill aa ai.|tk
■ ka l-luiaaalaa aa4 —pMUil* aa a
HENar C. Lba'b Son & Co.'8 VvnucAttotta—iOphthaimology).
WHLLS {J. aOELBERO),
A TRKATISE ON I)|:^KASK8 OP THE EYE. ThiM Arooriwn,
friini (h» Tbtfil Lonilikm Billiloo. TLornuptil,* rF>i-f<t, oilh cvpiuai nililttluBf. b; Cb-ii,
S. Hiill.M D., Sur);p4nitn'l Palholug^iKl III lh» New York Eya bbJ Kar iHflriBBrr Iliiw.
Irotfii witb kbiisi Soo «D|{t»T)iigii»t) wood, •nd tix colurc4l plMei Ti'r«(fc<<r«ilb *tlM-
tioni {torn lb* Tc^t-lvpci ol Jarft «nd SntlUs. In on* Urit* fti d Kr; buMtwa*
»rUvo rolmn* ot 900 iiagii. CIvlb, |A i Uaibir. tO ^ hklf Kitatlx, r«t««d bind*. $4 hi.
(Jut! Kt^y.}
Tba tonf; (anUna«i) illDtd oT lb* aalltor. «)lh Hi hUl Uriiim'liaB. hu Iwpl IbU «orh for
tome tiin* oat of iiiltil. aoJ bni d*t<tivr>l it of llis »il«anla(!a a( tka reiiriiia wbirb be ■nuj[bl
tu jive It during (ua tksl jeam ol lii- life. 'I'bi* ediiiun bni iltcrBfura b- cd pl»- ttk undir iba
citiinrUl luitcrriooa of Dr Bull. «h(i fa&a Uburcl Mtrnsitly lo inirniln.^t in It all thn ailvanoot
ubioh abMrvition ainl ex^neDce h»*e aeqiiirrd for the Ibcory Mid (jrartlna of t>i>lilkiiliacilogy
»inc* tba appaatancv nf Iba laul reritioa. To ■c«tirnpll>h tbl>, contlilarabta ndililli.ni Lain b^an
raigyired, MlJ (lia wiirk in boia pia>aniBd ID ih* (lurilidaui'a ihitl it will fullf daaaria k ooDUnu-
*iii;a of iha Teiy inaihM favor wkib whirtli tl lia* hiibirtii b*«iii grtaiail ka • oou|ilHa, hal oun*
eUo, ax|iiJi<iliiia cif lb* |>rinriiilea anil fttm of iii iHi|.>vttKnt ile|>aitii]*iii of ii>*>li(inl (ctan«a.
'flin additloba (iia4ie >n tfi* |ir«Tiiiut Aaiarlmin eitilinnii hf Ilr. Ilaja Uava bran laUinad,
in«lu'llng Iba varjr fait len** of iHudr.iliuba bdU ibe tetM^t" "^ Jaeger and eaallan.
Ttii* ucir Bllilitu lit Or, Wrlln'i grnai ir ilk tia lb* . ■»><<. la ll>a ikhaiI eill.luD> tba aaibur >k>-wad
««■• ■ Itl t>* ir*isi>fTi*>l lijr M.a ^ir'-.'^ii'iD al lurfa a* |aOiialrl*a> t'tocrcli la xl'IIUf Btw maiflrtai fiuia
wi-li m b/ Ibo <i«all>l tlcnhlalaa niixh »•■■ •■llet . ritrry ■(•laiui, anil hi* ■i^dl waa *maiail7 caadlii.
raU lag lo Uaalnin-I and ^lk"l>>(7.aitil I- tir<.a|l>l A w-iik lba> Vulli Dp b]r busaal ft^n • k'laid toi ti«
ll a* III 7 n^ Willi il> |><> rai itaiu* -if upliLbai- < didWiail lu die. ■><) wa are v'*a*«il !■• n«'ir* ilili
miivfj- It- cb>-t>l*r <.a ivltatlluk aud atcusini^ ' thUd idillua Iivoi Ibc h»a<t* vl Ur. Pul. Hi* lalur
Daii<-...~a luhjaci ami li itlKaiaai) ndaie jvan, aoii h .■ btaa ari)n»ii> a> ih> tarf |ini iiuaikar iif «ildt>
■>1 ITKI iHI">riaui;*— (« e1lc««4IB(l]P MftfUta.— Utub* bi*Cbi>t«4 with hi* l«i|l«l Mvllfy. I'kdaT
Lualtvll/i iliii. Ht U11, Ni(*. 1^, IMU. I Iba idllaKblp wklth Itia Uiitd uritilua liaa aaju^ad.
Tba »ant< *f Wall.-. iimiIm oa dUeaiaa af tba ! '^' *"'» J' ••'• <«•»•'•''• ''• <o-d iat.»ra<l«o, aad
a)oba»i.P(iaiuiial>rr>iLll7.Tttao>l>Ji>4.aada>a , t» nalaUU l.a a>af«lBa>a.->. T *.<.i/«a«i , Jan.
ku laiullUr lo alt wbv it^icm |'> har* il'oi aey at- "■''-
laniiuB to nphiliaiiiiln »wtftf, ihac ■nj' dWn»loB Thvra I* raallj do wurb ati)'h afpn>a*liaa It In
<i4lk*ii> at ilitr U:a d»r w" ** ■ wnitt (A'*f*t*'it- kdftpiatlva 'a ih* waaii of Iha »*•«*•■ I'rariifli'Mr,
intluu. Varj^ llitia ibai !■ |itavlkall; a*«(ol U ra whll< Ihe inv*! ad aadrad •(-•'itUIUi (auaui tl>a friin
oval aplilbalible liirraiair b** OF<a|>*d iitr idll»r, \ a pf ru>al ul itt awpl« pa(o> wliliciil UarlDf addad
auil Iba iMird A>-«noaa ■■lltl'.a li wnfl up iii tha i '■> nla kn.<wlKl(«. Xm AianiicaD t-ttini, tii Uait,
(I ma*. At a i«>i-l-.-vk uh ai-li lialmiftiraaiy Eur i ba ' Wi>B bit ipor* la '<|;<bili*>ni>']i'K)' •<>■» liiiii bath.
biijllidapaakltg |<i*«ilil*u*i, tl la witbuBi a rliai. I lli> addlUua* ivlbc WMk uf iba lain *a tad Wi lU <ra
~Am.Ju-rn i/JftJ. Hti , Jan. IfrM. nany, Jadlilui*. asd UtMly. and Id Ie>t w lansh
Tba w«r« ba. JoMly bald a «lgti ptMa in Koglitb I"'" "««<> "• "» '•'"• -•*"•■ /'wiWllMi.r. Ju.
ogtIiihaliBio llicratiir*. aad at lb* Una of li> titi a^ liUil.
P«aia»ce wtalbvtiMtliMIHa vniaklnd ig ib* las- {
7JETTLKSHIP (ED WAUD). F.lt.C.S.,
■X* (t|«tr*nfa>l«Xur; nivt tjtit. "m Ofiiltt. Surg nt SI T%ikhi>i' ttntpilal. totiltm.
MANUAL OF OI'HTHALMIC MEDICIXE. Id odc royal ISino
Tolnma of orer tbO pafea. with B« illBMnklloDi- Cloth, 9S. (Jurt RaaJf.)
Tbatuikoi la to b« 4''k(ra>BUiad n|>auiba«*t; lafdrnaiiaA ih^r to«iala. W« do kai taMIBIa M
•ll*rai»ial laaonar la whit it bab(iatcuia|i1lib*d bi* '' ' -■---•■•- ^ ,-:r:ii(i,ip'( b*ab tba baal naaUBl OB
laib. b- ba* ••uM*d>d In b*lu( uamHi wlUual ir tit Iba •*• •( alBdaaU aB4
■acridclvg claMiuaa*, asd, Ineiu'llui Ika wk>ii<i ■■!*" wllb wblcb Wa aia aa^«alB>
gioaad C>i**r4d b« Okura rulaMlB-nb laXC-^iik*. i<
Baa 4t*e« aa aiOsllaai r^(«in/ ot all Iba yrBcilaBl i
< "ir. Jttd.StUuM*, Apfll, UW.
f^ARTEK {li. BKCDEXELh), yh.CS..
A PRACTICAL TUIiATlSE ON DISEASES OFTUK EYE. EdiU
eil, with t«*t-ty|H)« and Additinaa. by Jons (Iubkb. U.ll. (nt Bt Lnul*. Mo,). In ob*
baiiclBOiaB oclnvo Talrnna «f aboal &l)U page*. Bud ISdillaalfBtloik* Ololk, ti Tk.
It l> wltB<rvalp»«aabivtliaiw*(»A«*<ii>r-<iliv«i-rb obbIiUT W dvrotvd tna'IIW<ia>tnii nt tb' VM«*Bd*aUv*
Jl-I ol r.|,l
aliaranfU
, vllaaltr
■ 111
. <>l
"a
. it-
Id
.i.d
-d.
a* a Biiiat faluibt* ftriiinb4ii»n iir itratfilFal i*i>bt&at^
ntillujC). Ur I'arirr arl>-(ii*ili>tr> flLUi ttl'fuJ lip bar
In VMW, aliit |>rMwa|iiiliaiul>j>i'lla ar-lear and f»tir>-
lUttJIiirr, KUy ul I1iiuij»h>iufc.u. abJ brIKe 111* tuur-
rviiiuiilfir Vk't vnald t«4|ifa7lally |wiAaai>d< iwi«a*vr, a*
htirLlty i>r tii^li |hr«k«ii.iba uanEiar lu vbii'b Iha Ificra-
p.-tiiiwDf dli->a>*ol taa«]i)la«lBbantad, toi beralli* ,
akiibi-r l> parlleulaily elaar and ptarii>iLl. a bars t'lhat i Oat. XI. 181^
wriKnat* ■nfurluitalnl)' loannaatltlHknl. Tk* Aaal ■
f>KO\V\E {KftOAH A.\, "
now TO USE THE Ol'UTHALMOSCOI'E. liting EUmL-ninry lo-
siriietlonilnOi'btl>*liiJi>*cop]', >rrBi>i»d fortbv Utaofi^iudeBia With thJr(y*ft*«UlB>Uit>
tUod. Id oKciuftJIvolsoiB r<ij>l iSbid. ofiao^jcvf: eltiili, 91.
UTISIVOI'ft HAKPf BOOK OP orHTHALliro ItiWHtiS'S IXJUK1I& TO THE STE. OBBIT
aUlttiUtt, f-'t Iha a-a af IT»«ilil«*»r( K4««ad I «N[i ITXUinb: (bait Imnarfut* ^ii\ VATau*
•illilua, ravUad asd nalaifad Wllb aainarL^iu | EfMt*. VTUk kV>ua\ niA ^%B4t«& \\\->«si V.\<>^
Ulaatmliia*. laaaa v«ij haadaaow a«lav« T«b-\ Ik «m ^atl b.MiA»^iii.» i«va.»a
BMa, aliKb. M 7a- \ *& W.
t<A'
«V
Henbt C. Lea's Son & Co.'b PtmuuTiOHS — (Mitr^fUaneous). 31
ft
I
Ji
OBBRTS(WILLiAil), M.D..
A PRACTICAL TUEATIS15 ON URINARY AVT) RENAL DIS-
BAtiBS.tD«ludlftKUrliiikry DcpMiu. lllutntrd b]rBaBi*r««ieu«i*ad «nKr*vlD|{B. Tbtrd
AmrriftP. fron lb* Tlilrtl tUviHcd And EtilarK*<l London Billlion. In una largi nnd
liuidioioa MtBTO TolnvB of ot«r AQt p«CM< Ciolh, $4. (Jwir BmM)/,)
/THOMPSON {SIR HESRT),
LECTUREB ON DI6EAt?Ef^ OF THE UlUNA ItY OROAN8. Wiih
tlliuiintttonf oa waod. EMoad Amtrlcan rrom lb« Tblrd Kngllih Kdltln. !■ on* nenl
OctATo volnmr. Clolb, (3 U.
pr ru« AaJrs actuvm. ■
ON TIIK PATHOLOGY AND TREATMENT OP STRICTURE OK
THE l-RETHBA AND fRINAKY FISTUL*. WUh plat** >nd wood-coU- fiom lU
Ihiid and r«*U«d Kagliibvdiiion. In ont vrrjr bandtomi o«taV« voluwa, elolh, (I Ai>,
frOKE {DANIEL HACK). M.D.,
ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON
THE BOPT IN UKALTD AND DI6BASB. Dcvicntd to tlliutraU tb« Aatlvn of iba
liDti()Batlon. In on« bandsosia i>«U*a ToloDia of 410 pagu, elvtb, (V 2t.
DLANDFORD (O. FIELDING). M.D., FRCP..
INSANITY AND ITS TREATMENT: Lctiuro3 on llie Treatment,
Hoilie»l and L«i;bI. of Intanv Paltvnia. Wilh a Suuaiarr ol iba Laot is feree In tha
rnlltd Slal» OB tk« ConBaanvni ol tba Insanr. &7 It^ac RlT, H.T>. In one very
bandMma oomtd Tolnnia af 471 pagM i eluUi , %'A ik. *
\% •altiDviaWBdl wbl(b ■ax kavs li**ttai>T*Iy «c(a>ll7 ■••• la ptaadc>aa4 Ibaapprniirliia Irmt*
fblibjr Ibaauay iaaaralrta«lliiua*t*aribU«aaalrr.i ■*ol lur <hcm, «* Bad la Ur llla«4L'nl'> v.vli a
It takit* lb* (orw ala Ulaaaoi o(cl1nlaat4M«rIpiliia' <oaM4*r»l>l' ailiaacavtar pioliia* irriilafa «» |b«
«rib* *artaaaforaiariBHBilr. with a dsKrli-iWaj tabjacl Hi* fltiaraa »r Ik* Taduaa rsrminrBaaUl
af tk* Moda af aainilaiBf ^riooa iioip*c<#d at Id- ' 4U»Ma •(• to cUMt aB4 food lb ■■ ao r«id«i cai fall
■■■Itf Va tall imtttcolif ailaaltoata ihl> faalara' to ba dmck »IIL tbvli •apaflvritf lu lliaia^iraa ta
•r tba iooll. aaflalBall a anl^aa lalaa lo tba !••*- tidlDaff uaaaal* ta iba KaflUb UBSBac*>>r ((ofat
tal prmdlllaaar. HirapaMrroalbaatatlaalfoatlda'' aaoarawa raadlaiaaiaadtilaaaf atbar.— L«ai<«B
rallvaa lodaMilptluBinflbt «arl*llaa«(lBiBBlljFa*. ftdctU'iHur, Fab. Ifllt.
f RA {HK.VRr C).
■''finPKRSTmON AND FORCE: F^SSAYS ON THB WAfiER OP
LAW. THE WAUKR OF BATTLE, XUEOItPKAL AND TOHTI'RR Tbiid R»tit*i
anJ Knlaritad B'litl'>B. In ona kandiava royal ISnO' toIubo of 5(3 p*t**- Clolb,
TUi tataatila wdrk 1> la xalll j ■ ^Utary of clrU tsora accarala lliaa allbsr at Iha pra«adto|, bnl,
lUatloa ai iattrpi*itO bj ibe pi> (in* of jarupra- Irom iti> iboroofh xib^tatlce. la ■«?• lit* a Iibt>
daiwa . . , lu "SupaiMiliifii a all PMrua" <•■ ba** ini)!)"!!! r>iB««ii aaJ lau lib* ■ balab u( ■ladlaa.—
a |iatIoaw^l« tarraj vf Iba Ivux p*'l ">I >»ttiifii\ut i TKt /•'tllon, Ai| I. I*lb.
baxraaa prt«ltlra barb....)r .uJ jl.llU.d a.lUbi. UmO, wlit b. taapl«l lo .aj that ibU, Ilk. tba
BB«.ot, ^b^f. I. hot a ft,.|.l.t iB.b. «urh ifi-l -Da,ii;,,ad|-.ii."'-"a.«flb«iaorlii<!l..bl.b*u»a'
thuald aolVt »■<■> Mfafailr •ia'lt'd.ai>dh,.ir.>ir i„,„„,„,„ft„e.^r ■ r ■ >j««wo.-inii.i, ,^4
Thaappoaraaaaora Bat*«dltl4Bi>I Mr. HaarrC p<>l«Diit. Tb«ai[b n« •tnviiiail)' t**U «b4 IbUka
La»'* "hupafDllllun aid Fiirra" !• a t'la Ibat oar aliniilf. h* (areaaJa la ■llalalBi lu>|iari!>ilir.
bigbaaiMaulariliip 1* b9i wiitioai b-^aor la It* a,k- . vrii»u*t laub«d«a aaa piciotu'ir aialii^.a imrk
lloeuaalrr. Hr. Lm ba* ual arsrjt fiaih ilaniaad aack a* (bl> has a laaUB( t%Xa9.^L*j^tntMt' »
lor bU varkviib t««ia(ai lariilaa ol kt. au^ibai Jfu^aalar, Uet. IHt,
ptataal aalUoa I* bui oaly fallat aad, l( poHlbta,
V r TUS SAMS AOTMOM.
STUDIES IN CHURCH HISTORY. THE RISE OP THE TEM-
PORAL POWER-BEHRPIT OF CLBROY— KXCOUMIINICATION. !■ ana lar,t"
royal lima. Tolame of S IS pp. ; atotb, t3 T6. ( /:>'>(W|r I'ntUtht^ }
Tba aisry «u aa**r i»U nor* criiMlfar >lib , Baiap««alU>iuit>Miautar>rrlb«Bagll*b Ma4ial.aad
n«alarl*arala«ar VlMtlbiMabL W*4aaM.lad*«d, 1 1* aihaptat on Aocleal Law llkalf Inli* rnfirlM a«
iraar niliar>iii4rarilit*l*M,cAgbaeaiap«r*4*llb taal. Wi cai birdlrPaa>fruM uar ^ . 'u
laU fur c'lftraat*. aeoara«7. aad l>u«*t. — CbtOil|;« wotk* aa ibaa*— wllti «li)rl> I Ual > 1
fsMMia^r, t>a«,lt70. Oallba**' tboaM ha lB*1ada4~w1> i> 'a
Mr. I.»'tUlulW4Tk.'*Sladla«lBCkBr«blllilorT." Iltararr pbaoaDiaBnaihaiitaahaag|.iri>st iriLilIrM
fllllf >u>IhIii> Ibii praaU* ot lb* Irii U daal* wflb aaiarlcaa LinanaUalBi' I La larilar ufaoBiaoflltMoat
tbraa tabiKia— ih* Tanporal powat. B*aatt af ar)|lBal bookt.— te*wlti« jlia««fliM), Jaa.l.lSTI.
Otarf7.ap4 lls««uiD«ai«auoa.tbar*««T4aI vhlak
^