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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&lti*  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 
•  • 

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= 

sS 

ti 

t> 

= 

1 

U" 

= 

.\, 

7 

•t 

= 

1 

S   " 

= 

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8 

It 

» 

t 

3    •' 

= 

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9 

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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 


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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 


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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&para  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- 
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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 
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moBl  ca»c»  (inil  it  tnom:  cuDveoient  to  dtui  with  thi-  iwiitTit  l>ou)(«<fHiT. 

IIKNUV  C.  LEA'S  SON  ft  CO. 

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INCRBASEIi  rXDUCBMBNT  FOR  SCDSCRtBBRS  TO 

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TiiK  AuKHiCAX  Jouk.NAL.  vf  Tiut  AIkpical  SciKMOXB,  whfin  not  paid  for  is 

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TuK  MEt>ic.\L  NKWtt  AM'  AusTKACT,  frou  of  poMiige,  in  advance.  Two  lloll^n 

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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. 


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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 
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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 


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