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■  lilliiliiJiiiliiHiiliniiltttlliiiiiMillttiihliiliilii 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


THE 

AMERICAN 
ENCYCLOPEDIA  AND  DICTIONARY 

OF 

OPHTHALMOLOGY 


EDITED  BY 

CASEY  A.  WOOD.  M.  D.,  C.  M..  D.  C.  L. 

Professor  of  Ophthalmology  and  Head  of  the  Department,  College  of  Medicine,  University  of  Illinois; 

Late  Professor  of    Ophthalmology  and    Head  of    the  Department,  Northwestern    University 

Medical  School;  Ex-President  of  the  American  Academy  of  Medicine,  of  the  American 

Academy  of  Ophthalmology,  and  of  the  Chicago  Ophthalmological  Society; 

Ex-Chairman    of  the    Ophthalmic    Section    of  the  American   Medical 

Association;  Editor  of  a  "System  of  Ophthalmic  Therapeutics"  and 

a  "System  of  Ophthalmic  Operations";  Mitglied  der  Oph- 

thalmologischen     Gesellschaft,     etc.;    Ophthalmic 

Surgeon  to  St.  Luke's  Hospital;  Consulting 

Ophthalmologist    to    Cook    County 

Hospital,  Chicago,  111. 


ASSISTED  BY  A   LARGE  STAFF  OF  COLLABORATORS 


FULLY  ILLUSTRATED 


Volume  VII — Exophthalmometer  to  Gyrus,  Angular 


CHICAGO 
CLEVELAND    PRESS 

1915 


COPTBIGHT   1915 

BY   THE 

CLEVELAND  PRESS 

All  Rights  Reserved. 


1113 

INITIALS  USED  IN  VOLUME  VII,  TO  IDENTIFY 
INDIVIDUAL  CONTRIBUTORS 


A.  A. — Adolf  Alt,  M.  D.,  M.  C.  P.  and  S.  0.,  St.  Louis,  Mo. 

Clinical  Professor  of  Ophthalmology,  Washington  University,  St.  Louis,  Mo. ; 
Author  of  Lectures  on  The  Iliinuni  Eye;  Treatise  on  Ophthalmology  for  the 
General  Practitioner ;  Original  Contribution  Concerning  the  Glandular  Struc- 
tures Appertaining  to  the  Jluman  Eye  and  its  Appendages.  Editor  of  the 
American  Journal  of  Ophthalmolog y. 

A.  C.  C.  — Alfred  C.  Croftan,  Pii.  D.,  M.  D.,  Chicago,  III. 

Author  of  Clinical  Urinology  and  of  Clinical  Therapeutics.  Member  of  the 
General  Staff  of  the  Michael  Reese  Hospital,  Chicago.  Formerly  Physician-in- 
chief  at  St.  Mary 's  Hospital ;  Physician  to  St.  Elizabeth 's  Hospital ;  Physician 
to  the  Chicago  Post-Graduate  Hospital;  Pathologist  to  St.  Luke's  Hospital. 
Late  Professor  of  Medicine  at  the  Chicago  Post-Graduate  College  and  the 
Chicago  Policlinic;  Assistant  I'rofessor  of  Clinical  Medicine,  College  of  Physi- 
cians and  Surgeons  (University  of  Illinois)  ;  Member  of  tlie  American  Thera- 
peutic Society. 

A.  E.  H. — Albert  E.  Halstead,  M.  D.,  Chicago,  III. 

Professor  of  Clinical  Surgery,  Northwestern  University  Medical  School;  At- 
tending Surgeon,  St.  Luke 's  and  Cook  County  Hospitals,  Chicago ;  Consulting 
Surgeon,  Illinois  Charitable  Eye  and  Ear  Infirmary;  Fellow  American  Surgical 
Association. 

A.  S.  R. — Alexander  S.  Rochester,  M,  D.,  Chicago,  111. 

Late  Adjunct  Eye  and  Ear  Surgeon  to  St.  Luke's  Hospital;  Member  of  the 
Chicago  Ophthalmological  Society, 

B.  C. — Burton  Chance,  M.  D.,  Philadelphia,  Pa. 

Assistant  Surgeon,  Wills  Hospital,  Philadelphia. 

C.  A.  0. — Charles  A.  Oliver,  (Deceased). 

Joint  Editor  of  A  System  of  Diseases  of  the  Eye;  Writer  of  numerous  mono- 
graphs on  ophthalmic  subjects. 

C.  E.  W. — Lieut.-Col.  Charles  E.  Woodruff,  ]\I.  D.,  U.  S.  Army,  Re- 
tired. ^ 

C.  F.  P. — Charles  F.  Prentice,  ]\I.  E.,  New  York  City,  N.  Y. 

President,  New  York  State  Board  of  Examiners  in  Optometry ;  Special  Lecturer 
on  Theoretic  Optometry,  Columbia  University,  New  York.  Author  of  A  Treatise 
on  Ophthalmic  Lenses  (1886);  Dioptric  Formuke  for  Combined  Cylindrical 
Lenses  (1888)  ;  A  Metric  System  of  Numbering  and  Measuring  Prisms  (the 
Prism-dioptry)  (1890);  The  Iris  as  Diaphragm  and  Photostat  (1895),  and 
other  optical  papers. 

C.  P.  S. — Charles  P.  Small,  A.  M.,  M.  D.,  Chicago,  III. 

/^  Late  Clinical  Assistant,  Department  of  Ophthalmology,  Rush  Medical  College. 

^  Author  of  A  Probable  Metastatic  Hypernephroma  of  the  Choroid. 

V  D.  II.— D'Orsay  Hecht,  :M.  D.,  Chicago,  III. 

^  Assistant  Professor  of  Nervous  and  Mental  Diseases,  Northwestern  University 

Medical  School ;  Consulting  Neurologist  to  the  Cook  County  Institution  for 
the  Insane  at  Dunning,  Illinois;  Attending  Neurologist  to  the  Michael  Reese 
and  St.  Elizabeth's  Hospitals,  Chicago. 

iii 


624254 


iv  INDIVIDUAL  CONTRIBUTORS 

D.  W.  G. — Duff  Warren  Greene,  :\1.  A.,  M.  S.,  M.  D.,  Dayton,  Ohio. 

(Deceased.) 

Formerly  Oculist  to  the  National  IMilitary  Home,  St.  Elizabeth's  Hospital,  and 
Ohio  Soldiers'  an-l  Sailors'  Orphans'  Home,  Xenia,  Ohio. 

E.  II. — Emory  Hill,  A.  B.,  M.  D.,  Chicago,  III. 

Late  House  Surj^eoii,  Wills  Eye  Hospital,  Philadelphia;  Assistant  in  Ophthal- 
mology, Rush  Medical  College  (in  afliliation  with  the  University  of  Chicago)  ; 
Assistant  Ophthalmologist  to  the  out-patient  department  of  the  Children's 
Memorial  Hospital,  Chicago;  Assistant  Instructor  in  Ojjhthalmology,  Chicago 
Policlinic.  Member  of  American  Academy  of  Ophthalmology  and  Oto- 
Laryngology. 

E.  K.  F. — Epiiraim  Kirkpatrick  Findlay,  M.  D.,  C.  M.,  Chicago,  III. 

Assistant  Clinical  Professor  of  Ophtiialmology,  Medical  Department,  University 
of  Illinois;  Attending  Surgeon  of  the  Illinois  Charitable  Eye  and  Ear  Infirm- 
ary; Assistant  Oculist  at  the  University  Hospital. 

E.  S.  T. — Edgar  Steiner  Thomson,  M.  D.,  New  York  City,  N.  Y. 

Surgeon  and  Pathologist,  Manhattan  Eye,  Ear  and  Throat  Hospital ;  Professor 
of  Ophthalmology,  New  York  Polyclinic  Medical  School  and  Hospital ;  Con- 
sulting Oi)hthalmologist  to  Perth  Amboy  and  Ossiiiing  Hospitals;  Member  of 
the  New  York  Academy  of  Medicine,  New  York  Ophthalniological,  and  Ameri- 
can Ophthalmological  Societies.  Author  of  Ehctric  Appliances  and  Their  Use 
in  Ophthalmic  Surgery,  in  Wood's  Systeni  of  Ophtlialmic  Operations,  and 
various  monographs. 

"P.  A. — Frank  Allport,  M.  D.,  LL.  D.,  Chicago,  III. 

Ex-Professor,  Ophthalmology  and  Otology,  Minnesota  State  University;  Ex- 
President,  Minnesota  State  Medical  Society;  Ex-Chairman  and  Secretary, 
Ophthalmic  Section,  American  Medical  Association;  Ex-Professor,  Ophthal- 
mology and  Otology,  Northwestern  University  Medical  School;  Ex-President, 
Chicago  Ophthalmological  Society.  Author  of  The  Eye  and  Its  Care;  Co- 
Author  of  An  American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose  and 
Throat;  A  System  of  Ophthalmic  Therapeutics,  and  A  System  of  Ophthalmic 
Operations.  Eye  and  Ear  Surgeon  to  the  Chicago  Board  of  Education  and 
to  St.  Luke's  Hospital,  Chicago. 

F.  C.  T.— Frank  C.  Todd,  D.  D.  S.,  M.  D.,  F.  A.  C.  S.,  Minneapolis, 

Minn. 

Professor  of  Ophthalmology  and  Chief  of  the  Division  of  Eye,  Ear,  Nose  and 
Throat,  University  of  Minnesota,  Medical  Department;  Chief  of  Eye,  Ear,  Nose 
and  Throat  Staff,  University  of  Minnesota  Hospitals;  Eye,  Ear,  Nose  and 
Throat  Surgeon  to  Hill  Crest  Hosjjital;  Eye  Surgeon  to  the  C.  M.  &  St.  P.  R.  K. 
Co.,  etc.;  Chairman  of  the  Section  of  Ophthalmology,  A.  M.  A.;  President  of 
the  Minnesota  Academy  of  Ophthalmology  and  Oto-Laryngology;  Vice-President 
of  the  A.  M.  A.,  etc.  Monographs:  An  Exact  and  Secure  Tucking  Operation  for 
Advancing  an  Ocular  Muscle;  A  Method  of  Performing  Tenotomy  which  En- 
ables the  Operator  to  Limit  the  Effect  as  Eequired;  Mules'  Operation;  Kera- 
tectasia;  Eeport  of  a  Case  with  Transparent  Cornea;  The  Implantation  of  an 
Artificial  Vitreous  as  a  Substitute  for-  Enucleation  of  the  Eyeball;  Simple 
Method  of  Suturing  the  Tendons  in  Enucleation;  Malingering  (Pretended 
Blindness)  ;  The  Physiological  and  Pathological  Pupil. 

F.  E.  B. — Frank  E.  Brawley,  Ph.  G.,  M.  D.,  Chicago,  III. 

Co-Aiithor  of  Commoner  Diseases  of  the  Eye,  A  System  of  Ophthalmic  Thera- 
peutics and  A  System  of  Ophthalmic  Operations ;  formerly  voluntary  assist- 
ant in  the  Universitaetes  Augenklinik,  Brcslau,  and  the  Eoyal  London  Ophthal- 
mic Hospital  (^loorfields)  ;  Oculist  and  Aurist  to  St.  Luke's  Hospital,  Chicago. 
Editorial  Secretary  of  I'hc  Ophtluilmic  Eecord. 


INDIVIDUAL  CONTRIBUTORS  v 

p.  P.  l._Francis  Park  Lewis,  M.  D.,  Buffalo,  N.  Y. 

President  American  Assoi-iatioii  for  the  Conservation  of  Vision;  President 
Board  of  Trnstees  N.  Y.  State  Sdiool  for  the  Iilin<l;  President  N.  Y.  State 
Commissions  for  the  I511nd  (ISKlM  and  llMKi)  ;  Chairman  Committee  on  Preven- 
tion of  Blindness,  American  Medical  Association;  Oplitliahnolof^ist  Bnffalo 
State  Hospital  and  Buffalo  Homeopathic  Hospital;  Consultinff  Ophthalmolofjist 
J.  N.  Adam  Memorial  Hospital;  l''ello\v  Acailemy  Ojilitlialmology  and  Oto- 
Laryngology. 

G.  C.  S.— G.  C.  Savage,  M.  D.,  Nashville,  Tenn. 

Professor  of  Ophthalmolo-ry  in  the  Medical  Department  of  Vanderbilt  Uni- 
versity; Ex-President  of  Iho  Nashville  Academy  of  Medicine;  Ex-President  of 
the  Tennessee  State  Medical  Society.  Author  of  New  Truths  in  Ophthalmology 
and  Ophthalmic  Myology. 

II.  B.  W.— Henry  Baldwin  Ward,  A.  B.,  A.  lAI.,  Pii.  D.,  Champaign, 

III. 

Professor  of  Zoology,  University  of  Illinois;  Ex-Dean  of  the  College  of  Medi- 
cine, University  of  Nebraska.  Author  of  Parasitic  Worms  of  Man  and  the 
Domestic  Animals;  Data  for  the  Determination  of  Human  Entozoa;  Icono- 
graphia  Parasitorum  Ilominis;  Human  Parasites  in  Nortli  America. 

H.  B.  C— H.  Beckles  Chandler,  C.  M.,  M.  D.,  Boston,  Mass. 

Professor  Ophthalmology,  Tufts  Medical  School,  Boston ;  Senior  Surgeon 
Massachusetts  Charitable  Eye  and  Ear  Infirmary. 

II.  S.  G. — Harry  Searls  Gradle,  A.  B.,  M.  D.,  Chicago,  III. 

Professor  of  Ophthalmology,  Chicago  Eye  and  Ear  College;  Director  of  Oph- 
thalmic Clinic,  West  Side  Pree  Dispensary;  Member  of  the  Ophthalmologische 
Gesellschaft,  American  Medical  Association,  American  Academy  of  Ophthal- 
mology and  Oto-Laryngology. 

H.  V.  W. — Harry  Vanderbilt  Wurdemann,  M.  D.,  Seattle,  Wash. 

Managing  Editor,  Ophthalmology,  since  1904;  Editorial  Staff  of  the  Ophthal- 
mic Record  since   1897;    Managing   Editor,   Annals   of   Ophthalmology,   1897- 

1904.  Member  American  Medical  Association;  Ex-Chairman  Section  on  Oph- 
thalmology, American  Medical  Association;  Hon.  Member,  Sociedad  Cientifica, 
Mexico;  N.  W.  Wisconsin  Medical  Society  and  Philosophical  Society.  Fel- 
low American  Academy  of  Ophthalmology  and  Oto-Laryngology,  Author  of 
Visual  Economics  (1901);  Injuries  to  the  Eye  (1912);  Bright 's  Disease  and 
the  Eye  (1912) ;  and  numerous  monographs  on  the  eye  and  its  diseases.  Col- 
laborator on  many  other  scientific  books. 

J.  D.  L. — Joseph  D.  Lewis,  A.  M.,  M.  D.,  Minneapolis,  ]\Iinn. 

Ophthalmic  and  Aural  Surgeon  to  the  Minneapolis  City  Hospital;  Consulting 
Ophthalmic  and  Aural  Surgeon  to  Hopewell  Hospital  and  Visiting  Nurses' 
Association;  Meml)er  Minnesota  Academy  of  Ophthalmology  and  Oto-Laryn- 
gology; Fellow  American  College  of  Surgeons. 

J.  L.  M.— John  L.  Moffat,  B.  S.,  M.  D.,  0.  et  A.  Chir.,  Ithaca,  N.  Y. 

Editor  Journal  of  Ophthalmology,  Otology  and  Laryngology.  Consulting 
Ophthalmic  Surgeon,  Cundierland   Street   Hospital,   New    York;    Member    (v.-p. 

1905,  1908)  American  Homceopathic  Ophthalmological,  Otological  and  Laryn- 
gological  Society;  Member  American  Medical  P^ditors'  Association;  Member 
(Senior)  American  Institute  of  HonKroi)athy ;  Senior  Member  (ex-pres.)  New 
York  State  Hom(ro]iathic  Medical  Society;  Senior  Member  (ex-|»res.)  Kings 
County  (N.  Y.)  Homoeopathic  Medical  Society;  Honorary  Member  N.  Y.  County 
Homoeopathic  Medical  Society. 

J.  ]\l.  B. — James  ]Moores  Ball,  ]\I.  D.,  LL.  D.,  St.  Louis,  Mo. 

Dean  and  Professor  of  Ophthalmology,  American  Medical  College  of  St.  Louis, 
Medical  Department  of  National  University  of  Arts  and  Sciences.  Author  of 
Modern  Ophthalmology ;  Andreas  Vesalius  the  Reformer  of  Anatomy. 


vi  INDIVIDUAL  CONTRIBUTORS 

M.  S. — ]\Iyles  Standish,  A.  M,,  M.  D.,  S.  D.,  Boston,  Mass. 

Williams  Professor  of  Ophthalmology,  Harvard  University;  Consulting  Oph- 
thalmic Surgeon,  Massachusetts  Charitable  Eye  and  Ear  Infirmary  and  Carney 
Hospital,  Boston,  Mass. 

N.  M.  B.— Nelson  M.  Black,  Pii.  G.,  M.  D.,  Milwaukee,  Wis. 

Autlior  of  The  Develoi)ment  of  the  Fusion  Center  in  the  Treatment  of  Strabis- 
mus; Examination  of  the  Eyes  of  Transi)ortation  Kmployes;  Artificial  Illumina- 
tion a  Factor  in  Ocular  Discomfort,  and  other  scientific  jjapers. 

P.  A.  C— Peter  A.  Callan,  M.  D.,  New  York  Cri-Y,  N.  Y. 

Surgeon,  New  York  Eye  and  Ear  Infirmary;  Ophthalmologist  to  St.  Vin- 
cent's Hospital;   Columbus  Hospital  and  St.  Joseph's  Hospital,  New  York. 

R.  D.  P. — Robert  D.  Pettet,  Chicago,  III. 

Author  of  The  Mechanics  of  Fitting  Glasses. 

S.  H.  McK. — Samuel  Hanford  McKee,  B.  A.,  M.  D.,  Montreal,  Que. 

Lecturer  in  Pathology  and  Bacteriology,  McGill  University;  Demonstrator  in 
Ophthalmology,  McGill  University;  Assistant  Oculist  and  Aurist  to  the  Mont- 
real General  Hospital;  Oculist  to  the  Montreal  Maternity  Hospital;  Oculist  to 
the  Alexandra  Hospital;  Member  of  The  American  Association  of  Patliologists 
and  Bacteriologists.  Author  of  The  Bacteriologif  of  Conjunctivitis ;  An  Anal- 
ysis' of  Three  Hundred  Cases  of  Morax-Axenfeld  Conjunctivitis ;  Demonstration 
of  the  Spirocheta  Pallida  from  a  Mucous  Patch  of  the  Conjunctiva;  The  Patho- 
logical Histology  of  Trachoma,  and  numerous  other  monographs. 

T.  H.  S.— Thomas  Hall  Shastid,  A.  B.,  A.  M.,  M.  D.,  LL.  B.,  F.  A.  C.  S., 
Superior,  Wis. 

Honorary  Professor  of  the  History  of  Medicine  in  the  American  Medical  Col- 
lege, St.  Louis,  Mo.,  Medical  Dept.  of  National  University  of  Arts  and  Sciences. 
Author  of  A  Coiintry  Doctor;  Practising  in  Pike;  Forensic  Belations  of 
Ophthalmic  Surgery  (in  Wood's  System  of  Ophthalmic  Operations)  ;  Legal  Re- 
lations of  Ophthalmology  (in  Ball's  Modern  Ophthalmology) ;  A  History  of 
Medical  Jurisprudence  in  America  (in  Kelly's  Cyclopedia  of  American  Medical 
Biography). 

W.  C.  P. — Wm.  Campbell  Posey,  B.  A.,  M.  D.,  Philadelphia,  Pa. 

Professor  of  Ophthalmology  in  the  Philadelphia  Polyclinic  Hospital  and 
Graduate  Medical  School;  Ophthalmic  Surgeon  to  the  Wills,  Howard  and 
Children's  Hospitals;  Chairman  of  the  Pennsylvania  Commission  for  the 
Conservation  of  Vision;  Chairman  of  Section  on  Ophthalmology,  College  of 
Physicians,  Philadelphia.  Editor  of  American  Edition  of  Nettleship's  Text- 
book of  Ophthalmology ;  Co-Editor,  with  Jonathan  Wright,  of  System  of  Dis- 
eases of  the  Eye,  Ear,  Nose  and  Throat;  Co-Editor,  with  Wm.  G.  Spiller,  of 
The  Eye  and  the  Nervous  System. 

\V.  F.  C. — W.  Franklin  Coleman,  M.  D.,  M.  R.  C.  S.  Eng.,  Chicago.  III. 

Professor  of  Ophthalmology  Post-Graduate  Medical  School;  Professor  Ophthal- 
mology Illinois  School  Electro-Therai)eutics;  Member  Chicago  Ophthalmological 
Society. 

W.  F.  H. — William  Frederic  Hardy,  M.  D.,  St.  Louis,  I\Io. 

Assistant  in  Ophthalmology,  Washington  University  Medical  School. 

W.  H.  W. — William  Hamlin  Wilder,  A.  I\I.,  M.  D.,  Chicago,  III. 

Professor  and  Head  of  Department  of  Ophthalmology,  Kush  Medical  College 
(in  affiliation  with  University  of  Chicago)  ;  Professor  of  Ophthalmology,  Chi- 
cago Policlinic;  Surgeon,  Illinois  Charita!)le  Kye  and  Ear  Infirmary:  Ophthal- 
mic Surgeon,  Presbyterian  Hospital;  Member  American  Ophthalmological  So 
ciety. 


LIST  OF  LEADING  SUBJECTS  IN  THIS 

VOLUME 


exophthalmometer 

Exophthalmos 

Exophthalmos,  pulsating 

Exophthalmos,  traumatic 

Exophthalmos,  voluntary 

Exudative  erythema,  ocular  complications  of 

Exudative  retinitis 

Eye-cup 

Eyeglasses  and  spectacles,  history  of 

Eyeglasses  and  spectacles,  mechanical  adjustment  of 

Eyelids,  angioma  of  the 

Eyelids,  angiosarcoma  of  the 

Eyelids,  epithelioma  of  the 

Eyelids,  gangrene  of  the 

Eyelids,  injuries  of  the 

Eyelids,  malignant  tumors  of  the 

Eyelids,  sarcoma  of  the 

Eyelids,  xanthoma  of  the 

Eye  shade 

Eyes  of  soldiers,  sailors,  railway  and  other  employ'ees,  examination 

of  the 
Eye-strain 
Facial  paralysis 
Facial  tic 

Familial  eye  affections 
Fatigue 

P\\T  implantation 
Faye,  George  de  la 

FiBROLYSIN 

Fibroma 
Fibromatosis 

FiLARIA 

Felix  mas 
Filtration,  ocular 
Fixation  instruments 
Flat  sarcoma 
Fluorescein 

Fluorescence,  lenticular 
Focal 

vii 


viii  LIST  OF  LEADIXG  SUBJECTS 

FoLTz,  Kent  Oscanyan 

Forceps,  oi'Iitiialmic 

Foreign  bodies  in  the  eye 

Formalin 

Fractires 

Frame,  trial 

Franklin,  Benjamin 

Frick,  George 

P'riebis,  George 

Friedenwald,  Aaron 

Frothingiiam,  George  Edward 

Fryer,  Blencowe  E. 

Fulguration 

Fundus  oculi 

Galen,  Claudius 

Ganglion,  gasserian 

General  diseases  and  ophthalmology 

Geography  of  ocular  affections 

Gestation 

Giant  magnet 

Gibson,  William 

Glaring 

Glass 

Glass,  optical 

Glaucoma 

Glaucoma,  malignant 

Glaucoma,  myopia  in 

Glioma  op  the  optic  nerve 

Glioma  of  the  retina 

Gloster 

Goblet  cell 

Godman,  John  D. 

Goethe,  Johann  Wolfgang 

Golf  ball 

Gonorrhea,  ocular  relations  of 

Gradle,  Henry 

Graefe,  Albrecht  von 

Graefe,  Alfred  Carl 

Greene,  Duff  Warren 

Green,  John 

Gumma 

GuNN,  Robert  Marcus 

Gunshot  injuries  of  the  ocular  apparatus 


Exophthalmometer.  An  instrument  for  measuring  the  degrees  of 
cxophthalnios  in  orbital  tumor,  Graves'  disease,  etc.  Although  the 
one  best  known  is  that  of  Ilertel,  yet  there  are  several  others  in  the 
market.  For  example,  the  instrument  of  Cohn  is  known  by  this  name, 
although  it  was  first  called  the  ophthalmoprostatometer, 

Tlie  apparatus  designed  by  Lohmann  {Archiv  f.  AugenheUk.,  Vol. 
75,  p.  85)  is  said  to  be  inexpensive  and  sufficiently  exact.  It  aims  to 
fulfill  chiefly  two  requirements.  1.  It  does  not  annoy  the  patient  and 
allows  of  reading  in  any  position  of  the  head.  2.  The  troublesome 
application  and  fixation  by  the  observer  during  the  examination  is 
avoided.    See  page  4597  of  this  Encyclopedia. 

Kiyosawa  {Ophthalmology,  Oct.,  1914)  has  invented  an  exthalmom- 
eter  on  the  principle  of  a  pelvimeter.  One  arm  is  placed  on  the 
occipital  protuberance,  the  other  on  the  cornea.  From  the  difference 
between  the  distances  from  the  occiput  to  the  right  and  left  eye  the 
degree  of  exophthalmus  is  calculated. 


Hertel  's  Exophthalmometer. 

The  Hertel  instrument  has  the  advantage,  according  to  the  makers, 
that  one  person  is  enabled  to  measure  the  degree  of  exophthalmia 
rapidly  and  accurately.  It  is  a  convenient  means  of  measuring  the 
increase  or  diminution  of  the  exophthalmia  occuring  in  inflammations 
of  the  orbital  cavity,  in  retrobulbar  hemorrhage,  with  foreign  bodies, 
in  tumlor  of  the  orbital  and  accessory  cavities  and  more  especially  in 
exophthalmic  goitre. 

The  working  principle  of  the  instrument  will  be  readily  gathered 
from  the  figure.  It  is  fitted  with  two  movable  mirror  and  scale-carriers 
with  sleeves,  by  which  the  former  may  be  slid  along  a  guide  bar  and 
accurately  set  to  the  outer  margins  of  the  orbital  cavities  of  the 
patient's  eyes.  The  distance  between  these  margins  is  shown  by  the 
scale  on  the  guide  bar.  Every  time  a  fresh  measurement  is  to  be  taken 
the  instrument  may  be  quickly  set  by  the  scale.  The  operator  looks 
with  both  eyes  into  the  left  or  right  pair  of  crossed  mirrors.  The 
lower  mirror  shows  the  lower  half  of  the  vertical  profile  of  the  cornea 

Vol.  VII— 1 

4849 


4850  EXOPHTHALMOS 

turucd  iii-ound  into  a  plane  at  right  angles  to  the  observer's  line  of 
sight,  whilst  the  upper  mirror  forms  an  image  of  the  scale  for  measur- 
ing the  protrusion  of  the  cornea  in  approximately  the  same  plane  in 
which  the  profile  of  the  cornea  is  seen ;  the  two  images  are  accordingly 
seen  without  any  appreciable  amount  of  stereoscopic  parallax.  In  the 
event  of  the  corneal  apex  being  situated  exactly  20  mm.  nearer  to  the 
meridional  plane  than  the  points  where  the  instrument  rests  on  the 
orbital  margins  the  plane  of  the  scale  image  and  that  of  the  corneal 
profile  are  strictly  coincident.  The  reading  gives  the  distance  in 
millimetres  from  a  frontal  plane  passing  through  the  points  of  appli- 
cation on  the  orbital  margins. 
Exophthalmos.  ExornxHALMOs  in  general.  ExopiiTJiALiius.  Propto- 
sii<.  Protrusion  of  the  eyeball.  Exophthalmia.  The  eyeball  may 
project  abnormally  on  account  of  many  different  causative  factors, 
and  although  it  is  invariably  but  a  symptom  of  some  underlying  con- 
dition, local  or  general,  yet  it  is  often  the  most  serious  symptom  of 
that  state  and  as  such  seems  to  deserve  separate  treatment. 

Birch-Hirschfeld  (Graefe-Saemisch  Handbuch  dcr  Ges.  Aug.,  Vol. 
IX,  1907)  gives  the  following  classification  of  the  causes  of  exopthal- 
mos:  a,  Protriisio  hulbi;  divided  into  (a)  encroachment  on  the  orbi- 
tal cavity  and  (6)  diminished  retraction,  including  paralysis  of  the 
third  and  seventh  nerves,  (a)  is  again  subdivided  into  (1)  deformity 
of  the  orbital  walls  and  (2)  increase  of  the  orbital  contents,  b,  Pro- 
tractio  hulhi;  (a)  due  to  increased  protraction  of  the  obliques,  and 
(b)  stimulation  of  the  sympathetic  system.  Both  subheads  (b)  may 
result  from  tenotomy  of  the  recti  and  from  muscular  pareses. 

Exophthalmos  may  be  pronounced  from  deformity  of  the  orbital 
walls,  oxycephaly,  "tower-skull."  sca])hocephaly  and  other  congenital 
malformations.  It  is  also,  though  rarely,  seen  in  the  orbital  anomalies 
of  rickets. 

Ectasia  of  and  deposits  in  the  neighboring  sinuses,  foreign  bodies 
in  the  orbit,  hemorrhage,  orbital  cellulitis,  orbital  tumors  and  ac- 
romegaly are  among  other  recognized  causes  of  this  symptom. 

The  most  frequent  accompaniment  of  exophthalmia  is,  however, 
exophthalmic  goitre,  which  is  separately  treated  in  this  Encyclopedia. 

Several  forms  of  exophthalmos  are  also  considered  under  separate 
headings. 

Occasionally  toxic  agents,  saponin  and  sulphur,  for  example,  pro- 
duce a  more  or  less  pronounced  proptosis.  not  to  mention  the  various 
forms  of  strangulation  and  suffocation. 

Measurement  of  exophthalmos.  As  Rollet  and  Durand  {Revue 
Generate  d'Ophtal.,  ^Nlay.  1912)  have  pointed  out  there  has  been  great 


EXOPHTHALMOS  4851 

need  of  ;i  precise  iiistniiiiciil  to  deinoiistrate  tlic  degrees  of  exophllial- 
mus.  One  is  easily  deceived  by  tiie  position  of  the  lids  and  the  degree 
of  prominence  of  the  eyes,  especially  in  Basedow's  disease,  where  it 
would  be  most  convenient  to  regulate  the  effects  of  the  therapy.  It  is 
also  most  interesting  in  cases  of  orbital  tumor,  strabismus,  errors  of 
refraction  and  other  diseases  of  the  eye.  The  writers  desired  to  prove 
by  their  results  a  coexistence  of  exophthalmus  and  atrophy  of  the 
optic  nerve,  also  a  connection  in  tlie  diagnosis  of  nephritis,  and  like- 
wise in  the  prognosis.  There  liave  been  numerous  models  of  an 
instrument  for  measuring.  The  Ilehnholtz  model  is  exact,  but  cumber- 
some and  very  complicated.  The  use  of  the  Java)  oplilhalnioiiicter  for 
this  purpose  needs  a  special  arrangement,  and  tliis  is  not  portable. 
The  instruments  of  Cohn,  Emmert,  Kayser,  \'()lkmann,  Zehender  and 
Bireh-Hirschfeld  fail,  they  say,  because  the  eye  is  viewed  from  the 
side,  and  it  is  impossible  to  replace  the  contrivance  in  exactly  the 
same  position  when  the  other  eye  is  viewed.  Other  exophthalmometers 
are  described  and  criticized.  The  most  perfect  apparatus  seems  to 
be  the  model  of  Hertel,  the  second  of  his  two  devices.  It  is  not  ex- 
pensive, is  compact  and  easily  applied.  However,  these  writers  state 
that  the  apparatus  is  not  precise,  since  different  observers  get  a  vari- 
ance of  1  to  3  mm.  in  their  measurements.  The  writers  have  modified 
the  Ilertel  instrument  by  adding  two  sights  on  a  scale,  one  fixed,  the 
other  sliding.  Upon  applying,  the  sights  are  moved  to  mark  the 
tangent  to  the  apex  of  the  cornea  and  the  exophthalmus  read  off  on 
the  modified  scale.  The  great  ol)jection  to  this  measure  is  that  the 
orbital  wall,  upon  which  the  principle  is  based,  is  not  a  fixed  point, 
the  same  in  every  case,  but  as  a  whole  about  as  near  as  we  can  come  at 
present.     See  Exophthalmometer. 

After  measuring  two  hundred  normal  eyes  the  authors  hold  that  the 
average  protrusion  is  between  12  and  14  mm.,  and  that  following 
extractions  the  figures  do  not  vary.  Exophthalmus  is  greater  than  14 
mm.,  enophthalmus  less  than  12  mm.  All  liypei-metropes  scarcely 
reached  the  lower  figure :  cases  of  myopia  varied  more,  but  showed  the 
larger  figure.  After  strabismus  tenotomies  we  find  a  rapidly  decreasing 
exophthalmus.     Glaucoma  shows  no  change  in  the  position  of  the  eyes. 

Atrophy  of  the  nerve  in  nineteen  of  twenty  ca.ses  had  protrusion  up 
to  nineteen,  especially  unexplainable  in  tabies.  Several  cases  of  Base- 
dow's disease  were  follow'ed  and  decrease  seen.  In  chronic  nephritis 
78  per  cent,  of  cases  examined  had  exophthalmus  with  bad  prognosis. 

Exophthalmos  with  general  diseases.  Cohen  (Amer.  Jour.  Med. 
Sc,  CXLIV,  p.  13)  urges  early  diagnosis  in  exophthalmic  goitre.  In 
15  to  20  per  cent,  of  cases,  surgery  is  made  necessary  by  failure  to 


4852  EXOPHTHALMOS 

promptly  institute  non-surgical  treatment;  and  in  about  5  per  cent, 
of  cases  surgical  measures  may  become  necessary,  in  spite  of  early 
skillful  treatment.  lie  advocates  individualization.  Both  mental  and 
physical  rest,  correction  of  errors  of  refraction,  removal  of  all  sources 
of  reflex  irritation,  ice  water  coils  over  the  heart  and  cervical  spine, 
organotherapy  and  various  forms  of  auxiliary  medicine.  Hoffmann 
{Klin.  Monatsbl.  f.  Augenh.,  May,  1912,  p.  557)  contends  that  cauteri- 
zation of  the  normal  nasal  mucous  membrane  will  cause  disappearance 
of  exophthalmus  in  Basedow's  disease  on  the  same  side  in  twenty-four 
hours;  due  probably  to  a  reflex  influence  on  the  unstriated  muscular 
tissue  of  the  orbit.  Hack  is  cited  who  cured  a  case  of  Basedow's 
disease  by  cauterization  of  the  inferior  turbinated  bone.  In  twenty-six 
cases  of  chronic  interstitial,  and  two  of  chronic  parenchymatous 
nephritis  observed  by  G-ardiner,  fourteen  presented  exophthalmos  of 
varying  degrees,  von  Graefe  and  Stellwag  signs,  and  seven  the  sign 
of  Moebius.  In  five  cases  of  exophthalmos  with  albuminuric  retinitis, 
nephritis  was  present  and  in  six  cases  arteriosclerotic  changes  in  the 
retinal  vessels.  He  gives  as  the  probable  explanation  of  exophthalmos 
and  associated  ocular  signs  in  chronic  nephritis,  irrigation  of  the  cervi- 
cal sympathetic  by  toxins  in  the  blood,  the  result  of  chronic  renal 
insuffieiency.  Levison  {New  York  Med.  Jour.,  Nov.  18,  1911,  p.  1021) 
reported  two  cases  of  chronic  nephritis  with  marked  exophthalmos 
without  marked  lid  symptoms.  One  ease  of  unequal  bilateral  exoph- 
thalmos had  optic  neuritis.  He  says  neither  circulatory  nor  muscle 
theory  explains  all  symptoms. 

Unilateral  exophthalmus  in  tumors  of  the  brain,  according  to 
Uhthoff  {Ophthalmologii,  July,  1913),  speaks  for  a  direct  spreading 
or  formation  of  metastases  in  the  orbit,  and  is  generally  not  accom- 
panied by  more  intense  ocular  palsies.  This  is  occasionally  of  great 
diagnostic  importance  in  making  a  choice  of  certain  surgical  measures. 
Exophthalmus  was  observed  in  3  per  cent,  of  abscesses  of  the  brain  and 
2  per  cent,  of  the  cerebellum. 

Exophthalmus  is  most  fre(iuent  in  septic  thrombosis  of  the  sinus 
(70  per  cent.)  complicated  witli  intense  inflammatory  symptoms  of  the 
orbit  and  septic  thrombosis  of  the  oi)ht]ialiiiic  vein.  Otogenous  throm- 
bosis of  the  sinus  much  more  rarely  leads  to  exophthahnus  (9  per 
cent.),  and  always  with  involvement  of  the  cavernous  sinus. 

Abstracts  of  important  articles  relating  to  the  subject  of  exophthal- 
mos in  its  various  relations,  not  treated  in  the  foregoing,  have  from 
time  to  time  appeared  in  the  Ophtluilmic  Y car-Book.  Some  of  these 
are  quoted.  To  measure  exophthalmos  Fehr  focuses  the  corneal  image 
of  the  sound  and  the  protruding  eye  with  the  telescope  of  the  ophthal- 


EXOPHTHALMOS  4853 

mometer.  The  degree  of  recession  of  tlie  telescope  required  to  give 
an  exact  image  of  each  in  turn,  measures  the  protrusion  of  the  eye. 
In  Bertram's  {ArcJi.  f.  Aiigoih.,  LIX,  4,  1908)  case  of  excessive  con- 
genital bihiteral  exophtlialmos  tlie  section  showed  that  forward  pressure 
of  the  brain  in  consequence  of  precocious  ossification  of  the  sutures 
had  narrowed  the  orbits.  The  brain  pressed  upon  the  excessively  thin 
walls  of  the  orbit  like  an  intracranial  growth,  causing  the  proptosis. 
Chevallereau  {Soc.  d'opht.  de  Paris,  March,  1908)  reports  a  case  of 
readily  reducible  exophthalmos  provokable  ])y  slight  efforts.  The  eye 
was  small  (II.SD)  ;  and  had  been  tenotomized  for  convergent  strabis- 
mus ;  probably  an  important  factor  in  the  production  of  the  phenom- 
enon. In  ]Meissner*s  {Wiener  Med.  Blatter,  No.  17,  1908)  case 
exophthalmos  with  distinct  pulsation  occurred  upon  bending  forward 
the  head.  The  visual  acuity  was  6/6  with  fundus  normal;  the  probable 
cause  was  varix  formation  in  the  orbital  veins.  Beauvois  (Rcc.  d'opht., 
Feb.,  1908)  has  observed  in  a  new-born  infant  an  exophthalmos  from 
inflammation  of  the  orbital  tissues,  transmitted  from  inflammation  in 
the  nose,  which  was  probably  caused  by  maxillary  sinusitis.  Anatomi- 
cal studies  show  that  the  antrum  although  rudimentary  at  birth,  may 
nevertheless  be  the  seat  of  inflammation.  In  sudden  exophthalmia  of  the 
new-born,  careful  examination  of  the  nasal  and  buccal  cavities  should 
be  instituted.  The  infection  may  be  due  to  secretion  from  the  parturi- 
ent canal,  or  by  contamination  of  the  l)ath.  or  from  the  atmosphere. 
When  the  cause  is  recognized  the  treatment  is  usually  quite  simple. 

In  Lafon's  (Soc,  franqaise  d'opht.,  1908)  case  sudden  exophthalmos 
occurred  about  12  times  in  two  years,  the  last  followed  by  necrosis  of 
the  cornea.  After  enucleation  a  pseudo-tumor,  due  to  degeneration  of 
all  the  orl)ital  tissues  in  consequence  of  repeated  hemorrhages,  was 
found.  Johnson  observed  cure  of  exophthalmos  follow  removal  of  the 
anterior  end  of  the  middle  turbinal,  allowing  drainage  of  the  inflamed 
frontal  sinus. 

In  Xatanson's  case,  following  the  firing  of  a  revolver  close  to  the 
left  ear,  extensive  exophthalmos  and  otlier  grave  symptoms  of  a  post- 
bulbar  growth,  including  optic  neuritis,  occurred.  There  were  also 
symptoms  of  concussion  of  the  labyrintli,  pain  in  the  distribution  of 
the  fifth  nerve,  tachycardia,  goitre,  and  tremor.  A  course  of  mercury 
and  iodide  caused  disappearance  of  almost  all  the  symptoms.  But  as 
slight  protrusion  and  distinct  pulsation  and  some  other  symptoms 
persisted,  a  lesion  of  the  carotid  was  suspected,  the  cause  of  which  being 
supposed  to  be  shock  from  firing  the  revolver.  In  a  second  case  the 
same  medical  treatment  brought  about  complete  recession  of  an 
exophthalmos  of  the  highest  degree  (almost  luxation).    The  eyeball  was 


4804  EXOPHTHALMOS 

j»cniiiiiiciit  ly  (lispl.irrd  iipwiii'ds,  diif  prrluips  to  I'ct  rjictioii  hy  a  cicatrix 
left   liy  lilt'  ^Miiiiiiia. 

Ill  the  case  icporl cd  hy  Foster  there  was  excessive  exophthalmos  in 
which  the  s(>at  of  the  disease  was  extremely  ohseure.  A  iiumher  of 
incisions  were  made  into  the  orhit  from  some  of  which  pus  was  ohtained 
hut  thes(!  interventions  were  inisleadinf]^  as  they  appeared  to  indicate 
the  nasal  side  and  the  accessory  sinuses  as  the  seat  of  the  disease. 
Incision  finally  showed  ahseess  of  the  zygomatic  fossa  that  had  entered 
the  orhit  through  the  spheno-maxillary  fissure. 

In  Lustig's  case  one  eye  was  l)lind  and  protruding,  from  a  retro- 
hulhar  sarcoma;  and  the  vision  of  the  other  had  hegun  to  suffer  from 
extension  of  the  growth  into  the  interior  of  the  cranium.  Severe 
cerehral  symptoms  were  also  present.  Removal  of  the  rather  volumi- 
nous tumor  together  with  the  right  eye  was  followed  by  rapid  cure  of 
the  other  eye  and  disappearance  of  the  cerebral  symptoms. 

In  their  monograph  on  pulsating  exophthalmos  de  Schweinitz  and 
Holloway  bring  together  and  analyze  69  cases,  which  are  presented  in 
tabular  form,  along  with  11  regarded  as  doubtful  or  atypical.  They 
conclude  that  in  view  oP  the  uniformly  successful  results  in  the  7  cases 
in  which  the  superior  ophthalmic  vein  was  ligated  that  this  procedure 
should  be  considered  before  ligation  of  a  carotid.  If  a  distended  vein 
can  be  felt  in  the  orbit  the}'  agree  with  Gilford  that  its  ligation  should 
be  the  operation  of  choice.  Mackay  {Trans.  Oplith.  Soc.  U.  Kingdom, 
Vol.  XXVIII,  1908)  reports  a  case  of  traumatic  arterio-venous 
aneurism  of  the  orlut  treated  hy  ligature  of  the  common  carotid  artery 
with  entirely  satisfactory  results.  The  exophthalmos  and  bruit  dis- 
appeared, vision  im])roved  from  counting  fingers  at  3i/^  meters  to  6-18, 
and  the  paresis  of  the  externus  witli  convergent  squint  diminished. 

In  Demicheri's  {Ann.  d'ocul.  Sept.,  1908)  case  the  pulsating 
exophthalmos  was  due  to  an  intracranial  hydatid  cyst,  puncture  of 
which,  with  lavage,  gave  relief.  Pooley's  case  of  pulsating  exophthal- 
mos followed  a  severe  lilow  upon  the  back  of  the  head.  Guibal's 
patient  was  a  cavalryman  who  had  been  thrown,  falling  on  his  head. 
He  was  rendered  unconscious  and  subset  piently  had  severe  cerebral 
symptoms.  Exophthalmos  appeared  about  the  seventeenth  day  with 
pulsation,  })ruit.  and  interference  with  the  orbital  circulation. 

In  Parkinson's  and  Ilosford's  lOphth.  Hcv.,  May,  1908)  case  there 
was  great  proptosis  of  both  eyes.  Double  neuro-retinitis  was  also 
present.  The  section  showed  a  firm  encapsulated  growth,  as  large  as  a 
pigeon's  ogg,  attached  to  the  pia  mater,  on  the  under  surface  of  the 
right  lobe  of  the  cerebellum.     Konigstein  entered  the  orbit  by  Kron- 


EXOPHTHALMOS  4855 

lein's  operation  for  a  supposed  tumor.  None  was  found,  hut  the  eye 
returned  to  its  normal  position. 

Hiirker  ;ind  Ihincs  (^1/**.  Jour.  Med.  So.,  p.  469,  1!)()!);  call  attention 
to  the  rr(M|iiciit  existence  of  exophthalmos  and  other  ocular  symptoms 
of  c.xophthaliuic  goiter  in  connection  with  chronic  nephritis.  Of  33 
cases  of  ncphi-itis,  16  showed  exoplithalmos.  All  the  fatal  cases,  7  in 
number,  and  all  the  eases  of  albuminuric  retinitis,  8,  showed  exophthal- 
mos. Of  these  16  cases  11  showed  the  von  Graefe  sign,  13  the  Stellwag 
sign,  and  7  Moebius'  symptom  of  exophtiialmic  goiter.  In  12  of  the 
16  cases  the  arterial  tension  was  above  160  mm.  They  suggest  that  both 
in  nephritis  and  in  exoplitlialmic  goiter  these  symptoms  depend  upon 
one  or  more  toxins  circuhiting  in  the  blood. 

In  Ilarman's  {'Trans.  Ophtli.  Soc.  United  Kingdom,  p.  107,  1910) 
case  there  was  extreme  proptosis  with  divergence  of  the  optic  axes;  the 
chin  receded  slightly,  the  lower  lip  protruded  in  front  of  tlie  upper 
as  is  usual  in  oxycephaly.  The  head  was  entirely  noi'inal.  In  tliis 
case  afl  the  ocular  and  facial  characteristics  commonly  associated  with 
oxycephaly  were  present,  without,  however,  any  deformity  of  the  skull 
cap,  showing  that  the  designation  of  these  cases  by  the  term  oxycephaly 
or  tower  skull  is  incorrect.  In  Weinkauff's  ( Graefe 's  Arch.  f.  Ophth., 
LXXIV,  p.  352,  1910)  case  there  was  bilateral  proptosis  with  im- 
mobility of  the  eyeball,  edema  of  the  bulbar  conjunctiva,  and  optic 
neuritis  with  retinal  hemorrhage.  Pulsation  and  a  loud  murmur 
appeared,  synchronous  with  the  arterial  pulse.  The  probable  cause 
was  believed  to  be  perforation  of  arteriosclerotic  foci  in  the  wall  of  one 
or  both  internal  carotids  within  the  cavernous  sinus.  In  Barbieri's 
{Klin.  Monto.shl.  f.  Augcnh.,  Feb.,  p.  244,  1910)  case  of  bilateral 
exophthalmos,  spontaneous  rupture  within  the  cavernous  sinus  of  the 
internal  carotid  was  regarded  as  the  cause.  Ligation  of  the  connnon 
carotid  first  on  one  side  and  subsequently  on  the  other,  or  still  better, 
ligation  of  the  common  carotid  was  recommended.  Richter  {Milnch. 
med.  Wocli.,  LVII,  p.  2767,  1910)  reports  a  case  of  exophthalmos  with 
severe  orbital  hemorrhage  from  a  ruptured  varix. 

Wilder  {Ophth.  Rec,  pp.  195  and  327,  April,  1910)  saw  a  case  of 
marked  bilateral  exophthalmos  of  five  years'  duration.  There  was 
beginning  optic  neuritis  in  each  eye.  The  skiagram  showed  no  bony 
growth.  A  large  tumor  mass  not  involving  the  muscle  cone  was  re- 
moved from  tlie  left  orbit  via  Krfhdein's  route  as  a  result  of  which 
the  condition  of  the  left  eye  improved.  Bollinger  {Zeitschr.  f.  Augcnh., 
XXV,  p.  359,  1910)  has  operated  during  the  past  ten  years  on  thirty- 
nine  cases  of  orbital  affections  which  had  caused  exophthalmos;  he  first 
attempts  to  reach  the  seat  of  the  disease  from  in  front  and  onlj^  opens 


4856  EXOPHTHALMOS 

the  lateral  wall  of  the  orbit  if  this  fails.  Jii  Risley's  {Ophth.  Rcc, 
XIX,  p.  144,  1910)  case,  beside  tlie  ])roptosis,  there  was  enlargenieiit  of 
the  parotid  gland  with  periostitis  of  the  jaw  and  ramus.  Three  injec- 
tions of  1  minini  each  of  tuberculin  were  followed  by  entire  disappear- 
ance of  the  symptoms.  Cases  of  pulsating  exophthalmos  reported  by 
Albertin  and  Desgouttes  {Recueil  d'Opht.,  XXXII,  p.  31,  1910)  and 
by  Schaefer  {Deutsche  med.  Woch.,  XXXVI,  p.  124,  1910)  were  both 
cured  by  ligation  of  the  common  carotid.  In  the  first  case  vision  was 
lost  by  corneal  opacity  following  infection  from  exposure.  In  the 
second,  enucleation  had  failed  to  effect  a  cure.  Van  der  Straeten 
(Bull,  de  la  Soc.  Beige  d'Ophi.,  No.  29,  p.  135,  1910)  reports  a  case 
of  doubtful  etiology,  but  regarded  as  due  to  aneurism  of  the  internal 
carotid.  Bergin  {Guy's  Hosp.  Rep.,  LXIII,  p.  245,  1910)  reviews  300 
cases  of  unilateral  exophthalmos,  and  De  Vaubercey  writes  on  un- 
ilateral ocular  s^uuptoms  in  exophthalmic  goiter. 

In  Becker's  {Ophthalmology,  YII,  p.  18,  1910)  case  there  were 
proptosis  of  one  eye  with  absolute  fixation  of  the  globe,  slight  edema  of 
the  upper  lid  which  was  almost  immovable,  slight  chemosis  of  the 
conjunctiva,  marked  photophobia,  and  some  lachrymation.  Pupil  di- 
lated and  immovable  part  of  the  time.  The  protrusion  of  the  conjunc- 
tiva was  due  partly  to  hypertroph}',  and  the  mass  was  removed.  The 
urine  showed  very  decided  indiean  reaction.  A  strict  dietetic  and 
therapeutic  regimen  was  instituted  for  the  enterogenous  decomposition ; 
the  final  result  being  complete  relief.  In  Fernandez '  case  the  nose  was 
filled  with  polypi  which  had  proliferated  into  the  orbit  through  a 
perforation  in  the  floor,  and  also  into  the  lachrymal  sac  giving  rise  to 
inflammation  there.  Xo  improvement  from  operation  on  the  maxillary 
sinus.  Enucleation  and  finally  death.  Endothelioma  w-as  diagnosed 
histologically.  Fry  {St.  Barth.  Hosp.  Jour.,  XVIII,  p.  40,  1910^ 
reports  two  cases  of  intra-orbital  aneurism. 

Exophthalmos  with  rare  orbital  lesions.  In  Wray's  {Ophth.  Soc. 
United  Kingdom,  XXXII,  p.  137)  case  of  exostosis  of  orbit  proptosis 
was  very  pronounced.  Movements  of  the  eye  were  free  in  all  direc- 
tions, and  exophthalmos  directed  straight  forward.  The  disk  was 
atrophic  with  remnants  of  retinitis  near  the  macula.  Vision  was 
reduced  to  light  perception.  A  Kroenlein  operation  was  performed 
showing  an  exostosis  growing  from  the  orbital  surface  of  the  great 
wing  of  the  sphenoid.  Sweet  relates  the  subsequent  history  of  a  case 
of  exostosis  of  the  orbit.  Tumors  grew  from  the  lateral  plate  of  the 
ethmoid  bone,  and  measured  41  by  25  mm.  A  discharging  fistulous 
opening  near  the  inner  canthus  was  regarded  as  being  due  to  latlirymal 


EXOPHTHALMOS  4857 

disease.  A  radiograj)!!  sliowcd  frontal  sinus  involvi-nifnt.  Operation 
resulted  in  cure. 

In  Konioto's  {Klin.  Munatshl.  f.  Augtnh.,  p.  500,  April,  1912)  case 
of  lyniphonia  of  the  orbit  the  patient  had  exophthalmos.  Extirpation 
of  the  eyeball  showed  a  diffuse  tumor  pressing  upon  the  eyeball  from 
behind.  The  tumor  consisted  of  single  round  cells,  plasma  cells  and 
endothelial  cells.  Mention  is  made  of  another  case  of  intraorbital 
lymphoma  with  inflammation  of  parotid,  neck,  and  cubital  and  inguinal 
glands,  without  implication  of  the  spleen  or  blood. 

Dreisch  {Cent.  f.  p.  Angenh.,  XXXV,  p.  136)  describes  a  case  of 
leontiasis  faciei  with  exophthalmos.  The  right  upper  and  lower  lids 
with  surrounding  tissue  were  greatly  enlarged,  and  hung  sack-like 
over  the  right  cheek,  including  the  eyeball  which  was  about  on  a  level 
with  the  right  ala  nasi.  The  optic  nerve  could  be  felt  through  the  skip. 
Vision  nil.  Both  upper  and  lower  orbital  margins  were  rough  and 
uneven. 

Sameh  Bey  reports  a  case  of  a  boy  of  14  years ;  attacked  with  chills, 
fever,  vomiting,  epistaxis,  swelling  of  lids  and  protrusion  of  eyeballs. 
Sinuses  were  intact.  Fundus  changes  resembled  the  first  stage  of 
choked  disc.  Evacuation  of  50  gm.  of  pus,  was  followed  by  healing 
after  eight  days.  V.  =  1/2.  In  a  second  similar  case  vision  remained 
impaired.  A  negress  aet.  25,  had  swelling  in  the  upper  part  of  the 
orbit.  The  eye  was  crowded  down ;  with  diplopia.  Vitreous  cloudy, 
V.  =  1/8.  Evacuation  of  40  gm.  of  pus  gave,  after  three  weeks,  V.  = 
1/2.  Another  case  was  of  a  boy  of  10  with  swelling  in  upper  inner 
region  of  the  orbit.  Vision  was  counting  fingers  at  2  nuu.  A  few  days 
later  evacuation  of  45  gm.  of  pus  was  followed  by  recovery. 

Dupuy-Dutemps  and  IMawas  {Soc.  d'Opht.  de  Paris,  Oct.,  1913 ;  Clin. 
Opht.,  V.  19,  p.  663)  report  three  cases  of  cavernous  angiomata  of  the 
orbit ;  while  they  had  similar  histological  structures  each  case  pre- 
sented special  interesting  points.  All  three  tumors  were  in  the  upper 
part  of  tlie  orbit,  strongly  adherent  to  the  bone  and  soft  tissues.  In 
the  first  case  electrolytic  treatment  resulted  disastrously,  the  eye 
being  lost  from  hemorrhage.  The  second  case  presented  repeated 
violent  attacks  of  exophthalmos  with  subsequent  return  to  the  normal, 
after  a  few  days,  with  ecchymosis.  This  Avas  probably  due  to  a 
hemorrhage  into  the  cellular  tissues  of  the  orbit.  In  their  third  case, 
of  a  woman  of  64  having  exophthalmos,  a  tumor  the  size  of  an  encap- 
sulated nut  was  extirpated  at  the  same  time  with  a  tumor  of  the 
mammary  gland. 

In  zur  Nedden's  case  of  a  boy  of  eight  years,  the  right  eye  w^as 
injured  by  the  handle  of  a  rake  applied  with  great  force.     At  first 


4858  EXOPHTHALMOS 

cxiiiniiiiitioii,  a  iiiontli  liitcr.  llicrc  was  a  slight  ('xoj)lillialiiios.  Then; 
was  Jio  change  in  motility  oT  1lif  c.Ncliall.  \'ision  was  normal.  Two 
months  later  exophthalmos  was  cnormons  and  interfered  with  motility. 
Firm  resistance  was  felt  on  pi-essing  hack  the  eyehall.  I'npillary 
reaction  was  veiw  slow.  Vision  reduced  to  1/10.  A  Krfinlein  opera 
tion  revealetl  an  infiltration  of  the  retrol)ul})ar  tissues  and  a  thickening 
of  the  lachrymal  gland.  Microscopic  examination  proved  interstitial 
inflammation  of  the  gland  and  retro-hulbar  tissues.  The  Wassermann 
reaction  was  negative,  but  the  von  Pirquet  test  indicated  tuberculosis. 
Rosenbach's  tuberculin  was  injected  with  the  result  that  exophthalmos 
receded  and  vision  became  normal. 

Snell  {Trans.  Amcr.  Ophtli.  Soc,  Vol.  lo,  p.  496)  reported  a  case 
of  cavernous  sinus  throml)osis,  occurring  in  a  man  of  24,  previously  in 
good  health,  from  a  small  abscess  in  the  skin  of  the  temple.  Twenty- 
four  hours  previous  to  his  first  visit  he  had  noticed  that  the  vision 
of  the  right  eye  was  growing  bad  rapidly,  and  accompanied  by  rapidly 
swelling  lids.  The  eyelids  showed  marked  swelling;  the  conjunctiva 
was  edematous,  exophthalmos  was  pronounced  and  ocular  movements 
were  almost  completely  limited.  The  cornea  was  steamy  and  the  pupil 
reacted  to  light  sluggishly.  On  the  fourth  day  a  small  ulcer  made  its 
appearance  on  the  cornea  and  a  slight  hypopyon.  Fundus  examination 
showed  swelling  and  edema  of  the  disk,  enlarged  tortuous  veins.  The 
small  temporal  abscess  was  probed  to  the  outer  bony  margin  of  the 
orbital  brim,  counter  puncture  made  and  it  was  washed  out  with 
bichlorid  solution.  Puncturing  the  orbital  cavity  deeply  brought 
no  pus.  On  the  sixth  day  fluctuation  was  found  in  the  upper  lid  and 
incised,  a  couple  of  drams  of  pus  flowing  out.  For  several  days  the 
patient  was  better  but  on  the  seventh  day  became  delirious.  After 
injecting  a  stock  preparation  of  antistreptococcic  serum  the  patient 
showed  daily  improvement  for  ten  days  while  exophthalmos  and  limita- 
tion of  motion  continued.  On  the  twenty-first  day  the  pulse  suddenly 
went  bad,  and  on  the  twenty-tliird  day  he  succumbed  despite  two  more 
doses  of  the  serum. 

W.  C.  Posey  {Annals  of  Ophth.,  p.  603,  July,  1912)  exhibited  a 
child  with  a  mild  degree  of  exophthalmos  in  both  eyes,  which  doubt- 
less was  occasioned  by  shallow  orbits,  in  whom  the  prominence  of  the 
globes  had  been  greatly  increased  by  the  presence  of  adenoids,  the 
proptosis  recovering  to  its  normal  degree  after  the  removal  of  the 
growths  at  the  Childi'en's  Hospital.  Posey  said  that  literature  con- 
tained many  such,  and  cited  cases  reported  by  llolz,  Spitler,  and  Hack. 
He  also  referred  to  a  case  reported  by  Patten,  whei-e  the  orbital 
involvement  a])peared  after  an  attack  of  tonsillitis.     Posey  also  pointed 


EXOPHTHALMOS  ANEMICUS  4859 

out  the  coiiiiectioii  which  existed  in  a  iiiiiiihei-  of  eases  in  the  litei'aturc! 
with  Graves'  disease,  and  ret'en-ed  in  |)arti<'idar  to  a  giii  of  17  years 
reported  by  Ilaek,  in  whom  the  exophtliaiuios  had  existed  siiiet;  early 
eliildhood.  Examination  revealed  a  marked  hyperphisia  of  tiie  erectile 
tissue  of  th(!  middle  and  h)wer  turbiiials.  The  lower  turbinals  were 
cauterized  and  the  foUowinjj:  day  the  exophthalmos  had  nearly  dis- 
appeared. The  Dairy mple  sii^n  and  the  Graefe  sign  which  had  been 
present  disappeared.  Also  the  nervous  cardiac  palpitation,  and  the 
size  of  the  thyroid  diminished;  and  a  slight  myopia,  which  had  been 
present  before  the  nasal  operation,  disappeared. 

The  exophthalmos  had  preceded  all  the  other  signs  of  Graves' 
disease  for  some  years,  and  Hack  thought  that  the  excitation  of  certain 
portions  of  the  peripiieral  sympathetic  by  the  swollen  tissues  of  the 
nose  had  occasioned  the  other  symptoms,  all  being,  according  to  him, 
of  the  nature  of  a  reflex  neurosis.  He  attributed  the  exophthalmos  to 
hyperemia  of  the  orbital  vessels,  caused  by  reflex  dilation  of  their  walls 
and  to  a  marked  turgesence  of  the  retrobulbar  fat,  which  he  said 
Michel  had  already  refei-red  to  as  cavernous  tissue.  See,  also,  the 
headings  under  Exophthalmic ;  and  the  others  beginning  with  Exoph- 
thalmos. 

Exophthalmos  anemicus.     (Obs.)     Exophthalmic  goitre. 

Exophthalmos  cachecticus.    An  obsolete  name  for  exophthalmie  goitre. 

Exophthalmos,  Intermittent.  In  this  rare  condition  the  eyeball  is  pro- 
truded when  the  subject  stooi)s  or  leans  forward,  and  recedes  within 
the  orbit  when  he  is  erect  or  in  the  recumbent  position ;  or  the  exoph- 
thalmos may  be  voluntarily  produced  l)y  the  act  of  blowing.  Posey 
reports  a  case  in  which  a  young  adult  could  in  this  numner  voluntarily 
proptose  the  left  eyeball  fifteen  millimetres  in  advance  of  its  fellow. 
The  cause  is  presumably  some  varicose  condition  of  the  veins  of  the 
orbit.  These  veins  are  not  in  communication  with  an  artery,  which 
differentiates  the  condition  from  pulsating  exophthalmos  (Fuchs). 
Weeks  has  observed  two  cases  due  to  i)osterior  ethmoiditis  in  which 
the  escape  of  secretions  was  temporarily  interfered  with.  The  eth- 
moidal cells  affected  passed  directly  under  the  floor  of  the  orbit 
posteriorly. —  (J.  M.  B.) 

A  careful  analysis  of  a  case  is  reported  by  Birch-Hirschfeld  and 
Romeick  {Klin.  MonatshL  f.  Augcnlieilh.,  Apr.,  1912).  It  was  caused 
by  a  retrobulbar  varix  which,  in  stooping  had  produced  by  venous 
stasis  an  exophthalmus  of  2.50  mm. ;  if  this  position  were  prolonged  it 
was  increased  to  G  nnn.  The  etiologic  element  in  the  retrobulbar  stasis 
was  attributed  to  abnormal  narrowness  of  the  anterior  efferent  paths, 
viz.,  the  facial  and  jugular  veins,  perhaps  by  pressure  of  a  retrosternal 


4860  EXOPHTHALMOS  PARALYTICUS 

goitre.  The  writers  believe  that  not  every  case  of  intermittent  ex- 
oi)hthalinus  ought  to  he  operated  on,  on  aeeount  of  the  danger  to  the 
optic  nerve  and  the  posterior  ciliary  vessels,  if  the  varix  lies  very 
deep. 

In  Loeweustein's  (Klin.  Monatshl.  f.  Augenh.,  p.  183,  Aug.,  1911) 
case  (a  primipara  three  weeks  after  confinement)  there  was  noticed 
after  having  bent  over,  a  tumor  of  the  left  lower  lid  and  protrusion  of 
the  eyeball,  recurring. after  every  greater  physical  effort.  V,  =  0.  Ex- 
tirpation of  convoluted  veins,  through  an  incision  in  the  lower  lid  along 
the  lower  orbital  margin  was  made  and  secured  vision  of  0.1. 

Colombo  {Ann.  di  Ott.,  Vol.  42,  p.  602)  reports  a  case  of  intermit- 
tent exophthalmos  in  a  girl  of  twelve  years,  who  had  been  affected  for 
two  years  with  a  right  suppurative  otitis  media.  The  parents  stated 
that  one  niglit  three  months  earlier,  the  child  had  waked  from  sleep 
with  a  severe  pain  in  the  right  eye,  which  was  followed  by  a  marked 
exophthalmos  of  short  duration.  The  child  was  brought  on  account 
of  a  second  attack  of  the  same  nature,  also  occurring  in  the  night. 
Trauma  was  denied.  There  was  ptosis  of  the  right  upper  lid.  The 
eye  was  exophthalmic  1.5  cm.;  and  the  movements  of  the  bulb  were 
limited  in  all  directions.  There  was  no  pulsation,  and  the  exophthal- 
mos was  not  reducible  by  pressure.  The  ear  condition  was  treated  and 
the  exophthalmos  disappeared.  The  mother  later  reported  two  relapses 
of  the  exophthalmos,  the  first  lasting  a  half  hour,  and  the  second  last- 
ing ten  minutes.  The  eye  was  found  to  be  normally  slightly  enophthal- 
mic.  It  became  exophthalmic  if  the  child  stood  and  inclined  her  head 
forward  and  downward  for  several  minutes,  or  if  she  lay  for  several 
seconds  on  her  face ;  or  in  the  erect  position  on  compression  of  the 
right  jugular;  or  if  the  head  was  kept  turned  to  the  right.  The 
otitis  media  had  completely  healed  and  Colombo  attributes  the  ex- 
ojjlitlialmos  to  varices  in  the  back  of  the  orbit.  See,  also.  Exoph- 
thalmos. 

Exophthalmos  paralyticus.  (L.)  Exophthalmia  resulting  from  total 
or  pai-tial  paralysis  of  tlie  oeulo-motor  or  other  muscles  of  the  eye. 

Exophthalmos,  Pulsating.  Aneurysmal  proptosis.  Vascular  pro- 
trusion OF  THE  EYE.  This  formidable  lesion  is  comparatively  rare, 
although  more  than  300  cases  are  now  on  record.  A  complete  analysis 
of  6ii  case  histories  has  been  made  by  de  Schweinitz  and  Holloway 
(1908),  to  whieli  the  reader  is  referred  for  a  more  detailed  account. 
In  typical  cases  the  condition  is  characterized  by  protrusion  of  the  eye- 
ball ;  noises  or  bruit  to  be  heard  at  the  entrance  of  the  orbit,  or  by 
auscultation  over  various  points  of  the  skull,  even  over  the  occiput ; 
and  by  pulsation  near  the  orbital  apex  transmitted  through  the  eyeball. 


EXOPHTHALMOS,  PULSATING  4861 

The  exophthalmos,  if  unilateral,  or  if  more  pronounced  on  one  side 
than  on  the  other,  gives  rise  to  diplopia.  The  bruit  is  both  a  subjective 
and  an  objective  symptom.  It  is  increased  ])y  lying  down  or  stooping, 
or  by  any  exertion  raising  the  blood-pressure.  The  noises  in  the  head 
are  incessant  and  cause  much  distress.  They  stop  or  are  greatly 
modified  when  the  blood-supply  to  the  side  of  the  head  affected  is 
interrupted  by  compression  of  the  common  carotid  artery.  The  pulsa- 
tion— generally  demonstrable  by  careful  palpation — is  sometimes 
visible.  The  veins  of  the  lids,  of  the  conjunctiva,  and  of  the  retina 
are  often  distended  and  tortuous — the  result  of  passive  hyperemia. 
In  a  certain  number  of  cases  optic  neuritis,  optic-nerve  atrophy,  retinal 
hemorrhages,  glaucoma,  and  cataract  have  been  noted.  More  frequent 
than  these  last-named  symptoms  is  paralysis  of  the  abducens  nerve. 
Vision  may  remain  intact  throughout  the  entire  course,  but  it  is  more 
frequently  impaired,  and  often  complete  blindness  results  (de  Schwei- 
nitz  and  Ilolloway). 

Exophthalmos  Avith  pulsation  may  be  due  to  a  variety  of  lesions, 
both  intra-orbital  and  extra-orbital.  Thus,  it  may  be  a  symptom  of 
extremely  vascular  tumors  within  the  orbit,  due  to  a  true  aneurism  of 
the  ophthalmic  artery  in  its  intra-orbital  or  intra-cranial  portion, 
aneilrism  of  the  internal  carotid  artery,  arterio-venous  communication, 
varicose  dilation  of  the  orbital  veins,  or  communication  between  the 
internal  carotid  artery  and  the  cavernous  sinus.  The  last-named  con- 
dition has  been  found  to  be  the  most  frequent  cause.  Thus,  the  disease 
in  the  majority  of  eases  is  of  intracranial  origin,  the  protrusion  of  the 
eyeball  and  the  other  orbital  symptoms  being  secondary  and  dependent 
upon  venous  obstruction.  Riviiigton  demonstrated  the  intracranial 
origin  of  pulsating  exophthalmos,  which  was  a  distinct  advance  in  the 
pathology  of  this  condition.  In  an  analysis  of  19  autopsies  Frost  found 
orbital  aneurism  in  3,  affection  of  the  cavernous  sinus  in  2,  aneurism 
of  the  intra-orbital  portion  of  the  ophthalmic  artery  in  2,  arterio- 
venous communication  in  8,  and  the  condition  undetermined  in  4. 

With  arterio-venous  or  arterio-sinus  communication  we  have  obstruc- 
tion of  the  venous  outflow  of  blood,  which  induces  marked  distension 
and  varicosity  of  the  veins.  The  blood-current  then  becomes  reversed, 
and  the  distended  veins  carry  arterial  blood  (Sattler).  At  this  stage 
pulsation  commences.  As  more  or  less  time  is  required  for  these 
changes  to  take  place,  and  as.  indeed,  they  may  not  take  place,  pulsa- 
tion may  not  appear  early  nor  need  it  occur  at  all. —  (J.  M.  B.) 

For  further  remarks  on  the  etiology,  pathology,  diagnosis,  and 
prognosis  of  this  disease,  see  Exophthalmos,  Traumatic. 


4862  EXOPHTHALMOS,  PULSATING 

Treatment.  Altlioiifi:li  the  most  rational  proccdurt'  in  the  conduct 
of  these  cases  is  ligature  of  the  conitnon  carotid  yet  de  Schweinitz 
believes  that  digital  compression  of  that  vessel,  with  or  without  the 
employment  of  full  doses  of  potassium  iodide,  injections  of  gelatin, 
doses  of  eoagulose,  etc.,  may  first  be  tried.  Spontaneous  cure  rarely 
occurs.  If  ligation  of  one  carotid  fails  the  other  may  be  tied  or,  if 
there  be  a  distended  ophthalmic  vein  (or  other  orbital  vein),  it  should 
be  dissected  out. 

The  various  forms  of  operative  and  other  ti-eatment  will  Ix-  further 
considered  in  the  subjoined  abstracts  of  papers  and  monographs. 
See,  also.  Exophthalmos. 

Beatson  Hird  gives  tlie  following  review  of  an  interesting  case- 
report  in  which  he  remarks  tliat  pulsating  exophthalmos  is  a  distressing 
condition  on  account  of  the  continuous  noises  in  the  head,  and  it  is 
imperative  to  relieve  this  symptom  if  possible.  The  operation  of 
ligation  of  the  common  and  internal  carotid  arteries  is  very  serious 
and  sometimes  fatal.  Further,  it  fails  in  a  large  number  of  cases  to 
produce  any  but  a  temporary  relief.  Several  cases  have  now  been 
recorded  of  successful  cures  by  ligation  of  the  orbital  veins,  an  opera- 
tion of  little  gravity, 

Buchtel  {Ophthalmic  Record,  Feb.,  1913)  reports  a  case  in  which 
cure  was  brought  about  by  such  an  operation.  His  case  was  that  of  a 
boy,  aged  11,  the  pulsating  exophthalmos  being  due  to  a  blow  on  the 
head  by  a  pitchfork:  "The  operation  is  very  simple,  merely  distal 
ligation  of  the  veins  in  the  orbit  and  the  mortality  should  be  almost 
nil.  The  eyebrow  was  shaved  and  general  anesthesia  used.  An  inci- 
sion in  the  eyebrow,  two  inches  long,  was  made  from  a  point  near  the 
middle  line.  The  skin  flaps  were  turned  up  and  down.  Many  dilated 
superficial  veins  were  cut  which  required  ligature.  The  angular  vein 
and  superficial  temporal  were  both  dilated  and  cut.  The  superior 
ophthalmic  formed  l)y  the  junction  of  the  two  radicals  above-named 
was  followed  into  the  orbit  back  as  far  as  possible  without  damage  to 
the  eyeball  and  ligated  with  plain  cat-gut.  A  subcuticular  stitch  of 
plain  cat-gut  brought  the  skin  surfaces  together." 

After  this  the  bruit  was  absent.  Following  the  operation  consider- 
able edenui  of  the  eyeball  developed  as  well  as  edema  of  the  conjunctiva. 
The  patient  was  kept  in  bed  a  week  and  the  eye  kept  cleansed  and 
argyrol  instilled.  The  exophthalmos  was  a  little  greater  than  before 
the  operation  at  first,  but  tliis  together  witli  the  edema  of  the  con- 
junctiva gradually  subsided  until  after  three  months  there  was  prac- 
tically no  difference  between  the  two  eyes.  The  vision  was  normal 
with  no  diplopia  or  change  in  the  eye.  The  scar  was  concealed  by  the 
eyebrow.     The  bruit  was  permanently  cured. 


EXOPHTHALMOS,  PULSATING  4863 

K.  Kaz  {Ophthal.  liCvUiv,  Aug.,  1912)  gives  a  review  of  Orloff's 
paper,  based  on  a  ease  of  pulsating  exophthalmos  that  developed  six 
months  after  a  deep  wound  in  the  region  of  the  left  parietal  and 
temporal  bones  in  a  thirty-year-old  patient.  A  suecessful  result  fol- 
lowed ligature  of  the  ophthalmic  vein  in  the  depths  of  the  orbit  after 
a  temporary  resection  of  tiie  external  wall  of  the  latter.  This  opera- 
tion, first  performed  in  1881  for  cases  arising  spontaneously  by  Noyes, 
and  in  1897  by  Golovin  for  traumatic  ones  has  proved  successful  even 
after  failure  of  ligature  of  the  carotid.  The  autlior  has  collected  36 
published  cases  of  one-sided  ligature  of  the  carotid  for  traumatic 
pulsating  exophthalmus  between  the  years  1898  and  1909  with  only 
ten  complete  cures.  Of  the  remaining  cases  14  showed  some  improve- 
ment, in  8  temporary  improvement  was  soon  followed  by  a  relapse 
and  in  tlie  remaining  3  the  operation  proved  fatal.  Including  his  own 
case  he  can  only  find  five  cases  recorded  in  which  tlie  ophthalmic  vein 
was  ligatured,  but  these  were  all  successful.  lie  lias  also  found  re- 
corded three  cases  in  which  non-surgical  treatment  by  the  injection  of 
gelatine  proved  efficacious;  Lebon,  1902,  Santos-Fernandez,  1907,  and 
Beauvois,  1907.  In  Lebon 's  case  this  treatment  was  adopted  after 
ligature  of  the  carotid  had  proved  a  failure.  Tlie  author  concludes 
that  in  these  cases  trial  should  ])e  made  of  gelatine  injections  first  and, 
if  these  fail,  of  ligature  of  the  ophthalmic  vein,  ligature  of  the  carotid 
being  reserved  for  those  cases  in  which  cerebral  symptoms  prevail. 

A  number  of  recent  abstracts  from  the  Ophthalmic  Y ear-Book  also 
throw  much  light  on  this  important  sul)ject. 

In  Lystad's  (Klin.  Monatshl.  f.  Augcnh.,  p.  88,  Jan.,  1912)  case  of 
pulsating  exophtlialmos  the  internal  carotid  was  ligated.  But  this  not 
being  sufficient,  the  external  earotid  and  jugular  vein  were  also  ligated. 
The  result  at  first  was  good,  but  as  exophthalmus  and  pulsation  re- 
turned the  pulsating  or])ital  veins  were  ligated.  followed  by  enormous 
protrusion  of  the  ■eyeball  which  gradually  diminished,  but  ended  in 
absolute  glaucoma  and  the  eye  was  enucleated.  Lystad  assumed  a 
communication  between  the  internal  carotid  and  cavernous  sinus. 
Wolff  [Arch,  of  Ophtli.,  XLI,  p.  514)  reports  the  case  of  a  man  of  54 
having  irregular  attacks  of  chemosis  and  exophthalmos  of  1  cm.,  last- 
ing three  or  four  days.  The  eye  had  the  appearance  of  an  orbital 
phlegmon  without  inflammatory  symptoms.    No  nasal  discharge. 

Friedenwald  {Amcr.  Jour.  Ophth.,  XXVIII,  p.  131)  reported  a 
ease  of  pulsating  exophthalmos  without  bruit,  in  a  woman  of  20  who 
had  pain  in  her  right  eye  and  said  it  bulged  out  of  its  socket  for  eleven 
or  twelve  years.  The  right  eye  was  very  prominent  and  displaced 
down   and   forward   and   pulsated   markedly.     It   was  about   12   mm. 


4864  EXOPHTHALMOS,  PULSATING 

lowci-  than  the  left,  and  forced  forwacd  at  least  5  to  6  iniii.  with  each 
pulsation ;  l)ut  could  be  easily  pushed  into  the  orbit  without  discom- 
fort. Vision,  L.,  16/15;  R.,  16/200;  field  of  vision  normal,  diplopia; 
no  congestion  or  tortuosity  of  blood  vessels.  Nose  examination  revealed 
a  distended  bulla  ethmoidalis.  In  Wilder 's  {Amer.  Ophth.  Soc,  XII, 
p.  832)  two  cases  of  pulsating  exophthalmos,  both  were  due  to  blows 
upon  the  head.  Exophthalmos  was  marked,  but  pulsation  slight.  In 
case  one,  ligation  of  the  common  carotid  resulted  in  permanent  cure. 
In  case  two,  ligation  of  common  carotid  gave  relief  from  bruit  and 
head  noises,  but  exophthalmos  did  not  recede  completely  until  the 
internal  carotid  was  ligated. 

Knapp's  case  of  spontaneous  bilateral  exophthalmos,  began  Avith 
headaches  and  head  noises,  congestion  of  cutaneous  veins,  eyelids  and 
conjunctival  vessels.  Paralysis  of  both  external  recti  and  loss  of  sensa- 
tion of  both  corneas.  Bruits  were  heard  in  front,  and  to  the  temporal 
sides  of  both  orbits.  Wassermann  positive.  After  inunctions  and  gray 
pills  the  right  eye  returned  to  its  normal  position  and  the  left  eye 
remained  somewhat  prominent. 

JMathewson  reports  a  case  of  a  man  of  32  who  was  thrown  from  the 
top  of  a  car  and  sustained  a  fracture  of  the  base  of  the  skull,  resulting 
four  weeks  later  in  exophthalmos,  complete  ptosis  of  the  left  upper  lid, 
swelling  of  the  conjunctiva  and  subsequent  loss  of  vision,  probably  due 
to  laceration  of  the  optic  nerve,  resulting  from  basal  fracture.  The 
movements  of  the  eyeball  were  restricted ;  a  loud,  l)lowing  murmur  was 
heard  most  intense  over  temporal  region.  After  ligating  the  common 
carotid  artery,  proptosis  became  less,  pulsation  and  l)ruit  disappeared. 

Balbuena  reports  a  case  of  a  man  of  25  years  who  was  shot  in  the 
middle  of  the  forehead.  Some  days  later  he  noticed  loss  of  vision, 
protrusion  of  the  eye  and  lids  of  the  left  eye.  The  proptosed  eye  had 
pulsated  synchronously  with  the  radial  pulse.  He  had  a  marked  bruit, 
very  distinctly  heard  at  the  upper  inner  angle  of  the  orbit.  The  optic 
disc  was  atrophic.  The  condition  of  the  eye  was  diagnosed  as  an 
aneurysm  located  in  the  orbital  vessels,  anterior  to  the  sphenoidal 
fissure.  Twenty-one  subcutaneous  injections  of  4  per  cent,  gelatin  were 
made  without  improvement  while  six  intravenous  injections  of  the 
serum  were  given  at  inteiwals  of  eight  to  ten  days,  eifecting  a  cure. 

Feruglio  {Ann.  di  Ott.,  Vol.  42,  p.  287)  emphasizes  the  value  of  a 
centrifugal  venous  pulse  in  establishing  the  diagnosis  of  arterio-venous 
aneurysm  in  a  case  of  exophthalmos.  The  exophth.almos  was  caused 
by  an  injury  at  the  internal  third  of  the  left  lower  lid  causing  etfusion 
of  blood  in  the  subcutaneous  tissue  and  conjunctiva,  vomiting,  cephal- 
algia and  marked  change  in  character.  The  hemorrhages  were  absorbed 


EXOPHTHALMOS,  PULSATING  4865 

but  the  exophthalmos  showed  no  teiuk'iiey  to  disappear.  Vision  was 
normal  but  the  eerebral  symptoms  recurred.  Ophthalmoscopic  exam- 
ination showed  slight  hyperemia  and  edematous  conditions  of  the 
vessels;  systolic  pulsation  of  the  veins  synchronous  with  the  arterial 
pulse.  The  bulb  could  l)e  easily  pushed  back  into  the  orbit  pulsating 
with  the  radial  artery.  A  loud  murmur  was  heard  with  the  stethoscope 
over  the  closed  lids  and  cranial  bones.  Ligation  of  the  left  common 
carotid  was  performed  resulting  in  great  reduction  of  the  exoplithalmos 
and  restoration  of  movements.  Fifteen  days  later  the  patient  returned 
with  recurrence  of  former  symptoms.  The  right  common  carotid  was 
ligated  without  favorable  results.  A  Kronlein  operation  was  advised 
but  not  accepted. 

As  has  been  seen,  the  chief  operative  measvres  that  have  been  em- 
ployed in  the  treatment  of  pulsating  exophthalmus  are,  (1)  ligation 
of  the  common  carotid  on  the  affected  sides,  (2)  ligation  of  both  com- 
mon carotids;  (3)  ligation  of  the  internal  carotid  on  the  affected  side; 

(4)  ligation  of  both  internal  and  external  carotids  on  the  same  side; 

(5)  ligation  of  the  common  external  carotid  and  superior  thyroid  ar- 
teries on  one  side;  (6)  orbital  operations,  as  (a)  ligation  of  superior 
ophthalmic  vein;  (b)  ligation  of  pulsating  veins  at  the  inner  angle  of 
the  orbit  with  excision  of  the  varices  that  are  a  common  accompaniment 
of  this  condition. 

In  a  case  operated  on  by  the  writer  at  the  St.  Luke's  Hospital, 
October  14,  1909  {Surgery,  Gynecologij  and  Obstetrics,  Jan.,  1910, 
p.  55),  the  internal  carotid  alone  was  ligated.  Immediate  cessation  of 
the  pulsation  and  bruit,  with  later  retraction  of  the  eyeball,  followed. 
There  were  no  untoward  after-effects  and  the  patient  has  been  free 
from  both  objective  and  subjective  symptoms  up  to  the  present  time. 

The  relief  from  pulsating  exophthalmus  by  orbital  operations  alone 
can  only  be  accomplished  in  those  cases  in  which  the  altered  tissues 
lie  within  the  orbit,  or  in  cases  where  an  aneurysm  of  the  carotid,  by 
pressure  upon  the  ophthalmic  vein,  is  the  cause  of  this  condition. 
Where  there  is  an  aneurysmal  varix,  which  constitutes  the  essential 
cause  in  about  70  per  cent,  of  the  cases,  no  intra-orbital  operation 
alone  will  relieve  the  patient. 

One  of  the  chief  symptoms  is  pulsation  with  dilatation  of  the  oph- 
thalmic vein.  When  this  results  from  pressure  upon  the  vein  by  an 
aneurysm  of  the  carotid,  ligation  of  the  vein  just  before  it  enters  the 
sphenoidal  fissure  may  relieve  the  objective  symptoms  of  pulsation  and 
exophthahuus,  but  cannot  remove  the  subjective  symptoms  occasioned 
by  the  aneurysm,  nor  cure  the  disease.  In  the  eases  treated  by  ligation 
of  the  angular  vein  and  of  the  ophthalmic  vein,  by  Noyes  {Trans.  Am. 

Vol.  VII— 2 


4866 


EXOPHTHALMOS,  PULSATING 


Ophth.  Soc,  Vol.  1 1 1.  |)t.  2, 1881,  p.  308),  we  must  assume,  in  the  absence 
of  any  anatomical  data,  that  the  symi)toiiis  were  not  the  effect  of  an  ar- 
terio-venous  aneurysm  involving;  the  carotid  and  the  cavernous  sinus. 
In  Noyes'  ease  his  description  fits  more  accurately  an  arterio-venous 
angrioma  involving  the  ophthalmic  artery  and  vein  than  it  does  an 
arterio-venous  aneurysm  of  the  carotid.     His  success  in  curing  the  dis- 


5UP  TH  Y  r?or  D     A. 


POquOSSAL     N. 


CAROTID    A 
CAROTio    A. 


AROT I O    A 


OMU-HYO  I  O     M 


The  Relations  of  the  Conimon,  External  and  Internal  Carotids  to  the  superior 
thyroid  and  other  neighboring  structures. 


ease  by  ligation  and  excision  of  the  pulsating  dilated  vessels  of  the 
orbit  he  attributes  to  a  thrombus  forming  and  extending  back  to  the 
sinus,  closing  the  opening  into  the  aneurysmal  sac. 

These  operations  on  orbital  vessels  have  been  successful  in  the  hands 
of  others,  both  as  primary  operations  and  as  secondary,  and  performed 
either  at  the  time  of  the  ligation  of  the  carotid  or  subsecjuent  to  it,  in 
cases  where  the  ligation  of  the  carotid  did  not  immediately  effect  a 
cure. 

In  a  case  reported  by  Boden  {Dcutsch.  Arcli.  f.  KUii.  Cliir..  Bd.  51, 


EXOPHTHALMOS,  PULSATING 


4867 


p.  605),  five  months  after  bilateral  ligation  of  the  earotid  the  ophthal- 
mic vein  was  ligated  with  success. 

In  the  eases  where  the  symptoms  are  the  result  of  an  aneurysm  of 
the  ophthalmic  artery,  it  goes  without  saying  that  proximal  ligation 


COnrnOM-CA  ROT lO 
A  RTERY 


J)issectioii  showing   tlio  Kclatiuiis   of  tlie   Conmion   Carotid  to  the  Onio-hyoiil 
muscle. 

of  the  artery,  if  this  operation  can  he  sueeessfully  perfdrmed,  will  give 
the  best  results.  Distal  ]i<iation,  when  the  proximal  operation  is  not 
possible,  will  in  a  relatively  small  projiortion  of  the  eases  prove 
successful. 

Tccluiic  of  ligation  of  Hk  coinmon  carofid.  The  seat  of  election  for 
the  eonnnon  earotid  is  al)ove  the  omo-hyoid  nnisele.  The  jiatient  is 
placed  upon  the  table  with  the  head  and  shoulders  elevated  by  means 


4868 


EXOPHTHALMOS,  PULSATING 


of  a  ])illo\v  j)la('('(l  hclwccii  tlic  sliouldci's.  'I'lic  chin  is  drawn  up  and 
turned  away  from  tiie  seat  of  operation.  An  incision,  three  and  one- 
half  inches  in  lenj^th,  is  made  with  the  center  corresponding  to  the 
cricoid  cartilage,  along  the  anterior  border  of  the  sterno-mastoid 
nniscle.  This  extends  through  the  skin,  platysma  and  the  deep  fascia, 
enclosing  the  sterno-mastoid  muscle.  The  superficial  veins,  including 
the  external  jugular,  are  caught  before  being  incised  and  then  divided 


Relations  of  the  Carotid  Arteries  and  Jugular  Veins  to  the  Ocular  region. 


and  ligatures  applied.  When  the  fascia  enclosing  the  sterno-mastoid 
is  reached,  it  is  grasped  with  a  Kocher  forceps  and  pulled  forward. 
It  is  then  incised  in  the  direction  of  the  skin  incision,  though  not  to 
the  same  extent.  The  sterno-mastoid  is  retracted  slightly  outwards  and 
the  omo-hyoid  downwards,  exposing  the  internal  jugular  with  the 
descending  branch  of  the  nintli  nerve.  The  sheath  of  the  fascia  en- 
closing the  vessel  is  now  opened  and  the  jugular  vein  drawn  outwards 
from  the  artery,  Tlie  artery  is  freed  from  the  surrounding  structures 
by  a  Kocher  director,  armed  with  a  catgut  ligature,  passed  underneath 
the  artery  from  without  inwards,  tlie  ligature  secured  and  the  director 
withdrawn.  Two  ligatures  are  thus  passed  about  the  vessel  and  tied, 
one  centimeter  apart.     The  ligatures  are  tied  tight  enough  to  occlude 


EXOPHTHALMOS  SIMPLEX  4869 

tlie  lumen.  No  effort  is  made  to  crush  the  vessel  wall.  If  thought 
desirable,  the  vessel  may  hy  means  of  an  artery  forceps  be  crushed 
between  the  ligatures  or  divided.  This  last  act  is  unnecessary.  The 
structures  that  must  be  avoitled  are  the  internal  jugular  vein,  the 
pneumogastric  and  descendens  hypoglossi  nerves. 

The  wound  is  closed  ])y  reuniting  the  fascia  over  the  vessels  with  a 
fine  catgut  suture  and  the  skin  by  silkworm  gut.  The  wound  is  dressed 
in  the  way  we  have  described  and  tiie  patient  placed  in  bed  with  the 
head  elevated. 

Ligation  of  the  internal  carotid.  An  incision  is  made  so  that  both 
internal  and  external  carotids  are  exposed  just  above  the  bifurcation  of 
the  common  carotid.  This  extends  along  tiie  anterior  border  of  the 
sterno-mastoid  from  the  angle  of  the  jaw  to  the  middle  of  the  neck,  the 
center  corresponding  to  a  point  on  a  level  with  the  upper  border  of 
the  thyroid  cartilage.  The  vessels  are  exposed  by  drawing  the  sterno- 
mastoid  outwards  and  the  digastric  muscle  upwards.  The  external 
carotid  should  be  drawn  inwards,  as  ni  this  part  the  internal  carotid 
lies  outside  and  rather  behind  tlie  external.  The  ligature  is  passed  on 
a  Kocher's  director  from  without  inwards,  avoiding  the  internal  jugu- 
lar vein  and  the  pneumogastric  nerve. 

The  external  carotid  may  ])e  ligated  through  the  same  incision,  and 
in  the  same  manner  as  the  internal  carotid. —  (A.  E.  H.)     See,  also, 
Exophthalmos,  Traumatic, 
Exophthalmos   simplex.      (L.)      Of  the   older  authors,   that   form   of 

exophthaliuia,  the  cause  of  which  is  unknown. 
Exophthalmos,  Traumatic.  Traumatic  exophthalmos  occurs  from  sev- 
eral forms  of  injury  to  the  eyeball  or  its  adnexa.  Protrusion  of  the 
eye  occurs  from  bleeding  into  the  orbit  and  from  movement  forward 
of  bone  fragments.  Here  we  deal  with  pulsating  exophthalmos, 
which  in  71  per  cent,  of  the  cases  is  due  to  traumatism. 

The  first  technical  description  of  this  lesion  was  given  by  Travers 
in  1809 ;  the  first  anatomic  examination  was  made  by  Barron  in  1835. 
Since  then  many  cases  have  been  reported  by  other  authors.  It  is  found 
most  often  (75  per  cent.)  in  men  between  thirty  and  fifty  years  of 
age,  i.  e.,  in  the  most  active  working  period  of  life  when  most  com- 
monly exposed  to  severe  exertion  and  accidents.  The  so-called  spon- 
taneous form  is  more  common  in  women. 

This  affection  may  be  due  to  an  arterio-venous  aneurysm  of  the 
internal  carotid  and  the  sinus  cavernosus.  aneurysm  of  the  ophthalmic 
artery,  anginous.  and  other  kinds  of  tumors,  especially  sarcoma  and 
encephalocele,  in  all  of  which  the  exciting  cause  of  the  protrusion  may 
be  a  traumatism,  l)ut  in  most  cases  it  is  due  to  a  rupture  of  the  internal 


4870 


EXOPHTHALMOS,  TRAUMATIC 


(.'urutid  iirtiTv  in  llic  sinus  cavcrnosus.  hy  wliicji  llic  aflcfial  stream 
passes  tlii'L'ctly  into  llic  \cins.  wliii-li  (ill  with  Mood  ami  push  the  eye 
outwards.  The  hhxxl  I'l-om  the  oplithalmie  veins  is  not  then  earried 
l)aek  into  the  eii-cuhition  |)ro])ei-ly  on  account  of  the  pressure  of  the 
carotid  in  thi'  simis  heing  more  than  in  the  veins,  so  tlie  vein  becomes 
practically  an  artery  and  forms  a  i)ulsating  tumor  al)Ove  and  to  the 
inner  side.  From  tliis  condition  of  i)ressure  all  the  clinical  symptoms 
arise.  In  cases  not  due  to  rupture,  such  as  aneurysm  of  the  carotid 
or  ophthalmic  arteries,  the  conditions  are  somewhat  different  and  due 
to  direct  pressure.  The  lesion,  in  most  cases,  is  situated  in  the  cranium 
and  not  in  the  or])it.    The  superior  thyroid  artery  plays  an  important 


%, 


/ 


Tiaiuuatic  I'ulsatiiiy    l-^xoplitlialiuos. 

part  in  the  compensatory  circulation  after  tying  of  the  common  carotid, 
when  it  is  found  dilated  and  strongly  pulsating. 

Soon  after,  Ijut  usually  not  immediately  upon,  receipt  of  the  trauma- 
tism, usually  a  few  hours  or  days,  sometimes  weeks  or  months  after- 
wards, the  patient  has  a  violent  pain  in  the  eye,  the  lids  become  red- 
dened and  swollen,  the  veins  fidl,  the  upi)er  lid  is  especially  swollen  and 
immovable  and  cannot  be  raised,  sometimes  on  account  of  its  weight 
and  sometimes  on  account  of  paralysis.  The  under  lid  becomes  swollen, 
the  conjunctiva  chemotic,  the  eyeball  protrudes  strongly,  usually  out- 
wards and  downwards,  and  is  generally  immovable  so  that  double 
images  occur.  An  even  pressure  upon  the  globe  may  force  it  back 
into  position,  but  it  soon  returns.  Bending  over  increases  the  symp- 
toms. Pulsation  of  the  eyeball,  synchronous  with  the  radial  pulse,  is 
then  apparent,  and  is  heard,  upon  ausculation  over  the  eyeball  in  tiie 
region  of  the  orbit  and  even  the  neck,  as  an  aneurysnuil  murmur 
which,  as  a  I'ulc.  Ilic  i)atient  himself  hears. 


EXOPHTHALMOS,  TRAUMATIC  4871 

III  true  I'liiitiirc  of  the  carotid  in  tlu'  siiiiis  the  bruit  is  increased  in 
systole.  On  prcs-sure  on  the  coniiiion  carotid  in  the  neck  the  syniptonis 
disappear.  As  a  rule  the  condition  appears  only  upon  one  side  and 
then  later  on  the  other.  The  conjunctiva  of  the  eyeball  becomes 
cheinosed,  its  blood  vessels  enlarged,  and  the  tension  increases. 

The  lid  aperture  becomes  enlarged,  no  longer  fully  protecting  the 
cornea,  and  when  the  lids  cannot  be  closed  the  cornea  becomes  dry  and 
ulcerated.  Foreign  ])odies  may  become  impacted  without  notice,  as  in 
most  cases  the  sensitiveness  is  lost.  The  anterior  chamber  becomes 
deeper,  the  iris  discolored,  the  pupil  moderately  enlarged  and  im- 
movable. The  vitreous  becomes  turbid  and  papillitis  develops.  The 
veins  enlarge,  the  arteries  diminish  in  size.  Capillary  hyperemia  fol- 
lows later.  Atrophy  of  the  optic  nerve  occurs  when  the  canalis  opticus 
is  injured.  The  sight  depends  upon  the  condition  of  the  media  and 
the  implication  of  the  optic  nerve.  It  may  be  normal  or  greatly 
diminished,  even  where  there  is  high  degree  of  papillitis,  as  in  choked 
disc,  the  sight  may  remain  good.  From  the  pressure  behind,  the  eye 
becomes  shorter  and  hyperopia  develops.  The  accommodation  is 
usually  diminished.  In  old  cases  the  sight  is  lost  through  disease  of 
the  uvea  and  increased  ocular  pressure  proceeding  to  degenerative 
changes,  or  through  ulceration  of  the  cornea. 

The  subjective  symptoms  at  first  are  pains  in  the  head  and  orbit, 
vertigo,  feeling  of  pressure,  blowing,  ringing,  and  knocking  sounds 
in  the  head.  The  patient  is  generally  uncomfortable,  although  in  but 
few  cases  does  the  pressure  extend  sufficiently  to  the  brain  to  cause 
changes  therein. 

The  clinical  picture  fully  explains  the  conditions  of  communication 
of  the  carotid  with  the  sinus.  The  symptoms,  as  a  rule,  do  not  occur 
immediately  upon  receipt  of  the  injury,  but  somewhat  later.  As  but 
little  blood  at  first  passes  from  the  carotid,  the  ophthalmic  veins  become 
more  filled  through  the  collateral  circulation.  Later  inflammatory 
changes  set  in  and  then  the  arteries  become  atrophic.  The  blood  now 
flows  from  the  carotid  through  the  cavernous  sinus  into  the  veins  of 
the  eye  and  lids,  which  accounts  for  the  synchronous  pulsation,  and 
the  picture  of  venous  stasis  of  the  retina.  Through  the  impact  of  the 
arterial  pressure  on  the  veins  come  the  noises  which  are  apparent  at 
the  time  of  systole,  produced  by  irregular  pressure  on  the  carotid 
artery  in  the  sinus.  Immovability  of  the  eye  outwards  occurs  from 
paralysis  of  the  abducens  nerve,  which  passes  by  the  cavernous  sinus. 
From  this  cause  likewise,  occurs  paralysis  of  the  oculomotor,  trochlear, 
and  the  first  twig  of  the  ti'igeminus. 


4872  EXOPHTHALMOS,  TRAUMATIC 

From  the  iiniiiovability  of  the  eye  and  the  wideiiess  of  the  lid 
apcrtui'c  the  i-oniea  may  get  dry  and  hecomt'  the  seat  of  infeetion  and 
uknTalion.  The  paralysis  is  caused  from  tlu'  first  twig  of  the  trige- 
minus.     Ill   many  eases  there  are  anomalies  of  liearing. 

lu  a  few  eases  all  symptoms  eease  or  ultimately  disappear  after  a 
year  or  two.  Death  may  be  due  to  the  In-cakiiig  of  the  hones  of  the 
skull,  and  involvement  of  the  brain  from  bleeding  or  infection.  In- 
flammation of  the  mediastinum  may  occur  from  thrombosis  in  the  sinus. 
AVhen  such  complications  do  not  occur  the  pulsating  exophthalmus 
may  become  less  and  sight  better,  but  as  a  rule  the  subjective  symptoms 
remain. 

The  diagnosis  is  made  from  the  cardinal  symptoms,  the  proptosis, 
pulsation,  objective  and  subjective  noises,  and  vertigo.  It  should  be 
differentiated  from  proptosis  due  to  Graves'  disease  and  tumors, 
cellulitis  and  orbital  phlegmon,  ethmoidal  mucocele,  rachitic  deformity 
of  the  skull,  osteoporosis.  The  differential  diagnosis  from  rupture  of 
the  carotid  or  aneur^'sm  of  the  ophtlialnnc  arteries  may  l)e  made,  as  in 
rupture  of  the  carotid  there  is  paralysis  of  the  nerves,  especially  of 
the  abducens,  and  in  aneurysm  of  the  ophthalmic  artery  the  vision 
is  much  affected  on  account  of  the  lesion  being  in  the  orbit. 

The  prognosis  is  not  so  bad.     In  80  cases  only  9  died;  11  per  cent. 

,  The  carotid  walls  seem  to  heal  in  about  half  the  cases,  either  through 

natural  means,  through  pressure,  or  the  result  of  operation.     Where 

pulsating    exophthalmus    depends    upon    fracture    of   the    skull    the 

prognosis  is  not  good. 

In  a  series  of  118  cases  of  ligature  operations  only  10  died,  3  from 
infection  (all  before  1880),  2  from  hemorrlmge,  1  from  changes  in 
the  blood  vessels,  1  from  anemia  and  1  from  general  debility. 

The  therapy  is  either  by  pressure  upon  the  carotid,  by  the  fingers 
or  instruments,  or  by  operative  procedures.  Only  a  few  cases  are 
relieved  by  compression,  in  most  of  which  it  has  been  of  short  duration, 
necessitating  frequent  repetition  during  the  day.  Of  seven  cases  not 
treated,  two  became  better,  two  grew  worse,  and  three  died,  one  of  the 
deaths  occurring  from  hemorrhage  after  operation  for  a  supposedly 
malignant  tumor.  Of  thirty-seven  cases  treated  1)y  compression  there 
was  a  complete  cure  in  three  cases,  an  incomplete  cure  in  six,  and 
sudden  death  in  one  case,  while  there  was  not  any  result  in  the  re- 
mainder. 

When  compression  does  not  lead  to  a  cure  the  radical  operation  of 
tying  the  common  carotid  in  the  neck  has  cirred  a  large  number  of 
eases,  the  general  mortality  being  not  over  10  per  cent.  The  cures 
by  this  operation  are  al)Out  50  per  cent.  There  are  six  cases  in  all 
recorded  of  tying  of  both  common  carotids. 


EXOPHTHALMOS,  UNILATERAL  4873 

111  every  case  the  operative  treatment  of  pulsating  exoplithaliiius 
must  be  individualized  according  to  the  clinical  form  of  the  affection. 
In  those  cases  where  marked  brain  symptoms  are  present,  as,  for  in- 
stance, vertigo,  distressing  sul)jective  noises,  etc.,  one  must  by  all 
means  ligate  the  common  carotid.  In  those  eases  where  the  clinical 
symptoms  are  confined  to  either  the  orbit  alone  or  to  the  orbit  and 
face  together,  it  is  better  to  perform  an  orbital  operation.  It  is 
probable  that  in  some  cases  one  would  get  a  good  result  ])y  ligating  the 
ophthalmic  vein,  making  the  incision  under  the  eyebrows.  The  ligation 
of  the  ophthalmic  vein  with  a  previous  resection  of  the  orbital  wall 
(Kroenlein)  will  be  found  generally  useful  in  those  cases  where  relapses 
have  occurred  or  where  ligation  of  the  carotid  has  failed.  In  such  cases, 
indeed,  this  operation  should  be  given  the  preference  to  ligating  the 
common  carotid  of  the  opposite  side  since  this  latter  is  apt  to  excite 
too  great  disturbance  of  tlie  cerebral  circulation.  Resection  of  the 
orbital  wall  must  be  performed  whenever  the  clinical  picture  of  the 
pulsating  exophthalmus  suggests  the  possibility  of  an  intraorbital 
growth. 

The  aneurysinatic  varix  may  be  first  ligated.  Since  the  ectatic  vessels 
almost  always  lie  near  the  medial  wall,  they  can  be  easier  and  less 
dangerously  approached  through  the  upper  lid  than  by  Kroeiilein's 
resection  of  the  lateral  orl)ital  walls. —  (H.  Y.  W.)  See,  also,  Exoph- 
thalmos in  g-eneral;  as  well  as  Exophthalmos,  Pulsating'.  Under  the 
latter  caption  will  be  found  a  description  of  the  operations  employed 
for  the  relief  of  pulsating  exophthalmos. 

Exophthalmos,  Unilateral.  Uhthoff  {Klin.  Monatshl.  fiir  Augenheilk., 
p.  4Ul,  Oct.,  1912)  found  that  unilateral  exophthalmos,  without 
involvement  of  the  orbit  (the  common  source  of  a  one-sided  exophthal- 
mos) was  in  11  cases  on  the  side  of  the  tumor  of  the  brain  that  produced 
the  proptosis  and  in  4  cases  of  bilateral  exophthalmos  more  intense 
on  that  side. 

Exophthalmos,  Voluntary.  Proptosis  can  occasionally  be  induced  at 
will.  A  classic  exami)le  is  that  of  the  man,  aged  19,  who  consulted 
Barriere  {Klin.  Monatshl.  f.  Augenheilk.,  March,  1912)  on  account 
of  exophthalmos  of  the  right  eye,  and  complained  of  diplopia  during 
mastication.  The  exophthalmos  (5  mm.)  had  existed  from  the  first 
years  of  his  life  and  gradually  progressed.  When  the  patient  pressed 
the  jaws  forcibly  together,  increase  of  exophthalmos  of  2.5  mm., 
homonymous  diplopia  in  tlie  right  half  of  the  field  of  fixation  and 
tumor-like  bulging  in  the  temporal  half  of  the  lower  lid  and  external 
canthus  were  all  noticed.  A  tumor  of  the  size  of  a  hazelnut  was  felt  in 
the  lower  temporal  portion  of  the  orbit,  which  could  not  be  pressed  back 


4874  EXOPHTHALMOS,  VOLUNTARY 

iiilo  the  orliil.  <  )ii  rrljixiit  ion  ol'  tiir  iiuist  ii-;i1ory  imisclcs  llic  liiiiior 
jiiid  (li|)lo|ii;i  coiiiplctcly  (lisjiupcjn'cd.  A  puiictiiiT  sliowrd  tliat  it  was 
a  (ieniioid  cyst  ('xt('ii(liii<;  tliroiigli  llic  infcrioi-  orliitnl  tissiircs  into  the 
tcmpoi-al  fossa.     It  \v;is  cxlirpatt'd  by  Kriddcin 's  opcralioii. 

The  plifiioiiima  diirin^^  inastical  ion  I'ound  tlie  following  explanation : 
Tlu'  tiuiil  contents  of  the  jjortioii  of  tiie  cyst  lying  in  tlie  temporal  fossa 
were  by  tlie  contraction  of  the  temporal  muscle  forced  into  the  orbital 
portion  of  tiie  cyst,  which  became  enlarged  and  displaced  the  globe. 

Another  account  of  another  of  these  curious  and  very  rare  eases  is 
reported  by  Denhaene  {Archiius  Midicalcs  Bdgrs,  11,  1912).  An  ab- 
stract of  it  appears  in  the  OphtJialmic  Review,  Sept.,  1913.  A  young 
soldier,  a  lancer  aged  20  years,  gave  a  history,  in  explanation  of  the 
peculiar  behavior  of  his  eye,  of  a  blow  at  the  lower  outer  margin  of  the 
left  orbit,  sustained  by  striking  his  head  on  a  lixed  stake,  while  he  was 
l)athing  in  a  river.  At  the  time  there  was  very  severe  pain,  some  dim- 
ness of  vision,  and  ccchymosis  of  lid  and  conjunctiva.  These  symptoms 
disappeared  rapidly,  and  he  was  considered  to  have  recovered,  but  a 
fortnight  later,  when  blowing  his  nose,  the  patient  felt  the  left  eye 
suddenly  "jump  out"  of  the  orl)it.  and  sul)se(iuently  return  to  place. 
At  the  date  of  consultation  this  phenomenon  occurred  at  any  forced 
expiration;  this  the  patient  took  good  care  to  avoid  "for  fear  he  should 
lose  his  eye."  He  stated  that  since  the  accident  he  had  been  somewhat 
liable  to  attacks  of  palpitation,  breathlessness,  and  nervousness,  these 
attacks  ])eing  chiefly  nocturnal.  There  does  not  appear  to  have  been 
any  definite  proof  of  the  genuine  existence  of  these  conditions,  nor  was 
tachycardia  found  to  exist  during  the  attacks.  His  eyes  had  always 
tended  to  be  somewhat  prominent;  on  examination  there  was  no  fault 
in  the  ocular  movements  whatever,  the  lids  moved  well,  and  showed 
nothing  of  v.  Graefe's  sign.  There  was  no  pulsation  in  the  orbit,  and 
no  sign,  when  examined  with  the  X-rays,  of  any  fracture.  The  ophthal- 
moscope showed  nothing  abnoruud  ;  there  was  full  vision  in  the  unaided 
right  eye,  and  in  the  left  on  correction  of  a  small  amount  of  myopic 
astigmatism. 

^Yhen  the  patient  voluntarily  made  an  expiratory  effort  the  left  eye 
leapt  forward  as  if  worked  by  a  spring;  there  was  no  deviation  of  the 
eye,  it  simply  came  directly  forwards;  on  cessation  of  such  effort  the 
eye  returned  to  its  place  at  once.  This  protrusion  was  accompanied 
by  somewhat  sharp  pain  in  the  orl)it ;  the  pupil  and  ophthalmoscopic 
appearances  remained  unaltered,  but  vision  liecame  indistinct;  mere 
mechanical  compression  of  the  jugular  did  not  produce  the  symptom 
at  all. 

It  seems  all  but  certain  that  the  peculiar  behavior  of  the  eye  must 


EXOPHTHALMUS  PULSANS  4875 

liave  liccii  due  to  a  i'onii  of  vascular  luiiioi-  or  aiiciii'isin  in  llic  dcpllis 
of  tile  orltit  wliidi  hccainc  heavily  charged  witli  hiood  wliei)  there  was 
any  temporary  ohsti'uctiou  to  the  outHow  of  blood;  this  may  he 
iavored  by  a  lax  (condition  of  the  Hhroiis  structures  in  the  orbit. 

The  case  seems  c()mpai"jil)h'  to  those  in  which  ex()|iht  halmos  occurs 
[see  Exophthalmos,  Intermittent  J  whenever  the  patient  bends  for- 
ward, tlu'  eye  receding  again,  sometimes  even  to  an  abnormal  tiegree, 
when  the  erect  position  is  resumed. 

Exophthalmus  pulsans.     Pulsating  exoi)hthalmos. 

Exorbitisme.     (F.j     lOxophthalmos;  also  enucleation  of  the  eye. 

Exosis.     (L.)     Protrusion;  dislocation. 

Exosma.     (L.)     A  protruded  part. 

Exosmometer.  Endosmometer.  An  instrument  lor  measuring  the 
rapidity  with  wiiicli  adjacent  liquids  pass  through  a  membrane  separat- 
ing them. 

Exostosis.  Osteoma.  A  morbid  bony  outgrowth  or  enlargement;  an 
osseou.s  tumor.  The  conjunctiva  and  walls  of  the  orbit  are,  though 
rarely,  the  sites  of  osteomata. 

An  ivory  exostosis  is  a  bony  outgrowth  of  extreme  hardness  and  of 
snuill  size,  rarely  exceeding  that  of  a  small  Avalnut.  It  springs 
usually  from  the  exterior  of  one  of  the  cranial  bones,  and  is  occa- 
sionally found  attached  to  the  orbital  walls.  Histologically,  it  is 
marked  by  the  absence  of  Haversian  canals.  See  Tumors  of  the  eye; 
as  Avell  as  Osteoma. 

Exothermic.    Keferring  to  the  chemical  action  of  light. 

Exothyropexy.  This  operation,  generally  done  for  relief  or  cure  of 
Graves'  disease,  consists  in  freeing  the  thyroid  gland  from  its 
environs  and  dislocating  it  upon  the  surface  of  the  skin,  where  it  is 
allowed  to  remain.  As  a  result  of  atrophy  and  resorption,  the  gland 
gradually  shrinks  and  becomes  cicatrized.  This  operation  has  been 
practised  chiefly  in  France,  and  there  by  but  a  few  surgeons.  Fol- 
loAving  exothyropexy,  symptoms  of  acute  thyroid  intoxication  are 
frequently  noted  from  the  escape  into  the  tissues  of  the  secretion  of 
the  gland.  An  im])rovement  in  the  most  favorable  cases  is  extremely 
slow.    See  Exophthalmic  goitre. 

Exotropia.  Divergent  strabismus.  See  Muscles,  Ocular;  as  well  as 
Divergence;  and  Divergent  squint. 

Experiment,  Bering's.  This  is  a  test  of  binocular  or  rather  of  stereo- 
scopic vision.  The  person  under  examination  looks  with  both  eyes 
through  a  tube  at  a  thread  stretched  vertically  in  front  of  it.  Little 
balls  are  dropped  alongside — sometimes  in  front,  sometimes  behind — 
the  thread  ;  if  the  patient  has  nornuil  binocular  vision  he  can  tell  at 


4876  EXPERT  TESTIMONY 

oiu'c  wlit'tlici-  cacli  liall  lias  ])as.s('(l  in  trout  or  Ix-liiiid  the  tliruad;  other- 
wise lu'  cannot,  and  often  makes  mistakes. 

Expert  testimony.  Sec  Legal  relations  of  ophthalmology,  in  tin-  first 
t  liii'd  of  t  lir  srct  ion. 

Expert  witness,  The  ophthalmic.  Sic  Legal  relations  of  ophthalmology, 
first  tliird  of  the  section. 

Expire.     (V.)     Exhaled. 

Explement.  The  amount  ))y  wliieh  an  angle  is  short  of  four  right 
an<j:h's. 

Expletif.     (F.)     Commissural. 

Explorateur.     (F.)     Exploratory. 

Exposure.  In  ophthalmic  practice  one  sometimes  speaks  of  the 
< .rposurr  of  ametropia — of  hypvrnutropia,  for  example.  This  means 
the  revelation  of  hidden  or  latent  hyperopia  by  means  of  eyeloplegics, 
as  a  result  of  age,  ciliary  paralysis,  etc. 

Another  sense  in  which  this  is  used,  ophthalmologically,  is  in  con- 
nection with  ocular  hygiene,  the  exposure  of  school  buildings,  particu- 
larly in  relation  to  their  situation  as  to  light  and  air. 

In  photography,  the  act  of  exposing  a  sensitive  surface  to  light. 

Expression.  This  term  is  generally  applied  to  an  operation  in  trachoma 
whereby  the  trachoma  bodies  are  removed  from  their  conjunctival 
situation  by  various  instruments,  rollers,  forceps,  etc.    See  Trachoma. 

Expressor.  An  instrument  for  the  expression  or  extrusion  of  the  lens 
or  of  cataract.    It  has  been  almost  exclusively  employed  in  the  expulsion 


Pagensteeher  's  Lens  Expressor. 

of  the  cataractous  lens  in  its  complete  capsule.  One  of  the  earliest 
expressors  is  that  of  Pagensteeher,  although  Henry  Smith  and  others 
have  devised  similar  instruments.  See  Vol.  Ill,  p.  1534,  of  this 
Encyclopedia. 

Expuer.     (F.)     To  expectorate  saliva,  mucus,  or  blood. 

Expuition.     (F.)     Spitting  out  saliva. 

Exsangue.     (F.)     l>loodless. 

Exsarcoma.     An  obsolete  term  for  sarcoma. 

Exsudat.     (F.)     Exudate. 

Exterioration.  The  mental  faculty  by  which  the  inuige  of  an  object 
seen  is  referred  to  the  actual  situation  of  the  object. 


EXTERIORITE  4877 

Exteriorite.  (F.)  The  physical  act  by  which  sensations  are  referred 
to  cxtci-iial  objects. 

Exterior  ophthalmoplegia.  Oimitiialmoplegia  externa.  Paresis  or 
paralysis  of  the  external  ocular  muscles. 

External  bi-orbital  diameter.  The  greatest  transverse  distance  be- 
tween tlie  outer  borders  of  the  external  orbital  apophyses  of  the 
frontal  bone. 

External  canthus.    Rec  Canthus. 

External  ophthalmoplegia.  Ophthalmoplegia  externa.  Exterior 
OPHTHALMOPLEGIA.    Paresis  or  paralysis  of  the  external  ocular  muscles. 

Externa  oculi.     (L.)     (Obs.)    The  sclera. 

Externus.  A  common  term  for  one  of  the  extrinsic  or  external  ocular 
muscles. 

Extinction  of  cclor.  The  point  in  the  diminution  of  the  intensity  of 
light  wliieh  just  causes  the  color  to  become  invisible.  As  pointed  out 
by  Abney  {Color-vision,  page  105),  orange  is  about  the  last  color  of 
the  spectrum  left,  some  of  the  others  still  appearing  as  grays.  The 
next  to  retain  its  color  is  green,  and  the  most  rapid  to  lose  them  are 
the  red  and  violet.  Colors  do  not  remain  of  the  same  hue  up  to  the 
time  they  vanish.  Pure  spectrum  red  remains  the  same  up  to  the  last, 
but  the  scarlet  becomes  orange,  and  the  orange  yellower,  and  the  green 
bluer.  At  nightfall  in  the  summer  the  order  of  disappearance  of  color 
may  often  be  seen ;  orange  flowers  may  be  plainly  visible,  yet  a  red 
geranium  may  appear  black  as  night ;  the  green  grass  will  be  gray  when 
the  color  of  the  yellow  flowers  may  yet  be  just  visible. —  (C.  P.  S.) 

Extirpation.    The  complete  removal  or  excision  of  a  part. 

Extra-atmospheric.     Beyond  or  outside  our  atmosphere. 

Extra-axial.    Outside  the  axis. 

Extracapsular.    Situated  outside  a  capsule,  e.  g.,  of  the  lens. 

Extraction  a  lambeau.     (F.)     Flap-extraction. 

Extraction  of  cataract.  This  subject  has  been  fully  discussed  under 
Cataract  in  general,  as  well  as  under  Cataract,  Senile,  and  various 
other  Cataract  headings  in  Vols.  11  and  111  of  this  Encyclopedia. 

Extraction  of  cataract  in  the  unruptured  capsules.  Commonly  known 
as  the  Smith-Indian  operation.  This  procedure  is  of  so  much  im- 
portance and  has  in  late  years  attracted  so  much  attention  that  it 
has  been  described  and  discussed  in  this  Encyclopedia  under  a  sepa- 
rate heading  by  its  principal  American  advocate,  the  late  D.  AV. 
Creene.    See  Cataract,  Intracapsular  extraction  of. 

Extracts  of  human  eye  tissues.  Experiments  with  extractives  from 
human  eyes  upon  the  ocular  organs  of  the  lower  animals  have  been 
rarely  undertaken.     However,  R.  Wissmann    (Graefe's  Archiv.  fiir 


4878  EXTRACT,  THYROID 

Ophlhdhn.,  LXXX,  p.  .'{!)!),  1J)13)  has  made  a  number  of  observations 
of  animals  treated  witli  extracts  from  normal  human  eyes,  and  from 
injured  eyes  wliich  wei-e  enueh-atetl  because  of  supi)osed  danger  to  the 
sound  eye.  The  eye  as  a  whole  was  very  toxic  to  the  guinea  pig, 
wliellier  the  animal  had  or  had  not  been  previously  sensitized.  When 
lens,  vitreous,  uveal  tract  and  retina  were,  as  far  as  possil)le,  separately 
injected,  the  results  were  completely  negative.  But  death  of  the  ani- 
mal followed  two  successive  combined  injections  of  extracts  from  each 
of  tlie  four  i)arts  of  tlie  eye,  mixed  in  tlie  proportion  occurring  in  tiie 
normal  eye.  Further  expcriinciit  pointed  to  the  uveal  tract  and  retina, 
and  particularly  the  formei-,  as  carriei's  of  the  toxic  substance.  This 
substance  is  destroyed  by  heating  1o  100°  C,  and  is  soluble  in  alcohol 
and  ether.  It  therefore  probably  belongs  to  the  class  of  lipoids.  No 
difference  was  found  between  the  effect  on  the  animal  organism  of 
extracts  from  normal  and  those  from  pathologic  eyes. 

Extract,  Thyroid.    See  Thyroid  extract. 

Extradural.  Outside  of  or  external  to  the  dura  mater  or  its  prolonga- 
tions. 

Extrait  de  feves  de  Calabar.     (F.)     Extract  of  calabar  bean. 

Extrait  thebaique.     (F.)     Liquid  extract  of  opium. 

Extramission.     Emission,  as  of  radiation. 

Extraocular.    External  to  or  outside  the  eye. 

Extra-ocular  iridotomy.  Tridotomy  in  Avhich  the  iris  is  allowed  to  pro- 
lapse or  is  drawn  out  through  a  wound  in  the  cornea  before  the 
incision  is  made  and  is  then  replaced. 

Extra-ocular  muscles.  The  extrinsic  oi-bital  or  recti  muscles.  See 
Anatomy  of  the  eye;  as  w^ell  as  Muscles,  Ocular. 

Extraorbital.    External  to  or  outside  the  orbit. 

Extraordinary  image.  One  of  the  images  produced  by  the  double  re- 
fraction of  calcite  ((i.  v.),  and  which  is  observed  to  rotate  around  the 
ordinary  image  that  remains  stationary  while  the  crystal  is  being 
turned.— (C.  F.  P.) 

Extraordinary  ray.  In  optics,  the  ray  which  does  not  follow  the  ordi- 
nary law  of  refraction  in  traversing  a  uniaxial  crystal,  through 
whose  double  refraction  both  the  cxtraordinarij  ray  and  the  ordinary 
ray  are  produced  and  polarized.  The  vibrations  of  the  extraordi- 
nary ray  are  parallel  to  the  axis ;  whereas,  those  of  the  ordinary  ray 
are  i)erpendicular  to  it.    Also  see  Calcite. —  (C.  F.  P.) 

Extra-papillary.     Outside  the  papilla  or  optic  disc. 

Extra-rectus.  An  obsolete  term  for  the  external  i-ectus  muscle  of  the 
eye. 

Extrinsic.     External ;  as  extrinsic  eye  nuiscles. 


EXUDATIVE  CHOROIDITIS  4879 

Exudative  choroiditis.  'I'liis  lorm  of  the  disease  is  usually  subacute  or 
chronic  and  includes  the  disseminated,  plastic  and  circumscribed  va- 
rieties.   See  Vol.  Ill,  J).  2147  of  tliis  Eticrjvloix <lia. 

Exudative  diathesis.  So  far  as  opiithalmology  is  concerned  Czerny 
{Brit.  Med.  Jour.,  A\n\  23,  1910)  is  responsil)le  for  this  term.  He 
regards  phlyctenular  disease  as  one  of  its  expressions.  In  his  opinion, 
although  the  condition  may  yield  positive  tests  witii  tuberculin,  it  is 
not  tuberculous,  being  readily  controlled  ])v  pi-oper  attention  to  diet. 
Excess  of  milk  and  eggs,  and  also  ol'  carbohydrates,  is  to  be  avoided. 

Exudative  erythema,  Ocular  complications  of.  The  exudative  erythe- 
mata  are  of  intei'cst  to  the  ophthalmologist  as  well  as  to  the  derma- 
tologist, because  of  the  occasional  manifestation  of  the  disease  on  the 
conjunctiva.  Erythema  multiforme  and  erythema  nodosum  are  the 
types  of  the  disease  Avhicii  have  been  noticed  to  present  such  a  com- 
plication. Because  neither  of  these  types  can  be  said  to  be  of  common 
or  frequent  occurrence,  and  because  cases  presenting  ocular  symptoms 
occur  but  seldom,  it  has  been  thought  well  in  this  work  to  give  a 
general  outline  of  the  dermatology  of  the  atfection  and  then  to  describe 
the  ocular  symptoms  which  have  been  observed. 

The  exudative  erytliemata  are  acute  inflammations  which  occur  in 
attacks  of  short  duration  but  with  a  tendency  to  relapse  at  short  or 
long  intervals.  The  lesions,  which  sometimes  become  vesicular  or  hem- 
orrhagic, are  deep-red,  symmetrical  yet  extremely  diverse  in  shape, 
size  and  degree  of  elevation  above  the  skin  surface. 

Erythema  multiforme,  as  its  name  implies,  presents  a  most  varied 
aspect,  occurring  in  numeron.s  scattered  or  grouped  lesions  of  various 
sizes  and  shapes.  It  is  characterized  by  reddish  or  purplish  nuicules, 
papules  and  tubercles,  which  occasionally  become  vesicular  or  bullous, 
or,  more  rarely,  hemorrhagic. 

While  usually  the  body  surface  nuiy  be  more  or  less  extensively 
affected,  the  face  is  infrequently  involved,  and  exceptionally  it  may 
be  limited  to  it,  thus  involving  the  eyelids  and  occasionally  the  con- 
junctiva. The  eruption,  as  a  rule,  makes  its  appearance  suddenly, 
and  may  present  itself  as  erythematous  patches  of  more  or  less  irreg- 
ular outline,  and  of  various  forms,  or  it  may  consist  of  small,  flattened 
papules  or  tubercles,  or  the  eruption  may  be  of  a  mixed  character,  but 
usually  there  is  a  predominance  of  one  type  of  lesion.  In  the  first  few 
days  the  lesions  are  likely  to  increase  in  size,  when  they  are  soon  fol- 
lowed by  the  appearance  of  new  efflorescences.  There  may  be  fresh 
outbreaks  daily,  but  by  the  end  of  ten  days  the  process  begins  to  de- 
cline. Other  cases  may  present  a  single  outbreak  only,  which  icmains 
stationarv  for  a  week  or  so.  and  then  it  gradually  fades. 


4880  EXUDATIVE  ERYTHEMA,  OCULAR 

Tlic  efflorescences  arc  of  a  l)right-piiik  or  i-cd  at  first,  becoming  later, 
as  H  rule,  violaceous  or  purplish,  espcciall\-  in  llie  papular  and  tuber- 
cular forms  of  the  disease. 

The  most  (iomiiion  type,  howevei-,  consists  of  papules  which  are  small 
and  flat,  having  sometimes  a  sunkeii-in  centi"il  portion.  The  j)apules 
may  be  discrete  or  crowded  togetlier,  in  color  dai'k  or  violaceous.  They 
are  frequently  interspersed  with  larger  and  deeper-seated  tubercles, 
and  sometimes  tlie  i)apules  are  arranged  in  single  and  in  concentric 
rings.  The  concentric  formations  occur  successively,  so  that  the  outer- 
most is  the  most  recent,  and  therefore  the  patch  is  of  different  tints, 
hence  "er^-thema  iris."  Other.s  may  consist  of  vesicular  or  bullous 
rings,  of  various  hues,  hence  "herpes  iris."  Or,  again,  the  rings  may 
have  sharply  defined  margins,  indeed  the  patches  may  appear  in  many 
forms,  making  (piite  ])izarre  figures.  The  patches  may  coalesce  and 
form  large  blebs  simulating  the  eruption  of  pemphigus.  In  other 
cases  vesicular  lesions  may  be  found  on  tlie  lips  and  in  the  mouth. 

Subjective  symptoms  may  be  entirely  wanting,  but  in  some  cases 
only  slight  burning  and  itching  are  complained  of,  yet  they  are  rarely 
troublesome.  In  the  vesicular  and  bullous  types,  how^ever,  the  patches 
are  often  painful. 

The  constitutional  symptoms  are  usually  insignificant,  and,  as  a 
rule,  in  the  average  cases  of  the  papular  type  limited  to  the  face  and 
hands,  there  are  no  perceptible  systemic  symptoms.  There  may  be, 
however,  a  slight  rise  of  temperature  and  swelling  of  the  cervical 
glands.  The  eruption  on  the  body  may  be  preceded  by  inflammation 
or  congestion,  or  an  eruptive  condition  of  the  face  and  of  the  conjunc- 
tiva, and,  when  there  is  an  extensive  general  eruption,  the  joints  of  the 
extremities  may  become  swollen  and  painful.  The  disease  usually, 
however,  runs  an  acute  and  benign  course. 

The  disease  has  been  observed  to  occur  more  frequently  in  the 
changeable  weather  of  the  spring  and  autumn.  One  attack  certainly 
predisposes  to  others,  which  for  several  years  may  recur  at  about  the 
same  time  of  the  year.  In  such  eases  it  may  be  accompanied  by  more 
or  less  pronounced  rheumatic  symptoms. 

Erythema  is  most  frequent  during  adolescence  and  early  adult  life, 
yet  all  ages  are  subject  to  it,  and  it  is  common  in  both  sexes,  but  it 
has  been  seen  more  frequently  in  females.  There  seem  to  be  no  pre- 
disposing causes,  but  certain  drugs,  such  as  ])ota.ssium  iodide  and  the 
coal-tar  products,  have  been  followed  by  erythematous  eruptions,  and 
it  has  been  noticed  that  antitoxins  and  serums  have  caused  it.  It  is 
prone  to  attack  newly  arrived  country  people. 

The  patliologic  cause  of  erythema   multiforme  is  unknown.     It   is 


EXUDATIVE  ERYTHEMA,  OCULAR  4881 

quite  proljablc  tliat  it  is  due  to  tlic  al)sorptioii  of  imperfect  products 
of  digestion,  and  it  tlierefore  may  be  said  to  depend  upon  intestinal 
toxemia,  as  it  lias  been  found  associated  especially  with  the  ingestion 
of  stale  fish,  shell  food  and  meats.  It  has  occurred  as  one  of  the  symp- 
toms of  pellagra,  which  may  be  considered  to  be  a  chronic  intoxication 
induced  by  the  ingestion  of  damaged  maize.  Nevertheless,  it  is  be- 
lievable that  all  cases  must  have  an  underlying  neurotic  basis,  so  that 
erythema  may  ))e  regarded  as  a  toxic  dermatosis.  Blood  examinations 
liave  yiekled  nothing  positive,  neither  have  specific  organisms  been 
isolated  in  the  serum  contained  in  the  vesicles.  It  has  been  found 
epidemic,  in  wliich  case  the  symptoms  have  been  grave. 

ErytJicma  multiforme  Ls  a  mildly  inflammatory  disease,  and  it  may 
be  said  to  be  allied  to  urticaria.  The  effusion  is  brought  about  proba- 
bly l)y  a  casomotor  disturbance  depending  upon  an  angioneurosis, 
which  may  be  considered  to  be  toxic  in  origin,  impressing  the  nervous 
system  and  the  peripheral  circulation.  Certain  observers  have  con- 
sidered it  to  be  a  form  of  purpura,  because  hemorrhages  have  been 
found,  and  as  grave  cases  have  exhibited  such  symptoms,  their  pres- 
ence is  therefore  strongly  suggestive  of  such  a  connection. 

The  epidermal  changes  are  more  marked  in  the  bullous  and  vesicular 
types  than  in  the  papular.  These  changes  consist  of  inflammation  in 
the  papillary  layer  as  shown  by  dilation  of  the  vessels  with  the  pro- 
liferation and  emigration  of  cells,  together  with  edema  and  sometimes 
extravasation  of  serum  and  red  blood  cells.  The  epidermis  is  edema- 
tous, the  edema  reaching  from  the  sub-epithelial  vascular  network. 
The  covering  of  the  vesicles  and  bullae  consists  of  the  corneous  layers 
and  sometimes  of  the  entire  epidermis. 

The  diagnosis  of  erythema  multiforme  should  rarely  give  rise  to 
difficulty  if  the  multiformity  of  the  eruption,  the  size  of  the  papules, 
the  tendency  to  ring-formation,  the  cause  of  the  disease  and  the  ab- 
sence of  subjective  symptoms  are  considered.  It  resembles  urticaria, 
yet  urticaria  is  intensely  itchy  and  is  evanescent,  while  erythema 
persists  for  several  days,  the  papules  of  which  are  dark-colored,  pur- 
plish or  violet  in  hue  and  often  present  a  slight  depression  of  the 
central  portion.  When  there  are  distinct  rings  it  might  be  mistaken 
for  ring-worm.  Imt  the  surface  of  ring-worm  is  scaly,  and  when  the 
vesicles  and  bulla?  become  confluent  the  large  blelis  may  suggest  pem- 
phigus, yet  in  such  cases  the  presence  of  other  characteristics  of  ery- 
thema multiforme  sliould  clear  up  the  diagnosis. 

The  prognosis  is,  as  a  rule  in  America,  favorable,  the  eruption  dis- 
appears in  a  week  or  two,  although  new  crops  may  recur  and  the  course 

Vol.  VII— 3 


4882  EXUDATIVE  ERYTHEMA,  OCULAR 

oi"  tlu'  disease  l)e  i)i'()loii<,n'(l.     'J'lie  graver  eases  are  apparently  more 
lVe(iueiit  ill  Kur()])e. 

It  is  (louhll'ul  whellier  the  causes  can  be  iiifliieiieed  l)y  ti'ealiiient. 
As  it  is  ])robable  that  it  depends  ui)on  the  development  of  intestinal 
toxins,  the  best  treatment  consists  of  .such  antiseptic  drugs  as  the 
saline  laxatives,  sodium  salicylate,  salol,  or  thymol  in  full  doses.  Ex- 
ternal treatment  is  simple.  When  tliere  is  intense  itching,  antipruritic 
remedies  may  be  u.sed.  In  eases  characterized  ])y  recurrences,  it  is 
well  to  anticipate  their  return  by  the  administration  of  saline  and  in- 
testinal antiseptics  previous  to  the  time  of  the  outbreak. 

(The  reader  is  referred  to  the  admirable  text-])ooks  on  diseases  of 
the  skin  by  Crocker  and  by  Stelwagon,  from  which  much  of  the  above 
account  has  been  taken.) 

Erythema  multiforme  involving  tlie  ocular  structures  is  a  rare 
affection  in  America,  and  in  Western  Europe.  It  is  found  in  the  East 
and  in  Turkey,  more  frequently  in  Italy,  Roumania  and  Bulgaria, 
w^here  it  is  said  to  be  common.  Cases  have  occurred  from  time  to  time 
as  reported  by  observers  in  various  parts  of  the  world,  yet  works  in 
ophthalmolog.y  have  given  small  place  to  descriptions  of  the  disease. 

Beaudonnet,  in  his  Paris  Thesis,  ''A  Cantrihiitian  to  th£  Study  of 
the  Ocular  Manifestations  in  Erythema  Polyniorphe,"  published  in 
1894,  notes  that  a  case  was  reported  by  Alibert  so  far  back  as  1822. 
Later  writers  have  observed  that  conjunctivitis  with  lachrymation 
and  photophobia  occurred  with  such  severity  as  to  constitute  a  dis- 
tinct complication  of  the  major  malady.  Others  have  noted  that  a 
diffuse  erythema  may  be  found  on  the  eyelids,  with  vesiculation, 
which  later  may  be  followed  by  scaling  and  pigmentation. 

The  occurrence  of  papules  and  vesicles  on  the  eye  are  quite  charac- 
teristic ;  the  first  appearances,  however,  are  varialile,  although  they 
usually  appear  in  the  course  of  the  eruption  on  the  skin.  Rarely  tiny 
rose-colored  papules  have  been  seen  on  the  conjunctiva  preceding  the 
general  efflorescence,  but  usually  tliey  appear  at  about  the  fourth  or 
sixth  day  of  the  eruption. 

The  simplest  symptoms  consist  in  congestion  of  the  conjunctiva 
with  mucoid  discharge,  implication  of  the  lid  borders  and  agglutina- 
tion of  the  lashes.  The  congestion  of  the  conjunctiva  is  sometimes 
accompanied  by  edema  of  the  lids.  Both  eyes  are  commonly  affected, 
but  it  may  be  confined  to  only  one  eye.  The  papules  are  commonly 
found  at  the  inner  angle,  where  they  give  one  the  impression  of  ptery- 
gium. In  other  cases  they  appear  to  be  more  like  nodules  of  episcler- 
itis, yet  here  the  papules  consist  of  more  or  less  circumscribed,  elevated 
buttons  over  wliiclt  1he  conjunctiva  can  glide  on  to  the  globe.    The  most 


EXUDATIVE  ERYTHEMA,  OCULAR  4883 

marked  areas  are  violaceous  and  have  the  same  color  as  the  papules 
and  vesicles  on  the  skin.  Others  may  be  paler  and  stand  out  distinctly 
on  the  injected  conjunctiva.  These  opalescent  papules  are  sometimes 
surrounded  by  whitish  vesicles,  which  may  break  down  into  ulcers.  In 
I'l'om  five  days  to  two  weeks  all  the  phenomena  amend,  the  photophobia 
and  laehrymation  cease,  the  nodules  diminish,  and  the  papules  fade  at 
the  same  time  as  those  of  the  general  eruption,  then  they  vanish  and 
leave  no  traces  behind.  Cases  have  lasted  longer,  merging  into  a  more 
or  less  chronic  state. 

More  severe  cases  have  arisen  in  which  a  false  membrane  has  formed 
on  the  tarsal  conjunctiva,  accompanied  l)y  similar  formations  on  the 
pharynx,  it  is  likely  that  such  severe  lesions  are  really  secondary  to 
contaiuiiiation  by  other  infections  l)ecause  chains  of  cocci  have  been 
found  in  them,  while  usually  erythema  papules  are  sterile. 

The  membranes  may  be  thick,  and,  stretching  from  the  lid  margin 
to  the  globe,  covering  the  plica,  give  the  appearance  of  .symblepharon. 
Such  membranes  are  not  true,  but  false,  for  they  can  be  detached. 
These  cases  are  likely  to  be  quite  serious  and  the  cornea  may  become 
implicated.  Instances  have  been  recorded  where  the  cornea  has  been 
infiltrated  beneath  the  denuded  epithelium,  yet  without  invasion  by 
septic  bacteria. 

These  conjunctival  complications  represent  a  real  manifestation  of 
the  specific  disease  exhibiting  modifications  according  to  the  differences 
between  the  structure  of  the  skin  and  of  the  mucous  membranes,  sub- 
ject to  the  changes  connected  with  differences  of  environment  and 
function.  jMoreover,  no  true  affections  of  the  conjunctiva  correspond 
to  erythema  or  to  herpes  iris.  The  catarrhal  form  of  conjunctival  erj'- 
thema  represents  the  erythematous  form  on  the  skin,  and  the  croupous 
is  the  vesicular  or  bullous,  modified  by  the  character  of  the  mucous 
surfaces.  It  is  important  not  to  confound  tliis  (|uite  benign  eruption 
with  pemphigus,  which  so  fre(iuently  terminates  in  xerosis  and  symble- 
pharon. 

Erythema  nodosum  is  an  acute  inflammation  of  the  skin  character- 
ized by  the  formation  of  various-sized,  roundish,  more  or  less  elevated 
erj'thematous  nodes  or  swellings  attended  with  a  variable  degree  of 
systemic  disturbance. 

It  is  usually  ushered  in  with  febrile  disturbance,  gastric  uneasiness, 
malaise,  and,  not  infrequently,  with  rheumatic  swellings  and  pains 
about  the  joints.  These  constitutional  symptoms  may  be  mild  and 
scarcely  noticeable,  or  they  may  be  quite  severe.  The  cutaneou.s  erup- 
tion makes  its  appearance  either  with,  before  or  after  the  constitu- 
tional symptoms.    The  lesions  commonly  affect  the  arms  and  legs,  but 


4884  EXUDATIVE  ERYTHEMA,  OCULAR 

they  may  ot-e-asioiially  be  Jouiid  on  the  lace,  and  rarely  in  the  iimcoiis 
surfaces  of  tlie  mouth  and  throat  and  in  the  conjunctiva,  liarely  are 
they  found  in  great  iniinhci's,  hut  come  out  two  or  tliree  at  a  time. 
They  begin  as  deep-.seated  nodules,  rapidly  becoming  larger  and  ele- 
vated. On  the  general  surface  llu-v  may  ))ecome  as  large  as  a  hen's 
egg,  and  are  louiided  or  oval,  teiidci-  and  painful,  and  have  a  glistening 
and  tense  look,  of  a  l)riglit,  erysipelatous  color,  and  as  they  are  not 
circumscribed,  the  color  gradually  merges  into  sound  skin.  Later  the 
eruption  becomes  of  a  "black  and  blue"  color,  gradually  changing 
and  fading  in  the  manner  of  a  bruise.  At  first  they  are  quite  free, 
but  later  undergo  softening  and  fluctuate;  they  may  become  hemor- 
rhagic, but  they  never  suppurate.  The  nodes  do  not  all  come  out  at 
once;  at  first  there  may  be  but  three  or  four,  but  after  a  few  days 
others  may  appear.  In  the  course  of  a  few  weeks,  or  in  some  cases 
months,  the  process  fades  and  entirely  disappears. 

There  may  be  rather  severe  subjective  symptoms  accompanied  by 
throbbing,  tenderness  and  pain.  The  constitutional  symptoms  subside 
after  a  few  days,  though  some  cases  may  continue  febrile  for  several 
weeks,  with  the  persistence  of  severe  visceral  and  cerebral  complica- 
tions. The  disease  is  usually  found  in  those  under  30,  females  being 
more  often  attacked  than  men,  and  commonly  in  cold  and  damp 
weather.  The  subjects  are  usually  the  weak  and  anemic,  though  it 
may  attack  those  in  good  health.  Rheumatism  frequently  accompanies 
it  and  it  may  be  associated  with  malaria,  digestive  disturbance  and  in- 
toxications. 

It  is  not  a  connnon  disease.  It  sometimes  occure  in  two  or  more 
members  of  a  family.  Its  nature  is  not  clear;  it  is  not  improbable  that 
it  is  due  to  septic  infection.  The  grave  cases  may  be  due  to  septic 
infection.  Its  association  with  tuberculosis  is  chiefly  a  coincidence, 
or  at  most  tuberculosis  acts  as  a  predisposing  factor;  and  the  same 
may  be  said  of  its  relation  to  syphilis.  It  lias  lieen  said  to  bear  a 
strong  relation  to  erythema  multiforme,  and  to  be  a  manifestation  of 
that  di.sease.  There  is  some  difference  of  opinion  as  to  how  the  lesions 
are  produced;  it  is  still  uncertain  wlicthrr  it  is  an  angioneurosis,  or 
whether  it  arises  from  intlamniation  of  llic  lyin])hatics  or  from  embo- 
lism. There  is  a  distinct  inflamiiiatioii.  li()wc\ci-,  for  the  ])lood  vessels 
are  dilated,  the  coi'ium  and  ])apillary  layers  are  crowded  with  cells, 
ac(;ompani('d  by  extravasations  of  blood  and  transudation  of  coloring 
mattci".  The  lymphatic  vessels  are  packed  with  cell  collections,  and  in 
the  blood  vessels,  especially  the  veins,  there  is  great  massing  of  the 
leucocytes.  The  epidermis  rarely  shares  in  the  process,  but  the  cuta- 
neous and  subcutaneous  tissues  are  infiltrated  with  serum. 


EXUDATIVE  ERYTHEMA,  OCULAR  4885 

Erythema  nodosum  must  not  hr  cont'oundccl  with  bruises,  abscesses, 
etc.  The  color  of  tht'  (eruption  with  the  hiter  changes;  the  violent 
character  of  the  process;  the  number  of  the  lesions  with  the  course  of 
the  eruption  ought  to  prevent  error  in  diagnosis.  Bruises  and  ab- 
scesses are  rarely  seen  more  than  two  or  three  in  number;  the  erasions 
of  erythema  nodosum  never  break  down,  while  the  disease  is  frequently 
accompanied  by  rheumatic  pains  in  the  joints. 

The  prognosis  is  favorable,  although  the  disease  usually  requires  a 
few  weeks,  perhaps  two  or  three  montlis,  to  run  its  course.  In  this 
country  the  disease  is  mild  and  ought  to  give  rise  to  but  little  anxiety, 
as  it  always  ends  in  recovery. 

The  disease  should  be  treated  syraptomatically.  Rest  should  be 
strictly  maintained.  The  diet  should  be  plain  and  unstimulating. 
The  alkalis,  .salines,  laxative  and  intestinal  antiseptics,  cpiinine  in  full 
doses,  constitute  the  essence  of  the  treatment.  Rheumatic  joints  need 
wadding. 

Just  as  ocular  complications  have  been  found  in  erythema  multi- 
forme, so  have  snch  been  seen  during  the  course  of  erythema  nodosum, 
and  the  ocular  manifestations  arise  and  fade  as  the  eruption  appears 
and  disappears  in  the  general  malady.  The  nodosities  are  larger  and 
denser  than  the  nodes  found  in  erythema  multiforme,  and  as  the  sys- 
temic condition  is  more  profoundly  depressed,  the  frequence  of  deep- 
seated  ocular  disease  has  likewise  been  greater.  Thus  the  eyeball  may 
be  tender  on  pressure ;  there  may  be  bilateral  iritis,  and  general  uveitis 
with  atrophy  of  the  optic  nerve  have  been  recorded. 

In  erythema,  or  herpes  iris,  or  liydroa,  the  general  symptoms  are 
comparable  to  those  already  described,  but  the  chief  distinguishing 
feature  of  it  is  the  formation  of  a  ring  of  vesicles  about  a  central  bulla. 
There  may  be  several  concentric  rings. 

The  disease  usually  recurs  annually,  and  at  about  the  same  time 
each  year,  but  with  lessening  severity  as  the  years  go  on. 

Enormous  bullae  have  been  seen  on  the  conjunctiva,  unaccompanied 
by  serious  symptoms  however,  as  they  fade  without  contracting  the 
conjunctiva  and  without  affecting  the  cornea. 

In  the  progress  of  the  early  symptoms  of  these  types  of  erythema, 
one  naturally  thinks  of  pemphigus,  but  because  their  course  is  usually 
brief  and  the  innnediate  symptoms  moderate,  their  status  is  discerned, 
for  the  effects  are  benign,  whereas  pemphigus  invariably  leads  to 
absorption  of  the  conjunctiva  with  contraction  of  the  tissues  and  the 
consequent  formation  of  symblepharon. 

In  all  these  conditions  the  local  treatment  should  be  expectant.  The 
lids  may  be  protected  by  boric  acid  ointment  or  other  bland  salves, 


4886  EXUDATIVE  RETINITIS 

and  in  simple  cases  asli'injfeiit  lotions  may  he  prescribed.  WIicm  the 
bulla-  oil  the  conjunctiva  are  ol"  great  size,  the  snipping  of  them  to 
drain  oil"  Ihe  contents  might  be  practised,  but  in  such  cases  extreme 
care  should  be  used  to  prevent  infection  of  the  raw  surface  thereby 
exposed.  Deeper-seated  troubles  must  be  managed  on  geueral  prin- 
ciples. 

All  cases  re(|uire  a  searching  for  any  cause  of  defective  health. 
The  food  should  be  inspected  as  to  its  freshness  and  purity,  as  •well 
as  to  its  preparation  and  digestibility.  The  system  must  be  sup- 
ported, the  intestinal  tract  cleansed  and  kept  as  antiseptic  as 
possible.  Kecurrences  must  be  anticipated,  and  the  patient  pro- 
tected by  the  means  already  outlined. — (B.  C.)  See,  also,  Skin 
diseases,  Ocular  relations  of. 
Exudative  retinitis.  Ketimtis  hemorrhagica  externa.  jMassive  ret- 
inal EXUDATION.  Of  this  rare  and  curious  disease  de  Schweinitz  {Dis- 
eases of  the  Eye,  p.  610,  1913)  says  that  the  most  conspicuous  feature 
is  a  large,  prominent  yellowish-white  circumscribed  lesion,  or  smaller 
areas  of  yellow  or  white  exudations  lying  beneath  the  retinal  vessels. 
Of  insidious  onset  and  slow  progress,  the  disease  most  often  attacks 
young  persons  (average  age  about  nineteen),  and  is  more  common 
among  males  than  females.  The  patients  are  usually  in  good  health 
(anemia  may  be  present),  and  their  clinical  and  family  histories  do  not 
yield  information  as  to  the  etiologic  factor.  In  late  stages  of  the 
disease  detachment  of  the  retina,  cataract,  iritis,  and  glaucoma  may 
develop.  The  affection  depends,  as  Coats  has  shown,  upon  hemorrhages 
in  the  inter-retinal  layers.  A  slow  organization  takes  place  with  forma- 
tion of  cicatricial  tissue  masses.  At  first  the  choroid  remains  free  from 
pathologic  alterations.  This  form  of  retinitis  is  probably  the  result 
of  local  vascular  disease ;  ophthalmoseopieally,  it  has  most  often  been 
mistaken  for  tuberculous  choroiditis. 

The  Oplithalmic  Year-Book  for  1913  furnishes  the  following  ref- 
erences. A  case  which  he  believes  to  be  of  this  character  is  reported  by 
von  Hippel  (Oraefe's  Arch.  f.  Ophth.,  Vol.  86,  p.  443).  The  patient 
was  a  man  of  49,  with  negative  Wassermann  and  tuberculin  reactions. 
Enucleation  was  done  about  fifteen  months  after  the  onset.  The  retina 
was  thickened  and  detached,  with  nodules  projecting  from  the  outer 
surface  and  a  layer  of  organizing  tissue  between  it  and  the  choroid. 
A  similar  layer  was  present  on  the  inner  surface  of  the  retina,  which 
had  undergone  much  degeneration,  and  was  invaded  and  destroyed  by 
cicatricial  bands.  The  retinal  vessels  did  not  show  gross  disease.  The 
anterior  choroid  was  infiltrated  and  its  inner  layers  disorganized. 
Von  IIii)pel  supposes  the  disease  began  anteriorly  and  spread  back- 


EXULCEREUX  4887 

wai'cl.  Coats  {Opiith.  Rev.,  Vol.  3;i,  p.  51)  thinks  the  round  cell  in- 
filtration of  the  ciioroid  in  this  ease  makes  it  questionable  as  a  case 
of  exudative  retinitis.  But  such  borderline  cases  should  be  welcomed 
for  the  assistance  they  give  in  exact  classification. 

Anotiier  borderline  case  is  reported  by  Hajauo  (Graefe's  Arch.  f. 
Ophtk.,  Vol.  84,  p.  80),  occurring  in  a  boy  2  years  old.  The  eye  was 
enucleated  on  a  diagnosis  of  glioma.  But  section  proved  this  erro- 
neous. The  retina  was  detached,  thickened,  folded  and  degenerated, 
with  cystoid  spaces.  The  vessels  were  thickened,  knotty,  and  some 
completely  obliterated  by  proliferation  of  the  inner  coat.  The  choroid, 
ciliary  body  and  iris  were  also  thickened,  but  without  inflammatory 
changes.  Hajano  also  reports  three  cases  in  which  white  exudates 
behind  the  retinal  vessels  were  found  in  different  parts  of  the  retina 
in  young  otherwise  healthy  persons ;  and  suggests  that  these  may  rep- 
resent an  early  stage  of  the  same  trouble.  A  case  is  reported  by  zur 
Nedden  {Klin.  Monatshl.  f.  Augenh.,  March,  1913,  p.  359),  as  possible 
glioma;  in  a  17-year-old  patient.  The  retina  was  thickened  with  shiny 
white  spots,  the  vessels  tortuous  and  dilated.  The  Wassermann  and 
tuberculin  reactions  were  negative. 

Exulcereux.     (F.)     Phagedenic;  derived  from  an  ulcer. 

Eye-ache.  Dolor  oculi.  Ophthalmodynia.  These  are  indefinite  terms 
api)lied  to  those  pains  that,  due  to  many  different  causes,  affect  the 
eyeball  and  the  region  of  the  orbit.  Although  they  generally  result 
from  eye-strain,  yet  they  often  form  one  of  the  symptoms  of  certain 
inflannnatory  diseases  of  the  eye,  neuritis,  odontalgia,  nasal  sinus  dis- 
ease, etc.,  or  they  occur  as  part  of  a  heraicrania.  The  treatment  of 
this  symptom  is,  of  course,  entirely  dependent  upon  its  cause. 

Eye-and-ear  observation.  An  astronomical  observation  by  the  method 
in  which  the  time  is  fixed  by  the  ear,  by  noting  the  beat  of  a  clock, 
while  the  transit  of  the  star  is  observed  in  the  telescope. 

Eye,  Artificial.    See  Vol.  I,  page  621  of  this  Encyclopedia. 

Eye,  Axis  of  the.    See  Vol.  T,  page  722  of  this  Encyclopedia. 

Eyeball.  Ocular  globe.  Sometimes,  tliough  incorrectly,  termed  the 
hull) us.  See  in  particular  Anatomy  of  the  eye,  as  well  as  Develop- 
ment of  the  eye.  Although  a  few  lesions  or  states  of  the  eyeball  as 
a  whole  will  be  considered  under  the  next  following  headings,  yet 
the  reader  is  referred  to  headings  that  indicate  the  condition  itself, 
such  as  Epibulbar  tumors ;  Enucleation  of  the  eye ;  Ocular  muscles, 
ete. 

Eyeball,  Atrophy  of  the.  Phthisis  bulbi.  Plastic  inflammation  of  the 
uveal  tract  (iridoelioroiditis)  often  ends  in  a  condition  in  wliich  the 


4888  EYEBALL-HEART  REFLEX 

eyeball  becomes  .soi't  and  lessened  in  all  its  diameters.    The  globe  is 
irregular  in  shape  from  Avrinkling  of  the  sclera.    The  retina  becomes 
detached.     When  the  exudation  lies  chiefly  behind  the  lens,  the  an- 
terior chamber  will  become  shallowed.     If  the  force  of  the  contract- 
ing exudate  is  exerted  more  in  a  backward  dii-ection,  the  chamber 
will  be  deepened.     The  condition  is  known  as  phthisis  bulbi.     See, 
also,  Vol.  1,  ])a<ie  667  of  this  Encjjclopcdkt. 
Eyeball-heart  reflex.    Loeper  and  IMougeot  {Journ.  Am.  Med.  Assocn., 
Feb.  14,  1914)  confirm  the  instructive  import  of  Aschner's  reflex,  the 
slowing  of  the  heart-beat  when  pressure  is  applied  to  the  eyeballs.    In 
two  or  three  seconds  at  most,  the  heart  slows  up  by  about  8  beats  to  the 
minute,  but  the  former  rate  returns  as  soon  as  the  pressure  is  released. 
In  tabes  this  reflex  seems  to  be  abolished.    In  some  cases  the  absence  of 
the  oculo-cardiac  reflex,  as  they  call  it,  was  the  first  sign  to  attract 
attention  to  the  tabes.     The  apparently  paradoxic  tachycardia  with 
abnormally  high  blood-pressure  does  not  affect  this  reflex,  but  this 
tachycardia  warns  of  impending  breakdown  of  the  left  heart  and  calls 
for  digitalis  unless  it  yields  to  other  measures.     They  explain  the 
mechanism  of  this  tachycardia,  saying  that  the  eyeball-heart  reflex 
first  threw  light  on  it.    They  published  several  communications  on  the 
reflex  in  the  Progres  medical,  1913,  xli,  211,  663  and  675.     With  a 
gastric  neurosis  this  reflex  is  an  indication  whether  the  pneumogastric 
or  the  vagus  is  predominantly  involved,  and  this  may  i)rove  a  guide 
to  treatment.    In  one  of  the  cases  reported  the  patient  had  an  ulcer  on 
the  lesser  curvature,  and  the  pulse  slowed  up  by  14  beats  on  pressure 
of  the  eyeballs.    Three  months  after  resection  of  the  stomach  the  pres- 
sure caused  the  pulse  to  drop  from  88  to  62,  a  loss  of  26  beats.       The 
pressure  on  the  eyeballs  never  seemed  to  do  any  harm.    It  exaggerates 
bradycardia  when  it  is  of  nervous  origin,  and  may  exaggerate  arhyth- 
mia.     With  rudimentary  exophthalmic  goitre  and  in  very  emotional 
subjects,  with  a  tendency  to  "hot  flashes"  and  profuse  sweating,  pres- 
sure on  the  eyeballs  is  liable  to  aceclcrate  the  pulse. 
Eyeball,  Movements  of.    See  Physiological  optics;  as  well  as  Muscles, 

Ocular. 
Eyeball,  Position  of  the.  The  globe  is  placed  not  in  the  axis  of  the 
orbit,  but  below  and  external  to  it.  The  prominence  of  the  eyeball  is 
largely  dependent  upon  the  amount  of  adipose  tissue  in  the  orbit:  the 
greater  the  amount  of  adipose,  the  greater  is  the  prominence.  In 
emaciated  subjects  the  eyel)alls  are  sunken  from  diminution  of  the  fat 
of  the  orbit.  During  sleep  or  unconsciousness  the  eyes  turn  slightly 
upwards  and  inwards. 


EYEBALL,  TENSION  OF  THE  4889 

Eyeball,  Tension  of  the.    Sit  Glaucoma;  jilso  Tonometer. 
Eye-box.    A  name  given  to  a  receptacle  for  single  artificial  eyes.     See 
the  illustration. 


Artificial  Eye  Box. 

Eye,  Brassy,  Ciialkitis.  Ciialcitis.  Vulgar  name  for  a  severe  iuflam- 
mation  of  the  eyes  marked  at  first  by  excessive  lachrymation  and  sensi- 
tiveness to  light,  resulting  in  blurred  vision  and  continued  flow  of 
mucus.  It  is  due  to  rubbing  the  eyes  after  the  hands  have  been  used 
on  brass,  as  in  the  case  of  trolley-car  conductors  and  employes  of  brass 
or  eoi)per  works. 

Eye-breek.    An  old  name  for  the  eyelid. 

Eye-breen.    An  obsolete  term  for  eyebrow. 

Eyebrigfht.  Once  supposed  to  be  of  marvelous  efficacy  in  clarifying 
the  vision.    See  Euphrasia. —  (T.  H.  S.) 

Eyebrow.  The  sipercilium.  The  eyebrows,  generally  nearly  straight, 
except  in  the  outer  part  which  slants  downward,  but  sometimes  de- 
cidedly arched  throughout,  are  of  very  varying  development.  They 
are  composed  of  coarse,  stiff  hairs  pointing  outward.  The  inner  half 
corresponds  pretty  closel\^  to  the  upper  border  of  the  orbit,  but  the 
outer  half,  on  account  of  the  downward  slope  of  the  orbit,  is  above  it, 
resting  against  the  forehead.  Sometimes  the  outer  half  is  wanting. 
Sometimes,  especially  in  dark-haired  races,  the  eyebrows  meet  at  the 
root  of  the  nose.  The  inner  half  is  the  strongest  and  thickest.  At  the 
outer  end  the  hairs  are  fewer  and  sjualler.  The  lower  hairs  slant  up- 
ward, and  the  upper  downward  as  well  as  outward.  Thus  the}'  meet 
to  make  a  raised  crest  in  the  middle.  The  shape  depends  largeh'  on 
the  direction  of  the  outer  end.  The  eyelirows  are  but  little  developed 
in  infancy.  They  rarely  are  strong  in  childhood.  At  about  puberty 
they  become  more  marked.  The  hairs  grow  longer  and  coarser  through- 
out life,  especially  in  men.  In  women  this  feature  is  more  delicate. 
Individual  differences  are  endless. —  (Norris  and  Oliver,  System  of 
Diseases  of  The  Eye,  Vol.  I,  p.  79.) 


4890 


EYEBROW,  PIEBALD 


Eyebrow,  Piebald.     I'atclics  of  wliilc  liaii-  in  a  dark  eyebrow. 

Eyebrows,  Supernumerary.  Tho.se  are  not  so  very  uncommon.  The 
usual  tyi)e  is  lliat  (h'serihed  by  Majocehi  (Klin.  Monatsbl.  f.  Augenh., 
Nov. -Dec,  p.  655,  1908),  who  observed  double  rows  of  eyebrows  8  to  10 
mm.  apart  with  smooth  skin  between.  A  low  grade  of  microphthalmos 
with  hydro-  and  acrocephalus  was  also  present.  Dodd  has  observed 
islets  of  hair  in  each  temporal  region ;  tlie  patches  in  no  way  resembled 
moles. 

Eye-cells.  Cup-shaped  cells  of  porcelain,  enameled  black,  to  place 
over  tiio  eye  after  operations. 

Eye,  Compound.  The  organ  of  vision  formed  by  several  crystal  spheres, 
as  ill  Sjiidcis  and  rrayfisb.    See  Comparative  ophthalmology. 

Eye,  Corrosion  of  the.  A  term  used  to  express  a  buiii  by  strong  acids 
or  alkalies. 

Eye-cup.  There  are  many  receptacles  for  retaining  collyria  in  contact 
with  the  globe  and  conjunctival  sac  for  detergent  purposes.     Of  these 


Eye-cup  of  Coulomb  with  Adaptable  Eubber  Eim. 


the  ordinary  eye-cup  is  a  useful  means  of  washing  out  the  conjunctival 
sac.  In  using  it  the  ett})  should  be  lialf  tilled  with  the  irrigating  fluid, 
then  fitted  snugly  about  the  margin  of  the  orbit.  The  head  should  then 
he  tilted  back,  or  the  patient  lie  down,  the  previously  closed  eye  opened 
and  the  liquid  allowed  to  flow  into  the  sac.  Now  open  and  close  the 
eye  slowly  half  a  dozen  times  so  that  the  irrigating  fluid  may  come 
directly  in  contact  with  all  the  parts  in  and  about  the  sac.  Shut  the 
eye,  remove  the  cup  and  keep  the  lids  closed  for  a  few  minutes. 


EYE-CUP  FOR  PNEUMO-MASSAGE 


4891 


An  ingenious  device  is  the  eye-cup  of  Meyer-Steinig.  It  is  one  of 
many  appliances  intended  to  provide  for  continuous  irrigation  of  the 
external  parts. 


lOye  Cup. 

H.  C.  Fenton  believes  that  instead  of  using  the  ordinary  cleansing 
collyria,  that  are  likely  to  decompose,  it  is  preferable  in  all  cases  to 
direct  the  patient  to  dissolve  one-fourth  teaspoonful  of  pure  crystalline 
boric  acid  in  one-fourth  glass  of  hot  Avater  and  use  with  an  eye-cup. 


The  ileyoi-Steinig  Eye-cup. 

This  avoids  the  manifold  dangers  of  dirty  dropx^ers  and  contaminated 
solutions. 
Eye-cup  for  pneumo-massage.      These  cups,  mostly  used  in  Bier's  arti- 
ficial coiujistioti  tnatnu  itt  of  the  eye  (see  Vol.  II,  p,  950  of  this  Encyclo- 
pedia), are  made  of  clear  glass,  through  whi -h  the  operator  can  clearly 


4892 


EYE  CURRENT 


l)('i'cci\c  the  ;ictinii  tli;it  is  ijikiii;^'  placr  duriiijj:  t I'l-iit iiiciit.  Tlicy  art; 
inoiildcd  to  coiii'dnii  lo  the  sliajX'  of  the  cxc-hall  as  closely  as  j)ossil»lc. 
They  caii  lie  used  in  ('onnection  witli  any  car  pnnij),  or  with  any 
apparatus  capable  of  compression,  suction  or  vibration  of  the  air.  See 
the  illustration. 


Glass  Eye  Cups  for  Pneiimo-massage. 

Eye  current.  An  appreciable  electric  current  which  maj^  be  observed 
in  a  freshly  removed  eye,  if  it  is  placed  in  a  suitable  galvanometer- 
circuit.  Its  direction  is  from  the  cornea  to  the  cut  section  of  the  optic 
nerve.    It  is  temporarily  increased  by  the  action  of  light. 

Eyed.    Having  an  eye,  or  visual  power. 

Eye,  Development  of  the.    See  Development  of  the  human  eye. 

Eye,  Dioptrics  of  the.    See  Dioptrics. 

Eye  douche.     See  p.  4071,  Vol.  VI  of  this  Encyclopedia. 

Eye-dropper.  In  addition  to  the  items  furnished  under  the  caption 
Dropper,    cuts  are   herewith   given   of   the   well-known   Strohschein 


StroliSL'lieiii  's    F^ye-Droi>iier. 

pipette  and  of  the  convolute  eye-dropper  that  fully  indicate  the  forn> 
and  mode  of  using  these  useful  Hit],-  devices. 


EYE,  EMBRYOLOGY  OF  THE  4893 

The  convolute  dropper  receives  its  name  from  a  si)iral  glass  tube 
arrangement  in  the  neck  of  the  device,  as  may  be  see^i  by  referring  to 
the  cut.  This  '"pigtail"  prevents  any  of  the  solution  rising  into  the 
top  of  the  dropper  and  coming  into  contact  with  the  rubber.  This  is 
prevented  even  if  the  dropper  is  allowed  to  lie  on  its  side.  The 
bottle  contains  approximately  one  ounce  and  has  a  comparatively 
broad  base.  The  rubber  cap  is  made  of  the  best  (|uality  bandage 
rubl)er,  is  greatly  superior  1o  the  onlinarx-  i-ul)l)('i-  toj),  ])esides  being 
easily  removable. 


Couyolute  Eye-Dropper. 

Eye,  Embryology  of  the.    See  Development  of  the  human  eye. 

Eye,  Emmetropic.    S.-e  Emmetropia. 

Eye,  Equator  of  the.    See  Equator. 

Eye,  The  evil.    See  Evil  eye. 

Eye,  Examination  of  the.    See  Examination  of  the  eye. 

Eye-fatigue.  A  synonym  of  asthenopia.  This  symptom  may  be  due 
to  ametropia,  heterophoria,  abnormal  work,  ill-health,  general  mental 
or  physical  fatigue,  poor  conditions  of  illumination  or  a  combination  of 
two  or  more  of  these  causes.  The  Ferree  test,  devised  by  Prof.  C.  E. 
Ferree  of  Bryn  Mawr  College,  is  as  follows:  The  observer  under  test  is 
required  to  gaze  steadily  for  a  short  period  of  time  (usually  about  three 
minutes)  at  a  card  upon  which  are  printed  certain  letters,  or  char- 
acters; these  letters  being  of  such  a  size  that  they  are  just  barely 
distinguishable  at  the  distance  selected  for  the  test.  During  the  period 
of  time  that  the  obsei-^'er  gazes  at  the  letters  he  is  required  to  record 
on  a  chronograph  or  stop  watch  by  the  pressing  of  a  button  the  in- 
tervals when  the  test  object  appears  blurred.  The  percentage  of  the 
time  which  the  observer  sees  the  letters  blurred  is  taken  as  an  indica- 
tion or  measure  of  the  amount  of  fatigue  of  the  eye  at  the  time  the 


4894  EYE-FIX 

test  is  iiuidc.  lii'fore  l)('ginniii<;^  sudi  a  lest  it  is  of  course  important 
to  detenninc  the  proper  distance  at  whieli  to  place  the  test  card  from 
the  eye  of  tlie  particular  observer  under  test,  because  if  too  great  a 
distance  is  taken  the  test  letters  may  appear  blurred  during  the  entire 
test  interval,  in  cases  where  tliere  has  been  considerable  eye  fatigue; 
and  on  tiie  other  hand  if  too  short  a  distance  is  taken  the  observer  may 
see  the  test  letters  clear  for  the  entire  time  during  tests  when  the  eyes 
are  but  little  fatigued. 

Eye-Fix.     'I'he  trade  name  of  a  rather  popular  quack  remedy,  adver 
tiscd  as  a  panacea  foi-  oplithaliiiic  ills. 

Eyeglasses  and  spectacles,  History  of.  Tlie  subject  of  glasses  as 
aids  to  vision  is  a  matter  of  conjecture  and  tradition  with  an  admix- 
ture of  superstition  previous  to  the  middle  ages.  A  Chinese  emperor 
is  said  to  have  used  lenses  to  ol)serve  the  stars  in  2283  B.  C.  The 
tortoise  was  a  sacred  animal  to  the  Chinese ;  therefore  tortoise-shell 
rimmed  glasses  were  considered  conducive  to  good  fortune  and  long 
life.  Lenses  were  made  of  rock  crystal,  quartz,  topaz  and  amethyst. 
These  stones,  found  among  the  sacred  mountains,  further  insured  good 
luck.  Moreover,  frames  did  not  necessarily  imply  lenses;  for  even  in 
modern  times  a  frame  devoid  of  lenses  is  a  badge  of  superior  social 
status  and  learning  among  the  Chinese.  An  interesting  etiquette  has 
grown  out  of  this  symbolism ;  an  inferior  must  remove  his  glasses  in 
the  presence  of  a  superior.  This  custom  survived  in  Germany  until 
a  very  recent  date. 

There  is  no  evidence  that  the  Hebrews,  Greeks,  or  Romans  had  any 
knowledge  of  glasses.  The  well-known  story  of  Nero  viewing  the 
gladiatorial  games  is  not  credited  by  scholars.  The  probable  explana- 
tion is  that  Nero  used  a  large  concave  mirror  from  which  the  scenes 
were  reflected.  Pliny,  in  the  first  century  A.  D.,  says  that  the  Phoeni- 
cians learned  the  art  of  glass  making  from  the  Chinese,  and  that 
Phoenician  nitre  merchants  discovered  that  nitre  mixed  with  sand  was 
melted  by  the  sun's  heat  into  a  coarse  glass.  The  remains  of  convex 
glass  found  in  the  excavations  of  Nineveh  and  Pompeii  do  not  prove  a 
knowledge  of  the  use  of  lenses  worn  before  the  eyes,  for  the  focus  of 
these  glasses  is  too  short.  Nevertheless  we  are  tempted  to  assume  such 
knowledge  as  essential  to  the  minute  and  exquisite  work  of  tlie  ancients 
in  gold  and  precious  stones.  The  hollow  globe  filled  with  water  may 
have  served  this  purpose.  It  is  certain  that  the  ancients  used  such  a 
globe  which  hiay  have  l)ecn  part  of  the  armamentarium  of  physicians. 
The  magnifying  and  hcat-i)rodueing  properties  were,  however,  attrib- 
uted to  the  water,  and  it  was  a  source  of  wonder  that  cold  water  could 
produce  heat. 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4895 

The  Saracen  iiiatliniiaticiaii  and  astronomer,  Alhazen  (died  1038), 
knew  something  of  optics.  The  Latin  transhition  of  his  work,  still 
extant,  treats  of  refraction  in  reference  to  astronomical  instruments. 
There  is  reason  to  ])elieve  that  his  woi-k  was  known  to  Roger  Bacon. 
The  high  state  of  scientific  knowledge  among  the  Arahians  would  make 
it  seem  likely  that  they  were  familiar  with  glasses;  yet  there  is  no 
evidence  to  suhstautiate  this  surmise. 

Hirsehberg  (Oraefe-Saeinisch  Handhuch  dcr  Augcnhcil.,  II,  Band 
13,  265)  thinks  that  the  Chinese  used  lenses  onl}^  as  mirrors  and  for 
kindling  fire  and  that  theii-  knowledge  of  glasses  came  from  Europe 
at  a  comparatively  late  time.  Another  view  is  that  this  knowledge 
spread  from  eastern  Asia  to  Europe  during  the  middle  ages.  In  the 
thirteenth  century  A.  D.,  following  the  inroad  of  the  Tartars  into 
Europe,  the  Pope  sent  missionaries  to  China  to  learn  the  wisdom  of  the 
East.  One  of  these  missionaries  later  visited  Roger  Bacon  in  Paris. 
Here  is  suggested  another  link  between  Bacon,  around  whose  name 
the  discussion  as  to  the  origin  of  glasses  has  centered,  and  his  pre- 
decessors. 

There  is  room  for  much  speculation  in  regard  to  the  communication 
between  Europe  and  the  Orient  in  medieval  times  and  the  possible 
origin  and  spread  of  glasses  from  one  to  the  other.  One  maj^  cite  the 
instance  of  the  introduction  of  the  mariner's  compass  and  of  gun- 
powder in  Europe  and  the  claim  that  they  are  European  inventions, 
whereas  they  were  actually  known  at  an  earlier  date  in  the  East.  To 
the  ]\Ioors  in  Spain,  to  the  crusades  and  the  oriental  trade  of  the 
Venetians,  may  be  traced  much  of  European  culture. 

Whatever  be  the  theories,  all  unproven,  of  the  origin  of  glasses,  we 
have  historical  data  for  the  statement  that  they  were  known  in  China 
and  in  Europe  in  the  thirteenth  century.  During  the  ^Mongolian 
Dynasty  (1260-1367)  old  people  used  lenses  to  distinguish  small  print. 
The  older  Chinese  word  for  lens  means  "muddy  cloud;"  in  later  times 
a  word  corresponding  to  the  German  "  Augenspiegel"  (eye  mirror)  was 
applied  to  transparent  glass.  These  medieval  glasses  are  said  to  have 
come  from  Turkestan.  Prisoners  from  Turkestan  made  glasses  which 
were  regarded  by  their  Chinese  captors  as  treasures ;  so  valuable  were 
they  that  they  could  be  traded  for  horses.  The  statement  that  Chinese 
glasses  were  imported  from  ^Malacca  refers  to  a  later  time,  for  ^Malacca 
is  first  mentioned  in  Chinese  literature  in  the  fifteenth  century.  In  the 
thirteenth  century,  however,  China  was  in  close  touch  with  other  Asiatic 
nations  following  the  migration  of  the  ^Mongolian  tribes.  Laufer,  to 
whose  studies  we  owe  our  knowledge  of  this  subject  (Mittcil.  zur 
Gcschich.  dcr  Mcdiziu  und  dcr  Xaturwis.,  Bd.  VI.  Nr.  4,  379),  thinks 


4896        EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


J 


Chiiu'se    (lla^isos.       (From    the    collection    of    the    Aiiierican    Mu^eniii    of     Natural 

History,  New  York.) 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4897 

that  the  culture  rehitious  of  the  Asiatic  peoples  of  this  period  make 
it  reasonable  to  attribute  the  source  of  glasses  to  India,  whence  they 
reached  China  througli  Turkestan.  Allowing  for  the  time  necessary 
for  this  transit,  he  dates  glasses  in  India  at  the  end  of  the  twelfth  or 
the  beginning  of  the  thirteenth  century'.  The  Chinese  learned  of 
the  making  of  ordinary  glass  from  the  Romans  in  the  early  Christian 
era,  and  they  came  in  contact  with  Arabian  traders  in  the  coast 
towns  of  southern  China  in  the  eighth  century.  Rock  crystal  is 
widespread  in  China  and  to  it  superstition  attributed  miraculous 
powers.  It  is  to  be  noted  that  early  Chinese  glasses  were  of  essen- 
tially different  design  from  early  European  glasses,  being  large 
lenses,  oval  rather  than  round,  with  rims  of  tortoise  shell  and 
bows  of  brass  or  copper  resting  against  the  temples.  European 
glasses  of  the  thirteenth  century,  on  the  contrary,  were  nose 
glasses  with  circular  lenses.  The  Chinese  variety  conforms  to  the 
type  found  in  Asia  and  suggests  a  separate  origin  from  the  Eu- 
ropean. Beginning  with  the  early  eighteenth  century  European 
glasses  were  imported  into  China  and  have  since  been  the  prevailing 
type. 

At  the  time  when  glasses  were  coming  into  use  in  China  (the  end 
of  the  thirteenth  century),  the  same  invention  began  to  attract  notice 
in  Europe.  The  name  of  Roger  Bacon,  the  English  monk-philos- 
opher, looms  large  in  many  matters  of  scientific  concern  at  this  period. 
So  great  was  his  learning  and  so  extensive  the  range  of  subjects 
treated  in  his  writings  that  he  has  gained  credit  for  numerous  in- 
ventions. It  is  certain  that  he  knew  of  glasses  and  understood  some- 
thing of  optics,  but  it  is  not  certain  that  his  knowledge  was  original. 
A  definite  claim  of  priority  to  Bacon  comes  from  Italy,  where  Armati 
was  said  to  have  invented  glasses  in  1285.  On  a  tombstone  in  a  Flor- 
entine church  was  found  the  inscription  :  "Here  lies  Salvino  d 'Armati 
of  Florence,  the  inventor  of  spectacles.  God  forgive  him  his  sins. 
Died  in  the  year  of  our  Lord  1317"  (see  p.  594  of  this  Encyclopedia). 
Alessandro  della  Spina,  a  Dominican  friar  of  Pisa,  is  said  to  have 
learned  the  art  from  Armati  and  to  have  devised  glasses  by  a  method 
he  refused  to  divulge.  Giordano  da  Rivalto,  a  distinguished  clergy- 
man of  the  time,  said  in  1305  that  he  had  seen  the  man  who  invented 
glasses,  but  he  did  not  give  the  inventor's  name. 

Opposed  to  the  Italian  claims  is  the  consideration  that  Bacon  was 
the  most  learned  man  of  his  time,  as  attested  by  his  monumental 
work,  the  Opus  Ma  jus  (1268),  which  antedates  the  supposed  inven- 
tion of  Armati  by  seventeen  years.  This  work  treats  of  the  science 
of  optics.    Bacon  made  drawings  of  liiconvex  lenses;  he  was  acquainted 

Vol.  VII— 4 


4898        EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

with  tile  shape  of  tlic  crystalline  lens;  he  advised  the  use  of  lenses  by 
the  oki  and  those  who  have  weak  eyes  for  the  purpose  of  maf^uifyinji 
objects  viewed.  Jiaeon's  knowledge  may  well  have  been  transferred 
to  Italy  by  one  of  the  members  of  his  ecclesiastical  order,  who  made 
a  prolonged  stay  in  Florence,  wliere  he  was  detained  on  a  journey  to 
intercede  with  the  Pope  in  behalf  of  his  order.  With  meager  com- 
munication among  the  several  countries  of  Europe,  a  new  invention 
might  readily  be  credited  to  each  community  in  which  it  appeared. 

AVith  characteristic  conservatism  clergy  and  medical  profession 
condemned  the  new  remedial  agency,  Bernard  Gordon,  professor  in 
]\IontpeIlier,  was  the  first  physician  to  mention  glas.ses,  which  he  de- 
clared to  be  unnecessary  if  his  famous  eye  remedies  were  used.  Guy 
de  Chauliac,  physician  to  several  popes,  recommended  glasses  if  his 
own  eye  lotion  did  not  first  effect  a  cure.  Though  individual  monks 
used  and  praised  glasses,  the  church  authorities  at  first  regarded 
these  man-made  devices  as  impertinent  efforts  to  defeat  the  divine 
purpose  of  inflicting  disabilities  upon  the  aged.  Bacon  had  already 
been  imprisoned  for  dealing  in  "black  magic"  and  he  had  abundant 
reason  for  not  wishing  to  increase  his  notoriety ;  hence  we  may  under- 
stand his  failure  to  clarify  his  own  connection  with  the  subject  of 
glasses. 

To  summarize:  the  inventor  of  glasses  is  unknown;  the  nations  of 
antiquity  probably  knew  nothing  of  these  instruments;  the  ancient 
classics  are  devoid  of  reference  to  glasses.  Alhazen  seems  to  have 
made  no  practical  use  of  his  knowledge  of  optics.  Near  the  end  of 
the  thirteenth  century  convex  spherical  lenses  came  into  use  in  China 
and  in  Europe.  It  is  probable  that  neither  obtained  their  knowledge 
directly  from  the  other.  European  evidence  favors  the  view  that 
Roger  Bacon  made  glasses  independently  of  Chinese  influence  or  dis 
covered  the  invention  of  some  learned  predecessor. 

Probably  the  earliest  illustrated  scientific  work  on  the  use  of 
spectacles  was  written  by  Daza  de  Valdes  (Benito),  a  notary  of  the 
Inquisition  at  Seville.  The  sub-title  reads  as  follows:  "Uso  de  los 
antoios  para  todo  genero  de  vista;  En  que  se  enseiia  a  conoeer  los 
grados  que  a  cada  uno  le  faltan  de  su  vista,  y  los  que  tienen  qualesquier 
antojos. "     Inipresso  en  Souilla,  i)or  Diego  Perez.     Ano  de  ]623. 

The  fi-ontispiece  presents  a  wood-cut  portrait  of  the  author  with 
diagrams,  'i'lie  work  is  a  (juarto  of  100  pages,  printed  on  liiin  water- 
mai'ked  paper.  It  is  dedicated  to  Our  Lady  of  Fuensanta,  whose 
ajipea ranee  at  llie  city  of  Cordova  is  also  celebrated  (as  an  introduc- 
tion) in  a  poem  wi'itten  by  a  friend  of  the  author.  Tabl(\s  for  sight 
testing  are  given.  This  l)Ook  is  of  excessive  rarity:  and  there  is  no 
copy  in  the  British  mu.seum. 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


4899 


The  earliest  known  lenses  seem  to  have  been  intended  exclusively 
for  the  relief  of  presbyopia,  the  strongest  lenses  being  -|-  3.00  spheres. 
They  were  plano-convex  or  weakly  concave  on  one  side.  It  is  prob- 
able that  they  were  first  used  as  the  modern  hand  glass  held  close  to 
the  object  viewed,  and  only  gradually  were  methods  devised  to  secure 
the  glasses  before  the  e^'es.  These  primitive  devices  were  essentially 
eyeglasses  and  not  spectacles.  They  consisted  of  one,  or  two,  lenses 
surrounded   by  heavy  rims.     Greeff   (Bcricht  dcr  39th.    Heidelberg. 


Medieval  Paintiug  Showing  Eyeglasses. 

Ophthalmolog.  Gescll.,  1913)  thinks  that  the  usual  opinion  that  the 
monocle  was  the  original  device  is  incorrect,  but  that  the  eyeglass 
with  two  lenses  preceded,  and  the  monocle  followed  as  an  affectation. 
The  rims,  of  various  materials,  metal  and  leather,  were  joined  by  a 
solid  bar  or  bow.  These  might  rest  against  the  nose,  but  were  inse- 
cure and  must  be  held  by  the  wearer's  hand.  For  convenience  handles 
were  attached,  so  that  the  hand  rested  at  the  chin  or  on  the  fore- 
head.   One  model  shows  a  branched  handle  attached  to  both  rims  and 


4900        EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

joined  below  the  chin.  Another  was  attached  to  tlie  wearer's  cap; 
this  is  still  seen  in  Persia.  Cords  were  tied  al)0ut  the  ears  or  sus- 
pended over  the  ears. 

The  oldest  pair  of  glasses  in  preservation  is  in  the  Nuremberg 
nuiseuin,  to  which  they  were  donated  by  the  antiquarian,  Jacques 
Rosenthal,  of  Munich,  who  found  them  in  an  old  volume  of  the  latter 
part  of  the  fifteenth  century,  Greeff  (Zeitsch.  fiir  OphtJuil.  Optik, 
July,  1913).  These  are  of  the  primitive  type  of  round  rimmed  eye- 
glasses with  a  solid  bow  joining  the  rims.  They  are  made  of  leather, 
partly  of  natural  color  and  partly  black.     The  lenses  are   lacking. 


Virgin  and  Child.     (Galleria  Corsini,  Rome.) 


The  frames  are  larger  and  thicker,  and  therefore  thought  to  be  older, 
than  the  interesting  glasses  of  AVilbrand  Perkheimer  (1470-1580), 
also  in  the  Nuremberg  museum.  Greeff  {Arch,  fiir  Augen.  72,  Heft 
1,  1912.)  When  Perkheimer 's  house  was  torn  down  in  1867  and  re- 
moved to  Wartburg,  where  it  remains  as  a  memorial  to  the  worthy 
burgomaster  who  was  a  friend  of  ^lartin  Luther  and  Albrecht  Diirer, 
an  ancient  pair  of  glasses  -was  found  in  a  cranny  of  the  wall,  where 
they  no  doubt  fell  from  the  wainscoting  on  which  the  old  man  placed 
them  when  he  laid  aside  his  reading.  They  are  of  leather  polished 
black  on  the  front  surface.  These  glasses,  like  the  older  pair  de- 
scribed, are  the  common  type  secii  in  tlic  jiicturcs  and  tapestries  of 
the  middle  ages. 

]\Iost  instructive  and  inti-ri'stinji:  arr  the  anai-hronisms  in   the  art 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF        4901 

oi"  this  time.  ^Icii  of  learning;  and  (li«,Miit\'  are  i)ortrayfd  with  glasses 
in  their  hands  or  before  their  eyes.  As  Shakespeare  ignored  the  in- 
consistency of  placing  the  inventions  of  his  own  day  in  the  scenes 
of  historical  plays  representing  more  primitive  times,  so  the  medieval 
artists  did  honor  to  their  historical  characters  by  furnishing  them 
■with  glasses.  A  favorite  honor  to  the  donor  of  a  picture  painted  for 
a  church  was  to  include  the  donor's  portrait  in  one  corner  of  the 
canvas,  indicating  his  high  position  in  the  intellectual  world  by  paint- 
ing a  pair  of  glasses  on  his  person,  liut  the  donor  was  not  the  only 
favoivd  on(\     Even  so  far  ])a('k  as  the  (Jarden  of  Eden  do  we  find 


Saint  .)( 


{H\   Poiiiy.; 


these  aids  to  vision,  as  shown  in  the  Spanish  tapestry  called  the 
Creation  of  Eve,  in  whicli  an  aged  priest  sits  reading  with  eye-glasses 
on  his  nose.  In  the  collection  of  the  late  Benjamin  Altman,  of  New 
York  City,  was  a  painting  entitled  Bathsheba  After  the  Bath,  in 
which  an  old  serving  woman  wears  glasses.  This  is  an  unusual  con- 
ception of  the  artist,  for  only  the  characters  of  dignity  and  impor- 
tance are  ordinarily  pictured  with  glasses.  The  picture  called  the 
Circumcision  of  Christ  contains  a  pair  of  glasses  worn  by  the  High 
Priest.  The  Death  of  the  Virgin  presents  another  such  anachronism ; 
an  apostle  is  wearing  nose  glasses.  A  beautiful  painting,  Avhose  style 
suggests  Leonardo  da  Vinci  shows  the  infant  Jesus  in  his  mother's 


4902        EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


Primitive  Types  of  Eyeglass.     (After  Greeff.) 


Two  Improved  Models  with  Semi-Elastic  Spriugs.    (After  Greeff.) 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4903 

arms  holding  a  i)air  of  glasses,  wliicli  may  be  supposed  to  belong  to 
liis  I'atlier  Joseph,  the  elderly  man  in  tile  background,  Greeff  (Zcitsclc. 


Glasses  with  Hinge  Joint,  to  Fold  One  over  the  Other.     (After  Greeff.) 


Prototype  of  the  Modern  Lorgnette.     (After  Greeff.) 

fur  Opthal.   Optik,  August,  1913).    Saint  Jerome,  patron  saint  of  the 
optician's  guilds,  is  usually  represented  with  glasses. 

In  place  of  the  solid  bow  the  substitution  of  a  jointed  band  of 


4904         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

metal  was  a  distinct  iiuproveiiieiit.  Tiiis  allowed  the  lenses  to  be 
separated  or  di-awii  closer  together,  according  to  the  width  of  the  nose, 
and  so  to  clas])  the  nose  with  additional  security.  A  further  con- 
venience was  a  hinge  joint  in  tlie  connecting  how.  allowing  the  lenses 


Early  Spectacles.      (After  Greeflf.) 


to  fold  one  over  tlie  other,  so  as  to  fit  into  a  small  case.  Iron,  silver, 
gold,  wood,  bone,  ivory,  horn  and  leather  were  used  for  frames.  These 
were  of  natural  color  or  polished,  and  sometimes  liighly  ornamented 
In-  carving  and  filigree  work.  But  few  of  the  early  lenses  have  been 
preserved,  the  old  frames  to  be  seen  in  the  museums  usually  being 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF        4905 

devoid  of  lenses.  They  were  made  of  rock-crystal,  topaz,  emerald, 
in  fact  any  fairly  transparent  stone.  A  variety  of  such  stones  were 
formerly  termed  beryl  (Latin  "berillus,"  French  "bericle,"  German 
"parille"  and  later  "brille"). 


Transitions  Between  Eyeglasses  and  Spectacles.    (After  Greeff.) 

Greeff  {Bericht  der  39th.  Heidelberg.  Ophthalnwlog.  Gesell.,  1913) 
has  depicted  the  evolution  of  glasses  from  the  earliest  crude  type  of 
rimmed  eyeglasses  with  a  heavy  inflexible  bar  to  the  modern  grace- 
ful and  comfortable  devices.  The  insecurity  of  the  primitive  forms 
led  to  the  gradual  development  of  methods  to  fix  the  glasses  on  the 


49()G         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

nose.  First  a  nail  iiiiitt-d  the  Iwo  halves  of  the  iioii  (•oiiiiccting  rod, 
allowing  a  little  motion.  This  type  was  widespread  in  the  fourteenth 
century.  Later  more  elastic  materials  were  substituted  until  some- 
thing comparable  to  the  spring  of  the  modem  eyeglass  was  invented. 
From  a  type  with  two  long  handles,  one  attached  to  each  rim  and 
joined  below,  was  evolved  the  French  binocle,  and  finally  the  mod- 
ern lorgnette  (19th  century). 


Transitions  Between  Eyeglasses  and  Spectacles.    (After  Pergeus.) 


It  is  likely  that  grosser  iiyperopic  defects  soon  received  relief  after 
the  first  era  of  the  use  of  lenses  to  correct  presbyopia  alone.  Not 
until  the  early  sixteenth  century  did  concave  lenses  for  the  correc- 
tion of  myopia  come  into  use.  The  earliest  picture  showing  them  is 
the  portrait  of  Pope  Leo  X,  by  Raphael  (1517)  in  the  Palazzo  Pitti 
in  Florence.  The  concavity  of  the  lens  is  well  shown  by  the  reflex. 
It  is  related  that  Leo  X  was  a  successful  huntsman  and  boasted  of 
seeing  better  than  his  companions  despite  his  nearsightedness. 

Cataract  glasses  are  mentioned  in  1623  by  Daea  de  Valdes. 

In  France  the  clerg>'  were  the  first  makers  of  glasses.  Later  came 
the  era  of  guilds  which  controlled  this  industry  along  with  many 
others.     As  early  as  1465  the  Spectacle  IMakers'  Guild  took  part  in 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4907 

a  review  of  merchants  and  ciartsnifii  hcl'orc  tlic  French  king.  This 
organization  survived  until  abolished  by  the  French  government  in 
1785.  Mention  is  iiuide  of  the  Si)ectach'  ^lakers'  (Juihl  in  P]ngland 
in  1563,  ami  several  charters  were  granted  to  opticians  hy  Charles  I 
and  Charles  II.  Witii  tlie  doing  away  with  guilds,  peddlers  became 
the  chief  source  of  glasses  for  the  general  public.  They  traveled 
through  the  land  selling  their  imperfect  wares  to  those  who  might 
select  convex  or  concave  lenses  for  the  grosser  defects  of  presbyopia, 
hyperopia,  or  myopia.  It  was  only  in  the  later  years  of  the  seven- 
teenth century  in  Europe  and  the  beginning  of  the  eighteenth  cen- 
tury in  America  that  opticians'  stores  became  numerous.     Previous 


From  the  Original  Copper  Plate  in  the  Collection  of  von  Pflugk  in  Dresden. 

to  the  days  of  scientific  concern  with  refraction  by  the  medical  pro- 
fession oul}'  a  few  reputable  opticians  succeeded.  Notable  among 
these  were  the  historical  firms  of  Nuremberg,  which  interesting  city 
now  contains  the  most  valual)le  collection  of  old  glasses.  Here  worked 
successive  generations  of  opticians  whose  names  are  preserved  on 
copper  plates  from  which  their  letter  heads  and  advertisements  were 
made.  The  famous  Schmidt  family  have  been  opticians  in  Nurem- 
berg from  1634  to  the  present  time.  Paul  Belgrad,  Paul  Egrad,  Gott- 
lieb Schaab  and  Hermann  Gunt  are  among  the  names  associated,  dur- 
ing the  eighteenth  and  nineteenth  centuries,  with  the  optical  industry 
in  Nuremberg. 

The  cases  designed  for  old  glasses  are  interesting  examples  of  the 
handicraft  of  the  times.  They  were  of  many  shapes  and  sizes,  gen- 
erally bulky,  and  varied  in  style  from  plain  leather  to  the  most  costly 
creations  in  metal  with  elaborate  ornamentation  of  gold,  silver  and 


4908         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


Old  Eyeglass  Cases. 


(i'^om  the  collection  of  Madame  Heyman  in  Paris. 
After  E.  C.  BuU.) 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


4909 


precious  stones.     The  largest  collections  of  these  old  cases  are  those 
of  the  Nuremberg  JMuseuni  and  of  ]Madam  Heymaii  in  Paris. 

Excepting  the  Chinese,  it  is  to  be  noted  that,  though  the  terms 
''spectacles"  and  "spectacle  makers"  Avere  used  in  earlier  times,  it 
was  not  until  the  eighteenth  century  that  spectacles  in  the  modern 
sense  of  the  word,  as  opposed  to  eyeglasses,  were  devised.  Through 
transition  forms  the  evolution  of  the  comfortable  and  secure  spectacles 


Very  Early  Spectacles.     (From  E.  C.  Bull's  private  coUeetiou.) 


of  today  can  be  traced  and  only  <iuite  recently  have  eyeglasses  at- 
tained any  such  degree  of  perfection  with  the  aid  of  clever  mechanical 
contrivances.  Thus  the  sequence  is  seen  to  be:  crude  eyeglasses, 
transition  forms,  crude  spectacles,  perfected  spectacles,  perfected  ej^e- 
glasses. 

In  1746  the  optician  Thomin,  of  Paris,  advertised  glasses  which 
"allow  free  breathing."  In  1752  Ayscough,  a  London  optician,  made 
spectacles.  The  first  models  had  sliort  temples  ending  in  a  plate  or 
ring  ill  Iroiit  of  the  ears;  next  the  temples  reached  behind  the  ears 
pressing  against  the  occiput,  or  were  united  l)y  threads  tied  behind 


Old  Eyeglasses.     (From  tlio  i-olloction  of  E.  C.  Bull.) 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF        4011 

the  occiput;  next  a  joiiil  was  added  witli  a  slioi't  piece  of  metal  extend- 
ing from  the  horizontal  temple  down  behind  the  ear.  This  vertical 
piece  was  also  curved  conforming  to  the  curve  of  the  ear.  Straight 
temples  continued  in  favor  until  very  recent  times  and  are  used  today 
by  a  few  individuals,  altliougli  the  solid  temi)le  of  one  piece  sufficiently 


E:skiiiio  Snow  Goggles.      (From  the  colleetioii  in  the  U.  S.  National  Museum, 

Washington,  D.  C.) 

flexible  to  allow  accurate  adjustment  to  the  contour  of  the  ear  has 
largely  superseded  all  the  older  models. 

An  important  function  of  glasses  has  long  been  that  of  protecting  the 
eyes  from  excessive  light.  How  far  into  antiquity  this  conception 
goes  we  do  not  know ;  but  primitive  tribes  in  various  parts  of  the 
world  devised  protective  goggles  before  contact  with  civilization 
brought  knowledge  of  glass.  The  Eskimos  have  long  used  wooden 
goggles  hollowed  out  to  fit  over  the  eyes  and  attached  behind  the  head 


4912        EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

by  strings  of  leather  or  sinew.  Small  round  holes  or  slits  served  to 
admit  a  minimum  of  light  while  the  back  of  the  wood  was  darkened 
with  smoke,  black  paint  or  graphite.  ]\Iore  ligiit  and  graceful  is  the 
model  consisting  of  two  small  wooden  travs  united  bv  a  broad  band 


Eskimo  Snow  Goggles. 


(From  the  collection  of  the  U.  S.  National  Museum, 
Washington,  D.  C.) 


of  dressed  hide,  rawhide  strings  fastening  the  whole  to  the  head.  The 
extensive  collection  in  the  National  (Smithsonian)  Institute  in  AVash- 
ington  shows  these  and  other  variations  and  improvements  marking 
the  contact  of  the  Eskimos. with  civilization.  Among  the  Chinese  a 
sort  of  visor,  like  the  peak  of  a  jockey's  cap,  has  been  used  as  well  as 
goggles.  From  Tibet  come  eye  shades  made  of  finely  woven  horsehair 
and  of  silk  with  the  ends  sewed  into  bits  of  embroidered  flannel  to  tie 
behind  the  head.     A  similar  Tibetan  device  is  to  be  seen  in  the  Field 


Eskimo  Snow  Goggles.     (From  the  collection  of  the  U.  S.  National  Museum, 

Washiijgton,  D.  C.) 
Vol.  VI 1-5  ' 


4914         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


Chinese  Visor  aiul  Case,  and   Tibetan  Eye  Shades.     (From  the  eolleetioii  of  the 
U.  S.  National   ]\luseuni,  Washington,   D.  C.) 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4915 

Columhian  ^lu.si'uiii  of  Natural  History  in  Clii('ay:o.  This  i)rot(.'C'tive 
shade  is  iiloiitieal  in  shape  with  tlie  present-day  automobile  goggles. 
The  drivers  of  dog  sledges  in  Siberia  wear  tin  proteetors  with  minute 
perforations  to  admit  light. 

Out  of  the  use  of  minute  openings,  round  and  slit-like,  in  opaque  pro- 
tecting devices  before  the  eyes  probably  grew  the  observation  that 
vision  could  be  improved  by  the  stenopeic  slit.  It  has  long  been 
known  that  myopes  see  better  by  producing,  through  the  partial 
closure  of  the  palpebral  fissure  ("squinting"),  a  stenopeic  slit  between 
the  lids.  ''Del  Duello,''  published  in  Venice  in  1551,  recognizes  and 
allows  a  slit-like  opening  in  the  visor  for  myopes  in  duelling  and  in 
battle,  flasks  were  utilized  in  the  treatment  of  strabismus  for  the 
purpose  of  forcing  the  faulty  eye  to  assume  a  normal  position  in  look- 
ing through  a  small  aperture,  the  location  of  the  apertures  varying 
according  as  the  strabismus  was  convergent  or  divergent.  Such  a 
mask  was  used  by  Ambrose  Pare  in  1575,  and  the  device  was  pictured 
in  Bartisch's  famous  text-book  in  1583.  Deformed  pupils,  scarred  cor- 
neas, nyctalopia,  and  albinism  are  mentioned  as  conditions  calling  for 
the  mask.  (Pergens,  ''Die  Geschich.  der  stenop.  Brille,"  Hermann 
Baas  Festschrift,  20th.  Ahhand.  zur  Gesch.  der  Medizin,  1908.)  These 
minor  uses  of  small  apertures  for  vision  naturally  disappeared  with 
the  advent  of  lenses  for  both  visual  and  protective  purposes. 

Another  protective  device  is  the  celluloid  spectacles  manufactured 
in  Stuttgart,  Germany.  These  are  white  or  gray  and  close-fitting  with 
holes  to  admit  air.  They  are  intended  for  protection  from  foreign 
bodies  and  from  bright  light,  for  wliidi  purpose  mountain  climbers  use 
them.  In  colors  they  have  been  used  in  testing  for  ocular  muscle 
palsies  and  malingering  (see  Vol.  Ill,  page  192-t,  of  this  Encyclo- 
pedia). 

Primitive  means  of  escaping  the  discomfort  and  harm  of  glaring 
light  reflected  from  snow,  sand,  and  water  have  gradually  given  way 
to  spectacles  containing  tinted  lenses.  Colored  glass  was  made  by  the 
ancients;  but  only  in  the  latter  half  of  the  sixteenth  century  were 
transparent,  colored  lenses  used  for  protection  against  glare.  In  the 
seventeenth  century  Venice  was  the  source  of  most  of  the  colored  glass. 
E.  E.  Schreiner,  of  New  York,  has  investigated  this  subject  (Short 
History  of  Colored  Glass  and  Lensoi  from  I'ifil  to  1913).  He  finds 
that  the  earliest  reference  is  to  green  lenses  manufactured  in  1561  by 
Aucott,  of  [Middlesex  County,  I^lngland.  In  1672,  Pierson.  of  London, 
sold  blue  glasses.  In  1767,  George  Adams,  of  London,  advertised 
smoke  glass  under  the  name  of  "gray."  The  first  American  record 
is  an  old   advertisement   of  one  James   Peters,   of   Philadelphia,   an- 


41)16         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

jiomiciiig  wliitf.  gfccii.  liliic.  and  i^vny  ]<'iis('s  for  .sale.  Aiiilx-r  lenses 
were  made  by  (Jeoi-j^e  and  Mlias  Solomons,  opticians  of  liedt'oi'd 
Siiuari',  J<]nj,dand,  in  the  year  LS;j2.  Ciievalier,  of  Paris,  in  l.sT^i,  used 
two  i)Iates  of  glass,  one  dark  blue  and  the  other  dark  smoke,  whieh 
he  calliMl  ■' i']leetrie.  "  in  1<S,S()  tile  (•hloi-o])hyll  <;reen  lens  was  made 
by  Fargier,  of  I'aris,  who  claimed  tor  it  the  j)roi)crt\-  of  absorbing 
ultra-violet  rays,  in  1885  William  Thompson,  of  Pliiiadelpiiia.  pro- 
])osed  the  amethyst  glass  obtained  fi-om  windows  tint<'d  by  long  ex- 
posure. 

Conditions  of  life  i)revious  to  the  ei<:hteentii  century  i-t-ndered  tin' 
use  of  glasses  luinecessary  1o  the  nui.joi'i1\-  of  iiulividuals  and  their 
costliness  was  fre(iuently  j)rohibitive.  The  al)ilit\'  to  read  and  write 
was  the  possession  of  tlu'  learned  few  and  no  adequate  ai)preciation 
of  optical  ])rincii)les  liatl  arisen  save  in  the  minds  of  a  few  scientists 
following  Kei)ler"s  observations  (160-4).  (ilasses  were  highly  valued 
by  their  wealthy  ])()ssessors.  In  1:379  the  will  of  Charles  ^^,  of  France, 
bequeathed  two  i^airs  of  glasses,  one  with  black  horn  rims  and  a  wooden 
handle,  one  of  gold  with  a  large  silver  case  weighing  ten  ])Ounds. 
Frederick  the  Great  is  said  to  have  had  Ilieronymus  Meyer  come  to 
Frankfort  to  make  him  a  pair  of  glasses.  Napoleon  I  had  a  "binocle" 
of  mother  of  pearl  with  l)ranches  of  gold,  the  lenses  being  made  of 
rock  cr^'stal. 

Such  luxuries  were  caricatured  by  Hogarth  in  England,  ami  in 
France  in  the  time  of  the  Directorate.  Physicians  knew  little  of  optics 
and  regarded  the  prescribing  of  glassL's  as  beneath  their  dignity.  The 
famous  German  ophthalmologist,  George  Bartisch,  in  his  text  book 
published  in  1583,  condemned  their  use  severely.  Von  Arlt,  in  the 
nineteenth  century,  was  the  first  ophthalmologist  of  note  to  pay  due 
attention  to  glasses  as  a  valuable  addition  to  the  therapeutic  armamen- 
tarium of  the  physician. 

In  the  early  nineteenth  centui'y  a  gi'eat  advance  was  made  in  the 
application  of  lenses  to  tiie  (toi'rection  of  ei-rors  of  I'efraction.  when  the 
English  scientist,  Thomas  Young,  demonstrated  the  condition  of  astig- 
matism (1801).  Sir  David  Brewster,  of  Edinburgh,  whose  name  is 
mentioned  in  this  connection,  })elonged  to  a  younger  generation  and 
no  doubt  his  experiments  were  based  on  Young's  previous  observa- 
tions. Sir  George  Aii'y  was  tlie  first  individual  to  receive  the  benefit 
of  the  cori'ection  of  his  astigmatism  which  he  worked  out  himself  and 
foi-  which  the  oj)tician  Fullei',  of  Ipswich,  England,  furnished  glasses 
in  1827.  The  optical  fii-m  of  McAllister,  of  Philadelphia,  ground 
cylindi-ical  lenses  in  1821).  and  it  is  l)elieved  that  sphero-cylinders  were 
first  ground  in  Amei'ica  by  the  optician  Zentmayer,  of  Philadelphia, 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         VMl 

who  had  the  distiiictiou  ol"  being  the  first  in  this  country  to  limit  iiis 

optical  business  to  the  filling  of  physicians'  prescriptions  for  glasses. 

When  the  factor  of  "eye  strain"  based  upon  astigmatism  received 


].   Heiijaniiii  Franklin's  Bit'ooals. 

-.  Kifhardson 's  Bifocals,  London,  1797. 

;{.  Thomas  Jefferson's  Bifocals,   1806.      (After  E.  C.  Bull.) 


appreciation,  tlie  making  of  glasses  rapidly  became  an  important 
industry  ministering  to  the  needs  of  thousands  who  were  unconcerned 
with  the  optician's  art  so  long  as  it  applied  only  to  the  aged  and  the 
grossly  farsighted  and  nearsighted  indiviihial. 

From  the  time  of  Koijci'  Bacon  to  the  hitter  half  of  tht»  nineteenth 


49 IS         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

(•('iitui-\'  fill'  <'V()liit  ion  of  till'  liistiiry  of  ^hisses  \\;is  slow,  consistently 
with  tile  civilization  of  this  jx-i'iod.  So  long  sis  tnins|»orlation  was 
(lillicult.  and  dangci-ous,  hooks  cuiiihcrsoiiic  and  few,  education  limited 
to  the  iiiiiiority  of  iiirii  and  dcnirij  allo;^ct  her  to  women,  and  life 
largely  rural  with  few  occupations  r(M|iiiiing  jnolonged  use  of  the  eyes 
at  close  range,  the  woi'ld  in  gt'iiei-al  endured  what  eye;  defects  nature 
had  inflicted  and  the  fifth  decade  of  life  brought  the  failing  of  near 
vision  which  was  accepted  along  with  gray  hairs  and  toothlessness. 
Johann  Kepler's  demonstration  of  the  principles  of  optics  was  of 
scientific  interest;  hut  the  medical  profession  awaited  the  oi)hthalino- 
scope  of  Ilelmholz  (1851),  the  classic  work  of  Donders  (The  l!( frac- 
tion and  Accommodation  of  the  Eye,  1864),  and  i)liarmacology's  gift 


Trifocals  of  John  Isaac  Hawkins,  London,  18li5.     (After  E.  C.  Bull.) 

of  cycloplegic  drugs  before  an  accurate  refraction  and  i)roof  of  the 
value  of  glasses  in  the  relief  of  eye  strain  incident  to  modern  condi- 
tions of  life  could  be  secured.  These  veritable  boons  to  mankind 
have  relieved  suffering,  prolonged  years  of  usefulness,  forestalled 
disaster  to  the  entire  organism  as  well  as  the  ocular  apparatus,  and 
added  to  the  sum  total  of  human  happiness  to  a  degree  which  it  taxes 
the  imagination  to  conceive. 

The  origin  and  early  uses  of  prismatic  lenses  are  unknown.  In 
1844,  Charles  Chevalier,  of  Paris,  recommended  glasses  for  the  cor- 
rection of  squint.  It  is  possible  that  he  meant  prisms,  for  at  that  time 
there  was  no  appreciation  of  the  relationship  between  errors  of  refrac- 
tion and  squint,  and  no  i)ractice  of  the  refinements  of  refraction  with 
the  aid  of  cycloplegics  as  understood  today.  In  1865.  Dyer  called  at- 
tention to  the  valui;  of  prisms  for  gymnastic  exercise  of  weak  ocular 
muscles.  For  the  past  fifty  years  prisms  have  been  widely  used. 
Accuracy  in  refraction  has  in  itself  so  righted  nuiscular  imbalance 
that  prisms  are  no  longer  used  exti'nsiv(!ly  as  part  of  the  correcting 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


4!)1!) 


lenses ;  hut  iis  iiisl  niniciits  I'oi'  <j:\iiiii;i.st  ii-  cxcreisc.  ;is  tests  lor  m.-iliii^^er- 
ing,  to  iiieiisui'e  the  j)()\vei'  of  the  sever;il  e\t  fiioeiihii'  iiiiiseh'S,  ;iii(l  to 
relieve  diplopiii  tliey  luive  ;i  hirji'e  pbiee  in  opht h;ihnic  |»riictice. 

The   snli.jei't    of   plisniiltjc    h'nses   is  tre;iti'(l    t'lllly    Iroiii    sever;il    stMluh 

points  in  ;in  ;irtii-h'  on  Ophthalmic  lenses  in  ;i  hitei'  \-ohinic  of  tliis 
Encijiiopedia. 


Auxiliary   Lenses   for   bifocals.      (After    E.    C.    Bull.) 
1.  Butterfield,   1895.     'l.  Orr,   189G.     3.  Taylor,   1S98. 

Tile  invention  of  l)ifoc'al  glasses  is  credited  to  Benjamin  1^'ranldin  in 
the  year  1784.  The  pnr})ose  and  results  of  this  convenient  arrangt'- 
nient  cannot  be  indicated  better  than  in  his  own  simple  statement  in 
a  letter  (quoted  from  the  Posthumous  Works  of  Benjamin  FranhUn, 
page  173)  :  "1  had  two  pairs  of  spectacles  that  1  used  alternately  be- 
cause when  traveling  sometimes  1  passed  the  time  in  reading,  some- 
times in  looking  at  the  country.  The  change  from  ont-  i>air  to  another 
was  troul)lesome  and  often  was  not  etfeeted  soon  enough  to  allow  me 
to  see  what  I  wanted.     So  I  had  my  glasses  cut  in  two  halves,  one  half 


4920         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

of  eacli  Ixiii^'  put  in  the  same  rraiiic  In  this  way  I  wear  my  spectacles 
constantly,  ami  I  liaxc  only  to  look  Ilir(tnf;li  tlic  nppci-  or  tlirouf^li  tin- 
lower  i)ai't  ill  older  to  see  distinctly  t'ai'  distant  objects  or  near 
objects." 

Many  cbanj^fs  in  the  l)ifocal  have  occurred  since  Franklin's  time. 
The  upjx'r  and  lower  lenses  liave  Ijcen  separated  by  a  shell  rim;  tlie 


' '  Grab  Fronts  ' '  and  ' '  Grab  Backs. ' '     (After  E.  C.  Bull.) 

lower  lens  has  been  tilted  in  at  the  bottom  to  occupy  a  better  position 
for  reading  (an  English  model  of  the  early  nineteenth  century)  ;  a 
small  segment  of  the  upper  lens  has  lieen  eut  out  and  the  reading 
glass  inserted  in  its  place  with  cement,  and  later  titted  into  a  groove 
in  the  upper  lens.  In  1826  John  Isaac  Hawkins,  of  London,  described 
his  invention  of  trifocal  glasses,  and  E.  C.  Bull,  of  Pasadena.  Califor- 
nia, (to  w^hom  the  writer  is  indebted  for  valuable  unpublished  notes 
descriptive   of  his   comprehensive   collection   of   glasses)    mentions   a 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4021 

patent  of  Beetle,  of  Lyons,  for  plaeing  in  oiif  I'rann'  lour  j;la.sses  ol" 
different  strengths  witli  (liH'erciit  inclinations,  tlif  foiii'  tn<rctlicr  mak- 
ing segments  of  a  common  circle.  (See,  also,  Franklin,  Benjamin.) 
As  early  as  1836  the  effort  was  made  to  obtain  with  oiif  piece  of  glass 
the  double  focus  recjuired  foi-  near  and  far  seeing.      I.  Schuster  aeeom- 


Ciral)  Front  with  Bar  Spring  Bridge. 

plished  this  by  grinding  off  a  small  portion  of  the  reading  lens  to  give 
distant  vision.  Numerous  opticians  in  England  and  America  followed 
this  plan,  until  eventually  we  find  the  exquisite  pieces  of  workmanship 
to  be  described  later  as  kryptok  and  one-piece  bifocals.  The  disadvan- 
tage of  crude  bifocals  was  that  they  did  not  admit  of  comfoi-t  in  walk- 
ing. To  obviate  this  difficulty  auxiliary  lenses  were  attached  to  the 
frames  so  as  to  be  withdrawn  from  the  field  of  vision  when  the  wearer 


Cement  Bifocals  of  Samuel  Gregg,  1866.     (After  E.  C.  Bull.) 


wished  to  use  distance  lenses  only,  and  to  be  swung  into  place  when 
he  wished  to  see  nearliy.  Of  the  numerous  models  devised,  all  con- 
sist essentially  of  a  short  arm  pivoted  to  the  temple,  bridge,  or  rim. 
None  of  these  has  attained  popularity.  Of  more  freijuent  use  are  the 
"grab-backs"  and  "grab-fronts''  which  hook  over  the  end  pieces  of 
the  temples  either  behind  or  in  front  of  the  distance  glasses. 

The  most  practical  bifocal  of  the  two-piece  variety  and  the  one  com- 
monly used  today  has  the  presbyopic  correction  made  by  a  small  seg- 
ment cemented  with  balsam  to  the  lower  part  of  the  distance  glass. 
This  originated  with  Samuel  Gregg  in  1866  and  was  re-invented  by 
several  other  opticians. 


4!)22        EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


Hogarth's  cjiricitiirt's  coiitjiiiicd  nuiny  dfjiw  iii;_'s  of  eyeglasses  hut 
only  one  of  spectacles.  This  lael  sii<i<icsls  that  it  \v;is  ahout  the  year 
IT")!)  when  spectacles  cjiiiie  into  use  in  Enj^land.  As  has  heen  stated, 
the  short  straight  hows  gave  way  to  longei-  jointed  hows  so  that  hy  the 
end  of  the  seventi-enth  century  something  like  the  pi'iniitive  Chinese 
types  were  in  vogue  in  Europe.  The  long  hows  were  called  "telescope 
sides"  and  "turn-pins"  according  to  the  mechanism  by  which  they 
were  reduced   in  length  to  (it  in  the  case.     The  long,  straight,  solid 


Cement  Bifoc-al  Lenses,  with  Various  Shajies  of  Se^^nients. 

temples  worn  by  George  Washington  ahout  1789  are  now  preserved  in 
Philadelphia. 

Al)ont  the  year  1840,  Waldstein,  of  Vienna,  devised  rimless  spec- 
tacles, attaching  bridge  and  ])0ws  to  the  lenses  by  means  of  clamps  and 
screws  in  place  of  the  former  method  of  inserting  the  bevel  edge  of  the 
lens  into  a  grooved  eye-wire.  Screws  had  heen  used  for  a  long  time 
in  the  frames,  as  shown  in  an  old  Xurembi'i'u-  i)air  made  of  ])rass,  l)ut 
holes  had  not  been  drilled  through  the  glass.  Sokleriiig,  as  applied  to 
both  rinnned  and  rindess  glasses,  was  not  known  until  the  nineteenth 
century.  Tin-  limless  form  in  both  eyeglasses  and  spectacles  has  be- 
come steadil\-  moi'e  populjir,  being  lighter  and  neatei'.  and  has  largely 


Old  Styles  of  Sjieetacles.     (I'luin  the  collection  of  11  C.  lUiil.j 


4924         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

superst'di'd  tile  riiiiiiicd   lonii  cxrcpt   foi-  cliildi'cii  ;iii<|  t'ni'  ;idult,s  wliost- 
occupations  .sul),)cct  llicir  ^hisses  to  rough  usage:  for  the  hoh'S  drilled 


I 


Straight  Templed  Spectacles. 


Spectacle  Temples. 


in  the  lenses  of  rimless  glasses  to  admit  the  screws  are  a  source  of 
weakness. 

By  the  year  1850,  rimless  spectacles  witli  liglit  hook  temples  appeared 
in  England.  These  temples,  ealled  "riding  bows,"  admit  of  smooth 
adjustment  to  the  curve  of  the  Icick  of  the  ears  where  they  rest  witli- 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF        4!)25 


Cylindrical   Bridge  -  x  Nose  Liebold  Nose 

Spectacle  Temples,  End  Pieces,  and  Bridyes. 


4!)2G         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

out  uikIuc  pressure.  Tliey  v;ii-\-  in  Hexihility  t'l-oui  tin;  stilf  lO-earat 
iSo\d  hows  to  the  very  soft  "eal)h'"  and  "half  cahle"  and  "spirals." 
Tlie  I'onner  luive  tlie  advautaj^e  of  <jjreater  permanence  of  adjustment; 
tile  hitter  are  more  apreeahh'  to  a  hyi)ersensitive  skin.  Tlie  very 
Mexihie  hows  are  of  vahie  in  inverse  ratio  to  the  skill  exercised  in 
adjustinfr  tlie  stiff  ami  durahle  liows. 


Prosont  Day  Riding  Bow  Spectacles  with  yaddle  Bridge. 

With  the  suhstitiition  of  the  saddle  bridge  for  the  older  C-bridge 
which  was  used  with  the  straight  temples,  and  the  riding  bows  already 
described,  spectacles  have  reached  the  present  highly  perfected  form. 
The  saddle  bridge  distributes  pressure  widely  and  evenlj^  over  the 
bridge  of  the  nose,  being  capable  of  infinite  variation  in  angle  accord- 
ing to  the  shape  of  the  nose.  It  also  allows  the  use  of  larger  lenses 
than  were  possible  with  the  C-bridge  without  altering  the  pupillary 


Eyeglass  Guards  witli  Sjoi-tailo  Bridge. 

distance,  ("onteinporary  spectacles,  therefore,  are  seen  to  consist  of 
riding  bows  connected  li\"  a  hinge  .joint  with  end  pieces  which  are 
soldei'ed  to  clamps  into  which  lenses  are  scrt'weil,  and  a  saddle  bridge 
likewise  soldered  to  clamps  to  hold  the  lenses.  Hiinmed  s])ec1acles 
are  devoid  of  clamps  and  screws,  hut  lia\'c  eye-wires  into  the  grooves 
of  which  the  bevel  v{\<>;c  of  the  lenses  lits.  hi'idm'  and  end  piece  being 
soldered  to  the  eye-wire. 

Px'yond  the  fact  that  early  lensi'S  were  cruile  affairs  iiKule  of  semi- 
transi)arent  stone  and  pebbles,  and  later  of  such  inferior  glass  as  was 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


4!)27 


m;iinir;i('tiii'c(l  in  iMii'opc,  little  cnii  he  said  of  the  art  of  iiiakiii<r  lenses 
hei'ore  tiie  iiiiieteeiit h  century.  \'enice  was  long  the  chief  source  of 
<;hi.ss.  In  l")!)!  lenses  were  nuide  by  saturating  amber  in  linseed  oil, 
and  slioi'tly  t lierea Iter  colored  glasses  for  protecting  the  eyes  against 
excessive  li<ilit   came  into  use. 


t'oinliiiiiitioii  of   I']_vegi;iss   .Momitiiii^s  and   Siicctiiclo  'roiiij)k'H. 

I'ntil  the  nineteenth  century  large  round  lenses  were  nuide.  These 
were  followed  by  small  round  lenses  which  were  ridiculed  as  an 
affectation.  A  succession  of  shapes  became  popular ;  namely  octagonal, 
(juadrilateral,  square,  and  finally  oval.     At  first  the  octagonal  form 


Leaf    Shape. 


Elliptical. 
Lenses  of  Odd  S|i;i|ies. 


Barnes   Crescent   No.   2. 


was  i-eser\c'(|  I'oi-  cylinders;  but  later  it  became  tlu'  couuiion  form  for 
all  lenses.  At  the  present  time  the  oval  lens  is  chiefly  used.  Odd 
shapes  to  give  a  longer  vertical  diameter,  and  crescents  to  allow^  free 
distant  vision  over  the  reading  lens,  are  also  seen.     Quite  recently 


4928         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


large  roiiiul  lenses  enclosed  in  shell  or  <rol(l  rims  have  become  a  fad. 
]t  is  interesting  to  recall  that  the  same  fad  existed  in  France  in  177"), 
as  illustrated  in  tiie  artist  Chardin's  portrait  of  himself. 

The  glass  used  for  lenses  is  manufactured  in  Germany.  The  best 
is  a  crown  glass  made  by  the  famous  firms  in  Jena,  Schott  und  Genos- 
sen  and  Zeiss.  The  situation  is  reversed,  however,  in  reference  to  the 
mountinprs  designed  to  hold  lenses. 


Portrait  ol  the  Fieiuli  Artist,  Chardiu.      (By  liiinsclf,  17/5.) 

European  glasses  were  imported  in  America  prior  to  1867.  From 
tiiat  date,  however,  the  tide  has  turned  \intil  now  Kurope  imports 
glasses  from  America.  The  optical  industry  in  the  United  States  has 
made  rapid  progress,  so  much  so  that  the  history  of  glasses  in  the  past 
half  century  is  essentially  American  history.  The  patents  granted  in 
this  country  since  1870  are  legion:  many  of  them  are  impractical:  and 
many  represent  so  little  change  from  their  predecessors  that  they 
scarcely  deserve  mention.  One  interested  in  the  subject  will  lind  un- 
liiiiiied  iiialerial  in  llie  i'e])(»i'ts  of  the  1'.  S.  I'atent  Office,  from  the 
mass  of  which  se\-er;il  Tairly  distinct  types  of  glasses  may  be  sifted. 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4929 


Eyeglass  Springs  ami  Guanls.    (After  E.  C.  Bull.) 


J.  K.  McDonald,  1868. 
G.  N.  Cumniiiigs,  ISOT. 
Prentice,  X.  Y.,  1867. 
F.  P.  Jannoroni",   1877. 
Burbank,  1875. 


Boyle,  1896. 

G.  B.  Bridgden,  ISTo. 

Flcmpler,  1877. 

J.  W.  Hassellund,  1886. 


N.  Fowler,  1876. 
J.  P.Miciiaels,  N.  Y.,1881. 
C.  C.  Parker,   1875. 
Joiiannes,  1877. 


Vol.  VII  -0 


K.V('n|;,ss  Splines  ;iinl  <  iiiMi.ls.    (Aflcr  !•;.  C.  liiill.) 

i;.  \\:nit.  ISCT.                              I'cckliiiiii,   IST").  K.  I\.  .lossclyn,  ISC. 

.1.  S.  S|.ciic.T.    ISTC.                    \\:illcr  S.   Wells.   18SS.  (iilboit.  ISSG. 

.1.  .1.  I'.aiiscii.  1SG8.                    BoiRol.  I.fvv.  1893. 

1.  (1. •incuts,   1871.                       IMcDowcll,  LSI);!.  Opdyko,   1882. 

\V.  r.arl.rr.   IST'.)                          K.  \V.  McAllister,  1885.  l.  Alcxaiulor,  1876. 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4931 

E.  C.  I>iill  has  iiuulc  a  tlioroiigli  study  of  tlio  sul)ject  of  American 
glasses  and  ])i-('S('iits  the  devi'lopinent  of  tht'  industry  in  a  series  of  con- 
tributions to  tlie  Optical  Journal.  lie  considers  the  year  1867  note- 
worthy as  the  tlate  of  nuiiici'ous  inii)()rtant  inventions.  Cummings,  of 
Providence,  R.  I.,  attachetl  the  lower  part  of  a  bow  spring  to  the  eye- 
wire  and  to  the  upper  part  of  the  eye-wire  a  loop  through  which  the 
l)Ow  spring  passed.  Jn  tliis  way  a  wide  disti'ibution  of  pressure  was 
obtained.  Prentice,  of  Xcw  Yoi'k,  in  the  same  year,  made  a  guard 
wliich  projected  far  towai'ds  the  nose  at  its  top,  instead  of  following 
the  curve  of  the  lens,  thus  fitting  closely  tiir  thin  part  of  the  nose. 
This  device  is  perpetuateil  in  the  common  shell  eyeglasses  of  today. 
Want,  of  New  Haven,  Conn.,  nuide  a  more  valuable  guard  attached 
only  by  its  upi)er  end  to  the  eye-wire,  the  entire  li'iigth  being  capable 
of  adjustment  to  the  nose.  Another  invention  which  had  many  imita- 
tors had  the  guard  attached  by  its  lower  end  to  the  eye-wire.  In  1S68 
McDonald,  of  Newark,  N.  J.,  used  a  soft  rubber  pad  as  a  guard,  at- 
taching it  to  an  older  model  which  barkens  back  to  primitive  times; 
nameh',  a  bridge  consisting  of  two  solid  bars  with  a  hinge  joint  to  be 
drawn  together  ])y  an  elastic  band.  In  the  same  year  Bausch,  of 
Rochester,  N.  Y.,  made  an  adjustable  spring  and  guard  regulated  by 
screws.  To  him  is  due  the  first  adjustment  of  the  lenses  before  the 
eyes,  and  to  Want  is  due  the  first  adjustment  to  the  nose. 

In  1871  Clements  invented  the  first  of  the  self-adjusting  guards, 
the  nose-piece  oscillating  upon  a  pivot  attached  to  the  eye-wire. 
Further  developments  of  this  idea  of  rocking  guards  were  made  by 
Burbank,  of  Springfield,  Mass.  (1875)  and  others.  In  1877  Ilempler, 
of  Washington,  utilized  a  curved  arm  traveling  down  from  the  eye- 
wire  through  the  center  of  which  was  a  hole  and  at  the  lower  end  a 
slot.  A  loop  passed  through  the  hole  and  slot  and  was  attached  to  the 
main  guard  which  had  considerable  vertical  play.  In  the  same  year 
a  ball  and  socket  rocking  guard  was  made  by  Johannes,  of  Washing- 
ton. In  1886  Gilbert,  of  Philadelphia,  utilized  pivoted  links  as  a 
guard,  and  Hassalund  made  a  guard  with  two  pivoted  centres  which 
allowed  a  variety  of  movements  in  eomformity  with  the  shape  of  the 
nose.  ^ 

With  a  view  to  limiting  the  movement  of  the  lenses,  several  devices 
were  otTered  in  which  the  guard  moves  upon  a  spring  of  its  own. 
Brigden  and  Bi-achett  had  a  guard  attached  by  its  lower  end  to  the 
eye-wire  and  by  its  center  to  a  small  spring  connected  with  the  post. 
Peckham,  of  Big  Spring,  Kas.,  improved  this  idea  by  attaching  a  guard 
by  means  of  a  post  to  the  top  of  the  eye-wire  and  allowing  it  to  pass 
through  a  loop  near  its  lower  end ;  a  supplementary  spring  passed 


49:J2         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

ht'iicatli  the  guard  and  pressed  it  in  towards  the  nose.  Bauseh  per- 
fected, in  1875,  a  form  with  a  guard  placed  on  a  light  spring  attached 
at  its  lower  end  to  the  eye-wire  and  having  at  its  upper  end  a  sliding 
attaehnient  to  hold  it  in  position.  This  was  the  forerunner  of  the 
popular  CJalezowsky  model.  Alexander,  of  ^Yashington,  used  a  set 
screw  to  adjust  the  guard,     l^arber,  of  Phihidclphia,  used  an  S-shaped 


Uoiible-liar   Spring   Eyeglass. 


Bar  Springs. 


Bauseh  Cork  Eyeglass  Guard. 


Wells'  Cork  Eyeglass  Guard  witn  iiuop  Spring. 

spring  attached  to  the  lower  part  of  tlu-  t>ye-wire  by  one  end  and 
bearing  on  the  other  end  a  disk  or  i)ad  to  rest  against  the  nose.  Op- 
dyke,  of  New  Haven,  had  a  pad  with  two  bearing  surfaces  and  a 
curved  inlet  between,  all  of  one  spring.  Borseh,  of  Chieago,  in  189;'). 
brought  out  several  guards  leading  to  his  important  '•  .\natomifal 
guni-d    which    remains   one   of   the   valuable  devii-es   today.      This   eon- 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         49:53 

sists  ot"  ;i  rijzid  offset  <iiiai'<l  wilh  :iii  jiuxiliiiry  j^iuird  cunstit  ii1c(l  hy  a 
light  spring  rigidly  attached  at  the  bottom  of  tho  main  guard,  running 
up  tho  outer  surface  of  the  latter  and  attached  at  right  angles  to  a 
short  arm  which  passes  through  a  slit  in  the  main  guard  at  its  toj)  and 
joins  a  small  disk  on  the  inner  asjfcct  of  the  guard.  This  disk  exerts 
slight  pressure  and  prevents  tilting  and  slipping  of  the  main  guard. 

Various  patents  have  been  secured  for  devices  which  permit  of  the 
ad.iustmeiit  of  the  lenses  before  the  eyes.     A  i'ub1)ei'  pad   was  made 


B E 


Hopkins'  Eyeglasses,  1880.     (After  E.  C.  Biili.) 


Meyrowitz's  Eyeglasses,  ISSG.     (After  E.  C.  Bull.) 

with  an  adjustable  pin  ruiuiing  tlirougli  it,  whereby  the  glasses  were 
lowered  or  raised  before  the  eyes  (Johannes,  of  Washington,  1887). 
Another  device  permitted  the  extension  of  the  glasses  forwards  to 
escape  the  lashes  by  sliding  the  guards  backwards  (McAllister,  of 
Philadelphia,  1885).  ^leyrowitz,  of  New  York,  in  1887,  invented  the 
"Champion"  clip,  allowing  a  tilting  of  the  glasses  for  reading. 
Further  im])rovements  resulted  in  his  pivot  guard.  This  form  admits 
of  considerable  adaptation  to  the  nose  by  virtue  of  the  attachment  of 
the  arm  rigidly  at  the  l)ottom  of  the  guard  while  pivoted  at  its  center, 


4934         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

the  ;inii  hriiin'  siiflii-ii'iil  ly  ticxililc  t(t  cli.'iii^'c  its  sli;i|)c  willi  the  iid.jusl 
iiinit  III'  till'  'iiiiii'd   '.sec  illiist  I'iit  ion  of  niodci-ii  eyeglass  guards). 

A  disjidvaiilagf  ul'  the  carlifi"  devices  was  that  tlic  guards.  Ix'iiig  in 
llie  |ilaiie  of  the  lenses,  iieeessarily  I'esled  I'orwai'd  on  the  thiekei'  part 
of  tile  nose.  To  prevent  this,  Ivan  h'ox,  ol'  I'hihidelpliia.  in  lSS-1-,  de- 
visetl  his  olTset  guai'd,  the  most  nijtewortliy  single  aelii<'venient  in  tlie 
art  of  adapting  eyeglass  mountings  to  the  individual  nose,  and  a 
distinctly  American  conception.  European  glasses  meet  the  needs  of 
an  average  nose — a  thing  rarely  found.  The  Fox  guard  allows  exact 
adjustment  to  that  j)ortion  of  the  nose  whei-e  security  is  consistent  with 
a  minimum  of  pressure.  This  is  accomj)iislu'd  by  a  single  piece  of 
metal  the  hladt'  of  which  has  a  heai'ing  surface  of  shell  or  cork,  at- 
tached to  the  post  by  means  of  a  shank  running  ])ack  of  the  plane  of  the 
lenses.     Thus  the  giuirds  fit  liigh  up  and  hack  on  the  thin  i)ortion  of 


^ 


t]yeglass  of  Fox  and  Brown  of  Pliiladclphia,   ISSS.      (After  K.  (.'.  Bull.) 


the  nose  close  l)eneath  the  ])row.  This  invention  wa.s  popularizetl  by 
Kerstein  after  a  period  of  neglect  due  to  objection  to  an  I'yeglass  which 
could  not  l)e  folded  together  and  placed  in  a  small  pocket  case.  It 
finally  became  evident  that  the  convenience  of  such  a  folding  eyeglass 
was  not  to  be  weighed  against  tlie  disadvantage  of  weakening  tlie 
spring,  scratching  the  lenses,  and  throwing  tliem  out  of  alignment,  as 
happens  when  they  are  folded. 

Auxiliary  guards  have  l)een  designed  to  secure  two  or  more  bearing 
surfaces,  in  an  effort  to  prevent  vibration,  hold  to  the  nose  more  tirndy, 
distribute  the  weight,  and  j)e)-mit  of  more  accurate  adjustment.  The 
fii'st  uuxiels  consisted  of  movable  auxiliary  guards  attached  to  fixed 
guards  and  capable  of  being  rotated  out  of  the  way  so  that  the  glasses 
might  be  folded  together;  a  mattei-  insistcnl  upon  ])y  opticians  and 
public  long  after  its  iiai'mfulness  should  have  been  realized.  Wells, 
of  .\ew  York,  in    1SSS,  invented  the   liist    practical   model   with   a   disk 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4935 

oil  a  small  arm  cxlciidiii^-  from  the  main  ^uaivl.  In  the  lollowinj^  year 
111'  added  a  second  arm  and  disk,  h'ni'tlier  a<i\ances  came  in  tlie  loi'm 
of  the  liauscli  "Anchor"  <iiiard  of  the  .Julius  Kin<;-  ("o.,  of  ("liicaj^o, 
and  the  "Four- Foot"  guard  of  -1.  .M.  .Johnston,  of  ('liicajro,  which  are 
ade(|ua1ely  exj)lained  in  the  illustrations.  Other  examples  might  he 
cited  different  in  detail,  hut  all  of  the  same  type. 

In  the  matter  of  eyeglass  springs  very  little  advance  over  the  crude 
medieval  models  is  noted  until  the  nineteenth  century.  In  England 
as  late  as  1825  the  hridge  was  heavv  and  there  was  no  flexibilitv  at 


^ 


<y 


/ 


V 


Two  -Models  of  Eyeglasses,  by  Martin  of  Philadelphia,  1SS9.     (After  E.  C.  Bull.) 


the  ends.  In  France  in  18;J!)  coiled  springs  were  used  and  the  bridge 
portion  was  of  light  weight.  Further  improvement  came  from  Amer- 
ica where  Cadman,  in  1872,  made  a  horizontal  band-spring  with  pads 
projecting  backwards  against  the  sides  of  the  nose.  In  1880  Hopkins, 
of  New  York,  devised  a  horizontal  projection  from  the  eyeglass  to  be 
attached  to  a  vertical  spring.  E.  B.  INIeyrowitz,  in  1886,  made  a 
spring  to  slant  forwards  escaping  contact  with  the  brow;  this  was 
called  the  "tilting  spring.''  In  1888.  Edward  Fox  and  1).  V.  Brown, 
of  Philadelphia,  made  the  "Grecian  Curve"  spring.  ^Martin,  of  I*hil- 
adelphia.  in   1889.  usimI  a   wire  spring-  with  coils  neai-  the  cutis :  and 


4936 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OP 


aiiotlit'i-  saddle-shaped  band-spring,  like  that  of  .Mcyi-owil/..  but  fitting 
close  to  the  nose.  In  1802  IIeiiii)lei',  of  Washiniirtoii,  used  two  circular 
turns  or  spirals  at  each  side  of  the  spring  to  carry  it  well  forwards 
from  the  brows.  In  1894  E.  C.  Bull,  then  of  I'ai-is,  made  two  styles  of 
ej'cglass  similar  to  ('adman's  and  to  those  of  Hardy,  of  Chicago,  and 
Beckwith,  of  New  York.  Heard,  6f  Cincinnati,  in  1897,  devised  a 
rigid  bridge  to  rest  over  the  nose  with  arms  projecting  back  and  up 
and  ])ack  and  down,  to  clasj)  the  nose  both  above  and  l»elow:  all  being 


Hempler's  Eyeglasses,  "Washington,  189l\     (After  E.  C.  Bull.) 


Eyeglasses  of  E.  C.  Bull,  1S94. 


made  of  one  piece  of  wire.  In  1904,  Charles  H,  Pixley,  of  Chicago, 
patented  a  mounting  which  may  be  considered  the  parent  of  the  very 
popular  finger-piece  eyeglasses  of  the  present  day.  He  made  a  saddle 
bridge  of  the  spectacle  type  with  a  shank  attached  to  the  lenses  without 
a  screw.  In  the  crotch  of  this  bridge  on  each  side  an  arm  was  welded 
which  extended  downwards  curving  on  itself  out  and  upwards  to  form 
a  guard  wliich  might  be  padded  or  not,  as  desired.  From  this  model, 
and  numerous  others  devised  l)y  Leo  F.  Adt,  of  Albany,  X.  Y..  Henry 
E.  Kerstein  has  developed  the  "Sure-On"  types  of  today. 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF        4937 

The  illustrations  of  these  various  models  will  reveal  two  distinct 
teudeiieies.  One  was  towards  an  inflexible  short  hridjjre  erossing  the 
nose  in  or  near  the  horizontal  i)lane  of  the  lenses;  the  other  was  a 
flexible  si)ring,  rising  above  the  level  of  the  lenses,  curving  in  front  of 


Model  of  0.  r.  Hilpert  of  Hill,  X.  H.,  1880. 


Model  of  George  W.  Phoenix  of  New  Brunswick,  N.  J.,  1881. 


Model  of  Louis  Bityer  of  Montague,  Mass.,  1886. 
Early  Finger  Piece  Eyeglass  Mountings.     (After  E.  C.  Bull.) 


the  brow.  The  former  has  become  the  bridge  of  the  finger-piece  eye- 
glass, manipulated  with  one  hand,  the  guards  being  spread  l)y  means 
of  levers,  the  lenses  and  bridge  l)eing  stationary;  the  latter  is  per- 
petuated in  the  common  eyeglass  of  today  manipulated  with  two  hands, 
the  guards  and  lenses  being  spread  by  means  of  the  elastieit}'  of  the 


4938         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

spring'.       'PIlCSC    two    (|cVcl(>|>lll('llts    lli;iy     lie     lulloWnl     rill'tlirl-     t'l'om     the 

standpoint   of  s|»i-in^s  jiikI  of  nimrds. 

About    ISTO  a   liofi/oiitall\    placed   hand-spring^  was   made   with   two 


.Model  of  Cynis  II.  Faiiey  of  Portlaiul,  Maine,  KS87, 


MuiU'l  of  Walter  C".  Westaway  of  Decara,  Iowa.  1S90. 


Model  of  Jules  Cottet  of  Moiez,  France,  IStK). 


Model  of  I.  II.  1<:.  De  Celles  and  (ieoroe  W.  Wells  of  Southbridy;e,  .Mass.,  lS9:i. 
Karly  Finfjer  Piece  Eyeglass  Mountings.     (After  E.  C.  Bull.) 

finger  pieces  in  front,  pressure  on  which  caused  the  lenses  to  be  bent 
outwards  and  the  guards  to  spread.  Next  a  horizontal  bar-spring  was 
made  to  open  by  holding  the  handle  and  pressing  on  the  bar,  wliieh 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4930 

piislicd  the  rui'tlicr  Iriis  ;i\\;iy  .tiid  opnird  llic  <,Mi;ir(ls.  Tlicii,  \ty  iiicaiis 
of  a  lever  and  i'lilcruiu  jilaecd  (ni  tin-  siniiit:.  ;iii  eyeglass  was  devised 
ill  which  the  lenses  and  guards  inoveil  up  when  pressure  was  made 
downwards  witli  the  tingers.  A  hiter  model  (1S,S6)  contained  small 
arms  beiieatli  llic  lenses;  by  pi-essing  these  towai-ds  tlie  lenses  the 
guards  were  macU-  to  open.  Again  (1887)  a  har-spring  eyeglass  was 
devised,  pressure  with  the  thumb  on  one  bar  and  with  the  finger  on  the 
other  causing  lenses  and  guards  to  spread.  IMore  complicated  was 
the  arrangement  (1890)  of  a  chain  or  bar  running  around  tlie  upper 
edge  of  one  lens  to  a  finger  piece  above  the  handle;  by  ])ressiiig  this 
together  with  the  handle  the  further  lens  and  guard   were  made  to 


4^,- 


^L-£) 


Shur-oii  Eyeglass  Mountings. 


lift  up.  In  these  several  models  we  observe  that  the  lenses  are  pushed 
away,  are  bent  out,  are  bent  up,  aiul  are  stationary;  the  last  being  the 
most  satisfactory  device. 

The  year  ]89;j  marks  an  important  invention  by  a  Frenchman,  Jules 
Cottet.  This  was  patented  in  France,  Germany,  England,  and  the 
United  States,  and  was  the  forerunner  of  the  successful  finger  piece 
eyeglasses.  It  consisted  of  '"a  ('-shaped  ])ridge  flattened  at  the  ends  to 
take  a  screw  supporting  and  carrying  levers,  the  inner  ends  of  which 
carried  guards  and  the  outer  ends  acted  as  finger  pieces,  the  whole 
being  eontroUed  by  a  spiral  spring"  (E.  C.  Bull).  Finch,  of  Colorado, 
devised  an  eyeglass  similar  to  Cottet 's,  but  luiving  a  saddle  lu'idge  and 
no  screws  to  secure  the  arms.  ]\Ieyrowitz  manufactured  this  anil 
made  it  the  fii*st  popular  finger  piece  eyeglass  in  America. 


4!)K)         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

Tilt'  liii;Lici'  piece  eyeglasses  jii-c  t()(l;iy  the  most  tVc(jiiciitl\-  sctMi  and 
popular  form  of  glasses.  They  are  neat  and  inconspicuous  and  easily 
maiiipulatcd  with  one  hand.  The  rigid  bridge  joining  the  lenses  gives 
a  solid  front  like  the  spectacle  bridge  and  lenses.  Tlius  tlie  adjustment 
is  confined  to  the  guards.  The  arm  of  each  guard  is  pivoted  to  the 
bridge  near  the  lens,  witli  a  projection  forwards  to  make  a  finger  piece 


Fits-u  Eyeglass  Mountings. 

and  a  projection  backwards  to  make  a  guard  which  may  have  various 
shapes,  as  seen  in  the  illustrations,  and  may  be  altered  to  conform  to 
the  surface  of  the  nose  on  which  it  rests,  to  vary  the  position  of  the 
lenses  up  or  down,  and  to  vary  the  angle  and  the  spread  of  the  guards 

at  top  and  Iwttoin.     Such  guards  are  rigid  or  pivotcMl  so  as  to  rock;  a 


Vici  Eyeglass  Mountings. 


combination  of  the  two  forms  is  utilized,  being  a  rigid  guard  with  an 
auxiliary  small  pivoted  guard  at  the  top.  In  general  the  guards  have  the 
shape  of  a  figure  8,  a  bearing  surface  both  above  and  below.  They  are 
"sanitary"  (metal  only)  or  covered  with  sliell.  They  may  or  may  not 
be  perforated.  The  present  tendency  is  towards  the  Wells  or  Fox 
type  of  guard.     The  additional  pressure  above  secured  liy  th(^  Anatom- 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4941 


•2  " 


—  -n-  ^:r  -u  '^  ^;: 
^  fe  ^  ||  fa  Zi 


o 


[^C§] 


"O    ^    ►_ 

"3    o    g 

'^    -i 

C     tn    S 

^  ►$  s 

Q 


4942         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

icjil    UUIircIs    is   Jilso    lltili/.rd    in    tllr    lill^rl-    piece    jjflasscs.      All    of    tliese 
•jfUiirds   on    llic    lin^^er    piece    I'ycglass    ai"e    conli'olled    liy    small    spii'al 


springs. 


V::-a^; 


"^^^O^ 


5^ 


op 


33  '^ 


»f» 


^t       EJ® 


As  has  heeii  ohsei'ViMl,  an  eyeji'lass  (piile  dilVerrnt  from  the  tinp'r 
|»icce  type  is  in  use  at  the  present  time.  This  I'oriii  consists  of  a  tlcxihle 
sprinu'  I'isin^'  alio\-e  the  lexcl  of  the  lenses,  sci-ewcd  to  liotli  studs  and 
arms  of  guards.  The  studs,  or  posts,  ai'e  attaclii'd  to  the  Icust's  l)y 
screws   (or  soldered  to  t-ye-wires  in   the   riuuued   lypi').     The  guards 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4943 


Q 


^^^^ 


4944         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 


^7~jtiM 


^•2 


A<2 


C2IJ 


^' 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4945 

conform  to  the  offset  ty[)v  of  wiiicli  tliciv  ai'c  Jiuiiicrous  varieties. 
Springs  are  heavy  or  slender;  in  the  phmc  of  the  h'nses  or  offset  (curv- 
ing forwards  to  escape  tlie  brow)  ;  ai)proach  roundness  in  contour  or 
are  quite  oblong.  The  posts  vary  in  length ;  are  in  tiie  i)lane  of  the 
lenses,  or  bend  at  a  right  angle  to  set  lenses  fui-thcr  forwards  or  back- 
wards or  downwards  as  the  individual  case  may  require.  This  type, 
until  recently  the  common  one,  is  rapidly  coming  to  be  regarded  as  the 
' '  old-fashioned ' '  eyeglass. 

From  the  ophthalmologist's  standpoint,  there  is  no  "liest"  eye- 
glass. Each  nose  presents  a  st'pai-ate  problem,  and  fi-om  tlie  great 
uundicr  of  mountings  on  Ihc  market  some  one  will  generally  l)e  found 
smoothly  and  securely  adjustable,  unless  the  nose  is  of  the  infantile 
type  or  very  deficient  in  bridge.  When  heavy  or  highly  astigmatic 
lenses  are  required  spectacles  offer  greater  satisfaction  through  the 
support  to  the  lenses  given  by  the  bows.  In  any  case,  accurate  and 
permanent  adjustment  sliouUl  not  l)e  sacrificed  to  tlic  diMiiands  of 
fashion  and  fad. 


Opifex  Eyeglasses. 

Three  valuable  improvements  in  bifocals  have  been  made  by  the 
present  generation  of  opticians.  The  cement  l)ifocal  was  refined  by 
the  use  of  a  very  thin  scale  with  a  knife  edge,  nuide  only  circular  in 
shape,  to  be  cemented  with  balsam  to  the  distance  lens.  This  is  known 
as  the  Opifex.  Tlie  advantages  claimed  for  it  are  accuracy  in  center- 
ing, cheapness  antl  lack  of  chromatic  alierration  as  compared  with  the 
Kryptok. 

The  Kryptok  lens  was  made  about  the  year  18i)0  by  the  optician 
Borsch,  of  Philadelphia.  He  first  cemented  together  two  large  pieces 
of  glass  and  a  scale,  the  latter  })eing  ])etween  the  surfaces  of  the  large 
lenses.  This  was  only  a  modified  cement  bifocal  and  had  the  drawback 
of  all  cements,  namely  the  cracking  of  the  lialsam  and  separation  of 
the  lenses  from  slight  jars  to  wliieh  all  glasses  are  subject.  Borsch 
later  conceived  the  idea  of  fusing  b}'  great  heat  two  pieces  of  glass,  one 
crown  and  the  other  flint,  the  greater  index  of  refraction  of  the  flint 
glass  making  the  difference  between  the  far  and  near  correction 
desired.     The  Kryptok  is  pi'actically  an  invisible  bifocal  and  hence 

Vol.  VII— 7 


4946         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

less  conspicuous  tlwin  tin-  (■cinciil  vjirirtw  It  is  difticult  to  j^riud  and 
therefore  expensive.  Some  individuals  ai'e  distressed  hy  a  rainbow  ap- 
l)earanee  at  the  junction  of  near  and  distance  lenses  when  the  presby- 
opic correction  is  stronger  than  2.50  1). 

Recently  the  One  Piece  bifocal  has  been  devised  by  the  F.  A.  Hardy 
Compan.y,  of  Chicago,  for  the  purj)Ose  of  doing  away  with  chromatic 
aberration.  Far  and  near  lens  are  both  gronntl  fiom  one  piece  of 
crown  glass  on  tiie  pci'iscopic  ])rinciple.  The  necess^iry  curve  to  makr 
the  presbyopic  diit'erence  is  ground  on  the  concave  posterior  surface, 
while  the  anterior  surface  comprises  sphere,  cylinder,  prism,  or  com- 
liination  of  these  as  recpiired. 


' '  Invisible ' '  Bifocal. 

In  the  year  180-1:  tliej)eriscopic  lens  was  devised  l)y  the  Englishman, 
Wollaston,  for  the  purpose  of  obviating  the  disadvantage  which  comes 
from  looking  obliquely  through  the  ordinary  lens.  It  is  well  known 
that  the  full  benefit  of  a  lens  is  realized  when  looking  through  the 
center  of  the  lens  at  right  angles  to  its  plane.  This  is  possible  in  a 
given  case  only  wlien  the  eye  looks  in  one  direction ;  every  rotation 
from  this  position  means  some  distortion  of  the  object  seen  and  some 
annoyance  from  reflections.  By  grinding  a  minus  curve  on  the  sur- 
face next  the  eye,  and  the  necessary  curve  to  give  the  required  refrac- 
tion on  the  other  surface,  a  lens  is  placed  closer  to  the  eye,  has  more 
nearly  the  same  refraction  in  all  parts  of  the  lens,  offers  a  larger  field, 
and  is  at  right  angles  to  the  line  of  vision  in  all  rotations  of  the  eye 
as  is  impossil)l('  in  the  ordinary  bi-convex  or  bi-eoncave  lens.  The  ordi- 
nary curve  in  tlic  periscopic  lens  is  — 1.2r)l);  a  deeper  curve  or  menis- 
cus is  also  used  ( — 6.0()D)  ;  these  two  being  the  standards  recognized 
today.  More  difficult  is  the  grinding  of  compound  lenses  in  the  per- 
iscopic style.  Such  lenses  are  called  Toric,  the  anterior  surface  having 
the  shape  of  a  torus  or  ellipse,  comprising  two  cylinders,  while  the 
minus  curve  is  on  the  posterior  surface.    The  very  distinct  advantages 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4947 

of  siU'li  lenses  liavc  hci'ii  in  pfii't  oH'sct  l).v  their  greater  eost  and  the  dif- 
iieulty  in  grinding  them  without  flaws. 

Lenticular  lenses  are  designed  to  reduce  the  weight  of  what  would 
be,  in  ordinary  form,  very  heavy  lenses,  as  in  high  degrees  of  myopia 
and  hyperopia  (especially  in  aphakic  eyes).  Convex  lenticular  lenses 
are  made  by  cementing  the  requisite  scale  on  the  center  of  a  piano  or 
plano-eylindej'.  Of  more  freciuent  use  are  the  concave  lenticular 
lenses,  witli  eillier  round  or  oval  depressions  in  the  center.  The  for- 
mer is  made  l)y  gi-inding  the  necessary  concave  surface  upon  one  side 
of  a  piano  or  plano-cylindei'.  This  depression  occupies  al)0ut  22  mm. 
in  tlie  centt'r  of  llie  lens.  The  lattei'.  or  oval,  type  is  made  by  grinding 
the  necessary  concavity  upon  the  cylindrical  side  of  a  strong  plano- 
convex cylinder  or  a  cross  cylinder.  Such  lenses  are  about  one-half 
the  weight  of  corresi)onding  ordinary  lenses  and  represent  great  skill 
in  grinding. 


Lenticular  Lenses. 


In  1879,  at  the  Heidelberg  Congress,  Raehlmann  proposed  hyperbolic 
lenses  for  conical  cornea  and  irregular  astigmatism.  His  suggestion 
was  a  lens  of  4  cm.  diameter  with  the  depth  to  the  cone  of  Y^  to  2  mm. 

J.  Herbert  Claiborne,  of  New  York,  has  quite  recently  {Aiuials  of 
Ophfhalniologij,  January,  1914)  devised  an  improved  cataract  glass. 
This  consists  of  a  toric  kryi)tok  I)Iank  ground  very  thin,  to  tlie  posterior 
surface  of  which  is  cemented  a  bi-convex  lens.  For  exami)le,  to  make 
a  bifocal  of  +  12  with  a  -|-  2  segment,  a  toric  kryptok  with  a  -[-  2 
segment  is  ground  to  a  1  mm.  tliickness  or  less,  having  a  —  6  curve 
behind  and  a  -j-  ^  curve  in  front.  On  the  posterior  surface  of  this  is 
cemented  a  bi-convex  sphere  with  a  -j-  6  curve  on  each  side.  This 
sphere  is  25  mm.  round,  with  a  knife  edge,  its  lower  edge  coinciding 
with  the  lower  edge  of  the  liasal  lens.  Such  a  ])ifocal  has  about  one- 
half  the  weight  of  the  ordiimry  liifocal  of  equal  strength. 

In  1!»1;5  tlie  so-called  Coywell  Hint  glass  was  suggestetl  for  the  pui"- 
pose  of  making  high  powei-  lenses  Ihiniier  and  lighter  in  weight,  as  is 


4948         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

(l('.sii"il)lc  in  the  catann't  ^'lass.      It   is  estimated  that  a  +  8  curve  on 
tliis  special  flint  glass  is  e(juivaleut  to  an  ordinary  -f  12  cui'vc 

Thr  history  of  colored  lenses  has  ali-eady  lieen  discussed.  Smoke, 
l)lii(',  amethyst  and  chlorophyll  are  tiic  tints  whidi  have  been  regarded 
with  favor.  Several  otliei-  varieties  are  to  he  mentioned;  Arundel 
(1872),  a  piidv  glass;  rraniuni  (lOOOj,  yellow;  the  Ilallauer  (1905), 
smoky   green:    Hnixanthos    (1906),    smoky    yellow;    Euphos    (1907), 


' '  Firnisett ' '  Eyoglas.'-es  and  ISpertiU'les. 

greenish  yellow;  Didymiuni  (11)09),  salmon  pink.  Each  of  these  is 
praised  as  })ossessing  the  j)r()perty  of  ahsorhing  certain  harmful  light 
rays,  I'speeially  the  ultra-\'iolet.  It  is  i)erha])s  more  correct  to  say 
that  the  virtue  of  all  tinted  glass  consists  inei-ely  in  shutting  out  an 
excess  of  light.  Recently  several  non-colored  lenses  have  been  intro- 
duced with  the  same  claim  of  al)sorl)ing  harmful  rays.  They  are  the 
Roentgen  (1908),  the  Erliium  and  Yttrium  (1910),  and  Radium  glass 
(1911).     See,  also,  Colored  glasses. 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4949 

A  iiiinihcr  of  iiiouiit  iii^-  aiid  oilier  drviffs  have  j^rown  out  of  tin; 
ott'ort  to  do  away  with  the  breaking  of  leuses  wliere  tliey  are  drilled 
to  admit  screws. 

As  usual  with  such  inventions,  iuan\-  o])tieians  experiinf'iited  before 
the  results  became  practical.  Truske  and  Hrayton,  of  Chicago,  more 
than  twenty  years  ago,  devised  the  forerunner  of  the  mounting  now 
used  which  was  patented  l)y  D.  F.  Green,  of  Fort  Wayne,  Indiana,  in 
1910.  C.  H.  Pixley,  of  Chicago,  also  developed  a  practical  cement  for 
such  a  device  as  the  "Firiiiselt."  The  George  S.  Jolinston  Company, 
of  Chicago,  now  itiainif.-n-tui-es  this  mounting,  which  consists  of  a  post 


Monocles. 


or  "box"  comprising  two  flangi'S,  which  emliracc  tlie  lens  where  it  is 
cut  to  an  apex  to  insert  deeply  into  tiiis  box.  Lens  and  post  are  held 
together  by  a  special  cement.  Such  a  device  allows  somewhat  larger 
lenses  to  be  used  without  altering  the  pupillary  distance ;  it  does  away 
with  holes  drilled  in  the  lenses;  and  the  cement  is  said  to  hold  per- 
manently, regardless  of  temperature  changes. 

Several  forms  of  glasses  deserve  mention  as  of  minor  utility.  The 
monocle  was  evolved  from  the  primitive  reading  glass  held  near  the 
page.  Later  the  glass  Avas  held  before  the  eye  with  the  hand ;  and 
finally  the  present-day  lens,  held  in  place  by  the  tension  of  the  hrow 
muscles,  came  into  being.  AVlieii  one  considers  the  rarity  of  one  de- 
fective eye  with  the  fellow  eye  eniiiietroiiic  and  the  gi-eater  ease  and 


4i)r)0         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

security,  even  if  such  ;i  condiliou  exist,  of  fvcfjlasst's  or  spci-tai-lcs  with 
a  plauo  he  fore  out*  eye,  it  is  easy  to  understand  tliat  tlic  monocle  is 
of  extremely  little  use,  and  it  is  rightly  regarded  as  an  affectation. 
The  device  is  almost  a  curiosity  in  America. 

Of  limited  but  real  value  is  the  lorgnette.  Its  prototypes  were  made 
with  an  unjointed  handle  at  first,  later  with  a  jointed  handle,  and 
finally  in  the  nineteenth  century  with  a  spring  allowing  the  lenses  to 
be  folded  together  in  compact  form  within  tlic  handlf,  which  serves 
also  as  a   case.     Such   a   device,  manipulati'd   witli   one  hand,  can  be 


Library  Spectacles  and  Eyeglasses,  of  Shell  aiicl  Zylonite. 


quickly  placed  l)efore  the  eyes  and  is  convenient  for  momentary  use 
by  prcsliyopes,  who  thus  avoid  lieing  burdened  with  other  glasses.  It 
is  to  be  observed  that  the  word  "Lorgnette"  is  a  misnomer,  meaning 
in  French  an  opera  glass ;  while  the  French  word  which  should  have 
been  adopted  is  "Ijorgnon." 

As  already  stated,  there  is  a  tendency  today  towards  the  use  of  very 
large  lenses  mounted  in  bulky  frames.  These  are  denominated  "Var- 
sity" and  "Library"  glasses.  Shell  and  imitation  shell  are  used  iii 
both  eyeglasses  and  spectacles,  and  also  gold  in  eyeglasses.  Lightness 
in  weight  of  frames  and  large  size  of  lenses  are  the  virtues  clainied 


EYEGLASSES  AND  SPECTACLES,  HISTORY  OF         4951 

for  tlu'se  i)opiilar  styles,  wliilc  tlic  iiii|)()rt;iiit  factor  of  accurate  center- 
ing of  lenses  is  too  often  ignored. 

An  extensive  field  for  protective  glasses  is  found  in  the  various  in- 
dustries wiiere  men  are  sub,ieett>d  to  injury  from  flying  particles  of 
stone,  wood,  or  metal,  and  from  molten  metals.  (See  article  on  Blind- 
ness, Prevention  of,  Vol.  II,  pages  1161-1168,  of  this  Encyclopedia). 


"Varsity"  Eyeglasses,  of   Gold,  Silver,  and  Zylonite. 

The  function  of  protection  against  wind,  dust  and  glare  has  assumed 
more  importance  with  the  growth  of  the  automobile  industry.  Many 
styles  of  goggles  are  to  be  seen,  all  of  the  same  general  design,  namely 
very  large  len.ses  and  closely  fitting.  These  may  l)e  flat  and  clear,  ])ut 
are  more  often  toric  and  colored,  and  may  have  auxiliary  protecting 


S])eetae'le  Frame  for  Tenuis  Players  and   Farmers,     (tiitl'ord.) 


lenses  at  the  sides  and  various  fabrics  to  cover  the  space  between  the 
margins  of  the  lenses  and  the  face. 

A  very  recent  device  is  ofTered  to  prevent  annoyance  from  perspira- 
tion in  the  case  of  athletes  and  workers  in  hot  weather.  II.  Gilford 
writes  as  follows  {Ophthalmic  Record,  February,  1915)  :  ''Having 
been  much  annoyed  while  playing  tennis  or  doing  any  hard  work  in 
hot  weather  by  sweat  running  down  from  my  eyebrows  upon  my 
glasses,  I  have  had  a  pair  of  gutters  made  in  aluminum  which  screw 
onto  the  sides  of  the  bridge  and  the  outside  posts,  which  prevent  this 


4952         EYEGLASSES  AND  SPECTACLES,  HISTORY  OF 

troulilc.  'I'lic  inner  edge  of  the  gutter  tits  elose  under  the  eyebrows 
;md  eai-rics  any  excessive  perspirntion  off'  to  the  sides.  I  think  the 
rrjiine  may  (ind  a  hn-ger  appli<;iition  among  larmers  than  among  txMinis 
players,  as  any  <tnr  who  lias  attempted  to  pitch  hay  oi-  (h)  other  hard 
woi'k  ill  tlie  liot  sun  will  readily  appreciate.  .Maii.\-  a  farmer  who 
ought  to  wear  ghisses  either  for  visual  jjurposes  or  to  protect  iiis  only 


\'aiii'ties  of  Automobile  Goggles. 


remaining  e_\-e  will  not  do  so  on  account  of  the  diinniing  of  the  glasses 
in  iiot  weather." 

The  very  noteworthy  ])rogress  in  the  optical  industry  in  the  past 
half  century,  esjx'cially  in  America,  has  kept  pace  admirably  with  the 
growing  intei-cst  in  rcfi-action  and  scientific  pursuit  of  this  important 
})liase  of  ophthalmologic  work,  which  in  turn  has  met  the  increasing 
need  brought  about  by  the  peculiar  conditions  of  modem  life  calling 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4953 

for  a  maximum  ol"  elosi".  usi*  oi'  the  eyes.  Xcatiicss,  i-hcapiM'Ss,  and  a(;cu- 
racy  in  adjustment  of  glasses,  with  many  variations  in  style  to  satisfy 
individual  taste,  are  obtainable  today  for  the  gi'eat  number  of  people 
wlio  need  glasses. 

The  writer  wishes  to  acknowledge  his  especial  indeliteilness  to  E.  C. 
Bull,  of  Pasadena,  California,  formerly  of  Paris,  France,  for  the  use  of 
his  valuable  material  dealing  with  numerous  phases  of  the  subject, 
more  particularly  with  the  development  of  tiie  American  optical  in- 
dustry in  the  latter  half  of  the  last  century,  in  wliich  Mr.  Hull  himself 
has  liad  a  coiisicU'raljle  share. —  (E.  II.) 
Eyeglasses  and  spectacles,  Mechanical  adjustment  of.  Frame-fitting 
j)lays  such  an  iiiiporlaiit  i)art  in  the  sui)plyiiig  of  ghisses  that  a  thor- 
ough study  of  tliis  work  will  prove  of  great  value  to  the  oculist.  Many 
times  a  carefully  prepared  lens  formula  representing  the  nearest  ap- 
proach to  an  accurate  correction  of  an  error  of  refraction  is  entirely 
changed  and  the  effect  of  the  lenses  neutralized  by  incorrectly  fitted 
frames  or  mountings.  Through  force  of  necessity  or  choice  a  large 
number  of  oculists  supply  glasses  directly'  to  patients  without  the  latter 
going  to  the  optician;  to  these  oculists  it  is  especially  important  that 
they  fully  understand  all  the  details  of  scientific  frame-fitting.  ]\Iore- 
over,  even  oculists  who  do  not  supply  glasses  should  possess  this  knowl- 
edge, because  it  will  not  only  increase  the  efficiency  of  their  work  but 
will  often  save  many  tedious,  trying  moments  spent  in  determining 
the  refraction  of  a  patient,  and  in  searching  for  a  defect  that  is  really 
caused  by  the  mal-adjustment  of  the  frame  or  mounting. 

In  these  pages  the  subject  will  be  discussed  as  fully  as  a  work  of 
this  nature  will  permit,  and  modern  methods  of  lens-centering  and 
frame-fitting  will  be  explained,  as  based  on  the  experience  of  the 
writer  and  others. 

Dcfiuitions.  Frames:  Fixtures  that  have  rims  going  around  the 
lenses.  J\lountings:  Fixtures  that  hold  rimless  lenses.  Spectacles: 
Fixtures  that  are  held  in  position  by  means  of  bows  (temples)  that  go 
around  the  side  of  the  head  and  by  a  bridge  that  rests  on  the  crown  of 
the  nose.  When  these  have  rims  around  the  lenses  they  are  known  as 
spectacle  frames  and  when  there  are  no  rims  around  the  lenses  they 
are  known  as  spectacle  mountings.  Eyeglasses :  Fixtures  that  are  held 
in  position  on  the  nose  by  springs  and  by  guards  that  press  on  the  sides 
of  tlie  nose.  With  rims  around  the  lenses  they  are  eyeglass  frames  and 
witliout  rims  they  are  eyegla.ss  mountings. 

Spectacles.  Temples :  Attachments  on  spectacles  that  go  around 
the  side  of  the  face  and  over  the  ears.  Straight  temples  go  straight 
back  and  do  not  circle  the  ears.     Kiding  temples   (sometimes  called 


4954       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

i-i(liiij^'  liows)  ;^(>  entirely  ;ii'(miihI  the  li;ii-k  ol'  llie  e;irs.  I  I;il  I'  ridiiiLT 
t('mi)l('s  iwv  liiill"  way  lietweeii  tile  straijilit  tciiiple  and  riding-'  lenipje 
varieties,  just  tiii-niiii?  slightly  ovei-  the  hack  of  the  ears. 

Regular  temples:     'I'he  oi'dinarv  wire  temples. 

Cable  temples:  Made  hy  wrapping-  two  pieces  of  j)lialili'  wire  about 
each  otlier. 

Half-cable  temples:  The  ])art  from  the  fi-ame  to  tlie  top  of  the  ear 
is  of  the  i-egulai-  stiff  wii-e,  the  pai't  <ioiiijj:  around  the  ears  is  cable. 


Spec'tafle  Fianu  . 

There  are  several  varieties  of  this  kind  :  Comfort  temples,  A])ex  tem- 
ples, Velvet  end  temples,  etc. ;  these  are  very  similar  in  eonstruetion 
and  differ  only  in  the  manner  in  which  the  soft  portion  that  encircles 
the  ear  is  attached  to  the  wire  that  goes  to  the  frame.  They  are  all 
very  soft  and  pliable  on  the  ear  end  and  are  intended  to  increase 
the  amount  of  comfort  and  eliminate  the  features  of  the  regular  wire 
temples  that  tend  to  make  the  latter  uncomfortable  a])0ut  the  ear. 


i; vi';^l;iss    Moniiti 


Eveglass  Frame. 


Bridge:  The  part  of  a  speclaeh'  that  rests  on  tlie  nose  and  con- 
nects the  two  lenses.  This  is  tiie  central  and  most  imi)ortant  portion 
of  a  spectacle. 

Shanks:  The  ends  of  the  briilge  that  i)oint  outward  from  the  nose 
and  connect  with  the  lenses. 

Straps:  The  attachments  at  the  end  of  the  shanks  and  temples  on 
riudess  mountings  by  means  of  which  the  lenses  are  held  to  the  mount- 
ing. 

End-pieces:  The  parts  to  which  the  temples  are  attached  in  rim- 
less mountings;  they  include  the  strai)s  which  ai'e  really  a   part  of 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4055 

thrill.      When   spoken   of   in   eoniiectioii    with    teiii])Ies   they   ;ire    I'jiiiiil 
i;irly    known    ;is    "ends."     Tor    iiist;iiiee.    w,-    s|)e;ik    of    ' "  leiiiplf-s    iind 
ends." 

Mye-wires :      The   rims  th;if    eiieireh-   the   h'nses  on    fi-aiiics. 

h\ij(<jl(iss(s  (nfjiihir).     Spi-in«;:     Tlie  centrjd   i);irl   of  the  frame  or 
mounting  corresponding  to  the  bridge  ol"  speetaeles.     Tliere  are  sev- 


Oblong.  Hoop. 


Full.  Reducpil.  ( iicci.iii. 


Tiltin,;;. 


Ailjiistalilo. 


era!  styles  of  springs  as  shown  hy  the  illustrations.  In  juhlition  to 
the  different  varieties  there  are  different  sizes;  the  usual  lengtli  of  the 
oblong  style  is  2i/s  inches,  and  of  the  hoop  style  2  inches.  Oblong 
springs  are  sometimes  called  "s(iuare"  springs  and  hooj)  sjirings  are 
sometimes  called  "oval." 


Wells. 


Lasso.  Anchor. 


Schwab.  Anatomical. 


Solid. 


Guards:  The  parts  that  lie  against  the  side  of  the  no.se  and  hold 
to  the  flesh;  often  called  by  the  laity  "clips."  By  consulting  cata- 
logs of  the  wholesale  optical  houses  it  will  be  seen  that  there  are  count- 
less styles  and  designs.    A  few  of  the  most  common  are  shown. 


Studs:     The  parts  that  hold  the  lenses  to  the  mounting  and  whicli 
join  tlie  guards  and  the  .spring. 


495G       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

open  studs:      Tliosr  in   wllicli   llic  ii;is;il   sidr  (if  the  slllds  is  left   oprli. 

liox  studs:  ill  these  tlic  portion  into  wliicli  the  «;u;ii'd  iiiul  spring 
tit  is  construclrd  like  a  liox  and  the  nasal  side  is  closed,  the  stud-screw 
is  coimtersuiiU,  and  tliiis  llicre  are  no  roii^li  parts  or  exposed  screws 
in  contact  with  tiie  patient. 

In  addition  to  theses  two  styles  there  are  many  sizes,  tliat  is,  some 
iiave  longer  posts  tlian  others,  the  purpose  of  wliieli  is  to  regulate  the 
distance  between  the  lenses.  There  are  also  "drop"  studs  to  lower 
the  lenses;  these  are  iiuule  in  two  sizes — 1-16  and  1-8  inch. 

It  will  be  observed  that  the  sizes  of  studs  (controlled  by  the  length 
of  the  post)  are  indicated  by  the  letters  A,  B,  C,  D,  and  E;  A  being 
the  shortest  and  F  the  longest,  with  about  one  millimeter  between 
each  succeeding  size. 

Inset  and  outset  studs :  ]\Iost  wholesale  catalogs  state  that  inset  studs 
set  the  lenses  farther  from  the  eyes  and  that  outset  studs  set  the  lenses 


tShowiug  i"'iuger-piece. 

closer  to  the  eyes.  To  the  mind  of  the  average  man  who  has  not  be- 
come accustomed  to  this  translation  of  the  terms  they  will  seem  to  be 
reversed.  AVhere  this  usage  of  the  terms  originated  was  with  the  idea 
that  inset  studs  set  the  mounting  in  toward  the  face  and  consequently 
the  lenses  were  set  farther  from  the  eyes;  however,  when  we  realize 
that  the  mounting  always  stays  in  the  same  position  on  the  nose  and 
it  is  the  lenses  themselves  that  are  moved  it  would  seem  that  studs  that 
set  the  lenses  out  should  be  termed  "outset,"  but  the  term  is  not  gen- 
erally accepted  this  way,  so  the  safest  plan  in  writing  prescriptions, 
etc.,  that  are  sent  away  to  be  filled  is  always  to  say  ' '  to  set  the  lenses 
closer  to  the  eyes"  or  "farther  away, "  as  may  be  wanted,  for  instance : 
"Inset  studs,  to  set  the  lenses  farther  from  the  eyes"  or  otherwise  so 
as  to  be  clearly  understood. 

Eyeglasses  (finger-piece).  Bridge:  Same  as  the  bridge  in  spec- 
tacles. This  usually  includes  tlie  studs,  as  th(\v  are  gen(>rally  made  in 
one  piece. 

Finger-pieces:  The  projecting  ends  in  front  tluit  are  grasped  by 
the  tips  of  the  fingers  in  oi'der  to  n])ernt(^  the  si)rea(liiig  of  the  guards. 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4057 

Springs:  These  connect  difcctly  with  the  iriuirds  and  cause  Iheni  to 
press  inward  towai-d  tlie  nose. 

Fin<i'ei"-piece  eyeglasses  are  made  in  a  great  iniinher  ot"  styles  and 
coinhiiiations  and  are  given  particuhir  names  li\'  the  vai'ious  nianu- 
faeturei's.  While  eyeglasses  of  tiiis  design  ajjjx-ar  at  lirst  sight  lo  l)e 
very  much  alike,  closer  inspection  will  show  that  there  are  several 
classifications. 

MisccUaneoiia  frames  and  mountings.  Grab  fronts  are  fixtures  to 
contain  lenses,  usually  the  addition  for  reading,  ^vhich  attach  to  the 
outside  of  spectacles,  and  may  be  taken  off  and  put  on  without  i-einov- 
ing  the  spectacles  proper.  Grab  fronts  may  be  either  with  rims  or 
rindess.  Grab  backs  are  similar  to  grab  fronts  except  that  they  attach 
to  the  back  of  the  spectacles  instead  of  the  front. 

Specalettes  are  a  combination  of  eyeglasses  and  .spectacles,  that  is 
they  arc  eyeglasses  with  temples.  These  are  desirable  where  the  patient 
has  a  straight  and  nearly  vertical  nose  and  experiences  difficulty  in  re- 
taining a  spectacle  bridge  in  the  proper  position,  and  in  cases  where 


(irab   Fronts 

the  skin  on  the  fi'ont  of  the?  nose  is  very  sensitive.  There  are  several 
forms  of  these  mountings  and  catalogs  of  wholesale  o])tical  houses  may 
be  consulted  on  the  matter. 

Lenses  in  common  use.  Double  convex  :  Convex  on  both  sides.  Ab- 
breviated, Dex. 

Double  concave :    Concave  on  both  sides.    Abbreviated  Dec.  or  Dcve. 

Periscopic :  This  form  may  have  either  a  convex  or  concave  equiv- 
alent value  for  the  lens,  but  to  be  periscopic  a  lens  must  have  a  con- 
vex curve  on  one  side  and  a  concave  curve  on  the  other.  The  ordinarily 
used  periscopic  lenses  have  a  minus  1.25  diopter  curve  on  the  concave 
side  of  lenses  having"  a  convex  power:  this  form  of  lens  is  generally 
accepted  as  better  than  the  double  variety.  Abbreviated,  Pcx.  for  con- 
vex and  Pec.  for  concave. 

Toric  :  A  lens  having  three  curves.  It  has  the  appearance  of  a  very 
deep  jx'riscopic,  having  one  side  deep  convex  and  the  other  deep  con- 
cave. By  reason  oL"  its  detinition  a  toric  lens  can  never  be  a  sphere,  Init 
is  always  either  a  cylinder  or  sphero-cylinder.  Tories  are  built  on 
three  base  curves — the  3,  6  and  9  D. 

^Meniscus:  A  lens  built  on  the  deep  periscopic  foi-ni.  This  kind  of 
lens  is  always  a  sphere   and  is  often,  though   incorrectly,   called   a 


4958       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

"splu'rical  toric"  This  latter  term  has  comic  into  smh  cominoii  use 
that  it  is  generally  accepted  without  question,  in  fact  there  nre  many 
who  do  not  know  that  the  term  is  technically  wroner. 


Specalettes. 

Bifocals:  Any  lenses  that  are  composed  of  two  parts  or  have  two 
foci.  Usually  these  lenses  combine  the  distant  and  near  correction,  the 
upper  part  for  distance  and  the  lower  for  readin<jf. 


Specalettes. 


Cement  bifocals :  Any  bifocal  lenses  in  which  the  reading  or  near 
correction  segments  are  attached  to  the  main  lens  by  cement,  but  usu- 
ally understood  to  mean  })ifocals  where  the  segments  (or  .scales)  are 
not  especially  thin  and  wliicli  are  elli])tical  in  shape. 


'  cnieiit  Bifocal. 

Opifex  bifocals:  Lenses  in  which  the  i-eading  segments  are  very  thin, 
usually  round,  and  attached  to  the  main  lens  by  cement.  Sometimes 
called  "seJiii-invisible"  bifocals. 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4959 

Kryptok  bifoc-als:  Lciisfs  in  wliidi  llie  reading  segments  are  prac- 
tically invisible  and  in  wliidi  the  segment  is  fused  to  the  main  lens 
forming  one  piece  of  glass.  The  segment  and  main  lens  are  of  differ- 
ent indices  of  refraction. 


Perfection   Bifocal. 


Perfection  l)ifocals :  Lenses  compo.sed  of  two  separate  pieces  of  glass 
held  in  position  hy  the  rims  of  the  frames. 

Lenticulars:  Lenses  of  a  miinis  jiower  in  which  tlie  peripheral  por- 
tions have  been  ground  off  flat  or  to  a  convex  edge  for  the  purpose  of 


Oval  Leiiti'ul: 


K'ouiid   Li'iitit'iiiar. 


lightening  tliu  weight  of  the  lenses  and  making  them  thiiuier  on  the 
edges. 

Colored  lenses:    There  are  many  different  kinds  and  colors  used,  the 
prime  purpose  being  to  reduce  the  amount  of  light  that  enters  the  eye. 


41)60       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

Smoked  lenses  are  made  in  varyin*^  shades  and  densities,  'i'liere  are 
also  green  and  liliie  lenses.  J\Iueii  has  heen  (  laimed  recently  for  amber 
lenses  with  the  iih-a  tliat  they  retiuee  the  number  of  ultra-violet  rays 
entering  the  eye.  Likewise  claims  have  l)eeii  made  for  pink  and  ame- 
thyst shades.  There  are  also  lenses  known  by  special  trade  names  most 
of  wliich  are  a  combination  of  light-green  and  light-andier. 


TABLE  OF  SIZES   OF   LENSES 


Eye. 

Inserts. 

Rimless. 

Short  Oval 

Eye. 

Inserts. 

mm 

mm 

Rimless. 

mm 

fjundx) 

46    x;i8 

46    x38 

44.5x39.5 

2 

35x25.5 

()()()() 

44.8x;36 

44    x36 

42.5x37.5 

3 

34x25 

()(M) 

4().l)x:U.!) 

41    x32 

39.5x33.5 

4 

33x24 

00 

a'j.Txao.T 

40    x31 

3^.3x32.5 

A 

39x25 

0 

37.8x28.8 

38.5x29.5 

37    x31 

B 

40x26 

1 

36.5x27.5 

37    x28 

35.5x29.5 

C 

37x21 

Shapes  of  lenses.  In  the  majority  of  cases  the  regular  shape  lenses 
should  be  used,  but  the  short  oval  is  often  very  advantageous.  Where 
the  patient  does  a  great  amount  of  near  work  the  short  oval  offers  a 
large  field  of  vision  up  and  down,  the  direction  in  Avhich  it  is  most 
needed.  This  shape  is  also  desirable  in  cases  of  narrow  P.  D.,  for  here 
it  is  usually  necessary  to  use  small  lenses  which  naturally  restrict  the 
field  of  vision. 

The  leaf  shape  is  designed  for  people  having  heavy  protruding 
brows;  it  resembles  the  siiort  oval  with  the  top  rounded  otf.  Odd 
shapes  of  lenses — that  is,  any  but  the  regular  and  short  oval — should 
be  generally  avoided,  for  their  appearance  is  far  from  pleasing  and 
gives  suggestion  of  grotesqueness  to  the  face. 

For  com])lete  illustrations  of  the  foregoing  shapes,  see  Eyeglasses 
and  spectacles,  History  of. 

The  correct  frame  or  mounting.  Tlu^  unit  of  measure.  The  P^ng- 
lish  system  of  lineal  measures  has  so  long  lieen  used  that  it  is  natural 
for  this  system  to  ])e  employed  by  American  opticians  in  giving  dimen- 
sions of  spectacles,  etc.,  but  since  we  have  arrived  at  a  place  where 
accuracy  and  definiteness  are  essential,  this  system  is  no  longer  prac- 
tical. The  continual  use  of  fractions  permits  tlu'  occurrence  of  too 
many  eri'oi-s  and  a.  s])eci(ieation  ol'  1-8  or  1-16  inch  gives  room  for  too 
nuicli  variation  one  way  or  the  othei".  whereas,  if  we  measure  by  the 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT   4!)61 

metric  system  when  dealing  with  short  distances  we  eliminate  a  large 
portion  of  the  element  of  error  both  in  calculations  and  in  the  mat- 
ter of  personal  equation. 

For  instance,  suppose  we  have  2i/s  and  2i^>  inches  to  compare.  We 
have  a  general  idea,  regarding  the  relation  of  these  two  quantities  and 
after  a  little  thought  realize  there  is  a  difference  of  %  inch.  Now  ex- 
press the  same  dimensions  in  millimeters — we  have  53  and  62  milli- 
uK^ters.  At  a  glance  we  have  a  definite  appreciation  of  the  relation 
and  know  instantly  thai  there  is  a  difference  of  9  millimeters.  Then 
again,  on  a  scale  graduated  in  millimeters  the  divisions  are  compara- 
tively close  together  and  a  slight  variance  around  the  mark  l)eeomes 
evident  at  once. 

Pupillary  distance.  There  is  just  one  simple  method  of  ascertaining 
the  exact  distance  between  the  eyes.  Place  yourself  in  a  position  direct- 
ly facing  the  patient.  Suppose  you  desire  his  P.  D.  for  distance  :  Have 
the  patient  look  over  your  head  at  an  object  on  the  wall  opposite.  Hold 
the  rule  in  your  right  hand  in  the  same  manner  as  a  pencil  and  steady 
your  hand  by  placing  your  free  fingers  upon  the  side  of  the  patient's 
head.  Now%  with  your  left  eye  (right  eye  closed)  bring  the  zero  of 
the  rule  opposite  the  line  of  demarcation  between  the  iris  and  sclera, 
say,  for  instance  in  this  case,  on  the  nasal  side  of  the  eye.  Holding  the 
rule  in  this  position  quickly  open  your  right  eye  and  close  your  left  and 
read  off  the  graduation  mark  opposite  the  edge  of  iris  (in  this  case 
temporal  side)  of  the  patient's  left  eye.  This  reading  will  give  the 
true  width  between  the  eyes.  Of  course  if  you  measure  from  the  nasal 
side  of  one  eye  you  measure  to  the  temporal  side  of  the  other  eye,  and 
vice  versa. 

If  you  measure  with  both  eyea  open  your  result  will  varv'  2  or  3 
millimeters,  because  you  will  not  be  sure  which  mark  is  opposite  the  pa- 
tient's eye.  If  you  measure  entirely  with  one  eye  the  error  of  parallax 
will  enter  so  much  that  your  readings  will  always  be  from  2  to  5  milli- 
meters too  narrow. 

To  prove  the  veracity  of  the  foregoing  statements,  make  two  marks 
about  two  inches  apart  on  a  piece  of  paper;  lay  the  paper  on  your 
desk  and  resting  your  hand  on  it  hold  your  rule  one  or  two  inches  above 
it.  First  measure  the  distance  with  both  eyes,  then  measure  it  entirely 
with  one  eye,  and  then  with  each  eye  separately  (the  zero  with  the 
left  and  the  total  width  with  the  right  eye)  and  you  will  find  a  decided 
variance  in  your  three  readings.  By  laying  the  rule  flat  on  the  paper 
and  measuring  tht^  exact  distance  you  will  find  your  third  measurcMuent 
to  lie  correct. 

Viil.  Vll — 8 


4!)G2   EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 


The  mx  clinic  bridtji .  Tliciv  arc  Iwo  ways  of  expressing  tlic  diineii- 
siniis  of  a  l)ri(ifj(' :  ^^y  giving  each  diiiUMision  in  figures  or  by  using  tiie 
size  letter  and  number.  Tlie  dimensions  con- 
sidered are  lieiglit,  inclination  of  crest,  angle 
and  width  of  base.  'I'he  following  letters  are 
used  to  designate  the  width  of  l)ridges,  begin- 
ning with  the  smalh'st:  L,  .M.  .\.  O,  P.  The 
heights'  ar(>  expressed  in  combination  witli  tlie 
h'ttei's  by  numbers,  as  i^,  1,  IVii-  2,  etc.  The 
shaid<s  are  called  regular,  long  and  extra  long. 
With  the  regular  shanks  the  lenses  are  held  a 
trifle  closer  to  the  eyes  than  the  crest  of  the 
bridge;  witii  long  shanks  the  lenses  and  crest 
of  bridge  are  on  the  same  plane;  with  extra 
long  shanks  the  lenses  are  further  from  the 
eyes  than  the  crest  of  the  bridge  is.  Thus  to  set 
the  lenses  away  from  the  eyes  to  escape  the 
lashes,  etc.,  we  use  long  and  extra  long  shanks. 
When  no  length  shank  is  stated  "regular"  is 
understood.  This  is  the  way  the  different  sizes 
of  bridges  are  expressed:  IM,  MV^,  N2  extra 
long  shanks. 

When  the  sizes  are  not  specified  as  above  it 
is  necessary  to  give  all  tlie  dimensions  in  fig- 
ures.   The  height  of  the  bridge  is  the  distance 
above  or  below  a  line  running  through  the  cen- 
ter of  the  lenses  to  the  lower  edge  of  the  center 
of  the  bridge ;  the  inclination  of  the  crest  is  the 
distance  from  the  inside  plane  of  the  lenses  to 
the  upper  edge  of  the  middle  of  the  ])ridge  and 
is  specified  "in"  or  "out,"  meaning  in  back 
or  in   front   of  the   lenses,    respectively.      The 
angle  of  the  bridge  is  considered  with  respect 
to  the  plane  of  th(»  lenses,  the  latter  being  90 
degrees.     The  angle   is  measured   at   the   cen- 
ter or  crest  of  the  bridge.  ' 
Temples.    The  length  ol'  the  temples  is  measured  fi'om  tip  to  tip,  that 
is  from  the  screw  hole  to  the  extreme  other  end.     The  average  length 
is  six  inches,  but  they  are  also  nuule  in  lengths  of  5i/l>,  B^A  and  7  inches. 
i^izes  of  lnis(s.    "Size  eye,"  as  it  is  ramiliai-ly  called,  represents  the 
outside  measurement.     The  regular  sizes  ai'c  .juml)o,  0(^00.  000.  00.  0. 


DIMENSIONS  OF  SAD- 
DLE BRIDGES. 

(Upper  figure  Incnes, 
lower  figure  Millimeters). 

4> 

n 
L 

M 

X 

1) 

u 

in 

n 

0 
0 

0 
0 

15 

L'2 

0 
0 

15 

Li 

1  ^ 
3 

0 
0 

15 

M 

0 
0 

A 

V/2 

16 

ty. 

15 

Ml 

3 

t, 

16 

MIJ^ 

1.4 

5s 
15 

M2 

'.4 
6 

"A 

VA 

17 

H 

18 

li 

18 

i?4 

18 

N 

0 
0 

fc 

NVa 

ifA 

fc 

Nl 

>-8 

3 

IJ-^ 

Nl>-^ 

t. 

fc 

N2 

6 

VA 

ii 

N2y2 

fe 

3 

20 

1^ 
20 

Vi 
2t 

N3 

9 

VA 

o 

0 
0 

0 
0 

01 
02 

3 

& 

'A 
21 

'A 
6 

t,, 

21 

03 

i- 

A 
VA 

23 

PI 

^' 

■h 
VA 

1 
26 

P2 

%' 

lA 

1 
25 

P3 

r- 

3 

1 
25 

1 

EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT        4963 

1,  2,  ami  .'},  hcLriiiiiiiij;'  a1  the  lari^fst  and  ^oinj^  to  the  sniallcst.  The 
"size  eye"  of  I'l-aiiies  agrees  witli  the  size  of  the  lenses. 

"Pupillary  dislanee"  is  a  term  so  often  used  that  we  have  eome 
to  know  it  familiarly  by  its  abbreviation,  P.  D.,  so  that  in  this  article 
we  shall  refer  to  Ibis  dimension  as  P.  I),  instead  of  wi'itinjx  the  words 
in  full. 

The  aec()mi)an\in<i'  illus1ra1i(in  shows  a  measuring  card  used  for 
measuring  spectacle  frames. 


50     "        60  70  m/m 

PUPILLARY   DISTANCE 


Card  tor  ^Measuring  Spectacle  Frames 

To  measure  P.  D.  and  height  of  bridge,  place  end  pieces  on  line 
A-A  with  inner  edge  of  left  eye  at  line  B.  The  figure  at  right  end 
of  right  lens  indicates  the  pupillary  distance  and  that  at  under  edge 
of  bridge  crest  indicates  the  height  of  bridge. 

To  measure  bridge  crest,  forward  or  back,  place  lenses  in  slots,  top 
down,  with  inner  surface  of  lenses  on  lower  edge  of  slots.  That  edge 
of  bridge  resting  on  card  will  indicate  position  of  crest. 

It  will  be  noticed  that  in  measuring  the  "pupillary  width"  of 
spectacles  and  eyeglasses,  a  similar  plan  is  followed  as  when  measuring 
over  the  eyes;  that  is,  the  distance  is  taken  from  the  nasal  edge  of  one 
lens  or  rim  to  the  temporal  edge  of  the  othei-  lens  oi-  rim.  This  is 
most  conveniently  accomplished  by  using  the  measuiiii<^'  card  designed 
for  this  purpose  shown  here. 

Mcdsiiriiifi  for  spectacles.  Before  going  further,  one  should  know 
exactly  all  llie  details  already  given,  othei-wise  lie  will  get  most  unsal- 
isfactory  i-esults.  For  instance,  one  ma\-  take  the  l)ase  of  the  briilge  to 
b(>  from  ceider  of  the  turns  of  the  shaid\s  and  the  optician  who  fills  the 


4964       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

order  will  tiikc  it  rroiu  the  hist  points  wlin-f  the  tlcsh  touches  tlie 
bridge,  with  tli(!  ('Oii.se(iU('iicc  thai  the  spectacles  received  will  always 
be  from  two  to  three  millimeters  too  narrow.  The  same  applies  to 
all  the  other  dimeiisioiis,  hut  this  is  cited  as  being  the  most  common 
error.     For  illustration : 

One  may  be  provided  with  a  6  or  (i'^-inch  rule  graduated  in  botii 
iiu'lies  and  millimeters;  a  measuring  card,  and  a  fitting  set  of  spec- 
tacle frames.  Then,  seated  directly  in  front  of  the  patient,  measure 
the  patient's  P.  D.  and  note  it  down.     Seh'ct  from  the  fitting  set  the 


Spectacle  Fitting  8et. 

})ridge  that  comes  nearest  to  fitting  the  patient's  nose.  Notice  the 
use  of  the  word  "nearest"  in  the  previous  sentence — it  is  only  once 
in  a  hundred  times  at  least  that  one  will  find  a  stock  size  that  will 
exactly  fit. 

Height  of  bridge.  Now  for  tlie  proper  bridge  dimensions:  With 
the  frame,  just  selected,  on  the  i)atient's  face,  note  whether  the  lenses 
set  too  low  or  too  high,  bearing  in  mind  the  use  that  the  patient  is 
going  to  make  of  his  new  glasses,  whether  for  reading,  distance  or 
both.  The  average  line  of  vision  should  l)e  through  the  center  of  the 
lenses.  Suppose  the  lenses  in  the  fitting  frame  set  too  low,  say  one 
millimeter.  Now,  if  we  mov*^  the  bridge  down  the  lenses  will  go  up 
a  corresponding  amount,  so.  in  this  case,  the  bridge  we  want  should 
be  one  milliiiietei'  lowii-  tluiii  tlie  oiie  on  the  fitting  frame.  Take  the 
frame  from  the  i)atient's  face  and  nu-asure  the  height  of  this  bridge; 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4965 

suppose  we  liiid  il  to  l)c  four  milliiiictci-s.  W'c  t'ouiid  tliis  was  one 
iiiilliiiiclcr  too  lii^li,  so  tile  hi'i(l<ic  \\c  wjiiit  should  lie  tlncc  iiiilliiuelers 
ill  lR'it;lit.     Mark  it  down  on  tlif  prescription  j)ad. 

Position  of  the  ck.sI.  Jxeplaee  the  frame  on  the  [)atient's  face. 
Note  whether  the  lenses  set  too  ehjse  or  too  near  tlie  eyes.  Suppose 
the  lenses  touch  the  lashes  ami  need  to  be  set  two  niilliiiieters  farther 
out  for  tlie  lashes  to  clear.  Take  the  frame  off  and  measure  tlie  posi- 
tion of  the  crest  of  the  bridge,  usiiiy  the  measuring  card  for  tliis 
purpose.  Suppose  we  liiid  it  to  be  three  millimeters  out,  then  as  with 
this  l)ridge  the  lenses  are  two  millimeters  too  close  to  the  eyes,  the 
l)ridge  we  want  should  be  two  millimeters  farther  back,  which  gives 
us  one  millimeter  out  (or  forward)  that  the  bridge  crest  should  be. 
Note  this  down  under  position  (or  inclination)  of  crest. 

Width  of  base.  Place  the  fitting  frame  on  the  patient's  face,  using 
a  bridge  of  sufficient  width  to  allow  the  crest  to  strike  the  nose ;  push 
the  frame  to  the  right  or  left,  so  that  all  the  space  between  the  bridge 
and  nose  wall  be  on  one  side.  By  ascertaining  how  much  this  space 
is  we  Imow  how  much  too  wide  the  bridge  is,  and  by  measuring  the 
bridge  and  making  the  deduction  for  oversize,  we  have  the  proper 
width. 

Remember,  that  the  base  width  is  measured  from  the  point  on  each 
side  where  the  flesli  last  touches,  and  not  from  the  middle  of  the  turns  of 
the  shanks.  The  width  of  base  is  one  of  the  most  important  dimen- 
sions of  the  bridge  and  decides  to  a  large  degree  whether  the  spec- 
tacles are  comfortable  or  not.  The  bridge  should  fit  the  nose  just 
like  a  saddle,  for  if  it  touches  all  around  it  will  help  support  the  weight 
and  relieve  some  of  the  strain  at  the  back  of  the  ears.  At  the  same 
time  a  bridge  too  narrow  at  the  base  will  press  into  the  nose  and  be 
very  uncomfortable. 

Angle  of  the  crest.  The  average  angle  subtended  by  the  bridge  of 
the  nose  is  45  degrees,  the  plane  of  the  face  being  90 ;  in  other  words, 
the  more  vertical  the  nose  the  higher  will  be  the  number  wdiich  rep- 
resents its  angle.  To  measure  this  angle  hold  a  rule  or  card  per- 
pendicular to  the  plane  of  the  face  and  note  the  size  of  the  angle 
betw^een  the  rule  and  the  nose  where  the  spectacle  bridge  will  rest. 

There  are  cards  made  to  take  this  measurement,  as  well  as  other 
little  contrivances. 

Length  of  temples.  There  are  two  ways  of  expressing  the  length 
of  temples  desired,  i.  e.,  the  distance  to  back  of  the  ear,  or  the  entire 
length  of  the  temple  from  tip  to  tip.  The  first  measurement  is  made 
with  file  fitting  spectacles  on  the  patient's  face,  the  two  extreme  points 
l)eing  the  plane  of  the  lenses  and  the  middle  of  the  back  of  the  ear. 


4966        EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

'I'llt'    (itlirr    llirtliod     is    to    lioticf     how    tllr     length    of    till'    Iflilplrs    oil     tllf 

fitting  frame  suits,  iiK'asiiring  tlic  full  length  of  these  temples  aii<l 
then  nddiiig  to  or  siihti'actiiig  IVoni  this  length  as  may  he  necessary. 

The  iiistrnetions  given  here  a|)i)ly  to  hotli  i-imh'ss  and  fi-aines.  Some 
use  four  or  five  spectaeles  of  ditl^'erent  sizes  to  ineasiire  ovi-i-.  Imt  tiie 
use  of  a  complete  set  of  12  sizes  is  advised. 

Eyeglasses.  The  finger-piece  type  has  conic  into  use  within  the  last 
ten  years  and  on  account  of  neatness  of  appearance,  the  property  of 
retaining  its  original  shape  and  adjustment,  and  simplicity  in  fitting, 
it  has  become  very  ])opular  and  widely  used.  However,  there  are  cases 
where  the  regular  style  is  more  desirable  than  the  finger-piece,  and 
vice  versa.  For  instance,  a  finger-piece  mounting  has  a  tendency  to 
cause  the  nose  to  appear  shorter  and  the  face  narrower,  while  the  reg- 


Regular. 

ular  mounting  gives  I'ise  to  reverse  impressions.  This  being  the  case, 
a  finger-piece  mounting  on  a  short  nose  makes  it  seem  shorter ;  a  reg- 
ular mounting  would  lengthen  it.  If  one  fits  a  finger-piece  mounting 
where  the  pupillary  distance  is  comparatively  narrow,  the  eyes  will 
seem  still  closer  together,  whereas  a  regular  niountiiig  will  seem  to  put 
more  space  between  the  eyes. 

"Regular"  style.  To  ascertain  the  correct  size  of  lens,  length  of 
stud,  style  of  guard,  etc.,  it  will  be  (piite  necessary  to  have  an  eyeglass 
mounting  to  measure  over. 

First  measure  the  i)atient's  P.  D.  Then  adjust  a  sample  mounting 
as  well  as  possible  and  ])lace  it  in  the  correct  position  on  the  patient's 
nose.  Now  measure  the  P.  D.  of  the  glasses  while  on  the  face  (meas- 
ure from  inside  edge  of  one  lens  to  outside  of  the  other)  ;  this  places 
one  in  position  to  know  how  large  to  nuike  thei  lenses  aiul  how  long 
the  studs.  Suppose,  for  illusti'ation,  that  the  sample  mounting  is 
equipix'd  with  regular  H  studs  and  0  eye  lenses,  that  your  patient's 
P.  D.  is  60,  and  that  the  P.  1).  of  the  glasses,  when  on.  is  fiS  milli- 
meters. One  sees  at  a  glance  that  these  glasses  would  be  too  narrow 
and  their  P.  1).  must  be  increased  2  millimeters.  There  are  two  ways 
in  which  this  can  be  accomplished;  by  using  longer  studs  or  larger 
lenses,      'i'lie  next  size  studs  to  those  on  the  sample  mounting  arc  known 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4JJ67 

as  C  .sliids.  tlifi-f  l(t'iii<;'  a  dirfcrciiff  of  diic  iiiilliiiictff  in  tlir  Icii^tli 
of  a  B  ami  a  ('.  l>y  usiiiy;  C  studs  in  the  case  we  ai'c  considcriii^  we 
will  increase  the  I'.  I),  of  tlic  glasses  2  nun.  i  1  mm.  on  eaeli  stud),  and 
thus  ()l)taiii  the  desired  width  of  00  mm.  By  iiiei-easing  the  size  of 
lenses  2  mm.  and  heaving  the  studs  as  they  are  in  the  sample  (B  size) 
we  ean  obtain  llie  same  result.  The  lenses  in  our  sample  are  0  eye 
size  ant!  their  length  therefore  is  39  mm.;  adding  2  nnii.  to  this  gives 
41,  whieli  is  the  length  of  000  eye  lenses,  hence  by  using  000  lenses  and 
B  studs  we  obtain  the  desired  P.  D.  With  these  two  methods  we  ean 
make  several  combinations  and  get  exactly  the  dimensions  we  want. 
For  instance,  we  have  studs  ranging  from  A  to  F  (about  1  mm.  dif- 
ference for  each  size)  and  lenses  ranging  from  1  eye  to  jumbo,  or  in 
figures,  from  31  to  46  mm.  long,  which  we  can  combine  in  a  great 
many  different  ways. 

Notice  when  the  mounting  is  in  the  proper  position  on  the  nose 
whether  the  lenses  are  too  close  to  or  too  far  away  from  the  eyes. 
If  they  are  too  close  use  inset  studs  to  put  them  farther  out,  if  too 
far  away  use  outset  studs  to  bring  them  closer.  Both  of  these  styles 
are  made  in  two  sizes,  1-1(5  and  Vs-i^ch,  and  one  can  easily  tell  wdiich 
size  is  required. 

If  the  brows  are  prominent  and  press  against  the  spring  use  a 
Grecian  or  a  tilting  spring.  Ol)long  springs  are  usually  used  for  men 
and  hoop  springs  foi-  women,  l)ut  this  is  a  matter  of  personal  choice. 

The  guards  selected  should  have  a  flat  surface  w'here  they  come  into 
contact  with  the  flesh — this  is  the  first  requisite  of  an  efficient  guard. 
In  adjusting  tlie  guards  it  must  be  borne  in  mind  that  contact  and 
adhesion  count  greater  for  desirable  I'esults  than  pressure,  and  for  this 
reason  the  guard  must  be  curved  and  bent  to  conform  with  the  cor- 
responding part  of  the  nose. 

One  should  have  about  six  eyeglass  mountings,  complete  with  lenses, 
and  having  different  styles  of  guards  and  springs.  With  this  equip- 
ment one  may  select  the  style  of  guard  that  will  be  best  for  each  par- 
ticular case. 

Some  styles  and  angles  of  guards  will  set  the  lenses  lower  than 
others,  but  usually  it  is  necessary  to  drill  the  holes  in  the  lenses  1-16 
or  i{s-i"<'h  above  center  to  lower  them,  especially  where  the  glasses  are 
to  be  bifocal  oi'  reading  lenses,  in  regular  eyeglass  mountings. 

Fingcr-picce  r}/<  cflass<  s.  Having  decided  what  mounting  fits  the 
best,  note  the  number  it  bears  that  represents  its  size.  I\Ieasure  the 
P.  D.  of  the  patit'ut  and  tlien  measun'  the  P.  D.  of  the  glasses.  If 
these  two  measurements  are  alike  prescribe  the  same  size  lenses  as 
those  in  the  fitting  mounting,   which   is  usuallv   0  eve  size.     If  the 


4968        EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

littiiig  glasses  arc  loo  narrow  in  P.  1).  iiicrcasf  the  size  of  the  lenses 
uutil  the  proper  P.  D.  is  obtained,  provided  of  course'  that  it  is  not 
more  than  a  Jew  inillimcters  and  does  not  make  the  Icnsi's  tpo  lai-ge. 
The  00  eye  lenses  are  one  millimeter  longer  than  0  eye  size  and  will 
increase  the  P.  1).  just  oik-  millimeter;  000  eye  lenses  are  two  milli- 
meters longer  than  0  eye  and  will  increase  the  P.  D.  the  same  amount. 
One  does  not  have  to  be  controlled,  however,  by  the  standard  sizes; 
000  eye  lenses  have  a  length  of  41  mm.,  we  can  use  42,  43  or  44  mm. 
lenses  if  desired.  There  is  usually  about  !)  mm.  difference  between 
the  length  and  breadth  of  regularly  shaped  lenses^  so  we  can  specify 
42x33  or  43x34,  etc.,  instead  of  trying  to  convert  these  lenses  to  a 
standard  size.  Likewise  where  it  is  desired  to  give  a  short  oval  effect 
one  may  specify  42x34  or  42x35,  etc.,  but  alwa3's  remember  that  when 
measuring  the  P.  D.  of  a  pair  of  glasses  to  measure  f  Jpn  the  inside 
edge  of  one  lens  to  the  outside  edge  of  the  other  lens  and  in  this  way 
the  length  of  only  one  lens  is  included  in  the  total  P.  D.  and  conse- 
quently an  increase  in  the  length  of  both  lenses  of  2  mm.  will  increase 
the  P.  D.  of  the  glasses  only  2  mm.  and  not  4  mm.  as  might  at  first 
be  supposed. 

Let  us  say  that,  in  order  to  cause  the  gllusst^s  to  have  the  proper 
P.  D.  it  would  be  necessary  to  use  larger  lenses  than  are  desired.  Li 
this  case  one  must  use  extended  posts ;  these  correspond  to  the  C  and 
D  studs  in  regular  eyeglass  mountings  and  are  made  in  just  two  sizes, 
iV  and  Vs  inch.  Should  we  put  on  ^V  extended  posts  we  w'ill  increase 
the  P.  D.  Vs  inch,  or  about  3  mm.,  and  Vs  inch  extended  posts  would 
increase  the  P.  D.  i/4  inch,  or  about  6  mm.  Here  it  will  be  seen  that 
l)oth  posts  must  be  considered  in  the  P.  D.,  as  we  include  them  both 
in  the  P.  D.  measurement. 

Now  observe  whether  the  lenses  are  too  close  or  too  far  from  the 
eyes;  if  so  prescribe  inset  or  outset  posts,  whichever  are  needed,  the 
same  as  when  fitting  regular  mountings.  Outset  and  inset  posts  are 
made  in  two  sizes,  Vo  and  Vs  inch,  and  it  will  be  found  comparatively 
easy  to  judge  which  size  is  needed. 

Summing  up,  the  things  w^e  need  to  know  in  prescribing  finger- 
piece  eyeglass  mountings  are:  The  number  or  size  of  the  mounting, 
extended,  inset  or  outset  posts  and  the  size  of  the  lenses. 

ADJUSTING   SPECTACLES. 

Before  considering  the  adjustment  of  spectacles  let  us  analyze  the 
conditions  tliat  must  l)e  presented  by  a  properly-fitting  spectacle  frame 
or   iiiouiitini,'.     The  lenses  must   center  before   the  eyes   and   sit   just 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4969 

as  close  as  possible  to  the  eyes  witliout  touching  tlie  lashes.  In  glasses 
that  are  to  be  used  for  general  work,  i.  e.,  both  distant  and  near,  the 
line  of  vision  should  be  just  a  trifle  above  the  center  of  the  lenses  when 
the  eyes  are  directed  straiglit  ahead.  Every  part  of  the  frame  must 
give  entire  comfort ;  the  bridge  must  fit  all  around  the  curve  of  the  nose 
like  a  saddle  on  a  horse's  back,  and  the  temples  must  l)e  just  the  right 
length. 

There  are  pliers  tluit  are  specially  designed  to  do  particular  kinds 
of  work,  and  it  will  be  advantageous  to  be  supplied  with  the  proper 
tools  and  to  know  their  respective  uses,  for  one  cainiot  accomplish 
satisfactory  results  when  not  properly  equipped  in  this  regard.  The 
following  styles  of  pliers  are  necessary  in  adjusting  spectacles :  Snipe- 
nose  (half  round),  full  round,  concavo-convex,  bridge  angling,  and 
stud  pliers.  There  are  other  styles  that  will  facilitate  the  work,  but 
these  just  enumerated  are  absolutely  needed. 

If  the  lenses  are  too  high  and  it  is  desired  to  lower  them,  bend  the 
shanks  of  the  l)ridge  downward,  but  remember  that  this  will  lower 
the  angle  of  the  bridge  and  allowance  must  be  made  accordingly.  If 
the  lenses  are  too  low,  bend  the  shanks  upward,  remem])ering  that 
this  will  also  alter  the  angle  of  the  bridge. 

The  angle  of  the  bridge  may  be  varied  by  angling  the  crest  with 
ordinary  snipe-nose  pliers  or  hy  curving  the  shanks  upward  or  down- 
ward at  the  eyewire  or  straj),  but  the  best  way  is  to  use  pliers  that 
are  especially  made  for  angling,  for  instance,  the  Berg  pliers,  by 
means  of  which  the  angle  can  be  changed  properly  in  a  very  short 
time. 

The  shanks  may  be  lengthened  or  shortened  to  control  the  distance 
of  the  lenses  from  the  eyes  l)y  changing  the  relative  position  of  the 
point  at  which  the  l)i-idge  curves  to  make  the  shanks.  First,  with  a 
pair  of  snipe-nose  ])lieis  flatten  out  the  curve  in  the  shank,  then  with 
a  pair  of  full  round  pliers  put  the  bend  in  the  ])ridge  just  where 
you  want  the  shanks  to  begin  and  continue  to  bend  the  shanks  over 
until  tliey  are  brought  into  the  proper  position.  It  is  quite  essential 
that  pliers  with  full  round  jaws  be  employed  for  making  these  curves, 
as  the  othei-  pliers  will  mark  and  cut  the  covering  of  the  bridge. 

The  pu])illary  width  of  the  glasses  should  be  controlled  by  the 
direction  taken  by  the  shanks  without  disturbing  the  width  of  the 
base  of  the  bridge. 

The  width  of  the  ])ase  should  be  altered  by  using  pliers  that  have 
one  jaw  concave  and  the  other  convex.  Changing  the  base  will  also 
affect  the  pupillaty  width.  In  l)ending  a  bridge  it  will  l)e  wisest  to 
ascertain  just  exactly  what  altei-ations  are  necessary  before  nmking 


4;)70   EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

jiiiy,  (liif  to  llir  tact  that  every  diiiieiisidii  is  (le|(ciiileiit  iii»()ii  the 
otiier  ami  a  ehaii^c  in  one  will  cause  a  corresjiondin;;  chanjic  in  sonic 
of  the  others. 

'I'o  liend  temples  so  as  lo  angle  the  lenses,  or  where  one  ear  is 
lii<i:lit'r  than  the  other  and  one  temple  must  be  raised,  use  two  paii's 
of  pliers;  with  stud-pliers  grasp  the  end-piece  close  to  the  edge  of 
the  lens  or  eyewire  and  with  a  jjair  of  snipe-nose  pliers  take  hold  of 
the  outside  end  of  the  end-piece  and  hend  the  part  of  the  end-piece  to 
which  the  temple  is  attached,  so  as  to  move  the  temple  upward  or 
down\\ard  as  may  be  desired;  in  other  words,  the  end-piece  is  slightly 
twisted.  Above  all  things  do  not  curve  or  bend  the  temple  itself,  but 
confine  the  bending  to  the  end-piece. 

To  curve  the  temples  for  the  turn  of  the  ear  use  a  pencil  or  some- 
thing else  round  ami  curl  the  temple  as  one  would  a  feather,  by  draw- 
ing the  end  of  the  temples  between  the  thumb  and  the  pencil.  Temples 
may  be  curved  outward  in  a  similar  manner  where  they  cut  into  the 
flesh  on  the  side  of  the  face. 

If  one  lens  sits  higher  than  the  other  it  nuiy  be  that  one  ear  is 
higher  than  the  other  and  the  trouble  should  be  rectified  by  angling 
the  temples. 

Adjusting  eyeglass  mountings.  AVe  siudl  consider  here  two  kinds 
of  eyeglass  mountings  in  general,  that  is,  those  of  the  finger-piece 
type  and  those  with  the  i-egular  hoop  springs.  In  differentiating 
between  these  two  kinds  the  spring  of  the  regular  and  the  bridge  of 
the  finger-})iece  mounting  are  the  essential  points  and  the  same  rules 
will  ap])ly  to  both  classes  of  mountings  except  where  they  ai)ply  to 
these  two  conflicting  portions. 

The  first  aim  in  fitting  the  eyeglass  is  to  make  it  stay  on  securely 
with  comfort,  and  in  effecting  this  we  cannot  sacrifice  correctness  of 
position,  so  that  many  times  we  are  confronted  with  a  complex  prob- 
lem w^hen  endeavoring  to  make  these  three  features  work  harmoniously. 

The  guards  themselves  must  present  a  smooth  surface  to  the  flesh 
and  must  be  curved  so  as  to  conform  to  the  contour  of  the  portion  of 
the  nose  over  which  they  rest.  To  curve  the  guards  in  this  manner 
it  is  quite  essential  to  have  the  proper  kind  of  jiliers ;  the  best  for  this 
purpose  are  those  that  have  one  convex  blade  and  one  concave,  so  that 
by  simi)l\-  pi-essing  tlie  blades  togethei-  that  poi'tion  of  the  guard 
assumes  a  corresponding  curvatui'e  in  degree  depending  on  the 
amount  of  pi-essure  given  the  pliei's.  Ky  using  pliers  of  this  kind 
the  guai'ds  may  be  accurately  (nu'Ncd  without  interfering  in  any  way 
with  the  remaindei-  of  the  guartl  or  its  general  angle,  etc.  i^uppose 
now   after   the    guards   liave   been    given    the   proper    curvature,    and 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT   4!)71 

^I'iiiit  iii]L;'  tile  iillitT  parts  of  the  iiioiiiit  iii^-  ai'c  cnciiI^n'  Italaiiccd  ami 
sti'ai^''lit,  tliat  one  lens  is  liiglicr  than  llic  otliei'.  We  will  say,  for 
instance,  that  tlic  left  lens  is  liij^licr  than  the  right.  Take  the  enrved 
pliers  ami  bend  the  hottoiii  of  the  left  ynard  out  slightly,  heiiig  care- 
ful not  to  bend  it  so  far  that  it  leaves  the  iiesh.  If  this  is  not  sullicieiit 
to  lower  the  lens,  bend  the  entire  guard  on  its  axis,  so  that  the  bot- 
tom portion  does  not  i)ress  so  hard;  this  will  bi-ing  tlu^  top  of  the 
guard  tighter,  but  care  must  be  exercised  not  to  bi-ing  this  in  too  tight. 
Further  lowering  of  the  left  may  be  aceomplished  by  raising  the 
right  lens,  which  is  doni'  by  bending  the  right  guard  in  toward  the 
nose  slightly  at  the  bottom.  It  is  surj)rising  how  IxMiding  of  the  guai-ds 
will  atfect  the  respective  heights  of  the  lenses. 

In  all  eases  the  top  of  the  guard  should  be  curved  out  slightly  to 
agree  with  the  curvature  of  the  nose  as  it  merges  into  the  brows;  if 
this  curving  is  not  done  here  the  top  of  the  guard  will  cut  into  the 
flesh  and  prove  very  uncomfortable.  It  is  the  bottom  of  the  guard 
that  supports  the  weight  of  the  glasses  and  the  top  that  prevents 
them  from  tilting  over,  so  that  the  top  of  the  guard  must  necessarily 
press  a  trifle  harder  than  the  bottom,  and  as  a  general  thing  more  pres- 
sure can  be  stood  here  than  at  the  bottom,  because  there  is  nearly 
always  a  little  cushion  of  flesh  here.  Wherever  the  guard  rests  on  a 
bony  part  of  the  nose  the  contact  must  be  very  even  and  the  pressure 
comparatively  light,  else  the  guard  will  cut  the  skin.  By  giving  the 
guards  the  same  curve  as  the  nose  they  will  stick  to  the  skin  and  much 
less  pressure  will  be  required  than  otherwise.  Another  good  plan 
is  to  bend  the  entire  guard  out  from  the  back,  so  that  there  is  more 
l)ressur(^  along  the  front  or  outside  edge  of  the  guard  than  at  the 
back;  this  will  cause  the  flesh  to  pile  up  slightly,  as  it  were,  in  front 
of  the  guard  and  form  a  wedge  of  the  flesh  which  prevents  the  mou?it- 
ing  from  slipping  forward. 

In  the  case  of  a  regular  mounting  with  the  hoop  spring  sometimes 
it  is  desirable  to  have  the  spring  tilting  slightly  at  the  top  away  from 
the  forehead  on  account  of  heavy  bi-ows  or  high  nose.  There  are 
springs  that  are  made  with  this  tilt,  but  if  the  mounting  one  is  adjust- 
ing is  not  tilting  and  it  would  be  preferable  to  have  it  so  one  can  very 
easily  bend  it  to  have  the  desirtMl  tilt.  To  do  this  use  what  is  known 
as  stud  pliers,  taking  them  in  one  ha  ml  and  gripping  the  strap  of  one 
of  the  studs  with  tliem.  Grip  the  ])liers  tightly  and  with  the  thuml) 
of  the  other  hand  ]iress  against  the  top  of  the  spring  and  one  will 
find  that  it  can  l)e  l)ent  outward.  After  doing  this  take  hold  of  the 
other  stud  with  the  pliers  in  a  similar  way  as  before  and  repeat  the 
operation  on  this  side,  thus  evening  up  the  tilt  from  both  sides. 


4972       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

W'lii'ii  |tl;iciiig  eyeglasses  on  ;i  p;iticiit 's  nose  do  not  liold  the  glasses 
l)y  plaeiiig  the  fingers  on  the  two  sides  of  the  lenses,  hut  allow  the 
fingers  to  toueli  only  the  edges  of  tlie  lenses. 

W  the  guards  are  covered  witli  shell,  be  sure  to  sniootii  olf  the  edges 
all  around,  using  a  fine,  flat  file  for  the  purpose.  It  will  often  be 
found  in  ea«es  where  the  mounting  is  not  eonifortable  and  the  guards 
are  covered  with  shell  or  a  similar  substance  that  the  trouble  can  be 
relieved  b}^  filing  the  edges  of  the  shell  on  the  guards. 

When  mountings  eont<iin  toric  lenses  the  efificieney  of  the  lenses  may 
be  increased  by  bending  the  lenses  in  toward  the  temples.  This 
enables  the  patient  to  look  sideways  without  being  annoyed  by  the 
edges  of  the  lenses. 

[Adjusting  bifocals.  Mr.  E.  E.  Maddox,  speaking  of  the  troubles 
that  most  people — especially  active-minded  neurasthenics — experience 
in  their  attempts  to  get  accustomed  to  bifocals,  says:  "So  great  is 
the  convenience  of  bifocals  that  they  should,  if  possible,  come  into 
universal  use  whenever  both  the  far  and  near  corrections  are  neces- 
sary. Yet  it  is  a  matter  of  common  observation  that  while  some 
patients  take  at  once  to  their  bifocals,  with  evident  satisfaction,  others 
experience  a  rather  stormy  introduction  to  their  use,  and  many  are 
obliged  to  abandon  the  attempt  to  wear  them  owing  to  the  'irritating 
effect,'  as  they  call  it,  of  the  upper  margin  of  the  reading  segment. 

' '  The  following  little  expedient,  I  find,  contributes  towards  the  edu- 
cation of  those  who  cannot  at  once  become  reconciled  to  the  presence 
of  the  dividing  line.  It  consists  in  painting  a  black  line  at  least  one 
millimetre  broad  on  the  posterior  surface  of  the  glasses,  along  the 
upper  edge  of  the  reading  segment.  Indian  ink,  mixed  with  gum  or 
'seccotine,'  which  can  be  easily  washed  off  when  required,  affords  a 
very  suitable  pigment.  The  mind  being  kept  conscious  of  the  pres- 
ence of  this  band,  finds  less  difficulty  in  learning  to  look  either  above 
or  below  it,  and,  when  the  lesson  is  well  learned,  the  band  can  be 
washed  off. 

' '  The  irritating  effect  of  the  dividing  line  is  due  partly  to  the  double 
vision  from  the  prismatic  action  of  the  edge  of  the  reading  segment, 
and  partly  also  to  scattered  light,  to  which  some  eyes  are  so  much  more 
sensitive  than  others,  and  which  acts  much  as  a  nebula  upon  the 
coniea  would  do.  A  black  band  is  far  more  soothing,  and  if  painted 
truly,  is  not  nearly  so  unsightly  as  might  be  anticipated.  It  has 
indeed  rather  a  ])urposeful  look. 

"As  distinct  from  tiiis  educational  band.  1  think  it  would  be  well 
to  make  a  practice  of  staining  the  margin  of  the  reading  segment  with 
a  dead  black  in  all  cases,  and  even  in  the  uni-bifoeals.  the  lower  edge 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4973 

of  the  larger  segment  sliould  ])v  thus  stained,  so  as  to  lessen  adven- 
titious retleetions  into  the  eye.  Since  the  stained  margin  looks 
upward  or  downward,  it  would  not  be  sufficiently  visible  from  the 
front  to  counterbalance  its  advantage  to  at  least  those  who  have  some 
retinal  hyperesthesia." — Ed.] 

One  of  the  chief  objections  to  finger-piece  mountings  is  that  they 
are  apt  to  sit  too  high  and  to  sit  farther  from  tlie  face  at  the  liottoin 
of  the  lenses  than  at  the  top.  Great  care  must  be  exercised  to  pre- 
vent these  two  conditions,  and  it  will  be  well  to  understand  how  to 
overcome  these  difficulties.  The  standing  away  from  the  face  at  the 
bottom  of  the  lenses  can  be  rectified  by  spreading  tlie  guards  at  the 
bottom  and  by  making  them  incline  somewhat  fi'om  the  vertical.  The 
custom  of  l)ending  the  ends  of  the  bridge  dowiiwai'd  and  drilling  the 
holes  above  center  is  not  advised  in  cases  where  it  is  desired  to  set 
the  lenses  lower,  because  it  spoils  the  appearance  of  the  mounting, 
narrows  the  base  of  the  bridge  and  disrupts  the  proper  working  of 
the  springs  and  finger-pieces.  The  better  plan  would  be  to  fit  mount- 
ings in  which  the  guard-arms  are  so  constructed  that  the  guards  may 
be  raised  without  changing  their  angle,  or  mountings  that  are  sup- 
plied with  drop-studs,  or  "tangent"  studs,  as  they  are  called  by  some. 
To  increase  the  tension  of  springs  on  finger-piece  mountings  detach 
the  long  end  of  the  spring,  gripping  it  with  a  pair  of  pliers,  and 
pull  the  spring  tighter  on  the  coil.  To  decrease  the  tension  push  back 
on  the  coil.  In  cases  of  springs  of  the  lever  variety  in  which  it  is 
not  possible  to  adjust  the  tension  of  the  coil,  bend  the  long  free  end ; 
to  increase  the  tension  bend  it  toward  the  side  it  presses ;  to  decrease, 
press  toward  the  opposite  side. 

HOW    TO    ORDER    OPTICAL    WORK. 

This  is  one  of  the  most  important  subjects  and  sliould  receive  very 
careful  attention.  As  far  as  possible  in  describing  the  style  of  frames 
or  mountings  catalog  nuinl)ers  should  be  used. 

Fundamental  rules.  Use  a  separate  blank  for  each  order  or  each 
pair  of  glasses.    Write  clearly  and  avoid  vague  descriptions. 

When  ordering  lenses  be  sure  to  state  the  size  of  the  eye,  and 
whether  rimless  or  for  frames. 

Give  eaeh  presci'iption  a  number  or  patient's  name  and  the  date. 

Sign  your  name  at  the  1)ottom. 

Do  not  write  instructions  acro.ss  printed  matter,  as  this  makes  them 
\ory  difficult  to  read. 

Name  or  number.     It  is  well  to  give  i-acli  oi'der  a  name  or  number. 


4117  t        EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

wliicli  will  he  useful  wlicii  wi'itin;^"  about  au  oi'dn-  or  lor  otlu-r  future 
references. 

Formulas  of  lenses.  W'licii  the  usual  form  is  followed  of  writing 
the  si)li(T('  first,  the  cyliiidrical  \;dur  next,  and  the  axis  of  cylinder 
next,  it  is  not  necessary  to  apjx'ud  the  atilti't'viations  "Spli.,"  "Cyl.," 
or  "axis,"  even  when  not  wi'ilten  on  a  tabulated  blank,  in  which  case 
the  foi'iii  should  be  thus:  —  ]..")()  —  .75x90. 

When  distance  lenst-s  oidy,  or  I'eadin^  lenses  only,  are  wantetl  give 
the  fui'iiiula  for  the  particular  correction  you  want,  and  not  both. 
AVIieii  both  foniiuhis  ai'e  given,  as  in  casi^s  where  bifocals  are  desired, 
it  is  best  to  give  the  total  I'eading  correction  in  full  and  not  the  addi- 
tion for  the  l)ifocal  portion.  In  such  cases  where  the  addition  is  given 
you  should  l)e  very  i)articular  to  append  the  word  "Add"  after  the 
amount  to  be  added.  It  is  ))ecause  it  is  so  easy  to  forget  to  affix  this 
little  word  that  it  is  much  better  to  alwaj's  give  the  full  reading  cor- 
rection after  the  addition  has  been  made. 

Other  lc)is  specifications.  Always  state  whether  you  want  "toric" 
or  "flat"  lenses.  While,  strictly  speaking,  there  is  no  such  thing  as 
a  "spherical  toric,"  the  correct  term  being  "meniscus,"  the  term 
"toric"  is  generally  accepted  as  applying  to  all  lenses  constructed  on 
a  deep  periscopic  base.  By  "flat"  lenses  is  meant  all  lenses  that  are 
not  toric  (or  meniscus). 

Give  the  "size  of  eye"  in  the  proper  space;  this  is  the  size  of  lens 
as  has  been  previously  described. 

When  lenses  only  are  being  ordered  and  one  does  not  want  them 
put  into  a  frame  or  mounting,  be  sure  to  state  whether  they  are  to  be 
rimless  or  inserts  (for  rims),  and  if  rimless  how  many  holes  to  be 
drilled  in  them.  In  specifying  for  the  drilling  of  holes  always  specify 
the  number  of  holes  per  pair,  exvu  in  cases  where  only  one  lens  is 
ordered. 

Should  one  order  just  a  single  lens,  and  not  send  the  other  lens  to 
be  matched  for  thickness,  l)e  sure  to  give  the  tliickness  of  the  lens  at 
the  "strap,"  or,  in  other  w^ords,  where  it  is  attached  to  the  mounting. 
This  thickness  may  be  ascertained  by  measuring  with  a  millimeter  rule 
or  by  using  a  strap  gauge. 

If  one  does  not  giv(>  any  instructions  regarding  how  the  holes  shall 
he  drilled  they  will  be  drilled  "on  line;"  in  cases  where  one  wants 
the  lenses  to  set  lower  when  using  eyeglass  mountings,  specify  that 
the  holes  should  be  drilled  above  centiM".  stating  how  nnieh,  thus: 
l)i-ill  one-eighth  altove.  oi"  di'ill  one-sixteenth  altove.  as  the  case  may 
re(|uire. 

The  frame  or  moii )il i)i(/.     Know  just  what  is  wauled  heiv  and  give 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4975 

spccilic  iiislriK'tioiis,  loi-  this  pjiil  oT  the  oi'dci'  is  just  as  important  as 
tliat  which  refers  to  the  h'lises:  reineinlx'r  the  iiuiii  who  tills  your  order 
does  not  see  the  patient  and  must  have  deHnite  dimensions  by  which 
to  be  guided  if  he  is  to  make  up  a  frame  or  mounting  that  will  lit. 

Eycgl(iss(S.  In  the  proper  si)ace  state  whal  style  of  mounting  is 
desired  and  what  kind  of  material  wanted,  su<-h  as  gold  filled,  solid 
gold,  nickel,  etc.  As  far  as  possible  il  is  well  to  give  catalog  or  stock 
mnnbers,  Ijccause  these  ai'e  (piickly  read  antl  undci'stood,  save  space  on 
the  order  blank  and  save  time  in  the  shop.  When  oi'dcriiig  Hnger- 
piece  mountings  remcmhci'  that  the  numbers  given  in  the  lifting  set 
refer  to  size  of  the  bridge  only  and  not  to  the  particular  style  of 
mounting.  For  instance,  let  us  say  one  is  fitting  from  a  set  of 
mountings  known  as  the  "Staylherc  ^lountings,"  and  decides  that  a 
No.  842  is  the  size  desired  and  the  patient  orders  gold  filled,  on  the 
order  specify  "G.  F.  Staythere  842."  Thus  one  covers  every  point 
of  style  wanted,  so  that  the  man  who  fills  the  order  knows  positively 
just  w^hat  is  'svanted.  It  will  take  but  a  moment  to  decide  what  size 
lenses  are  needed  and  to  mark  it  down  on  the  order.  Remem])er  that 
000  eye  size  is  just  one  millimeter  longer  than  00  eye,  and  that  00 
eye  is  just  one  millimeter  longer  than  0  eye,  and  each  change  of  eye 
size  will  make  just  one  millimeter  difference  in  the  pupillary  width 
of  the  glasses.  In  ordering  eyeglasses  of  the  finger-piece  type  the  only 
data  necessary  are : 

^Material,  style,  size  of  mounting  and  size  of  lenses.  Pupillary  width 
and  "spread  of  guards"  are  superfluous  when  ordering  .any  kind  of 
eyeglass  mountings  or  frames,  because  the  pupillary  width  will  be 
controlled  by  the  size  of  lens  and  size  of  mounting,  and  the  "spread 
of  guards"  will  have  to  be  effected  when  one  fits  the  mounting  to 
the  patient's  face,  for  eyeglass  guards  cannot  be  adjusted  "by  mail." 

Most  of  the  foregoing  ai)plies  to  finger-piece  mountings;  hoop  spring 
mountings  must  be  ordered  in  a  somewhat  different  manner.  Give 
the  kind  of  material,  size  of  lenses,  size  and  style  of  studs,  .style  of 
guards,  size  and  style  of  spring. 

Spectacles.  State  the  style  of  frame  or  mounting  and  what  kind 
of  material  wanted,  the  s'v/.e  of  eye,  pupillary  width  :  give  the  bridge 
dimensions  regarding  height  and  position  of  crest,  either  in  figures  or 
by  a  bridge  number;  state  the  angle  of  crest  and  width  of  base.  The 
length  of  temple  may  lie  expi-essed  either  by  giving  the  total  length 
from  tip  to  ti]).  or  by  giving  the  distance  in  a  straight  line  from  the 
l^lane  of  the  lens  to  the  middle  of  the  liack  of  the  ear;  the  former  is 
preferable,  because  it  is  definite.  The  style  of  temple  should  be  statiMl 
at  the  same  time  of  specifying  the  style  of  the  mounting. 


4;»76   EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

Tlici'c  arc  stock  si/cs  of  bridjjcs  lliat  liavc  stated  dini<;nsions  and 
these  various  sizes  are  dcsi«rJia1c(l  l)y  letters,  such  as  M,  N,  0,  etc. 
Where  the  dimensions  of  the  bridge  wanted  are  not  given  in  figures 
the  h'ttcr  representing  the  size  desired  may  l)c  <;ivcii  in  the  space  on 
Ihc  hiank  usually  headed  "bridire  number;"  it  is  much   more  desir- 


ed 


e7 


2  Holes  Per  Pair  "1/lG  above  line. 


3  Holes  Per  Pair  "on  line." 


4  Holes  Per  Pair  ' '  on  line. 


able  to  give  the  dimensions  in  figures,  however,  as  this  insures  a  well- 
fitting  bridge.  Where  the  letter  is  used  to  denote  the  size  of  In-idge 
wanted  it  is  not  necessary  to  enter  the  figures  for  height,  position  of 
crest  or  base,  as  these  dimensions  are  covered  by  the  letter  given  as 
the  bridge  num])er. 

See  illustration  of  strap  gauge  for  ascertaining  tliickncss  of  lenses, 
and  how  drilling  of  lenses  is  specified. — (R.  D.  P.) 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4977 

Rhoades  (Prac.  Med.  Scr.,  p.  16,  11)11)  has  put  into  practice  a  plan 
to  remove  color  aberrations  and  reflections  from  the  edges  of  frame- 
less  eye-lenses  and  cemented  bifocal  segments,  and  at  the  same  time 
get  rid  of  the  harassing  band  of  white  light  which  comes  from  the 
same  source,  by  beveling  the  edges  of  the  lenses,  as  shown  in  the  figures 
of  this  text.  The  relief  is  especially  marked  when  the  patient  has  a 
tired  retina. 


A  "R 

Method  of  Preventing  Aberration  in  Frameless  Glasses.    (Rhoades.) 

The  edges  of  nil  frameless  lenses  should  be  ground  to  a  bevel  of 
about  45°,  as  shown  in  the  cut,  and  they  willjook  to  one  in  front  of 
the  glass,  as  in  the  second  figure,  indicated  by  the  broken  line.  In  high 
hyperopes  the  angle  would  be  sharper.  In  low  myopes  the  angle  would 
be  lower.  Then,  too,  the  angle  would  alter  a  little  with  the  sliape  of 
the  lens.  If,  to  be  sure,  the  lens  was  circular  the  angle  would  be  the 
same  all  around,  but  being  oblong  the  angle  should  vary  accordingly. 
In  short,  the  angle  of  the  edge  of  the  lens  should  be  from  40°  to  45° 
and  should  be  governed  by  the  size  of  the  lens  and  the  degree  of 
asthenopia.  The  length  of  the  lashes  and  the  contour  of  the  face 
would  also  enter  into  the  perfect  elimination  of  this  vicious  subtile 
halo,  and  the  final  result  will  be  good  or  bad  in  proportion  to  the  skill 
of  the  optician. 

The  prismatic  hues  which  are  sometimes  so  bitterh^  complained  of  by 
people  wearing  cemented  bifocals  can  be  entirely  overcome  by  grind- 
ing the  segment  to  the  retinal  angle,  i.  e.,  all  its  edges  should  be  ground 
so  as  to  point  to  a  focus  on  the  retina.  On  top  the  edge  should  be 
square  and  should  be  gradually  beveled  at  both  ends  until  the  bottom 
is  reached.  The  bottom  edge  should  be  ground  to  the  same  angle  as 
the  distant  lens.  The  fused  bifocal  cannot  be  entireh'  rendered  achro- 
matic ;  however,  the  bottom  edge  can  be. 

Recently,  Rhoades  has  been  impressed  with  the  fact  that  the  bright- 
yellow  gold  straps  are  a  rich  source  of  chromatism,  and  are  as  harmful 

Vol.  VII— 9 


4978        EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

to  the  eye  ;i.s  is  llic  coloi-  froiii  the  edges  of  lln'  lenses.  He  lil;iekeiie(l 
these  stra])s  with  iiidia  ink  and  was  amazed  at  tiie  result.  Not  only 
was  the  color  trouble  from  this  souree  corrected,  but  the  baud  of  bright- 
wliite  light  was  changed  into  a  dull  neutral  gray.  Ia'I  it  be  under- 
stood, that  Khoades  is  speaking  of  the  vicious  band  of  light  from  the 
unbeveled  edges  of  the  lenses,  and  that  the  blending  to  a  dull  gray 
was  due  to  l)laekening  the  straps  and  not  l)la(.'kening  the  edges  of  t\ut 
glasses.  lie  did  l)laeken  the  edges  afterwards  with  the  result  that  the 
live,  white  reflecting  lens  was  changed  into  a  dead  neutral  one. 

The  writer  quoted  is  fully  alive  to  the  fact  that  this  pathologic  ray 
is  not  going  to  be  disturbed  in  its  citadel.  lie  says  this  for  two 
reasons.  First:  The  oculist  and  the  optician  are  not  going  to  urge 
the  use  of  such  glasses,  and  what  is  worse  will  condemn  them  without 
trial.  They  will  rarely,  if  ever,  order  glasses  with  blackened  inner 
straps  and  beveled  edges,  fearing  their  patients  will  upl)raid  them  for 
I^rescribing  such  an  unfashionable  device.  Second  :  The  average  patient 
will  not  wear  them  if  prescribed.  They  would,  however,  wear  any 
fashionable  glass,  even  if  told  that  it  might  immediately  do  them  some 
slight  harm,  and  would  take  all  kinds  of  liberty  if  told  they  would  have 
to  pay  a  severe  penalty  only  in  the  dim  future.  There  are  some  who 
have  already  begun  to  pay  this  penalty,  and  others  with  slow'  tired 
retinas,  who  are  willing  to  do  anything  to  get  relief.  At  least,  let 
relief  be  given  to  those  who  are  willing  to  accept  it.  ChaufiFeurs, 
motormen,  engineers,  and  all  those  who  must  face  the  vicious  horizontal 
rays,  will  be  relieved  and  safeguarded  l)y  using  this  kind  of  glass. 

There  can  be  no  doul)t  l)ut  that  in  neurasthenic  patients,  in  many 
myopes  and  in  most  i)atients  with  diseased  fundi  the  foregoing  remarks 
are  well  wortiiy  of  consideration. 

To  (liiiiinisli  the  annoyance  of  bifocal  glasses,  JNIaddox  {Ophthal- 
moscope, Vol.  JX,  p.  413,  1911)  advises  i)ainting  a  black  line  at  least 
1  mm.  broad  on  the  posterior  surface  of  the  glass(>s  along  the  uppei" 
edge  of  the  reading  segment.  India-ink  mixed  with  gum  is  a  suitable 
pigment.  This  expedient  is  intended  principally  toward  the  education 
of  such  as  do  not  readily  become  accustomed  to  l)ifocals.  The  min-d 
being  kept  conscious  of  the  prescMice  of  this  band,  liiul.s  less  difticulty  in 
learning  to  look  either  al)0ve  or  below  it,  and  when  tiie  lesson  is  well 
leai'iied  the  l)and  can  l)e  washed  off.  As  distinct  from  this  educational 
band,  he  thinks  it  would  be  well  to  make  a  practice  of  staining  the 
nuirgin  of  the  reading  segment  with  a  dead-black  in  all  cases;  even  in 
the  unibifocals  th(>  lowei-  edge  of  the  larger  segnu'ut  should  be  thus 
stained  so  as  to  lessen  adventitious  reflections  into  the  eye.  Th(> 
stained    inaruin    would    not    be   sul'licienth-    visible    from    the    front    to 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4979 

counterbalance  its  advaiitage  in  cases  of  retinal  hyperesthesia,  lie 
truly  observes  that  it  is  the  neurasthenics  who  find  the  greatest  difficulty 
with  bifocals. 

Baker  {Opiithalmoscope,  Vol.  IX,  p.  4*J9,  liJllj  has  placed  the  read- 
ing segment  upon  the  upper  part  of  the  distance  glasses  and  mounted 
the  combined  lenses  on  a  trunion  so  that  they  can  be  reversed  when 
the  segment  is  requireil  for  near  work.  Such  an  arrangement  can 
ol)viously  only  ])e  used  in  the  case  of  spheres  and  where  the  axes  in 
astigmatism  are  just  horizontal  and  vertical,  and  even  here  the  centra- 
tion  would  be  apt  to  be  disturbed  from  the  frequent  changes  which 
would  have  to  be  made  in  passing  from  distant  to  near  vision.  Torie 
lenses  could  not  be  handled  in  this  way. 

Fingcr-irucc  mountings  for  eyeglasses.  Altliough  we  are  not  in  th.; 
habit  of  noticing  articles  in  trade  journals  yet  the  following  (Hardy 
Messenger,  Aug.,  1910)  is  so  instructive  to  the  oculist  that  we  copy 
it  without  further  comment. 

Within  the  last  few  years  there  has  been  placcil  upon  the  market  a 
new  style  of  eyeglass  mounting,  the  principles  of  which  are  radically 
different  from  those  formerly  in  vogue.  This  new  style  almost  immedi- 
ately received  public  favor  and  has  grown  more  and  more  popular 
as  its  utility  and  beauty  have  become  known. 

This  mounting  is  fast  superseding  all  other  styles  of  lens  mountings. 
It  is  known  as  a  finger-piece  eyeglass  and  is  so  called  because  it  may 
be  removed  or  adjusted  without  touching  the  lenses.  The.se  mountings 
have  many  excellent  features;  they  also  have  some  bad  ones.  Among 
their  good  features  may  be  noted  a  rigid  bridge,  or  one  that  holds 
the  lenses  in  perfect  horizontal  and  vertical  alignment,  or  in  the  same 
position  as  would  a  riding  bow  spectacle  with  a  saddle  bridge.  With 
such  an  eyeglass  the  axis  of  cylindrical  lenses  will  be  held  correctly, 
or  as  nearly  so  as  they  would  be  if  mounted  in  a  spectacle. 

The  guards  of  these  mountings  are  of  various  shapes.  They  are 
made  to  grip  the  nose  by  small  springs  which  force  them  together  or 
against  the  nose.  The  arms  of  the  guards  are  pivoted  to  the  bridge 
near  the  lenses;  they  project  lioth  forward  and  rearward.  The  forward 
ends  are  bent  outward  over  the  lens  clamps  and  form  finger  pieces 
wiiich  may  be  gripped  by  the  thumb  and  forefinger  when  the  glasses 
are  to  be  removed  or  adjusted.  The  guards  are  attached  to  the  rear- 
ward extension  of  the  arms.  Some  of  them  are  attached  rigidly  and 
others  loosely,  or  in  such  a  manner  as  to  allow  them  to  rock.  The 
former  are  known  as  "rigid,"  and  the  latter  as  "rocking"  guards. 
Those  styles  having  rigid  guards  are  susceptible  of  much  greater  ad- 


4980       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

justiueiil  than   are  those   with  rockinj^  guards,  yet  both   styles  have 
both  good  and  bad  features. 

Tlie  rearward  ends  of  the  guard  arms  may  be  bent  up  for  the 
purpose  of  lowering  the  lenses  or  down  if  it  is  desired  to  raise  the 
lenses  or  to  set  them  higher.  This  makes  the  adjustment  for  height 
very  easy  and  allows  the  lenses  to  be  drilled  at  the  center.  The  angle 
of  the  guards  may  be  changed  at  will,  also  the  spread  at  the  top  or 
bottom  or  at  both  top  and  bottom.  The  flare  may  also  be  quickly 
'changed  to  any  angle  desired,  so  that  the  guards  will  lie  flat  upon  a 
nose  of  any  shape.  As  a  rule  the  guards  are  made  entirely  of  metal 
and  are  easily  given  any  curve  desired,  either  at  their  tops  or  bottoms, 
or  l)oth  ends  may  be  curved  as  desired.  The  bridges  have  different 
lengths  and  different  heights,  also  different  inclinations. 

The  dimensions  of  the  bridges  are  practically  the  same  as  are  those 
on  riding  bow  spectacles.  When  one  of  these  mountings  is  correctly 
adjusted  the  bridge  will  rest  upon  and  have  the  same  contour  as  the 
nose,  thus  doing  away  with  the  unsightly  spring  of  the  old  style 
eyeglass.  It  was  almost  impossible  to  place  the  old  style  upon  the  nose 
twice  alike,  for  if  the  guards  did  not  rest  upon  the  identical  spot  each 
time  the  lenses  would  not  occupy  the  same  position.  They  might  have 
a  greater  or  less  pupillary  distance,  or  thej^  might  not  lie  in  the  same 
horizontal  or  vertical  plane  or  have  the  same  inclination  or  height  twice 
in  succession. 

One  great  fault  with  the  old  style  was  the  drooping  of  the  lenses. 
This  drooping  was  a  vital  error  if  the  lenses  contained  a  cylindrical 
element,  for  the  axis  of  the  cylinder  was  surely  removed  from  its  true 
position  if  the  lenses  drooped. 

Practically  all  of  the  faulty  features  of  the  old  style  eyeglass  have 
been  eliminated  in  the  new  style.  The  bridge  being  rigid,  the  distance 
between  the  centers  of  the  lenses  is  always  maintained  and  they  are 
always  held  in  the  same  vertical  and  horizontal  plane.  The  inclination 
may  not  always  be  exactly  the  same  (this  is  not  vital,  however),  but 
it  is  more  nearly  maintained  in  the  new  than  it  is  in  tlie  old  style. 
This  is  due  to  the  fact  that  w'hen  tlie  new  style  is  lieing  adjusted  the- 
bridge  is  made  to  rest  upon  the  nose,  and  when  the  fingers  are  removed 
fi-oin  the  clips  the  guards  fall  upon  the  same  parts  of  the  nose  every 
time.  The  optician,  when  fitting  the  old  style,  had  to  choose  his  guards 
from  a  score  or  more  of  different  styles  and  his  spring  from  dozens 
of  different  shapes  and  sizes,  and  liis  studs  from  many  different  lengths 
and  styles,  and  then  to  assemlile  them  and  afterward  to  adjust  tliem 
to  the  patient's  nose.  This  seleetion  of  the  most  suitable  material  and 
the  final  adjustment  requires  not  alone  experience,  Imt  lioth  experience 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4981 

and  skill.  For  this  reason  many  oculists  have  practically  refused  to 
preseri])e  eyejj;] asses  in  many  eases.  They  could  not  1)8  confident  tliat 
certain  lenses  would  prov^j  satisfactory  if  mounted  in  an  eyeglass. 
This  fear  of  eyeglasses  is  wearing  away  and  they  are  now  prescribing 
the  new  style  with  confidence.  The  springs  on  these  jnountings  have 
given  the  manufaeturei-s  more  or  less  trouble,  but  evolution  has  been 
and  is  still  going  on  and  in  time  this  new  mounting  will  be  worn  almost 
universally  except  by  the  aged  and  infirm  and  by  children.  The 
beauty  of  the  new  style  is  universally  admitted  and  there  is  no  question, 
especially  among  the  ladies,  that  tlie  wearer  of  a  modem  rimless  eye- 
glass looks  many  years  younger  tlian  she  would  if  she  wore  spectacles. 


Pliers  (Actual  Size)  for  General  Adjustment  Work 


These  mountings  are  adapted  for  all  styles  of  lenses,  pai'tieularly  for 
the  "peritorie"  stales,  and  for  bifocals.  Any  interpupillary  distance 
may  be  obtained  by  prescr-ibing  a  lens  wiiose  length,  plus  the  length  of 
the  bridge,  eciuals  the  inter])U])i]lai-y  distance.  Short  ovals  and  torics 
are  popular  shapes. 

Tools  used  in  ordinary  adjustments  and  mounting  of  lenses.  In 
the  bending  and  adjusting  of  spectacles  and  eyegla.sses  the  surgeon 
who  elects  to  do  this  work  should  have  sufficient  tools  for  the  purpose. 
Even  then  he  should  not  attempt  those  tasks  that  are  the  part  of,  and 
can  only  be  properly  done  l)y.  a  workman  whose  shop  is  equipped  with 
appropriate  machinery. 

The  plier  is  a  necessary  instrument  for  almost  every  adjustment. 
The  one  mostly  used  has  a  long  narrow  snipe  nose,  ])oth  for  bending  the 
bridges  of  spectacles  and  for  adjusting  eye-glass  mountings,  because 
so  much  of  this  work  is  the  "lining  up"  of  glasses,  and  also  grasping 
one  part  of  a  mounting  while  bending  another.  For  this  work  we 
need  a  flat  jaw  plier  the  nose  of  which  is  so  narrow  that  we  may  be 


4082       EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

alilr  Id  insert  it  into  small  ciiils.  and  to  have;  siifTicicnt  purchase  while 
heiKlinj;,  tliat  tlie  plier  will  not  slip,  thus  pi-eventing  aeeident  or  nuir- 
rin^'  the  uuiunting. 

The  round  oi-  15  nose  plier  is  used  lor  I'olling  the  l)ri(lfi:e.s  in  orch-r  to 
set  lenses  farther  forward  or  closer  to  the  eyes.  To  set  lenses  farther 
forward  we  gras])  a  hridye  at  the  eurl  with  one  hand,  and  by  holding 
the  bridge  securely  with  the  other  hand  loll  the  bridge  around  the  plier, 
thereby  lengthening  the  sluudv.  To  set  lenses  nearer  the  ej'es  we 
reverse  the  operatioji. 

The  coneave-convex  plier  is  used  either  to  make  a  liridge  narrower 
at  the  base  or  to  bend  eye-glass  guards  to  conform  to  tlie  contour  of  the 
nose.  The  narrow  jaw  or  G  plier  is  best  suited  for  ej'e-glasses,  and 
the  wider  or  E  nose  plier  for  spectacles.  These  pliers  should  never  be 
used  for  making  the  l)ase  wider,  as  they  make  a  very  uneven  bend  and 
mar  the  metal  too  much.  The  pliers  can  also  be  used  to  bend  the 
temples  so  as  to  conform  to  the  back  of  the  ear. 

The  plier,  known  as  the  J,  is  used  for  tilting  end  pieces  when  it  is 
desired  to  make  lenses  pantoscopic  for  near  work  or  when  one  ear  is 
higher  than  the  other.  In  rare  eases  we  find  both  ears  are  so  high 
that  it  is  necessary  to  bend  the  end  pieces  in  order  to  set  the  lenses 
retroscopic.  To  tilt  lenses  for  near  work,  grasp  the  end  piece  to  be 
tilted  with  the  flat  side  next  the  rim  and  with  a  snipe-nose  plier  held 
on  the  outer  end  of  the  end  piece  twist  it  to  set  the  temple  higher  or 
lower  as  the  case  may  require;  care  must  be  taken  to  only  twist  the 
end  piece  and  not  bend  it  up  or  down. 

The  many  cases  of  irritated  and  cut  nose  from  an  ill-fitting  spectacle 
bridge  crest  can  be  remedied  with  this  plier.  It  has  always  been 
necessary  to  send  this  work  to  the  optical  shop,  but  with  this  plier  it 
is  very  simple.  If  the  lower  edge  of  the  crest  cuts  the  nose,  the  crest 
must  be  made  more  horizontal.  By  placing  the  bridge  in  the  plier 
with  the  lower  edge  of  the  crest  toward  the  ends  of  the  plier  we  can 
change  the  angle  to  15°  more  horizontal,  and  by  setting  the  bridge  in 
the  plier  the  reverse  way  we  can  make  the  crest  15°  more  vertical. 
It  is  only  necessary  to  line  the  glasses  up  again  after  making  this 
adjustment,  as  the  use  of  the  crest  plier  does  not  change  any  other 
measurements. 

The  Peterson  slianking  plier  is  used  principally  to  change  the  height 
of  a  spectacle  bridge  for  the  purpose  of  raising  or  lowering  the  lenses. 
To  lower  the  })ridge  we  grasp  the  shank  of  the  bridge  from  the  front 
just  inside  the  lens  .strap,  allowing  the  lenses  to  rest  in  the  grooved  part 
of  the  plier  for  the  purpose.  Hold  the  plier  very  securely  in  one 
hand,  and  with  a  snipe-nose  plier  in  the  other  hand  bend  the  shank 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4983 

down  iit  tilt'  cui'l :  rclcjisc  tlic  I'ctt'i-son  i)licr  and  while  still  holding  the 
•shank  piisli  the  crest  of  the  hridfjc  down  to  the  desired  lieight,  therehy 
raising  the  lenses  and  finishing:  the  ojiei-ation.     AVhen  it  is  necessary 


The  Peterson  Shanking  Plier. 
T'sed  iiiiii(i|>MlI_v  to  alter  the  height  of  the  spoetacle  briilge. 

to  lower  the  lenses,  bend  the  shank  and  crest  up  instead  of  down, 
using  the  Peterson  plier  as  before. 

In  adjusting  eye-glass  mountings  we  use  a  snipe-nose  plier  for  regular 


The  Vici  Plier. 
Used   for   tilting  and   "truing   up"'   eyeglasses. 

bending  and  "truing  up,"  and  the  round-nose  plier  for  rolling  the 
arms  of  guards  forward  or  back,  in  order  to  set  lenses  at  the  proper 
distance  in  front  of  the  eves. 


The   Hardy   Strap   Plier. 

The  Vici  plier  is  made  especially  for  tilting  the  outer  ends  of  lenses 
up  or  down  in  ''truing  up"  eye-glasses.  The  holes  which  are  drilled 
in  the  inside  of  the  jaws  are  to  engage  the  spring  screw  at  the  top  ajid 
bottom.     They   iiold  tlie  screw  securely  and  prevent  any  danger  of 


4984        EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT 

bending  the  screw  or  springing  the  threads,  which  is  sure  to  occur  if 
any  other  plier  is  used  for  tliis  work.  Tliis  plier  can  be  used  efjually 
well  on  all  styles  of  finger-piece  eye-glass  mountings. 


Strap  Pliers. 


i\Iany  times  it  is  necessary  for  the  oculist  to  order  lenses  from  the 
optician,  and  tlien  to  insert  them  into  the  mountings  himself.  In  order 
to  do  this  work  satisfactorily  he  must  be  (Miuiiijicd  with  a  few  s])<'(-i;d 


Skeleton  Screw  Tap  Mounted  in  Jlaiulie. 

forms  of  pliers.     The  first  plier  to  be  considered  is  one  used  for  shap- 
ing the  strap  to  fit  the  new  lenses. 

If  the  mountings  are  too  wide,  first  determine  the  thickness  of  the 


Kat-tail   Files. 
Used  for  enlarging  screw  holes  of  lenses. 

lens  at  its  edge  by  inserting  the  end  of  the  lens  into  the  slots  in  the 
sliding  bar  of  the  plier,  then  insert  the  corresponding  lug  of  the  plier 
into  the  strap  of  the  mounting,  and  by  one  squeeze  of  the  plier  the 
strap  is  changed  to  the  exact  width  of  the  new  lenses. 

In  case  tlie  mountings  are  too  narrow  for  the  new  lenses,  insert  the 
short  jaw  of  this  plier  into  the  strap,  as  illustrated,  and  roll  the 
shoulder  of  the  strap  to  the  desired  thickness.  Care  should  be  taken 
in  shaj)ing  straps,  to  have  the  inside  face  of  the  strap  fit  perfectly 
flat  on  the  lens.  Tliis  is  a  very  important  point,  as  lenses  very  easily 
crack  if  the  straps  are  not  parallel  with  the  lenses. 

If  necessary  the  holes  may  be  enlarged  a  little  with  a  rat-Uul  file 


EYEGLASSES  AND  SPECTACLES,  ADJUSTMENT       4985 

in  order  to  have  the  strap  not  loo  light  and  to  avoid  chipping  the  lens 
at  the  screw  hole. 

After  the  straps  are  pi-oix-rly  sliapcd  the  skeleton  screw  tap  is  used 
to  cut  a  new  llircad  which  will  allow  the  screw  to  fit  easily  and  prevent 
turning  off  the  head  or  breaking  a  lens  by  forcing  the  screw  through 
the  old  thread.  New  screws  should  be  used  in  place  of  the  old  ones, 
to  insure  perfect  results. 


The  Chappel  Cutting  Plier. 


Tweezers. 
A  useful  iustiunient  for  picking  screws  from  bottles,  etc. 

The  Chappel  cutting  plier  is  the  best  cutting  plier  because  it  obviates 
the  neccssitv  of  tiling  the  ends  of  screws  after  cutting.     The  cutting 


Metal   Screw   Driver,   witli   Eevolving   Kubber   Head. 


knives  are  sharpened  to  so  line  an  edge  they  must  be  used  only  for 
cutting  gold,  gold  filled  or  soft  metal  screws,  and  with  this  precaution 
will  give  good  service  for  a  long  time.  "When  thej^  become  dull  or 
worn  the}^  may  be  sharpened  by  the  optical  jobber. 

A  pair  of  long  narrow-nose  tweezers  will  be  found  very  useful  in 
picking  screws  from  bottles,  etc. 

A  strong  metal  screw  driver  with  revolving  rubber  head  and  sharp 
thin  point  is  recommended. 

The  rimless  lens  screws  may  be  purchased  from  the  optical  jobber 
in  bottles  containing  1,000  each. —  (B.  A.  Weeks.) 


4986  EYEGLASSES,  FITTING  OF 

Eyeglasses,  Fitting  of.  S.c  Eyeglasses  and  spectacles,  Mechanical 
adjustment  of. 

Tlii.s  «'X])i-c.ssi()ii  is  also  used  in  llic  sense  of  deleriiiinin^  or  ■'working 
out"  the  refraetion  of  a  |)atient. 

Eye-gflass  frames.  Sec  Eyeglasses  and  spectacles,  Mechanical  adjust- 
ment of. 

Eye-ground.     Kiuidus  oculi  ((|.  v.). 

Eye  jar.  A  container,  usually  made  entirely  of  glass,  to  hold  the 
preserved  eyeball  (or  a  i)ortion  of  it)  as  a  museum  or  laboratory 
specimen.    See  Museum  preparations. 

Eyelashes.  Cilia.  These  are  well-developed  hairs  of  various  colors, 
aiianged  in  two  and  sometimes  three  row.s  at  the  j)alpebro-conjunc- 
tival  junction.  The  cilia  of  the  upper  lid  are  longer  and  more  luimer- 
ous  than  in  the  lower.  In  the  former  .situation  they  number  from  90 
to  150,  while  in  the  lower  lid  from  40  to  80  are  generally  seen.  The 
hairs  curve  in  opposite  directions  in  tiie  lids,  so  as  to  present  their 
convex  curves  to  one  another.  The  e.yelashes  are  of  different  ages  and 
exhibit  different  stages  of  growth.  They  are  constantly  falling  out  in 
a  perfectly  normal  fashion — the  life  period  of  each  cilium  being  about 
four  months. 

They  are  entirelj^  of  ectodermal  origin  and  develop  in  the  same  way 
as  hairs  over  other  portions  of  the  skin. 

As  part  of  an  external  examination  of  the  eye,  the  eyelashes  should 
be  carefully  inspected  as  to  tlieir  number  and  direction.  Search 
should  be  made  for  small  white  downy  hairs,  especially  near  the 
inner  canthus,  where  they  are  apt  to  rub  on  the  globe  or  caruncle. 
Short,  thick,  black  hairs,  the  so-called  "wild-hairs,"  often  produce 
much  irritation.  Parasites  may  be  found  al)out  the  roots  of  the 
lashes.  See  Examination  of  the  eye;  also  Cilia;  as  well  as  under 
Comparative  ophthalmology,  Vol.  iV,  p.  2625,  of  this  Eneyelopedia. 

Eyelashes,  Bleaching  of  the.  Poliosis  op  the  cilia.  This  condition, 
in  a  subject  otherwise  normal,  and  free  from  any  discoveralile  heredi- 
tary taint,  is  of  very  infrequent  occurrence.  A  case  was  reported  by 
Usher  {Trans.  OphtJi.  Soa.  Unit.  King.,  1906,  p.  23)  of  a  three-year-old 
girl,  normal  in  every  other  way,  in  whom  all  the  eyelashes  on  the  left 
side,  on  ])oth  lids,  were  quite  white,  and  there  were  two  tufts  of  white 
hair  on  the  left  side  of  the  head.  On  the  right  side  all  the  eyelashes 
were  light-brown.  There  was  more  hair  on  the  body  than  is  usual, 
especially  at  the  spine  and  neck,  which  was  nearly  white,  and  downy. 
See  page  2224,  Vol.  Ill,  of  this  Eneyelopedia. 

Eyelash,  Implantation  of  an.  This  injury,  consisting  of  the  "planting" 
of  a   eiliniii    in   sonu'   of   the   tissues   or   cavities — anterior   chamber 


EYE  LENS  4987 

('sj)('ci;illy  \\ill  also  he  (Icscrilicd  uiidrr  Injuries  of  the  eye.  A  typ- 
ical ease  is  tliat  dcsci-ihcd  hy  I J  ii'scldx-i'^  {Ophthdlmic  licconl,  'July, 
]JK)9j,  ill  which  the  porcelain  stopper  of  an  exploding  beer  hottle 
struck  the  left  eye  of  a  man,  aged  31.  There  was  a  small  penetrating 
wound  at  the  lower,  nasal  quadrant  of  the  corneo-scleral  junction, 
coagulated  blood  in  the  anterior  chamber,  and  the  pupil  was  covered 
with  exudates.  The  eyeball  was  very  soft  and  painful.  The  continuous 
pain  and  irritation  of  the  other  eye  suggested  the  presence  of  a  foreign 
body  in  the  globe.  Eleven  days  after  the  injury  Hirschberg  detected 
with  the  loupe,  on  oblique  illuiiiination,  a  very  fine  eyelash  implanted 
in  the  iris  at  the  medial  pupillary  margin  at  the  nasal  upper  portion 
of  the  cornea.  The  iris,  at  this  place,  showed  a  slight  circumscribed 
swelling,  with  new-formed,  fine  blood  vessels. 

In  deep  narcosis,  tlic  iiKnlial  limbus  of  the  cornea  was  incised  with 
a  lance-shaped  knife,  and  the  eyelasli  grasped  with  a  forceps.  The 
hair,  however,  was  not  extracted  with  the  forceps,  but  lay  in  the  wound 
from  which  it  was  removed.  The  diseased  portion  of  the  iris  was  ex- 
cised. The  pain  ceased  at  once,  and  after  two  weeks  the  eye  was  with- 
out irritation.  Ilir.schberg  mentions  another  case  of  purulent  iritis 
caused  by  a  penetrating  eyelash,  which  he  publislied  in  1892.  In  both 
cases  the  speedy  removal  of  the  cilium  saved  the  eyes  and  prevented 
sympathetic  ophthalmia. 

Eye-lens.  In  opiics,  tlic  lens  placed  immediately  in  front  of  the  eye  and 
through  which  the  virtual  image  produced  within  the  tube  by  the 
object-gJass  or  objective  of  an  astronomical  telescope  is  seen  under 
a  greater  angle  than  that  subtended  by  the  object  viewed  by  the  naked 
eye.  The  eye-lens  may  be  either  convergent  or  divergent.  If  the 
former  is  u.scd,  the  distance  between  the  objective  and  the  ej^e-lens  is 
slightly  less  than,  or  at  most  numerically  equal  to,  the  sum  of  their 
focal  lengths,  the  image  being  magnified  and  inverted;  whereas,  when 
the  divergent  lens  is  used,  the  distance  between  the  lenses  is  equal  to 
the  difference  between  their  focal  lengths  when  the  rays  from  the 
objective  converge  to  the  first  principal  focus  of  the  eye-lens,  the  final 
image  formed  being  erect.  This  arrangement  was  devised  by  Ualileo, 
and,  being  shorter  than  the  former  combination,  is.  adopted  in  the  con- 
struction of  opera  glasses  that  require  an  erect  image. —  (C.  F.  P.) 

Eyelids.  Lins.  Palpebr.i:.  Tlie  cartilaginous,  cutaneous,  and  mu- 
cous coverings  of  the  ej^es.  The  eyeball  is  ])artially  protected  as 
well  as  cleansed  by  the  eyelids.  Between  the  loose  folds  of  skin  on 
the  outer  surface,  and  the  inner  covering  of  mucous  membrane,  the 
conjunctival  surface,  are  found  connective  tissue  plates, — the  tarsi, 
or  so-called  tarsal  cartilages — to  stiffen  them  and  to  enalile  them  to 


4988 


EYELIDS,  ABSCESS  OF  THE 


retain  tlieir  I'onn.  The  lids  are  closed  by  the  powerful  sphincter 
muscle — the  orbicularis;  they  arc  opened  chiefly  by  the  levator 
l)alpebrai  superioris  above,  and  by  i)rolont?ati()iis  from  the  inferior 
rectus  below.'  See,  also.  Anatomy  of  the  human  eye;  as  well  as 
Histology  of  the  eye. 

Instead  of  attemi)liiig  to  describe  the  numerous  and  important  sub- 
sections of  this  heading  under  one  rubric,  the  various  subjects  will  be 
separately  treated. 

That  these  subjects  may  be  brought  uj)  to  date  of  publication  many 
of  them  will  be  further  treated  under  Lid  headings,  to  which  the 
reader  is  referred. 
Eyelids,  Abscess  of  the.  This  occurs  most  frequently  as  a  result  of 
injui  y.  thougli  it  may  have  its  origin  from  orbital  disease.  Spontane- 
ous abscess  rarely  occurs  in  adults,  but  is  occasionally  met  with  in  ill- 


Absiess  of  the  Lid. 


nourished  children.  According  to  Berger,  deep  abscesses  of  the  upper 
lid,  wliicli  have  been  observed  as  a  result  of  influenza,  may  have  been 
due  to  infiam Illation  of  the  frontal  sinus.  If  not  promptly  opened, 
large  aliscesses  sometimes  cause  sufficient  sloughing  to  produce  con- 
siderable deformity  of  tlie  lid,  with  lagophtlialmos,  or  ectropion.  An 
abscess  situated  in  fi-oiit  of  the  lachrymal  sac  closely  simulates  dacryo- 
cystitis. 


EYELIDS,  ACNE  ROSACEA  OF  THE  4989 

In  the  treatment  of  abscess  of  the  lid,  iced  applications  in  the  early 
stages  give  relief,  but  as  soon  as  induration  is  detected,  hot  fomenta- 
tions should  be  applied.  AVhen  evidences  of  pus  appear,  a  free  incision, 
l^arallel  with  the  fibres  of  the  orbicularis  muscle,  should  be  made. 

Eyelids,  Acne  rosacea  of  the.  This  condition  occurs  about  the  eyelids 
in  severe  cases,  and  is  easily  recognized  by  the  presence  of  the  trouble 
in  the  face.  The  lids  are  conge.sted  and  somewhat  chemosed,  hence  the 
disease  is  liable  to  be  chronic.  In  the  treatment  of  this  condition  a 
simple  ointment,  such  as  a  three  to  five  per  cent,  sulphur  ointment, 
acts  favorably.  Lotions  should  not  be  used,  as  they  are  apt  to  irritate 
the  conjunctiva.    See,  also,  page  76,  Vol.  I.  of  this  Encyclopedia. 

Eyelids,  Adenoma  of  the.  This  rare  form  of  growth  involves  the 
lids  (mostly  llic  ^Meibomian  glands)  which  become  nodular,  stiff  and 
board-like.  Only  about  ten  eases  of  this  condition  have  been  recorded. 
Tlic  mass  sliouM  Ix'  excised  and  examined  microscopically. 

Eyelids,  Albinism  of  the.  A  congenital  deficiency  of  the  pigment  of  the 
skin,  which  presents  a  milky-white  color.  The  appearance  is  the 
same  as  in  vitiligo,  which  is  an  acquired  condition.  There  is  no  effi- 
cient treatment.    See  Albinism. 

Eyelids,  Aleppo  boil  of  the.  Delhi  boil.  Biskra  button.  Furunculus 
ORiEXTALis.  This  is  a  local  infectious  disease  endemic  in  the  tropics, 
and  characterized  by  the  formation  of  papules,  nodules,  scabs  and 
punched-out  ulcers.  The  uncovered  parts  of  the  face  are  chiefly  at- 
tacked, the  eyelids  often  being  involved.  The  disease  is  inoculable  in 
both  men  and  animals.  Laveran  attributes  its  spread  to  flies.  It  is 
a  local  disease  without  constitutional  disturbance,  and  occurs  among  all 
tropical  races,  lieing  distingui.shed  from  yaws,  which  presents  marked 
constitutional  sj-mptoms  and  is  found  almost  entirely  among  the  col- 
ored races.  The  prognosis  of  the  disease  is  favorable.  The  treatment 
includes  the  use  of  the  galvanic  cautery  in  "the  early  stage:  hypodermic 
injections  of  10  per  cent,  carbolic  solution  around  the  boil,  and  curette- 
ment  or  the  application  of  caustics,  when  the  process  has  gone  on  to 
suppuration  and  the  formation  of  granulations.  See  also  Aleppo 
button.  Vol.  I,  page  217,  of  this  Encyclopedia. 

Eyelids,  Alopecia  areata  of  the.  This  condition  of  baldness  in  spots 
occurs  sometimes  in  the  eyelids.  Uysfcrical  alopecia  of  the  lids  is 
occasionally  seen  in  neurotic  females  and  in  hj'sterical  children  of  both 
sexes.  Such  subjects  systematically  pull  out  the  cilia.  Local  stimu- 
lating ai)iili('atioiis  should  be  combined  with  appropriate  general  treat- 
ment. 

Eyelids,  Alopecia  of  the.  Simple  defects  of  the  cilia  usually  result 
from  chronic  bleiiberitis  margiimlis  and  syphilis.  A  case  is,  however, 
mentioned  by  ]\lorax  which  he  proved  to  be  due  to  keratosis  pilaris. 


4990 


EYELIDS,  AMBOYNA  BUTTON  OF  THE 


Four  cases  of  tliis  cluu-actcr  were  reported  l)y  Gifford  {Ophth. 
Record,  Jainuny.  1!H)1)  in  some  of  wliicli  lie  questions  the  propriety 
of  classifying  them  as  hysterical.  It  was  suggested  that  the  trouble 
was  more  in  the  nature  of  a  habit  akin  to  tliat  of  biting  tiie  nails, 
although  the  i-a])id  efK'ect  of  the  mental  therapeutics  employed  con- 
tradicts this  idea.  It  is  sometimes  hard  to  draw  the  line  between 
pure  meanness  or  a  simple  desire  to  excite  sympathy,  on  the  one  hand, 
and  well  marked  hysteria,  on  1lie  other.  See,  also,  page  249,  Vol.  I, 
of  tills  /'J ii(!)(l()ji<(li(i. 

Eyelids,  Amboyna  button  of  the.    See  Eyelids,  Frambesia  of  the. 

Eyelids,  Anakhre  of  the.  This  term  is  applied  to  an  affection  character- 
ized by  bony  tumors  on  each  side  <»f  llie  nose,  found  among  "West 
African  neproes.    See  Eyelids,  Goundon  of  the. 

EyeUds,  Angiofibroma  of  the.  Angiomata  constitute  rather  rare 
tumors  of  the  eyelids,  although  the  lymphangioma,  especially  the  fibro- 


Plcxifonii   .^iiyioliliioina   of  Kyelitl.      (.Meycrhof.) 


matous  form  of  it  (elephantiasis,  for  example)  is  not  uncommon. 
Meyerhof  (Ophihalmic  Record,  June,  1910)  has  described  a  case  of 
plexiform  angioma  of  the  lids  in  a  young  girl,  who  appeared  perfectly 
strong  and  healthy.  Six  j'ears  before,  a  bluish  spot  was  noticed  on 
the  upper  left  lid.  Tliis  spread  until,  three  years  ago,  it  had  grown 
into  a  tumor  that  entirely  covered  the  left  eye,  excluding  the  vision, 
and  so  disfiguring  her  that  slie  desired  to  have  it  removed.  Two  at- 
tempts to  extirpate  tlie  new  prowl h  were  made  with  tht>  actual  cautery, 
but  without  success. 

'i'iie  writer  says  that  in  its  "present  condition  the  bluisli  tumor  is 
a  gi'eat  disfigurement,  as'  it  entirely  covers  the  left  eye,  forming  an 


EYELIDS,  ANGIOMA  OF  THE  4991 

irrcyuljir,  lobular  mass.  It  involves  the  whole  oi"  the  left  upi)er  lid 
and  has  invaded  the  tissues  about  the  external  angle  as  well  as  the 
temporal  i)ortion  of  tlie  lower  lid  (see  figure).  In  the  upper  lid  the 
mass  measui-es  2x4  em.,  while  its  thiei<ness  is  al)Out  1.5  cm.  Its  con- 
si.stence  is  very  soft ;  pressure  l)etween  two  fingers  is  painless,  but  re- 
duces the  size  of  tile  tumor  somewhat.  Tiie  inferior  portion  of  the 
neoplasm,  affecting  the  clieel^  and  lower  lid,  measures  3  x  2.5  cm.  and 
is  not  compressible.  A  scar,  due  to  a  previous  cauterization,  shows  on 
its  surface." 

]\lost  of  the  tumoi'  mass  was  exci.sed  under  chloroform  and  the  wound 
of  operation  liealed  satisfactorily  after  a  delay  of  seven  days.  Two 
secondary  excisions,  under  local  anesthesia  (for  the  extirpation  of  a 
small  renuiining  portion  of  the  tumor)  were  nuide,  as  well  as  the  elec- 
trolysis, a  week  later,  of  a  superficial  vein  in  the  cheek 

The  mici'opliotograph  presents  the  characteristic  api)earances  of  a 
subcutaneous  fibroma  containing  numerous  veins  (especial!}'  venocav- 
ernous  plexuses)  distributed  rather  regularly  throughout  the  tumor 
mass.     In  other  words,  we  have  to  deal  with  a  plexiform  angiofibroma. 

In  tile  absence  of  a  history  of  traumatism  or  other  recognized 
etiologic  factor,  one  is  constrained  to  regard  this  growth  as  congen- 
ital. So  far  as  prognosis  is  concerned,  statistics  prove  that  tlie  radical 
extirpation  of  angiofibromas  is  rarely  or  never  followed  by  relapse. 
The  cosmetic  result  of  the  operation  depends,  of  course,  upon  the 
extent  to  Avliich  the  lid  muscles  (which  should  always  be  protected 
as  far  as  possible)  are  involved  in  operative  ])rocedurcs  undertaken 
for  the  removal  of  the  growth.  See,  also,  Eyelids,  Lymphangioma  of 
the. 
Eyelids,  Angioma  of  the.  Telangiectasis  of  the  lids.  Several  forms 
of  angioma  occur  in  the  eyelids.  The  simple  vascular  nevus,  or  " moth- 
er's-mark,"  is  a  congenital  condition  resulting  from  excessive  develop- 
ment of  capillaries,  and  appears  as  a  bright-red  spot,  varying  in  size 
from  that  of  a  pin-head  to  the  entire  area  of  the  surface  of  the  lid.  It 
occasionally  disappears  spontaneously,  but  is  usually  permanent.  It 
rarely  increases  in  size. 

Telangiectasis  consists  of  a  collection  of  enlarged  capillaries,  arter- 
ioles and  venules  in  the  skin  and  subcutaneous  tissue,  which  may  exist 
at  birth  but  generally  appears  later,  and  in  either  case  tend.s  to  in- 
crease. 

Cavernous  angioma  forms  a  distinct  tumor  consisting  of  cells  and 
sinuses  and  enlarged  vessels,  with  a  framework  of  connective  tissue.  It 
may  be  congenital  but  more  frequently  originates  after  birth,  and  is 
sometimes  developed  from  the  preceding  variety.     These  tumors  can 


4992  EYELIDS.  ANGIOMA  OF  THE 

gciHM-ally  he  emptied  by  pressure,  but  occasionally  pulsate,  if  chiefly 
arterial  in  cliaraeter. 

Treat nioit  consists  in  ol)litei'ation  of  the  vessels,  destruction  by  cau- 
terization, or  removal  with  tlie  knife.  Small  superficial  nevi  may  be 
successfully  treated  by  caustics.  In  the  case  of  infants,  vaccination 
at  several  points  will  often  excite  sufficient  inflammation  to  obliterate 
the  vessels.  A  larj?er  growth  may  be  treated  liy  penetrating  a  fine 
thermo-cautery  needle  obliquely  under  the  skin  at  numerous  points 
around  the  l)ase.  Coagulating  injections  are  not  Avithout  danger,  and 
ligatures  are  likely  to  cause  sui)puration  and  leave  cicatrices.  Cavern- 
ous angiomata  are  frequently  encapsulated,  when  they  can  be  safely 
enucleated.  In  other  cases  removal  should  be  accomplished  by  incision 
carried  well  into  the  sound  skin.  A  blepharoplastic  operation  may  be 
necessary.  (Harlan.)  Carbonic  acid  snow  has  been  successfully  em- 
ployed in  a  number  of  cases.  Capauner  (Klin.  Monatshl.  f.  Augen- 
lieilkundc,  Vol.  XLIX,  Nov.,  1911)  has  used  carbonic  acid  snow  very 
successfully  in  two  cases  of  large  angiomata  of  the  lids  in  little  chil- 
dren. Applications  were  made  at  intervals  of  about  ten  days  to  allow 
all  inflammatory  symptoms  to  pass  away  between  treatments.  The 
snow  is  forced  into  a  small  glass  tube  1  cm.  broad  by  1  cm,  long  and 
about  1mm.  thick,  by  means  of  a  wooden  plug.  Pressure  upon  the 
plug  forces  out  the  snow  as  desired  without  danger  of  injury  to  the 
conjunctiva.  Toleration  is  established  by  the  skin  after  a  few  applica- 
tions, so  that  the  time  of  treatment  may  be  lengthened  from  thirty  to 
sixty  seconds.  The  author's  experience  in  one  case  of  trachoma  leads 
him  to  believe  that  expression  and  massage  with  bichlorid  solution 
are  superior  to  applications  of  carbonic  acid  snow.  Knapp  {Arch,  of 
Ophthal.,  Jan.,  1911)  reported  the  case  of  an  eleven-months-old  infant 
with  an  angioma  of  the  eyelid  characterized  by  thickening  of  the  skin 
and  a  mass  of  large  blood  vessels.  The  growth  involved  the  edge  of 
the  lid,  making  excision  with  the  knife  undesirable.  One  application 
of  the  carbonic  acid  snow  caused  the  growth  to  shrivel  up  and  drop  off. 
Risley  {Ophthalmic  Record,  ]\Iarch,  1906)  reported  the  case  of  an  an- 
gioma of  unusual  dimensions,  and  the  method  employed  in  its  removal, 
which  is  of  interest.  The  patient  was  an  eleven-Aveeks-old  infant,  and 
the  tumor  occupied  about  three-fourths  of  the  entire  length  of  the 
right  lower  lid.  The  tumor  was  soft  and  fluctuating,  but  grew  tense 
when  the  child  cried,  so  that  ])ursting  of  the  nuich-thinned  pellicle  of 
enveloping  skin  seemed  imminent.  The  method  of  procedure  adopted 
for  its  removal  is  thus  described  by  Risley:  "A  single  electrolytic 
needle  was  inserted  at  many  points  into  the  base  of  the  tumor,  at  first 
superficially,  and  gradually  made  to  penetrate  its  mass  more  deeply, 


EYELIDS,  ANGIOMEGALY  OF  THE  4993 

but  only  in  its  deeper  i)ortion,  in  order  to  secure  a  firm  coagulum,  first 
in  the  region  of  the  emerging  vessels  at  its  periphery,  and  then  over  the 
entire  base.  Under  the  electrolysis  the  entire  mass  became  hard,  lost 
its  liuctuating  quality  and  shrank.  The  surface  was  then  covered  with 
a  thick  coat  of  collodion.  In  forty-eight  hours  the  rounded,  overhang- 
ing borders,  had  disappeared,  the  surface  was  corrugated  and  much 
flattened.  In  a  week  the  electrolysis  was  repeated,  and  later  with  mul- 
tiple needles  three  times  at  intervals  of  a  week  or  ten  days,  but  without 
any  marked  improvement  beyond  that  secured  by  the  first  attempt. 
The  tumor  remained  hard  and  quite  dense  at  the  center,  but  showed 
an  unmistakable  tendency  to  spread  laterally,  and  it  became  obvious 
that  some  more  radical  procedure  was  required  if  a  cure  was  to  be 
effected.  Deep  electrolysis  was  again  repeated  and  the  following  day 
an  Ericson's  suture  was  introduced.  A  large  curved  needle  with  an 
ample  eye  was  threaded  with  one  black  and  one  white  heavy  silk  thread 
a  yard  long.  Beginning  at  the  nasal  extremity  of  the  tumor,  the  suture 
was  carried  vertically  upward  through  it,  being  careful  to  include  the 
mass  down  to  the  surface  of  the  lid  cartilage,  but  not  including  it. 
Then  reversing  the  procedure,  the  thread  was  carried  through  the  mass 
downward  to  a  point  5  mm.  from  the  first,  and  so  back  and  forth  until 
the  entire  tumor  was  ejiclosed  in  a  series  of  loops,  above  and  below. 
The  extremity  of  the  loops  of  white  thread  were  then  cut  above,  leav- 
ing them  intact  below.  They  were  then  drawn  tightly  home  and  tied. 
The  black  loops  were  then  cut  below  and  in  a  like  manner  brought 
firmly  liome  and  tied,  in  tlii.s  manner  effecting  a  complete  strangula- 
tiou  of  the  entire  mass,  whieli  sloughed  off  in  about  a  week  without 
hemorrliage,  leaving  a  granulation  mass  at  each  extremity.  These  were 
also  removed  b}^  strangulation  with  a  silk  thread,  after  which  the  sur- 
face cicatrized  rapidly,  manifesting  ])ut  little  tendency  to  cause  ectro- 
pion."    See,  also.  Tumors  of  the  eye. 

Eyelids,  Angiomegaly  of  the.  In  certain  forms  of  senile  ptosis,  the 
essential  features  are  afroi)hy  of  the  derma  and  of  the  elastic  fibres, 
with  enlargement  of  the  blood-vessels.  To  this  condition  has  recently 
been  applied  the  foregoing  term.    See,  also.  Ptosis. 

Eyelids,  Angiosarcoma  of  the.  This  form  of  sarcoma,  as  Avell  as  the 
alveolar  vai'iely,  occurs  at  times  in  the  lid.  According  to  Parsons, 
they  are  probably  endotheliomata.  About  one  half  of  the  cases  are 
pigmented.  The  following  case  was  reported  by  Claiborne  (Ophthal- 
mic Record,  June,  1907).  A  strong,  healthy  hoy,  13  years  of  age, 
during  two  months'  time,  developed  a  red,  pedunculated  tumor  the 
size  of  a  small  ])eannt  from  the  cutaneous  surface  of  the  lower  lid 
about  1  mm.  below  the  edge  of  the  conjunctiva,  between  the  punctum 

Vol.  VII— 10 


4994 


EYELIDS,  ANGIOSARCOMA  OF  THE 


4 


Angiosaifoma  of  the  Lid.      (Claiborne.) 


Aiififiosarcoiiia  of  the   l/nl.      (Clailioiiie.) 


EYELIDS,  ANKYLOBLEPHARON  OF  THE  4995 

and  tlic  wall  of  the  nose.  The  tuiuor  was  corrugated  and  bled  easily.. 
The  eyeball  was  unaffected.  An  attempt  was  made  to  excise  the 
tumor  without  general  anesthesia,  but  was  only  partially  successful. 
A  second  effort  was  later  made  to  excise  the  remaining  portion,  but 
recurrence  of  the  tumor  and  a  report  from  E.  B.  Coburn  that  it  was 
an  angiosarcoma  warranted  an  operation  under  ether.  AVhen  the 
tumor  area  Avas  freely  cautei-ized  the  i)art  healed  in  two  weeks,  leav- 
ing a  white  scar.    See,  also,  Eyelids,  Endothelioma  of  the. 

Eyelids,  Ankyloblepharon  of  the.  Adhesion  of  the  lids  along  the  palpe- 
bi'al  margins.  Jt  may  be  partial  or  total;  is  rarely  congenital,  but 
usually  results  from  ulcerations,  burns,  or  other  injuries.  It  has 
occasionally  occurred  after  erou])OUs  conjunctivitis.  It  may  occur 
alone  but  more  frequently  symblepiiaron  also  is  present.  A  few 
case^  have  been  observed  in  which  at  birth  a  filiform  band  passed 
from  one  lid  to  the  other.    See  page  486,  Vol.  I,  of  this  Encyclopedia. 

Eyelids,  Anomalies  of  the.  Congenital  defects  of  the  eyelids.  The 
eyelids  are  the  subjects  of  a  variety  of  congenital  anomalies,  both  as  to 
structure  and  innervation.  For  a  complete  account  of  these,  see  Vol. 
IV,  p.  2776,  of  this  E)i cyclopedia. 

Eyelids,  Anthrax  of  the.  ]\Ialignant  pustule.  This  disease,  due  to 
inoculation  with  the  anthrax  bacillus,  may  involve  the  eyelids. 

A  case  has  been  reported  by  Leplat,  Riviere  and  Bettremieux  (Clin. 
Opht.,  V.  19,  p.  624).  It  is  chiefly  of  interest  from  the  point  of  view 
of  diagnosis,  inasmuch  as  anthrax  of  the  lids  is  not  infrequently  taken 
for  gangrenous  erysipelas.  The  patient,  a  man  of  24  years,  worked 
in  a  wool  factory.  The  eschar  was  surrounded  by  the  usual  halo  of 
vesicles.  Bacteriologic  examination  and  culture  were  negative,  but  the 
beginning  of  the  disease  in  a  small  swelling  surmounted  by  a  vesicle, 
the  febrile  reaction,  and  the  characteristic  deep-black  color  of  the 
eschar  left  no  doubt  as  to  the  diagnosis.  See  Vol.  I,  p.  512,  of  this 
Enci/clopcdia. 

Eyelids,  Argyria  of  the.  Staining  of  the  eyelids  by  nitrate  of  silver  is 
but  rarely  seen.    See  Vol.  I,  ]i.  574,  of  this  Encyclopedia. 

Eyelids,  Arteries  of  the.  See  Eyelids,  Blood-vessels  of  the;  as  well  as 
Anatomy  of  the  eye. 

Eyelids,  Asteatosis  of  the.  A  deficiency  of  the  secretion  of  sebum.  In 
Iji-onounced  cases  ecti'opion  may  result.  The  prognosis  as  to  perma- 
nent improvement  is  unfavorable,  but  the  best  results  follow  the  reg- 
ular application  of  animal  fats  and  the  internal  administration  of 
arsenic. 

Eyelids,  Auto-eversion  of  the.  This  must  be  a  rare  although  ajipar- 
ently  trivial  anomaly  of  the  eye.     Santos  Fernandez  {An(dcs  dc  Oft., 


4996     EYELIDS,  BLASTOMYCETIC  DERMATITIS  OF  THE 

XIV,  p.  323,  19] 2)  observed  a  buy  ol'  eight  years  who  was  able  to  turn 
the  upper  lid  of  the  right  eye  with  the  help  of  one  finger,  but  could 
turn  the  left  upper  lid  without  touching  it.  The  edge  of  the  upper  lid 
was  apparently  pushed  up  by  the' edge  of  the  lower  lid  during  vigorous 
contraction  of  the  orbicularis. 
Eyelids,  Blastomycetic  dermatitis  of  the.  This  is  a  local  infective 
proee.ss,  rare  in  oeciiirenee,  and  elironie  in  eliaracter,  which  often  in- 
volves the  eyelids.  The  lesion  begins  as  a  papule  or  papulo-pustule 
and  slowly  enlarges  peripherally  in  the  form  of  an  indolent,  flat,  wart- 
like or  crusted  papule  (Montgomery).  The  surface  presents  irregular 
papilliform  elevations  between  which  pus  oozes  on  pressure.     The  bor- 


Blastomvifti 


11-    tilt 


(Walker.) 


der  is  of  a  purple  or  reddish  color,  and  is  .studded  with  minute  ab- 
scesses. The  disease  may  remain  indolent  for  months  or  years,  with 
occasional  exacerbations.  The  lesions  may  heal  centrally  while  extend- 
ing peripherally.  AVhen  involving  the  eyelid,  the  disease  causes  ectro- 
pion. (See  figure.)  Blastomycetic  dermatitis  is  to  be  differentiated 
from  syphilis,  eareinonui,  lupus  vulgaris  and  verrucous  tuberculosis. 
The  characteristic  features  are  the  miliary  abscesses  and  the  presence 
of  distinct  budding  organisms  seen  on  microscopic  examination.  The 
treatment  includes  exci.sion  of  the  diseased  areas,  the  internal  use  of 
large  doses  of  potassium  iodid,  and  the  use  of  the  x-rays.  Cleansing  or 
antiseptic  washes  or  dry  dressings  can  he  used  locally  with  benefit. 
—(J.  M.  B.) 

For  a  more  extended  account  of  this  disease,  as  it  affects  the  eye  as 
a  whole,  see  Vol.  II,  p.  1008,  of  this  Encyclopedia. 


EYELIDS,  BLEPHARITIS  OF  THE 


4997 


Eyelids,  Blepharitis  of  the.  For  a  description  of  the  numerous  forms 
of  this  (list'iisc  sec  ^\)l.  II,  p.  1022,  of  this  Encyclopedia. 

Eyelids,  Blood-vessels  of  the.  The  arteries  of  the  eyelids  are  the 
internal  and  external  palpebral,  the  former  being  derived  from  the 
ophthalmic  and  the  latter  from  the  lachrj^mal.  The  vessels  pass 
from  the  outer  and  inner  angles  toward  the  centre  of  the  lid,  form- 
ing an  arch,  the  tarsal  arch,  along  the  edge  of  the  lids.     A  second 


Arteries  of  the   (Eight)   Eyelids.      (Ball.) 

(Original  drawing  by  E.  W.  Mills.) 

1,  Anastomosis  between  the  lachrymal  and  superficial  temporal.  2,  Superficial 
temi)oral.  '.',  Supra-orbital.  4,  Fronto-nasal.  5,  Transverse  facial.  6,  Superior 
palpel)ral.     7,  Infra-orbital.     8,  Inferior  palpebral.     9,  Facinl. 


arch,  the  external  tarsal  arch,  is  found  in  the  upper  eyelid,  where  it 
runs  in  front  of  the  upper  edge  of  the  tarsal  plate.  The  same  ar- 
rangement is  found  in  the  lower  lid.  The  tarsal  arches  are  joined 
by  small  anastamosing  branches.     (See  figure.) 

The  veins  of  the  eyelids  are  disposed  in  two  series :   the  pre-tarsal 
and  the  post-tarsal.    The  former  empty  into  the  superficial  temporal 


4998 


EYELIDS,  BOTRYOMYCOSIS  OF  THE 


Veins  of  the  (Left)  Eyelids.     (After  Soemmering.)      (Ball.) 
1,  Branch  to  the  deep  temporal  vein.    2,  Facial  vein.   3,  Supra-orbital.  4,  Angular. 
5,  Branch    connecting    the    temporal    and    facial.     6,  Dorsal    vein    of    the    nose. 
7,  Frontal  vein. 


and  facial  veins,  while  the  latter  pass  into  the  oi)hthalmic  vein. 
(See  figure.)  See,  also,  Anatomy  of  the  human  eye;  as  Avell  as 
Vol.  II,  p.  1228,  of  this  Encudopcdki. 

Eyelids,  Botryomycosis  of  the.  A  small  tumor  in  the  middle  of  the 
margin  of  the  upper  lid  was  observed  by  Fa])er  ( Xedoiandschc 
Ooghcvlk,  1897,  3,  p.  24)  which  contained  nodules,  each  of  which  pre- 
sented a  small  opening,  from  which  a  mucoid,  granular  mass  could  be 
exj)ressed.  The  small  spherical  granules  consisted  of  the  fungus 
botrvomyces.     See  Vol.  II,  p.  1253,  of  this  Encyclopedia. 

Eyelids,  Burns  of  the.  These  are  of  importance  on  account  of  the 
danger  of  disfigurement  produced  by  cicatricial  contraction  after 
extensive  destruction  of  lid-tissue,  and  of  the  complication  with 
burns  of  the  surface  of  the  globe.  They  are  commonly  caused  by 
hot  water,  caustics,  acids,  or  from  the  exjilosion  of  gun-powder. 
When  the  burn  is  slight,  the  simple  application  of  oil,  with  a  light 
moist  dressing  of  carbonate  of  soda  to  relieve  the  pain  will  suffice. 
In  severe  burns  the  entire  thickness  of  the  lid  may  bi?  involved,  ami 
the  cornea  damaged.     Various  degrees  of  ectropion  or  of  sj'mble- 


EYELIDS,  CANCROID  ULCER  OF  THE  499^) 

|)haroii  may  be  proiliu-cd,  iifcessitatiiig  operative  treatment  to  re- 
lieve the  eoiiditioii.  In  the  case  of  powder  burns  all  loose  ])owder 
should  be  immediately  removed  and,  if  i)Ossible,  each  grain  picked 
out  of  the  skin  with  a  fine  needle,  or  destroyed  with  an  electro- 
cautery needle,  as  recommended  by  Jackson.  Peroxide  of  hydrogen 
has  been  el'iieiently  employed  to  remove  powder  grains.  It  may  be 
applied  in  full  strength  oi'  in  a  solution  of  thi-ee  parts  to  one  of 
glycerin.  See  Eyelids,  Injuries  of  the;  also  Vol.  11,  p.  i;U6,  of  this 
I'Jiicijclopcdia. 

Eyelids,  Cancroid  ulcer  of  the.  Kodent  ulcer.  Jacob's  ulcer.  See 
\o\.  II,  p.  1381,  of  this  Encyclopedia. 

Eyelids,  Canities  of  the.  Poliosis.  The  absence  of  pigment  in  the  cilia, 
without  other  reeognizabh'  lesion.  See  Vol.  II,  p.  1382,  of  this  Ency- 
clopedia. 

Eyelids,  Carbuncle  of  the.    See  Vol.  II,  p.  1406,  of  this  Encyclopedia. 

Eyelids,  Carcinoma  of  the.    See  Vol.  II,  p.  1410,  of  this  Encyclopedia. 

Eyelids,  Cavernous  angioma  of  the.  See  Vol.  11,  p.  1794,  of  this 
Encyclopedia;  as  well  as  Tumors  of  the  eye. 

Eyelids,  Chancre  of  the.  About  one  case  in  twent^^-five  of  syphilis 
is  due  to  an  extragenital  primary  lesion,  so  the  chance  of  the  lid  be- 
coming affected  is  very  small.  The  sore  usually  appears  near  the  lid 
margin.    See  Vol.  Ill,  p.  2003,  of  this  Encyclopedia. 

In  Kowalewski's  case  {Centralbl.  f.  p.  Augenh.,  Jan.,  1908)  a  sore, 
1  cm.  long  and  0.5  cm.  wide  with  indurated  edges,  was  situated  at  the 
nasal  half  of  the  upper  fornix.  Scrapings  showed  spirochetse.  The 
aural  and  maxillary  glands  were  enlarged.  The  wife  of  the  patient 
was  syphilitic.  In  Zazkin's  case  {h'oussky  Vratch,  No.  28)  although 
no  spirochetae  were  found,  secondary  symptoms  followed. 

Rollet  and  Genet  {Revue  Generale  d'Ophtal.,  April,  1912)  describe 
the  case  of  a  man  twenty-two  years  of  age,  no  hereditary  taint,  with 
two  chancres  of  the  face.  The  one  on  the  lower  left  lid  embraced  prac- 
tically that  entire  structure.  The  other  was  situated  at  the  outer  angle 
of  the  mouth,  not  involving  the  mucous  membrane,  oval  in  shape  and 
about  25  X  14  mm.  The  glands  were  swollen  so  that  some  were  visible 
upon  inspection.  Date  of  contamination  was  not  obtainable,  but 
seemed  to  have  taken  place  through  acne  pustules.  Next  day  a  roseolar- 
eruption  appeared,  and  the  treponema  pallidnni  was  isolated.  The 
patient  received  0.5  grm.  arsenobenzol,  and  twelve  days  later  a  similar 
dose.  Two  weeks  later,  the  chancres  had  cicatrized  and  the  roseola 
disappeared. 

The  o])servation  is  absolutely  classic  as  to  the  course  of  the  disease 
and  is  cited  to  remark  upon  accidental  initial  lesions.     This  case,  by 


5000  EYELIDS,  CHLOASMA  OF  THE 

lia\  iiig  two  i)oiiits  of  entry  upon  tlie  face,  is  also  noteworthy.  Both  im- 
proved simultaneously  under  treatment  and  were  healed  in  fifteen 
days.  The  arsenol)enzoI  was  given  by  rectum,  dissolved  in  300.0  grains 
of  artificial  serum,  to  whicii  was  added  twelve  drops  of  laudanum,  and 
introduced  high  up  hy  means  of  a  soft  catheter.  The  injections  were 
twelve  days  apart. 

The  authors  do  uot  consider  syphilis  with  the  chancres  on  the 
face  as  severe  as  infection  at  other  points.  See,  also,  Chancre  of  the 
lid. 

Eyelids,  Chloasma  of  the.  A  pigmentary  iiypertropliy  sometimes  seen 
during  the  course  of  uterine  diseases,  and  in  pregnancy.  See  Vol.  Ill, 
]).  2062,  of  this  Encyclopedia. 

Eyelids,  Chromidrosis  of  the.  Palpebral  ciiromidrosis.  Seborrhcea 
NIGRICANS.  This  formation  of  a  variously  colored  secretion  from  func- 
tionally disordered  sweat-glands  is  sometimes  located  upon  the  eyelids. 
Here  it  consists  of  a  bluish-black  discoloration,  usually  upon  the  lower 
lid,  which  is  somewhat  oleaginous.  It  is  probably  genuine  in  rare 
cases,  but  is  most  commonly  found  in  neurasthenic  and  hysterical 
women;  occasionally  in  malingerers.  See,  also.  Vol.  Ill,  p.  2206,  of 
this  Encyclopedia. 

Eyelids,  Colloid  degeneration  of  the.  A  very  rare  affection  which 
may  involve  the  forehead,  bridge  of  the  nose,  eyelids,  and  at  times 
the  conjunctiva.    See  Vol.  IV,  p.  2327,  of  this  Encyclopedia. 

Eyelids,  Coloboma  of  the.    See  Congenital  anomalies  of  the  eye. 

Eyelids,  Congenital  abnormalities  of  the.  See  Eyelids,  Anomalies  of 
the. 

Eyelids,  Congenital  growths  of  the.  The  lids  may  be  the  seat  of  con- 
genital growths,  such  as  moles,  nevi,  and  cysts.  The  nevi  may  be 
either  lymphatic  or  vascular.  Both  forms  tend  to  increase  in  size 
after  birth.  Lymphatic  nevi  are  rare;  at  times  they  are  very  large, 
extending  into  the  oi-bit  and  involving  the  conjunctiva.  See  Con- 
genital anomalies  of  the  eye.  Vol.  IV,  p.  2776,  of  this  Encyclopedia. 

Eyelids,  Congenital  ptosis  of  the.    See  Congenital  anomalies  of  the  eye. 

Eyelids,  Contusion  of  the.  Immediately  following  this  form  of  injury 
tlu're  is  an  extravasation  of  blood  into  the  cellular  tissue,  producing" 
what  is  commonly  known  as  "black  eye."  The  effused  blood  may 
be  in  the  form  of  a  diffused  ecchymosis,  or  as  a  hematoma.  In  some 
cases  of  fracture  of  the  base  of  the  skull  or  in  rupture  of  the  orbital 
vessels,  the  ecchymosis  of  the  lids  develops  later.  The  ordinary 
''black  eye"  disapponi-.s  in  two  or  tliroe  weeks.  See  Black  eye;  as 
well  as  Eyelids,  Injuries  of  the.  and  Ecchymosis  of  the  lids. 

Eyelids,  Cornu  cutanemn  of  the.     A  snmll  cutaneous  horn  which  gen- 


EYELIDS,  CYANOSIS  OF  THE  5001 

erally  involves  tlie  lower  lid.     See  Vol.  V,  p.  3524,  of  this  Encyclo- 
pedia. 

Eyelids,  Cyanosis  of  the.  In  grave  cases  of  cholera,  the  skin  of  the 
eyelids  Ironi  the  tirst  moment  is  bluish  (cyanosis).  On  account  of 
the  weakness  of  the  orbicularis  muscle,  as  well  as  from  the  contraction 
of  the  cellular  tissue  of  the  orbit,  it  is  difficult  to  keep  the  eyes  closed, 
and  they  remain  half  open.    See  Vol.  V,  p.  3606,  of  this  Encyclopedia. 

Eyelids,  Cysticercus  of  the.  This  may  develop  without  inflammatory 
synii)toins  in  the  form  of  a  round,  elastic,  movable  tumor  resembling 
an  ordinary  cyst.  It  may  involve  either  eyelid  or  may  be  found  be- 
neath the  skin  of  the  eyebrow.  It  is  of  exceedingly  rare  occurrence. 
See  Vol.  V.  p.  .3661,  of  this  Encijclopcdia. 

Eyelids,  Cyst  of  the.  See  Cyst  formation  in  the  lid;  as  well  as  Cyst, 
Sebaceous,  of  the  eyelid,  in  Vol.  V,  of  this  E)icyclopedia. 

Eyelids,  Dermatitis  of  the.  Various  forms  of  dermatitis  when  appear- 
ing on  the  iaee  may  also  attack  the  eyelids..  An  account  of  the 
chief  of  these  w411  be  found  under  Dermatitis,  Ocular  relations  of. 

Eyelids,  Dermoid  cysts  of  the.  The  usual  site  of  these  tumors  is  the 
region  of  tlie  external  angular  process  of  the  frontal  bone,  but  they 
seldom  occur  in  the  eyelids.  In  exceptional  instances  they  are  located 
at  the  inner  angle  of  the  upper  lid,  in  which  situation  they  may 
have  a  pedicle  connected  with  the  dura  mater,  resembling  a  meningo- 
cele, in  that  the  brain  pulsation  is  communicated  to  it.  Dermoids  of 
the  upper  lid,  wlien  not  connected  with  bone  or  ])eriosteum,  are 
stated  b}'  Sutton  to  arise  in  the  fissure  between  the  fronto-nasal 
plate  and  the  fold  of  skin  from  which  the  lid  is  formed.  Dermoids 
are  to  be  treated  by  excision.  See,  also,  p.  3841,  Vol.  V,  of  this 
Encyclopedia:  as  well  as  Tumors  of  the  eye. 

Eyelids,  Development  of  the.    See  p.  3913,  Vol.  V,  of  this  Encyclopedia. 

Eyelids,  Discoloration  of  the.  This  is  sometimes  seen  as  a  result  of 
the  internal  administration  of  drugs,  or  by  accident.  The  internal 
use  of  nitrate  of  silver  has  been  followed  by  staining  of  the  lids 
(Argyrosis).  An  excess  of  iron  present  in  the  system  sometimes 
results  in  staining,  in  the  form  of  small  brown  spots  (Siderosis). 
The  accidental  deposit  of  grains  of  gun-powder  frequently  causes  a 
taftooiiifi  of  the  eyelids. 

Eyelids,  Diseases  of  the.  Owing  to  the  eomi)lexity  of  structures  enter- 
ing into  the  formation  of  the  eyelids,  they  show  many  symptoms 
pertaining  to  general  diseases.  The  eyelids  are  also  subject  to  con- 
genital anomalies,  tumors,  inflammations,  degenerations,  infiltra- 
tions, etc.  All  of  these  are  discussed  under  their  proper  captions, 
especially  under  Blephar-headings. 


5002  EYELIDS,  DROOPING  OF  THE 

Eyelids,  Drooping- of  the.  Ptosis.  'I'liis  dclCci  iii;iy  he  citlicr  con^^-iiilal 
or  ;i('<|iiiic(|,  partial  or  complete,  unilateral  or  Itilateral.     See  Ptosis. 

Eyelids,  Ecchymosis  of  the.  Plack-eye.  An  extrava.sation  oi"  blood 
into  the  .subcutaneous  cellular  tis.suo  of  tlie  lids.  It  i.s  most  frequently 
caused  by  direct  violence,  as  fi-om  a  blow  of  the  fist,  or  from  a  fall.  It 
may  l)e  induced  spontaneously  by  excessive  exertion  and  .severe  parox- 
ysms of  coughing.  Because  of  the  tliinncss  of  skin  in  this  locality 
and  the  loose  areolar  tissue,  the  effused  blood  spreads  rapidly  before 
coagulation  takes  place,  pi'oducing  an  extensive  discolored  area.  At 
first  of  a  dark-blue  or  purple  color,  the  affected  area  changes  during 
the  process  of  absorption  to  violet,  then  to  yellowish-green,  remaining 
visible  for  a])Out  two  weeks  as  a  faint  coffee-colored  or  yellowish  stain. 
There  is  usually  some  swelling  of  the  eyelid  present,  causing  difficulty 
in  opening  the  eyes.  Occasionally  the  blood  is  not  absorbed  and  an 
abscess  forms  in  the  lid. 

Injury  to  some  remote  region  of  the  head,  especially  a  fracture  of 
the  base  of  the  skull,  may  be  followed  several  hours  later  on  by  ecchy- 
mosis of  the  lids.  In  some  instances  a  hematoma  is  produced,  as  in 
the  case  reported  by  Jannulis  {Kim.  ther.  Wocli.,  1912,  No.  45)  in 
which  during  an  operation  for  the  removal  of  nasal  polypus,  a  rather 
profuse  hemorrhage  occurred,  necessitating  tampouage.  Soon  after- 
wards the  patient  experienced  pain  in  the  eye,  a.ssociated  with  swelling 
of  the  upper  lid,  going  on  to  a  complete  hematoma.  The  complication 
was  probably  due  to  retrograde  stasis  because  of  the  tamponade  of  a 
severed  anomalous  vein.  See,  also,  p.  4122,  Vol.  VI,  of  this  Ency- 
clopedia. 

Poulard  and  Canque  (Ann.  d'OcuL,  Feb.,  1911)  observed  subcon- 
junctival ecchymosis  which  followed  powerful  compression  of  the 
thorax.  The  case  was  noteworthy  for  its  intensity,  and  persistence 
even  after  the  disappearance  of  all  cyanosis  of  the  face. 

Eyelids,  Ectropion  of  the.    See  Vol.  VI,  p.  4140,  of  this  Encijclopcdla. 

Eyelids,  Eczema  of  the.  This  affection  occurs  in  the  same  forms  and 
from  the  same  causes  as  upon  the  skin  in  other  parts  of  the  body. 
See  Vol.  VT,  p.  4147,  of  this  Encyclopediu. 

Eyelids,  Edema  of  the.  This  is  of  connnon  occurrence,  often  seen  fol- 
lowing trauma,  and  is  a  frequent  accompaniment  of  inflammation  of 
the  conjunctiva  or  infection  after  operations  on  the  globe.  It  may 
follow  attempts  to  probe  the  laclirymo-nasal  duct  or  the  injection  of 
fluids  into  the  adjacent  ti.ssu(\s.  It  occurs  in  cardiac  and  renal  diseases, 
arsenical  poisoning,  malaria,  etc.  In  these  conditions  the  swelling  is 
l)ale  and  translucent,  as  contra.sted  with  that  due  to  inflannnatory  con- 
ditions, when  it  is  reddi.sh,  opa(|ue,  tense,  and  shining.     As  edema  is 


EYELIDS,  ELEPHANTIASIS  OF  THE  5003 

only  a  .syinj)t()iii,  llic  li'caliiinil  will  (Icpciid  ii[)()ii  the  uiidci'lying  cause. 
When  so  extensive  as  to  prevent  opening  of  the  eye,  it  can  he  relieved 
hy  puncture  and  the  use  of  a  compress  handage. 

Sedwick  {Jour.  Ophth.  and  Oto-Larijiujol.,  Jan.,  1911,  p.  17)  reported 
a  young  woman  whose  lids  swelled  intci-mittrntly,  accompanied  ])y  red- 
ness of  the  globes.  No  sinus  involvement  could  be  discovered  in  thi.s 
case.     See,  also,  Vol.  VI,  p.  4155,  of  this  Encyclopedia: 

Eyelids,  Elephantiasis  of  the.  See  Vol.  VI,  p.  4279,  of  this  EncijclopecUa. 

Eyelids,  Emphysema  of  the.  The  ])resence  of  air  in  the  cellular  tissues 
of  the  eyelids  is  produced  by  a  comnumication  between  the  subcu- 
taneous tissue  and  the  neighboring  air-cavities,  the  lachrymal,  nasal, 
frontal  or  maxillary.    See  Vol.  VI,  p.  4301,  of  this  Encyclopedia. 

Eyelids,  Endothelioma  of  the.  See  Vol.  VI,  p.  4312,  of  this  Encyclo- 
pcd'ui. 

Eyelids,  Entropion  of  the.  Turning  in  of  the  eyelids,  so  that  the 
lashes  I'ub  on  the  glol)e,  is  generally  caused  by  trachoma.  It  also 
follows  diphtheritic  conjunctivitis,  and  essential  shrinking  of  the  con- 
junctiva. A  muscular  form  of  entropion  is  seen  as  a  result  of  bandag- 
ing in  elderly  people,  whose  eyes  lie  deeply  in  the  orbits.  The  presence 
of  foreign  bodies  in  the  eye,  and  the  irritation  accompanying  conjunc- 
tivitis and  keratitis  may  cau.se  a  spasmodic  entropion.  Excessive  devel- 
opment of  the  orbicularis  muscle  may  produce  an  entropion  at  birth. 
The  effect  of  entropion  is  to  place  the  skin  of  tlie  lid  in  contact  with 
the  globe.  The  constant  rubbing  of  the  lashes  against  the  cornea  pro- 
duces characteristic  changes  in  tiiat  tissue.  The  epithelium  becomes 
abraded  and  the  deeper  layers  of  the  cornea  become  necrotic.  Pannus 
develops  and  vision  is  nuich  reduced.  See  Vol.  VI,  p.  4331,  of  this 
Encyclo})edin. 

Eyelids,  Epithelioma  of  the.  Carcinoma  in  the  form  of  skin-cancer  or 
ei)ith('lioma  is  one  of  the  commonest  tumors  of  this  region.  It  usually 
begins  at  the  margin  of  tile  lid.  more  frtMiuently  on  the  lower  lid  and 
at  the  inner  caiilluis,  whence  it  extends  to  tlie  upper  lid.  In  the  be- 
ginning it  appears  as  a  snudl  elevation,  the  apex  of  which  at  first  be- 
comes scaly,  and  may  soon  be  covered  with  a  light  crust.  There  is 
sometimes  a  watery,  viscid  secretion,  or  occasionally  a  sanious  fluid, 
which  forms  a  brownish  crust.  I'eneatli  this  cnist  appears  a  super- 
ficial, grayish  excavated  ulcer  with  a  slightly  raised  base  surrounded 
by  induration.  There  is  a  development  of  epithelial  processes  which 
grow  down  into  the  .subcutaneous  tissue.  ]\Iasses  of  epithelial  cells 
are  found  growing  in  the  deeper  structures,  entirely  separate  from  the 
primary  processes.  Circular  masses  of  cells  (whorls)  are  met  with  in 
various  parts  of  the  growth.     The  disease  generally  progresses  very 


5004  EYELIDS,  EPITHELIOMA  OF  THE 

slowly,  but  sooner  or  later  tlu;  neighboring  lymphatic  (pre-auricular, 
submaxillary)  glands  are  involved.  The  process  extends  and  ends  in 
death  by  hemorrhage  or  exhaustion.  In  the  early  stages  there  is  but 
little  pain ;  later,  when  the  destruction  of  tissue  is  extensive,  the  suffer- 
ing is  severe.  The  disease  occurs  chiefly  in  persons  past  middle  age, 
and  in  men  more  frequently  than  in  women. 

Epithelioma  is  to  be  differentiated  from  lupus,  syphilitic  gummata 
and  nodules,  rodent  ulcer,  chancre,  and  tul)erculosis.  It  may  be  con- 
founded wdth  molluscura  contagiosum.  Epithelioma  is  peculiar  to  ad- 
vanced adult  life,  whereas  lupus  is  a  disease  of  youth,  and  the  history 
is  decidedly  different.  In  syphilitic  processes  the  progress  of  the  dis- 
ease is  usually  rapid  and  there  is  a  history  of  infection.  In  gumma- 
tous ulceration  there  is  no  hardness  around  the  ulcers,  which  are  mul- 
tiple and  punched  out,  and  present  an  abundant  purulent  discharge. 
In  epithelioma  the  process  is  slow  and  the  discharge  scanty,  thick,  and 
bloody.  Chancre  may  be  differentiated  by  its  history  and  rapid  devel- 
opment. A  broad,  flat,  slowly-growing  epithelioma  which  has  de- 
stroyed the  lid-margin  and  invaded  the  conjunctiva,  which  presents  a 
mammillated  appearance,  may  so  closely  resemble  tuberculosis  that 
only  a  microscopic  examination  can  determine  the  diagnosis. 

In  the  treatment  of  epithelioma  excision  in  the  very  early  stage  of 
the  growth  is  followed  by  excellent  results.  In  advanced  eases  pallia- 
tive measures  only  are  advisable.  The  Roentgen  ray,  Finsen's  light, 
and  the  use  of  radium  should  be  mentioned  among  the  more  recent 
methods  of  treatment  which  have  shown  encouraging  results.  Hirsch 
{Klin.  Monatsbl.  f.  Augcnh.,  Aug.,  1911)  reports  most  satisfactory 
results  in  one  case,  from  the  combined  Roentgen-radium  treatment. 
An  instructive  paper  by  Zentmayer  {Ophih.  Record,  Aug.,  1907)  re- 
lates how  the  ulcerating  skin  surface  of  the  lower  eyelid,  following  the 
removal  of  a  mole  eight  years  before,  healed  completely  after  applica- 
tion of  powdered  potassium  chlorate.  Subjecting  the  growth  to  the 
influence  of  radium  bromide  has  been  followed  by  some  excellent 
results,  where  the  growth  has  not  involved  the  deeper  structures  to  any 
great  extent.     If  left  to  itself  epithelioma  is  fatal. 

Bialetti  (Avn.  di  Ott.,  V.  41,  p.  526)  reports  the  cure  of  two  cases 
of  lid  opitliclioma  with  jequiritin.  One  tumor  was  a  phagedenic  epithe- 
liomatus  ulcer  at  the  outer  canthus,  extending  on  to  the  upper  and 
lower  lids.  Rampoldi's  jequiritin  discs  No.  2  were  applied  at  intervals 
suited  to  the  duration  of  the  previous  reaction,  and  continued  for  a 
period  of  four  weeks.  In  the  second  patient  the  tumor  had  recurred 
after  surgical  removal  a  year  earlier,  and  was  a  fungoid,  sessile  epithe- 
lioma at  the  center  of  the  lower  lid,   ulcerated  at  its  center.     The 


EYELIDS,  ERYSIPELAS  OF  THE  5005 

jequii'itiii  discs  were  applied  to  the  raw  surface  after  removing  the 
mass  with  a  l)istoury,  and  tlie  treatment  lasted  forty  days.  The  report 
was  made  in  the  latter  i)art  of  1912,  the  first  case  having  been  treated 
in  li)10  and  the  second  in  1911,  and  so  far  there  had  been  no  recurrence. 
See  Epithelioma,  as  well  as  Tumors  of  the  eye. 

Eyelids,  Erysipelas  of  the.  This  disease  rarely  begins  in  the  eyelids, 
though  they  aic  u.sually  involved  by  extension  from  the  face  or  some 
part  of  the  head.  It  is  characterized  by  a  diffuse  cellulitis  caused  by 
the  streptococcus.  The  lids  become  much  swollen,  of  a  dusky-red  color, 
and  are  stitf  and  painful.  The  swelling  is  at  times  so  great  as  to  extend 
over  the  brow  and  cheek.  Conjunctivitis  and  chemosis  are  sometimes 
present.  By  extension  into  the  orbit  the  disease  may  cause  exophthal- 
mos, atrophy  of  the  optic  nerve,  and  even  meningitis  and  death. 

Erysipelas  may  be  confounded  with  an  inflammatory  condition  of  the 
lachrymal  sac.  Tenderness  over  the  sac  and  fluctuation  will  serve  to 
differentiate  between  the  two.  Traumatic  swelling  and  herpes  zoster 
in  the  early  stages  may  also  be  mistaken  for  erj^sipelas.  The  prognosis 
in  the  majority  of  the  cases  is  good.  The  general  and  local  treatment 
is  tlie  same  as  that  for  erysipelas  located  elsewhere.  ]\Ioist  compresses 
of  lead  and  opium  wash,  or  the  application  of  ichthj^ol  are  among  the 
best  local  remedies.     See.  also,  Vol.  VI,  p.  4510,  of  this  Encyclopedia. 

Eyelids,  Erythema  cf  the.  The  skin  of  the  lids  may  at  times  become 
reddened,  dry  and  painful,  as  a  result  of  exposure  to  strong  wind, 
glare  of  light,  prolonged  weeping,  wakeful  nights,  excessive  strain 
or  use  of  the  eyes,  particularly  when  errors  of  refraction  are  uncor- 
rected, burns,  poisoning,  traumatism,  or  the  presence  of  irritating 
fluids.  Although  these  cases  properly  belong  to  the  domain  of  the 
dermatologist,  they  frequently  fall  into  the  hands  of  the  oculist  on 
account  of  the  concomitant  conjunctivitis  which  requires  attention. 
The  hyperemia  may  be  active  or  passive.  In  active  hyperemia,  which 
is  the  first  stage  of  all  inflammations  of  the  lids,  the  arteries  and 
capillaries  are  overfull.  In  the  passive  form  there  is  venous  stasis, 
and  the  color  is  somewhat  darker  than  in  the  active  form.  Idiopathic 
erj'thema  of  the  eyelids  is  rare.  The  affection  is  generally  transient, 
disappearing  spontaneously  in  a  few  days,  but  occasionally  more  per- 
sistent and  sometimes  recurrent.  Treatment  must  be  directed  to  the 
caus(\     See,  also.  Vol.  VI,  p.  4514,  of  this  Encyclopedia. 

Eyelids,  Eversion  of  the.    See  Vol.  VI,  p.  4584,  of  this  Encyclopedia. 

Eyelids,  Examination  of  the.    See  Examination  of  the  Eye. 

Eyelids,  Favus  of  the.  This  disease,  which  is  exceedingly  rare,  first 
shows  itself  as  yellowish-red,  painful  vesicles.  Later  there  is  a  dry, 
fissured  crust,  elevated  above  the  level  of  the  surrounding  skin.     The 


5006  EYELIDS,  FIBROMA  OF  THE 

ci'ust  is  of  a  .siil|>liiii'-ycll()\v  color,  with  a  cciitfal  depression,  and  show- 
inj2:  a  variety  of  colois  varying  from  wliite  to  sepia  brown.  Micro- 
scopic examination  .shows  the  presence  of  tlie  sporidia  and  mycelia  of 
achorion  Sclioenleinii.  Treatment  consists  in  the  use  of  an  oiled 
compress  in  the  evelli^^^  and  ff('(|urnt  washing's  willi  hichhjrid  solution 

(^  to  40011).— (J.  M.  ]•>.  I 

Eyelids,  Fibrcma  of  the.  This  di.sease,  consisting  of  bundles  of  densely 
packed  fibrous  tissue  containing  numerous  blood-vessels,  may  be  found 
in  the  lid  as  a  small,  hard,  rounded  mass,  freely  movable,  and  not  tend- 
ing to  increase  in  size.  Several  forms  of  fibromata  occur.  The  "painful 
subcutaneous  tubercle"  is  situated  in  the  connective  tissue  immediately 
under  the  skin.  These  little  tumors  are  painful  and  sensitive  to  the 
touch.  They  wei'e  first  desei-ihcd  by  Wood  in  1812  (Ediii.  Med.  and 
Surg.  Journ.,  p.  283).  F'ibromata  of  the  lid  sometimes  assume  the 
form  and  consi.stence  of  plates  of  cartilage.  Von  Graefe  {Klin. 
Monatshl.  f.  Ai((jciili('il.,  Jan.,  1863)  described  a  tumor,  situated  in 
the  cul-de-sac,  which  contained  true  l)one.  Fibroma  molluscum  involv- 
ing the  skin  and  the  subcutaneous  connective  tissue  may  form  an 
extensive  pendulous  tumor  in  the  loose  and  distensible  integument  of 
the  lid.     The  treatment  of  these  tumors  is  by  removal. 

Eyelids,  Fissures  of  the.  Riiagadeh.  In  cases  of  eczema,  and  in  those 
types  of  ocular  diseases  accompanied  by  photophobia  and  blepharo- 
spasm, fissures  of  the  external  canthus  are  often  present.  The  condi- 
tion is  relieved  ])y  the  application  of  nitrate  of  silver,  either  in  the  form 
of  a  strong  solution  or  the  solid  stick,  to  the  raw  spots.  Canthotomy 
may  be  required  in  obstinate  cases. —  (J.  ]M.  B.) 

Eyelids,  Fistula  of  the.  This  is  a  rather  rare  condition,  due  to  non- 
closure of  the  fronto-maxillary  fi.ssure ;  or  it  occurs  as  a  remains  of  a 
frontal  sinus  abscess  that  has  bi'okeii  through  the  palpebral  skin. 

Eyelids,  Frambesia  of  the.  Yaws.  AiMboyxa  button.  Piax.  This  is  a 
contagious  disease  seen  in  tropical  climates,  characterized  by  the  pres- 
ence of  raspberry-like  nodules  in  the  skin  and  by  more  or  less  consti- 
tutional disturbance.  The  papules  undergo  suppuration  and  scal)bing, 
with  the  formation  of  a  sligiit  scar.  In  some  instances  there  is  serious 
ulceration  of  the  skin  and  subcutaneous  tissues.  The  entire  course  of 
tlie  di.sease  occupies  several  montlis.  The  t'ruption,  which  begins  on 
the  face  and  extends  downward,  may  involve  the  eyelid.s,  leading  to 
localized  thickening,  conjunctivitis,  and  sometimes  necrosis.  The 
disease  is  to  be  differentiated  from  small-pox  and  the  lesions  of  heredi- 
tary syphilis.  Its  marked  resemblanc(>  to  blastomycetic  dermatitis  has 
been  noted.  The  progno.sis  is  generally  favorable.  The  treatment  in- 
cludes improved  hygienic  surroundings,  tonics,  diaphoretics,  and  local 


EYELIDS,  FRECKLES  OF  THE  5007 

jippliciitioiis  of  carljoIic-Mcid  lotion  or  the  diluted  nitrate  of  mercury 
ointment. —  (J.  ^I.  B.)  See,  also,  Aleppo  button,  Vol.  I,  p.  217,  of  this 
I'JiicuclopcfJw. 

Eyelids,  Freckles  of  the.  Lkntico.  Small  eireumscribed  spots  of  pig- 
ment oeeur  on  the  eyelids  as  well  as  on  other  exposed  portions  of  the 
skin.  They  may  l)e  eongenital,  hut  they  usually  oeeur  about  the  second 
decade  of  life. 

Eyelids,  Furuncle  of  the.  This  form  of  localized  inflammation  of  the 
skin  and  subcutaneous  tissue,  due  to  infection  by  one  or  more  of  the 
pus-cocci,  is  occasionally  seen  upon  the  eyelids.  The  local  use  of  an 
ointment  of  salicylic  acid  {gr.  xv  to  .")  i),  and  the  occasional  application 
of  cloths  wrung  out  of  hot  water,  will  be  ai)propriate.  An  incision 
uuiy  be  necessarj^  in  neglected  cases. 

Eyelids,  Furunculus  orientalis  of  the.     Oriental  boil.     Aleppo  boil. 

DkLHI  BOIL.    P>IS('AHA  BTTTOX.     ( J  AFSA  BUTTON'.    KaNDAIIAR  SORE.    PUED- 

JEH  SORE.  Natal  sore.  A  local  disease,  common  along  the  shores  of 
the  Mediterranean  sea,  marked  by  the  successive  formation  of  papule, 
tubercle,  scab,  and  sharply  circum.scribed  ulcer.  See  Vol.  I,  page  217, 
of  this  Encyclopedia. 
Eyelids,  Gangrene  of  the.  Spontaneous  gangrene.  Phagedenic  ul- 
ceration. ^Ialigxant  edema.  Noma.  This  rare  condition  has  been 
observed  by  several  writers.  The  disease  appears  in  emaciated  infants 
and  children,  and  is  characterized  by  swelling  of  the  lid,  the  formation 
of  a  pimple,  which  is  soon  converted  into  a  pu.stule  and  is  followed 
by  ulceration,  and  the  presence  of  a  thin  conjunctival  discharge.  The 
skin,  conjunctiva,  and  intervening  structures  soon  break  down,  and 
may  be  partly  or  entirely  destroyed.  The  ulcer  presents  sharply- 
defined,  undermined  edges,  bordered  by  a  zone  of  darkly-congested 
skin.  There  is  greenish  pus  and  a  dirty  slough.  The  cornea  is  opaque 
anil  ulcerated  and  perforation  results.  The  ulceration  may  spread  into 
the  eyebrow  and  on  to  the  cheek.  The  bacterial  cause  of  the  disease 
has  not  been  determined.  The  prognosis  will  depend  on  the  time  when 
the  patient  is  brought  for  treatment  and  on  the  general  condition. 
The-  treatment  consists  in  cleansing  and  antiseptic  applications,  and 
supportive  measures  internally.  The  administration  of  diphtheria 
antitoxin  has  been  recommended.  A  case  following  an  attack  of 
diphtheria  was  reported  ])y  INIarlow  {Ophth.  Bee,  Dec,  1901 )  in  which 
there  was  complete  destruction  of  both  the  upper  and  lower  lid. 
including  skin,  conjunctiva,  and  all  the  intervening  structures. 

Cases  of  gangrene  of  the  eyelids,  as  a  sequel  of  measles,  have  been 
recorded.  Fieuzal  {Ccnfralhlaft  f.  prakt.  Augcnhcilk.,  1887)  described 
this  condition.     Stoewer  {Klin.  Monatsbl.  f.  Augcnhcilk.,  July,  1908; 


5008  EYELIDS,  GANGRENE  OF  THE 

ir\  irw  ill  Oiili.  h'(  rii  ir,  Oct.,  lJ>O.Sj  ik'Scrilx'S  a  case  of  partial  gangrene 
(tf  the  liil.  with  coiisctiucnt  hcinon-liagic  diathesis.  The  case  cited  Ls 
that  of  a  tlin'('-y('ai--ol(l  chihl  in  whom  a  small  ulcer  developed  on  the 
right  lowc-r  lid  mar^'iii.  'I'hc  child  had  just  recovered  from  measles. 
A  few  days  after  the  ulcer  was  noticed  the  lower  lid  became  much 
swollen  and  the  skin  over  it  dark-blue  in  color.  At  the  same 
lime  thei-e  was  a  constant  Iricklin^^  of  blood  from  the  lid  aperture. 
Kxnndiuition  under  chloroform  showed  that  the  l)leeding  came  from 
the  general  conjunctival  surface,  no  eroded  spot  being  found.  Com- 
pression failed  to  stop  the  bleeding  and  Stoewer  contented  himself 
with  a  slight  application  of  nitrate  of  silver  to  the  conjunctiva  and 
the  use  of  a  wet  dressing.  Within  the  next  few  days  the  submaxillary 
lymph  glands  became  iinich  swollen  and  hemorrhages  were  observed 
on  the  mucous  mem])rane  of  the  tongue  and  in  the  skin.  Eventually 
the  child  made  a  good  recovery,  and  though  a  triangular  area  sloughed 
from  the  edge  of  the  lid,  little  deformity  was  left.  Stoewer  looks  upon 
the  whole  process  as  a  local  and  general  sepsis  due  to  the  staphylo- 
coccus aureus  which  was  found  present  in  the  lid  ulcer.  There  was 
no  suspicion  of  hemophilia,  and  Stoewer  considers  the  hemorrhagic 
tendency  was  the  effect  of  the  septic  proeess.  The  disease  ran  the 
course  of  a  case  of  typical  morbus  raaculosus  Werhoffi  (purpura 
hemorrhagica). 

In  Bergmeister's  case  {OpJitJialmic  Year  Book,  p.  283,  1909)  gan- 
grene affecting  particularly  the  lower  lid  occurred  in  conjunction 
w'ith  ophthalmia  neonatorum.  Gonocoeci  and  streptococci  were  pres- 
ent. The  reporter  ascribes  the  affection  to  the  circulatory  disturbance 
caused  by  the  great  tension  and  swelling  of  the  lids  for  a  week  before 
advice  was  sought.  Tertseh  reports  a  case  of  gangrene  of  all  four 
lids  in  a  new-born  syphilitic  infant.  Francke,  observed  gangrene  of 
the  upper  and  lower  lids  of  ))oth  eyes  in  an  infant  followed  by  good 
recovery.  No  cause  could  be  found  other  than  a  cold  and  damp  dwell- 
ing house;  he  accordingly  denominated  the  affection  "noma." 

Bossalino  {Aim.  di  Ott.,  V.  41,  p.  610)  reports  the  case  of  a  healthy 
man  of  20  years,  w'ho  received  a  slight  blow'  on  the  right  upper  lid. 
The  following  night  the  lid  began  to  swell,  and  the  patient  had  a  chill. 
Tiiree  days  later  there  was  intense  edema  of  the  lids,  affecting  espe- 
cially the  upper,  and  extending  on  to  the  forehead,  cheek  and  neck. 
The  ii|)j)(r  lid  was  covered  by  a  large  black,  eschar,  which  reached 
from  llie  siipei-ciliary  ridge  to  just  .short  of  the  ciliary  margin.  For 
the  following  three  days  the  temperature  was  constantly  elevated, 
reaching  a  nuiximum  of  between  102  and  103  degrees  each  day.  Three 
weeks  from  the  onset  of  the  affection  the  necrotic  tissue  was  excised 


EYELIDS.  GOUNDON  OF  THE  5009 

Extensive  plastie  work  Mas  necessary.  Baeteriologic  study  was  nega- 
tive, with  the  exception  of  a  few  white  staphylococci,  but  the  author 
believes  the  condition  to  have  been  due  to  the  streptococcus.  It  seems 
not  unlikely  that  this  case  may  have  been  one  of  anthrax, 

Jarnatowski  (Ophtli.  Rev.,  V.  32,  p.  262)  describes  a  case  of  necrotic 
tarsitis.    without   antecedent   inflammation    of   the   conjunctiva.      The 
slough,  wliich  measured  2  or  3  mm.  by  10  mm.,  was  easily  removed 
with  foreeps,  and  smooth  healinc:  followed.     The  necrotic  tissue  in- 
cluded tarsus  and  acini  of  the  ^Meibomian  glands. 
Eyelids,  Goundou  of  the.     Anakiibe  of  the  lids.  Gros  nez.    This  is  a 
rare  disease,  found  on  the  "West  coast  of  Africa.     It  occurs  in  child- 
hood, usually  l)egins  with  headache,  and  is  characterized  by  a  sanguino- 
purulent discharge  from  the  nostrils,  and  the  formation  of  symmetrical 
swellings  on  the  side  of  the  nose,  involving  apparently  the  nasal  proc- 
ess of  the   superior   maxilla.      The   enlargements   encroach   upon   the 
orbits  and  finally  destroy  the  eyes. 
Eyelids,   Granuloma  of  the.     The  mass  of  granulation  tissue  wdiich 
results    from    inflammation   of  the   ]\Ieil)omian   glands   received   from 
Virchow  the  name  of  granuloma.     See  Chalazion,  Vol.  Ill,  p.  1983, 
of  this  E)i(!)(Joj>('dia. 
Eyelids,  Gumma  of  the.    Tertiary  syphilitic  lesions  are  most  frequently 
seen  as  a  general  thickening  of  the  lid,  a  "tarsitis;"  while  a  gumma, 
which  is  a  circumscribed  tumefaction,  is  the  rarest  of  all  specific  lesions. 
The  lids  become  swollen  and  tense.     Ulceration  follows,  the  ulcer 
having  an  irregular,  eroded,  ''punched-out"  appearance.     Its  floor  is 
covered  with  dirty-yellowish,  or  gray,  debris,  and  if  unchecked  there 
may  be  extensive  destruction  of  the  tissues.    In  the  absence  of  a  history 
of  infection  the  diagnosis  may  be  difficult.    The  prognosis  of  gumma  of 
the  lid  is  favorable,  the  condition  yielding  to  iodid  of  potassium  inter- 
nally and  mercurial  salve  locally.     Cauterization  is  contra-indicated. 
When  seen  before  necrosis  takes  place,  gummata  bear  a  very  strong 
resemblance  to  chalazia,  but  nearly  always  progress  toward  the  skin 
and  leave  the   conjunctival   surface   normal.     The   conjunctiva    and 
cornea  may,  however,  be  involved,  as  in  a  case  reported  by  Clapp 
(Ophfh.  Be  cord,  June,  1912)   in  which  there  developed  a  small  ulcer 
of  the  conjunctiva  close  to  the  limbus,  which  gradually  extended  until 
it  involved  the  cornea  for  about  2  mm.  with  superficial  ulceration. 
This  condition  healed  very  rapidly  a.s  soon  as  treatment  was  begun. 

AVhile  the  syphilitic  tarsitis  is  usually  a  painless  condition,  those 
reporting  gummata  have  generally  found  it  associated  %vith  consid- 
erable pain.  De  Wecker  (Traitc  d'OphfalmoIofiie,  Vol.  I)  reports 
such  a  case,  which  he  mistook  for  chalazion,  which  was  very  painful ; 

Vol.  VII— 11 


5010  EYELIDS,  GUNPOWDER  GRAINS  IN  THE 

wliilc  linll  {Trans.  Amer.  Ophthal.  Soc,  1878 j  rei)orted  a  case  of 
prnnima  of  the  left  lower  lid  tho  sizo  of  a  robin's  0??;,  with  little 
or  no  ]);iin.    See,  also.  Eyelids,  Syphilis  of  the;  also  Syphilis. 

Eyelids,  Gunpowder  grains  in  the.  Tattooing  of  the  lids.  If  the  pa- 
tiriit  is  si'cn  sliortly  alter  an  explosion  of  powder  the  black  grains  of 
powder  can  be  removed  by  scrubbing  with  a  nail-brush.  Tattooing  of 
the  eyelids  from  grains  of  gunpowder  is  of  comparatively  frequent 
occurrence.  After  the  carbonized  particles  have  stained  the  integu- 
ment, puncture  with  the  electrolytic  needle  will  give  satisfactory  re- 
sults. The  continued  use  of  gauze  soaked  in  hydrogen  peroxid,  if 
a])i>lif(l  soon  after  the  accident,  is  said  to  be  of  value.  See,  also.  Eye- 
lids, Injuries  of  the. 

Eyelids,  Hernia  of  the.  In  elderly  persons,  as  a  result  of  atrophy,  or 
from  trauma  dui'ing  ;iny  period  of  life,  the  fatty  tissue  of  the  orbit, 
which  is  normally  held  in  place  by  the  tarso-orbital  fascia,  orbicularis 
muscle,  and  skin,  may  i)rotrude  between  these  weakened  tissues.  The 
hernia  can  be  pushed  l)ack  into  the  orbit,  or  if  of  sufficient  size  to 
cause  deformity,  the  protruding  tissue  may  be  removed  through  an 
incision  made  parallel  with  the  fibres  of  the  orbicularis  muscle. 

Eyelids,  Herpes  of  the.  Herpes  of  the  fifth  nerve  occurs  in  both  sexes 
with  abiiost  (M|ual  frequency,  and  attacks  adults  as  a  rule,  although 
it  is  not  rarely  observed  in  children  and  young  subjects  with  appar- 
ently unimpaired  nutrition.  The  vesicles  occur  in  patches  of  three  or 
more,  having  a  tendency  to  group  in  a  round  form.  They  appear  in 
the  temporal  region,  on  the  forehead,  upper  lid,  conjunctiva,  and 
cornea.  The  lower  lid  and  elieek  are  rarely  involved  in  the  eruption. 
See  Herpes  zoster  ophthalmicus. 

Eyelids,  Hives  of  the.  Urticaria.  This  inflammatory  disorder  of  the 
skin  often  involves  the  eyelids.  It  is  characterized  by  the  presence  of 
wlieals,  with  a  sensation  of  burning  and  itching.  It  is  seen  to  follow 
eye  strain  or  upon  improperly  corrected  errors  of  refraction,  but 
gastric  disorders  account  for  the  majority  of  cases.  The  disease  should 
be  treated  by  attention  to  the  source  of  irritation  when  this  ean  be 
discovered.  The  chronic  form  of  urticaria  is  called  cnidosis.  It  is  to 
be  treated  by  pilocarpin,  and  quinine  and  bromides  internally,  but  in 
spite  of  all  treatment  it  sometimes  continues  for  years. 

Eyelids,  Hordeolum  of  the.     Stye.    Perifolliculitis.    See  Hordeolum. 

Eyelids,  Horny  growths  on  the.  Corxu  cutaneum.  See  \o\.  V.  p. 
2-').14,  of  tills  K IK  iichijx  (lid. 

Eyelids,  Hyaline  degeneration  of  the.  Ilyalin  may  occur  as  a  pre- 
liminaiy  stage  in  the  development  of  amyloid,  but  generally  it  repre- 
sents a  varietv  of  tissue  degeneration  distinct  fi'om  aiinloid.  and  show- 


EYELIDS,  HYPEREMIA  OF  MARGINS  OF  THE  5011 

ing  no  tendency  to  pass  over  into  the  latter.  Hyaline  and  amyloid 
degenerations  present  almost  precisely  tlie  same  clinical  picture,  so 
that  a  positive  distinction  between  the  two  can  be  made  only  by  exam- 
ining excised  pieces  of  conjunctiva.  Calcification  or  ossification  may 
take  place  in  the  degenerated  mucous  membrane.  The  disease  attacks 
people  in  middle  life,  and  ordinarily  both  eyes  are  affected.  Such 
swellings  situated  in  the  retrotarsal  fold,  protrude  between  the  lids 
and  the  eyeball ;  the  plica  semilunaris  also  is  enlarged  until  it  forms  a 
misshapen  mass.  These  various  swellings  are  so  friable  that  they  often 
tear  wiien  an  attempt  is  made  simply  to  sei)arate  tlie  lids  for  examina- 
tion, although  in  doing  so  they  bleed  very  little.  The  disease  runs  a 
yevy  chronic  course,  dragging  on  for  years  without  any  real  inflamma- 
tory symptoms,  until  at  length  the  patient  is  deprived  of  the  use  of  his 
eyes  by  his  inability  to  open  the  misshapen  lids.  ^ledical  treatment  is 
powerless  against  this  disease.  We  must  confine  ourselves  to  removing 
the  growths  upon  the  conjunctiva  to  such  an  extent  that  the  lids  can 
be  opened  and  vision  thus  rendered  possible.    (Fuchs.) 

Morax  and  Landrieu  (Ann.  d'Ocul.,  147,  p.  25)  have  reported  an 
instance  of  hyaline  degeneration  of  the  submucous  tissue  of  the  lids 
in  a  subject  60  years  of  age.  Large,  irregular,  brownish  hypertro- 
phies were  visible  in  the  conjunctiva  of  the  tarsus  and  fornix.  His- 
tological examination  of  these  when  excised  confirmed  the  diag- 
nosis. The  bacteriological  examination  was  negative.  Ossification 
was  present  at  the  margin  of  the  diseased  zone,  over  which  the 
epithelium  was  preserved.  The  connective  tissue  elements  Avere 
degenerated,  softened  and  structureless.  Hyaline  masses,  giant 
and  plasma  cells,  were  situated  deeply  in  the  tissue.  Tlie  ])lood 
vessels  were  normal.  See,  also.  Conjunctiva,  Amyloid  degeneration 
of  the. 

Eyelids,  Hyperemia  of  margins  of  the.  This  is  often  present  in  per- 
sons who  use  their  eyes  excessively  for  close  work,  or  among  those 
Avho  follow  their  vocations  in  a  vitiated  atmosphere  or  unfavorable 
illumination.  It  is  common  also  in  persons  with  errors  of  refrac- 
tion, and  in  those  addicted  to  the  use  of  alcohol  and  tobacco.  AVhen, 
in  addition  to  hyi)eremia,  scales  or  crusts  form  on  the  lid  margins, 
it  then  constitutes  one  of  the  various  forms  of  blepharitis.  See,  also. 
Blepharitis. 

Eyelids,  Hyperidrosis  of  the.  Excessive  sweating  of  the  eyelids  occurs 
in  coiuiection  with  the  disease  on  the  face  and  body.  It  may  be  con- 
fined to  the  lids  of  one  eye  when  there  is  unilateral  facial  hyperidrosis. 
In  this  case  it  indicates  an  ii-iitation  or  lesion  of  the  sympathetic  nerve. 

Eyelids,  Hyperkeratosis  of  the.     This  is  a  congenital  condition  and 


5012  EYELIDS,  IMPETIGO  OF  THE 

wlicii  file  .slsiii  <)i'  the  faci'  is  affected,  the  eyelids  may  become  involved. 
In  mild  grades  of  llic  disease,  when  the  victim  survives,  there  some- 
times results  ectroi)ion,  loss  of  eyebrows  and  eyelashes,  conjunctivitis 
and  keratitis,  symblepheron,  and  atrophy  of  the  conjunctiva.  Treat- 
ment sliouhl  include  alkaline  and  bi-an  baths  to  loosen  the  scales,  and 
the  application  of  lanolin  or  other  unctuous  substance.  The  internal 
administration  of  thyroid  extract  has  been  recommended. 

Eyelids,  Impetigo  of  the.  This  disease  manifests  itself  as  pustules 
of  the  size  of  a  split-pea,  which  disappear  spontaneously  in  a  few 
weeks.     There  are  no  subjective  symptoms. 

Eyelids,  Injuries  of  the.  Traumatisms  of  the  lids  are  commonly  met 
with  and  are  of  considerable  importance. 

Wounds  of  the  eyelids  may  be  punctured,  incised,  lacerated,  or  con- 
tused. Punctured  wounds  are  of  little  importance,  provided  other  ocu- 
lar structures  are  not  injured.  They  generally  heal  without  scars. 
It  must  be  remembered  that  numerous  cases  are  recorded  in  which 
foreign  bodies,  after  traversing  the  lids,  have  lodged  and  remained 
in  the  orbit  without  producing  acute  symptoms.  Incised  and  lacerated 
wounds  call  for  careful  attention.  They  should  be  cleansed  and  accu- 
rately approximated  w'ith  catgut  sutures.  It  is  especially  important 
to  note  whether  the  canaliculus  has  been  cut  or  the  globe  injured. 
Horizontal  cuts  do  little  harm  except  the  suspensory  ligament  of  the 
upper  lid  is  severed.  Vertical  and  oblique  incised  wounds,  unless  seen 
early  and  properly  sutured,  will  lead  to  coloboma,  ectropion,  entropion, 
or  ti'ichiasis.  AVhen  the  internal  palpebral  ligament  and  eanalieuli 
are  cut,  the  function  of  the  lachrymal  apparatus  will  be  interfered 
with.  Lacerated  wounds,  often  produced  by  bursting  bottles,  meat- 
hook.s,  blows,  or  thrusts  with  pieces  of  wood  or  a  cow's  horn,  button- 
hooks, etc.,  if  treated  early  wdll  generally  give  good  results.  If  the 
canaliculus  is  torn,  the  remaining  portion  should  be  sought  and  opened 
into  tiie  sac.  It  may  be  possible  to  unite  the  two  portions  by  passing 
a  short  probe,  suturing  the  lid  upon  it,  and  leaving  the  instrument  in 
place  for  a  few  days.  Each  ease  of  laceration  must  be  judged  by  itself, 
and  often  the  ingenuity  of  the  .surgeon  will  ])e  taxed. 

Contused  wounds  of  the  lids,  frecpient  in  persons  pugilistically  in- 
clined, are  followed  almost  immediately  l)y  extravasation  of  blood  into 
the  cellular  tissue,  producing  a  condition  commonly  called  ''lilack 
eye."  The  blood  may  be  in  the  form  of  a  dit1^"used  ecchymosis  or  as 
a  hematoma.  For  prognostic  reasons,  it  is  important  to  distinguish 
between  .such  an  immediate  ecchymosis  and  that  which,  occurring  in 
fractures  of  the  base  of  tlie  skull  or  lupture  of  oi'bital  vessels,  appears 
later.     In  such  serious  injui-ies,  the  Mood  not  infrequently  is  forced 


EYELIDS,  INJURIES  OF  THE  5018 

foi-Wrird  into  tlie  eyelids.  Tlie  lower  part  of  the  oeular  conjunctiva 
and  the  lower  eyelid  (rarely  the  upper  lid  also)  show  hemorrhages. 
The  ordinary  "black  eye"  disappears  in  two  or  three  weeks.  If  a 
fracture  has  involved  the  frontal  or  ethmoidal  sinus,  emphysema, 
occurring  early,  may  l)e  associated  with  a  tardy  ecchymosis.  P^dema 
of  the  lids  is  a  common  result  of  a  blow. 

A  "black  eye"  should  be  bathed  with  cold  water  and  treated  with 
freijuent  a])p]ications  of  arnica,  lead-water,  laudanum  or  hamamelis. 
If  the  blood  is  present  as  a  hematoma,  it  will  be  best  to  incise  the  lid 
and  evacuate  the  clots  under  aseptic  precautions.  Abscess  of  the  lid 
should  be  treated  by  incision  and  the  frequent  use  of  a  bichlorid  solu- 
tion. Leeches  are  of  no  particular  value  in  the  treatment  of  black 
eye.  In  sensitive  persons  the  surgeon  may  conceal  the  injury  by  paint- 
ing the  eyelids. 

Burns  and  scalds  of  the  eyelids,  if  of  the  fir.st  or  second  degrees, 
generally  heal  without  deformity.  Deeper  lesions  are  frequently  fol- 
lowed by  cicatricial  contraction,  displacement  of  the  lid-borders  (ectro- 
pion), ankyloblepharon,  or  symblepharon.  These  conditions  will  re- 
quire appropriate  surgical  treatment.  When  called  to  a  case  of  burn 
or  scald,  involving  the  lids,  the  surgeon  should  note  carefully  the  con- 
dition of  the  conjunctiva  and  cornea.  The  injured  area  should  be 
treated  with  gauze  soaked  in  carron-oil,  or  with  lint  soaked  in  a  solu- 
tion of  borax  or  sodium  ])icarbonate,  or  painted  daily  with  white  lead. 
Iodoform  may  be  dusted  on  the  surface  daily.  Large  granulating 
surfaces  should  be  covered  with  Thiersch 's  skin-grafts.  The  principles 
which  guide  the  surgeon  in  the  treatment  of  burns  and  scalds  elsewhere 
in  the  body  will  apply  to  lid  injuries.  Pain  may  be  so  severe  as  to  call 
for  the  use  of  morphin. 

Foreign  bodies  in  the  eyelids.  "With  the  exception  of  grains  of 
powder,  the  retention  of  foreign  bodies  within  the  eyelids  is  of  com- 
paratively rare  occurrence.  Pieces  of  iron,  steel,  gun-caps,  coal, 
pencils,  splinters  of  wood,  birdshot,  dirt,  sand,  and  pebbles  are 
among  the  substances  occasionally  found  in  the  lids.  ^lost  foreign 
bodies  carry  infection  with  them  and  produce  localized  abscesses. 
In  the  course  of  the  inflammation  the  foreign  body  often  is  extruded, 
iletallic  bodies,  which  have  been  propelled  by  an  explosion,  are  often 
sterile  and  remain  imbedded  in  the  lids  without  causing  reaction. 
Large  foreign  bodies  can  be  removed  through  suitable  incisions. 
Small  ones  can  be  picked  out  with  a  cataract-needle.  If  the  patient 
is  seen  shortly  after  the  accident,  grains  of  powder  can  be  removed 
by  scrubbing  with  a  nail-brush.  The  continued  use  of  gauze  soaked 
in  hydrogen  peroxid.  applied  soon  after  the  accident,  is  said  to  be 


5014  EYELIDS,  KELOID  OF  THE 

of  \;iliic.      If  these  iiicasiii'i's  f;iil,  IIk-  sui'j^'coii   sliould   Wiii1   until  the 
ju'uto  st;i^^'  lias  passed,  -when  tlic  individual   grains  may  be  picked 
out  tlirouf^ii  small  incisions  oi'  destroyed   with   the  fine  point  of  an 
eloctrie  eautery. —  (J.  .M.  I'..)     See,  also,  Injuries  of  the  eye. 
Eyelids,  Keloid  of  the.     A  connective-tissue  ]ieo|)lasm,  fi-ecjueiitly  the 
icsult  ol'  a  1 1  auniat  ism.     It  is  often  seen  in  the  negro,     it  only  rarely 
nttacks  the  eyelids. 
Eyelids,  Keratosis  foUicularis  of  the.     See  Daxier's  disease. 
Eyelids,  Lentigo  of  the.       P'kixkles.     Small     circumserihed     spots     or 
splotches  of  pigment  occur  on  the  eyelids  as  on  other  exposed  portions 
of  skin.    They  nsually  occur  in  early  life,  but  may  be  congenital.     No 
treatment  is  called  for. 
Eyelids,  Lepra  of  the.    See  Eyelids,  Leprosy  of  the. 
Eyelids,  Leprosy  of  the.     When  the  eyelids  are  involved  in  this  disease 
process,  tlu'y  present  a  condition  that  does  not  differ  from  leprosy  of 
the  skin  in  other  parts  of  the  body.     There  is  thickening  of  the  skin, 
and  destruction  of  a  part  or  the  whole  of  the  eyelid  as  a  result  of  the 
formation  of  leprous  tubercles.     The  eyebrows  and  lashes  are  apt  to 
lui'ii  white,  or  they  may  drop  out,  and  anesthetic  patches  of  a  color 
paler  than  the  surrounding  skin  not  infrequently  develop.     Leprosy 
is  distinguished  from  lupus  by  the  total  absence  of  pain  in  the  former. 
All  treatment  for  leprosy  has  proven  ineffectual,  although  chaulmoogra 
oil  is  said  to  be  useful.     Recently  the  hypodermic  injection  of  Cal- 
mette's  antivenene  serum  has  given  promise  of  good  results.    (Dyer.) 
Eyelids,  Lipoma  of  the.    P'atty  tumors  of  the  eyelids  are  of  infrequent 
occurrence.     They  are   circumscribed,  soft,   elastic,   and   lobulated. 
Treatment  is  by  excision.     See  Tumors  of  the  eye. 
Eyelids,  Lippitudo  of  the.     When,  in  an  old  case  of  blepharitis  ulcerosa 
the    lid   border    becomes    smooth,    red,    glazed,    everted,    thickened, 
weeping,  and  destitute  of  lashes,  the  term  liijpitudo  is  applied.    See 
Blepharitis. 
Eyelids,  Lupus  erythematosus  of  the.    This  affection  of  the  skin  which 
occasionally  extends  from  the  face  on  to  the  lids,  is  regarded  by  most 
dernuitologists  as  a  form  of  tuberculosis  of  the  skin.     It  is  not  easy 
to  diagnose  this  affection.    The  disease  is  characterized  by  well-defined 
patches,  with  reddish,  elevated,  irregular  borders.     The  centre  of  the 
patch  is  atrophic  and  slightly  sunken,  and  is  covered  by  light-yellow 
scales  or  crusts  of  sebaceous  matter.    The  patches  may  coalesce.    They 
may  leave  i^ale,  superficial  cicatrices,  or  the  cicatrix  may  be  bright- 
red  in  coloi-.     in  the  treatment  of  this  condition  it  must  be  remembered 
that  all  procedui'es,  to  be  successful,  must  be  sufficiently  comprehensive 
to  take  in  the  entire  affected  area.     Curetting  followed  bv  thorough 


EYELIDS,  LUPUS  VULGARIS  OF  THE  5015 

cauterization  gives  good  results.  The.  ulcerated  surface  may  be  re- 
moved by  caustic  paste.  Excision  may  be  practised  if  the  affected 
area  is  not  too  extensive,  the  loss  of  tissue  being  replaced  by  appro- 
priate transj)lantatiou  of  cutaneous  flaps.  Multiple  scarification  with 
the  subsequent  application  of  iodoform  may  be  employed.  Exposure 
to  llie  Kiintgeii  rays  is  now  being  tried  with  some  promise  of  success. 

Eyelids,  Lupus  vulgaris  of  the.  This  disease,  which  is  more  common 
in  European  countries  than  it  is  in  America,  may  affect  the  eyelids 
when  present  on  the  face  or  nose.  It  is  characterized  by  the  presence 
of  papules,  nodules  and  patches,  which  either  ulcerate  or  atrophy, 
leaving  scars.  It  appears  almost  invariably  before  pubert}',  and  is 
more  frequent  in  females  than  in  males.  The  disease  begins  as  small 
reddish  spots  which  change  into  nodules,  of  a  brownish,  translucent 
appearance.  After  months,  or  perhaps  years,  the  nodules  coalesce 
and  ulceration  occurs,  which  spreads  and  then  cicatrizes  spontaneously. 
Cicatricial  ectropion,  or  entire  destruction  of  the  lid,  may  result,  and 
changes  in  the  eyeball  are  often  found  which  may  even  produce  com- 
plete blindness. 

The  disease  may  remain  unrecognized  for  a  long  time,  as  the  diag- 
nosis is  difficult.  It  should  be  treated  by  complete  removal  of  the  dis- 
eased tissue. —  (J.  ]\r.  B.) 

Eyelids,  Lymphangioma  of  the.  Lymphoma.  In  consideration  of  the 
complicated  structure  of  the  lids,  in  which  such  a  manifold  variety  of 
tissue  takes  part,  the  most  dissimilar  kinds  of  neoplasms  at  times 
come  under  observation  in  them.  Lymphangioma  is  a  rare  form  of 
growth,  appearing  in  the  form  of  an  elongated,  sausage-shaped  tumor, 
elastic  and  painful.  The  skin  over  the  mass  is  often  tense,  shining, 
and  traversed  by  dilated  veins.  Lymphoma  develops  in  the  course  of 
leukemia  and  pseudoleukemia.  Optic  neuritis,  retinitis,  and  retinal 
hemorrhages  are  often  present  in  these  diseases.  The  prognosis  is  un- 
favorable. Extirpation  of  the  growths  gives  only  temporary  relief. 
The  prolonged  internal  administration  of  arsenic  has  been  recom- 
mended. 

Eyelids,  Lymphoma  of  the.    See  Eyelids,  Lymphangioma  of  the. 

Eyelids,  Madarosis  of  the.  A  condition  of  the  lids  in  wiiich  there  is 
destruction  of  the  cilia,  as  a  sequel  to  blepharitis  ulcerosa.  See,  also, 
Blepharitis. 

Eyelids,  Malignant  edema  of  the.    Sec  Eyelids,  Gangrene  of  the. 

Eyelids,  Malignant  pustule  of  the.  Antiikax.  See  Vol.  1.  p.  512,  of 
this  Eiiciiclopidki. 

Eyelids,  Malignant  tumors  of  the.  See  Vol.  II,  p.  1410,  of  this  Eu- 
cyclopedUi. 


5016  EYELIDS,  MALIGNANT  TUMORS  OF  THE 

In  tulditioii,  it  may  Ix'  said  licrt'  of  lymplioina  of  the  lower  lid  that 
a  ea.sc  rcpoi'tcd  liy  De  Lavi^'crie  and  Onfray  {Ann.  d'OcuL,  V.  1-lIi,  p. 
281)  ill  a  woman  of  58  years  was  part  of  a  general  lymphomatosis. 
The  lid  liiiiior  was  the  size  of  a  large  almond,  and  appeared  as  a  firm 
swelling  heiieath  the  external  half  of  the  palpel)ral  conjunctiva,  which 
was  normal.  Theiv  were  a  number  of  smaller  tumors  beneath  the  skin 
of  the  face,  and  in  the  soft  palate.  There  was  a  history  of  multiple 
tumors,  dating  back  three  years,  with  temporary  improvement  from 
time  to  time.  Repeated  examination  of  the  blood  pointed  to  a  marked 
and  progressive  anemia,  without  leukemia  or  abnormal  leukocytic 
form.s.  An  excised  portion  of  the  lid  tumor  show'ed  the  characteristic 
structure  of  lymphoma.  The  patient  died  a  few  months  later  in 
cachexia. 

Lamb  {OpJtthalmoscope,  July,  1913)  reports  in  detail  a  very  inter- 
esting case  of  perithelioma  of  the  eyelids.  It  is  described  as  a  type  of 
tumor  of  the  larger  group  of  lymphangio-endothelioma,  characterized 
as  exhibiting  capillary  channels  cut  in  various  directions  and  lined 
by  recognizable  endothelium.  Around  each  capillary  is  a  collection 
of  cells  many  layers  deep,  arranged  radially.  The  cells  are  not  espe- 
cially elongated,  but  the  arrangement  in  rows  at  right  angles  to  the 
capillary  axis  is  most  characteristic.  The  probable  origin  is  from 
the  lymphoid  endothelium  of  the  perivascular  space,  thus  forming 
one  variety  of  lymphangio-endothelioma. 

The  case  reported  occurred  in  a  mulatto,  50  years  of  age,  with  a 
history  of  injury  to  the  left  eye  by  a  flying  wire  nail.  A  tumor  half 
the  size  of  a  pea,  suspended  by  a  small  pedicle  and  spread  out  over 
the  sclera,  had  been  dissected  off  and  diagnosed  as  malignant.  The 
growth  recurred,  suggesting  keloid,  and  wa.s  again  removed.  When 
first  seen  by  the  writer,  llie  upper  and  lower  lids  of  the  left  eye  were 
swollen,  especiall,y  at  the  outer  canthus,  and  the  lids  were  pushed 
forward  and  away  from  the  eyel)all  by  the  growth  upon  the  eyeball 
itself. 

Upon  everting  the  lower  lid,  a  soft,  grayish,  gelatinous  mass,  a  tessel- 
lated homogeneous  outgrowth  with  a  .suggestion  of  pseudomeml)rane, 
was  present,  extending  from  the  outer  canthus  to  about  the  middle  of 
the  lower  lid,  and  from  the  ciliary  margin  to  the  fornix,  and  any  at- 
tempt to  remove  it  was  accompanied  l)y  bleeding  from  the  underlying 
membrane.  On  everting  the  upper  lid  a  similar  growth,  similarly 
located,  l)ut  smaller  in  size,  was  found,  covered  by  a  thick,  yellowish, 
gelatinous  exudate,  wiiich  hung  down  and  l)athed  the  outer  portion  of 
the  bulb.  Oil  the  eycliall.  half  way  between  the  outer  eaiithus  and  the 
outside  of  the  limbus,  was  found  a  soft,  "mushy"  tumor,  apparently 


EYELIDS,  MEIBOMIAN  CYST  OF  THE  5017 

of  subconjunctival  orip^in,  aliout  7  iiiiii.  in  its  horizontal  diameter  and 
5  nun.  in  the  vertical,  overlyinfi;  the  external  rectus  and  in  nowise  lim- 
iting motion  of  the  eyeball.  The  vision,  20/13,  was  often  obscured  by 
superabundant  secretion  of  mucus.  Wassermann  reaction  was  nega- 
tive, as  also  von  Pirquet  and  Moro  tuberculin  tests.  Removal  was 
followed  by  recurrence  and  complete  exenteration  became  necessary. 
The  early  removal  and  the  fact  that  all  glands  communicating  by  lym- 
phatic vessels  were  perfectly  iiornial  in  size,  gave  a  good  prognosis  for 
prolonged  life. 

Adeno-carcinoma  very  rarely  arises  from  sweat-glands.  Coats,  how- 
ever {Roij.  Loud.  Ophth.  Hosp.  Uep.,  xviii,  p.  266),  is  satisfied  that 
such  was  the  origin  of  a  fleshy  growth  removed  from  the  upper  lid 
of  a  woman  of  53  years.  Near  the  skin  surface  on  one  side  of  the 
growth  was  a  collection  of  glandular  tubules,  larger  and  more  irregu- 
larly disposed  than  in  the  case  of  an  ordinary  sweat  gland,  yet  imitat- 
ing its  well-known  coiled  arrangement.  The  deeper  tissue  showed  a 
widespread  infiltration  of  epithelial  cell  masses  o*f  a  malignant  type. 

Fleischer's  case  of  papillo-sarcoma  of  the  lid  {Klin.  Monatahl.  f. 
Augenhiel.,  May,  1911,  p.  689)  suggests  the  importance  of  microscopic 
aid  in  tumor  diagnosis.  A  new-growth  of  the  lower  lid  in  a  boy  of 
10  years  presented  on  the  palpebral  conjunctiva  the  appearance  of  a 
papilloma.  But  it  extended  to  deep  tissues,  and  microscopic  examina- 
tion led  to  a  diagnosis  of  sarcoma  and  to  exenteration  of  the  orbit. 

AYith  malignant  tumors  there  occurs  an  enlargement  of  the  neigh- 
boring glands,  first  in  the  preauricular  gland,  afterwards  in  the  glands 
along  the  lower  jaw  and  in  the  neck. 

The  extirpation  of  tumors  of  the  lids  is  conducted  according  to 
the  -well-knoAvn  rules.  In  extensive  tumors  it  is  often  necessary  to 
remove  the  eyeball,  and  even  the  entire  contents  of  the  orbit.  See, 
also,  Eyelids,  Epithelioma  of  the,  as  well  as  Eyelids,  Rodent  ulcer  of 
the. 

Eyelids,  Meibomian  cyst  of  the.    See  Chalazion. 

Eyelids,  Milium  of  the.  This  is  a  small  tumor  made  up  of  an  agglom- 
eration of  the  pi-ickle  layer  of  the  epidermis  which  has  become  snared 
oft'  into  the  corium  during  embryonic  life.  It  is  considered  by  some  to 
be  a  retention  cyst  of  the  sebaceous  glands.  It  is  of  connnon  occur- 
rence, and  is  seen  generally  in  the  lower  lid,  but  often  in  the  upper 
one  also.  It  is  usually  seen  aliout  the  time  of  puberty,  although  it  is 
occasionally  congenital.  Milia  may  occur  sparsely,  or  may  be  thickly 
studded  over  the  aft'ected  area,  and  the  tendency  of  the  di-stribution  is 
toward  the  outer  cantlius.  AVhen  occurring  in  patches  the  disease 
somewhat  reseml)les  xanlhoiiia.     The  treatment  consists  of  enucleating 


5018       EYELIDS,  MOLLUSCUM  CONTAGIOSUM  OF  THE 

cvi'i-y  iiiiliiiiii  with  a  iiiiliuiii  lU'cdlf,  and  at  the  same  time  destroying 
tlif  lining'  inciiihraiH'  of  the  cyst  to  prevent  reeiirrenee. —  (J.  M.  B.) 

Eyelids,  Molluscum  contagiosum  of  the.  ]Moli.i:scum  epitiieliale. 
'riiis  tlisease  is  generally  eonsidered  to  be  contagious  and  autotrans- 
ferable.  It  is  not  of  common  occurrence,  but  seen  most  frequently  in 
children,  and  the  eyelids  are  frequently  attacked.  It  is  characterized 
by  the  presence  of  somewhat  translucent  warts,  the  largest  being  um- 
bilieated.  Treatment  consists  of  removal  of  the  sac  and  its  contents. 
Electrolysis  may  also  be  employed,  or  the  application  of  acid-nitrate- 
of-mercury  ointment.  A  case  of  generalized  pigmented  molluscum 
fibrosum  which  involved  the  lids,  was  reported  by  Gabrielides  (Ann. 
d'Ocul.,  147,  p.  105).  A  tumor  on  the  lid  had  reached  the  size  of  a 
walnut.  It  was  not  sharply  distinguished  from  the  surrounding  con- 
nective tissue.— (J.  M.  B.) 

Eyelids,  Morphoea  of  the.  ]\Iorpiicea  alba  plassa.  A  trophoneurosis 
al'lccting-  the  skin  of  tiie  lid.  It  is  characterized  by  the  formation  of 
a  well-defined,  smooth  patch,  often  slightly  elevated,  and  hard  to  the 
touch.  Later  atrophy  ensues  and  the  patch  becomes  slightly  sunken 
(Weeks). 

Eyelids,  Movements  of  the.  These  are  accomplished  in  the  following 
way:  In  opening  the  eye  tlie  upper  lid  is  raised  by  the  levator  pal- 
pe])ra'  sui)erioris,  the  musculas  tarsalis  sujierior  and  the  superior 
rectus.  The  tendon  of  tlie  latter  is  so  solidly  united  with  that  of  the 
levator  by  fascial  ])ands  that  it  may  be  said  to  have  a  common  insertion 
with  the  levator  in  tlie  tarsus  of  the  upper  lid.  Hence,  when  the  supe- 
rior rectus  contracts  and  raises  the  eye,  it  assists  in  lifting  the  upper 
lid  and  the  retrotarsal  fold  at  the  same  time.  If  the  superior  rectus 
retracts  from  any  cause,  e.  g.,  as  the  result  of  a  complete  tenotomy 
producing  a  traumatic  paralysis,  the  upper  lid  is  pulled  up  and  the 
eye  consecjuently  is  wider  open  than  its  fellow.  On  the  contrary,  in 
an  advancement,  in  which  the  tendon  of  the  superior  rectus,  and  with 
it  the  fascial  bands,  are  brought  forward,  the  upper  lid  is  carried  for- 
ward, too,  and  the  ej'e  is  1  or  2  mm.  less  open  than  its  fellow.  The 
same  thing  happens  in  a  complete  paralysis  of  the  superior  rectus, 
not  due  to  division  of  its  tendon ;  the  relaxed  muscle  allows  the  lid  to 
droop  somewhat,  especially  when  the  eyes  are  carried  up. 

The  lower  lid  is  carried  down  not  only  by  its  weight,  but  also  by 
the  action  of  the  musculus  tarsalis  inferior  (supplied  by  the  sympa- 
thetic) and  by  a  sli])  which  runs  from  the  tendon  of  the  inferior  rectus 
directly  to  the  tarsus.  Hence,  when  the  inferior  rectus  pulls  the  eye 
down  it  depresses  the  lower  lid  at  the  same  time,  and  hence,  also,  as  in 
the  case  of  the  superior  rectus,  a  complete  tenotomy  of  the  inferior 


EYELIDS,  NEUROFIBROMA  OF  THE  5010 

rectus  makes  tlie  paljx'hral  fissure  widfi-.  and  an  advancement  of  tliis 
muscle  makes  the  palpebral  fissure  narrower.  By  expansions  from 
their  tendons  the  external  and  internal  recti  also  act  upon  the  lids,  as 
has  been  shown  by  Dwight ;  so  that  when  the  eye  is  turned  outward 
the  outer  canthus  is  pulled  outward,  and  when  the  eye  is  turned  in- 
ward the  inner  canthus  is  pulled  back  and  in. 

With  regard  to  the  shutting  of  the  eyes,  we  must  distinguish  be- 
tween winking  and  tight  closure  of  the  lids.  Winking  consists  in  a 
quick  contraction  of  the  palpebral  fissure,  in  which  the  lids  do  not 
come  into  perfect  contact.  It  can  be  performed  voluntarily,  but  usu- 
ally results  through  reflex  action,  which  is  excited  by  the  sense  of  dry- 
ness in  the  eye,  or  by  the  presence  of  foreign  bodies — dust,  smoke,  etc. 
It  is  effected  by  means  of  the  trigeminus,  which  is  the  sensory  nerve 
of  the  eye  and  its  vicinity,  and  is  hence  rightly  called  the  sentinel  of 
the  eye. 

In  firm  closure  of  the  lids,  which  usually  is  done  voluntarily,  the 
edges  of  the  lids  are  brought  into  complete  contact.  This  may  be  done 
gently,  as  in  sleep,  or  forcibly  as  in  the  act  of  squeezing  the  lids  to- 
gether. When  the  lids  become  closed  in  sleep,  the  eyeball  also  per- 
forms a  movement,  rolling  upward  (Bell's  phenomenon).  This  be- 
havior on  the  part  of  the  eyeball  is  important,  inasmuch  as  the  pro- 
tection of  the  cornea  by  the  upper  lid  is  thus  provided  for,  even  when 
the  palpebral  fissure  is  not  completely  closed  in  sleep.  It  is  not  until 
lagophthalmus  reaches  quite  a  high  degree  that  a  portion  of  the  cornea 
remains  constantly  visible  in  the  palpebral  fissure ;  and  this  portion  is, 
in  fact,  always  the  lowest  part  of  the  cornea,  which  consequently  is 
most  exposed  to  the  danofer  of  undergoing  desiccation. —  (Fuchs.) 

Eyelids,  Neurofibroma  of  the.  Neuroma  of  the  lids.  Plexiform  neu- 
roma. Elephantiasis  neuromatosa.  The  lids  are  very  rarely  involved 
in  this  form  of  tumor,  which  is  really  a  fibroma  developing  from  the 
sheaths  of  peripheral  nerves,  there  being  no  new  development  of  nerve- 
fibres.  The  growth  is  either  congenital  or  generally  appears  in  early 
infancy.  The  lid  becomes  greatly  enlarged  and  of  elephantiasis-like 
appearance,  and  ptosis  results.  The  tumor  is  soft  in  general,  with 
localized,  cord-like  spots  which  can  be  traced  backward  into  the  orbit. 
Usually  the  growth  is  not  painful.  ^licroseopically  they  are  composed 
of  nerve-bundles  iml)edded  in  masses  of  connective  tissue.  The  treat- 
ment is  excision.  If  not  completely  removed,  the  growth  will  return. 
Se(\  also.  Neurofibroma. 

Eyelids,  Noma  of  the.    Sec  Eyelids,  Gangrene  of  the. 

Eyelids,  Papilloma  of  the.  Waht  of  the  lids.  Sec  Eyelids,  Verruca 
of  the. 


5020  EYELIDS,  PEMPHIGUS  OF  THE 

Eyelids,  Pemphigus  of  the.  rnnpliiyus  and  otlici-  hiilloiis  alTcctioiis  of 
the  eyelitls,  sucli  as  dermatitis  herpetiformis,  are  occasionally  seen. 
In  iK'iiiplii^us  tlie  lesions  are  large  and  scattered,  while  in  the  latter 
alfccfion  they  are  small  and  grouped.  Essential  shrinking  of  the  con- 
junctiva sometimes  accompanies  pemphigus.  Relapses  are  frequent, 
hence  tlie  prognosis  should  be  guarded.  The  treatment  of  these  condi- 
tions is  jiroperly  in  the  domain  of  tlie  dermatologist.  See  Vol.  IV,  p. 
.'}();")(),  of  this  En(!jdop<-(Ua. 

Eyelids,  Perifolliculitis  of  the.    S.c  Hordeolum. 

Eyelids,  Perithelioma  of  the.    Sec  Eyelids,  Malignant  tumors  of  the. 

Eyelids,  Phagedenic  ulcer  of  the.    See  Eyelids,  Gangrene  of  the. 

Eyelids,  Phlebitis  of  the.  The  lids  may  ])e  involved  witli  neighboring 
])ai-t.s  in  facial  ])lilcljitis.  The  affection  is  liable  to  result  fatally 
from  extension  to  the  cavernous  sinus. 

Eyelids,  Phlebolith  of  the.  Vein  stones  are  usually  found  in  the  optic 
veins  dui'ing  a  search  for  some  other  foreign  body.  Thurston  Holland 
claims  they  occur  so  freciuently  in  persons  over  40  that  in  his  600  radio- 
graphs it  is  the  exception  not  to  find  some  of  these  shadows.  Clarke 
states  that,  although  the  exact  metamorphosis  does  not  seem  to  be 
recorded,  i)lileboliths  are  defined  as  having  originally  been  white 
tliroiid)i  in  veins  which  have  undergone  calcification  analogous  to  that 
of  arterio-.sclerosis.  Apparently  the  calcification  starts  about  a  central 
nucleus,  forming  layer  after  layer,  like  the  growth  of  a  pearl.  Cramp- 
ton  {Trans.  Coll.  Phys.,  Pliila.,  I\Iar.  20,  1913)  mentions  the  useful- 
ness of  the  X-ray  in  locating  i)blel)oliths.  He  reports  the  case  of  a 
man.  aged  28  years,  who  had  a  small  network  of  varicose  veins,  about 
1  cm.  in  diameter,  l)eneath  the  skin  of  the  lower  eyelid.  On  palpation 
a  shot-like  body  was  found  in  a  vein  and  removed  through  a  small  in- 
cision. The  phlebolith,  which  was  white,  round,  and  quite  hard,  was 
tile  size  of  a  No.  6  shot  and  resembled  a  lusterless  pearl.  The  patient 
had  l)een  aware  of  its  presence  for  nine  years.  There  was  no  history 
of  trauma  or  syphilis. 

Eyelids,  Phosphoridrosis  of  the.  Phosphorescent  and  urinous  SAveat 
ai'e  seen  aboul  the  eyelids  and  always  in  connection  with  a  gener- 
alized form  of  the  diseases,  which  depend  upon  an  involvement  of 
1  he  ent  il'e  system. 

Eyelids,  Pigmentation  of  the.  A  brown  ])igmentation  of  the  lids  has 
been  observed  by  Jellinck  as  an  early  symptom  of  Graves'  disease. 

Poulard  and  Canque  {Bulletins  de  lu  Soc.  d'Ophf.  dc  Paris,  April, 
190,S)  also  repoi-t  the  case  of  a  soldier,  wlio  received  a  blow  in  the  eye, 
cau.sing  impaired  vision,  loss  of  the  upper  part  of  the  field  and  vision 
(Mpial    1    1(1.  although   the  o])htlialmoscoi)ic  appearances  were  normal. 


EYELIDS.  POLIOSIS  OF  THE 


5021 


A  few  weeks  later  the  lids  showed  discoloration,  whieh  involved  the 
eyeball  and  extended  to  tiic  area  shown  in  the  figure  herewith.  After 
two  years,  the  skin  was  slate-color,  the  eyeball  blackish,  and  the  iris 
more  deeply  colored  than  its  fellow. 


I 'i lamentation  of  Eye  and  Adjoining  Parts. 
Tlie  shaded  aioti  shows  the  part  affected.     (Poulard  and  Canquc.) 

Eyelids,  Poliosis  of  the.  The  absence  of  pigment  in  llie  eilia.  See  Vol. 
1 1,  p.  I'ISl*.  of  this  Encyclopedia:  as  well  as  Eyelids,  Bleaching  of  the. 

Eyelids,  Reconstruction  of  the.  Although  this  subject  is  discussed  on 
p.  1084  (ct  S(q.),  Xo\.  II,  of  this  Encyclopedia,  to  which  the  reader  is 
referred,  it  nuiy  be  added  here  that,  recently,  Carruccio  {La  Clinica 
Oculistica,  p.  1604,  1914)  has  reported  a  successful  case  operated  on 
by  the  method  of  Cirincione.  The  writer  says  that  as  regards  the  ex- 
tensive use  of  the  skin  of  the  ear,  together  with  cartilage  for  replace- 
ment of  the  tarsus,  the  traunuitism  produced  by  the  growth  of  hair 
in  contact  with  tiie  eoi-nea  is  a  serious  o])jection.  The  method  de- 
scribed by  Cirincione  in  the  Clinica  Oculistica  for  1901  satisfies  all  the 
requirements  of  such  a  case,  using  for  the  new  conjunctival  surface 
the  normal  conjunctiva,  and  for  the  skin  layer  a  pedunculated  cuta- 
neous flap.  Yet,  says  Carruccio,  the  fairly  recent  Encyclopedic  Fran- 
gaise  d'Ophtalmologie  does  not  mention  any  process  which  may  be 
used  to  reconstruct  a  lid  which  has  been  entirely  lost. 

Carruccio  describes  the  method  as  applied  to  the  case  of  a  woman 
of  71  years,  the  whole  of  whose  lower  lid  was  removed  on  account  of 
extensive  epithelioma.  The  residual  conjunctiva  of  the  lower  fornix 
was  loosened  so  as  to  form  a  lun-row  flap  about  0.5  em.  wide.    By  an 


5022  EYELID  RETRACTOR 

inlraiiijii'^niinl  im-isioii  tlic  upprr  lid  was  dividt'd  in  its  whole  length 
into  two  layers,  a  nnisi-ulo-cutaneous  and  a  tarso-conjiinctival.  After 
passint?  tlie  adherent  upj)er  margin  of  the  tarsus,  the  outer  layer  was 
drawn  up  l)y  an  assistant,  while  the  inner  layer  was  drawn  down  and 
the  separation  'of  the  con.junetiva  extended  as  far  as  the  upper  fornix. 
The  tarso-eonjunetival  layer  thus  dissected  was  easily  stretched  down- 
ward so  as  to  reach  the  narrow  flap  formed  from  the  conjunctiva  of 
the  lower  fornix,  to  which  it  was  sutured  w-ith  catgut. 

In  this  particular  instance  the  inability  of  the  patient  to  endure  a 
more  lengthy  operation  at  one  sitting  caused  postponement  of  the  re- 
maining steps  until  two  days  later.  On  this  second  occasion  the  ex- 
ternal surface  of  the  conjunctival  layer  w^as  freshened  by  curettement, 
and  a  pedunculated  flap  from  the  temple  was  utilized  to  form  the  outer 
layer  of  the  new  lower  lid,  interrupted  sutures  being  inserted  along 
the  skin  margin  at  the  inner  and  lower  sides  of  the  dehiscence  and 
along  the  free  border  of  the  musculo-cutaneous  layer  of  the  upper  lid, 
avoiding  the  eyelashes. 

At  the  end  of  24  days  the  lids  w^ere  found  distended  with  lachrv-mal 
fluid,  which  was  evacuated  through  a  small  incision  at  the  inner 
canthus.  At  the  end  of  a  month  from  the  original  operation  the  palpe- 
bral aperture  was  re-established  by  the  surgeon,  the  conjunctival  and 
skin  margins  of  the  new  lower  lid  being  approximated  with  a  few 
sutures  to  hasten  their  union.  It  was  necessary  at  the  same  time  to 
remove  an  exuberant  cutaneous  fold  corresponding  to  the  peduncle  of 
the  skin  flap.  In  time  the  new^  lid  assumed  a  normal  position,  apply- 
ing itself  accurately  to  the  eyeball.  Equally  good  results  were  ob- 
tained in  cases  operated  upon  with  the  same  technique  by  Cirincione 
and  Calderaro  {OphtJialmic  Litcraiure,  Feb.,  1915). 

Eyelid  retractor.    See  Lid  retractor. 

Eyelids,  Rhagades  of  the.    See  Eyelids,  Fissures  of  the. 

Eyelids,  Rodent  ulcer  of  the.  Jacob's  tlcer.  Cancroid  ulcer.  See 
Eyelids,  Malignant  tumors  of  the;  as  well  as  Vol.  II,  p.  1381,  of  this 

Etiiijiloj))  (lid. 

Eyelids,  Rubeola  of  the.    See  Measles. 

Eyelids,  Sarcoma  of  the.  Primary  sarcoma  of  the  eyelid  is  of  rare 
occurrence.  It  (leveloi)S  from  the  connective  tissue  of  the  lid.  appear- 
ing at  first  as  a  i-ounded,  usually  slightly  reddened,  elevation  of  the 
lid,  somewhat  resembling  a  chalazion,  although  the  position  i.s  not 
always  over  the  tarsus  and  the  skin  is  not  freely  movable  over  it.  The 
growth  is  usually  slow,  but  it  may  advance  rapidly  to  a  fatal  result, 
otlin-  |iai-ts  being  affected  by  metastasis.  The  cause  is  obscure.  In  a 
.small  percentage  of  cases  traumatism  has  been  followed  by  sarcoma. 


EYELIDS,  SARCOMA  OF  THE  5023 

Histologically  the  ^rowtli  is  composed  of  round  or  spindle  cells,  or 
both.  Pioinent  may  be  present  in  the  cells  or  stroma  (melano-sar- 
coma).  fSarcoma  is  to  be  differentiated  from  lymphoma,  syphilitic 
tubercle  and  gumma.  In  the  last  two  named,  spirochaeta  pallida  may 
])('  found. 

Treatment  of  sarcoma  demands  early  excision  in  order  to  afford 
any  chance  of  recovery.  Recurrences  are  extremely  common,  even 
after  early  operation.  Tf  tlie  growth  is  very  small,  the  use  of  radium 
may  be  successful  in  arresting  the  disease.  Roentgen  rays  are  of  no 
service.  In  cases  where  a  sufficiently  clear  diagnosis  has  not  been 
made  witli  the  microscope,  antisyphilitic  treatment  should  be  employed 
sufficiently  long  to  decide  the  true  character  of  the  growth. 

A  case  of  sarcoma  of  the  lids  was  reported  by  Ailing  {Ophth.  Record, 
June,  1907)  in  a  child  of  7  years,  who  during  six  weeks'  time  developed 
a  hard  tumor  the  size  of  a  pea  underneath  the  skin,  a  little  below  and 
outward  from  the  left  outer  canthus,  with  three  or  four  smaller  ones 
lying  on  the  tarsal  plate  of  the  lower  lid  and  one  over  the  outer  part 
of  the  tarsus  of  the  upper  lid.  There  was  no  glandular  involvement. 
During  two  weeks  the  growths  had  increased  in  size  decidedly.  They 
were  removed  through  a  skin  incision  which  exposed  all  of  them.  The 
wound  healed  kindly,  but  two  months  later  there  was  evidence  of  re- 
currence. They  were  now  known  to  be  malignant,  and  a  month  later 
a  more  radical  operation  was  done,  but  the  child  died  shortly  after 
from  scarlet  fever.  The  report  of  the  pathologist  was  that  the  growths 
were  fibro-rayxo-sarcoma. 

Two  cases  of  mclanosarcoma  of  the  lids  are  reported  by  IMontano 
(Anales  de  Oftalmologia,  May,  1913).  The  first  patient  was  a  man 
of  26  years.  A  small,  ulcerated,  black  growth  had  been  removed  by 
an  oculist  twelve  months  after  its  first  appearance  as  a  black  spot  at 
the  internal  angle  of  the  left  eye.  The  growth  recurred  four  months 
later,  was  again  extirpated,  and  again  reappeared  after  another  three 
months,  this  time  infiltrating  the  two  lids.  At  this  time  there  was  a 
large  swelling  of  the  lids  on  the  left  side.  Diagnosis  of  melanosarcoma 
originating  in  the  lachrymal  caruncle  was  made;  and  the  lids  were 
entirely  removed,  together  with  the  eyeball.  There  had  been  no  re- 
currence in  the  short  period  of  two  months  elapsing  since  the  operation. 
In  the  second  patient,  a  woman  of  40  years,  a  small,  blackish  tumor 
had  appeared  in  the  lower  lid  of  the  right  eye  four  years  previously, 
and  had  been  removed,  with  the  exception  of  a  small  crescentic  area 
which  had  remained  stationary  for  three  years.  Recent  growth  had 
been  so  rapid  that  closure  of  the  lids  was  impossible. 


5024  EYELIDS,  SCALDS  OF  THE 

III  tilt'  tnnhiK  III  of  sarcoma  ol"  the  lids,  tlie  X-ray  and  radium  has 
bei'ii  used,  but  because  of  the  tendency  to  return  rapidly,  excision 
of  tlie  tumor  should  be  pronijit  and  radical.  See,  also,  Eyelids, 
Malignant  tumors  of  the;  as  well  as  Tumors  of  the  eye. 

Eyelids,  Scalds  of  the.    See  Eyelids,  Injuries  of  the. 

Eyelids,  Seborrhea  of  the.  Tlie  dry  form  of  seborrhea  is  seen  occa- 
sionally on  the  upi)er  lid,  and  the  oily  form  on  both  lids.  Local  appli- 
cations of  sul])liur  ointment,  or  of  equal  parts  of  sulphur  and  a  5  per 
cent,  oleate  of  mercury  ointment,  give  good  resultij.  Appropriate 
internal  treatment  is  also  indicated. 

Eyelids,  Serpiginous  syphilide  of  the.  This  may  closely  resemble 
lupus  or  tuberculosis,  and  i)roduces  extensive  destruction  unless 
checked  by  appropriate  internal  treatment. 

Eyelids,  Siderosis  of  the.  Discoloration  of  the  lids,  caused  by  the 
j)enetratioii  of  the  skin  by  small  pieces  of  steel.  It  shows  itself  as 
small  brown  spots. 

Eyelids,  Solid  edema  of  the.  This  term  is  applied  to  a  swelling  of  the 
eyelids,  generally  the  lower  lid,  Avhich  is  often  so  great  as  to  conceal 
the  interpalpebral  fissure.  The  swelling  is  soft  and  elastic,  of  a  reddish- 
brown  color,  without  evidences  of  inflammation  or  involvement  of 
other  tissues,  and  pits  on  pressure.  The  disease  in  most  cases  has  fol- 
lowed an  attack  of  erysipelas.  Some  of  the  eases  have  terminated  in 
tuberculosis  of  the  conjunctiva.  It  is  supposed  to  be  a  recurrent  lym- 
phangitis, but  the  nature  of  the  disease  is  obscure.  No  permanent 
benefit  has  followed  any  of  the  methods  of  treatment. 

It  is  also  used  as  a  synonym  of  elephantiasis.  See  Vol.  VI,  p.  4279, 
of  this  E)ir;jr1nprdia. 

Eyelids,  Sporotrichosis  of  the.    See  the  major  heading:  Sporotrichosis. 

Eyelids,  Steatoma  of  the.  This  appears  as  a  smooth  round  tumor 
vai-ying  in  size  from  a  pin-head  to  that  of  a  hazelnut.  It  is  supposed 
to  belong  to  the  class  of  dermoids.  It  is  situated  usually  near  the 
outer  canthus  on  either  the  upper  or  lower  lid.  The  gi'owth  is  caused 
by  some  injury  to  the  opening  of  the  sebaceous  gland.  It  grows 
slowly.  The  cyst  contains  broken-down  epithelial  cells,  forming  a  pul- 
taceous  mass.  There  are  well-defined  walls  to  the  tumor.  They  occur 
at  any  period  of  life.  The  treatment  consists  in  emptying  the  tumor 
of  its  contents  and  destroying  the  lining  sac. 

Eyelids,  Sudamina  of  the.  These  small  vesicles  which  are  seen  most 
fre(|iicntly  on  the  hands,  are  also  rarely  observed  on  the  eyelids.  The 
condition  is  caused  by  a  too  rapid  formation  of  sweat,  and  occurs  mo.st 
fre(|Ueiitly  in  summer.  It  disappears  rapidly  under  the  influence  of 
a  1  per  cent,  solution  of  chromic  acid,  applied  twice  daily. 


EYELIDS,  SYPHILIS  OF  THE  5025 

Eyelids,  Syphilis  of  the.  Piiiuary,  secoiulary,  or  tertiary  lesions  of 
.s\  pliilis  may  be  present  in  the  eyelids,  or  the  disease  may  occur  there 
as  an  hereditary  manifestation.  Chancre  may  appear  at  any  period 
of  life,  and  until  the  development  of  secondary  symptoms  the  diag- 
nosis may  he  in  doul)t.  It  shows  as  an  ulcer  with  an  indurated  base ; 
the  pre-auricular  gland  is  always,  and  the  sul)maxillary  is  frequently, 
indurated.  The  eondition  might  be  confounded  with  the  pustules  of 
vaccinia,  or  witli  tuberculous  ulcer. 

In  a  case  reported  ])y  Shoemaker  {An)L  of  Ophth.,  XX,  p.  544)  of  a 
woman  aged  30,  the  first  symptoms  were  swelling  of  glands  in  front 
of  the  riglit  ear  and  beneath  the  lower  jaw  on  the  same  side,  followed 
by  slight  irritation  at  the  inner  corner  of  the  right  eye.  The  appear- 
ances were  almost  exactly  those  of  a  hordeolum,  hut  in  a  few  days  a 
ring  or  M^all  of  marked  induration,  with  more  or  less  glazed  or  indolent- 
looking  central  areas,  made  the  clinical  diagnosis  of  chancre  easy.  The 
lesion  sul)sequently  spread  somewhat  and  came  to  involve  both  lids. 
Examination  showed  spirocha^tes.  Rollet  and  Genet  (Ann.  of  Ophth., 
XXI,  p.  571)  observed  two  chancres  of  the  face  in  the  same  subject, 
one  upon  the  lower  eyelid  and  the  other  upon  the  chin.  The  conjunc- 
tiva and  mucous  membrane  of  the  mouth  were  unaffected.  Crigler 
{Arch,  of  Oplitli.,  XI,  p.  281)  obtained  cicatrization  of  rupial  syphilis 
of  the  eyelid  which  had  developed  during  mercurial  treatment,  from 
three  or  four  injections  of  eacodjdate  of  soda ;  in  about  one  month  the 
Wassermann  reaction  was  negative.  Fisher  {Ophth.  Sac,  Unit.  King., 
XXXI,  p.  268)  reports  a  case  of  gummatous  tarsitis  with  loss  of  sub- 
stance from  ulceration  of  the  lid  margin. 

Chancre  is  found  more  frequently  on  the  lower  than  on  the  upper 
lid,  and  in  men  more  frequently  than  in  women.  The  infection  may 
be  carried  by  unclean  fingers,  towels,  in.struments,  by  kissing,  or  in 
attempting  to  remove  foreign  bodies  by  licking.  In  a  small  towTi  in 
Russia  34  cases  of  chancre  of  the  eyelids  were  known  to  have  been 
caused  by  a  female  quack  who  treated  granular  conjunctivitis  by 
everting  the  lids  and  licking  them. 

IMarbiax's  patient  {Soc.  Beige  d'Ophi.,  V.  34,  p.  86)  apparently  re- 
ceived his  primary  luetic  infection  through  dressing  a  burn  at  his  in- 
ternal commissure  with  pig  omentum  furnished  him  by  a  syphilitic 
butcher.  The  use  of  salvarsan  was  followed  by  a  neurorecidive  affect- 
ing the  auditory  nerve.  In  Bielsky's  case  {Arch.  d'Ophth.,  V.  33,  p. 
126)  the  infection  was  introduced  by  the  bite  of  an  adversary  on  the 
upper  lid. 

Sec,  also.  Vol.  Ill,  p.  2003.  of  this  Encijclopcdia;  as  well  as  Eyelids, 
Gumma  of  the. 

Vol.  VII— 12 


5026  EYELIDS,  SYPHILITIC  ULCER  OF  THE 

J'liysiciaiis,  wliilc  trcatiiij,'  the  tliroats  of  syphilitics,  have  become 
inocuhitc'd  by  tlie  patient's  saliva  projected  by  coughing.  The  prog- 
nosis is  favorable  under  the  appropriate  treatment  by  the  local  appli- 
cation of  tlie  yellow  wash,  and  the  administration  of  mercury  internally 
()!•  by   inunction. 

Eyelids,  S3T)hilitic  ulcer  of  the.  This,  as  a  secondary  lesion,  is  most 
fre(iuently  located  in  the  skin  near  the  lid  mai-gin  or  below  the 
inner  canthus.  It  may  result  from  the  breaking  down  of  a  tubercle 
of  the  skin,  or  of  a  gumma  originating  in  the  skin,  or  more  frequently 
in  the  subcutaneous  tissue  and  cartilage.  It  is  a  late  manifestation, 
and,  though  usually  classified  as  secondary,  might  perhaps  more  cor- 
rectly be  placed  among  the  tertiary  lesions.  This  ulcer  is  sometimes 
first  seen  long  after  other  syphilitic  symptoms  have  subsided,  thus 
making  the  diagnosis  more  difficult.  It  may  be  mistaken  for  lupus 
or  epithelioma,  from  which  it  is  sometimes  difficult  to  distinguish  it. 
When  situated  over  the  lachrymal  sac  it  may  be  taken  for  dacry- 
ocystitis (Mackenzie).  It  is  important  to  make  a  prompt  diagnosis, 
as  while  the  syphilitic  ulcer  usually  yields  promptly  to  constitu- 
tional treatment,  caustics  are  useless,  and  the  knife  is  dangerous 
(Tlarlan).    Sec  S5T)hilis. 

Eyelids,  Tarsal  tumor  of  the.    See  Chalazion. 

Eyelids,  Tattooing  of  the.    Sec  Eyelids,  Gunpowder  grains  in  the. 

Eyelids,  Telangiectasis  of  the.    See  Eyelids,  Angioma  of  the. 

Eyelids,  Tuberculosis  of  the.  True  tuberculosis  of  the  lid  skin  is  a 
rare  disease.  It  shows  itself  in  the  form  of  discrete,  shallow,  painless 
ulcers  with  eroded,  irregular  edges.  The  ulcers  never  heal ;  when 
the  crusts  are  removed,  a  reddish-yellow  granular  surface  is  exposed. 
The  ulcers  spread  continuou-sl}^,  and  coalesce  with  other  ulcers  to  form 
large  areas.  The  disease  is  found  most  frequently  in  regions  where 
skin  and  mucous  membrane  join.  Since  tubercle  bacilli  are  found  in 
Itipiis  vulgaris,  scrofuloderma,  tuberculous  ulceration,  and  tuberculosis 
verrucosa  cutis,  the  term  tuberculosis  of  the  skin  is  loosely  applied  to 
affections  which,  however  similar  they  may  be  microscopically  and 
pathologically,  present  marked  clinical  differences  (Crocker).  The 
prognosis  of  tuberculosis  of  the  skin  is  unfavorable. —  (J.  M.  B.) 

Boer  (Graefe's  Arch.  f.  Oplith.,  V.  85,  p.  273,  1913;  review  in  the 
Ophthalmic  Year  Book)  relates  a  number  of  case  histories  to  illustrate 
the  frequency  with  which  a  diagnosis  of  ocular  tuberculosis  may  de- 
pend ni)on  the  clinical  appearance,  together  with  the  general  condi- 
tion of  the  patient,  although  the  tubercle  bacillus  may  not  be  den>on- 
strated  in  the  local  lesion,  and  animal  inoculation  may  prove  negative. 
One  case  was  that  of  a  21-months-old  child,  who  during  a  severe  con- 


EYELIDS,  TUMORS  OF  THE  5027 

juiiclivitis  developed  a  thickening  of  the  upper  lid,  which  increased 
after  recovery  from  tlie  conjunctivitis.  The  condition  was  unilateral, 
ran  a  chronic  course  and  was  accompanied  by  marked  thickening  of 
the  tarsus.  The  von  Pirquet  test  was  positive,  and  microscopic  exami- 
nation of  e.Kcised  tarsal  tissue  showed  typical  tubercles. 

Under  the  title  of  primary  tuberculous  lupus,  ]\Iorax  and  Landrieu 
{Ann.  cVOcnl.,  V.  150,  p.  266,  1913)  describe  a  non-ulcerative  affection 
wliicli  had  existed  for  one  year  in  both  lids  of  a  man  of  20  years.  The 
lesions  consisted  in  a  thickening  of  the  skin  of  the  lid  margin  and  of 
the  neighboring  parts.  There  was  some  crusting  of  the  most  promi- 
nent parts  of  the  swelling,  but  no  actual  ulceration.  Some  of  the 
Meibomian  glands  looked  like  ehalazia  of  moderate  size.  Histologically 
the  infiltration  involved  the  skin  and  the  Meibomian  glands.  The 
tuberculous  character  of  the  lesions  was  clearly  proved  by  animal  inoc- 
ulation.   Free  excision  of  the  affected  parts  resulted  in  cure. 

Of  the  two  cases  reported  by  Friedenwald  {Am.  Jour.  Oplith., 
v.  ;30,  p.  65,  191;}),  one  was  that  of  a  man  of  60  years  who  had  an 
inflammation  involving  the  inner  half  of  the  right  lower  lid,  which 
looked  a  good  deal  like  an  inflamed  chalazion.  An  excised  fragment 
showed  numerous  tubercles.  Slow^  recovery  folloAved  Roentgen  ray 
applications.  The  patient's  health  wa«  otherwise  normal.  The  sec- 
ond patient  was  a  girl  of  13  years,  who  had  an  inflamed  and  swollen 
area  around  the  inner  eanthus  of  the  left  eye.  An  excised  jiortion 
of  the  skin  surface  showed  tul)ercles.  See,  also.  Conjunctiva,  Tuber- 
culosis of  the;  as  well  as  Tuberculosis  of  the  eye;  also  Phlyctenular 
conjunctivitis. 
Eyelids,  Tumors  of  the.  Tumors  of  the  lids  seated  in  the  cellular 
tissues,  such  as  dermoid  and  sebaceous  cysts,  etc.,  may  be  easily 
removed  by  ordinary  surgical  methods,  the  incision  being  made, 
when  possible,  parallel  to  the  fibers  of  the  orbicularis. 

Small  tumors,  as  papillomata,  adenomata,  etc.,  seated  on  the 
border  of  the  lid,  may  frequently  be  excised  without  destroying  the 
lid  border,  if  the  posterior  margin  is  not  involved.  The  lid  margin  is 
split  behind  the  growth,  and  a  V-shaped  piece  of  the  skin,  including 
the  small  growth,  is  then  excised,  the  lips  of  the  wound  being  united 
by  fine  sutures. 

If  the  grow'th  is  larger  and  involves  the  tarsus,  it  ma}^  be  neces- 
sary to  remove  a  wedge-shaped  piece  from  the  whole  lid,  after  which 
the  defect  must  be  immediately  closed  with  sutures  after  the  man- 
ner described  under  Blepharoplasty. 

Large  tumors,  that  involve  a  considerable  part  of  the  skin  of  the 
lids,  must  be  removed  according  to  surgical  rules  for  such  conditions, 


5028  EYELIDS,  TYLOSIS  OF  THE 

ami  tilt'  (Ifl'ti't  closrd  by  an  apj)r()piMat('  plastic  operation. — (W.  11. 
W.J    Sec,  also.  Tumors  of  the  eye. 

Alt  {Am.  Jour,  (fjililh.,  V .  2!>.  p.  863,  1913)  describes  an  unusually 
large  cyst  in  tlif  lower  eyelid  of  a  hoy  of  9  years.  The  cyst,  develop- 
ment of  which  had  been  noticed  for  a  year,  involved  a  little  more  than 
the  inner  half  of  the  lid,  reaehinj]:  about  4  mm.  above  the  lid  margin, 
and  |)artl\'  (•()\-ering  Ihe  pupil.  The  ^Meibomian  glands  were  repre- 
sented by  delicate  lines  on  the  cyst  wall.  The  growth  was  dealt  with 
by  incision  and  i)acking. 

The  myoma  of  the  orbicularis  recorded  by  Schnaudigel  (Graefe's 
Arch.  f.  OpJith.,  74,  p.  372,  1913)  in  1910,  recurred  18  months  after 
removal.  The  secondary  growth  reached  a  size  of  20  x  17  x  7  mm.  Its 
general  characteristics  corresponded  precisely  with  those  of  the  orig- 
inal growth,  of  which  it  is  assumed  that  a  small  portion  must  have 
been  overlooked  at  the  first  operation. 

Angioma,  angiofibroma  and  lymphangioma  wvAy  also  be  removed 
by  excision,  provided  this  can  be  done  without  too  much  loss  of  the 
skin  surface.  If  the  tumor  is  beneath  the  skin  and  does  not  involve 
it,  an  incision  may  be  made  down  to  the  tumor,  which  can  then  be  dis- 
sected out.  The  lid  clamp  will  ])e  useful  in  such  cases  {Archiv.  f. 
Augen.  u.  OJircnh.,  VI,  p.  38). 

If  the  tumor  is  too  extensive  for  excision,  one  may  have  recourse  to 
electro-puncture  or  electrolysis.  The  positive  pole  of  a  galvanic  bat- 
tery, with  a  sponge  or  plate  electrode,  is  placed  on  the  face.  The  nega- 
tive pole  is  attached  to  a  needle  mounted  in  a  suitable  handle.  "When 
the  needle  is  plunged  into  the  tumor,  the  current  is  turned  on,  and 
electrolysis  is  indicated  by  the  appearance  of  bubbles  of  hydrogen  gas 
at  the  point  of  puncture.  The  needle  is  then  withdrawn  and  inserted 
at  a  different  place,  and  a  number  of  punctures  are  made  at  the  same 
sitting.  Several  such  treatments  will  be  necessary,  and  care  must  be 
taken  that  the  punctures  are  not  too  numerous,  nor  too  near  together, 
to  avoid  exten.sive  necrosis.  The  electrolytic  action  causes  coagulation 
of  tlie  l)lood  in  the  vessels  of  the  groAvth,  and  their  eventual  obliteration. 
Eyelids,  Tylosis  of  the.  A  frequent  sequel  of  blepharitis  marginalis,  in 
which  the  lid-margin  becomes  hypertrophied  and  rounded,  and 
liordered  with  tlesliy-looking  conjunctiva.  See  Blepharitis. 
Eyelids,  Ulcer  of  the.  Ulcers  on  the  skin  of  the  eyelids  may  l)e  jiro- 
duced  as  the  result  of  injuries,  burns,  caustics,  scrofula,  lupus,  and 
syphilitic  ulcers.  In  children  scrofulous  ulcers  are  often  found  in 
conjunct  ion  with  caries  of  the  adjacent  bone.  Lupus  is  likewise  of 
frequent  occui'i-tMice  in  the  lids,  usually  migrating  to  them  from  the 
nose  or  cheek.     The  syphilitic  ulcers  of  tlie  lids  are  either  examples 


EYELIDS,  URIDROSIS  OF  THE  5029 

ol'  iiiiti.il  sclerosis  or  degenerating  gummata.  Soft  chancre  also  occurs 
on  llic  lids.  \'aceine  ulcers  occasionally  develop  on  the  lids,  generally 
ill  children,  tlirough  carelessness,  as  a  result  of  the  transference  of 
some  of  the  secretion  from  vaccine  pustules  from  some  other  part  of 
the  body.  They  form  large,  very  coated  ulcers,  situated  on  the  edges 
of  the  lids,  and  even  of  the  conjunctiva.  The  preauricular  lymphatic 
gland  is  swollen,  and  sometimes  fever  is  present  (Fuchs). 

Eyelids,  Uridrosis  of  the.  Urinous  sweat  is  occasionally  seen  about 
the  eyeli(.ls,  ahvjiys  in  connection  Avitli  some  systemic  form  of  the 
disease. 

Eyelids,  Urticaria  of  the.    See  Eyelids,  Hives  of  the. 

Eyelids,  Vaccinal  eruption  on  the.    See  Eyelids,  Ulcer  of  the. 

Eyelids,  Varicella  of  the.  Chicken-pox  of  the  lids.  This  affection 
occurs  infrequently,  and  when  found  is  of  little  importance,  often  but 
a  single  lesion  being  present.  There  are  practically  no  subjective 
symptoms  until  a  crust  forms,  when  there  will  usually  be  a  slight 
itching.  If  the  crust  is  removed  a  rather  marked  and  deep  pit  will 
lie  left.      It  re(j Hires  no  special  treatment. 

Eyelids,  Varicose  veins  of  the.  Dilated  and  tortuous  veins  are  occa- 
sionally seen,  especially  in  the  upper  lid. 

Eyelids,  Variola  of  the.  Small-pox  of  the  lids.  The  eruption  of  small- 
pox manifests  itself  on  the  eyelids  in  the  papular,  vesicular,  and 
pustular  stages.  The  integument  becomes  swollen  and  edematous,  and 
of  a  bright-red  color.  ]\lore  or  less  conjunctivitis  is  present  with  some 
muco-purulent  tlischarge.  There  is  Inirning  and  itching  of  the  lids 
which  can  be  relieved  by  the  use  of  red  rays,  which  will  also  tend  to 
prevent  pitting.  Antiseptic  instillations  should  be  used  to  prevent 
as  far  as  possible  the  further  development  of  pus.  Although  not 
usually  severe  on  the  lids,  the  eruption  at  times  becomes  confluent.  See 
Small-pox;  as  well  as  Vol.  Ill,  p.  2056,  of  this  Encyclopedia. 

Eyelids,  Verruca  of  the.  Wart.  P.vlpebral  papilloma.  The  most  com- 
mon form  of  wart  occurring  on  the  lid.s  is  the  so-called  filiform  variety, 
ami  is  found  chiefly  in  old  persons.  These  growths  should  be  removed 
by  acids,  caustics,  electrolysis,  or  by  surgical  means. 

Eyelids,  Vitiligo  of  the.  This  term  is  usually  employed  to  denote  an 
ac<iuire(l  achromatism  of  the  skin,  as  distinguished  from  aJhinisni,  which 
is  a  congenital  condition.  Hecau.se  of  a  deficiency  of  the  pigment,  the 
skin  pi'esents  patches  of  a  milky-white  color.  There  appears  to  be  no 
efficient  treatment   for  tliis  condition. 

Eyelids,  Warts  on  the.    Stn^  Eyelids,  Verruca  of  the. 

Eyelids,  Wounds  of  the.    See  Eyelids,  Injuries  of  the. 

Eyelids,  Xanthelasma  of  the.    See  Eyelids,  Xanthoma  of  the. 


5030  EYELIDS,  XANTHOMA  OF  THE 

Eyelids,  Xanthoma  of  the.  The  plane  variety  of  xanthoma  is  of  not 
inf re(iueut  occurrence  in  the  skin  of  the  eyelids.  It  appears  as  oval 
or  crescentic  patches  of  a  straw  or  sulphur-yellow  color,  varying  in 
size  from  a  pin-head  to  the  thumb  nail.  The  lesions  present  the 
appearance  of  a  piece  of  chamois  set  into  the  skin.  The  macules 
occasionally  become  confluent.  Their  most  common  situation  is  on 
the  upper  lid  near  tlie  inner  canthus.  The  tubercular  form  of 
xanthoma  rarely  occurs  on  the  eyelids.  There  is  an  abundance  of 
cholesterin  crystals,  and  a  number  of  new  cells  known  as  xanthoma 
bodies.  The  condition  is  accompanied  by  a  fatty  degeneration,  which 
in  this  situation  affects  the  fibres  of  the  orbicularis  palpebrarum 
muscle.  Treatment  by  the  X-rays  and  electrolysis  are  recommended, 
and  have  been  followed  by  good  results  in  a  few  instances. 

Schindler  {Zeit.  f.  Augenh.,  25,  p.  62)  effected  a  cure  by  three  ex- 
posures to  radium. —  (J.  M.  B.) 

The  Editor  has  had  many  satisfactory  cures,  with  little  scarring, 
after  a  single  application  of  a  one  per  cent,  mixture  or  solution  of 
mercuric  chloride,  the  eschar  falling  off  in  from  ten  to  fifteen  days, 
leaving  a  smooth  surface. 

The  pathological  aspects  of  this  condition  are  well  presented  in  a  case 
reported  by  van  Lint  and  Steinhaus  {Ann.  d'Oculist.,  Vol.  148,  July, 
1912).  The  i)atient  was  a  woman,  50  j'ears  of  age,  who  had  a  tumor  in 
each  temporal  region.  All  her  lids  were  completely  covered  with 
typical,  slightly  raised,  xanthelasma.  They  had  become  so  two  years 
before — after  three  years  slow  steady  growth  from  a  spot  near  left 
inner  canthus — at  which  time  a  lump  appeared  just  behind  the  right 
outer  orbital  margin,  to  be  quickly  succeeded  b}'  one  on  the  left  side. 
The  right  tumor  was  now  the  size  of  a  pigeon's  egg,  mobile  under  the 
skin,  firm  and  cartilaginous  in  consistence,  painless,  without  fluctua- 
tion, covered  by  normal  skin  without  vascular  or  pigmentary  change. 
The  left  tumor  was  similar  but  onl}-  the  size  of  a  nut.  No  xanthelasnm 
anywhere  else.  She  was  fully  examined  medically  but  nothing  abnor- 
mal was  made  out  about  the  liver,  no  icterus;  no  diabetes.  Previous 
history  good,  and  family  history  showed  that  neither  her  father  nor 
mother,  who  died  respectively  at  76  and  79,  nor  her  two  brothers  nor 
sister  had  any  xanthoma.  The  tumor  was  found  to  be  localized  but  not 
eucapsuled,  hard  like  a  fibroma  and  not  at  all  like  a  lipoma,  and  of 
the  typical  chamois-leather  color.  It  was  free  from  the  skin  but  on 
its  iiuicr  aspect  yellow  tracks  were  seen  continuous  with  the  deeper 
layers  of  the  lid  skin,  while  on  the  external  side  it  seemed  continuous 
with  a  layer  of  tissue  over  the  temporal  aponeurosis,  but  the  limits 
of  extension  in  this  direction  were  not  determined. 


EYELIDS,  XANTHOMA  OF  THE  5031 

Steinhaus  says  tliat  till  1*J08  the  contents  were  considered  to  be  fat 
that  had  intiltrated  the  -cells  of  a  new  formation  variously  described 
as  fibroma,  sarcoma  and  endothelioma.  The  yellow  pigment  i^'rains 
found  in  the  cells  relatively  free  of  this  infiltrated  fat  are  lipochrome. 
A  coiniection  between  diabetes  and  liver  diseases  with  icterus  on  the 
one  hand  and  xanthoma  on  the  other  can  be  established  in  50  per  cent, 
of  cases,  in  the  rest  family  disposition  seems  the  only  explanation.  But 
in  1908  Pincus  and  Pick,  of  Berlin,  found  that  the  substance,  till  then 
considered  as  common  fat,  was  really  anisotropic,  i.  e.,  doubly  refracting 
by  the  polariseope,  and  that  the  staining  of  it  with  Sudan  iii  an  un- 
stable gray  coloration  with  osmic  acid  showed  it  to  be  nearly  related  to 
fat,  probal)ly  a  lipoid.  (Just  as  fat  is  a  glycerin  -f-  a  fatty  acid,  so 
is  lipoid  cholesterin  -|-  a  fatty  acid.)  Twenty-five  years  before  Touton 
had  found  crystals  of  cholesterin  in  xanthoma,  although  none  are  to  be 
found  in  normal  skin.  Pick  suggested  that  this  cholesterin  might  be 
the  product  of  decomposition  of  an  ester  of  cholesterin  and  of  a  fatty 
acid,  and  this  supposition  has  been  substantiated  fully  by  chemical 
analyses  by  Pringsheim,  of  Berlin.  In  the  blood  of  diabetic  and  icteric 
patients  the  presence  of  an  ester  of  cholesterin  and  of  fatty  acids  has 
been  proved,  and  Pick  jumped  to  the  conclusion  that  in  such  patients 
with  xanthoniata  there  was  a  deposit  from  the  blood  of  these  lipoids, 
while  in  the  idiopathic  cases  he  postulated  true  neoplasms  with  xantho- 
matous characters.  Steinhaus  is  not  satisfied  that  there  is  ground  for 
supposing  the  existence  of  both  xanthomatous  infiltrations  and  neo- 
plasms. 

Steinhaus  found  the  mass  to  consist  in  great  part  of  a  new-formed 
fibrous  tissue  cells  with  fibres  regularly  disposed  in  bundles,  the  proto- 
plasm in  places  being  voluminous,  with  an  oval  nucleus  and  drops  of 
lipoid.  The  lipoid  cells  form  quite  a  thick  waU  round  the  vessels. 
Over  large  areas  there  may  be  few  fibres  but  many  cells.  These  cells 
are  mostly  mononuclear  but  bi-  and  polj'-nuclear  ones  are  seen,  mostly 
around  the  vessels. 

When  the  lipoid  substance  has  been  extracted  from  the  tissue  there 
remains  quite  a  lot  of  tissue  which  Steinhaus  thinks  must  be  considered 
as  new-formed  and  not  merely  the  normal  tissues  that  have  been 
infiltrated.  This  tissue  may  be  neoplastic,  hyperplastic  or  inflamma- 
tory, but  Steinhaus  sums  up  in  favor  of  neoplastic  proliferation.  He 
points  out  that  the  cells  stain  deeply  and  have  plenty  of  protoplasm, 
with  a  fine  chromatic  network,  a  central  nucleolus  and  a  relatively  large 
number  of  mitotic  figures.  As  the  cells  become  gorged  with  lipoid  these 
details  disappear  and  even  the  pigment  goes.  The  eorium  may  have 
its  thickness  doubled  or  even  more  than  trebled.     Small  lymphocytes 


5032  EYELIDS,  YAWS  OF  THE 

ami  plasiiia  crlls  iiia\-  l)r  loiiiKi.  The  hypothesis  of  a  siiiij»!i'  lipoid 
inliltratioii  of  the  tioniial  cfllular  clcinciits  of  the  coriuiii  is  in  ahsohite 
eoiillict  witli  thr  I'acts.  Tlic  cells  found  in  inflannnations  and  infeetious 
granuloniata  aic  tlic  nciitrophile  h'ueoeytes,  the  lyinpliocytes  and  their 
tlerivativcs  the  ])lasiiia  ('cll-s,  l)ut  the  lii)oid  cells  do  not  resemble  these 
at  all. 

An  aiialotry  has  been  drawn,  especially  by  Hoi-st,  between  xanthomata 
and  nevi. 

Usually  the  xanthoma  does  not  have  a  limitless  proliferation  and 
may  arrest  itself  after  a  time  and  remain  stationary  or  even  recede 
as  when  the  lipoid  cells  necrose.  Steinhaus  thinks  the  formation  of 
lipoid  within  the  cells  is  the  most  plausible  view,  like  the  production, 
of  glycogen  in  some  endotheliomata.  Although  in  many  cases  of 
xanthoma  there  seems  to  be  a  connection  with  diabetes  or  icterus,  there 
are  very  many  such  patients  who  never  get  xanthoma  and  it  may  l)e 
that  some  germ  is  at  work.  (W.  C.  Sonter,  review  of  the  Ophthalmic 
Review,  p.  84,  ]\Iarch,  1913.) 

Eyelids,  Yaws  of  the.    See  Eyelids,  Frambesia  of  the. 

Eyelid,  Third.     Plica  semiluixaris.     See  Comparative  ophthalmology, 
Vol.  IV,  p.  2()82,  of  this  Eneyclopcelia. 

Eye  Lotion.     Kvr  wash.    Eye  water.     See  Collyrium. 

Eye,  Methods  of  examining  the.    See  Examination  of  the  eye. 

Eye-needle  of  Mooij.     This  instrument  is,  as  the  illustration  shows,  a 
mounted  needle  for  the  same  use  in  ophthalmic  surgery  as  the  cor- 


Mooij  's  Ej-e  Needle. 

responding  device  in  general  surgery.  It  may.  however,  also  be  em- 
j)lo\-e(l  for  introducing  sutui'es,  setons,  etc.,  into  and  arouiul  the  ocular 
muscles  and  into  the  eyel)all  itself. 
Eye,  Normal.  The  (piestion,  what  constitutes  a  normal  eye?,  has  been 
variously  answered  by  ditVei-eiit  authorities.  The  Editor  agrees,  how- 
ever, witli  the  dicta  of  Chai'les  Oliver  {Systim  of  Disea.ses  of  the  Eye, 


EYE  OF  PASCAL.  THE  5033 

\'()l.  I\\  p.  402)  that  liy  tliis  tcnn  is  not  nicaiit  the  fiii(liii<;.s  of  tlie 
iiiatliciiiatical  foi'iiiula-  of  the  ai'itliiiicliciaii.  which  irivc  ratios  oi'  suj)- 
posi'd  dioptric  pcrfcctiK'SS  that  arc  used  to  spci-ify  tlic  ciiiiiK'tropic 
organ.  Tlie  " normal  eye"  is  not  designated  hy  the  dividing  line 
between  the  convex  and  the  concave  correcting  lenses  that  has  been 
assigned  as  the  exi)ression  of  an  emmetropic  ideal  by  the  working 
clinician.  Neither  is  the  "normal  eye''  the  result  of  the  solution  of 
the  geometric  and  triginometric  problems  that  otter  some  optical 
theoi'ists  the  assumi)tion  of  the  condition  of  al)solute  sphericity. 

Just  as  with  any  other  eye.  the  existence  of  such  a  normal  eye  is 
dependent  on  the  freedom  of  the  structures  from  disease,  in  association 
with  an  undisturl)ing  physiologic  action  giving  as  near  a  normal  visual 
result  for  both  near  and  far  as  possible.  Provided  that  these  condi- 
tions be  present,  it  is  of  no  con.sequence  what  the  shape  or  what  the 
size  of  the  organ  may  l)c.  If  it  be  healthy  and  if  it  be  acting  properly, 
it  is  normal. 
Eye  of  Pascal,  The.  The  cognizance  of  Blaise  Pascal.  It  consisted  of 
an  eye  surroundctl  l)y  a  crown  of  tliorn.s  and  these  words:  " Scio  cui 
crcdidi. ' ' 

The  story  of  tliis  cognizance  is.  in  brief,  as  follows :  A  little  niece 
of  Pascal,  who  had  an  incurable  "ulcer  in  the  lachrymal  gland,"  etc., 
and  who  was  one  of  the  pupils  in  the  Port  Royal  School  at  Paris, 
was  being  nursed  and  otherwise  cared  for  by  the  nuns  connected  with 
that  institution.  Now.  in  this  school  there  happened  to  be  a  certain 
reliquary,  which  contained  one  of  the  thorns  from  the  Saviour's  crown. 
The  affected  eye,  having  been  touched  with  this  reliquary,  became  at 
once  and  completely  cured.  Thereupon  Pascal  adopted  as  his  cogniz- 
ance the  above-described  device. —  (  T.  H.  S.) 
Eye,  Parietal.  Median  eye.  This  organ,  seen  in  some  reptiles,  am- 
phibians and  fishes,  is  a  more  or  less  well  developed  vestige  derived 
ancestrally  from  the  extension  forward  and  u])wai'd  into  a  median- 
dorsal  position  of  the  head.  See  Comparative  ophthalmology;  as 
well  as  Evolution  of  the  eye. 
Eye  phantom.    A  masl<  used  for  teaching,  or  learning  to  do.  operations 

on  the  eye.  See  Phantom  face. 
Eye-piece.  A  combination  of  two  lenses  used  to  supplant  the  single 
eye-lens  to  which  the  eye  is  applied  in  viewing  the  image  produced 
within  the  tube  by  the  objective  of  a  telescope  or  microscope.  It 
consists  of  the  eye-lens  and  the  field-lens  that  is  interposed  between 
the  former  and  the  objective  for  the  purpose  of  enlarging  the  field 
of  view.  The  relative  power  of  the  lenses  and  their  distance  apart 
depend  upon  the  requirements  sought  to  be  attained.     Huijghcns'  eye- 


5034  EYE-PIECE  INDICATOR 

piece  is  designed  to  (liiuiuish  the  effects  of  spherical  aberration  as 
much  as  possibk' ;  w  lici'cfoie,  the  focal  lengths  and  the  positions  of 
tlie  fiehl  and  eye  lenses  are  so  chosen  that  each  lens  shall  produce 
an  ('(]ual  increment  of  deviation  in  a  ray  initially  parallel  to  the 
axis.  In  this  eye-piece,  which  is  known  as  a  negative  eye-piece,  the 
focal  lengtlis  of  the  fiehl  and  eye  lenses  are  in  the  ratio  3:1,  while 
the  distance  l)etween  them  is  numerically  equal  to  twice  the  focal 
length  of  the  eye-lens.  The  Iluyghenian  eye-piece  is  especially  adapted 
to  the  microscope.  Ii'anisdcn's  eye-piece  is  designed  to  observe  the 
coincidence  of  a  point  of  the  image  with  the  intersection  of  cross-hairs, 
or  to  measure  the  dimensions  of  the  image  by  the  aid  of  a  scale  in  the 
eye-piece.  It  consists  of  two  plano-convex  lenses,  of  equal  focal 
lengths,  whose  convex  surfaces  face  each  other  and  are  separated  by  a 
distance  equal  to  two-thirds  of  the  numerical  value  of  the  focal  length 
of  either  lens.  This  eye-piece  is  termed  a  positive  eye-piece.  Reflect- 
ing eye-pieces  comprise  the  diagonal  or  prismatic  eye-piece,  which 
deflects  the  emergent  rays  at  right-angles  to  the  axis  of  incident  rays, 
and  the  collimating  eye-piece  used  to  determine  the  error  of  collima- 
tion  in  a  transit  instrument.  Terrestrial  or  erecting  eye-piece  presents 
the  object  erect  instead  of  inverted. —  (C.  F.  P.) 

Eye-piece  indicator.  A  printing  device  used  in  connection  with  an 
eyepiece  for  marking  any  object  in  the  field  of  view\ 

Eye-piece  micrometer.  An  eyepiece  connected  with  a  micrometer  for 
the  purpose  of  measuring  the  size  of  the  real  image  of  an  object. 

Eye,  Pineal.  Epiphyseal  eye.  The  rudimentary  median  eye  in  some 
lizards  and  other  animals.  See  Evolution  of  the  eye;  as  well  as 
Comparative  ophthalmology. 

Eye-point.  An  eye-spot ;  an  ocellus.  Also,  the  bright  circle  at  the 
crossing  point,  or  nearest  approximation  of  the  rays  above  the  ocular 
of  a  microscope.  It  is  best  seen  with  a  strong  illumination  for  the 
microscope,  and  a  piece  of  ground  glass  or  thin  paper  a])ove  the  ocular 
for  a  screen. 

Eye-protector.    A  name  variously  applied  to  eye-shades,  masks,  shields, 


Eye  Protector,  for  Both  Eyes. 


EYE,  REDUCED 


5035 


tinted  glasses,  goggles,  etc.,  for  protecting  the  eyes  from  traumatisms, 

light,  dust,  wind  and  infective  material. 

A  shield  for  protection  against  accidents  after  operations  is  shown 

in  the  accompanying  cut,  and  the  whole  subject  is  fully  discussed  on 

pages  156  et  seq.  in  Vol.  I  of  this  Encyclopedia. 
Eye,  Reduced.    Se.-  Physiolog-ical  optics. 
Eye  rods.     Tliese  are  simply  hard  rubber  or  glass  rods  provided  with 


Eye-Salve  Eods  of  Fuehs  and  Kells^^. 


pointed,  flat  or  bulbous  ends  and  used  for  applying  ointments  and 

solutions  to  the  eye.    See  the  cut. 
Eye,  Schematic.    See  Physiological  optics. 
Eye  shade.     This  form  of  protection  has  been  and  will  be  described 


King's  Ocular  Mask. 


Panama  Eve  Shade. 


further  in  tliis  Encyclopedia  under  various  captions,  such  as  Eye 
masks;  Eye-protector,  as  well  as  under  headings  such  as  Cataract, 


Oppenheiin  's  Eye-Shield 


"Cartella"  Eye  Shade. 


that  involve  a  reference  to  or  description  of  them.  Here  it  may  suffice 
to  say  of  them  that  eye  shades  are  sold  in  a  variety  of  shapes,  colors 
and  sizes.     The  Extra  Pharmacopeia  divides  them  into  the  following 


r)n:}6 


EYE  SHADE 


classes  (dri'.'it  r>ril;iiii  i  :  1.  ("jii'd  ('ovci'cd  with  silk,  flat  or  concave, 
siiitalilr  U>i  I'illici-  rVf.  L*.  ( 'clliildid,  Hcsli-color,  I'or  rijL^iit  or  left  eye, 
or  suitalilc  I'or  citlicr  cyt'.  -i.  Of  pith,  the  "sym(''tri(jiu'."  4.  Straw, 
l)lait('(l,  ill  three  sizes.     5.  Douhle  eye  shades,  card,  pith  and  celluloid. 


Buller  's  Shield. 


•  Triaiiyular  ' '  Ban(lat:e. 


In  addition  to  tlie  forms  already  pictured  tlie  so-called  Panama 
eye  shade  protects  the  eye  in  all  directions  and  may  be  worn  by  auto- 
mobiliiits  as  a  dust  siiield.  It  is  nuule  of  opacpie,  translucent  and 
transparent  celluloid  and  also  of  leather.  It  has  adjustable  head 
straps  without  prongs  to  taii.ule  tiie  hair. 


EYESIGHT,  PRESERVATION  OF  5037 

The  Cartella  is  a  Iradc  name  foi-  a  useful  eye-shade,  made  of  eard- 
hoai'd,  piereed  with  ventilating  hoh'S,  and  adai)table  to  the  margin  of 
the  oi'bit.  It  can  ])e  employed  as  an  ordinary  protector  or  arranged  to 
liold  di'essings  in  i^hice  after  operations  on  the  eye.  See,  also,  p.  156, 
Vol.  1,  of  this  Encjjilupcdia. 


Moorfields  Bandage. 


Fuchs'  Wire  Mask. 


Onlinarv  Kve  iShieM. 


Eyesight,  Preservation  of.    See  Blindness,  Prevention  of,  p.  IIHS,  Vol. 

II;  as  well  as  Conservation  of  vision,  p.  213G,  Vol.  IV.  of  this  En- 

(i/clopcclia. 
Eyes,  Multiple.    See  Comparative  ophthalmology. 


5038  EYES  OF  BIRDS 

Eyes  of  birds.  Sec  Birds,  Eyes  of,  i).  !I7!),  Vol.  I  f,  of  tliis  Encyclopedia; 
;ils(.  Comparative  ophthalmology. 

Eyes  of  soldiers,  sailors,  railway  and  other  employees,  Examination 
of  the.  This  section  will  be  considered  under  the  following  captions, 
and  in  the  following  order:  1.  Nece.ssity  for  examination.  2  and  3. 
Delinition  and  descrii)tion,.  (a)  Army;  (b)  Navy;  (c)  Railway. 
4.  Visibility  of  signals,  (a)  Navy;  (b)  Kailway.  5.  Factors  interfer- 
ing with  visibility  of  signals.  G.  Rules  and  regulations  governing  ex- 
anunation  of  vision  in  the  army,  naval  and  railway  and  .street  railway 
services.  7.  Tests  for  visual  acuity.  8.  Edridge-Green's  theory  of 
vision  and  color  vision.  9.  Tests  for  color  vision  not  already  described 
in  this  Encyclopedia.  10.  Value  of  office  tests.  11.  Adequacy  of  color 
vi.sion  tests.  12.  Advantages  and  disadvautages  of  gla.sses.  13.  Pro- 
tection of  the  eyes. 

The  amount  of  ametropia,  manifest  and  latent,  regularly  found  upon 
examination  of  the  eyes  of  apparently  otherwise  healthy  individuals 
is  astounding.  Considered  in  conjunction  with  the  congenital  defect 
of  the  visual  apparatus  known  as  color-blindness  it  is  certainly  a  suffi- 
cient argument  as  to  the  necessity  of  a  rigid  examination  of  the  eyes 
of  m(>n  engaged  in  professions  or  occupations  in  which  the  determina- 
tion of  shape,  position,  movement  and  color  is  used  as  a  means  of 
information  or  communication.  Under  this  heading  fall  members  of 
the  army,  naval  and  marine  services,  pilots,  employees  of  steam  and 
electric  railways,  other  corporation  employees  and  those  in  charge  of 
motor-driven  vehicles. 

NECESSITY    OP    EXAMINATION.       DESCRIPTION    OP    SIGNALS. 

Signals  are  conventional  or  intelligible  signs  designed  for  informa- 
tion, guidance  or  a  means  of  connnunication.  Those  in  Mdiieh  shape, 
l)Osition,  motion  or  color  is  used  for  such  purpose  are  made  manifest 
to  the  individual  through  the  medium  of  the  visual  apparatus. 

Signaling  in  the  army  has  not  developed  to  the  extent  it  has  in 
navy  and  railway  signal  work,  other  means  of  communication,  such 
as  the  telegraph  and  telephone,  being  as  a  rule  easily  accessible  and 
a  ])art  of  the  sigiud  corps  equipment.  Those  chiefiy  used  by  day  are 
motion  signals,  witli  the  wigwag  flags,  15x15  inches  square,  and  the 
heliograph.  Night  wigwagging  is  accomplished  by  means  of  two 
lights,  or  the  flash  light  is  used. 

Signaling  in  the  marine  scrvir<  has  bi'cume  a  relincment,  especially 
in  the  Navy,  as  it  is  the  oidy  visible  means  of  communication  between 
vessels.  Good  vision  and  the  recogintion  of  color  are  absolutely  essen- 
tial to  enable  one  to  understand  the  various  signals. 

The  signals  are  flxed  and  moving.     The  colors  used  are  white,  red, 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5039 

yellow  and  green,  blue,  and  various  combinations  of  the  above  col- 
ors. Day  fixed  signals  in  which  colors  must  be  recognized  are  bargees, 
pennants  and  flags,  buoys,  etc.  Bargees,  pennants  and  flags  are  of 
different  sizes. 

Size  3  Size  6 

Hoist.       Fly.       Hoist.       Fly. 

Bargee    7.25         7.25         2.90         2.90 

Pennant   5.83       18.00         2.00         5.00 

Square  flag   7.25         7.25         2.90         2.90 

These  signals  are  used  for  communicating  in  tlie  international  code. 
Storm  flags  are  eight  feet  square,  and  pennants  eight  feet  hoist  and 
fifteen  feet  fly. 

"A  buoy  is  a  floating  ol)ject  fixed  at  a  certain  place  to  show  the 
position  of  objects  beneath  the  water,  as  shoals,  rocks,  etc.,  to  mark 
out  a  channel  and  the  like.  ...  In  the  waters  of  the  United 
States  the  following  system  of  placing  buoys  as  aids  to  navigation  is 
prescribed  by  law :  Red  buoys  mark  the  starboard  or  right-hand  side 
of  the  channel  coming  from  seaward,  and  black  the  port  or  left-hand 
side ;  midehannel  dangers  and  obstructions  are  marked  with  buoys 
having  black  and  red  tran.sverse  stripes,  and  midehannel  buoys  mark- 
ing the  fair-way  have  longitudinal  black  and  white  stripes;  buoys 
marking  sunken  wrecks  are  painted  green.  The  starboard  and  port 
buoys  are  numbered  from  the  seaward  end  of  the  channel,  the  black 
bearing  odd  and  the  red  even  numbers."  White  buoys  are  used  for 
special  purposes,  and  yellow  mark  quarantined  grounds. 

.Moving  day  signals  are  the  wigwag  flags  fifteen  inches  by  fifteen 
inches  and  the  two-arm  semaphore  flags,  which  are  twelve  to  fifteen 
inches  square.  Night  fixed  signals  consist  of  light  houses,  light  ships, 
occulting  lights,  illuiniiiated  l)Uoys,  ship's  lights,  electric  night  signals, 
Very's  night  signals,  rockets,  and  drawbridge  lights. 

AVhite  and  red  lights  are  used  in  the  United  States  Light  House 
Service.  Ship's  lights  are  white,  red,  and  green.  Electric  night 
signals  consist  of  a  system  of  four  double  lanterns  white  and  red,  in 
which  difi'erent  letters  and  figures  are  indicated  by  the  relative  posi- 
tion of  the  red  and  Aviiite  lights,  shown  when  reading  from  above 
down.  Very's  night  signals  is  a  system  whereby  numbers  are  made 
by  red  and  green  liglits  fired  into  the  air  from  a  pistol;  rockets  of 
various  colors  are  also  used.  A  blue  light  burned  every  fifteen  minutes 
is  a  signal  for  a  pilot.  Drawbridge  lights  are  red  and  green  lights 
which  designate  the  condition  of  the  draw  and  position  of  channel. 

The  rules  and  regulations  for  preventing  colli-sions  at  sea  {Fideral 


5040  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Stdlutcs,  \'(il.  X  I .  |>;i,i:c  ir)4)  (l('S('i"il)('  ;iii»l  ^i\c  (•crhiiii  spccKicatioiis 
iis  to  sliip's  IJLilits  ;iii(!  Mi'c  as  follows: 

Ai'ticlf  1.  Tile  culi's  coiicrniiii'i-  lijilits  sluill  he  coiiiplicd  witli  in  all 
wcatliiTs  rioiii  siiiisi't  lo  siiiirisc,  and  diifiiij,^  sudi  lime  no  otlicr  lights 
\\lii(;ii   may   he  mistaken   t'oi-  tlic   in-cscfilird    linhts  shall   he  cxhihitcd. 

Article  2.  A  steam  vessel  when  undef  way  shall  carry — 

(a)  On  Of  in  IVont  of  the  foi-emast,  or  il'  a  vessel  without  a  fore- 
mast, then  in  the  foi'e|)art  of  the  vessel,  at  a  height  ahove  the  hull  of 
not  less  than  twenty  feet,  and  if  the  ])readth  of  the  vessel  exceeds 
twenty  feel,  then  at  a  iieiiiht  ahove  the  hnll  not  h-ss  tlian  such  hreadth. 
so,  however,  that  the  light  need  not  he  carried  at  a  greater  height 
ahove  the  hull  than  forty  feet,  a  bright  white  light,  so  constructed  as 
to  show  an  unbroken  light  over  an  arc  of  the  horizon  of  twenty  points 
of  the  compass,  so  fixed  as  to  throw  the  light  ten  points  on  each  side 
of  the  ves.sel,  viz.,  from  right  ahead  to  two  points  abaft  the  beam  on 
either  side,  and  of  such  a  character  as  to  be  visible  at  a  distance  of 
at  least  five  miles. 

(1))  On  the  starboard  side  a  green  light  so  constructed  as  to  show 
an  unbroken  light  over  an  arc  of  the  horizon  of  ten  points  of  the  com- 
pass, so  fixed  as  to  throw  the  light  from  right  ahead  to  two  points 
abaft  the  lieam  on  the  starboard  side,  and  of  such  a  character  as  to 
be  visible  at  a  distance  of  at  least  two  miles. 

(c)  On  the  port  side  a  red  light  so  constructed  as  to  show  an 
unbroken  light  over  an  arc  of  the  horizon  of  ten  points  of  the  compass, 
so  fixed  as  to  throw  the  light  from  right  ahead  to  two  points  abaft 
the  beam  on  the  port  side,  and  of  such  a  character  as  to  be  visible  at 
a  distance  of  at  least  two  miles. 

(d)  The  said  green  and  red  liglits  .shall  be  fitted  with  inboard 
screens  projecting  at  least  three  feet  forward  from  the  light,  so  as 
to  prevent  these  lights  from  being  seen  across  tlu'  l)ow. 

(e)  A  steam  vessel  when  under  way  may  carry  an  additional  white 
light  similar  in  construction  to  the  liglit  mentioned  in  subdivision  (a). 
These  two  lights  .shall  be  so  placed  in  line  with  the  keel  that  one  shall 
be  at  least  fifteen  feet  higher  than  the  other,  and  in  such  a  position 
with  reference  to  each  othei-  tluit  the  lower  light  shall  be  forward  of 
the  upper  one.  The  vertical  distance  between  these  lights  shall  be 
less  than  the  Imrizontal  distance. 

Thr  above  rules  are  general  and  only  a  part  of  the  many  which 
ap|)ly  to  vessels  of  different  sizes,  and  those  employed  in  the  various 
vocations  re<|uired  upon  the  sea. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5041 

V.  S.  Navy  Department  specifications  as  to  colored  lenses  are  as 
follows : 

C'oloi-ed  lenses  iiinsl  he  solid  coioi',  no  Hjislit-d  lenses  being  acceptable. 

Green  lens. — The  color  shall  be  that  known  as  "Admiralty  green," 
having  a  .slightly  blue  tint  when  tested  with  a  Navy  standard  32  c.  p. 
lamp  as  the  source  of  illumination.  The  spectrum  shall  show  very 
little  yellow,  and  shall  l)e  a  full  green  with  .some  blue.  The  total 
percentage  of  light  transmitted  shall  not  fall  below  the  minimum 
sufficient  to  insure  a  distinct  iiulication  at  the  distance  prescribed  by 
the  international  regulations. 

Red  lens. — The  color  shall  be  of  such  quality  that  all  the  yellow^  rays 
of  light  are  absorbed,  and  the  spectrum  shall  ])e  either  red  or  red  and 
orange  when  tested  with  a  Navy  .standard  32  c.  p.  lamp  as  the  source  of 
illumination.  The  total  jx'i'centage  of  light  transmitted  shall  not  fall 
below  the  minimum  sufficient  to  insure  distinct  indication  at  the 
distance  prescrilx'd  by  the  international  regulations. 

RAILWAY    SIGNALS. 

Thret'  distinct  forms  of  signals  are  necessary  in  railway  operations — 
"All  Clear,  Proceed;"  "Caution,  Proceed  Slowly,"  and  "Danger, 
Stop." 

Railway  signals  are  divided  into  two  grand  classes,  fixed  and  moving. 
It  is  quite  generally  accepted  that  red  designates  danger;  green  or 
yellow,  caution,  and  white  or  green,  clear.  Blue  is  used  as  a  caution 
signal  to  indicate  repairs  being  made. 

The  day  fixed  sigiuds  are  flags,  switch  targets,  train  order  signals, 
semaphores,  interlocking  block  .signals,  and  drawbridge  signals. 

Flags. — These  are  displayed  at  stations  or  are  placed  along  the 
track  l)y  trackmen  to  indicate  danger,  or  caution  to  regulate  speed  of 
trains  over  a  section  of  track  in  poor  condition,  etc.  They  are  also 
displayed  on  the  pilots  of  engines  as  classification  signals  and  on  the 
rear  of  trains  as  nuirkers.  They  are  made  of  bunting  about  sixteen 
inches  by  eighteen  inches,  and  are  red,  white,  green,  yellow  and  blue 
when  new. 

Switch  targets. — These  are  used  to  designate  the  condition  of  the 
switches  in  relation  to  the  main  track  or  side  tracks,  and  are  of  three 
general  divisions,  high,  medium  and  low,  depending  upon  the  height 
above  the  road-bed.  They  indicate  the  position  of  the  switch-divert- 
ing rails  by  the  shape,  position  and  color  of  the  target,  which  may  lie 
square,  oval,  round,  kidney-shaped,  an  aiTOW,  a  bar  or  feather,  etc. 
The  colors  used  are  red,  green,  white,  yellow,  black,  or  any  combination 

Vol.  VII— 13 


5042 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


«  2 

r^  - 


CO    C 


~    ■'■■ 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5043 

of  these  colors,  according  to  the  judgment  of  the  officers  of  the  various 
roads. 

Train-order  signals. — Tliese  are  used  to  stop  a  train  to  receive 
orders.  They  commonly  are  sheet  iron  discs  of  various  shapes,  attached 
to  station  buildings  and  under  control  of  the  station  master.  The 
newer  forms  are  semaphore  arms  attached  to  the  buildings  or  on  a 
mast  isolated  from  the  building.  The  colors  used  in  the  oUl  form  are 
red,  green,  white,  and  black,  or  a  combination  of  the  same. 

Interlocking  signals. — The.se  are  usually  of  the  semaphore  type,  and 
are  located  alongside  the  track  on  the  right-hand  side  antl  adjacent 
to,  where  possible,  or  on  bi-idges  immediately  over  the  track  they 
govern.  The  blades  are  painted  red,  white,  green,  yellow  and  black, 
or  combinations. 

These  signals  are  used  at  points  where  interlocking  plants  are 
installed  to  protect  train  movements  over  intersecting  tracks,  and, 
therefore,  are  extremely  important. 

Block  signals. — These  indicate  whetlici-  the  section  of  track  ahead 
of  them  is  occupied  or  not,  and  are  very  important  signals  in  this 
age  of  limited  trains.  They  are  of  three  types;  in  the  first,  the  posi- 
tion; in  the  seeoiid,  tlio  color  displayed  gives  the  information;  while 
in  the  third,  the  combination  of  shape  and  color  gives  the  indication. 
The  same  colors  are  used  as  with  interlocking  signals. 

The  semaphore  is  the  best  ty])e  of  position  block  signals,  and  con- 
sists of  a  tall  pole  with  a  blade  at  or  near  the  toj),  arranged  so  that  it 
can  be  placed  at  various  angles  to  the  perpendicular.  These  semaphores 
are  u.sed  as  three-position  and  two-position  signals  in  block  signaling, 
as  well  as  in  interlocking.  The  three-position  signal  is  of  three  varie- 
ties, i.  e.,  in  the  first  type  the  blade  stands  at  right  angles  to  the 
perpendicular  for  ' '  Stop  ; ' '  dropped  to  45  degrees  ' '  Proceed  with 
Caution,"  and  dropped  vertically  and  parallel  with  the  pole  for 
"Clear."  In  another  type  the  blade  is  placed  horizontally  for  "'Stop;" 
at  ai)i)roximately  45  dejrrees  with  the  horizontal  pointing  ujiwards, 
'•Proceed  with  Caution,"  and  at  an  angle  of  approximately  45  degrees 
pointing  downward,  "Clear."  The  new  upper  ([uadrant  system  with 
the  blade  horizontal,  "Stop;"  pointing  upward  at  45  degrees,  "Pro- 
ceed with  Caution:"  pointing  upwards  at  90  degrees,  "Clear." 

AVith  the  two-position  semaphore  the  blade  is  at  horizontal  for 
"Stop,"  and  dropped  at  an  angle  at  from  45  to  80  degrees  with  the 
horizontal   for  "Clear." 

Tile  shape  of  the  ends  of  the  ])lades  are  usually  square,  pointed, 
fish-tail  or  round  (concave  or  convex),  and  each  shape  has  a  special 
significance.     On  roads  wliere  pointed  blades  are  used  for  train  order 


5044 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


<)!•  hlock  si^'iials  the  scjUiiiT  fiul  blade  is  used  for  lioiiif  signals  ill 
c'oniicctioii  with  iiitcrlockiiij;  ])laiits.  These  must  not  l)e  passed  when 
in  the  "Stop"  position,  as  they  are  usually  connected  with  "Derails," 
and  tile  enginenian  running  by  would  derail  his  train,  or  if  derails 
were  not  in  use  would  foul  a  eonflicting  route.  Such  signals  are  often 
placed  before  draw  bridges,  railroad  crossings,  etc.  The  fish-tail  end 
is  generally  used  for  "Distant  signals"  when  the  "Home  signal" 
can  not  be  seen  at  sufficient  distance  on  account  of  cur\'es  or  some 
obstruction  to  allow  tiie  engineman  space  in  which  to  stop  his  train ; 
the  "Distant  signal"  indicates  the  condition  of  the  "Home  signal" 
or  is  a  repeater. 


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Corresponding  Aspects  of  Semaphore  and  Position  Light  Signals  with  Their  Indi- 
cations.     ("The  Signal  Engineer.") 


"As  the  color  of  the  blade  has  nothing  to  do  with  semaphore  signal 
indications — position  and  shape  of  blade  onl}^  governing  in  this  matter 
— the  color  best  adai)ted  to  local  conditions  may  be  used.  On  many 
lines  home  and  advance  signal  blades  are  painted  red,  with  a  broad 
white  strii)e  across  near  the  outer  end,  and  distant  signals  are  painted 
green  with  a  similar  white  stripe.  On  other  lines  orange  has  been 
adopted  as  the  color  for  distant  signals.  Local  characteristics,  such 
as  the  color  of  the  background  and  atmospheric  conditions,  may  be 
allowed  to  govern,  altlinngli  for  many  reasons  a  uniloi'm  standard  is 
tjesil-able." 

The  liome  inlei'locking  and  train  order  signals  are  connuoidy  painted 
red  with  a  wliite  band  near  tlie  free  end.  and  the  "Distant  jignal" 
green  or  xcllow  with  a  white  band  near  the  end. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5045 

There  is  also  a  dwarl"  siuiial  used,  wliicli  is  a  miniature  scniaphort', 
about  three  feet  in  height,  ami  which  is  used  where  the  train  move- 
ments are  slow  or  where  there  is  not  room  for  a  standard  iiigh  signal. 

The  one-armed  standard  high  semaphore  pole  is  usually  about  2G 
feet  above  the  ground.  The  two-armed  is  about  32  feet  high,  and  the 
bracket  pole  is  about  38  to  50  feet,  as  are  also  semaphores  displayed 
on  bridges.     The  blades  are  all  about  4  feet  in  lengtli. 

The  disc  signal. — This  is  a  type  of  a  color  block  signal  and  consists 
of  white  or  transparent  background,  before  which  a  disc  of  red  or 
green  cloth  is  dropped,  all  mechanism  being  protected  by  a  wood  and 
glass  case. 

The  banner. — This  is  a  type  of  a  shape  and  color  signal,  and  consists 
of  an  oval  shaped  white  disc  with  a  black  background,  outlined  by 
a  white  circle  in  the  proceed  position,  and  a  red  disc  outlined  by  a 
white  circle  on  a  black  background  in  the  stop  position. 

Moving  signals. — These  consist  of  red,  green,  yellow  and  white  flags, 
and  the  motions  of  the  arm  and  hand  used  by  trainmen  in  transmitting 
information  to  the  engine  crew.  The  color  of  the  flag  affects  the 
indication. 

There  is  a  general  rule  on  many  roads  that  tlie  ai'm  or  any  object 
waved  violently  is  a  "Stop"  signal. 

Xight  signals. — Hy  night,  at  the  present  time,  information  as  to 
the  condition  of  the  right  of  way  is  given  by  means  of  colored  lights. 
As  the  trainmen  are  almost  entirely  dependent  on  signals  at  night 
for  infornuition  as  to  track  ol).structions,  location,  warnings  and  means 
of  communication,  this  is  the  most  important  part  of  railway  signaling 
— it  should  therefore  be  the  simplest,  surest,  and  have  the  contrasts 
most  marked.  The  colors  used  are  red,  white,  green  and  yellow. 

The  principles  of  niglit  signal  indications  adopted  by  the  Railway 
Signal  Association  are,  "red,  stop;"  "yellow,  proceed  with  caution, 
expecting  to  stop  at  next  signal;"  "green,  proceed."  The  general 
practice  uj)  to  twenty  years  ago  for  night  signaling  was,  "red,  stop;" 
"green,  caution;"  "white,  proceed."  The  change  from  white  to 
green  for  the  "proceed"  indication,  and  the  adoption  of  yellow  for 
caution,  was  because  of  the  many  incandescent  and  arc  lights  on  and 
about  the  right  of  way  being  mistaken  for  proceed  indications.  ]\Iore 
than  half  the  mileage  of  this  country  has  now  adopted  yellow  for 
caution  and  green  for  proceed. 

The  fixed  night  signals  are  white,  red,  yellow  and  green  lights  or 
lanterns,  with  purple  or  dark-l)lue  in  use  for  back  lights  at  inter- 
locking plants.  Red  and  green  fuzees  are  used  for  emergency  signals 
and  to  indicate  track  conditions.  A  red  fuzee  must  not  be  passed 
until  it  is  burned  out.     "When  burning  green  it  is  a  caution  signal. 


5046 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


'IMic  condition  of  switclics  is  iiidicatcil  li,\-  wliiti',  yellow,  red  or  fri'ccn 
lamps  jilaci'd  on  the  top  of  llir  larjt^i'ts.  dates  and  hars  art-  indicated 
in  the  same  mannei'. 

In  all   ni'-dit  si«?naliii<i:,  while  the  coloi'  is  the  main   indication,  the 


3^' 


FPONT  VIEW 
Three-Light  Vertical  ElcL-trie  Light  Signal  Unit. 

location  of  the  lights  has  something  to  do  with  determining  the  mean- 
ing of  signals,  i.  e.,  a  red  above  a  white  or  green  will  indicate  one 
thinfr,  and  a  white  or  green  above  a  red  another;  hence  the  necessity 
for  perfect  color  j^ei-ception.  Yellow  is  used  as  a  caution  signal  on 
roads  where  green  is  used  for  clear.     Its  usefulness  is  in  ease  a  glass 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5047 


should  lii'cjik  ill  iiiiy  si^Miiil.  ;i  white  li<ilit  \voiil<l  show  when  it  should 
he  yellow,  red  or  jireeii,  and  indicates  that  something  is  wrong.  Draw- 
britlge  signals  are  red  and  green  balls  in  ilay  time  and  red  and  green 
lights  at  night,  usually  guarded  by  a  distant  signal. 

Lujht  signals  for  day  and  night  indication. — It  is  interesting  to 
note  that  in  connection  with  the  Philadelphia  suburban  electrification 
it  was  originally  decided  to  employ  transverse  bridge  supports  for 


Three-Liiilit  Triangular  Electric  Light  Signal  Unit. 


the  overhead  catenary  construction  and  in  order  to  prevent  the  inter- 
ference and  liability  of  error  in  observing  the  semaphore  arm  signals 
against  the  background  of  cross  supporting  beams,  it  was  decided  to 
employ  the  electric  lamp  signal  for  both  night  and  day.  Although 
experiments  siibsequently  proved  the  desirability  of  using  transverse 
cable  supports  and  poles  instead  of  transverse  bridges,  the  advantages 
of  the  electric  day  signal  are  realized  to  be  so  important  that  the 
original  plan  of  using  this  type  of  signal  has  been  adhered  to. 


5048  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

With  spfcijillv  coiisti-iii'ltMl  l;iiii]ts,  wlici-c  llic  liliiiiifiit  is  coiiccii- 
trati'cl  ill  liclical  form  so  that  practically  the  entire  light  lliix  of  tlu; 
laiiip  is  located  in  the  focal  /.one  of  the  leJis,  it  is  found  that  a  one 
eandle  power  electric  lamp  will  illuminate  the  signal  so  brilliantly 
that  it  can  be  readily  distinguished  at  a  distance  of  two  miles.  This 
current  consumption  is  so  low  that  it  has  been  decided  to  burn  the 
lamps  day  and  night  and  thus  eliminate  the  complication  of  control 
cii'cuits. 

These  .small  candle  power  lamp  installations  were  designed  to  operate 
in  eomiection  with  the  usual  semaphore  systems,  simply  replacing 
the  oil  flame  as  illuminant,  but  even  a  more  radical  departure  from  past 
practice  is  found  in  the  successful  trials  of  powerful  electric  lamp 
signals  for  both  day  and  night  use  to  replace  entirely  the  semaphore 
anil   with  its  complicated  operating  and  control. 

In  numerous  tests  on  the  Pennsylvania  railroad  at  Pittsburgh 
where  20  watt  Mazda  lamps  with  concentrated  filament  have  been  used 
in  connection  with  10  in.  lens,  even  in  the  smoky  atmosphere  prevalent 
at  Pittsburgh  these  lamps  are  easily  visible  by  day  or  night  at  from 
4,000  to  5,000  feet. 

If  practical  experience  proves  this  system  of  signaling  to  be  as 
effective  as  preliminary  tests  would  indicate  it  will,  no  doubt,  have  a 
revolutionary  effect  upon  all  future  signal  installations. 

The  new  beam  light  signal. — The,  following  description  is  furnished 
by  ]Mr.  A.  IT.  Rudd,  Signal  Engineer  of  the  Pennsylvania  Railroad 
System  : 

In  place  of  semaphore  block  signals,  a  novel  arrangement  of  lights, 
uneolored.  is  used  by  which  both  motion  and  color  will  be  done  away 
with,  the  lights  being  used  by  day  and  night.  "We  have  developed 
what  we  call,  for  lack  of  a  better  iiainc.  the  'beam-light'  signal,  and 
are  to  install  it  between  Over])rook  and  Paoli,  about  16  miles  of  four- 
track  road  with  five  interlockings.  The  signals  will  give  three-block 
indications,  and  will  be  located  approximately  3,500  feet  apart.  If 
the  scheme  {)roves  satisfactory  it  will  be  useful  especially  where  a.  c. 
track  circuits  are  installed,  as  with  it  the  only  moving  part  in  the  sys- 
tem is  the  control  relay,  which  is  necessary  with  any  system.  As  de- 
signed each  unit  is  generally  arranged  as  shown.  Four  fixed  lights  in  a 
row,  one  light  Ix'ing  common  to  all  three  rows.  The  containers  for  the 
lamps,  lenses,  etc..  are  clamped  to  steel  tubes  diverging  from  a  center 
casting,  a  suitable  background  being  attaclied  to  the  center  support 
but  back  of  and  se])arate  from  the  tulies  supi)oi-ting  the  lamps. 

"The  l.iiiips  arc  spaced  IS  iiidirs  apai't,  center  to  center,  and  are 
12-volt,  4-caiidl('p()wei-,  .l-watt  .Ma/da:  concentrated  iilament  with  ad- 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5049 


justablo  l)ase.  biiniiu^'  at  11 -volts  in  lii'i<i:lit  djiyli^lit  or  in  fog,  6-voIt.s 
at  twili^lit  and  .i-volts  at  iiiulit.  Tlic  cuncMt  coiisimiptioii  will  average 
11})  about  ten  watts  for  the  four  liglits.  Sj)ecial  inverted  5;',s  in. 
lenses  and  very  light  yellow  cover  gla.s.ses,  eoinniereially  known  as 
No  Glare  Glass,  are  plaeed  in  front  of  the  lamps;  and  a  reflecting 
niii-ror  above  the  cover  glass  to  throw  some  of  the  rays  down  for  close 
I'ange.  There  will  be  a  hood  over  each  unit.  These  lights  are  readily 
seen  in  brightest  sunlight  at  4,000  feet  or  more.  Scareheads  of  news- 
})aper.s  can  be  read  by  them  at  night  1,000  feet  away  if  the  full  day 
voltage  is  used :  hence  the  necessity  of  dampening  down  at  night. 
The  voltage  will  be  controlled  from  the  nearest  signal  cabin  by  the 
signalman.     Tlie  entire  arrangement  is  immova})le,  the  rows  of  lamps 


Beam  Light  Signal  Unit. 


being  lighted  as  conditions  require.  Two  units  will  be  used  on  all 
signals — equivalent  to  two  senuiphore  arms — thus  making  a  uniform 
system,  the  aspects  corresponding  to  the  position  of  the  arms  as  in 
standard  practice,  but  at  interlocking  signals  the  ])ottom  (low-speed) 
arm  will  not  be  displayed  in  the  stop  position  at  all.  When  it  is 
recjuired  two  short-range  lights  will  ])e  shown,  diagonal  or  vertical,  in 
addition  to  the  two  u])pi'r  arms  horizontal.  This  is  a  decided  advan- 
tage, as  the  engineman  will  know  that  unless  two  full  size  beams 
appear,  the  signal  is  improperly  displayed.  No  permissive  aspect 
will  be  required,  but  if  needed  it  can  be  shown  by  a  row  of  lights 
diagonal  (45  deg.)  in  lower  right-hand  (piadrant. 

"The  staggered  light  effect  to  distinguish  stop  and  proceed  signals 
from  stop  and  stay  will  be  produced  by  having  the  bottom  horizontal 
beam  moved  to  the  left  one  light,  the  difference  being  recjuired  only 
in  the  stop  indication. 


5050  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

'•  l-'(»i-  dwarl'  si<iii;il.s.  wliidi  ciiiiiiot  he  hooded  lest  close  range  reading 
should  he  oliscured,  frost. -d  wliitr  cover  f^dasses  and  higher  candle- 
power  lamps  will   he   used. 

"This  arrangement  will  eliminate  all  lailuivs  due  to  moving  parts 
of  .signals  and  mechaiusms  (excei)t  the  n-lays;,  and  all  chances  of 
freezing  or  sticking  clear.  From  our  records  it  appears  that  this 
should  reduce  all  failures,  with  their  consequent  delays,  at  least  10 
per  cent.,  and  all  dangerous  failures  40  per  cent.  The  scheme  .solves 
the  colored-light  prohlem  for  night  indications  completely,  hy  eliminat- 
ing all  colors  and  estahlishing  signaling  by  position  only." 

Classification  signals.  Single  track  rules  are  as  follows:  The  fol- 
lowing signals  will  l)e  displayed,  one  on  each  side  of  the  rear  of  every 
train,  as  markers,  to  indicate  the  rear  of  the  train :  By  day,  green 
flags.  By  night,  green  lights  to  the  front  and  side  and  red  lights  to 
the  rear ;  except  .when  the  train  is  clear  of  the  main  track,  when  green 
lights  must  be  displayed  to  the  front,  side  and  rear. 

All  sections  except  the  last  will  display  two  green  flags,  and  in  addi- 
tion, two  green  lights  by  night,  in  the  places  provided  for  that  purpose 
on  the  front  of  the  engine. 

Extra  trains  will  display  two  white  flags,  and,  in  addition,  two  white 
lights  by  night,  in  the  places  provided  for  that  purpose  on  the  front 
of  the  engine. 

When  two  or  more  engines  are  coupled,  the  leading  engine  only 
shall  display  the  signals  as  prescribed. 

One  flag  or  light  displaj^ed  where  in  the  above  rules  two  are  pre- 
scribed will  indicate  the  same  as  two;  but  the  proper  display  of  all 
train  signals  is  required. 

AVhen  cars  are  pushed  by  an  engine  (except  when  shifting  or  making 
up  trains  in  yards)  a  white  light  must  be  displayed  on  the  front  of 
the  leading  car  hy  night.  Each  car  on  a  passenger  train  must  be 
coiniected  with  the  engine  by  a  communicating  signal  appliance. 

A  blue  flag  by  day  and  a  blue  light  by  night,  displayed  at  one  or 
both  ends  of  an  engine,  car  or  train,  indicates  that  workmen  are  under 
or  about  it :  when  thus  protected  it  must  not  be  coupled  to  or  moved. 
Workmen  will  display  the  l)lue  signals  and  the  same  workmen  are 
alone  authorized  to  remove  them.  Other  cars  nnist  not  be  placed  on 
the  same  track  so  as  to  intercept  the  view  of  the  blue  signals,  without 
first  notifying  the  workmen.  A  combined  green  and  white  signal  is 
to  be  u.sed  to  stop  a  train  at  the  Hag  stations  indicated  on  its  schedule. 
When  it  is  necessary  to  stop  a  train  at  a  point  that  is  not  a  flag  sta- 
tion on   its  sclieilule,  a   red  signal  must  be  used. 

Diiuhh    I  rail,-   ruhs  are  the   following:     The  following  signals  will 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5051 

he  displayed,  one  on  cicii  side  of  llic  rt'jic  ol"  ('vcr\'  train,  as  markers, 
to  indieate  the  vvnv  of  the  ti-aiii:  By  day,  green  flags.  Hy  night, 
green  lights  to  tlie  front  and  side  and  red  lights  to  tiie  rear,  except 
when  tlie  train  is  clear  of  the  main  track,  when  green  lights  must 
he  dis])Iayed  to  tiie  front,  side  and  rear,  and  exeei)t  when  a  train  is 
turned  out  against  tlie  current  of  traffic,  when  green  lights  must  he 
displayed  to  the  front  and  side,  and  to  tlie  rear,  a  green  light  toward 
the  inside  and  a  red  light  to  tlie  op[)osite  .side. 

'Three  and  four  track  ruhs. — A  train  hy  night  running  with  the 
current  of  trafific,  on  a  high  s|)eed  track,  will  disi)lay  two  red  lights 
to  tlie   rear. 

A  train  hy  night  I'liiining  with  the  current  of  traffic,  on  a  slow 
speed  track,  or  a  train  ))y  iiiglit  using  any  track  against  the  current 
of  traffic,  will  display  a  green  light  to  the  rear  on  the  side  next  to  the 
high  speed  track  in  the  dii'ecfion  of  the  current  of  traffic,  and  a  red 
light  on  the  opposite  side. 

A  train  hy  night  on  a  siding  w  ill  display  two  green  lights  to  the  rear. 

VISIBILITY    OF    SIGNALS. 

As  wall  be  seen  from  the  (juotation  from  the  foregoing  Federal 
Statutes,  the  visibility  of  the  signal  lights  on  vessels  is  fixed  by  law, 
i.  e.,  a  white  light  must  be  visible  at  distance  of  five  miles  and  a  red 
and  green  light  at  a  distance  of  two  miles,  the  word  "visible"  in 
these  rules  when  applied  to  lights  shall  mean  visible  on  a  dark  night 
with  a  clear  atmosphere. 

The  American  Railway-  Signal  Association  has  adopted  specifications 
for  the  glass  used  for  signal  roundels,  lenses  and  glass  slides  which 
give  a  maximum  range  for  colored  signals  under  all  weather  conditions. 
With  the  source  of  illumination  40  to  70  candlepower  as  found  in 
actual  practice,  depending  upon  the  type  and  size  of  burner,  the  lens, 
focal  adjustment  of  the  flame,  the  reflector,  the  conditions  of  the 
lamp,  etc.,  such  specified  red  and  green  glass  give  signals  with  an 
api)roximate  range  of  three  miles  in  clear  atmosphere.  The  yellow- 
glass  is  less  effective,  having  a  range  of  1  to  IV2  niiles.  Blue  glass  has 
a  very  much  less  range  owing  to  its  lessened  intensity  and  low  pene- 
trating power.  As  noted  under  the  description  of  beam  light  signals 
these  lights  are  readily  seen  in  the  brightest  sunlight  at  -4,000  feet  or 
more. 

The  following  table  gives  the  spectro-iihotometric  analysis  of  roundels 
of  the  various  colors  of  medium  intensity  as  specified  by  the  Railway 
Signal  Association.     The  letters  indicate  the  Fraunhofer  lines  of  the 


5052 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


spi'ct  I'liiii,  ;iii(l  tile  lij,nii'cs  show  ]t('ri-('iil;ijr<'.s  of  \\'^\\t  t  r;iiisiiii.s.sioii  at 
tlic  (iilVci-t'iil  points.  K'ouiidcls  of  iiicfliiuii  iDtcn.sity  should  tniiisniit 
li<ilil  as  iicai-ly  as  possihh'  of  this  coiiiposition,  a  reasonable  variation 
being  allowed  foi*  light   and  (hirk  limits. 


Non-sweating  Ventilation  Semaphore  Lamp,  with  Corrugated  Lens.    The  source 
of  ilhimination  for  night  signaling. 

A         a         H         C         D         E         1)         F         G         II 

Red  60     Gf)     70     72       0       0       0       0       0       0 

Green 0       0       0       0       4     27     40  45     25       0 

Yellow 0     ;}8     50     4:i     41     12       9       8       0       0 

Blue 0       0       0       0       8       4       6  24     40     4ti 

Purple 0     42     42       0       0       0       0       2     48     42 

Lunar   white 0     62     4!)     17     15     25     38  65     74       0 

Red  shall  lu-  of  sueh  a  quality  that  all  yellow  rays  of  liglit  are  ab- 
sorbed, thr  spectrum  being  cither  red,  or  red  and  orange.     The  i)hoto- 

mctric   value  shall   he,   li^ht   one   hundred   and   thirty  (130),  .standard 
one  hnndi'ed   (100).  d.n'k  se\-eiitv   (  70  i . 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5053 


Grc'cii  shall  Ix'  of  tlic  color  known  as  adiiiii'alty  green,  having  a 
slightly  bluish  tint.  The  speetruni  shall  show  very  little  yellow,  being 
a  full  green  with  some  blue.  The  photometric  value  shall  be,  light  one 
hundred  and  twenty-five  (125),  standard  one  hundred  (100),  dark 
seventy-five  (75). 

Yellow  shall  give  a  si)e('trum  showing  a  full  yellow  band,  most  of 
the  red  and  sliglitly  of  the  green.  The  photometric  value  shall  be,  light 
one  hundred  and  twenty  (120),  standard  one  hundred  (100),  dark 
eighty   (80). 


Semaphore  Lamp,  in  which  Two  Colors,  Usually  Bed  and  Green,  are  shown  at 

the  same  time. 


Blue  shall  give  a  spectrum  having  a  full  liluc  band,  with  a  narrow 
band  of  green.  The  photometric  value  shall  be,  light  one  hundred  and 
twenty-five  (125),  standard  one  hundred  (100),  dark  seventy-five  (75). 

Purple  shall  give  a  specti'um  showing  a  considerable  proportion  of 
both  red  and  blue.  Tlic  piiotometrie  value  shall  be,  light  one  hundred 
and  twcnty-tive  (125  ),  .standard  one  liundi'cd  MOO),  dark  seventy-five 
(75). 

Lunar  white  shall  show  a  maximum  of  absorjition  for  the  yellow. 
The  })liotometric  value  shall  l)e,  lighr  one  hundred  and  twenty  (120), 
standard  one  hundred   (100),  dark  eighty   (80). 


5054 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


Tile  i-(iIoi-s  Irjiiisiiiiltrd  liy  irlass  incctiiif^  tlic  above  spofifications  are 
not   mixed  with  white  so  ai-e  in  a  state  of  f^i-eatest  saturation. 

'I'lie  (juantity  of  ii^dit  of  eaeii  wave-len^^tli  transmitted  from  the 
sonice  of  illumination  by  each  eoloi-ed  uhiss  is  shown  in  the  table. 
The  (|uantity  of  lif?ht  transmitted  by  the  red  and  green  roundels  is 
from  25  per  cent,  to  35  per  cent,  of  the  original  source,  for  the  yellow 
85  per  cent,  to  45  per  cent. 

Signal  observations  nuist  be  made  by  the  engineman  at  a  sufficient 
distance  witliin  wliicli  to  control  his  train. 


Switch  Lamp. 


^Vitll  the  ordinary  brakes,  seventy  pounds  trainline  pressure,  a  six- 
car  train  running  .seventy  miles  an  hour  can  be  stopped  inside  of  2.000 
feet,  approximately  1,900  feet,  and  when  the  high-speed  brake,  110 
pounds  trainline  pressure,  is  used,  the  train  can  be  stopped  within 
1,527.25  feet. 

It  will  be  seen  that  tlie  signitieanee  of  the  signal  must  be  determined 
at  not  much  less  than  one-half  mile  (2,640  feet),  as  a  few  seconds  are 
necessary  foi-  the  engineman  to  shut  off  his  steam  and  apply  his  air, 
and  in  each  one  of  these  seconds  a  ti'ain  traveling  seventy  miles  an 
honi'  is  covering  |)fact icnlly  lOM  feet. 

.\.   11.   Kudd.  Signal    j-lngineei-  of  the   Pennsylvania   Kaili'oad  Com- 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5055 


paiiy,  st.itt's:     "We  allow  .'}.30()  feet  for  .stoi)j)iii<jr  a  tcaiii  a1   7<»  miles 
per  hour  under  all  eonditions." 

There  is  no  ijuestion  that  next  to  tin-  necessary  practical  knowledge 


B 


Cross-section    of   Lenses   Used   in    Semaphore   Lamps   in   Kaihvay   Signaling.      A, 
Optical  Lens;   B,  Wide-angle  Lens. 

of  his  engine  the  vision  and  color  preception  of  the  engineiiian  are  the 
most  imi)ortant. 


FACTORS  INTERFERING  WITH  THE  VISIBILITY  OF  SIGNALS. 

Tile  atmospheric  conditions  interfering  with  the  visibility  of  marine 
signals  are  often  sufficient  to  completely  obscure  them  from  view,  but 
vessels  not  being  of  necessity  held  to  a  particular  course  as  with  a 
train  eau  receive  and  give  warnings  by  means  of  whistles,  bells,  etc., 
etc.  Fog  is  particularly  dangerous,  as  the  rays  of  long  wave  length 
are  the  only  ones  which  can  penetrate  it  and  an  individual  with 
abnormal  color  vision  having  a  shortening  of  the  red  end  of  the 
spectrum  would  be  unable  to  detect  the  presence  of  any  light  made 
up  of  wave  lengths  which  escape  being  absorbed  by  the  fog.  Also 
those  who  confuse  red  and  green  would  be  unable  to  detect  a  green 
light  where  atmospheric  conditions  were  such  as  to  filter  out  the  blue, 
green,  and  yellow  rays  and  only  allow  the  orange  and  red  rays  to  pass. 

Conditions  existing  about  an  engine,  such  as  the  escape  of  st^^im 
when  an  injector  is  used,  when  the  whistle  is  blown,  from  leaking 
valves  or  connections,  from  the  poorly  packed  piston  rods  of  air  pumps, 


5056  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

cvliiidcrs,  ;iii(l  slcjiiii  clicsts,  will  often  com j)|c1c|y  ciiN'clop  the  t'llgine 
Jiiul  cal).  Stcjmi  Jiiid  soot  Iroiii  the  smoke  .staek  arc  oftvn  blown  hack 
ajraiiisl  the  eal)  wiiidows,  covering  them  with  moisture  and  dirt  and 
makiiii;'  it  next  to  impossilile  to  see  tlii'ough  them,  to  say  nothing  of 
obtaining  a  view  of  anything  through  the  condensed  steam  and  smoke. 
Tiiis  is  especially  true  in  i)a.ssing  through  tunnels  and  under  the  via- 
ducts 01'  hi-idges  entering  the  raili'oad  yai-ds  of  large  cities;  where 
there  are  many  moving  engines  and  trains,  all  signals  must  be  closely 
watched.  In  freezing  weather  the  escaping  steam  Ls  especially  bad,  as 
the  windows  are  coated  with  ice,  and  vision  through  them  is  out  of 
the  (juestion.  The  dust  raised  by  i)assing  trains  often  coats  the  win- 
dows, especially  if  they  are  damp  from  escai)ing  .steam;  the  engine- 
man's  position,  being  on  the  I'ight  side,  escapes  most  of  this,  however, 
on  roads  which  run  theii-  trains  right-handed  on  double  tracks.  The 
cloud  I'aised  from  ])loughing  through  snow  dril't.s  shuts  off  all  vision 
l"()r  the  time.  Some  considerable  complaint  is  made  of  the  drive  wheels 
of  the  engine  throwing  mud  and  dirt  on  the  front  windows  in  moist 
weather. 

The  glare  from  tht'  furnace  door  when  the  engine  is  stoked  makes 
the  recognition  of  night  signals  very  difficult.  There  is  an  iron  shield 
above  the  furnace  door  on  the  engineman's  side,  which  protects  him 
somewhat.  Many  enginemen  have  their  seats  curtained  off  to  relieve 
them  from  this  glare.  After  looking  into  this  glow  from  the  position 
of  a  fireman  during  the  time  required  to  shovel  in  five  or  six  shovels 
of  coal,  it  is  an  utter  impossibility  for  a  novice  to  read  a  signal. 
Firemen  .state  that  they  cannot  even  see  their  steam  gauge  for  several 
seconds  after  stoking,  and  when  one  takes  into  consideration  that  from 
three  to  ten  tons  of  coal  are  handled  in  a  two  to  five  hours'  run,  there 
is  not  much  let-up  from  looking  into  the  fire  box,  and  when  this  is 
done  daily  for  five  or  six  years,  or  even  longer,  before  a  fireman  can 
expect  to  become  an  engineman,  it  must  be  a  good  pair  of  eyes  that 
can  stand  it,  without  some  protection. 

The  terrific  glare  from  the  intense  light  of  acetylene  and  electric 
headlights,  when  running  against  them  on  double  track  roads  very 
seriously  interferes  with  the  recognition  of  color  signals.  The  diverg- 
ing rays  of  an  intense  headlight  completely  obliterates  the  less  lumi- 
nous signal  lights,  such  as  classification  signals.  The  scotoma  pro- 
duced by  a  few  seconds'  regard  of  these  sources  of  light  often  lasts 
several  minutes.  Phantom  signals,  the  result  of  reflection  from  the 
glass  in  the  semaphores,  are  complained  of  in  time  of  sleet,  snow,  fog 
or  rain ;  the  reflection  from  these  elements  prevents  observation  ahead. 
Fusees  cannot  be  seen  under  the  ravs  of  the  electric  arc. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5057 

The  constant  .j;iniii<r,  witli  the  swayinjr  and  rolling;  of  an  engine 
traveling  at  a  high  rate  of  speed,  is  another  factor  in  making  signal 
reading  difficult. 

The  supervision  of  an  engine  takes  no  small  part  of  an  engineman's 
time  and  attention,  and  his  duties  are  far  more  than  sitting  on  a  .seat 
and  watching  for  signals.  This  is  especially  true  when  there  is  any 
troul)le  with  the  various  ineclianisms  under  his  care. 

Certain  atmospheric  conditions  are  not  only  a  source  of  great 
annoyance  in  reading  signals,  ])ut  often  completely  obscure  them  at  a 
distance  sufficient  within  whicii  to  control  a  train.  Fog,  snow,  mist 
antl  rain  take  precedence  in  the  order  given,  and  when  it  is  necessary 
for  better  vi.sion  to  have  the  head  out  of  the  cal)  window  the  impinging 
of  fine  particles  of  snow,  mist  or  rain  against  the  eyea  blinds  one 
almost  instantly.  The  force  of  the  wind  when  running  at  a  high  rate 
of  speed  causes  the  tears  to  flow  and  ])lurs  the  vision  after  a  very 
short  exposure.  Night  (illuminated)  signals  are  usually  seen  at  a 
greater  distance  than  the  day  (position)  signals  in  these  atmospheric 
conditions. 

Atmosphere  laden  with  watery  vapor  such  as  fog  is  a  great  factor  in 
absorbing  light,  and  while  the  greatest  absorption  is  at  the  red  end  of 
the  spectrum  witii  a  gradual  decrease  towards  the  violet  end,  light 
having  a  preponderance  of  blue  rays  such  as  an  arc  light  has  a  much 
shorter  range  in  fog  than  a  light  source  having  a  greater  intensity  in 
the  red  end  of  the  spectrum,  such  as  a  kerosene  flame.  There  are  no 
recorded  data  as  to  range  reduction  caused  by  fog,  but  observation  has 
led  to  the  conclusion  that  the  range  of  a  signal  is  frequently  cut  down 
to  l/20th  of  the  clear  weather  range,  while  in  dense  fog  the  reduction 
is  probably  much  more. 

Rain  and  hail  do  not  interfere  as  much  witii  tlie  range  of  a  signal 
as  other  atmospheric  conditions;  however,  tests  conducted  by  the 
German  Light  House  Board  showed  30  per  cent,  reduction,  on  an 
average,  in  rainy  weather. 

Snow  interferes  greatly  by  accumulating  upon  the  roundels  and 
lenses  and  markedly  reduces  the  range  of  a  signal  if  the  air  is  full 
of  flakes. 

Dust  and  smoke  in  the  atmosphere  tend  to  shift  the  hue  of  a  light 
toward  the  red  end  of  the  spectrum  as  they  interfere  with  the  trans- 
mission of  the  shorter  wave-lengths.  Dense  smoke  has  an  effect  upon 
the  range  of  a  light  similar  to  fog.  As  may  naturally  be  expected 
dirty  roundels,  lenses  or  reflectors  greatly  reduce  the  range  as  well  as 
change  the  saturation  of  the  color.  Alignment  of  the  semaphore  lamp 
with  reference  to  the  track  has  much  to  do  with  the  distance  a  signal 

Vol.  VII— 14 


5058  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

iiia\'  !»(•  scrii.  Tlic  lens  is  so  (lonstructcd  as  to  coiivpi-'^c  tlic  rays  of 
li^'lif  lalliiii:  upon  it  in  a  i-rlativdy  pai-alld  l)('aiii,  a  slight  dcviatiou 
ill  tilt'  adjust iiK'iit  of  a  lamp  will  throw  tho  axis  of  the  heam  off  the 
li-ack  as  Well  as  icduce  the  amount  of  light  projected  in  the  desired 
ilirection. 

Neighhoring  ligiits  w  liicii  iiuiy  tic  mislakcn  foi*  signal  lights  are  kero- 
sene, gas,  incandescent  (carbon),  arc  and  acetylene  lamps.  This  is 
more  liable  to  occur  if  there  is  smoke  or  dust  in  the  air. 

Dusk  and  early  dawn  are  times  of  day  when  signals  are  most  hard  to 
recognize.  There  is  not  sutificient  daylight  to  determine  the  position 
signals  and  what  daylight  there  is  seriously  interferes  with  recognition 
of  the  night  signals. 

]\Iany  of  the  above  conditions  not  only  reduce  the  range,  but  diminish 
the  intensity  and  change  the  hne  of  night  signals  to  such  an  extent 
that  men  with  even  slight  defects  in  their  color  perception,  who 
easily  pass  the  average  examiner,  are  very  liable  to  mistake  the  indica- 
tion. 

The  foreground  and  the  backgi-ound  of  day  signals  make  a  great 
difference  with  their  being  easily  seen.  A  sky  background  is  the  ideal. 
Signals  displayed  on  roads  running  through  mountainous  country,  and 
especially  where  there  are  many  curves  in  valleys,  are  very  hard  to 
distinguish  from  the  elevated  position  on  either  side.  AVoods  stripped 
of  their  leaves  or  in  full  foliage,  the  proximity  of  buildings  and 
bridges — all  tend  to  make  the  position  of  signals  less  distinct,  while 
the  cross-bars  of  telegraph  poles  are  very  confusing.  I'ndoubtedly 
night  signals  are  much  easier  to  read,  as  the  contrast  is  so  much 
greater,  but  as  to  their  being  seen  any  farther,  or  so  far,  atmospheric 
conditions  being  the  same,  is  questionable. 

The  reflections  from  snow,  from  a  body  of  water  or  from  the  solid 
green  of  foliage,  running  toward  the  sun  when  near  the  horizon,  the 
shimmer  in  the  atmosphere  on  hot  summer  days,  all  are  features  which 
add  iiiuch  to  the  dit'ticnlty  of  seeing  signals.    ' 

RULES    AND    REGULATIONS    GOVERNING    EXAMINATIONS    OF    VISION    IN    THE 
ARMY,  NAVY  AND  TRACTION  SERVICES. 

ExamUtalhoH  as  to  the  visual  acuity  and  color  sense  of  all  applkonts 
for  army,  navy  and  railway  services  is  practically  universal.  From 
repoi-ts  ol)tained  in  1!)10  on  color- vision  tests  in  use  in  the  principal 
maritime  count i-ics  of  the  world  for  their  merchant  service,  it  appears 
that  (Jreece  and  Italy  alone  have  no  color-vision  test;  while  the  Holm- 
gren wool  Test,  cither  alone  or  as  an  alternative  or  sui)i)lement  to  other 
tests,  is  used  in  the  I'liited  King(l(tin.  Austi'ia,  France.  Germany,  the 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5059 

NollK'rlaiuls.  Norway,  Russia,  Sweden,  and  Hie  (Inited  States.  Japan 
also  employs  a  wool  test,  tliouj^li  not  apparently  one  based  on  Holm- 
gren 's  principles. 

The  following  are  extracts  from  the  rules  issued  by  the  AVar  Depart- 
ment for  the  examination  of  recruits  for  the  United  States  Army. 

The  visual  acuity  of  tlie  applicant  will  l)e  ascertained  and  recorded 
in  accordance  witli  special  instructions  issued  for  that  purpos<:>  from 
the  War  Department.  Test  each  eye  separately,  carefully  covering 
the  other  eye  with  a  piece  of  cardboard.  Especial  care  should  be  taken 
to  see  that  the  vision  in  the  covered  eye  is  completely  occluded. 

Examine  the  eyes  for  chronic  inflannnations.  triangular  or  fan- 
shaped  growths  on  eyeball  with  the  apex  encroaching  upon  the  cornea 
(extensive  pterygium),  marked  squint,  and  drooping  of  the  upper  lid. 

The  vision  of  the  applicant  will  be  tested  as  prescribed  in  paragraph 
9  of  these  rules.  Unless  a  diiferent  rule  be  established  by  instruc- 
tions from  the  War  Department,  any  case  having  a  visual  acuity  of 
20/30  or  less  in  either  eye  will  be  examined  further  to  determine  the 
exact  cause  of  the  error. 

The  following  mininnim  visual  requirements  for  recruits  are  an- 
nounced and  will  supersede  such  requirements  of  the  Epitome  of  Trip- 
ler's  Manual  as  are  in  conflict  therewith : 

For  the  line  of  the  Army  and  for  the  Signal  Corps:  20/40  for  the 
right  eye  and  20/100  for  the  left  eye,  provided  that  no  organic  dis- 
ease exists  in  either  eye. 

a.  Recruits  may  be  accepted  for  the  line  of  the  Army  when  unable 
with  the  right  eye  to  read  correctly  all  of  the  letters  on  the  20/40 
line,  provided  that  they  are  able  to  read  some  of  the  letters  on  the 
20/30  line. 

For  the  Ordnance  Department  and  for  the  Hospital  Corps :  20/70 
in  each  eye,  correctible  to  20/40  with  glasses,  i)rovided  that  no  or- 
ganic disease  exists  in  either  eye. 

Tests  for  color-blindness  will  be  made  in  all  cases  in  which  such 
tests  are  required  by  orders  or  instructions  from  the  War  Depart- 
ment. 

Each  eye  will  be  inspected  for  evidence  of  muscular  or  other  defect 
and  for  disease,  the  lids  being  everted  and  examined  for  trachoma. 

Color-blindness  is  a  cause  for  rejection  only  in  the  case  of  applicants 
for  enlistment  in  those  branches  of  the  service  for  which  color-blind- 
ness is  specifically  declared  by  orders  or  instructions  from  the  War 
Department  to  be  disqualifying. 

Asthenopia  accompanying  any  ocular  defect  is  a  cause  for  rejection 
for  any  branch  of  the  service. 


5060  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Coiiiplctc  or  cxlciisivc  destruction  of  the  lids,  disfiguring  cicatrices, 
iidlicsioii  (if  till'  lids  to  rjicli  other  or  to  the  eyeball,  marked  inversion 
or  i'vcrsiou  of  the  eyelids,  trichiasis,  ptosis,  ])lepharospasm.  and 
chronic  blepliai-itis  are  causes  for  rejection. 

Epiphora  and  chronic  dacryocystitis  are  causes  for  rejection. 

Chronic  conjunctivitis,  acute  or  contagious  trachoma,  and  pterygium 
extending  uj)on  the  cornea  are  causes  for  rejection. 

Chronic  kei-atitis,  deep  ulcers  of  the  cornea,  staphyloma,  and  corneal 
opacities  encroaching  on  the  pupillary  area  and  reducing  the  acuity  of 
vision  below  the  standard  are  causes  for  rejection. 

Irregularities  in  the  foiiii  of  the  iris  and  anterior  or  posterior  .syne- 
chijy  sufificient  to  reduce  the  visual  acuity  below  the  standard  are  causes 
for  rejection. 

Opacities  of  the  lens  or  its  capsule,  sufficient  to  reduce  the  vision 
])elow  the  standard,  and  progressive  cataract  of  any  degree  are  causes 
for  rejection. 

Extensive  coloboma  of  the  choroid  or  iris,  alisence  of  pigment,  exten- 
sive or  pi'ogressive  choroiditis  and  glaucoma  are  causes  for  rejection. 

Retiintis,  detachment  of  the  retina,  neuroretinitis  and  optic  neuritis, 
and  atrophy  of  the  optic  nerve  are  causes  for  rejection. 

Loss  or  disorganization  of  either  eye  and  pronounced  exophthalmos 
are  causes  for  rejection. 

Pronounced  nystagmus  and  permanent  or  well-marked  strabismus 
are  causes  for  rejection. 

The  following  methods  for  determining  and  recording  acuity  of 
vision  and  color-sense  are  prescribed  for  the  army  and  will  be  fol- 
lowed whenever  practica])le  in  the  examination  of  applicants  for  ad- 
mission to  the  Ihiited  States  Military  Academy  and  of  applicants  for 
commission,  promotion  and  in  any  case  of  disease  or  disability  of 
offi:cers  or  enlisted  men  where  these  senses  may  be  affected : 

In  case  of  applicants  for  enlistment  the  existing  methods  of  examina- 
tion will  be  continued  at  the  general  recruiting  station,  but  the 
methods  herein  prescribed  will  be  applied  at  the  recruit  d(^pots,  depot- 
posts,  and  other  garrison  posts. 

The  test-type  should  be  placed  in  a  good  light,  about  the  height  of 
the  eye.  If  the  room  is  not  well  ligiited  by  daylight,  an  artificial  liglit 
with  a  reflector  should  l)e  used,  as  it  will  be  more  uniform. 

Place  the  candidate  or  patient  with  back  to  the  window  or  source 
of  light,  at  a  distance  of  20  feet,  or  G  meters,  from  the  type. 

Examine  each  eye,  covering  the  otiier  eye  with  a  card  or  an  opaque 
disc  in  a  trial  frame.  The  hand  should  not  be  used  for  the  purpose,  a§ 
it  tcmporai-ily  l)lni"s  vision, 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5061 

The  ri^jlit  eye  should  ordinarily  be  examined  lirst  hefore  the  candi- 
date heeoiiies  familiar  with  tlu;  types. 

The  candidate  slioukl  be  directed  to  read  the  test-type  from  the  top 
of  the  card  down  as  far  as  he  can  see,  and  his  acuity  of  vision  recorded 
for  each  eye  with  the  distance  of  20  feet  as  numerator,  and  the  proper 
distance  of  tlie  lowest  line  he  can  read  correctly  as  the  denominator 
of  a  fraction. 

If  the  acuity  of  vision  is  less  than  20/20  and  is  corrected  by  glasses, 
the  acuity  without  glasses  and  with  glasses  is  given  and  the  correct- 
ing formula  is  noted  as : 

Vision,  R.  K.  20/40,  corrected  to  20/20  by— I.  D.  cy.  180°. 

Vision,  L.  E.  20/100,  corrected  to  20/30  by— .50  D.  cy.  180°— 2.00 
D.  S. 

If  he  cannot  read  the  type  at  any  distance,  the  distance  at  which 
he  can  count  lingers  is  recorded  as :  Vision  R.  E.  can  count  fingers  at 
20  inches. 

If  he  cannot  count  fingers,  the  distance  at  which  a  light  can  be  dis- 
tinguished is  recorded. 

If  a  light  cannot  be  distinguished  he  is  recorded  as  blind. 

As  the  types  are  memorized  easily,  they  should  not  be  left  where 
applicants  can  read  them,  and  it  is  well  in  examining  the  left  eye  to 
direct  that  the  lines  be  read  from  right  to  left  and  to  use  new  type  in 
case  of  doubt,  or  to  expose  one  letter  at  a  time  by  means  of  a  small 
opening  in  a  card  or  sheet  of  paper. 

A  more  correct  idea  may  be  obtained  by  having  the  candidate  read 
from  the  top  of  the  card  down.  Do  not  direct  him  to  read  the  lowest 
line  he  can  see,  and  always  use  a  card  having  type  from  10  feet  to 
200  feet. 

The  distance  of  20  feet  should  not  ordinarily  be  reduced,  as  a  shorter 
distance  leads  to  some  error  from  the  action  of  the  accommodation 
and  from  the  fact  that  the  type  may  then  be  within  the  far  point  of 
moderate  myopia. 

The  method  of  Holmgren  (see  page  244:8,  Vol.  IV,  of  this  Encyclo- 
pedia) is  used  for  the  detection  of  color-hlindness  and  the  tests  should 
be  applied  to  all  persons  examined  for  admission  to  the  army  and  the 
result  recorded. 

In  recording  the  results  of  the  examination  the  terms,  "color-sense 
normal,"  "color-sense  feeble,"  "incompletely  color-])liiid. "  "com- 
pletely red-blind,"  "completely  green-blind,"  "completely  violet- 
blind"  and  "completely  color-blind"  (all  colors)  will  be  used. 

The  following  is  extracted  from  the  regulation  of  the  Bureau  of 
Public  Health  Service,  relative  to  making  physical  examination : 


5062  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

'J'Ik!  eyesight  will  l)i'  ttstcd  by  the  test  types  furnished  by  the 
Jiurcau,  and  the  Jloliiigreii  worsted  test  will  be  employed  iu  testing 
for  eolor-sense.     The  test  must  be  made  for  eaeli  eye  separately. 

1.  A  candidate  must  have  at  least  20/40  uncorrected  vision  in  one 
eye  and  at  least  20/70  in  the  other,  and  corrected  vision  must  equal 
20/20  in  one  eye  and  at  least  20/40  in  the  other. 

2.  The  examiner  will  observe  that  the  Snellen  charts  used  in  the  test 
are  exhibited  to  the  candidate  at  a  height  of  4  or  5  feet  from  the 
ground,  and  at  a  distance  of  20  feet  exactly,  and  this  distance  must  be 
maintained  throughout  the  test.  A  good  light  must  fall  on  the  chart, 
and  during  the  tests  charts  with  different  lettering  should  be  emiDloyed 
in  such  a  manner  that  the  candidate  cannot  become  familiar  with 
the  letters  on  the  various  lines. 

3.  Each  eye  should  be  tested  separately  by  carefully  excluding  the 
eye  which  is  not  being  examined  by  holding  a  card  before  it.  No 
pressure  should  be  exerted,  nor  should  the  excluded  eye  be  closed. 

4.  As  soon  as  the  examiner  has  ascertained  the  lowest  line  which 
the  candidate  has  been  able  to  read,  the  vision  should  be  recorded 
in  the  form  of  a  fraction,  the  numerator  of  which  wall  represent  the 
distance  at-  which  the  test  was  made,  i.  e.,  20  feet;  the  denominator, 
the  number  on  the  chart  opposite  the  last  line  which  was  read. 

5.  The  fellow  eye  is  now  similarly  tested. 

6.  During  the  performance  of  the  test  the  lids  must  remain  natu- 
rally open,  squinting  being  prohibited.  In  the  event  that  the  candidate 
is  unable  to  read  all  the  letters  on  the  line  designated  as  his  minimum 
vision,  he  will  be  passed,  provided  he  is  able  to  read  three  of  the 
letters  on  the  next  smallest  line  with  both  eyes  directed  on  the  chart. 

Test  for  color-hlindness. — The  entire  set  of  worsteds  should  be 
spread  out  on  a  table  before  the  candidate  in  good  da^dight.  Each  set 
of  Holmgren's  worsteds  contains  three  large  skeins:  No.  1,  green;  No. 
2,  rose  pink ;  and  No.  3,  red. 

Test  No.  1.  Place  the  large  green  test  skein  before  the  candidate,  at 
a  distance  of  about  2  feet  from  the  others,  and  request  him  to  select 
from  the  heap  of  skeins  all  that  most  resemble  the  test-skein  and  place 
them  beside  it.  The  whole  test  should  be  based  only  upon  a  com- 
parison of  colors,  and  in  making  it  no  color  should  be  named.  In 
the  first  place,  it  is  necessary  that  the  candidate  should  thoroughly 
understand  what  is  required  of  him — that  is,  that  he  should  search 
the  pile  for  the  skeins  making  an  impression  on  his  color-sense,  inde- 
l)endent  of  any  name  he  may  give  the  color,  similar  to  that  made  by 
the  sample.  He  should  be  informed  that  there  are  no  two  skeins 
exactly  alike,  and  that  th(^  only  question  is  the  resemblance  of  the 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  50G3 

color.  Til!  must  therefore  oudcaAor  to  find  .something  simihir  of  the 
same  shade,  something  lighter  and  darker  of  the  same  eolor.  If  the 
persoji  being  examined  does  not  succeed  in  understanding  tliis  by  a 
verbal  explanation,  the  person  making  the  examination  must  make  the 
trial  by  searching  for  the  skeins  and  placing  them  by  the  sample  skein, 
thereby  showing  in  a  practical  manner  what  is  meant  by  shade,  and 
then  restore  all  skeins  to  the  pile  except  the  sample. 

With  test  No.  1,  the  completely  color-blind,  whether  to  red  or  green, 
will  select,  with  or  without  the  green,  some  confusion  colors,  such  as 
yellows,  fawns,  or  grays. 

This  examination  must  continue  until  the  candidate  has  placed  near 
the  samj)le  all  the  other  skeins  of  the  same  shade  as  the  sample,  or 
else,  with  these  or  separately,  one  of  several  skeins  of  the  class  corre- 
sponding to  the  confusion  colors.  The  candidate  who,  while  not  finally 
placing  the  confusion  colors  beside  the  test-skein,  evinces  a  manifest 
disposition  to  do  so,  has  a  feeble  chromatic  sense,  and  is  partially  color- 
blind. 

To  ascertain  the  kind  and  degree  of  color-blindness  present,  test 
No.  2  should  be  used. 

Test  No.  2.  Thoroughly  mix  all  tiie  colors  together.  Then  place 
the  large  rose  skein  a  distance  of  about  2  feet  from  the  pile  of  worsteds, 
and  request  the  candidate,  as  before,  to  select  from  the  pile  and  place 
with  the  sami)le  all  that  look  to  him  to  be  shades  of  that  color,  lighter 
or  darker,  until  all  of  the  same  shades  have  been  placed  by  the  sample, 
or  else,  simultaneously  or  separately,  one  or  several  of  the  confusion 
colors  have  been  placed  b}^  it. 

He  W'ho  confuses  the  colors  in  this  test,  selecting  either  the  light 
or  deep  shades  of  blue  and  violet,  especially  the  deep,  with  or  without 
purple,  is  completely  red-blind. 

If  he  selects  the  light  or  deep  shades  of  one  kind  of  green  or  gray, 
either  with  or  without  purple,  he  is  completely  green-blind. 

The  fact  that  many  green-blind  select  in  this  test,  besides  gray  and 
green  or  one  of  these  colors,  also  bright  l)lue,  has  led  to  misunderstand- 
ing. Some  have  from  this  concluded  that  red-and-green-blindness 
may  exist  together  in  the  same  individual.  This  conclusion  is  not 
correct.  Red-and-green-blindness  are  two  sharply-defined  species. 
The  characteristics  or  sign  with  green-blindness  is  confusing  the  rose 
with  gray  or  green,  or  both.  This  confusion  is  the  point  to  be  deter- 
mined. 

Test  No.  3.  The  large  red  skein  is  presented  to  the  candidate ;  it 
is  necessary  to  liave  a  vivid  red  color.     The  red- blind  will  choose,  be- 


3064  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

siili's  till'  H'd,  ^M'l'cii  iiiid  brown  sluulcs  wliicli  to  tlu-  normal  sense  seem 
darker  than  r»'<l. 

The  gi'ecii-ltlind  will  seleet  green  and  Iti-own  shades  whii-li  appear 
lighter  than  red. 

Any  one  of  the  following  defects  will  be  sufficient  for  rejection,  viz. : 
Impaired  vision,  color-blindness,  chronic  disease  of  the  visual  organs. 

The  followuig  are  extracts  pertaining  to  vision  from  the  regulations 
and  instructions  in  relation  to  the  Physical  Examiiuition  of  litcruits 
for  Enlistment  in  tJie  Navy  and  Marine  Corps  (1912). 

No  person  other  than  a  medical  officer  shall  be  permitted  to  conduct 
any  part  of  a  physical  examination,  to  make  any  measurement,  or  to 
make  an  original  entry  on  any  medical  record  of  enlistment. 

Eyes  (absence  of  ciliae,  tarsal  redness,  obstructed  puncta,  corneal 
opacities,  adhesions  of  iris,  defective  vision,  color-blindness,  abnornml 
condition  of  conjunctiva^,  etc.). 

Eyes,  blue;  gray;  blue-gray;  yellow-gray;  hazel  (light-brown); 
brown;  dark-brown;  bicolored  (as  when  the  pupillary  border  is  of  a 
ditl'erent  color  from  rest  of  iris)  ;  also  state  when  the  two  eyes  are 
of  different  colors. 

]\Iedical  officers  on  recruiting  duty  shall  exercise  the  greatest  care 
and  thoroughness  in  conducting  the  physical  examination  of  persons 
presenting  themselves  for  enlistment  in  the  Navy  and  ^Marine  Corps. 
AVhile  the  instructions  are  applicable  in  general  to  all  physical  exam- 
inations, they  are  intended  to  cover  more  particularly  the  examina- 
tions of  applicants  presenting  themselves  for  original  enlistment. 

The  examination  for  visual  acuteness  is  of  the  utmost  importance, 
and  shall  be  conducted  b,y  the  medical  officer  with  the  greatest  care 
and  patience.  An  appreciable  percentage  of  men  are  the  subjects 
of  slight  visual  defects,  and  in  the  cases  of  many  of  those  present- 
ing themselves  for  reenlistment  and  enlistment  these  defects  may  not 
be  sufficiently  serious  to  disqualify  them  for  the  naval  service.  The 
ignorance,  stupidity,  or  fear  on  the  part  of  an  applicant  undergoing 
examination  should  be  taken  into  consideration  by  the  examining  sur- 
geon, and  nidcss  the  examination  is  conducted  with  care  and  delibera- 
tion an  ai)plicant  may  be  rejected  whose  vision  is  in  reality  good. 
Slight  errors  on  the  part  of  tlie  applicant,  such  as  misreading  a  P  or 
T  foi-  an  V.  pi-ovided  the  majority  of  the  letters  or  test  characters 
are  rea(J  with  facility,  uihmI  not  l)e  regarded  as  sufficient  cau.se  for 
rejection.  The  examination  shall  be  conducted  in  a  large,  well-lighted 
apartment,  and  the  test  cards  shall  be  placed  in  a  good  light.  The 
applicant  stands  at  a  distance  of  20  feet,  one  eye  being  tested  at  a 
time,  and  the  other  covered  by  a  card.     Vision  is  to  be  expressed  as 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  50G5 

a  fraction,  of  which  the  uuiucralor  sliall  be  the  distance  at  which 
Snellen's  2()-foot  test  can  be  determined,  and  tlie  denominator  20 
Xoi-mal  vision  (20/20)  for  each  eye,  tested  separately,  shall  be  re- 
(liiired.  hut  in  candidates  who  are  otherwise  physically  sound  a  mini- 
mum visual  acuteness  of  15/20  shall  suffice.  The  existence  of  several 
minor  defects,  combined  with  a  visual  acuteness  of  15/20  in  each 
eye,  shall  cause  the  rejection  of  the  a{)plicant. 

Color  perception  is  to  be  always  carefully  determined.  The  usual 
examination  is  by  Holmgren's  method. 

Special  disqualifications.  The  eye. — Loss  of  eye,  total  loss  of  sight 
of  either  eye,  conjunctival  affections,  including  trachoma,  entropion: 
opacities  of  the  cornea,  if  covering  a  part  of  a  moderately  dilated  pupil ; 
pterygium,  if  extensive;  strabismus,  hydrophthalmia,  exophthalmia, 
conical  cornea,  cataract,  loss  of  crystalline  lens,  diseases  of  the  lach- 
rymal apparatus,  ectropion,  ptosis,  incessant  spasmodic  motion  of  the 
lids,  adhesion  of  the  lids,  large  encysted  tumors,  abscess  of  the  orbit, 
muscular  asthenoi)ia,  ny.stagmus.  Any  aflFection  of  the  globe  of  the 
eye  or  its  contents ;  defective  vision,  including  anomalies  of  accommo- 
dation and  refraction ;  myopia ;  hypermetropia,  if  accompanied  by  as- 
thenopia, astigmatism,  amblyopia,  glaucoma,  diplopia,  color-blindness. 

Special  Order  Xo.  79.  As  it  is  important  that  no  men  be  employed 
as  gun  pointers,  who  are  materially  deficient  in  eyesight  it  is  directed 
that  all  candidates  for  this  position,  shall,  before  being  placed  in 
training,  be  referred  by  the  commanding  officer  to  the  medical  officer 
for  examination,  and  that  hereafter  no  man  shall  be  trained  as  gun 
pointers  who  cannot  read  with  the  right  eye  (or  the  left  eye  if  used  in 
aiming)  at  20  feet  the  line  in  Snellen's  test  card,  which  is  normally 
seen  at  15  feet — that  is  20/15  vision  and  a  minimum  of  20/20  shall 
be  required  with  the  eye  not  used  in  aiming. 

This  degree  of  visual  acuity  in  gun  pointers  is  deemed  necessary  in 
order  to  eliminate  those  men  having  ocular  defects,  which  would  tend 
to  prevent  continuous  accurate  aiming  during  a  considerable  period 
of  time. 

Before  each  record  target  practice  all  <|ualified  and  acting  gun 
pointers  shall  be  examined  for  acuity  of  vision  and  the  result  entered 
on  the  Gunnery  Record.  A  report  will  also  be  submitted  to  the 
Department. 

All  examinations  in  connection  witli  tliis  order  shall  be  carried  out 
with  the  test  card  well  illuminated. 

Rules  for  visual  examination  of  pilots,  masters  and  mates  of  the 
marine  service.  These  were  kindly  furnislied  by  W.  AVyman,  Surgeon 
General,  Public  Health  and  ^larine  Hospital  Sen'ice. 


5066  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

The  examinations  are  made  1)}  medical  officers  of  the  Public  Health 
and  Marine  Ilosi)ital  Service. 

Tlu'  niininiuiu  amount  of  vi.sual  capacity  required  for  an  a])plicant 
for  the  ]>osition  of  pilot  is  not  less  than  15/20  vision  in  both  eyes  (not 
inrhulin^^  errors  of  refraction  corrected  by  gla.sses). 

The  visual  acuity  for  i)ilots,  masters  and  mates  is  the  same. 

Any  red  or  green  color-blindness  is  sufficient  cause  for  rejection 
of  the  candidate. 

The  Holmgren  worsted  tests  are  employed  for  testing  color-sen.se, 
and  the  eyesight  is  tested  by  the  use  of  the  Snellen  test-type,  each  eye 
being  tested  separately. 

Lantern  tests  are  not  used  in  addition  to  the  Holmgren  worsted  test. 

The  following  is  taken  from  the  General  Rules  and  Regulations 
prescribed  by  the  Board  of  Supervising  Inspectors,  Department  of 
Commerce,  Steamboat  Inspection  Service : 

Candidates  must  have  normal  color-sense.  (No  method  of  test- 
ing color-sense  is  given  but  as  the  examinations  are  made  b}'  surgeons 
of  the  U.  S.  Public  Health  Service,  the  methods  described  above  are 
probably  used.) 

Candidates  must  have,  without  glasses,  at  least  20/40  vision  in  one 
eye  and  at  least  20/70  in  the  other.  Vision  with  glasses  must  be  at 
least  20/20  in  one  eye  and  at  least  20/40  in  the  other.  If  a  candidate 
has  at  least  20/20  in  one  eye  and  at  least  20/40  in  the  other,  without 
glasses,  the  examination  for  visual  acuity  need  not  be  carried  further. 

Officers  of  the  Naval  Militia  who  are  applicants  for  license  as  mas- 
ters or  pilots  of  steam  vessels  of  the  Naval  iMilitia,  after  passing  an 
examination  for  color-blindness,  may  be  examined  by  the  inspectors 
as  to  their  knowledge  of  the  pilot  rules  and  handling  of  vessels;  and 
if  the  applicant  be  found  qualified  in  the  judgment  of  the  inspectors, 
he  may  be  granted  a  special  license  as  master,  mate  or  pilot  on  such 
vessels  on  the  waters  of  the  district  in  which  such  license  is  granted  and 
for  no  other  purpose. 

No  original  license  as  master,  mate  or  pilot  of  any  vessel  propelled 
in  whole  or  in  part  by  steam,  gas,  fluid,  naphtha,  also  vapor,  electric 
or  other  light  motors,  or  master  or  mate  of  said  vessels,  shall  be  granted 
except  on  the  official  certificate  of  a  surgeon  of  the  Public  Health  and 
Marine  Hospital  Service  that  the  applicant  is  free  from  the  defect 
known  as  color-blindness.  No  renewal  of  license  shall  be  gi-anted 
to  any  officer  of  the  classes  named  who  has  not  been  previou.sly  exam- 
ined and  passed  for  color-blindness. 

Any  person  requiring  examination  for  color-blindness  who  is  living 
at  a  distance  of  100  miles  or  more  from  a  surgeon  of  the  Public  Health 


EYES  OP  SOLDIERS,  SAILORS,  ETC.  5067 

and  Marine  Hospital  Service  may  be  examined  for  color-blindness  by 
any  repntal)le  i)hysician ;  and  the  physician  sliall  t'uniisli  a  duplicate 
report  of  the  examination  made  upon  the  regulation  blanks,  one  copy 
of  which  sliall  be  furnished  the  applicant  and  the  other  sent  to  the 
local  inspectors  of  steam  vessels  to  whom  the  applicant  shall  apply 
for  such  original  or  renewal  of  license. 

Requirements  of  the  British  Naval  and  Marim  Service.  The  British 
Admiralty  uses  for  detecting  color-blindness  the  Edridge-Green  classi- 
lication  test,  with  the  use  of  the  Edridge-Green  lantern.  The  final 
test  in  ease  of  appeal  being  the  Edridge-Green  spectrometer. 

The  English  Board  of  Trade  Tests :  A  committee  was  appointed 
by  the  English  Board  of  Trade  in  1910  "to  inquire  what  degree  of 
color-blindness  or  defective  form  vision  in  pei-sons  holding  responsible 
positions  at  sea  causes  them  to  be  incompetent  to  discharge  their  duties, 
and  to  advise  whether  any,  and  if  so,  what  alterations  are  desirable 
in  the  Board  of  Trade  sight  tests  at  present  in  force  for  persons  serving 
or  intending  to  serve  in  the  merchant  service  or  in  fishing  vessels,  or 
the  way  in  which  these  tests  are  applied. ' ' 

The  report  of  this  committee  made  in  1912  is  divided  in  five  parts. 
Part  1  deals  with  existing  regulations,  practice  and  the  results  ob- 
tained. Part  2  recounts  experiments  conducted  in  the  open  air. 
Part  3  considers  the  degree  of  defect  involving  incompetency.  Part  -1 
advises  certain  alterations.  Part  5  gives  an  account  of  various  experi- 
ments conducted  by  the  committee. 

The  committee  summarizes  its  recommendations  as  follows: 

1.  When  an  inquiry  is  held  regarding  a  shipping  casualty,  witnesses 
who  give  evidence  with  reference  to  colored  lights  should  alwaj's  be 
tested  for  form  and  color-vision. 

2.  The  approximate  limits  of  color  defect  compatible  with  efficiency 
should  provisionally  be  considered  to  lie  between  some  such  values  of 
the  illuminosity  ratio  as  1.5  and  0.85. 

3.  The  wool  test  should  be  modified;  (a)  by  substituting  a  dark- 
brown  skein  for  the  third  (deep-red)  test  skein  at  present  in  use; 
(b)  dividing  the  skeins  into  specified  groups,  one  group  for  each  test 
skein,  and  requiring  a  candidate  to  divide  each  group  into  two  parts, 
those  which  resemble  in  color  the  test  skein  and  those  which  do  not. 

4.  That  the  lantern  suggested  by  the  committee  be  used  as  well  as 
tJie  wool  test. 

5.  It  is  unnecessary  to  reexamine  for  color-vision  a  person  who  has 
satisfactorily  passed  both  the  lantern  and  wool  test. 

6.  That  the  1911  standard  of  form  vision  be  adhered  to  (5/5  partly 
in  one  eye,  5/10  in  the  second  eye). 


5068  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

7.  Tlmt  ;iiiv  olliccr-  whose  vision  in  llic  Ix'tter  eye  is  less  tlian  5/10  be 
coiisidiTcd  to  he  incoinpctcnt. 

8.  Parents  and  ant lioril ics  of  ti-ainiii^^-sliips  siiould  be  advised  tbat 
the  eyesipbt  of  boys  adopting  the  sea  as  a  profession  should  be  exam- 
ined b.\-  aji  expert  (to  exclude  hyperopia  and  defects). 

!>.  That  the  local  tests  be  left  in  the  iiaiids  of  the  present  type  of 
examiners. 

10.  That  these  men  should  receive  a  careful  course  of  instruction. 

11.  That  a  distinction  be  drawn  l)etvveen  "appeal"  and  "referred" 
cases  of  failure  to  pass  tiie  local  tests. 

12.  That  an  oi)hthalmic  surgeon  be  added  to  the  present  Board  of 
Examiners  in  appeal  cases. 

Tlie  standard's  and  methods  for  determining  eolor-defects  in  Ger- 
man i/:  The  sole  method  of  examination  for  color-blindness  as  pre- 
scribed by  law  on  the  Gernmn  railways  and  in  the  army  and  navy  is 
Nagel's  plates. 

Regulations  of  the  Austrian  Navy  as  to  color  tests :  If  all  the  pseudo- 
isochromatic  plates  of  Stilling  (13  Edition)  are  read  correctly  and 
without  any  hesitation  at  the  prescribed  distance,  normal  color  vision 
is  assumed  and  further  examination  is  waived.  If  there  is  an  un- 
certainty or  incapability  of  deciphering  some  plates,  the  applicant 
is  rejected.  A  further  test  in  such  cases  is  made  with  Nagel's  plates 
to  determine  the  type  of  color  anomaly.* 

RAILWAY  REGULATIONS  OP  VISION  AND   COLOR  VISION, 

Reports  (see  Report  of  Committee  on  Color-Blindness,  Trans.  Ophth. 
See.  A.  M.  A.,  1914)  from  52  railways  representing  every  large  sys- 
tem of  the  United  States  and  Canada  show  without  exception  that  all 
roads  require  visual  examinations  and  use  the  Holmgren  worsted  test 
or  one  of  its  modifications  for  detecting  color  defects.  Eleven  railway 
systems  use  the  Thomson  stick  or  Thomson's  set  of  40  tagged  worsteds, 
as  reconnnended  by  the  American  Railway  Association  (1905).  The 
majority  use  the  full  Holmgren  set  of  tagged  worsteds  and  furnish 
blanks  to  record  the  numbers  chosen. 

There  is,  however,  no  uniformity  in  the  test-skeins  used.  Those 
originally  reconnnended  by  Holmgren  were  light-green,  rose  and  red. 
Some  roads  use  green  and  red  only,  others  green  and  rose.  The  ma- 
jority use  the  colors  as  originally  recommended.     Some  add  a  yellow 


*The  standards  and  nictliods  of  oxamination  for  color  defects  used  in  France, 
Norway,  Sweden,  Russia.  Spain  and  tlie  Netherlands  were  not  at  hand  at  the 
time  litis  report  was  written. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5069 

test-skt'in,  some  add  a  blue  test-skoiii  and  others  leave  out  the  rod  and 
add  yellow  and  blue  skeins. 

Directions  for  carrying:  out  the  wool  test,  with  few  exceptions,  are 
uniform  and  follow  fairly  well  IIolmj;i'en's  directions  which  make  it 
entirely  a  comparison  test. 

A  lantern  test  is  always  used  on  25  roads.  6  roads  use  a  lantern  lest 
in  special  cases  and  21  roads  never  use  a  lantern  test. 

Four  roads  employ  oculists,  29  local  surgeons  and  19  laymen  to 
make  the  examinations.  AVlien  the  examination  is  made  by  a  laynu\n 
every  doubtful  ease  is  referred  to  an  oculist  for  final  settlement. 

A  field  test  or  test  under  actual  working  conditions  is  used  occa- 
sionall}^  in  the  reexamination  of  old  employes. 

The  committee  on  Safety  Appliances  of  the  American  Railway 
Association  a  number  of  years  ago  reported  unanimously  on  "Rules 
Governing  the  Determination  of  Physical  and  Educational  Qualifica- 
tions of  Employes."  These  were  adopted  by  the  Association  on  April 
5,  1905. 

There  was  consideralile  leeway  allowed  in  these  rules.  This  un- 
doubtedly was  for  the  purpose  of  giving  the  various  roads  time  to 
swing  into  line,  as  too  decided  changes  could  not  be  expected  to  be 
adopted  at  once,  this  being  the  first  step  of  the  American  Railway 
Association  in  this  direction. 

The  rules  adopted  by  tlie  New  York  Central  System  February  1, 
1908,  are  the  most  compreiiensive,  thorough  and  fair  to  the  employes 
in  existence.     They  are  herewith  copied  in  full : 

Rule  1. — Each  person  selected  to  make  examinations  must  first  be 
examined  and  instructed  by  an  oculist  designated  by  the  Company. 

Rule  2. — Each  examiner  should  be  provided  with:  (a)  A  set  of 
Snellen's  test  types,  with  at  least  three  cards  of  each  size  of  letters 
shown  in  different  comliinations  (a  single  line  on  each  card),  for 
testing  acuteness  of  vision,  (b)  An  American  Railway  Association 
standard  reading  card  for  testing  near  vision,  (c)  A  Holmgren  or 
Tliomson  color-selection  test,  and  instructions  for  use  of  .same,  (d)  A 
Williams  lantern,  or  one  similarly  constructed,  and  instructions  for 
use  of  same,  (e)  A  pair  of  spectacles,  or  shade,  for  testing  each  eye 
separately,  (f)  A  triple  grooved  trial  franu>  with  one  pair  of  plus 
two  diopter  lenses,  one  pair  of  plus  one  diopter  lenses,  and  one  pair 
of  plane  glass  roundels,  (g)  Blank  forms  for  examinations,  and  certi- 
ficates. 

Rule  3. — Examinations  should  be  contlucted  in  a  room,  or  car,  in 
which  a  distance  of  twenty  feet  can  be  measured  from  test  type,  or 


5070  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

face  of  l.iiitiiii.  to  candidate;  shades  or  curtains  should  be  provided 
in  oi-ch'r  to  darken  tlie  room,  or  car,  for  the  lantern  test. 

llule  4. — In  testing  vision,  color-perception  and  hearing,  only  the 
person  to  be  examined  and  the  examiners  should  be  in  the  room  or  car 
at  tlie  time,  except  that  if  an  employe  so  desires,  he  shall  be  permitted 
to  call  in  another  employe  who  lias  successfully  passed  to  witness  the 
examination. 

Rule  5. —  (a)  The  result  of  each  examination  must  be  shown  in 
duplicate  on-  the  prescribed  form,  one  copy  to  be  preserved  for  refer- 
ence by  the  examiners,  the  other  to  be  forwarded  to  the  division  super- 
intendent for  inspection,  record  and  file,  (b)  Those  charged  with 
the  duty  of  making  examinations  on  each  division  must  keep  proper 
check  to  insure  reexamination  of  all  employes  when  due,  and  must 
see  that  all  employes  who  should  be  examined  by  an  expert  or  oculist 
under  the  rules,  are  required  to  take  such  examinations  promptly, 
and  that  all  glasses  to  be  used  by  employes  are  sent  to  the  oculist 
for  approval  as  per  rule  11.  (e)  Examiners  will  issue  to  each  person 
who  passes  a  satisfactory  examination,  a  certificate  to  that  effect,  and 
will,  if  desired,  furnish  employes  who  fail  to  pass,  a  written  statement 
of  their  rating  and  cause  of  failure,  (d)  Division  Superintendent 
must  report  to  the  General  Superintendent  all  cases  wherein  an  em- 
ploye should  be  examined  by  committee,  or  appears  to  be  disqualified, 
giving  full  information  as  to  result  of  examination,  (e)  Oculists  or 
experts  will  report  result  of  their  examinations  to  the  Division  Super- 
intendent. 

Rule  6. — All  persons  desiring  to  enter  the  service  (applicants)  must 
take  entrance  examination  witliout  the  use  of  glasses  for  distant  vision, 
excepting  Class  E. 

Rule  7. — A])i)li('ants  for  entrance  to  service  as  Enginemen,  Fire- 
men, Trainmen  or  Brakemen,  will  not  be  accepted  if  they  have  to  use 
glasses  for  near  vision.  Applicants  for  other  positions,  and  employes 
in  all  l)ranches  of  the  service,  may  use  glasses  for  near  vision  when 
undergoing  examination. 

Rule  8. — When  the  distant  vision  of  an  employe  can  be  improved 
])y  tlic  aid  of  glasses,  he  should  wear  them,  except  yard  brakemen,  who 
are  prohibited  from  doing  so. 

Rule  9. — All  employes  who  require  the  aid  of  glasses  for  distant 
vision  must  wear  them  at  all  times  when  on  duty  and  must  carry  a 
dui)licate  pair  for  use  in  case  of  emergency,  and  will  be  examined  with 
each  pair. 

Rule  10. — All  employes,  excepting  those  indoors,  who  are  permitted 
to  wear  glasses  for  distant  vision,  wlien  on  duty,  must  use  the  spec- 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5071 

tac'le  or  automobile  goggle  form.  There  is  no  objection  to  the  use  of 
automobile  goggles  fitted  with  ghiss  for  protection  of  the  eyes  in  engine 
or  freight  train  service.  Tlie  use  of  amber  glasses  by  Mremeu,  as  a 
guard  against  temporary  fire  blindness,  is  encouraged. 

Rule  11. — Glasses  of  all  kinds  must  be  ai)prove(|  In-  an  oculist  desig- 
nated by  the  Company. 

Rule  12. — Applicants  having  a  squint,  or  who  are  cross-eyed,  will 
not  be  accepted.  Examiners  who  suspect  a  case  of  double  vision  should 
use  some  simple  test  to  determine  its  presence. 

Rule  13. — Enginemen  who  have  less  than  20/30  vision  in  either  eye, 
without  glasses,  must  be  examined  by  an  expert  or  by  an  oculist  desig- 
nated by  the  Company. 

Rule  14. — Enginemen  in  Class  A,  who  fail  to  reach  required  stand- 
ard, must  be  examined  by  a  committee  of  two,  appointed  by  the  General 
Superintendent,  and  upon  recommendation  of  this  committee  they  may 
be  permitted  to  w^ear  glasses,  provided  their  combined  vision  can  be 
brought  to  20/20 ;  committee  to  recommend  service  to  which  they  may 
be  assigned. 

Rule  15. — Enginemen  in  Class  B,  whose  vision  without  glasses  is 
less  than  20/50,  and  either  eye  less  than  20/70,  or  nil,  must  be  exam- 
ined by  a  committee  of  two,  appointed  by  the  General  Superintendent, 
and  if  the  vision  by  the  aid  of  glasses  can  be  brought  to  20/30,  must 
wear  glasses;  committee  to  recommend  service  to  which  they  may  be 
assigned.     See  rules  13  and  16. 

Rule  16. — Enginemen  having  20/20  vision  in  one  eye  and  less  than 
20/70,  or  nil,  in  the  other,  must  be  examined  by  a  committee  of  two, 
appointed  by  the  General  Superintendent;  committee  to  recommend 
the  service  to  which  tliey  may  be  assigned. 

Rule  17. — Where  promotion  standard  is  not  specified,  employes  ap- 
plying for  transfer  from  one  kind  of  service  to  another,  or  being 
promoted,  must  pass  entrance  examination  of  class  they  desire  to  enter, 
except  that  those  who  have  been  in.iured  in  service,  or  who  have  been 
in  continuous  service  for  at  least  two  years,  may  be  transferred  to 
positions  as  hostlers,  switch  tenders  and  crossing  tiagmen;  also  from 
one  position  to  another  under  Class  E,  upon  passing  the  respective  re- 
examination standards. 

Rule  18. — An  employe  in  Class  C,  D,  E,  or  F.  who  has  been  in  con- 
tinuous service  for  a  period  of  not  less  than  fifteen  yeai*s,  and  who, 
through  diminution  of  vision,  or  muscular  imbalance,  fails  to  reach 
re({uired  standard,  will  be  considered  satisfactoiy  if  his  acuteness  of 
vision,  with  or  without  glasses,  reaches  the  maximum  standard  specified 
for  the  class  of  service  in  which  he  is  employed. 


5072  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Iviilr  1!>. — Tlic  trst  type  slioiild  hf  ill  ^'ood  light,  tlic  bottom  of  the 
ciivd  ;il)out  on  a  h-vcl  witii  the  eye.  Place  the  eaiididate  twenty  feet 
from  the  card  antl  ask  him  to  read  the  type  with  hotii  eyes  open,  then 
cover  one  of  his  eyes  with  a  card,  or  shaih',  held  firndy  against  the 
nose,  taking  care  not  to  let  it  press  the  eye-ball,  and  instruct  him  to 
read  with  the  other  eye  such  type  as  may  be  indicated.  Each  eye 
should  be  tested  separately,  (a)  Examiners  are  reminded  that  the 
normal-eyed  should  read  the  twenty-foot  (or  6  meter)  letters  at  20  feet, 
in  which  case  the  visual  power  should  be  expressed  by  the  fraction 
20/20.  Should  a  candidate  be  unable  to  read  the  twenty-foot  letters 
at  20  feet,  but  be  able  to  read  the  thirty-foot  letters,  result  should 
be  indicated  by  the  fraction  20/30.  If  he  can  only  read  the  forty-foot 
letters  record  should  be  20/40,  etc.  (b)  The  candidate,  as  provided  in 
Rule  No.  7,  must  he  able  to  read  the  print  in  paragraph  Xo.  2  of  the 
Standard  Card  at  a  distance  of  from  fourteen  to  eighteen  inches  to  pass 
the  test.  Further  tests  should  be  made  by  having  the  candidate  read 
written  train  orders. 

Rule  20. — Applicants  for  entrance  to  service  in  Classes  A  and  C, 
will  undergo  additional  test  to  ascertain  if  far-sighted  to  the  extent  of 
two  diopters.  Examiners  will  use  combinations  in  trial  frame  repre- 
senting plane  and  convex  lenses,  varying  the  test  so  that  a  candidate's 
former  experience  or  knowledge  obtained  from  others  may  be  value- 
less. If  an  applicant  reads  without  difficulty  the  twenty-foot  letters 
at  20  feet  through  convex  lenses  of  2D,  he  will  not  be  considered  satis- 
factory. 

Rule  21. — Examiners  will  adhere  to  instructions  laid  down  by  Holm- 
gren or  Thomson  in  using  color-selecting  test,  and  will  examine  the 
color-sense  of  each  eye  separately.  Further  examinations  will  be  made 
with  Williams  lantern,  or  one  similai'ly  constructed,  in  the  manner 
specified  by  Dr.  Williams. 

Rule  22. — No  applicant  will  be  accepted  into  the  serv'ice,  and  no 
employe  retained  in  any  of  the  classes  specified  in  following  standards, 
who  has  defective  color-sense. 

Rule  23. — No  employe  will  be  disqualified  from  service  by  reason 
of  defective  color-sense  without  j.n  examination  by  an  oculist  desig- 
nated by  the  Company. 

Rule  24. — In  examination  of  hearing  (which  will  be  with  human 
voice)  each  ear  will  be  tested  separately,  and  the  candidate^  should 
not  see  the  movement  of  examiner's  lip. 

Rule  25. — Applicants  for  entrance  to  service  must  lie  able  to  liear  and 
repeat  an  ordinary  conversation,  or  names  and  ninnbei-s  spoken  in  a 
conversational  tone,  at  a  distance  of  20  feet,  in  which  case  the  hear- 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5073 

iiig  sliould  be  expressed  by  the  fraction  20/20.  Where  eonversatiou  can 
be  heard  at  only  10  IVct,  the  hearing  should  be  expressed  by  the  frac- 
tion 10/20. 

liule  26. — Employes  will  not  be  retained  in  the  service  if  hearing 
is  less  than  15/20  in  one  car  and  5/20  in  the  other;  or  less  than  10/20 
in  each  ear. 

Rule  27. — Employes  included  in  the  standard  of  vision  must  be  re- 
examined as  follows:  (a)  All  classes  every  two  years,  (b)  Employes 
in  engine,  train  or  yard  service,  who  wear  glasses  for  distant  vision, 
enginemen  having  less  than  20/30  vision  in  either  eye,  and  other  em- 
ployes who  have  less  than  20/70  vision  in  either  eye,  must  be  exam- 
ined annually,  (c)  After  any  accident,  in  which  they  are  concerned, 
which  may  have  been  caused  by  defective  vision,  color-sense  or  hear- 
ing, (d)  After  any  serious  accident  or  illness  or  severe  infiammatiou 
of  the  eye  or  eyelids,  (e)  Before  promotion,  (f)  Employes  with 
hearing  less  than  20/20  in  either  ear  must  be  examined  semi-annually. 
Rule  28. —  (a)  Employes  in  Class  A  or  B,  who  are  examined  by  a 
committee,  shall  be  given  an  outside  or  field  test.  A  bracket  pole  with 
two  dolls  or  two  straight  poles  (spaced  the  same  distance  as  dolls  on 
the  standard  bracket  pole),  carrying  four  standard  semaphore  arms 
and  lights  wall  be  used.  A  clear  sky  back-ground,  tests  to  be  made 
standing,  (b)  In  making  the  test  candidates  should  approach  the  sig- 
nals from  a  point  where  they  are  unable  to  see  them  and  not  be  credited 
with  being  able  to  read  the  signals  unless  they  can  promptly  call 
changes  as  made  in  position  of  arjns  and  color  of  lights,  (c)  The  test 
with  and  without  glasses  should  be  made  at  distances  varjdng  from 
5,000  to  200  feet,  (d)  Committee  to  record  the  different  distances 
at  which  the  employe  being  examined  can  promptly  see  the  signals,  and 
will  forward  this  information,  together  wdth  their  recommendation  as 
to  the  service  to  which  he  may  be  assigned,  to  the  General  Superin- 
tendent. 

The  standard  required  in  railway  service  throughout  the  United 
Kingdom  is  normal  color-perception.  The  minimum  visual  acuity  does 
not  vary  greatly  from  the  standard  required  in  the  United  States  and 
Canada.  The  wearing  of  glasses  is  forbidden.  The  methods  of  deter- 
mining color-defects  vary  with  different  roads,  the  ma.iority  using  the 
Holmgren  wool-test  or  some  modification.  A  few  used  cards  on  which 
four  colors  are  ]irinted,  or  a  board  placed  at  30  feet  distant  with  a 
numlier  of  colored  spots  painted  on  it.  Others  use  a  tube  20  feet 
long  at  the  end  of  which  is  a  revolving  disk  containing  a  series  of 
colored  glasses.  In  many  instances  these  tests  are  supplemented  with 
some  lantern  test,  the  final  test  on  a  few  roads,  in  case  the  question  of 

Vol.  VII— 1.-3 


5074 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 

STANDARDS  OP  VISUAL  ACUITY  INDOOR  TESTS 


CLASS 

KNTBANCK    TO 
SICItVICE 

rito.\r(»Ti()\ 

nE-KXAMINATION 

Class  A 
KntrliU'nieii.     road 

service. 
IIostliTs  who  run  on 

main   track. 

20-2    combined,    not 
less  than   20-30   in 
elllicr     eye,      with- 
out  glasses.     Musi 
not    accept    a    plus 
2  1)  lens. 

20-20  combined  and 
not    less    than    20- 
4  0     in    cither    eye 
wilhout     glasses. 

20-20  combined,  not  less  than  20-70  In 
eltlier  eyo:  or  20-30  combined,  not 
Ie«s  than  20-4  0  in  either  eye,  without 
glasses.    See  rules  .S.   13,  14  and  16. 

Class  B 
Bngliiemeii.    yard 

service. 
Hostlei-s   who   do   not 

run       on       m  a  1  n 

track. 

20-30  combined,  not  less  than  20-.')0  In 
either  eye,  wilhout  gla-sses.  \ATieii 
combined  vision  without  glasses  is 
not  less  than  2O-.50.  and  neither  eye 
less  than  20-70.  and  by  the  aid 
of  glasses  combined  vision  can  be 
brought  to  no  less  than  20-30,  en- 
glnemen  must  wear  glasses.  Sec  rules 
S,  9,   10,  11,   13.  l.'i.  aJid  16. 

Class  C 
Firemen. 
Trainmen. 
KreiKht  Hrakenien. 
Yard  Brakemen. 
Switchtenders. 

20-20  combined,  and 
in  each  eye,  tested 
separately.        witli- 
out    gla.sses.      Must 
not    accept    a    plus 
2   D  lens. 

20-30   combined,   nol 
less  than  20-40  in 
either     eye,     with- 
out glasb-es. 

20-30  combined,  not  less  thaii  20-40  in 
either  eye.  with  or  without  glasses, 
providing  neither  eye  is  less  than  20- 
70  without  glasses;  or  20-20  in  one 
eye  and  less  than  20-7  0  or  nil  in  the 
other,  without  glasses.  See  rule  8 — 
(Yard  Brakemen). 

Class  D 
Passenger   Con- 

ductors. 
Freight  Conductors. 
Yardniiisters. 
Yard  Conductors. 
Train  Baggagemen. 

20-20   combined,  nut 
less  than   20-;fO  in 
either     eye.      with- 
out glasses. 

2  0-30   combined,   not 
less  than   20-4  0   in 
either     eye.     with- 
out glasses. 

20-40  combined,  not  less  than  20-50  in 
either  eye,  with  or  without  glasses; 
or  20-30  combined,  not  less  than  20- 
7  0  in  either  eye,  with  or  without 
glasses;  or  20-20  in  one  eye  and  less 
than  20-70  or  nil  in  the  other,  with- 
out glasses. 

Cla.ss  B 
Station   Agents. 
Telegraph  Operators. 
Signal  Foremen. 
Signalmen. 
Bridge  Foremen. 
Track  I'oremon. 
Drawliridge    Tenders. 
Car   and    Engine   In- 
spectors. 

20-30  combined,  not 
less  than   20-4  0  in 
eillier  eye.   with  or 
without   glasses. 

(.See  liule   17.) 

20-3  0  combined,  not  less  than  20-7  0  In 
either  eye.  with  or  without  glasses; 
or  20-30  in  one  eye  and  less  than  20- 
70  or  nil  in  the  other,  without  glasses. 

Class  F 
Crossing         inagmen 
and  Gatemen. 

20-40     combined     or 
not   less    than    20- 
.'iO    hi    either    eyo, 
without    glasses. 

(See    Itule    17.) 

20-30  combined,  not  less  than  20-70  In 
either  eye,  with  or  without  glasses; 
or  20-40  in  one  eye  and  less  than  20- 
7  0  or  nil  in  tlie  other,  without  glasses. 

FIELD  TESTS 


CL.ASS 

WITHOXIT 
GLASSES 

WITII   GLASSES 

Class  A 

Bnginemen.     r  o 

a  d 

By   day.    sunlight. 

200,   400  and   2, COO 

200.   400   and   ,".,000   feet. 

service. 

Or  by  day  if  cloudy, 
with    clear    atmos- 
phere. 

leet. 

200.   400   and  2.000 
feet. 

200.   400   and  4,000   feet. 

By  night. 

200.   400  and  2.000 
feet. 

200.  400  and  4.000  feet. 

Class  B 

Knglnemen.    y  a 
service. 

r  d 

By  day  or  night. 

200,    400    and    800 
feet. 

200,  400  and  2.600  feet. 

EYES  OF  SOLDIERS,  SAILORS,  ETC.  5075 

defective  color-pcrcfptioii  arises  in  the  reexamination  of  an  old  eni- 
jdoye,  hviug  to  plaee  the  examinee  on  an  engine  accompanied  l>y  an 
official  of  the  road  and  have  him  call  signals  as  they  appear  on  an 
average  run.  Tlie  Edridge-Green  method  of  testing  has  been  adopted 
by  a  nnml)er  of  Knglisli  raili-oads.  This  method  consists  of  a  "classifi- 
cation test,''  which  is  regarded  only  as  supplementary  to  the  lantern 
test. 

The  final  test  in  case  of  an  appeal  or  a  questionabl?  color  defect  is 
the  Edridge-Green  color-perception  spectrometer.  ^Nlost  of  the  Eng- 
lish railways  employ  qualified  ophthalmologists  to  conduct  the  exam- 
inations. 

The  regulations  of  the  Austrian  Railways  of  1909  prescribe  two 
methods  of  examination  for  color-vision.  (1)  Stilling 's  pseudo- 
isochromic  charts,  Nagel's  charts  and  the  wool  plates  of  Reuss. 
(2)  Holmgren  s  worsteds.  If  there  is  the  least  suspicion  of  abnormal 
color-sense,  the  applicant  is  referred  to  the  chief  surgeon  for  examina- 
tion with  Nagel's  anomaloscope.  Railway  surgeons  must  undergo  an 
examination  for  color-vision  and  if  any  abnonualit}'  is  discovered  are 
not  allowed  to  make  color  tests.  If  employes  are  found  to  have  normal 
color-sense  upon  each  of  three  examinations  further  reexamination  as 
to  color-vision  is  omitted. 

The  Swiss  regulations  require  color-vision  examinations  by  means  of 
Holmgren  wools  and  Stilling's  color  charts  and  a  practical  test  for 
Engineers  with  flags  at  250  meters  and  lanterns  at  400  meters.  The 
Commission  of  Swiss  Ophthalmologists  in  1913  recommended  Stilling's 
charts  for  general  examinations,  Xagel  's  plates  to  determine  the  nature 
of  the  color  anomaly  and  as  an  accessory-  Holmgren 's  worsteds  and  the 
color  mixing  apparatus  of  Eversbusch.  All  doubtful  cases  to  be  exam- 
ined by  Nagel's  anonuiloscope. 

The  regulations  for  testing  the  eye  sight  of  employes  of  the  Putch 
State  Railways  are,  (a)  for  the  post  of  engine  driver  or  fireman, 
externally  healthy  eyes  and  eyelids,  free  from  chronic  congestion  or 
inflammation.  With  both  eyes  open ;  an  unrestricted  field  of  vision, 
normal  acuteness  of  vision,  normal  infraction  and  power  of  distin- 
guisliing  colors  of  at  least  four-fifths.  In  looking  with  each  eye  sepa- 
rately, the  other  being  covered;  unlimited  field  of  vision,  acuteness  of 
vision  (withont  glasses),  as  well  as  color-sense  of  not  less  than  one- 
half,  (b)  For  the  post  of  station-master  and  his  substitutes,  petty 
station-master,  head  conductor,  conductor,  brakesman,  pointsman,  fore- 
man, In-idge  watcher,  signalman,  assistant  bridge  watcher,  surface-man 
and  surface-woman,  assistant  watchman,  line  surveyor,  chief  snow 
ploughman,    inspector    of    the    locomotive    and    train    service,    and 


5076  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

inspecting  engineer,  externally  healthy  eyes  and  eyelids.  In  looking 
with  both  eyes  simultaneously,  unrestricted  field  of  vision,  normal 
visual  acuteness  (without  glasses),  and  free  from  hypeniietropia  of 
more  tliaii  one  diopter,  i)ower  of  distinguishing  colors  of  at  least  three- 
fifths,  in  looking  with  each  eye  .sei)arately,  the  other  being  closed; 
visual  acuteness  (without  glasses)  and  color-sense  not  less  than  one- 
fourth  ;  both  eyes  free  from  i)rogressive  ailments. 

If  the  person  examined  should  appear  to  be  unfit  for  class  a,  it  must 
be  specified  on  the  certificate  whether  the  candidate  is  fit  for  class  b. 

The  visual  acuteness  is  estimated  by  Snellen's  optotypes,  or  with 
letters  which  corivspond  therewith  in  size  and  clearness,  at  a  distance 
of  six  meters,  first  without  glasses  tlien  with  glasses,  by  which  means 
the  refra(ttion  also  is  ascertained.  Tlie  test  types  are  to  be  suspended 
in  a  good  clear  light ;  the  person  to  be  examined  standing  with  his  back 
to  the  light. 

The  color-sense  is  estimated  (iualitatively,  by  the  pseudo-isochronuitic 
tal)les  of  Stilling,  and  with  wools,  according  to  Holmgren's  method. 
Quantitatively,  by  Bonders'  method,  which  must  be  applied  in  every 
instance. 

The  following  are  the  recommendations  of  the  Committee  (C.  H. 
Williams,  Nelson  IM.  Black  and  J.  Ellis  Jennings)  on  Standards  and 
Methods  of  Examining  the  Color  Vision  appointed  by  the  Ophthalmic 
Section  of  the  American  IMedical  Association  (1914)  : 

1.  In  every  ease  the  color-sense  should  be  examined  by  the  Holm- 
gren worsteds  exactly  according  to  the  directions  given.  As  some 
cases  of  defective  color-sense  may  occasionalh^  pass  the  Holmgren  test 
it  is  necessary  that  another  test  with  a  lantern  should  be  used  in  every 
case  to  determine  the  color-sense  of  the  macula  region  where  the  colors 
of  signal-lights  must  be  quickly  recognized. 

2.  (a)  Those  who  pass  the  test  with  the  worsteds  and  with  the  lan- 
tern, without  making  a  mistake,  should  be  classed,  for  signal  purposes, 
as  normal,  (b)  Those  who  make  the  characteristic  mistakes  in  select- 
ing colors  which  look  like  the  green,  or  the  rose  test-skein,  of  the  Holm- 
gren worsteds,  or,  Mdio  make  mistakes  in  naming  the  colors  of  the  lan- 
tern, should  be  classed  as  abnormal,  (c)  Of  the  abnonnal  eases: 
Those  who  select  with  the  green  test-skein  some  greens  and  also  some 
grays,  browns,  rarely  a  red,  or  who  select  with  the  rose  test-skein  some 
rose  or  red  colors,  and  also  blues.  pur])les.  grays  or  gr(>ens.  oi-  with  the 
lantern  test  call  a  red  light  gi'ceii  or  wliite,  a  green  light  red  (U-  white. 
()!•  a  white  light  red  or  green,  should  be  classed  as  dangerously  defective 
in  their  color-sense. 

Tliose  who  make  other  mistakes  than  th(^  foregoing,  or  who  are  verv 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5077 

licsilatiiii;'  in  tlieir  selection  or  naming  of  colors,  should  be  classed  as 
having  a  weak  color-sense.  It'  these  persons  wish  to  work  where  they 
will  use  colored  signals,  they  should  be  reexaniinetl  under  medical  su- 
pervision by  repeating  the  tests  with  the  Holmgren  worsteds,  and  the 
lantern;  and  in  addition  with  Stilling's  i)lates  (Fourteenth  edition, 
1913),  and  also  with  some  form  of  spectroscope  test  to  determine  the 
extent  of  the  visible  red  end  of  the  spectrum,  and,  if  possible,  with  Jen- 
ning's  self-recording  worsted  test,  and  with  the  Nagel  anomaloscope. 

3.  Cases  of  appeal  from  the  original  examination  sliould  be  reexam- 
ined as  provided  in  the  foregoing  paragraph. 

4.  Some  plan  should  be  adopted  to  ensure  a  proper  and  uniform 
standard  in  the  colors  of  the  worsteds,  especially  the  green  and  the 
rose  test-skeins,  and  in  the  colors  of  the  lantern, 

5.  On  large  railway  systems,  and  in  the  marine  service,  there  should 
be  some  central  point  where  a  complete  equipment  can  be  maintained 
in  charge  of  a  competent  medical  examiner,  for  the  reexamination  of 
doubtful  or  appealed  eases.  There  should  also  be  a  periodic  examina- 
tion by  such  examiner  of  all  the  equipment  used  in  these  tests  over  the 
whole  system,  to  be  sure  that  it  is  kept  in  proper  condition  and  renewed 
when  necessary. 

6.  Reports  of  the  examinations  should  be  kept  on  file  at  some  central 
point  and  should  be  supervised  by  some  competent  medical  authority 
to  see  that  the  tests  are  made  according  to  the  instructions. 

7.  The  Section  of  Ophthalmology  should  adopt  some  standard  form 
of  instructions  and  record  blanks  which  may  serve  as  a  guide  for  those 
who  make  the  tests. 

It  will  be  noted  that  in  the  foregoing  recommendations  no  mention  is 
made  of  red-blind,  or  green-blind,  or  blue-l)lind.  The  border-lines  be- 
tween the  various  forms  of  defective  color-sense  are  not  sharply 
marked,  and  with  the  means  at  the  disposal  of  the  examiner  in  making 
tlie  routine  tests  of  large  numlx-rs  of  men,  it  is  not  possible  for  him  to 
determine  with  certainty  the  exact  quality  of  the  defective  color-sense, 
nor  is  it  essential.  It  is  sufficient  if  he  can  pick  out  those  who  are 
dangerously  defective  in  their  color-vision,  or  who  need  a  further  spe- 
cial examination,  and  your  Conunittee  believes  that  a  careful  study  of 
its  report,  and  a  strict  compliance  with  the  methods  and  standards 
there  explained,  will  enal)le  the  examiner  to  make  these  tests  for  color- 
vision  fairly  and  accurately. 

The  following  are  the  proposed  Rules  and  Regulations  to  be  adopted 
by  the  Association  of  lidilnxid  ('lii(  f  Surgeons  (1!)15). 

Classification.  I.  All  tliosc  handling  trains  and  train  signals,  i.  e., 
Engineers,  Firemen,  j\lotornien,  Engine  Hostlers,  Conductors,  Brake- 


5078  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

111(11,  I'lii^nmii,  Ttiiiii  rortcrs,  Yai'dinastcrs,  Switchmen,  Si^alincii 
and  TowtTiiifii.  J  I.  Station  Agents,  Tclcf^r-aplicrs,  Train  Tdcpiione 
()l)iTators,  Station  liuf^j^agemen.  Switch  Tenders,  Section  Foremen, 
Bridge  Fori-men,  Railroad  Crossing  Flagmen,  Watchmen  and  Crossing 
Flagmen.     111.  All  other  employes. 

li( quircmoits.  (1)  Vision:  Normal  (20/20  required  in  eacii  eye.) 
Firemen  and  Engineers  entering  the  service  must  be  tested  with  plus 
2d  lens,  and  if  able  to  read  20-foot  line,  must  be  rejected.  Hearing: 
Normal  (Whisper  at  20  feet,  acoumeter  or  watch  at  20  inches.)  Color 
perception:  Normal.  (By  worsted  and  lantern.)  Note:  Firemen 
for  promotion  to  Engineers,  and  Brakemen  for  promotion  to  Con- 
ductors, must  have  combined  vision  of  20/20,  provided  vision  in  one 
eye  is  not  less  than  20/40  without  glasses.  Physical  defects:  All 
physical  defects  tending  to  impair  the  efficiency  of  the  individual  dis- 
(lualify.  Re-examination :  Re-examination  of  employes  in  this  class 
must  be  made  once  every  three  years.  Vision — Only  those  whose 
vision  does  not  fall  below  normal  in  one  eye  and  20/40  in  the  other 
may  be  allowed  to  hold  preferred  or  main  line  runs.  Hearing — One- 
half  of  the  requirements  for  entrance  to  service.  (II)  Vision:  20/20 
required  in  one  eye  and  not  less  than  20/30  in  the  other.  Hearing: 
Normal.  (Whisper  at  20  feet,  acoumeter  or  watch  20  inches.)  Color 
perception:  Normal.  (By  worsted  and  lantern.)  Phj^sieal  defects: 
All  physical  defects  tending  to  impair  the  efficiency  of  the  individual 
disqualify.  Re-examination  :  Re-examination  of  employes  in  this  class 
must  be  made  once  every  three  years.  Vision — Combined  vision  must 
be  20/30  and  not  less  than  20/40  in  one  eye  with  or  without  glasses. 
(Ill)  Vision :  Combined  20/40,  not  less  than  20/70  in  one  eye  without 
glasses.  Hearing:  One-half  normal.  (Whisper  at  li)  feet,  acoumeter 
or  watch  10  inches.)  Color  perception:  Car-repairers  and  others 
wliose  duties  require  liaiuUing  of  signals  (flags  or  lanterns)  must  have 
normal  color  perception.  Physical  defects:  All  physical  defects  tend- 
ing to  impair  the  r-fficiency  of  the  individual  disqualify.  Employes 
over  fifty  (50)  years  of  age,  or  employes  who  require  glasses  to  bring 
their  vision  to  standard,  must  l)e  examined  ev.ery  year.  Employes  who 
have  suffered  severe  injury  or  illness  iinist  lie  exainiued  before  they 
re-enter  the  service. 

Hides  for  Visual  Examination  of  the  Employes  of  The  Milwaukee 
Electric  Iiailwaij  <(•  Li<jht  Companii  (Kindhi  fuDiisInd  hi/  Jh\  CJias. 
H.  Lemon,  Chief  Surgeon). 

1.  Motormen  must  have  20/20  vision  in  each  evi' :  no  exception 
made  to  tliis  rule.  They  are  re-examined  when  they  go  on  tlie  inti'i*- 
ui'lian  sei'vice  and  the  same  i"e(iuirements  are  observed,  20/20  vision. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  507!) 

2.  Coiuluclons  imist  liavc  2()/2<)  in  one  eye  and  not  less  than  20/30 
in  tlio  other  eye.  When  they  are  re-examined  for  the  interurban  ser- 
vice 20/30  in  each  eye  is  aeeepted. 

3.  The  eye  test  is  made  l)y  a  trans-ilhimined  chart,  furnished  by 
F.  A.  Hardy  &  Co.,  the  illumination  of  the  eliart  being  designed  by  the 
Ilolophane  Company. 

4.  No  re-examination  of  motoniien  and  conductors  is  made  unless 
specific  complaint  is  made. 

5.  For  the  color  test,  a  card  liaving  various  colored  yarns  upon  it  is 
used  and  the  men  are  required  to  name  tlie  colors.  If  they  name  these 
colors  without  hesitation  they  are  passed,  if  they  hesitate  they  are 
given  the  usual  Holmgren  test. 

(').  ISlvn  are  not  accepted  who  wear  glasses  for  the  correction  of  any 
visual  defect.  If  they  need  glasses  after  serving  a  few  years  they  are 
permitted  to  wear  them.  Exi)erience  of  twelve  years  has  demonstrated 
that  the  men  themselves  are  more  satisfied  with  the  results  obtained 
])y  the  trans-illumined  chart  tlian  they  were  formerly  with  the  card- 
hoard  chai't  which  grew  yellow  witli  age  and  had  a  light  thrown 
upon  it. 

In  the  Inited  States  many  of  the  railway  lines  are  so  long  that  it 
is  impossible  to  have  all  the  candidates  for  examination  or  employes 
for  re-examination  come  to  the  terminal  offices  or  where  their  opiithal- 
mologist  is  located.  In  order  to  overcome  this  they  have  provided  a 
car  equipped  for  the  purpose  which  goes  over  the  line  at  stated  inter- 
vals. The  following  is  a  description  by  Dr.  W.  R.  Parker  of  the  car 
used  by  the  ^Michigan  Central  Railway  in  which  visual  examinations 
are  conducted:  "An  ordinary  day  coach  was  partially  dismantled  by 
taking  out  all  the  seats  except  eight,  which  are  left  at  one  end  of  tlie 
coach  to  serve  as  a  waiting  room.  Just  forward  of  the  seats  fifteen 
feet  from  the  rear  end  of  car,  leaving  room  to  pass  out  of  the  hallway 
at  the  side,  a  partition  is  built  from  the  side  of  the  coach  to  the  parti- 
tion which  runs  lengthwise  of  the  car  twenty-five  inches  from  the  side. 
At  a  distance  of  nine  feet  nine  inches  from  the  front  of  the  car  a  par- 
tition is  built  across  from  the  side  to  the  hall  partition,  forming  a  small 
L-shaped  room  which  is  used  as  a  dark  room,  the  windows  are  care- 
fully covered  and  an  oil  lamp  set  in  a  swinging  bracket.  Doors 
are  so  arranged  that  employees  enter  the  testing  room  from  the  waiting 
room ;  and  after  the  examination  is  completed  they  pass  out  into  tiie 
hallway  and  out  of  the  front  of  the  car,  thus  preventing  intercourse 
with  the  unexamined.  In  testing  the  color-sense  in  the  day  time  by  the 
use  of  the  Williams'  lantern  it  is  necessary  to  hang  the  lantern  in  the 
dark  room  opposite  the  door.     By  the  means  of  ordinary  curtains  in 


5080  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

the  testing  room,  tlic  room  will  be  made  darlc  euougli  for  accurate 
results. ' ' 

Visiun  of  aut(»nahil€  drivers.  Owing  to  tiie  raiudly  increasing 
numbers  of  automobiles,  used  for  ))usiness  as  well  as  pleasure  pui'poses, 
every  state  should  require  that  all  applicants  for  a  license  to  drive  a 
motor  vehicle  pa.ss  an  eyesight  test.  Yet,  in  the  great  majority  of 
states,  the  prospective  driver  of  an  automobile  need  only  affirm  in  his 
application  that  he  has  no  physical  or  mental  infirmities.  AVhen  one 
stops  to  consider  that  a  railroad  engineer  drives  over  a  steel  track, 
guarded  by  signals  and  watchmen,  and  over  a  route  with  which  he  is 
thoroughly  familiar,  whereas  the  autoist  drives  over  any  road  he 
chooses,  not  protected  by  lights  and  signals,  and  in  some  cases  traveling 
almost  as  rapidly  as  a  locomotive,  it  is  plainly  imperative  that  he 
possess  as  good  sight  as  the  man  in  the  engine  cab.  If  one  eye  is  highly 
defective  the  field  of  vision  is  greatly  impaired  and  the  driver  less 
able  to  maneuver  his  car  in  an  emergency.  Paris,  ]\Iunich  and  other 
European  cities  have  seen  the  necessity  of  an  examination  of  the  eyes 
of  all  taxi-drivers  and  are  strict  in  the  enforcement  of  this  protective 
measure.  It  is  more  than  likely  that  defective  vision  is  next  in  order 
of  frequency  to  the  overuse  of  alcoholic  drinks  as  a  cause  of  automobile 
accidents.  We  can,  and  should,  protect  pedestrians  and  drivers  of 
vehicles  from  injury  to  a  much  greater  extent  than  we  do.  Each 
applicant  for  a  license  to  drive  a  motor  vehicle  should  be  required  to 
give  satisfactory  proof  of  at  least  moderately  good  vision. 

TESTS  OF  THE  VISI'AL  ACUITY. 

Visual  acuity  tests  are  as  a  rule  made  with  the  Snellen  optotypes, 
the  letters  or  characters  subtending  a  visual  angle  of  5  minutes  and 
each  stroke  of  the  letter  or  character  subtending  a  1  minute  angle  at 
the  specified  distance  they  are  to  be  used.  The  broken  ring  of  Landolt 
adopted  by  the  International  Ophthalmological  Congress  as  the  Inter- 
national Standard  Test  for  Visual  Acuity  is  used  in  some  instances 
on  the  continent.  Some  railroads  in  England  use  a  card  shown  at  15 
feet  upon  which  are  printed  in  an  irregular  pattern  black  squares 
%x%  inch  in  size,  the  examinee  being  required  to  count  the  number 
of  squares  exposed.  "With  perfectly  acute  vision  these  test  dots  ought 
to  be  clearly  visible  in  full  daylight  at  19  yards." 

Chas.  II.  Williams  devised  what  is  designated  as  a  "semaphore 
chart"  consisting  of  a  white  card  upon  which  are  printed  black  figures 
representing  semaphoi-e  signals  with  the  blades  in  different  positions. 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5081 


AVlit'ii  seen  at  a  distance  of  I'D  iVd  tlic  sciiiapliore  sii,Mials  eorrcspond 
to  the  apparent  size  of  a  standard  seniaplioro  arm  46  iDclies  long  seen 
at  a  distance  of  Vii  mile. 

This  chart  was  improved  by  Nelson  -M.  Pdack  who  lias  had  repro- 
duced a  scale-reduced  fac-simile  of  the  Chicago,  Milwaukee  &  St.  Paul 

Kri-Kht-hf- 

20    Feet 

Williams   Semaphore   Charts. 

Ky.  block  signals  which  at  20  feet  represent  a  standard  semaphore 
pole  and  arm  seen  at  one-half  mile  (2640  feet)  with  actual  colors  u.sed 
for  distance  and  home  signals,  placed  upon  a  neutral  grayish  back- 
ground, which  corresponds  to  the  average  tint  of  the  horizon  against 


A 


£11 


"Williams  New  Model  Semajihore  Charts. 

wliich  a  semaphore  in  an  ideal  position  is  seen.  In  this  reduced  tigure, 
at  20  feet  the  arm  of  the  semaphore  subtends  an  angle  of  0°-5'.  The 
person  examined  is  requested  to  state  the  position  of  the  blade,  whether 
"up  or  down"  or  may  state  "Caution,"  "Clear"  or  "Danger," 
depending  upon  the  usage  on  this  particular  road  for  which  they  are 
being  examined. 

"With  the  Hall  or  "banjo"  signal  chart  tlie  color  of  the  disc  e.\i)oscd 


5082 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


Black  's  Semaphore  Charts. 
(For  testing  the  vision  of  railroad  employes.) 


Q   O   @    O 


Disc  or   Hall   Charts  for  Testing   Vision  of  Railroad    Employes. 
The  center  areas  of  the  charts  are  colored  red  and  green  for  various  indications. 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


)083 


gives  the  iiulical  ion.  'IMic  cxjiiiiiiiee  iii;i\-  cilliri'  iiaiiir  tlic  coloi'  or  state 
whether  the  iiidieatioii  is  "'  Danger,  Caution  or  Ch'ar. "  (Williams  lias 
recently  gotten  out  a  new  form  of  semaphore  ehart,  whieh  shows  repro- 
ductions of  two-position  senuiphore  signals.) 

The  above  mentioned  visual  test  charts  are  all  seen  by  reflected  light 
and,  especially  when  used  with  daylight,  naturally  vary  in  visibility 
with  the  intensity  of  light  reflected  from  their  surface.    To  overcome 


BlaL-k's  Testing  Cabinet  No.   1. 


this  Black  devised  a  test  chart  with  the  eharacters  placed  upon  trans- 
lucent glass  which  is  illnminated  by  electricity  and  maintained 
practically  at  a  constant  intensity  of  surface  brightness  and  contrast 
with  the  letters. 

It  liappens  that  candidates  sometimes  memorize  the  test  cards  upon 
which  the  letters  from  6/LX  to  ()/V  vision  are  printed  and  then  pass 
on  the  information  to  others.  They  are  consequently  able  to  pass  the 
visual  acuity  test  with  actual  vision  ])elow  the  re»iuired  standard.  To 
overcome  this,  test  cards  are  made  up  with  one  line  of  letters  ujion 
each  card  with  three  cards  for  each  size  of  letters  used. 


5084 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


EI)llID(iK-(JKKEN  S  THEORY   OE  VISION   AM)  COI/)Il-VISION. 

Before    lakiiii,'-    up    IIk^    various    tests    for    eolor-liliiidiiess    Edridge- 
(il-eell's  tlieol'X   of  eolor  vision  will  he  lirietiv  tleserihed  as  it  is  iiierelv 


'\^ 


[If 


D 

L2 

T  C  E3 

X  c 

V  r  4 

Z  A  0 

r  T  E 

T  H  5 

V  L  C     O 

B 

9 

Black's  Testing  Cabinet  No.  2. 


mentioned  uudei-  Theories  of  color-vision,  page  24!>4,  Vol.  IV  of  this 
Encyclopedia,  as  "based  upon  eh'Ctro-physiological  phenomena,  and  it 
is  quite  certain  at  present  that  the  aetual  retinal  processes  are  of  a 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5085 

l)lu)to-elu'ini('a]  cliaractc'r. "  (Tlie  Pklitor  stati'S  a  more  complete  treat- 
ment of  this  subject  will  ai)})ear  in  a  later  volume.)  This  is  done  for 
the  purpose  of  making  more  clearly  understood  some  of  the  criticisms 
as  to  the  adequacy  of  the  various  tests  for  color-blindness. 

Edridge-Green's  theory  of  vision  (llunterian  Lectures,  Ophth.  Rev., 
Sept.,  1914)  is:  The  cones  are  the  terminal  perceptive  visual  organs. 
The  rods  are  not  perceptive  elements,  but  are  concerned  with  the 
formation  and  distribution  of  the  visual  purple.  Vision  takes  place 
by  stimulation  of  the  cones  tlirougli  the  photo-chemical  decomposition, 
by  light,  of  the  liquid  surrounding  tlicm  which  is  sensitized  by  the 
visual  purple.  Tlie  cliaracter  of  the  stimulus  differs  according  to  the 
wave  length  of  the  light  causing  it.  In  tiie  excitation  itself  we  have 
the  ph^'siologieal  l)asis  of  tlie  sensation  of  light,  and  in  the  quality,  or 
wave  length,  of  the  excitation  of  the  physiological  basis  for  the  sensa- 
tion of  color.  The  impulse  being  conveyed  along  the  optic  nerve  to 
the  brain,  stimulates  the  visual  center,  causing  a  sensation  of  light, 
and  then  passing  on  to  the  color-perceiving  center,  causes  a  sensation 
of  color.  But  though  the  impulses  vary  in  character  according  to  the 
wave  length  of  the  light  causing  them,  the  retino-cerebral  apparatus  is 
not  able  to  discriminate  between  the  character  of  adjacent  stimuli,  not 
being  sufficiently  developed  for  the  purpose.  At  most,  seven  distinct 
colors  are  seen  by  some ;  others  see  in  proportion  to  the  development  of 
their  color-perceiving  centers,  only  six,  tive,  four,  three,  or  two.  This 
constitutes  color-blindness,  the  person  seeing  only  two  or  three  colors 
instead  of  the  normal  six,  putting  colors  together  as  alike  which  are 
seen  by  the  normal  sighted  to  be  different.  In  the  degree  of  color- 
blindness just  preceding  total,  only  the  colors  at  the  extremes  of  the 
spectrinn  are  recognized  as  different,  the  remainder  of  the  spectrum 
appearing  gray.  "Though  my  own  opinion  is  that  the  ordinary  form 
of  congenital  color-blindness  is  caused  by  a  tiefective  development  of 
the  portion  of  the  lu-ain  wliicli  has  the  function  of  the  perception  of 
color,  we  must  not  exclude  any  poi-lion  of  the  retino-cerebral  apparatus, 
defect  of  which  would  have  exactly  the  same  result.  It  will  be  noticed 
that  the  theory  really  consists  of  two  parts,  one  concerned  with  tlie 
retina  and  the  other  with  tlie  whole  retino-cerebral  apparatus." 

Other  theories  of  color-vision  are  mentioned  or  described  in  Vol.  IV 
of  tliis  Encjfclopcdia,  as  follows:  Franklin's  theory,  i>age  2305; 
Oliver's  correlative  theory,  page  2410:  Ebbinghaus's  theory,  i^age 
2410;  Helmholtz's  theory,  pages  2410  and  242(i :  Hering's  theory, 
])ages  2410  and  24:50;  Young's  theory,  pages  2414  and  242(i:  Fryer's 
theory,  pages  2414  and  2430:  Parinaud's  theory,  page  24;n  :  von 


5086  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Kries's  theory,  paj^c  24;n  ;  Koenig-'s  theory,  page  24:51.  No  two  of 
tliosc  agree  and  not  one  is  entirely  satisfactory. 

The  following  trsts  for  color  blindness  (arranged  alphabetically j, 
have  a1  various  times  been  used  for  the  purposes  described  in  this 
section.  Most  of  them  (as  well  as  others  not  tabulated  here)  have 
already  been  discussed  in  this  Enriirloprdid,  especially  under  Examina- 
tion of  the  eye  and  Color-sense  and  color-blindness.  However,  it 
seems  proper  to  speak  again  of  certain  of  these  here,  with  a  reference 
to  the  precise  volume  and  page  of  this  Encyclopedia,  where  additional 
information  regarding  them  and  other  tests  may  be  found. 

Ahney's  color  [Mitch  apparatus  (described  on  page  2408,  Vol.  IV, 
of  this  Encyclopedia)  :  "A  very  fair  idea  of  the  amount  of  deficiency 
in  the  red  and  green  .seiisations  is  given  by  noting  the  names  given 
to  the  coloi's  a1  vai'ious  pai'ts  of  the  spectrum." 

Abncy's  test  by  water-color  washes.  Edridge-Green  mentions  this 
test  in  his  book  on  "Color  Blindness"  {I nt emotioned  Scientific  Series, 
1891) .  It  is  simply  a  test  for  those  who  are  not  color  ignorant.  Water- 
color  paints  are  wa.slied  upon  drawing  paper  and  when  dry  the  candi- 
date is  asked  to  name  the  hue  of  the  wasli.  The  author  states:  "By 
mastering  the  principles  which  underlie  the  trichromatic  theory  it  is 
easy  to  make  tests  by  colored  materials  other  than  wools." 

Abncy's  test  by  colored  discs.  "A  test  which  can  be  applied  quali- 
tatively as  well  a.s  (luantitatively  is  that  of  rotating  color  discs  of  red 
and  green,  with  black  and  wliite  sectors  behind  the  smaller  pair.  The 
examinee  may  make  a  match  in  daylight  looking  through  a  chromatic 
cell  containing  chromate  of  potash  in  solution.  The  angle  of  the  red 
or  green  is  altered  until  the  two  give  a  yellow  which  matches  in  hue 
the  outside  disc  .  .  .  when  a  match  is  made,  the  angles  of  the 
discs  should  be  noted  and  a  rough  estinuite  can  be  made  by  a  compari- 
son of  the  normal  equation  with  that  of  the  examinee.  If  the  red 
sector  is  the  greater  the  latter  will  be  incomi)letely  red-blind :  and  if 
the  green  sector  i.s  the  greater  (compared  witli  the  normal)  there  is 
incomplete  green-lijiiidiiess." 

Abney's  dot  test.  Different  colors  are  tlii'own  on  a  small  wliite  disc 
about  %  inch  in  diameter,  mounted  on  black  velvet.  The  examinee, 
standing  12  lo  20  feet  away,  is  required  to  name  the  color.  By 
diminishing  the  angle  subtended  by  a  patch  of  color,  it  becomes  color- 
less. As  one  of  the  color  sensations  to  the  color-blind  is  less  than  to 
normal  vision,  it  follows  that  the  small  patch  may  fail  to  show  the 
color  to  the  color-blind  when  it  is  visible  to  the  normal  eye. 

Adler's  color  crayons  ( meiit  inned  in  Vol.  TV,  pages  2388,  2442.  of 
this  Encyclopedia).     An   a.ssortmeiit   of  colored  crayons  is  used   in- 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5087 

stciid  of  file  wools  of  Holmgren's  test.  'I'lic  priii(ij)lc  of  the  test  is  the 
same,  however.  'I'lic  candidate  is  asked  to  seleet  from  a  large  numl)er 
of  erayons  all  tlie  hlues,  greens,  and  so  on.  These  ehoices  are  ntiii/ed 
to  mark  a  paper  with,  and  so  a  permanent  record  is  obtained. 

Armaignac's  modification  of  Holmgren's  wool  test.  Forty-three 
strands  of  wool  of  different  eolors  and  shades  are  twisted  into  a  cord 
and  formed  into  a  tassel.  The  candidate  examined  is  first  shown  the 
end  of  the  tassel,  where  merely  the  end  of  a  strand  of  each  color 
appears,  and  asked  to  name  the  colors ;  if  he  is  not  successful  the  cord 
is  unwound  for  about  a  centimeter,  showing  a  longer  strand  of  each 
color.  With  this  cord,  also,  candidates  are  required  to  comi)are  and 
match  colors  and  shades. 

Badal's  color  cylinders  (mentioned  in  \'ol.  \V,  pages  2388  and  2457, 
of  Ihis  Encyclopedia). 

Bckcss'  lantern  (described  in  Vol.  IV,  page  2370,  of  this  Encyclo- 
pedia). 

Benham's  top  (described  in  Vol.  IT,  page  931,  of  this  Encyclopedia). 

Browning's  pocket  spectroscope  (descril)ed  in  Vol.  IV,  page  2460.  of 
this  Encyclopedia) . 

Burch's  color  test  (described  on  page  2487  of  this  Encyclopedia). 

Buxton's  telechrome  (described  on  page  2462  of  this  Encyclopedia). 

Carter's  test  (described  on  page  2465  of  this  Encyclopedia). 

Chihret's  chromatoptometcr  (described  in  Vol.  Ill,  page  2197,  and 
mentioned  on  pages  2382  and  2443  of  this  Encyclopedia) . 

(John's  chromashiopticon  (mentioned  in  Vol  IV,  page  2443,  of  this 
Encyclopedia).  An  apparatus  for  detecting  color  defects  by  means 
of  the  complementary  colors  of  shadows.  "If  we  hold  before  a  lamp 
a  piece  of  colored  glass,  and  allow  the  light  thus  colored  to  fall  upon 
a  white  screen,  this  will  then  appear  colored.  Now  holding  a  pencil, 
for  instance,  before  the  screen,  we  will  have  a  shadow'  cast  on  the 
colored  surface.  This  shadow  will,  to  the  normal  eye,  appear  of  a 
complementary  color  of  the  glass  before  the  lamp;  whilst  to  the  color- 
blind the  shadow^  will  appear  colorless,  or  black  or  gray"  (Jeffries). 
The  chronuiskiopticon  of  Cohn  uses  oil  lamps  with  seven  colored  glasses; 
red,  orange,  yellow,  liright-green,  dark-green,  violet  and  blue,  and  a 
piece  of  wood  the  size  of  a  finger  to  produce  the  shadow. 

Cohn's  onhroidery  patterns  (mentioned  in  Vol.  IV,  pages  2443  and 
2457,  of  this  Encyclopedia),  in  which  colored  worsted  letters  are  worked 
on  a  ])ackground  of  a  color  witli  which  they  are  usually  confounded 
by  tlie  co]or-])lind. 

Colored  shadow  test  (described  in  Vol.  IV,  page  2459,  of  tliis  Ency- 
clopedia).    (See  Cohn's  chromaskiopticon  above.) 


)088  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Dane's  color  lablc  ((U'sci-ihcd  in  N'ol.  1  V,  pages  245G  and  2481,  of  this 
Enc\jvlopcdia). 

Dondcrs'  color  chart  ((k'seribetl  in  Vol.  IV,  page  2387,  of  tliis  Ency- 
cloprdia).  A  iiictliod  of  quantitatively  determining  color  perception 
Avilli  reflected  light.  Discs  of  colored  paper,  1,  2,  .■)  or  more  milli- 
meters, are  each  separately  glued  to  small  pieces  of  l)lack  velvet,  also, 
in  like  manner,  pieces  from  the  white,  red  and  green  signal  flags.  These 
little  pieces  of  velvet  are  placed  against  a  larger  piece  of  velvet  1  meter 
square.  The  candidate  with  perfect  color-sense  (ametropia  corrected) 
shoidd  recognize  the  color  of  the  1  millimeter  disc  at  5  meters. 

Bonders'  lantern  (descrilied  in  Vol.  IV,  pages  2381  and  2461,  of  this 
Encyclopedia). 

Dondcrs'  pscudo-iscJiromatic  patterns  (described  in  Vol.  IV,  page 
2458,  of  this  Encyclopedia) . 

Dondcrs'  wools  (mentioned  in  Vol.  IV,  pages  2443,  2457,  2466,  of 
this  Encyclopedia).  On  a  number  of  little  discs  of  wood  a  color  is 
wound;  another  color,  which  the  color-blind  can  not  distinguish  from 
the  first,  is  so  wound  over  it  as  to  form  rays  of  a  star.  A  color-blind 
person  is  detected  in  not  being  able  to  select  discs  which  present  to 
tlie  normal  eye  contrasting  colors. 

Dor's  test.  Like  Donders'  test  this  one  is  based  on  the  fact  that 
when  a  person  approaches  a  small  colored  ol)ject,  the  normal  eye  detects' 
the  color  ])ut  little  later  than  the  light.  Dor  made  six  chromatic  plates 
(lithographs)  each  made  up  of  seven  different  colored  di.scs  of  different 
sizes  on  the  black  background  ;  the  colors  are  yellow,  red,  orange,  green, 
l)hi(',  violet  and  purple.  The  distance  at  which  the  person  tested 
observes  and  names  the  color  is  compared  with  the  distance  at  which  a 
normal  person  observes  a  disc  of  the  same  size  and  color.     Donders' 

d 
formula  may  l)e  .simplified  to  K  ^  —  in  wliidi  d  =  actual  distance, 

D 
D  =  distance  a1  which  normal  eye  perceives  color  (the  m  in  Donders' 
fornnila  lieing  constant).     Three  of  Dor's  plates  are  for  daylight  tests 
and  three  for  artificial  light. 

Dunn's  color  test  (described  in  Vol  IV,  ])age  2487,  of  this  Enc]i- 
clopcdia). 

Edrid()c-(ircen's  head  test  (described  and  illiistraled  in  Vol.  IV.  on 
page  2409,  of  this  Encyclopedia) . 

Edrvlge-Grcen's  classification  test  (erroneously  di'serilied  under 
"bead  test"  on  page  2458  of  this  Encyclopedia)  i.s  regarded  as  only 
supplementary  lo  bis  lantern  test  and  is  made  up  of  four  test  colors 
and  180  confusion  color.s,  150  colored  wools,  ten  skeins  of  silk,  ten  small 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5089 


S(|iiar('.s  of  colored  cjndljoariK  and  ten  small  sfiuarcs  of  colored  glass. 
The  whole  series  of  colors  is  represented,  both  the  simple  and  modified 
units.  In  addition  there  are  a  large  number  of  colors  which  have  been 
chosen  by  color-blind  persons  as  matching  the  test  colors.  The  test 
colons  are  orange,  violet,  red  and  blue-green,  labelled  I,  II,  III  and  IV, 
respectively.  The  colors  are  chosen  with  the  view  of  presenting  as 
much  (lifficnlty  as  i)0ssible  to  the  color-blind,  and  as  little  as  possible 
to  the  noi'inal-siglited.  in  addition  to  choosing  those  colors  for  tests 
which  ai-e  ])articular]y  lialile  to  be  mistaken  for  other  colors  by  the 
color-blind,  colored  materials  of  different  kinds  are  used — wools,  silks, 
glass  and  cards  so  as  to  force  the  color-blind  to  judge  by  color,  and 
not  by  shade  of  luminosity. 


Edridiie-Green  's    New    ^lodel    Lantern. 


Edridge-Green's  pocket  test  consists  of  nineteen  cards,  on  nine  of 
wliicli  are  112  single  threads  of  wool,  and  fourteen  pieces  of  twisted 
silk,  similar  to  those  in  the  classification  test.  These  are  numbered 
consecutively,  with  the  exception  of  the  first  thread  of  the  first  four 
cards,  and  the  last  thread  of  the  next  four  cards.  The  end  threads  of 
the  first  four  cards,  I  to  IV,  form  the  tests;  they  are  orange,  violet,  red 
and  l)lue-green.  There  are  also  cards  on  which  red,  orange,  green,  blue, 
violet  and  purple,  and  gray,  respectively,  are  to  be  found.  There  are 
also  two  special  cards  marked  "Without  TJed"  and  two  .special  cards 
marked  ' '  Without  Green. ' ' 

Edridge-Green's  color  perception  spectrometer  (described  and  illus- 
trated in  Vol.  IV,  page  2412,  of  this  Encyclopedia). 

Edridge-Green's  color  visian  spectroscope  (described  in  Vol.  IV,  page 
2493,  of  this  Encyclopedia). 

Vol.  VII— 16 


5090 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


Ktlri<l(j(  -(!>■(  nt's  lantern  (mentioned  in  Vol.  IV,  pages  2380,  2447, 
2457;  described  and  ilhistrated  on  page  2410  of  this  J'Jncijrloprdia). 

EnglUh  Board  of  Trade  lantern  test.  Consi.sts  of  a  paraffin  lantern 
showing  red,  green  and  white  which  shows  one  or  Iwo  small  lights 
simultaneou.sly ;  these  are  refleeted  from  a  min-or  withont  means  of 
regulating  the  intensity  of  the  illumination. 


E.aMEVROlVITZ  i|PWB     HEW  YORK. 


Friilenberg's  Test  for  Central  Color  Perception. 


English  Board  of  Trade  modification  of  the  Holmgren  icorsted  test 
consists  of  (a)  .substituting  a  dark-brown  .skein  for  the  third  (deep-red) 
test  .skein  at  present  in  use ;  (b)  by  dividing  the  skeins  into  speeitied 
groups,  one  group  for  each  test  skein,  and  requiring  the  candidate  to 
divide  each  group  into  two  parts,  those  which  resemble  in  color  the 
test  skein  and  those  which  do  not. 

Favrc's  test  consists  merely  in  naming  the  color  of  certain  olijects, 
but  Jeffries  states  that  it  iinolNcs  the  same  jirinciple  as  the  tests  of 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5091 


Donders  iiiid  Dor,  i.  c,  the  (lislaiicc  at  wliidi  \\\r  color  is  observed  and 
named. 

Fridi;Hbcr(j\s  test  for  c(niral  color  perception.  Tliis  instrument 
resembles  an  ophtbahnoseope,  but  instead  of  lenses  it  is  supplied  with 
a  series  of  colored  discs  and  a  diapliragm  with  various  sized  openinprs. 

The  color  in  situ  is  exposed  by  drawing  down  tlie  slide  wliieh  is 
spring  actuated,  and  terminates  the  exposure  instantaneously  when 
released  and  liefore  i)atient  can  l)i-in«r  another  part  of  retina  into 
position. 


Holmgren  Wool  Test. 


nddelhcrg  color  booh-  (mentioned  in  Vol.  IV,  page  2443,  of  tliis 
Encyclopedia). 

Hierlingcr's  tables  (mentioned  in  Vol.  IV.  page  2443,  of  this  Ency- 
clopedia) . 

Hirschherg's  double  spectroscope  (mentioned  in  ^'ol.  IV,  page  2443, 
of  this  Encyclopedia),  consists  of  two  spectra  shown  one  above  the  other 
in  reversed  order;  movable  slits  allow  monochromatic  portions  of  each 
spectrum  to  be  shown.  Tlie  candidate  being  required  to  match  the 
color  on  the  lower  spectrum  with  that  shown  throuixh  the  slit  of  the 
upper. 

Holmgren's  icorst(ds  (mentioned  in  A^ol.  IV,  pages  2442,  2447; 
described  on  page  2448  of  this  Encyelop'di<i). 

Holmgren's  lantern  is  provided  with  three  shades,  each,  of  red  and 


5092 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


green  glass  Hint  can  In-  lui-iicd  hriorc  a  flame.  It  was  chiefly  used  to 
eoiiviiice  the  oHicials  ol"  a  raili'oad  of  the  aftual  presence  and  danger  of 
eolor-l)lindness. 

Jeaffrcson's  modification  of  IIohnfj7-cn's  test  (described  in  \'ol.  IV, 
page  2455,  of  this  Encijcloprdui ) . 

Jennings'  sdf-revordinci  modification  of  Holmgren's  test  is  fully 
described  and  i)icturcd  on  |»age  4676,  Vol.  IV,  of  this  Encyclopedia. 


Jeiiiiuigs'  Self-rei-oriliiig  Test  for  the  Detection  of  C'olor-Blin<lness. 


Kolhe's  truncated-  cones  (mentioned  in  Vol.  IV,  page  2448,  of  this 
Encyclopedia)  consists  of  two  o])tnse  cones,  placed  apex  to  apex  and 
rotating  on  a  vertical  axis.  The  side  triangles  are  covered  with  various 
colored  paper,  so  tiiat  one  triangle  in  the  cone  with  its  base  upward 
shows  one  color,  for  example,  blue;  the  corresponding  triangle  in  the 
other  cone  shows  a  contrasting  color,  e.  g.,  red.  By  rotation  mixed 
colors  may  be  produced.  The  api)aratus  is  covered  so  that  shutters 
can  be  raised  to  show  part  of  the  apparatus  at  a  time.  The  person 
tested  stands  at  1  meter  from  the  apparatus,  and  as  the  cones  are 
rotated  and  a  shutter  is  raised,  he  is  asked  to  pick  out  the  colors  cor- 
responding to  tliosc  sliowii  ill  a  color  tal)lc  or  a  collection  of  colored 
wools. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  509:j 

Li2)'s  color  IrUitiyle  (ineiitioiied  in  \'ol.  i\',  pages  2443,  249U,  of  tliis 
Encyclopedia) . 

Luminosity  curves  (described  and  illustrated  in  Vol.  IV,  page  2434, 
of  this  E ncyclopedia) . 

Magnus's  modification  of  lloltnyrcn's  test  requires  the  candidate  to 
pick  from  bundles  of  colored  worsteds  those  which  match  the  colors 
of  the  solar  spectrum  shown  at  the  same  time. 

Magnus's  tables  (mentioned  in  Vol.  IV,  page  2443,  of  this  Encyclo- 
pedia) consist  of  nine  rows  of  colored  cards  in  brown,  purple,  red, 
orange,  yellow,  green,  blue,  violet,  black  (or  gray),  each  in  four 
different  shades.  With  these  tables  a  portfolio  of  72  different  colors 
in  miscellaneous  arrangement  is  used,  each  color  in  the  tables  appearing 
twice  in  this  portfolio.  The  miscellaneous  colors  are  shown  the  person 
tested  and  he  is  required  to  sort  out  quickly  the  same  color  as  the  one 
shown  him  on  the  tables;  if  he  is  successful  he  may  then  be  asked  to 
sort  out  similar  colors  and  different  shades  of  the  color  indicated. 

The  test  may  be  varied  by  employing  colored  wools  instead  of  the 
color  tables. 

Mauthncr's  powders  (described  in  Vol.  IV,  page  2457,  of  this  Ency- 
clopedia). 

Maxwell's  color  box  (described  in  Vol.  IV,  page  2431,  of  this  Ency- 
clopedia) . 

Maxwell's  revolving  discs  (mentioned  in  Vol.  IV,  page  2490)  is  a  test 
of  the  chromatic  sense  by  means  of  colored  discs  revolving  on  a  top, 
so  arranged  that  the  various  colors  can  be  combined  in  any  proportion. 

Meyer's  tissue-paper  test  (described  in  Vol.  IV,  page  2459,  of  this 
Encyclopedia) . 

Middleton's  lamp  (described  in  Vol.  IV,  page  2488,  of  this  Ency- 
clopedia). 

Nagel's  anomaloscope  (mentioned  in  Vol.  IV,  page  2442,  of  this 
Encyclopedia)  is  an  instrument  for  making  the  Rayleigh  test.  It 
serves,  as  the  name  suggests,  not  only  to  unmask  color-blindness 
(dichromatism),  but  also  to  detect  anomalous  trichromatism.  The 
anomaloscope  consists  es.sentially  of  a  telescope,  in  which  the  examinee 
sees  a  small  circular  Held.  The  field  is  divided  into  two  by  a  horizontal 
line.  The  Iowht  lialf  obtains  its  light  from  a  prism  which  is  so 
adjusted  that  only  yellow  (sodium  light)  illuminates  it.  This  is  done 
by  a  screw,  which  is  called  for  convenience,  the  "yellow  screw."  If 
the  scale  attached  to  the  screw  stands  at  zero,  the  field  is  quite  dark, 
88  indicates  its  maximum  brilliancy.  It  is  therefore  possible  by  turn- 
ing the  vellow  screw  to  vary  the  brightness  of  the  lower  field  between 


5094 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


Ilic  widest   limits.     Tiic  color,  however  (sodium  yellow j,  remains  coii- 
staiitly  the  same. 

Tile  upper  half  of  the  eirenlar  field  is  .simultaneously  lij^lited  hy  two 
prisuis,  one  of  which  is  adjusted  to  furnish  green  light  (thallium  green), 
the  other  red  light  (lithium  red).  In  this  case,  also,  slits  are  placed 
heliiiid  the  j)risiiis  wliicli  can  he  a<l.juste(l  at  will  eithei'  fully  opened  or 


H- 

G          «* 

S,              I' 

3 

J, 

1 

f^T 

K 

L 

^^^n 

A 

iJPj 

k 

f> 

Nagel  's  Anomaloscope,   for   Testing   Color-Vision. 

K,  collimator  tube;  F,  eyepiece  tube;  D,  prism;  M  and  lower  D,  screws  to 
control  position  of  eyepiece  tube ;  B,  diajjliragm  to  alter  size  of  visual  field ;  A, 
holder  for  alcohol ;  L,  mantle  lamp  using  alcohol  vapor ;  H,  asbestos  chimney  sur- 
rounding glass  chimney  of  lamp ;  G,  ground  glass  plate,  source  of  illumination  for 
anomaloscope;  S,,  right-hand  screw  (G,  of  Fig.  9),  controlling  width  of  upper  slit 
and  lower  half  of  field  as  seen  at  the  eyepiece  F.  This  screw  regulates  the  bright- 
ness of  the  pure  yellow  half  of  the  field.  S.,  left-hand  screw,  (G.  of  Fig.  9),  con- 
trolling the  width  of  the  two  coupled  slits  and  the  u]>per  half  of  the  field  as  seen 
at  the  eyepiece.  Through  one  slit  light  is  transmitted  through  the  })rism,  which, 
when  seen  at  the  eyepiece,  corresj)onds  to  the  lithium  red;  through  the  other  slit 
comes  the  thallium  green.  By  moving  the  screw,  S^,  the  upper  half  of  the  field 
is  illuminated  by  a  i)roportional  amount  of  the  red-green  mixture,  from  a  red  to  a 
yellow  and  then  to  a  green. 


quite  shut.  But  it  is  only  possihle  to  alter  the  two  slits  simultaneously, 
and  their  motions  are  complementary  in  the  sense  that  as  one  opens 
the  other  shuts  in  an  equal  degree. 

In  this  way  it  is  possible  to  modify  the  light  mixture  as  desired.  Any 
mixture  of  red  or  green  may  be  made  or  either  color  entirely  cut  out. 
The  slits  are  adjusted  by  a  screw  which  is  called  the  "red-green  screw." 
The  milled  head  of  the  screw  is  graduated  from  0  to  88.  If  the  pointer 
stands  at  0  the  field  is  pure  spectral  green,  if  it  is  turned  red  is  iutro- 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5095 

duecd.  Tile  iiiorr  I'cd  is  iiddcd,  tlic  more  colorless  the  green,  until  at 
a  certain  .si)ot  (Hfty-ci^dit  on  tlic  .scale)  the  upper  half  of  the  field 
becomes  a  coloi'less  ycnow,  neither  green  nor  red.  As  the  screw  is 
tui-ned  tile  nppei-  liehl  takes  on  a  red  tone,  which  l)econies  more 
mai-ked,  until  ultimately  all  the  y-i'een  is  shut  out  and  the  field  is  a 
pure  spectral  red. 

NagcVs  plates  consist  of  a  set  of  cards,  each  bearing  a  series  of 
little  colored  discs  arranged  in  a  ring.  In  some  rings  the  discs  are  all 
one  color,  but  of  slightly  different  shades;  in  others  the  discs  are  of 
two  or  three  different  colors  (confusion  colors).  By  making  the  patient 
state  which  rings  are  monochi-omatic,  and  then  nuike  him  pick  out  in 
the  dichromatic  or  trichi-omatic  rings  all  the  discs  that  are  one  special 
coloi",  one  can  readil\-  ascertain  wiiether  he  is  color-l)lind  and  what  sort 
of  color-blindness  he  has. 

F.  Vierling  {Arch.  f.  Aug.,  11,  p.  242,  1915)  has  motlitied  the  appara- 
tus of  color  equalization  of  Nagel  by  exchanging  the  colored  glasses 
by  gelatine  leaves  made  with  finer  distinction  of  the  required  shades 
of  color.  The  apparatus  does  not  supplant  the  anomaloscope,  but  it 
has  detected  minor  anomalies  in  patients  who  passed  the  tests  witii 
Nagel 's  or  Stilling 's  plates. 

Oliver's  color-sense  measure  (described  in  Vol.  IV,  pages  2461  and 
2469,  of  this  Encyclopedia) . 

Olirer's  worsted  test  is  intended  as  a  ready,  and  yet  strictl}'  scien- 
tific clinical  test,  which  can  be  used  for  short  distances.  In  this  set 
there  are  three  series  of  colors : 

First.  Five  principal  test  skeins  of  large  size ;  these  are  pure  colors. 
Latin  names  have  been  employed  to  represent  them.  Pure  green  has 
been  styled  ' '  Viridis ; ' '  pure  red  has  been  termed  * '  Ruber ; ' '  pure  blue, 
"Ccrrulem;"  pure  yellow,  "Flavus,"  and  rose,  "Rosa."  The  colors 
of  these  skeins  are  of  equal  intensities. 

Second.  Five  small,  pure  nuitch  skeins.  Each  skein  is  a  pure 
shade  of  one  of  the  large  skeins;  each  skein  has  a  bangle  containing 
an  inscription  which  indicates  that  the  attached  skein  is  a  shade  of 
one  of  the  principal  test  skeins  fastened  to  it.  Thus  for  example,  in 
the  first  series  V  0  I  U  indicates  that  the  color  is  a  pure  green,  one 
shade  darker  than  the  larger  sample  shade  of  green,  the  initial  letter  U 
designating  the  word  "Umbra,"  the  Latin  name  for  shade. 

Third.  Eighteen  small  confusion  skeins,  each  of  which  is  composed 
of  equal  percentages  of  two  of  the  pure  match  skeins,  the  component 
colors  being  designated  l)y  the  initial  letters  of  the  colors  contained 
therein,  the  upper  initial  giving  the  prepoiulerant  color  of  the  two. 


509G 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


Tims,  I'oi'  (■\.iiiij)l(',  y  \\  {  I  rcpi'csciils  a  coiiriisioii  color  composed  of 
green  aiitl  red,  the  iirst  color  being  i)ri'poii(lei'aiit  in  the  proportion  of 
two  to  one;  while  R  V  V  I  is  two  to  one  in  excess  of  tiie  red.  In  this 
way  evej-y  color  is  coi-related,  thus  hi'inging  the  match  skeins  series, 
both  i)ure  and  confusion,  to  one  degree  of  color  intensity. 

For  examination,  diffuse  daylight  is  necessary.  A  scjuare  of  black 
muslin  is  placed  upon  a  table  situated  at  about  one  meter's  distance 
away  from  the  candidate's  eye.  The  eyes  of  the  subject  are  to  be  tried 
sej)arat('ly.     The  five  large  test  skeins  are  separated  from  the  twenty- 


PUBLISHED     BY 
E.B.MEYROWITZ,  N.Y. 


«■  «■  ">55  ";SC'  ^' 


Oliver's  Wool  Test. 


three  match  skeins.  One  of  the  large  test  skeins  (preferably  the  green 
one)  is  handed  to  the  candidate,  and  he  is  requested  to  select  the  nearest 
matches  to  this  skein  from  the  pile  of  wools,  and  to  lay  them  alongside 
of  the  test  wool  in  the  order  of  their  matching.  If  necessary,  the 
examiner  should  go  through  the  jorocedure  and  show  the  candidate  what 
is  w'anted,  taking  care  so  to  disarrange  hi.s  choice  that  it  will  be 
impossible  for  the  candidate  to  gain  knowledge  from  the  selection.  The 
letterings  upon  the  tags  of  the  chosen  wools  are  then  to  be  registered  in 
the  order  of  the  color  choice,  upon  a  properly  arranged  blank.  This 
finished,  the  wools  are  to  be  replaced  among  the  general  mass  of  wools 
and  the  same  method  of  selection  continued  with  the  rose,  the  red,  the 
l)luc  and  tlic  xcllow  series.  The  procedure  does  not,  as  a  rule,  consume 
mort'  than  a  few  iiiimitcs'  time  fni'  cadi  candidate.     In  fact,  if  care  be 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5097 

taken  to  prevent  iiiter-coiiiimiiiicatioii,  .scvci'al  caiidiilates  may  be  ex- 
amined witli  different  sets  al  the  same  time. 

Oliver 'n  modificution  of  Abncy's  pdht  test  for  detecting  color 
scotomata  consists  of  a  wooden  disc,  ii])on  the  upper  surface  of  which 
definitely-tinted,  spherical  i)ellets  are  loosely  laid,  the  whole  being 
covered  with  a  transparent  lid.  The  disc  which  has  been  painted  dead 
black  and  which  is  ten  centimeters  in  diameter,  is  constructed  like  a 
plano-concave  lens,  with  its  upper  concave  surface  made  equal  to  the 
cuivature  seen  in  a  minus  spherical  lens  of  four  diopters  strength.  The 
lid,  which  is  of  clear  plane  glass,  surrounded  by  a  beveled  rim  of 
blackened  metal,  is  hinged  upon  the  disc  base  and  is  fixed  in  position 
by  a  metallic  push  spring-clip.  The  pellets,  each  of  which  is  four 
millimeters  in  diameter,  are  composed  of  ivory,  and  are  definitely 
gauged  ill  tlu'ir  relative  tiiitiiigs  to  equal  degrees  of  color  .saturation. 


The  Oliver-Abney  Pellet  Test. 

A  pair  of  ingeniously  contrived  forceps  so  fashioned  that  each  i)ellet 
is  most  easily  held  in  position  when  once  grasped,  accompanies  each 
box. 

The  plan  of  procedure  Ls  to  employ  but  one  eye  at  a  time,  taking 
care  that  the  unused  one  is  excluded  from  participation  in  the  test. 
The  apparatus,  placed  upon  some  broad  black  surface  such  as  a  large 
dead  black  table  cloth,  is  then  brought  into  view. 

The  green  pellet  is  removed  from  the  rest  of  the  colored  pellets  in 
the  color  tray  and  laid  upon  the  cloth  alongside  of  the  forceps.  The 
color  tray  with  the  remaining  pellets  is  left  open  and  exposed.  The 
patient  is  shown  tlie  separated  pellet  and  the  forceps.  Nothing  is  said 
to  him  in  regard  to  the  name  of  the  tint  or  the  color.  He  is  then 
requested  to  pick  up  the  pellet  with  the  forceps  and  hold  it  in  the 
position  ])efore  him  at  which  it  seems  the  brightest  and  the  plainest. 
If  lie  holds  it  eccentrically  or  turns  his  head  to  one  side  in  order  better 
to  see  the  pellet,  his  defect  will  become  quite  evident.  He  is  tlien 
asked  to  hold  his  head  in  .such  a  position  that  his  exposed  eye  is  situ- 
ated at  some  forty  to  fifty  centimetei's  distance  directly  above  the  color 
tray.     While  in  tliis  situation  he  is  nuule  to  drop  the  pellet  among  its 


5098  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

fellows  ill  tlic  coloi-  tiJiy.  The  iiioinciit  that  the  pellet  lias  been  placed 
in  tlu;  ti'ay  the  box  is  given  a  slight  twist  so  that  the  pellets  will  be 
made  to  assume  new  relative  jxisitions.  This  done,  the  i)atient  Ls 
requested  to  select  the  pellet  from  among  its  companions.  If  he  has  a 
central  scotoma  for  green  of  Init  a  couj)le  of  degrees  in  diameter  when 
the  test  tray  is  iield  in  this  position,  it  will  be  almost  impossible  for 
him  to  regain  the  green  color  pellet — thus  again  objectively  showing 
the  central  field  defect  for  the  perception  of  green  and  at  the  same 
time  objectively  proving  its  existence.  The  test  is  to  be  repeated  with 
the  fellow  eye,  and  if  desired,  W'ith  the  red,  the  blue,  and  the  yellow 
series  of  pellets. 

PJlugcr's  tissue  paper  test  is  a  modification  of  ^leyer's  (described 
in  Vol.  IV,  page  2459,  of  this  Encyclopedia). 

Pfluger^s  color  hook  (mentioned  in  Vol.  IV,  page  2448,  of  this 
Eneyciopedia)  consists  of  black  letters  printed  on  colored  paper  and 
covered  with  tissue  paper,  the  letters  appearing  in  the  color  comple- 
mentary to  the  background. 

Polariscope  test  (mentioned  in  Vol.  TV,  page  2460.  of  this  Ency- 
clopedia). See  Chromatophotoptometer  cf  Chibret  and  Tomlinson's 
tests. 

h'agona  Scina  contrast  test  (described  in  Vol.  IV,  page  2459,  of  this 
Eneyciopedia). 

Ramsay's  spectroscope  (described  in  Vol.  IV,  page  2469.  of  this 
Encyclopedia). 

L'ayleigh's  matching  test  (mentioned  in  Vol.  IV,  page  2436,  of  this 
Encyclopedia). 

Rayleigh's  color  mixing  apparatus  necessitates  matching  the  sodium 
D  light  of  the  spectrum  by  a  mitxure  of  red  and  green  light.  There 
are  different  instruments  used  for  the  purpose.  (See  Xagel's  anomalo- 
scope and  Williams'  spectroscope.) 

Reuss's  color  tables  (mentioned  in  Vol.  IV,  pages  2443,  2457,  2485, 
of  this  Encyclopedia) .  Von  Reuss  has  arranged  32  cards,  each  with 
ten  strands  of  colored  wool  fastened  on,  arranged  partly  in  isochro- 
matic  groups  showing  only  one  shade,  partly  isoehromatic,  showing 
several  nuances,  and  partly  pseudo-isochromatic.  The  person  tested  is 
re(|uired  to  sort  out  all  the  isoehromatic  cards.     (Schenke.) 

Roberts'  color  tables  (mentioned  in  Vol.  IV,  page  2443,  of  this 
Encyclopedia) . 

Rose's  polariscope  (mentioned  in  Vol.  IV,  page  2443.  of  tliis  Ency- 
clopedi-a).  Rose  utilized  colors  .shown  by  a  quartz  plate  in  polarized 
light.     The  tube  of  his  polariscope  contained  a  Xicol  prism,  a  rectangu- 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  50f)f) 

lar  (liapliragin,  a  (l()ul)k'  refract iiij,^  pi-isiii.  (juartz  plate  ( .l  iniii.  tliick  i, 
a  second  Nieol  prism. 

The  person  looking  into  this  i)oIariscope  sees  two  images  of  con- 
trasting colors,  which  can  he  moditied  hy  rotating  the  second  Xicol 
prism.  The  rotation  of  the  Nicol  prism  modifies  their  intensity  only. 
A  normal  person  cannot  make  the  two  colors  eqnivalent,  hut  a  person 
if  color-hlind  will  find  on  turning  the  prism  that  in  a  certain  position 
the  two  complementary  colors  are  equal,  which  shows  at  once  what 
colors  are  confounded  hy  him.  The  Rose  polariscope  is  expensive 
and  is  not  much  used. 

Rostschewski's  modification  of  Holmgren's  test  consists  of  small  balls 
of  wool,  diameter  5  to  7  mm.,  using  136  shades,  the  classic  Holmgren 
assortment.  Small  pieces  of.  metal  of  gray  color  are  used  to  liandle 
and  arrange  the  l)alLs.  Three  test  balls  are  used — green,  pui-plc  and 
red — and  the  candidate  recpiested  to  sort  out  the  balls  of  similar  colors. 
A  simpler  assortment  of  halls  for  the  green  test  alone  can  be  used 
as  a  preliminary  test. 

Numhle's  ^c^^^  (described  in  Vol.  IV,  page  2456,  of  this  Ency- 
clopedia) . 

Sanvincau's  test  (described  in  Vol.  IV,  page  2489,  of  this  Ency- 
clopedia). 

Sch(  nke's  yarn  covered  spools  (mentioned  in  Vol.  IV,  pages  2443, 
2457,  of  this  Encyclopedia).  Schenke  uses  a  collection  of  40  to  50 
small  rods  covered  Avith  colored  wools,  which  are  easily  arranged  in  a 
wooden  ring,  from  which  they  may  be  easily  withdrawn,  so  jilaced  that 
they  form  a  star.  The  test  colors  are  chosen  from  tiie  two  vertical 
radii,  and  the  i)erson  tested  required  to  take  out  all  the  rods  showing 
similar,  not  identical,  colors :  the  test  is  continued  until  the  star  appears 
to  him  to  consist  of  only  one  color  in  various  shades.  The  manner  in 
which  the  person  j^erforms  this  test,  what  colors  he  chooses  first,  and 
which  puzzle  him  most,  indicates  the  correctness  of  his  color  vision. 

Schirmcr's  test.  Colin  states  that  this  test  is  based  on  the  pi'inciple 
of  successive  contrast,  the  fact  that  with  the  normal  person  certain 
colors  give  certain  definite  after-images,  e.  g.,  a  yellow  piece  of  paper 
looked  at  steadily  for  a  minute  leaves  an  after-image  of  a  blue  spot 
of  the  same  size.  The  test  is  begun  with  yellow,  the  other  colors  are 
shown  in  succession,  and  the  candidate  asked  to  name  both  the  original 
color  and  tliat  of  the  after-image,  the  replies  being  noted  in  order. 

Secbeck's  test.  In  this  test  about  20  ])ieces  of  colored  pajier  are 
used,  the  candidate  sorting  these  and  putting  together  those  which  to 
him  look  alike. 


5100  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

SlnndldiK  Otis  coiitnisl  tisfa.  Sec  (.'asscl's,  Cohn's,  Pfluger's, 
Kagoua.  Sriiia  Jiiid   Waldslcin  "s  tests. 

i<iiill(  ti's  ophjIi/jK  .  Snellen  gives  a  deseriplioii  of  his  eolor  tesis  in 
the  Eny:lisli  edition  of  his  hook  on  2'cst  Types. 

Sni/dachcr's  color  sqiaircs  (described  in  \'oL  IV,  page  2474,  of  this 
Encijvlopcilui). 

Sfilli>Kj\s  cliroiiialoshiomcter  (mentioned  in  ^'ol.  I\',  page  2443,  of 
this  Encyclopedia). 

StiUiug's  shindtaiuous  contrast  test  (described  in  Vol.  IV,  page 
2459,  of  this  Encyclopedia). 

Stilling's  plates.  These  are  partially  described  in  Vol.  IV,  pages 
2383,  2457,  2485,  of  this  Encyclopedia,  and  are  ten  in  ininiber,  each 
plate  containing  fonr  squares  filk'd  with  small  colored  spots,  among 
w iiieh  otlier  spots  in  a  confusion  color  arc  so  arranged  as  to  represent 
a  letter  or  figure. 

Stilling  was  aided  in  the  pn^paration  of  these  plates  by  a  red-green 
blind  painter  and  a  blue-yellow  blind  teacher  and  in  this  way  he  built 
up  two  classes  of  interchaJigcable  colors.  (1)  Fiery-red,  interchange- 
able with  dark-yellow.  Intense  green,  interchangeable  with  dull-loam 
color.  Faint-rose,  interchangeable  with  bright-gray.  Faint  blue-green, 
interchangcal)le  with  liright-gray.  (2)  Fiery-red,  interchangeable  with 
intense  gold-yellow.  (Jreenish-yellow,  interchangeable  with  faint 
bright-blue.  The  last  two,  interchangeable  with  bright-gray.  Green, 
interchangeable  with  blue.     These  two,  interchangeable  with  dark-gray. 

In  using  this  test,  "the  test  plate  is  held  in  a  good  light  and  the 
candidate  required  to  distinguish  the  letters  or  figures.  An  important 
feature  of  this  test  is  that  there  is  no  inquiry  as  to  color,  but  only  as 
to  letters  and  figures. ' '    The  test  is  made  at  20  feet  distance. 

Spectroscopic  tests.  See  Edridge-Green's,  Nagel's,  Rayleigh's,  Ram- 
say's and  Williams'  tests. 

Successive  contrast  tests  (mentioned  in  Vol.  IV,  page  2443,  of  this 
Encyclopedia).  The  complementary  color  appears  after  looking  stead- 
ily at  a  colored  surface  on  a  gray  back-ground  for  a  time,  if  the 
colored  object  is  quickly  removed. 

Thomson's  lantern  (mentioned  in  Vol.  IV,  page  2380,  of  this  Ency- 
clopedia). It  consists  of  an  asbestos  chimney  which  can  be  placed  on 
a  kerosene  lanq)  in  universal  use  on  railroads,  or  over  an  Argand 
burner  or  other  gas  light,  electric  lamp  or  spring  candle  stick. 

There  ai'e  two  discs  three  and  one-lialf  inches  in  diameter,  each 
containing  seven  openings  wliieli  carry  the  colors,  which  revolve  over 
each  other  so  the  colors  may  l)e  seen  separately  through  the  opening 
at  wliich  llicy  ai'e  presented,  oi-  lu"  superimposed. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5101 

The  openings  ill  the  discs  wlien;  tlic  colors  are  shown  are  one-half 
inch  and  one-twelfth  inch  in  diaiiieler,  and  an;  made  of  the  size  to 
simulate  signals  at  diil'ereiit  cILstanees.  Taking  Donders'  formula  for 
measurement  of  color  perception,  the  small  opening  of  one-twelfth  inch, 
when  placed  in  front  of  a  color,  is  equal  to  normal  color  vision  at 
thirty-two  feet.  The  one-half  inch  opening  is  equal  to  normal  vision 
at  200  feet  and  for  pi'actical  purposes  the  one-half  inch  opening  at 
twenty  feet  is  equal  to  the  ordinary  five-inch  seiiiai)liorc  light  at  one- 
half  mile. 

The  lower  disc  contains  the  slainhird  colors  u.scd  as  signals  on  the 
railroads:  red,  blue-green,  blue  of  the  inspector's  light,  and  yellow. 
This  disc  is  known  as  the  examination  in  chief. 

The  colors  have  been  carefully  selected  and  are  identical  witii  the 
standards  used  on  the  railroad  when  shown  in  the  lantern.  These 
colors  are  designated  by  numbers,  1  to  7. 

,  The  upper  disc  contains  the  confusion  colors,  and  the  small  opening 
of  one-twelfth  inch  which  is  used  as  a  quantitative  measure  of  color 
perception.  This  is  known  as  the  cross-examination  and  its  colors  are 
designated  by  letters  of  the  alphabet — A,  B,  C,  etc. 

The  colors  of  this  disc  are  pink,  yellow-green,  cobalt,  deep  London 
smoke,  and  gray-ground  glass  and  are  the  most  important  in  detecting 
the  different  types  of  color-})lindness,  and  especially  those  varieties  that 
are  not  perfectly  determined  by  the  wool  test.  F'or  example,  the  three 
colors,  pink,  yellow-green,  and  gray-ground  glass  are  the  typical  neutral 
colors  of  the  color-blind  and  represent  the  confusion  colors  of  the  wool 
test.  The  pink,  which  to  the  normal  eye  appears  light-red,  is  composed 
by  the  spectroscope  of  pure  red  and  blue.  This  cannot  be  imitated  in 
glass,  so  it  is  made  of  a  piece  of  colored  gelatin  and  placed  between  two 
layers  of  glass.  If  this  color  is  regarded  through  a  piece  of  peacock- 
blue  glass,  cutting  off  the  red  it  appears  blue.  The  normal  eye  sees  it 
as  light-red,  the  red-blind  man,  having  his  red  sensation  defective, 
sees  only  the  blue  and  as  these  three  colors,  pink,  >(>1  low-green  and  gray, 
are  the  color-l)lind  man's  white,  so  the  pink  may  l)e  mistaken  for  white  ; 
the  same  holds  good  with  yellow-green  or  gray  ground  glass,  which  may 
lie  mistaken  for  white,  red,  or  green.  It  will  be  found  in  the  practical 
examination  of  one  who  has  a  defect  in  his  color  sensation  that  these 
three  colors  are  invariably  designated  as  the  same  color;  the  only  dis- 
tinction he  makes  is  that  they  are  different  shades  of  the  same  color, 
while  to  the  normal  eye  they  are  three  distinct  colors. 

The  Ijondon  smoke  is  used  to  reduce  the  intensity  of  the  color  and 
for  ])ractical  purposes  simulates  the  changes  that  take  place  in  the 
atmosphere,  rain,  fog,  etc.     The  cobalt  transmits  both  red  and  blue  and 


5102 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


is  also  a  good  tcsl  and  a1  tlic  same  time  wImmi  usimI  with  otlier  colors, 
makes  valuable  coiul)iMatioiis. 

Hy  beiiifj  ahle  to  sujx'iiiiiposc  llic  colors  one  over  the  otlier  one  is 
able  to  p't  uol  oidy  a  coiisidiialilc  variety  of  different  colors,  but  many 
shades  of  the  same  color,  for  example,  seven  shades  of  red,  ranging  from 
an  exceedingly  dai-k-red  color-  that  might  be  represented  by  a  lamp 
burning  very  low,  up  to  a  vci-y  light  pink.  These  can  all  be  shown 
in  I'apid  succession. 

The  addition  of  the  cori'Ugated  lens  in  the  present  lantern  is  of  great 
improvement.  It  overcomes  the  former  difficulties  by  giving  a  uniform 
opening  and  at  the  same  time  does  not  reduce  the  intensity  and  satu- 
ration of  the  color,  and  secondly  the  corrugations  of  the  glass  being 


Thoiiison  's  Stick  of  Colored  Wools. 


very  small,  is  practically  a  miniature  semaphore  light,  and  acts  pre- 
cisely the  same  at  the  distance  we  use  it,  as  the  railroad  semaphore. 

In  the  lantern  only  one  color  at  a  time  is  presented  for  examination, 
and  in  this  it  differs  from  some  other  lanterns  which  are  now  in  use. 
The  colors  are  luimed  or  their  indication  specitied. 

TJiomson's  t<st  iritJi  colxdi  blue  gla.'is  consists  in  making  a  patient 
look  through  a  good  cobalt  glass  at  a  light  which  to  an  eye  accom- 
modated foi"  tile  distance  of  the  light  or  a  nearer  point  will  appear 
red  with  a  blue  halo  around  it,  wliilst  to  an  eye  accommodated  to  a 
distance  greater  than  that  of  the  light  it  will  api)ear  blue  with  a  red 
halo  around  it.  The  red-blind  or  green-blind  will  .see  the  blue  very 
well,  but  the  red  will  betray  him  soon  by  its  absence. 

Tliotnson's  \rool  siivk  (described  in  Vol.  TV,  pages  2453  and  2480. 
of  this  Kncydopedia). 

Thomson's  wools  (described  in  \q\.  IV,  page  2454.  of  this  Ency- 
clopedia). 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 


5103 


To)nIiiison\s  polariscopc  (described  in  \'ol.  I\',  page  2470,  of  lliis 
Encyclopedia). 

Verhoeff's  test  for  color-vision  (deserilicd  on  page  4678  of  this 
Encyclopedia.) 

Waldstcin's  chromatoscope  test  is  applied  by  holding  before  a  lamp 
a  piece  of  colored  glass,  and  allowing  the  light  thus  colored  to  fall  upon 
a  white  screen,  wliicli  will  tlicn  ai)pear  colored.  Now,  holding  a  pencil, 
for  instance,  before  the  screen,  one  notices  a  shadow  cast  on  the  colored 
surface.     This  shadow  will  to  the  normal  eye  appear  of  the  complc- 


^^'elsh  "s  Lautern. 


meiitary  color  of  the  gla.ss  before  the  lamp;  while  to  the  color-blind  the 
shadow  \vill  appear  colorless,  black  or  gray. 

Welsh's  lantern  (mentioned  in  Vol.  IV,  page  2457,  of  this  Ency- 
clopedia). Welsh  had  for  his  lautern  test  a  "caboose"  end  built  in 
a  recess  of  his  office.  He  used  four  lanterns,  one  on  the  top,  one  at 
each  side,  and  one  on  the  platform  of  this  caboose  end.  These  lanterns 
were  of  the  same  type  as  those  in  use  on  the  rear  ends  of  trains ;  they 
were  equipped  with  colored  glass  and  with  electric  lights.  The  lights 
are  flashed  on  quickly  and  the  candidate  placed  at  a  distance  of  30 
to  40  feet,  and  asked  to  name  the  light  flashed.  The  colors  shown 
were  red,  green  and  white. 

Welsh's  latest  model  consists  of  a  box  11  inches  long,  7  inclics  wide 
and  7  inches  high,  fastened  on  a  wooden  base.     The  apertures  through 


5104  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

which  the  color  is  visihh'  vai'v  in  si/c  from  i/s  of  ii'i  i'K'l'  to  an  inch 
ill  (liamt'ter.  The  {^hiss  is  arranged  in  a  seeond  slide  in  sections  IV^ 
by  2  inches,  in  front  of  wiiich  there  is  an  opening  l^/s  inches.  Slide 
No.  1  passes  over  slide  No.  2  in  a  vertical  and  horizontal  plane.  The 
top  of  the  box  is  open  to  admit  an  electric  light  and  the  bottom 
ari-anged  with  an  opening  in  which  to  place  an  oil  light  or  pot  similar 
to  those  used  on  passenger  coaches.  Tiie  api)licant  is  taken  into  a 
(hirk  room  and  the  colors  are  flashed.  The  lantern  slides  consist  of 
wliite.  red,  green  and  blue  glass,  which  are  arranged  in  front  of  the 
light.  Over  this  slide  is  run  a  second  slide  with  apertures  varN'ing  in 
size  as  the  dimensions  in  the  lantern  show.  With  a  defective  the  find- 
ings are  always  confirmed  by  a  yarn  test. 

Williarns'  lantern  (mentioned  in  Vol.  IV,  page  2380,  described  and 
illustrated  on  page  24:10,  of  this  Encyclopedia) . 

Willianis'  spectroscope  consists  of  an  addition  to  the  Ives  duplex 
ditTraction  spectroscope,  which  allows  monochromatic  areas  of  the 
spectrum  to  be  observed  and  by  an  ingenious  adaptation  the  red-green 
junction  in  the  spectrum  may  he  matched  with  a  constant  yellow  intro- 
duced by  means  of  a  total  reflecting  prism  and  a  yellow  glass  wedge. 

Wilson's  test  consists  of  little  l)undles  of  colored  worsteds,  which  the 
applicant  sorts  out  and  places  together  those  seeming  alike.  The 
l)rinciple  l)eing  one  of  comparison,  the  applicant  not  l)eing  obliged  to 
name  any  colors. 

Woinoiv's  revolvinej  elisJ:  shows  an  inner  circle  of  which  one-half  is 
})lack  and  the  other  half  white.  It  appears  to  be  gray  when  revolving. 
Three  rings  outside  of  this  are  composed  of  equal  parts  of  two  of  the 
three  primary  colors,  red,  green,  violet.  To  a  person  blind  to  the  color 
not  represented  in  one  of  the  rings,  this  ring  will  appear  gray.  Later 
he  may  modify  his  disk,  as  he  accepts  four  primary  colors.  The  inner 
I'ing  is  now  to  be  red  and  violet  (or  l)lue )  ;  the  outer,  green  and  vioh^t 
(or  blue)  ;  the  third  is  left  out.  If  the  outer  appears  gray  like  the 
center  we  have  green-blindness;  if  the  inner,  red-blindness;  if  both., 
red-green-blindness. 

Zceman  and  Were  color  mixing  apparatus  (mentioned  on  page  24-l:J: 
of  this  Encyclopedia).  Zeeman  and  Weve  use  an  ordinary  projection 
apparatus  and  a  combination  of  lenses,  and  mirrors  to  throw  the  colors 
on  a  field  in  such  a  way  as  to  divide  the  spectrum  into  two  parts ;  each 
half  can  be  sub-divided  into  two  or  three  parts  by  a  small  lever. 

In  the  upper  half  the  light  is  made  yellow  with  natrium  ;  in  the  lower 
half  there  are  two  parts,  one  green  and  one  red;  the  test  is  to  make  a 
yellow  similar  to  the  upper  yellow  by  combining  red  and  green. 

The  apparatus  is  designed  also  to  test  effects  of  different  intensities 
and  the  wave  lengths  of  the  spectrum  colors  used. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5105 

VALUE  or  OFFICE  TESTS. 

The  value  of  a  test  of  visual  acuity  by  means  of  characters  which 
sul)t('nd  a  five  luinutc  aiifjle  exposed  at  5  to  G  inetcrs  distance  has  been 
questioned  ])y  many  i)rominent  opbthalmoloj^ists  as  an  adequate  means 
of  determiiiint?  the  actual  vision  of  individuals  where  occupation 
recjuires  the  observation  of  details  at  many  times  tluit  distance.  Some 
of  the  objections  raised  are:  that  the  effect  of  different  backgrounds 
can  be  determined  only  in  a  limited  way;  there  is  no  method  of  pro- 
ducino:  the  effects  of  diffei'cnt  atmospheric  conditions.  None  of  the 
actual  conditions  found  in  railroad  service  is  simulated,  except  the 
use  of  lanterns  fftr  testing  color-vision.  The  standards  should  be  based 
ni)on  wliat  th(»  eye  can  see  at  one-half  mile  or  beyond. 

While  these  objections  are  valid  and  actual  tests  have  shown  con- 
clusively that  enginemen  with  greatly  reduced  vision,  according  to 
office  tests,  are  able  to  determine  the  position  of  day  signals  and  the 
color  of  night  signals  at  remarkal)le  distances,  it  does  not  indicate  that 
an  individual  with  6/LX  test  card  vision  can  read  signals  at  any- 
where near  the  distance  one  can  who  has  fi/VI  test  card  vision.  The 
question  is  raised  more  for  the  purpose  of  arguing  in  favor  of  minimum 
requirement  of  less  than  6/VI  or  6/VIII  vision  and  by  those  who  favor 
a  field  test  rather  than  an  office  test. 

There  is  one  decided  objection  to  any  office  test  for  color-blindness ; 
no  test  so  far  devised  will  detect  "chromic  myopes,"  i.  e.,  those  whose 
color-vision  is  normal  for  objects  within  certain  distances  but  to  whom 
all  colors  beyond  this  limit  are  a  neutral  gray. 

The  following  is  a  report  of  a  few  results  obtained  in  the  field  tests 
made  at  Noble,  0.,  in  August,  1907.  These  were  made  upon  engine- 
men  long  in  service  whose  vision  had  become  reduced  in  the  majority 
of  instances  by  latent  refractive  errors  becoming  manifest  with  increas- 
ing age.  This  report  also  shows  the  improved  distance  vision  obtained 
])y  correcting  errors  of  refraction  and  bringing  the  vision  up  to 
standard  according  to  office  tests. 

Age,  42  years ;  service,  22  years ;  16  years  as  engineman. 

Daylight  test :  Bright  sunlight : 

Both  eyes  (without  glasses)  8,000  feet,  read  signals. 

3.000  feet,  called  flags. 
Both  eyes  (with  glasses)  5,280  feet,  read  signals. 

Kight  eye  (without  glasses)  2,400  feet,  read  signals. 

Night  indication:  Weather  clear: 

Both  eyes  (without  glasses)  2.700  feet,  read  signals. 

Both  eyes  (with  glasses)  4,000  feet,  read  signals. 

Right  eye  (without  glasses)  2,100  feet,  read  signals. 

Vol.  VII— 17 


5106  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Chart  test,  August  ;U,  1907. 

Vision :  Without  glasses :  Witli  glasses : 

Right 20/70  20/30 

Left 20/50  20/20 

Combined 20/40  20/20 

Age,  59  years ;  serviee,  44  years ;  37  years  as  engineinan. 

Daylight  test:  Bright  sunlight: 

]5oth  eyes  (without  glasses)  2,000  feet,  read  signals. 

2,000  feet,  called  Hags. 

Hoth  eyes  (with  glasses)  5,280  feet,  read  signals. 

Right  eye  (without  glasses)  1,100  feet,  read  signals. 

Niglit  indication:  Weather  clear: 

Both  eyes  (without  glasses)  1,800  feet,  read  signals. 

Both  eyes  (with  glasses)  3,300  feet,  read  signals. 

Right  eye  (without  glasses)  1,250  feet,  read  signals. 

Chart  test,  August  31,  1907. 

Vision :  Without  glasses :  With  glasses : 

Right 20/100  20/70 

Left 20/50  20/20 

Combined 20/50  20/20 

History  of  visual  tests. 

Field  of  vision       Interior  of  eye  Cause  of  diminished  vision 

Normal  Healthy  Right  eye  amblyopic.    Left  eye, 

relaxed  accommodation,  as  an  ac- 
companiment of  age,  in  simple 
hyperopia  of  1  diopter. 

Age,  65  years;  service,  20  years;  20  years  as  engineman. 

Daylight  test :  Bright  sunlight : 

Both  eyes  (without  glasses)  2,900  feet,  read  signals. 

2,600  feet,  called  flags. 

Both  eyes  (with  glasses)  5,280  feet,  read  signals. 

Right  eye  (without  glasses)  1,700  feet,  read  signals. 

Xiglit  indication  :  Weather  clear: 

liotli  eyes  (without  glasses)  2,500  feet,  read  signals. 

I^otli  eyes  (with  glasses)  5,000  feet,  read  signals. 

Right  eye  (without  glasses)  2.400  feet,  read  signals. 


EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Chart  tost,  August  M,  liJ07. 

Vision :  Without  glasses :         With  glasses : 

Right 20/70  20/20 

Left  20/70  20/20 

Comhiiunl 20/50  20/20 


5107 


History  of  visual  tests. 

Field  of  visiu)t        Iiihrior  of  cijc  Came  of  diminished  vision 

Normal  Healthy  Relaxed  accommodation,  as  an 

accompaniment  of  age  in  simple 
hyperopia,  of  2  diopters  in  each 
eye. 

R  L  C 

JMay  18,  1!)0;J 20/100  20/100  20/40 

June  11,  190-1 20/100  20/100  20/50 


Age,  53  years ;  service, 
Daylight  test : 
Both  eyes  (without  glasses) 

Both  eyes  (with  glasses) 
Right  eye  (without  glasses) 

Twilight  test : 
Both  eyes  (without  glasses) 
Both  eyes  (with  glasses) 
Right  eye  (without  glasses) 

Night  indication  : 
Both  eyes  (without  glasses) 
Both  eyes  (with  glasses) 
Right  eye  (without  glasses^ 


31  years ;  28  years  as  engineer. 

Bright  sunlight : 

2,600  feet,  read  signals. 
1,800  feet,  called  flag. 
5,280  feet,  read  signals. 
1,800  feet,  read  signals. 


1,800  feet, 

5,280  feet, 

1,400  feet, 
W(>ather 

2.750  feet, 

5,000  feet, 

2.600  feet. 


read  signals, 

read  signals, 

read  signals, 
clear: 

read  signals, 

read  signals, 

read  signals. 


Chart  test,  August  3],  li)07 

Vision  :  Without  gla.sses : 

Riglit 20/100 

Left  20/70 

Coml)incd 20/70 


Witli  glasses : 

20/20 
20/20 
20/20 


5108  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Afxc  .")1  yciii'S;  sL'i'vicc,  28  years;  25  years  as  eiigineiiiaii. 
Daylight  test :  iJright  sunlight : 

Hoth  eyes  (wilhout  glasses)  2,000  feet,  read  signals. 

1,500  feet,  called  red  flag. 

1,400  feet,  called  white  flag. 
Night  indication  :  Weather  clear: 

Both  eyes  (with  glasses)  5,280  feet,  read  signals,  all  colors. 

Both  eyes  (without  glasses)  2,200  feet,  read  signals. 

While  a  candidate  could  at  times  distinguish  night  signals  at  2,200 
feet  with  both  eyes  without  glasses,  the  next  minute  he  wouhl  ])e  uiial)le 
to  see  them  at  all  and  it  would  l)e  necessary  to  move  up  to  within  700 
feet  before  he  could  eleaily  distinguish  signals,  which  indicated  a  vary- 
ing condition  of  the  eye,  which  very  materially  affected  distances  at 
which  he  could  read  signals.  That  condition  did  not  appear  to  be 
present  in  the  daytime. 

Another  ])eculiar  condition  was  that  witli  the  very  bright  sunliglit 
signals  could  be  read  2,000  feet,  and  shortly  after,  when  the  sun  had 
gone  behind  the  clouds  but  still  while  it  was  bright  daylight,  signals 
could  be  read  only  at  distances  varying  from  1,100  to  1.-400  feet. 

Chart  test,  August  29,  1907. 

Vision:  AVi th out  glasses :         With  glasses: 

Right 20/200  20/20 

Left   20/200  20/20 

Combined 20/200  20/20 

History  of  visual  tests. 

Fidd  of  vision  Inferior  of  cue  Cause  of  diminished  vision 

Slightly  contracted  Healthy  Compound  myopic  astigmatism 

Grow  points  out  that  the  simple  tests  in  current  use  for  candidates 
for  the  naval  service  do  not  eliminate  dangerous  amounts  of  hyperopia  : 
and  recommends  a  special  examination  to  determine  the  amount  of 
hyperopia,  anything  over  3  D.  being  a  cause  for  rejection. 

The  value  of  field  tests  is  certainly  demonstratt'd  in  the  reports  on 
preceding  pages.  It  is,  however,  a  supertliious  test  with  those  having 
20/20  vision:  except  as  a  nighl  test  for  the  jiurpose  of  detecting 
' '  chromic  myopes. ' ' 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5109 

An  official  of  one  ot"  our  largest  railway  systems  volunteeretl  the 
information,  that  the  night  tield  test  was  frequently  tried  with  those 
showing  color  defects  with  the  Holmgren  and  lantern  tests  and  that 
invariably  the  same  character  of  defect  was  demonstrated  by  the  field 
test. 

The  enginemen,  as  a  rule,  would  certainly  i)refer  a  field  test  to  an 
office  examination,  as  it  would  more  nearly  simulate  actual  working 
conditions.  There  are,  however,  several  objections  to  this  method;  in 
the  first  place  it  consumes  so  mucii  time ;  secondly,  the  roads  would 
hardly  go  to  the  expense  of  building  a  testing  line  of  sufficient  lengtli 
for  such  a  purpo.se,  and  the  congested  condition  of  the  traffic  on  the 
majority  of  the  roads  would  not  warrant  the  undertaking  of  sut'h  a 
method,  as,  in  order  to  carry  out  the  scheme  fully,  the  examiner  would 
have  to  arrange  beforehand  for  designated  signals  to  be  in  certain 
positions;  thirdly,  there  would  have  to  be  a  test  for  signals  by  night 
as  well  as  by  day ;  fourthly,  the  tests  would  not  be  equal,  for  some 
men  would  be  tested  under  perfect  weather  conditions  and  others 
under  adverse.  The  result  is,  we  must  be  content  with  an  office  or 
inside  test,  the  exception  being  those  cases  especially  referred  for 
such  a  test. 

ADEQUxVCY  OF  VARIOI'S  TESTS  FOR  COLOR-BLINDNESS. 

This  subject  is  also  discussed  in  Vol.  IV  of  this  Encyclapcdia.;  e.  g., 
unskillfulness  in  employing  the  tests,  page  2371 ;  futility  of  some  tests, 
page  237-1;  superiority  of  lantern  tests,  page  2381;  Adler's  colored 
crayons  unreliable,  page  2388  ;  fixity  of  tests;  limited  number  of  colors; 
liability  of  methods  becoming  known  and  undei-stood,  and  thus  ren- 
dered practically  worthless;  why  some  tests  camiot  satisfactorily  be 
employed ;  prohibitive  cost  of  apparatus  in  spectroscopic  tests,  as  well 
as  amount  of  time  consumed ;  liability  of  complicated  mechanism  to 
become  disarranged,  and  intelligence  necessary  on  the  part  of  candidate 
and  examiner.  Tests  by  means  of  subjective  after-color  sensations  are 
unsatisfactory  because  of  the  vague  subjective  colors  dealt  with  and 
the  uncertain  color  intensities  used.  Adjustments  of  instrumental 
technique  are  also  uncertain,  and  the  tests  have  no  advantage  over  the 
comparison  tests  with  wools,  etc.,  as  shown  on  page  2443.  Shadow 
tests  maj'  be  easih'  guessed  even  by  color-blind  candidates,  and  require 
a  large  number  of  color  shadows  to  be  cast,  as  discussed  on  page  2459. 

That  the  report  of  the  committee  appointed  by  the  English  Board 
of  Trade  does  not  meet  the  approval  of  many  of  the  foremost  ophthal- 
mologists of  the  United  Kingdom  is  evident  from  the  following  protest : 
"We  consider  the  report,  then,  to  be  singularly  defective:  first,  because 


illO  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

it  fails  to  rccojfiiizc  that  accidents  caused  l)y  defective  vision  liave  haj)- 
poned  and  do  liapjx-ii;  secondly,  hecause  it  neglects  the  fact  tliat  quite 
a  sensibh'  ]ti'o])ortion  of  officers  at  sea  are  color-blind  and  have 
defective  form  vision;  thiidiy,  because  it  I'etains  tiie  Holmgren  test, 
which  has  been  siiown  to  be  utterly  inefficient,  and  whicii  allows  a  large 
percentage  of  color-blind  i)ersons  to  pass ;  fourthly,  because  it  suggests 
a  lantern  which  has  no  neutral  modifying  glasses ;  and,  finally,  because 
it  retains  examiners  who  are  admittedly  too  inexpert  to  use  anything 
like  a  proper  instrument. 

"As  some  sort  of  set-off,  certain  of  the  recommendations  of  the  com- 
mittee are  excellent.  Tliey  suggest  that  the  responsible  persons  should 
be  examined  for  visual  defects,  after  accidents  at  sea.  They  have 
introduced  a  lantern,  a  bad  one  it  is  true ;  but  then  any  lantern  is 
better  than  none  at  all.  They  have  advised  that  the  higher  standard 
of  form  vision  be  adhered  to." 

Edridge-Green  pointed  out  man}-  years  ago  the  inadequacies  of  the 
Holmgren  wool  test  (although  Stargardt  and  Oloff  give  the  priority  to 
Nagel).  He  says:  "The  Holmgren  test  misses  about  half  (or  accord- 
ing to  German  authorities,  more  than  half)  of  those  who  are  danger- 
ously color-blind,  in  addition  to  rejecting  many  normal-sighted  persons 
and  those  with  slight  and  unimportant  defects  of  color  perception." 

He  found  that  it  was  impossible  to  construct  a  wool  test  that  was 
satisfactory  and  discarded  it  entirely  for  a  lantern  test  in  which  the 
names  of  colors  must  be  used. 

The  following  is  contained  in  the  report  of  the  committee  of  the 
Ophthabnologieal  Society  of  the  United  Kingdom  on  color-vision,  1904 : 

"We  agree  with  Edridge-Green  that  some  cases  of  color-blindness 
cannot  be  detected  by  Holmgren's  test,  however  skilfully  and  fully 
used;  and  that  others  that  satisfy  Holmgren's  first  test  (pale  green) 
easily,  and  would  therefore  be  passed  as  normal  in  most  ordinary 
routine  examinations,  are  exposed  by  a  careful  use  of  Holmgren's 
second  test  (rose  test  color).  We  further  agree  with  Edridge-Green 
that  some  at  least  of  the  cases  just  referred  to,  when  tried  with  the 
signal  lantern,  make  mistakes  that  at  once  disfjualify  them.  The  dis- 
covery of  the  defect  in  such  cases  can  be  made  with  certainty,  and,  as 
a  rule,  easily  by  a  modification  of  the  wool  test,  such  as  that  of  Edridge- 
Green,  in  which,  as  the  result  of  his  investigations,  he  recommends  a 
series  of  colors  different  from  Holmgren's." 

Schlodtmann  considers  Holmgren's  skeins  not  sufficient  for  exact 
determination  of  color  distinction,  and  that  Nagel 's  plates  are  much 
better,  especially  the  re(|uired  ability  to  distinguish  slightly  saturated 
green  from  the  various  shades  of  gi  ay.    For  those  wlio  make  only  slight 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5111 

mistakes  with  the  hitter  test  lie  recommends  a  practical  test  on  a  Ujco- 
motive  in  the  presenee  of  an  oculist  and  railway  expert. 

Ahney,  one  of  the  .strongest  upholders  of  llie  Holmgren  test,  .says 
of  the  three  colors  sugge.sted  by  Holmgren  as  test-skeins:  "The 
standard  colors  selected  are  most  suited  for  the  detection  of  complete 
or  nearly  complete  blindness  I'ather  than  for  color-blindne.ss  which  is 
incomplete  and  is  small.  .  .  .  Except  for  the  fairly  pronounced 
examples  of  incomplete  color-bliudness,  it  is  not  uncommon  for  the 
incomplete  color-blind  to  pass  these  three  tests  with  but  slight  errors. 
,  If  the  examinee  is  asked  to  name  some  oi"  the  confusion 
colors,  the  giving  of  the  wi'ong  name  to  any  of  them  will  confirm  what 
has  probably  been  found  out  by  the  matctlies. " 

Rostschewski-Saraton  states  most  decidedly  that  tiie  ordinary  Holm- 
gren test  is  useless.  To  get  an  accurate  determination  of  the  color- 
vision  of  the  fovea  the  objects  must  not  subtend  a  greater  angle  than 
1  degree. 

Nydegger  says  it  nuiy  well  be  stated  that  the  Holmgren  color  test, 
as  employed  in  examinations  for  color-blindness,  is  in  many  instances 
unsatisfactory,  and  with  our  present  knowledge  inadequate,  and  should, 
when  used,  ])e  sui)plemented  by  an  additional  examination,  and  is  a 
matter  which  warrants  earnest  consideration.  It  has  been  shown  that 
when  used  alone,  the  Holmgren  method  fails  to  detect  all  cases  of  color- 
blindness. He  suggests  that  the  worsted  test  should  be  supplemented 
by  a  lantern  test,  which  is  more  accurate  and  better  adapted  for  the 
detection  of  color-blindness. 

The  British  Board  of  Trade  has  issued  a  report  on  the  new  sight 
tests  used  in  the  Mercantile  ^larine.  This  report  covers  the  period  of 
April  1st  to  Dec.  31st,  1913.  An  improved  wool  test,  in  which  the 
candidate  has  to  match  five  colors,  and  a  lantern  test  were  used.  The 
cases  of  color-blindness  are  divided  into  those  definitely  rejected  by 
the  local  examiners  and  those  referred  for  a  special  examination,  the 
local  examiner  being  dou])tful.  Of  the  280  definitely  rejected  in  the 
local  examinations,  148  failed  in  both  the  lantern  and  the  wool  test  and 
138  failed  in  the  lantern  test  only ;  there  was  no  failure  with  the  wool 
test  if  they  passed  the  lantern  test.  Of  the  286,  93  appealed.  26  being 
successful.  Of  125  referred  cases,  20  were  referred  on  both  the  lantern 
and  wools,  101  on  the  lantern  only,  3  on  the  wools  only,  and  1  on  form 
vision  as  well.  Of  this  nmnber  there  were  30  failures;  3  of  these  were 
referred  on  both  the  lantern  and  wool  test,  26  on  the  lantern  only,  and 
1  on  form  vision  as  well.  Those  referred  on  the  wool  test  alone  were 
passed.     From  this  rei)ort  it  is  perfectly  evident   that   the  Board  of 


5112  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

Trade  will  no  longer  rely  on  llic  wool  test,  and  oJ)lltllallllol()^dsl^ 
liresuniably  will  be  in  aeeord  with  the  iioai'd. 

The  lantern  test,  while  neither  so  aec.-nrate  iH>r  so  severe  as  the 
laboratory  eolor  i)ateli  or  tlot  test,  is  admitted  to  be  sutlfieieutly  so  for 
praetieal  purposes,  and  is  easily  understood  b\  tlic  ordinary  person 
who  has  no  tlieories  on  color-vision. 

Professor  Stargardt  and  Fleet-Surgeon  Oloff  of  the  Germany  Navy, 
from  long-continued  and  mutual  experience,  state  tbat  they  are  unable 
to  share  the  widely  spread  opinion  that  the  whole  question  of  color- 
vision  testing  in  the  army,  the  naval  services,  and  on  railways  was 
settled,  finally  and  absolutely,  wlien  Nagel's  plates  were  adopted  by 
law  as  the  sole  examination  method  used  in  the  navy  and  on  the  rail- 
ways; although  they  are  greatly  superior  to  the  earlier  tests,  and 
especially  to  Holmgren's  wool,  they  leave  mucli  to  be  desired  and  in 
practice  are  not  always  sufficient. 

They  state  that ' '  the  Holmgren  wool  test  and  Adler  's  colored  crayons 
must  be  rejected  at  once"  and  go  on  to  say:  "It  would  be  better,  if 
we  could,  to  eliminate  pigment  tests  entirely  and  use  only  the  natural 
color  of  the  spectrum  which  we  obtain  by  the  prismatic  dispersion  of 
white  light  in  the  spectroscope."'  This  is  prohibitive  in  practice 
because  of  the  expense  of  a  trustworthy  instrument,  quite  apart  from 
the  fact  that  special  knowledge  of  the  physiology  of  color-perception  is 
necessary  for  its  use. 

Dowdall  of  the  Illinois  Central  Railway  says : 

' '  My  experience  has  been  that  some  of  the  men  examined,  who  show 
defective  color-vision  with  the  skeins,  show  normal  color-vision  with 
the  lantern  test." 

Ainsworth  of  the  Southern  Pacific  says : 

"We  have  found  men  to  be  color-blind  with  the  worsted  test  but  who 
could  pass  the  lantern  test,  whereas  Ave  have  never  found  a  man  shown 
to  be  color-blind  with  the  lantern  test,  who  had  successfully  passed  the 
Holmgren  test. ' ' 

Knox  of  the  Sunset-Central  Lines  says : 

"The  examiner  carries  the  Williams  lantern  with  him  but  it  is  only 
used  to  confirm  the  Holmgren  test.  We  have  found  some  who  were 
only  slightly  defective  with  the  yarns  who  did  not  do  so  well  with  the 
lantern,  and  vice  versa.  We  have  found  the  Holmgren  test  very 
relial)le  if  properly  handled  and  we  do  not  tliink  it  necessary  to  use 
the  lantern  if  the  former  is  passed  successfully." 

Parker  of  the  IMichigan  Central  says: 

"Examination  for  color-blindness  made  by  worsteds  is  in  every  case 
connniicd  bv  a  Williams  lantern.     Personalh-  T  luivo  lost  confidence  in 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  511^ 

tile  ;iccin'a<'3'  of  ciii  cXiiiiiiiiiil  ion  iiiiidr  liy  woi'stnls  (tiily.  I  liavr  had  a 
few  eases  of  men  who  couhl  jiass  the  woi-steds  perfectly,  but  were 
unable  to  pass  tiie  lantern,  and  many  eases  where  the  worsted  exaniina- 
tioji  left  one  in  doubt  were  entirely  cleared  up  by  the  use  of  the  lantei-ii. 
I  think  the  lantern  is  absolutely  essential  for  the  pi-opcr  dctiTiiiiiialion 
of  the  color-sense." 

Bohart  of  the  Chicago  and  Easlcrii  llliuois  says: 

"I  personally  made  the  cxamiiiation  in  two  ca.ses,  where  men  failed 
to  pass  the  lantern  test  who  had  successfully  passed  the  Holmgren  test. 
It  is  just  possible  that  1  was  Ihv  lea.st  ])it  careless  in  regard  to  tin- 
worsted  test,  but  I  laid  out  the  three  colors,  rose,  red  and  green,  and 
they  were  matched  perfectly  with  no  apparent  hesitation.  In  tlic 
lantern  test  the  first  two  or  three  colors  were  properly  called,  and  then 
the  applicants  became  confused  between  the  red  and  gi*een,  and  the 
red  was  called  green  and  the  green  was  called  red.  Then  I  went  over 
this  test  slowly  again,  and  in  both  instances  the  applicants  were  con- 
fused on  the  reds  and  greens. ' ' 

JMitchell  of  the  New  York,  New  Haven  and  Hartford  says : 

"We  do  occasionally  find  a  man  who  has  a  .scotoma  or  tobacco 
amblyopia,  who  is  able  to  correctly  identify  the  Holmgren  worsteds, 
owing  to  the  larger  color-field  presented  by  the  skein  at  close  range, 
but  is  utterly  unable  to  identify  the  small  lights  of  the  Williams 
lantern  and  will  perhaps  call  several  of  them  white  or  one  color  in 
succession,  which  indicates  that  he  sees  the  light  but  is  utterly  unable 
to  distinguish  the  color.  In  regard  to  suggestions  for  the  wool  test,  it 
seems  to  me  that  the  Holmgren  worsteds  are  very  satisfactory  in  their 
present  form  and  when  used  in  conjunction  with  the  Williams  testing 
lantern,  I  believe  sufficiently  protect  the  corporation  and  the  public." 

The  Ophthalmic  Review  (March,  1915),  in  commenting  upon  the 
report  of  the  Committee  of  the  Ophthalmic  S(>ction  of  the  A.  M.  A.  on 
Standards  and  IMethods  of  Examining  the  Color- Vision,  states 
"Though  a  lantern  (Williams)  is  largely  used  it  must  be  one  which  is 
almost  useless  because  few  of  those  using  it  have  found  cases  rejected 
by  it  which  have  escaped  the  Holmgren  test." 

Taylor  states  that  the  old  Williams  lantern  does  not  detect  all  cases 
of  defective  color-sense,  and  a  modified  lantern  has  been  used  by  him 
for  the  past  five  years. 

Relative  to  tlic  lantern  adopted  by  the  Departmental  Committee  of 
the  Englisli  Boai-d  of  Trade.  Edridge-Green  says:  "This  instrument 
has  no  neutral  tinted  glasses,  and  shows  one  or  two  small  lights  siiind- 
taneously,  which  are  reflected  l)y  a  mii-ror.  Having  no  means  of 
regulating  the  luminosity  of  the  light,  the  lantci'u  can  not  detect  ea.ses 


5114  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

wliicli  liavc  ;i  slioftciiin^'  of  tlic  red  end  of  the  sprctfiiiii.  The  exhibition 
of  two  c'oh)r('(l  li<ilits  to{i:c'tlR'r  introduces  Ww  ])li('iioiii('iioii  of  siimilta- 
iicous  colli rast,  and  is  likclx-  to  cause  the  rejection  of  normal  si<;liled 
iiidix  idiials,  ami  tlmse  willi  ii  iiiiiiportaiit  (hd'ects  in  color-perception.'' 
Jn  liis  opinion  this  lantern  test  can  be  evaded  by  the  eoh)r-blind  who 
could  be  coached  up  in  it  to  differentiate  its  coloi-s  by  differences  in 
luminosity. 

ITallibertoii,  Schafer.  Porter,  Percival,  Taylor,  Orossinan  and  many 
others  are  unstinted  in  tlieii-  i)raise  as  to  the  reliability  of  the  Kdridge- 
Green  lantern  in  detecting  color-blindness. 

Stargardt  and  Oloff'  recomnieiid  Nagel's  anomaloscope  as  being  the 
test  most  free  from  objection  and  being  necessary  in  the  diagnosis  of 
doubtful  eases,  Imt  go  on  to  state  that  it  is  possilile  that  dichromatics 
and  extreme  anomalous  trichromat ics  may  match  the  colors  either  cor- 
rectly or  nearly  so,  and  also  if  the  examination  is  made  absolutely 
according  to  the  directions  a  large  number  of  these  anomalies  will  be 
overlooked ;  so  that  if  they  wish  to  avoid  making  mistakes  in  using  the 
anomaloscope  they  must  always  begin  the  examination  with  Stilling 's 
or  the  despised  Nagel  's  plates  and  then  employ  the  anomaloscope  in  a 
definite  manner.  The  following  is  interesting  in  view  of  the  foregoing: 
"After  what  we  have  said  about  the  use  of  the  anomaloscope,  it  is  at 
once  obvious  that  a  certain  knowledge  of  the  theory  of  color-vision 
and  its  anomalies  is  necessary  before  it  can  be  employed."  The 
expense  of  the  instrument  is  also  a  factor,  against  its  use.  "For  these 
reasons  the  anomaloscope  cannot  be  considered  as  a  suitable  instrument 
for  general  practice.  .  .  .  Stilling 's  test  is  not  only  to  be  recom- 
mended as  a  practical  method  but  it  is  indispensable.  .  .  .  AVe 
have  found  that  our  results  with  Stilling 's  tests  were  always  confirmed 
by  the  anomaloscope.  We  have  also  noted  that  Stilling 's  test  has 
shown  up  errors  of  color-sense  which  have  escaped  detection  by  Nagel 's 
test  and  the  result  has  been  confirmed  by  the  anomaloscope. ' ' 

Siklossy  stated  at  the  Fourteenth  International  Medical  Congress  at 
Budapest  with  reference  to  a  suggested  statute  for  the  general  inspec- 
torate of  the  Hungarian  railways  and  steamships  that  Nagel's  plate 
test  "is  too  difficult  to  manage."  Answering  the  questions  demanded 
too  much  "intelligence,  education,  and  logical  deduction"  and  was 
"too  far  advanced  for  candidates." 

Stilling  thinks  that  "Nagel's  plates  gave  too  much  play  to  the 
judgment  of  tlu'  candidate,  and  that  the  distinction  asked  for  between 
very  dull  greenish  gray  and  ])ure  gi-ay  left  far  too  much  to  judgment." 

Seydel  comes  to  the  same  conclusion,  (^f  352  persons  who.  when 
tested    with    Nagel's    plates,    appeared    to    be    color-l)lind,    or    at    least 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  3115 

(louhtful,  l.'iD,  or  40  pur  cent.,  were  found  to  have  norinal  perception  of 
colors  when  tested  by  otlier  methods,  Stilling 's  plates  and  the  anomalo- 
scope. He  also  has  noted  that  Nagel's  plates  have  been  read  "pat  off" 
by  color-blind  canditUites.  lie  especially  notes  a  case  of  well-marked 
deuteranoi)ia  in  which  Nagel's  plates  were  read  correctly.  Seydcl 
thinks  that  Nagel's  plates  are  too  diflficult  for  many  not  exactly  unin- 
telligent persons,  especially  regarding  the  difference  between  gray  and 
green.  Further,  the  test  allows  too  much  room  for  the  personal  opinion 
of  the  examiner.  One  examiner  may  see.  color-blindness  when  a  few 
green  and  gray  spots  are  confused ;  another,  less  scrupulous,  does  not 
object  to  a  candidate  calling  gray  dots  between  red-green,  and  so  over- 
looks an  anomalous  trichromatic.  Seydel,  since  he  lias  been  able  to 
conform  his  results  by  a  more  exhaustive  method,  has  gradually  lost 
confidence  in  the  value  of  Nagel's  tests. 

Edridge-Green  says  that  among  the  tests  for  color-blindness,  pseudo- 
isochromatic  methods  have  occupied  a  first  place.  If  cases  of  color- 
blindness were  identical,  these  methods  would  be  more  reliable  than 
they  are.  Cases  of  color-blindness,  however,  differ ;  in  fact,  it  is  difficult 
to  find  two  cases  exactly  alike.  If  a  pseudo-isochromatic  match  be 
found  for  one  dichromatic,  and  letters  of  the  one  color  be  printed  on 
a  background  of  the  confusion  color,  he  will  not  be  able  to  read  them. 
Another  dichromatic,  however,  may  be  able  to  read  these  letters  quite 
easily.  For  instance,  he  may  have  much  greater  shortening  of  the  red 
end  of  the  spectrum,  and  the  subtraction  of  the  red  rays  from  one  color 
will  make  that  color  much  darker  than  the  other  confusion  color.  On 
account  of  the  fact  that  simultaneous  contrast  is  increased  in  the  color- 
blind, it  is  necessary  that  both  colors  of  confusion  should  correspond  to 
two  points  well  within  the  monochromatic  regions  of  the  observer. 
These  are  the  main  objections  to  pseudo-isochromatic  tables  if  we 
exclude  the  extreme  difficulty  of  accurately  producing  them.  Quite 
apart  from  this,  tlie  fact  that  the  two  colors  are  regarded  as  identical 
by  the  color-blind  can  be  utilized  in  a  far  easier  and  more  satisfactory 
manner. 

Van  Marie  thinks  that  color-blindness  can  be  diagnosed  with 
sufficient  certainty  by  combining  the  pseudo-isochromatic  tables  of 
Stilling's  with  Nagel's  lantern.  Quantitative  methods  are  necessar\-. 
however,  to  put  the  incomplete  color-blind  in  their  right  place,  but  we 
have  no  reason  to  measure  the  phenomenon.  The  quantitative  methods 
are  those  of  Holmgren,  Adler  and  Stilling:  quantitative  examination  is 
also  done  with  a  lantern  of  Nagel's,  the  instrument  of  Herring  or  the 
lantern  of  Bonders.  Ole  liull's  method  is  of  little  value  for  the 
abnormal  color-sense.     Color  (Miualions  are  made  with  Cliibret's  instru- 


5116  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

iiK'ut,  l)ut  tlu!  (lat;i  fii't'  mii'cliiihlc.  'I'lic  \u-s\  iiit-tliod  of  (Iclccliu^'  the 
color-weak  is  the  spectroseoi)e,  ii.sed  l\y  DoikUts  on  tlic  instigation  of 
Lord  Ra^leigli,  but  it  is  not  suitable  for  polyclinic  use. 

13ekess  considers  the  methods  of  Holmgren,  Stilling  and  Xagel  a« 
practically  equivalent  and  that  any  new  employee  who  passes  these 
examinations  should  be  accepted.  He  thinks  that  the  fault  is  not  with 
the  method  but  due  to  the  unskilfulness  with  which  it  is  employed. 
Therefore  railway  surgeons  must  be  tauglit  to  conduct  these  examina- 
tions correctly. 

Tile  Eevista  de  Ciencias  Medicas  thinks  tlie  Adler  pencil  or  crayon 
test  an  excellent  one  for  the  following  reasons : 

1.  It  is  rapid  and  can  be  easily  employed  by  any  physician. 

2.  There  is  no  fear  or  suggestion  in  it,  and  it  appeals  to  the  one 
examined  as  objective  and  impartial. 

3.  A  mistake  is  inexcusable — lack  of  light,  confusion  of  shades,  soil- 
ing of  woods  by  exposure  or  use,  etc.,  being  impossible. 

4.  There  is  at  the  same  time  given  a  test  of  color-perception  and 
documentary  evidence  of  the  tested  person 's  capabilities. 

C.  Devereux  Marshall  believes  that  the  "test  most  advocated  by 
Stargardt  and  Oloff  for  general  use  is  that  of  Stilling  (which,  however, 
is  not  based  on  the  trichromatic  theory),  'the  results  of  which  are 
always  confirmed  by  the  anomaloscope. '  A  great  advantage  according 
to  Stargardt  and  Oloff  lies  in  the  fact  that  any  naming  of  colors  is 
unnecessary.  When  will  the  old  prejudice  against  the  use  of  names  be 
laitl  to  rest?  If  any  person  were  to  suggest  that  an  examination,  say, 
in  surgery,  should  be  conducted  without  the  use  of  anatomic  names  or 
the  names  of  instruments,  would  he  be  considered  sane  ?  What  possible 
advantage  can  there  be  in  examining  a  man  in  colors  in  dumb-show?" 

Von  Kries  declares:  "It  is  generally  impossible  to  determine  witli 
certaintj^  what  or  how  otlier  persons  perceive  and  that  it  is  in  conse- 
quence of  little  value  to  know  how  an  examinee  calls  this  or  that  colored 
object." 

Roemer  in  his  text-l)ook  of  ophthalmology  holds  that  any  method  of 
testing  color-perception  in  which  the  examijiee  is  required  to  name  the 
color  cannot  be  regarded  as  decisive. 

Stargardt  and  OlofiF  constantly  find  that  they  must  as  far  as  possible 
avoid  naming  colors  if  they  wisli  to  obtain  accuratt^  results,  and  have 
also  found  that  the  diflficulty  wliich  ])ersons  have  in  naming  colors  has 
caused  a  great  waste  of  time  in  examinations.  This  o])inion  is  based 
on  the  use  of  Nagel's  plates  and  his  color-matcliing  apparatus,  the  lat- 
ter of  which  they  accord  as  being  "cheap  and  nasty"  and  just  as 
useless  as  the  anomaloscope  is  useful. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5117 

Edridge-Green  says:  "It  is  iiol  necessary  tluit  tlic  color  names  used 
be  those  used  by  nie;  any  name  will  do.  The  es.sential  point  is  that 
color-blindness  is  shown  by  a  person  including  two  colors  of  the  noi'mal 
sighted  under  one  name. ' ' 

C.  Devereux  IMarshall  asserts  that,  "Edridge-Green  has  shown  tiiat 
the  test  with  Nagel's  anomaloscope  is  hopelessly  inadequate  because 
many  normal-sighted  people  vary  greatly  in  the  proportions  of  red 
and  green  which  they  use  in  order  to  produce  yellow,  while  many  color- 
blind peoj)le  make  the  match  with  precisely  the  same  proportions  as 
the  majority  of  normal  sighted  people."  Further,  "in  a  recent  paper 
before  the  Ro^'al  Society,  Edridge-Green  showed  tliat  color-weakness 
and  anomalous  trichromatism  are  not  necessarily  associated  and  if  this 
be  so  the  test  fails  at  once." 

As  a  result  of  the  examination  of  the  coloi'-vision  of  thirty-eight 
persons  with  Lord  Kayleigh's  color-nuitching  apparatus,  Edridge- 
Green  arrives  at  the  conclusion  that  inasmuch  as  four  cases  of  ordinary 
green-blindness  were  "not  only  able  to  make  the  match,  but  mean 
variation  is  not  excessive  and  not  more  than  many  persons  possessing 
good  color-perception.  These  cases  definitely  show  that  the  opinion 
that  appears  to  have  held  universally  that  the  ordinary  red-green-blind 
is  not  able  to  make  a  match  with  Rayleigh's  apparatus  is  untenable." 

Kollner  has  pointed  out  that  all  kinds  of  intermediate  forms  exist 
between  normal  color-vision,  decided  color-weakness  and  complete 
color-blindness,  and  that  this  circumstance  introduces  great  difficulties 
in  diagnosis.  Rayleigh's  matching  test  was  responsible  for  much  of 
the  confusion  which  existed.  Tn  the  form  of  Nagel's  anomaloscope  it 
had  ])een  adopted  by  the  railways,  and  had  almost  brought  the  method 
into  discredit,  because  candidates  who  showed  abnormalities  with  the 
anomaloscope  appeared  to  be  normal  wlien  tested  with  other  apparatus. 
The  reverse  condition  has  also  l)een  noted :  candidates  rejected  In- 
ordinary tests  matched  the  Rayleigh  spectral  colors  without  difficulty. 
This  apparent  paradox  only  applies  to  the  match  between  yellow  and 
the  red-green  mixture,  and  depends  on  the  relative  brightness  of  the 
colors.  AVith  correct  regulation  of  this  factor,  Kollner  tinds  that  all 
persons  with  color-weakness  can  Ix*  unmasked  with  Kayleigh's 
apparatus. 

Kiillner  comes  to  the  following  conclusions: 

1.  Up  to  the  ])resent  evei-y  person  who  has  appeared  abnormal  when 
tested  by  other  methods  has  made  mistakes  with  the  anomaloscope. 

2.  On  the  other  hand,  Rayleigh's  ai)paratus  has  detected  abnoi-nud- 
ities  wliii-h  do  not  render  the  individual  incapable  of  distinguishing 
color  for  all  practical  purposes. 


5118  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

li.  The  (litTci'ciicc  ill  the  liri<4lit  iicss  ol'  1  he  fields  lias  s(5  iiiiu-h  iiilliiciicti 
on  llic  lest  lliat  f,n't'at  t-ai'c  iinist  he  taken  to  exelude  tliis  source  oi" 
error. 

Au^sleiii,  who  in  the  hist  t\vent\-live  years  lias  examined  ."j/J^l  per- 
sons for  the  railway  department  at  Bromherg,  notes  that  the  deeper 
one  pcoes  into  the  diiifieidt  question  of  color-vision,  the  more  all  observers 
are  agreed  that  all  defects  occur  in  a  graduated  manner.  They  grad- 
ually inerfease  from  the  smallest  anomalies,  which  are  only  detected  by 
the  anomaloscope,  to  gross  forms,  in  w^hich  spectral  red  and  green  are 
confused.  lie  then  discusses  the  question  as  to  what  degree  of  abnor- 
mality must  be  held  to  render  a  man  incapable  of  service  on  the  rail- 
way, and  what  tests  ena])le  us  to  settle  this  question.  lie  agrees  with 
Stargardt  and  Oloff  as  to  Nagel's  test  and  is  surprised  at  the  small 
recognition  accorded  Cohn's  test.  He  says:  "The  final  conclusion  is, 
that  to  detect  color-blindness  tw'o  tests  are  needed,  Cohn's  and  Still- 
ing's.  In  compensation  cases,  Xagel's  test  and  the  anomaloscope  must 
be  added.  It  is  of  no  use  to  place  the  anomaloscope  in  the  hands  of  an 
ordinary  railway  doctor,  because  he  rarely  has  the  necessary  knowledge 
to  use  it."    The  Holmgren  test  is  not  even  discussed. 

According  to  Jeffries,  Cohn's  "embroidery  patterns"  detect  color 
defects  only  when  the  colors  of  the  letters  and  liackground  are  just 
suited  to  the  special  kind  and  degree  of  color-blindness  of  the  examinee. 
Also  that  Daaes  color  tables  require  confirmatory  tests  by  some  other 
means  in  most  cases. 

ADVANTAGES   AND    DISADVANTAGES    OF    GLASSES    IN    ARMY,    NAVY    AND 

RAILWAY  SERVICE. 

The  objections  to  the  wearing  of  glasses  in  the  above  mentioned 
services  are  not  many  but  on  first  thought  they  may  seem  serious.  The 
following  list  al)Out  covers  them  :  (1)  They  become  smeared  and  dirty  ; 
(2)  they  become  covered  with  fog,  mist,  rain  or  snow;  (.S)  they  become 
fogged  on  coming  from  cold  into  wannth ;  (4)  they  are  always  in 
danger  of  being  broken  ;  (5)  glasses  which  give  a  visual  acuity  of  6/VI 
(20/20)  with  an  office  test  do  not  give  an  equivalent  visual  acuity  of 
6/VI  (20/20)  when  used  at  long  ranges,  particularly  under  certain 
weather  conditions. 

On  the  otlier  hand,  the  following  are  some  of  tlie  distinct  advantaijcs 
of  glasses:  (1)  The  correction  of  refractive  errors  in  marksmen,  rail- 
way men,  etc.,  repairs  the  loss  of  vision  due  to  latent  hyperopia  becom- 
ing manifest  with  increasing  age,  in  men  long  in  army,  naval  or  rail- 
way service;  (2)  relief  from  glai'e  l)y  wearing  colored  lenses;  (3) 
improving  distant   vision    with   colored   lenses   by   eliminating  haze- 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  :,IV.) 

proiliK'iiig  fju'tors  in  tlu'  atiiiosplicrc ;  (4)  i)fot('cti<)ii,  i-spccijilly  in 
railway  service,  against  the  effects  of  wind,  dust,  mist,  rain,  snow  and 
sleet;  (5)  in  railway  service  relieving  the  retlection  when  running 
beside  rivers  or  lakes,  from  snow  in  the  winter  lime  antl  from  sand 
in  Western  deserts;  (6)  overcoming  tlic  disturliancc  of  vision  in  rail- 
way service  MJien  running  towartl  electric  or  acetylene  headlights 
and  when  ruiniing  toward  the  rising  or  setting  sun;  (7)  doing  away 
witli  the  disturbing  effect  of  glare  and  heat  from  llic  fire-box  during 
the  stoking  of  an  engine;  (8)  the  protection  atfordcd  in  railway  serv- 
ice against  many  serious  eye  complications,  produced  by  hot  cinders, 
burns,  scalds,  etc. 

There  are  no  particular  disadvantages  in  the  use  of  fjhisscs  in  Annij 
service  other  than  those  which  are  coiinnonly  raised  against  wearing 
glasses  in  any  walk  in  life,  ^lany  officers  wear  them  constantly  and 
candidates  for  West  Point  are  accepted  with  low  refractive  errors 
which  may  be  overcome  by  corrective  lenses. 

Lt.  Col.  J.  M.  Banister  and  i\Iajor  Ileni-y  A.  Shaw  {Circular  No.  5, 
AVar  Department,  1908)  after  making  many  careful  tests  with  ten 
sharpsliooters  firing  five  shots  with  the  naked  eye,  five  each  with  vision 
blurred  by  plus  lenses  to  make  it  20/40,  and  five  eacli  with  vision 
blurred  to  20/70,  in  whicli  the  results  were  equally  good  arrived  at 
the  following  conclusions:  1.  That  a  perfectly  sharp  image  of  the 
target  or  bull's-eye  is  not  necessary  for  good  shooting.  2.  That  a  visual 
acuity  of  20/40,  or  even  20/70,  in  the  aiming  eye  is  consistent  with 
good  shooting,  provided  that  tiie  soldier  is  able  to  accurately  focus  the 
sights  of  his  rifle.  3.  That  as  rifle  shooting  is  an  act  of  monocular 
vision  a  comparatively  high  standard  of  vision  is  necessary  for  one 
eye  only.  4.  That  with  regard  to  the  visual  acuity  necessary  to  the 
perception  of  distant  objects  a  soldier  with  a  visual  power  of  20/40 
in  the  better  eye  and  20/100  in  the  poorer  will  be  able  to  meet  all  re- 
ciuirements  for  service  in  the  field.  5.  That  in  consequence  of  tiie  dif- 
ferent visual  requirements  of  thf  various  branches  of  the  service  a 
graded  standard  of  visual  acuity  should  be  adopted. 

Their  deductions  are  that  sharp,  clear-cut  vision  of  the  target  or 
bull's-eye  is  not  necessary,  the  essential  factor  being  an  accurate  focus 
of  the  sights. 

J.  A.  Donovan  in  criticising  this  report  remarks  tiiat  "They  (Ban- 
ister and  Shaw)  do  not  take  into  aecouni  that  once  the  expert  finds 
the  bull's  eye  and  is  'holding'  well  he  can  make  each  successive  shot 
come  near  the  other  as  long  as  he  retains  his  flxed  position.  Nor  do 
they  consider  that  the  bull's  eye  is  a  spot ;  thus  its  distinctness  deixiids 
on  its  illumination,  and  the  law  a[>plicable  to  Snellen's  test  type  would 


il20  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

not  hear  the  same  relation.  1  liave  sliowii  tliat  tlio  bull's-eye  has 
sufiieient  si/i'  to  he  easily  discornahle  hy  a  man  with  at  least  1/3  nor- 
mal vision.'*  Tile  only  requirement  is  to  have  sights  distinct  euougli 
1()  ])i()duce  a  definite  retinal  impression,  once  they  come  into  perfect 
alignment  witli  the  object;  the  sharp-shooter  then  becomes  unconscious 
of  his  sights." 

Donovan  concludes:  "The  eyes  of  the  expert  rifleman  re(iuire  the 
greatest  care.  Full  correcting  lenses  should  be  not  only  allowed,  but 
constantly  worn.  They  must  be  made  iiigh  enough,  in  far  enough 
and  large  enough  so  that  wlicn  the  liead  is  down  and  the  eye  look- 
ing upward  to  almost  its  limit,  vision  will  be  distinct  through  the  glass. 
The  cylinder,  if  strong,  must  be  rotated  in  the  trial  frame,  with  the 
head  in  llie  fii-ing  i)osition,  to  determine  that  vertical  lines  appear  as 
such  with  tlie  glasses  on;  otherwise,  the  rifle  will  be  canted  and  will 
shoot  to  one  side.  A  toric  lens  is  necessary,  and  for  shooting  in  bright 
lights  or  artificial  lights,  a  light-amber  or  some  other  color  is  essential. 
For  presbyopia,  bifocals  are  preferable  or  a  pocket  lens  should  be  car- 
ried to  adjust  the  sight  and  do  other  near  work.  .  .  .  Finally,  to 
the  ametrope.  large,  tinted  lenses,  properly  correcting  the  ametropia  and 
snugly  fitting,  will  more  than  compensate  the  soldier,  in  relief  from 
fatigue,  and  in  the  protection  of  his  eyes  from  accidents,  for  all  the 
disadvantages  at  present  urged  against  them.  The  frame  should  be 
of  stiif  material,  solid  temples  with  soft  ear  pieces." 

This  is  the  consensus  of  opinion  among  ophthalmologists. 

Glasses  in  naval  service.  The  Departmental  Committee  of  the 
British  Board  of  Trade  (1912)  in  answer  to  the  question:  "Is  it 
practicable  for  Navigating  Officers  to  use  spectacles  to  improve  their 
distant  vision?"  gave  the  following  answer:  "The  evidence  which 
we  have  heard  given  by  nautical  witnesses  forces  us  to  the  conclusion 
that  with  every  allowance  for  exceptional  cases  the  circumstances 
which  attend  navigational  duties  render  it  quite  impracticable  to 
allow  officers  to  depend  upon  the  aid  of  spectacles  for  distant  vision." 

This  conclusion  is  assailed  in  no  uncertain  terms  by  Karl  Grossmann 
{British  Medical  Journal,  Oct.  19,  1912).  Some  of  the  objections  made 
to  the  use  of  glasses  at  sea  are :  ' '  Even  if  it  were  possible  to  prevent 
glasses  from  getting  broken  and  inislaid,  fog,  mist,  and  spray  would 
render  them  useless."  Practically  the  same  objections  are  nuide  in 
the  United  Kingdom  and  upon  the  conti*iient  to  the  wearing  of  gla.sses 


■  DiiiU'iisioii  o(  bull's  eves  used  in  taipot  y)ia('ticp  in  U.  S.  Army:  for  200-.'50() 
yards  raii<;c,  S  iiiclics;  fur  50()-()()0  yards  raiijio,  20  inches?;  for  800-1000  yards  range, 
iif)  inches. 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5121 

by  enginemen  and  firemen.  This  subject  has  been  thoroughly  consid- 
ered in  this  country  and  the  leading  opinion  of  the  ophthalmologists 
in  the  United  States  is  that  enginemen  and  firemen  are  decidedly  more 
efficient  while  wearing  glasses  for  protection  and  to  correct  refractive 
errors.  Tiie  result  has  been  that  the  railway  officials  of  the  largest 
systems  in  the  Tnited  States  and  Canada  not  only  do  not  object  to 
the  use  of  glasses  in  service,  but  advise  and  reciuire  their  use,  with 
the  idea  of  preserving  the  eyes  and  vision  of  their  employees.  The 
arguments  raised  as  to  the  disadvantages  or  the  impracticability  of 
the  use  of  glasses  in  naval  service  are  essentially  the  same  as  those 
arising  in  railway  service  and  actual  use  and  experience  has  shown 
conclusively  the  objections  are  theoretical  only. 

It  is  a  well  known  fact  that  men  entering  the  railway  service  at  from 
eighteen  to  twenty-five  years  of  age  may  possess  from  1 — 4  D.  of  latent 
hypermetropia  and  a  considerable  amount  of  a.stigmatism,  and  be  able 
to  pass  the  required  examinations,  as  many  are  now  conducted,  with 
ease,  the  muscle  of  accommodation  being  able  to  overcome  the  latent 
refractive  error.*  These  men  on  coming  up  for  re-examination  five, 
ten  and  fifteen  years  later  will  be  unable  to  meet  the  required  standard 
of  vision  because  of  a  reduction  in  accommodative  power  from  in- 
creasing years.  They  are  at  their  most  useful  time  of  life  in  all  other 
respects,  their  experience  resulting  fi-om  long  years  of  training  and  the 
caution  acquired  with  advancing  years  more  than  compensates  for 
the  loss  in  vision,  and  when  it  can  be  brought  up  to  the  .standard  re- 
quii'cd  with  glasses,  renders  them  far  more  useful  and  safe  than 
those  with  perfect  eyesight  and  less  experience. 

With  the  vision  of  these  men  raised  to  the  required  standard  and 
protected  from  wind,  dust,  mist,  rain,  snow  and  sleet  liy  glasses,  it 
stands  to  reason  they  are  safe  men,  safer  in  fact  than  the  man  witli 
standard  vision  who  has  less  experience  and  unprotected  eyes. 

The  protection  afforded  the  eyes  by  glasses  against  the  impact  of 
wind,  dust,  rain,  snow  and  sleet,  when  an  engine  is  traveling  from  .35 
to  70  miles  an  hour,  can  only  be  appreciated  by  one  who  has  ex- 
perienced it.  and  it  is  absolutely  necessary  for  an  engineman  to  have 
his  head  out  of  the  cab  window  more  or  less,  in  order  to  be  sure  of  his 
signals  in  such  weather  conditions. 

The  protection  of  firemen's  eyes  is  of  especial  importance  for  tlie 
reason  that  the  engineman  almost  always  calls  on  his  fireman  to  verify 


*  Tlio   rules   frovorninpr  the   examination   of   railway   men   in   force  on   the  Xew 
York  Central  system   eliminate  a   certain  per  cent,  of  the  hy])eropos.    See  rnlea 
2  (f)   and  20  in  this  section. 
Vol.  VII— IS 


5122  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

signals  located  at  points  of  iiii|)()rtaiiiT  oi'  w  here  the  signal  is  somewhat 
obscure;  and  with  the  scotoma  piodm-ed  in  the  naked  eye  from  the 
fire-box  this  is  almost  impossible. 

The  use  of  tinted  glasses.  Objecti()nal)le  reflection  from  snow,  and 
from  bodies  of  water,  not  to  mention  the  disturbance  of  vision  when 
running  toward  the  rising  or  setting  sun,  the  glare  and  heat  of  the 
fire-box  and  the  intense  glare  from  opposing  acetylene  and  electric 
headlights — all  these  are  best  met  by  the  use  of  colored  lenses.  Such 
glasses  must  have  peculiar  characteristics  to  meet  satisfactorily  the  re- 
quirements under  all  conditions. 

1.  They  must  relieve  the  eyes  from  glare  without  reducing  to  any 
appreciable  extent  the  proper  amount  of  light  entering  the  eye,  or  the 
object  desired  will  be  defeated.  An  insufficient  amount  of  light  strik- 
ing the  retina  will  not  produce  the  required  stimulus  necessary  for 
sharp,  quick  vision,  which  also  brings  about  the  proper  pupillary  con- 
trol to  admit  of  the  least  amount  of  chromatic  and  spherical  a))erration 
such  as  obtains  with  dilated  pupils. 

2.  The  glass  must  have  the  power  of  absorbing  those  rays  of  the 
various  spectra  of  the  illuminants  met  with  in  common  use,  which  in 
their  diffused,  refracted  and  diffracted  state  produce  fog  and  haze  and 
thus  obscure  distant  objects. 

3.  The  glass  must  be  such  as  may  be  ground  to  correct  various  re- 
fractive errors  and  still  maintain  its  depth  of  color. 

4.  The  glass  must  be  such  as  will  not  diminish  the  intejisity  or  the 
hue  of  night  color  indications,  or,  in  other  words,  cut  down  the  range 
of  a  night  signal. 

All  colors  have  been  tried  with  the  result  that  until  the  summer 
of  1913  ophthalmologists  and  railroad  men  were  almost  unanimously 
in  favor  of  amber-tinted  glasses. 

It  has  ])een  determined  that  the  good  results  obtained  with  the 
amber-tinted  glass,  is  due  to  the  partial  absorption  of  the  invisible 
ultra-violet  of  the  spectrum,  and  the  violet  and  ])lue  rays  of  the  visible 
spectrum,  which  are  the  important  factoi-s  in  producing  glare  effects. 
The  haze  in  the  atmosphere  which  tends  to  obscure  distant  objects  is 
also  the  result  of  the  refraction,  diffraction  and  diffusion  of  the  more 
refrangible  rays  of  the  solar  spectrum  ;  i.  e.,  the  blue,  violet,  and  ultra- 
violet rays.  Thus  a  glass  which  will  j)artly  absorb,  or  filter  out,  such 
rays  will  relieve  the  eyes  to  a  inai-ked  extent  from  glare  and  also 
imi)rove  vision. 

The  glass  largely  used  by  engiiiemen  and  firenuMi  at  present  ami 
which  is  recommended  bv  the  officials  of  many  roads  is  a  medium 


EYES  OF  SOLDIERS,  SAILORS,  ETC.  5123 

shade  of  ainhcr.  Tliis  glass  pai-tially  cuts  out  tin-  ulti-a-violct  rays  of 
the  invisible  spectrum,  and  slightly  reduces  the  intensity  of  the  violet 
and  blue  rays  but  is  not  a  sut^cient  i)rotection  to  the  eye  from  the 
glare-producing  effects  of  the  visible  spectrum.  Fieuzal,  Euphos,  Ilal- 
lauer,  Akopos,  Radex  and  many  other  glasses  of  like  luiture  have  been 
suggested  for  the  purpose.  However,  while  they  meet  the  require- 
ments above  mentioned  to  a  small  degree,  and  while  practically  all 
eliminate  the  ultra-violet  and  a  portion  of  the  visible  violet  and  blue, 
if  of  a  shade  of  sutificient  depth  to  act  as  a  real  protection  against  tlu! 
glare  from  the  fire-box  and  approaching  headlights,  they  diminisli  the 
intensity  and  hue  of  night  signals  to  a  marked  degree  and  consequently 
reduce  their  range.  For  this  reason  they  are  a  menace  when  worn 
by  individuals  with  weak  chromatic  sense,  especially  in  unfavorable 
w'eather  conditions.  It  is  well  known  that  as  a  result  of  the  present 
unscientific  manner  of  carrying  out  examinations  for  color-vision, 
chiefly  due  to  the  employment  of  untrained  men  who  nuike  the  exam- 
inations in  the  majority  of  instances,  as  well  as  to  the  imperfect 
methods  used,  many  candidates  with  defective  color-perception  are 
passed  as  normal. 

A  glass  called  Noviol,  meeting  the  above  requirements  and  having 
to  a  markedly  less  degree  the  disadvantages  above  mentioned,  luis  re- 
cently been  placed  upon  the  market.  In  its  deepest  shade  (it  is  sup- 
plied in  light,  medium  and  deep  shades)  Noviol  gla.ss  1.6  nun.  thick 
transmits  (including  reflection)  87.9  per  cent,  of  the  incident  light. 
All  w-ave  lengths  of  the  spectrum  shorter  than  470  /^/a  are  al).solutely 
absor]>ed ;  i.  e. : — red,  orange,  yellow,  and  a  small  percentage  of  the 
blue  are  transmitted ;  no  violet  or  ultra-violet.  Of  the  heat  rays, 
or  infra-red  radiations,  48  per  cent,  are  absorbed.  Thus  it  seems  to  be 
a  glass  which  comes  closest  to  meeting  every  requirement  of  the  rail- 
way service. 

The  following  from  Warren  S.  Stone,  Grand  Chief,  I^rotherhood  of 
Locomotive  Engineers,  bears  out  the  above  statement:  ''I  question 
very  much  if  Xoviol  glass  can  be  improved  upon.  I  b(»lieve  on  account 
of  the  rigid  visual  examinations  to  which  the  men  in  engine  service  • 
are  subject,  that  the  time  has  arrived  when  they  should  use  a  protec- 
tive glass  of  some  kind,  not  only  to  protect  their  eyes  from  the  wind 
strain,  but  also  to  give  them  protection  from  the  arc  lights,  which  are 
now  in  univt  rsal  use  in  every  town,  many  of  tliciii  being  hung  directly 
ove)"  the  right  of  way.  and  also  the  glai'e  of  electiMc  headlights  on  double 
tracks.  P]verywliere  T  go  T  reconnnend  to  the  men  that  they  u.se  a 
protective  glass  and  T  am  trying  to  imj^ress  upon  them  the  importance 


il24  EYES  OF  SOLDIERS,  SAILORS,  ETC. 

of  making  every  efforl  to  ])n'.s('rve  tlieir  eye-sight,  because  it  is  the  most 
valuable  asset  that  the  man  in  the  cab  of  a  locomotive  possesses  today." 

With  deeji  Noviol  glass  the  hue  of  the  standard  ivd  signal  is  appar- 
ently nnehanged.  The  composition  of  the  glass  in  the  green  signal 
for  use  with  coal  oil  illuiinnation  contains  consideral)le  blue,  which  is 
to  neutralize  the  large  percentage  of  yellow  in  the  coal  oil  flame  used 
to  illuminate  the  signal  lamps,  the  effect  of  the  Noviol  is  to  make  this 
signal  a  more  intense  green.  Blue  and  purple  roundels  have  in  their 
composition  a  large  percentage  of  the  red,  green  and  yellow  and  are 
seen  as  yellowish  and  reddish-green.  However,  with  the  present  illum- 
inate (oil  or  incandescent  lamps)  blue  and  purple  are  only  used  for 
short  range  signals  on  account  of  their  low  intensity. 

Again  quoting  from  Grand  Chief  Stone  "The  only  objection  to  deep 
Xoviol  is  that  it  is  hard  to  distinguisli  blue.  We  knew  that  it  wouhl 
have  this  effect  and  I  am  surprised  to  learn  that  any  road  is  using  blue 
for  its  signals.  The  only  blue  signal  that  I  know  of  is  that  used 
when  car  repairers  were  working  upon  a  train ;  then  they  always  hang 
out  a  blue  flag  or  a  blue  light." 

]\Iedium  shade  Noviol  is  suggested  as  best  adapted  for  the  use  of 
enginemen  and  firemen  unless  the  eyes  are  very  sensitive  to  light,  when 
the  deep  shade  should  be  used. 

PROTECTION  OF  THE  EYES. 

Conservation  of  vision — "safety  first" — by  attempting  to  prevent 
accidents  to  the  eye  is  a  question  which  practically  every  large  manu- 
facturing establishment  and  corporation  has  seriously  considered. 
Protective  glasses  or  goggles  being  furnished  by  the  company  gratis 
to  their  employees,  and  in  many  instances  stringent  rules  relative  to 
their  l)eing  worn  in  all  hazardous  occupations  enforced.  The  Wiscon- 
sin Industrial  Commission  having  ruled  that  in  case  of  accident  in 
which  protective  measures  are  provided  by  the  employer  gratis,  the 
indemnity  resulting  in  tlie  case  of  accident  is  subject  to  15  per  cent, 
reduction  Avhere  such  protective  means  are  not  made  use  of  by  the  em- 
])loyee. 

The  importance  of  the  use  of  protective  measures  in  railway  service, 
especially  in  the  occupation  of  enginemen  and  firemen,  may  be  appre- 
ciated from  the  following  report  of  claims  paid  on  aceount  of  toidl 
and  pei-nianent  loss  of  sight  in  one  or  both  eyes  by  the  Locomotive 
p]ngineers'  ^lutual  Life  and  Accident  Insurance  Association  from  June 
1.  lIMIf),  to  April  10,  1!)!").  inclusive.  This  report  was  furnisiied  by 
INI.  II.  Shav,  Geiiei'al   Seeretai-x-  and  Ti'easui'ei-. 


EYE-SOUFFLE  r,125 

MciiilxTsliii) 

•liiii.'  1  to  D.r.  ;{],  ]!)():, IL'  .June,  1905,  43,857 

Jan.  1  to  Deu.  SI,  ]!J()(i 35  Juno,  1906,  47,519 

Jan.  1  to  Dee.  31,  1907 36  June,  1907,  52,340 

Jan.  1  to  Dee.  31,  1908 50  June,  1908,  55,918 

Jan.  1  to  Dec.  31,  1909 3!)  June,  1909,  56,841 

Jan.  1  to  Dee.  31,  1910 39  Jinu',  1910,  59,608 

Jan.  1  to  Dee.  31,  1911 22  June,  1911,  63,155 

Jan.  1  to  Dee.  31,  1912 21  June,  1912,  64,984 

Jan.  1  to  Dee.  31,  1913 51  .Junr,  1913,  67,540 

Jan.  1  to  Dee.  31,  1!)14 14  June,  1914,  69,497 

Jan.  1  to  Apr.  10,  1915 4  April,  li)15.  69,273 


Total    323 

An  analysis  of  the  causes  of  blindness  and  of  the  eases  in  which 
removal  of  the  eye  occurred  is  ,u:iven  as  follows: 

Eyes  blind  from  injuries   (traumatic  cataract) 8 

Eyes  blind  from  injuries  nature  not  stated 39 

Eyes  blind  from  injuries  nature  stated 62 

Eyes  removed  on  account  of  injuries  (nature  not  stated) '3G 

Eyes  removed  on  account  of  injui-ies  (nature  stated) 12 

Total  157 

Eyes  blind,  cataract   50 

Eyes  blind,  disease 63 

Eyes  blind,  no  cause  given 22 

Eyes  removed,  no  cause  given 28 

Eyes  removed,  diseased 3 

Total  166 

Grand   total    ■. 323 

Since  1909  the  use  of  glass  for  protection  as  well  as  for  eorrection 
of  refractive  errors  has  been  encouraged  by  the  ofHeials  on  many  lines. 
Notwithstanding  the  large  increase  in  membership  during  this  period 
apparently  the  number  of  eyes  lost  from  injury  has  decreased. — (N. 
:\I.  B.) 

Eye-souifle.  A  murmur  said  to  l)e  heard  in  ;iiiriiiia  by  means  of  the 
stethoscope  on  the  globe  of  the  eye. 

Eye-speck.     Eve-spot.     Ockllis.     See  Comparative  ophthalmology. 


5126  EYE  SPECULUM 

Eye  speculum.    See  Speculum. 

Eye-stone.  A  sniiill,  ctilciin'ou.s,  disc-like  slicil,  llic  oi-])ort'ulum  of 
various  Gasteropcd  inolliiscs;  also  a  tlattciiod  concretion  from  the 
stomach  of  a  European  ci'awfish,  the  Lapillus  cancri.  in  domestic 
practice  it  is  placed  unch-i-  the  eyi-lid  lor  the  i-emovai  of  a  foreign  body 
that  has  found  its  way  into  the  eye,  being  jiut  into  the  inner  corner 
of  the  eye  and  allowed  to  work  its  way  out  at  the  outer  canthus. 

Eye-strain.  This  extremely  important,  though  ill-defined  and  often 
complex  subject,  touches  many  dei)artments  of  oplithahnology.  In 
one  sense  the  term  is  almost  synonymous  with  (istli(  nopia  (s(>e  p. 
(J,")!,  Vol.  1,  of  this  Excijclopcdkt)  ;  ([uite  as  frecpiently  it  iiappens  that 
the  symptoms  of  eye-strain  are  not  so  much  due  to  weakness  in  or 
defects  of  the  ocular  apparatus  (especially  ametrupia  and  Jietero- 
phoria)  as  to  positive  abuse  of  the  system  generally,  or  of  eyes 
that  are  themselves  practically  norinal.  This  latter  aspect  of  the 
subject  has  been  considered  under  Conservation  of  vision,  and  to 
some  extent  under  the  caption  Blindness,  Prevention  of.  The  other 
})ortions  of  it  are  discussed  under  a  nuud)i'r  of  headings,  i)articularly 
Headache,  Ocular;  Refraction  and  accommodation,  as  well  as  under 
Muscles,  Ocular  and  Fatig-ue. 

In  1910  the  Census  Bureau  issued  a  classified  li.st  of  between  7,000 
and  8,000  separate  and  distinct  occupations.  Dividing  these  occupa- 
tions into  groups,  designed  to  indicate  their  roles  in  creating  or  in- 
creasing the  disease  directly  or  indirectly  the  result  of  eye-strain,  it  has 
been  shown  that  the  least  eye-strain  will,  as  a  rule,  be  found  in  that 
group  classed  as  farmers,  agricultural  laborers,  common  laborers, 
soldiers  and  railwaj'  workmen;  and  the  most  eye-strain  found  in  the 
group  classed  as  students,  clergymen,  all  professional  men,  clerks, 
engravers,  draftsmen  and  the  like. 

In  the  first  group,  composing  40  per  cent,  of  the  population,  1  to  20 
per  cent,  have  ocular  or  eye-strain  diseases.  In  the  last  group,  com- 
posing 20  per  cent,  of  the  population,  80  to  100  per  cent,  have  ocular 
or  eye-strain  diseases.  Eye-strain  increases  with  w^ork  at  near  range 
— as  in  office,  store  and  home — and  the  modern  growth  of  population 
ia  largely  taken  up  by  the  town  and  cit.y.  The  nearer  the  work,  and 
the  more  minute,  the  greater  the  eye-strain.  The  more  constant  this 
focalization,  the  more  severe  the  eye-strain.  With  decrease  of  the 
illumination  below  a  high  physiologic  standard  there  is  a  geometrical 
increase  of  eye-strain.  It  is  a  well-established  fact  that  either  the 
overuse  of  the  eyes,  or  the  use  of  eye.s  under  bad  eoiulitions,  may  give 
rise  to  eye-fatigue  or  to  eye-strain,  and  many  eye  specialists  believe 
that  at  least  80  to  90  per  cent,  of  headaches  are  dei^endent  on  eye-strain. 


EYE-STRAIN  5127 

It  is  impossible  to  ignore  tla'  probability  that  many  individuals  working,' 
by  gas  light,  or  even  by  clcetric  light,  in  dirty,  unpainti-d,  overlu-atfd 
rooms,  with  imi)ure  air  and  excessive'  moi.sture,  for  ten  hours  a  day, 
or  merely  for  the  last  two  iiours  during  the  day,  use  up  a  great  deal  of 
nervous  energy  and  suffer  from  eye-fatigue  or  eye-strain  and  its  eon- 
sequences. 

Of  late  years  increasing  attention  lias  been  given  to  working  condi- 
tions in  factories,  shops  and  offiees  in  regard  to  illumination,  ventilation, 
hours  and  character  of  work,  and  this  is  bound  to  result  in  greater 
efficiency  and  less  time  lost  in  sickness  and  nervous  disorders. 

The  prol)abilities  are  that  the  eyes  of  the  human  race  are  neither 
weaker  nor  .stronger  today  than  were  those  of  our  forefathers,  unless 
it  can  be  proven  that  the  whole  physique  of  the  race  today  is  weaker 
or  stronger.     As  is  the  whole  physical  body,  so  are  the  eyes. 

But  much  more  is  recjuired  of  our  eyes  now  than  was  ever  required 
of  our  ancestors.  The  strenuous  struggle  for  existence  today,  the  ever 
increasing  comi)lexity  of  our  modern  civilized  life,  the  multiplying 
knowledge  of  the  world  in  all  lines  of  human  endeavor,  knowledge  that 
must  be  mastered  if  we  would  rise  and  achieve  success,  put  far  greater 
strain  on  the  eyes  of  this  generation  than  on  those  that  have  gone 
before. 

Our  schools  are  far  more  exacting  and  severe,  the  business  and 
scientific  world  retjuire  closer  application  and  more  painstaking  care 
than  ever  before.  Electricity  has  turned  night  into  day,  and  much 
more  work  is  now  done  by  artificial  illumination  than  in  the  past. 
Sharp  competition  in  every  line  makes  it  necessary  to  have  the  best 
vision  obtainable. 

Because  of  these  exacting  demands  on  our  eyes  latent  imperfections, 
errors  of  refraction  causing  eye-strain,  are  brought  out  and  made  mani- 
fest by  symptoms  of  discomfort  and  distress,  compelling  ils  to  seek 
the  improvement  of  vision  and  the  comfort  afforded  by  properly  fitting 
lenses. 

Investigation  has  shown  that  primitive  races  of  men  have  the  same 
irregularities  in  shape  and  form  of  the  eyes  as  are  found  in  civilized 
races.  The  difference  lies  in  the  occupation,  out-of-door  life,  anil  tiie 
limited  use  made  of  the  vision  by  the  savage  races. 

Examination  of  the  eyes  of  the  Indian  .students  at  Carlisle  and  other 
Indian  schools  shows  that  about  30  per  cent,  of  them  have  refractive 
errors,  and  need  correcting  lenses.  This  is  approximately  as  large  a 
percentage  as  i.s  exhibited  by  the  white  races. 

Even  the  lower  animals  show  tlie  same  irregularities  and  imperfec- 


5128  EYE-STRAIN 

tious  ill  shape  aiid  form  of  eye  which  give  rise  to  the  discomforts  caused 
by  refractive  eiTors  in  man. 

Tile  percentage  of  people  wearing  glasses,  in  a  community,  or  group, 
or  society,  is  an  index  to  the  educational  and  scholastic  attainments  of 
that  group  or  society.  The  more  the  eyes  are  used  for  prolonged  study 
and  close  work,  the  more  necessary  it  becomes  to  wear  correcting  lenses 
lor  any  existing  refractive  errors.  It  will  frequently  be  found  in  any 
group  of  professional  and  scientific  men,  scholars,  professors,  teachers, 
lawyers,  doctors,  etc.,  that  from  30  to  60  i)cr  cent,  of  tliem  are  wearing 
glasses.— (/>'»//rfm  Jour.  A.  31.  A.,  May  17,  1915.) 

In  pa.ssiiig,  it  must  be  remembered  that  general  diseases  and  the 
nervous  inability  following  or  accompanying  these,  as  well  as  that 
condition  of  the  brain  or  cord,  neurasthenia  itself,  may  be  wholly  or 
in  part  the  cause  of  eye-strain.  An  excellent  paper  on  the  former 
subject  is  by  A.  A.  Bradburne,  in  the  London  Lancet,  p.  698,  ^lar.  11, 
1911. 

The  relations  of  ej'e-straiu  to  crime  is  discussed  on  p.  3560,  Vol.  V, 
of  this  Encyclopedia. 

Gould  {Jour.  A.  M.  A.,  p.  2254,  Dec.  21,  1912)  points  out  that  the 
cinematograph  is  well  adapted  to  develop  the  symptoms  of  eye-strain, 
especially  in  eyes  with  uncorrected  ametropia.  The  fixation  point  is 
unstable,  tremulous  and  jerky.  The  individual  images  generally  fol- 
low each  other  on  the  screen  so  slowly  as  to  be  separately  perceived; 
instead  of  making  a  continuous  impression.  The  ceaseless,  exacting 
conflict  of  impressions  of  different  parts  of  the  picture,  and  the  poor 
illumination  tend  to  make  matters  worse.  The  symptoms  of  eye-strain 
from  this  source,  as  noted  by  Bahn  {New  Orleans  Med.  and  Surg. 
Jour.,  p.  304,  Oct.,  1912),  include  injection  of  the  lid  margins  and 
conjunctiva,  lachrymation,  retinal  fatigue  and  a  sense  of  tire,  heat  in 
the  eyes,  pain  in  the  ciliary  region,  headache,  muscae  volitantes,  and 
dizziness.  Even  when  favorably  presented  the  moving  pictures  con- 
stitute a  severe  test  of  distant  vision  and  endurance. 

Since  inadequacies  of  focus  or  motility  of  the  eyes  may  give  rise  to 
disturbance  of  digestion  and  assimilation ;  and  lowered  vitality,  espe- 
cially in  the  neurotic,  predisposes  to  tubercular  infection,  Linvis  {Trans. 
Sec.  on  Ophth.  A.  M.  A.,  1908)  thinks  that  every  patient  suspected  of 
having  tuberculosis  should  have  a  complete  examination  of  the  refrac- 
tion and  motility  of  the  eyes.  He  reports  two  cases  in  which  very 
serious  disturbances  of  nutrition,  and  nausea  with  intestinal  indiges- 
tion, were  relieved  l)y  the  correction  of  errors  of  refraction,  and  marked 
gain  ill  weight  followed.     Siiannon  {Amcr.  Med.,  May,  1908)  also  re- 


EYE-STRAIN  5i2fj 

ports  three  eases  in  uliicli  tlic  patk-nts  who  had  broken  down  in  gmcral 
health  recovered  by  the  wearing  of  correcting  glasses. 

The  treatment  of  eye-strain  has  been  indicated  in  the  foregoing 
account  of  its  causes.  The  most  important  consideration  is,  of  course, 
the  correction  of  the  sufferer's  ametropia  and,  if  it  appears  to  be 
responsible  for  any  symptom,  of  his  heteroplioi-ia.  Improvement  in 
defective  health  and  avoidance  of  abuse  of  reading,  studying  and 
similar  pursuits  are  also  essential  to  recovery;  indeed,  persons  who 
suffer  from  eye-strain  should  carefully  follow  all  the  well-known  rules 
of  ocular  hygiene. 

For  example,  Carhart  {Med.  Review  of  Reviews,  Sept.,  1908),  speak- 
ing of  the  mental  and  ocular  overstrain  involved  in  the  education  of 
children  and  in  the  occupation  of  many  adults,  suggests,  for  the  former 
especially  :  1.  That  no  calendared  or  coated  paper  be  permitted  in  the 
text-books  given  to  children,  as  the  dazzle  of  such  paper  is  injurious 
to  their  eyes.  2.  That  half-tone  pictures  be  not  permitted  in  school 
books,  but  that  simple,  easily  seen  outline  pictures  be  substituted  for 
them.  8.  That  the  length  of  lines  in  school  l)Ooks  be  of  a  minimum  of 
two  and  one-half  inches  to  a  maximum  of  three  inches,  with  a  space 
between  the  lines  of  not  less  than  3  mm.  4.  That  in  reading  the  cliild 
be  advised  to  hold  his  book  at  an  angle  of  approximately  45  degrees, 
and  that  in  oral  reading  they  be  recpured  to  look  up  frequently, 
5.  That  after  a  lesson  demanding  close  work  the  children  be  asked  to 
look  up  at  the  ceiling  or  out  of  the  window  to  change  the  focus  of  their 
eyes  and  rest  the  muscles  of  accommodation.  6.  That  class  rooms  be 
equipped  with  loose  chairs  of  different  sizes  so  that  the  children  may 
sit  in  seats  that  fit  them  and  placed  where  they  can  see  best.  7.  That 
in  the  first  two  years  of  school  all  writing  be  upon  blackboards  instead 
of  upon  paper.  8.  That  all  room.s  where  artificial  light  is  burned  con- 
tinually be  closed;  that  no  part-time  classes  be  permitted  to  occupy  any 
room  in  which  the  light  is  not  entirely  satisfactory.  9.  All  electric 
light  bulbs  used  in  lighting  class  rooms  to  l)e  made  of  frosted  glass, 
and  that  clusters  of  such  bulb.s  be  provided  with  pale  amber  shades  to 
screen  the  pupils'  eyes  from  the  direct  rays  of  the  light. 

Again,  after  an  apparent  cure  of  a  local  or  constitutional  disease, 
especially  after  recovery  from  the  acute  exanthemata,  children  so 
affected  should  be  granted  a  considerable  vacation,  and  that  is  the 
eye-strain  which  almost  invariably  accompanies  these  diseases,  anil 
continues  with  the  sufferer  for  some  time  after  apparent  bodily 
recovery.  If  we  permit  children  so  to  enter  school  at  once,  at  the 
time  when  the  physicians  permit  them  to  return  as  free  from  contagion, 
there  is  great  probabilily  tliat  bad  results  will  follow,  so  far  as  the 


5130  EYE-STRAIN 

eves  iiiT  coiMTiiird.  l-'or  llu'v  nrv  ill  this  tiino  weakened  for  use  at  near 
objects,  and  llic  sudden  i-m  rtion  demanded  from  tliem,  as,  for  instance, 
in  writing  in  a  liook  and  tlieii  looking'  a1  a  distant  hlaekhoard  for  notes, 
oi-  in  looking;  at  a  liook  and  (lien  at  an  exami)le  on  the  l)laekl)Oard, 
exerts  tile  aeconnuodation  <t|'  the  eyes  to  an  unusual  degree  and  leads 
to  eye-strain  from  vvhieh  recovery  may  not  take  place  for  montiis.  In- 
stances of  this  sort  have  also  been  recently  observed  after  the  mumps, 
in  which  the  eyes  could  not  be  used  for  near  work  for  seven  weeks, 
the  least  exertion  being  followed  by  a  flow  of  tears,  smarting  and 
burning  of  the  eyes. 

Instances  of  this  sort  of  eye-strain,  occurring  daily  in  the  practice  of 
oculists,  prove  how  intinuitely  the  eyes  are  connected  with  the  body 
and  the  folly  of  regarding  them  as  mere  things  by  themselves,  the 
sight  of  wliich  needs  only  to  be  tested  by  inexperienced  men.  People 
have  to  be  taught  ])y  constant  repetition,  that  the  eyes  are  a  part  of 
the  body,  and  are  constantly  exhibiting  symptoms,  such  as  have 
above  been  mentioned,  to  prove  their  close  relationship. —  {Joiirn.  A. 
M.  A.,  Oct.,  11)14.) 

A.  J.  Sweet  {Practical  Medicine  Scries,  p.  34,  1913)  regards  defec- 
tive or  other  imi)roj)er  illumination  as  a  prolific  source  of  eye-strain  and 
condemns  any  condition  of  illumination  which,  under  normal  conditions 
of  service,  permits  light-giving  or  light-reHecting  objects  to  send  light 
into  the  eye  to  a  degree  vastly  in  excess  of  that  required  adequately  to 
disclose  these  ol).ieets.  In  practice  this  would  involve  the  observation 
of  at  least  the  following  principles:  Avoid  the  necessity  of  i)erform- 
ing  close  visual  work  when  facing  any  considerable  window  area.  In 
interiors  where  close  visual  work  is  performed,  emj)Ioy  as  dark  walls  as 
possible,  avoiding,  however,  a  gloomy  or  depressing  effect.  Employ 
white  or  vei-y  light  ceilings  that  glare  from  glazed  surfaces  may  be 
reduced.  In  interioi's  where  close  visual  work  is  performed,  the  light 
units  .should  have  a  moderately  liroad  type  of  distribution,  and  should 
not  ])e  spaced  too  far  apart,  in  order  that  surfaces  may  be  lighted  from 
a  large  number  of  different  directions,  and  glare  largely  eliminated. 
If  highly  glazed  surfaces  must  l)e  employed  under  conditions  recpiiring 
close  visual  work,  light  by  indirect  or  semi-indirect  units.  Avoid  glazed 
surfaces  so  far  as  possible.  ]\Iount  the  liglit  units  high,  well  out  of 
the  field  of  vision.  Avoid  the  use  of  wall  brackets,  which  are  not  only 
an  inefficient  method  of  lighting,  but  highly  ol)jectionable  because  of 
the  amount  of  light  which  they  throw  into  the  eye.  Kememlier  that 
these  olijections  to  wall  brackets  are  not  removed  by  surrounding  the 
light  unit  with  a  diffusing  shade.  Unless  the  walls  are  very  dark, 
employ  types  of  liglit   units  tlii'owing  as  little  light  on  the  walls  as 


EYE,  TEA-LEAF  5131 

possiMf.  Ill  llic  present  slate  of  the  art,  the  h'ast  possible  will  l)e 
too  iiiiu-ii.  Avoid  the  use  of  types  of  units  characterized  by  relatively 
high  caiuile-power  values  in  the  zone  between  50  degrees  from  the 
vertical  and  90  degrees  from  the  vertical.  Avoid  over-illumination  of 
the  work  as  zealously  as  under-illumination. 

The  relations  of  cije-strain  to  cpikpsy  have  already  been  discussed 
on  p.  4484,  Vol.  VI,  of  this  Encyclopedia.  E.  H.  Linnell  (Jour. 
Ophthal.,  Otol.  and  Laryng.,  May,  1915)  believes  that  true  epilepsy 
may  result  from  long-continued  irritation  of  the  nervous  system  in 
individuals  where  it  is  unstable.  He  thinks  errors  of  refraction  and 
muscle  balance  may  serve  to  cause  this  irritation  and  in  the  course  of 
time  epilepsy  develops  and  becomes  chronic.  He  reports  two  cases 
cured  by  the  correction  of  low  errors  of  astigmia,  and  muscle  balance. 

Eye,  Tea-leaf.  A  peculiar  pathologic  condition  of  the  eye  which  exists 
among  the  lower  classes  of  the  Southern  States,  especially  negroes. 
It  is  jn-oduced  by  poultices,  particular)}'  one  of  tea  leaves. 

Eye,  Third-rail.  A  diseased  condition  of  the  eye  due  to  minute  par- 
ticles of  metal  that  have  fallen  in  it  from  elevated  railways. 

Eye,  Trichromic.  A  term  used  in  speaking  of  theories  based  on  the 
assumption  that  there  are  three  primary  color-sensations.  See  Color- 
sense  and  color-blindness. 

Eyewart.    See  Euphrasia. 

Eyewater,  Benvenuto's.    See  page  932,  Vol.  I,  of  this  Encyclopedia. 

Eyewater,  Horst's.    See  Horst's  eyewater. 

Eyewater,  Battler's.    See  Sattler's  solution. 

Eye-winker.     An  eyelash. 


F.  AhhiH'vialioii  of  Fali.n  hIkU  and  (in  prescriptions)  oi  Fac,  make, 
and  of  Fini,  let  IIicit  he  iiuulc;  also  ciiiploycd  hy  some  as  the  cliciiiieal 
s.\iiil)oI  for  jlHorin. 

Faba  calabarica.     (L.)     Calabar  bean. 

Fabini,  Friedrich.  I'.oin  at  Siebenbiirgen,  he  received  his  medical 
degree  at  Peslii,  llmi.uary,  in  .1822.  In  1823  he  became  Fellow  of  the 
Medical  Faculty  at  Pestli.  A  year  or  two  later  he  settled  at  Klausen- 
berg,  where  he  pi-actised  for  many  years.  His  most  important  oph- 
thalmologic writings  are:  " I*)eobaciitungen  iiber  den  Grauen  Staar" 
(v.  Graefe  u.  Walther's  Jo»r.  drr  Cliir.,  xiv,  1830)  ;  "Pflege  Gesunder 
und  Krankci-  Augen"  (Leipsic,  and  Pesth,  1831,  1835).— (T.  H.  S.) 

Fabini,  Johann  Gottlieb.  Born  at  Siebenbiirgen  about  1786,  he  ob- 
tained liis  medical  degree  at  Vienna,  presenting  as  his  dissertation 
'*Dc  Amaurosc."  In  tlie  same  year  he  became  Assistant  at  the  Public 
Eye  Hospital,  Full  Professor  of  ()i)lithalmology  at  the  University  of 
Pesth,  Director  of  the  Institution  lor  the  Indigent  Blind,  and  Super- 
intendent of  the  Infirmary  for  Eye  Patients.  He  wrote:  1.  ''Doc- 
tvina  de  Morbis  Oculorum"  (Pesthini,  1823.  This  book  is  called  by 
Hirschberg  ''die  letzte  Lateinische  Augenheilkunde. ")  2.  "Prolusio 
de  Precipuis  Coniece  Morbis"  (Budae,  1830).  3.  "Einige  Bemer- 
kungen  iiber  d^is  Schielcn"  (Med.  Jahrb.  des.  J,\  /.-.  Osterr.  Staatcs, 
xxxiv,  1841.)  4.  Numerous  articles  in  the  Encyclopedic  Dictionary  of 
the  Medical  Sciences  and  in  "Orvosi  Tar." — (T.  H.  S.) 

Fabricius  ab  Acquapendente.    See  Fabricius,  Hieronymus. 

Fabricius,  Hieronymus.  lie  is  also  called  Fabicius  ab  Acquapendente. 
Born  in  1537  at  Acquapendente  (Aquila  Tuseia)  near  Orvieto,  Italy, 
he  studied,  at  Padua,  first  the  ancient  languages  and  philosophy,  and, 
later,  medicine  and  surgery.  He  was  pupil  and  successor  of  Falloppio, 
as  well  as  eminent  teacher  of  "William  Harvey,  the  discoverer  of  the 
circulation  of  \\\v  blood.  Though  Fabricius  was  one  of  the  most 
celebrated  surgeons  of  all  time,  and  author  of  the  greatest  work  on 
surgery  composed  in  the  Renaissance  period,  he  nevertheless  possesses 
but  little  ophthalmologic  importance.  Thus,  his  ocular  operations  are 
all  essentially  taken  from  the  Gi'eeks  and  the  Arabians — chiefly  Celsus, 
Paulus  and  Albucases — and  lie  even  admits  that  he  himself  has  per- 

5132 


FABRICIUS  HILDANUS  5133 

rormed  the  cataract  operation  only  twice  or  thrice  all  told.  Later,  he 
renounced  tliis  opci-ation  absolutely,  reconiniciiding  for  cataract  tlic 
use  of  a  certain  coUyriuni  in  an  eye-cup.  Fabricius  died  of  gout  and 
asthma,  Feb.  14,  1634.— (T.  II.  S.) 

Fabricius  Hildanus.    Sec  Fabry,  Wilhelm. 

Fabriz,  Wilhelm.    See  Fabry,  Wilhelm. 

Fabry,  Wilhelm.  lie  is  also  called  Wilhelm  Fabriz,  Fabricius  Hildanus, 
and  "The  Other"  Fabricius  (in  contradistinction  to  Fabricius  ab 
Aequapendente).  The  son  of  P.  A.  Fabry,  clerk  of  a  court  at  Hilden, 
Germany,  the  subject  of  this  sketch  was  born  at  Hilden  (hence  the 
name,  "Hildanu.s"),  June  25,  1560.  He  was  a  classical  scholar  and  a 
brilliant  and  resourceful  surgeon.  He  is  often  called,  and  properly, 
"the  first  learned  German  surgeon."  He  was  the  first  to  amputate 
the  thigh,  and  was  equally  daring  and  ingenious  in  otology  and  oph- 
thalmology. 

He  is  often  said  to  have  been  the  first  in  history  to  remove  from  the 
eye  a  piece  of  steel  or  similar  foreign  body  by  means  of  the  lodestone 
or  magnet.  This  honor,  no  doubt,  belongs  to  Braunschweig,  or  Bruns- 
wick (q.  v.),  but  Fabry's  operation  is,  nevertheless,  so  extremely 
important  and  the  original  narrative  thereof  is  so  quaintly  exact  and 
interesting  that  we  here  subjoin  an  almost  literal  translation : 

"A  patient  from  the  region  of  the  'Bieler  See'  wishing  to  buy  a 
fire-steel,  first  tested  it  by  striking  it  on  a  stone.  A  spark  then  flew 
up  into  that  part  of  the  cornea,  where  the  iris  can  be  seen,  and  took 
fast  hold,  under  heavy  pain.  His  neighborhood  employed  upon  him 
for  many  days  all  its  industry,  but  in  vain.  "When  the  pain  and 
inflammation  had  powerfully  increased,  he  came  to  me  at  Bern  on 
the  5th  of  ]\larch,  1624.  I  put  him  on  right  diet,  emptied  his  body 
by  purgatives  and  phlebotomy,  for  he  was  plethoric,  and  sought  at 
various  times  and  on  divers  days  to  remove  the  iron  splinter.  But 
it  was  so  small  that  it  could  not  be  removed  by  means  of  instruments. 
Then  my  wife  thought  up  the  most  appropriate  cure.  While  I,  that 
is  to  say,  with  my  two  hands,  open  the  lids,  brings  she  the  magnet 
to  the  eye,  as  near  as  the  patient  can  bear  it.  When  we  had  done  this 
many  times  and  repeatedly  (for  not  long  could  he  bear  the  daylight, 
which  however  in  this  matter  was  an  absolute  necessity)  then,  finally, 
.sprang  forward  before  our  eyes  the  splinter  onto  the  magnetstone. 
After  that,  the  patient  got  well  rapidly  under  the  employment  of  a 
pain-relieving  collyrium.  So  you  see  that  much  which  cannot  be 
carried  out  by  main  strength  can  be  easily  performed  by  care.  One 
must,  however,  well  observe  that  mostly  the  opposed  powers  of  this 
magnetstone  must  lie  found  in  one  and  the  same  piece — that  is,  that 


5134  FACE  OF  PRISM 

the  ii'oii  atti'.Hrts  at  llir  one  ciid,  hut  at  the  otlicr  repels :  wliicli  indeed 
was  looked  aftci-  in  tlic  case  of  our  ina{i;iiet.  In  order,  tlierefore, 
to  avoid  error,  one  nnist,  before  the  operation,  test  all  the  eorners  of 
the  stone  exaetly,  in  ordei-  that  no  part  whieh  drives  iron  away  from 
it  may  he  hrouj^dit  towai-d  the  eye.  That  is,  moreover,  easy  to  test,  by 
hi-in<j;iu<j  the  uuif^net  gradually  toward  iron  filings  which  have  ))ecn 
strewed  upon  a  tahle  or  on  a  clean  piece  of  paper." 

Allot liei-  remarkable  operation  of  Fabry's  (which,  once  more,  he 
was  not  the  first,  bnt  the  second,  to  perform)  was  that  of  total  removal 
of  an  eyeball.  Tliis  operation  (which  he  carried  out  in  the  case  of 
a  very  old  man  with  a  pi'ominent,  blind,  and  extremely  painful  eye) 
he  performed  in  the  following  manner:  First,  he  tied  the  eye  up 
tightly  in  a  strong  leathern  purse,  whose  moutli  he  had  slipped  well 
over  the  ball.  Then,  having  made  an  incision  at  the  inner  canthus, 
below  the  upjx'r  lid,  he  pres.sed  the  eyeball  downward  and  cut  around' 
it,  including  the  optic  Jierve  in  the  incision,  with  a  specially  constructed 
knife.  When  the  eye  had  been  taken  away,  he  strewed  into  the  cavity 
a  styptic  powder,  filled  the  cavity  with  lint  and  bandaged.  The 
patient  made  an  excellent  recovery.  (The  first  to  remove  the  entire 
eye  was  Bartisch,  q.  v.) 

Fabricius  seems  to  have  been  a  man  of  the  highest  moral  character. 
All  his  contemi^oraries  speak  well  of  him  in  this  respect.  He  was  also 
very  pious.  His  motto,  engraved  on  a  copper  plate,  was  "Omnis  tutela 
a  Deo." 

lie  died  of  gout  and  asthma,  after  a  very  long  illness  borne  patiently, 
Feb.  14,  1634  (1619?).— (T.  II.  S.) 

Face  of  prism.  That  surface  of  a  prism  which  is  designed  to  reflect 
or  i-efi'act  rays  of  light. 

Face  powder  ophthalmia.  Face  powder  has  its  dangers  the  same  as 
gunpoAvder.  For  several  years  occasional  cases  have  come  under 
the  observation  of  oculists  in  wdiich  the  patients,  invariably  women, 
complain  of  vision  being  blurred,  inability  to  use  the  eyes  for  any 
length  of  time  and  severe  itching  of  the  lids.  The  slightest  rubbing 
of  the  lids  i)roduces  a  marked  redness  of  the  eyes  and  only  aggra- 
vates the  itching.  In  severe  cases  the  lids  are  frequently  swollen 
from  constant  rubbing.  There  is  a  sticky,  elastic  secretion  whieh. 
■when  being  removed,  i)ulls  out  in  long  strings.  ^Microscopic 
examination  of  the  secretion  icveals  ituisses  of  what  appear  to  be 
crystals.  I'ntil  recently,  as  stated  in  a  Ilulhtin  of  the  A.  M.  A.,  no 
satisfactory  exi)lanation  of  the  presence  of  these  crystals  in  the  eye 
has  been  given.  Secretion  taken  from  the  eyes  of  two  sisters  suffer- 
ing fi-om   this  peculiar  com])laint   were  submitted   to  the   ])rofessor 


FACE  REST,  KALLMANN'S  5135 

of  i)athology  of  one  of  the  uiiivcisity  lut'dical  schools,  who  found 
that  the  cryslais  cainc  from  r'n-v  face  powch'r.  Seven  other  i)atienls 
in  whoni  llie  same  symptoms  and  uucroscopic  conditions  wei'e  found 
all  used  the  same  make  of  face  [xjwdei-.  Wlicii  Ilie  powder  is  applied 
to  the  face  Avith  a  })uff  a  portion  of  the  tine  dust  is  driven  upward 
•diul  lodges  on  the  moist  eyeball.  Tiu'  rice  ])()wder  in  tlie  presence 
of  the  tears  then  becomes  mucilaginous  in  chai'actei-  and  is  not 
Wcished  from  under  the  eyelids.  The  powder  ])roduces  the  irritation, 
which  is  aggravated  by  rubbing.  Those  who  use  a  chanu)is-skin  in 
applying  the  powder  are  less  liable  to  cause  the  tiiu'  dust  to  arise, 
wdiich  probably  accounts  for  the  condition  not  being  found  in  every 
woman  using  face  powder.  The  condition  is  (juickly  relieved  by 
flushing  the  eye  with  boric  acid  solution.  The  irritation  rapidly 
disappears  when  the  e>'es  ai'e  kept  w.ished  out  with  a  soothing  eye- 
wash.   See,  also,  Conjunctivitis,  Face-pov^^der. 

Face-rest,  Kallmann's.  This  is  a  tleviee  for  preventing  cliildrcn  from 
stooping  over  their  desks  at  school  and,  presumably,  increasing  their 
myopia.  Cohn  .speaks  highly  of  it.  He  says:  "I  never  allow  my 
own  children  to  write  without  it,  whether  at  home  or  in  school,  even 
when  sitting  at  the  best  possible  desk."  It  is  screwed  to  the  desk, 
and  causes  little,  if  any,  ainioyance.  The  introduction  of  this  rest  for 
all  children  with  tender  eyes,  both  at  school  and  in  their  homes,  is 
worthy  of  commendation. 

Facet.  In  biology,  a  segment  of  the  compound  eye  of  an  insect.  In 
ophtlialmic  surgery  a  i\at,  transparent  or  opaque  area  (sear)  in  the 
coiiiea.    See  Cornea,  Ulcer  of  the. 

Facher,     (G.)     A  fan. 

Fachite.      (It.)      (Obs.)      Phakitis — intlammation  of  the  lens. 

Facial  expression  in  ocular  affections.  As  assistance  in  making  a 
diagnosis  of  oi)hthalmie  diseases,  facial  appearance  and  characteristics 
should  not  be  forgotten.  They  should  especially  be  kept  in  mind  in  a 
preliminary  examination  of  the  eye.  ]\Iany  writers  have  emphasized 
the  value  of  this  method  of  investigation  but  it  is  difficult  to  define  it. 
Oliver  {System  of  Diseases  of  the  Eye,  Vol.  IV,  p.  439)  says  that  with 
the  head  twisted  to  one  side  in  accordance  with  the  axes  of  the 
principal  meridians  of  the  astigmatism,  the  general  attitude,  and  the 
mental  characteristics  of  the  subject;  such  as,  for  example,  the  peculiar- 
ities shown  in  the  selection  of  dress-material,  wall-paper,  carpet,  furni- 
ture-coverings, (4c.,  evince  not  only  the  presence  of  some  form  of 
ametropia,  but,  to  an  observant  clinician  of  experience,  give  a  clue 
to  the  type  of  the  special  disorder.  For  example,  the  half-nipped 
eyelids  of  the  astigmatic  myope  in  his  endeavors  for  distant  vision  are 


r,i;}G  FACIALGEBIET 

ill  colli liist  with  the  widely-opened  palpebral  fissures  of  the  correspond- 
in;^'  liypcniiotrope. 

Facialgebiet.     (G.)     'IMic  area  ol'  distribution  ot  tlic  I'acial  nerve. 

Facialis.     (G.)     Facial  nerve. 

Facialislcrampf.  (G.j  Si)asiii  of  the  mustdes  supplied  hy  the  facial 
nerve. 

Facialislahmung.     (G.)     Paralysis  of  the  faeial  nerve. 

Facial  nerve.  Seventh  nerve.  This  is  a  pure  motor  nerve,  whose 
nucleus  is  in  the  floor  of  the  fourth  ventricle  beneath  the  superior 
fovea.  It  appears  at  the  upper  part  of  the  medulla  in  the  groove 
between  the  olivary  and  restiform  bodies,  close  to  the  lower  edge  of  the 
pons.  Outside  of  it  is  the  auditory  nerve  with  a  strand,  the  ff^fs  inter- 
media of  Wrisherg,  arising  in  a  nucleus  beneath  the  inferior  fovea  and 
connecting  with  the  auditory.  The  facial,  auditory,  and  pars  inter- 
media all  enter  the  internal  auditory  meatus  together.  At  the  bottom 
of  the  meatus,  however,  the  facial  parts  company  from  the  others 
and  enters  the  aqueduct  of  Fallopius,  following  the  windings  of  the 
canal  through  the  temporal  bone  to  the  stylo-mastoid  foramen.  In 
the  canal  it  gives  off  two  important  branches,  the  chorda  tympani, 
wlii(di  seems  to  be  a  taste  nerve,  and  unites  with  the  lingual  branch 
of  the  fifth  to  innervate  the  anterior  two-thirds  of  the  tongue,  and 
the  branch  to  the  stapedius  muscle.  After  its  emergence  from  the 
skull,  the  main  trunk  of  the  nerve  passes  downwards  and  forwards 
througli  the  parotid  gland  and  terminates  by  dividing  just  behind  the 
ramus  of  the  jaw  into  the  temporo-facial  above  and  temporo-ccrvical 
l)elow,  each  of  which  sends  numerous  branches  to  the  side  of  the  head, 
the  face  and  the  upper  part  of  the  neck.  As  these  branches  inter- 
communicate freely,  they  form  a  sort  of  a  plexus  which  is  often  called 
the  pes  anserinus.  As  the  muscles  to  which  these  filaments  go,  namely, 
the  buccinator  and  all  those  of  the  face  except  the  muscles  of  mastica- 
tion, play  so  prominent  a  role  in  expression,  the  facial  is  sometimes 
called  the  "artist's  nerve." 

The  nerve,  then,  is  distriliuted  to  the  muscles  of  the  scalp,  of  the 
external  ear,  nose,  mouth,  eyelids  (excepting  the  levator  palpebral 
superioris)  and  to  the  platysma.  It  also  supplies  the  muscles  of  the 
tympanum,  the  levator  palati  and  azygos  uvuhp  (through  the  large 
superficial  petrosal)  and  the  stylo-hyoid  and  the  posterior  hvWy  of 
the  digastric. —  (Mettler.) 

Facial  neuralgia.     See  Trigeminal  neuralgia. 

Facial  paralysis.  Pjeli/s  rAUALvsis.  Seventh  nerve  parma'sis. 
Facial  or  Bell's  palsy.     This  lesion  of  the  faci;d  nerve  may  be  basal, 


FACIAL  PARALYSIS  5137 

fascicular  or  miclcaf.  Tlic  coiiditioii  is  fully  (U'scriljcd  on  p.  926, 
Vol.  II,  of  this  Encyclopedia. 

To  this  may  be  added  some  practical  observations.  For  instance, 
Dutoit  (Archir  f.  Ophthal..  p.  145,  Vol.  86,  1914)  reports  the  following 
case  of  Bell 's  palsy  : 

A  motorcyclist,  colliding  with  an  automobile,  was  picked  up  uncon- 
scious, and  bleeding  from  the  left  ear.  He  was  subconscious  for  48 
hours  and  showed  a  peripheral  total  paralysis  of  the  left  facial  nerve, 
which  after  about  a  month  began  to  subside.  During  his  illness  the 
following  phenomena  were  observed:  After  two  days  the  patient 
could  close  the  lids  sufficiently  if  he  forcil)ly  turned  the  left  eye  out- 
ward. Ha.sse  has  explained  that  a  patient  with  peripheral  paralysis 
of  the  facial  nerve  can  occasionally  lower  the  paralyzed  upper  lid  by 
a  partly  half  unconscious,  partly  voluntary,  relaxation  of  the  levator. 
Hence,  Dutoit  concludes,  that  if  the  abducens  receives  an  impulse  of 
intention,  and  the  third  nerve  yields  to  its  antagonist,  the  levator  as 
antagonist  to  the  orbicularis  (facial  nerve)  yields  to  the  intention 
impulse  of  the  abducens  by  passive  relaxation.  The  resistance  of  the 
levator  under  natural  conditions  to  closure  of  the  lids  seems  super- 
fluous in  paralysis  of  the  facial  nerve.  Therefore  the  indirect  support 
by  an  impulse  of  intention,  which  stimulates  the  abducens,  may  also 
reach  and  incite  the  orbicularis. 

Again,  at  the  attempt  to  close  the  lids,  the  eye  of  the  paralyzed  side 
in  Dutoit 's  case  turned  up  :  the  other  eye  did  not.  The  writer  explains 
thi-s  by  lack  of  tonus  in  the  third  nerve  and  the  inclination  of  the  eye 
to  assume  its  position  of  rest. 

To  all  this  Leber  adds  that  the  involuntary  raising  of  the  eye  at 
the  attempt  of  closing  the  lids  is  simply  due  to  the  innervation  of  the 
raising  muscles,  always  associated  with  the  closure  of  the  lids.  In 
facial  paralysis  the  iiicn>ase  of  innervation  of  the  orbicularis  is  trans- 
mitted to  the  simultaneous  innervation  of  the  raisers  of  the  eye,  so 
that  the  eye  turns  u])  while  the  palpebral  fissure  remains  open. 

The  involuntary  closure  of  the  lids  in  laughing,  with  sinuiltaneous 
involuntaiy  raising  of  the  angle  of  the  mouth,  is  an  indication  of 
improvement  in  a  peripheral  paralysis  of  the  facial  nerve  and  suggests 
treatment  by  methodical  exercises. 

Dutoit  explains  the  muscular  crepitation,  or  dysacusis,  in  the  ear 
of  the  paralyzed  side  by  the  paralysis  of  the  stapedius  muscle.  From  the 
lack  of  the  regulating  movements  of  this  muscle  the  stapes  is  exposed, 
and  yields  to  the  slightest  fluctuations  of  pressure  of  the  labyrinthine 
fluid.  He  infers  from  this  disproportion,  which  corresponds  to  a 
disturbance  of  equilibrium  within  the  labyrinth,  an  unnatural  excita- 

Vol.  VII— 19 


5138  FACIAL  PARALYSIS 

tioii  of  till'  tciniiiiatioiis  of  tlic  liUrcs  of  the  eoelilear  nerve,  wliieh  the 
patient  perceives  as  noise. 

The  treatment  of  seventh  ncrvc  ])aralysis  is  discussed  by  Hecht 
(Wood's  Systevi  of  (>/>lilli<ihiii(  Tlirrapeiitics,  pp.  '.i\6,  'Ml )  as  follows: 
In  tile  rhenniatie  or  neui'itie  forms  (Hell's  type)  the  paralysis  is  pres- 
ent and  (•oini)lete  before  any  causal  or  abortive  tiierai)y  can  be  thought 
of,  iiiiicli  less  applied.  The  damage  has  been  done  and  subsequently 
retpiires  symptomatic  treatment. 

When  pharyngeal  or  j^arotid  gland  inflaiiiiiiations,  middle  ear  or 
mastoid  disease  are  known  to  exist,  careful  attention  to  these  will  re- 
duce the  liability  to  facial  paralysis.  liasal  fractures  and  injuries  to 
the  nerve  at  its  foraminal  exit  from  blows,  falls,  or  the  obstetrical 
forceps,  require  surgical  service. 

It  is  a  fact,  ])ut  one  not  sufficiently  known  or  appreciated,  that  a 
considerable  number  of  facial  paralyses  get  well  without  any  form  of 
treatment.  Assuming  a  rheumatic  basis  upon  which  some  cases  are 
supposed  to  rest,  a  brisk  saline  purge,  followed  l)y  the  administration 
of  salicylates  and  alkaline  beverages  for  some  days,  seems  rational. 
Locally,  to  the  affected  side  of  the  face  an  alternating  fine  spray  (or 
douche)  of  hot  and  cold  water  under  some  pressure  will  stimulate 
capillary  circulation  and  thereby  improve  the  tone  of  tiaccid  muscles. 
Gentle  friction  may  be  made  an  adjuvant  to  this  measure,  but  mas- 
sage by  an  experienced  person  should  be  reserved  for  the  subacute  and 
chronic  stage  when  repair  sets  in.  If  counter-irritation  is  used  at  all, 
it  should  be  by  blisters  or  leeches  applied  not  to  the  face,  but  to  the 
nerve  trunk  in  the  region  of  the  stylomastoid  foramen. 

Since  the  facial  distortion  is  intensified  with  every  elfort  at  eating, 
smiling  or  talking,  it  should  be  the  aim  of  the  patient  to  keep  the 
features  as  passive  as  possible,  constantly  correcting  the  exaggerated 
position  of  the  cheek  and  mouth  after  eating,  drawing  the  eyelid  down 
to  cover  the  eyeball,  and  wearing  a  light  compression  pad  to  ensure 
closure  of  the  eye  during  the  night  and  when  out  in  dusty  or  in- 
clement weather.  Conjunctivitis  and  corneal  ulcerations  are  not  so 
likely  to  develop  in  an  eye  relatively  well  protected. 

Immediately  after  the  onset  of  paralj'sis,  the  muscles  should  be  sub- 
jected for  five  minutes  and  less  each  day  to  the  galvanic  current,  the 
anode  being  placed  over  the  motor  points  of  the  affected  side  of  the 
face,  and  gentle  contractions  made  by  anodal  closure.  It  is  well  to 
discontinue  electrical  treatment  after  six  months,  for  the  reason  that 
the  severer  type  of  cases,  lasting  beyond  this  time,  show  a  tendency  to 
develop  contractures  inider  long-continued  stimulation.     Strj'chnine, 


FACIAL  PERCEPTION  OF  THE  BLIND  5L39 

in  doses  of  gr.  1-60  to  1-30,  three  times  daily  by  nioutli,  for  a  eoii- 
tinuous  period,  is  of  service  as  a  general  tonic. 

In  two  classes  of  cases  surgical  iuterference  is  indicated  and  seems 
desirable:  (1)  The  congenital,  which  after  an  interval  of  two  years 
shows  little  if  any  improvement,  and  (2)  the  chronic,  which  after  one 
and  a  half  to  two  years  remain  stationary.  The  operations  contem- 
plate an  anastomosis  of  the  facial  with  the  hypoglossal  or  the  facial 
with  the  spinal  accessory.  Spiller  favors  the  former,  and  Gushing 
thinks  well  of  the  spino-facial  operation. 

Facial  perception  of  the  blind.     See  Blind,  Sixth  sense  of  the. 

Facial  spasm.  Blepharospasm.  See  p.  1112,  \'ol.  11,  of  this  Ency- 
clopedia. 

Facial  tic.  This  neurotic  att'ection  of  the  facial  nerve,  as  Ilecht 
(Wood's  System  of  Ophthalmic  Therapeutics,  p.  ;j.31)  points  out, 
requires  to  be  carefully  differentiated  from  facial  spcism  before  a  prog- 
nosis may  be  ventured  or  treatment  advised.  The  participation  of  the 
eye  and  eyelids  in  the  two  affections  so  alike  in  their  external  mani- 
festations yet  so  diametrically  opposed  in  respect  to  etiology  and 
pathology,  frequently  causes  confusion  in  ophthalmologic  diagnosis 
and  error  in  treatment. 

Tic  is  a  mental  affection  amenable  to  cure  ''if  one  can  will  to  cure 
it."  Spasm  results  from  a  material  irritative  lesion  in  any  part  of 
the  facial  nerve  from  its  cerebral  or  nuclear  origin  to  its  terminal 
branches.  The  idea  of  the  incurability  of  tic  has  prevailed  for  so  long 
that  the  majority  of  cases,  except  for  some  feeble  effort,  remain  un- 
treated. This  neglect  is  not  justified,  since  some  improvement  may 
be  afforded  even  the  most  refractor}^  types,  and  in  the  milder  forms, 
cures  effected. 

Although  they  have,  on  the  whole,  proven  inert  in  reducing  or  con- 
trolling the  convulsive  movements,  sedatives  and  hypnotics,  such  as 
bromides  in  large  doses,  chloral  or  the  various  preparations  of  opium, 
may  afford  some  transient  improvement.  In  this  connection  it  may 
be  observed  that  the  tendency  of  "ticquers"  to  develop  mental  dis- 
turbance renders  the  use  of  heavy  hypnotics  in  general  and  opium  in 
particular  inadvisable.  A  variety  of  other  drugs,  zinc  valerianate, 
gelsemium,  quinine,  arsenic  and  cannabis  indica.  have  from  time  to 
time  been  tried,  with  negative  results. 

Electricity,  massage,  facial  douching  in  one  form  or  another  are  to 
be  discouraged  except  when  they  are  known  to  exercise  a  good  psychic 
effect,  but  mechanical  devices  to  arrest  the  tic  are  valueless. 

Hypnosis  is  credited  with  some  good  results,  and  suggestion  during 
waking  hours  is  favorably  regarded,  but  as  some  authorities  reflect. 


5140  FACIES  HIPPOCRATICA 

"To  ciicoiiiii^^'  lilt'  i>;iti<'iit  ;iii(l  assure  him  ol"  progress,  to  reproach 
or  rt'priniiiiKl  him  on  occasion,  is  to  employ  an  integral  and  invaluable 
factor  in  ail  rc-educatioiuil  treatment  of  tics;  but  is  liiis  truly  sug- 
gestion?" "Ti'eatment  Ity  re-education"  has  tlirough  the  effort  of 
lirissand,  ^leige  and  Feindel  and  others  of  the  modern  French  school 
of  neurology  become  a  I'ecognized  method,  re(iuiring  infinite  patience 
and  ingenuity  on  tiie  part  of  the  doctor  and  patient.  One  can  only 
enunciate  the  principles,  not  the  rules,  tiiat  apply  in  this  ])road  method. 
They  are:  (1)  The  value  of  motor  tliscipline,  the  discipline  of  im- 
mobilization. (2)  ^lirror  exercises,  enabling  close  observation  and 
direction  of  motor  control.  For  instance,  in  tic  of  the  eyelids  the 
repeated  i-liythmical  opening  and  closing  of  the  eyes,  the  steadying 
of  the  lid  in  a  half  open  or  half  closed  eye,  all  of  which  exercises  are 
to  be  done  with  the  head  in  different  positions,  are  of  distinct  value. 
In  eyeball  tic  other  maneuvers  have  been  described  (I\Ieige),  such  as 
dissociating  the  movements  of  eyes  and  head ;  keeping  the  head  sta- 
tionary where  the  eye  is  made  to  slowly  follow  an  object  or  conversely 
letting  the  head  rotate  in  horizontal  and  vertical  planes  while  the 
eyes  are  fixed. 

These  are  but  fragmentary  suggestions  of  a  metliod  which  to  be 
highly  effective  must  be  individualistic  in  application. 

Absolute  rest  in  bed  for  all  cases  has  been  authorized  l)y  some  observ- 
ers as  the  best  treatment,  whereas  others  have  found  it  doing  far  more 
harm  than  good.  I  can  personally  subscribe  to  the  view  that  even 
much  bed  rest  as  a  g'^neral  measure  is  undesirable.  Nine  sleeping  hours 
by  night  for  a  psychoneurotic  individual  and  perhaps  one  or  two  hours 
of  midday  napping  is  very  beneficial  as  a  relaxant.  If  unusual  nervous 
irritability  obtains  with  marked  obsessional  plienomena  in  a  run-down 
and  anemic  ticquer,  then  a  rest-cure  treatment  seems  indicated. 

The  wisdom  of  enforcing  isolation  in  these  eases  should  depend  more 
upon  the  nervous  and  mental  complex  of  the  patient  tlian  upon  the 
severity  of  the  tic.  Relative  retirement,  with  appropriate  diversion 
and  an  agreealile  occupation,  does  more  good  in  the  average  case. 
Rational  psycliotherapy  in  addition  to  motor  discipline  of  the  order 
mentioned  rounds  out  the  medical  treatment  of  tic. 

For  a  purely  obsessive  disease  tliere  can  be  no  raison  d'etre  in  sur- 
gical treatment  excei)t  in  so  far  as  it  may  suliserve  a  psychotherapeutic 
purpose,  in  which  event  it  seems  more  heroic  than  wise. 
Facies  hippocratica.  A  ])eculiar  facies  first  described  by  Ilipjiocrates 
as  an  indit-ation  of  ai)i)roaclHng  death,  but  which  may  result  from 
long-continued  diarrhea.  It  consists  in  a  sliarj)  nose,  lioUow  eyes, 
collapsed  temples,  cold,  contracted  ears,  the  lobes  being  turned  out- 


FACIES  HUTCHINSONIA  5141 

ward,  the  skin  of  the  forehead  rough,  distended  and  parched,  and  the 

(;()h)r  of  the  face  green,  black,  livid,  or  lead-colored.     (Foster.) 
Facies    Hutchinsonia.      Tlie    peculiar    facial    exjjression,    described    by 

•lonathan  Hutchinson,  caused  by  innnobility  of  the  eyeballs  in  oph- 

thfdnioplegia  externa. 
Facies  leontina.     Facies  lepkosa.     The   distigurement  of  the   face   in 

lei)rosy  by  the  puffed,  knotty  thickening  of  the  skin  over  the  eyes, 

giving  to  it  a  wild,  morose  appearance. 
Faciometer.     A  device  for  making  such  ocular  and  facial  measurements 

as  are  needed  for  the  adjustment  of  lenses. 
Facodonesi.     (ll.)     Trembling  of  the  lens. 
Facultative  hypermetropia.     A   form   of   manifest   hypermetropia   in 

which  ol)jects  can  be  seen  accurately  in  the  distance  both  with  and 

without  convex  lenses,  and  without  use  of  the  convergence. 
Fadchenkeratitis.    Filiform  or  filamentous  keratitis. 
Fadenkreuz.     (G.)     Cross  wires. 
Fadenoperation.    (G.)   Thread  operation,  generally  applied  to  Snellen's 

met  ll  0(1  of  treating  entropion. 
Fadenpilze.     (G.)     Sciiimmelpilz.     The  hypomycetes  fungus. 
Fadenwiirmer.     (G.)     Threadworms. 
Fahrenheit's  hydrometer.      A   glass  tube   provided  with   a  mercury 

counterpoise  and  having  a  standard  mark  on  the  stem  and  a  scale-pan 

on  the  top.     The  hydrometer  floats  in  the  liquid  to  be  examined,  the 

specific  gravity  of  which  can  then  be  deduced  from  the  weight  of  the 

load  that  has  to  be  placed  in  the  scale-pan  in  order  to  sink  the  stem  to 

the  mark. 
Faiblesse.     (F.)     Weakness. 
Faim.     (F.)     Hunger. 
Faisceau.     (F.)     Bundle ;  fasciculus. 
Faisceau  d'aigriilles.      (F.)      Needles  arranged   in  bundle  form — for 

tattooing. 
Faisceau  lumineux,     (F.)     Pencil  of  rays. 
Faisceaiix  optiques.     (F.)     Optic  tract. 
Faith-cure.     The  system  or  practice  of  attempting  or  pretending  to 

cure  diseases  by  religious  faith  and  prayer  alone.     Someone  has  said 

that  "it  differs  from  mind-cure,  in  that  the  faith-curers  have  no  mind, 

while  the  mind-curers  have  no  faith." 
Faith-healer.     One  who  practises  the  faith-cure. 
Falce  da  distrazione.     (It.)     IMyopic  cornea. 
Falce  da  supertrazione.     (It.)     Supertraction  {([.  v.)  crescent. 
Fallacia.     (L.)     An  illusion. 
Fallacia  optica.     Any  visual  illusion. 


r,142  FALLOPIA 

Fallopia.  Next  to  \'csalius,  the  most  impdrtiiiit  of  all  aiiiitoinists.  See 
Falloppio. 

Falloppio,  Gabriele.  lie  was  also  called  Failoj)io,  Kallojiius,  l<'alloi)iMa, 
l^'allopia.  This  ^i-cat  coiitciiiporary  and  pupil  of  Vesalius,  and,  after 
that  iiiai'\('lous  master,  the  most  impoi'tant  of  all  anatomists,  was  born 
at  Modena,  Italy,  in  1523.  lie  studied  at  Padua,  travelled  in  Greece 
and  France,  became  professor  of  anatomy  at  Ferrara,  then  at  Paris, 
and,  finally  at  Padua.  He  was  the  teacher  of  Fabrieius  ab  Acqua- 
l)endente,  who,  in  turn,  became  a  teacher  of  William  Harvey.  Fal- 
loppio is  said  to  have  been  just,  modest,  and  s^entle,  but,  on  the  other 
hand,  he  is  also  declared,  at  least  by  some,  to  have  accepted  gifts  from 
certain  convicts  and  then  to  have  destroyed  these  poor  creatures  by 
poisoning. 

In  our  especial  field,  Falloppio  is  to  be  remembered  because  of  his 
having  shown  that  the  retractor  bulbi  muscle  (Choanoides)  does  not 
exist  in  the  human  subject.  This  structure  was  described  as  a  portion 
of  the  human  ocular  apparatus  by  Galen  (who  had  really  observed 
such  a  muscle  in  cattle,  sheep  and  other  large  herbivora)  and  the  error 
had  been  conscientiously  propagated  for  more  than  thirteen  hundred 
years.— (T.  H.  S.) 

Fallot,  Salomon  Louis.  A  well  known  Dutcli-Pelgian  military  phy- 
sician, who  devoted  considerable  attention  to  ophthalmology.  Born 
at  The  Hague,  March  11,  1783,  the  son  and  grandson  of  physicians, 
he  accompanied  a  series  of  military  expeditions  in  his  medical  and 
surgical  capacity,  and  at  last  settled  down  in  Brussels  as  surgeon, 
and  chiefly  as  ophthalmologist.  He  died  Feb.  11,  1873,  almost  90 
years  of  age. 

Fallot's  ophthalmologic  writings  appear  chiefly  in  the  ''Amialcs 
d'Oculistique."  The  most  important  is  entitled  "Recherches  sur  les 
Causes  de  I'Ophthalmie  (|ui  Regne  dans  quelques  Garnisons  de  I'Armee 
des  Pays-Bas,  etc."  (Brussels,  1829),  once  possessed  of  a  modicum  of 
value,  but  long  since  superceded. —  (T.  H.  S.) 

Falscher  Staar.     (G.)     False  cataract. 

False  attribution  (of  ocular  diseases  and  injuries).  The  assignment  of 
an  untrue  cause  to  an  actually  existent  injury  or  disease.  See  Legal 
relations  of  ophthalmology,  in  middle  third  of  article. 

False  cataract.  An  obsolete  term  for  an  opacity  in  the  axis  of  the 
visual  rays,  but  not  in  the  lens  (e.  g.,  in  the  cornea  or  the  aqueous 
humor). 

False  heterophoria.    See  Muscles,  Ocular;  also  Heterophoria. 

False  image.     The  image  seen  by  the  deviating  or  non-fixing  eye. 

False  macula.     This  i-atber  rare  condition  is  occasionally  seen,  espe- 


FALSE  PROJECTION  514.} 

cially  ill  strabisiims.  it  is  a  very  annoying  complication  after  opera- 
tion, as  the  patient  may  acquire  diplopia,  with  its  annoyances.  The 
vision  in  such  a  ease  is  poor,  rarely  more  than  1/6.  As  Worth  {Squint, 
p.  36)  explains,  in  an  old  case  of  squint,  in  which  the  angle  of  the 
deviation  has  remained  exactly  the  same  for  several  years,  and  in 
which  the  suppression  of  the  vision  of  the  deviating  eye  is  not  pro- 
found, the  mind  sometimes  learns  to  make  full  allowance  for  the  faulty 
position  of  this  eye.  So  that  the  eccentric  image,  formed  in  the  devi- 
ating eye,  is  mentally  projected  to  the  same  spot  as  the  true  macular 
image,  formed  in  the  normally-directed  eye,  and  is  blended  with  it. 
This  false  macula  is  merely  a  small  area  which  has  escaped  the  loss 
of  function  which  has  overtaken  the  surrounding  {lart  of  the  retina. 
The  visual  acuity  of  a  false  macula  is  never  greater  than  the  normal 
visual  acuity  of  the  region  in  which  it  is  situated. 

In  a  case  reported  by  Angus  ^laciiab  {Ophlhalmic  lievieiv,  p.  94, 
March,  1911)  a  woman,  a3t.  40,  had  suft'ered  from  convergent  squint 
when  £et.  5,  for  which  she  had  tenotomy  of  the  left  internal  rectus. 
Subsecpiently  the  eye  diverged  to  about  48°.  At  this  date  she  wai? 
■myopic.  The  deformity  was  reduced  by  advancement  of  the  left  inter- 
nal rectus  and  tenotomy  of  left  external  rectus;  22°  of  divergence 
remained.  Symptoms  of  homonymous  diplopia  were  now  obtained, 
which,  being  measured  and  adjusted  to  the  operative  effect,  indicated 
a  false  "macula"  in  the  temporal  tiekl.  Monocular  diplopia  was  not 
found. 
False  projection.  As  Landolt  (System  of  Diseases  of  the  Eye,  Vol.  IV, 
p.  17)  very  properly  points  out,  it  is  by  the  aid  of  the  muscular  sense 
that  we  make  our  way  about,  and  particularly  by  the  aid  of  the  sense 
of  the  ocular  muscles. 

The  patient  affected  with  paresis  of  the  left  external  rectus  will, 
then,  suppose  the  object  fixed  to  be  so  much  the  more  to  the  left  side, 
as  he  has  brought  more  energy  into  play  in  order  to  reach  it  with  the 
visual  line. 

If,  guided  only  by  the  paretic  left  eye,  he  hastens  towards  an  open 
door,  he  runs  the  risk  of  a  collision  with  the  left  side  of  the  door- 
frame. Hence  the  very  characteristic  gait  of  such  a  patient :  instead 
of  going  straight  towards  the  point  of  destination,  he  at  first  goes  too 
much  to  the  left,  and  it  is  only  later,  on  perceiving  his  error,  that  he 
rectifies  his  course,  often  betaking  himself  suddenly  to  the  opposite 
side,  where  the  object  actually  is.  For  the  same  reason,  he  pours 
water  to  the  left  side  of  the  glass;  instead  of  dipping  his  pen  in  the 
inkstand,  he  puts  it  to  the  left  side  of  the  stand,  etc. 


5144  FALSE  PTERYGIUM 

Til  is  fjilse  in'ojrL'tion,  as  it  is  called,  iiuL-cssarily  takes  place  always 
ill  the  (lireclioii  ol'  the  iioniial  action  of  the  paretic  muscle,  exactly 
like  the  jiro.jectinii  of  the  false  retinal  image  which  gives  rise  to 
(liltlo]>ia. 

lluueviT,  tlu;  two  pheiiouu'iia  must  not  be  confounded  witli  each 
other.  They  are  not  at  all  identical.  Diplopia  is  produced  even  when 
the  eyes  are  at  rest  in  their  position  of  equilibrium,  and.  results,  as 
we  have  explained,  from  the  comparison  of  the  place  in  the  retina 
where  the  image  is  formed  in  the  healthy  eye,  with  the  one  where  it 
is  produced  in  the  deviated  eye. 

False  muscular  projection  does  not  come  into  play  until  the  moment 
when  an  effort  is  demanded,  of  the  paretic  muscle.  If,  instead  of 
directing  the  deviated  eye  towards  the  fixation-object,  the  patient  dis- 
places the  latter  or  turns  his  head  so  that  its  image  is  received  on  the 
fovea  centralis  without  any  effort  of  the  affected  muscle,  he  will  not 
be  deceived  as  to  the  position  of  the  object.  Thus,  the  false  projec- 
tion diminishes  in  the  direction  of  the  deviation,  while  it  increases  in 
the  direction  of  the  paretic  muscle. 

Hence  this  pathological  phenomenon  to  which  the  paralysis  giv<?s 
rise  follows  also  from  the  physiological  action  of  tlte  muscle.  To  a 
person  one  of  whose  a])ductors  is  paralyzed,  the  ambient  world  will 
seem  displaced  towards  the  affected  side.  If  it  be  the  internal  rectus 
that  is  paretic,  the  false  projection  will  be  towards  the  healthy  side. 
In  the  same  way,  the  hand  will  seem  an  object  below  its  real  position, 
and  at  the  temporal  side  of  where  it  really  is,  when  the  patient  fixes 
only  with  an  eye  affected  witli  paresis  of  the  superior  oblique. 
False  pterygium.  That  form  of  pterygium  ])roduecd  by  burns,  ulcer- 
ation, diphtheria,  etc.  It  may  occur  on  any  part  of  the  globe,  unlike 
the  true  growth  that  appears  usually  at  the  inner  (though  occasionally 
at  the  outer)  cantlius. 
Falta's  collyrium  bottle.  This  useful  little  device  is  fully  depicted  and 
described  in  the  accompanying  figui-e  and  legend. 


9-QS 


Fnlta  's  Oollyiiiim  Bottle. 
It  is  licltl  over  tlic  llaiiic,  lor  sterilization,  with  a  special  wire  holder. 


FALTE  5145 

Falte.     (G.)     A  fold.     A  name  given  by  Kcil  to  the  lii{)i)oeainj)us  minor. 

Faltenkranz.     (d.)     Corona  eiliaris. 

Falz.      ((i.)      A  fold  or  groove. 

Familial  eye  affections.  Family  eye  diseases  in  general.  Although 
each  of  these  peculiar  diseases — in  the  strict  sense  generally  heredi- 
tary— are  or  will  be  full}'  described  under  their  proper  headings, 
yet  it  is  considered  fitting  to  say  something  about  several  of  them 
here.  The  reader  is  also  referred  to  such  captions  as  Congenital 
anomalies  of  the  eye,  as  well  as  to  Hereditary  diseases  of  the  eye, 
for  additional  informatiOTi  on  the  subject. 


(So 


Familial  Diseases. 
Piiestley  Smith's  Sj'mbols  for  the  Slaking  of  Pedigree  Charts. 

The  best  known  examples  of  family  eye  diseases  are  certain  forms 
of  corneal  opacity;  congenital  cataract;  clioraiclitis  and  chorioretinitis; 
amaurotic  idiocy;  hiiphtlialmos;  color-hlindncss;  hcmcralopia;  colo- 
hanm;  optic  atrophy  (Leber's  disease)  ;  albinism,'  Miie  sclerotics  and 
ataxia. 

In  this  connection  Priestley  Smith  {Ophth.  Record,  Vol.  XIX,  p. 
35)  proposes  for  making  pedigree  charts  the  use  of  standard  symbols 
printed  on  slips  of  paper.  The  slips  which  he  has  prepared  are  one 
inch  square  and  the  signs  are  illustrated  in  the  accompanying  cut. 
The  interpretation  of  these  symbols  is  as  follows :  The  ring,  with  an 
arrow-head  pointing  upwards,  means  male,  unaffected.  The  same,  in- 
verted, means  fenmle,  unaffected.  A  black  disc,  in  place  of  the  ring, 
means  affected.  A  line  drawn  across  the  stem  of  the  arrow  means 
examined.  The  omission  of  this  line  means  rcliahU  evidence,  hut  not 
examined.     A  horseshoe  instead  of  the  ring  means  no  evidence  as  to 


il46  FAMILIAL  EYE  AFFECTIONS 

affection:  deletion  of  llie  ariow-liead,  .svr  unknown ;  a  large  ring  or 
horseshoe  with  miineral,  .so  nidni/  of  that  kind ;  the  same  witli  interro- 
gation niai'k,  niinihir  iinknoiot;  a  hori/oiital  line  lieh)\v  a  symbol,  no 
issue.  It  is  to  Ite  iioped  that,  in  particular,  writers  on  liere(litai\\-  dis- 
eases or  familial  jx'culiarities  will  bear  in  mind  and  eontimie  to  employ 
these  symbols,  ajid  so  eonti'ibnte  to  a  most  useful  form  of  standai'diz- 
iug  these  observations. 

Famili^il  blue  scUrotics.  This  peculiar  affection  has  been  fully  de- 
scribed l)y  many  observers,  especially  by  Hishop  Ilai-man.  See  page 
1287,  Vol.  II.  of  this  Encyclopedia. 

Here  but  one  instance  will  Ix;  mentioned,  tliat  reported  by  C.  A.  A. 
Drighton  (Ophtlialmoscopc,  April,  1912),  a  family  of  Welsli  extrac- 
tion sliowing  l)lue  sclerotics.  Patient,  aged  49  years,  head  of  the 
present  generation,  had  marked  azure  blue  sclerotics,  with  slight  hyper- 
metropia  of  both  eyes.  He  liad  fracture  of  both  legs  as  a  child,  and  in 
recent  years  fractured  the  olecranon  of  the  right  arm  while  swinnning. 

His  father  also  had  blue  sclera,  but  his  father's  two  sisters  had  no 
sign  of  them.  Patient  is  married ;  his  wife,  a  woman  aged  42,  has  not 
blue  sclerotics.  From  this  marriage  there  are  seven  children.  Two 
daughters  have  ])lue  sclerotics,  and  each  had  fractured  legs  from 
trifling  causes.  Of  the  five  sons,  four  have  blue  sclerotics,  and  two 
of  them  had  fractured  bones. 

See  Cornea,  Family  degeneration  of  the,  in  Avliich  tlie  familial  form 
of  latticc-shupcd  opacity  is  discussed. 

Family  colohmna  of  the  iris.  Tobias  {Klin.  Mo^wtshl.  f.  AugenheUk., 
April,  1911)  records  an  instance  where  a  mother  with  bilateral  opera- 
tive colobomata  of  the  iris  gave  birth  to  two  children  in  a  family  of 
five  with  congenital  colobomata  of  the  iris  and  choroid.  The  oldest 
children  had  normal  eyes.  The  operation  had  been  performed  four 
years  before  her  marriage.  In  the  right  eye  the  coloboma  was  below 
and  in,  and  in  the  left  eye,  up  and  in.  The  one,  male  child,  which 
died  in  its  first  year,  had  bilateral  colobomata  below.  The  living, 
female  child,  19  years  of  age,  had  a  coloboma  of  the  iris  and  choroid 
down  and  in. 

Familial  cataract.  A  family  history  of  cataract  including  eleven 
persons  is  reported  by  Campbell  (Jour.  Ophth.  Otol.  and  Laryn., 
V.  17,  p.  144,  1913).  Two  brothers  and  three  sisters,  aged  respectively 
30,  26  and  27  years,  came  to  operation  on  account  of  difi'use  lens 
opacities.  The  father  of  these  patients  liad  been  operated  on  when 
under  30  years  of  age  for  cataract  in  both  eyes  which  had  developed 
two  or  three  vears  eai'lier.     lie  had  five  other  children,  all  of  whom 


FAMILIAL  EYE  AFFECTIONS  5147 

lijul  developed  eatiii'aet  in  ])i'evi()usly  iioniial  eyes,  and  his  sister  and 
her-  daugliter  were  atl'eeted  in  the  same  wa\'.  In  every  instance  in 
wliicli  the  history  was  clearly  stated  the  lens  change  had  been  first 
noticed  helween  the  ages  of  25  and  29  years.  Excellent  vision  was 
obtained  l>y  operation  in  the  threi;  cases  first  nn-ntioned.  See,  also, 
Cataract,  Hereditary. 

Family  dislocation  of  the  lens.  The  reviewer  in  the  Annals  of  Oph- 
thalmology, p.  5.'i8,  July,  1912,  furnishes  an  excellent  abstract  of  the 
paper  by  A.  R.  Gunn  {Ophthalmoscope,  April,  1912)  who  records  dis- 
located lenses  occurring  in  a  family  through  four  generations.  Eighteen 
were  aflfected  and  nine  were  normal.  Six  affected  individuals  had 
been  examined,  three  adults  and  three  children.  In  the  children  the 
lens  in  each  case  could  be  seen  floating  free  in  the  vitreous  chamber. 
The  vision  in  each  case  was  markedly  improved  by  -)-  10  D  spheres.  Jn 
the  other  members  of  the  pedigree  the  histories  clearly  pointed  to  a  simi- 
lar condition,  and  the  author  assumes  there  was  congenital  aphakia  due 
to  dislocation  of  the  lens,  not  improbably  as  a  result  of  absence  or  im- 
perfect development  of  the  suspensory  ligament.  Each  family  con- 
tained both  affected  and  unatfected  individuals. 

Examination  of  the  pedigree  shows  at  once  that  the  condition  is  cer- 
tainly not  a  IMendelian  recessive ;  also  that  it  affects  both  sexes  in  equal 
numbers.  In  two  families  with  four  and  two  children,  respectively,  it 
seems  to  behave  as  a  pure  dominant;  in  all  the  others  there  are  both 
aifected  and  unaffected  individuals,  the  former  preponderating.  The 
only  unaffected  individual  who  has  a  family,  it  is  interesting  to  note, 
has  all  his  children  (four)  unaffected.  We  may  assume,  then,  that 
the  normal  condition  is  recessive  to  the  abnormal,  and  that,  therefore, 
the  latter  probably  differ  from  the  others,  not  in  lacking  something 
essential  to  complete  development,  but  rather  in  possessing  some  addi- 
tional character  or  factor  in  virtue  of  which  the  normal  development 
of  the  suspensory  ligament  is  interfered  with.  On  this  assumption, 
and  owing  to  the  fact  that  the  majority  of  the  families  contain  both 
affected  and  unaffected  individuals,  we  must  regard  the  affected  indi- 
viduals as  heterozygous  for  this  inhibitory  factor.  Assuming,  further, 
that  each  marriage  has  been  between  such  a  heterozygote  and  a 
homozygous  normal,  which  we  are  justified  in  doing  in  the  absence  of 
any  history  of  cousin  or  other  interrelation  marriages,  we  should  expect 
as  a  result  an  equal  number  of  affected  and  of  unaffected  offspring. 
The  actual  results,  however,  show  a  large  preponderance  of  affected 
individuals.  Tabulating  the  offspring  of  the  union  of  an  affected  with 
a  noiuift'ected  parent,  we  find  as  follows: 


,148  FAMILIAL  EYE  AFFECTIONS 

Affected.  Nonaffected. 
4  1 

4  1 

4  0 

3  3 

2  0 

17  5 

The  total  of  the  five  such  families  is  twenty-two,  viz.,  seventeen 
atTeeted  and  five  nonafit'ected  individuals,  a  result  suspiciously  like 
the  3  to  1  simple  Mendelian  ratio.  Further,  on  examination  of  the 
individual  families,  it  is  curious  to  find  two  containing  (1)  members 
which  apparently  throw  off  only  affected  individuals  when  married  to 
a  normal  recessive;  (2)  members  which  throw  off  both  recessive  and 
dominants,  in  one  instance,  in  equal  numbers;  and  (3)  one  member  at 
least  breeding  true  to  the  recessive  character.  Such  a  result,  however, 
is  not  in  this  instance  found  in  association  with  the  union  of  two 
heterozygotes,  and  at  present  we  must  regard  its  significance  as  un- 
known. 

We  are  justified,  however,  in  tentatively  concluding  that  (1)   nor- 
mal is  recessive  to  abnormal,  and  (2)   the  individuals  exhibiting  the 
latter  condition  are  heterozygous  in  composition  for  a  certain  factor  in 
-  presence  of  which  the  usual  development  of  the  suspensory  ligament 
of  the  lens  is  inhibited. 

But  what  is  this  inhibitory  agent?  Two  hypotheses  suggest  them- 
selves: (1)  the  suspensory  ligament  may  become  ruptured  after  its 
formation,  a  suggestion  the  advanced  development  of  the  lens  lends 
some  color  to,  although,  on  the  other  hand,  the  exact  nature  and 
mechanism  of  the  etiologic  factor  on  this  assumption  is  difficult  to 
conceive,  or  (2)  it  may  be  prevented  from  forming  at  all.  In  an  early 
stage  of  development  the  lens  vesicle  practically  fills  the  optic  cup, 
which  afterwards,  in  virtue  of  its  more  rapid  increase  in  size,  grows 
away  from  it.  But  it  is  during  this  stage  of  contact  that  the  cellular 
adhesions  between  the  equator  of  the  lens  vesicle  and  the  ciliary  body, 
described  by  Treacher  Collins  as  the  mode  of  formation  of  the  suspen- 
sory ligament,  occur,  and  anything  which  would  interfere  with  inti- 
mate contact  until  the  increase  in  size  of  the  optic  cup  became  pro- 
nounced, w'ould,  of  course,  render  difficult  the  formation  of  a  func- 
tional susjx'nsory  ligament.  Such  a  condition  would  seem  to  be  ful- 
lilh'd  l)y  an  niidiic  persistence  of  that  portion  of  the  intruding  meso- 
lilast  known  iis  tile  posterior  fibrovascular  sheath,  although  the  com- 


FAMILIAL  EYE  AFFECTIONS  5140 

I)l('te  (]('vcl()|)iii('nt  of  the  iris  and  llic  clinical  absence  of  any  remnants 
indicate  that  such  a.  persistence  could  not  have  l)e<!n  unduly  prolonged. 

Familidl  choroiditis.  Doijitr's  choroiditis,  lloncycamh  choroiditis. 
R.  W.  Doyne  {Ophth(d>ii.  Review,  July,  1910)  describes  several  cases 
(in  addition  to  those  previously  reported)  in  which  the  changes  were 
mostly  observed  in  the  region  of  the  disc  and  macula,  but  in  other  cases 
showed  the  margin  of  the  disc  maiidy  or  solely  affected,  while,  on  the 
other  hand,  the  macula  in  some  cases  was  the  only  part  where  the  con- 
dition was  found.  In  one  of  the  cases  there  was  a  white  spot,  partly  on 
the  disc,  showing  that  these  areas  were  exudates,  and  not  of  atrophic 
origin. 

He  remarks  tliat  family  choroiditis  appears  in  early  adult  life, 
though  more  commonly  later.  It  may  affect  either  the  disc  neighbor- 
hood or  the  macula  region,  or  both.  It  consists  of  circular  patches 
of  exudation,  which  increase  during  middle  life,  and  at  last  set  up 
some  irritation  and  pigmentary  disturbance,  for,  though  pigment  is 
not  always  present,  in  some  cases  there  is  a  good  deal  to  be  seen. 
During  this  stage  the  sight  is  not  much  affected,  but  in  old  age  there 
is  optic  atrophy  with  corresponding  failure  of  vision. 

Lutz  (Klin.  Monatshl.  f.  Augenh.,  p.  690,  19U)  has  described  a 
form  of  family  choroido-retinitis  somewhat  resembling  that  reported 
by  Doyne.  The  family  consisted  of  nine  children,  six  girls  and  three 
boys ;  of  these  four  girls  were  affected.  Both  parents  were  seen,  and 
were  unaffected;  on  the  father's  side  all  the  antecedents  for  two  gen- 
erations had  had  good  sight;  on  the  mother's  side  nothing  was  known 
of  any  eye  affection,  l)ut  the  data  were  not  so  full ;  there  was  no  con- 
sanguinity. In  all  cases  the  disease  began  in  the  11th  or  12th  year, 
and  was  of  rapid  onset.  Both  eyes  were  affected.  AVithin  a  few 
months  the  vision  Avas  reduced  to  ^/^^ — y^,^.  The  fundus  changes 
were  confined  to  the  posterior  pole,  and  consisted  of  very  fine,  pale, 
yellow-gray  dots,  with  minute  pigmented  spots  between.  In  places 
there  was  some  confluence  of  the  spots  into  larger  areas.  Nerve  and 
vessels  normal.  Light  sense  reduced  and  no  evidence  of  tubercle  or 
syphilis. 

Collins  (Ophthcdmoscopc,  Vol.  II,  p.  537,  1913)  gives  the  micro- 
scopic details  of  a  case  of  Doyne 's  choroiditis.  In  the  region  of  the 
macula  and  optic  disc  a  layer  of  hyalin  extended  between  the  retina 
and  the  choroid,  from  near  the  margin  of  the  disc  inward  for  two 
disc  diameters,  and  outward  for  six.  Its  inner  surface  presented  sev- 
eral rounded  elevations.  Over  the  layer  of  hyalin  the  internal  capil- 
lary layer  of  the  choroid  was  much  thinned,  and  in  places  absent.  The 
outer  layers  of  the  retina  in  the  same  region  were  extensivelv  dis- 


5150  FAMILIAL  EYE  AFFECTIONS 

oi'^Miii/ctl.  The  piiiii.iry  cliaiif^e  appeared  to  liave  oc«'iiriT(l  in  the  pig- 
menl  cpithcliuiii.  In  a  case  recorded  by  Weiss  {Worh.  f.  Thcrap.  u. 
Ifijtj.  d.  Auij(s.,  \o\.  17,  p.  4.  l!)l;5)  tlie  whole  fundus  of  the  right  eye 
showed  the  choroidal  vascular  system  as  a  network  of  yellowish-white 
cords.    The  patient  had  seen  poorly  witli  this  eye  from  early  childhood. 

See,  also,  p.  2148,  Vol.  Ill,  of  tliis  Envijclupcdid. 

F(iniil)/  r(ti)i<il  (Jiscasfs.  Several  retinal  affections  are  found  in 
mem))ei-s  of  the  same  family.  Foi-  example,  Zani  {Ann.  <U  Ott.,  XL, 
1!)12,  p.  2'.i6)  reports  cases  of  retinitis  i)unctata  all)escens  in  a  lirothei-, 
aged  12,  and  a  sister  aged  6,  all  who  were  affected  out  of  a  family 
of  five.  There  were  hemeralopia  and  lowered  vision,  and  white  dots 
in  the  fundus.  In  the  ])oy's  eyes  the  white  spots  were  seen  in  the 
pei-ipher\'  and  aliout  the  disc;  in  the  girl's  they  were  finer,  and  only 
in  the  periphery  of  the  retina.  Oguchi  (Ann.  of  Ophth.,  LXXXI, 
1912,  p.  109:  Ann.  of  Ophth.,  XXI,  1912,  p.  562)  reports  three  cases 
resembling  this  condition,  showing  hemeralopia,  but  instead  of  isolated 
whitish  specks  a  ditt'use  grayish-white  discoloration  of  the  fundus. 
The  optic  nerve  and  vessels  were  normal,  the  macula  appeared  un- 
usually dark.  A  similar  case  has  l)een  reported  by  Kusama  {Klin. 
Manatshl.  f.  Augcnh.,  April,  1912,  p.  500),  who  calls  the  condition 
Oguchi 's  disease. 

Ballantyne  {Ophthal.  Review,  Dec,  1909)  gives  a  review  of  a  paper 
by  Stargardt  (Graefe's  Archiv.  f.  Ophthal,  71,  3,  1909),  who  has 
described  a  hitherto  unrecognized  progressive  family  degeneration  in 
the  macidar  region.  The  patients  are  members  of  two  families.  The 
first  (family  H.)  consists  of  four  persons,  all  affected:  while  the  second 
(family  N.)  consists  of  five  persons  of  whom  three  are  affected.  The 
parents  in  each  ease  were  quite  healthy.  The  ages  of  the  patients  at 
the  time  of  observation  were  from  12  to  20. 

The  condition  affects  brothers  and  sisters  whose  parents  are  healthy 
and  give  no  evidence  of  ocular  disease.  There  is  no  history  of  eye  dis- 
ease in  the  family  and  the  parents  are  not  blood  relations.  The  visual 
defect  first  makes  itself  felt  about  the  12th  to  the  15th  year  and  pro- 
gresses steadily,  though  apparently  very  slowly  at  the  beginning  and 
end  of  its  course.  The  defect  involves  the  central  vision.  In  the  earliest 
period  there  is  a  central  scotoma  for  red  and  green,  later  a  relative 
scotoma  also  for  white  and  the  other  colors,  and  finally  total  loss  of 
central  vision. 

The  striking  fact  that  the  ])atients  could  all  writi'  well,  in  spite  of 
reduction  of  visual  acuity  to  the  counting  of  fingers,  shows  that  the 
defect  had  not  lu'cn  congenital  but  must  have  come  on  after  some  years 
of  school  life.     The  peripheral  field  of  vision  is  always  normal  l)Oth 


FAMILIAL  EYE  AFFECTIONS  5151 

foi-  white  and  for  coloi's.  ( "olor-visioii  is  nofiiuil  aiul  there  is  no  dis- 
turhance  of  the  light  sense  or  powei'  of  adaptation.  It  is  possible  that 
the  macular  changes  ])egin  hefoi'e  subjective  loss  is  noticed,  but  in  one; 
case  at  least  the  defect  was  present  subjectively  before  any  changes 
were  visible. 

The  disease  is  essentially  one  of  the  maeulai'  region,  although  the 
complete  ])icture  includes  (dianges  beyond  the  limits  of  that  area. 

In  its  earliest  form  we  find  a  certain  ii-regularity  of  pigmentation 
in  the  macula,  and  some  yellowish-gray  spots  in  that  region  scarcely 
contrasted  with  th(>  fundus.  At  the  same  time  there  is  loss  of  the 
foveal  reflex.  At  a  later  stage  small  yellow  or  orange  spots  appear, 
which  may  coalesce  to  form  larger  ones,  but  they  are  always  small  and 
only  visible  in  the  erect  image.  At  this  stage  small  amorphous  spots  of 
pigment  are  scattered  over  th(>  affected  area.  Both  the  foveal  and  the 
nuicular  reflex  are  lost.  The  yellow  spots  spread  over  a  mdre  extended 
area  while  the  changes  at  the  center  become  more  intense. 

The  foveal  change  may  take  the  form  of  a  dirty  grayish-yellow  spot 
one-third  of  a  disc  diameter  surrounded  by  a  pigment  ring,  or  of  an 
orange-yellow  spot  of  circular  shape  surrounded  by  a  gray  line  sharply 
defined  on  its  central  side  but  gradually  fading  off  towards  the  periph- 
ery (this  form  resembles  the  "macular  holes''  of  Haab),  or  there  is 
a  deposit  of  dense  amorphous  pigment  masses  at  the  center,  while  in 
some  cases  we  may  see  choroidal  vessels  shining  through.  In  one  case, 
at  this  stage,  there  were  at  the  center  fine  white  specks  like  those  of 
albuminuric  retinitis  with  fine  white  streaks  radiating  from  them  to 
beyond  the  limits  of  the  affected  area.  In  the  same  case  there  were  a 
few  individual  "bone  corpuscle"  clumps  of  pigment. 

Finally  a  somewhat  sharply-defined  area  is  formed  at  the  macula, 
horizontally  oval,  with  a  diameter  of  li/>  to  2  disc  diameters,  its  edges 
pigmented,  its  base  of  dirty  yellowish-grey  color,  covered  with  fine 
amorphous  pigment  masses,  and  witii  a  few  greyish-yellow  choroidal 
vessels  showing  through. 

In  all  cases  except  the  earliest  there  were  also  some  small  white 
spots,  only  visible  on  direct  examination,  something  like  those  of 
retinitis  punctata  albescens,  and  probably  situated  in  the  deeper  retinal 
layers;  either  confined  to  the  neighborhood  of  the  macula  or  extending 
as  far  as  the  larger  vessels,  or  even  beyond  the  disc.  The  fundi  were 
otherwise  normal,  with  the  exception  of  slight  temporal  pallor  of  the 
discs  in  the  later  stages,  and  there  were  no  other  eye  defects,  no  general 
disease  or  congenital  anomaly,  aiul  no  past  illnesses  of  any  significance. 
One  notable  feature  is  the  very  close  resemblance  of  the  changes  in 
the  two  eyes  at  all  stages. 


5152  FAMILIAL  EYE  AFFECTIONS 

Tlif  (liscjisc  jippjii'fiilly  Ix'f^ins  in  the  "fovcola"  jiiid  iilt iiiwilfly  alTccts 
an  area  wider  tliaii  tlic  limits  of  tiie  macular  reflex.  In  many  eases  the 
appearances  sugjjest  complete  atrophy  of  the  retina  at  the  macula. 
There  is  some  doubt  as  to  whether  the  primary  change  is  choroidal  or 
retinal  ;  on  the  whole  the  facts  seem  to  sugfjest  the  latter.  The  author 
thinks  the  condition  is  degenerative  rather  than  inflammatory,  and  he 
points  out  that  it  is  somewhat  analogous  to  retinitis  pigmentosa  while 
it  affects  the  part  of  the  retina  in  which  cones  predominate.  The 
proximate  cause  is  probably  a  circulating  cyto-toxin. 

Familial  optic  neuritis.  A  complete  account  of  this  rare  condition 
is  supplied  by  A.  van  Lint  and  G.  Kleefeld  {Annalcs  (.rOculist.,  Vol. 
152,  August,  1914).  It  deals  with  a  remarkable  group  of  cases  occur- 
ring in  one  sibship,  of  interference  with  the  endocrinous  secretions, 
but  whether  the  thyroid  alone  should  be  impugned  for  the  optic  nerve 
changes — simple  optic  atrophy  in  two  cases  and  slight  neuritis  passing 
to  atrophy  in  the  other  case — it  is  not  easy  to  tell  from  the  data  given. 
Further  details  would  be  needed,  including  a  note  as  to  the  carbo- 
hydrate tolerance,  before  the  diagnosis  of  dyspituitarism  could  be  fully 
excluded. 

In  a  family  of  seven,  of  whom  three  died  of  pleurisy'  between  the 
ages  of  three  and  seven,  and  one  at  sixteen  of  pulmonary  tuberculosis, 
were  two  boys  and  a  girl  in  the  order — Edmond,  Josephine  and  Joseph. 
At  the  age  of  21  Edmond  presented  marked  defect  of  sight  in  each 
eye,  counting  of  fingers  at  about  five  metres  in  each,  seven  years* 
history,  with  simple  optic  atrophy,  macular  areas  normal,  no 
choroiditis.  Right  field  contracted  nasally  and  above,  left  concentrically 
contracted,  no  central  scotoma.  Horizontal  nystagmus,  divergent 
stral)ismus,  refraction  1.5  D.  II.  He  looked  puny,  resend)ling  a  boy 
of  14;  forehead  large,  hair  dry  and  friable,  no  moustache  or  beard, 
only  down ;  pubic  and  axillary  hair  slight ;  nails  striate  and  brittle, 
teeth  good,  regular.  Skin  dry  and  rough;  hands  and  feet  cold;  no 
actual  skeletal  deformity.  Infantile  genitalia,  and  on  left  side  an 
imperfectly  descended  testis  in  the  inguinal  canal.  Some  pleurisy, 
aortic  stenosis.  Very  nervous,  emotional ;  intelligence  normal ;  knee- 
jerks  active,  Babinski  negative,  cremasteric  reflex  absent,  abdominal 
reflexes  exaggerated.     Height  about  5  feet  3  inches. 

Jose])hine  at  age  of  16  gave  a  five  years'  history  of  failure  of  sight: 
R.  V.  =  1/50 ;  L.  V.  r=:  fingers  at  1  metre  ;  R.  field  contracted  nasally  and 
above;  no  central  scotoma;  divergent  strabismus,  no  nystagmus;  R.  TI. 
2  1).  li.  H.  5  I);  siini)le  optic  atroi)liy  as  in  Joseph.  Nails,  teeth  and 
skin  and  bicasls  were  all  noi'inal,  l)ut  hair  was  scanty  and  dry,  hands 
small,   forehead   large,   face   iiioon-sliaped.   height  5   feet.      Secondary 


FAMILIAL  EYE  AFFECTIONS  5153 

sexual  characters  developed  at  13.  Old  pleurisy.  Whole  body  shows 
ahnonnal  development  of  cellular  and  fatty  tissues.  Nervous  system 
normal,  except  for  epileptiform  tremors.     Cold  feet. 

Joseph — at  the  age  of  15  gave  history  of  about  six  months'  defect  of 
vision,  R.  V.  =r  fingers  at  one  metre ;  L.  V.  =  fin^^ers  at  21/.  metres.  R. 
field  was  normal.  Left  slightly  contracted;  no  al)solute  central  scotoma; 
alternating  divergent  strabismus ;  slight  H. ;  slight  oi)tic  neuritis  of 
each  with  temporal  segment  in  i)roeess  of  atrophy,  edge  of  papiHa 
softened;  macular  area  normal.  Height  5  feet,  forehead  large,  moon- 
face,  hair  not  very  silky,  slight  moustache,  thin  down  on  face,  no  body 
hair,  no  pubic  or  axillary  down ;  nails  striate,  teeth  good.  Genitalia 
still  infantile.  All  reflexes  exaggerated;  intelligence  mediocre.  No 
signs  of  rickets. 

In  the  antecedents  two  conditions  were  specially  noted — adiposity  or 
family  myxedema  and  nervousness,  and  in  discussing  the  etiology  of  the 
optic  atrophy  the  authors  think  they  have  excluded  the  possibility  of 
any  pressure  on  the  optic  nerves  by  hypertrophy  of  tissues  because  a 
rhinoscopic  examination  was  negative.  They  dismiss  hypophysis  con- 
ditions because  the  fields  have  shown  no  bi-temporal  heraianopia  and 
X-rays  show  in  one  case  only — Joseph — a  slight  enlargement  of  the 
sella  turcica.  They  then  thought  of  some  infection  or  intoxication  but 
Wassennann  reaction  was  negative,  and  the  patients  presented  no 
sign  of  tubercle,  nor  was  there  any  albumin  or  sugar  in  the  urine. 
They  next  turned  to  the  internal  secretions.  Slosse,  of  Brussels,  had 
shown  that  in  hypothyroidism  there  were  definite  changes  in  the 
nitrogenous  metabolism,  and  a  table  is  given  showing  the  proportions 
of  the  different  nitrogen  compounds  as  found  by  him  in  Joseph's  urine 
before  and  after  treatment  with  thyroid,  with  those  of  a  normal 
individual  for  comparison.  The  authors  noted  that  there  was  no 
further  deterioration  of  vision  after  treatment  with  thyroid  tabloids  was 
begun,  while  the  fields  of  vision  actually  increased. 

In  hypothyroidism  alteration  of  cornea,  optic  atrophy,  neuroretinitis 
in  a  case  very  like  Joseph's  ])ut  where  there  is  said  to  have  been 
bi-temporal  hemianopia  from  vicarious  hypertrophy  of  the  hypophysis 
(Sanesi),  have  each  been  recorded,  while  in  hypersecretion  retrobulbar 
neuritis,  and  secondary  optic  atrophy  have  been  met  with.  Leber's 
disease  usually  affects  several  males,  there  is  a  short  history,  central 
scotoma  with  full  fields.  Coste  had  four  cases  of  family  optic  atrophy 
with  congenital  narrowing  of  anterior  segment  of  skull,  explaining  the 
compression  of  the  optic  nerve. 

The  authors  say  they  cannot  put  their  case  under  Leber's  disease 
since  the  affection  appeared  in  a  family  involving  the  sister  in  addition 

Vol.  VII— 20 


5154  FAMILIAL  EYE  AFFECTIONS 

to  tlic  two  brotlicrs,  ami  that  witliout  previous  oceurreuee  in  the  family, 
while  further  tlio  visiou  was  altered  without  eentral  scotoma  but  with 
retractiou  of  the  visual  tields.  In  this  latter  eonnection,  however,  it 
is  well  to  recollect  that  ouly  in  two-thirds  of  the  cases  of  Leber's 
disease  is  there  a  central  scotonui ;  the  peripheral  field  is  usually  normal, 
but  concentric  conti'action  for  whit(?  may  occur;  in  74  families  (Ilor- 
muth)  72  per  cent,  had  only  males  affected,  and  28  per  cent,  had  both 
nudes  and  females  affected,  while  collateral  inheritance — the  type  of 
inlieritance  in  tliis  pedigree — occurred  in  32  of  71  families.  In  his 
l>ownuui  Lecture,  Nettleship  concluded  that  there  seemed  to  be  some 
connection  between  early  age  of  onset  and  the  female  sex  in  Leber's 
disease. 

All  cases  of  family  optic  atrophy  present  great  difficulty  in  diagnosis 
and  call  for  very  complete  examination  and  investigation. —  (Review 
hy  W.  C.  Souter  in  the  Oph.  Review,  p.  52,  Feb.,  1915.) 

Familial  optic  atrophy.  Leber's  disease.  Hereditary  central  retini- 
tis (Cargill).  Cargill  (Ophthalnwscope,  X,  p.  62,  1912)  thinks  that 
the  primary  pathologic  changes  are  in  the  retina.  He  points  out  that, 
as  a  rule,  the  sight  remains  stationary  after  a  rather  rapid  initial 
onset,  and  improvement  may  be  delayed  for  as  long  as  one,  two  or  even 
three  years.  Hence  a  hopeful  and  expectant  attitude  should  be  taken 
during  that  period. 

Four  cases  are  recorded  by  Miigge  (Zcitschr.  f.  AugenlieHk.,  p.  236, 
Vol.  25,  1912)  in  two  families.  The  first  family  consisted  of  five 
sons  and  one  daughter.  The  first  and  third  sons  were  affected.  At 
the  time  of  entering  school  vision  was  already  much  affected.  At  the 
age  of  23  the  discs  Avere  pallid,  especially  in  the  temporal  halves. 
The  right  visual  field  showed  a  sector  defect  for  colors  above  and  a 
central  scotoma.  The  left  field  was  not  taken.  The  other  affected 
child  began  to  have  failing  vision  at  12  years.  At  the  age  of  19  there 
was  characteristic  pallor  of  the  discs.  The  fields  for  color  were 
slijihtly  contracted.  In  both  eases  some  permanent  imin'ovement 
followed  treatment  by  strychnin  injections.  In  the  second  family 
the  two  eldest  out  of  three  sons  were  affected.  The  eldest,  27  years 
of  age,  accidentally  discovered  poor  vision  in  the  left  eye  at  the  age 
of  17  years.  Two  years  later  the  other  eye  began  to  fail.  The 
l)atient  became  almost  blind  but  after  prolonged  use  of  electricity 
steady  improvement  occurred.  Vision  e<|ualled  about  5  ^30.  There 
was  absolute  centi-al  scotoma  and  contraction  for  eoloi-.  The  discs 
were  white  and  the  vessels  contracted.  The  other  brother,  at  26, 
discovered  one  eye  almost  blind.  Two  weeks  later  the  other  eye 
became  affected.     In  this  ease  tlu'  discs  were  red-gray  and  swollen 


FAMILIAL  EYE  AFFECTIONS  5155 

with  i)erii)ai)illary  t'dcma.     Later  atro])liy  set  in.     Sec,  also,  Leber's 
disease  and  Hereditary  diseases  of  the  eye. 

Finiiili/  (iiiKun-otic  idiocjj.  T(n/-S<ulis  disease.  This  is  a  fatal  and 
probably  congenital  disease,  seen  almost  entirely  in  IIt'I)re\v  patients. 
It  exhibits  itself  in  early  life  and  few  patients  survive  until  the  tenth 
year,  although  in  the  so-called  juvenile  form  the  symptoms  may  set 
in  later,  and  subjects  live  longer.  In  nearly  all  the  cases  a  white  or 
gray  ring  is  found  in  the  fundus  surrounding  a  red  spot  at  the  fovea. 

Cohen  and  Dixon  {Journ.  Am.  Med.  Assocn.,  ^Nlay  25,  1907)  are 
among  the  earliest  writers  to  give  a  histologic  report  on  the  eye  in 
amaurotic  family  idiocy.  The  globes  were  enucleated  less  than  three 
hours  after  death  and  the  only  changes  detected  were  swelling  of  the 
multipolar  ganglion  cells,  displacement  of  their  nuclei,  retraction  of 
the  cell  reticulum,  occasional  disappearance  of  ganglion  cells,  and  the 
general  disappearance  of  Xissl  's  granules.  The  appearance  of  dark 
granules  by  Weigert's  stain  in  all  the  ganglion  cells,  the  peculiar 
formation  of  the  macula  and  fovea  (there  were  six  layers  of  multipolar 
cells  at  the  macula  on  the  temporal  side  and  eleven  on  the  disc  side, 
doubtless  due  to  a  fold  in  the  macula),  the  so-called  "spacing  out"  of 
the  external  reticular  layer  near  the  macula,  and  ])eginning  simple 
atrophy  of  the  optic  nerve  were  also  noted.  Zenker's  fluid  is  the  best 
solution  for  fixing  the  retina :  formalin  the  worst.  Some  at  least  of 
the  finer  cytologic  changes  may  have  occurred  soon  after  circulation 
ceased.  The  arrested  development  theory  of  Sachs,  the  degeneration 
theory  of  Kingdom  and  Russell  and  the  toxin  theory  of  Hirsch  fit 
together  very  well.  If  the  central  nervous  system  fails  to  develop 
properly  the  finer  degenerations  must  follow,  and  it  is  only  a  step 
further  to  the  development  of  toxins  due  to  errors  of  metabolism. 

One  of  the  best  reviews  of  this  subject  is  furnished  by  Lawford 
(Ophthalmic  Rrvirw,  July.  1911)  of  papers  by  Carlyll  and  :\lott  (Pro. 
Roy.  Soc.  of  Med.,  ^h\v..  1911)  and  Gordon  Holmes  (Ibid.).  Eight 
cases  are  reported  by  tiiese  observers. 

Seven  patients  (5  girls,  2  boys)  were  all  children  of  Jewisli  parents 
from  Russia  or  Poland.  The  families  were  not  related.  In  two  in- 
stances (case  1  and  case  3)  2  children  in  the  family  were  victims 
of  the  disea.se.  In  all  the  cases  death  occurred  under  the  age  of 
three  years. 

In  the  family  of  Case  T.  the  fourth  and  fifth  children  were  affected. 
Case  II  was  the  fourtli  child  in  the  family. 

In  Case  Til.  the  first  and  second  children  were  affected. 

Case  IV  was  the  second  child.  Case  V  the  fourth  child.  Case  VI  the 
third  child,  and  Case  VII  the  seventh  child,  of  the  respective  families. 


5156  FAMILIAL  EYE  AFFECTIONS 

Iligier's  proposal  to  call  the  disease  " Tay-Saclis, "  after  the  two 
earliest  observers,  has  much  in  its  favor — at  least  until  its  pathogenesis 
is  diseovered.  Mott  ol)jeets  to  the  tenn  amaurotic  faj^ily  idiocy,  and 
has  already  pointed  out  that  in  the  cases  which  have  come  under  his 
ol)servation,  the  brains  were  of  normal  size,  or  even  larger  than  normal 
average,  and  also  that  the  convolutional  pattern  was  in  no  respect  like 
that  of  an  idiot's  or  imbecile's  brain.  lie  also  noted  that  the  super- 
ficial surface  of  gray  matter,  owing  to  the  complexity  of  the  convolu- 
tions, was  by  no  means  deficient  in  extent ;  neither  was  there  a  deficiency 
in  the  number  of  cells  in  the  cortex  cerebri,  and,  moreover,  the  char- 
acteristic change  which  is  present  in  the  cerebro-spinal  ganglion  cells 
is  also  found  in  those  of  the  sympathetic  system. 

It  seems,  therefore,  reasonable  to  conclude  that  the  disease  is  an 
affection  of  the  whole  of  the  neurons  of  the  body.  It  cannot  be  present 
long  before  birth,  or  the  convolutional  pattern  would  not  develop  to 
its  perfect  form. 

Beyond  the  fact  that  the  disease  is  limited  to  the  offspring  of  Jewish 
parents,  nothing  definite  is  known  as  to  its  etiology.  It  has  not  been 
possil)le  to  associate  it  with  any  condition  of  food  or  environment  -.  it 
appears  to  occur  in  both  breast-fed  and  artificially-fed  children. 

In  discussing  the  pathogenesis  of  Tay-Sachs  disease,  Mott  is  of  the 
opinion  that  the  pathological  evidence  shows  that  all  the  nervous  units 
are  present  at  birth,  but  from  some  cause  as  yet  undetermined  their 
vital  energy  is  so  deficient  that  they  are  unable  to  store  any  reserve 
of  Nissl  substance  which  many  authors  regard  as  the  material  basis 
of  nervous  energy ;  in  consequence  of  this,  the  conduetile  mechanism 
(neuro-fibrils)  undergoes  destruction  Avith  morphological  and  bio- 
chemical changes  in  tlie  neurons.  As  the  neurons  degenerate  and  die, 
the  neuroglial  cells  proportionately  proliferate  and  increase  in  size, 
and  the  consistency  of  the  l)rain  l)eeomes  tough  and  leathery. 

The  experiments  of  Verworn  and  others  tend  to  sliow  tliat  the  Xissl 
substance  is  a  store  of  reserve  neural  energy  and  is  contained  in  the 
mesli-work  of  the  conduetile  neuro-fibrillary  substance. 

In  Tay-Saclis  disease  there  is  a  remarkable  and  cliaracteristic  dis- 
appearance of  the  Xissl  substance  taking  place  from  witliout  inwards 
towards  the  nucleus,  and  as  the  substance  vanishes  tlie  cell  swells  as 
if  a  ])rocess  of  hydrolysis  had  occurred.  In  the  later  stages  no  Nissl 
substance  can  be  seen  \\])0u  the  dendrons  or  in  the  greater  i>art  of  the 
cell  l)ody  which  lattei-  is  often  distended  and  distoi'ted  into  an  hour- 
glass shape.  Till'  swelling  and  distortion  of  the  cell  is  generally  pro- 
poi'tional  to  the  (lisai)pearance  of  the  Nissl  substance. 

Chemical  analysis  does  not  throw  much  light  upon  the  (luestion  ;  the 


FAMILIAL  EYE  AFFECTIONS  5157 

tliiuiiiutioii  of  the  lipoid  forms  of  pliospiionis  and  sulphiii'  is  j)rol)al)ly 
due  to  the  diminution  of  myelin  owing  to  the  failun'  of  development  of 
the  myelinated  tihers.  The  eorresi)on(ling  increase  of  extractive  forms 
of  phosphorus  and  sulphur  may  possibly  l)e  due  to  a  breaking  down  of 
the  more  complex  to  simpler  forms  of  lipoids. 

The  morphological  changes  are  quite  characteristic  of  the  disease. 
All  the  ganglion  cells  stained  with  Seharlach  in  degrees  of  intensity 
which  vary  in  proportion  to  tlu;  degree  of  swelling  and  obvious  morpho- 
logical change;  they  also  stained  with  all  the  methods  which  stain  the 
myelin  sheath  or  fat.  They  did  not,  however,  stain  satisfactorily  by 
Marchi,  like  degenerated  myelin  does  when  the  process  of  decomposition 
to  choline,  glycero-phosphoric  and  oleic  acid  has  been  comjDlete.  Con- 
sequently, it  is  more  correct  to  say  that  the  cytoplasm  may  be  on  the 
way  to  this  complete  decomposition. 

In  advanced  cases  there  are  innnense  numbers  of  cells  containing 
coarse  ruby-red  glol)ules  of  stained  fatty  sul)stances;  they  are  neuroglia 
cells  which  have  taken  up  the  fat  from  the  dead  and  decayed  ganglion 
cells.  It  is  probable  that  they  have  the  power  of  decomposing  this 
lipoid  of  the  dead  ganglion  cells,  and  jjossibly,  of  recomposing  nuclear 
substance  necessary  for  proliferation  out  of  it. 

Othe]'  methods  of  staining  show  that  the  intra-eellular  fibrils  are 
ruptured  and  destroyed  by  the  swelling,  leaving  only  the  peripheral 
neuro-flbrils  which  can  be  followed  from  the  dendrons  in  their  course 
around  the  swollen  cell  to  other  dendrons,  or  to  the  axon. 

The  cells  of  the  retina,  when  this  structure  is  stained  with  Scharlaeh, 
show  a  similar  change  to  the  nerve  cells  of  the  central  nervous  system. 

In  two  of  the  three  brains  examined,  there  was  an  accumulation  of 
grainilation  cells  along  the  course  of  the  blood  vessels ;  also  endothelial 
and  connective  tissue  cells  of  the  peri-vascular  sheath  could  often  be 
seen  filled  with  the  dark,  red-stained  fat  globules. 

Any  one  of  the  methods  employed  for  demonstrating  neuroglia  shows 
a  numerous  overgrowth  of  fibrils,  especially  in  the  superficial  layers, 
where  it  forms  a  dense  felt  work — both  in  the  cerebrum  and  the 
cerebellum.  This  overgrowth  is  proportional  to  the  duration  of  the 
disease.  • 

Holmes  describes  the  pathological  appearances  in  a  case  which,  with- 
out reasonable  doubt,  was  an  example  of  Tay-Sachs  disease,  although 
unusual  in  some  respects.  The  clinical  record  is  incomplete.  The 
child  died  at  the  age  of  2  years  and  10  months  and  was  the  brother 
of  one  of  Carlyll's  cases  (No.  III).  The  brain,  portions  of  which  were 
sent  to  Holmes,  was  found  to  be  abnormally  large,  weighing  1,450  grm. 
anil  was  very  firm  and  liard  to  the  tom-h. 


5158  FAMILIAL  EYE  AFFECTIONS 

The  gyri  of  the  i)or1ions  received  were  well  developed,  and  tlic 
attached  portions  of  tlir  inciiinges  were  apparently  normal.  Tlie  cortex 
was  well  developed  and  l)i'()ader  than  that  of  a  normal  (child's  hrain. 
The  folia  of  the  pieces  of  cerehellum  were  very  slender  and  wasted. 

The  changes  in  the  cerebral  cortex,  found  on  microscopic  examina- 
tion, were  identical  with  those  in  eases  previously  examined  by  the 
writer,  and  those  described  by  Risien  liussell.  Spiller,  ^lott,  Schaffer 
and  others. 

In  this  ease  there  was  an  enormous  increase  of  the  neurofjlial  elements, 
both  lil)rillar  and  celluhir,  so  that  under  a  medium  magnification,  the 
1  issue  appeared  as  a  dense  felt-work  of  neuroglial  fibrils.  This  sclerosis 
was  on  the  whole  greater  in  the  superficial  than  in  the  deeper  layei's 
of  the  cortex. 

This  neuroglial  proliferation  was  almost  as  pronounced  in  the  white 
as  in  the  gray  matter,  and  it  was  undoubtedly  responsible  for  the 
abnormal  size  and  weight  of  the  brain. 

It  is  notewoi'thy  tliat  in  the  ease  of  the  sister  of  Holmes'  patient, 
I\Iott  found  evidence  of  decided  sclerosis. 

Holmes  considers  that  the  cerebellar  atrophy,  which  was  a  noticeable 
feature  in  his  case,  is  not  to  be  looked  upon  as  an  essential  feature 
of  the  disease. 

The  Opkthalmic  Year  Book,  1909-1913,  furnishes  a  number  of  ab- 
stracts of  both  typical  and  atypical  cases  and  mentions  the  reports  of 
Dupuy-Dutemps  {Ann.  d'ocidist.,  Feb.,  1908),  Apert  {Senvauw  Med., 
July  15,  1908),  and  Buchanan  {Sec.  on  Ophth.,  Coll.  Phys.  of  Phila., 
Oct.  15,  1908).  Nettleship  {Trans.  Ophth.  Soc.  U.  Kingdom,  Vol. 
XXYTII,  1908)  brings  together  a  series  of  thirteen  cases  of  amblyopia 
(congenital  or  arising  in  early  childhood)  accompanied  by  slight 
fundus  changes,  and  attempts  to  trace  their  possil)le  relationship  to 
amaurotic  family  idiocy.  He  thinks  that  cases  of  this  latter  condition 
surviving  tlie  usual  period,  might  present  some  such  characters,  and 
suggests  that  the  factors  of  race  and  of  diet  should  be  carefully  in- 
vestigated with  reference  to  their  bearing  upon  these  conditions.  In 
some  of  these  cases  there  was  a  history  of  great  feebleness  at  birth ;  in 
others  the  amblyopia  appeared,  or  might  have  begun,  after  an  attack 
of  measles  or  varicella. 

A  group  of  cases  reported  b.y  Stock  {Klin.  Monatshl.  f.  Augenh., 
March,  1908)  seems  more  closely  allied  to  amaurotic  family  idiocy. 
These  patients  were  two  sisters  and  a  brother,  healthy  until  about  six 
years  old,  and  then  l)eeoming  blind  and  idiotic.  Later  tlu>y  developed 
the  pigment  changes  of  retinitis  pigmentosa.  ^Microscopic  examination 
of  file  eyes  sliowed  pi-iniai'v  degeneration  of  the  neuro-epithelial  strue- 


FAMILIAL  EYE  AFFECTIONS  5159 

tures  of  the  retina,  with  secondary  involvement  of  the  pigment  epithe- 
lium, and  slight  dogenerative  changes  in  the  ganglion  cells,  although  the 
nerve  fiber  and  ganglion  cell  layer  was  not  atroi)liie.  In  contrast  with 
amaurotic  family  idiocy,  Stock  points  out  that  these  cases  showed  idiocy 
without  paralysis;  blindness  was  slowly  progressive,  with  the  clinical 
picture  of  retinitis  pignu-ntosa;  and  tiie  anatomic  examination  showed 
a  primary  lesion  of  the  ueuro-epithelium  without  optic  atrophy. 

Of  other  atypical  cases  Ferjukowa  {Klin.  Monatshl.  f.  Augenh., 
April,  1911,  p.  i324:j  reported  the  disease  in  a  brother  and  sister  in 
whom  arrest  of  mental  development  and  failure  of  vision  began  at  G 
years.  The  fundus  showed  optic  atrophy,  narrowed  vessels,  specks 
of  brownish-black  pigment  toward  the  periphery,  some  of  them  of 
bone  corpuscle  shape.  There  was  hereditary  syphilis.  The  cases  sug- 
gest an  approach  to  retinitis  pigmentosa.  Oatman  {Amcr.  Jour.  Med. 
Sc,  1911,  p.  221)  saw  a  brother  and  sister  whose  sight  and  intelligence 
began  to  fail  at  6  and  7  years.  There  was  at  first  central  scotoma, 
and  vision  gradually  declined  to  perception  of  moving  objects.  The 
tfundus  changes  showed  a  general  similarity  to  those  of  the  preceding 
cases.  Gifford  [Oplith.  Rcc,  XXI,  p.  8,  1912),  besides  reporting  the 
cases  of  a  brother  and  sister  similar  to  the  above,  and  a  fauuly  group 
of  five  cases  with  little  tendency  to  progress,  has  collected  a  large  series 
of  more  or  less  related  cases.  He  proposes  to  call  this  the  juvenile 
form  of  amaurotic  family  idiocy,  in  contradistinction  to  the  typical 
or  infantile  form,  or  Tay-Sachs  disease.  ]\Iagnus  {Xor.sk.  Mag.  for 
Laegeviderisk.,  LXXIII,  1912,  p.  1598)  reports  a  boy  of  7  with  defec- 
tive vision  and  motor  disorders  with  optic  atrophy  whose  sister  had 
died  at  14  after  suffering  blindness,  palsy,  and  dementia.  ^Magnus  also 
reports  a  case  resembling  typical  amaurotic  "family"  idiocy  (infantile 
type)  occurring  in  a  family  of  seven.  The  other  six  children  were 
healthy.  The  parents  were  of  old  Norwegian  peasant  origin,  without 
admixture  of  Jewish  blood,  were  not  related,  and  there  had  been  no 
nervous  or  mental  disease  in  their  families  so  far  as  their  records 
went.  Ochi  {Xippon  Ganh.  Zasski,  Nov.,  1912)  reports,  with  micro- 
scopic study  of  the  eyeball,  a  typical  case  of  ' '  Tay-Sachs  disease, ' '  the 
first  case  reported  from  Jai)an.  He  found  the  usual  degeneration  of 
the  ganglion  cell  layer  and  atrophy  of  the  nerve  fi])er  layer.  Smith 
{Boston  Med.  and  Surg.  Jour.,  ^larch  7,  1911)  reports  two  typical  eases, 
one  a  first  cliild,  the  other  the  seventh  child,  the  oldest  of  the  family 
having  died  of  the  same  disease. 

A  family  group,  including  three  cases  of  the  so-called  juvenile  form, 
is  reported  by  Harbitz  {Arch.  f.  Augenh.,  V.  7:5,  p.  UO,  191.3).  The 
parents  were  healthy  and  had  been   married  eleven  years  when  the 


r,160  FAMILIAL  EYE  AFFECTIONS 

oldest  child  was  boru.  She  continued  well,  witii  normal  intelligence 
and  sight,  until  she  was  7.  Then  vision  became  impaired  with  central 
scotoma,  and  pale  optic  nerve.  Later  the  field  of  vision  contracted 
and  she  became  completely  blind.  Mental  deterioration  began  at  12 
years  old ;  she  became  epileptic  and  died  at  13.  The  eyes  were  not 
examined,  l)ut  the  brain  i^resented  the  ganglion  cell  changes  of 
amaurotic  family  idiocy.  The  next  child,  a  boy,  was  normal  until  5 
years  old,  and  then  ran  a  similar  course,  dying  at  the  age  of  9  years. 
Six  years  later  another  boy  was  born  who  continued  healthy  until  he 
was  6  years  old,  and  then  became  amblyopic  in  the  same  way,  although 
still  al)le  to  see  in  the  periphery  of  his  field  a  year  or  more  later. 

Speaking  of  family  affections  of  the  optic  nerve  in  general,  H. 
Frenkel  {Archives  d'Ophtal.,  Nov.,  1913)  : 

(1)  That  just  as  there  are  numerous  types  of  familial  affections  of 
the  nervous  system,  so  also  are  there  of  familial  optic  atrophies,  the 
one  main  branch  being  hereditary  and  familial  (type  Leber),  the  other 
not  hereditary  but  limited  to  a  single  generation.  It  is  those  of  the 
latter  type,  giving  the  aspect  of  a  primary  and  not  neuritic  atrophy 
which  seem  to  have  a  certain  tendency  to  be  associated  in  the  same 
individuals,  with  familial  affections  of  the  nervous  system.  The  author 
has  only  been  able  to  find  one  ease  of  Friedreich's  disease  with  heredi- 
tary atrophy  and  only  one  of  Leber's  disease  associated  with  a  familial 
affection  of  the  nervous  sj'stem,  and  that  affection  was  onl}'  observed 
in  one  generation. 

(2)  Thosa  affections  of  the  nervous  system  reputed  to  rarelj'  give 
rise  to  isolated  oi)tic  atrophy  (cerebral  diplegia,  Friedreich's  disease) 
are  often  found  amongst  those  which,  in  a  hereditary  or  familial  form 
are  accompanied  by  atrophy  of  the  optic  nerve  in  several  members 
of  the  same  famil}'.  On  the  contrary',  amongst  the  numerous  affections 
wliich  are  frequently  accompanied  by  isolated  optic  atrophy  (tabes, 
disemminated  sclerosis,  etc.)  few  cases  of  the  coincidence  of  both  are 
to  be  found  amongst  many  members  of  the  same  family. 

(3)  The  non-hereditary  familial  affections  of  the  optic  nerve  often 
start  in  infancy  (Tay-Sachs,  retinitis  pigmentosa,  simple  atrophy). 
Possibly  the  severity  of  these  cases  that  begin  early  partially  explains 
the  fact  that  they  are  not  observed  in  several  generations.  The 
familial  and  hereditary  affections  of  the  optic  nerve  (type  Leber)  begin 
in  youth  or  adiilt  age  and  are  more  benign.  In  fact,  from  the  point 
of  vision  prognosis  is  much  more  favoral)le  in  those  familial  atVcctions 
which  start  in  later  life. 

(4)  Consanguinity  ai)pears  to  l>lay  an  important  part  in  the  etiology 
of  the  familial  association  of  crr('bi'o-si)inal  and  ojitic  nerve  affections. 


FAMILIAL  EYE  AFFECTIONS  5161 

(5)  Infectious  and  indaminalory  complaints  appear  to  play  no  part 
in  the  aflt'cctions  here  discus-sed.  Jicher's  disease,  a  retro-bulhar  neu- 
ritis, is  foreign  to  the  s}  lulronie  here  considered.  Frenkel  approves 
of  the  term  familial  degeneration  to  characterize  this  syndrome. 

(6)  In  Tay-!Sachs  disease  familial  degeneration  affects  both  central 
and  peripheral  neurones.  In  this  complaint  the  lesions  of  the  macula 
are  to  be  explained  as  primitive  lesions  of  the  centripetal  retinal 
neurones.  Analogously  it  miglit  be  reasonable  to  suppose  that  the 
optic  atrophies  under  consideration  might  start  in  cellular  lesions  of 
the  retina  without  any  visible  ophtlialmoscopic  change. —  (E.  E.  H.  in 
the  Ophihul.  Review,  Dec,  li)14.) 

Family  ataxia.  Friedreich's  disease — the  so-called  hereditary 
ataxia  (see  page  662,  Vol.  I,  of  this  Encyclopedia) — has  a  distinct 
familial  tentlency  and,  as  such,  finds  a  brief  mention  here.  See 
Hereditary  ataxia. 

To  Stargardt's  account  Darier  {La  CUnique  Ophtalmol.,  Jan.  10, 
1914)  has  been  able  to  add  personal  observations  of  five  cases  of  this 
rare  nialadj^  carried  over  a.  period  of  twenty-five  years.  The  affection 
begins  in  early  youth  and  is  in  general  insidious  and  progressive,  but 
in  some  recorded  cases  (Lutz,  Stirling)  the  onset  has  been  sudden.  In 
some  cases  at  the  start  no  ophthalmoscopic  change  is  found  while  in 
others  the  fundus  lesion  makes  its  appearance  before  the  vision  is 
affected.  In  all  cases  central  vision  is  affected.  Both  eyes  are  in 
general  simultaneously  and  equally  affected,  but  the  rate  of  diminution 
of  vision  varies  considerably.  In  the  majority  of  eases  the  lesions  have 
been  confined  to  the  macula,  but  in  exceptional  cases  (three  of  Star- 
gardt  and  two  of  Darier)  lesions  have  also  been  found  in  the  neighbor- 
hood of  the  papilla  and  in  the  periphery  of  the  retina.  It  is  obvious 
that  as  far  as  the  eye  changes  are  concerned  these  cases  are  similar 
to  the  amaurotic  family  idiot  type,  and  Darier  proposes  to  differentiate 
two  types,  i.  e.,  familial  macular  degeneration  with  or  without  idiocy. 
He  inclines  to  the  view  that  the  earlier  in  life  the  macula  is  affected 
the  greater  the  chance  of  the  cerebral  functions  being  also  attacked. 
How  and  why  the  lesions  appear  there  is  no  evidence  to  show.  Syphilis 
can  be  excluded  apparently. 

The  author's  new  cases  come  from  two  separate  families.  In  the 
first  group  two  out  of  four  surviving  children  were  affected,  botli 
females.  In  the  second  group  there  were  three  affected  out  of  seven, 
and  these  were  all  males.  In  two  of  these  the  lesions  had  extended 
considerably  beyond  the  maculae. —  (E.  E.  H.  in  the  Oph.  Review, 
May,  1915.) 

FamUial   crypophthaJmus   and   ankylohlepliaron.     II.    G.    Goldberg 


5162  FAMILY  EYE  DISEASES 

{Aniuils  of  Oplitlidl.,  p.  58;{,  July,  1912)  lias  described  this  defect  as 
oeeuiTiii^  in  live  inciiihci's  of  one  family,  and  extending  tlirougli  four 
generations.  Altiiougli  the  cases  were  only  i)artial.  it  was  tliouglit 
proper  to  classify  llicm  among  tlic  aiikylolilc|iliai'a  ratlicr  than  cpican- 
thus,  because  tiie  ])artial  obliteration  of  the  jiaipfbral  space  was  a])- 
l)arently  due  to  a  perfect  union  Ix'tween  the  lid  margins  instead  of  an 
overlapping  with  tiic  production  of  a  fold;  the  unusu;il  distance  of 
the  puucta  from  the  bifurcation,  and  becaus<'  it  was  possible  to  restore 
a  considerable  portion  of  the  space  by  elevating  the  tissue  uniting  the 
lid  margins.  It  did  not  appear  that  any  of  the  shortening  operations 
suggested  for  the  correction  of  ej)icanthus  would  i)rove  of  value  in  his 
case,  but  instead  he  contemi)lated  the  division  of  the  united  lid  margins 
after  transfixing  them  ui)on  a  lachi-ymal  probe,  the  resulting  surfaces 
to  be  joinetl  by  tine  sutures. 

Family  eye  diseases.     See  Familial  eye  affections. 

Fano,  Salvador.  A  well  known  Dutch-Parisian  ophthalmologist,  born 
at  Amsterdam,  Holland,  in  1824.  He  received  his  medical  degree  at 
Paris  in  1851,  and,  in  that  city,  taught,  investigated  and  practised  until 
his  death,  in  May,  1895. 

He  wrote:  "Recherches  sur  la  Contusion  du  Cerveau"  (Paris, 
1851;  graduation  thesis)  ;  "Des  Tumeurs  de  la  Voiite  Palatine  et  du 
Voile  du  Palais"  (1857,  av.  2  pi.)  ;  "Mem.  sur  la  Catarrhe  du  Sac 
Lacrymal,  etc."  (Paris,  1863)  ;  "Des  Lunettes  et  de  leur  Emploi  en 
Oculistique"  (Paris,  1867)  ;  "Traite  Pratique  des  Maladies  des  Yeux" 
(Paris,  1866)  ;  "Traite  Elementaire  de  Chirurgie"  (T.  2,  1869-72). 

From  1873  to  1882  he  was  editor  of  the  Journal  d'OcuUstique  et 
dc  Chirurgie.— {T.  H.  S.) 

Fantascopy.     One  of  the  names  for  retinoscopy  or  skiascopy. 

Fantoscopie  retinienne.     (F.)     Skiascopy. 

Farad.     Tlie  unit  of  electrical  capacity. 

Faraday,  Michael  (1791-1867),  one  of  the  most  distinguished  of  Eng- 
lish chemists  and  natural  philosophers,  was  born  at  Newington  Butts, 
near  London,  England,  where  his  father  was  a  blacksmith.  Chance 
having  procured  him  admission,  in  1812,  to  the  chemical  lectiires  of 
Sir  Humphry  Davy,  the  latter  engaged  him  as  his  assistant  at  the 
Royal  Institution.  In  1827  he  s\u*ceeded  to  Davy's  chair  of  chemistry 
in  the  Royal  Institution. 

Some  of  his  chemical  discoveries  or  investigations  were:  new 
compounds  of  chlorin  and  carbon  (1821);  alloys  of  steel  (1822); 
comj)ounds  of  hydrogen  and  carbon  (1825)  ;  and  the  very  valuable 
series  of  experiments,  made  in  1829-30,  on  the  manufacture  of  glass 
for  o])1ical  ]iurposes.     See  Glass,  Optical.     As  practical  applications 


FARBENGLEICHUNG  5163 

of  scit'iu'o  liis  sii^gt'stions  as  to  the  preparation  of  tlic  lungs  for  diving 
and  the  ventilation  of  lighthouse  lamps  are  eonspieuous.  Amongst  his 
most  prominent  publications  are  those;  eoneerning  the  condensation 
of  the  gases,  limits  of  vaporization,  optical  deceptions,  acoustical  fig- 
ures, re-gelation,  relation  of  gold  and  otiier  nielals  to  light,  and  con- 
servation of  force. 

The  great  work  of  his  life  is  the  series  of  E.rpcrinicntai  Researches 
on  Electricity,  published  in  the  Philosophical  Transactions  during 
forty  years  and  more.  These  give  an  account  of  his  many  discoveries 
relating  to  electricity,  magnetism,  electro-magnetism,  and  dia-mag- 
netism.  Some  of  the  most  important  of  his  discoveries  are:  induced 
electricity;  identity  of  electricity  from  different  sources;  equivalents 
in  electro-chemical  decomposition;  relation  of  electric  and  magnetic 
forces;  hydro-electricity;  magnetic  rotatory  polarization,  and  many 
others. — (Standard  Encyclopedia.) 

Farbengleichung.     (G.)     Color  equation. 

Farbe.     (G.)"     Color. 

Farbebild.     (0.)     The  spectrum. 

Farbenblindheit.     (G.)     Color-blindness. 

Farbenbog-en.     (G.)     The  iris. 

Farbendreieck.     (G.)     Helmholtz's  color  triangle. 

Farben,  Einfache.     (G.)     Primary  colors. 

Farbenempfindung.     (G.)     Color  sensation. 

Farbenempfindlich.     (G.)     Sensitive  to  color. 

Farbenhoren.     (G.)     Color-hearing.     Color-audition. 

Farbengleichung.     (G.)     Color  equation. 

Farbenkreisel.     (G.)     Color  disc. 

Farbenlehre.     (G.)     Chromatography.    Treatise  on  color. 

Farbenmachend.     (G.)     Colorific.    Color-producing. 

Farbenmessung.     (G.)     Chromatometry. 

Farbennuancen.     (G.)     Color  shades  or  tints. 

Farbenoctaeder.     (G.)     Color  octahedron, 

Farbenproben.     (G.)     Color  tests. 

Farbenreiber.     (G.)     Color  mixer. 

Farbenringe.     (G.)     Newton's  rings. 

Farbenscheu.     (G.)     Chromatophobia. 

Farbenscheibe.     (G.)     Color  disc. 

Farbensehen.     (G.)     Chromatopsia. 

Farbensinn.     iG.)     Color-sense. 

Farbensinnpriifung.     (G.)     Testing  the  color  sense. 

Farbensinnstorung.     (G.)     Disturbance  or  defect  of  the  color  sense. 

Farbenspiel.     (G.)     A  play  of  colors. 


5164  FARBENUNTERSCHEIDUNGSVERMOGEN 

Farbenunterscheidungsvermogen.       (G.)      Tlu-  ability   to  distinguisli 

lM)lol"S. 

Farbenwerth.     ((r.)     Color  value. 

Farbenzerstreuung.     ((ij     The  (li.sjx'i.siou  of  colored  rays. 

Farbestoff.     (U.)     Coloring  matter,  pigment  oi-  dyu. 

Farbige  Glaser.     (G.)     Colored  glasses. 

Farbige  Nachbilder.     (G.)     Colored  afterimages. 

Farbung.     {Li.)     Coloration,  staining,. 

Farcy.    See  Glanders. 

Fard  noir.  (F.j  A  cosmetic  in  the  form  of  a  paste,  jjowder,  or  i)encil, 
having  for  its  base  lamp-black;  used  to  blacken  the  eyelashes  and  eye- 
brows. 

Fario,  Leovigildo  Paolo.  A  well-known  Italian  ophthalmologist. 
According  to  Hirsch  's  Lexicon,  Vol.  II,  p.  339,  he  founded  the  Annali 
Ottalmologiei.  Born  Nov.  16,  1810,  at  Asola,  Italy,  he  studied  at 
Padua,  Pisa,  Florence,  Pavia  and  Bologna,  practised  at  Venice,  later 
(and  longer)  at  Brescia,  and  died  in  1863. —  (T.  II.  S.) 

Far  point.  The  farthest  i)oint  at  which  an  object  can  be  distinctly  seen 
with  suspended  accommodation.  In  the  emmetropic  eye  it  is  the- 
oretically at  an  infinite  distance;  in  the  myopic  eye  it  is  in  front  and 
in  the  hyperopic  eye  it  is  theoretically  beyond  this,  as  the  latter  eye 
is  adai)ted  only  for  convergent  rays. 

Farre,  Frederick  John.  A  well-known  London  ophthalmologist,  second 
son  of  the  still  more  distinguished  John  Richard  Farre.  Born  Dee.  16, 
1804,  he  studied  at  St.  Bartholomew's  Hospital  from  1829  to  1837. 
In  1834  he  became  Assistant  Physician  to  the  Royal  London  Oph- 
thalmic Hospital,  and  also  at  St.  Bartholomew's.  In  1854  he  was 
made  physician  to  the  latter  institution,  as  well  as  to  the  Charter- 
house. In  1838  he  became  a  F.  R.  C.  S.  He  Avrote  little  if  any- 
thing about  the  eye.  He  edited,  however,  the  first  edition  of  the 
British  Pharmacopoeia,  and  Pereira's  Materia  Medica.  Farre  died  at 
Kensington  Nov.  10,  1886.— (T.  II.  S.) 

Farre,  John  Richard.  A  celebrated  London  pathological  anatomist 
and  ophtlialniologist,  co-founder  with  Saunders  of  the  Royal  London 
Ophthalmic  Hospital.  Born  in  1774,  on  the  Island  of  Barbadoes, 
the  son  of  a  physician,  he  studied  at  Guy's  Hospital  and  St.  Thomas's 
Hospital,  London,  and  practised  for  a  time  in  the  Antilles.  Later,  he 
practised  in  Glasgow,  Aberdeen  and  London.  He  also  became  phy- 
sician to  the  London  Dispensary.  He  made  an  enormous  collection 
of  pathologieo-anatomical  specimens,  which  became  the  property  of 
St.  Bartholomew's  Hospital.  He  died  May  7,  1862,  aged  88. — 
(T.  H.  S.) 


FAR  SIGHT  5165 

Far  sight.     Ilyperinetropia. 

Far-sightedness.    A  colloquial  tcnii  for  liypermotropia. 

Fascetto.     (It.)     Bundle. 

Faschia  bulbi.  A  synonym  for  Tenon's  capsule.  See  Fascia,  Bulbar 
and  Anatomy  of  the  eye. 

Faschia  Tenoni.     A  synonym  for  Tenon's  capsule. 

Fascia,  Bulbar.  A  name  for  the  capsule  of  Tenon,  which  is  derived  from 
the  fact  that  this  capsule  is  really  the  lining  membrane  of  a  lymph 
cavity  and  has  many  communications  with  the  intraocular  space 
between  the  choroid  and  sclera.  It  is  also  supplied  to  the  perineural 
space  around  the  optic  nerve  and  thence  onward  through  to  the  dural 
slieath  and  sub-dural  interspaces  of  the  cerebral  envelopes. 

Fascia  ocularis.  Fascia  oculi.  (L.)  A  name  given  to  an  old  form  of 
bandage  for  retaining  a  dressing  on  the  eye  or  to  prevent  the  use  of 


Fascia  Ocularis  (Bandage). 

the  eye.     A  few  horizontal  turns  with  a  roller  are  made  around  the 

head,  then  a  number  of  oblique  spiral  turns  over  the  eye,  and  finally 

a  few  additional  horizontal  circular  turns. 
Fascia,  Oculo-orbital.    A  name  for  Tenon's  capsule.    See  Anatomy  of 

the  eye. 
Fascia,  Oculo-palpebral.     A  name  for  Tenon's  capsule. 
Fascia,  Orbital.     ORBiTOOtuivAR  fascia.     Synonyms  of  Tenon's  capsule. 
Fascia,  Palpebral.    The  tarsal  ligament  of  the  eyelids.    The  same  name 

is  also  applied  to  the  subconjunctival  tissue  of  the  eyelids. 
Fascia,   Tarso-orbital.     Septum  orbitale.      This    fascia    connects    the 

tarsus  with  the  margin  of  the  orbit,  and  in  the  upper  lid  blends  with 

the  tendon  of  the  levator  palpebrje  superioris. 
Fascia  Tenoni.    Fascia  tenonis.    Tenon's  capsule. 
Fasciatura.     (It.)     Bandage. 
Fasciatura  protettiva.     (It.)     Protective  bandage. 


5166  FASCICULAR  KERATITIS 

Fascicular  keratitis.    Sec  Keratitis,  Fascicular. 

Fascicular  palsy.  I'aicsis  oi-  pinalysis  ol'  in-rvcs  caiisL'd  by  a  k*sion  situ- 
ated soiiicwlitTc  hctwccii  tile  cerebral  center  and  their  exit  from  the 
skull. 

Faser.     {(I.)    Fibre. 

Faserbiindel.    (G.)    Fasciculus. 

Faserchen.     (G.)    Fibril. 

Faserkorbe.  (G.)  A  name  given  by  i\l.  Schultzc  to  the  basket  or  crate- 
like appearance  of  the  mendirana  liniitans  externa  of  the  retina  after 
the  removal  of  the  rods  and  cones.  This  appearance  is  due  to  tlie 
delicate  terminal  processes  of  the  radial  or  ]\Iiillerian  fi])res  extending 
outward  from  the  external  limiting  layer  to  surround  and  support 
the  rods  and  cones. 

Faserkreuzung.    (G.)    A  decussation  of  fibres. 

Faserverlauf.    (G.)    The  course  of  fibres. 

Faserzug.     (G.)    A  tract  or  bundle  of  fibres. 

Fast  colors.  Colors  are  so  designated  that  fade  little  or  not  at  all  under 
the  influence  of  light,  heat,  water  and  ordinary  exposure  to  wear  and 
weather. 

Fat-embolism.  Fatty  embolism.  A  condition  sometimes  observed  as  a 
sequence  of  fractures,  consisting  essentially  in  the  passage  into  the 
veins  of  liquefied  fat,  which  is  carried  into  the  lungs,  brain,  etc.,  block- 
ing up  the  capillaries  of  those  organs. 

Fatigue.  This  theoretically  important  subject  is  closely  related  to  the 
practical  one  of  eye-strain  (q.  v.).  Cattell  (System  of  Diseases  of  the 
Eye,  I,  p.  526)  says  of  it  that  when  the  retina  is  continually  exposed 
to  light,  perception  begins  to  fade,  and  finally  loses  its  quality  and  may 
disappear  altogether.  The  effects  of  fatigue  may  be  seen  by  placing 
a  small,  black  cross  (see  the  cut),  on  a  sheet  of  white  paper  to  which 
a  thread  is  attached.  If  after  looking  at  the  cross  for  ten  seconds  it 
be  jerked  away  by  the  thread,  a  very  white  cross  will  be  seen  on  the 
sheet  of  paper.  The  eye  has  become  fatigued  for  the  white  excepting 
the  part  covered  by  the  cross,  which  consequently  appears  the  brighter. 
The  same  experiment  may  be  made  for  colors  by  placing  the  black 
cross  on  a  sheet  of  colored  paper.  The  part  Avhich  had  been  covered 
by  the  cross  will  look  much  more  intense  and  saturated  than  the  rest. 
In  making  such  experiments  a  halo  is  usually  seen  al)out  the  cross, 
this  being  due  to  involuntary  movements  of  the  eyes.  According  to 
Fechner,  a  bright  white  light  (as  white  paper  in  the  sunlight)  does 
not  simply  become  less  bright,  but  passes  through  a  series  of  colors. 
The  white  at  first  looks  yellow,  then  blue-green  or  blue,  and  finally 
red-violet  or  red.     These  changes  in  color  are  thought  bv  Fechner  to 


FATIGUE  5167 

he  due  to  soiiu'  of  the  coiiipoiiciits  of  wliitc  liglit  producing  fatigue 
sooiuT  tlian  the  otliers. 

C'atteli  furtlicr  remarks  that  I  less  has  made  a  eoinplete  study  of  the 
appearance  of  spectrum  colors  after  the  eye  had  previously  been 
fatigued  for  certain  colors.  He  used  nine  points  in  the  specti'um  and 
two  cond)inations  of  red  and  violet,  and  was  able  to  obtain  quantitative 
results.  He  thinks  the  alterations  do  not  accord  with  the  requirements 
of  V.  Hehnholtz's  color  triangle. 

If  a  small  colored  bit  be  placed  on  a  sheet  of  gray  paper  it  can  be 
looked  at  until  the  color  disappears  altogether.  As  first  shown  by 
]\raria  Bokowa,  fatigue  amounting  to  color-blindness  may  be  brought 
about  l)y  wearing  spectacles  with  colored  glasses,  all  side-light  being 
cut  off.  Indeed,  the  same  fact  is  illustrated  by  comparing  our  sensation 
on  going  from  the  daylight  into  a  room  lit  uji  by  gas  or  lamps  with 


Cross  Illustrating  Fatigue  Experiments. 

that  which  we  have  in  the  same  room  in  the  evening.  In  the  former 
ease  the  light  seems  reddish,  in  the  latter  we  notice  no  color.  Quantita- 
tive determination.::  of  fatigue  have  been  obtained  by  C.  F.  Midler  in 
Fick's  laboratory,  by  Exner,  and  by  Schon.  According  to  Miiller,  if 
the  intensity  of  the  original  sensation  be  1,  the  intensity  after  three 
seconds  will  be  0.72,  after  five  seconds  0.66,  after  ten  seconds  0.49, 
after  fifteen  seconds  0.46,  after  twenty  seconds  0.43,  after  twenty-five 
seconds  0.37,  and  after  thirty  seconds  0.35.  Fatigue  conse(|uently 
follows  most' rapidly  at  first,  and  more  slowly  afterwards,  the  appar- 
ent intensity  waning  to  half  in  aliout  ten  seconds.  Fullerton  and  the 
writer  have  found  that  when  two  lights  are  viewed  in  succession  the 
second  is  apt  to  appear  the  fainter,  the  constant  error  ])eing  on  the 
average  one-twelfth  of  the  light.  Scluin  used  colors  of  the  spectrum 
and  obtained  results  corresponding  to  Miiller's.  After  three  seconds 
red  decreased  to  0.59.  green  to  0.52.  and  blue  to  0.37.  The  visual 
mechanism  is  most  sensitive  when  we  first  awake  in  tlie  morning. 
According  to  Midler,  the  .sensitiveness  decreases  during  the  day,  and 
objects  appear  only  half  as  briglit  in  the  evening  as  in  the  early  morn- 


5168  FATIGUE-FIELD 

iiij;.  If  this  were  the  cjisc,  the  time  of  day  sliould  be  considered  in 
making;  tests  for  the  shai-piiess  of  vision.  (Certain  experiments  by  Fiek 
anil  CJriiber,  however,  show  that  fatigne  reaehes  its  maxiinnin  in  tliree- 
quarters  of  an  honr  or  less  aftei-  awakening,  and  that  so  long  as  the 
light  is  kei)t  constant  no  fnrther  decrease  in  sensitiveness  occurs  in  the 
course  of  the  day.  These  writers  hold  that  the  sensitiveness  of  tlie 
retina  is  restored  by  movements  of  the  eyelids  and  of  accommodation ; 
but  this  view  seems  to  l)e  refuted  by  Plering. 

G.  Viale  {Annali  di  Oltalmologia,  xl,  p.  669,  1013)  has  noticed  that 
after  one  eye  had  been  fatigued  by  exposure  to  strong  light,  colors 
seen  with  the  other  eye  appeared  much  clearer.     Thus,  dark-green 
looked  very  bright,  and  yellow  was  greenish.    In  experiments  in  which 
the  periphery  of  one  retina  (this  part  of  the  retina  having  only  light 
sense)  was  stimulated,  and  the  other  retina  kept  at  rest,  the  non-stinni- 
lated  retina  afterwards  showed  no  change,  either  in  light  or  color- 
sense.     Therefore  fatigue  of  one  retina  affects  the  color  sensibility, 
luit  not  the  light  sensil)ility  of  the  other  retina.    Investigations  by  Mon- 
akow  and  others  point  to  the  existence  of  fibres  passing  l)etween  each 
retina  and  the  anterior  corpora  quadrigemina,  and  to  stimulation  of  the 
cones  of  one  retina  when  light  falls  only  upon  the  other.     Hence  the 
writer  argues  that,   as  the  cones  are  the   organ   of  color-sense,   the 
change  of  color-vision  which  he  has  observed  is  due  to  reflex  stimuli 
passing  from  one  retina  to  the  other  by  way  of  the  anterior  (juadri- 
geminate  bodies.    See  Ferree-test. 
Fatigue-field.    This  term  is  commonly  used  to  indicate  the  limits  of  the 
field  of  vision  found  in  neurasthenics.     The  asthenopia  of  the  neu- 
rasthenic may  also  show  in  the  shifting  field  of  Forster,  in  which  the 
extent  of  the  field  is  greater  on  that  side  where  the  test  is  begun,  i.  e.. 
if  we  begin  on  the  nasal  side  and  cross  over  to  the  temporal  side, 
througli  the  fixation-point,  the  test-object  will  disappear  on  the  tem- 
jioral  side  neai'er  to  the  fixation-point,  showing  greater  contraction  on 
that  side.     If,  however,  we  commence  on  the  temporal  side,  wc  will 
find  that  side  of  the  field  will  be  the  greater.     In  other  words,  tlie 
broader  side  of  the  field  shifts. 

Wilbrand's  exhaustion  test  is  ])ractieally  the  same  confined  to  the 
horizontal  meridian,  l^^ach  repetition  of  the  test  in  the  same  meridian" 
reduces  the  field.  The  smallest  field  that  can  be  ol)tained  is  called  the 
"minimal  visual  field,"  and  the  hirgest  the  "maximal  visual  field." 
When  the  test  is  made  with  the  white  test-object,  it  is  found  that  the 
fatigue  for  coloi'  is  not  alTeeted  as  it  is  for  white,  and  vice  versa. 

If  a  complete  Held  is  taken  and  repeatedly  taken  it  becomes  smaller 
and  smallei-,  and  a   line  cDnnerting  the  points  assumes  a  spiral  form. 


FAT  IMPLANTATION  5169 

111  tlu'  oscillating  visual  field  of  Wilhrand  the  test-object  disappears 
and  reappears,  when  moved  radially,  produeing:  line-like  scotoinata. 

Ill  explaiialion  of  the  Fatigue-fields,  Willirand  believes  that  the 
insiirficieiiey  ol'  the  retina  is  due  to  ciianged  conditions  of  metabolisiii, 
aCreeting  the  external  layer  of  the  retina.  Peters  ascribes  such  fields 
to  a  disturbance  of  innervation  in  the  transniission  of  nerve-stimuli 
from  the  retina  to  the  optic  tracts.  Plazek  thinks  there  is  a  blunting 
of  the  centre  of  consciousness.  Simon  believes  that  there  is  a  fatigue 
of  the  psychic  sphere.  Schinidt-Rimpler  believes  that  inattention  and 
lack  of  the  powei-  of  concentration  account  for  tlie  contraction  of  tiie 
visual  fi(.hjs^— (J.  M.  B.) 
Fat  implantation.  The  introduction  of  a  fatty  mass,  from  the  abdom- 
inal or  gluteal  region  of  the  patient,  into  the  socket  after  enucleation 
of  the  eye  has  been  discussed  already  on  page  4446,  Vol.  VI  of  this 
Encyclopdeia.  To  the  account  there  given  of  that  procedure  it  may 
here  be  added  that  Lauber's  {OphtJialmologij,  Vol.  VII,  p.  148,  1911) 
method  of  fat  implantation  is  to  enucleate  in  the  usual  manner  after 
transfixing  each  rectus  muscle  with  a  double-armed  catgut  suture. 
All  hemorrhage  having  been  checked,  a  mass  of  fat  of  sufficient  size 
to  fill,  without  overstretching,  the  capsule  of  Tenon  is  inserted.  The 
excision  of  the  fat  from  the  abdominal  walls  is  facilitated  by  making 
a  right-angled  incision  in  the  skin.  Care  must  be  taken  not  to  muti- 
late the  fat  and  to  check  hemorrhage  with  ligatures.  After  the  fat 
has  been  inserted  the  recti  are  sutured  crosswise,  then  the  capsule  of 
Tenon  is  closed  with  catgut  also,  and  finally  the  conjunctiva  with  silk. 
This  method  has  been  used  in  thirty-seven  cases  since  1908  with  but 
six  failures.  In  the  course  of  the  first  two  or  three  months  there  is  a 
decided  shrinkage  of  the  implanted  fat  but  from  then  on  it  remains 
unchanged.  Marx  {Opltthalmologij,  Vol.  VII,  p.  147,  1911)  has  used 
fat  both  in  the  scleral  cup  and  in  the  capsule  of  Tenon.  In  the  latter 
■operation  good  results  have  been  obtained  without  suturing  the  oppo- 
site recti.  He  believes  that  this  operation  deserves  preference  over 
other  procedures,  as  extrusion  never  occurs  and  a  prothesis  never 
causes  trouble. 

In  C.  N.  Spratt's  cases  (Oph.  Record,  Oct.,  1913)  he  was  much 
impressed  with  its  advantages  over  the  other  substances  suggested. 
]W  the  use  of  fat,  a  sterile,  autogenous  graft  is  secured,  which,  when 
inserted  in  Tenon's  capsule,  has  less  tendency  to  change  its  position 
than  any  of  the  other  substances  suggested.  It  offers  little  or  no 
chance  for  extrusion,  unless  an  infection  takes  place,  or  faulty  nu'tli- 
ods  of  suturing  are  used. 

The  method  used  by  the  writer  is  as  follows:    Warm  ether  vapor 

Vol.  Vll— 21 


5170 


FAT  IMPLANTATION 


is  </\\ri\  tliroii^li  ii  tiihc  ill  llic  nose,  or  by  the  iiit i-;i-t racheal  method. 
The  skill  alioul  llic  eye  is  clfaiicd  with  ah-ohol,  uthcr  and  oxycyanide  of 
iiu'i-cui-y  1:1, (•<•(),  and  the  coiijunctival  sac  is  Huslied  with  a  solution 
of  1  :;5,(M)()  of  the  latter.  The  face  is  covered  by  a  layer  of  wet  gauze. 
The  coiijiinctiva  is  divided  close  to  the  limbus  and  dissected  back- 
wards, beyond  the  insertion  of  the  recti  muscles.  These  are  picked 
up  on  a  strabisiiiiis  hook  and  separated  from  the  surrounding  tissue. 
Hefore  dividing  the  tendons,  each  is  caught  by  a  small  Ilalsted  "mos- 
quite."  After  dividing  the  tendons  at  their  insei-tions,  the  eye  is 
enucleated  in  tiie  usual  manner  and  tiie  cavity  is  packed  with  a  moist 
sponge,  to  stop  the  hemorrhage. 


Iiiipliuitation  of  Fat  in  Tenon's  Capsule.      (Pratt.) 

After  cleaning  the  skin  of  the  abdomen,  a  horizontal  incision  -i-ti 
cm.  long  is  made  below  the  umbilicus  and  a  piece  of  subcutaneous  fat 
is  removed.  Even  in  thin  individuals,  there  is  a  sufficient  layer  of 
fat  for  this  purpose.  A  larger  piece  of  fat  can  be  placed  in  Tenon's 
capsule  than  can  be  inserted  when  of  paraiifin  or  glass,  as  the  fat 
is  more  elastic  and  is  not  forced  out  ])etween  the  muscles,  as  is  a 
smooth,  hard  mass. 

On  removing  the  packing  from  Tenon 's  capsule,  it  will  generally 
be  found  that  the  hemorrhage  has  ceased.  The  fat  is  inserted  and 
the  superior  rectus  is  sutured  to  the  inferior  rectus  by  a  mattress 
suture  of  double  00  chromieized  catgut.  The  loop  of  tlie  catgut 
is  placed  beneath  the  inferior,  and  the  knot  on  the  outer  surface  of 
the  superior  rectus.  Tliis  makes  the  strongest  possible  suture.  The 
two  lateral  recti  are  sutured  in  a  similar  manner,  each  needle  Innng 
passed  through  tlie  previously  sutured  recti.  Hy  this  method  a  tixed 
point  for  all  four  muscles  is  formed. 


FAT  IMPLANTATION 


5171 


When  tlie  sutures  are  beiuj^  tied,  an  assistant  approximates  the 
ends  of  the  muscles  by  means  of  the  heraostats,  thus  preventing  trac- 
tion and  cutting  of  tlie  sutures.  Tenon's  capsule  is  closed  over  tlie 
muscles  and  fat,  by  means  of  a  deeply  placed  catgut  suture.  This 
relieves  the  tension  on  the  muscles,  covers  the  fat  with  an  extra  layer 
of  tissue  and  prevents  the  fat  from  protruding  between  the  muscles. 

The  conjunctiva  is  closed  by  another  purse-string  suture.  A  firm 
pressure  bandage  with  a  thick  layer  of  soft  gauze  is  applied.  This  is 
rather  uncomfortable,  but  its  use  is  advised,  as,  with  it,  the  swelling 
is  less  and  convalescence  is  shortened.  The  incision  in  the  skin  of  the 
abdomen  is  closed  by  subcutaneous  sutures. 


Imiilantation  of  Fat  in  Tenon's  Capsule.      (Pratt.) 


Implantation  of  Fat  in  Tenon's  Capsule.      (Pratt.) 


Less  swelling  has  followed  the  use  of  fat  than  formerly  occurred 
when  paraflfin  was  used.  An  artificial  eye  was  used  in  Spratt's  three 
cases,  at  the  end  of  18  to  24  days. 

The  movements  of  the  stump  have  been  excellent,  the  average  being: 
28°  upwards,  15°  downward,  22°  nasalward,  20°  temporalward. 
According  to  Reber,  the  average  rotation  in  100  normal  eyes,  was, 
upward  36°,  downward  52°,  nasalward  50°,  temporalward  48°.  After 
the  swelling,  due  to  the  trauma  of  the  operation,  has  disappeared, 
there  is  an  apparent  shrinking  of  the  contents  of  the  orbit.  Unques- 
tionably, there  is  some  atrophy  of  the  fat.  but  it  has  not  been  found 
to  be  as  great  as  that  reported  by  Weidler,  who  states  that,  in  his 
cases,  there  was  apparent  shrinking  to  1/2  to  1/3  of  the  original  size. 


5172  FAULNISMICROCOCCUS 

I'ratt  (haws  tlu'  following  coiiclusions :  1.  Tlu-  aim  of  the  surgeon 
should  be  to  ol)tain  a  good,  luoxahlc  stuiiip  after  an  enucleation. 
2.  Fat,  being  an  autogenous  graft,  is  least  liable  to  be  extruded,  as  it 
becomes  a  living  ])art  of  the  orbit,  'i.  Fat  ean  be  obtained  in  a  sterile 
condition  and  forms  a  soft,  elastic  mass  tliat  is  non-irritating  and  will 
not  slip  its  position  as  do  smooth,  hanl,  foreign  bodies. 

11.  S.  Gradle  {Arch,  of  OphthaL,  p.  154,  March,  1915)  tabulates  2!) 
cases  of  enucleation  and  54  eases  of  evisceration  with  fat  implantation. 
Of  the  29  enucleated  cases  the  fat  was  extruded  in  two,  and  of  the  54 
cases  of  exenteration,  the  fat  was  extruded  in  six.  Gradle  considers 
an  acute  infection  of  the  coats  of  the  e^^e  to  be  a  distinct  contraindi- 
cation to  the  implantation  of  fat.  In  half  the  cases  the  implanted 
fat  had  shrunken  to  about  one-half  the  original  amount.  This,  the 
author  states,  can  be  counteracted  by  injecting  sterile  vaseline  into 
the  stump. 

Faulnismicrococcus.     (G.)     Infective  organism. 

Faulnisshemmung.  (G.)  Measure  intended  to  prevent  putrefaction  or 
infection. 

Faure.  A  celebrated  quack  of  the  early  nineteenth  century,  ophthal- 
mologist to  the  Due  de  Berry.  He  wrote  a  work,  no  longer  extant, 
entitled  "Description  graphique  des  Yeux  de  Plusieurs  Aveugles 
Juge  Incurables  qui  out  Reeouvre  la  Vue  au  raoyen  d'un  Instrument 
et  d'un  Procede  Invente  par  I'Auteur"  (Paris,  1820)  ;  and  another, 
entitled  "Observation  sur  I'lris, "  in  which  he  pretends  to  have  in- 
vented the  operation  (already  old)  called  "Discission  of  the  Lens." 
—  (T.  H.  S.) 

Fauteuil  a  operations.    (F.)    Oi)erating  table. 

Favus.  KiXGWoRM.  See  page  60,  Vol.  1,  of  this  Encijdopcdia.  In  addi- 
tion. Parsons  {Pathology  of  the  Eye,  p.  8)  says  that  very  few  cases 
of  favus  of  the  lid  are  on  record,  but  its  occurrence  is  proliably  more 
frequent  than  the  paucity  of  reported  cases  would  lead  one  to  expect. 
The  disease  commences  with  the  formation  of  yellowish-red  vesicles, 
and  rapidly  goes  on  to  the  formation  of  a  bright-yellow  crust,  which 
is  ver}^  characteristic.  lie  examined  one  case,  and  there  was  no  dif- 
ficulty in  demonstrating  the  Achorion  Schonleinii.  The  patient's  eat 
was  also  examined,  but  without  result,  though  the  source  of  the  dis- 
ease in   eats  or  mice  has  1)een  almost   certain  in  some  cases. 

Fawcett,  Henry.  "The  Blind  Postmaster-General."  He  was  born  at 
Salis))ury,  England,  Aug.  25,  1833,  of  parents  who  were  both  well- 
known  political  economists.  He  attended  King's  College  School,  Lon- 
don; and,' later,  at  Cam])ridge,  became  seventh  wrangler  (1856)  and 
was  elected   to  a   fellowshiji   in  his  college.     Soon  after  he  began  to 


FAYE,  GEORGE  DE  LA  517:i 

study  law   lie  lost   his  sight  by  the  accidental  discharge  of  a  gun  in 
the  hands  of  his  father. 

After  this  occui'rence,  lie  abandoned  the  study  of  the  law,  and 
began  to  specialize  in  political  econoniy.  lie  gave  a  rather  large  num- 
ber of  lectures  on  i)olitieal  science,  and  in  \HiVA  published  his  '\Ma)imd 
of  Political  Ecoitomjj."  As  a  result  of  this  scholai-ly  production,  he 
was  elected  to  the  chair  of  l*olitical   Economy  at  Cambridge. 

In  1865  lie  was  elected  to  Parliament.  At  first  he  was  a  follower 
of  Gladstone,  but  later  (in  187.'))  by  his  bittei-  opi)Osition  to  the  Irish 
education  scheme,  he  contributed  not  a  little  to  the  defeat  of  the 
Gladstone  ministry.  In  1880,  however,  when  the  l^iberal  party  had 
been  restored  to  ])ower,  Gladstone  made  Fawcett  postmaster-general. 
In  this  position  the  great,  l)lind  man  was  an  ardent  reformer.  The 
parcels  post,  money  orders,  stamp-banking,  the  table  of  "Hours  of 
Collection"  on  pillar-boxes,  and  numerous  other  improvements  were 
due  to  his  executive  ability  and  genius. 

He  wrote  a  large  nuiid)er  of  books,  was  made  an  honorary  D.  C.  L. 
of  Oxford,  a  Fellow  of  the  Koyal  Society,  and  Lord  Rector  of  Glas- 
gow University. 

He  was  a  man  of  impressive  appearance,  six  feet  four  inches  tall, 
lean  and  lithe,  and  very  (juick  and  active.  Prior  to  his  blindness,  he 
is  said  to  have  been  somewhat  overbearing  in  his  manner,  but,  after 
that  terrible  calamity  he  was  kind  and  gentle  to  a  fault. 

He  died  Nov.  6,  1884,  of  congestion  of  the  lungs.  He  was  buried 
at  Cambridge,  but  a  monument  has  been  erected  to  his  honor  in  West- 
minster Abliey.— (T.  H.  S.) 
Faye,  George  de  la.  This  distinguished  French  ophthalmologist  was 
born  at  Palis,  in  the  Faubourg  du  Roule.  Oct.  10,  1699.  The  son  of  a 
well-known  surgeon  and  the  nephew  of  the  Surgeon-]Major  in  the 
Military  Hospital  at  Berg-Saiut-Vinox,  he  began  to  study  surgery 
with  his  uncle  at  the  age  of  about  fifteen.  With  the  uncle,  however, 
he  remained  only  for  three  years.  Returning  to  Paris,  he  entered  the 
Charite  as  a  pupil  of  de  la  Peyronie,  but  shortly  afterward  became  an 
interne  in  the  Hotel-Dieu.  In  this  capacity  he  labored  at  the  cele- 
brated institution  for  more  than  ten  years — until,  in  fact,  1730.  The 
year  following,  he  received  the  degree  of  master  of  surgery.  Almost 
immediately  thereafter  he  became  assistant-surgeon  (aide-major)  in 
the  army,  in  which  position  he  served  throughout  the  siege  of  Kehl. 

Returning  to  Paris,  he  entered  into  private  practice,  and  though 
he  wrote  and  published  nuich.  and  invented  many  useful  instruments, 
he  never  became  again  attached  to  a  public  institution  until,  in  17-12, 
he  accepted  the  position  of  Demonstrator  Royal  of  Operations.     In 


5174  FAYE,  GEORGE  DE  LA 

17")]  he  was  elected  Vice-Diivetor  of  the  Koyal  Academy  of  Surgery, 
lie  retired  from  practice  about  1775,  and  died  Aug.  17,  1781. 

Among  his  gem-ral  compositions  are:  "Observations  sur  les  Bees 
de  Lievre  de  Naissance"  (Mem.  de  I' Acad.  Roy.  de  Chir.,  T.  I,  1748)  ; 
" Principe s  de  Chirurgic"  (Paris,  1731,  and  numerous  succeeding  edi- 
tions both  in  Paris  and  Berlin,  as  well  as  several  in  Strassburg,  Ven- 
ice, Stockhohn,  and  Madrid).  He  also  wrote  a  number  of  ophthal- 
mologic articles,  the  most  important  of  which  was  "The  Reform  of 
Instruments  for  Cataract  Extraction"  {Mem.  de  I' Acad.  Royale  de 
Chirurgie,  T.  II). 

Among  his  inventions  for  the  use  of  general  practitioners  was  an 
apparatus  for  the  protection  of  shattered  limbs,  a  device  which  re- 
mained in  use  for  many  years.  Ophthalmologically,  he  was  still  more 
useful.  He  it  was  who  invented  the  first  cataract  knife  and  the  first 
cystotome,  as  well  as  also  the  name  itself  (not  a  very  happy  one)  of 
the  latter  instrument. 

Here  is  what  the  inventor  of  the  first  cystotome  and  first  cataract 
knife  had  to  say  about  these  instruments  in  an  article  offered  to  the 
Royal  Academy,  and  entitled  "Memoire  pour  Servir  a  Perfectionner 
la  Nouvelle  Methode  de  Faire  1 'Operation  de  la  Cataracte"  {Memo-ires 
de  I'Academie  Ixoyale  de  Chirurgie,  Tome  II,  pp.  563-577)  :  "When 
I  saw  the  cataract  operation  performed  by  extraction,  I  saw,  like 
every  master  of  the  art  [this  was  merely  the  customary  modesty  of 
the  day]  that  this  method  possessed  certain  advantages  over  the  old 
one ;  but  I  discovered  at  once  that  tlie  great  number  of  instruments 
wliich  M.  Daviel  employs,  rendered  the  performance  very  complicated, 
and  that  one  could  shorten  and  simplify  it  by  the  use  of  one  single 
instrument  for  tlie  corneal  incision  and  only  one  other  for  the  open- 
ing of  the  capsule.     .     .     . 

"The  knife  for  tlie  cataract  incision  is  a  small  bistoury,  fastened 
immovably  in  a  handle ;  the  blade  is  thin,  a  little  curved  on  the  sur- 
face, 20  lines  long,  2  lines  in  the  greatest  breadth.  It  cuts  on  one  edge 
only,  except  at  the  point,  where  the  l)ack  is  also  sharp  for  2  lines. 
It  is  held  after  the  fashion  of  a  pen. 

"The  second  instrument,  which  I  call  eystitomr,  resembles  a  pha- 
ryngotome,  only  it  is  somewhat  snudler.  Tlie  slieath  is  curved  a  lit- 
tle on  the  flat,  1  line  wide,  7  lines  long.  The  lancette  is  very  small, 
and  protrudes  only  Vi  line,  when  tlie  spring  is  released.  One  needs 
no  spoon  with  which  to  lift  the  cornea,  and  so  has  the  second  hand 
free. 

"After  I  had  shown  the  instruments  to  the  pupils,  and  tried  them 
on  the  cadaver,  I  performed  with  them  at  the  Hotel  des  Invalides, 


FEAR,  OCULAR  SIGNS  OF  5175 

June  11,  1753,  6  cataract  operations.  I  enter  the  knife  into  the 
cornea  Y2  li"^'  from  the  temporal  margin  thereof,  opposite  the  pupil, 
carry  it  through  the  anterior  chamber,  tiirust  it  out  at  an  equal  dis- 
tance from  the  corni';!!  margin,  incline  tlic  cutting  edge  a  trifle  for- 
ward, and  let  it  slowly  glide:  thus  1  complete  to  the  lower  border  of 
the  cornea  a  half-moon-shaped  incision,  with  an  obliipie  incision-sur- 
face, and  large  enough  to  pciniit  the  egress  of  the  lens.  When  I  press 
gently  on  the  eyeball,  the  lens  comes  forward  from  its  bed  and  falls 
upon  the  cheek.  Now  and  then  the  lens-capsule  prevents  the  emerg- 
ence of  the  lens.  In  sueh  cases  one  employs  the  cystitome.  This  1 
had  to  do  in  two  out  of  the  si.\  cases.  The  operation  lasts  no  longer 
than  a  minute.'' 

The  entire  article  in  the  " Mcmoircs'"  fills  but  fourteen  pages,  yet 
what  an  important  article  it  is  for  the  history  of  ophthalmology!  If 
Daviel  invented  cataract-extraction,  de  la  Faye  at  all  events  rendered 
the  procedure  practical. 

A  more  complete  understanding  of  the  progress  made  in  cataract 
surgery  by  de  la  Faye  can  be  had  by  reading  in  connection  with  the 
present  article  that  on  Daviel. — (T.  II.  S.) 
Fear,  Ocular  signs  of.  Fear  is  one  of  the  })rimai"y  emotions,  and  arises 
from  the  expectation  of  harm  and  the  desire  to  escape  it.  Stout 
assumes  that  it  is  due  to  circumstances  and  experiences  which  are  un- 
familiar ;  Bain  that  it  is  due  to  the  foreboding  of  evil ;  while  Spencer, 
thinking  of  race-experience  and  instinctive  fear,  attributes  it  to  the 
memory  of  past  pain.  In  fear  the  nnnd  concentrates  on  one  single 
idea.  This  results  in  specific  pain  and  misery,  which  sometimes  lead 
to  temporary  paralysis  of  the  active  forces.  The  physical  expressions 
of  fear  are  among  the  most  familiar  of  experiences.  In  detail,  fear 
involves  a  disturbance  of  ])oth  the  muscular  and  the  visceral  systems. 
The  physical  signs  of  a  typical  case  are  mainly  these :  open  mouth 
due  to  relaxation  of  jaw  muscles,  raised  eyebrows,  arrest  of  muscular 
activity,  sometimes  crouching  "as  if  instinctively  to  escape  observa- 
tion" (Darwin),  hurried  respiration,  enfeebled  expiration,  palpitation 
of  the  heart,  pallor  of  skin,  perspiration  (cold  sweat,  due  to  vaso- 
motor and  secretory  nerve  disturbances),  erection  of  skin  hairs 
(goose-skin),  tremor  of  superficial  muscles,  arrest  of  salivary  secretion, 
disturbance  of  other  glandular  secretions  (e.  g.,  breasts),  trembling  of 
limbs,  lips,  etc.,  huskiness,  indistinctness  or  total  failure  of  voice,  dila- 
tation of  nostrils.  In  extreme  terror  there  may  ])e  staring  and  pro- 
trusion of  eyeballs,  extreme  dilatation  of  the  pupils,  convulsions,  the 
specific  scream  or  screech  or  howd  of  terror,  followed  by  relaxation  of 
muscles  and  total  collapse. —  {Standard  Encijclopcdui.) 


5176  FEBBRE  RICORRENTE 

Febbre  ricorrente.     <ltj     Kt'ciin-ciit  IVver. 

Febrile  herpes.    Sec  X'ol.  V,  p.  3:^72,  of  this  Encycloprdw. 

Feces  in  ophthalmic  diseases.  The  exaiuiiiation  of  the  dejecta  in  juaiiy 
diseases  of  the  eye  is  of  considerable  importance,  and  especially  in 
those  disorders  of  nietaholisni  that  are  directly  or  indirectly  respon- 
sible for  a  number  of  ophthalmic  affections — particularly  of  the  uveal 
tract  and  optic  nerve.  This  subject  is  discussed  under  General 
diseases,  as  well  as  under  several  special  headings.  An  excellent 
])aper  on  this  subject  is  by  S.  II.  Browning  (Imi)ortance  of  Examina- 
tion of  Feces  and  Trine  in  Eye  Diseases,  Opktli.  Rev.,  xxxii,  p.  101, 
1913). 

Fechner,  Gustav  Theodor  (1801-87),  one  of  the  founders  of  psycho- 
physics,  was  born  at  Gross-Siirchen  in  Lower  Lusatia,  Germany.  He 
became  a  professor  of  physics  at  Leipzig  in  1834.  Five  years  later,  he 
abandoned  these  branches  for  that  of  philosophy  and  psychophysics. 
His  most  important  book  on  this  subject  is  Elcmcnte  dcr  Psychophijsik. 
He  l)rought  out  an  enlarged  translation  of  Biot's  Handbook  of  Experi- 
)ni  )if(d  I'Injsiis. — (Stinidard  E)irii<l<>pc'dia.) 

Fechner 's  (paradoxical)  experiment.  An  exi)eriment  introduced  by 
Fechner  in  the  domain  of  the  color-sense  for  the  determination  of 
binocular  light-perception.  In  the  case  of  most  observers,  when  one 
eye  is  closed,  Fechner  found  that  at  first  there  was  a  slight  clouding 
of  the  common  visual  field,  but  tliis  was  quickly  followed  by  an  equal 
clearing  \\\)  of  the  field.  If  the  visual  field  of  one  eye  is  darkened  by 
a  gray  glass  held  before  the  eye,  and  then  the  common  visual  field  or 
a  white  object  in  it  be  regardetl.  the  latter  appears  darker  than  when 
the  eye  liehind  the  gray  glass  is  entirely  closed. —  (Foster.) 

Fechner 's  law.  The  so-called  psycho-physical  law  of  Fechner,  relating 
to  the  light  sense,  is  as  follows:  The  impression  made  on  our  senses 
by  light  is  not  proportional  to  the  intensity  of  the  light,  but  is  approxi- 
mately proportional  to  its  logarithm.  The  sensation,  therefore, 
changes  very  much  less  than  the  intensity  of  the  light  whicli  causes  it. 
Thus  a  change  in  intensity  from  1  to  1,000  eandle-])Ower  is  a  thousand 
times  as  great  as  from  1  to  2  candle-power,  l)ut  the  change  of  sensa- 
tion in  the  first  case  is  only  about  ten  times  as  great  as  in  the  lattiM-. 
Mathematically   this  law   can   be   expressed  as  follows-. 

i 
L=:  AXlog  — ; 
io 

wliei'e     L  =  i)h\si()l()gi('al     effect;     A  =  a     proportionality     constant: 
i  =  intensitv      of      illumination;      i„  =  the      miniiimm       iierceptible 


FEDERBAROMETER  5177 

value  of  illiiiiiiiiatioii,   llic  so-called   "Ihivshold   value,"  helow   wiiieii 
sensation  eeases. 

From  Fecimer's  law  can  he  drawn  the  important  conclusion  that  the 
snuillest  perceptible  (and  thei-efore  also  the  largest  permissible)  varia- 
tion in  illumination  is  a  constant  fraction  of  such  illumination.  For 
the  average  human  eye  this  fraction  is  about  1.6  per  cent.  There- 
fore, in  order  to  be  satisfactory  for  close  work,  a  commercial  illuminant 
must  not  flicker  or  in  any  otlier  way  deviate  from  the  normal  by  more 
than  this  i)ercentage. 
Federbarometer.  (G.)  Anei-oid  barometer,  devised  by  Higi  in  1847. 
This  is  a  small,  round  metallic  box,  nearly  exhausted  of  air,  with  a 
thin,  corrugated  lid  which  the  weight  of  the  atmosphere  tends  to  press 
in  more  or  less.  A  system  of  levers  causes  an  index,  sweeping  over  a 
dial,  to  mark  the  slightest  movements  of  the  thin  lid. 
Fees  cf  the  ophthalmolog-ist.  It  is  quite  impossible  to  treat  this  subject 
in  a  i)racti(al  fashion  since  the  variation  of  fees  in  all  countries,  but 
especially  in  America,  prevents  a  satisfactory  account  of  the  ophthal- 
mologists' charges  for  services.  Occasionally  some  medical  society, 
more  or  less  prominent,  issues  a  table  of  fees,  but  not  even  the  mem- 
bers of  the  society  appear  to  be  bound  by  it  in  any  particular.  Even 
the  law  courts,  in  allowing  compensation  to  specialists,  vary  greatly 
in  their  decisions.  In  the  United  States,  in  particular,  this  matter  is 
generally  settled  out  of  court.  When  a  judicial  decision  is  given  it 
is  largely  determined  by  circumstances  of  the  locality,  reputation  of 
the  surgeon,  the  wealth  or  otherwise  of  the  patient,  etc. 

The  Practica  Oculistica,  Rome,  November,  1912,  publishes  the  fees 
of  the  Italian  oculist.  These,  in  part,  are  as  follows,  a  lire  being 
worth  in  American  money  about  20  cents:  Office  consultation,  10-20 
lire ;  succeeding  visits,  5-10 ;  visit  to  the  patient 's  house,  20 ;  succeed- 
ing visits,  5-10 ;  consultation  fee,  20-50 ;  complete  examination  with- 
out report,  20-50;  complete  examination  with  report.  50-100;  pre- 
scription for  spherical  lenses.  10;  prescription  for  cylindrical  lenses, 
20;  prescription  for  combineil  lenses,  25-80;  cataract  operation,  500- 
5000;  iris  operation,  250-500;  removal  of  foreign  bodies  from  the 
cornea.  20-50;  removal  of  tumors  from  the  conjunctiva,  50-300;  para- 
centesis, 25-50;  orbital  operation,  200-2000;  squint  operation.  200- 
1000;  enucleation,  200-500;  exenteration,  100-200;  ptosis  operation. 
200-500;  excision  of  tlie  lachrymal  sac,  200-500;  lachrymal  probing. 
10-20;  pterygium  operation.  50-100;  penetrating  wounds  of  the  globe, 
suture  and  excision  of  prolapsed  tissue,  200-300. 

As  regards  fees  for  expert  testimony  it  is  somewhat  different.  As 
Thonuis  Hall   Shastid    {Mfld(rn   Ophthahnologi/,  p.   841)    states,  "In 


5178  FEHLERAUSGLEICHUNG 

civil  (Uses,  tlir  mileage  and  per  diem  must  be  paid,  or  at  least  tendered, 
to  render  tlie  service  of  tile  subpena  effective,  while,  in  criminal  eases, 
not  even  so  much  as  that  is  necessary.  This  is  trne  of  all  witnesses — 
mere  fact  witnesses  and  expert,  oi-  opinion,  witnesses  alike.  However,  in 
the  ease  of  expert  witnesses  the  qu<'Stion  arises  whether  the  same  slen- 
der payment  that  is  made  in  the  ease  of  a  fact  witness  should  be  held 
to  be  sufficient  in  the  case  of  iiini  who  renders  scientific  testimony — 
testimony  involving,  i)resumably,  the  possession  of  learning  and  skill. 
Ought,  or  ought  not,  an  opinion  witness,  an  expert,  to  l)e  obliged  l)y 
law  to  hold  his  store  of  knowledge  free  for  tlie  use  of  all  wlio  take  it 
into  their  heads  to  litigate?  The  ablest  authors  answer  this  rpiestion 
in  the  negative.  They  say  that  the  expert's  learning  and  skill  are  his 
])roperty.  and  tliat  the  law  has  no  more  riglit  to  compel  him  to  render 
expert  testimony  without  adequate  compensation  than  it  has  to  com- 
pel him  to  render,  without  adequate  compensation,  i)rofessional  serv- 
ices of  any  other  sort.  However,  the  writers  and  the  courts  are  not 
in  harmony  on  this  point.  The  courts  indeed  hold,  with  very  unusual 
unanimity,  that  the  expert,  medical  or  lay,  may  be  compelled  to 
testify  in  his  expert  capacity  without  other  compensation  than  that 
of  an  ordinary  witness.  However,  in  a  few  States  provision  has  been 
mad(^  by  statute  for  the  payment  of  special  fees  to  experts. 

Fehlerausg-leichung.     (G.)     Compensation  of  errors. 

Feig-ned  blindness.    See  Blindness,  Simulation  of. 

Fellenhauer.     (G.)     File  cutter. 

Fel.    (L.)    IJile. 

Feld.    (G.)    A  field,  area  or  tract. 

Felke  process.  A  quack  method  of  diagnosing  disease,  originating  in 
Germany.  Considerable  literature,  lay  and  professional,  has  grown 
up  about  this  form  of  empiricism.  See  a  paper  on  the  subject  by 
Salzer  {Muncli.  med.  Woch.,  Ivii,  p.  417,  1911),  who  reviews  the  Ger- 
man literature  with  regard  to  the  Felke  process,  which  has  been  ad- 
versely passed  on  by  the  German  courts. 

Fellmongers'  disease.  Anthrax.  So  called  because  it  often  attacks 
dealers  in  fells,  i.  e.,  pelts  and  skins. 

Fel  metallorum.     (L.)     An  old  term  for  crystallized  silver  niti-ate. 

Fenchel.     ((r.)     Fennel. 

Fenestra  oculi.     (L.)     An  obsolete  term  for  the  i)upil. 

Fenestrated  cataract.  A  ])artially  opaque  lens  in  the  midst  of  which 
there  is  a  windowlike  opening  of  transpariMit  crystalline  substance 
through  which  vision  is  more  or  less  i)reserved.  This  condition  is  not 
unconnnoidy  found  in  senile  cataract. 

Fenetre.     (F.)     Fenestrated. 


FENNEL  5179 

Fennel.  FoBuiculum  vidgare.  The  dried  fruit  of  this  and  other  varieties 
yields  from  2  to  5  per  eent.  of  a  camphoraeeous,  sweet-tasting,  vola- 
tile oil  to  which  the  medicinal  qualities  of  the  plant  are  mainly  due. 
This  plant  furnishes  a  numl>er  of  ophthalmic  mixtures,  most  of 
them  belonging  to  the  home-treatment  variety,  and  it  is  difficult  to 
say  what  tlierapeutie  value,  if  any,  is  to  be  attached  to  them.  A  weak 
tincture  of  the  seeds  enters  into  the  composition  of  Romerhausen 's 
eyewater  (q.  v.),  and  fennel  water  (aqua  fooniculi)  is  a  frequent  addi- 
tion to  European  collyria  for  the  relief  of  simple  conjunctivitis  and 
hyperemia  of  the  lids.  The  latter  ])i-('paratioii  is  used  for  this  pur- 
pose abroad  as  mueii  as  rose  or  cainplior  water  is  prescribed  in 
America. 

[Fennel  was  greatly  esteemed  ])y  ancient  Greco- Roman  physicians 
(it  is  mentioned  by  Archigenes,  Dioscorides,  Pliny  and  Scribonius 
Largus)  as  an  ingredient  of  numerous  collyria.  The  root,  further- 
more, was  sometimes  employed  in  the  form  of  a  poultice  to  the  fore- 
head for  ocular  affections.  It  was  thought  that  fennel  was  eaten  by 
serpents  to  assist  in  the  castings  of  the  skin  and  also  to  strengthen 
the  eyes.— (T.  11.  S.)] 

Fente.     (F.)     ("left;  crevice;  fissure;  slit. 

Fente  palpebrale.    Pali)ebral  fissure. 

Fer.    (F.)    Iron. 

Fer-chaud.    (F.)    Heartburn ;  pyrosis. 

Ferite.     (It.)    Wounds;  injuries. 

Ferment.  An  organic  l)ody,  ea])able,  in  small  (piantities,  of  decompos- 
ing other  organic  bodies  without  yielding  any  of  its  own  sul)stance 
to  the  product  of  the  fermentation.  Ferments  are  generally  divided 
into  two  classes,  the  organized  and  the  soluble  ferments. 

An  essay  on  the  actions  of  ferments  on  the  eye,  especially  in  their 
relation  to  sympathetic  ophthalmia,  is  published  by  H.  Guillery 
{Arcliiv  f.  Augenheilk.,  68,  p.  242,  1911). 

Fermentation  saccharimeter.  An  instrument  for  measuring  the  amount 
of  su<iar  in  urine. 

Femobjectiv.     (G.)     Telephotographic  lens. 

Fernpunkt.     (G.)     The  punctum  remotum,  or  far  point. 

Fernpunktsbestimmungf.  (G.)  Determination  of  the  punctum  remo- 
tum. 

Fernrohr.    (G.)    Telescope. 

Fernsehen.     (G.)     Ilypermetropia. 

Fernsichtig-keit.     (G.)    Far-sightedness  or  hypermetropia. 

Ferrall-Bonnet  operation.  P>onnet  operation.  See  Enucleation  of  the 
eye. 


5180  FERRE 

Ferre.     (  K. )     ("onfainiii.tr  ifoii  or  our  of  its  coiiiijouimIs. 

Ferree  test.  The  (U'tcniiinatioii  of  cyi'-fatigiu'.  Tlio  inctliod  of  con- 
diR'tiug  the  Ferree  test  is  as  follows:  Tiie  observer  under  test  is  re- 
quired to  gaze  steadily  for  a  short  pci-iod  of  time  (usually  about  three 
minutes)  at  a  eard  upon  wliieli  are  piinted  certain  letters,  or  eharae- 
ters;  these  letters  being  of  sueh  a  size  that  they  are  just  barely  dis- 
tinguishable at  the  distance  selected  for  the  test.  During  the  period 
of  time  that  the  observer  gazes  at  the  letters  he  is  re(|uired  to  record 
on  a  chronograph  or  stop  watch,  by  the  pressing  of  a  button,  tile 
intervals  when  the  test  object  appears  blurred.  The  percentage  of 
the  time  which  the  observer  sees  the  letters  blurred  is  taken  as  an 
indication  or  measure  of  the  amount  of  fatigue  of  the  eye  at  the 
time  the  test  is  made.  Before  beginning  such  a  test  it  is  of  course 
important  to  determine  the  proper  distance  at  which  to  place  the  test 
card  from  the  eye  of  the  particular  observer  under  test  because,  if 
too  great  a  distance  is  taken,  the  test  letters  may  appear  blurred  dur- 
ing the  entire  test  intervals,  in  cases  where  there  has  been  consider- 
able eye  fatigue;  and,  on  the  other  hand,  if  too  short  a  distance  is 
taken  the  observer  may  see  the  test  letter  clear  for  the  entire  time 
during  tests  when  the  eyes  are  but  little  fatigued. 

The  experiments  of  T.  R.  Cravath  {Trans.  Ilium.  Engin.  Soc,  Cleve- 
land, Sept.  21,  1914)  indicate  that  the  Ferree  method  is  reasonably 
sensitive  both  to  eye  fatigue  caused  by  illumination  and  to  eye  fatigue 
due  to  other  conditions  such  as  abnormal  eye-strain,  headaches, 
unusually  dilificult  eye  work  and  irritation  due  to  dust  in  the  eyes. 
If  it  is  used  as  a  test  of  illumination  conditions  care  should  be  taken  to 
eliminate  as  far  as  possible  the  other  variables  and  to  throw  out  tests 
where  these  variables  influence  the  result.  See,  also,  Fatigue  and 
Eye-strain. 

Ferrein,  Antoine.  Born  at  Frespech,  Argenois,  Oct.  25,  1(J92,  he  studied 
at  first  theology,  mathematics  and  law  wuth  the  Jesuits  at  Agen.  His 
attention  having  been  turned  toward  medicine  by  Borrelli's  "De 
Mortu  Animalium,"  he  betook  himself  to  ]\Iontpellier,  where  he  re- 
ceived the  Bachelor's  degree  in  1716,  and,  a  little  later,  the  Doctor's 
degree.  He  served  for  a  time  as  army  physician  in  the  French  cam- 
paign in  Italy,  then,  in  1741  (after  many  vicissitudes)  he  became 
anatomist  at  the  Academy  of  Sciences.  Next  year  he  was  made  pro- 
fessor of  medicine  and  surgery  at  the  Royal  College  in  Paris. 

Ferrein  composed  a  handbook,  or  treatise,  on  practical  surgery  and 
medicine,  and  a  number  of  articles  on  the  anatomy  and  therapy  of 
the  tear-apparatus. 

Ferrein  claimod  that  lie  was  file  first  to  propose  and  practise  lacera- 


FERREIN,  CANAL  OF  5181 

tioii  of  the  }){).st('rioi'  iiifci-ior  ((iiadrant  of  tlic  Iciis-eapsule  as  a  pre- 
liiuiiiary  to  ri'dinatioii  of  the  lens.  The  opening  in  the  capsule  Fer- 
rein  called  "the  button-hole."  History  lias  awarded  the  palm  for 
priority  in  this  i)rocedure  to  Petit,  who,  at  all  events,  was  the  first 
to  ^\\v  iiifoi'iiiation  concerning  the  matter  to  the  public. —  (T.  H.  S.) 

Ferrein,  Canal  of.  A  triangular  channel  once  sui)posed  by  Ferreiu  to 
exist  between  tlie  free  edges  of  the  eyelids  when  they  are  closed,  and 
to  serve  for  conducting  the  tears  towai'd  the  puncta  lachrymalia  dur- 
ing sleep. 

Ferrer,  Henry.  A  Aveli-known  ophthalmologist  of  California.  Horn 
Feb.  17,  1850,  at  Santiago  de  Cuba,  he  obtained  his  general  education 
at  Bordeaux,  France,  then  studied  medicine  at  Heidelberg,  receiv- 
ing his  degree  in  1872.  After  a  considerable  graduate  period,  at  Lon- 
don, Paris,  and  Vienna,  lie  became  assistant  to  Professor  Soelberg 
Wells,  at  London. 

In  1875  he  settled  in  San  Francisco,  Cal.,  where  he  soon  had  a  large 
practice. 

Among  his  most  important  writings  are :  ' '  Abscess  of  the  ^liddle 
Ear  and  Mastoid  Cells"  (1877)  ;  "R<^port  of  a  Case  of  Disease  of  the 
Mastoid  Process,  with  Remarks"  (Knapp's  Archives  of  Otology,  Vol. 
XVII  and  XVIII). 

Dr.  Ferrer  was  a  small,  l)ut  finely  built  man,  a  very  dark  brunette, 
with  soft  and  delicate  hands,  which,  in  conjunction  with  a  naturally 
surgical  mind,  made  him  an  operator  of  remarkable  dexterity.  He 
was  lovable  in  character,  and  had  many  friends. 

He  died  at  Santa  Barbara,  Cal.,  Oct.  22,  1890,  at  the  early  age  of 
,  40.— (T.  H.  S.) 

Ferripyrin.  Ferropyrin.  This  agent  is  a  mixture  of  chloride  of  iron 
and  antipyrin.  It  is  an  orange-red  powder,  soluble  in  water,  contain- 
ing 12  per  cent,  of  iron  and  64  per  cent,  of  antipyrin.  Locally  it  acts 
as  a  styptic ;  internally,  it  is  given  in  anemia  and  chlorosis,  three  or 
four  times  daily  in  0.05  grm.  doses. 

Ferro-sajodin.  This  iodine-iron  compound  is  occasionally  recommended 
in  ophthalmic  affections  due  to  general  causes.  A  paper  on  the  sub- 
ject is  by  P.  Cohn  {La  Cliniquc,  Vol.  IX,  I\Iay  13,  p.  531,  1911),  to 
whicli  the  reader  is  referred. 

Ferrotype.     A  ])hofographic  i)ositive  on  a  sheet-iron  su|)i)()rf. 

Ferruginous  collyrium.  A  eollyrium  introduced  by  Niemann,  mad(>  by 
mixing  fVoiii  2  to  5  parts  of  iron  sulphate  and  60  of  white  sugai-. 

Feste  Aug-enhaut.  (G.)  The  cornea,  in  the  sense  of  the  older  anato- 
mists. 

Fester  Staar.     (G.)    Fixed  cataract. 


5182  FETAL  EYE 

Fetal  eye.    Sec  Development  of  the  human  eye. 

Fetid  cataract.    See  page  14!).'{,  Vol.  II  of  lliis  I'J n cyclopedia. 

Fett.     ((.'.I     Kat. 

Fettablag-erung-.    (G.)    A  fatly  deposit. 

Fettblaschen.    (G.)    Fat  cell. 

Fettdriisen.     (G.)    Sebaceous  glands. 

Fettentartung.     (G.)       Fatty  degeneration. 

Fettes  Aug-enfell.     (G.)    Pterygium. 

Fettgewebe.     ((I.)     Adipose  tissue. 

Fettgewebslappchen.     (G.)     Fat  lobules. 

Fettherd.     (G.)    A  collection  of  fat. 

Fettkornchen.  (G.)  Granules  of  fatty  matter  found  in  the  various  tis- 
sues and  lluids  of  the  body. 

Feu.  (F.)  Fire,  combustion.  A  Inirning  sensation.  The  application 
of  tlie  aetual  cautery.  A  i)oi)ular  name  for  certain  skin  diseases  char- 
acterized by  redness,  itching,  etc.,  such  as  acne  and  erysipelas. 

Feuchtigkeit.    ( G. )    Humidity. 

Feu  de  Saint- Antoine.    (F.)    Erysipelas. 

Feuer.     (Gj     Fire. 

Feuille.    (F.)    Leaf ;  lamina;  layer. 

Feuille  nervoso-cutane.     (F.)     The  epiblast  (Remak). 

Feuillet.     (F.j     Layer;  lamina. 

Feuillete.    (F.)    Laminated. 

Feuillet  moto-germinatif.     (F.)     The  mesoblast  (Remak). 

Feuillet  moyen.    ( 1^\  )    JMesoderm. 

Feuillet  proligere  externa.     (F.)    The  primordial  ectoderm. 

Feuillet  proligere  interne.     (F.)     The  primordial  entoderm. 

Feuillet  sensoriel.     (F.)     The  epiblast  (Iluguier). 

Feuillet  vasculaire.    (F.)    The  mesoderm. 

Feu  nu.     (F.)     The  application  of  the  actual  cautery. 

Feu  sacre.    (F.)    Erysipelas. 

Feu  Saint- Antoine.     (F.)     Gangrenous  erysipelas. 

Feu  Saint-Marcel.    (F.)    Erysipelas. 

Feve.     (F.;     Lean. 

Fever.  This  symptom  (rise  of  bodily  temperature)  of  many  diflferent 
pathological  conditions  is  thought  by  some  to  be  now  and  then  pro- 
ductive, per  se,  of  eye  symptoms.  For  example,  see  a  paper  by 
E.  von  Czyhlarz  {Berlin.  Klin.  Woclienschr.,  Jan.  20,  p.  112,  1913), 
where  the  nystagmus  as  a  result  of  fever  is  discussed. 

Ilirschberg  also  discusses  fever  in  ocular  inflammations  in  tli(^  Cen- 
tral}}, f.  pkt.  Auffrnhrilk.,  35,  p.  193,  1911.  See,  also.  General  diseases; 
as  well  as  Exanthemata. 


FIBERS,  MUELLER'S  5183 

Fibers,  Mueller's.  Fihei-s  of  connective  tisue  which  run  perpendicularly 
throuyli  the  i-ctina. 

Fibrse  arcuatae.  A  term  ai)piied  by  the  older  writers  to  tlie  obli(iue 
fibres  of  the  cornea,  showing  most  plainly  just  behind  Bowman's 
niciiibrane. 

Fibralbumine.     (F.)     Globulin. 

Fibre-axe.     (F.)     Axis-cylinder. 

Fibre-cellule.     (F.)     Unstriped  muscular  fibre. 

Fibre-cross.  Cross-wire.  Cross-iiair.  A  fine  strand,  as  of  spider's 
tiiread,  or  a  pair  of  parallel  or  transverse  wires  or  strands,  mounted 
in  the  focal  plane  of  an  optical  instrument. 

Fibres  a  moelle.  (F.)  IMedullated  nerve  fibers.  The  naked  axis-cylin- 
ders seen  in  the  gray  substance  of  the  central  nervous  system. 

Fibres  a  myeline.  (F.)  The  naked  axis-cylinders  found  in  the  gray 
substance  of  tlie  central  nervous  system. 

Fibres,  Association.  Almost  every  cerebral  center  is  connected  with 
every  other  by  fibres  of  communication,  which  bear  the  foregoing 
name. 

Fibres,  Bechterew's.    See  p.  918,  Vol.  II  of  this  Encyclopedia. 

Fibres,  Bernheimer's.    See  Vol.  II,  p..  941  of  this  Encyclopedia. 

Fibres,  Bogrow's.    See  Vol.  11,  p.  Vl-il  of  this  Encyclopedia. 

Fibres,  Centrifugal.    See  Centripetal  fibres  of  the  optic  nerve. 

Fibres,  Centripetal.    See  page  1966,  Vol.  Ill  of  this  Encyclopedia. 

Fibres,  Cilio-equatorial.  One  of  the  several  classes  of  fibres  constituting 
tlie  zonula  of  Zinn. 

Fibres  cortico-optiques.  (F.)  The  nerve-fibres  Avhich  connect  the  optic 
thalamus  with  the  cortex  cerebri. 

Fibres,  Darkschewitz's.    See  page  3749,  Vol.  V,  of  this  Encyclopedia. 

Fibres,  Edinger's.    See  Vol.  VI,  p.  4156  of  this  Encyclopedia. 

Fibres,  Gudden's.  These  connect  the  basal  optic  centres  with  the  trac- 
tus  pcduncularis  transversus. 

Fibres,  Monakow's.  The  o])tic  fibres  that  run  from  the  collieulus  ante- 
v\ov  to  the  eyeball. 

Fibres,  Perlia's.  These  connect  the  medulla  oblongata  with  the  optic 
centres  at  the  base  of  the  brain. 

Fibres,  Projection.  Fibres  of  the  corona  radiata.  constituting  (in  oppo- 
sition to  "association"  fibres)  the  medullary  substance  of  the  occipi- 
tal lobe. 

Fibres  suturales.  A  synoiiym  of  arcuate  fibres — of  the  anterior  limiting 
membrane  of  the  cornea— for  which  see  Anatomy  of  the  eye,  as  well 
as  Histology  of  the  eye. 

Fibreux.     (F.)     Fibrous. 


5184  FIBRINOUS  CATARACT 

Fibrinous  cataract.  I-'iukoid  cataract.  (Obs.)  Tliis  form  of  opacity 
of  tlk'  oriilar  iiit'dia,  constitutinf?  one  form  of  false  cataract,  lias  noth- 
ing to  do  with  the  lens  or  its  capsules.  It  is  in  most  instances  a  de- 
posit on  the  surface  of  the  anterior  capsule  without  implication  of 
that  mcMuhrane,  and  is  the  result  of  an  iritis.  ;i  ""descemetitis, "  or  it 
may  even  he  a  keratitis.     See  Cataract,  Spurious. 

Fibro.  This  picti.x  in  the  nomeiudature  of  tumoi-s  indicates  the  presence 
of  a  certain  pei"centay:e  of  fibrous  tissue  in  the  mass.  Sometimes  this 
connective  tissue  or  fibroid  material  predominates;  in  other  instances 
it  does  not.  Thus  we  have  fibro-angiama,  fihro-aurcoma,  fibro-chon- 
(Iroiixi.  flhro-glioma,  fihro-lipoma,  etc.     See  Tumors  of  the  eye. 

Fibrolysin,  Tiiis  is  a  trade  name  for  a  sterilized  solution  of  thiosinamin 
and  sodium  salicylate.  It  contains  15  per  cent,  of  the  double  salt. 
In  addition  to  the  matter  to  be  found  under  Thiosinamin,  Gi'ossman 
{The  Lancet,  Jan.  16,  li)(J9)  gives  the  following  account  of  this  agent. 
It  was  introduced  in  1905  by  Mendel  of  Essen,  although  as  far  back 
as  1892  von  Ilebra  published  the  favorable  results  he  had  obtained 
in  the  healing  of  lupus  and  of  cicatricial  tissue  by  means  of  thiosina- 
min, a  preparation  made  from  the  oil  of  mustard,  smelling  strongly 
of  garlic,  and  having  the  chemical  composition  of  allyl-sulpho-urea. 
These  good  results  were  verified  by  others,  but  the  remedy  did  not 
become  popular,  for  one  good  reason — its  almost  complete  insolubility 
in  water. 

Fibrolysin  represents  a  combination  of  one  molecule  of  thiosinamin 
with  half  a  molecule  of  salicylate  of  sodium.  Its  principal  advantage 
over  thiosinamin  is  its  easy  solubility  in  water  and  the  absence  of 
any  irritant  effect  when  injected  subcutaneously.  The  drug  itself  is  a 
white,  crj^stalline  substance  with  a  bitter  taste.  It  decomposes  easily 
when  exposed  to  air  and  light  and  is  therefore  put  up  in  closed  tubes 
of  brown  glass  in  doses  of  2.3  cubic  centimetres  of  a  15  per  cent, 
aqueous  solution,  equivalent  to  two  decigrams  (three  grains)  of  thi- 
osinamin. 

The  effect  of  fibrolysin  on  cicatricial  tissue  is  very  remarkable; 
turgescence  takes  place,  the  individual  fibers  lose  their  sharpness  of 
outline,  the  nuclei  are  pushed  asunder,  and  the  tissue  appears  more 
succulent  and  swollen  and  altogether  enlarged.  The  whole  scar  be- 
comes more  relaxed  and  permits  of  movenu'nts  altogether  impossible 
before  injection.  This  effect  Grossman  believes  to  be  due  to  a  serous 
infiltration,  or  flooding,  which  softens  the  old,  inflammatory  and  now 
hardened  tissues  similar  to  the  hyperemia  of  the  Bier  method,  and 
renders  them  more  amenable  to  absorption  by  the  lymph  stream.  The 
result,  transient  at  first,  is  greatly  increased  by  repeated  injections. 


FIBROMA  5185 

It  is  noteworthy  that  librolysiii  has  this  cfTt'ct  only  on  pathologic  con- 
nective tissue. 

The  mode  of  ai)i)li('ation  is  l)y  injection,  cither  intravenous,  intra- 
muscular, or  suhcutaiicous.  rn(h'i-  ihc  inthicncc  of  tlie  drug  dilation 
of  strictures  and  stenoses  of  the  esopliagus,  pylorus  and  lachrymal 
passages  by  bougies  becomes  i)ossible  and  renuiins  permanent. 

Grossman  reports  several  cases,  one  of  cicatricial  shortening  of  the 
eyelids,  wliich  would  usually  have  been  subjected  to  a  not  altogether 
successful  plastic  operation  in  which  after  ten  injections,  tirst  of  1  cc, 
later  of  2,  3  cc,  the  eyelids  opened  and  closed  well;  another  of  retro- 
bull)ar  neuritis  after  influenza  in  which  six  injections  were  "thor- 
ouiiidy  satisfactoi-y "';  clearing  of  corneal  opacities  not  so  satisfactory, 
I)ut  all  improved  a  little;  "great  success"  in  2  cases  of  posterior  syne- 
chia'; three  injections  in  lachrymal  stenosis  rendered  further  probing 
unnecessary. 

He  mentions  some  disagreeable  symptoms  whicii  have  been  described 
as  sometimes  accom])anying  or  following  tlie  application  of  fibrolysin 
—viz.,  a  burning  sensation  round  the  point  of  injection  lasting  half  a 
minute  to  a  couple  of  hours,  discoloration  of  a  yellowish,  later  bluish, 
tint,  formation  of  a  hard  nodule  of  the  size  of  a  cherry  which  may 
take  weeks  or  even  months  to  disappear.  There  are  also  general  symp- 
toms reported ;  headache,  lassitude,  and  heaviness  lasting  from  a  few 
hours  to  a  day  or  more.  Urbantschitsch  mentions  a  case  where,  regu- 
larly 12  hours  after  each  injection,  menstruation  occurred;  this  re- 
sembled normal  menstruation  and  lasted  from  two  to  three  days.  For 
this  reason  the  further  administration  of  the  drug  had  to  be  aban- 
doned.    Another  case  is  mentioned  in  which  epistaxis  occurred. 

As  a  note  of  warning  Grossman  quotes  the  experience  wdiich  Glas 
relates  in  1903  in  a  case  of  nasopharyngeal  syphilis.  After  the  fourth 
injection  of  thiosinamin  edema  and  swelling  of  the  epiglottis  set 
in  and  developed  to  such  a  degree  that  tracheotomy  had  to  be  resorted 
to.  It  is,  consequently,  best  to  begin  Avith  a  small  dose,  1.0  cc,  and 
avoid  the  time  of  menstruation. 

Woltfberg  (Wochenschr.  f.  Thcr.  und  Hyg.  clcs  Augcs,  Aug.  21, 
1913)  also  recommends  it  as  a  local  application  in  obstruction  of  the 
lachi-ymal  canals  due  to  cicatricial  tissue. 
Fibroma.  A  generic  term  for  fibrous  tumors  developed  from  ]iroliferous 
connective-tissue  cells.  Hence  they  are  mostly  found  in  the  nerves, 
skin,  fasciae,  periosteum,  and  glandular  organs.  Though  multiple  they 
do  not  give  rise  to  metastatic  tumors. 

Tile  best  knoAvn  ocular  Hbromata  are  those  found  in  the  lids.  See 
Eyelids,  Fibroma  of  the. 

Vol.  VII  — J 2 


5186  FIBROMA 

I).  Vclluiircn  {('(itl.  f.  I'ral.t.  Aiu;.,  Fi']).,  T!)12,  j).  '.V-h  lias  described 
a  rare  I'oriii  of  Jihrouui  iiiolhisciini  in  the  u])i)er  lid.  A  pear-sliaped 
tumor,  iusei'ted  with  a  thin  pcdich'  on  liic  nasal  portion  of  the  border 
of  Ihc  left  iip|)cr  liil  of  a  woman,  a^^t-d  (id,  liun<,'  friM-  on  Ihe  face  as 
far  as  the  nasolabial  fold.  It  was  30  mm.  long,  its  greatest  width 
being  25  mm.  It  was  of  soft  eonsisteiiey  and  eovered  Witii  snujoth 
skin.  Otherwise  the  lid  was  ])erfe('tly  noiiiial  and  the  palpebral  fissure 
as  wide  as  the  other.  There  was  a  wart  of  the  upper  lid,  10  small 
angiomas  of  1.5  mm.  eireumferenee  and  a  few^  specimens  of  cutis  p<  n- 
dula  on  the  skin  of  the  neck.  The  i)atient  first  noticed  the  tumor  :iO 
years  before.  It  grew  slowly  until  five  years  ago.  It  was  easily 
removed  and  on  microscopical  examination  found  to  be  a  neurofibroma. 

Fibromata  of  the  conjunctiva,  cornea,  iris  and  orhital  cavity  are  also 
known. 

For  example,  a  mucous  fibroma  of  the  bul])ar  conjunctiva  is  reported 
by  Trousseau  {Annalcs  d'Oculistique,  JNIarcli,  1906).  A  man,  57  years 
of  age,  stated  that  tbe  trouble  in  bis  eye  had  commenced  fifteen  years 
before  he  applied  for  treatment.  At  that  time  he  noticed  a  little, 
whitish  tumor,  scarcely  as  large  as  a  millet  seed,  on  the  nasal  side  of 
the  bulbar  conjunctiva  of  his  left  eye.  It  occurred  without  trauma- 
tism, irritation  or  preceding  disease  of  the  eye.  His  general  health 
was  excellent,  and  he  gave  himself  little  concern  al)out  the  growth, 
which  did  not  inconvenience  him.  It  develoi)ed  slowly  but  steadily  and 
gradually  assumed  a  reddish  tint.  At  the  time  of  the  examination  it 
extended  from  the  caruncle  to  the  corneal  limbus,  but  was  not  adherent 
to  the  latter.  The  size  of  the  tumor  was  that  of  a  large  olive.  It  was 
of  a  reddish  color,  and  the  conjunctiva  over  it  Avas  traversed  by  large 
vessels.  It  was  enucleated  without  difficulty,  as  it  had  no  firm  adhe- 
sions. Examination  showed  it  to  be  a  fibrous  tumor  of  the  submucous 
connective  tissue.  Trousseau  believed  that  no  similar  tumor  in  this 
location  had  been  reported  before. 

Cosmettatos  {Annalcs  d'Oculist.,  145,  p.  282,  1912)  describes  a 
congenital  fibroma  of  the  orbit.  The  low^er  border  of  the  left,  normal, 
eye  corresponded  in  level  to  the  upper  part  of  the  globe  of  the  right, 
affected,  eye.  The  lid  of  the  right  eye  eovered  the  greater  part  of  the 
eye,  and  was  raised  with  difficulty.  The  antero-posterior  axis  was 
directed  downward  and  outward.  The  vertical  diameter  of  the  right 
orbit  at  its  margin  was  2  mm.  greater  than  that  of  the  left.  The 
increase  in  size  of  the  right  orbital  cavity  was  at  the  expense  of  the 
malar  l)one,  and  of  the  superior  maxilla.  The  patient .  who  was  twen- 
ty-two years  old,  stated  that  he  had  been  l)orn  with  the  right  eye  in 
the  relative  position  which  it  still  occupied.     This  statement  was  con- 


FIBROMA,  SCLEROCORNEAL  5187 

firmed  by  a  brother.  A  fil)i-oina  was  rt^'inoved  through  an  incision  in 
the  upper  lid.  It  liad  been  attached  to  the  external  orl)ital  wall,  and 
had  pressed  upon  the  upper  surfaee  of  the  globe.  After  the  operation 
the  eye  took  a  somewhat  higher  position,  but  still  not  so  high  as  that 
of  the  left  eye.  The  author  rcjrards  the  tumor  as  having  developed 
during  fetal  life.  See,  also.  Fibromatosis. 
Fibroma,  Scleroccrneal.  A  name  for  vernal  conjunctivitis. 
Fibromatosis.  This  term  is  generally  applied  in  ophthalmology  to  intra- 
dural tumors  of  the  optic  nerve — fibromatosis  ncni  optici.  The  phrase 
was  applied  by  Byers  in  1901  to  true  intradural  and  primary  tumors 
of  the  nerve,  he  having  been  able  to  collect  accounts  of  102  cases  in 
the  literature. 

Age  is  a  factor  in  this  disease.  Of  85  cases  collected  by  Byers  in 
which  the  age  was  recorded,  67  occurred  at  fifteen  years  or  younger ; 
32  cases  occurred  between  the  first  and  fifth  years.  The  disease  is 
found  more  frequently  in  females  than  in  males,  and  more  often  on 
the  left  side.  Trauma  and  febrile  disturbance  or  infectious  disease 
are  apparent  etiologic  factors. 

The  most  striking  symptom  is  the  gradual  development  of  painless 
exophthalmos,  the  direction  of  the  proptosis  being  in  the  majority  of 
cases  directly  forward,  or  forward,  downward  and  outward,  although 
it  may  be  forward  and  upward,  outward,  or  inward.  Exceptionally 
the  exophthalmos  has  developed  rapidly.  The  patient  may  complain 
of  pain  throughout  the  distribution  of  the  fifth  nerve.  The  proptosis 
is  attributed  chiefly  to  the  direct  influence  of  the  tumor,  although,  in 
some  instances,  it  is  influenced  by  the  state  of  the  orbital  blood-vessels, 
or  by  stasis  in  Tenon's  space  and  in  the  supravaginal  lymph-space  of 
the  nerve. 

A  second  symptom  of  importance  is  the  early  and  great  loss  of  vision. 
In  69  per  cent,  of  the  eases  tabulated  by  Bj'ers  vision  was  absolutely 
lost  in  the  affected  eye  at  the  time  of  first  examination.  Variations 
in  visual  acuity  have  been  recorded  in  individual  cases. 

The  ophthalmoscopic  changes  are  various.  Of  82  cases  in  which 
mention  is  made  of  the  condition  of  the  fundus,  8  showed  simple 
atrophy  of  the  optic  nerve,  34  presented  optic  neuritis,  and  36  gave 
evidence  of  post-neuritic  atrophy.  In  3  cases  the  fundus  was  normal. 
Among  the  ophthalmoscopic  appearances  rarely  found  in  primary 
tumors  of  the  nerve  are  dilation  of  the  retinal  veins,  partial  detach- 
ment of  the  retina,  and  hemorrhages.  The  majority  of  patients  present 
no  lesion  of  the  orbital  muscles,  although  strabismus  sometimes  is 
noted,  and,  indeed,  may  precede  the  exophthalmos.  In  some  eases 
palpation  will  enable  the  surgeon  to  determine  the  presence  of  an 


5188  FIBROMATOSIS 

iiitra-()i-l)it;il  fji-owtli  wliicli  is  not  adherent  to  the  orbital  walls.  The 
general  appearance  of  the  patient  does  not  usually  differ  from  the 
normal;  hut  eei-ebral  symptoms — su(;h  as  convulsions  and  epileptic 
seizures — have  heeii  noted  in  i-are  instances.  Vertigo  and  tinnitus 
aurium  are  rarely  pi-esent.  As  regards  the  eyeball,  tension  is  usually 
nornuil,  but  may  be  minus  or  plus.  A  characteristic  symptom  is 
antero-posterior  llattening  of  the  globe  from  pressure  of  the  tumor 
posteriorly,  causing  the  eye  to  become  hyi)ermetropic.  Lagophthalmos 
and  keratitis  have  also  l)een  found  present. 

The  dural  covering  of  tile  nerve  forms  a  capsule,  one-half  to  one 
millimetre  in  thickness,  which  envelops  the  tumor.  The  growth  may 
vary  in  size  from  a  slight  enlargement  of  the  optic  nerve  to  a  mass  the 
dimensions  of  a  goose  egg.  Usually  a  piece  of  nornuil  nerve  separates 
the  tumor  from  the  eyeball.  In  the  opposite  direction,  however,  the 
growth  may  extend  up  to  or  tlirough  the  optic  foramen,  and  involve 
the  brain.  The  microscopic  diagnosis  of  tiie  reported  cases  shows  a 
large  numlier  of  different  forms,  the  majority  being  set  down  as 
myxosarcomata,  myxoinata,  myxofiliromata,  or  sarcomata.  Since 
tumors  of  the  optic  nerve  show,  in  one  and  the  same  specimen,  sev- 
eral j)hases  of  developing  connective  tissue,  Byers  considers  that  they 
should  all  be  classed  as  fibromata.  When  cerebral  symptoms  occur, 
and  death  ensues  after  removal  of  a  primary  tumor  of  the  optic  nerve, 
the  result  is  to  be  attrilnited  not  to  recurrence,  but  to  the  continued 
growth  of  the  intracranial  portion  of  the  neoplasm,  which  could  not 
be  removed  liy  operation. 

The  symptoms  enumerated  above  will  enable  the  surgeon  to  assert 
the  presence  of  a  growth  connected  with  the  optic  nerve,  but  it  is 
doubtful  if  intradural  growths  can  always  be  differentiated  from 
extradural  ones.  The  prognosis  is  serious.  The  eye  in  many  instances 
must  be  sacrificed,  and  in  some  cases  there  is  a  continued  development 
of  the  intracranial  portion  of  the  tumor,  which  could  not  be  removed 
at  the  time  of  operation.  Where  the  tumor  is  located  chiefly  in  the 
anterior  portion  of  the  optic  nerve,  total  removal  is  feasible. 

Since  the  condition  rarely  shows  a  tendency  toward  malignancy, 
and  because  in  most  cases  the  neoplasm  does  not  encroach  on  the 
globe,  modern  ophthalmologists  have  sought  to  extirpate  the  growth 
while  preserving  the  eyeball.  Scarpa,  in  1816,  Critchett,  in  18;'i2, 
Knapp,  in  1874,  were  the  first  to  follow  this  method.  Kna]ip,  in 
operating  on  an  extradural  tumor,  made  his  opening  thi'ough  the 
conjunctiva  and  Tenon's  capsule  between  the  su]ierior  and  internal 
recti,  separated  the  o])tic  nerve  from  the  globe,  then  cut  the  nerve 
at  the  optic  foramen,  and  pried  the  tumor  out  with  scissors.    Gruen- 


FIBROSARCOMA  5189 

ing,  of  New  York,  Ava.s  tlu;  first  to  remove  a  primary  inti'adural  tumor 
of  the  nerve  with  preservation  of  tiie  globe.  Kronleiu  (see  Orbit, 
Diseases  of  the)  has  devised  an  operation  wdiich  is  suitable  for  these 
eases. —  (J.  M,  B.) 

In  an  enucleated  eye  which  had  a  clinical  history  of  keratitis  and 
glaucoma,  Goldberg  {Ophthul.  liecord,  p.  100,  1908)  found  upon 
mieroseopie  examination  a  fibromatosis  involving  the  cornea  and  uveal 
tract.  The  cornea  was  split  into  two  equal  parts,  one  superficial,  which 
had  changed  to  opaque  dense  cartilaginous  material,  the  other  deep, 
unaffected  and  transparent.  The  epithelium  had  invaded  the  diseased 
portion  showing,  perhaps,  efforts  at  repair.  Such  new-formed  epithe- 
lium was  observed  also  by  Gilbert  upon  the  surface  of  a  pannus 
degencrativus,  after  it  had  undergone  a  sclerotic  change. 

Fibrosarcoma.  Combinations — primary  or  secondary — of  fibrous  tissue 
witli  various  neoplasms  are  not  uncommon  in  the  ocular  structures. 
They  will  be  discussed  under  Tumors  of  the  eye,  as  well  as  under  the 
sti'uctures  tliey  mostly  affect. 

Fibroser  Staar.     (G.)     Fibroid  cataract. 

Fibrosis.  Thickening  of  a  part  of  an  organ  or  vessel  due  to  the  forma- 
tion of  fibrous  tissue. 

Fibrous  coat.    A  synonym  of  the  cornea-selera. 

Fibrous  cordage.  A  tei-m  ap{)lied  by  Ranvier  to  corneal  filaments  found 
in  the  Kay  and  other  fishes,  iiowman  has  described  similar  structures 
in  man. 

Fibrous  tunic.    Tlie  sclera  and  cornea  together. 

Fick,  Bacillus  of.    See  Vol.  II,  p.  739  of  this  Encyclopedia. 

Fieber.    (G.)    Fever. 

Fiel.     (F.)     Gall;  bile. 

Field  glass.  A  small,  portable  terrestrial  telescope,  either  monocular  or 
binocular.     See  Opera  glass. 

Fielding,  George  Hunsley.  A  i)opular  English  anatomist,  who  j)aid 
considerable  attention  to  ophthalmology.  Born  at  Hull,  England,  the 
son  of  a  physician,  Oct.  26,  1801,  he  became  in  1824  a  ^lember  of 
the  Royal  College  of  Surgeons  of  England,  and  practised  for  a  number 
of  years  in  his  native  town.  He  then  proceeded  to  Erlangen,  Germany, 
where  he  received  the  degree  of  Doctor  in  ^Medicine  in  1836.  Return- 
■  ing  to  England,  he  settled  at  Tunbridge,  Kent,  where  he  j^ractised  for 
many  jears.  In  1843  he  was  made  a  Fellow  of  the  Royal  Society.  He 
died  at  Dry  Hill,  near  Tunbridge,  j\Iay  24,  1871. 

Fielding  wrote  but  two  ophthalmologic  articles,  as  follows:  1.  On 
a  New  Membrane  in  the  Eye,  etc.  (London,  1832.)  2.  On  the  Influ- 
ence of  Color  on  the  Effect  of  Light,  Heat  and  Odors.— (T.  H.  S.) 


5190  FIELDING,  SIR  JOHN 

Fielding,  Sir  John.  A  cclchiali'd  lawyci-,  jiii'ist,  and  pliilaiitlu-opist,  son 
of  General  Ecliminil  l-'iclding  and  lialf-l)rotlier  of  the  author  of  "Toin 
Jones."  lie  was  totally  blind  from  childhood,  and  yet,  so  great  were 
his  varied  al)ilities,  that  lie  received  the  lionor  of  knighthood,  wrote 
numerous  excellent  books  on  various  subjects  of  importance,  and, 
finally,  became  the  first  chief  magistrate  of  the  United  Kingdom. 

The  place  and  the  date  of  his  birth  are  alike  unknown.  After  the 
onset  of  blindness  he  received  from  his  parents  an  excellent  general 
and  legal  education.  On  the  death  of  his  half-brother,  Henry,  the 
celebrated  novelist,  "blind  Sir  John"  was  appointed  in  his  stead  as 
magistrate  at  the  Bow  Street  Police  Court.  So  acute  was  Sir  John's 
legal  understanding  that  he  was  sometimes  called  "Blind  f'ielding,  the 
Thief-Catcher,"  and,  again,  "the  English  Solomon."  He  never  for- 
got, it  is  said,  a  former  culprit's  voice,  character  or  history.  It  is,  in 
fact,  asserted  that  he  knew  over  three  thousand  thieves  by  their  voices. 
He  was  probably  the  first  to  abolish  absolutely  the  giving  and  taking 
of  bribes. 

In  1761  he  was  made  chief  magistrate,  and,  soon  after,  received  the 
order  of  knighthood. 

In  1785  he  established,  it  is  said,  the  first  orphan  asylum  in  England. 
This  was  known  as  "The  Female  Orphan  Asylum,"  and  was  situated 
on  Westminster  Road,  Lambeth.  He  was  also  one  of  the  benefactors 
of  the  jMarine  Society  and  of  the  Magdalen  Hospital. 

He  was  a  man  of  excellent  wit  and  fond  of  telling  stories.  Those 
which  he  most  enjoyed  narrating  were,  as  a  rule,  about  Irishmen. 
There  is  one  that  he  told  repeatedly:  When  Sir  John  was  a  magis- 
trate at  Bow  Street,  an  Irishman,  hrought  before  him  on  some  minor 
charge,  attempted  to  pose  as  an  Englishman.  In  fact,  he  declared 
that  he  "came  from"  Chester.  "What!"  exclaimed  Sir  John,  noting 
the  rich  Irish  brogue,  "were  you  ever  in  Chester?"  "To  be  sure  I 
was,"  replied  the  culprit;  "w^asn't  I  l)orn  there?"  "How  dare  you," 
cried  the  irascible  magistrate,  "with  that  brogue  pretend  you  were 
horn  in  Chester?"  "I  didn't  say  I  was  born  there,"  answered  the 
Irishman,  "I  only  asked  your  honor  wdiether  I  was  or  not." 

A  list  of  Sir  John  Fielding's  more  important  writings  is  as  follows: 

1.  A  Charge  to  the  Crand  Jury  of  Westminster.  (1735.  Published 
at  the  request  of  a  large  munber  of  i^eople.) 

2.  Extracts  from  Sueh  of  the  Penal  Laws  as  Particularly  Kclate  to 
the  Peace  and  Good  Order  of  the  .Metropolis.     (1761.) 

3.  The  Universal  Mentor,  containing  Essays  on  the  INIost  Important 
Suhjects  in  Life;  Composed  of  Observations.  Sentiments,  and  Exam- 
ples of  Virtue.     (1762.) 


PIELD-LENS  5101 

4.  Another  Charge  to  the  Grand  Jiny  of  Westminster.     (1766.) 

5.  A  Plan  for  Preventing  Kobbei-ies  within  Twenty  ]\Iih's  of  Lon- 
don, with  Adviee  to  Pawnbrokers.     (1768.) 

6.  An  Aeeount  of  the  Origin  and  Effects  of  a  Police  Set  on  Foot 
by  his  Grace  the  Dnke  of  Newcastle,  in  the  year  1753,  upon  a  Plan 
Presented  to  his  Grace  by  the  late  Henry  Fielding,  Ks(i.     (1768.J 

7.  A  Plan  for  Preserving  those  Deserted  Girls  in  this  Town,  who 
become  Prostitutes  from  Necessity.     (1768.) 

8.  A  Brief  Description  of  the  Cities  of  London  and  Westminster. 
(1777.) 

9.  "Sir  John  Fielding's  Jests."  Published  after  Fielding's  death, 
and  probably  spurious — at  least  in  greater  part. 

Sir  Jolni  died  at  lirompton  place,  Sept.  -4,  1780,  one  of  the  best 
loved  men  in  England. —  (T.  H.  S.) 

Field-lens.  The  lens  mounted  opposite  to  the  eye-lens  in  au  eye-piece 
and  which  is  exposed  to  the  image  projected  by  the  objective  within 
the  tul)e  of  a  microscope  or  telescope,  its  purpose  being  to  enlarge  the 
field  of  view.— (C.  F.  P.) 

Field  of  a  lens.  TJie  surface  approximately  passing  through  the  foci 
of  all  points  within  tiie  efficient  range  of  a  lens.  This  surface  is  in 
most  instances  somewhat  curved,  but  it  is  preferable  that  it  should  be 
as  flat  as  possible. 

Field  of  fixation.  The  field  of  fixation  is  determined  in  the  same  man- 
ner as  is  the  visual  field,  except  that  the  patient  is  directed  to  follow 
with  the  affected  eye  the  test-object  (which  may  consist  of  a  small 
printed  letter)  as  it  is  carried  outward  along  the  arc  of  the  perimeter 
and  make  known  when  he  can  no  longer  decipher  it.  This  method  is 
of  especial  value  where  the  defect  is  slight  or  where  more  than  one 
muscle  is  affected.  Example :  In  pai-alysis  of  the  inferior  oblique  the 
field  of  fixation  would  show  contraction  above  and  to  the  outside. 
Stevens  has  designed  an  instrument  for  measuring  the  rotation  of  the 
eyes  in  all  directions. —  (J.  M.  B.) 

The  editor  has  also  made  use  of  the  perimeter  for  determining  the 
limits  of  the  monocular  field  of  fixation.    See  Vol.  VI,  p.  4696  of  this 

EHClJclopCclM. 

The  binocular  field  of  fixation  is  of  extreme  importance  in  cases  of 
squint.  It  is  defined  by  Landolt  (Norris  and  Oliver's  System,  Vol.  IV, 
p.  53)  to  be  the  extent  of  the  space  over  which  "the  lines  of  sight  of 
the  two  eyes  can  meet  in  the  same  point  of  fixation.  This  experiment 
should  be  made  at  such  a  distance  that  the  convergence  may  be  disre- 
garded. AVe  use  for  this  the  mural  division  which  we  have  described 
in  the  discussion  of  subjective  stabometry.    AVe  have  marked  for  this 


5192  FIELD  OF  REGARD 

ltui'i)osf  upon  tlir  Willi  tlu'  liiiij^M'iits  of  llic  iiiiiltiplcs  of  T)'^  in  nine 
iiu'i'idiaiis.  scparatfd  l)\-  20  I'l'oni  cadi  other,  also  the  nin-idiaiis, 
iiicliiiccl  at  4")  .  (See  the  figure.)  The  person  to  be  examined  is 
placed  before  this  division  in  such  a  way  that  his  e\-es  cori'esj)ond  to 
the  centre  of  the  imaginary  hemisphere  whose  projection  is  insci-ibed 
on  the  wall  and  floor.  The  head  is  fixed  by  means  of  a  dental  strap 
supported  by  a  solid  jx'destal.  Tiieii  one  moves,  along  th(;  principal 
meridians  of  the  eliart,  a  lighted  candle,  which  the  patient  follows  with 
his  eyes  until  he  commences  to  see  it  double.  The  point  at  which  this 
diplopia  ai)pcai's  constitutes  the  limit  of  the  field  of  binocular  fixation 
in  each  given  direction.     This  is  recorded  on  a  scheme  like  that  ui^ed 


Binocular  Field  of   Fixation. 

for  the  record  of  the  monocular  field.  The  perception  of  the  diplopia 
is  favored  by  a  colored  glass,  wdiich  is  best  held  by  the  patient  himself 
before  one  of  his  eyes.  The  full  line  in  the  figure  corresponds  to  the 
normal  field  of  binoculdr  fixation  of  the  author.  The  pointed  curves 
at  the  left  and  right  of  the  lower  part  of  the  figure  are  nothing  else 
than  the  infero-external  limits  of  tlie  monocular  fields  of  fixation.  The 
nose  prevents  this  space  from  being  dominated  simultaneously  l)y 
both  eyes." 

Field  of  reg-ard.    A  name  for  the  visual  field,  or  field  of  vision. 

Field  of  view.  In  general,  the  area  at  any  distance  of  view  that  is  en- 
compassed by  the  naked  eye,  or  through  the  aid  of  an  instrument,  such 
as  the  telescope  or  microscope. 

This  term  is,  however,  generally  a])plied  to  the  area  visible  through 
the  microscope  when  it  is  in  focus.  Wlien  properly  lighted  and  there 
is  no  object  inuler  the  microscope,  tlie  field  appears  as  a  circle  of  light. 
When  examining  an  object  it  appears  in  a  part  or  the  whole  of  the 


FIELD  OF  VISION  510:] 

light  circle,  and  In  moving-  the  object,  if  of  sufficient  size,  different 
parts  are  hi-oii^dit  into  tlic  lirld  of  view.  Tlie  ^'reater  the  niagnilieation 
of  the  entiiv  niiernseopc,  whether  the  magnitication  is  produced  mainly 
hy  the  ohjective,  the  o(;uhir,  or  tlie  lengthening  of  tlie  tube  of  tlie 
iuieroseoi)e,  or  hy  a  cond)ination  of  these,  tlie  smaller  is  the  held.  The 
exact  size  of  the  field  of  view  may  be  determined  directly  by  the  use 
of  a  stage  miei-ometer. 

Field  of  vision.  This  most  important  and  extensive  subject  Avill  be 
fountl  fully  treated  undei-  Perimetry.  The  practical  side  of  it  has 
been  considered  to  some  extent  on  page  4765  (ct  scq.),  Vol.  VI,  of  this 
Eiicijcloix  dia. 

Field-stop.  In  optics,  the  annulai-  diaphragm  which  limits  the  held  of 
view  in  an  optical  instrument ;  it  is  the  material  stop  that  subtends  the 
smallest  visual  angle  at  the  center  of  the  entrance-pupil  (q.  v.). 

Fieno.       (It.)     Hay.    F(  bbrc  del  ficno,  hay  iever. 

Fievre.     (F.)    Fever. 

Fifth  nerve.  Trifacial  nerve.  Trigeminal  nerve.  Trigeminus.  The 
branch  of  this  great  nerve  of  sensation  with  which  the  ophthalmologist 
is  especially  interested  is  the  ophthalmic  nerve.  It  is  one  of  three 
primary  l)ranches  and  enters  the  orbit  via  the  sphenoidal  fissure,  after 
dividing  into  the  frontal,  lachrymal  and  nasal  nerves.  The  frontal 
nerve  passes  between  the  periorbita  and  the  levator  muscle.  Imme- 
diately behind  the  margin  of  the  orl)it  it  divides  into  supratrochlear 
and  supra-orbital  branches.  The  former  escapes  from  the  orbit  internal 
to  the  trochlea  and  supplies  the  periosteum,  the  skin  at  the  root  of 
tiie  nose,  and  inner  part  of  the  upper  eyelid.  The  latter  emerges  via 
the  supra-orbital  foramen  and  supplies  the  upper  eyelid,  periosteum  of 
the  forehead,  and  scalp.  The  lachrymal  nerve  sends  branches  to  the 
lachrymal  gland,  conjunctiva  of  the  external  canthus,  and  upper  eye- 
lid, and  gives  off  an  inferior  branch,  which  joins  branches  of  the 
superior  maxillary  nerve.  Branches  from  the  resulting  arc  supply 
the  lachrymal  gland.  Stimulation  of  either  stem  of  this  loop  causes 
lachrymation.  Division  results  in  the  pouring  out  of  a  paralytic 
secretion.  The  nasal  nerve  enters  the  orbit  between  the  heads  of  the 
external  rectus,  passes  obliquely  across  the  orbit,  enters  the  anterior 
ethmoidal  foramen,  passes  between  two  fronto-ethmoidal  cells,  enters 
the  nasal  cavity,  crosses  the  ethmoidal  plate,  enters  a  slit  by  the  side 
of  the  crista  galli.  grooves  the  inner  surface  of  the  nasal  bone,  and 
divides  into  three  branches.  These  are  distributed  to  the  nasal  mucous 
lining  and  the  skin  as  far  as  the  tip  of  the  nose.  Before  entering  the 
ethmoidal  foramen  the  nerve  gives  off  branches  to  the  ciliai'v  ganglion, 


5194  FIFTH-NERVE  PARALYSIS 

and  tlif  l(tii<;  ciliary  iici'vcs  wliidi  pierce  the  sclera  and  end  in  the 
ey.-hall.— (.1.  -M.  15.) 
Fifth-nerve  paralysis.  .\l:^K()l^\l^\l,^■■|•|<■  ki;i{ aiiiis.  i'aralysis  ol"  the 
oi)hthaliiiic  division  of  tlie  liflli  nerve  may  he  (hie  to  any  one  of  many 
causes:  tumors  in  the  ])ituitary  region  oi-  at  tiie  hase  of  the  hrain ; 
syphilitic,  traumatic,  oi*  epiih-mie  meninj^itis;  caries  of  the  temporal 
bone;  fracture  of  the  skull  ;  piimary  neuritis,  a  rare  cause;  disease  of 
the  nuclei  of  the  trigeminal  nerve ;  or  o])eration  for  removal  of  the 
G-asserian  ganglion  for  the  cure  of  neuralgia.  Whether  the  lesion  is 
located  in  the  nerve-tinink  or  in  its  nuclei  of  origin  in  the  brain,  the 
result  is  the  same.  In  paralysis  of  the  fifth  nerve  \viid<ing  and  lachry- 
mation  do  not  occur;  hence  the  cornea  becomes  di'y  and  minute  foreign 
bodies  settle  upon  it.  Infection  takes  place  and  destruction  of  tissue 
follows.  Since  the  time  of  i\Iagendie  it  has  been  custonuiry  to  attribute 
neuroparalytic  keratitis  to  the  loss  of  the  influence  of  trophic  nerve- 
fibres  supposed  to  be  located  in  the  trigeminus,  but  in  the  light  of 
modern  pathology  it  is  no  longer  necessary  to  adopt  this  hypothesis. 
Snellen's  explanation,  that  the  insensibility  of  the  eye  occurring  in 
paralysis  of  the  fifth  nerve  enables  ordinary  causes  to  act  unmolested 
on  the  cornea,  is  now  generally  accepted. 

The  chief  symptom  is  anesthesia.  In  paralysis  of  the  entire  fifth 
nerve  or  of  its  ophthalmic  branch,  both  cornea  and  conjunctiva  become 
anesthetic.  After  optico-ciliary  neurectomy  the  cornea  alone  is  anes- 
thetic, winking  and  lachrymation  remaining  and  no  harm  resulting  to 
the  cornea.  If,  however,  the  branch  of  the  seventh  nerve  supplying 
the  orbicularis  muscle  is  also  paralyzed,  the  cornea  is  likely  to  slough. 
Neuralgic  pain,  through  the  region  supplied  by  the  affected  ophthalmic 
branch  of  the  fifth  nerve,  may  precede  the  anesthesia. 

Following  paralysis  of  the  fifth  nerve  the  cornea  becomes  cloudy, 
the  epithelium  of  its  centre  is  loosened  and  removed,  and  this  process 
extends  until  only  a  narrow  peripheral  rim  remains.  The  central 
ulcer  is  at  first  gray ;  then  it  becomes  yellowish,  hypoi)yon  forms,  the 
ulcer  perforates,  and  the  iris  is  engaged  in  the  cicatrix.  Healing  is 
followed  by  a  flat  scar.  Not  every  case  runs  a  course  so  severe  as  this, 
since  the  process  may  not  lead  to  perforation.  In  neuroparalytic 
keratitis  ciliary  injection  is  present,  but  lachrymation  is  absent. 

The  corneal  changes  following  excision  of  the  Gasserian  ganglion 
can  be  prevented  l)y  stitching  the  lids  together  and  at  the  first  dressing 
applying  a  Buller  shield.  If  these  precautions  are  not  observed,  the 
cornea  may  necrose  and  the  eye  be  lost.  In  necrosis  and  suppuration 
of  neuroparalytic  keratitis,  pain,  lachrymation.  and  blepharospasm 
are  absent.    Ocular  tension  is  usually  reduced. 


FIG  5195 

Neuroparalytic  keratitis  is  always  a  serious  disease.  If  treated 
early  and  propei'ly  the  pi'oeess  ean  usually  he  cheeked  and  useful 
vision  can  be  saved.  In  such  eases,  after  restoration  of  tissue  has 
occurred,  an  iridectomy  may  improve  vision. 

The  preventive  treatment  has  been  mentioned  above.  The  curative 
treatment  consists  in  the  application  of  a  bandage,  the  use  of  atropin 
or  eserin,  and  the  frequent  cleansing  of  the  eye  with  an  antiseptic 
solution.  Electricity  may  be  tried.  Xieden  advises  the  hypodcnnic 
injection  of  strychnin  in  the  temple. —  (J.  M.  B.)  See,  also.  Keratitis, 
Neuroparaljrtic. 

Fig.  ficHs  carica.  The  common  tig  was  recommended  as  an  ophtlial- 
mic  remedy  by  Dioscorides  and  Pliny :  the  pulp,  cooked  together  with 
pomegranates,  for  pterygium,  and  the  juice  for  ulcers  of  the  lids. — 
(T.  II.  S.) 

The  juice  of  the  fruit  of  Ficus  tsjela  found  in  the  East  Indies,  is 
still  employed  in  ophthalmia. 

Fil.     (P.)     Thread,  for  sutures;  a  thread-like  structure. 

Filaccia.    (It.)    Charpie ;  lint. 

Filamentary  keratitis.    See  Keratitis,  Filamentary. 

Filamentous  cataract.  An  old  term  for  a  cataract  in  which  the  lens 
appears  to  l)e  full  of  fine  filaments. 

Filaments  of  Ammon.  A  name  for  the  lamina  hasalis  of  the  choroid. 
See  Histology  of  the  eye;  also  Vol.  I,  p.  319  of  this  Encyclopedia. 

Filaria.  A  genus  of  nematodes  or  thread  worms.  It  is  an  endoparasite 
which  in  hot  climates  (Africa)  often  attacks  man.  It  has  been  found 
in  practically  all  the  eye  structures. 

The  filaria  sanguinis  Jiominis,  the  larva  of  the  worm,  filaria  han- 
crofti,  is  found  in  the  blood  during  the  night  in  ehyluria,  and  in  the 
lymph-vessels  of  the  lower  limbs  and  scrotum.  It  causes  dilatation 
of  the  lymphatics,  hematuria,  ehyluria,  abscesses,  lymph-scrotum  and 
elei)hantiasis.  The  filaria  is  conveyed  to  man  througii  the  bite  of 
mosquitoes  of  the  genus  culcx. 

Filaria  medincnsis,  the  guinea-worm,  is  an  animal  parasite  the 
female  of  which  burrows  under  the  skin  and  then  deposits  its  embryos, 
which  finally  cause  abscess-formation. 

Filaria  loa  is  an  African  species  inhabiting  the  connective  tissue  of 
the  body,  which  it  traverses  freely.  It  is  seen  especially  around  the 
eye,  where  it  causes  itching  and,  occasionally,  edematous  swellings. 

Filaria'  affecting  tlie  human  eyes  are  rarely  encountered  in  America. 
Vail  {Amcr.  Jour,  of  OphtJial.,  December,  1905)  reports  the  second 
case  in  which  the  filaria  loa  was  extracted  within  the  confines  of  the 
United  States.     The  patient  had  become  affected  while  residing  in 


5196  FILARIA 

Afi-ica  ill  ISDI);  a  imiiihcr  of  worms  uci'c  extracted  from  beneath  the 
skin  of  tlif  eyelids  and  otliei-  parts  of  tlie  l)ody  during  the  stay  of  the 
patient  in  Africa.  In  August,  11)01,  the  writer's  examination  failed 
to  reveal  the  existeii<-e  of  any  parasite;  hut  in  dune,  1!)03,  the  patient 
retui'ued  and  stated  that  he  felt  these  "eye  worms''  at  times  in  the 
eyelitis,  again  in  the  eyeball  and  fi-e(juently  about  the  ankles,  ribs  and 
wrists.  In  September,  1903,  the  writei-  saw-  "a  distinct,  independent 
movenient,  like  what  would  be  imide  by  a  small  worm  an  inch  long, 
crawling  about  under  the  skin  of  the  upper  eyelid.  The  movements 
were  slow  and  somewhat  clonic.  During  one  of  these  contractions  he 
grasped  the  most  prominent  loop  of  the  worm  with  a  pair  of  fixation 
forceps,  and  then  by  means  of  scissors  and  forceps  succeeded  in 
extracting  the  worm  without  its  being  severed  or  wounded."  Two 
years  and  eight  months  since  the  patient  left  Africa,  these  worms 
were  as  active  as  ever,  four  being  felt  at  various  times,  limiting  their 
peregrinations  to  the  extremities  and  especially  the  tissues  about  the 
eyes,  particularly  on  chilly  days  out  of  season  and  cold  days  following 
a  warm  spell,  and  without  interference  with  the  general  health. 

Rochat  {Practical  Medicine  Series,  p.  34,  1907)  was  consulted  by  a 
man  whom  he  had  previously  treated  for  hordeola  and  whose  eyes 
were  normal.  He  now  complained  that  his  eyes  itched  and  watered. 
Before  the  looking  glass  he  had  noticed  in  the  white  of  the  eye  a  "small 
nerve  which  moved."  On  looking  strongly  downward  and  after  lifting 
of  the  upper  eyelid,  near  the  upper  fornix,  a  transparent  thread  was 
seen,  with  slow,  tortuous  movements.  It  was  removed  with  a  pair  of 
forceps  through  an  opening  in  the  conjunctiva  and  proved  to  be  a 
filaria  loa.  The  patient  had  returned  from  the  Congo  three  years  before 
without  noticing  any  abnormal  symptom ;  his  blood  was  free  of 
embryos,  the  urine  normal  (he  had  hematuria  in  the  Congo)  ;  no 
other  specimens  have  since  shown  themselves. 

Terrien  and  Prelat  (Arch.  d'Ophtal.,  May,  1914)  have  added 
another  to  the  comparatively  small  number  of  cases  of  filaria  loa  in 
the  eye,  already  published.  Their  patient  was  a  man,  a^t.  33  years, 
who  came  under  observation  in  ]\Iarch,  1914,  asking  to  have  the  para- 
site removed.  He  had  become  aware  of  its  presence  in  his  eye  the 
same  morning  when  making  his  toilet.  At  that  time  the  filaria  was 
near  the  inner  canthus,  but  when  he  came  to  the  hospital  it  was  plainly 
visible  beneath  the  conjunctiva  near  the  outer  canthus.  It  showed  as 
a  very  wavy,  slightly-raised  body  comparable  to  a  fragment  of  vermi- 
celli, moving  fairly  rapidly  inwards  and  outwards  on  the  surface  of 
the  sclera.  No  symptoms  were  noticed  beyond  an  unusual  sensation 
due  to  the  movement  of  the  parasite.  The  examination  of  the  eye 
revealed  no  other  abnormality,  and  the  patient  was  in  perfect  health. 


FILARIA  INERMIS  GRASSI  5197 

From  iSiJO  to  !!)()!»  the  man  lived  in  the  Congo  territory;  at  the 
latter  date  he  retnrned  to  Franee.  In  1!)06  he  first  became  aware  of 
the  presence  of  the  tilaria  in  his  right  upper  eyelid,  from  wliieli  posi- 
tion it  disappeared  in  a  few  hours.  After  that  date  it  returned  on 
several  oeeasions.  always  in  the  early  part  of  the  day.  .sometimes  in 
the  upper  lid,  sometimes  beneath  the  eonjunetiva,  appearing  near  the 
caruncle  and  disappearing  quickly  towards  the  outer  angle  of  the 
palpebral  fi.ssure. 

During  his  sojourn  in  Africa  the  patient  liad  had  several  attacks 
of  malaria,  but  had  been  quite  free  from  this  malady  since  his  return. 
Not  infrequently,  but  at  irregular  intervals,  he  had  noticed  the  appear- 
ance of  very  transient  small  tumefactions  in  the  skin,  which  arose  in 
various  places.  They  were  painless  and  underwent  absorption  in  2 
or  3  days,  leaving  no  trace.  These  were  evidently  the  nodules  com- 
monly known  as  Calabar  tumors,  due  to  the  presence  of  a  filaria  or  to 
the  action  of  a  toxin  secreted  by  the  parasite. 

The  filaria  beneath  the  conjunctiva  was  easily  removed  and  proved 
to  be  a  male ;  it  measured  approximately  5  cm.  in  length.  Several 
examinations  of  the  blood  of  the  patient  failed  to  discover  any 
embryos  (the  filaria  divina).  but  the  blood  showed  a  well  marked 
eosinophilia. 

The  authors  append  a  list  of  published  cases  of  filaria  loa  in  the 
eye,  but  this  list  does  not  include  one  of  the  earliest  and  most  accu- 
rately reported  examples,  that  of  Argyll  Robertson,  published  in  the 
Trans.  Ophthal.  Soc,  1895-1897.  (Lawford  in  the  Oph.  Review,  p. 
279,  Sept.,  1914.) 

The  best  account  of  this  parasite  will  be  found  in  the  monograph 
l)y  Henry  B.  Ward,  who  will  furnish  a  further  report  in  this  Encyclo- 
pedia under  Parasites,  Ocular. 

Filaria  Inermis  Grassi.  Thi.s  species  is  chiefiy  found  in  the  ass  and 
liorsc,  and  lias  attacked  the  conjunctiva  of  man. 

Filaria  in  the  orbit.    Sec  Parasites,  Ocular. 

Filaria  in  the  vitreous  humor.    See  Parasites,  Ocular. 

Filaria  medinensis  Gurel.  This  species,  according  to  Salzmann,  has 
been  found  under  the  skin  near  the  eye,  but  never  under  the  con- 
junctiva. 

Filaria  oculi.  Owing  to  its  freciuent  invasion  of  the  eye  this  term  is 
occasionall.v  applied  to  the  filaria  loa. 

Filariasis.  (L.)  A  chronic  disease,  often  terminating  in  spontaneous 
recovery,  caused  by  the  presence  in  the  system  of  one  or  other  species 
of  filaria ;  characterized  bv  soft  tumefaction  of  the  inguinal  glands. 


5198  FILAR  MICROSCOPE 

liciii;itiiri;i  or  rli vliii'ia,  and  tlic  pci'iodical  ix'csciicc  of  tlit'  parasites  in 
t  lif  1i1()(kI. 

Filar  microscope.     A  inicrosropc  having  ci-o.ss-wircs  in  its  focus. 

Filasse.     (F.)     Tow. 

Filemot.     (F.)     A  yt']l()wisli-l)i-()\vii  oi-  faded  leaf  color. 

Filet.     (F.)     The  ramifications  of  the  smaUest  vessels  and  nerves. 

Fili.     (It.)     Sutures. 

Filicism.     Poisoning  from  overdosage  of  exti-act  of  male-fern. 

Filius  Mesue.  A  mediaeval  Arabian  ophthalmologist.  See  Abu  Zaka- 
rija  Juhanna  b.  Masawaih. 

Filix  mas.  Male  p^ern.  Aspidium.  Male  shield-fern.  This  is  the 
dried  rhizome  of  Dryopteris  (Aspidium)  filix  mas.  It  contains  filicic 
acid,  filicin  and  other  active  ingredients — especially  an  active  oleo- 
resin.     Dose :  2-8  grms. ;  Fl-ext.  2  to  6  cc. 

The  amblyopia  from  this  agent  has  long  been  recognized.  Parsons 
(Pathology  of  the  Eye,  p.  1340)  thinks  the  visual  disturbances 
caused  by  filix  mas  show  resemblance  to  quinine  amlyopia  on  the  one 
hand  and  to  lead  poisoning  on  the  other.  Whether  the  toxic  agent  is 
filieic  acid  or  aspidin  and  aspidinin  remains  uncertain,  and  there  is 
also  great  divergence  of  opinion  as  to  the  toxic  dose  of  the  drug. 
Bokai  puts  the  latter  as  low  as  4  grms.,  whilst  Sidler-Huguenin  found 
that  20  to  45  grms.  might  be  innocuous  amongst  the  workers  in  the 
St.  Gotthard  tunnel.  Probably  the  general  health  of  the  patient  is 
the  determining  factor.  Katayama  and  Okamoto  found  ocular  symp- 
toms in  32.5  per  cent,  of  cases  of  filix  poisoning,  and  35.7  per  cent. 
in  dogs.  IMaj  found  2  eases  of  blindness  amongst  70  people.  Sidler- 
Huguenin  in  78  cases  found  12  deaths,  18  bilateral  and  15  unilateral 
blindness,  4  bilateral  and  1  unilateral  permanent  amblyopia,  and  1 
bilateral  and  3  unilateral  transient  amblyopia.  The  amblyopia  gen- 
erally involves  the  whole  field,  thus  accounting  for  the  striking 
absence  of  details  of  the  condition  of  the  fields  in  the  recorded  cases. 
Quite  a  consideral)le  proportion  of  the  cases  are  unilateral,  but  too 
much  stress  must  not  be  laid  upon  this  fact,  since  the  other  seldom 
escapes  entirely,  especially  in  the  early  stages. 

The  chief  ophthalmoscopic  feature  observed  is  extreme  pallor  of 
the  disc  witli  sharply-defined  edges.  Tn  transitory  eases  the  ojihthal- 
moscopic  picture  may  be  normal.  In  numy  eases  the  retinal  vesst4s 
sliow  abnormalities,  especially  constriction.  Anatomically  in  experi- 
mental cases  IMasius  and  IMahaim  found  perivascular  infiltration  and 
breaking  up  of  tlic  myelin  sheaths  in  tlie  optic  nerve.  ]iarticularly  in 
the  neighborhood  of  tlie  optic  foranuMi.  iMarkt'd  retinal  clianges — 
bright   wliitc   spols,  etc. — have   been   observed,  but   it   is   known   that 


FILM  PREPARATIONS  5199 

filix  iiia.s  nuiy  cause  iicpliril  is,  and  these  eliaii<ij<',s  may  be  secondary 
to  tliis  coiiiplieatioii.  No  post-morteii  examination  in  man  lias  been 
reported,  but  there  is  a  hirge  literature  of  experimental  observations 
on  animals.  The  most  extensive  changes  are  recorded  by  Nuel,  but 
the  most  accurate  are  those  of  Bireh-llirschfeld,  who,  using  the  deli- 
cate Nissl  method,  found  chromatolysis  in  the  retinal  ganglion  cells 
and  in  the  cells  of  tlie  inner  nuclear  layer.  Degenerative  changes  are 
found  in  the  optic  nerve,  attributed  by  some  to  the  degeneration  of 
the  ganglion  cells,  by  others  to  the  direct  action  of  the  poison.  Masius 
and  Mahaim,  again,  attril)ute  the  cellular  changes  to  defective  nutri- 
tion following  the  vascular  disorder.  In  any  case  there  can  be  little 
doubt  that  the  lesion  is  essentially  perii)heral.  There  is  only  slight 
evidence  of  a  specific  action  upon  the  sympathetic  system,  but  it  is 
not  disproved. 

Schoening  {Zeitschr.  f.  Augcnh.,  INIarch,  1908)  records  a  case  of 
bilateral  filix  mas  amaurosis,  in  a  patient  to  whom  the  drug  was  admin- 
istered for  the  expulsion  of  intestinal  worms.  He  considers  as  notable 
the  facts  that  the  patient  was  a  young,  robust  man,  that  no  prepara-- 
tory  weakening  treatment  had  been  used,  that  he  possessed  no  idiosyn- 
crasy toward  the  drug,  as  was  shown  by  a  previously  well-borne  treat- 
ment with  the  same  remedy;  that  no  castor  oil  was  administered 
afterward  as  a  laxative ;  and  further,  that  ophthalmoscopic  examina- 
tion was  made  within  seven  hours  after  the  appearance  of  the  visual 
disturbance,  which  at  first  manifested  itself  as  contracted  arteries  and 
dilated  veins,  but  later  by  a  peculiar  folding  of  the  retina,  probably 
dependent  upon  edema.  The  first  perception  of  light  appeared  in  the 
left  eye  14  days  after  the  blindness,  and  not  in  the  center,  as  Nieden 
saj's  is  the  rule,  but  in  the  periphery,  A  case  of  poisoning  by  extract 
of  male  fern  is  also  reported  by  von  Kriidener  {Arch.  cVOphtal.,  p. 
716,  Nov.,  1908),  who  thinks  the  drug  acts  on  the  ganglionic  layer  of 
the  retina. 

Perrod's  patient  {Ann.  cU  OH.,  xli,  p.  17, 1912)  had  taken  135  grains 
of  male  fern  at  night,  and  90  grains  on  rising,  with  a  saline  purgative. 
The  following  morning  he  was  comi)letely  blind.  The  ophthalmo- 
scope showed  papilledema  which  was  succeeded  by  atrophy.  Loss  of 
sight  was  permanent.  See,  also,  Toxic  ajnblyopia. 
Film  preparations.  Tn  bacteriology  a  method  of  examining  discharges 
and  secretions.  For  example,  Hanford  McKee  {Oph.  Jiccord,  Jan., 
1912)  describes  slides  for  demonstrating  the  presiMice  of  the  gonococ- 
cus.  With  an  ear  curette  the  palpebral  conjunctiva  is  gently  stroked, 
and  the  material  spread  carefully  over  a  glass  slide.  It  is  then  dried 
in  the  air,  and  fixed  in  80  per  cent,  alcohol  for  ten  minutes  and  then 


5200  FILTERING  SCAR 

stiiiiifd  with  (iiiMiisa  solution,  one  to  t\Vfiit\'  pai'ts  of  (lislilic(l  water, 
for  twenty  minutes.  In  each  of  these  eases  where,  hy  examining  the 
pus,  the  results  ai'e  negative,  the  epitiielial  cells  are  found  crowded 
witli  l)iscui1-shapc(l  diplococci. 
Filtering-  scar.  Fii/ikr  (jicatrix.  ('ystoid  cicatrix.  Especially  in  cer- 
tain glaucoma  opei'ations  it  is  considered  essential  tliat  a  satisfactory 
drainage  path  shall  he  established  between  the  anterioi-  chainln'i-  and 
the  subconjunctival  space,  or  even  that  the  discharge  occur  npon  the 
external  bulbar  surface.  It  was  at  one  time  thought  that  this  process 
was  osmotic  in  character,  through  the  thinned  cicatricial  tissues  of 
the  (operation)  wound.  Now  it  is  known  that  in  such  procedures  as 
the  Lagrange  and  Elliot  operations  successfid  drainage  occurs  by  way 
of  minute  openings  or  fistulettes.  See  Glaucoma. 
Filter,  Wood's.    See  Wood's  filter. 

Filtration  ang"le.  Iriuocokxeal  angle.  Angle  of  the  anterior  cham- 
ber, important  in  glaucoma  and  other  ophthalmic  diseases. 
Filtration  chemosis.  Filtration  edema.  This  occurs  when  the  aqueous 
humor  escapes  beneath  the  conjunctiva  through  a  fistula  at  the  sclero- 
corneal  junction. 
Filtration,  Ocular.  The  reader  is  referred  to  incidental  discussions  of 
this  subject  under  various  headings,  especially  under  Circulation  of 
the  intraocular  fluids  (page  2256,  A^ol.  Ill,  of  this  Encyclopedia)  ; 
Glaucoma;  Tension  and  allied  captions. 

To  the  information  there  given  it  may  here  be  said  that  one  of  the 
best  demonstrations  of  the  process  of  ocular  filtration  as  it  occurs  in 
the  lower  animal  eye,  is  furnished  by  the  experiments  of  Uribe  Tron- 
coso  {Anualcs  d'Oculist.,  Oct.,  1909).  This  observer  devised  an 
ingenious  method  by  means  of  which  the  amount  of  aqueous  secreted 
can  be  accurately  measured,  and  the  paths  by  Avhich  the  secretion 
leaves  the  globe  can  be  made  visible  to  the  naked  eye.  Experiments 
made  by  means  of  his  appliances  go  to  support  Troneoso's  views,  that 
Lel)er's  estimates  of  the  rate  of  filtration  iiuule  with  the  manometer 
are  unrelial)le.  For  the  puri)Ose  of  his  experiments  Troncoso  found 
that  rabl)its^  eyes  were  very  suitable  owing  to  the  ease  with  which 
they  can  be  luxated  from  the  orbit. 

The  animal  having  been  fixed,  and  the  lids  and  neighboring  parts 
shaved  and  disinfected,  the  eye  is  dislocated  forwards  by  means  of 
forceps  traction  applied  to  the  conjunctiva  and  the  superior  rectus. 
The  conjunctiva  is  then  cut  all  round  the  limbus  and  separated  from 
the  sclei-otic  as  far  l)ack  as  the  equator.  The  recti  may  be  cut  or  not 
as  desired,  as  that  nud<es  no  ditVcrence  in  the  experimental  results. 
The  eye  is  held  in   |)ositioii  by  the  closure  of  the  lids  behind  it.  but 


FILTRATION.  OCULAR  5201 

tliis  may  be  made  imoil'  si-curc  by  a  stitch  tliroiigh  the  lids  near  the 
canthus.  The  slight  heinorrliage  having  been  allayed  the  eye  is 
plunged  into  a  glass  cup,  a  little  larger  in  diameter  than  the  eye,  con- 
taining pure  olive  oil,  and  held  vertically  below  the  eye,  which  is  so 
arrangetl  that  the  cornea  looks  downwards. 

The  glass  cup  is  connected  below  with  a  horizontal  graduated  tube 
— which,  however,  is  not  generally  used  for  measuring  the  amount  of 
secretion.  Tiiis  is  clamped  to  a  stand  which  holds  the  whole  arrange- 
ment in  position.  The  eye  is  immersed  as  far  as  its  equator  in  the 
cup  whose  edge  is  made  to  fit  the  orl)ital  margins  accurately  by  means 
of  a  rubber  memljrane  having  a  perforation  just  large  enough  to 
admit  the  globe.  This  membrane  is  not  absolutely  necessary,  but  it 
has  the  advantage  that  it  more  completely  isolates  the  eye  and  keeps 
out  an}'  liquids  oozing  from  the  lids  and  conjunctiva,  though  it  inter- 
feres somewhat  with  the  view  of  the  changes  at  the  limbus. 

A  few  minutes  after  the  immersion  of  the  eye  in  the  oil  the  slight 
hemorrhage  from  the  limbic  vessels  becomes  arrested,  but  continues 
a  little  time  longer  from  the  muscular  vessels,  from  which  two  or  three 
big  drops  hang  down,  and  after  about  ten  minutes  let  fall  into  the 
oil  large  drops  of  slightly  rose-tinted  lymph.  The  aqueous  also  escapes 
in  the  form  of  very  small  transparent  drops  arranged  in  a  circle  like 
a  string  of  pearls  around  the  corneal  limbus.  These  generally  fuse 
and  also  fall  into  the  oil,  but  occasional!}'  they  have  to  be  shaken  off 
by  stroking  the  eye  with  a  spatula.  Both  large  and  small  drops  gravi- 
tate to  the  bottom  of  the  cup  and  form  a  clear  or  slightly  rose-colored 
globule.  Its  volume  is  further  increased  by  detaching  the  liquid  and 
clots,  still  adherent  to  the  eye,  by  stroking  with  a  spatula  or  by  means 
of  forceps.  The  oil  and  the  exudate  are  centrifugalized  so  that  all 
the  fine  drops  dispersed  through  the  oil  join  the  rest  of  the  lymph, 
which  is  then  measured  in  a  graduated  tube  and  its  respective  ingre- 
dients estimated.  As  a  rule  the  lymph  is  allowed  to  exude  for  half 
an  hour  to  an  hour.  The  experiments  can  be  repeated  after  the  eye 
has  been  cleaned  and  fresh  oil  placed  in  the  cup.  In  the  repeated 
experiments  the  amount  of  blood  and  fibrinous  clot  is  negligible. 

Troncoso  finds  that  the  rate  of  filtration  in  the  same  eye  is  remark- 
ably uniform — about  5  cubic  millimetres  per  minute — but  the  rate  of 
filtration  in  the  eyes  of  different  animals  may  vary  from  3  to  8.9  cubic 
millimetres  per  minute. 

As  the  amount  of  blood  and  fibrinous  clot  varied  in  different  animals 
careful  calculations  for  these  factors  had  to  be  made  in  each  case. 
The  liquid  in  the  graduated  tube  forms  three  layers,  viz.,  (1)  blood- 
clot;    (2)    aqueous  humor  and  blood  serum  mixed;   (3)   very  small 

Vol.  VII— 23 


5202  FILTRATION,  OCULAR 

layer  of  lihriiious  c-lot.  To  find  Ihc  aiiiouiit  of  pure  atiucous  liuiuor 
the  quantity  of  .scrum  which  represents  the  amount  of  blood-elot  regis- 
tered is  subtracli'd  from  the  reading  of  the  second  layer.  The  relative 
(piantity  of  coi'i)Uscles  and  serum  in  the  rabbits'  blood  is  determined 
beforeluind  by  means  of  a  hematocrite,  or,  more  accurately,  by  running 
blood  tlirect  from  a  vein  in  tiie  rabbit's  ear  into  a  graduated  tube 
containing  oil.  \Vlien  centrifugalized  the  relative  amount  of  cor- 
puscles and  serum  can  be  read  olf.  Tlie  average  amoujit  of  serum 
to  clot  is  02 :  100. 

The  technicjue  of  the  experiments  is  such  tliat  the  .slight  traumatism 
incurred  in  no  way  invalidates  or  impairs  tlie  accuracy  of  the  results. 
This  ocular  demonstration  of  filtration  in  tlie  living  eye  disposes  of  the 
doubts  expressed  by  Weiss  and  Abadie,  as  to  the  existence  of  intra- 
ocular currents  and  the  constant  secretion  and  excretion  of  aqueous, 
and  confirms  the  classical  views  on  the  subject. 

The  amount  of  aqueous  excretion  varies  with  intraocular  pressure, 
and  the  secretion  of  the  ciliar}-  processes  is  dependent  on  the  intra- 
vascular pressure.  The  discharge  of  lymph  by  the  canal  of  Schlemm 
results  from  a  veritable  filtration  through  the  membrane  which  forms 
its  inner  wall,  and  is  due,  as  all  filtration,  principall}'  to  the  pressure 
of  the  filtering  liquids,  which  varies  with  intraocular  pressure.  The 
latter  is  the  result  of  two  factors — (1)  the  blood  pressure  in  the  uveal 
and  retinal  vessels;  (2)  the  secretion  of  aqueous  humor.  The  second 
is  in  direct  relation  to  the  first,  but  this  relationship  is  not  absolute, 
and  the  eye  retains  a  certain  autonomy  of  tension  according  to  the 
quantity  of  liquids  it  contains.  As  the  author  has  already  pointed 
out  {Antiales  d'Oculistique,  February,  1907),  intraocular  tension  may 
fall  w'hen  the  uveal  blood  supply  is  abnormal,  as  in  the  terminal  stages 
of  plastic  or  serous  iridocyclitis.  On  the  contrary,  excretion  and 
secretion  are  normally  so  well  balanced  that  intraocular  tension 
remains  tlie  same,  notwithstanding  variations  of  blood  pressure. 

The  paths  of  aqueous  excretion  include  not  only  the  canal  of 
Schlemm,  but  also  the  anterior  surface  of  the  iris,  as  shown  by  Nisei 
and  Benoit.  but  it  is  highly  probable  that  the  spaces  of  Fontana  and 
the  canal  of  Schlemm  represent  the  anatomically  and  physiologically 
specialized  path,  and  that  under  normal  conditions  the  whole  excretion 
passes  this  way.  Assuming  this  to  be  correct,  and  that  secretion  and 
excretion  are  approximately  equal,  the  experiments  show  that  the 
average  secretion  in  a  rabbit  is  5.2  cubic  millimetres  per  minute. 

By  cauterizing  the  anterior  ciliary  vessels  the  amount  of  lymph  ex- 
creted was  found  to  be  2.1  cubic  millimetres  per  miimte,  and  tliis  may 


FILTRATIONSWINKEL  5203 

be  regarded  as  the  quantity  passing  through  the  perforating  vessels 
at  the  limbiis. 

In  one  abnormal  ease  tlie  transudation  at  tlie  limbus  was  praetically 
absent,  and  the  rate  of  filtration  was  2.9  cubic  millimetres  per  minute, 
which  closely  represents  the  (luaiitity  discharged  by  the  anterior  ciliary 
veins. 

An  examination  of  the  blood  in  the  anterior  ciliary  veins  also  shows 
that  the  proportion  of  serum  to  eorpuscles  is  much  higher  than  it  is  in 
blood  taken  from  other  parts  of  the  body,  indicating  that  there  is  a 
decided  admixture  of  aqueous  humor  in  the  former. —  (J.  Jameson 
Kvaiis,  Oph.  Review,  Feb.,  1910.) 

Filtrationswinkel.     (G.)     Filtration  angle. 

Filzlaus.     (G.)    Pediculus  pubis. 

Finder.  In  microscopy,  any  device  enabling  one  to  find  easily  some 
object  or  part  in  a  microscopical  preparation.  It  may  consist 
simply  of  a  ring  painted  around  the  object,  of  verniers  on  the  stage  of 
the  microscope,  or  of  a  glass  slide  ruled  in  squares  for  registering  the 
position  of  the  microscopical  specimen  when  the  object  is  in  the  field. 
Then  by  putting  the  slide  back  in  the  same  position  on  the  stage  of 
the  microscope  the  object  will  be  in  the  field.  Frequently,  as  with  a 
telescope,  an  objective  of  low  power  is  used  to  find  the  object  and  get 
it  into  the  middle  of  the  field,  where  it  can  be  found  easily  by  the  high 
objective.     (Foster.) 

Fine  adjustment.  The  adjustment  of  an  optical  instrument  by  means 
of  a  luierometer  screw. 

Finger  mirror.    A  mirror  attached  to  the  finger  by  a  clasp. 

Finger-piece  eyeglasses.    See  Eyeglasses  and  spectacles,  History  of. 

Finite  rays.  Foi-  practical  purposes  it  is  assumed  that  (and  this  name 
is  given  to)  rays  of  light  that  come  from  a  less  distance  than  six 
metres. 

Finne.     (G.)     Cysticercus. 

Finsen  lamp.  Finsen  light.  The  concentrated  light  produced  by  this 
lamp  is  (Extra  Pharmacopeia)  violet  and  ultra-violet.  It  is  produced 
by  an  arc  lamp  in  which  the  heat  rays  are  cut  off.  Finsen 's  original 
lamp  has  been  improved,  and  is  known  as  the  "  Finsen-R<^yn "  lamp. 
It  is  portable,  suitable  for  one  patient  at  a  time,  and  Finsen  acknowl- 
edges its  efficacy. 

Fluorescent  substances,  e.  g.,  esculin  (5  minims  of  a  5  per  cent,  solu- 
tion) injected  innnediately  beneath  the  skin  to  be  treated  are  some- 
times used  as  adjuvants. 

The  rays  obtained  from  carbon  electrodes  are  more  effective  than 
those  given  off  bv  ii'on  ones.     The  current  used  in  the  lamp  has  a 


5204  FINSEN,  NIELS  R. 

strength  of  40  to  80  amperes  and  an  electromotive  force  of  from  45  to 
50  volts.  Rock-crystal  lenses  are  enii)loyed  wliicli  allow  of  the  com- 
plete passage  of  tlie  ultra-violet  light. 

Trachoma,  chronic,  siiuph'  granuiai-  lids  and  many  other  eye  dis- 
eases have  been  reported  as  cured  or  improved  by  tliis  agent,  but  the 
Editor  has  not  l)een  al)le,  after  a  fair  trial,  to  corroborate  this  evidence. 

However,  several  observers  appear  to  be  much  impressed  by  the 
light  as  a  therapeutic  agent.  Among  them  Gronholra  and  Ileiberg 
(Graefe's  Archiv  f.  Ophthalm.,  Vol.  8i),  1,  pt.  1)  treated  72  patients 
(400  sittings)  for  six  months.  A  small  area  of  the  conjunctiva  was 
treated  at  a  time  for  a  period  of  from  5  to  40  minutes  and  a  sitting 
lasted  from  one  to  two  hours.     (Trachoma.) 

The  most  rapid  improvement  was  obtained  by  using  the  light  about 
a  week  after  a  previous  expression  of  the  granulations.  Considerable 
reaction  follows,  lasting  two  or  three  weeks,  and  leaving  a  smooth 
pale  surface  with  scarring  more  superficial  than  that  produced  by 
copper  sulphate.  As  a  rule  one  application  sufficed,  in  a  few  more 
obstinate  cases  up  to  six  were  required.  In  many  cases  the  treatment 
was  completed  in  a  month. 

After  a  year  60  of  the  eyes  were  reported  on,  of  which  over  50  per 
cent,  were  still  healthy.  The  remainder  showed  recurrence,  most  fre- 
quently in  cases  which  had  been  in  an  advanced  state  of  the  disease 
with  considerable  shrinkage  of  the  conjunctiva  when  the  treatment 
was  begun. 

In  several  cases  corneal  complications  occurred,  or  when  present, 
W'Cre  aggravated. 

The  authors  conclude  that  the  Fiusen  light  has  a  special  power  of 
destroying  the  trachomatous  tissue  and  is  in  this  respect  distinctly 
superior  to  copper  sulphate. 

Lunsgaard  {Klin.  Mon.  f.  AngcnhcUk.,  Dec,  1911,  p.  763)  also 
reports  good  results  from  Finsen's  light  in  20  cases  of  lupus  and  pri- 
mary tuberculosis  of  the  conjunctiva,  without  injury  to  the  eyeball  and 
without  relapses. 

One  of  the  important  discoveries  made  by  Finsen  was  that  it  is  the 
blood  in  the  skin  wdiich  absorbs  most  of  the  ultra-violet  light.  Sun- 
light ultra-violet  can  penetrate  blood-filled  skin  only  a  fraction  of  a 
millimeter.  But  if  the  skin  is  made  anemic  by  the  pressing  out  of  the 
blood,  ])acteria  can  be  killed  by  the  ultra-violet  light  wliieh  has  passed 
throu'^h  4.25  millimeters  of  skin. 
Finsen,  Niels  R.  (1861-1004),  discoverer  of  the  curative  i)ower  of  the 
chemical  rays  of  light  (sunlight,  electric  light,  Kontgen  rays,  etc.) 
and   founder  of  phototherapy,   was  born   in   the   Faroe   Isles,   and 


FIOLAX  GLASS  5205 

tauglit  anatomy  at  tlie  University  of  Copenhagen.  He  has  shown 
that  the  effects  of  light  upon  biological  processes  are  due  almost 
exclusively  to  the  chemical,  or  violet  and  ultra-violet,  rays  of  the 
spectrum.  The  Finsen  lamj),  which  is  employed  to  destroy  certain 
pathogenic  organisms,  as  in  lupus,  favus,  ring-worm,  and  alopecia 
areata,  concentrates  the  rays  of  an  electric  arc  lamp  by  means  of  a 
lens  composed  of  one  tiat  and  one  curved  disc,  between  which  is 
interposed  a  solution  of  coi)i)er  suli)hate.  In  1903  he  was  awarded 
the  Nobel  prize  for  medicine. — (Standard  Encyclopedia.)  See  his 
Chemical  rays  and  variola  (1894)  ;  also  Pliototlicrapy. 

Fiolax  g"lass.  Glass  free  of  alkaline  salts,  and  when  tinted  supposed  to 
act  as  a  protection  to  the  eye  from  excess  of  actinic  rays. 

Fire-gazers.  This  term  was  probably  first  introduced  into  ophthal- 
mology by  Xettleship  {Trans.  Oph.  Soc.  U.  K.,  Vol.  32,  p.  388,  1912), 
who  referred  to  dogs  that  look  steadily  into  a  fire  at  close  range,  and 
are,  in  consequence,  lia])le  to  get  the  cornea  encroached  upon  by  black 
pigment.  In  one  such  case  which  he  saw  the  cornea  was  covered  with 
what  appeared  to  be  a  melanotic  deposit.  It  was  only  on  the  surface, 
and  there  was  no  central  thickening;  nothing  like  a  tumor. 

Firemen,  Railway,  Examination  of  the  eyes  of.  See  Eyes  of  soldiers, 
sailors,  railway  and  other  employees,  Examination  of  the. 

First  aid  in  ophthalmic  surgery.  The  emergency  treatment  of  urgent 
eye  symptoms — traumatic  lesions  es})ecially — often  falls  to  the  general 
practitioner  and  not  infrequently  to  the  layman.  Those  ophthalmolo- 
gists who  lecture  to  nurses,  lay  members  of  Red  Cross  societies,  and 
other  semi-professional  organizations,  are  advised  to  read  M.  Buchan- 
an's First  Aid  to  the  Injured  Eye  {Woman's  Med.  Jour.,  Feb., 
1911),  as  well  as  the  caption  Injuries  of  the  eye  in  this  E ncyclapedia. 

First-base  character.  In  alphabets  and  print  for  the  blind  (q.  v.),  this 
is  a  character  having  a  dot  or  dots  in  the  first  vertical  column  only. 
A  second-base  character  has  dots  in  the  first  and  second  vertical  col- 
umns only.  Third-base  characters,  fourth-base  charactei's,  etc.,  may 
be  similarly  defined. 

First  intention.  An  immediate  union  in  which  the  surfaces  of  the  wound 
become  glued  together  by  an  albuminous  fluid  and  the  wound  heals 
without  further  redness,  swelling,  or  the  formation  of  pus. 

First  principal  focus.    See  Focus. 

Fischer,  Jchann  Friedrich  Christoph.  A  German  physician,  surgeon 
and  ophthalmologist,  especially  celebrated  as  an  operator  for  cataract. 
Born  at  Erfurt,  April  9,  1772,  he  became  at  first  an  apothecary,  in 
which  capacity  he  lived  for  a  time  at  Wetzlar,  ]\Iainz,  Blankenhain. 
and  Erfurt.     Turning  his  attention  to  medicine,  he  studied  at  Jena 


5206  FISCHER,  JOHANN  NEPOMUK 

and  Kifiirt,  at  the  latter  institution  receiving  his  degree.  After  a 
t'Oiisi(k'ra])le  i)('riod  of  military  service  he  studied  again,  at  Vienna, 
and,  settling  as  a  piiysician,  but  chieHy  as  an  ophthalmologist,  in  his 
native  city,  Erfurt,  he  founded  there,  in  connection  with  a  minister, 
an  "Institution  for  the  Hlind  and  for  Eye  Patients."  lie  died  Sept. 
14,  1849. 

Fischer's   most    important    (or   only)    ophthalmologic   writing   was 
"Einige    Bemcrkungeii    iibcr    das    Verliidtniss    der    Extraction    des 
Grauen    Staares    zur    Keratonyxis    liinsiehtlicli    der   Gefiihrlichkeit," 
etc.     (Langenbeck's  Neue  Bibliothek,  1819.)  —  (T.  H.  S.) 
Fischer,  Johann  Nepomuk.     The  founder  of  modern  o])hthalmology  in 
Bohemia.     Boiii   at    l\uiiil)urg,   Bohemia,   ]\Iay   29,   1777,   he   received 
his  medical  degree  at  Vienna  in  1806.     Later,  he  became  Professor  of 
Oi)lithalmology  at  the  University  of  Prague,  and  the  first  physician 
ever  appointed  to  the  Prague  Oi)litlialmic  Institute.     lie  was  chiefly 
active  as  a  teacher  and  oi)erator.  l)ut  wrote  :    "Lehrhuch  der  Gesamten 
Entziindungen  und  Organischen  KrankJiciteti  des  MenscJdichen  Auges, 
Seiner  Schutz-  und  Hilfsorgane''  (Prague,  1846).— (T.  H.  S.) 
Fischer,  Waldemar  Edward.    A  well-know^n  St.  Louis  ophthalmologist, 
of  great  promise,  who  died  young.     He  was  born  at  St.  Louis,  Mo., 
Sept.  13,  1877,  son  of  Dr.  Joseph  A.  Fischer,  a  dentist,  and  Alma  C. 
Fischer.    His  medical  degree  was  received  at  the  Marion  Sims  College 
of  Medicine,  St.  Louis,  in  1898.    He  then  took  a  special  course  in  oph- 
thalmology at  Berlin,  Germany,  and  Vienna,  Au.stria,  from  1899  till 
1901.    Returning  to  St.  Louis,  Fischer  became  an  assistant  in  the  eye 
clinic  of  the  Clarion  Sims  College,  and  at  the  American  ]\ledical  Col- 
lege, the  Medical  Department  of  the  National  University.     He  was 
also  ophthalmic  surgeon  at  the  Missouri  Baptist  Sanitarium. 

He  w^as  a  man  of  impressive  presence,  tall  and  lean,  with  dark  com- 
plexion and  very  dark  eyes  and  hair.  He  was  quiet,  earnest  and  digni- 
fied in  his  manner,  and  made  many  friends. 

"When  only  thirty-seven  years  of  age,  Dr.  Fischer,  being  seriously  ill 
from  overwork,  committed  suicide,  Jan.  9,  1915.  The  circumstances 
of  this  tragical  occurrence,  as  well  as  a  number  of  further  particulars 
concerning  the  Doctor's  work  and  personality,  appear  in  the  following 
quotation  from  the  St.  Louis  Globe -Democrat:  "Dr.  Waldemar  E. 
Fischer,  37  years  old,  an  oculist  with  offices  in  the  Wall  Building, 
committed  suicide  yesterday  at  his  home,  3634A  Connecticut  Street, 
by  asphyxiating  himself  with  illuminating  gas.  A  nervous  breakdown 
due  to  overwork  is  ascribed  by  his  father.  Dr.  Joseph  A.  Fischer,  of 
the  same  address,  as  responsi))le  for  the  suicide. 

"The  father  informed  the  police  that  his  son  had  been  overworked. 


FISCHVERGIFTUNG  5207 

ami  that,  on  Dec.  25  last,  he  liad  closed  his  office  intending  to  go  to 
Asheville,  N,  C,  to  take  a  rest. 

"Dr.  James  JNloores  Ball,  dean  of  the  Medical  School  of  the  National 
University  of  Arts  and  Sciences,  said  yesterday:  'The  death  of  Dr. 
AValdemar  Fischer  is  a  tlistinct  loss  to  oplithalmology.  While  his  con- 
tributions to  the  literature  of  tliis  branch  of  medical  science  were  not 
numerous,  he  had  in  him  much  promise,  and  the  articles  which  he  did 
write  were  beyond  adverse  criticism. 

"  'His  paper  on  "Coloboma  Macula;  Luteae,"  published  in  the 
Annals  of  Ophthalmology,  January,  1906,  was  quoted  in  scientific 
journals  all  over  the  world.' 

"Dr.  Fischer  also  wrote  the  chapter  on  'Methods  Employed  in  the 
Microscopic  Examination  of  the  Eye'  for  Ball's  'Modern  Ophthalmol- 
ogy.'   Dr.  Ball  said  that  this  chapter  was  one  of  the  best  in  his  work. 

*'Dr.  Fischer  was  a  man  of  the  highest  integrity,  and  politeness 
under  any  and  all  conditions  was  one  of  his  chief  characteristics.  The 
word  geutlenmn  describes  him  completely. 

"He  was  a  generous  man,  and  much  of  his  work  was  done  for  char- 
ity."—(T.  H.  S.) 
Fischvergiftung.  (G.)  Poisoning  from  (decomposed)  fish. 
Fishes,  Eyes  of.  The  eyeballs  of  fishes  are  rarely  spherical,  owing  to 
their  flattened  cornea.  There  are  no  movable  eyelids,  but  sometimes 
the  eye  is  provided  with  fixed  dermal  folds,  evidently  the  analogues 
of  lids.  In  the  mackerel  and  the  herring  a  transparent  membrane 
partially  surrounds  the  eye,  while  in  some  sharks  there  is  a  well- 
defined,  movable,  nictitating  membrane  drawn  over  the  cornea,  as  in 
birds,  by  adductor  muscles.  The  sclera  is  well  developed;  externally 
of  fibrous  tissue,  internally  a  cartilaginous  layer,  which,  as  in  the 
sturgeon,  is  sometimes  very  thick.  In  the  bony  fishes  this  layer  of 
cartilage  is  further  stiffened  at  the  corneal  border  by  two  osseous 
plates.  In  some  cases  these  plates,  as  in  birds,  form  a  complete  ring 
about  the  cornea.  The  piscian  choroid  is  composed  of  several  layers; 
externally  one  notices  the  silvery  sheen  of  the  tunica  argcntea,  a  thin 
areolar  tissue  layer  studded  with  crystals.  In  the  dogfish,  sharks,  etc., 
and  the  cartilaginous  ganoids,  occurs  a  true  light-reflecting  tapetum. 
In  the  osseous  fishes  is  found  the  so-called  "choroid  gland,"  a  large, 
horseshoe-shaped  organ  placed  in  the  neighborhood  of  the  optic  nerve. 
These  animals  also  exhibit  the  processus  falciformis,  often  described 
as  a  fold  of  the  choroid,  the  analogue  of  the  pecten  in  birds  and 
attached,  like  it,  within  the  eyeball  along  the  optic  nerve  entrance. 

Referring  to  a  few  of  the  questions  involved  in  the  visual  apparatus 
and  eyesight  of  fishes,  R.  W.  "Wood  {Johns  Tlopliins  University  Circu- 


5208  FISH-POISONING 

lar,  Aj)ril,  1!)0(>J  i-cniarks  tliat  a  liiiiiiaii  eye  below  the  surface  of 
water  sees  the  sky  compressed  into  a  comparatively  small  area  of 
light,  the  center  of  which  is  always  immediately  above  the  observer, 
the  appearance  being  as  if  the  pond  were  covered  with  an  opaque  roof 
with  a  circular  window  cut  in  it.  Surrounding  objects  appear  around 
the  rim  of  the  circle  of  light,  but  of  these  we  are  unable  to  get  a  clear 
notion,  since  our  eyes  are  not  adapted  to  clear  vision  under  water. 
By  immersing  a  camera  in  water  and  photographing  the  circle  of 
light  we  can  get  an  idea  of  how  these  things  appear  to  the  fish.  A 
niimber  of  interesting  pictures  were  obtained  with  a  device  equivalent 
to  a  lens  having  a  working  angle  of  180  degrees.  A  pin  hole  in  place 
of  the  lens  gives  even  better  definition.  The  apparatus  in  a  horizontal 
position  represents  things  as  seen  by  a  fish  looking  through  the  glass 
sides  of  an  aquarium.  The  cone  of  light  entering  a  fish's  eyes  has  an 
aperture  of  about  96  degrees,  but  the  rays  within  it  came  originally 
from  a  cone  of  180  degrees.  Thus,  all  three  sides  and  the  complete 
ceiling  and  floor  of  a  room  may  be  photographed,  or  when  placed  at  a 
point  where  four  streets  meet  at  a  right  angle  we  can  get  a  view  looking 
down  any  three  streets,  the  view  including  the  ground  up  to  the  base 
of  the  tripod  and  the  sky  from  the  horizon  to  the  zenith.  Suspended 
from  a  balloon,  it  will  photograph  the  entire  surface  of  the  earth  out 
to  the  horizon  in  all  directions.  There  is  a  good  deal  of  distortion 
near  the  circumference  of  the  circular  picture.  See,  also.  Blind  fishes ; 
as  well  as  Comparative  ophthalmology. 

Fish-poisoning.  The  toxic  effects  of  certain  i)tomaines  formed  in  decom- 
posing fish.  The  symptoms  are  choleraic,  paralytic,  or  exanthematic. 
AVith  the  first  there  are  vertigo,  headache,  pallor,  thirst,  abdominal 
pain,  diarrhea,  and  anuria ;  with  the  second  the  preceding  symptoms 
are  present,  as  well  as  mydriasis,  ptosis,  decrease  of  body  tempera- 
ture, weakness  of  the  heart's  action,  and  eventually  coma  and  death. 
In  the  exanthematic  form  there  are  fever  and  an  erysipelatous  erup- 
tion, followed  by  desquamation,.    See  Toxic  amblyopia. 

Fissile.    Suscei)tible  of  cleavage. 

Fission.  A  mode  of  generation  or  of  cell-division  in  which  the  organ- 
ism separates  into  two  or  more  ecpial  jiarts,  each  of  Avliich  becomes 
(Icvclopcd  to  the  size  and  form  of  the  original. 

Fissura  facialis.  A  name  for  congenital  lachrymal  tistula.  The  ojion- 
ing  probably  corresponds  to  the  nasal  pouches  of  fishes  and  the 
lacliryiiial  sinus  of  several  of  the  higher  vertebrates.  See  Congenital 
anomalies  of  the  eye. 

Fissura  palpebrarum.     (  L.)     'i'lie  space  betAveen  the  eyelids. 


FISSURE  5209 

Fissure.  A  groove  or  clcfl.  A  tci'in  applied  to  llic  clefts  or  grooves 
ill  various  organs. 

Fissure,  Ammon's.  During  tlie  early  i'etai  period,  a  pyrilorni  fissure  iu 
the  lower  ])()iti<)ii  of  the  sclerotie  coat  of  the  eye. 

Fissure,  Calcarine.  A  fissure  on  the  mesial  aspect  of  the  cerehruin, 
extending  from  near  the  occipital  end  and  joining  tlie  occipital  fissure ; 
it  is  collocated  with  the  calcar  or  hippocam])us  minor.  Jn  this  region 
is  the  cortical  center  for  vision.  See,  also,  p.  ];i.")(),  Vol.  11,  of  this 
Encyclopedia  as  well  as  Neurology  of  the  eye. 

Fissure,  Choroid.    See  Development  of  the  eye. 

Fissure,  Collateral.  The  inferior  occipito-temporal,  or  collateral,  fissure 
is  a  comi)lete  fissure  which  gives  rise  to  the  eminentia  collateralis  in 
the  descending  horn  of  the  ventricle,  and  cuts  deeply  into  the  tem- 
poral and  o('eii)ital  lobes.  It  is  closely  related  to  the  cortical  visual 
centre. 

Fissure,  Fetal  ocular.  In  the  embryonic  eye,  a  fissure  in  the  thick  wall 
surrounding  the  lens.    A  coloboma  results  if  it  be  not  closed. 

Fissure,  Infra-orbital.  Sl?borbital  fissure.  S^henq- maxillary  fis- 
siRE.  A  fissure  in  the  superior  maxillary  portion  of  the  fioor  of  the 
orbit,  the  ui)per  termination  of  the  infraorbital  canal. 

Fissure,  Interpalpebral.  Palpebral  fissure.  Interp.vlpebral  aper- 
TiKK.  Interpam'Ebkal  SPACE.  The  space  between  the  eyelids,  extend- 
ing from  the  outer  to  the  inner  canthus. 

Anomalies  of  shape,  size  and  situation  of  this  space  are  involved  in 
such  affections  as  blepharophimosis,  epicanthus,  ankyloblepharon, 
ptosis,  ectropion,  blepharospasm,  lagophthalmos  and  entropion.  With- 
out added  remarks  on  most  of  these  subjects,  all  of  which  will  be  dis- 
cussed under  their  proper  headings,  Elschnig  (Klin.  Monatsbl.  f. 
AugenheUk.,  p.  17,  Jan.,  li)12)  refers  to  the  different  processes  which 
lead  to  shortening  of  the  palpebral  fissure  without  abnormal  adhesions 
of  the  lid  borders,  for  which  alone  the  term  ankyloblepharon  must  be 
reserved.  In  eases  of  true  blepharophimosis  the  palpebral  fissure  is  con- 
siderably shortened  in  the  horizontal  direction  and  the  temporal  com- 
missure may,  if  the  patient  looks  straight  forward,  touch  or  even 
surpass  the  temporal  margin  of  the  cornea.  If  the  lids  are  opened  wide, 
the  palpebral  fissure  may  be  just  as  high  as  wide,  and  the  temporal  an- 
gle almost  completely  rouiuled.  (ienuine  blepharoi)himosis  occurs  in 
old  people,  in  whom  the  skin  of  the  lids  is  of  senile  condition,  wrinkled 
and  easily  mova])le.  By  a  slight  traction  on  the  skin  of  the  temple 
the  normal  position  of  the  temporal  conunissure  and  the  normal  length 
of  the  palpebral  fissure  can  be  restored.  By  this  possibility  of  instan- 
taneous  restitution    the    condition    is   distinguished    from    ankyloble- 


5210  FISSURE  OF  ROLANDO 

l)liaroii.  Kuiliiiinitary  blcitliaropliiiuosis  is  very  frequent  in  old  peo- 
ple. Aeeorcling  to  von  Michel,  the  afl'eetion  is  due  to  relaxation  of  the 
lateral  palpebral  ligament,  or  tarso-orhital  fascia,  and  to  contracture 
of  the  orbicularis  muscle.  The  same  condition  is  occasionally  observed 
in  normal  elasticity  of  the  lateral  palpebral  ligament  at  every  forcible 
closure  of  the  lids. 

In  trachoma  two  forms  of  true  shortening  of  the  palpebral  fissure 
may  occur.  The  first  differs  from  senile  blepharophimosis  in  that  it 
is  also  observed  in  young  persons,  when  it  is  due  to  softening  of  all 
tissues  of  the  lids  plus  blepharospasm. 

In  the  second  and  irreparable  form  a  cicatricial  blepharophimosis 
leads  to  a  progressive  stretching  of  the  lateral  palpe])ral  ligament  and 
to  a  displacement  of  the  temporal  canthus.  True  blepharophimosis  is 
thus  either  senile,  spastic  or  cicatricial.  In  its  lighter  degi-ees  it  has 
only  a  cosmetic  significance ;  in  the  more  intense  forms  it  may  inter- 
fere with  vision  towards  the  side. 

Lateral  epicanthus  (congenital  or  spastic),  is  a  winglike  protrac- 
tion of  the  temporal  lid-skin  over  the  lateral  canthus,  produced  by 
spastic  contraction  of  the  orbicularis  muscle. 

Elschnig  has  also  ol)served  in  two  out  of  50,000  eye  patients  an 
abnormal  length  of  the  palpebral  fissure.  This  seems  to  be  a  con- 
genital afifection.  In  none  of  the  cases  did  the  exposed  conjunctiva 
give  rise  to  irritation. 

Veasey  descriljes  rhythmic  alterations  in  undth  of  the  palpehral  fis- 
sure {Ophthalmic  Y ear-Book,  p.  283,  1909)  in  a  child  subject  to  spasm 
of  the  levator.  Cure  followed  correction  of  the  hypermetropic  astig- 
matism present,  and  administration  of  arsenic.  Rhoads  has  also  ob- 
served dilatation  of  the  alffi  nasi  coincident  with  winking. 

Fissure  of  Rolando.    A  depression  in  the  occipital  lobe  of  the  brain. 

Fissure  of  the  canthus.  A  disagreeable  and  fre(|iitMitly  painful  condi- 
tion, gciici'jilly  of  llu'  outer  commissure.    See  Canthus,  Fissure  of  the. 

Fissure,  Sphenoidal.  Tlie  sphenoidal  fissure,  or  foramen  laccrum  ante- 
rins,  is  a  slit-like  opening  between  the  greater  and  lesser  wings  of  the 
sphenoid.  It  transmits  the  third,  fourth  and  sixth  nerves;  the  frontal, 
nasal  and  lachrymal  branches  of  the  ophthalmic,  or  first  division  of  the 
fifth  nerve;  filaments  from  the  cavernous  ])lexus  of  the  sympatlietic 
nerve,  the  orbital  branch  of  the  middle  meningeal  artery,  the  recurrent 
lachrymal  artery,  and  the  ophthalmic  vein. —  (J.  ]M.  B.) 

Fissure,  Spheno-maxillary.  This  oj)ening  forms  the  external  boundary 
of  the  fioor  of  the  orbit.  It  is  formed  chiefly  by  the  orbital  plate  of 
the  superior  maxillary  bone,  with  a  small  part  of  the  malar  in  front 
and  the   or])ital  plate  of  the   palate  bone  ])elnnd.     It   transmits  the 


FISTEL  5211 

superior  maxillary  nerve  and  its  orhital  l)iaii(li,  the  infra-orbital  ves- 
sels, and  ascending  branches  from  Meckel's  ganglion.  By  means  of 
the  spheno-maxillary  fissure  the  orbit  communicates  with  three  fossa; : 
the  temporal,  zygomatic,  and  spheno-maxillary. —  (J.  ^I.  B.) 

Flstel.     (G.)     Fistula. 

Fistola.     (It.)     Fistula. 

Fistula,  Capillary,  of  the  lachrymal  sac.  A  listulous  opening  into  the 
laciirymal  sac  caused  by  the  nii)ture  of  an  abscess  of  tliat  cavity. 
Se(>  Capillary  fistula  of  the  lachrymal  sac. 

Fistula,  Corneal.    See  page  '.VM'u,  \'o\.  V,  of  this  Encyclopedia. 

Fistula,  Lachrymal.     See  Lachrymal  apparatus.  Diseases  of  the. 

Fistula  of  the  lachrymal  gland.  Tiiis  lesion  may  oeeur  from  tiauma, 
dacryops,  or  a])seess,  or  it  may  be  i)resent  as  a  congenital  condition.  The 
fistula  opens  on  to  the  upper  lid,  and  presents  a  minute  orifice  through 
which  tears  ooze  forth.  Under  excitement  or  irritation  the  fiow 
becomes  profuse.  The  closure  of  such  an  opening  is  sometimes  diffi- 
cult, and,  if  the  effort  succeeds,  it  may  cause  dacryoadenitis.  The  older 
ophthalmologists  resorted  to  heroic  measures.  Beer  closed  a  fistula 
by  passing  a  red-hot  knitting  needle  into  the  opening,  and  Mackenzie 
used  a  probe  coated  with  lunar  caustic.  The  simplest  and  most  satis- 
factory way  to  deal  with  such  cases  is  to  excise  the  lachrymal  gland, 
and  at  the  same  time  cut  out  the  tissue  around  the  fistulous  tract. 
FistulfE  due  to  caries  or  necrosis  of  the  orbital  wall  will  heal  only 
after  the  removal  of  the  diseased  bone. —  (J.  M.  B.) 

Fistulation.  Foi-mation  of  a  fistula  for  remedial  ])urposes — as  in  the 
eyeball  for  the  relief  of  glaucoma. 

Fistulette.  Cai)illai\v  or  small  fistula.  This  term  is  generally  used  to 
designate  the  microscopic  canals  that  penetrate  the  scar-tissue  fol- 
lowing operative  wounds  for  the  relief  of  glaucoma. 

Fistulous  staphyloma.  A  synonym  of  fistula  of  the  cornea.  See  p.  8367, 
Vol.  ^^  of  this  I'J lie ji doped ia. 

Fitiriasi  delle  palpebre.     (It.)  Pityriasis  of  the  lids. 

Fitow's  test.  In  this  case  the  Snellen  or  some  other  form  of  test  type  is 
shown  to  the  individual  suspected  of  ocular  malingering  one  letter 
at  a  time,  characters  of  smaller  dimensions  than  those  which  corre- 
spond to  the  distance  from  the  patient  being  chosen  in  each  instance. 
The  distance  from  the  test  chart  is  then  greatly  diminished  but  always 
to  a  less  degree  than  the  size  of  the  types.  True  malingerers  are 
almost  certain  to  betra.v  themselves  wliile  reading  the  letters,  espe- 
cially if  they  y>retend  a  unilateral  amblyopia. 

Fitting  and  adjusting  glasses.  See  Eyeglasses  and  spectacles.  Mechani- 
cal adjustment  of. 


5212  FITTING  OF  ARTIFICIAL  EYES 

Fitting-  of  artificial  eyes.    Sec  ])a<,'('  (J2(),  Vol.  I,  of  this  IJ ncyclopedia. 

Five-leaf.  roTKNTiLLA.  CiiKiuefoil  was  liiglily  recouiineuded  by  the 
aucitiit  (ireeks  and  Roinans  as  a  remedy  in  almost  all  diseases  of  the 
eye.— (T.  H.  S.) 

Fix.    Sec  Fixation. 

Fixate.  To  iciider,  or  to  hccomc,  fixed.  A  synonym  oi  fix,  to  gaze  at; 
also  used  in  the  sense  ot"  Ji.r,  to  render  immobile  in  a  preservative 
fluid. 

Fixation.  Worth  {Squint,  p.  3)  reminds  us  that  in  the  centre  of  the 
retina  is  the  macula  lutea,  which,  in  the  human  eye  is  far  more  sensi- 
tive to  ordinary  visual  imi)ressions  than  any  other  part.  It  is  desir- 
able, therefore,  that  the  eye  be  brought  into  such  a  position  that  the 
image  of  any  object  which  especially  engages  our  attention  shall  be 
formed  upon  the  macula  lutea.  The  eye  is  then  said  to  "fix"  the 
object. 

The  same  writi-r  also  says  that  in  a  case  of  monolateral  convergent 
squint,  if  the  fixing  eye  be  covered  the  vision  of  the  (previously) 
deviating  eye  temi)orarily  ceases  to  be  suppressed.  In  a  fairly  recent 
ease  this  eye  is  then  directed  so  as  to  receive,  upon  its  macula  lutea, 
the  inuige  of  the  ob.iect  looked  at.  But  if  the  case  be  long  neglected, 
this  sensitive  central  region  of  the  retina  suffers  much  more  from  dis- 
use than  the  paracentral  zone,  while  the  peripheral  region  suffers 
very  little,  if  at  all.  As  the  blindness  progresses  in  this  disused  eye, 
a  stage  is  at  length  reached  when  the  visual  acuity  of  the  central  re- 
gion falls  ])elow  that  of  the  paracentral  zone,  and  later,  even  below 
that  of  the  periphery  of  the  retina.  If  the  fixing  eye  be  now  covered, 
the  deviating  eye  is  not  directed  so  as  to  receive  upon  its  macula  the 
image  of  the  object  which  engages  the  attention,  because  the  macula 
has  ceased  to  be  the  most  sensitive  i)art  of  the  retina.  This  eye  then 
wanders  without  remaining  steadily  in  any  definite  position  (lost  fix- 
ation). Or  it  nuiy  fix  with  some  part  of  the  paracentral  region,  or 
roll  still  further  in  towards  the  nose  so  as  to  present  the  extreme  nasal 
])eriphei'y  of  the  retina  for  the  purpose  (false  fixation). 

Fixation,  Field  of.  In  optics,  the  region  boundetl  by  the  utmost  limits 
of  distinct  or  central  vision,  and  which  the  eye  has  under  its  direct 
coiitfol  thi'ough  its  excui'sions,  witluiut  movements  of  the  head.  See 
Field  of  fixation. 

Fixation-forceps.  An  insti-umenl  used  for  fixing  or  holding  a  part, 
the  eyeball,  in  position,  foi-  iustauee,  during  a  surgical  operation.  See 
the  following  heading. 

Fixation  instruments.  Ociitii  \i>:\iostats.  Fixatiox  forceps.  Fixing 
FORCEPS.    As  stated  in  the  Editor's  Sijston  of  OplitJiahnic  Oix  rations, 


FIXATION  INSTRUMENTS 


5213 


Vol.  I,  page  201,  ])y  far  tlic  coimiioiicst  insti'uiiicut  for  this  i)iirpose 
is  the  well-known  fixation  foreei)s  provided  witii  three  or  four  teeth. 
The  latter  should  not  be,  as  they  often  are,  pi-ovided  with  shai'p  points 


Allport  's  Fixation  Forceps. 


or  cutting  edges,  as  they  lacerate  the  tissues.  The  purpose  of  the  for- 
ceps is  to  gras])  the  soft  parts  and  not  to  cut  them.  Elschnig  {Aug- 
endrztliche  Opcrutiancn,  2nd  Edition,  Vol.  1,  p.  6)  recommends  (see 


Baiii'i  'h  i'ixation  Forceps. 

the  figure)  a  straight  forceps  provided  with  three  teeth,  one  blade 
with  one  tooth,  the  other  with  two,  set  at  an  angle  of  45  degrees.  AVhen 
the  blades  are  placed  about  two  nun.  apart  near  the  sclero-corneal 


Batten's  Fixation  Fork. 
The  sclera  is  held  above  while  a  needle  is  introduced  from  below. 

jmietion,  gently  i)ressed  against  the  globe  and  then  closed,  the  epi- 
scleral tissues  are  caught  in  the  teeth  without  dauuiging  them,  yet 
fixing  the  eye  securely. 


5214 


FIXATION  INSTRUMENTS 


The  lixiilioii  i'()i-('('])s  arc  generally  placed  close  to  the  limbus  be- 
cause tile  coiijuiictiva  in  that  situation  is  less  inov('al)le  than  else- 
where. If  tlie  operator  should  tear  the  iiiucous  nieinhrane  and  still 
desire  tixation,  llic  iiiKicilyiiiu:  scleral  tissue,  or  even  the  tendon  of  a 
straifjht  iiniscle  can  be  jjfi'asped,  but  the  latter  method  is  a  painful  one 
and  to  be  avoided  as  much  as  possible.     Apart  from  ignorance  or  care- 


Barr's  Fixation  Forceps. 

lessness  this  accident  is  most  likely  to  happen  when  the  patient  is 
under  a  general  anestlietic  and  the  operator  attempts  to  drag  in  the 
opposite  direction  an  eyeball  that  has  rotated  beyond  his  reach.     It 


Boettcher's  New  Chalazion  Forceps. 
(See,  also,  p.  1992,  Vol.  Ill,  of  this  Encyclopedia.) 

is  not  to  be  forgotten  that  gentleness,  quite  as  much  as  firmness,  is  a 
part  of  ophthalnuc  operations. 

Generally  the  teeth  of  the  fixation  forceps  are  placed  on  the  oppo- 
site and  corresponding  part  of  tlie  glol)e  to  the  point  of  puncture. 
In  the  corneal  incision  of  cataract  exti-action  with  an  upper  fiap  the 
area  of  fixation  is  l)est  chosen  a  few  mm.  l)elow  the  meridian  of  the 
counter-punctun;  so  that  the  knit'(\  ;is  it  cuts  its  way  out,  may  not 
come  in  contact  with  the  forceps. 


FIXATION  INSTRUMENTS 


5215 


The  assistant  should  j^articuhn-ly  l)ear  in  mind  wliih-  lioldiiig  tlie 
fixation  forceps  that  ncithci-  prcssui-e  nor  dragf^ing  movements  should 
be  made  upon  the  eyeball.     The  purpose  of  the  forceps  is  to  steady 


/^_^\= 


Brailey  's  Eye  Speculum  for  Fixation. 

or  fi.\  the  globe  as  securely  as  possible  without  injury  to  its  tissues  or 
discomfort  to  the  patient,  if  it  is  necessary  to  rotate  the  globe  the 
patient  should  be  requested  to  look  in  the  required  direction  while 
the  forceps,  although  held  in  their  closed  condition,  should  simply 


Combined  Lid  and  Fixation  Forceps. 


follow  the  globular  movement.  If  the  patient  be  under  a  general 
anesthetic,  or  if  for  any  other  reason  he  cannot  look  in  the  required 
direction,  the  eyeball  may  be  rotated,  not  pulled  or  pushed,  the  for- 
ceps being  always  held  at  the  same  tangent  to  the  globe.  When  it  is 
desirable  to  fix  the  eyeball  with  greater  security  than  usual,  as  for 


Critchett's  Fixation  Forceps. 

example  in  trephining  the  cornea,  two  forceps  are  employed,  one  at 
each  end  of  the  same  corneal  meridian.  These  are  held  in  each  hand 
of  the  same  assistant.  Double  fixation  forceps  have  been  devised  for 
this  purpose,  but  in  general  these  are  not  very  satisfactory,  because 
it  is  difficult  to  secure  equal  fixation  with  the  two  sides  of  the  forceps, 
and  there  is  more  apt  to  be  unnecessary  and  perhaps  dangerous  trac- 


5216 


FIXATION  INSTRUMENTS 


lion  on  one  side  or  the  other  if  there  is  a  siul(h'n  and  unexpected  move- 
nient  of  the  eyeball. 

There  is,  as  a  rule,  not  only  no  need  for  a  eatch,  or  lock,  in  the 


Desmarres'  Fixation  Instrument.    (Serretelle.; 

fixation  forceps,  but  they  are  generally  a  nuisance  if  not  a  positive 
danger,  because  too  much  valuable  time  is  wasted  in  applying  and 
releasing  them. 

If  there  is  a  particular  objection  to  making  even  the  slightest  wound 


Dujardin  's  Forceps,  without  Spring. 

in  the  conjunctiva  and  no  special  reason  for  securing  fixation  of  the 
globe,  as  in  tattooing  the  cornea,  a  blunt  forceps  may  be  used — one 
provided  with  serrated  ivory,  celluloid  or  hard-rubber  terminals. 

In  some  cases,  as  in  enucleation  of  the  globe,  operations  on  the  vitre- 
ous, etc.,  where  forceps  are  inconvenient,  a  needle  and  thread  are 


Elschnig's  Straight  Fixation  Forceps. 

passed  through  the  conjunctival  and  episcleral  tissues  at  the  limbus 
and  brought  out  about  a  cm.  from  the  point  of  entrance.  The  ends 
of  the  suture,  which  may  be  about  23  cm.  long,  are  held  by  the  assist- 
ant who  can  easily  rotate  the  globe  to  any  desired  condition. 

In  the  following  pages  and  illustrations  other  methods  and  instru- 
ments for  fixing  the  e^^eball  will  also  be  found  described. 

The  purpose  and  modus  operandi  of  many  of  these  instruments 
are  indicated  by  the  accompanying  illustrations  and  their  legends; 


FIXATION  INSTRUMENTS 


5217 


ill  wliicli  cjisc  flicy  arc  passed  ovci"  willioiit   dllicr  inciilion  of  the  use 
for  which  tlicy  arc  intended.     Aiiioii<i:  tlicsc  may  he  dcscrihcd  tlie  (ix- 


Ewinjr's    I'^ixatioii   For(*oi)s. 


ing  instruiuc'iits  of  Hadei",  CritclicU,   Du.jai'diii,  Ewiiig,  Kciiier,  Loi- 
ter, Monoyer,  Noyes,  Schweigger  and  Streatfeild. 

Frank  Allport   {OpHlidl.  Hi  cord,  Aug.,  1018)   lias  devised  a  pair 


I'ork-piongfd   Forceps,   witliout   Catch,      (lleinor.) 

of  fixation  forceps  witliout  teeth,  but  with  serrated  or  roughened 
points  that  hold  the  conjunctival  tissues  firmly,  but  do  not  tear  or 
pierce  them. 


George 's  Fixation  Forceps. 

Batten's  fixation  fork  is  a  useful  instrument,  especially  when  it  is 
necessary  to  push  a  needle — particularly  a  large  needle  or  one  with- 
out cutting  edges — through  the  tough  and  resisting  sclera.  The  cut 
illustrates  the  method  of  its  employment. 


Graileiiigo 's  Fixation  Forceps,  with  Spring  and  Latch. 

This  instrument  belongs  to  the  type  of  non-jjenetrating  devices.  A  fold  of 
conjunctiva  is  sinijdy  graspeil  (not  cut  or  otiierwise  injured)  hv  tiie  terminals 
whose  shape  conforms  to  the  outline  of  the  eyeball. 

Barr's  fixation  forceps  has  curvcil  l)lades  for  ready  application  to 
the  globe  in  tiie  presence  of  a  i)romineiit  nose  and  orbital  margin. 
BeartVs  fixation  forceps  are  made  on  the  principle  of  de  Wecker's 

Vol.  VII— J4 


5218 


FIXATION  INSTRUMENTS 


scissors  and  ^Masp  the  ('ycball  in  virtue  of  "('losiiif^  in"  on  it,  instead 
of  taking  hold  in  th(!  usual  fashion  from  above.  See  page  UlS,  Vol. 
11,  of  this  ICnrijclopcdiu. 


Heymann's  Claw  Forceps. 

This  instninient  is  provided  with  one  sharji-jiointed  l)lade  that  enables  it  to 
secure  a  more  complete  bidl)ar  fi.xation. 

Brailey's  fixation  speculum  was  designed  to  ol)viate  the  dit^enlty 
whieh  is  experienced  in  fixing  the  eye  in  various  operations,  such  as 
cataract  extraction  or  iridectomy.  "With  tliis  instrument  an  assistant 
may  be  dispensed  with. 


Leiter's  Two-tined  Fixation  Forceps,  with  Catch. 


The  fixation  speculum  consists  of  the  particular  pattern  usually 
favored  by  the  surgeon,  with  tlie  addition  of  two  arms  on  the  lower 
blade,  each  bearing  two  rounded  spikes.     To  insert  this,  the  upper 


Monoyer  's  Fixation  Forceps. 


blade  is  first  put  into  place  under  the  lid,  and  then  the  points  on  the 
lower  blade  are  pressed  against  the  conjunctiva,  just  external  to  the 
corueo-scleral  junction,  about  3  mm.  from  tlie  lowest  part  of  the  cor- 


Pamard's  Fixation  Point  or  Spear. 

nea;  next,  the  blade  is  put  into  position  behind  the  lower  lid,  so  rotat- 
ing the  eye  down  and  holding  it  there,  leaving  the  hands  of  the  sur- 
geon free  for  the  oi)eration. 


FIXATION  INSTRUMENTS 


5219 


To  rciHovc  it  tlu'  upper  blade  is  taken  oul  first. 
Cmnhincd  lid  and  firdtion  forceps.     In  many  operations  on  the  lid, 
notably  in  the  removal  of  eartilaj^e  in  ehi-onic  trachoma  cases,  it  is 


Noyes'  Fixation  J-'oiceps. 

usual  to  employ  both  a.  lid  plate  of  some  kind  and  a  fixation  forceps 
in  addition.     The  instrument  here  presented  is  a  combination  of  the 


m\fm 


Prince's  Fijfation  Forceps. 


two  and  has  been  employed  with  great  satisfaction  at  the  New  York 
Eye  and  Ear  Infirmary  for  several  years. 


Scholer's  Fixation  Instrument  for  Tattooing. 

Fork-pronged  forceps.     This  is  a  two-tined  instrument  and  used 
like  other  fixation  devices  for  steadying  the  eyeball  during  operations 


Sehweigger's  Fixation  Biilent. 

on  the  globe.     There  are  several  of  these  instruments  figured  in  the 
text. 

Scholcr's   fixation    iustrunu  nt,   employed    in    tattooing   the   cornea. 


5220  FIXATION-LINE 

not  i)iil\'  liolils  liiit   |)i-()trcts  that   jtoi'lioii  oi"  the  '^\o]h;  not  intended  to 
be  reached  li\   the  tattooing?  needh'. 

For  further  inroniiation  refjardin*,'  the  use  of  fixative  inventions, 


lujjjLujjijro;^ 


StreatfciM 's  Fixation  Forceps. 

see  the  text  of  such  ca]itioiis  as  Iridectomy;  Cataract,  Senile;  Cata- 
ract, Intracapsular  extraction  of;  as  well  as  Glaucoma;  Trachoma, 
and  espeeiall}^  Instruments,  Ophthalmic. 

Fixation-line.  Line  of  fixation.  In  physiologic  optics^  the  Hue  which 
connects  the  center  of  the  object  viewed  with  the  center  of  motility  of 
the  eyeball. 

Fixation  speculum.    See  Fixation  instruments. 

Fixation  test.  This  term  is  generally  construed  as  meaning  a  test  of 
binocular  fixation  for  near.  The  patient  is  told  to  observe  the  sur- 
geon's finger  placed  at  13  inches  from  and  on  a  level  with  the  eyes. 
The  finger  is  then  advanced  slowly  toward  the  patient 's  nose  to  within 
31/2  inches  (8  centimetres).  If  one  eye  turns  outward,  there  is  exo- 
phoria.  The  test  is  a  rough  one,  and  its  chief  value  is  in  determining 
which  of  the  interni  is  the  weaker. 

Fixator.  An  ophthalmostat  or  fixation  instrument  (q.  v.)  ;  for  steady- 
ing oi'  fixing  file  eyeball  during  an  operation  on  or  examination  of  it. 

Fixed  bodies  is  a  terra  applied  in  chemistry  to  those  substances  which 
are  not  volatilized  at  moderately  high  temperatures.  Fixed  oils  are 
those  oils  which,  on  the  application  of  lieat,  do  not  volatilize  without 
decomposition. 

Fixed  cataract.  An  ol)soh'te  term  used  to  distinguish  an  immovable 
oj)aque  lens  from  one  that  trembles  or  oscillates. 

Fixed  cells  (of  the  cornea).  These  are  found  in  the  lymph  spaces  of 
the  coj-nea.    Sec  Histology  of  the  eye. 

Fixed  focus.  That  point  in  the  axis  in  the  field  of  a  lens  through  which 
all  objects  situated  beyond  a  certain  distance  from  the  lens  are 
approximately  focused. 

Fixierg-abel.     di.)     Fixation  fork,  or  bident. 

Fixing-  eye  specimens.  See  Laboratory  technique  and  museum  prepara- 
tions. 

Fixing  forceps.    See  Fixation  instruments. 


FLACHE  5221 

Flache.     (G.)     Plane;  surface,. 

Flachensarcom.     (G.)     Flat  sarcoma. 

Flacon  compte-gouttes.     (F.)     Drop  bottle. 

Flag-signaling-.     See  iSignaliufj.    Eyes  of  soldiers,  sailors,  etc. 

Flajani,  Joseph.  A  celebrated  Italian  surgeon  and  ophthalmologist  of 
tile  18tli  century,  especially  famous  for  his  work  in  connection 
with  the  artificial  pupil  and  the  treatment  of  dacryocystitis.  He  is 
sometimes  said  to  have  been  the  discoverer  of  exophthalmic  goitre, 
which  affection,  therefore,  is  now  and  then  designated  by  the  term, 
" Flajani 's  disease."  Flajani,  however,  cannot,  in  any  proper  sense, 
be  said  to  have  discovered  the  malady  in  question,  which  is  far 
more  properly  known  as  "Graves'  disease"  and  "Basedow's  dis- 
ease." (See  in  this  Encyclopcdki,  Graves  and  Basedow.;  All  that 
P'lajani  did  was  to  describe  in  Vol.  Ill,  at  p.  270,  of  his  ''Collezione 
cVOsservationi  e  Rifiessioni  di  Chirurgia,"'  (1802)  three  cases  of 
bronchocele  accompanied  (among  other  symptoms)  l)y  palpitation  of 
the  heart.  He  seems  to  have  had  no  clear  idea  either  that  the  goitre 
caused  the  palpitation,  or  that  both  the  palpitation  and  the  goitre 
might  have  been  engendered  by  some  common  cause.  Flajani  was 
born  in  1741,  near  Aseoli,  received  the  degree  of  Doctor  of  Philoso- 
phy and  ^Medicine  at  Rome,  settled  in  that  city,  there  became  surgeon 
at  the  Hospital  San  Spirito,  as  well  as  body  physician  to  Pope  Pius 
VI,  and  died  Aug.  1,  1808. 

Hirschberg  gives  the  year  of  Flajani 's  death  as  1802,  probably  a 
mistake,  inasmuch  as  both  Ilirsch  and  Lippincott's  " Biographkal 
Dictionary' '  agree  on  1808.  Probably  Hirschberg,  when  he  wrote 
"1802."  liad  still  in  mind  the  date  of  Flajani 's  book.— (T.  H.  S.) 

Flajani 's  disease.  Although  the  main  features  of  exophthalmic  goitre 
have  been  universally  connected  with  the  names  of  Graves,  Basedow 
and  Parry  yet  Flajani,  earlier  than  any  of  the  foregoing,  recognized 
a  few  signs  of  the  malad}'  but  did  not— clearly  at  least — realize  that 
they  form  part  of  a  symptom-comi)lex  that  corresponds  to  a  generally 
well-defined  disease.    See  Flajani. 

Flame  gauge.    An  instrunu'nt  for  measuring  the  intensity  of  a  flame. 

Flame-shaped  marginal  epithelial  keratitis.  This  form  of  corneal  dis- 
ease was  (probalily)  first  described  and  named  by  W.  T.  Holmes 
Spicer  {Trans.  Oph.  Soc.  U.  K.,  Vol.  32.  p.  386,  1912),  who  reports  a 
case  of  a  cook,  get.  26,  whose  eyes  had  ])een  inflamed  on  and  oft*  for 
about  four  years. 

Spicer  found  slight  punetuate  staining  of  the  cornea  with  fluo- 
rescein at  the  lower  part  only.  These  proved  to  be  a  number  of 
superficial,   gray,  slightly-raised,  pointed  fingers  or  flames,  starting 


5222  FLAP-EXTRACTION 

with  tlieir  base  at  llie  liiiilius  aiul  reaching  rather  more  thau  a 
third  of  the  way  across  the  cornea;  some  of  these  are  split  at  their 
bases  or  iu  their  whole  length;  they  are  broader  in  the  right  thau  in 
the  left  eye,  and  less  clearly  defined  in  the  latter  owing  to  the  scrap- 
ing.   There  is  no  staining  of  the  tiames  as  a  whole." 

Spicer  believed  tlie  tiame-sliaped  elevations  to  be  due  to  exposure 
to  the  heat  of  the  fire,  because  after  the  patient  had  had  a  holiday  and 
went  home  there  was  no  disturbance  of  the  kind,  but  when  she  returned 
to  work  the  condition  recurred.  He  had  never  seen  any  material 
change  in  the  flames.  When  she  first  came  for  advice  she  liad  slight 
angular  conjunctivitis,  and  the  conjunctiva  had  always  seemed  slightly 
red.  The  flames  were  superficial,  and  in  staining  they  did  so  not  as  a 
whole,  but  in  a  punctate  way.  The  left  eye  had  been  scraped,  when  it 
was  somewhat  better  in  consequence.  Once  or  twice  she  had  had  a 
filament  hanging  from  the  cornea.  There  had  never  been  deep  irri- 
tation in  the  eye. 

Flap-extraction.  Daviel's  method  of  cataract  extraction.  It  was 
improved  by  Beer,  and  consists  in  making  a  semicircular  flap 
(upward  in  Daviel's,  downward  in  Beer's)  in  the  cornea,  or  at  the 
margin,  with  rupture  of  the  capsule  and  expression  of  the  lens.  This 
method,  since  revived,  with  modifications,  has  been  adopted  by  a 
number  of  operators.    See  Cataract,  Senile. 

Flaps  in  eye  surgery.  The  uses  of  skin,  conjunctival  mucous,  lip  and 
other  forms  of  the  flap  in  ophthalmic  operations  are  discussed  under 
the  various  headings  to  which  they  jn'opcrly  belong — such  as  Ble- 
pharoplasty;  Cornea,  Ulcer  of  the;  Injuries  of  the  eye.  A  full 
account  of  conjunctivoplastij  in  the  treatment  of  perforating  ulcer 
of  the  cornea  will  be  found  on  page  3508,  Vol.  V,  of  this  Encyclopcdki. 
The  reader  is  also  referred  to  an  excellent  article  on  the  protection 
afforded  by  a  double  conjunctival  flap  by  L.  M.  Francis  {Trans.  Oph. 
Sec.  A.  M.  A.,  June,  1913)  in  penetrating  injuries  of  the  sclera. 

Flare.  A  blurred  or  fogged  portion  on  a  developed  plate,  generally  due 
to  reflection  of  light  Avithin  the  camera. 

Flarer,  Francesco.  A  celebrated  Italian  ophthalmologist,  especially 
remembered  as  the  inventor  of  Flarer 's  operation  for  trichiasis  (q.  v. 
in  this  Encyciopedui) .  The  dates  of  his  birth  and  death  are  not  pro- 
curable. He  became,  however,  professor  of  ophthalmology  at  Pavia  in 
1819,  as  well  as  director  of  the  Pavian  Ophthalmic  Hospital.  His  best 
known  writing  is  "Riflessioni  sulki  Trichuisi  suUc  Distichuisi  c  suW 
Entropio  Acndo,  Particolare  Biguardo  ai  Mctodi  di  Jaeger  e  di  Vacci" 
(Milan,  1828).— (T.  H.  S.) 

Flarer 's  operation.    Sec  Entropion. 


FLASCHENKURBIS  5223 

Flaschenkiirbis.       (G.)     Logcnaria  vulgaris  (q.  v.),  or  bottle-gourd. 

Flat  eye.     A  vul^ai-  iiaiuc  tor  liypermetropia. 

Flatness  of  field.  The  absence  of  appreeiabh;  curvature  in  the  field  of 
a  lens. 

Flat  sarcoma.  Ring  sarcoma.  Annular  sarcom^v.  Tliis  rather  rare 
form  of  malignant  neoplasm  may  affect  the  whole  ciliary  body,  but 
it  is  usually  found  in  the  choroid.  A  good  account  is  given  by  Wes- 
cott  {Tram.  Am.  Opii.  ^'oc,  1912),  who  describes  the  disease  and  gives 
a  history  of  two  examples  of  this  tumor.  Herbert  Parsons  {Archives 
of  Ophthal.,  Vol.  33,  1904:)  reported  a  case  of  ring  sarcoma  of  the 
ciliary  body  and  iris,  and  reviewed  the  literature  of  diffuse  sarcoma 
of  the  uveal  tract.  He  recorded  35  cases,  including  his  own,  but  re- 
garded two  cases  reported  by  Sehiess  in  1864  and  1865,  and  two  re- 
ported by  Hirschberg  in  1869  and  1870,  as  probably  inflammatory 
and  not  to  be  counted.  A.  N.  Ailing  and  Arnold  Kuapp  reported  a 
case  of  ring  sarcouui  of  the  ciliary  body,  and  reviewed  the  literature 
of  that  variety  of  the  diffuse  sarcomata.  They  refer  to  nine  cases, 
including  their  own,  four  of  which  are  described  by  Parsons,  "in 
which  a-  diffuse  growth  was  present  in  the  form  of  a  complete  ring, 
involving  the  ciliary  body  and  apparently  originating  therein."  In 
addition  to  the  40  cases  referred  to  in  these  two  papers,  Arnold 
Knapp  reported  a  tlat  sarcoma  of  the  choroid,  and  Paul  G.  Woolley, 
a  flat  tumor  of  the  ciliary  body  and  choroid  (Johns  Hopkins  Hospital 
Bulletin)  in  1905;  E.  E.  Henderson,  a  flat  sarcoma  of  the  choroid 
(Trans.  OpJithaUnological  Society,  JJ.  K.)  in  1908;  Harold  Goldberg, 
a  diffuse  tumor  of  the  entire  uveal  tract  {Annals  of  Ophthalmology, 
1909),  and  H.  Luedde,  a  diffuse  tumor  of  the  choroid  (Graefe's 
Archiv)  in  1909,  making  45  cases  in  all. 

To  Fuchs  has  been  given  the  credit  of  first  distinguishing  between 
diffuse  and  circumscribed  sarcomata  of  the  uveal  tract  and  he  re- 
ported three  cases  in  1882.  De  Wecker,  however,  in  1876,  in  the 
Graefe-Saemisch  Handbuch,  stated  that  in  two  cases  such  a  diffuse 
tumor  had  been  seen.  In  1894  jMitvalsky  reported  two  cases,  and 
first  used  the  very  descriptive  term,  "Flachensarcom."  Ewetzky  in 
1898  first  used  the  term  "ring  sarcoma"  to  describe  those  tumors 
confined  to  the  ciliary  body  and  encircling  the  eye.  A  stud}'  of  the 
recorded  cases  shows  tliat  the  sexes  have  been  about  equally  affected. 
The  youngest  patient  was  twelve  and  the  oldest  seventy-two  veal's 
old.  In  many  of  the  cases  the  disease  was  evidently  of  long  duration 
— from  seven  months  to  ten  years.  There  is  a  history  of  injury  or 
operation  in  quite  a  percentage,  the  trauma  dating  from  nine  weeks 
to  seven  years  before  the  discovery  of  the  tumor.     In  most  of  the 


5224  FLAT-SPRING  KYMOGRAPH 

cases  glaucoma  was  j)n'st'iitj  hut  was  not  coiistaiit  in  all.  Parsons 
calls  attention  to  tlie  fact  that  a  numher  of  the  eyes  were  enucleated 
hecause  of  ahsolute  glaucoma,  and  the  tumor  was  discovered  in  the 
lahoratory.  G-oldherg  suggests  that  many  eyes  excised  for  glaucoma 
may  contain  flat  sarcomata  which  are  not  discovered.  In  iiis  case 
there  was  no  suggestion  of  tumor  before  operation,  and  no  macro- 
scopic evidence  of  it  on  section  of  the  globe.  Extra-ocular  extension 
occurs  frequently,  sometimes  early,  is  often  multiple,  and  follows 
the  perivascular  lymph-channels  through  the  sclera.  All  observers 
have  been  impressed  by  the  tendency  of  these  tumors  to  infiltrate  the 
tissues,  as  opposed  to  the  formation  of  a  definite  tumor.  Parsons  is 
of  the  opinion  that  they  are  endothelial  in  origin.  lie  bases  his  opin- 
ion upon  the  character  of  the  cells,  the  frequency  of  an  alveolar 
arrangement,  the  tendency  to  myxomatous  degeneration  and  necro- 
sis, and  the  ease  and  rapidity  with  which  they  invade  the  lymph- 
spaces  of  the  neighborhood.    See,  also,  Tumors  of  the  eye. 

Flat-spring  kymograph,  of  Fick.  A  narrow  U-shaped  tube  connected 
with  a  blood-vessel  by  means  of  a  cannula,  and  over  the  expanded 
free  extremity  is  a  caoutchouc  membrance  with  a  projecting  point 
pressing  against  a  horizontal  spring  that  is  connected  with  a  writing 
lever. —  (Foster.) 

Flattem.     (G.)     To  flutter;  to  be  irregular. 

Flavescent.    Becoming  yellowish. 

Flax.  Litium  usitatissimum.  The  juice  of  the  flax  was  employed  by 
the  ancient  Greeks  and  Romans  as  a  sharpener  of  the  sight;  the  seed, 
for  ophthalmic  inflammations. —  (T.  H.  S.) 

Flax-weed.  Linaria  graca.  In  ancient  Greco-Roman  times,  the  leaves 
of  the  flax-\veed  were  employed  as  a  poultice  for  "rheuma"'  (any 
kind  or  sort  of  discharging  eye). —  (T.  H.  S.) 

Fleabane.  Plantagium  psyllium.  Fleabane  was  recommended  by  the 
ancient  Greco-Roman  physicians  for  epiphora.  The  leaves  were  sim- 
ply laid  upon  the  forehead. —  (T.  H.  S.) 

Flea-glass.  An  early  form  of  the  simple  microscope,  with  a  plano- 
convex lens. 

Flecke.    (G.)     Spot;  macula. 

Fleischfliegen.     (G.)     I\Ieat  flies. 

Fleischgift.  (G.)  F^leisciivekgifti'NG.  Ptomaine  poisoning  from  de- 
composed meat. 

Fleischl  von  Marxow,  Ernst.  A  celebrated  German  pliysiologist.  path- 
ologist and  physiologic  optician.  Born  at  Vienna  Aug.  5,  18-16,  he 
studied  at  Vienna  and  Leipsic,  at  the  latter  institution  receiving  his 
degree  in  1870.     In  1880  be  was  extraordinary  professor  of  physiol- 


FLEMA  SALADA  5225 

ogy  at  the  rnivcrsity  of  \'icnna,  aiul,  scvou  years  later,  correspond- 
ing fellow  of  the  Viennese  Academy.  He  died  Oct.  22,  1891.  A  like- 
ness in  relief  of  this  physiologist  was  unveiled  in  the  Arcades  of  the 
University  of  Vienna  Oct.  16,  1898,  on  which  occasion  a  memorial 
address  was  delivered  by  Exner. 

Fleischl  von  Marxow's  most  important  writings  are:  "Die  Dop- 
pelte  Brechung  dcs  Lichtcs  in  Fliissighi  itcn''  and  "Die  Deformation 
der  Lichtcmccllenfiachc  in  Magnctischcn  Felde."  A  complete  collec- 
tion of  his  works  was  jiublished  by  Exner  in  1893,  together  with  a 
portrait  of  this  distinguished  physiologist  and  optician. —  (T.  II.  S.) 

Flema  salada.  (Sp.)  Literally,  salty  phlegm;  in  the  north  of  Spain, 
an  epidemic  disease  formerly  supposed  to  be  pellagra,  but  having 
the  features  of  aerodynia,  and  now  attributed  to  eating  diseased 
grain.     It  occasionally  presents  indefinite  eye  symptoms. 

Flemmone.     (It.)     Phlegmon. 

Fles'  box.  A  test  for  ocular  nmlingering.  See  Fles's  test;  as  well  as 
Blindness,  Simulation  of. 

Fles,  Joseph  Alexander.  A  distinguished  Dutch  ophthalmologist.  Born 
at  Breda  in  ISID.  he  received  the  degree  of  Doctor  in  Medicine  in 
1843  at  the  University  of  Utrecht.  In  1851  he  was  appointed  docent 
for  descriptive  and  ])athologic  anatomy'  at  his  alma  mater,  and  in 
1862  for  ophthalmology.  In  1868  he  severed  his  connection  with  the 
University,  and  devoted  himself  to  private  practice  as  an  ophthal- 
mologist until  liis  death.— (T.  H.  S.) 

Fles'  sches  Kastchen,     (G.)     The  Fles  box-test  for  ocular  malingering. 

Flesch,  Jacob  Gustav  Adam.  A  Geiman  physician,  who  devoted  con- 
siderable attention  to  ophthalmology.  Bom  at  Frankfort-on-the-]\Iain 
June  2.  1819,  he  studied  at  Heidelberg  and  Berlin,  at  the  latter  in- 
stitution receiving  his  degree  in  1839.  His  dissertation,  on  this  occa- 
sion, was  "De  Glancomate."  He  practised  in  Frankfort  from  1841 
until  his  death,  Nov.  28,  1892.— (T.  II.  S.) 

Fles's  test.  The  Fles'  box.  This  was  one  of  the  earliest,  as  it  is  one 
of  the  best,  devices  for  making  the  alleged  blind  eye  see  an  image 
which  the  malingerer  imagines  he  is  seeing  with  his  good  eye.  It 
consists  of  a  rectangular  box  in  which  two  mirrors  of  a  definite  size 
and  orientation  are  placed  vertically  witii  an  inclination  of  one  hun- 
dred and  twenty  degrees.  The  small  dinu'usions  of  the  apparatus, 
causing  prolonged  efforts  of  accommodation  before  the  images  are 
found,  and  the  images  being  formiHl  so  near  to  one  another  that  they 
have  a  tendency  to  blend,  produces  a  lack  of  precision  in  the  answers 
of  the  patient.  Consequently,  with  the  object  of  rendering  the  plan 
more  practical,  Fles's  box  has  undergone  many  modifications.     Barof- 


5226  FLEUR 

lio  iiK'liiu's  llic  iiiiiToi's  at  one  liiiiidiTd  and  twenty-live  degrees;  Bin- 
uedijk  and  Annaigiiac  make  IIk m  movable  on  a  hinge  in  such  a  way 
as  to  vary  tlie  angle  which  they  form,  and  to  obtain  such  relations 
of  the  images  that,  without  closing  one  of  the  eyes,  it  is  impossible 
to  know  which  is  the  image  i)erceived  by  the  right  eye  and  which  is 
seen  b}'  the  left  eye. 

Fleur.     (F.)     Flower. 

Flexile  collodion.  1^'lexible  collodion.  This  useful  agent  is  made 
from  one  i)art  of  pyroxylin  (gun-cotton),  12  parts  of  90  per  cent, 
alcohol,  anil  36  parts  of  ether.  It  is  a  useful  solvent  of  iodoform, 
cantharides,  salol,  salicylic  acid  and  other  agents.  Both  pure  and 
mixed  with  one  of  these  remedies  it  is  commonly  used  in  wounds  and 
other  injuries  about  the  eye.  As  a  protective  for  operations  upon  the 
lid-skin  it  is  often  invaluable.  Flexible  collodion  contains  Canada 
turpentine  and  castor  oil,  and  makes  a  more  elastic  film  than  the  older 
contractile  collodion.     (See,  also,  Camphoid.) 

Formalized  gelatin  is  largely  used  in  Great  Britain  as  a  substitute 
for  collodion.  Ten  per  cent,  gelatin  solution  in  water  is  stored  in 
wide  mouth  test  tubes  holding  three  ounces  each.  The  tubes  are 
plugged  with  cotton  wool  and  sterilized  at  100°  C.  for  15  minutes  on 
three  successive  days.  When  required  for  use  they  are  melted  in  a 
water  bath  and  1  drachm  of  formalin  added.  Tlie  mixture  contains 
21/2  per  cent,  of  commercial  formalin. 

Formalized  gelatin  is  applied  with  a  brush  or  swab  on  the  top  of 
the  dressing  beyond  the  limit  of  the  wound  and  the  dressing  is  thus 
held  in  place  without  a  bandage.  See,  also,  p.  2325,  Vol.  IV,  of  this 
Encuclopcdio. 

Flexure,  The  cranial.    See  Development  of  the  eye. 

Flibbertigibbet.  In  English  folk-lore,  a  fiend  who  causes,  among  other 
injuries,  various  diseases  of  the  eye,  especially  strabismus.  Thus, 
Shakespeare,  "King  Lear,"  Act  III,  Sc.  4  (1605):  "This  is  the 
foul  fiend  Flibbertigibbet.  He  l)egins  at  curfew  and  walks  at  first 
cock;  he  gives  the  web  and  the  pin  [various  ocular  diseases;  see, 
herein,  Web  and  Pin],  squints  the  eye,  and  makes  tlie  hare-lip;  mil- 
dews the  white  wheat;  and  hurts  the  poor  creature  of  the  earth." — 
(T.  IT.  S.) 

Flicker  photometer.  This  instrument  is  used  botli  as  a  chroHU)nu>ter 
and  liglit-intensity  measurer.  Its  action  is  based  on  the  principle  that 
when  two  lights  of  different  intensities  are  alternated  with  medium 
rapidity  before  the  eye  they  produce  a  sensation  of  flickering  that 
continues  until  the  two  lights  are  rendered  of  equal  intensity.     A 


FLIEGE 


5227 


scale  01-  index  is  jjrovided  for  recoil  liii>^'  the  illiiiiiiiuit  iiig  power  of 
the  liglits  iiuder  examination.    See,  also.  Photometer. 

Fliege.    ((I.)    Fly. 

Flight  of  steps,  Schroder's.  An  illustration  of  hinoeular  vision.  As 
Brodhun  explains  {System  of  Diseases  of  the  Eye,  Vol.  1,  p.  540)  the 
picture  in  tiiis  text  as  producing  at  once  the  impression  of  a  fiiglit 
of  steps  against  a  wall,  begiiuiing  at  the  right  hand  and  ending  at 
the  left,  this  being  so  whether  one  looks  at  it  with  the  line  ac  below, 
or,  after  turning  it  through  an  angle  of  180°,  with  the  line  hd  be- 
low. If  the  first  iiui)ression  })e  kept  distinctly  in  mind  while  turning 
the  picture  upside  down,  an  overhanging,  stair-like  piece  of  masonry 
leaning  against  a  wall  will  be  seen.     If  now  the  first  impression  be 


\zzz\ 


L-C^ 


kz;r 


Schroder's  Flight  of  Steps. 

recalled  to  ndnd,  the  ob.ject  looked  at  will  be  suddenly  transformed 
into  a  flight  of  steps  beginning  at  cl.  Moreover,  while  before  the  im- 
pression predominated  that  the  surface  a  was  the  nearer  to  the  eye, 
the  surface  b  will  now  appear  the  nearer.  After  some  practice,  either 
impression  can  be  produced  at  will. 

Flimmerleiste.    (G.)    Ciliary  body. 

FlimmerscGtom.     (G.)     Scintillating  scotoma — in  migraine. 

Flint  glass.  A  variety  of  optical  glass  made  of  silica,  lead  and  potash 
in  proportions  of  about  1/2,  1/3  and  1/6,  respectively,  but  varying 
in  different  specimens.  The  admixture  of  lead  increases  the  density 
and  the  refractive  power  of  the  glass,  which  is  also  softer  than  crown 
glass  having  a  lesser  refractive  index.  The  name  flint  glass  origi- 
nated with  the  use  of  flint,  from  which  the  silica  was  first  made  in 
England.  The  difference  in  the  refractive  and  dispersive  powers  of 
flint  and  crown  glass  is  utilized  to  secure  achromatism  in  prisms  and 
lenses,  and  which  in  the  latter  is  ett'ected  through  cementing  together 
two  contra-generic  lenses  whose  curvatures  are  so  proportioned  that 
the  chromatic  dispersion  produced  by  one  lens  is  counteracted  by  the 
other.  For  instance,  the  curvatures  of  a  convergent  lens  of  flint  glass 
and  a  divergent  lens  of  crown  glass  with  a  different  power  may  be 
so  chosen  as  to  produce  the  same  dispersion  in  opposite  directions  for 


5228  FLITTENE 

a  fi.r(  <l  lin(  in  the  sped  ruin,  while  tlicii-  coiiibiiKMl  contra-generic  and 
nncqual  I'cfractivc  i)Owi'rs  still  all'ortl  an  available  refractive  j)()\ver  of 
desired  anionnt  in  the  so  ei'cated  uchromalic  lens.  See  Achromatism. 
— (C.  F.  P.)     See,  also.  Glass. 

Flittene.     Mtj     Phlyctenules. 

Flocculent  cataract.  (Obs.)  A  false  cataract.  An  exudative,  libriiious 
oj)acity  like  a  fine  network  in  the  area  or  field  of  the  pupil. 

Floccn.     (F.)    Flake. 

Floh.     (G.)     Flea. 

Floor  of  the  orbit.    See  page  401,  \'ol.  1  of  this  E  it  cyclopedia. 

Florascope.    A  botanical  lens. 

Flores  cinae.  I^'lowers  of  the  Artcmcsia  peniciflora,  from  which  santonin 
is  extracted. 

Florpapierversuch.     (G.)     Flower-paper  experiment. 

Flower-paper  test.  Heidelberg  or  ^Ieyer's  flower-paper  experiment. 
In  perinieti'\',  to  mark  the  limit  for  a  wdiite  object  it  suffices  to  note 
the  places  where  the  patient  gets  the  sensation  of  the  appearance  of 
a  light  spot.  For  the  determination  of  the  peripheral  limits  of  col- 
ored objects  the  sensation  of  color  must  be  present.  Instead  of  Fors- 
ter's  slide,  which  makes  a  sound,  and  by  it  informs  the  patient  of  the 
approach  of  the  test-object,  dull-black  rods,  fifty  centimetres  long, 
to  the  end  of  which  the  object  is  fastened,  can  be  substituted.  The 
test  objects  generally  employed  are  white  and  colored  squares  of  five 
millimetres  each.  The  colored  object!^  are  made  of  so-called  Heidel- 
berg flower-paper.  For  the  examination  of  high  grades  of  amblyopia, 
white  and  colored  squares  of  ten,  twenty,  and  more  centimetres'  side- 
length  are  often  necessary  for  employment.  Likewise  squares  of  one 
or  two  millimetres'  side-length  for  the  discovery  of  small  central  de- 
fects in  the  field  of  vision  are  of  value.     See  Perimetry. 

Flowers  of  zinc.    See  Zinc  oxide. 

Fluctuant.     Wavering. 

Fluer.     (F.)     To  flow  or  run  from  an  oi-gan. 

Fllig-elfell.     (G.)     Pteiygium. 

Fliigelformiges  Augenfell.     (G.)     I'terygimu. 

Fluid  cataract.    See  Cataract,  Morgagnian. 

Fluid  compass.  A  magnetic  compass  in  which  the  weight  of  the  card  is 
])aitly  iieutrali/ed  by  its  immersion  in  a  fluid. 

Fluid  lens.    A  hollow  lens  filled  with  a  refractive  fluid. 

Fluoresce.    To  be,  or  to  become,  fluorescent. 

Fluorescein.  Fluorescin.  Kesorcinolpiitiialein  anhydride.  Co 
II,, 0„.  This  salt  occurs  in  yellowish  or  yellowish-brown  crystals  ob- 
tained by  fusing  7  parts  of  resorcin  and  5  parts  of  phthnlic  anhydride. 
It  is  slightlv  soluble  in  water  and  ether;  very  soluble  in  alcohol  with  a 


FLUORESCEIN  5229 

yellow-grc'i'ii  fluorescence.  It  forms  variously  colored  solutions  (so- 
called  fluoi'esreids  or  lluoresceinates)  with  aiiiiiioiiia,  liijuor  sodie  and 
liquor  i)otass{V. 

Whether  used  alone  or  in  coinhination  with  j)otassiiuii  or  sodium 
solutions,  this  stain  for  corneal  ahi-asions  and  ulcers  exhibits  beauti- 
ful tints  of  yellow  and  green,  lienson  in  early  tests  with  the  salts 
concluded  that  when  a  cornea  stains  in  wliole  or  in  |)art.  the  stained 
part  represents  either  (1)  an  ulcer  not  yet  covered  with  epithelium; 
or  (2)  an  abrasion  of  ei)itheliuni ;  or  (8)  epitlielium  in  a  dead  or  dis- 
eased condition,  though  not  necessarily  in  a  dying  state.  The  fact  of 
staining  is  not  therefore  to  be  in  all  cases  taken  as  an  indication  for 
active  treatment  (thongli  this  doctrine  is  often  taught),  for  in  many 
cases  an  ulcer  which  stains  is  nevertheless  healing  (juite  satisfactorily, 
and  the  fact  of  the  epithelium  taking  on  the  stain  is  not  necessarily 
an  indication  that  an  ulcer  will  certainly  form. 

After  trials  of  the  various  preparations  of  fluorescein,  the  Editor 
finds  that  a  2  per  cent,  solution  of  potassic  tiuorescide  (potassium 
fluoresceinate,  Merck),  dropped  on  the  cornea  without  the  prelimi- 
nary use  of  cocain  and  after  subsequent  gentle  cleansing  of  the  parts 
with  sterile  water,  or  a  borated  solution,  forms  the  best  method  of 
employing  this  valuable  reagent.  The  test  is  further  robbed  of  its 
o]),iections  if  tlie  patient  closes  his  eyes  for  a  few  minutes  after  the 
instillation  and  all  superfluous  stain  be  then  washed  off  by  flooding 
the  eye  with  sterile  water. 

He  prefers  the  following  formula:  Fluorescein.,  gr.  viii  (grm. 
1.1)  ;  liq.  potass«,  foss  (grm.  2,0)  ;  aqua?  dest.,  f5i  (30.00). 

Allow  this  to  stand  for  ten  days  in  a  cool,  dark  place  and  then 
filter.  For  diagnostic  purposes  instill  a  single  drop  into  the  con- 
junctival sac  or  allow  it  to  fall  on  the  cornea.  Close  the  eye  for 
two  minutes.  Gently  irrigate  the  globe  and  sac  with  warm  normal 
salt  solution  or  a  2  per  cent,  boric  acid  mixture.  The  stain  is  a  bright 
yellow-green  which  aecuratel}^  maps  out  the  disturbed  area  and  does 
not  irritate  the  most  sensitive  eye. 

Uranine,  the  sodium  salt  of  fluorescein,  very  soluble  in  alcohol  and 
water,  may  be  used  like  the  potassium  compound,  but,  in  the  Editor's 
judgment,  it  is  not  so  satisfactory.  It  is  a  yellow-brown  powder  and 
interesting  because  of  its  use  as  a  test  of  death.  If  15  grains  (1  grm.), 
dissolved  in  water,  be  injected  into  the  human  body  the  sclertr  will  be 
stained  green  within  an  hour,  if  life  still  exists. 

Under  the  name  cavihlen,  C.  Bruck  (Niedcrl.  Ophthah  Gcmllsch., 
June  14,  1914)  advised  the  use  of  a  fluorescein-uranin-silver  prepara- 
tion in  gonori'lieal  diseases.    Following  this  hint  L.  K.  Wolff  {Mi'ntch. 


5230  FLUORESCENCE 

M((l.  W'ocin  iisclir.,  Sept.  2!),  1914)  has  used  a  similar  combination 
with  zinc  (instead  of  silver)  wliidi  In'  finds  very  useful  against  the 
.M()i;ix-Axenfeld  bacillus.     See  Fluorescin-zinc. 

Fluorescence  is  the  proj)ei'ty  ])oss('ss(mI  by  soiiu;  ti'aiispiirt'iit  sul)stances 
of  bccoiuing  sclf-Iuiniiious  wlicii  exposed  to  the  direct  action  of 
light-rays.  A  fiuoresciiig  substance  is  one  which  rejects  or  throws 
back  to  the  eye  rays  of  light  of  a  color  or  wave-length  quite  different 
from  the  color  or  wave-length  of  any  of  the  rays  originally  falling 
upon  it.  The  ])henomenon  was  first  ol)served  by  Sir  David  Brewster 
and  Sir  John  llci-scliei.  but  Sii-  (icorge  Stokes  in  1852  was  the  first 
to  discover  its  real  nature.  lie  filled  a  test-tube  with  a  dilute  solu- 
tion of  quinine  sulpliate,  ])laced  it  just  outside  the  red  end  of  a  pure 
spectrum  of  the  sun's  rays,  and  then  slowly  moved  it  along  the  spec- 
trum to  tile  oilier  end.  Nothing  was  observed  until  the  violet  portion 
was  reached,  when  a  ghost-like  gleam  of  blue  light  shot  right  across 
the  tube.  Stokes  found  that  most  organic  substances  show  signs  of 
fluorescence.  Barium  platinocyanide,  which  is  used  in  the  fluorescent 
screens  employed  in  work  with  tlie  Rontgen  rays,  shows  a  brilliant 
green  fluorescence  with  ordinary  light.  Phosphorescence  and  fluores- 
cence are  the  same  phenomena,  the  one  difference  being  in  the  longer 
duration  of  the  former.  Fluorescence  ceases  when  the  incident  radi- 
ation is  withdrawn ;  phosphorescence  continues  for  a  longer  or  shorter 
time.  No  satisfactory  or  complete  theory  of  fluorescence  has  yet  been 
offered.  Some  bodies  fluoresce  in  the  solid  state,  but  not  in  solution, 
others  only  in  solution.  Fluorescence  is  always  associated  with  ab- 
sorption ;  but  on  the  other  hand  many  bodies  are  absorbent  without 
being  fluorescent.  The  most  recent  theory  is  that  of  Voigt,  who  bases 
his  exi^lauation  on  the  theory  of  electrons. — (Standard  Encyclopedia.) 

Fluorescence,  Lenticular.  That  the  human  crystalline  exhibits  a  pecul- 
iar bluish-white  fluorescence  was  observed  by  Helmholtz.  Among 
others,  A.  Vogt  (Klin.  Mon.  f.  Aug.,  51,  I,  February,  1913,  p.  129) 
has  investigated  this  phenomenon  in  individuals  of  from  1  to  75 
years,  on  about  40  fresh  lenses  of  human  cadavers,  on  recently  ex- 
tracted cataracts  and  on  many  lenses  of  calves  and  cattle  of  different 
ages.  All  lenses  were  placed  on  porcelain  dishes  and  exposed  to  dif- 
ferent kinds  of  rays,  viz. :  ultra-violet,  violet,  blue  (adulterated  by 
violet  and  green),  violet-blue  (adulterated  by  green),  and  to  violet -|- 
blue+ultra-violet  (adulterated  by  red  and  green).  In  this  way  he 
corrected  and  supplemented  our  knowledge  of  fluorescence  of  the 
lens.  He  finds  that  Helmholtz 's  observation  of  the  whitish-blue  fluor- 
escence of  the  lens  is  only  conditionally  correct. 


FLUORESCENCE,  LENTICULAR  5231 

He  believes  tliat  liuniaii  and  Ijovine  lenses  fluoresce  in  whitish-blue 
color  in  the  ultra-violet  of  the  arc  light.  This  whitish-blue  is  modi- 
fied and  tinted  yellowish-green,  if  it  is  filtered  through  yellow  lens 
substance,  which  weakens  its  blue  and  violet  components.  The  de- 
gree of  this  modification  depends  on  the  intensity  of  the  yellow  colora- 
tion of  the  lens  and  its  thickness,  as  well  as  on  the  intensities  of  the 
fluorescence  and  the  admixed  ultra-violet.  Violet  light  produces  fluor- 
escence only  in  j'ellow  lenses.  Colorless  lenses,  e.  g.,  of  the  calf,  trans- 
mit violet  unaltered  and  therefore  do  not  fluoresce.  But  the  human 
lens  always  fluoresces  in  violet,  even  in  earliest  infancy,  on  account 
of  its  yellowish  coloration.  Thus  the  fluorescence  of  the  lens  shows 
that  without  absorption  there  is  no  fluorescence.  The  fluorescent  light 
of  violet  varies  from  yellowish-green  to  yellow.  The  fluorescent  light 
of  blue  is  of  slight  intensity.  It  depends  on  the  absorption  of  the 
exciting  light,  requiring  a  more  intense  yellow  coloration  of  the  lens 
than  that  of  fluorescence  by  violet.  This  fluorescent  light  contains 
no  ultra-violet  nor  violet  components.  In  the  light  nebula  produced 
by  ultra-violet  the  yellow  color  of  the  lens  can  be  perceived  entoptic- 
ally.  Objective  proof  of  the  presence  of  the  lens  in  the  eye  is  fur- 
nished by  means  of  fluorescent  light,  in  cases  in  which  this  is  impossi- 
ble by  any  other  method,  e.  g.,  in  pupillary  exudations.  The  visual 
disadvantages  ascribed  by  Schanz  and  Stockhausen  to  the  fluorescence 
of  the  lens  do  not  exist.  In  daylight  the  fluorescence  cannot  be  per- 
ceived both  objectively  and  subjectively.  The  diffuse  light  nebula  in 
radiation  with  ultra-violet  light  is  not  identical  wth  the  fluorescence 
of  the  lens,  as  asserted  by  Schanz  and  Stockhausen,  but  only  a  small 
part  of  it.  Vogt  shows  that  it  is  also  caused  by  rays  which  do  not 
produce  fluorescence.     {Ophthalmology  review,  p.  593,  July,  1913.) 

Von  Sepibus  (Zeit.  f.  Augenh.  v.  29,  p.  407,  1913)  comments  on 
the  difference  of  opinion  as  to  the  exact  color  seen  by  various  ob- 
servers of  the  fluorescent  lens.  He  attributes  these  discrepancies  to 
the  fact  that  each  writer  has  adopted  a  different  method  for  indu- 
cing fluorescence.  He  himself  uses  a  Schott  uviol  glass  plate,  6  ram. 
thick,  which  absorl)s  all  light  except  ultra-violet,  blue  and  a  little  red. 
He  also  tried  Lehmann's  ultra-violet  filter,  which  practically  allows 
only  ultra-violet  rays  to  pass.  The  source  of  light  used  was  a  Finsen 
apparatus,  which  gives  a  light  exceedingly  rich  in  nltra-violet  rays. 
With  the  ultra-violet  filter  the  fluorescence  of  the  human  lens  was 
very  slight,  although  discernible,  and  had  a  blue  tinge.  With  the 
uviol  glass  filter  he  obtained  a  greenish-yellow  fluorescence,  which  was 
more  marked  in  old  than  in  young  lenses.  In  normal  hog  lenses 
Chalupecky   {^yicncr  Jclin.   Woch.,  v.  63,  pp.  1902  and  1913,  1986) 


5232  FLUORESCENT  EYEPIECE 

was  <il)lc  to  pi'odiicc  cliangcs  analogous  to  those  of  senile  cataract,  by 
exposing  them  for  three  hours  to  the  action  of  a  quartz  lamp;  and 
he  regartls  his  findings  as  furtiicr  illustrating  the  chemical  intiuence 
of  ultra-violet  rays  on  tlie  crystalline  lens. 

Fluorescent  eyepiece.  A  form  of  eyepiece  used  in  examining  the  ultra- 
violet speclium  uuule  visible  by  tluorescenee. 

Fluorescin-zinc.  Tlie  double  transposition  of  a  potassium  thiorate  ami 
zinc  sulphate  resulted  in  the  production  of  a  fluorescin-zinc  compound. 
This  is  a  reddish-yellow  powder,  soluble  in  water  only  in  1  to  KJOO 
solution,  and  contains  15.8  per  cent,  of  zinc.  With  this  compound 
L.  K.  AVolff  {Miinch.  Med.  Wochenschr.,  p.  2002,  1914)  treated  ten 
])atients  with  true  Morax-Axenfeld  conjunctivitis  by  distributing  this 
linely  powdered  substance  onto  the  conjunctiva  and  following  it  by 
light  massage.  All  the  patients  were  cured  by  one,  or  at  the  most  two, 
applications  within  from  twenty-four  to  forty-eight  hours,  and  the 
only  disadvantage  manifest  was  the  green  discoloration  of  the  tears 
for  twenty-four  hours. 

Experimentally  the  compound  proved  to  have  a  higher  bactericidal 
power  than  zinc  suli)hate  or  any  of  the  astringents  in  common  use. 
Wolff  attempted  to  decide  whether  the  success  of  the  compound  was 
due  to  bacteriacidins,  described  by  Schneider,  but  w^as  unable  to  find 
the  presence  of  these  bodies  at  all.  He  believes  that  the  more  rapid 
effect  of  the  drug  is  due  to  its  continued  action  upon  the  infecting 
organisms.  As  the  compound  is  only  slightly  soluble,  it  remains  for 
a  long  time  in  the  conjunctival  sac  and  consequently  its  action  is  pro- 
longed. 

Fluornatrium.    Sodium  fluoride. 

Fluorcl.  Sodium  fltoride.  Clear  white  crystals  or  powder.  It  is 
sometimes  used  as  an  antiseptic  dressing  in  wounds  (5  to  10:1000) 
and  is  also  given  internally  (gr.  1/12  — 1/5)  as  an  antispasmodic  in 
epilepsy  and  malaria.  A  1 :200  to  400  solution  is  recommended  by 
Duclos  for  washing  out  the  laclirymal  sac  in  dacryocystitis,  especially 
as  it  is  decidedly  antiseptic  without  causing  irritation.  (See  Ccn- 
irnlbl.  f.  pkt.  Augothfilk.,  p.  726.  1906.) 

Fluorcmeter.  A  device  for  adjusting  the  shadow  in  skiagraphy;  a 
local i/er  in  X-ray  examination. 

Fluoroscope.  Cryptoscope.  A  device  for  holding  the  fluorescent  screen 
in  X-ray  examinations,  while  inspecting  tissues  or  an  organ. 

In  the  Victor  fluoi-oseope  there  is  a  small  lead-glass  shield  which 
fits  in  the  instrument,  ])eing  placed  belnnd  the  screen  but  in  fi'ont 
of  tlie  eves;  this  does  not  obscure  the  imat^e  on  the  screen,  but  is  a 


FLUOROSCOPY 


5233 


protection  to  tlic  eyes.  In  addition  to  this  an  opaque,  imprecated 
nil)l)('r  a])ron  is  attached  at  a  i)oint  on  the  fl Horoscope  just  in  front 
of  the  handle  and  liaugs  in  sucli  a  i)osition  as  to  protect  the  hand 
and  lower  part  of  tlie  ojjorator's  face.    See  tlie  cut.    See,  also,  X-rays. 


Victor  Fliioioscope. 


Fluoroscopy.  Tlic  process  of  examining  the  tissues  by  means  of  a 
fluorescent  screen. 

Fluor-spar.    Native  fluoride  of  calcium. 

Flussigkeit.    (G.)    Fluid ;  fluidity. 

Fluted  spectrum.  A  spectrum  consisting  of  a  number  of  broad 
luminous  bands,  sharply-defined  at  one  edge,  and  shading  off  gradu- 
ally at  the  other  edge.  Wlien  examined  by  a  spectrometer  of  great 
dispersive  power,  each  fluting  is  found  to  consist  of  a  considerable 
number  of  lines,  closely  packed  toward  the  definite  edge  of  the  fluting, 
and  more  and  more  widely  spaced  as  the  blurred  edge  of  the  fluting 
is  approached. 

Fly.  (6r.  Muia;  L.  Musca.)  In  ancient  Greco-Roman  times,  hordeolum, 
or  stye,  was  treated  by  means  of  the  musca,  which  probably  (but  not 
certainly)  was  identical  with  our  modern  house-fly.  The  head  of  the 
fly  being  removed,  the  body  was  rubbed  vigorously  against  the  horde- 
olum. Triturated  flies  were  also  rubbed  on  the  eyebrows  in  order  to 
make  them  blacker,  and  the  ashes  of  flies,  made  into  a  salve  with  anti- 
mony, mouse-dung  and  wool-fat,  was  used  to  prevent  the  return  of 
cilia  after  epilation. —  (T.  H.  S.) 

Vol.  VII— 25 


5234  FOCAL 

Focal,  or,  or  pertaining  to,  a  focus;  as,  a  focal  point  (seo  Focus). 
Focal  distance,  in  optics,  of  a  mirror  or  lens,  the  distance  (also  called 
the  focal  length)  from  its  center  to  the  principal  focus  (.see  Focus j. 
Focal  interval,  see  Astigmatism.  Focal  line,  the  locus  of  foci  in  an 
astigmatic  pencil  of  light  (see  Astigmatism).  Foced  plane,  a  plane 
perxK'ndicular  to  the  optical  axis,  the  locus  of  the  foci  of  infinitely 
distant  objects,  with  reference  to  points  upon  the  principal  axis  of  a 
lens  (see  Axis).  Focal  point,  see  Focus.  Elementary  focal  plane  con- 
tains the  principed  focal  line  of  a  cylindric  lens  when  considered  sepa- 
rately as  one  of  the  elements  in  a  combination  of  two  superposed 
cylindric  lenses,  and  whose  combined  refraction  produces  two  other 
focal  lines  which  are  located  in  the  primary  and  secondary  focal 
planes  (see  Astigmatism).  The  positions  of  the  latter  are  respec- 
tively defined  by  the  refractive  powers  in  the  meridians  of  greatest 
.  and  least  refraction  of  the  combined  cylindric  lenses.  In  a  mono- 
graph, "Dioptric  Formulce.  (q.  v.)  for  Combined  Cylindric  Lenses," 
New  York,  1888,  Prentice  first  published  the  folloAving  laws  govern- 
ing such  combinations:  1.  The  primary  and  secondary  planes  (q.  v.) 
of  refraction  are  at  right  angles  to  each  other  for  any  angular  devi- 
ation of  the  axes  of  two  combined  congeneric  (q.  v.)  cylindrical  lenses. 

2.  For  combined  congeneric  c^dinders  of  equal  refraction,  the  pri- 
mary plane  equally  divides  the  angle  between  the  active  planes  of  the 
cylinders,  and  the  secondary  plane  similarly  divides  the  angle  be- 
tween the  axial  planes  of  the  cylinders. 

3.  For  combined  congeneric  cylinders  of  unequal  refraction,  the 
primary  plane,  in  dividing  the  angle  between  the  active  planes  of  the 
cylinders,  will  be  nearer  to  the  active  plane  of  the  stronger  cylinder, 
and  the  secondary  plane  consequently  nearer  to  the  axial  plane  of 
the  same  cylinder. 

4.  When  the  axes  of  the  congeneric  cylinders  coincide,  the  primary 
focal  plane  will  correspond  to  that  focal  plane  which  is  defined  by  the 
sum  of  the  refractions  of  the  cylinders,  whereas  the  secondary  focal 
plane  will  be  at  infinity. 

5.  The  primary  and  secondary'  focal  plan(>s  coincide  with  their  cor- 
relative elementary  focal  planes,  when  the  axes  of  the  congeneric 
cylinders  of  unequal  refraction  are  at  right  angles  to  each  other. 

6.  The  primary,  secondary,  and  elementary  focal  planes  all  merge 
into  one  plane,  when  the  axes  of  the  congeneric  cylinders  of  equal 
refraction  are  at  right  angles  to  each  other. 

7.  The  primary  and  secondary  focal  planes  are  conjugate  planes, 
subject  to  variations  of  the  angle  between  tlie  axes  of  the  congeneric 
cylinders. 


FOCAL  CENTERS  (OF  A  LENS)  5235 

8.  For  combined  contra-generic  (q.  v.)  cylinders  of  equal  refrac- 
tion, the  plane  of  greatest  positive  refraction  equally  divides  the 
angle  between  the  active  plane  of  the  convex  and  the  axial  plane  of 
the  concave  cylinder;  and  the  plane  of  greatest  negative  refraction 
similarl}'  divides  the  angle  between  the  active  plane  of  the  concave 
and  the  axial  plane  of  the  convex  cylinder. 

9.  When  the  convex  cylinder  is  stronger  tliaii  the  concave  cylinder, 
the  plane  of  greatest  positive  refraction  will  be  nearer  to  the  active 
plane  of  the  convex,  while  the  plane  of  greatest  negative  refraction  will 
be  proportionately  farther  from  the  active  plane  of  the  concave  cyl- 
inder, 

10.  When  the  concave  cylinder  is  stronger  than  the  convex  cylinder, 
the  plane  of  greatest  negative  refraction  will  be  nearer  to  the  active 
plane  of  the  concave,  while  the  plane  of  greatest  positive  refraction 
will  be  proportionately  farther  from  the  active  plane  of  the  convex 
cjdinder. 

11.  When  the  convex  cylinder  is  of  greater  refraction  than  the  con- 
cave, and  their  axes  are  coincident,  the  positive  focal  plane  will  coin- 
cide with  that  focal  plane  which  is  defined  by  the  difference  (or  sum 
of  their  refractions  when  taken  as  positive  and  negative  elements)  of 
the  refractions  of  the  cylinders,  whereas  the  negative  focal  plane  will 
be  at  infinity. 

12.  When  the  concave  cylinder  is  of  greater  refraction  than  the 
convex,  and  their  axes  are  coincident,  the  negative  focal  plane  will 
coincide  with  the  focal  plane  which  is  defined  by  the  difference  of  the 
refractions  of  the  cylinders,  whereas  the  positive  focal  plane  will  be 
at  infinity. 

13.  The  positive  and  negative  focal  planes  coincide  with  their  cor- 
relative elementary  focal  planes,  when  the  axes  of  the  contra-generic 
cylinders  are  at  right  angles  to  each  other. 

14.  The  positive  and  negative  focal  planes  are  conjugate  planes, 
subject  to  variations  of  the  angle  between  the  axes  of  the  contra-generic 
cylinders. 

15.  The  sum  of  the  i)rimary  and  secondary  refractions  is  a  con- 
stant, being  equal  to  tlie  sum  of  the  elementaiy  refractions  for  any 
combination,  and  all  deviations  of  the  axes  of  two  combined  congeneric 
cylinders. 

16.  Tile  sum  of  the  principal  positive  and  negative  refractions  is 
a  constant,  being  equal  to  the  sum  of  the  positive  and  negative  ele- 
mentary refractions  for  any  combination,  and  all  deviations  of  the 
axes  of  two  coml)ined  contra-generic  cylinders. —  (C.  F.  P.) 

Focal  centers  (of  a  lens).     Two  conjugate  axial  points  located  where 


5236  FOCAL  CONIC 

tlu'  incident  and  llic  I'Mu-rgcnt  ray  cut  tlic  optical  axis  when  the 
refracted  ray  between  the  leiis-surfaees  passes  througii  the  optieal 
center  of  a  lens.  Tlio  incident  and  the  emergent  ray  are  then  par- 
allel.—(C.  F.  r.) 

Focal  conic.     A  locus  of  foci  of  a  quadric  surface. 

Focal  curve.    The  locus  of  foci  of  a  surface. 

Focal  depth.  The  i)enetrating  power  of  a  lens;  tiie  range  tiirough  wliicli 
the  parts  of  an  object,  a  scene,  etc.,  projected  by  the  lens  are  pro- 
duced with  satisfactory  distinctness. 

Focal  disease.  Focal  lesion.  This  term  was  formerly  used  to  desig- 
nate a  localized  affection  of  the  brain — tumor,  abscess,  etc.  More 
recently  it  has  l)ecome  tlie  fashion  to  employ  the  term,  also,  in  referring 
to  a  circumscribed  infected  ai'ea  or  lesion  from  which  to.xins,  etc., 
spread  throughout  the  system  or  are  carried  to  a  distant  organ. 

Focalebene.     (G.)     Focal  plane. 

Focal  illumination.  The  concentration  in  a  darkened  room,  by  means 
of  a  convex  lens,  of  the  tiame  of  a  lamp  upon  the  object  to  be 
examined.    See  Examination  of  the  eye. 

Focal  interval  (of  Sturm).    See  Astigmatism. 

Focalization.  The  art  or  process  of  bringing  to  a  focus,  or  of  i)lacing 
in  focus. 

Focalize.    To  bring  to  a  focus ;  to  focus. 

Focal  line.    See  Focal. 

Focal  lines.  The  lines,  anterior  and  ])osterior,  that  bound  the  focal 
inteival.    See  Focal;  as  well  as  Astigmatism. 

Focal  plane.  A  plane  through  the  focus  of  a  lens  perpendicular  to  its 
axis.    See  Focal. 

Focal  points.  The  two  princii)al  foci  of  a  compound  dioptric  system. 
See  Focal. 

Foci,  Aplanatic.     Aplanatic  focal  ])oints.     See  Aplanatic. 

Foci,  Conjugate.    See  Foci. 

Focimeter.  An  instrument  for  assisting  in  focusing  an  object  in  or  before 
a  photographic  camera. 

Foci.    Plural  of  focus. 

Focus;  plural,  foci.  In  optics,  (introduced  by  Keppler  in  1604),  a  point 
at  which  rays  of  light  that  originally  diverge  from  one  point  meet 
again,  oi-  a  point  from  which  they  appear  to  proceed.  The  former  is 
called  a  real,  the  latter  a  virtual  focus.  A  focus  may  be  defined  as 
the  point  to  which  a  spheric  wave  converges,  or  from  which  it  diverges. 
It  may  also  be  defined  as  the  point  at  which  little  waves  from  all  parts 
of  a  great  wave  arrive  at  the  same  tinu>.  (Airy,  Optics,  p.  44.)  The 
principal  focus  of  a  lens  is  the  focus  of  rays  that  are  iiu-ident  to  the 


FOCUS,  EQUIVALENT  5237 

lens  parallel  to  its  axis,  and  there  arc  two  principal  foci,  /j  and  f^, 
respectively,  on  each  side  of  I  he  lens.  An  incident  nxy  pi'oceeding 
from  the  first  principal  focns  (/,  nej>a1ive),  or  towai-d  that  point  (/i 
positive)  is  reiidci'cd  pai'allcl  to  the  axis  after  refraction  Ihrougli  the 
lens;  whereas  aji  incident  ray  i)arallcl  to  the  axis  ;:,ivcs  risi;  to  a 
refracted  ray  which  virtually  proceeds  fi'oni  the  second  i)rincipal 
focus  {f.,  negative),  or  which  actually  passers  through  that  point  (/a 
positive)  ;  see  Convention  of  signs.  As  parallel  incidence  corresponds 
to  the  second  i)rincipal  focus,  tlu^  latter  is  universally  used  to  designate 
and  determine  the  prinvipal  focal  length,  f,  of  a  lens  whose  refractive 
index  is  n,  and  whose  radii  of  curvature  are  r,  and  r^.     Their  relation  to 

1                          11 
each  other  is:     — =  («  —  1)    ( ).     In  the  case  of  a  spherical 

mirror,  the  focal  length  /  is  one-half  of  the  radius,  or  /  :=  r/5.  The 
principal  foci  are  two  points  on  the  axis  and  on  opposite  sides  of  the 
lens,  the  one  on  the  object-side  in  the  ohject-space  being  called  the 
front  focus,  the  one  on  the  image  side  in  the  imagc-apacc  the  back 
focus.  Every  lens  which  increases  in  thickness  towards  its  periphery 
has  virtual  foci ;  and  vice  versa,  for  the  focus  of  a  lens  to  be  real,  the 
lens  must  be  thicker  in  the  middle  than  at  the  edge.  Therefore,  a  eon- 
cave  lens  produces  a  virtual,  and  a  convex  lens,  a  real  image  of  the 
object.  The  conjugate  foci  of  a  mirror  or  lens  are  two  points  so  sit- 
uated that  the  rays  emitted  from  a  luminous  body  or  illuminated 
object  at  either  point  are  reflected  (by  the  mirror)  or  refracted  (by 
the  lens)  to  the  other.  The  equation  expressing  this  relation,  when  n 
is  the  object-distance  and  v  the  image-distance  from  a  mirror,  with  a 
112 

.    radius  r,  is 1 =  — .     Sinulai'ly,  for  a  lens  whose  focal  length  is 

V         u         r 

111 

f,  the  equation  is : ^  — .     When  using  these  f ormuhr  for 

V         u        f 
numerical  valuers  of  \i,  r.  r  and  /,  regard  must  be  had  for  the  conti- 
nental Convention  of  signs,  which  see. —  (C.  F.  P.) 

Focus,  Equivalent.  In  microscopy,  when  the  real  image  of  an  objective 
of  a  certain  focal  length  is  of  the  same  size  as  that  produced  by  a 
simple  converging  lens  whose  focal  distance  equals  that  of  the  objec- 
tive, it  is  said  to  have  an  equivalent  focus.     (Gould.) 

Focus,  First  principal.    See  Focus. 

Focusing-  cloth.     A  cloth  thi-own  over  the  camera  and  the  head  of  the 


5238  FOCUSING  FRAME 

photo^'raplu'i-  when  I'ocusiiig,  with  the  object  of  excluding  any  other 
light  than  that  coming  through  the  lens. 

Focusing  frame.  In  photography,  the  frame  which  holds  the  ground 
glass  on  ^\•|lil•h  the  image  is  focused. 

Focusing  glass.  A  simple  microscope  for  determining  when  the  image 
in  a  ])hot()graphi('  or  mici-ophotograpliie  camera  is  shai'ply  focused  on 
the  grountl-glass.  The  focusing  glass  is  so  adjusted  that  when  its 
mounting  is  placed  against  the  fi'ont  or  smooth  side  of  the  ground- 
glass  or  focusing  screen  of  the  camera  an  object  or  real  image  on  the 
ground  side,  i.  e.,  in  the  plane  occupied  l)y  the  film  of  the  sensitive 
plate,  will  be  in  the  sharpest  focus  possible.     (Foster.) 

Focusing  screen.  A  contrivance  by  means  of  which  the  photographer 
adjusts  the  size  and  focus  of  the  object  to  be  photographed. 

Focus,  Negative.     See  Focus. 

Focus,  Real.    See  Focus. 

Focustiefe.     (G.)    Dei)th  of  focus. 

Foedus  virginum.    (L.)     Chlorosis. 

Fceniculum  vulgare.    See  Fennel. 

Foerster,  Richard.  A  celebrated  German  ophthalmologist,  inventor  of 
the  photometer  (1857)  and  of  the  perimeter*  (1868).  Born  Nov.  15, 
1825,  at  Lissa,  he  studied  medicine  at  Breslau,  Heidelberg  and  Berlin, 
at  the  latter  institution  receiving  his  degree  in  1849.  In  1857  he  set- 
tled in  Breslau  as  ophthalmologist.  In  189-4  he  became  a  life  member 
of  the  Prussian  House  of  Lords.  July  31,  1899,  he  celebrated  the 
jubilee,  or  50th  anniversary,  of  his  doctorate  in  medicine,  and  formally 
retired  from  practice.  He  published  :  1.  Ueher  Hemeralopie.  (Bres- 
lau, 1857.)  2.  Ophthahnologische  Beitrage.  (Berlin,  1862.) 
3.  Beziehungen  der  AUgemeinleiden  zu  den  Erkranknngen  des  Sehor- 
gans.  (Graefe-Saemiseh  Handbuch,  Bd.  V,  1877.)  4.  Kiinstliche 
Reifung  des  Cataracts.  {Archiv  f.  Augenhcilk.,  1883.)  5.  Eintluss 
der  Concavglaser  auf  die  Weiterentwicklung  der  ]\lyopie.  (Archiv 
f.  AugenhfilkiDule;  Bd.  XIV.)  — (T.  H.  S.) 

Fogging  maneuver.     Fogging  method.    In  the  "repression"  treatment 


*A  very  brief  history  of  our  knowledge  of  the  visual  field  may  be  thus  stated : 
Hemianopia  was  mentioned  by  Hippocrates  (fifth  century  B.  C).  The  first 
attempt  to  measure  the  field  was  made  by  Ptolemy  (who  flourished  150  B.  C). 
(The  account  of  this  has  come  down  to  us  only  riti  Damianus.)  The  blind  spot 
was  discovered  liy  Mariotte,  a  Frenchman,  in  l(i()().  Siotomata  were  mentioned  by 
Boerhaave  in  1708.  The  first  exact  measurement  of  the  visual  field  was  made  by 
the  Knglish  physicist,  Thomas  Young,  in  ISOl.  Next,  concentric  contractions  were 
described  by  Beer  in  1S17.  The  value  of  perimetry  as  a  means  of  diagnosis  was 
pointed  out  by  von  Graefe  in  185(i.  Then  came  Fiirster  with  the  first  jierinu^ter 
in  1868.  This  and  the  various  later  forms,  or  patterns,  of  tlie  instrument  are 
sufficiently  pictured  and  described  in  the  non-historical  portions  of  this  Ency- 
clopedia.   See,  also.  Perimetry  and  Examination  of  the  eye. 


FOIE  5239 

of  esophoria,  the  reduction  of  vision  to  about  20/70  by  combining 
l)risnis  (varying  with  the  muscuhir  imbalance),  bases  in  and  combined 
with  a  convex  si)here,  with  which  combination  glasses  the  patient 
reads  half  an  hour  at  night  before  retiring. 

These  terms  are  also  used  to  indicate  attempts  to  relax  the  accommo- 
dation prescribing  an  over-correction  in  hyperopia,  the  patient  wearing 
the  lenses  for  a  longer  or  shorter  period,  preliminary  to  determining 
the  static  refraction. 

Fridenberg  {Klin.  Monutshl.  f.  Augenk.,  Jan.,  1908)  advocates  the 
"fogging  method"  (over-correction  of  hyperopia),  in  cases  of  per- 
sistent spasm  of  the  ciliary  muscle  in  which  condition  a  certain  degree 
of  functional  activity  rather  than  complete  immobility  should  be 
attained,  and  which  is  permitted  by  the  method  in  question.  When 
the  spasm  has  been  overcome  a  wc^aker  glass,  giving  the  best  vision, 
may  be  substituted. 

Foie.     (P.)     Liver. 

Fold  of  transmission.  Fornix  conjunctivae.  Conjunctival  cul-de- 
sac.  Fornix  (Gerlach).  These  terms  are  applied  to  the  parts  and 
the  localities  where  the  conjunctiva  of  the  lid  is  reflected  upon  the 
eyeball — there  to  become  the  ocidar  conjunctiva.  See  Cul-de-sac, 
Conjunctival;  as  well  as  Anatomy  of  the  eye  and  Fornix  con- 
junctivae. 

Folds,  Ciliary.  The  smaller  of  the  ])lications  of  the  ciliary  processes. 
See  Histology  of  the  eye. 

Folie.     (F. )     Insanity. 

Folie  choreique.  (  F. )  Insanity  in  which  there  is  incoherent  delirium 
with  maniacal  excitement,  and  eliorea.  A  second  form,  described  by 
.Marce,  begins  with  hallucinations  of  sight,  with  extreme  agitation,  and 
an  eventual  condition  simulating  the  delirium  of  fever. 

Folklore  of  ophthalmology.  Domestic  opiitii alaiology.  See  Popular 
ophthalmology;  as  well  as  Ophthalmology,  History  of. 

Follicles.  Lymphocytes  of  the  conjunctiva,  as  ])art  of  the  adenoid 
layer,  may  or  may  not  be  normal.  Certain  it  is  that  tiiey  are  nornial 
in  the  rabbit,  cat,  etc.,  but  are  not  always  readily  demonstrated  in 
man.  They  are  ahvays  easily  seen  in  most  forms  of  conjunctivitis. 
esi)ecially  in  trachoma.  See  Histology  of  the  eye;  as  Avell  as  page 
.'51 0:5,  Vol.  TV,  of  this  Encyclopedia. 

Follicles,  Palpebral.    The  ]\Ieibomian  glands. 

Follicular  conjunctivitis.  A  form  of  conjunctivitis  in  which  the  ordi- 
nary inllamniatory  catarrhal  changes  are  accompanied  by  the  develop- 
ment of  round,  pale-red,  hemispherical  structures,  which  project 
above  the  level  of  this  membrane,  and  sulise(piently  disapi)i'ar  with- 


5240  FOLLICULAR  OPHTHALMIA 

out  Itaviiij;  ;i  lijicc  bfliind.     »See  page  310li,  \'ol.  I\',  oi"  tliis  Encyclo- 

jKilid :  ;is  well  ;is  Bacteriology  of  the  eye. 
Follicular  ophthalmia.    ►Sec  Conjunctivitis,  Follicular. 
Folliculi  ciliares.     (L.J     A  term  sonietimes  used  to  designate  the  Mei- 

l)oiiii;in  ducts  or  glands  in  the  eyelids. 

FolliCUlOSis.       FoLLICl'LAR  CATARRH.      SIMPLE  GRANULAR  CONJUNCTIVITIS. 

Follicular  ophthalmia.  Follicular  trachoma.  This  form  of 
chronic  catarrhal  inflammation  of  the  eonjuiictiva,  Ix'St  seen  in  children, 
lias  been  variously  desei'itx'd.  See  Catarrh,  Follicular. 

FoUin,  Francois  Anthime  Eugene.  A  well-known  French  pathologist, 
surgeon  and  ophthalmologist.  Born  at  Hartieur,  France,  Nov.  25, 
1823,  he  studied  his  profession  at  Paris,  becoming  in  1845  interne,  in 
1847  Aide  d'Anatoinie,  in  1850  prosector  to  the  faculty,  and  in  1853 
surgeon  to  the  Central  Bureau.  His  degree  was  received  in  1850, 
presenting  as  dissertation  "Etudes  sur  les  Corps  de  Wolf."  In  1853 
he  was  made  extraordinary  professor  of  surgery  at  the  University. 
Up  to  this  time  he  had  written  a  number  of  books  and  articles  dealing 
with  anatomy,  pathology  and  general  surgery.  Now,  however,  al)0ut 
1853,  he  began  to  devote  his  attention  more  especially  to  ophtbal- 
mology,  and  became  a  celebrated  operator  on  the  eye.  He  wrote  a 
large  nundjer  of  articles  on  this  subject,  dealing  with  glaucoma,  its 
pathology  and  treatment,  iridectomy,  illumination,  accommodation, 
retinal  hemorrhage  and  the  medical  and  surgical  treatment  of  diseases 
of  the  lachrymal  passages.  His  most  important  writing,  from  the 
point  of  view  of  ophthalmology,  was  that  entitled  Lc<^ons  sur  V Appli- 
cation de  rOphtalmoscope  uu  Diagnostic  des  Maladies  de  I'Oeil 
(Paris,  1859;  Ger.  Trans.,  AVeimar,  1859).  This  atlas  was  the  earliest 
work  in  the  French  language,  devoted  to  the  use  of  the  ophthalmo- 
scope.   Follin  died  May  21,  1867,  only  44  years  of  age. —  (T.  H.  S.) 

Foltz,  Jean  Charles  Eugene.  A  French  anatomist,  physiologist  and  oph- 
thalmologist. IJoni  at  Nancy,  Jan.  28,  1822,  he  studied  at  the  Stras- 
burg  Military  School  and  at  Val  de  Grace.  Settling  in  Lyons,  he  was 
appointed  in  1854  assistant  professor  of  anatomy  and  physiology,  and, 
in  1865,  full  professor  of  the  same  subject,  in  the  place  of  his  uncle, 
Richard  Foltz.  He  died  Nov.  18,  1876.  His  ophthalmologic  writings 
are:  1.  Sur  le  Traitement  IMechanique  de  la  ]\Iyopie.  {Ann.  de  la 
Sac.  de  Med.  de  Lijon,  1859.)  2.  Anatomic  et  Physiologic  des  Conduits 
Laerymaux.     (Ibid.,  1862.)  — (T.  H.  S.) 

Foltz,  Kent  Oscanyan.  A  prominent  eclectic  ophthalmologist  of  Cin- 
cinnati, Ohio,  lie  was  boni  in  Lafayette,  ]\Iedina  County,  Ohio.  Feb. 
16,  1857,  the  son  of  Dr.  \Villiain  K.  Foltz.  who  was  one  of  the  earliest 
and  best  known  of  eclectic  physicians  in  the  middle  west. 


FOLTZ,  KENT  OSCANYAN 


5241 


I)i-.  Kent  Oseanyan  Foltz  fri-adujitcd  from  the  Asliland,  O.,  Iligli 
School  in  1872,  and  attendt-d  Uuclitcl  (,'olk'ge,  at  Akron,  Ohio,  for  two 
or  three  years.  P'or  a  time  he  worked  at  the  retail,  then  at  the  whole- 
sai.."  drug  business.  Then  he  bi'camc  an  oi)ti('ian.  At  length,  under 
his  lather's  preceptorship,  he  began  lo  study  mt'dicine.  His  medical 
degree  was  received  at  the  Ecleetic  .Medieal  Institute,  Cincinnati, 
Ohio,  in  1886.    For  a  brief  period  he  practised  general  medicine,  but, 


Kent  Oseanyan  Foltz. 

in  1888  and  1889,  at  the  New  York  Post-Graduate  IMedical  School,  he 
made  a  thorough  study  of  the  eye,  ear,  nose  and  throat.  In  1890  he 
became  connected  with  the  Polyclinic,  the  Manhattan  Eye  and  Ear 
Infirmary,  and  the  Harlem  Dispensary.  Soon  after,  however,  he 
gave  up  institutional  practice,  and  engaged  again  in  general  work. 
In  1898  he  removed  to  Cincinnati,  having  been  appointed  to  the  chair 
of  Didactic  and  Clinical  Ophthalmology,  Otology,  Rhinology  and 
Laryngology  in  his  alma  matc^r — tlu>  Eclectic  Medical  Institute. 


5242  FOLTZ,  VALVES  OF 

In  ]8!)l-!)2  he  was  I'nsidciit  ol"  tlic  Oliio  State  Eclectic  Medical 
Association.  lie  was  also  one  of  the  associate  editors  of  the  Eclectic 
Medical  Journal  for  a  number  of  years,  during  a  part  of  which  time 
he  conducted  the  Ey(^,  Fait,  Nose  and  Throat  Department  of  that 
publication. 

He  wrote:  "Manual  of  Eye  Diseases"  (1900)  and  "Manual  of 
Diseases  of  the  Nose,  Throat,  and  Ear"  (1906).  lie  also  contributed 
iiuiiii-rou.s  articles  to  Prof,  llerlx-rt  T.  Wcl)st('r"s  " D'ynamical  Thera- 
peutics." 

Dr.  Foltz  was  al)out  five  feet  eight  inches  high,  and  remarkably 
well  built.  He  had  red  hair,  a  rudd}'  complexion  and  a  sandy  mus- 
tache. Ilis  eyes  were  a  clear  blue-gray.  He  was  a  great  story-teller, 
and  a  most  enjoyal)le  comi)anion.  He  was  fond  of  music,  art  and 
literature,  and  had  a  large  library,  especially  rich  in  works  on  crimi- 
nology and  psychology. 

The  only  kind  of  books  which  Dr.  Foltz  would  never  read  were 
those  which  related  to  religion.  These  he  a])horred.  In  fact  he  was 
a  most  pronounced  agnostic,  never  losing  an  opportunity  to  express 
his  convictions  on  matters  of  religion  as  forci])ly  as  possible. 

He  was  a  very  kindly,  although  impetuous  man,  and  many  a  strug- 
gling student  and  young  practitioner  had  cause  to  l)less  the  open- 
handed  generosity  of  Dr.  Foltz. 

He  died  at  Seton  Hospital,  Cincinnati,  Ohio,  June  6,  1908,  shortly 
after  an  oix'ration  on  the  nasal  passages. —  (T.  H.  S.) 
Foltz,  Valves  of.  Valves  (reduplication  of  the  mucous  membrane  lin- 
ing) of  the  lachrymal  canals. 
Fomentation.  This  term  is  generally  accepted  as  meaning  hot,  wet, 
applications  to  an  organ  or  part  of  the  body,  but  is  sometimes  (per- 
haps erroneously)  used  to  include  cold  applications  similarly  applied. 
On  the  whole,  the  most  useful  method  of  fomenting  the  eyes  is  the 
following,  especially  when  employed  in  conjunction  with  collyria : 
The  patient  should  lean  well  forward  with  the  head  over  a  basin  full 
of  hot  (or  cold)  water,  and,  holding  in  each  hand  an  end  of  a  wash 
cloth  or  small  towel  (folded  so  as  to  measure  4x12  inches),  lift  or 
"scoop"  the  water  repeatedly  up  to  the  tightly-closed  eyes,  forehead 
and  temples  for  a  period  of  three  minutes.  This  is  to  lie  done  as  often 
as  desired  and  to  be  followed  by  two  or  three  drops  of  the  eye  water. 
])ut  into  each  eye  with  tlie  medicine  dropper.  When  cold  water  is 
ordered  it  should  be  quite  cold  but  never  so  cold  as  to  make  the  liands. 
eyes  or  head  ache.  After  using  hot  water  the  patient  should  not 
venture  out  for  half  an  hour  after  its  application.  Neither  hot  nor 
cold  water  should  ])e  used  for  a  longer  time  than  prescribed. 


FOND  5243 

Fond.     (F.)     P.aekyi'ouiKl  (of  tlit'  eye). 

Fcndant.     (F.)     Dissolvent. 

Fondo  dell  'occhio.     (It.)     Ocular  fundus. 

Fons  lacrimariim,     (L.)     The  inner  cantlius  of  the  eye. 

Fontana,  Canal  of.  Spaces  of  Fontana.  A  series  of  passages  or  spaces 
(very  small  in  man,  but  of  great  size  in  some  of  the  lower  animals) 
formed  hy  the  iulei-Jacing  of  the  connective-tissue  fibres  forming  the 
framework  of  tiie  periphei-al  processes,  or  roots,  of  the  iris;  situated 
in  the  angle  of  the  anterior  chamber  and  sei'ving  as  the  medium 
of  transudation  of  the  a(iueous  humor  f)-om  the  interior  to  the  exterior 
of  the  eye. — (Foster)  See  Histology  of  the  eye;  as  well  as  Anatomy 
of  the  eye. 

Fontana,  Felice.  A  celebrated  Italian  physicist,  chemist,  and  physiolo- 
gist, whose  name  has  been  preserved  for  ophthalmologists  in  the 
expression,  canal  of  Fontana  (q.  v.).  Bom  at  Pomarolo,  near  Rove- 
reto,  April  15,  1720,  he  studied  at  Padua,  Bologna,  and  Rome,  After 
a  brief  period  spent  as  instructor  in  philosophy  at  Pisa,  he  was  com- 
missioned by  the  Duke  of  Tuscany  to  establish  in  Florence  a  natural 
history  museum.  He  wrote  "Sui  Moti  dell'  Iride"  (Lucca,  1765), 
and  died  IMarch  9,  1805.— (T.  II.  S.) 

Fontorbe's  test.  This  is  one  of  the  numerous  tests  for  simulated  blind- 
ness, something  after  the  style  of  the  red  and  green  glasses  of  the 
Snellen  test  (q.  v.),. 

Foot,  Jesse.  An  English  ophthalmologist  of  the  early  19th  century, 
whose  life-dates  cannot  be  ascertained.  He  was  physician  to  the  West- 
minster Ophthaliuic  Hospital,  London,  and  published  a  work  entitled 
''Ophthalmic  Memoranda"  (London,  1838).— (T.  H.  S.) 

Foot  of  a  microscope.  The  part  of  a  niicrosco]ie  by  which  it  rests  on 
the  table. 

Foot-screw.     A  form  of  adjusting-screw  for  leveling  purposes. 

Foramen.     (L.)     An  oi)eniiig,  a  perforation  or  pit. 

Foramen  centrale.     A  synonym  of  fovea  centrales. 

Foramen  cornese.  If  the  sclera  be  regarded  as  a  large  segment  of  the 
s})heroidal  eyeball  tlie  space  occupied  by  the  cornea  is  known  by 
several  names,  one  of  which  is  the  foregoing. 

Foramen  lacerum  orbitale.    (L.)    The  sphenoidal  fissure. 

Foramen  of  Soemmering.  A  term  applied  to  the  appearance  (some- 
times depressed)  i)resented  by  the  retina  at  the  yellow  spot. 

Foramen,  Optic.  The  orifice  of  a  short  canal  through  the  lesser  wing 
of  the  sphenoid.  Its  diameter  is  about  five  millimetres  transversely. 
It  is  often  a  little  larger  from  above  downward. 

Foramen  opticum  sclerotica.     A  synonym  of  foramen  cornea\ 


5244  FORAMEN  ORBITARIUM  SUPERIUS 

Foramen  orbitarium  superius.     (L.)     Siij)r;i()il)ital  loi-jiincii. 

Foramen  sclerae  anterius.     A  s.\ii(>n,\ m  of  cofnc.il  iii1civ;il. 

Forbes,  C.  F.  Am  Ki)«j:lisii  iiiililary  sui-gcoii  (lilc  dates  not  obtainable) 
who  wi'ote  "Ohsfrvdtions  on  tlir  Ilistorij  and  Trcdtnirnt  of  an  Epi- 
demic (>i)ht}iii!tnia,  which  appeared  in  the  Fourth  Battalion  of  the 
Boyals,  in  Edinburgh  Castle,  during  the  months  of  Julij  and  August, 
1807."— (T.  TI.  S.) 

Forbes,  Edward  (l(Sir)-r)4),  naturalist,  l)orn  at  Douglas,  Isle  of  .Man, 
entered  the  University  of  Edinburfjii  as  a  student  of  medicine;  and 
in  183G  reliiKjuished  medical  studies  to  devote  iiiinself  to  the  natural 
sciences.  In  1836-37  he  studied  at  Paris  under  Geoffroy  St.  Hilaire, 
Jussieu,  and  De  Blainville.  In  1841  lie  joined  the  surveying  ship 
Beacon  as  naturalist,  and  accompanied  that  vessel  during  the  survey 
of  a  part  of  Asia  Minor.  On  his  return  to  England  (1843)  he  became 
professor  of  botany  in  King's  College,  London,  and  curator  of  the 
Geological  Society.  In  1844  he  was  appointed  paleontologist  to  the 
Museum  of  Geology ;  in  1851  professor  of  natural  history  in  the  School 
of  Mines;  in  1852  president  of  the  Geological  Society;  and  in  1853  he 
was  elected  to  the  chair  of  natural  history  in  the  University  of  Edin- 
burgh. Forbes  did  much  to  advance  and  systematize  special  depart- 
ments of  natural  history.  His  classification  of  the  British  starfishes 
opened  a  new  era  in  that  branch  of  zoology ;  and  his  discover^'  that 
air-breathing  molluscs  lived  at  the  period  of  the  Purbeck  beds  recti- 
fied many  erroneous  hypotheses.  Among  his  separate  works,  may  be 
instanced,  as  of  interest  to  ophthalmologists:  Xakcd-cycd  Medusa 
(1847) . — (Standard  Encyclopedia.) 

Forbes,  John.  An  English  naval  surgeon  who  wrote  "Observations  on 
Tr()i)ical  Nyctalopia"  {Edinburgh  Med.  and  Surg.  Jour.,  1811). — 
(T.  II.  S.)  * 

Forbici.     (It.)     Forceps. 

Forceps,  Bull-dog'.  A  small  forceps  with  serrated  edges  for  holding  an 
artery ;  a  scrre  fine. 

Forceps,  Capsule.  The  removal  of  a  portion  of  the  anterior  capsule,  as 
a  preliminary  to  the  extraction  of  cataract,  depends  for  its  success 
upon  certain  nuinipulations. 

In  performing  the  operation  the  patient  is  asked  to  look  down  and 
the  eyeball  is  fixed  below  in  the  vertical  meridian.  The  surgeon  should 
have  a  clear  view  of  the  anterior  capsule.  The  forceps  are  then  intro- 
duced (closed)  and  the  blades  directed  straight  downwards.  They  are 
passed  to  the  lower  border  of  the  pupil,  and  slowly  opened  to  their 
fullest  extent.  The  terminals  are  than  pressed  very  carefidly  and 
slightly  backward  against  the  anterior  surface  of  the  lens  and  closed. 


FORCEPS,  FIXING 


5245 


The  forceps  are  then — always  j^'ciitly — pushed  dovvuvvards.  By  this 
latter  maneuver  the  capsule  generally  ruptures  above.  With  a  careful 
side-to-side  movement  the  instrument,  with  the  torn  piece  of  capsule, 
is  removed  from  the  anterior  chamber.  If  this  maneuver  has  been 
properly  performed  the  lens  will  come  forward  and  the  subsequent 
extraction  is  easy.  Failure  to  seize  the  capsule  in  the  first  instance 
may  be  followed  by  a  second  trial.  In  soft,  semi-fluid  or  swollen 
cataracts,  especially  if  the  capsule  be  tough,  it  is  not  easy  to  grasp 
the  membrane.  In  attempting  to  tear  out  a  piece  of  capsule  in  this 
way  care  should  be  exercised  not  to  use  force  of  any  kind  or  in  any 
direction  lest  the  suspensory  ligament  be  torn,  the  lens  dislocated  or 
some  other  injury  be  done  to  the  ciliary  bod3\  If  a  reasonable  attempt 
to  use  the  capsule  forceps  fails  a  cystotome  should  be  substituted,  as 
repeated  attempts  to  perform  any  step  of  a  cataract  operation  is  likely 
to  demoralize  the  patient,  while  the  efforts  themselves  may  cause  loss 
of  \itreous  or  produce  some  other  und('siral)le  trauina.  See  Cataract, 
Senile  niul  Capsulectomy. 

Forceps,  Fixing.     See  Fixation  instruments. 

Forceps-scissors.  These  insti-uments  are  cutting  scissors  with  forceps- 
like handles.    See  Forceps,  Ophthalmic. 

Forcipula  claudibilis.     (Obs.)     Small  forceps  with  a  catch. 

Forceps,  Ophthalmic.  Forceps  in  general.  The  number  of  instru- 
ments of  the  forceps  type  employed  in  oplithalmic  surgery  is  very 


Abadie  "s  Capsule  Forceps. 

large.  Descri])tions  of  many  will  be  found  scattered  throughout  the 
pages  of  this  Eiicjjdopidia,  and  the  reader  is  referred  for  further 
information  regarding  their  uses  antl  forms  to  such  headings  as 
Fixation  instruments ;  Cataract,  Senile ;  Entropion ;  Chalazion ;  Ptosis ; 


AlliiDit  I'liiice  AiUanci'ineiit  t'oieops. 

Expression;  Cilia,  Misplaced;  Instruments,  Ophthalmic;  Blepharo- 
plasty;  Trachoma;  Canthoplasty,  and  generally  speaking,  to  eaptions 
of  the  name  of  the  operator,  inventor  or  dealer  with  whom  the 
instrument  in  question  is  mostly  associated.     In  the  following  sub- 


5246 


FORCEPS,  OPHTHALMIC 


lu'a(liM<:s  llic  l.ist-njiincd   (alpliabeticiil j   order  is  followod  as  nearly 
as  possible. 

No  description  of  a  i)articidai'  forceps  is  given  where  a  cut  obviously 
furnishes  the  required  information. 


Aubaret's  Forceps  foi'   Lid   Operations. 

So  far  as  fixation  forceps  is  concerned  they  constitute  a  (large) 
class  which  is  best  included  under  the  caption  Fixation  instruments, 
to  which  the  reader  is  referred. 


Automatic  Forceps  for  Putting  in  .Metal  Sutures. 

The  Allport-Prince  advancement  forceps  is  arranged  so  that  the 
teeth  of  the  male  blade  fit  into  a  narrow  fenestrum  in  the  opposing 
blade — with  the  purpose  of  a  firmer  grasp  on  the  tendon  than  is 
secured  by  some  other  instruments  of  the  kind. 


Forceps  magazine  for  Holding  the  ^Mctal  Sutures. 

Automatic  forceps  for  placing  metal  sutures  are  not  much  used  by 
the  ophthalmic  surgeon,  but  they  will  be  found  valuable  in  the  more 
extensive  forms  of  lid  surgery',  in  certain  operations  on  the  orbit, 
Kronlein's  procedure  for  instance,  and  by  those  ophthalmologists  who 
operate  on  brain  structures. 


FORCEPS,  OPHTHALMIC 


5247 


Barraqiicr's  forccps-cijstitomr  is  intended  to  remove  a  considerable 
portion  of  the  anterior  ctipsule  as  a  part  of  tlie  extraction  of  cataract. 

The  lid  forceps  of  Bettreniieux  is  intended  to  enable  the  operator  to 
evert  the  eyelid  and  expose  the  fornix.  It  is  recommended  for  use  in 
ophthalmia  of  tlie  new-born  to  permit  of  tliorough  cleansing  and  treat- 


Bader's  Epilation  Forceps. 


Barraquor  's  roix-cjis-Cystitome. 


Beauiirc-  "s  Cilia  Forceps. 


Forceps  and   Clamp  of  Bettreniieux   for  Complete  Eversion  of  the   Lid. 


Nelson  Black's  .Self  rctaiuing  Lid  Plate,   for  Operating  on  the  Eyelids. 


ment  of  tlie  lining  of  the  conjunctival  cul-de-sac,  in  which  case  it  is 
to  be  employed  only  by  the  (ver^'  cautious)  surgeon  himself.  It  is 
made  in  two  sizes. 

The   cystectomy    (capsule)   forceps  of   Bourgeois   is   introduced   in 
the  usual  manner   (See  Forceps,   Capsule)   but  when  the  anterior 


5248 


FORCEPS,   OPHTHALMIC 


capsule  is  ^I'aspcd  and  llic  hranclics  of  tlic  forceps  are  closed  the 
ivuioval  of  tli(^  iiicliuled  anterior  capsule  is  ac(;oiiiplislie(l  l)y  f^entle 
torsion  and  not  by  tearing  away  the  membrane  from  tlu;  lens. 

Bourgeois'  forceps  for  the  pcrfoiinaiice  of  hlrpharorrhaphij.     It  is 


Tlu>  ('jiiisulo  or  C'ystcctoiiiy    l'\)ic('i>s  of  IJoiirgeois. 


Capsiiliitoniy   Fon-ciis   of  A.   Bourgeois. 


often  a  difficult  matter  to  freshen  the  internal  horder  of  the  palpebral 
margin  because  of  scar  tissue,  due  to  injuries  or  disease,  in  inany  forms 
of  blepharoplasty.  These  cutting  pincers  readily  pierce  the  densest 
tissue  and  are  recommended  for  the  purpose  indicated.     They  cut  out 


Cutting  Forceps  for  Blephnrorrluiiiliy.     (Bourgeois.) 


Bruch's  Forceps  for   Everting  tlie   Eyelid. 

a  i)iece  of  tissue  one  cm.  lont;,  aftei'  which  the  opei'ation  may  l)e  com- 
pleted ))y  scissors,  or  in  the  usual  way. 

The  needle  forceps  of  Cantoiniet  is  employed  t'oi-  removal  of  capsu- 
iai'  membranes  remaining  after  cataract  exti'actioii. 

Chil)ret's  lid  forceps  is  intended  to  evi-rt  the  lids  and  freely  expose 


FORCEPS,   OPHTHALMIC 


5249 


^<fi^ 


"cS"^ 


Cantoiinct  's  Forceps-Needle. 


<smm>-~ 


Chaker  Bey's  Forceps  for  Coiiiplcte  Eversion   of  tlio   Iji<ls. 


Charamis'  Forceps  and  Lid-plate  for  Operations  on  Trichiasis  and  Entropion. 


Chibret's  Forceps  for  Everting  the  Li<l  and  Exposini;  the  Cid  de-sac. 


Claiborne's  Roller  Forceps  for  Expression  of  the  (Jranuiar  Tissue  iu  Trachoma. 


Vol.  VII — 26 


Chibret's  Enueleation  or  Luxation  Forceps. 


5250 


FORCEPS,  OPHTHALMIC 


Treacher  Collins'  Entropion  Forceps. 


Darier  's  Forceps  for  Grasping  and  Everting  tlie  Lid. 


Illustrating  the  Use  of  Darier 's  Forceps. 


FORCEPS,  OPHTHALMIC 


5251 


Deschamps'  Strabismus  or  Advancement  Forceps. 


Didikas'  Lid  Forceps. 


Donberg  's  Forceps   for   Expression   of  Granulation   Tissue. 


Donberg's   Capsule   Foneps   for   Cataract   Operations. 


Dowel's  Forceps-Cj-stitome,  with  Teeth  on  the  Convexity  of  the  Blades. 


5252 


FORCEPS,  OPHTHALMIC 


Lid  Forceiis  oi'  DuIkjvs  Lavigerie. 


Duckworth's  Cilia  (Epilation)  Forcei)s. 


Ehrhanlt's  Clamp  Forceps  lor  Controlling  the  Liils  during  Operation. 


Eisenstein's  Forceps  for  Fixing  and  Everting  the  Lids. 


Falta's   Forceps   and    Clamp   lor   Lid   Oi>erations 


iuuER        ^' 


Figarola 's  Forceps  for  Comjdete  Eversion  of  the  Eyeliil. 


(Collin's)  Fisher's  Iridectomy  Forceps. 


FORCEPS,  OPHTHALMIC 


5253 


the  cul-de-sac,  especially  for  ojxTalive  purposes.     Its  modus  operandi 
is  sufficieutly  iiulicaled  Ity  llic  liij^ure  in  the  text. 

In  Uidikas'  lid-pUilv  forceps  for  operatious  ou  tlie  eyelids  the  for- 
ceps may  be  pla(a'd  on  either  the  wide  or  narrow  plate,  and  the 
pressure  is  regulated  by  screws. 


Francis'  Cajisiile  Forceps. 

Eisenstein's  forceps  for  everting  the  lid.  For  operations  on  the 
lids  this  device  will  l)e  found  useful  though  the  l)ody  and  blades  are 
often  made  too  lieavy  and  cuinhersome. 

Francis   {Practiced  Med.  tiei'ics,  1910)    claims  for  the  iris  forceps 


Francis 's  Chalazion  Forceps. 

that  appear  in  the  accompanying  figure  the  following  advantages: 
1.  While  sufficiently  strong  to  be  stable,  its  small  size  and  light  weight 
makes  mauijndation  easier  than  with  a  larger  and  less  delicate  instru- 
ment.    2.  The  teeth  are  placed  iu  tlie  rear  and  are  smoothed  down  so 


Francis's  Iris  Forceps 


that  when  the  blades  are  closed  no  uneven  surface  is  presented  to 
engage  in  the  wound  or  prematurely  entangle  the  iris.  3.  A  firm  and 
steady  liold  is  permitted  on  account  of  the  wide  grasp  for  finger  and 
thumb.  4.  Tile  blades  opeu  readily  so  that  control  is  q?ls\.  5.  Tht^ 
instrument,  being  made  with  an  aseptic  lock  and  a  threaded  pin,  is 
readily  taken  ai>art  foi-  clcaniug.     0.  On  account  of  the  crossed  blades 


5254 


FORCEPS,   OPHTHALMIC 


the  for(*('j)s  in;iy  he  iiitrodiiccil  tlifoujrh  a  very  small  corneal  incision. 
llaiTv  (iradlc  has  devised  ;ui  S-sliiiped  bi'iid  in  llie  shank  of  his  iris 
forceps,  just  above  the  tooth  area,  so  that  the  end  of  the  instrument 
can  easily  slide  over  the  iris  and  engage  the  anterior  capsule  while 
the  iris  i)roi)er  is  well  below  the  shank,  and  in  no  danger  of  being 
entangled. 

Galezowski's    (Trachonia)    (Jranulation   Forceps. 


(iraetV's  ('apsule   Forceps. 


1 1 TFiTTT  1 1 1 1  r^ii^ 


Graefe's  Entroi)iiim  Forceps,  for  Grasping  the  Lid  Margin. 


(iracfe's   Fixation    Forceps   witlioiit   Catch. 


Greene's  Tendon  Tucking  Forceps. 

Ilolth's  vitreous  forceps  are  variously  used  for  the  extraction  of 
foreign  bodies  from  the  vitreous;  (:580)  for  use  near  the  meridional 
incision;  (381)  for  use  behind  the  lens  and  the  ciliary  body;  (382, 
382a)  for  use  in  the  posterior  tAvo-thirds  of  the  vitreous,  with  circular 
or  oval  blades.  They  are  made  with  plane  blades,  transversally 
ridged,  or  with  blades  slightly  concave  on  the  inside  and  smooth. 
See  Injuries  of  the  eye. 


FORCEPS,  OPHTHALMIC 


5255 


Holth's  Forceps  for  the  Extraction   of   Foreign   Bodies   from   A'arious   Parts   of 

the  Vitreous  Body. 


Houzel's   Forceps  for  Grasping  and  Fastening  Compresses. 


Israelson's  Forcei)S  for  Transjilanting  Mucous  Grafts  from  the  Lip  in  Trichiasis 

and  Entropion. 


5256 


FORCEPS,   OPHTHALMIC 


Jewell's  Str:il)isiiius  ( Ailv:incement)   Forceps. 


Knai)2j  's  Trachoma-Expression   or  Roller  Forceps. 


1 1  \'A 


Kuhnt  's  Forceps  for  Placing  Corneal  Sutures. 


Knlint's  Forcei)s-l'ystitunic,  with  Antoniatif  ^^iu 


]vuhnt 's  Expression    (Tiachoina)    Forceps. 


FORCEPS,  OPHTHALMIC 


5257 


Landolt's  Lid  Forceps  with  Hard  Eublier  I'late. 


Lai>ersonne 's  Punch-Forceps  for  Cutting  a  Ficce  out  of  Post-operative  Capsular 


Membranes. 


Levinsohn's    Scissors-forceps    for    Making    an    Opening    in    Thickened    Capsular 

Membranes. 


Liebreich's   Forceps-Cystitome,   Provided   with   Toetii   on   the   Convex   Surface   of 

tlie  Terminals. 


Luer's  Iris  Forcejjs,  with  Triple  Articulation. 


Forceps,  with  Spring,  for  Fastening  Compresses. 


5258 


FORCEPS,  OPHTHALMIC 


Luer's  Fork-Forcex)s  for  Removing  Instruments   from  Boiling  Water. 


^letal  Sutures,  for  Use  with  Forceps. 


Luer's  Forceps,  with  Spring,  for  Putting  in  Metal  Sutures. 


Luer's  Simple  Forceps  for  Putting  in  Metal   Sutures. 


Forceps  for  Taking  out  Metal  Sutures. 


liUer 's  Forcei)S  for  IJotli   Putting  in  and  Taking  out    Metal  Sutures. 


FORCEPS.  OPHTHALMIC 


5259 


Luer's   Triple   Artiinilation    Foreeps-Cyi^titome,   with   Teetli   on   the   Convexity   of 

the  Terminals. 


Luer's  Forceps  Gouge. 


JUi\ 


Luer's  Forceps  Gouge,  of  Additional  Patterns. 


The   Marczel-Falta   Traehoina   Forceps,   with   Ivory   Tips,   for   Massage  with 

Sublimate  Solution. 


Mutais'    Cystei-tuiny   Forceps. 


Mules'  Forceps  for  the  Removal  of  Sutures. 


)2r)() 


FORCEPS,  OPHTHALMIC 


Musseux's  Forceps  for  Grasping  tlie  Lachrymal  Sac. 


Nicati's    Wire    Forceps-Cystitome,    with    Teeth    on    the    Convex    Surface    of    tlie 

Terminals. 


Noyes'   Exjjression   Forceps  for   Trachoma. 


o 

Peilrazzoli 's  Forccj)s  for  Separating  the  Fyelids. 


FORCEPS,  OPHTHALMIC 


5261 


Pflugk's  Grooved  Forceps  for  Oculoniusciilar  Advancement. 
This  instrument  is  locked  by  means  of  a  secure  bolt  and  catch,  and  may  be 
used  on  either  the  ri<:ht  or  left  side. 


Piccaluga's  Modification  of  Desmarres'  Lid  Forceps. 


Pley's  Anterior  Capsule  Forceps. 
Prince's  Trachoma    (Expression)   Forceps. 


Eeisinger 's  Hook  Forceps,  for  tlie  Extraction  of  the  Nucleus  in   Certain  Forms 

of  Hard  Cataract. 


5262 


FORCEPS,  OPHTHALMIC 


i^V      fH    L_,t^..k_,lh'~,J^-- 


Koisingcr's  Iris  Forceps  in  Cataract   Extraction. 

b -^ 


Eeiss '  Chalazion  and  Lid  Forceps. 


Eing  Forceps. 


D 


Eolston  's  Expression  Forceps,  Employed  in  Certain  Forms  of  Trachoma. 


Saril's  Traciionia  Forcej^s. 
Curved  blades;  to  be  adapted  (in  expression  of  granulations)  to  the  margins  of 
the  upper  lids. 


Saril's  Trachoma  Forceps. 
Flat  blades,  for  use  on  tlie  lower  lids. 


FORCEPS,   OPHTHALMIC 


5263 


-.1  111-    I'l  .I'hoiiia   Forceps. 
Trinni^iil.-ir  Mii.lfs  iiitfiidod  tu  squoczi;  out  <,naimlations  from  all  conjunctival  areas. 


Sattler  's  Advancement  Forceps. 
Three  points  on   the  male  blade  fit  into  openings  on  the  second  branch,  and 
securely  hold  the  tendon  or  muscle. 


Schmidt's  Spoon  Forceps,   for  the  Extraction   of   Lenticuhir   Remains. 


Sichel  's  Forceps  for  Making  an  Artificial  Pujiil. 


Sichel's  Forceps  for  the  Kelief  of  Ptosis. 


lel leu's  Trachoma  Forceps. 


5264 


FORCEPS,  OPHTHALMIC 


Sodcrliiili  's   Forceps   for   Canthoplasty. 


Stevenson's  Advancement  Forceps. 
The  handles  are  bent  to  follow  the  ontline  of  orbital  margins    (so  that  the 
instrument  is  applied  to  the  face)  while  three  needle  points  pierce  and  keep  firmly 
in  place  the  oculomuscular  tissues. 


-'Straiylit  Cilia   (Epilation)   Forceps. 


Straight   Iris   I'orccps. 


Terson's  Forceps-Cystitome,  or  Anterior  Capsule   (Cataract)   Forceps. 
There  are  three  forms  of  this  instrument— according  to  the  number  of  teeth 
in  each  blade— 2  and  2,  4  and  4,  5  and  5. 


Terson's  Forceps-Cvstitome,  with  Special   Handle. 
Two  forms  are  generally  used;  one  with  2  and  2  teeth,  another  with  4  and  4  teeth. 


Terson's  Three  and   Fivetootlied  Anterior  Capsule  Forceps. 


FORCEPS,   OPHTHALMIC 


5265 


Tliit'haufs    I'oreeps  for  Comj)lete  Eversion  of  the   Eyelids. 
The  instruiiient  is  proviiled  with  needle-points  for  the  more  effective  fixation 
of  the  lids. 


Trousseau  's  Canthoplastic  Forceps. 


Tyrrell's  Trachoma  Forceps. 
This  instrument  is  intended  to  reach  and  squeeze,  in  particular,  otherwise  inac- 
cessible granulations  at  the  ocular  canthi. 
Vol.  VII— 27 


5266 


FORCEPS,  OPHTHALMIC 


Valiide's  Orbital  ii'tug  Forceps. 


Pe  Wi'ckor's  Forcejis  with  Caoutchouc  Toriuinals  ami  Sliiiiiitf  Catcli  for  Fvcrtiiij^ 

the  Eyelids. 


De   Weclter's   Larger  Hemostatic   Foiceps. 


oftunwugainir  (<v 


Spencer  Wells'  Miiii;iturc  Artery   Forccjts,  Useful  iu  Ophthalmic  Operations. 


FOREHEAD   LAMP 


5267 


I. tier's  nuhd-siilurc  forceps  arc  sold  in  at,  least  two  patterns;  oiu; 
is  employed  for  both  inserting  and  icinoving  the  sutures,  and  another 
(see  the  figures)  for  phicing  them  iti  silu.  Still  another  model  (see 
the  cut)  is  useful  for  both  purposes. 


ita^Pui^ 


Wilde's  Caiisule  Forccjis  and  Scissors. 


K'lug   ((,'liaiazioii,  etc)   Forceps  of  ^'acoritlcs. 

The  forceps  gouge  of  Luer,  mainly  employed  for  operations  in  and 
about  the  orbit,  are  made  of  several  sizes  and  shapes,  and  with  the 
jaws  set  at  various  angles  with  the  handles. 
Forehead  lamp.  Numerous  devices,  most  of  them  electrically  arranged, 
are  elsewliei'e  depicted  in  this  Encyclopedia  for  illuminating  the 
external  eye.    See,  among  other  headings,  Examination  of  the  eye. 


Klectric    l'V)reiiead    Laiiiji,  for  Exaiiiininji-  the   J'^xterior    Kye. 

Foreest,  Pieter  van.  'Fiiis  I'emarkable  man  is  known  as  the  •'liatavian 
llippoerates. "  Il(>  is  also  often  referred  to  by  his  Latin  name,  Petrus 
Forestus.  Born  in  Holland  in  1522,  he  received  his  medical  degree  at 
Bologna,  and  afterwards  studied  for  a  long  time  at  Rome,  Padua,  and 
Paris.  He  practised  for  a  time  at  l>ordeaux,  then  at  Pluviers,  but 
settled  at  length  in  Alkmaar,  Holland,  whieli  seems  to  have  been  his 
native  town.  Here  he  practised  for  twelve  years,  and  then  removed 
to  Delft.  At  the  founding  of  the  Leyden  liniversity  he  was  made  (of 
course,  the  first)  professor  of  internal  medicine  at  that  institution. 
He  devoted  considerable  attention  to  diseases  of  the  eye,  and  was  one 
of  the  first  physicians  to  prescribe  concave  lenses  for  myopia.     He 


5268  FOREIGN  BODIES  IN  THE  EYE 

seems,  liowcvci-,  not  to  have  performed  the  cataract  operation.  After 
forty  years  of  both  metlieal  and  surgical  activity  at  Delft,  he  returned 
to  Alkmaar,  where  he  died  in  15iJ7,  aged  75. 

His  most  important  works,  both  of  which  contain  ophthalmic  obser- 
vations of  some  importance  in  their  day,  are: 

1.  Obscrvatianum  et  Curationum  Mediciiialium  Libri  xxxii  (Ley- 
den,  1587-1610). 

2.  Observationmn  et  Curationum  Chirurgicorum,  Libri  xi. —  (T. 
H.  S.) 

Foreign  bodies  in  the  eye.  This  extensive  and  important  subject  will 
be  fully  treated  under  the  heading  Injuries  of  the  eye.  It  has 
already  had  some  attention  in  the  section  devoted  to  Electromagnet, 
where  the  detection  and  removal  of  certain  intraocular  foreign 
bodies  are  discussed  and  illustrated ;  also  under  such  captions  as 
Cornea,  Foreign  bodies  in  the,  not  to  mention  Sympathetic  oph- 
thalmia, tliis  heading  will,  in  addition,  be  studied. 

Here,  it  may  be  allowable  to  add  a  few  paragraphs  from  the 
Ophthalmic  Y car-Book  dealing  with  recent  improvements  in  methods 
for  localizing  intraocular  foreign  bodies  and  the  means  of  removing 
them.  To  this  is  appended  some  observations  on  foreign  bodies  in 
the  orbit. 

The  eyeball  being  invisible  in  the  skiagraph,  and  thus  rendering  it 
difficult  to  determine  whether  a  foreign  body  is  in  the  eyeball  or  orbit, 
Wessely  {Arch,  filr  Augenh.,  page  161,  1912,  and  Ophthalmology, 
viii,  p.  247,  1912)  recommends  placing  a  thin  glass  shell  in  the  con- 
junctival sac.  The  part  corresponding  to  the  cornea  contains  a  high 
percentage  of  lead  so  that  this  shows  as  a  darker  shadow  in  the  skia- 
gram, and  thus  facilitates  fixing  the  situation  of  the  foreign  body. 
Holth  (Ophthnlm^scope,  vol.  ix,  p.  550,  1912)  sutures  a  pair  of  lead 
buttons  at  the  upper  and  lower  margins  of  the  cornea.  These  give 
shadows  which  have  a  definite  relation  to  the  eyeball,  no  matter  what 
position  the  latter  may  assume  when  the  skiagraph  is  taken. 

Oifford  (Ophth.  Rcc,  xxi,  p.  8,  1912)  has  for  eight  or  ten  years 
tucked  snudl  bits  of  brass  or  silver  wire  into  a  conjunctival  pocket  at 
the  upper  and  lower  corneal  margins,  with  a  very  satisfactory  result. 
He  observes  that  the  great  advantage  of  fixed  limbus  localizers  as 
opposed  to  those  methods  in  which  the  localizers  ar(>  outsidt>  of  the  eye. 
or  even  on  the  outside  of  the  lids,  is  the  possible  movement  of  the 
eyeball  after  closure  of  the  circuit ;  under  thes(»  eii'eumstances  the 
latter  class  of  localizers  would  give  an  erroneous  idea  of  the  ])osition 
of  the  foreign  body,  which  would  not  happen  with  the  limbus  local- 


FOREIGN  BODIES  IN  THE  EYE  5269 

izers.     Mick   ( ircs^.  Med.  Rev.,  Aug.,  1911)   also  has  described  this 
method. 

Alt  {Amer.  Jour.  Opliih.,  xxiii,  p.  328,  1912)  reports  a  case  of  infec- 
tiou  following  a  perforating  wound  with  no  history  and  which  was 
treated  by  insufflation  of  xeroforni.  A  skiagram  showed  a  number  of 
rather  strangely  placed  foreign  bodies  within  the  eye;  these  shadows 
were  in  all  probability  caused  by  the  bismuth  contained  in  the  xero- 
form  powder.  The  iridocyclitis  recovered  though  leaving  the  eye 
blind ;  there  have  never  been  any  symptoms  of  irritation  of  the  other 
eye.  A  case  like  this  throws  some  light  upon  those  instances  in  which 
eyes  were  removed  foi-  the  supposed  presence  of  foreign  bodies  as 
shown  upon  the  plate  hut  wliich  could  not  be  found  in  the  enucleated 
eyeball. 

Arcelin  {Rev.  Gen.  d'Opht.,  xxxi,  p.  241,  1912)  points  out  that  to 
estimate  the  size  of  a  foreign  body  by  radiography  one  must  have  a 
sharp  print  and  know  the  divergence  of  the  rays  and  the  angle  that 
the  foreign  body  makes  with  the  plate.  He  says  the  radiographer 
should  never  state  that  no  foreign  body  was  present,  and  gives  a  case 
in  which  such  a  statement  was  proven  erroneous. 

Randolph  (OpJdh.  Rec,  xx,  p.  113,  1912)  reports  two  eases  in  which 
the  x-rays  failed  to  locate  foreign  bodies  which  were  afterwards  found 
in  the  enucleated  eyes.  Both  were  steel.  The  first  had  been  carried 
in  the  eye  for  nineteen  years  with  resultant  blindness.  A  recent 
injury  set  up  recurrent  attacks  of  inflammation  for  which  the  eye  was 
enucleated.  The  piece  protruded  from  the  eyeball  behind,  well  out  into 
the  orbit,  and  about  half  an  inch  to  the  nasal  side  of  the  optic  nerve. 
It  was  a  little  thicker  in  one  part,  and  the  extra-ocular  part  was  en- 
meshed in  a  tough  (-apsule.  Three-fourths  of  it  lay  without  the  eye 
while  the  inner  end  was  sticking  through  the  retina.  But  for  the 
recent  injury  the  man  would  doubtless  have  carried  the  sliver  of  steel 
the  rest  of  his  life.  In  the  second  ease  the  day  after  the  injury  there 
was  a  perforation  at  the  liml)us  and  a  probal)le  minute  slit  in  the  iris. 
The  media  were  cloudy,  so  that  the  fundus  details  were  not  discern- 
ible. A  foreign  ])ody  was  strongly  suspected  but  three  plates  were 
negative,  the  first  taken  at  once,  the  other  two  at  the  end  of  a  month. 
As  the  eye  continued  to  grow  worse  it  was  eiuudeated,  and  far  back  in 
the  vitreous  surrounded  by  a  mass  of  exudate  was  an  irregularly- 
shaped  bit  of  steel. 

In  Allport's  (Oplith.  Rcc,  xxi,  p.  65,  1912)  case  a  piece  of  steel  was 
found  after  enucleation,  in  a  small  mass  of  exudate  attached  to  the 
eyeball,  having  passed  completely  tlirougli  the  globe.  The  x-rays 
showed  that  the  foreign  bodv  moved  witli  the  eyeball ;  it  could  not  be 


;VJ7()  FOREIGN  BODIES  IN  THE  EYE 

detected  or  rcmovt-d  by  tlic  iiuij^Mict.  .Jung  {Deutsche  Med.  Woch., 
Oct.  5,  I'Jll)  calls  attontioii  to  11h'  iinpossihility  of  positively  recog- 
iii/iiig  the  j)rc'seiice  of  m  foi'cign  body,  as  in  the  eye  and  not  in  tiie 
orbit,  in  every  case,  by  any  known  iiictlKid.  Where  the  shadow 
remains  sharply -detlned  and  single  ujion  movements  of  the  eyeball, 
the  foreign  body  is  naturally  extra-ocular.  Kohler's  assumption,  that 
doubling  of  the  shadow  upon  movements  of  the  e^'e  is  a  positive  indi- 
cation of  the  presence  of  a  foreign  body  within  the  same,  lias  been 
found  not  to  hold  good  in  every  case. 

When  the  sideroseopc  has  but  a  single  magnetic  needh;  tlic  instru- 
ment must  be  placed  in  the  magnetic  meridian.  To  avoid  this  neces- 
sity an  astatic  system  has  ])een  employed.  As  the  lower  needle  was 
innnovable  the  system  was  only  partially  astatic.  If  the  astatic  needles 
are  arranged  close  together  in  a  single  tube  the  two  needles  mutually 
interfere  in  their  action  upon  the  bit  of  iron  so  that  they  are  less 
sensitive  than  the  single  needle.  Spuler  (Klin.  M.  f.  Augenh.,  Oct., 
]i)]l)  has  united  the  astatic  needles  so  that  they  may  swing  together 
in  the  same  plane,  each  in  its  own  tube.  Tlie  distance  between  the  two 
needles,  being  about  12  cm.,  is  of  no  importance  as  regards  the  influ- 
ence of  terrestrial  magnetism,  but  as  regards  the  effect  upon  the  bit  of 
iron  such  disturbing  influence  is  excluded  by  the  second  needle.  To 
abolish  the  influence  of  electric  currents  and  large  accumulations  of 
iron,  as  also  to  vary  the  zero  point  and  to  make  the  needles  as  sensitive 
as  possible,  two  revolving  magnets  are  attached  to  the  bottom  plate. 
These  magnets  can  l)e  revolved  in  opposite  directions  al)out  a  vertical 
axis.  Each  magnet  moreover  is  movable  by  itself.  Tiie  reflecting 
mirror  is  obtained  from  the  surface  of  a  weak  convex  lens  (0.5  D.) 
silvered  on  one  side,  set  in  a  cell  in  the  center  of  the  frame  between 
the  magnets.  A  sharp  image  of  an  illuminated  thread  or  slit  is  thrown 
upon  the  scale  at  a  fixed  distance  by  the  reflecting  surface  of  the  lens. 

In  Gallemaert's  {Arch.  cVOphi.,  xxxi,  p.  497,  1912)  magnetometer 
the  signal  magnet  is  replaced  by  three  superimposed  magnets  with 
their  poles  in  the  same  direction.  Two  inde])endent  magnets  are  so 
disposed  as  to  facilitate  the  regulating  of  the  indicator  magnet ;  a 
mirror,  telescope  and  graduated  rule  complete  the  apparatus.  The 
inventor  claims  extreme  sensibility  for  his  apparatus  permitting  ready 
recognition  of  bits  of  iron  weigliing  less  than  a  milligram. 

Ilaab  {Arch.  f.  Augenh.,  Ixix,  p.  Ill,  1912.    Ophthalmoscope,  x,  p. 

•    052,  1912.     Ophthalmology,  viii,  p.  20,  1912)  considers  localization  of 

the  foreign  body  l)y  the  x-rays  and  sideroscope  as  useless,  since  the 

magnet  seeks  the  body  wherever  it  is.     Extraction  is  to  be  practised 

through  the  anterior  chamber  whenever  possil)l(\  to  o])via1e  the  danger 


FOREIGN  BODIES  IN  THE  EYE  5271 

of  subsequent  detachment  of  the  retina  from  the  scleral  incision.  The 
magnet  can  never  be  too  powerful;  its  action  can  be  weakened  by 
keeping  it  at  a  distance  from  the  eye  and  using  a  longer  point.  Care 
must  be  taken  tliat  the  foreign  body  does  not  become  imbedded  during 
extraction  in  the  posterior  surface  of  the  iris.  The  patient  should  be 
operated  upon  sitting  so  that  he  can  easily  draw  his  head  back  and 
the  current  should  be  closed  and  opened  by  the  foot. 

Weill  {Am.  Jour-.  Ophth.,  xxix,  p.  129,  1912)  advocates  the  corneal 
route  without  scleral  incision  for  the  extraction  of  magnetic  bodies 
with  the  fixed  giant  nuignet.  The  magnet  cannot  be  too  strong,  but 
the  technique  of  its  application  must  be  well  understood,  as  irrepara- 
ble damage  can  be  (piickly  wrought  by  its  faulty  use.  Before  the 
attempt  at  extraction  is  made  cocain  with  perhaps  adrenalin  is 
instilled,  the  skin  about  the  eye  made  as  sterile  as  possible,  as  also 
the  magnet  tip  and  atljoining  parts,  and  the  conjunctival  sac  irri- 
gated with  a  suitable  bland  sterile  solution.  The  pupil  must  usually 
be  dilated.  A  sterile  rubber  fitting  that  portion  of  the  magnet  adjoin- 
ing the  tip  is  to  be  recommended.  A  cap  of  sterile  material  is  to  be 
placed  over  the  patient's  hair  and  a  mask  is  advisable.  Examination 
with  the  x-rays  he  considers  unnecessary,  as  costing  valuable  time  and 
adding  to  the  danger  of  infection.  The  same  magnet  is  useful  in  the 
removal  of  steel  needles,  pins,  tacks,  etc.,  from  other  accessible  parts 
of  the  body ;  the  application  should  not  be  discontinued  too  soon.  This 
l^aper  very  properly  insists  upon  the  necessity  of  proper  knowledge 
upon  the  part  of  the  operator  who  proposes  to  use  the  magnet.  Haab 
himself  has  given  minute  directions  and  has  sought  to  show  that  the 
poor  results  obtained  by  some  operators  were  due  in  large  part  to 
its  unskillful  use. 

Although  a  partisan  of  the  giant  magnet,  Nance  {Jour.  Ophth.  and 
Oto-Laryngol.,  vi,  p.  325,  1912)  thinks  it  is  better,  wherever  possible, 
for  the  surgeon  to  know  what  he  is  doing,  rather  than  to  guess.  His 
experience  has  taught  him  that  the  X-ray  examination  is  of  the  great- 
est assistance  in  intelligently  handling  eases.  One  should  know  the 
approximate  size,  shape,  character,  and  location  of  the  foreign  body, 
and  should  endeavor  to  remove  it  with  as  little  violence  to  the  e3'e  as 
possible.  Rollet  {Arch.  d'Opht.,  xxxii,  p.  321,  1912)  reports  eighteen 
cases  of  extraction  with  the  giant  magnet.  In  two  of  foreign  body  in 
the  cornea  and  iris  the  results  were  good ;  vision  over  2/3  in  both.  Of 
the  sixteen  eases  of  foreign  l)ody  extracted  from  the  posterior  segment 
of  the  eye,  two  eyes  required  enucleation,  in  nine  the  eyeball  was 
saved  without  vision,  in  three  operable  traumatic  cataract  was  left, 
and  in  five  visual  acuity  of  i/s  to  1,  was  attained.     Sir  {Cent.  f.  p. 


5272  FOREIGN  BODIES  IN  THE  EYE 

Augenh.,  xxxv,  p.  333,  1912.  Ophlhaltnoluijij,  viii,  p.  386,  1912) 
reports  tlmt  147  cases  treated  iu  the  Bolieniiaii  cliuie,  iu  ninety-eight 
the  foreign  body  consisted  of  steel.  Removal  from  the  anterior  parts 
was  always  successful.  Of  forty-six  cases  in  tlie  interior  of  tlie  eye- 
ball, twenty-five  were  saved. 

Lamb  {OpJithalmology,  viii,  p.  507,  1912)  thinks  that  tlie  foreign 
body  should  not  be  removed  through  the  wound  of  entrance  in  the 
cornea,  but  rather  through  a  scleral  incision  preferably  at  the  lower 
outer  quadrant  between  the  tendons  of  the  inferior  and  external  rectus. 
Inasmuch  as  the  Volkmann  giant  magnet  cannot  always  be  readily 
brought  into  the  joosition  desired,  Gallemaerts  {Soc.  Beige  d'Opht., 
No.  30,  1912.  OpIitJialmology,  viii,  p.  68,  1912)  has  attached  to  the 
magnet  movable  poles,  which  may  be  of  various  forms  like  those  of  a 
hand  magnet.  In  Risley's  (Ophth.  Bee,  xi,  p.  258,  1912)  case  violent 
orbital  cellulitis  with  panophthalmitis  and  profound  general  infection 
came  on  within  twenty-four  hours  after  magnet  extraction  of  a  rusty, 
friable  scale  of  metal  from  the  vitreous.  The  discharge  contained 
Friedliinder's  bacillus,  numerous  streptococci  and  staphylococci.  The 
reporter  raised  the  question  whether,  in  view  of  the  rapid  destruction 
of  the  organ  by  local  mixed  infection,  the  general  infection  was  not 
already  present  at  the  time  the  injury  was  received ;  and  the  local 
condition  secondary ;  or  did  the  general  disorder  result  from  absorp- 
tion of  the  local  infection.  The  patient  had  suffered  from  a  severe 
attack  of  pleuro-pneumonia  a  few  years  before,  and  was  in  poor  health 
at  the  time  the  injury  was  received. 

In  Birkhaiiser's  (Klin.  M.  f.  Augenh.,  p.  23,  July,  1911.  Ann.  of 
Ophth.,  xxi,  p.  150,  1912)  case  of  foreign  body  in  the  orljit,  sudden 
blindness  of  one  eye  followed  perforation  of  the  hard  palate  by  a  pipe 
stem.  The  x-rays  showed  that  the  foreign  body  Jiad  entered  the  orbit. 
The  nerve  was  divided  just  anterior  to  the  optic  foramen,  either 
directly  by  the  foreign  body  itself,  or  througli  compression  by  the  sur- 
rounding parts.  A  large  region  of  the  fundus  around  the  papilla 
presented  for  some  weeks  a  white  discoloration  with  numerous  liemor- 
rhages;  which  appearances  are  believed  by  the  reporter  to  have  been 
due  to  edema  from  partial  and  temporary  compression  of  the  retinal 
and  ciliary  arteries. 

Gallemaerts  {Acad,  de  Med.  de  Belgique.  Ophthalmology,  viii,  p. 
379,  1912)  reports  the  result  of  an  accidental  injury  to  a  child  a?t.  5, 
who  fell  and  pierced  the  upper  eyelid  with  a  slate  ]HMieil,  a  fragment 
of  which  remained  in  the  orbit  for  twenty-four  hours.  The  extracted 
fragment  measured  38  l)y  5  mm.  Fetid  pus  mixed  with  air  bubbles 
discharged  from  the  wound.     A  drain  9  cm.  long  was  shown  by  a 


FORENSIC  5273 

radiograph  to  penetrate  \\\f  I'tontal  lolx-.  Perfect  recovery  occurred 
after  two  months.  Selioute  {Zdtsdir.  f.  Aiigcnh.,  xxvii,  p.  185,  1912) 
reports  a  case  in  M^iich  a  fragment  of  lead  pencil  17  mm.  long  was 
supposed  to  have  remained  in  the  upper  cul-de-sac  of  the  conjunctiva 
for  twenty-nine  years.  Both  ends  were  imbedded  in  tlie  tissue  of  tlie 
fornix,  while  the  middle  portion  lay  free  in  tlie  conjunctival  sac. 

Forensic.  Pertaining  to  a  court  of  law.  In  medicine,  that  part  of 
the  science  connected  witli  judicial  inquiry.  Also,  medical  jurispru- 
dence. 

Forensic  relations  of  ophthalmology.  See  iiuijor  heading.  Legal  rela- 
tions of  ophthalmology;  as  well  as  Visual  economics. 

Foreshortening.  This  term  is  used  in  painting  and  drawing,  and  is 
applied  to  signify  that  a  figure,  or  a  portion  of  a  figure,  which  is 
intended  to  be  viewed  by  the  spectator  directly  or  nearly  in  front,  is 
so  represented  as  to  convey  the  notion  of  its  being  projected  forward ; 
and,  though  by  mere  comparative  measurement  occupying  a  much 
smaller  space  on  the  surface,  yet  to  give  the  same  idea  of  length  or 
size  as  if  it  had  been  projected  laterally. 

Forestus,  Petrus.  "The  Batavian  Hippocrates."  See  Foreest,  Pieter 
van. 

Fork,  Fixation.  A  fixation  fork  devised  for  insertion  of  sutures  in  the 
sclerotic  is  descrilied  in  the  Trans.  Oph.  Sac.  U.  K.,  p.  131,  1912.  See 
Fixation  instruments. 

Forlenze,  Joseph  Nicolas  Blaise.  A  well-known  Italian  ophthalmolo- 
gist, who  was  born  at  Kicerno  in  1769.  He  studied  at  first  in  various 
Italian  and  Greek  universities,  then,  under  Desault  and  Louis,  at 
Paris,  and  under  John  Hunter  at  London.  He  settled  as  ophthalmolo- 
gist in  France,  presumably  at  Paris.  His  death  date  cannot  be  learned. 
Forlenze 's  ophthalmologic  writings  are  as  follows:  1.  Considera- 
tions sur  rOperation  de  la  Pupille  Artificielle.  (Strasburg  and  Paris, 
1804.)  2.  Observations  et  Refiections  sur  plusieurs  Cataractes.  {An- 
nunire  de  la  Soc.  cle  Med.  du  Department  de  I'Eure,  1809.)  — (T.  H.  S.) 

Formaldehyde.  Formic  aldehyde.  Methyl  aldehyde.  IICHO.  This 
pungent  and  poisonous  compound  is  made  by  the  partial  oxidation  of 
methyl  alcohol.  Its  solutions  should  be  kept  cool,  in  well-stoppered 
bottles,  and  away  from  the  light.  At  ordinary  temperatures  formic 
aldehyde  is  a  colorless  gas  with  a  pungent,  irritating  odor.  Fifty  per 
cent,  solutions  in  water  are  obtainable,  but  at  that  strength  the  solu- 
tion decomposes;  hence  the  use  of  a  weaker  solution  for  surgical 
purposes. 

Formaldehyde  is  incompatible  with  alkaline  preparations,  tannin, 
gelatine,  and  the  salts  of  silver  and  copper. 


5274  FORMALIN 

Valuck'  was  tliL'  lirst  to  hriiij;  this  valiialdo  remedy  to  our  notice 
as  an  aMtisc{»ti(*  foi'  opiitlialiiiie  use.  In  its  pure  form  it  proved  very 
irritating,  ])ro(lucing  luiniing,  smarting  and  laclirvmati(>n  even  when 
used  in  1:100(1  or  1  :2000  solutions  for  conjunctivitis.  More  recently 
we  have  come  to  rely  upon  its  40  i)er  cent,  solution  under  the  commer- 
cial title  of  formalin  (q.  v.),  in  which  state  it  lias  proved  a  most 
valuable  germicide  and  substitute  for  corrosive  sublimate.  Formalde- 
hyde in  its  gaseous  form  is  used  as  a  disinfectant  for  ophthalmic 
instruments,  special  disinfectant  apparatus  having  been  devised  for 
this  purpose. 
Formalin.  Formol.  Liqi^or  form.vi.deiiydi,  U.  8.  Solution  of  for- 
.MALDEiiYDE.  This  valuable  antisei)tie  is  the  official  solution,  a  color- 
less liquid  with  a  l)urning  taste  and  pungent  odor,  which  has  an  irri- 
tant etfect  upon  the  skin  and  mucous  membranes.  It  mixes  in  all 
proportions  with  water  and  alcohol. 

It  lessens  secretion  in  almost  all  forms  of  conjunctival  infection  and 
for  this  particular  purpose  is  employed  in  about  the  same  proportion 
as  corrosive  sublimate.  It  is  just  as  efficacious  as  that  salt  without 
possessing  its  irritant  and  poisonous  qualities.  As  it  does  not  form 
insoluble  compounds  with  the  tissues  and  is  not  incompatible  with 
most  of  the  remedies  used  in  ophthalmic  practice  it  is  much  to  be 
preferred  to  bichloride  of  mercury.  It  is  most  valuable  as  a  germi- 
cide, either  alone  or  in  conjunction  with  other  remedies,  in  the  propor- 
tion of  1-10,000  to  5,000.  It  is  also  excellent  as  a  preservative  of 
alkaloidal  solutions  in  the  1-10,000  strength  and  it  can  be  used,  with- 
out damage  to  them,  as  strong  as  1-100  for  the  preparation  of  instru- 
ments for  operation. 

n.  McI.  Morton  uses  formalin,  one  part  to  80  as  a  direct  applica- 
tion to  corneal  ulcers,  and  finds  it  more  useful  than  the  nuijority  of 
applications  he  has  employed. 

E.  C.  Boyd  prefers  as  a  simple  collyrium  one  drop  of  formalin  in 
four  fluid  ounces  of  distilled  water  to  be  used  in  an  eye-cup  several 
times  a  day. 

Occasionally  cases  of  formalin  amblyopia  are  published.  For  exam- 
ple, Sager  {Ths  Ophthalmoscope,  February,  1906)  reports  a  ease  in 
which  a  single  drop  was  accidentally  introduced  into  the  eye  of  a 
patient.  It  was  washed  out  with  water  within  fifteen  seconds.  No 
pain  was  experienced  until  six  hours  afterward,  when  the  eye  became 
very  painful  and  much  inflamed.  For  a  number  of  days  the  lids  and 
conjunctiva  were  edcumtous.  The  cornea  was  steamy.  Six  months 
later  the  patient  was  seen  by  Sager,  when  it  was  found  that  the  cornea 
was  still  slightly  o])a(|ue.  with  vision  i-educed  more  than  one-lialf. 


FORMATION  OF  THE  EYE  5275 

Lewiii  and  Guillory  give  the  following  history:  A  45-year-old 
woman,  while  cutting  grass,  slightly  injured  hei'  right  eye.  After  a 
few  days  a  physieian  dropped  formalin  solution,  erroneously  markecl 
cocaine,  into  her  eye.  The  pain  increased.  Drops  placed  in  normal 
eyes  also  caused  severe  pain,  and  thus  the  mistake  was  recognized. 
The  clinical  picture  was  not  closely  studied,  but  after  five  weeks' 
treatment  there  was  vision  in  the  affected  eye  of  only  6/200. 

It  must  be  remembered,  also,  that  persevering  with  the  local  use  of 
too  strong  solutions  may  set  up  a  troul)lesome  conjunctivitis. 

Formation  of  the  eye.    See  Development  of  the  eye. 

Formensinn.     (G.)     Form  sense. 

Formes  frustes.     (F. )      Incomjilete  forms  of  Graves'  disease. 

Form,  Estimation  of.     See  Form-sense. 

Formic  acid.     See  Acid,  Formic. 

Formic  aldehyde.     See  Formaldehyde. 

Formidine.  ^Methylene  DiyAEicvLic  acid  iodide.  CisHioOcL.  It  is  a 
reddish-yellow  powder,  nearly  odorless  and  tasteless;  contains  about 
46  per  cent,  of  iodine  and  is  marketed  by  Parke,  Davis  &  Co.  as  a. 
substitute  for  iodoform.  It  seems  to  be  admira])ly  adapted  for  use  as 
a  dusting  powder  in  lid  wounds,  oi)erative  and  other.  It  is  found  in 
sprinkler-top  bottles. 

Formol.     See  Formalin. 

Formol-Miiller  fluid.  This  preservative — very  useful  in  the  preparation 
of  nniseum  and  other  laboratory  ocular  material — is  made  as  follows: 
Potassium  ])iclironuite  2.5;  sodium  sulphate  1.0;  formol  10.0;  distilled 
water  100.0;  or  to  100  cubic  centimetres  of  ^Midler's  Huid  ten  cubic 
centimetres  of  concentrated  formol  solution.  The  specimen  is  fixed  in 
from  six  to  fifteen  hours.  Wash  in  flowing  water  for  twenty-four 
hours.  The  formol  is  preferalily  added  immediately  before  the  solu- 
tion is  used,  since  the  mixture  loses  its  efficacy  in  a  week. —  (Fischer.) 

Form-sense.  This  is  the  (|uality  or  power  of  the  eye  to  distinguisii 
the  form  of  an  o])jcct,  and  is  of  particular  interest  to  the  ophthalmolo- 
gist because  it  is  used  in  test  letters  and  figures  employed  in  deter- 
mining the  visual  acuity.  Test-types  are  for  this  reason  sometimes 
caUed  "forms;"  thus,  forms  of  Snellen. 

Formula  for  the  value  of  vision.     See  Visual  economics. 

Formyl  tribromide.  BK().^U)F()RM.  CHBr„.  This  heavy,  colorless 
liquid  has  a  taste  and  odor  resembling  chloroform.  It  is  an  anes- 
thetic and  nervine  sedative.  See  p.  181.S,  Vol.  TI,  of  this  Encijch^- 
pcdut. 

Fcrmyl  triiodide  or  teriodide.     See  Iodoform. 


5276  FORNICES 

Fornices.  1*1  mal  of  i'oniix;  in  ophthalmology,  generally  the  fornix 
coiijuiict  i\a'   ( ({.  V,.). 

Fornicoblepharon.  (G.j  Abnormal  union  of  the  eonjunelival  niem- 
braneis  of  the  fornix. 

Fornix  conjunctivae.  Con.ji'nctival  cul-de>sac.  Fornix  (Gerlacii). 
i^'uLDs  OF  TKANSMissiON.  Thesc  tcrms  are  applied  to  the  parts  and 
the  locality  where  the  conjunctiva  of  the  lid  is  reflected  upon  the 
eyeball — there  to  become  the  ocular  conjunctiva.  Dwight  (Norris 
and  Oliver's  System,  Vol.  1,  p.  122)  says  that  when  the  eyes  are 
open  the  fornix  is  about  thirteen  millimetres  from  the  edge  of  the 
upper  lid,  while  it  is  but  nine  millimetres  from  the  lower  lid.  On 
the  sides  also  the  sac  varies  in  depth,  forming  at  the  lateral  angle 
a  shallow  pocket  five  millimetres  deep,  but  at  the  medial  angle 
beconnng  almost  obliterated  by  the  semilunar  fold,  under  which  it 
passes  for  only  two  millimetres.  The  fornix  is  five  millimetres  from 
the  orbital  rim  above,  six  millimetres  below,  and  four  millimetres 
at  the  lateral  angle.  (Gerlach.)  Its  distance  from  the  cornea  is 
stated  by  Testut  to  be  ten  millimetres  above,  eight  millimetres 
below,  fourteen  millimetres  at  the  lateral  angle,  and  seven  milli- 
metres at  the  medial  angle.  Merkel  gives  the  distance  above  as 
eight  millimetres;  below,  ten  millimetres.  It  doubtless  varies  con- 
siderably with  the  prominence  of  the  eyes.  See,  also,  Cul-de-sac, 
Conjunctival. 

Forster's  self -registering  perimeter.     See  Perimetry. 

Fortification  spectrum.  Fortification  scotoma.  Teichop.sia.  This  is 
a  peculiar  subjective,  visual  sensation  in  migraine.  Its  outer  edge 
assumes  a  luminous,  zigzag  form,  with  angles  like  those  of  a  fortifi- 
cation.   See  Migraine. 

Fortpflanzung.     (G.)     Propagation. 

Fortsatz.     HI.)     Process;  apophysis. 

Fortschreitender  Staar.     (G.)     Progressive  cataract. 

Fortsetzung".     (G.)     A  continuation;  prosecution;  extension. 

Fossa  glandulae  lacrimalis.  Fossa  glandilaris.  Fossa  lachry.aialts. 
The  (Icjircssion  in  the  frontal  bone  for  the  reception  of  the  laehrynml 
gland. 

Fossa,  Hyaloid.  Fossa  hyaloidea.  Lenticular  fossa.  The  depression 
in  the  aiitci'ior  surface  of  the  vitreous  body  for  the  crystalline  lens. 

Fossa  hypophyseos.     (L.)     Pituitary  fossa. 

Fossa,  Lenticular.     See  Fossa,  Hyaloid. 

Fosse.      (  F.  )       Hole;  pit;   depression;  fossa. 

Fosse  des  nerfs  oculo-musculaires.  (F.)  The  small  depression  on  the 
surface  of  the  cms  cerebri,  Avhich  lodges  the  motor  oculi. 


FOSSULA  OF  THE  CORNEA  5277 

Fossula  of  the  cornea.  A  deep  ulcer  of  the  cornea  with  a  clear  base 
in  ]ii-ot'ess  of  lie;iliii<if. 

Foster,  Gard.  Wilmarth.  A  proniinent  ophthalmologist  and  otolaryn- 
gologist of  Auburn,  New  York.  Born  at  Burlington,  Vt.,  June  15, 
1S53,  son  of  the  K<3V.  Salmon  II.  Foster  and  Jane  Ann  Tripp  Foster, 
he  received  the  medical  degree  at  Detroit  Medical  College  in  1873. 
He  was  for  a  time  surgeon  to  St.  Luke's  Hospital,  New  York  City, 
and,  in  1882.  to  the  New  York  Ophthalmic  Hospital.  About  this  time 
he  settled  in  Auburn,  where  he  resided  until  his  death. 
Dr.  Foster  married,  ]\Iay  12,  1898,  Cornelia  E.  de  Zeng. 
He  was  a  medium-sized  man,  of  fair  complexion,  with  blue  eyes  and 
white,  curly  hair.  He  was  a  collector  of  fine  books,  and  an  omnivorous 
reader.  He  was  especially  friendly  and  helpful  to  the  younger  men  in 
his  specialty,  was  a  Kepublican  in  politics,  and  took  a  great  interest 
in  public  affairs.  He  was  also  interested  in  all  charitable  work,  and 
founded  The  Auburn  Free  Dispensary  for  Worthy  Poor. 

Dr.  Foster  died  while  on  his  way  to  Bermuda  in  search  of  health, 
Dec.  2,  1914,  at  Schenectady,  N.  Y.,  from  pneumonia,  after  a  surgical 
operation.— (T.  H.  S.) 

Fotales  Auge.     (G.)     Fetal  eye. 

Fotale  Augenspalte.     (G.)     Fetal  ocular  fissure. 

Fothergill's  disease.     Trigeminal  neuralgia. 

Fotometro.     ilt.i      Photometer. 

Foucault,  Jean  Bernard  Leon  (1819-68),  French  physicist,  was  born  in 
Paris.  He  improved  Daguerre's  photographic  processes,  and  con- 
ducted, in  cooperation  with  Fizeau,  investigations  on  the  properties  of 
light.  He  was  enabled  to  demonstrate  in  1850  that  the  velocity  of 
light  is  greater  in  air  than  in  water,  and  that  in  different  media  the 
velocity  varies  inversely  as  the  refractive  indices  of  the  respective 
media.  In  1857  Foucault  invented  his  polarizer ;  and  two  years  later 
(1859)  his  reflector  for  the  great  telescope  at  Paris  was  completed. 
Foucault  also  invented  apparatus  for  the  better  application  of  the 
electric  light.  He  edited  the  scientific  part  of  the  Journal  cles  Dchats 
from  1845,  and  was  elected  a  foreign  member  of  the  Royal  Society  of 
London  in  1864. — (Stand-ard  Encyclopedia.) 

Foucault 's  prism.  Sometimes  (and  erroneously)  written  Foucauld. 
The  i)rism  in  which  a  film  of  air  is  substituted  for  the  Canada  balsam 
used  in  the  construction  of  Nicol's  prism  (q.  v.).  The  air-film  permits 
of  considerable  shortening  of  the  calcite  (q.  v.)  rhomb,  yet  there  is 
more  loss  of  illumination  by  reflection  than  in  the  longer  and  conse- 
quently more  expensive  Nieol  's  prism. 

Foucher,  Jean  Thimothee  Emile.     A  celebrated  Parisian  surgeon  and 


5278  FOUDROYANT 

()j)litlialiii()lotj;ist,  who  was  lioni  in  1S2;5  and  died  in  1SG7.  lie  was 
l)roseetor  to  the  I'aris  Faculty,  and  delivered  the  supplementary 
courses  in  ophtlialniology.  lie  is  said  to  have  written  141  w^orks  and 
articles,  Plis  chief  ophtiialmologic  writing  is  "Du  Glaucome,  de  sa 
Nature,  de  son  Traitenient"  (Hcv.  Tlicr.  Medico-ChirJ.  He  also 
translated  Wharton  Jones's  ''Diseases  of  the  Eye"  (Paris,  1866). — 
(T.  H.  S.) 

Foudroyant.     (  F. )     Fulminating ;  crushing ;  sudden  and  overwhelming. 

Fcuillioy,  Louis  Mathurin.  A  French  naval  physician,  who  paid  con- 
siderable attention  to  ophthalmology.  Born  at  Landerneau,  Dec.  23, 
1790,  he  received  his  medical  and  surgical  degree  in  1813,  at  Brest,  in 
the  "Ecole  de  Sante."  He  was  a  very  remarkable  operator  on  every 
portion  of  the  l)ody,  and  invented  a  number  of  amputations  and  pros- 
thetic apparatuses.  In  1843  he  settled  in  Paris  as  Adjunct  General 
Superintendent  of  Naval  Sanitary  Affairs,  and  two  years  later  became 
the  superintendent  in  chief.     He  died  Nov.  15,  1848. 

Fouillioy's  chief  ophthalmologic  writing  is  entitled  "Notice  sur 
uu  Procede  de  Tenotomie  Oculaire,  Demontre  et  Pratique  a  I'Hopital 
de  la  Marine  de  Brest"  {Annal.  Marit.  et  Colon,  1841 ;  Gaz.  des  Ilopit., 
1841).— (T.  H.  S.) 

Foulage.     (F.)     A  form  of  inauipulation  of  the  tissues  in  massage. 

Foule.     (F.)     Sprained. 

Four-dot  test.  A  test  for  binocular  vision,  devised  by  Worth  {Squint, 
p.  14) .  •  It  is  a  modification  of  the  well-known  Snellen  colored-glass 
test.  A  piece  of  plain  ground  glass,  12  inches  by  9  inches,  is  covered  on 
the  back  with  opaque  black  paper.  The  black  paper  has  four  round 
holes  cut  in  it,  each  3  inches  in  diameter,  as  shown  in  the  diagram. 
The  lower  hole  is  left  clear.  Behind  the  upper  hole  is  cemented  a 
piece  of  red  glass.  Behind  each  of  the  other  two  is  cemented  a  piece 
of  green  glass.  The  arrangement  can  either  be  hung  up  in  a  window 
or  mounted  in  front  of  an  electric  or  other  light.  (See  fig.  on  next 
page.) 

The  patient,  standing  five  or  six  yards  away,  wears  a  trial  frame 
with  a  red  glass  before  the  right  eye  and  a  green  glass  before  the  left. 
If  now  he  sees  two  dots  (white  and  red)  he  is  using  the  right  eye  only. 
If  he  sees  three  dots  (w^hite  and  two  green)  he  is  using  the  left  eye 
only.  If  he  sees  four  dots  (white,  red.  and  two  green)  he  uses  both 
eyes,  and  has  at  least  grade  1  l)ino(ular  vision.  If  he  sees  five  dots 
(red,  two  green,  and  the  white  seen  dou])le)  he  has  diplopia.  If  the 
accuracy  of  the  patient's  answers  be  doubted,  it  may  be  tested  by 
changing  the  glasses  in  the  spectacle  frame  from  one  eye  to  the  other. 

Fourmi.     (F.)     Ant. 

Fourmillement.     (F.)     Formication. 


FOURNIER  DE  PESCAY,  FRANCOIS 


5279 


Worth's  Four-dot  Test. 


Fournier  de  Pescay,  Francois.  A  -\vell-knoAvn  French  surgeon,  who 
paid  eon8ideral)le  attention  to  ophthahnology.  Born  Sept.  7,  1771,  at 
Bordeaux,  France,  the  son  of  a  San  Domingau  planter,  he  studied 
medicine  at  Paris,  and  became  a  military  surgeon.  After  a  number 
of  years  of  military  service,  he  settled  in  Brussels,  where  he  became 
at  the  Secondary  School  professor  of  pathology  and  co-founder  of 
the  Societe  de  la  Medicine,  Chirurgie  et  Pharmacie  and  sole  founder 
of  a  journal,  "Nouvel  Esprit  des  Journaux."  He  afterwards  lived 
at  Paris,  at  Port-au-Prince,  and  at  Pan.  While  his  home  was  at  Pau 
he  passed  away;  the  date  of  his  death  is,  however,  uncertain. 

Fournier  de  Pescay  translated,  together  with  Begin,  Scarpa's 
"Traite  dcs  Priucipalfs  Maladi-rs  dfs  Yeux"  (2  vols.,  Paris,  1S21). — 
(T.  H.  S.) 

Fourth  nerve,  Paralysis  of  the.  Trocldear  jiaralysis  is  seldom  found 
alone.  It  is  usually  caused  by  syphilis,  tabes,  multiple  sclerosis,  and 
meningitis  at  the  base  of  the  brain,  and  by  pressure  in  the  valve  of 
Yieussens.      It    mav    be    associated    with    third-    and    sixth-    nerve 


5280  FOURTH  NERVE 

paralyses  fi-oiii  diseases  affecting  those  nerves. —  (J.  M.  I>.)  See,  also, 
Neurology  of  the  eye. 

Fourth  nerve.  I'atiietici  s.  Tkuchlear  nerve.  This  is  the  smallest 
of  the  cranial  nerves.  It  enters  the  orbital  cavity  through  the  sphen- 
oidal fissure,  and  is  distril)uted  to  the  superior  ol)lique  musele  on  its 
upper  surfae.e.  It  consists  of  about  2,000  coarse  fibres,  which  inner- 
vate a  muscle  having  about  the  same  number  of  fibres. 

Fovea  centralis.  Foveola  centralis.  Foramen  centrale.  The  very 
centre  of  the  retinal  yellow  spot  or  macula  luiea.  It  is  placed  nearly 
in  the  axis  of  the  globe  at  an  average  distance  of  3.915  millimetres 
from  the  centre  of  the  optic  disk  and  0.785  millimetre  below  the  hori- 
zontal meridian  (Landolt),  a  distance  which  varies  according  to  the 
shape  of  the  ball,  being  greater  in  hypermetropes  and  less  in  myopes. 
It  is  the  region  of  most  acute  vision,  and  it  is  because  of  the  localized 
character  of  this  acuity  that  the  eye  must  be  moved  when  scanning 
carefully  a  surface  of  any  extent.  Its  diameter  is  from  0.2  to  0.4 
millimetre,  and  it  is  so  deep  that  the  retina  at  its  bottom  or  fundus  is 
thinner  than  at  any  other  place,  being  only  0.1  to  0.08  millimetre  thick. 
With  the  ophthalmoscope  it  can  usually  be  discerned  as  a  clear  speck 
situated  in  the  darker  area  of  the  yellow  spot.  See,  also,  Histology  of 
the  eye ;  as  well  as  Fundus  oculi. 

Fovea  externa.  The  outer  depression,  described  by  Schafer,  in  the 
macula  lutea. 

Fovea  interna.  The  inner  of  the  two  depressions  described  by  Schafer 
as  occurrino'  in  the  human  macula  lutea. 

Fovea  patellaris.  (L.)  An  indentation  or  depression  in  the  anterior 
surface  of  the  vitreous  formed  by  the  membrana  hyaloidea,  for  the 
reception  of  the  crystalline  lens. 

Fovea  retinae.  (L.)  Foveola.  A  very  small,  dark  spot  in  the  fovea 
centralis  retinas  where  the  hexagonal  pigment  shows,  owing  to  the 
thinness  of  the  retina  at  this  point. 

Foveau-Trouve  apparatus.  A  device  for  phototherapy.  It  consists  of 
a  parabolic  mirror  with  an  incandescent  or  arc  lamp  in  tlie  focus;  the 
former  is  joined  to  a  concentrating  cone  which  terminates  in  two 
quartz  plates  with  a  chamber  between  them ;  cold  water  circulates 
through  this  chamber  and  through  the  whole  apparatus,  absorbing  the 
heat-rays.  The  quartz  plate  is  pressed  directly  upon  the  part  to  be 
treated.     (Gould.) 

Foveola.     A  synonym  of  fovea  (centralis). 

Fowler's  solution.  Liquor  potash  arsenitis.  This  solution  of  potassic 
arsenite  really  contains  about  one  per  cent,  of  arsenic  trioxide,  two  per 


FOWL,  THE  5281 

cent,  of  potassium  l)i('<n'l)oii<itt!  and  tlii'ee  per  ct'iit.  of  compound  tinc- 
ture of  lavender. 

Arsenical  compounds  are  rarely  applied  directly  to  the  eye,  but  in 
the  treatment  for  trachoma  J.  G.  Dorsey  uses  a  mixture  containing 
Fowler's  solution. 

Fowl,  The.  IIen.  Cock.  The  various  products  of  the  domestic,  or 
barnyard,  fowl,  cock  or  hen,  were  highly  esteemed  in  Greco-Roman 
times  as  remedies  for  many  diseases  and  even  for  wounds  of  the  eye. 
Chicken  broth  was  thought  to  be  especially  valuable  in  epiphora.  The 
dung  of  a  red  hen  was  an  excellent  remedy  for  nyctalopia  (q.  v.).  The 
gall  of  a  white  hen  was  good  for  "suffusio"  (cataract),  caligo,  albugo, 

^  and  the  various  sorts  of  ocular  ulcers.  The  white  of  an  egg  possessed 
an  especial  virtue  in  blennorhea  neonatorum,  and,  mixed  with  various 
other  medicaments,  was  employed  as  a  poultice  to  the  forehead  or  eyes. 
The  yolk  of  the  egg,  raw  or  cooked,  was  believed  to  be  an  ocular  anes- 
thetic—(T.  H.  S.) 

Fox.  According  to  Pliny  (XXVIII,  47)  the  tongue  of  a  fox,  worn  in 
a  l)racelet,  or  armlet,  is  a  protection  against  lippitude. — (T.  H.  S.) 

Foyer.     (F.)     Focus. 

Foyer  reel.     (F.)     Real  focus. 

Foyers  conjugues.     (F.)     Conjugate  foci. 

Fractures.  Injuries  involving  the  bones  of  the  head  will  be  discussed 
under  various  appropriate  captions,  especially  under  Orbit  rubrics; 
and  Injuries  of  the  eye.  Here  a  few  observations  will  be  made, 
introductory  to  these  studies,  regarding  fractures  of  a  few  of  the 
facial  and  cranial  ])ones,  and  the  effects  of  these  traumatisms  on  the 
ocular  apparatus. 

Fracture  of  the  cranial  hones  often  implicates  the  optic  foramen. 
Parsons  {Pathology  of  the  Eye,  p.  1182)  points  out  that  in  v.  Holder's 
cases  two-thirds  were  shot  wounds,  and  one-third  affected  the  head. 
Nine-tenths  of  Leber's  cases  were  due  to  falls  on  the  head;  others  were 
due  to  blows  on  the  head,  etc.  The  injury  may  also  occur  during 
birth  from  forceps  pressure.  Blows  on  the  skull  in  any  situation  may 
cause  the  injury:  shot  wounds  are  usually  suicidal  through  the  mouth. 
V.  Holder  records  a  case  in  which  the  patient  was  run  over,  Vossius 
one  in  which  the  patient  fell  while  in  a  sitting  posture. 

Prescott  Ilewett  found  that  the  fracture  extended  into  the  orbital 
roof  in  twenty-three  cases  out  of  sixty-eight  fractures  of  the  base; 
V.  Holder,  in  one  hundred  and  twenty-four  cases  of  fracture  of  the 
skull,  found  eiglity-six  fractures  of  the  base,  with  seventy-nine  of  the 
orl)ital  roof;  in  fifty-four,  or  sixty  per  cent.,  the  walls  of  the  optic 
foramen  were  broken. 

Vol.  VII— 28 


5282  FRACTURES 

BergiiKimi  sliowcd  lliat  i'roiiljil  i'l-aclurcs  and  those  passing  forwards 
or  inwards  in  the  iiuddic  fossa  all  tend  to  pass  through  the  foramen, 
the  latter  soiiictimes  passing  llifough  both  and  surrounding  the  clinoid 
processes.     The  injui-y  is.  hovvcvci-,  only  occasionally  bilateral. 

Fracture  of  the  orbit (d  walls,  involving  the  soft  parts  within  the 
orbit,  are  usually  coniplieateil  with  those  of  the  lids,  except  in  inipacled 
fracture.  Under  antiseptic  surgical  conditions  a  drain  may  be  laid 
and  the  external  wound  sutured,  when,  if  healing  by  first  intention 
has  set  in,  the  drain  may  be  removed  after  24  hours,  and  the  parts 
allowed  to  heal  together.  If  a  piece  of  skin  has  been  completely  torn 
or  excised  from  the  brows  or  lids  a  Thiersch  graft  may  be  applied. 
The  wound  should  always  be  carefully  prol)ed  to  determine  the  extent 
of  a  possible  foreign  l)ody  and  the  X-ray  examination  should  not  be 
neglected.  If  the  supraorbital  fascia  be  opened  catgut  stitches  may 
be  put  in,  otherwise  the  wound  should  be  fully  sutured.  In  splintering 
and  fracture  of  the  bones  accompanying  external  wounds  in  compli- 
cated fractures,  the  loose  fragments  should  be  removed  by  forceps. 
Those  that  remain  attached  by  a  good -sized  band  of  periosteum  which 
can  be  replaced  and  held  in  position,  will  heal  if  put  in  place.  Frag- 
ments that  may  have  pierced  the  soft  tissues  should  be  elevated, 
cleared  from  the  tissues,  properly  replaced,  and  held  by  periosteal 
catgut  sutures,  metal  clamps,  or  even  by  sutures  placed  in  the  soft 
tissues;  then  a  bandage. 

Fractures  without  solution  of  continuity  of  the  external  skin  or 
mucous  lining  of  the  walls  of  the  sinuses  or  the  dura  mater  of  the 
cerebral  cavity  are  generally  sim.ple  fractures.  The  complicated  frac- 
tures, which  open  up  the  sinuses,  need  no  direct  form  of  surgical 
interference.  They  are  generally  upwards  and  inwards,  or  inwards 
and  downwards,  and  lead  to  infective  processes  from  tearing  of  the 
mucous  membrane  lining  the  pneumatic  sinus.  Displaced  bones 
forming  the  inner-upper  w^alls  cannot  be  replaced  except  by  external 
incision,  which  may  be  made  below  the  eye-brow  and  the  bones  repos- 
ited  by  periosteal  probes  and  forceps.  The  bones  of  the  inner  wall 
and  of  the  nasal  processes  may  be  replaced  by  numipulation  (through 
the  nasal  passages)  with  the  flat  nasal  probe  and  held  in  place  by 
nasal  tampons.  The  treatment  is  usually  combined  with  that  of 
fracture  of  the  nasal  bones. 

Fracture  of  the  zygoma  may  extend  into,  and  a  piece  of  bone  pene- 
trate the  maxillary  antrum.  This  dislocation  may  be  re]>laced  by  a 
forefinger  of  one  hand  in  the  patient's  mouth,  well  behind  the  zygoma, 
and  the  s])linter  raised  into  i)laee,  the  head  being  steadied  by  the 
operator's  other  hand.     If  Ibis  is  not  possible  a  strong  resection-hook 


FRACTURES  5283 

is  passed  around  the  zyj^oma  at  the  nasal  prowss  and  by  it  the  boue 
is  puslied  into  phice.  If  the  fraetiire  be  complicated  hy  an  open 
wountl  tlien  the  splintered  hone  may  lie  ri'aehed  through  the  opening 
and  raised  by  foreei)s. 

In  complicated,  or  ol<l  healed,  fracture  of  this  character,  when  the 
defornnty  is  the  only  defect,  it  may  be  well  to  leave  the  matter  alone, 
as  no  evil  results  have  been  reported  from  such  conditions. 

In  old,  healed  fractures  of  the  orbital  rim,  as  well  as  in  uncompli- 
cated fractures,  an  external  incision  may  be  made,  with  resection  of 
the  bone,  i.  e.,  an  osteotomy  or  an  ostectomy,  to  reach  the  injured  part, 
to  free  it  from  the  inipaetion  and  replace  it. 

Direct  fractures  of  the  orbital  rim  arc  the  rule.  Indirect  fractures, 
without  misplacement  of  the  fragments,  require  no  operative  interfer- 
ence. They  are  accom[)anied  by  indirect  fracture  of  the  orbital  wall 
and  usually  with  fracture  of  the  base  of  the  skull. 

Direct  fractures  of  the  orbital  walls  are  as  a  rule  due  to  pene- 
trating injuries  of  the  orbit.  They  are  isolated,  and  are  more 
amenable  to  surgical  intervention  than  the  indirect  forms.  Under 
rigid  antiseptic  precautions  one  should  freely  open  the  wound  of 
entrance,  remove  foreign  bodies,  bone  splinters  and  secretions.  Prob- 
ing and  irrigation  are  not  to  be  done,  as  pathologic  (infective)  prod- 
ucts may  be  carried  deeper  into  the  tissues.  This  rule  is  also  to  be 
remembered  in  dealing  with  orbital  abscesses.  Drainage  through  the 
opening  will  remove  the  secretions  and  lessen  the  danger. 

The  operation  for  fracture  of  the  roof  of  the  orbit  will  best  be 
conducted  by  an  incision  through  the  brow,  with  the  skin  well  retracted 
and,  if  necessary,  resection  of  the  margin  of  the  orbit,  to  reach  safely 
the  foreign  body  and  remove  it  together  with  any  bone  splinters.  The 
finger  makes  the  best  probe  for  the  purpose  of  making  a  diagnosis; 
the  splinters  are  seized  and  removed  by  forceps. 

When  the  roof  of  the  orbit  is  known  to  be  fractured,  a  foreign  body 
impacted  therein  and  the  eye-ball  destroyed,  enucleation  of  the  globe 
or  a  partial  exenteration  of  the  orbit  may  be  done.  In  this  way  direct 
access  is  given  to  the  fracture,  the  foreign  body  and  bone  splinters 
are  brought  into  view  and  easily  removed,  and  the  wound  secretion 
better  drained.  All  splintei'^  should  be  taken  away,  as  even  very 
small  ones  may  cause  meniiiiiitis,  brain  abscess,  and  loss  of  life.  If 
a  localized  brain,  abscess  common  in  bullet  fractures,  is  found,  it  should 
be  opened  and  drained. 

In  the  lighter  cases,  when  bi'aiii  symptoms  do  not  occur,  the  eye- 
l)all  may  be  retained  and  simple  drainage  of  the  wound  secured ;  but 
when  the  bulb  is  injured  th(>re  should  be  no  cominuiction  about  an 


5284  FRAME  FOR  SQUARE  PRISMS 

cnuclt'ation  since  we  thus  secure  a  satisfactory  diagnosis  and  are  better 
iible  to  (li'aiii  the  <l.'i)tlis  of  the  wound.— (II.  V.  W.) 
Frame  for  square  prisms.     The  illustration  of  this  device  sufficiently 
explains  its  purpose  and  mode  of  employment.     It  is  a  useful  and 
practical  instrument   in   office   practice. 


Eevolvinp  Cell  Frame  for  Square  Prisms. 

Frameless  glasses.     See  Eyeglasses  and  spectacles,  History  of. 

Frames  of  eyeglasses  and  spectacles.  See  Eyeglasses  and  spectacles, 
History  of.  Since  spectacles  are  a  necessity  for  infants  in  the  treat- 
ment of  squint,  it  becomes  a  prolilem  how  to  adjust  the  frames  without 
injuring  the  delicate  tissues  of  the  infant  face.  Hook  temples  do 
not  answer,  since,  if  heavy  and  strong,  they  produce  abrasion,  and 
if  frail,  they  fail  to  retain  the  adjustment  of  the  lenses.  B.  Harman 
{Practical  Med.  Series,  p.  26,  1909)  uses  the  following  expedient: 
A  piece  of  tape,  elastic  or  not,  is  looped  under  the  nucha,  its  ends 
threaded  through  the  eyes  of  the  spectacle  bows,  then  carried  on  to 
the  vertex,  where  they  are  tied  together.  This  circuit  of  tape  holds 
the  spectacles  firmly  in  position,  yet  allows  of  sufficient  elasticity  to 
avoid  pressure  on  the  nose,  and  the  bows  are  not  dragged  down  on 
the  tops  of  the  ears. 


Biirehardt  "s   Test  Frame. 

Frame,  Trial.     Test  frames.     This  important  adjunct  to  the  armament 
of  the  refractionist  forms  as  nunu-rous  and  as  diversified  a  class — 


FRAME,  TRIAL 


5285 


both  simple  and  complicated — as  any  instrument  employed  by  the 
ophthalmic  surgeon.  Tiial  oi-  ti-st  frames  have  already  beeu  dis- 
cussed and  depicted  under  Examination  of  the  eye  (p.  4;57,  p.  4731, 
Vol.  VI),  and  elsewhere  in  this  Kxcuvlopi  <Ua.  Here  a  few  additiomil 
frames  are  pictured. 


Nelson   Black 's  Trial  Frame. 


Trial  Frame.     (Luer.) 


Luer's   Simjiler   Trial   Frame. 

The  trial-frame  of  Nelson  Black  is  adjustable  for  any  interpupil 
distance  and  has  long,  straight  temples.  It  is  comfortable  for  most 
patients,  as  the  side  does  not  come  in  contact  with  the  delicate  skiu 
behind  the  ears. 

The  two  Luer  frames  figured  in  the  text  have  adjustable  nose-pieces, 
lens-holders  moved  by  a  toothed  disk  in  one  case,  in  another  by  a 
simpler  device,  as  well  as  other  advantages  readily  seen  on  examina- 
tion. 


528(i     FRANCE,  LAWS  OF,  RELATING  TO  OPHTHALMOLOGY 


The   So-callcil   Clinical    l"'raiii(',   with   Adjustahlo    Nose-piece. 
Aiiaii<ieil  for  three  pairs  of  louses. 


Improved  Clinical  Frame. 
This  frame  is  similar  to  the  preceding,  but  is  ]>rovided  with  a  pupillary  adjust- 
ment, operated   from  either  side  by  means  of  thumb-screws;   for  three  i)airs  of 
lenses. 


France,  Laws  of,  Relating  to  ophthalmology.  See  Legal  relations  of 
ophthalmology. 

Franco,  Pierre.  A  pupil  of  Pare,  and,  thouuli  chiefly  a  g-eiieral  surgeon, 
the  greatest  cataract  de])ressor  of  the  Renaissance,  or,  rather,  post- 
Renaissance,  period.  He  was  l)orn  at  Turiers,  near  Sisterou,  Prov- 
ence, about  1500.  He  led  for  many  years  the  life  of  a  wandering 
"cataract-sticker,"  "hernia-operator,"  and  "cutter-for-stone."  At 
last,  however,  he  settled  witii  some  degree  of  permanence  in  I^ausanne, 
Bern,  and  Orange  of  Provence.  Concerning  the  cataract  operation 
(which,  in  those  times,  was  either  depression  or  suction)  he  was  very 
enthusiastic.  Tlius,  he  says,  "Yes,  I  do  assure  you  that,  if  I  had 
to  renounce  either  this  cataract  operation  or  all  the  rest  of  surgery, 
1  would  rather  give  up  all  the  rest  of  surgery."  Various  details  of 
his  instructions  for  the  catai'act  operation  evidence  unmistakably  a 
w  i<li'  jx'rsonal  expi^rieneo  as  well  as  the  very  keenest  powers  of  observa- 
lioii.     Tlius,  in  telling-  what  to  do,  in  case  the  catai'act  appears  in  the 


FRANGE  5287 

pupil  again  after  it  has  been  depressed,  he  says  that  it  must,  of  course, 
be  couched  again,  but  not  ih rough  the  former  opcnimj,  for  it  is  less 
painful,  he  dcchircs  (and  rigiitly)  to  perforate  the  sclera  anew  than 
to  pass  the  instrument  in  once  more  by  way  of  the  old  opening. 
Franco  died  about  15G1.— (T.  II.  S.) 
Frang-e.     (F.)     Fringed. 

Frankenius,  Johann.  A  Swedish  physician  and  physicist,  who  wrote 
"X>c  Oculo"  (1G51),  a  purely  i)hih)so])hical  work.  He  was  born  in 
1590  in  the  Province  of  Westermannland,  settled  in  Upsala,  and  died 
in  1661.— (T.  li.  S.) 
Franklin,  Benjamin.  This  versatile  genius,  called  by  his  entluisiastic 
compatriots,  "the  greatest  American,"  "the  embodiment  of  the 
genius  of  common  sense,"  "the  darling  of  American  biography," 
"the  greatest  American  diph)nuit,"  "the  first  American  scientist," 
"the  first  of  American  journalists,"  "the  second  Prometheus,"  was 
also — a  fact  not  commonly  known — the  inventor  of  bifocal  spectacles. 

Pie  was  born  at  Boston,  in  the  colony  of  Massachusetts  Bay,  Jan- 
uary 17,  1706.  He  was  only  in  school  four  years.  At  the  age  of 
twelve  he  was  apprenticed  to  his  brother  James,  a  printer,  a  man 
with  whom  he  could  never  agree.  In  October,  1723,  he  proceeded 
alone  to  Philadelphia,  whence  he  was  sent  by  Keith,  the  governor  of 
Pennsylvania,  on  some  diplomatic  errand  to  England.  Three  years 
later,  he  returned  to  Philadelphia,  where,  in  1729,  he  purchased  the 
'' Pennsylvania  Gazette" — a  i)ublication  which  he  proceeded  at  once 
to  make  useful  and  famous. 

From  that  time  onward,  his  success — journalistically,  scientifically, 
diplomatically,  and  politically — was  uninterrupted.  He  invented  the 
musical  glasses.  He  made  the  first  successful  stove.  He  organized 
the  first  police  force  and  the  first  fire  company  in  the  colonies.  He 
was  really  the  founder  of  the  University  of  Pennsylvania,  and,  admit- 
tedly, of  the  American  Philosophical  Society.  He  was,  as  every 
schoolboy  knows,  the  first  to  demonstrate  the  absolute  identity  of  the 
natural  "lightning"  witli  the  artificial  "electricity."  This  discovery 
alone  would,  of  course,  have  entitled  him  to  rank  among  the  immor- 
tals. 

We  have  no  space  in  a  work  like  this  for  even  the  barest  list  of 
Franklin's  i)olitical  and  diplonuitic  activities.  His  achievements, 
moreover,  in  these  particular  categories,  can  easily  be  found  in  almost 
any  history  of  the  United  States. 

Ophthalmologically,  I  find,  in  the  letters  of  Franklin,  the  following 
accounts  of  his  own  theories  and  achievements  in  the  field  of  oi)tics. 
The  collection  I  believe  to  be  absolutelv  exhaustive. 


5288  FRANKLIN,  BENJAMIN 

Letter  to  Mrs.  Jane  Mecoiii,  Loiuloii,  J;5  Jan.,  1772:  "1  doubl 
you  have  taken  too  old  a  pair  of  glasses,  being  ti'iiipted  by  tiieir  mag- 
nifying greatly.  But  people  iu  elioosiug  should  only  aim  at  rem- 
edying the  defect.  The  glasses  that  enable  them  to  see  as  well,  at  the 
same  distance  they  used  to  hold  tlioir  book  or  work,  while  their  eyes 
were  good,  are  those  they  should  choose ;  not  such  as  make  them  see 
better,  for  such  contribute  to  hasten  the  time  when  still  older  glasses 
will  become  necessary." 

Letter  to  Edward  Nairne,  Passy,  18  October,  1783:  "What  you 
have  heard  of  the  eyes  of  sheep  forced  out  by  a  stroke  of  lightning 
which  killed  them,  puts  me  in  mind  of  having  formerly  seen  at  Phila- 
delphia six  horses  all  killed  by  lightning  in  a  stable,  every  one  of 
whom  appeared  to  have  bled  at  the  eyes,  nose,  and  mouth,  though  I 
do  not  recollect  that  any  of  their  eyes  were  out." 

Letter  to  George  Whately,  Passy,  21  August,  1784:  "Your  eyes 
must  continue  very  good,  since  you  can  write  so  small  a  hand  without 
spectacles.  I  cannot  distinguish  a  letter,  even  of  large  print,  but  am 
happy  in  the  invention  of  double  spectacles,  which  serving  for  dis- 
tant objects  as  well  as  near  ones,  make  my  eyes  as  useful  to  me  as 
ever  they  were.  If  all  the  other  defects  and  infirmities  were  as  easily 
and  cheaply  remedied,  it  would  be  worth  while  for  friends  to  live  a 
great  deal  longer,  but  I  look  upon  death  to  be  as  necessary  to  our 
constitution  as  sleep.     We  shall  rise  refreshed  in  the  morning." 

Letter  from  George  Whately  to  Franklin,  London,  15  November, 
1784:  "I  have  spoken  to  Dolland  about  your  invention  of  double 
spectacles,  and,  by  all  I  can  gather,  they  can  only  serve  for  particular 
eyes,  not  in  general." 

Letter  from  Franklin  to  George  AVhately,  Passy,  23  :\Iay,  1785: 
"By  Mr.  Dolland 's  saying  that  my  double  spectacles  can  only  serve 
particular  eyes,  I  doubt  he  has  not  been  rightly  informed  of  their 
construction.  I  imagine  it  will  be  found  pretty  generally  true,  that 
the  same  convexity  of  glass,  through  which  a  man  sees  clearest  and 
best  at  the  distance  proper  for  reading,  is  not  the  best  for  greater 
distances.  I  therefore  had  formerly  two  pairs  of  spectacles,  which 
I  shifted  occasionally,  as  in  travelling  I  sometimes  read,  and  often 
wanted  to  regard  the  prospects.  Finding  this  change  troublesome, 
and  not  always  sufficiently  ready,  I  had  the  glasses  cut  and  half  of 
each  kind  associated  in  the  same  circle.  By  this  means,  as  I  wear 
my  spectacles  constantly,  I  have  only  to  move  my  eyes  up  or  down, 
as  I  want  to  see  distinctly  far  or  near,  the  proper  glasses  being  always 
ready.  This  I  find  more  i)artieularly  convenient  since  my  being  in 
France,  the  glasses  that  serve  me  best  at  table  to  see  what  I  eat  not 


FRANKLIN  GLASSES  528!) 

Ix'iiig  the  best  to  see  tlu^  faces  of  those  on  the  other  side  of  the  tabUi 
wlio  speak  to  lue ;  and  wlieii  one's  ears  are  not  well  accustomed  to 
the  sounds  of  a  language,  a  sight  of  the  nu)venients  in  the  features 
of  him  that  speaks  helps  to  explain;  so  that  1  understand  French 
better  l)y  the  help  of  my  spectacles." 

Franklin  died  as  the  result  of  eom]>lieations  j)rodu('ed  by  a  vesical 
calculus,  April  17,  17!)().  The  following  eharaeteristic  epitaph  was 
written  by  himself  nuuiy  years  before  his  death: 

THE  BODY 

OF 

BENJAMIN  FRANKLIN, 

(LIKE  THE  COVER  OF  AN  OLD  BOOK, 

ITS  CONTENTS  TORN  OUT, 

AND  STRIPT  OF  ITS  LETTERING  AND  GILDING) 

LIES  HERE  FOOD  FOR  WORMS; 

YET  THE  WORK  ITSELF  SHALL  NOT  BE  LOST, 

FOR  IT  WILL  (AS  HE  BELIEVED)  APPEAR  ONCE  MORE 

IN  A  NEW 

AND  MORE  BEAUTIFUL  EDITION 

CORRECTED  AND  AMENDED 

BY 

THE  AUTHOR. 

—  (T.  II.  S.) 
Franklin  glasses.     Bifocal  spectacles  with  horizontally  divided  lenses. 

See  Franklin,  Benjamin. 
Franklin's,  Ladd,  theory  of  color.     See  Evolution  theory  of  color- 
sensation. 
Franz,  John  Charles  Augustus,     The  dates  of  liis  birth  and  death  can- 
not be  ascertained.     He  received  his  medical  degree  at  Leipsic,  Ger- 
many, practised  for  a  long  time  in   Brighton,   England,  and  wrote 
"The  Eye,  A  Treatise  on  the  Art  of  Preserving  this  Organ"  (Lon- 
don, 1889).— (T.  II.  S.) 
Fraser,  Thomas  Richard.     A  Scotch  pharmacologist,  of  some,  if  slight, 
ophthalmologic  im])ortance,  because  of  his  "Physiological  Action  of 
the  Calabar  Bean,  Physostigma  Venenosum"  {Trans.  Hoy.  Soc.  Edinh., 
Vol.  XXIV).     Fraser  received  his  medical  degree  at  Edinburgh  in 
1862,  and  became  F.  R.  C.  P.  Edin.  in  1869.     The  exact  dates  of  his 
birth  and  death  cannot  be  ascertained. —  (T.  II.  S.) 
Frattura.     (It.)     Fracture. 

Fraunhofer's  lines.     In  physics,  a  series  of  fixed  lines  in   the  solar 
spectrum  tirst  mapped  out  in  181-1  by  Fraunhofer,  who  designated 


5290  FRAUNHOFER,  JOSEPH  VON 

the   more  prominent   of  them  by  the   capital   letters  A   to  II.     Sec 
Spectrum;  also  Achromatism. 

Fraunhofer,  Joseph  von.  A  ceicl)!;!!!'!!  (iciiaaii  optician,  the  inventor 
of  a  luachint:  for  j)()lisliing  matheniatically  uniform  lenses,  of  the 
stage-micrometer,  of  a  form  of  heliometer,  of  certain  kinds  of  achro- 
matic lenses,  and,  finally,  the  first  to  observe  very  carefully  the  dark 
lines  of  the  solar  spectrum,  which  lines,  in  consequence,  are  called  to 
this  day  by  his  name.  lie  was  born  at  Straubing,  Bavaria,  March  6, 
1787.  His  father  was  very  poor,  and,  till  his  14tli  year,  the  subject 
of  this  sketch  could  neither  read  nor  write.  Having  become  appren- 
tice to  a  lens  and  looking-glass  maker,  he  studied  at  night  the  more 
scientific  aspects  of  his  occupation.  In  1806  he  became  optician  in 
the  Matheuuitical  Institute  at  .Munich.  In  1809,  with  three  of  his 
friends,  he  established  an  optical  institute  at  Benedictheuern,  Bavaria. 
In  1811:-15  he  pul)lished  in  the  " Denkscluiften  ckr  Milnchcnrr 
Akademie"  a  series  of  articles  in  which  "he  laid  the  foundation  of 
solar  and  stellar  chemistry. ' '  He  became  Conservator  of  the  Physical 
Cabinet  at  ^Munich  in  1823,  and  died  in  that  cit}^  June  7,  1826. 
On  his  monument  appear  these  words:    "Approximavit  Sidera!*' 

— (T.  H.  S.) 

Frebault,  J.  F.  A  French  physician  and  oplithalmologist  of  mediocre 
ability.  The  dates  of  his  birth  and  death  cannot  be  ascertained.  He 
received  his  medical  degree,  however,  at  Paris  in  1806,  presenting  as 
dissertation  "Sur  les  Hernies  Abdominales."  His  only  ophthal- 
mologic writing  is  entitled  "Observation  sur  un  Cristallin  qui  a 
Passe  par  la  Pupille  dans  la  Chambre  Anterieure  de  TOeil  Droit,  a 
la  Suite  de  Cephalalgies  Violentes  et  Chroniques,  etc."  {Jour.  Gener. 
dc  Med.,  1817).— (T.  II.  S.) 

Freckles.    Lentigo.     See  Eyelids,  Lentigo  of  the. 

Free  cheeks.  In  certain  of  the  Crustacea,  the  lateral,  movable  portions 
of  tile  (M'plialic  shield,  which  bear  the  eyes. 

Freezing  mixtures,  Anesthetic.    See  Anesthesia  in  ophthalmic  surgery. 

Fremdkdrper.     (G.)     Foreign  body. 

Fremdkorpermeissel.     (G.)     Spud,  or  foreign  body  remover. 

Fremissement.     (F.)     Shivering;  rigor ;  thrill ;  tremor. 

French,  Hays  Clifton.  A  |»i'ominent  Western  homeopathic  ophthal- 
mologist. He  was  born  in  England,  of  Irish  extraction,  in  18-40.  In 
very  early  youth  he  removed  with  his  father's  family  to  America. 
His  general  education  was  received  at  the  Wt'stern  Reserve  Univer- 
sity, Cleveland,  Ohio,  and  he  was  also  iiraduatcd  at  the  New  York 
Ophthalmic  Hospital  in  1878. 

In  1879  he  formed  a  ])artnership  with   Dr.  A.  C.  Peterson,  of  San 


FREQUENCY  5291 

Francisco,  widely  known  in  homeopathic  circles  aiul  a  man  of  great 
ability.  To  Dr.  IV'tt-rson,  in  fact.  Dr.  Fi-i-iich  was  wont  to  ascribi; 
an  inthifnce  to  which  a  hii'^c  proportion  of  his  own  success  was  diic. 
Dr.  Frcncii  was  one  of  llie  founders  of  tlu^  Hahnemann  Hospital 
College,  at  San  Francisco,  and  al)l\  lilled  the  chair  of  ophthalmology 
in  that  institution  nntil  failing  health  compelled  ium  to  resign  the 
position  as  well  as  to  relinquish  a  large  and  lucrative  practice. 
He  died  of  paresis  in  1901,  aged  61  years. 

Dr.  French  was  about  five  feet  eight  inches  tall,  and  was  rather 
inclined  to  corpulency.  He  was,  on  the  whole,  decidedly  handsome. 
His  features  were  all  fine  and  cleanly  chiseled,  and  his  complexion 
was  soft  and  creamy.  He  wore  a  nuistache,  but  no  other  beard.  His 
eyes  were  blue  and  liad  that  peculiarly  merry  twinkle  found  mostly  in 
persons  of  Irish  descent,  but  they  were  also  capable  of  indignation 
and  resentment.  His  hair  was  thick  and  wavy,  and  prematurely 
iron-gray.  A  colleague  writes:  "He  possessed  a  fund  of  wit  and 
humor,  and  could  tell  a  story,  that  might  be  classed  as  slightly  shady, 
or  lead  in  prayer,  with  equal  ease  and  impunity  and  almost  in  the 
same  breath,  as  he  was  one  of  those  fortunate  persons  who  rarely 
give  offense,  and  are  allowed  more  than  ordinary  privileges.  During 
the  last  few  years  of  his  life  he  was  extremely  religious;  so  much  so 
that  he  became  almost,  if  not  quite,  a  religious  monomaniac,  through 
the  loss  of  his  little  boy,  whom  he  idolized  and  for  whom  he  had  high 
hopes  and  aspirations ;  and  he  became  obsessed  by  the  idea  that  the 
child's  death  was  a  punishment  sent  upon  him  because  of  his  over- 
devotion  to,  and  ambition  for,  the  child.  In  the  classroom  he  was  a 
favorite  with  the  students,  for  he  was  always  genial,  considerate  and 
helpful.  Dr.  French  had  his  faults  and  his  foibles,  but,  taken  alto- 
gether, he  was  above  the  average  in  ability  and  virtue." — (T.  H.  S.) 

Frequency.  The  number  of  times  any  regularly  repeated  phenonu'non 
occui's  in  a  unit  of  time. 

Frere  Come.  A  celebrated  18th  century  lithotomist  and  oculist.  See 
Baseilhac,  Jean. —  (T.  II.  S.^i 

Fresenius,  Johann  Baptist  Georg  Wolfgang.  A  German  botanist  and 
physician,  of  some  importance  in  o])hthalmology.  Born  at  Frankfort- 
on-tlie-]\Iain  September  25,  1808,  he  studied  medicine  at  Heidelberg 
and  Griesscn,  at  the  latter  institution  receiving  his  degree  in  1829. 
Immediately  thereafter  he  settled  at  Frankfort,  and  two  years  later 
became  instructor  in  botany  at  the  Senckenberg  ^ledical  Institute. 
Thirty-two  years  later  his  title  was  changed  to  '"professor."  He 
died  December  1,  1866. 

Fresenius   wrote   a   great   deal   on    botany,    but    his    only    ojihthal- 


5292  FRESNEL,  JEAN  AUGUSTIN 

mologie  writing  was  '"Utbcr  die  Traunuitische  Amblyopie  \ind  Ama- 
rose."—{'V.  II.  S.) 

Fresnel,  Jean  Augustin.  A  ei'k'bi-Htud  French  military  L'liginci'r  and 
]»li\sicist,  who  fstal)lished  finally  and  absolutely  the  truth  of  the 
undulatory  theory  of  light.  He  also  very  much  enlarged  our  knowl- 
edge of  diffraetioji  and  of  the  interference  of  light — both  of  which 
phenomena  had  been  discovered  by  Grimaldi.  He  was  born  May 
16,  1788,  at  Broglie,  Department  of  Eure,  Normandy,  France.  He 
studied  at  the  Central  School  at  Caen,  at  the  Polytechnic  School,  and 
at  the  Ecole  des  Tonts-et-Chausees.  He  became  successively  Engineer 
ill  the  Department  of  Vendee  and  Drome,  Engineer  in  Paris,  Exam- 
iner at  the  Polytechnic  Scliool,  and  Fellow  of  the  Academy.  He 
received  the  Runiford  Medal  of  the  Royal  Society  in  1827,  and  shortly 
afterward  (July  14,  1827)  died  at  Ville  d'Avray,  near  Paris. — 
(T.  H.  S.) 

Fresnel  lens.  Fresnel  s  bipklsm.  A  lens  (bearing  the  name  of  its 
inventor)  formed  of  a  central  plano-convex  lens  surrounded  by 
segmental  rings  of  glass,  all  having  the  same  focus.  The  separate 
pieces  are  cemented  to  a  plane  glass  or  set  in  a  metal  frame.  It  is 
used  in  lighthouses  and  signal  lamps.    See  Fresnel,  Jean  Augustin. 

Fresnel's  rhomb.  A  rhomb  of  glass  so  constructed  that  a  ray  of  light 
may  enter  and  emerge  from  it  normally  at  either  end,  after  being  twice 
internally  reflected  through  equal  angles  of  incidence  of  55  degrees 
at  opposite  sides  of  the  rhomb.     See  Fresnel,  Jean  Augustin. 

Freytag,  Johann  Conrad.  A  famous  Swiss  surgeon,  of  considerable 
importance  in  ophthalmology,  being  generally  called  the  discoverer 
of  membranous  cataract.  The  date  of  his  birth  is  unknown ;  the 
place,  however,  was  Ilongg,  a  village  near  Ziirich.  Before  1699  he 
was  well  established  in  Zurich,  and  was  widely  known  as  an  operator, 
especially  on  the  eye.    He  died  in  1738. 

Freytag  left  no  ophthalmologic  writing,  but  his  son,  Johann 
Heinrich  (q.  v.),  described  his  father's  cataract  procedures  in  a 
work  entitled  "De  Cataracta"  (Strasburg,  1721).  According  to 
this  work,  the  elder  Freytag  "extracted"  a  cataract  on  three 
occasions.  The  "cataract,"  however,  in  each  instance,  was  only  a 
membranous  cataract,  and  it  was  removed  by  means  of  a  small  hook, 
passed  through  a  tiny  incision.  The  first  extraction  in  the  modern 
sensi*  was  performed  by  Daviel  in  1748.  (See  Daviel,  in  this 
E)ic!jcIop<dia.)  —  {T.  II.  S.) 

Freytag,  Johann  Heinrich.  A  Swiss  surgeon,  -who  paid  consideral)le 
attention  to  oi)htlia]niol()gy.  He  was  the  son  of  the  Ziirich  surgeon, 
J.  C.  Freitag  (or  Freytag),  received  his  medical  degree  at  Strasburg, 


FRICKE,  JOHANN  KARL  GEORG  5293 

wrote  "Dc  Cataracta"  (in  which  he  described  the  cataract  operation 
of  his  father)  and  died  in  1725 — thirteen  years  before  his  father. 

Freytag  was  one  of  the  less  important  opponents  of  the  new  doctrine 
concerning  the  nature  and  location  of  cataract.  Throughout  antiquity, 
the  middle  ages,  and  well  on  into  the  modern  period,  it  was  firmly 
believed  that  a  cataract  is  a  deposit  of  corrupt  and  inspissated 
"humor"  in  a  (wholly  imaginary)  space  between  the  pupil  and  the 
lens.  Quarre,  about  1643,  first  theoretically  taught  the  true  doctrine, 
and  a  German,  Rolfinck,  in  1656,  confirmed  his  theory  by  anatomical 
dissection.  The  matter  seemed  soon  after  to  have  sunk  into  oblivion, 
until,  in  fact,  Brisseau  and  ]\Iaitre  Jan,  just  after  the  beginning  of 
the  18th  century,  re-discovered  this  most  important  truth,  and  com- 
pelled the  scientific  world  to  grant  it  recognition.  Before,  however, 
the  recognition  was  accorded,  a  bitter  contest  arose  concerning  the 
question.  The  opposition  to  the  new  theory  was  led  by  Thomas 
Woolhouse,  an  English  oculist  resident  in  Paris.  Among  his  followers 
was  Freytag,  the  su])ject  of  this  sketch. —  (T.  H.  S.) 
Fricke,  Johann  Karl  Georg.  A  well-known  German  military  surgeon, 
of  slight  oj)lithalinologic  importance.  Born  at  Braunschweig  January 
28,  1790,  the  son  of  a  physician  and  professor  of  chemistry  and 
physics,  he  studied  medicine  both  at  Braunschweig  and  at  Giessen, 
at  the  latter  institution  receiving  his  degree  in  1810.  He  then  pro- 
ceeded to  Berlin,  and  completed  his  surgical  training  under  Carl 
Ferdinand  Graefe.  He  practised  mostly  at  Hamburg,  but  was  often 
engaged  in  military  service  in  connection  with  various  expeditions. 
Together  with  Dieffenbach  and  Oppenheim  lie  published  the  " Zcit- 
schrift  f.  d.  Gcsammte  Mcdicin:"  He  died  at  Naples,  whither  he  had 
gone  in  search  of  health,  December  4,  1841. 

His  only  ophthalmologic  writing  was  "Die  Bildung  Neucr  Augcn- 
lider  (Blcpharoplostik)  nacli  Storungen/'  etc.  (Hamburg,  1829,  4 
plates).— (T.  H.  S.) 
Frick,  George.  The  first  American  to  publish  a  book  on  ophthalmology, 
and  perhaps  the  first*  to  restrict  his  practice  to  diseases  of  the  eye : 
on  these  grounds  often  called  "The  Father  of  American  Ophthal- 
mology." He  was  born  in  Baltimore,  ]\1(1..  in  1793.  After  an  excel- 
lent education  in  the  liberal  arts  and  sciences,  he  entered  the  I\Iedical 
Department  of  the  I^niversity  of  Pennsylvania,  receiving  his  degree 
in  1815.  Tn  1817  he  was  admitted  to  practice  by  becoming  a  licentiate 
of  The  Medical  and  Chirurgical  Faculty  of  ^laryland. 

For   a   number   of   years  he   studied    abroad,    paying   considerable 


*It  would  seem  to  1ie  impossible  to  detenuiue  this  matter  exactly.     Tlie  honor 
belongs  either  to  Dr.  Frick  or  to  Dr.  Henry  Willard  Williams,  of  Boston. 


i294 


FRICK,   GEORGE 


atlciitioii  Id  (iplillialiiiolo^y.  In  Vienna  lie  het-anie  acijuaintcd  with 
the  great  Beer,  by  whom  he  seems  to  have  jjeen  profoundly  inllueiiced 
throuijliont  the  remainder  of  his  life. 

In  liSl!)  h(^  returned  to  lialtimore,  l)egan  to  practise  oi)hthalniology, 
and  seems  to  have  had  extraordinary  success.  Some  years  later,  how- 
ever, he  became  very  deaf,  and,  in  1840,  abandoned  his  practice 
entirely,  and  removed  to  Europe,  returning  to  America  from  time 
to  time  for  the  purpose  of  visiting  relatives  and  friends. 

lie  never  married.  He  was  a  shy,  kind-hearted  man,  whom  every- 
body loved,  upright  and  honorable  in  all  his  dealings.  lie  died  in 
Dresden,  Germany,  March  26,  1870. 


George  Fiick. 

His  most  important  journal  articles  are  as  follows : 
"On  the  Meloe  Vesicatorium"  (1815)  ;  "Observations  on  Cataract 
and  the  Various  Modes  of  Operating  for  its  Cure"  {Am.  Med. 
Recorder,  Phila.,  1820-21);  "Observations  of  the  Various  Forms  of 
Conjunctivitis"  {Ibidem,  1821)  ;  "Observations  on  Artificial  Pupil 
and  the  Modes  of  Operating  for  its  Cure"   (182:5). 

The  only  book  he  ever  wrote  was  that  above  referred  to,  entitled 
"A  Treatise  on  the  Diseases  of  the  Eije;  Ineluding  the  Doctrines  and 
Practice  of  the  Most  Eminent  Modern  Surgeons  and  ParticuUirhi 
Those  of  Prof.  Beer"  (Baltimore,  182:5;  2(1  .■(!.,  with  imtes  by  Richard 
AVelhank,  London,  1826).  Thougli  based  on  the  books  of  Beer,  tliis 
lii-st  American  work  on  o|)lithabn()logy  contained  a  great  deal  of 
original  matter  and  was  wiittcii  in  a  clear,  forceful,  even,  beautiful 
style.  On  the  whole,  it  was  an  api>ro])i-iati'  bt'giiniing  for  Amei'ican 
oplithalmograi)hy. —  (T.  II.  S.) 


FRIEBIS,   GEORGE  5205 

Friebis,  George.  IJor-n  at  Edelsheiin,  (Jcrmaiiy,  Dec  18,  1847,  he  re- 
moved with  liis  fatlicr  to  France  in  1848,  and,  a  few  years  later,  to 
America.  His  general  education  was  received  in  the  Philadelphia 
public  schools,  his  medical  training  from  the  Jefferson  Medical  Col- 
lege, where  he  received  his  degree  in  1879.  He  at  once  became 
assistant  to  Prof.  AVm.  Pancoast,  then  Professor  of  Anatomy  at  Jef- 


George  Friebis. 

fersou.  Later  lie  bi-canie  successively  Demonstrator  of  Anatomy, 
Lecturer  on  Diseases  of  the  Skin,  and  assistant  to  Dr.  Lawrence 
Turnbull,.  then  Professor  of  Otology  and  Rhino-Laryngology  in  the 
Jefferson   school. 

In  1884.  deciding  to  devote  himself  exclusively  to  ophthalmology, 
he  became  assistant  to  the  famous  professor  of  oi)litlialmology  at 
Jefferson,  AVilliam  Thomson.  Tn  this  position  he  sci'ved  for  eleven 
years,  during  the  last  six  of  which  lie  was  Clinieal  Chief  and  Lec- 
turer on  Diseases  of  the  Eye. 


5296  FRIEDENWALD,  AARON 

In  liis  pi-ivatc  practice  lie  confined  liis  work  almost  exclusively  to 
errors  of  refraction. 

For  many  years  lie  was  assistant  editor  of  "The  Medical  Bul- 
letin," and  to  this  and  certain  other  journals  he  contributed  a  number 
of  ophthalmologic  articles. 

lie  was  a  very  courteous  and  honorable  nuiii,  especially  kind  to  the 
I)oor.  He  died  suddenly  .January  26,  1912.— (T.  II.  S.) 
Friedenwald,  Aaron.  A  well-known  American  ophthalmologist  and 
luedico-econoinist.  He  was  born  December  20,  1886,  at  Baltimore, 
Maryland,  the  son  of  Jonas  and  IMerle  (Bar)  Friedenwald.  His  early 
education  was  received  at  the  school  maintained  hy  the  Baltimore 
Hebrew  Congregation.  At  the  age  of  about  fifteen,  however,  he  had 
to  relinquish  his  studies  in  order  to  accept  a  situation  as  bookkeeper 
in  a  clothing  store.  Finding  the  position  uncongenial,  he  decided, 
when  twenty-one  years  of  age,  to  study  medicine.  For  awhile  he 
studied,  after  the  custom  of  the  day,  with  a  preceptor.  Dr.  N.  R. 
Smith.  Entering,  just  a  little  later,  the  University  of  ^Maryland,  he 
received  from  that  institution  his  professional  degree  in  1860.  He 
then  went  to  Europe,  where  he  studied  ophthalmology,  as  well  as 
general  medicine,  in  Berlin,  Prague,  Vienna,  Paris  and  London. 
While  abroad  he  was  chiefly  influenced  by  Arlt  and  von  Graefe, 
hence,  for  the  remainder  of  his  life,  though  he  never  wholly  gave 
up  general  medicine,  his  heart  was  mostly  in  his  work  as  an  ophthal- 
mologist. For  a  long  time  he  was  the  only  ophthalmologist  in 
Baltimore. 

In  1873  he  was  made  professor  of  diseases  of  the  eye  and  ear  in 
the  College  of  Physicians  and  Surgeons  at  Baltimore.  In  this  capacity 
he  labored  with  conspicuous  success  for  twenty-nine  years. 

In  1889  he  was  elected  president  of  the  ]\Iedical  and  Chirurgical 
Faculty  of  ^Maryland.  He  was  also  the  first  president  of  the  ]Mary- 
land  Ophthalmological  Society. 

Always  interested  in  medical  economics,  especially  in  the  part 
thereof  relating  to  the  communal  life  of  physicians,  he  it  was  who. 
to  all  intents  and  purposes,  created,  in  1890,  the  present  Association 
of  American  Medical  Colleges.  "It  was  on  his  motion,  as  a  repre- 
sentative of  the  College  of  Physicians  and  Surgeons,  that  the  Asso- 
ciation of  Baltimore  I\Iedical  Colleges  .  .  .  became  a  national 
organization  at  Nashville."  {Anuals  of  Ophihahnolorjii,  October, 
1902.) 

Dr.  Friedenwald  was  a  man  of  social,  even  jovial,  character.  He 
was  also  upright,  patriotic  and  very  devoutly  religious.  His  genial 
nature  is  characteristicallv  shown  bv  the  fact  that,  during  his  daily 


FRIEDENWALD,  AARON  5297 

nap,  wliicli  lie  took  for  a  very  few  minutes  after  dinner,  he  always 
desired  to  have  the  ehildren  rompiiitr  al)()ut  liiin  in  the  room,  or  at 
least  a  number  of  persons  talkin<i:  and  hiughing.  Sueh  matters  never 
amioyed,  they  meri^ly  sootlied  and  comforted  him.  His  patients,  too, 
were  wont  to  say  that  the  pleasant  manners  of  Dr.  Friedenwald  were 
a  kind  of  medicine  in  themselves. 


Aaron  Friedenwald. 

That  his  genial  nature  was  by  no  means  unaccompanied  by  the 
extreme  of  tirnniess,  whenever  occasion  demanded,  could  be  shown  by 
numerous  anecdotes.  Of  these,  let  one  or  two  suffice  as  being  wholly 
typical.  One  day,  when  a  student  in  tlie  University  Infirmarj%  he 
received  an  unsigned  note,  insulting  to  liimself  and  his  religion. 
Below  the  illiterate  message,  he  penned  these  words:  "The  man 
who  wrote  the  above  lines  is  as  great  a  coward  as  he  is  a  scoundrel, 
or  he  would  have  signed  his  name.  A.  Friedenwald."  And  he  posted 
the  note.     In  a  very  short  time,  he  was  facing  an  angry  crowd  of 

Vol.  VII— 29 


5298  FRIEDENWALD,  AARON 

rowdies,  some  of  whom  (lemaiidcd  in  language  more  vigorous  than 
polite,  if  lie  had  written  "those  words."  '^'oiuig  Friedenwald 
responded  so  emphatieally  and  stood  so  i)laiidy  I'cady  to  back  his 
words  with  actions,  that  the  rowdies,  one  by  one,  sluid-c  out  of  view. 
In  consecpienee  of  this  atfair,  h(!  was  soon  elected  to  mend)ership  in  a 
very  select  and  scholarly  organization,  known  as  "The  Hush  Club." 

Here  is  yet  another  anecdote  to  the  same  etfect.  While  still  a 
student  of  medicine,  he  stoj)ped  one  tlay  at  the  clothing  store  kept 
by  his  brothers.  A  thief  ran  in,  gra])l)ed  up  an  armful  of  clothes, 
and  dashed  out  again — pursued,  liowever,  by  the  embryo  doctor.  The 
thief  threw  away  the  clothes,  but  Dr.  Friedenwald  was  not  to  be 
diverted  from  the  more  important  purpose.  The  scoundrel  even  drew 
a  revolver,  and,  aiming  it  squarely  at  liis  pursuer's  head,  declared 
his  intention  to  shoot,  liut  still  Dr.  Friedenwald  did  not  stop.  He 
ran  up,  seized  the  fellow,  threw  him  down,  and,  taking  away  his 
revolver,  kept  it  aimed  at  the  scoundrel's  head  until  the  arrival  of 
a  policeman. 

Dr.  Friedenwald 's  patriotism,  too,  could  l)e  shown  by  numerous 
examples.  The  following  passage,  however,  from  one  of  his  letters, 
written  to  friends  at  Baltimore,  while  he  was  still  a  student  at  Berlin, 
may  stand  as  representative :  " .  .  .  A  few  evenings  since,  being  in 
a  beer  garden,  I  heard  some  one  in  the  crowd  whistling  'Yankee 
Doodle.'  I  was  affected  as  by  an  electric  shock,  was  almost  involun- 
tarily drawn  to  the  spot,  and  found  that  the  melody  emanated  from 
a  respectable-looking,  well-dressed  young  gentleman.  I  accosted  him 
with,  'What  right  have  you  to  whistle  my  songs?'  No  further  alter- 
cation took  place,  he  having  established  his  right  by  stating  that  he 
was  an  American,  and  a  Baltimorean  at  that." 

As  already  suggested.  Dr.  Friedenwald  was  brought  up  in  accord- 
ance with  the  strictest  traditions  of  orthodox  Judaism.  We  may  now 
add  that,  from  these  old-time  principles,  he  never  swerved  even  to 
the  last  moment  of  his  life.  While  still  a  student  in  Berlin,  he  wrote 
to  his  father :  ' '  Dear  Father,  you  entertained  great  fears  on  my 
departure  that  I  would  entirely  forget  my  religion,  but  rest  assured 
that  what  I  have  seen  of  'enlightened  Judaism'  here  has  disclosed 
our  old,  assailed,  insulted  orthodoxy  in  a  more  beautiful  form  than 
I  have  3'et  beheld  it."  At  a  very  much  later  period,  he  used  the 
following  language:  "Thank  God  that  I  have  not  been  infected  with 
that  dangerous  spirit  of  the  age,  whicli  questions  His  existence.  He 
who  in  His  goodness  has  shielded  me  from  the  pernicious  influence 
of  the  small-pox  and  cholera  and  yellow  fever  and  other  pestilences, 
has   shielded    me    from   this   greater   plague."     He   was   a    constant 


FRIEDENWALD,  AARON  5299 

attendant  at  the  synagogue,  and  was  one  of  the  founders  and  also  an 
officer  of  the  Shearith  Israel  congregation.  He  was  later  a  member 
of  the  Chizuk  Emoonah  congregation,  in  wliich  he  succeeded  his 
father,  Jonas  Friedenwald,  as  president.  He  was  always  a  student 
of  the  ancient  Hebrew,  kept  numerous  Hebrew  books  beside  him  on 
his  desk,  because  of  their  cheering  companionship,  and  now  and  then 
composed  a  letter  to  a  friend  in  Hebrew. 

He  married,  June  14,  1863,  Miss  Bertha  Bamberger,  to  whom  he 
had  become  engaged  before  he  went  al)road.  Of  the  union  five  chil- 
dren were  born,  all  sons :  Harry,  now  a  well-known  ophthalmologist 
of  Baltimore;  Julius;  Bernard  Daniel;  Norman;  and  Edgar  Bar. 

Dr.  Aaron  Friedenwald  died  at  Baltimore,  August  26,  1902,  after 
an  operation  for  cancer  of  the  stomach.  Memorial  services  were  held 
in  his  lienor  at  the  McCulloh  Street  Synagogue,  November  9,  1902, 
addresses  being  made  by  the  R^v.  Drs.  Mendes,  of  New  York  City; 
Schnuberger,  of  Baltimore;  Cyrus  Adler,  of  New  York;  and  Solomon 
Soils  Cohen,  of  Philadelphia. 

Among  the  more  important  writings  of  Dr.  Aaron  Friedenwald 
are  the  following:* 

1.  "Letter  from  Berlin"  (dealing  with  Glaucoma  and  Iridec- 
tomy), Maryland  and  Virginia  Medical  Journal,  1861,  Vol.  XVI,  p. 
349.^ 

2.  "The  Pulse,"  a  paper  read  before  one  of  the  Baltimore  medical 
societies. 

3.  "Diseases  of  the  Lachrymal  Apparatus,"  a  paper  read  before 
the  Baltimore  Medical  Association,  1869. 

4.  "Sympathetic  Oplithalinia,"  a  paper  read  before  the  Baltimore 
]\Iedical  Association,   1S69. 

5.  "Exophthalmic  Goitre,"  a  paper  read  before  the  Pathological 
Society  of  Baltimore.  1870  (?). 

6.  "Purulent  Ophthalmia,"  a  paper  read  lief  ore  the  Baltimore 
Medical  Association,  April,  1870. 

7.  "Traumatic  Cataract,"  a  paper  read  before  the  Baltimore 
Medical  Association,  April  24.  1871. 

8.  "Various  Conditions  of  the  Nerves  of  the  Eye  Regulating 
the  Contraction  and  Dilatation  of  the  Pupil,"  a  paper  read  before 
the  ]\ledical  and  Surgical  Society  of  Baltimore,  May  4,  1871. 


*For  the  whole  of  this  exeollont  bibliojjraiihy,  as  well  as  for  the  most  of  the 
material  used  in  the  body  of  the  sketch.  T  am  deeply  indebted  to  a  book  by  Dr. 
Harry  Friedenwald,  of  Baltimore,  ^Id.,  son  of  Dr.  Aaron  Friedenwald,  entitled 
"Aaron  Friedenwald,  His  Life,  Letters  and  Addresses" — a  beautiful  tribute,  by 
the  way,  to  a  master  oidithalmologist  and  old-time  father  in  Israel. 


5300  FRIEDENWALD,  AARON 

9.  "Iritis,"  a  paper  read  before  the  Baltimore  Medical  Asso- 
ciation, September,  1871. 

10.  "Retinitis  Complicated  witli  Bright 's  Disease,"  Trans.  Med. 
and  Cliir.  Faculty,  October,  1871. 

11.  "Eczema,"  a  paper  read  before  the  Medical  and  Surgical 
Society  of  Baltimore,  February  8,  1872. 

12.  "Grlaucoma,"  a  paper  read  before  the  Baltimore  Medical 
Association,  November  11,  1872, 

13.  "Plilyctenular  Ophthalmia."  a  paper  read  before  the  Med- 
ical and  Surgical  Society  of  Baltimore,  May  1,  1873. 

14.  Introductory  Lecture  to  the  Course  on  Diseases  of  the  Eye 
and  Ear,  delivered  })efore  the  Class  of  the  College  of  Physicians  and 
Surgeons,  Baltimore,  October,  1873. 

15.  "Report  on  Surgery:  Indications  for  the  Enucleation  of  the 
Eye-ball  and  the  Correction  of  the  Deformity  by  the  Insertion  of  an 
Artificial  Eye,"  read  before  the  Medical  and  Chirurgical  Faculty  of 
Maryland,  April,  1876;  Trans.  Med.  and  Chir.  Fa-cidty,  1876,  p.  82; 
also  Cincinnati  Medical  Xcivs,  November,  1877. 

16.  " Oplithalmological  Notes"  (including  "Anaesthetics  in  Oph- 
thalmic Surgery"  and  "Spasm  of  the  Accommodation"),  a  paper 
read  before  the  ]\Iedieal  and  Chirurgical  Faculty  of  Maryland,  April, 
1878;  Trans.  Med.  and  Chir.  Faculty,  1878,  p.  94. 

17.  "The  Eye,"  a  Lecture  delivered  before  the  Hebrew  Young 
Men's  xVssoeiation  of  Baltimore,  1878. 

18.  "Optic  Neuritis,"  a  paper  read  before  the  Baltimore  ]\Iedical 
Association,  April  11,  1881;  Maryland  Medical  Journal,  August  1 
and  15,  1881 ;  also  reprinted  separately. 

19.  "Introductory  Address  delivered  before  the  Class  of  the  Col- 
lege of  Physicians  and  Surgeons  of  Baltimore  City,  September  14, 
1881,     .     .     .     Published  by  the  Class." 

20.  "Address  on  the  Occasion  of  the  Dedication  of  the  Newly 
Acquired  Ground  at  the  Sirachath  Thorah  Festival  of  the  Hebrew 
Hospital  and  Asylum  Association  of  Baltimore  City,  October  16, 
1881,"  published  by  the  Association.  Baltimore,  1881. 

21.  "Old  Foes  and  New  Friends,"  an  Address  upon  Anti-Sem- 
itism, delivered  before  the  Hebrew  Young  Men's  Association  of  Balti- 
more'(1882?). 

22  "Enucleation  and  Optico-Ciliary  Neurotomy,"  a  Clinical  Lec- 
ture before  the  Class  of  the  College  of  Physicians  and  Surgeons: 
Medical  Chronicle  (Baltimore),  Vol.  I,  1883,  p.  150. 

23.  "Four  Cases  of  Syphilitic  Brain  Disease  Complicated  with 
Eye  Disease"  (1883?), 


FRIEDENWALD,  AARON  5301 

24.  "Relation  of  Eye  and  Spinal  Diseases,"  a  paper  read  before 
the  Medical  and  Cliirurgieal  Faculty  of  Maryland ;  Trans.  Med.  and 
Cliir.  Faculty,  1883,  p.  187;  also  reprinted  separately.  (Abstracted 
in  Medical  News  [Philadelphia],  Vol.  XLII,  1883,  p.  505,  and  in  the 
Maryland  Medical  Journal,  Vol.  X,  1883-4,  p.  25.) 

25.  "Uremic  Amaurosis,"  a  paper  read  before  the  Baltimore 
Medical  Association,  June  9,  1883;  Medical  News  (Philadelphia), 
April  9,  1884;  abstracted  in  the  Medical  Chronicle  (Baltimore), 
November,  1884. 

26.  "Recent  Progress  in  Ophthalmology,"  a  review  of  current 
literature,  Medical  Chronicle  (Baltimore),  August,  1883. 

27.  Address  Commemorative  of  Dr.  Andrew  Ilartman  (December 
15,  1884). 

28.  Address  delivered  at  the  Purim  Banquet  of  the  Hebrew  Ladies' 
Orphans'  Aid  Society,  Baltimore,  February  27,  1885. 

29.  "Foreign  Bodies  in  the  Eye,"  a  paper  read  before  the  Clin- 
ical Society  of  Baltimore,  March  20,  1885. 

30.  "Four  Cases  of  Eye-Injuries,"  described  at  the  meeting  of 
the  Baltimore  Medical  Association,  November  10,  1885 ;  Medical 
Times  (Philadelphia),  December  12,  1885. 

31.  "Osteosarcoma  at  Base  of  Skull,"  Maryland  Medical  Journal, 
1886,  p.  500. 

32.  "A  Case  of  Optic  Neuritis  with  Brain  Sjnnptoms;  Recovery, 
with  Remarks, ' '  a  paper  read  before  the  Clinical  Society  of  Baltimore, 
December,  1885;  New  York  Medical  Jourmd,  February  5,  1887. 

33.  Address  Commemorative  of  Professor  John  S.  Lynch,  M.  D., 
delivered  before  the  Medical  and  Chirurgieal  Faculty  of  Maryland, 
October  7,  1888;  published  in  al)stract  in  Trans.  Med.  and  Ckir. 
Faculty,  1889,  p.  42. 

34.  "Disturbed  Eciuilibrium  of  the  Muscles  of  the  Eye  as  a  Factor 
in  the  Causation  of  Nervous  Diseases,"  a  paper  read  before  the  ]\led- 
ieal  and  Chirurgieal  Faculty  of  Maryland;  Trans.  Med.  and  Chir. 
Faculty,  1889,  p.  199;  also  reprinted  separately. 

35.  "Iodoform  in  Gonorrhceal  Ophthalmia,"  a  paper  read  before 
one  of  the  Baltimore  medical  societies,  1889. 

36.  Address  delivered  at  the  Opening  of  the  New  City  Hospital, 
Baltimore,  January  1,  1889. 

37.  "Detachment  of  the  Retina,"  a  paper  read  before  the  Balti- 
more Medical  Association,  November  11,  1889;  Maryland  Medical 
Journal,  Vol.  XXII,  1889,  p.  205. 

38.  Address  at  the  Semi-Annual  Session  of  the  Medical  and  Chir- 


5302  FRIEDENWALD,  AARON 

urgical  Faculty  of  Maryland,  Ila^^Tstown,  November  12,  1889;  pub- 
lished ill  part  ill  Trans.  Med.  and  Cliir.  Facidtu,  1890,  p.  10. 

39.  Address  delivered  at  the  Simeliath  Torah  Festival  of  tlie 
Hebrew  Hospital  and  Asylum  Association,  1890. 

40.  "The  Modern  Hospital,"  Presidential  Address  before  the 
Medical  and  Chirurgical  Faculty  of  Baltimore,  1890;  Trans.  Med. 
arid  Cldr.  Faculty,  1890,  p.  145;  also  Maryland  Medical  Journal,  Vol. 
XXIII,  1890,  p.  1. 

41.  "Jewish  Immigration,"  an  Address,  published  in  the  Ameri- 
can Hebrew  (New  York),   (1891?). 

42.  Address  at  the  Celebration  in  Honor  of  the  Seventieth  Birth- 
day of  Professor  Virchow,  held  in  the  Johns  Hopkins  University, 
Baltimore,  October  13,  1891 ;  published  in  the  Johns  Hopkins  Uni- 
versity Circular. 

43.  "Charity,"  an  Address  delivered  at  the  Annual  Banquet  of 
the  Hebrew  Benevolent  Society,  Baltimore,  December  1,  1892. 

44.  Address  delivered  at  the  Annual  Meeting  of  the  Baltimore 
Branch  of  the  Alliance  Israelite  Universelle,  March  19,  1893. 

45.  "Paralysis  of  the  Eye  Muscles  of  Central  and  Peripheral 
Origin,"  a  paper  read  before  the  Medical  and  Chirurgical  Faculty 
of  Maryland,  April,  1894;  Maryland  Medical  Journal,  May  26,  1894; 
also  reprinted  separately. 

46.  "Lovers  of  Zion,"  an  address  delivered  before  the  Miekve 
Israel  Association  of  Philadelphia.  December  23,  1894;  published  in 
the  Jewish  Exponent  (Philadelphia)  and  reprinted  by  the  Zion  Asso- 
ciation of  Baltimore. 

47.  "Jewish  Physicians  and  the  Contributions  of  Jews  to  the 
Science  of  ]\Iedicine :  a  Lecture  delivered  before  the  Gratz  College 
of  Philadelphia,  January  20,  1896";  Publications  of  Gratz  College, 
No.  1 ;  also  reprinted  separately,  Philadelphia,  1897. 

48.  "A  Trip  to  Palestine,"  an  Address  read  before  the  Young 
Men's  Hebrew  Association  of  Philadelphia,  February  25,  1899,  and 
also  l)efore  societies  in  Baltimore  and  New  York;  published  in  the 
Jewish  Exponent    (Philadelphia). 

49.  "Glimpses  in  Palestine,"  an  Address  delivered  before  a  Jew- 
ish society  in  Baltimore   (1899?). 

50.  "History  of  Medicine  before  Hippocrates,"  a  paper  published 
in  the  Jourml  of  the  Alumni  Association  of  the  College  of  Physicians 
and  Surgeons,  April,  1900. 

51.  "Circumcision"  (Medical  Aspects),  an  Article  in  the  Jewish 
Encyclopedia,  Vol.  IV. 

52.  "Doctor  George  II.  Robe:    A  Memoir,"  read  at  the  Memorial 


PRIEDLAENDER,  LUDWIG  HERMANN  5303 

Meeting  of  the   Maryhiiid    Health  Association,  May   23,  1901;   pub- 
lished in  pamphlet  form. 

53.  "Kemoval  of  the  Crystalline  Leus  for  High  Degrees  of 
Myopia,"  Journal  of  the  Alumni  Association  of  the  College  of  Phy- 
sicians and  Surgeons,  Baltimore,  July,  1901. 

54.  xVddrcss  at  the  Celebration  held  in  Honor  of  the  Completion  of 
the  Twenty-tifth  Year  of  tlie  Reverend  Dr.  Henry  W.  Schneeberger's 
Service  as  Rabbi  of  the  Chizuk  Emoonali  Congregation,  Baltimore, 
October  20,  1901. 

55.  "The  National  Jewisli  Hospital  for  Consumptives,"  an  Article 
published  posthumously  in  the  Jewish  Comment  (Baltimore),  Novem- 
ber 11,  1902.— (T.  II.  S.) 

Friedlaender,  Ludwig-  Hermann.  A  well  known  German  military  sur- 
geon of  a  little  ophthalmologic  importance  because  of  his  "De  Medi- 
cina  Oculorum  apud  Cdsum  Commentatio"  (1817).  He  was  born 
at  Konigsberg,  Prussia,  April  20,  1790,  studied  both  'there  and  at 
Berlin,  settled  in  Halle,  there  became  privat-docent  in  medicine,  in 
1819  extraordinarius  and  in  1823  ordinarius  of  theoretic  medicine, 
and  died  in  1851.— (T.  II.  S.) 

Friedlander 's  bacillus.  Bacillus  pneumonia  friedlanderl  This 
organism  was  tirst  obtained  from  the  exudates  in  the  pulmonary 
aveoli  in  cases  of  croupous  pneumonia.  It  is  aerobic,  as  well  as 
facultative  anaerobic.  It  is  a  large,  non-liquef active,  non-motile, 
Gram  negative,  cai)sulated  bacillus,  which  grows  very  profusely  on 
ordinary  media  and  furnishes  a  typical  "nail  culture"  in  gelatine. 
Pure  infections  of  the  conjunctiva  with  Friedlander 's  bacillus  have 
been  frequently  noted.  The  organism  is  i)i-()bably  identical  with 
Bacillus  mucosus  capsulatus.  See  Bacteriology  of  the  eye. — (S. 
H.  M.) 

Friedreich's  disease.  Sec  Hereditary  diseases;  as  well  as  famihj  ataxia 
under  Familial  affections,  and  page  (i(i2,  Vol.  1  of  this  Encyclopedia. 

Frisson.      (E.)      Rigor;  shivering;  shiver. 

Fritschl.  An  almost  wholly  unknown  privat  docent  at  Freiburg,  who 
wrote:  1.  Die  Bosartigen  Schwammgeschwiilste  des  Auges  und  seiner 
Niichsten  Umgebung.      (Freiburg,  18-13.) 

2.  Uber  die  Wirksamkeit  einiger  Arzneimittel  gegen  Augenleiden. 
Besonders  gegen  Gewisse  Formen  der  Augen-Entziindung.  Jour, 
d.  Chir.  u.  A.,  vol.  36,  pp.  62-150  and  223-273,  1817.)  — (T.  H.  S.) 

Frog.  The  frog,  in  Greco-Roman  antiiiuity,  was  sui)i)osed  to  be  of 
value  in  various  diseases  of  the  eye.  Thus,  the  fluid  which  could  be 
scraped  from  a  frog's  back  was  employed  in  a  general  way  as  a 
strengthener  of  the  sight.     The  flesh  was  laid  upon  an  eye  as  a  styptic 


5304  FROG'S  MOUTH  MUCOSA 

and  analgesic.  The  blood  was  also  used  to  prevent  the  return  of 
cilia  after  epilation.  The  most  remarkable  use  of  all,  however,  was 
that  for  which  the  elder  Pliny  is  alone  responsible.  At  the  time  of 
the  new  moon,  the  eyes  were  torn  from  a  living  frog,  and  then, 
enclosed  in  either  a  cloth  or  an  egg-shell,  carried  by  a  patient  for 
either  an  albugo  or  a  lippituch.  Great  care,  however,  was  necessary 
that  the  right  eye  of  the  frog  should  be  worn  on  the  left  side  of  the 
l)atient,  and  vice  versa. —  (T.  H.  S.) 
Frog-'s  mouth  mucosa.  The  membrane  lining  the  month  of  the  common 
frog  has  been  used  both  in  ophthalmic  and  general  surgery. 

Leslie  Paton  {The  Lancet,  April  23,  1904)  operated  upon  an  eye 
in  W'hich  there  was  complete  attachment  of  the  lower  lid  to  the  eye- 
ball causing  limitation  of  movement  and  dij^lopia  in  every  direction 
so  that  the  fellow  eye  had  to  be  covered  constantly.  He  used  mem- 
brane from  the  roof  of  the  frog's  mouth  to  form  a  re-lining  of  the 
lower  conjunctival  sac.  He  says  that  three  frogs  were  used  and 
from  these,  three  flaps  were  prepared,  the  largest  being  about  two 
centimetres  in  breadth;  the  other  two,  from  smaller  frogs,  were 
approximately  the  same  breadth  but  shorter.  These  were  kept  in 
warm  sterilized  saline  solution  while  the  eye  Avas  prepared.  In  dis- 
secting the  surface,  care  was  taken  to  leave  any  normal  conjunctiva 
attached  to  the  ocular  surface.  The  dissection  was  carried  down 
until  over  a  centimetre  of  raw  palpebral  surface  was  exposed.  To 
this  the  larger  piece  of  mucous  membrane  was  attached  by  four  fine 
silk  sutures  along  the  upper  margin,  the  lower  margin  being  left 
unattached.  The  other  two  pieces  of  mucous  membrane  were  sim- 
ilarly sewn  to  the  fringe  of  conjunctiva  on  the  ocular  surface.  They 
were  carefully  arranged  in  position  and  a  piece  of  green  protective 
was  pushed  in  and  the  eye  closed  and  bandaged.  On  the  sixth  day 
the  protective  was  taken  out  and  the  stitches  removed.  All  three 
grafts  had  taken,  the  palpebral  one  and  the  outer  ocular  one  per- 
fectly, the  inner  ocular  one  not  quite  so  well,  and  at  the  line  of  its 
suture  there  was  a  fleshy  granulation.  The  movements  of  the  eye 
were  now  free  except  that  on  extreme  movement  outward  there  was 
some  diplopia. 

At  the  time  of  writing  the  appearance  of  the  eye  was  almost  natural. 
There  was  an  irregularity  of  the  lower  lid  margin,  which,  however, 
was  not  marked.  On  pulling  down  the  lower  lid  at  the  inner  margin 
there  was  one  cicatricial  band  passing  to  the  eye  about  a  centimetre 
in  length  and  about  three  millimetres  in  breadth.  In  the  rest  of  its 
extent  the  conjunctival  sac  was  almost  normal  in  appearance. 


FROG'S  SPAWN  5305 

Frog's  spawn.  The  appoaraiu'cs  of  the  granular  loiiii  ol'  trachoma — 
the  gray,  translucent,  liciiiispliciical  bodies  also  called  ''sago  grains." 

Froid.     (F.)     Cold;  coldness. 

Frcidure.     (F.)     Congelation;  fi-ee/ing. 

Froissement.     (F.)     Bruising;  contusion  (by  violent  friction), 

Frolich's  test.  This  test  for  simulated  blindness  is  a  modification  of 
Mouoyer's  examination  with  double  ])rism.s.  The  inventor  added  to 
the  ch)uble  i)rism  a  red  glass  Avhieh  can  be  adjusted  sometimes  before 
tile  two  i)risms  j)Iaeed  base  to  base  and  sometimes  before  the  space 
which  separates  them  ;  sometimes  before  one  or  the  other  prisms. 
In  either  case  three  images  are  formed  in  the  Frolich  test.  The 
upper  and  the  lower,  or  the  single  middle  image,  can  thus  l)e  colored 

.  red  at  the  will  of  the  examiner.  The  ap{)aratus  is  more  complicated 
than  that  of  Monoyer.  The  fact  that  the  second  red  glass,  which 
is  placed  before  the  eye  that  is  said  to  be  defective,  must  render 
ditHcult  the  incessant  surveillance  that  is  indispensable  to  exercise  in 
order  to  prevent  a  malingerer  from  closing  the  eye  and  discovering 
the  number  and  color  of  the  images  which  it  is  to  his  interest  to 
declare  that  he  sees  or  does  not  see.  For  this  reason  this  test  is  less 
valuable  than  others  described  under  Blindness,  Simulation  of. 

Fromag'e.     (F.)     Cheese. 

Froment.     (F.)     AVheat. 

Fremont's  figures.  Images  used  in  the  stereoscope  of  the  inventor, 
and  described  in  Javal's  Manual  de  Strahisme,  1896. 

Fronce.     (F.)     A  furrow. 

Fronde.     (F.)     Four-tailed  bandage. 

Fronmiiller,  \  well-knoAvn  German  physician  and  ophthalmologist, 
inventor  of  the  trial-case, — i.  e.,  the  case  of  trial  lenses,  frames,  etc., 
substantially  as  used  today.  The  dates  and  the  place,  or  places,  of  his 
birth  and  death  cannot  be  ascertained.  He  was  the  son  of  a  physician, 
and  he  practised  at  Ftirth.  For  the  earliest  accounts  of  his  excellent 
and  memorable  invention,  see  Jour.  d.  Chir.  u.  Augenhcilk.,  Vol.  32, 
p.  174-187,  1843,  and  Annahs  d'Oculist,  Vol.  x,  p.  283,  1843.— (T. 
II.  S.) 

Frontal  bone.  See  Cavities,  Neighboring;  as  well  as  Anatomy  of  the 
eye. 

Frontal  distance.  The  space  between  the  objective  and  the  cover  glass 
when  the  object  is  in  focus. 

Frontal  nerve.  One  of  the  three  branches  of  the  first  division  of  the 
fifth  nerve.    See  Fifth  nerve. 

A  method  of  resect ing  the  external  frontal  nerve  and  its  branches 
has  been  descril)ed  by  IMotais   {Ophthalmic  Ycar-Book,  i\  44.  1913). 


5306  FRONTAL  SINUS 

A  2 J/)  to  3  cm.  incision  is  made  below  the  arch  of  the  orbit,  extending 
through  the  skin  and  orbicularis.  The  aponeurosis  is  similarly  opened, 
autl  the  orbital  notch  found  witii  the  finger.  To  catch  the  nerve  a 
strabismus  hook  may  be  passed  under  the  roof  of  the  orbit.  The  nerve 
being  isolated  is  seized  with  forceps,  dissected  out  and  divided  5  to  12 
mm.  back  from  the  orbital  margin.  The  slight  hemorrhage  is  arrested 
by  pressure.  By  this  procedure  the  principal  branches  of  the  nerve 
are  secured  and  removed. 

Frontal  sinus.     See  Cavities,  Neighboring. 

Frontal  vein.  This  is  a  hii'gc  vessel  I'unning  along  tlie  inner  side  of 
the  orbit  and  communicating  with  branches  of  the  ophthalmic  vein. 
According  to  Dwight,  a  branch  connecting  it  with  the  anterior  tem- 
poral forms  an  arch  along  the  top  of  the  orbit.  The  facial  vein 
receives  some  distance  below  the  orbit  a  vein  from  its  outer  border. 
The  branches  in  the  lids  do  not  form  definite  arches  like  the  arteries, 
but  run  in  the  main  at  right  angles  to  the  palpebral  opening.  The 
artery  lies  a  little  higher.  Merkel  points  out  that  most  of  the  superior 
branches  and  all  the  internal  ones  pass  through  the  orbicularis,  so  that 
its  continued  contraction  must  cause  a  congestion.  Probably  under 
these  circumstances  more  of  the  blood  passes  off  into  the  cranium  or 
into  the  sj'stem  of  the  internal  maxillary  vein,  but  under  ordinary 
circumstances  the  current  is  superficial. 

Front  focus.     See  Focus. 

Fronto-lachrymal.  Belonging  to  the  forehead  and  to  the  lachrymal 
bont'. 

Fronto-maxillary  fissure.     See  Development  of  the  eyes. 

Fronts.  Grabs.  Colloquial  names  for  the  lenses  temporarily  attached 
to  spectacles,  to  increase  their  visual  powers. 

Front-stop.  In  optics,  an  annular  diaphragm  centi-ally  i)laced  in  front 
of  a  lens-system  in  order  to  restrict  the  aperture  to  bundles  of 
effective  rays.  In  the  absence  of  a  stop  the  circular  rim  of  a  single 
lens  is  the  common  base  of  the  cones  of  incident  and  refracted  rays 
that  take  part  in  the  production  of  the  image,  which  is.  consequently, 
less  free  from  distortion.     See,  also,  Aperture. —  (C.  F.  P.) 

Froriep,  Robert.  A  celebrated  German  ])ath()h)gist,  of  a  slight  oi)h- 
thalmologic  importance  because  of  his  ''De  Corneitide  Scrofulosa" 
(1880).  He  was  born  at  Weimar,  Feb.  21,  1807,  received  his  medical 
degree  at  Bonn  in  1828,  studied  also  in  Paris,  and  in  18.80  made  his 
home  in  Jena.  He  later  resided  in  Berlin  and  AVeimar.  At  the  latter 
place  he  died.  June  14,  1861.— rT.  II.  S.) 

Frost-Lang  operation.     See  Enucleation  of  the  eye. 


FROTHINGHAM,  GEORGE  EDWARD 


5:507 


Frothing-ham,  George  Edward.  ISoni  at  Host  on,  Mass.,  April  2:},  18;5(i, 
he  received  his  lilxTal  educalion  at  IMiillips  Academy,  Andover.  For 
a  time  he  tauglit  seliool.  Then  he  l)egan  to  study  medicine  with  Dr. 
W.  W.  Greene,  Professor  of  Surgery  in  the  Medical  Department  of 
Bowdoin  College.  Later,  he  proceeded  to  Aim  Arbor,  ]\Iich.,  where  he 
received  the  degree  of  M.  D.  in  1864. 


George  E.  Frotliingham. 


Returning  to  ]\Iassaehusetts,  he  practised  for  three  years  at  North 
Becket.  Then  he  returned  to  Ann  Arbor,  in  order  to  accept  the  demon- 
stratorship of  anatomy  and  the  prosectorship  of  surgery  in  his  alma 
mater. 

Deciding  to  devote  himself  to  ophthalmology  and  oto-laryngology 
exclusively,  he  studied  for  a  time  in  the  ophthalmic  and  aural  hos- 
pitals of  New  York.  Then,  returning  to  Ann  Ar])or,  he  was  appointed 
full  professor  to  the  chair  of  ophthalmology  and  otology,  then  just 
created.  As  a  matter  of  convenience  to  the  faculty,  he  taught,  at 
times,  in  addition  to  his  own  bi-anches.  anatomy,  materia  medica.  and 


5308  FROTTEMENT 

therapeutics.  He  was  a  genial  man  and  iinicli  beloved  by  his  confreres 
and  he  was  for  many  years  in  close  touch  with  the  large  student  body, 
lie  Mas  a  member  of  numerous  medical  societies.  In  1874  he  was 
President  of  the  Washtenaw  County  Medical  Society,  in  1880  Presi- 
dent of  the  Michigan  State  ]\ledical  Society.  He  also  held  a  number 
of  appointments  as  ophthalmologist  and  otologist  to  various  hospitals 
in  Ann  Arbor  and  Detroit ;  and,  from  1869  to  1871,  was  an  editor  of 
the  Michigan  University  Medical  Journal. 

In  1800  he  married  Lucy  E.  Barbour.  Of  the  union  were  born  four 
children,  of  whom  one,  George  Edward,  Jr.,  is  a  well-known  ophtlial- 
mologist,  being  ophthalmic  surgeon  to  the  Harper  Hospital,  Detroit, 
and  Clinical  Professor  of  Ophthalmology  in  the  Detroit  College  of 
Medicine. 

Dr.  Frothingham,  Sr.,  died  at  his  home  in  Detroit,  of  arterio-sclero- 
sis,  April  24,  1900.— (T.  H.  S.) 

Frottement.     (E.)     Rubbing;  friction. 

Frottoir.     (F.)     An  instrument  used  in  massage. 

Frlihjahrskatarrh.     (G.)     Vernal  conjunctivitis. 

Fruste.     ( F. )     Abortive,  in  the  sense  of  incomplete  or  anomalous. 

Frustrane.     (F.)     Useless;  sterile. 

Fryer,  Blencowe  E.  An  oplitlialmologist  of  the  American  middle  west. 
He  was  born  in  Somerset  Co.,  England,  Oct.  26,  1837,  the  son  of  an 
English  army  officer.  He  lost  his  father  at  a  very  early  age,  and,  when 
only  seven  years  old,  removed  with  his  widowed  mother  and  five 
brothers  and  sisters  to  America.  Here  the  family  settled  in  Phila- 
delphia, and,  in  1859,  at  the  University  of  Pennsylvania,  young  Fryer 
received  the  degree  of  Doctor  in  ]\Iedieine.  Until  the  civil  war  broke 
out  he  served  as  interne  in  a  Philadelphia  hospital. 

On  May  28,  1861,  he  was  appointed  Assistant  Surgeon  in  the  Union 
Army,  and,  from  that  date  till  1887,  he  was  engaged  in  active  U.  S. 
army  service.  In  JMay,  1887,  however,  he  was  ordered  before  the 
appropriate  board  in  San  Francisco,  and  was  there  retired  from  active 
service  on  account  of  disability. 

Doctor  Fryer  then  removed  to  Kansas  City,  Mo.,  where  he  practised 
ophthalmology  and  oto-laryngology  exclusively,  until  about  a  week 
before  his  death. 

In  1865  he  married  Miss  Elizabeth  Caroline  Potter,  of  German- 
town,  Pa.  Of  the  union  two  boys  and  one  girl  were  born.  One  of 
these,  Dr.  J.  S.  Fryer,  is  Surgeon-in-Chief  of  tlie  National  ^Military 
Home  at  Leavenworth,  Kansas. 

Dr.  Fryer  was  fond  of  reading  ami  liad  an  excellent  library.  He 
is  said  to  have  had  a  remarkable  memory,  recalling,  in  fact,  the  very 


FUCHS'  COLOBOMA 


5309 


pages  on  which  laigf  iiiimhcrs  of  artidos  could  )k;  found.  On  this 
account  he  was  facetiously  termed  by  a  friend  "The  index  catalogue 
of  the  Surgeon  General's  library. "  llis  chief  amusement  was  horse- 
back riding — in  which  he  indulged,  as  a  rule,  in  company  with  his 
daughter. 

At  the  time  of  his  death  he  was  Professor  of  Diseases  of  the  Eye  and 
Ear  in  the  Kansas  City  Post-Graduate  Medical  College.  He  had  also 
held  the  chair  of  the  same  subjects  in  the  old  Kansas  City  Medical 
College,  the  University  Medical  College,  and  the  oMedico-Chirurgical 
College.     For  more  than  eight   years  Dr.   Fryer  had  in   charge  the 


Blencowe  E.  Fryer. 

Department  of  French  Literature  in  the  well-known  journal.  Ophthal- 
mology. 

He  died  in  Sault  Ste.  Marie,  U.  S.  A.,  Aug.  12,  1911.— (T.  11.  S.) 

Fuchs'  coloboma.  See  page  2355,  Vol.  IV,  of  this  Encyclopedia;  as 
well  as  Congenital  anomalies. 

Fuchs'  disease  of  the  macula.     See  Myopia. 

Fuchsin.  J\riii.\.  A  commercial  name  for  any  monacid  salt  of  a 
rosanilin,  especially  a  mixture  of  rosanilin  hydrochloride  and  para- 
rosanilin,  hydrochloride.  It  is  used  in  solution  in  varous  liijuids  as  a 
dye  for  microscopical  sections.  Therapeutically,  it  has  been  employed 
in  albuminuria,  but  its  remedial  value  is  uncertan.  On  account  of  the 
claim  that  it  corrects  defective  color-sense  when  a  color-blind  pereon 


5310  FUCHS,  LEONHART 

looks  throii<:li  a  f'uchsin  solution,  Dclbeuf  lias  suggested  its  use  in  such 
cases.     1^  l^'ostcf.) 

Fuchs,  Leonhart.  One  ol"  the  greatest  botanists  and  general  prac- 
titioners of  medicine  of  the  Renaissance  period.  He  was  born  Jan.  17, 
1501,  at  ^lenibdingen,  Bavaria.  In  151JJ  he  entered  the  University  of 
Ingolstadt,  at  which  institution,  after  an  extremely  brilliant  career, 
he  received  the  degree  of  Master  of  Arts  in  1521.  He  then  pursued 
the  study  of  medicine  in  the  same  institution,  and  received  his  pro- 
fessional degree  in  1524.  For  the  two  years  following,  he  practised 
medicine  in  Munich,  the  next  two  he  passed  as  Professor  of  Medicine 
in  Ingolstadt,  and  then  became  physician-iu-ordinary  to  the  ]\Iark- 
grave  George  of  Brandenburg  in  Anspach.  This  position  he  held  for 
five  years.     He  was  ennobled  by  the  Emperor  Charles  V. 

His  literary  activities  began  in  1529.  Among  his  numerous  writ- 
ings, we  can  mention  only:  "Errata  Receutiorum  medicorum  LX 
numero,  Adjectis  eorun  conputationibus"  (Hagenau,  1530).  "Cor- 
narius  Furens"  (Basel,  1533).  "Ilippocratis  Epidemion  Liber 
Sextus  Latinitate  Donatus  et  Luculentissima  Commentatione  Illus- 
tratus"  (Basel,  1537).  " Claudii  GaUni  Aliquot  Opera"  (3  vols., 
Paris,  1549-54) . 

In  1538  he  published  an  ophthalmologic  work,  entitled,  ''Tabula 
Oculorum  Morhos  Comprehcndcns,"  which  seems  to  be  no  longer 
extant.  In  his  "Institutiones  Mcdicce,"  first  published  in  1556,  he 
exhibits  a  chapter  entitled  "Vitiorum  Oculi  Succincta  Explicatio. " 
A  work  in  German,  entitled  " AUe  Krankheitcn  der  Augen  durch  d^n 
Hochgelehrten  Doctor  Leonhart  Luchsen"  (Strassburg,  1539)  is 
declared  by  Hirsehberg  to  be  nothing  but  a  badly  garbled  translation 
of  the  above-mentioned  chapter  from  the  " Institutiaucs/'  issued  by  a 
trio  of  quacks — ' '  Herrn  Jorgen  Vogtherren,  Canonicus  und  Pf arrher- 
ren  zu  Feuchtwangen,  und  Conradi  und  Bartholomei  Vogtherren" — 
who  had,  in  fact,  altered  Fuchs 's  work  to  suit  their  own  purposes. 

Fuchs  himself  was  a  man  of  high  ideals  and  spotless  character. — 
(T.  II.  S.I 

Fugacious  episcleritis.     See  page  4498,  Vol.  VI  of  this  Encyclopedia. 

Fugitive  color.  As  opposed  to  fast  color,  one  that  is  readily  dissipated 
or  fjided  by  exposure  to  light,  heat,  water,  etc. 

FUgung.     (G.)     Ai-ticulation. 

Fiihlen.     (G.)     A  feeling,  sensation. 

Fukala's  operation.  Removal  of  the  lens  for  the  relief  of  excessive 
myopia.. 

Fulgent.     Very  bright. 

Fulgid.     Glittering. 


FULGURATION  5311 

Fulguration.  liii'oL.vii  voltaization.  Alto-frequent  cytolysis. 
Alto-frec^uext  scintillation.  Efflelvation.  Electrocoagula- 
tion. These  terms  have  l)een  very  loosely  applied  to  several  forms  of 
electrical  dischai-ges — natural  and  artificial — aud  their  effects  upon 
living  animal  tissues. 

The  th<:rap(  utic  use  of  liigh-fre(iueuey  and  otlier  electric  currents, 
as  well  as  their  deleterious  effects  on  the  human  ocular  apparatus 
have  already  been  more  or  less  discussed  uiKh-i-  Electrocoagulation; 
Electrodes;  Dazzling-  and  Eclipse  amblyopia;  as  well  as  in  the  sec- 
tions devoted  to  Electricity  in  ophthalmic  surgery  and  Diathermy. 
To  the  foregoing  may  be  added  an  excellent  report  on  fulguration 
by  W.  S.  Bainbridge  {Journ.  of  Advanced  Tlicrap.,  Jan.,  1913)  so 
far  as  it  affects  cancer  and  other  neoplasms. 

According  to  de  Keating-Hart's  method  {Medical  Record,  July  6 
and  20,  1912)  the  monoplar  long  spark  of  high  frequency  and  high 
tension  acts  not  upon  the  neoplasm,  but  upon  the  soil  on  which  the 
neoplasm  has  developed.  Three  groups  of  facts  are  relied  upon  by 
him  to  establish  the  premise  : 

(1)  That  sparking,  even  wlien  used  with  inadequate  surgical  opera- 
tion, giv'es  undenial)le  results,  insufficient,  perhaps.  l)ut  already  very 
definite.  (2)  That  the  tumor  is  in  no  way  modified  in  its  appearance 
or  in  its  vitality,  from  which  one  may  reasonably  conclude  that  it  is 
not  the  tumor  itself,  but  the  condition  of  its  nutrition — that  is  to  saj', 
the  environment  in  wliich  it  develops — that  is  transformed.  (3)  That 
laboratory  experiments  and  clinical  observation  furnish  plausible 
explanations  of  the  foregoing. 

The  production  of  fulguration  sparks  may  be  accomplished  by 
means  of  very  differently  adjusted  apparatus.  Static  electricity  and 
the  city  current  may  be  utilized,  according  to  the  case.  The  following 
list  comprises  the  equipment  to  which  de  Keating-Hart  gives  prefer- 
ence: (1)  Electric  current:  city  current,  dynamos,  or  accumulators, 
etc.,  may  be  used.  (2)  A  table  holding  the  rheostats,  amperemeters, 
etc.  (3)  A  transformer  coil  with  rapid  interrupter,  or  transformer 
in  the  closed  magnetic  current  (alternating  curent).  (4)  A  condenser 
furnished  with  a  spark  gap.  (5)  Oudin's  resonator.  (6)  A  bellows 
furnished,  according  to  the  case,  with  a  foot-pedal  or  with  a  tube  of 
carbonic  acid,  or  an  electric  pump  with  disinfected  air,  the  latter 
being  nsed  by  ns.  (7)  Special  electrodes  of  de  Keating-Hart.  (8) 
An  operating  table  of  wood  or  metal.  The  latter  is  used  at  the  New 
York  Skin  and  Cancer  Hospital.  When  a  wooden  table  is  employed 
it  must  be  grounded  in  order  to  prevent  burning  the  patient. 


5312  FULGURATION 

The  first  step  of  fidguration  is  purely  sui-gic.il.  This  depends 
entirely  upon  the  exigencies  of  the  ease,  and  need  not  be  given  detailed 
consideration  here.  Fulguration  is  essentially  a  method  of  treatment 
for  operable  cancers.  The  more  complete  the  removal  of  diseased 
tissue,  the  more  certain,  according  to  de  Keating-Hart,  is  the  freedom 
from  recurrence.  The  possibility  of  complete  cure  and  absolute  pre- 
vention of  recurrence  is  commensurate  with  the  extent  to  which  eradi- 
cation may  be  carried.  Where  only  partial  removal  of  diseased  tissue 
is  possible  the  method  of  fulguration  is  palliative  rather  than  curative. 
In  these  cases  thermo-radiotherapy  is  advocated. 

The  electrical  technic  is  simple  in  its  description  and  delicate  in  its 
application.  The  general  rule  laid  down  by  de  Keating-IIart  is  as  fol- 
lows :  Spark  for  a  long  time,  using  powerful  sparks  of  high  frequency 
and  high  tension,  applying  them  to  the  area  from  which  every  macro- 
scopic trace  of  cancer  has  been  removed.  It  is,  then,  under  the  cancer, 
and  not  upon  it,  that  the  electrical  discharge  is  applied. 

The  spark  should  be  white,  producing  the  sensation  of  a  violent 
shock,  its  mean  length  to  be  from  ten  to  twelve  centimeters.  An 
important  detail  is  to  utilize  the  spark  at  its  maximum  length.  The 
electrode  should  be  kept  in  constant  motion,  and  should  be  regularly 
passed  over  the  surface  being  treated.  The  reason  for  this  is  twofold : 
(1)  In  order  to  avoid  carbonization  of  the  points  at  which  the  sparks 
strike  the  tissue;  (2)  in  order  to  equalize  the  dosage,  save  at  sus- 
pected points  where  one  must  work  energetically. 

The  dosage  or  the  duration  of  the  application  of  the  spark  upon  the 
given  point  cannot  be  established  in  other  than  an  empirical  manner. 
It  is  not  difficult  to  comprehend  the  reason  for  this,  when  one  realizes 
that  no  two  makes  of  apparatus  are  exactly  alike,  and  that  in  the  same 
apparatus  there  may  be  great  variations  in  the  primary  current,  the 
distance  of  the  spark-gap,  and  the  conductibility  of  the  air  which 
surrounds  it,  all  of  whicli  bear  an  influence,  as  does  likewise  the  insula- 
tion of  the  patient.  Under  such  conditions  the  electrical  properties 
of  the  spark  are  subject  to  enormous  variation.  As  a  general  rule, 
however,  one  may  advise  "ten  minutes  of  fulguration  for  an  area  of 
ten  square  centimeters."  Tliis  is  near  enough  for  ordinary  purposes 
in  the  majority  of  eases  and  with  the  usual  apparatus. 

Another  guide  in  the  matter  of  duration  is  the  change  in  the  color 
of  the  tissues  being  fulgurated.  All  tissues  take  on  a  slightly  darker 
tinge,  not  from  destruction,  but  from  the  deposit  of  small  lilood-elots 
produced  at  the  surface  tlirough  contact  with  the  spark.  This  change 
of  color  varies  Avith  the  tissue  involved.  "While  the  muscles  take  on 
the  tinge  of  smoked  meat  the  bones  become  slightly  yellow.    In  reality 


FULGURATION  5313 

these  appearances  are  apt  to  l)e  deceptive,  depending  upon  the  manner 
in  which  the  sparking  is  c.inicd  out,  and  upon  the  thickness  of  the 
sanguinolent  Huid  througli  wliicli  it  i)asses.  As  a  rule,  bones  should 
not  be  fulgurated  as  long  as  the  muscles,  or  the  vessels  as  long  as  the 
tendons. 

The  two  main  points  to  l)e  emphasized  are:  (1)  Sufficient  removal 
of  the  diseased  tissue;  (2)  powerful  spai'king  of  the  underlying  tissues. 

The  employment  of  the  high-frequency  short  spark  (from  1  to  4 
centimeters),  at  a  relatively  low  tension,  produces  the  effect  of  cel- 
lular stimulation ;  it  provokes  a  rapid  cicatrization  of  wounds,  and 
exerts  a  remarkable  action  upon  torpid  ulcers.  On  the  other  hand, 
the  high  tension  spark,  of  a  minimum  length  of  eight  centimeters, 
applied  for  a  sufficiently  long  period  of  time  in  proportion  to  the 
surface  fulgurated,  retards  cicatrization  and  transforms  a  given  area 
into  a  torpid  wound.  The  wound  fills  up,  but  the  surrounding  healthy 
tissue  contracts.     There  is,  according  to  de  Keating-IIart,  a  natural 


zz3-;) 


Simple  Fulguration  Electrode.      (Victor.) 

autoplasty,  not  a  cicatrization.  He  considered  that  the  same  trophic 
phenomenon  that  prevented  the  reformation  of  healthy  epidermis 
after  fulguration,  retarded  or  suppressed  the  propagation  of  cancer 
i)t  situ.  The  microscopic  cancer  cell,  not  the  macroscopic  growth,  is 
attacked  indirectly  and  destroyed  by  this  method. 

]t  is  claimed  by  de  Keating-IIart  that  all  kinds  of  cancer  have  given 
good  results  under  fulguration.  In  very  advanced  cases,  he  says, 
important  palliative  effects,  such  as  the  suppression  of  pain  and 
hemorrhage,  cicatrization,  increase  of  strength,  prolongation  of  life, 
have  been  noted  in  more  than  70  per  cent,  of  the  tumors  treated  by 
the  method.  Cancer  of  the  breast  has  given  him  39.5  per  cent,  cures. 
Cancers  of  the  buccal  mucosa  have  given  83  per  cent,  of  freedom  from 
recurrence  for  periods  varj^ing  from  714  months  to  2  years.  He 
reports  89  per  cent,  of  successes,  for  a  mean  duration  of  16  months, 
in  inoperable  sarcomas  treated  by  means  of  fulguration. 

Fulguration  electrodes  for  the  convenient,  local  use  of  high-fre- 
quency currents  are  on  the  market,  two  of  these  being  pictured  in  this 

Vol.  VII— 30 


5314  FULGURATION 

toxt.  Ac'cortiiiij,'  to  the  vendors,  tln^  N'ictoi-  Hlectric  Co.,  the  simpler 
device  is  intended  to  destroy  small  growths,  such  as  warts,  moles,  port- 
wine  marks,  vascular  nevi  and  the  smaller  epitheliomata  especially  in 
their  ineii)ieney.  The  electrode  is  made  in  two  parts,  the  outer  or 
sheath  consisting  of  a  glass  tube  with  ends  or  lips  slightly  everted ; 
the  inner  portion  consists  of  a  similar  glass  tube  into  wiiich  a  copper 
wire  has  been  fused.  At  the  upper  end  of  the  inner  portion  a  glass 
ring  is  attached,  through  which  the  index  finger  of  the  right  hand  is 
passed  while  the  thumb  and  middle  finger  holds  the  sheath.  When  the 
inner  portion  is  plunged  at  full  length  into  its  sheath,  a  glass  collar  is 
so  arranged  upon  the  inner  portion  as  to  prevent  its  passage  at  a  point 
one  thirty-second  of  an  inch  from  the  bottom  of  the  outer  sheath. 

For  the  removal  of  a  lesion,  the  outer  sheath  is  placed  over  the 
growth,  while  the  inner  is  drawn  upward  just  beyond  sparking  dis- 
tance, about  two  inches.  The  end  of  the  copper  wire  is  attached  to 
the  high  frequency  current.     When  everything  is  in  readiness,  sud- 


Iniproved  Fulguration  Electrode.      (Victor.) 

deuly  plunge  the  electrode  downward ;  allow  it  to  remain  for  from 
one-quarter  to  one  second,  then  Avith  the  index  finger  withdraw  the 
inner  tube  as  before.  Select  a  new  spot  upon  the  same  lesion  until 
the  entire  surface  of  the  lesion  has  been  covered,  when  it  has  a 
blanched  appearance.  At  least  one  week  should  elapse  before  a  second 
treatment  upon  the  same  lesion  is  deemed  necessary. 

In  the  improved  electrode  the  strength  of  the  convective  spark  can 
be  controlled  with  the  greatest  refinement  from  a  thin  mild  spark  to 
the  heaviest  flaming  discharge  the  energizing  apparatus  is  capable  of 
producing. 

The  controlling  is  accomplisluMl  by  varying  the  distance  of  a  series 
spark  gap  on  the  electrode  handle  by  means  of  a  small  button  which 
the  operator  adjusts  with  his  thumb  or  finger  while  the  electrode  is  in 
operative  position.  The  wider  the  spark  gap  the  milder  the  convective 
spark  and  vice  versa. 

The  conducting  wire  from  the  apparatus  is  connected  to  the  small 
eye,  which  will  be  noted  on  the  under  side  of  the  metal  collar  in  the 
illustration. 


FULLER'S  EARTH  5315 

Two  metallic  points  are  furiiislictl  witli  each  electrode,  one  bent  at 
an  angle  of  45  degrees  and  the  other  straight. 

Fuller's  earth.  An  aniorplious,  greenish-white,  yellow,  or  brown  earth 
found  in  layers  intercalated  between  the  oolitic  and  cretaceous  strata. 
It  is  only  partially  niiscible  with  water,  and  easily  absorbs  fatty  sub- 
stances; hence  its  use  in  the  cloth  industries.  It  is  employed  as  an 
absorbent  application  to  irritated  surfaces.     (Foster.) 

Fuller's  herb.  Puller's  weed.  Soap-wort.  Saponaria  officinalis. 
According  to  Pliny  and  Dioscorides  fuller's  herb,  or  soap-wort,  was 
an  excellent  agent  for  the  clarification  of  the  sight.  It  formed  an 
ingredient  of  numerous  ophthalmic  ointments. —  (T.  II.  S.) 

Fulminating".  Of  diseases,  developing  suddenly  and  running  on  very 
rapidly  to  a  fatal  issue,  or  to  the  destruction  of  an  organ  or  organs. 

Fulmine.     (It.)     A  discharge  of  electricity  ;  the  electric  shock  or  spark. 

Fulvescent.     Ai)proacliing  a  fulvous  or  yelloAvish  color. 

Fulvous.     Having  a  tawny  or  reddish-yellow  color. 

Fumee.     (F.)     Smoke. 

Fumitory.  Fumaria  officinalis.  One  of  numerous  plant  remedies  em- 
ployed by  ancient  Greco-Roman  ophthalmologists  (and  mentioned  by 
Archigenes,  Dioscorides  and  Pliny)  as  a  preventive  of  recurrences 
after  epilation.  It  was  also  thought  to  be  a  sharpener  of  the  sight. — 
(T.  II.  S.) 

Functionspriifungen  des  Auges.  (G.)  Subjective  examination  of  the 
eye. 

Fundamental  ray.  The  usual  oi)tical  systems,  when  the  aperture  is 
somewhat  large,  unite  the  refracted  pencil  not  into  a  single  point  but 
in  a  caustic  surface,  the  apex  of  which  is  the  focus  for  paraxial  rays. 
The  ray  which  passes  through  the  apex  is  termed  by  Gleichen  the 
fundamental  ray. 

Fundus  oculi.  The  appearance  of  the  bottom  or  background  of  the 
eye  (commonly  called  "the  fundus")  as  discovered  by  the  ophthal- 
moscope in  health  and  its  variations  in  disease,  will  be  fully  described 
under  Medical  ophthalmoscopy.  The  minute  anatomy  of  the  normal 
tissues  seen  in  the  ocular  fundus  is  described  under  Histology  of  the 
eye.  Here  it  may  be  (briefly)  stated  regarding  the  ordinary  fundus 
view  that  the  optic  nerve  is  the  oidy  one  that  can  be  examined  during 
the  life  of  the  patient  without  dissection.  By  means  of  the  ophthal- 
moscope the  interior  of  the  eye  can  be  studied.  The  parts  of  chief 
interest  in  the  fundus  are  the  ojitic  disc,  the  blood-vessels,  the  macula 
lutea,  and  the  choroid. 

The  optic,  disc  is  situated  about  'A  millinu^tres  to  the  nasal  side  of 
the  posterior  pole  of  the  eye,  and  is  the  point  of  entry  of  the  optic 


5316  FUNDUS  OCULI 

nerve  into  tlic  retina.  It  is  often  called  the  head  of  the  optic  nerve. 
It  measures  from  1.4  to  1.7  millimetres  in  diameter  and  is  generally 
cireiilar  or  ellipsoidal  in  sliape.  In  the  astigmatic  eye  the  optic  disc 
oft(!n  a})j)ears  oval  or  ellipsoidal  when  in  reality  it  is  round.  Owing 
to  the  magnitication  when  the  ophthalmoscope  is  used,  the  papilla 
appears  to  be  from  9  to  18  millimetres  in  diameter.  Near  its  centre 
is  a  depression,  the  physiologic  excavation,  which  marks  the  divergence 
of  nerve-fibres.  The  excavation  is  funnel-shaped,  the  base  befng 
anterior.  A  trace  of  the  hyaloid  artery  of  fetal  life  is  occasionally 
seen  here  as  a  thread  of  coiniective  tissue  running  from  the  papilla 
into  the  vitreous.  Surrounding  the  papilla  are  two  rings:  an  inner, 
due  to  exposure  of  the  sclera,  is  whitish,  and  is  called  the  scleral  ring; 
and  an  outer  one,  due  to  the  showing  of  choroidal  pigment,  is  named 
the  choroidal  ring.  At  the  bottom  of  the  excavation  a  few  dark  spots 
are  seen,  from  the  gray  stippling  of  the  lamina  cribrosa.  In  color  the 
papilla  is  grayish-pink  or  reddish,  and  stands  out  in  marked  contrast 
to  the  reddish-yellow  of  the  remaining  parts  of  the  fundus.  The  color 
of  the  papilla  varies  with  the  age  and  complexion  of  the  individual, 
the  color  of  the  surrounding  parts  of  the  fundus,  and  with  the  illu- 
mination used.  A  bluish  discoloration  of  the  disc  has  been  observed 
as  a  congenital  abnormality.  A  more  common  anomaly  is  the  presence 
of  opaque  nerve-fibres,  which  condition  is  due  to  the  fact  that  the 
medullary  covering  of  the  axis-cylinders  exists  in  the  fibre-layer  of 
the  retina.  In  such  a  ease  the  fundus  shows  a  patch  of  a  brilliant 
white  color  extending  out  from  the  disc.  Generally  the  white  area  is 
in  contact  with  the  disc.  It  rarely  occurs  that  the  opaque  fibres  are 
found  at  a  great  distance  from  the  nerve-head  or  that  they  occupy  a 
large  area  of  the  fundus.  The  physiologic  cup  or  depression  may 
occupy  a  large  part  of  the  nerve-head,  but  never  extends  to  the  scleral 
ring.  Under  normal  conditions  many  variations  are  seen  in  the  size 
and  depth  of  the  cup  and  in  the  arrangement  of  the  blood-vessels. 

The  hlood-vessels  are  the  central  artery  and  vein.  They  run  in  the 
nerve-fibre  layer  of  the  retina,  and,  althongh  often  presenting  varia- 
tions, are  of  sufficiently  regular  distribution  to  justify  the  naming  of 
the  following  branches :  Superior  and  inferior  nasal,  superior  and 
inferior  temporal,  and  macular.  The  retinal  arteries  are  terminal 
arteries,  each  arteriole  supplying  its  own  territory  without  anasto- 
mosis. Hence,  if  a  branch  is  obstructed  by  an  embolus,  its  territory 
becomes  ischemic  and  vision  is  lost.  (While  this  statement  is  true  for 
almost  all  cases,  in  a  few  instances  of  embolism  of  the  central  artery 
anastomoses  have  occurred.)  The  middle  of  the  fovea  centralis  has 
no  blood-vessels. 


FUNDUS  OCUILI  5J17 

Wliile  it  is  often  stated  that  the  retinal  vessels  can  be  seen  on  oph- 
thalmoscopic examination,  as  a  fact  it  is  the  column  of  blood,  and  not 
the  vessel-wall,  which  is  visible.  In  the  larger  retinal  vessels  the 
blood-column  in  the  arteries  is  brigiiter  than  that  in  the  veins.  In 
the  smaller  branches  this  difference  is  less  marked.  The  brighter  color 
of  the  arteries  is  due  to  the  presence  of  a  central  streak  of  light,  whicli 
is  less  marked  in  the  veins.  The  cause  of  this  light-streak  is  not 
definitely  known.  The  retinal  arteries  never  pulsate  under  normal 
conditions.  (To  this  statement,  which  is  true  for  the  vast  majority  of 
individuals,  excei)tions  must  be  made,  since  Jaeger,  von  Graefe,  Bon- 
ders, and  other  competent  observers,  have  seen  spontaneous  arterial 
pulsation  in  normal  eyes.)  The  reason  for  the  non-pulsatiou  in  the 
retinal  arteries  is  this:  the  normal  intra-ocular  tension  is  sufficient  to 
overcome  tin;  diastole  of  the  heart.  Arterial  pulsation  may  be  pro- 
duced easily  in  the  normal  eye  by  pressure  on  the  globe.  Whenever 
a  disproportion  exists  between  intra-ocular  and  intra-arterial  pressure, 
arterial  pulsation  occurs.  Venous  pulsation  occurs  spontaneously  in 
from  GO  to  75  per  cent,  of  normal  eyes. 

Besides  the  blood-vessels  enumerated  above,  it  is  necessary  to  men- 
tion the  cilio-retinal  vessels.  These  are  commonly  small,  solitary  ves- 
sels which  arise  from  the  circle  of  Haller,  and  emerge  at  the  temporal 
border  of  the  disc.  Such  a  vessel  may  come  from  the  central  vessel 
in  the  substance  of  the  nerve,  and  may  be  of  larger  size.  Generally 
it  supplies  blood  to  a  small  area  between  the  disc  and  macula.  Cilio- 
retinal  vessels  are  present  in  from  10  to  16  per  cent,  of  normal  eyes. 
Their  presence  has  been  known  to  permit  a  portion  of  the  retina  to 
retain  its  functions  in  cases  of  embolism  of  the  central  retinal  artery. 
]\Iost  cilio-retinal  vessels  are  arteries. 

Having  described  the  usual  arrangement  of  the  blood-vessels,  it  is 
necessary  to  mention  some  of  the  unusual  appearances  found  in  normal 
eyes.  Twisting  of  a  vein  and  artery  often  occurs;  but  it  rarely  hap- 
pens that  an  artery  crosses  an  artery,  or  a  vein  crosses  a  vein. 
Anastomoses  are  very  rarely  anomalies,  and  occur  on  the  optic  disc. 
Instances  of  bifurcating  arteries  and  veins  are  shown  in  several  oph- 
thalmoscopic atlases.  Although  the  retinal  vessels  do  not  pursue  a 
straight  course,  their  tortuosity  is  su))ject  to  much  variation.  A  rare 
anonmly  is  the  presence  of  a  projecting  loop.  In  Lawford's  case  a 
vein  formed  a  loop  each  end  of  which  disappeared  in  the  disc. 

The  macula  liit(a  (yellow  spot)  is  situated  a])0ut  3  millimetres  to 
the  outer  side  of  the  optic-nerve  head,  and  slightly  below  the  horizontal 
meridian.  It  is  a  spot  darker  than  the  surrounding  retina  and 
apparently  devoid  of  blood-vessels.     It  is  the  area  of  greatest  visual 


5318  FUNDUS  OCULI 

acuity.  The  centre  of  tlie  inacula  presents  tlie  foveal  reflex,  while  the 
periphery  shows  a  whitish,  glistening  ring,  or  halo,  known  as  the 
macular  reflex.  It  is  strange  that  no  two  ophthalmic  writers  agree 
as  to  the  color  and  appearance  of  a  part  of  the  retina  so  accessihle  to 
examination  as  the  macula,  and  that  the  errors  of  forty  years  ago 
should  appear  in  modern  text-books.  ]\Iany  writers  have  portrayed 
the  macula  as  oval,  with  its  long  diameter  placed  transversely. 
Schmidt-Rimpler  described  it  as  anatomically  circular,  but  ophthal- 
moscopically  oval.  Panas  and  Mauthner  saw  it  as  a  brilliantly  sil- 
vered ring.  Power  spoke  of  it  as  "a  soft,  whitish  line";  and  Landolt 
described  it  as  "a  bright,  oval  line,  sometimes  glistening,  with  a  red 
floor  and  intensely  red,  almost  black,  centre,  the  dark  point  in  the 
centre  being  hardly  ever  absent."  These  differences  in  appearance 
are  doubtless  due  to  several  causes:  to  the  diff'erence  in  methods  of 
examination ;  to  differences  in  the  age,  complexion,  and  refraction  of 
individuals;  and  to  variations  in  the  distribution  of  pigment.  John- 
son states  that,  when  observed  in  a  certain  way  the  macular  ring  in 
its  whole  circumference  can  be  seen  in  every  person  under  thirty-five 
years  of  age,  and  frequently  in  older  subjects.  If  the  illumination  is 
loW'Cred,  reflection  from  the  fundus  decreases  more  rapidly  than  from 
the  macula,  until  a  moment  arrives  when  the  ring  appears.  He 
asserts  that  the  macular  ring  is  invariably  circular,  and  probably 
corresponds  to  the  extreme  limit  of  the  macular  region.  When 
observed  as  an  oval  the  appearance  is  due  to  distortion  produced  by 
the  lens  and  mirror.  When  examined  carefully  by  the  direct  method 
of  ophthalmoscopy  the  macula  is  always  round.  In  elderly  persons 
it  can  be  recognized,  although  with  more  difficulty  than  in  the  young, 
by  its  darker  color  and  by  the  absence  of  vessels. 

There  are  several  forms  of  macular  rings.  Johnson  states  that  the 
most  common  is  a  bright,  scintillating  reflex  resembling  shot-silk,  very 
marked  in  dark  eyes,  scarcely  visible  in  fair  ones,  and  best  seen  watli 
feeble  illumination.  This  ring  is  supposed  to  be  due  partly  to  reflec- 
tion from  Midler's  fibres,  where  they  expand  into  the  internal  limiting 
membrane,  partly  to  the  fibrous  sheaths  of  the  vessels  whic-h  lift  up 
the  retina  overlying  them.  A  second  form  of  ring  is  a  radiating  circle 
of  grayish-white  lustre,  the  radii  being  directed  toward  the  fovea  and 
resembling  nerve-fibres.  The  appearance  is  supposed  to  be  due  to  a 
partial  translucency  of  the  nerve-fibres.  The  third  form  of  ring  can 
])e  seen  with  the  brightest  illumination  as  a  whitish  or  golden  ring  of 
metallic  lustre,  oval  in  shape  by  indirect  oplithalmoscopy,  but  circular 
when  seen  by  the  direct  method.  It  is  narrower  than  the  other  two 
rings. 


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Hifiht   Eye — Upright  liiia^i'. 

Xoniial  fundus  of  a  youug  subject. 

There  is  a  moderate,  or  averajje,  amount  of  pigment.  The  chorio-capillaris  is 
well-developed.  The  choroidal  arteries,  with  interspaces  of  stromal  pigment,  siiow 
faintly  near  the  jierijihery.  The  pigment  ring  of  the  iiajiilla  is  complete.  The  scleral 
ring  is  complete,  but  very  narrow.  The  zone  of  nerve  libres  of  the  jiapilla  extends 
almost  to  the  center.  The  lamina  cribrosa  is  not  visible.  The  thick  layer  of  optic 
nerve  fibres  over  and  near  the  disc  causes  a  light  halo,  characterized  by  radiating 
striations.  The  details  of  the  macular  region  are  somewhat  idealized,  though  no 
single  one  is  more  strongly  accentuated  than  it  is  often  found  in  nature.  The  idealiza- 
tion is  only  as  regards  tnttcmblc,  and  is  for  greater  clearness.  From  without  inward 
there  is  first,  the  ellipsoidal  macular  halo;  next  the  somewhat  ilensely  pigmented  area 
of  the  fovea,  with  a  few  small  retinal  vessels  visible  in  it.  Next,  the  brink  of  the 
foveola,  ai)pearing  as  an  indefinite,  yellowish  circle.  Next,  the  glowing  red<lish  area 
of  the  foveola;  and,  lastly,  at  the  center,  the  circular  reHex  from  the  bottom  of  the 
foveola,  or  fundus  reflex  of  the  foveola. —  (From  Original  Drawing  by  Dr.  ('lias.  If. 
Beard.) 


FUNDUS-REFLEX  TEST  5319 

The  foveal  reflex  is  found  in  the  eeiitre  of  the  macula  as  a  very 
small  ring,  or  as  a  circular  or  horseshoe-shaped  spot  of  ligiit,  or  as  a 
"comet-flare."     It  is  due  to  reflection  of  the  edge  of  the  fovea, 

TJie  choroid.  AVhile  each  ocular  tunic  contributes  sometliing  to  the 
ophthalmoscopic  picture,  the  chief  part  must  be  credited  to  the  clioroid. 
Light  reflected  from  the  mirror  of  the  ophthalmoscope  passes  through 
the  transi)arent  part  of  the  retina  to  the  pigment  epithelium,  and  is 
partly  absorbed,  partly  reflected.  Although  the  pigment  layer  belongs 
embryologically  to  the  retina,  it  generally  adheres  to  the  retinal  sur- 
face of  the  choroid,  and  is  accredited  ophthalmoscopically  to  tiie  latter 
tunic.  The  brightness  of  the  fundus  picture  depends  on  the  amount 
of  pigment.  The  greater  the  pigment,  the  greater  the  absorption  of 
light  and  the  darker  the  fuiulus  picture.  In  the  negro  and  the  native 
of  India  the  fundus  is  of  a  brownish,  brown-red,  or  slate  color,  while 
in  the  Anglo-Saxon,  and  particularly  in  blondes,  it  is  of  a  bright-red 
color.  If  the  pigment  layer  is  very  thin,  the  choroidal  vessels  are  cor- 
respondingly exposed  and  are  seen  as  a  network  of  large,  Hat  vessels, 
without  a  light-streak,  between  which  are  spaces  of  light  or  dark 
color.  They  are  seen  best  in  albinos.  It  is  generally  impossible  to 
differentiate  between  the  choroidal  arteries  and  veins,  although  at  the 
equatorial  region  the  latter  converge  to  form  the  venae  vorticosai.  In 
brunettes  the  vessels  appear  as  "light  streams  separated  by  dark 
islands,"  because  the  spaces  are  more  deeply  colored  than  the  vessels. 
The  sclera,  which  may  be  spoken  of  as  the  panel  on  which  the  fundus 
picture  is  painted,  is  commonly  invisible,  being  covered  by  the  nearly 
opaque  choroid.  Yet  it  is  probable  that  in  all  eyes  some  light  passes 
through  the  choroid,  and  thus  the  sclera  has  some  influence  on  the 
ophthalmoscopic  picture,  serving  to  make  it  lighter.  In  albinos  the 
sclera  appears  as  a  white  surface  between  the  choroidal  vessels.  It 
is  best  seen  where  the  choroid  is  absent,  as  in  coloboma,  or  patho- 
logically as  a  result  of  destruction  of  tlie  retina  and  choroid. — 
(J.  M.  H.) 

Fundus -reflex  test.     Skiascopy. 

Fungismus.     Poisoning  by  fungi. 

Fungus  haematodes  oculi.     An  ancient  name  for  the  third  or  advanced 
stage  of  glioma  retime. 

Fungus  medullaris   oculi.     Fungus  retix.t:.     (L.)     An  obsolete  syn- 
onym for  glioiiia  retina?. 

Fungus  trichcphyton.     A  vegetable  fungus  sometimes  found  on  the 
edges  and  in  the  sebaceous  follicles  of  the  eyelid. 

Funiculus  sclerae.     In  the  region  of  the  fovea  centralis  is  found  a  strand 
of  nerve  iibres  to  which  Hannover  gave  this  name.    He  believed  it  to 


5320  FUNKENSEHEN 

be  a  scar  showing  wliere  the  choroidal  lissurc  of  fetal  life  had  closed 
up.  However,  JSchwalbe  concluded  that  it  is  merely  a  strand  of  cou- 
uective  tissue  that  accompanies  the  posterior  ciliary  arteries. 

Funkensehen.     (G.)     Colored  or  scintillating  vision.     Phospheues. 

Funzione  ottica.     (It.)     Optical  function. 

Furca.     (L.j     A  fork. 

Furca  orbitalis.  The'  orbital  fork.  This  is  one  of  the  earliest  signs 
of  the  orbit  seen  in  the  embryo,  and  is  simply  a  trace  of  bifurcated 
bony  tissue. 

Furchenkeratitis.     (G.)     Mycotic  or  dendritic  keratitis. 

Furfurol.  One  of  the  poisonous  constituents  of  impure  brandy  that 
adds  to  its  evil  eti'ects  on  the  ocular  tissues. 

Furnace-blindness.  A  name  given  to  that  form  of  dazzling  (q.  v.) 
observed  in  Mast  and  electric  furnace  workers. 

Furnari,  Salvatore.  Born  in  Sicily,  he  received  his  medical  degree  at 
Palermo,  and,  in  1834,  was  licensed  to  practise  in  France.  In  1841  he 
was  sent  by  the  French  Government  to  Algiers  on  some  political  mis- 
sion, during  which  he  made  many  ophthalmic  observations  of  the 
native  tribes,  including  the  absence  of  myopia  among  the  Kabyles. 
In  1848  he  returned  to  Palermo  in  order  to  accept  the  professorship  of 
ophthalmology — a  position  which  he  held  till  his  death,  in  1866.  His 
only  important  ophthalmologic  writing  is  '"Essai  sur  les  Causes,  la 
Nature  et  le  Traitement  des  Oplitlialmies  en  Afrique"  (Paris,  1841), 
—  (T.  H.  S.) 

Furniture,  School.     See  Conservation  of  vision. 

Furrow  keratitis.  One  of  the  many  synonyms  of  dendritic  keratitis. 
See  Keratitis,  Mycotic. 

Forster's  method.  Forster's  operation.  A  procedure  for  the  ripen- 
ing of  immature  cataract.  This  operator  {Bericht  der  Oph.  Gesell- 
sclmft,  p.  138,  1881)  believed  that  tlie  sudden  emptying  of  the  interior 
chamber  and  the  subsequent  rapid  change  in  the  shape  of  the  lens 
would,  by  a  kind  of  rubbing  together  of  their  already  partially  dis- 
organized fibers,  bring  about  a  further  opacification  of  the  tissues. 
He,  however,  did  not  rely  upon  this  agent  alone  but,  in  Ms  artificial 
ripening  operation,  after  an  iridectomy,  firmly  stroked  the  cornea 
with  a  strabismus  hook  for  2  or  3  minutes.  There  can  be  no  doubt 
but  that  this  massage  of  the  lens  through  the  cornea  is  effective  in 
many  cases.  Forster  and  others  have  reported  many  instances  where 
six  or  eiglit  weeks  after  corneal  massage  the  immature  cataract  was 
found  to  l)e  ({uite  ready  for  extraction'. 
Furuncle.  FuritncitI/OSis  in  gkneraTj.  Although  the  oiihtlialmie  rela- 
tions of  extraocular  furuncle  (boil  or  carbuncle)  to  the  eye  struc- 


FURUNCLE  OF  THE  EYELIDS  5321 

tures  are  by  no  moans  intimate  yet  occasional  examples  occnr  in 
which  tlie  ophthalmologist  may  be  called  upon  to  treat  the  general 
disease,  which,  by  Ihe  way,  is  generally  a  stapiiylococcus  infection. 
Palpebral  furuncle  (see  Eyelids,  Furuncle  of  the;  has  already  been 
discussed. 

Peretz  {Ecvue  Generate  d'Ophtal.,  July,  1912)  relates  the  history 
of  a  woman,  sixty-three  years  of  age,  afflicted  with  diabetes  for  some 
time,  who,  while  suffering  from  a  boil  on  her  neck,  developed  a 
panophthalmitis.  Because  of  other  complications  the  disease  was 
handled  symptoraatically  for  three  months.  When  the  author  saw 
the  case  there  was  exophthahnus,  ectropion  and  hypertrophy  of  the 
lower  lids,  great  sensitiveness  and  increase  of  tension  to  -\-  3.  The 
neck  condition  healed.  Pain  becoming  great,  exenteration  of  the  globe 
was  performed.  Upon  incision  into  the  eye  pus  similar  to  that  from 
the  furuncle  welled  out.  This  was  a  case  of  metastasis  through  the 
blood,  and  staphylococci  were  found  as  in  the  primary'  infection. 

The  treatment  of  furuneulosis,  both  local  and  general,  cannot  be 
fully  considered  here  except  to  say  that  furuneulosis  vaccine  (bae- 
terins)  has  been  found  of  signal  value  in  the  disease.  Each  c.  c.  of 
the  Parke-Davis  i)rodu('t  is  said  to  contain  killetl  cultures  of  staphy- 
lococcus aureus  obtained  from  the  furuncular  lesions  (boils  or  other 
circumscribed  abscesses)  of  a  considerable  number  of  cases.  This 
vaccine  is  indicated  in  the  treatment  of  infections  from  the  staphylo- 
coccus pyogenes  aureus,  and  is  of  specific  etJicieney  in  the  treatment  of 
boils,  carbuncles,  impetigo  contagiosa,  pustular  acne,  and  sycosis 
staphylogenes.  The  initial  dose  should  not  exceed  100  to  150  mil- 
lions ;  the  second  dose,  within  four  days,  is  200  to  250  millions ;  should 
a  third  dose  be  necessary,  300  to  400  millions  may  be  administered 
four  days  after  the  second  dose.  Subsequent  dosage  must  be  gov- 
erned, as  regards  both  intervals  and  amounts,  by  the  clinical  indica- 
tions. Furuneulosis  vaccine  is  supplied  in  rubber-stoppered  bulbs 
and  in  graduated  syringes  of  400  millions,  the  bulbs  in  packages  of 
four,  and  the  syringes  in  packages  of  one  and  four ;  also  in  bulk  pack- 
ages of  5  cc.  and  20  cc. 

Furuncle  of  the  eyelids.     See  Eyelids,  Furuncle  of  the. 

Furunculin  (zyma).  This  is  a  permanent,  active,  ferment  in  the  form 
of  a  white  powder.  It  has  proved  effective  as  a  disinfectant  in  internal 
and  external  diseases,  especially  in  such  affections  of  the  skin  as  acne, 
psoriaris,  furuneulosis,  pruritis  of  the  vulva,  etc.  Internally,  it 
removes  dyspeptic  disturbances,  increases  the  appetite  and  regulates 
the  movement  of  the  bowels,  with  subsequent  improvement  of  the 
general  condition.    A.  Dutoit  (Archiv  f.  Augenheilk.,  p.  154,  Vol.  74) 


5322  FURUNCULUS  ORIENTALIS 

I'oi'folioratcs  this  hy  his  cxpcriciicc  with  the  intci'iial  use  of  furun- 
euliii  (/yiua)  in  ('('/.cinatoiis  vyr.  jin'cctioiis.  lie  I'cports  that,  exter- 
nally in  the  i'onii  of  a  paste  or  powdei',  it  is  well  borne  by  the  eon- 
junctiva  and  cornea.  It  checks  the  seci-ction  of  tlie  conjunctiva  and 
weakens  the  virulence  of  the  patliogenic  niicro()rganisnis  in  it.  It 
promotes  the  healing  of  defects  of  substance  of  tiie  lids  (ulcerous 
blepharitis),  conjunctiva  and  cornea  ( kerato-conjunctivitis,  febrile 
herpes  of  the  cornea).  It  favors  tlie  formation  of  new  corneal  tissue 
and  the  clearing  of  corneal  opacities  from  various  causes  (paniuis, 
keratitis  scleroticans).  In  episcleritis  anterior,  scleritis  and  keratitis 
scleroticans,  the  internal  administration  of  furunculin  (zyma;  alone, 
or  in  coml)ination  with  local  a[)plications,  is  of  invaluable  service  in 
the  rapitl  alleviation  of  irritation,  especially  from  episeleritic  attacks. 

Furunculus  orientalis.     See  Aleppo  boil. 

Fuscescent.     Approaching  to,  or  tingctl  Avitli,  dark  brown. 

Fuscin.  Retinal  melanin.  A  pigment  found  as  nunute  granules 
indjedded  in  the  cell-substance  and  processes  of  the  retinal  epi- 
thelium. 

Fuscous.     Of  a  dark-brown  color. 

Fused  cylinders.     See  Pencils. 

Fusee.     (  F. )      Fistulous  tract ;  fistula. 

Fusiform  cataract.  Coralliform  cataract.  A  synonym  of  spindle  or 
axial  cataract.  It  is  generally  congenital,  or  show's  itself  early  in  life, 
is  often  hereditary  and  resembles  the  lamellar  variety.  AVhcn  of 
the  transmitted  type  it  frequently  affects  successive  siblings;  more 
often  the  first  born.  Nettleship  gives  one  extraordinary  pedigree  of 
five  generations  containing  more  than  ninety  individuals,  thirty  of 
whom  are  known  to  have  had  cataract.  From  the  history  the  cataract 
must  have  been  congenital  in  every  case  and  proliably  due  to  intra- 
uterine changes. 

Fusion.  (G.)  A  blending  of  objects,  inuiges  or  sensations.  In  oph- 
thalmology the  term  commonly,  tliough  not  always,  I'efers  to  binocu- 
lar vision. 

Fusion  center.  The  eeiiti-al  neurons  presiding  over  the  fusion  sense  or 
faculty. 

Fusion  faculty.  Fusion  sense.  The  ability  to  blend  in  the  l)rain  the 
two  impressions  received  from  the  eyes.  The  practical  a])plication 
of  this  function  to  S(iuint  wull  be  considered  uiuh'r  Stereoscope.  See. 
also,  Muscles,  Ocular,  and  Fusion  field. 

As  AVorth  proj)erly  says,  the  vision  of  each  eye  separately,  the 
preponderance  of  the  macular  region,  and  the  conjugation  of  the  two 
eyes  in  vortical  movements,  the  human  infant  has  fairly  well  devel- 


FUSION  FIELD 


5323 


oped  at  birtli.  The  coiijiifiatioii  of  tlic  eyes  for  horizontal  movements 
(intended  to  subserve  tlie  function  of  binocular  vision)  is  perfected 
within  the  first  few  months  of  life.  Between  five  and  six  months  one 
finds  the  first  certain  evidence  of  a  "desire  for  binocular  vision," 
though  prol)ably  a  certain  degree  of  binocular  vision  is  present  at  a 
much  earlier  period.  At  first,  if  any  obstacle  be  interposed,  it  is  a 
question  whether  an  effort  shall  be  made  to  overcome  it,  or  whether 
the  newly  acquired  art  shall  be  abandoned  and  the  vision  of  one  eye 
temporarily  suppressed.  Towards  the  end  of  the  first  year  the  eyes 
will  make  a  considerable  effort  in  the  interests  of  binocular  vision. 
If  the  obstacle  prove  insuperable  the  child  suffers  from  diplopia,  being 
no  longer  a))le  to  suppress  the  vision  of  one  eye. 

The  results  of  fusion  training  in  the  case  of  squinters  would  seem 
to  show  that  tlie  fusion  faculty  normally  reaches  its  full  development 
before  the  end  of  the  sixth  year. 
Fusion  field.     According  to  Savage  this  is  related  to  the  field  of  rota- 
tion but  can  be  determined  only  by  the  use  of  prisms.     He  does  not 


Rl&HT  UEFT 

Fields  of  Binocular  Fusion. 


believe  that  it  is  important  to  measure  the  extent  of  the  field  except 
in  the  four  cardinal  directions,  and  pictures  approximately  the  shape 
and  size  of  the  fusion  field — as  shown  in  the  accompanj'ing  cuts. 
AVhen  an  image  is  displaced  by  a  prism  to  any  point  within  the  field, 
while  the  image  in  the  other  eye  is  on  the  macula,  an  effort  at  fusion 
will  be  made,  and  if  the  muscle  that  must  respond  is  sufficiently 
strong,  fusion  will  at  once  take  place,  caused  by  such  rotation  as  will 
bring  the  macula  under  the  displaced  image.  When  the  image  is 
thrown,  by  a  stronger  prism,  entirely  outside  of  the  field  of  fusion, 
the  guiding  sensation,  which  seems  to  reside  in  this  area  only,  will  not 
call  on  any  muscle  to  move  the  eye  for  the  purpose  of  fusion.     The 


5324  FUSION  FREQUENCY 

nasal  limit  of  this  retinal  area,  as  measured  by  a  prism  in  front  of  the 
eye,  is  S'';  tlie  temporal  limit,  25'^;  the  upper  limit,  3  ■" ;  and  the  lower 
limit,  3°.  Tile  line  drawn  through  tiiese  four  points  marks  the  entire 
boundary  of  the  Held.  Tliis  may  be  considered  the  normal  size  of  the 
fusion  area.  In  some  eases  it  may  ai)i)ear  to  be  smaller,  while  in  still 
other  cases  it  may  be  larger.     {Ophthalmic  Myoloyy,  p.  83.) 

Fusion  frequency.  When  a  revolving-  disk  carrying  alternating  sec- 
tions of  black  anil  white  is  looked  at,  the  sectors,  seen  separately  when 
the  disk  revolves  slowly,  cause  a  siiimmering  as  the  rate  of  revolution 
is  increased,  which  gives  place  to  a  uniform  appearance  when  the  revo- 
lutions become  sufficiently  rapid.  The  rate  of  revolution  required  to 
produce  this  uniform  appearance  gives  the  fusion  frequency.  Loh- 
niann  (Graefe's  Arch.  f.  Ophtli.,  Ixviii,  p.  3,  1908)  finds  this  is  greater 
for  images  falling  on  the  periphery  of  the  retina  than  near  its  center, 
about  three-quarters  greater  for  a  part  of  the  retina  removed  45 
degrees  from  the  fixation  point.  In  congenital  amblyopia  with  squint, 
however,  the  increase  from  the  center  towards  the  periphery  of  the 
retina  was  very  much  less.  Hessberg  (Graefe's  Arch.  f.  Ophth.,  Ixix, 
let.  2,  1908)  studied  the  fusion  frequency  in  a  series  of  11  cases  exhib- 
iting pathological  conditions  of  the  fundus.  Comparison  of  the  dis- 
eased with  the  better  eye  showed,  in  abnost  every  case,  a  slightly 
higher  record  for  the  former,  and  this  was  the  case  whether  the  disk 
was  divided  into  two  parts,  one-half  white  and  one-half  black,  or  into 
sixty-four  alternating  sectors.  Hessberg  concludes,  however,  that  for 
clinical  purposes  this  method  of  investigation  is  yet  of  slight  impor- 
tance.    {Oph.  Y ear-Book,  p.  230,  1909.) 

Fusion  pictures.  These  are  practically  the  pictures,  diagrams,  etc., 
used  in  the  stereoscope  and  especially  in  specially  devised  instru- 
ments for  the  exercise  of  binocular  vision  and  the  training  of  the 
fusion  sense  or  faculty.    They  will  be  described  under  Stereoscope. 

Fusion,  Potential.  The  fusion  of  two  images  perceived  simultaneously 
by  both  eyes. 

Fusion  povvrer.  The  ability  to  obtain  and  maintain  binocular  vision 
and  the  fusion  of  images.  Maddox  {OpJithal.  liccord,  April,  1907) 
has  perfected  an  instrument  which  is  designed  for  the  measurement 
and  enlargement  of  the  fusion  power,.  It  is  intended  to  meet  his 
ideas  of  a  rotating  prism  suggested  by  him  in  his  book  on  jn-isms  in 
1889.  It  consists  of  a  spectacle  frame  in  which  two  6°  prisms  are 
so  mounted  that  they  are  simultaneously  rotated  in  ojiposite  direc- 
tions. It  is  made  available  for  intei'i)U])illai'y  distances  of  from  50 
to  7f)  mm.  One  prism  is  ]>ermanently  jilaced  in  the  toothed  disc 
su])poi't,  while  tlie  other  may  l)e  slipped  out  and  reversed,  making 


FUSIONSBREITE  5325 

the  iiisl  ruiiiciit  iLsul'iil  for  both  horizontal  and  vertical  vergence.    See 

Prism  verger. 
Fusionsbreite.     (d.)     Anijilitndc  of  fusion. 
Fusion  sense.     Sec  Fusion  faculty. 
Fusion  tubes.     A  miniature  stereoscope  used  in  eases  of  concomitant 

conver<ient  sti'abismns  to  test  the  ability  of  the  oyos  to  ])prceive  two 

imanfos  simultaneously  and  to  fuse  them.    See  Amblyoscope. 
Fuzzy  image.     A  picture  not  in  focus. 


G.     Ahhreviation  of  gram. 

Gaal,  Gustav.  A  "well-known  Iliingaiian  ])hy.sieian,  who  devoted  con- 
siderable attention  to  the  eye  and  ear.  Born  at  Eisenstadt,  Hungary, 
in  1818,  or  1819,  he  received  his  medical  degree  and  practised  for  a 
time  in  that  city.  In  1848,  because  of  political  troubles,  he  fled  from 
Vienna,  where  he  happened  to  be  at  the  time,  to  Hungary.  After- 
wards he  lived  in  Turkey,  where  he  turned  ^Mohammedan  and  became 
a  Turkish  military  surgeon  under  the  name  of  Yeli-Bey.  For  a  time 
he  resided  at  Sarajevo,  Bosnia.    He  died  in  1870. 

Among  Gaal's  writings  the  only  one  of  ophthalmologic  interest  is 
"Physikalisclic  Diagnostik  unci  derer  Anwemlung  in  cler  Medicin, 
Chirurgic,  Oculufik,  etc."  (Vienna,  1848).— (T.  H.  S.) 

Gabbett's  method.  A  method  of  detecting  tubercle  bacilli  in  cover- 
ulass  preparations. 

Gabelkrallenpinzette.  (G.)  Fork-shaped  forceps — for  use  in  fixing 
the  eyeball  during  operation  or  examination.  See  Forceps,  Two- 
tined. 

Gafsa  button.     One  of  the  numerous  names  for  Aleppo  boil. 

Gal'ass.     (G.)     A  vessel. 

Gaillard,  Francois  Lucien.  A  distinguished  French  surgeon,  inventor 
of  the  cyclid-sutui'c  wliich  bears  his  name  and  Avhich  is  often  used 
today.  (See  Gaillard 's  suture.)  Born  in  Poitiers,  France,  in  1805, 
he  received  his  professional  degree  at  Paris  in  1829,  presenting  as 
thesis,  "Considerations  sur  TUtilite  et  I'Abus  des  Theories  en  Mede- 
cine,  Suivies  de  Propositions  Chirurgicales."  He  settled  for  practice 
in  Poitiers  and  became  a  distinguished  surgeon.  He  Avrote  a  large 
number  of  Avorks  of  a  general,  but  none  of  an  ophthalmologic, 
character.    He  died  in  January,  1869. —  (T.  H.  S.) 

Gaillard's  suture.  See  Entropion;  ]).  4:lU,  Vol.  VI,  of  this  Encgclo- 
l>(  (lid. 

Galactocataracta.  (L.)  An  old  and  obsolete  name  for  a  milky  (Mor- 
gagnian i  cataract. 

Galactometer.  Creamometer.  Lactometer.  Lactodexsimeter.  A 
graduated  (per  cent.)  tube  for  measuring  the  proportion  of  cream  in 
a  given  quantity  of  milk. 

5326 


GALACTOSCOPE  5327 

Galactoscope.  An  iiisli-uiuciit  I'or  the  oplical  Icstin^'  of  the  c-oiistit- 
uciits,  cspccijilly  the  cream,  of  milk.     See  Donne's  galactoscope. 

Galactotoxicon.     'I'lic  active  aj^eiit  in  j^oisonous  milk. 

Galassi  pupillary  phenomenon.  Wlicn  the  orbicularis  is  energetically 
eontraetecl  and  tiie  eye  tiglitly  closed  there  is  luii-iowing  of  the 
j)npil,  which  dilates  when  the  eye  is  opened. 

Galbanum.  G-um-resin  from  Ferula  gulbaniflua.  It  contains  a  volatile 
oil,  resin  and  gum,  and  is  commonly  used  as  an  antispasmodic,  rube- 
facient and  resolvent ;  dose  5  to  20  grains. 

According  to  Lewin  and  Guillery  (Vol.  I,  p.  393)  ill-defined  ocular 
symptoms  (cloudy  vision,  pliosphcncs)  liave  resulted  from  large  doses 
of  this  remedy. 

Gale.     (P.)     Itch. 

Gale,  James  (1833-1907),  English  inventor  and  electrician,  born  near 
Plymouth ;  he  lost  his  sight  at  seventeen,  but  was  very  successful  as 
a  medical  electrician  and  inventor.  He  was  founder  of  the  South 
Devon  and  Cornwall  Institution  for  the  Blind.  Gale  received  prob- 
ably the  largest  fee  ever  known  to  be  paid  for  medical  electrical  attend- 
ance— viz.,  $250,000.  See  J.  Plummer's  The  Story  of  a  Blind  Inventor 
(1868). 

Galeamaurosis.  A  name  for  amaurotic  cat's  eye — the  condition  in 
Avliich  there  is  a  light-refiex  through  the  pupil,  in  suppurative 
choroiditis. 

Galen,  Claudius.  The  greatest  physician  of  all  time,  except  Hippocra- 
tes, and  the  idol  of  the  medical  world  for  more  than  a  thousand  years. 
Galen  was  born  at  Pergamos,  in  J\Iysia,  A.  D.  131,  and  died  in  210. 
His  father,  Nicon,  was  an  architect.  Of  him  the  sn])jeet  of  this 
sketch  speaks  with  the  greatest  affection  and  admiration,  but  his 
mother  he  calls  a  virago.  His  father,  he  says,  "Was  of  surpassing 
skill  in  geometry,  architecture,  astronomy,  arithmetic  and  logic ;  but 
was  even  better  known  for  his  justice,  modesty  and  goodness." 
Because  of  a  dr(^am,  the  father  decided  to  dedicate  his  son  to  medicine. 
Galen  received  his  education  not  oidy  in  his  native  town  but  also 
in  many  other  cities — Smyrna,  Corinth,  a  place  or  two  in  Palestine, 
and.  of  course,  in  Alexandria.  In  the  school  at  the  last  named  place 
he  saw  a  luunan  skeleton,  an  experience  that  seems  to  have  made  a 
great  impression  on  him.  In  159,  being  28  years  of  age,  he  returned 
to  his  native  city  of  Pergamos,  and  became  a  gladiatorial  physician. 
Six  years  later  he  went  to  Rome. 

In  Rome  he  met  with  an  accident,  almost  upon  arriving.  Going  to 
a  wrestling  school,  or  else  a  school  for  gladiators,  he  indulged  in  a 
wrestle,  and,  being  heavily  thrown,  received  a  dislocation  of  the  shoul- 


5328  GALEN,  CLAUDIUS 

(Icr.  'I'lic  l)()ii('  was  set,  as  it  seems,  by  one  who  happened  to  be  stand- 
iiifj:  near,  luider,  of  course,  tlie  instnietions  of  the  learned  patient 
liinisolf. 

Galen,  in  Rome,  soon  became  tlie  greatest  physician  of  tlie  known 
woi'ld,*  although  engaged  in  constant  controversy  with  other  mem- 
l)ers  of  his  profession.  He  fought  especially  the  sect  of  the  ^lethodists. 
Owing  to  the  rancor  engendered  by  his  continual  professional  dis- 
putes, he  (juitted  Rome  when  37  years  of  age,  went  again  upon  scien- 
tific travels,  and,  finally  (as  it  must  have  appeared  to  him)  settled  in 
his  native  Pergamos.  It  was  not  quite  ''finally,"  however,  for,  in 
a  very  short  time,  he  was  summoned  back  to  Rome  by  the  Emperor, 
Marcus  Aurelius,  for  the  purpose  of  accompanying  that  philosopher- 
warrior  on  a  military  expedition  into  Germany.  The  great  phj-sician, 
however,  very  conveniently  had  a  dream,  which  rendered  his  trip  to 
Germany  inauspicious.  Later,  he  was  appointed  body  physician  to 
the  Emperor  Commodus.  Here  ends  our  knowledge  of  the  external 
life  of  the  great  physician,  Galen. 

As  to  Galen's  personal  character,  he  is  said  to  have  been  very 
pompous  and  overbearing.  He  was  also  impetuous  and  magnetic, 
capable  of  making  the  bitterest  enemies  and  the  most  profound  con- 
verts. He — unlike  Hippocrates — was  extremely  talkative  and  highly 
circumstantial.  Hence  he  has  been  declared  by  some  authorities  to 
have  been  more  of  a  converser,  lecturer,  and  writer  than  practitioner. 

In  anatomy  Galen  was  very  original,  as  can  easily  be  imagined  from 
the  years  which  he  had  devoted  to  the  study  of  that  subject.  ]\Iost 
of  his  anatomical  mistakes  arose  from  the  fact  that  his  dissections 
were,  for  the  most  part,  necessarily  confined  to  the  cadavers  of  animals. 
People,  in  those  days,  possessed  a  profound  respect  for  the  human 
body — ^when  it  was  dead.  Human  osteology,  however,  Galen  knew 
very  thoroughly,  because,  perhaps,  of  the  human  skeleton  which  he 
had  run  across  in  the  school  at  Alexandria.  He  described,  too.  a 
number  of  individual  muscles  and  muscular  appendages — the  platysma 
myoides,  the  masticatory  muscles,  the  popliteus,  the  tendo  Achilles. 
He  even  described  the  six  extrinsic  muscles  of  the  eye,  and  some  of 
the  muscles  of  the  larynx.  Altogether,  he  made  a  great  advance  in 
myology.  He  mentions  with  greater  or  less  detail  the  aorta,  the 
jugular  veins,  the  three  coats  of  the  larger  arteries,  the  lachrymal 
glands,  the  puncta  lachrymalia,  and  the  lachrymal  ducts.  The  heart 
he  did  not  seem  to  regard  as  a  muscle,  yet  he  described  it  much  more 
accurately  than   any  preceding  writer.     He  placed   it,   wrongly,   of 


*  His  fees  were,  for  tlie  times,  simply  enormous.     Tims,  for  curing  the  wife  of 
the  consul,  Boethius,  he  received  the  equivalent  of  about  $1,800.00. 


GALEN,  CLAUDIUS  5329 

course,  ill  the  center  of  llie  tlioi-ax.  Yet  he  described  it  as  consisting 
of  straight,  oblique,  and  ti'ausvei-se  fibres. 

In  physiology  he  did  not  advance  far  beyond  Hippocrates.  Like 
IIi])])Ocrates,  he  believetl  in  the  exi.stejice  of  the  four  elements  of  matter 
— earth,  air,  fire  and  water — and  the  primary  qualities  thai  belonged 
to  them,  dryness,  coldness,  warmth,  ami  moisture,  respectively.  As  a 
result  of  these  four  primaiy  qualities  of  matter,  there  exists  in  the 
human  body  the  four  so-called  "cardinal"  humors — mncns,  which  is 
moist  and  cold,  and  which  is  secreted  by  the  brain;  blood,  which  is 
moist  and  warm,  and  which  is  manufactured  in  the  liver;  yellow  bile, 
which  is  dr.y  and  warm,  and  which,  like  the  blood,  is  formed  within 
the  liver;  and,  finally,  black  bile,  which  is  dry  and  cold,  and  which  has 
its  origin  in  the  spleen. 

From  different  sorts  of  mixtures  of  the  primary  qualities  resulted 
the  so-called  "secondary"  qualities.  Only  the  secondary,  or  mixed, 
(lualities  were  cognizable  by  the  senses.  Thus,  for  example,  the  cardi- 
nal humors  of  the  l)ody  possessed,  as  we  have  seen,  each  one,  a  mixture 
of  the  primary  qualities — otherwise  thc}^  would  not  have  been  appre- 
ciable by  the  senses. 

He  did  not  advance  much  beyond  his  predecessors  in  the  physiology 
of  respiration  and  circulation.  As  to  respiration,  he  was  a  close  fol- 
lower of  the  school  of  Pneumatists.  Portions  of  the  world-soul  are 
continually  being  taken  via  the  lungs  into  the  heart,  and  this  indi- 
vidual portion  of  the  world-soul  tlius  inspired  is  the  soul  of  the  indi- 
vidual. From  this  view  seems  to  have  come  the  idea  that  a  child  does 
not  possess  a  soul  until  it  has  been  liorn  and  has  received  its  first 
br(»ath — a  view  Avhich  prevails  in  this  country  among  the  laity  today 
and  which  accounts  for  the  great  readiness  of  some  persons  to  con- 
sider feticide  as  a  matter  of  no  great  importance.  By  the  heart  the 
world-soul,  or  pneuma,  is  diffused  through  the  various  portions  of  the 
body,  where,  according  to  the  region  to  which  it  is  sent,  it  becomes 
one  or  another  kind  of  "spirits."  AVhile  still  in  the  heart  and  arteries 
it  is  called  "vital"  spirits.  In  the  brain  and  in  the  nerves  it  becomes 
"animal"  spirits.  In  the  liver  and  the  renal  veins  it  became  "nat- 
ural" spirits. 

Galen's  circulatory  physiology  was  intimately  bound  up,  as  we  can 
see  already,  with  his  physiology-  of  the  respiration.  The  object  of  the 
circulation  is,  in  fact,  the  distribution  through  the  body  of  the  pneuma 
which  had  been  in-taken  by  the  heart  by  the  way  of  the  respiration. 
From  the  lungs,  the  air,  or  at  least  the  pneuma,  entered  the  left  side 
of  the  heart,  and,  thence,  the  arteries.  From  this  point  onward  his 
view  of  the  circidation  was  undoubtedly  obscure,  even  to  himself,     'We 

Vol.  VII— 31 


5330  GALEN,  CLAUDIUS 

may  add,  liowcvcr,  thai,  in  liis  opinion,  tlu;  food,  after  undergoing 
"coetion''  in  tlic  stoniaeh,  gets  somehow  to  the  liver,  where  it  is  con- 
verted into  blootl.  Next  it  goes  to  the  heart.  Then  it  is  driven,  via 
the  puhnonary  arteries,  to  the  lungs,  with  the  object  of  nourishing 
those  viscera,  and  (now,  however,  througli  the  veins),  to  various  other 
portions  of  the  body. 

Galen  was  the  first  to  divide  the  causes  of  disease  into  "predis- 
posing and  exciting,"  and  also  into  "proximate  and  remote."  In  gen- 
eral pathology,  it  is  true,  he  blundered  round  and  round,  by  reason  of 
his  baseless  views  concerning  the  primary  elements,  the  primary  and 
secondary  qualities,  and  especially  the  cardinal  humors.  Nevertheless, 
in  special  pathology,  he  was  far  in  advance  of  his  time — a  fact  due, 
chiefl}^,  to  his  strict  adherence  in  this  field  to  observation  and  experi- 
ment. He  seems  to  have  vivisected  and  even  to  have  experimented 
hy  various  other  methods  systematically,  persistently,  and  thoroughly. 
Cutting  the  fifth  cervical  nerve,  he  noted  the  consequent  paralysis  of 
the  supra-  and  infra-spinati. 

Galen  believed  devoutly  in  the  efificacy  of  drugs — as,  in  fact,  the  best 
of  physicians  have  done  in  all  times.  His  list  of  remedies,  too,  was 
large.  He  was  guilty,  however,  at  times,  of  ridiculous  polypharmacy, 
and  he  made  the  gross  mistake  of  rejecting  all  metallic  remedies.  He 
had,  in  particular,  an  abhorrence  of  mercury. 

In  surgery  he  was  also  at  least  in  the  vanguard  of  his  day,  if  not 
actually  the  leader.  An  expert  minor  surgeon,  he  introduced  the 
aeeipiter,  the  sling,  the  spica,  and  the  testudo — all  in  use  to-day. 

This  second  greatest  physician  of  all  time  was  much  greater  as  an 
ophthalmologist  than  was  his  only  superior  in  general  medicine,  and 
his  forerunner  by  six  or  seven  hundred  years,  Hippocrates.  His 
strictly  ophthalmologic  writings — '^ Optics"  and  '' Diagnostics  of  Dis- 
eases of  the  Eye" — have,  most  unfortunately,  been  lost  in  the  stream 
of  time.  Putting,  however,  one  thing  with  another  from  various  por- 
tions of  extant  writings,  w^e  get  the  following  mosaic  of  Galenic  oph- 
thalmology. And,  first,  let  us  consider  the  Galenic  oculcir  anotomij. 
The  lids  of  the  eye  are  composed  of  an  outward  skin  and  also  of  an 
inner  skin,  called  periosteum  (conjunctiva).  Between  the  two  lies 
the  tarsus,  from  which  the  eye-lashes  extend,  as  well  as  a  fat-containing 
web,  in  the  interstices  of  which  lie  certain  fat-producing  liydatids.  the 
purpose  of  which  is  to  keep  the  edges  of  the  lids  well  oiled. 

The  outer  portion  of  the  eye  itself  is  composed  of  a  hard,  tough 
membrane  which,  l)eginning  at  the  entrance  of  the  optic  nerve,  runs 
forward  without  transparency  until  it  reaches  the  ring  around  which 
all  the  difTerciif  liumors  and  membranes  of  the  eye  commingle — tlie 


GALEN,  CLAUDIUS  5331 

iris.  From  the  iris  on,  it  is  thin  and  transparent.  This  portion  of 
the  tunic  is  called  the  keratoidea,  and  is  much  more  boldly  curved 
tlian  tlie  posterior  portion.  Beliind  the  pupil  lies  the  corpus  crystal- 
linum.  Between  this  body  and  tiie  keratoidea  lies  a  tiny  chamber 
filled  with  a  watery  liquid  and  with  pneuma.  Beneath  this  outermost 
tunie,  or  membrane,  of  the  eye,  is  a  second,  which  arises  from  the  pm 
mater  of  the  brain  and  is  very  rich  in  vessels.  It  enters  the  eye  accom- 
panied by  the  optic  nerve  and  by  an  artery  and  vein.  This  covering 
is  called  the  "choroid  coat."  From  the  choroid  coat  extend  in  a 
forward  direction  certain  processes  [our  ciliary  processes]  and,  from 
this  point  onward,  the  chorioidea  can  be  perceived  through  the  trans- 
parent portion  of  the  outermost  membrane,  the  keratoidea.  In  the 
center  of  this  portion  of  the  chorioidea  is  an  opening,  the  pupil.  The 
purpose  of  the  pupil  is  to  weaken  the  light  and  so  to  protect  the  corpus 
cri/stallinum.  In  the  little  space  between  the  pupil  and  the  chorioidea 
lies  a  liquid  which  resembles  the  white  part  of  an  egg,  and  the  object 
of  which  is  to  keep  supplied  with  moisture  certain  portions  of  the 
eye,  as  well  as  to  stretch  the  keratoidea  sut^ciently  outward,  for,  in 
case  the  keratoidea  is  perforated,  the  liquid,  escaping,  allows  the  cornea 
to  become  flaccid  and  wrinkled. 

The  pupil  itself  is  occupied  by  pneuma,  which  arrives  in  that  situa- 
tion by  pressing  forward  from  the  brain  through  the  "pore"  of  the 
optic  nerve.     The  pneuma  serves  to  keep  the  pupil  open. 

The  optic  nerves  arise  from  the  lateral  ventricles  of  the  brain,  and 
contain  a  lengthwise  pore,  or  passage,  for  the  pneuma.  The  nerves 
come  together  before  they  leave  the  cerebral  cavity,  but  part  again. 
However,  they  do  not  intermingle  where  they  cross,  but  only  lie  the 
one  upon  the  other,  so  that  no  communication  takes  place  between 
them,  excepting  only  between  their  pores.  The  place  of  overlying 
is  called  the  chiasms.  From  this  point  on,  each  nerve  is  accompanied 
by  a  vein  and  a  rather  large  branch  of  the  carotis  interna  into  the  very 
interior  of  the  eye  itself. 

Inside  the  eye,  the  behavior  of  the  optic  nerve  is  vastly  different 
from  what  we  see  in  the  case  of  any  other  nerve  of  the  body.  It 
expands  into  a  beautifully  curving  reticulated  structure  which  cor- 
responds exactly  to  the  globe-like  form  of  the  eye,  and  tits  into  every 
part.  Now  this  remarkable  network  is  of  use  not  merely  as  a  circum- 
scribing membrane  for  the  ocular  humors,  but  its  most  important  pur- 
pose is  to  announce  in  the  lateral  ventricles  of  the  brain  the  changes 
which  have  been  induced  in  the  corpus  cnjstaUinum  by  the  falling 
thereupon  of  the  light-rays. 

In  the  deepest  portion  of  the  eye,  at  the  hinder  part,  is  a  viscous, 


5332  GALEN,  CLAUDIUS 

glassy-looking  humor,  which  is  raUci]  the  vitreous  liunior,  or  liygron- 
hyaloi(k-s.  In  front  of  this  is  a  transparent  hody,  or  humor,  called 
the  crystalline  humor.  It  is  something  like  a  spiiere  in  form,  but  is 
flattened  just  a  little  on  its  anterior  surface.  It  rests  behind  in  a 
little  socket  which  exists  for  the  purpose  on  the  anterior  aspect  of  the 
vitreous  humor.  It  is  covered  in  front  by  a  membrane  which  is  very 
tough,  but  also  very  clear  and  as  delicate  as  the  finest  woven  spider- 
web.  The  corpus  crystallinum  is  retained  in  place  by  the  forward 
expansion  of  the  optic  nerve,  which  runs  as  far  as  the  crystalline 
border.*  For  plate  illustrating  Galenic  ocular  anatomy  see  History 
of  Ophthalmology, 

AVhere  the  ditt'erent  humors  and  membranes  of  the  eye  come  all 
together,  the  tendinous  expansions  of  the  ocular  muscles  are  inserted 
into  the  outermost  membrane,  and  of  these  all  are  covered  by  the  for- 
ward prolongation  of  the  periosteum,  or  nutrient  covering  of  the  bones 
which  constitute  the  orbit.  The  muscles  are  seven  in  number,  two 
oblique,  four  straight,  and  one  retractory.f  The  oblique  muscles  give 
to  the  eye  its  rotatory  movements. 

The  tear  apparatus  consists,  for  the  greater  part,  of  an  upper  and  a 
lower  gland,  which,  through  their  ducts,  pour  out  the  lachrymal  secre- 
tion on  the  surface  of  the  eye  continually.  A  certain  amount  of  tears 
arises  also  from  tw^o  canals  which  are  found  in  the  edges  of  the  lids  at 
the  nasal  corner.  These  canals  serve  also  to  gather  up  any  excess  of 
tears  and  carry  it  down  to  the  nose.  They  are  assisted  in  their  work 
by  a  small  fleshy  body  (the  caruncula  lachrymalis)  which  covers  a 
portion  of  the  canals  and  serves  to  give  to  the  superabundant  lach- 
rymal secretion  its  appropriate  direction. 

Not  so  bad  ocular  anatomy,  everything  considered,  for  the  second 
century  A.  D.  At  all  events  it  stood  as  the  final  word  concerning  the 
structure  of  the  human  eye  for  more  than  a  thousand  years. 

But  Galen's  contributions  to  ophthalmology  consisted  of  more,  far 
more,  than  merely  anatomical  (even  combined  with  physiological) 
observations.  Thus,  his  pathologA-  and  his  treatment  both  show  a 
very  decided  advance  as  compared  with  those  of  any  of  the  earlier 
writers.  And,  first,  as  to  Galen's  pathology.  Numerous  visual  hallu- 
cinations are  produced  not  by  disease  of  the  eye  itself,  but  by  aflPeetions 
of  the  brain  or  of  the  esophageal  orifice  of  the  stomach.     These  are 


*  A  mistake,  of  course.  Galen  is  olmnat  thinking  of  what  we  eall  the  zonula 
of  Zinn.    Yet  he  did  not  really  discover  that  structure. 

+  An  error  due  to  the  fact  that  Galen,  as  before  statcl,  dissected,  like  other 
anatomists  of  his  time,  only  tlie  lower  animals.  Recall  in  this  connection  the  en- 
thusiasm, above  referred  to.  with  whii  h  Galen  mentions  his  having  once  beheld  in 
Alexandri;i  a  human  skeleton.  The  muscle  referred  to  really  exists  in  certain  ani- 
mals,    i5ec,  in  this  Encyclopedia,  Choanoides. 


GALEN,  CLAUDIUS  5333 

often  1(t  ])v  (listiii^uislicd  iVom  those  i)ro(liU'('(l  l)y  incipient  cntaraet. 
Those  produced  by  a  conuneiiciiig  cataract  seldom  affect  both  eyes 
simultaneously,  or  (at  a  later  stage)  to  the  same  degree.  The  reverse 
is  true  of  the  other  class  of  cases.  Further,  tiie  pupil  will,  in  the  course 
of  time,  if  a  cataract  (hypochyma)  ])e  forming,  exhiljit  the  character- 
istic color  changes  of  that  part.  Then  again,  complete  remissions  of 
the  trouble,  at  any  time,  forbid  the  diagnosis  of  hypochyma. 

The  causes  of  the  vai'ious  symptoms  in  the  eye  relate  to :  1.  The 
essential  organ,  the  crystalline  body.  II.  The  ])rain  and  the  visual 
nerve  (for  the  visual  power  proceeds  from  the  brain  to  the  eye  by 
means  of  the  visual  nerve).  III.  All  the  i)ortions  of  the  eye  other 
than  the  crystalline  body. 

I.  Diseases  of  the  crystalline  body  correspond  to  the  eight  dyscra- 
sije.  (See,  in  this  Eucyrloprdiri,  Hippocrates.)  The  structure  ean 
also  undergo  a  solution  of  continuity,  and  can  be  dislocated.  If  it  be 
dislocated  to  the  right  or  to  the  left,  the  evil  is  l)ut  slight ;  but  if  it  be 
displaced  in  an  upward  or  downward  direction,  there  results  diplopia. 

II.  Likewise,  the  brain  and  optic  nerve  exhibit  diseases,  which 
correspond  to  the  eight  dyscrasia\  and  these  parts,  too,  can  suffer 
solutions  of  continuity. 

III.  The  att'ections  of  the  various  other  portions  of  the  eye  occur 
(chiefly)  when,  either  in  the  pupil  or  in  the  space  between  the  pupil 
and  the  crystalline  body,  air  or  liquid  so  comports  itself  as  to  hinder 
the  perception  of  objects  by  the  crystalline  body.  It  can  also  happen 
when  that  portion  of  the  keratoidea  wdiich  lies  before  the  pupil  becomes 
abnormal ;  and  in  inflammations  of  the  conjunctiva,  in  kemosis  and  in 
pterygium.  It  can  also  occur,  again,  in  consequence  either  of  enlarge- 
ment, diminution,  distortion  or  rupture  of  the  pupil.  Once  again, 
the  aqueous  humor  may  be  either  increased  or  diminished,  as  well  as 
thickened  and  discolored,  and  so  produce  disturbances  of  vision. 
Thickening  of  the  aqueous  produces  loss  of  vision,  as  well  as  short- 
sightedness. If  the  thickening  be  complete  (as  happens  in  hypochynui 
or  cataract)  the  vision  is  completely  shut  off.  If  the  thickening  cor- 
respond to  a  portion  of  the  pupil  only,  then  the  patient  sees  as  dis- 
tinctly as  ever  before,  but  not  so  many  things  at  once,  because  of  the 
narrowing  which  has  been  produced  in  the  cone  of  visual  rays.  If 
tiny,  thickened  bodies,  unconnected  with  each  other,  swim  round  in 
the  aqueous  humor,  they  produce  in  the  paticMit  an  optical  illusion,  as 
if,  in  the  outer  world,  gnats  or  flies  were  floating.  If  the  aqueous 
humor  has  been  darkened,  then  the  patient  sees  as  if  through  fog  or 
smoke.  If  the  aqueous  be  changed  to  any  other  color,  then  that  color 
seems  to  be  diffused  throughout  the  external  world.     Among  these 


i334  GALEN,  CLAUDIUS 

cases  should  be  grouped  tlie  optical  illusions  which  occur  in  conse- 
quence of  a  bogiiniing  hypochyma,  and  which  have  to  be  distinguished 
from  similar  illusions  produced  by  vapors  from  the  stomach. 

Finally,  the  patient  may  be  affected  by  disturbances  of  the  innerva- 
tional  pneuma.  If  the  pneuma  be  abundant  and  clear,  like  ether,  then 
the  subject  sees  distinctly  and  into  the  farthest  distance.  If  it  is  only 
scantily  present,  but  pure,  he  sees  nearby  exactly,  but  distant  objects 
not  at  all.  If  it  be  abundant  but  moist,  he  sees  far  but  not  exactly.  If 
moist  and  scanty,  he  sees  neither  clearly  nor  far. 

G-alen's  treatment  is,  as  a  whole,  even  more  interesting  than  his 
pathology. 

Falling  of  the  lashes.  Persons  wlio  lose  their  eyelashes  should  be 
treated  with  remedies  like  those  employed  for  the  falling  of  hair  from 
the  head.  Such  remedies,  which,  as  Galen  says,  "I  have  already  con- 
sidered in  my  Materia  Medica,"  should  not  be  allowed  to  reach  the 
membranes  of  the  eye  itself. 

Foreign  substances  should  be  removed,  but  nothing  which  naturally 
belongs  to  the  eye,  and  which  has  simply  been  corrupted.  A  pterygium 
is  of  a  nature  foreign  to  the  healthy  eye.  It  is,  however,  not  so  plainly 
foreign  as  a  honey-tumor.  The  larger  sort  of  water  blisters  [cystic 
tumors]  are  to  be  treated  by  operation,  the  smaller,  however,  by  drying 
remedies.  The  chalazion,  on  the  other  hand,  is,  in  its  very  nature, 
an  abnormality,  and  so  sliould  be  removed. 

A  cataract  can,  in  the  lieginning,  be  dispersed,  but  not  later. 
Among  the  oculists  of  our  day,  Galen  continues,  a  certain  Justus 
has  cured  numerous  patients  of  their  hypopion  by  shaking  their  heads 
He  places  the  patient  upright  on  a  chair,  grasps  the  head  between 
his  hands,  and  shakes  it  till  the  pus  runs  down  before  the  eyes.  It 
then  remains  below  because  of  the  heaviness  of  its  substance.  On  the 
other  hand,  a  cataract  does  not  remain  below  [i.  e.,  after  it  is  couched] 
unless  one  carefully  fastens  it  down. 

However,  there  are  exceptions.  A  few  cataracts  are  of  a  more 
whey-like  consistency,  and,  when  these  are  depressed,  at  once  break 
up,  and,  a  little  later,  settle  down  as  a  sediment. 

When,  however,  we  wish  to  dissipate  pus  in  an  eye.  we  have  to 
resort  chiefly  to  the  collyria  containing  myrrh.  Next  in  efficiency 
come  those  containing  frankincense.  Galen  remarks,  in  this  connec- 
tion:  "Often  I  have  evacuated  the  pus  at  once  by  means  of  a  punc- 
ture in  the  cornea,  just  a  little  above  its  border." 

Remedies  for  conjunctivitis  must  of  necessity  belong  to  those  of  the 
general  class  which  are  used  in  inflammations  everywhere,  yet,  in  addi- 
tion, they  have  to  be  adjusted  to  the  tender  condition  of  the  parts. 


GALEN,  CLAUDIUS  5335 

Astringent  remedies  must  not  cauterize,  and  sliould  be  modified  witli 
some  demulcent  liquid,  as  white  of  egg,  decoction  of  goat's  liorn,  or 
milk.  The  milk  should  be  from  a  young  and  healthy  woman,  and  be 
pressed  from  the  breasts  themselves  on  to  the  whetstone  on  which 
the  collyrium  is  triturated,  in  order  that  it  may  be  instilled  into  the 
eyes  lukewarm.  But  the  milk  is  only  necessary  in  the  case  of  pains, 
whether  in  consequence  of  the  strength  of  the  infiammation  or  the 
acridity  of  the  secretion.  As  a  rule,  it  is  enough  to  employ  the  white 
of  egg  with  fitting  remedies,  in  order  to  cure  the  ocular  infiammations 
by  means  of  what  are  called  "one-day  eollyria."  Not  infrequently 
these  so  reduce  even  the  severe  forms  of  ocular  inflanunations,  that, 
towards  evening,  the  patient  may  bathe,  and,  on  the  following  morn- 
ing, may  employ  the  hard  collyrium  for  a  confirmation  of  tlie  cure. 
At  the  first  inunction  with  this  remedy,  a  trace  of  some  sharp,  astrin- 
gent substance  should  be  commingled  with  it ;  at  the  second  inunction, 
a  trifle  more.  The  two  applications,  conjoined  with  a  moderate 
promenade  before  the  bath,  suffice. 

The  "one-day  eollyria"  (of  which  a  few,  especially  those  which  are 
known  as  the  "barm-colored,"  contain  an  abundance  of  gum  acacia, 
others,  however,  little  or  none  at  all)  contain,  in  addition,  parth-  cop- 
per filings,  partly  a  little  annealed  copper,  and  many  other  moderately 
astringent,  ripening  and  dissipating  substances,  such  as  saffron,  myrrh, 
catechu,  castorium  and  frankincense. 

After  the  use  of  the  collyrium,  sponge  baths  should  be  employed: 
when  the  pain  is  moderate,  once  or  twice  a  day ;  when  it  is  severe, 
three  to  four  times,  especially  in  the  long  summer  days.  The  bath 
should  be  taken  in  a  decoction  of  melilot  and  goat's  horn. 

Ulcers  in  the  eyes  require  the  remedies  appropriate  for  ulcers  in 
any  portion  of  the  body,  only  they  should  be  of  the  mildest,  e.  g., 
flowers  of  zinc.  The  pain-relieving  juices  of  various  plants,  for  exam- 
ple, the  mandragora,  may  be  included  in  the  prescription  with  advan- 
tage. The  chief  aim  of  the  treatment  is  to  keep  the  ulcer  clean,  for 
the  nature  of  the  parts  will  of  itself  fill  out  the  excavation  and  lead 
to  cicatrization.  Ulcers  attended  by  perforation  of  the  cornea  and 
prolapse  of  the  iris,  require  astringent  remedies.  In  pustules  and 
abscesses  of  the  cornea,  dissipating  remedies  are  proper,  mixed,  for 
recent  cases,  with  myrrh,  frankincense  and  saffron. 

In  pterygium  and  trachoma  the  purifying  remedies  are  proper, 
employed  partly  in  the  form  of  eollyria,  partly  as  dry  powder. 

In  severe  eases  of  trachoma,  physicians  have,  in  their  perplexity, 
thought  out  a  singular  remedy,  namely,  having  everted  the  lids,  to 
cleanse  them  thoroughly  and  then  to  scrape  them  off  without  the  appli- 


5336  GALENICAL 

cation  of  drugs.  A  few  senipe  only  sui)erficially  with  a  small  sharp 
spoon  against  the  scalpel  and  afterwards  wipe  up  with  a  soft  sponge 
tiiat  which  flows  away,  and  then  adstriuge  the  lids  as  far  as  any 
roughness  remains.  Others  employ,  also,  the  su]H'rtieially  rough  skins 
of  certiiin  sea-aninuils  in  a  manner  entirely  approi)riate  for  tliis  pur- 
pose. "One  of  my  teachers  even  prepared  an  eye-pencil  of  pumice- 
stone,  and  having  everted  the  lids,  rubbed  the  roughnesses  away  from 
them  with  this  instrument."  As  a  matter  of  course,  a  person  must 
pulverize  the  pumice-stone,  and  make  it  into  a  pencil  with  tragacaiith 
or  gum.  When,  under  the  employment  of  the  pencil  mentioned,  the 
discharge  begins  to  cease,  then  we  may  venture  to  rub  into  the  lids 
purifying  medicines ;  but,  at  first,  we  should  employ  only  a  weak  solu- 
tion, and  later,  when  it  is  found  that  the  patient  ])ears  this  well,  we 
should  gradually  strengthen  it. 

Despite  his  many  faults,  Galen  was  a  great  physician  and  ophthal- 
mologist, and,  though  not  possessed  of  the  marvelous  inventive  power 
and  the  clear,  all-seeing  eye  of  Hippocrates,  he  remained  the  lord  and 
god  of  medicine  to  and  through  the  middle  ages.  His  influence,  how- 
ever, was  not  entirely  without  harm.  Boerhaave,  in  fact,  observed 
that  "Galen  has  done  more  harm  than  good."  But,  if  so,  it  was  not 
the  great  Pergamene's  fault,  l)ut  the  vice  of  those  who,  century  after 
century,  devoid  of  originative  power,  must  needs  follow  "authority" 
in  matters  medical,  as  well  as  in  almost  every  other  field  of  endeavor 
that  was  known  to  man. —  (T.  H.  S.) 
Galenical.  Pertaining  to  remedies  prepared  according  to  an  official 
formula,  especially  to  the  preparation  of  remedies  used  for  human 
beings  as  opposed  to  veterinary  remedies. 
Galeocore.  (L.)  One  of  the  numerous  synonyms  of  cat's-eye  amau- 
rosis. 
Galeropia,  or  Galeropsia.     An  abnormally  clear  and  light  appearance 

of  o])jects,  due  to  some  perversion  of  the  visual  apparatus. 
Galezowski's  test.       Galezowski's  prism.     See  page  1180,  Vol.  II,  of 

this  Encyclopedia. 
Galezowski,  Xavier.  A  distinguished  and  world-renowned  Parisian 
ophthalmologist.  He  was  born  at  Lipowice,  Poland,  in  1832,  the  nephew 
of  a  distinguished  general  surgeon,  Severin  Galezowski.  He  began 
the  study  of  medicine  at  St.  Petersburg,  where  he  received  his  degree 
in  1858.  He  then  proceeded  to  Paris,  where,  in  1865.  he  received  the 
ad  cundem  degree.  He  studied  for  a  time  with  Trousseau,  and  was 
for  a  brief  period  Chef-de-Clinique  to  Desmarres.  During  the  course 
of  a  long  and  active  professional  life  he  invented  a  number  of  instru- 
ments and  devised  many  operations  that  still  bear  his  name. 


GALILEAN  TELESCOPE 


5337 


lie  foiiiulfd  the  liccucil  d'Ophtalmologu,  and  was  for  a  long  time 
its  editor.  Ilis  eliiiic  for  many  years  attracted  liimdreds  of  students 
and  was  attended  liy  many  thousands  of  devoted  and  entiiusiastie 
patients.  lie  wrote  a  large  number  of  articles,  which  appeared  in  his 
own  journal  as  well  as  in  the  "Archives  Gencrales  dc  Midrcinc/'  Ga- 
zette dcs  Ilopitaux,  Le  Mouvcmcnt  Medical,  Union  Medicate,  Revue 
d'Hygiene,  and  the  Aniwles  d'Ocidistique. 

He  died  March  22,  1907,  at  76  years  of  age.— (T.  H.  S.) 


Xavier  Galezowski. 


Galilean  telescope.     A  telescope  with  a  concave  lens  for  its  eyepiece. 

Galileo  Galilei  (1564-1642),  one  of  the  fathers  of  experimental  science, 
was  born  at  Pisa,  Ital.y.  Entering  the  University  of  Pisa  in  1581.  he 
was  two  years  later  struck  with  the  fact  that  the  oscillations  of  a 
pendulum,  no  matter  what  their  range,  seemed  to  be  accomplished  in 
equal  times.  About  this  time  he  invented  a  hydrostatic  balance  and 
wrote  a  treatise  on  the  specific  gravity  of  solid  bodies.  These  achieve- 
ments secured  him  the  appointment  of  professor  of  mathematics  in 
the  University  of  Pisa,  where  he  propounded  the  novel  theorem,  that 
all  falling  bodies,  great  or  small,  descend  with  equal  velocity,  and 
proved  its  correctness  by  several  experiments  made  from  the  summit 
of  the   leaning   tower   of   Pisa.     Tliis   provoked   the   enmity   of   tlie 


5338  GALIPOT 

Aristotelians,  and  Galileo  resigned  his  eliair  at  Pisa  and  retired  to 
Morenee  in  1591. 

In  tlie  following  year  he  was  nominated  to  the  ehair  oi"  mathematics 
in  the  University  of  Padua,  where  his  lectures  attracted  crowds  of 
pupils  from  all  parts  of  Europe.  Here  he  taught  and  worked  for 
eighteen  years,  from  15'J2  to  l(ilO.  Galileo  now  began  a  series  of 
astronomical  investigations,  all  of  which  tended  to  convince  him  still 
more  of  the  correctness  of  the  Copernican  heliocentric  theory  of  the 
heavens.  He  concluded  tliat  the  moon,  instead  of  being  a  self-luminous 
and  perfectly  smooth  sphere,  owed  her  illumination  to  reflection,  and 
that  she  presented  an  unequal  surface,  diversified  by  valleys  and 
mountains.  The  milky-way  he  pronounced  a  track  of  countless  sepa- 
rate stars.  Still  more  important,  however,  was  the  series  of  observa- 
tions which  led  to  the  discovery  of  the  four  satellites  of  Jupiter  on  the 
night  of  January  7,  1610.  lie  also  first  noticed  movable  spots  on  the 
disc  of  the  sun,  from  which  he  inferred  the  rotation  of  that  orb.  In 
this  year  he  was  recalled  to  Florence  by  the  Grand  Duke  of  Tuscany, 
who  nominated  him  his  philosopher  and  mathematician  extraordinary. 
At  Florence,  continuing  his  astronomical  observations,  he  discovered 
the  triple  form  of  Saturn  and  the  phases  of  Venus  and  of  ]\Iars. 

In  1611  Galileo  visited  Rome  and  was  received  with  great  distinc- 
tion, being  enrolled  a  member  of  the  Lincei  Academy.  Yet  the  pub- 
lication, two  years  later,  of  his  Dissirtatian  on  the  Solar  Spots,  in 
which  he  openly  and  boldly  professed  his  adliesion  to  the  Copernican 
view,  provoked  against  him  the  censure  and  warning  of  the  eccle- 
siastical authorities.  Galileo,  however,  promised  (Feb.  26,  1616)  to 
obey  Pope  Paul  Vs  injunction,  thenceforward  not  to  "hold,  teach  or 
defend"  the  condemned  doctrines.  But  in  1632,  ignoring  his  pledge, 
he  published  the  Dialogo  sopra  i  (hie  massimi  Sistcmi  del  Monde. 
Pope  Urban  VIII  was  led  to  believe  that  Galileo  had  satirized  him  in 
this  work.  In  spite  of  his  seventy  years  and  heavy  infirmities,  Galileo 
was  summoned  before  the  Inquisition,  and  after  a  wearisome  trial  and 
incarceration,  was  condemned  to  abjure  by  oath  on  his  knees  the 
truths  of  his  scientific  creed.  Since  the  year  1761  a  legend  has  been 
current  to  the  effect  that  on  concluding  his  recantation  he  exclaimed, 
sotto  voce,  "Epur  si  muove"  (Nevertheless  it  does  move).  In  his 
retreat  at  Areetri,  near  Florence,  he  continued  with  unflagging  ardor 
his  learned  researches,  even  when  hearing  grew  enfeebled  and  sight 
was  extinguished.  Just  before  he  became  totally  blind,  in  1637,  he 
made  yet  another  astronomical  discovery,  that  of  the  moon's  monthly 
and  animal  lil)rations. — (Sfandard  Encyclopedia.) 
Galipot.     See  Turpentine. 


GALLANILIDE  5339 

Gallanilide.     Sec  Gallanol. 

Gallanol.  Gallic  acid  anilide.  Gallinol.  Gall.\nilide.  This  is  a 
brownish,  crystalline  powder,  slightly  soluble  in  water;  more  so  in 
ether  and  alcohol.  Experiments  have  been  made  with  this  substance 
in  eye  diseases  as  5  to  20  per  cent,  ointments  or  as  a  dusting  powder 
with  talc,  but  the  outcome  has  not  been  satisfactory. 

Gall-apples.  These  were  much  employed  in  Greco-Roman  times  for 
various  diseases  of  the  eyes,  Hefoi-e  they  were  used,  they  w'ere 
boiled  in  vinegar. —  (T.  IT.  S.) 

Gallemaert's  magnetometer.'    See  Magnetometer,  Gallemaert's. 

Gallenfarbstoff.     (G.)     l>iliary  coloring  matter. 

Gallenfett.     (G.)     Cholesteriii. 

Gallereux,  A.  C,  Ambroise  Martin.  Honi  at  Gliichee.  France,  about 
1780  he  received  his  medical  degree  at  Paris,  and  settled  at  Tonnerre, 
where  he  seems  to  have  lived  until  his  death.  His  exact  life  dates  are 
not  procurable.  He  wrote :  1.  ^lem.  sur  les  Soins  a  Donner  aux  Per- 
sonnes  qui  Ont  ete  Operees  de  la  Cataracte  (Paris,  1816)  ;  2.  Avis  au 
Peuple  sur  la  Cataracte  (Paris,  1826)  ;  3.  Observations  Relatives  a 
Deux  Modes  d 'Alteration  du  Xerf  Optique,  etc.  (in  Sedillot's  Rec. 
Period,  de  la-  Soc.  de  Med.  de  Paris)  ;  4.  Sur  I'Application  Topique 
des  Dissolutions  d 'Opium  dans  les  Ophtlialmies. —  (T.  H.  S.) 

Gallic  acid  anilide.     See  Gallanol. 

Gallicin.  Methyl  gallate.  CcHoCOOCH,.  This  proprietary  remedy, 
said  to  be  gallic-aeid-methyl-ester  (Merck),  is  a  dirty-white  crystalline 
substance  made  by  heating  a  methylated  solution  of  gallic  acid  with 
sulpburic  acid. 

Its  use  in  ocular  tberapy  is  as  a  dusting  powder  in  many  external 
diseases  of  the  eye,  such  as  the  various  forms  of  chronic  and  sub-acute 
conjunctivitis,  or  it  may  be  applied  with  a  camel's-hair  pencil  to 
phlyctenules  or  in  superficial  ulcer  of  the  cornea. 

This  is  the  method  advised  by  the  Editor  a  number  of  years  ago, 
after  the  instillation  of  a  couple  of  drops  of  holocain  (1-5  per  cent.) 
before  applying  the  powder,  because  it  is  likely  to  irritate  and  cause 
pain. 

Gallinol.     See  Gallanol. 

Gall,  James.  This  philanthropist  was  a  printer  of  Edinburgh.  Scotland, 
who  became  much  interested  in  devising  tangible  type  for  the  blind. 
His  enthusiasm  lead  him  to  make  extravagant  claims  for  his  type, 
which  he  considered  not  only  the  best  ever  constructed  up  to  that  date 
(1834)  but  the  most  perfect  that  could  be  made.  In  a  work  which 
he  wrote  on  the  education  of  the  blind  he  insisted  that  "they  (the 
blind)  were  able  to  skim  over  the  letters  with  great  rapidity  in  read- 


5340  GALL  OF  MAN  AND  ANIMALS 

iii<r,  jiiid  tliiil  ali'ciidy  tlic  blind  wci'r  ;il)l('  to  I'ccl  llic  letters  and  could 
read  hooks  pi'intcd  witii  tlu^  coimiion  Kiij^lisli  size  of  type."  When 
tests  wei'e  made  it  was  found  that  these  claims  were  <rreatly  exag- 
gerated. His  pid)lishe(l  u  ritiiijis,  h()we\'ei\  did  iiiuch  in  di'awing  atten- 
tion to  the  subject.  "And,  although,"  he  said,  "tiiis  surpassed  all  that 
was  formerly  hoped  for,  even  this  is  not  to  be  considered  tlu;  smallest 
size  whicli  tlie  blind  will  be  able  to  read.  And  so  plain  were  the 
letters  to  them,  that  they  can  read  with  a  stout  glove  upon  the  hand,  or 
a  piece  of  linen  laid  upon  the  book."  A  contemporary,  Thomas  An- 
derson, ]\Ianager  of  the  Asylum  for  the  Blind  in  Edinburgh,  afterward 
nu^ntioned  the  fact  that  Gall  was  tiu'  first  in  Scotland  to  call  atten- 
tion to  the  fact  that  the  blind  might  be  a])le  to  read  raised  print. 
He  said:  "In  1881  he  i)ublished  some  elementary  works  in  what  may 
perhai)s  he  called  the  angular  roman  character — the  roman,  with  all 
the  circles  turned  into  angles.  When  these  books  came  out,  he 
requested  that  some  of  the  boys  belonging  to  the  Asylum  in  Edin- 
burgh might  be  allowed  to  take  lessons  from  him.  This  the  directors 
with  pleasure  immediately  granted;  and,  I  think,  three  if  not  four  of 
our  sharpest  youngsters  were  under  his  care  twice  or  three  times  a 
week.  No  restriction  as  to  time  was  laid  upon  him — he  had  them 
quite  at  his  own  disposal — and  they  continued  with  him  for  some 
months.  But,  even  with  all  Gall's  own  attention — and,  I  am  sure 
when  I  say  so,  every  security  is  given  that  all  that  perseverance,  kind- 
ness, and  ardor  in  a  favorite  pursuit  could  do  was  done  in  their 
case — yet  the  result  was  nothing  more  than  their  being  able  to  make 
out  letter  by  letter,  and  a  few  short  words,  some  of  them  hardly  that. 
As  to  anything  like  "reading"  in  the  common  acceptation  of  the 
word,  it  was  out  of  the  question,  Mr.  Gall  himself  being  the  judge." 
Gall's  publications  were  adopted  in  the  Asylum  at  Glasgow,  but  were 
soon  afterward  relinquished  for  roman  capitals  devised  by  Fry  of 
London.  These  received  the  name  of  the  treasurer  of  the  Asylum,  Mr. 
Alston  (q.  v.),  and  took  the  name  of  Alston's  type.  Anderson  men- 
tioned the  fact,  too  often  forgotten  in  the  types  for  the  blind  at  the 
present  day,  that  a  type  that  appears  satisfactory  to  the  eyes  must 
therefore  be  the  best  for  the  blind,  but  this  by  no  means  follows,  as  has 
been  demonstrated  later  in  the  universal  use  of  the  punctuate  form. — 
(F.  P.  L.) 
Gall  of  man  and  animals.  The  gall  of  any  of  the  lower  animals 
(excepting  only  that  of  the  horse)  was  supposed  to  be  efficacious  in 
almost  all  the  diseases  of  the  eye.  Human  gall  was  especially  recom- 
mended  by   an   oculist   nanu'd   ^liletus,   but    was   not    so    universally 


GALLOTANNIC  ACID  5341 

employed.     The  gall  of  the  horse  was  supposed  to  be  poisonous;  hence 
it  was  never  used. —  (T.  II.  S.) 

Gallotannic  acid.     See  Tannin. 

Gallstones,  Ocular  symptoms  of.  Although  it  may  be  rather  far- 
fetched, yet  a  connection  is  occasionally  shown  to  exist  between  the 
occurrence  of  gallstones  and  eye  symptoms.  One  of  these  is  related 
by  Axenfeld  {Anhiv  f.  Ophthalm.,  Vol.  40,  Xo.  8).  He  gives  the 
history  of  a  woman  witli  gallstones  who  died  from  a  metastatic  endo- 
carditis, meningitis,  etc.  There  was  also  a  metastasis  to  the  left  eye, 
with  nmrked  orbital  edema,  ptosis  and  i)roj)tosis,  followed  by  purulent 
uveitis  and  perforation  of  the  globe. 

Galvani,  Luigi.  (1737-98.)  This  famous  anatomi.st  was  born  at 
Bologna,  Italy,  where  he  studied  theology  and,  subsequently,  medicine 
at  the  University  there  and  in  1762  was  elected  professor  of  anatomy. 
Galvani  owes  the  wide  celebrity  attached  to  his  name  to  his  discoveries 
in  animal  electricity ;  and  there  is  evidence  that  his  views  were  based 
on  experiments  patiently  conducted  for  many  3'ears  before  the  pub- 
lication of  his  De  virihus  Elcctricitatis  in  Mortu  Musculari  Com- 
mentarins  (1791).  He  died  in  Bologna,  where  his  statue  was  erected 
in  1879.  Most  of  his  writings  were  published  in  a  quarto  edition  in 
1841-42  by  the  Academy  of  Sciences  of  his  native  city ;  but  several 
manuscript  treatises  by  him  were  discovered  there  in  April,  1889. — 
(Standard  Encyclopedia.) 

Galvanism.     See  Electricity  in  ophthalmology. 

Galvanocautery.  Sec  Cornea,  Serpent  ulcer  of  the;  as  well  as  Elec- 
tricity in  ophthalmology. 

Galvano-puncture,  Haberkamp's.  This  author  {La  CUnique  Ophtalmol., 
July  10,  1905 J  devised  an  extremely  radical  procedure  for  the 
relief  of  the  agonizing  pain  of  fulminating  glaucoma  in  which  enucle- 
ation is  deemed  essential.  This  operation  in  the  hands  of  one  who  is 
unskilled  in  the  use  of  the  cautery,  would  be,  in  Beard's  opinion  (in 
which  the  writer  thoroughly  concurs),  "a  delicate  undertaking,  as 
overheating  of  the  aqueous,  with  conseijuent  injury  to  the  iris  and  the 
crystalline  could  easily  be  brought  about. " ' 

The  method  consists  in  a  paracentesis  of  the  anterior  chamber  by 
galvano-puncture.  As  the  healing  of  the  wound  is  slow,  a  prolonga- 
tion of  the  effect  from  that  which  would  be  obtained  from  an  ordinary 
paracentesis,  can  be  gotten. — (C.  A.  0.) 

Gambasio,  Giovanni.  A  blind  Italian  sculptor  of  considerable  merit. 
See  Gonelli. 

Gamete.     A  germ-cell. 


5342  GAMMA,  ANGLE 

Gamma,  Angle.  See  ]).  471,  Vol.  1  of  tliis  Encyclopedia;  also  Physio- 
logical optics. 

Ganglion  anesthesia,  (iliakv  c.wcr.iox  amcstiiksia.  Thi.s  subject  is 
clisc-u.ssed  uiuk'i'  Anesthesia  in  ophthalmic  surgery,  page  436,  Vol.  I, 
of  this  Encyclopedia.  J.  S.  Wyler  {Ophtluilmic  Record,  Vol.  22,  p. 
302,  1913)  has  written  favorably  of  it  and  there  is  no  doubt  but  that 
under  certain  conditions  it  has  an  important  place  in  ophthalmic 
surgery. 

Ganglion  cells  (of  the  retina).     ,Sce  Histology  of  the  eye. 

Ganglion,  Cervical.  See  page  4843,  VoL.  \l,  of  this  Encyclopedia; 
also  Glaucoma,  near  the  end  of  the  section. 

Ganglion  ciliare.     (L.)     Ophthalmic  or  ciliary  ganglion. 

Ganglion  ciliare  accessorium  inferius.  (L.)  An  anomalous  ganglion 
connected  Avith  the  ciliary  branches  of  the  ophthalmic  nerve. 

Ganglion,  Ciliary.     See  Ganglion,  Ophthalmic. 

Ganglion,  Gasserian.  Semilunar  gaxgliox.  Ganglion  of  Gasseb. 
Sometimes  written  Gasserian  ganglion.  This  separate  and  independ- 
ent nerve  center  lies  in  the  fossa  on  the  anterior  part  of  the  petrosa 
near  the  apex.  Its  roots  join  the  carotid  plexus  and  fifth  nerve,  and 
its  fibres  are  distributed  to  the  ophthalmic,  superior  and  inferior  max- 
illary nerves. 

The  chief  interest  to  the  ophthalmologist  of  this  ganglion  is  its 
removal  for  tlie  relief  of  trigeminal  neuralgia  and  the  subsequent  onset 
of  neuroparalytic  keratitis  (q.  v.).  For  example,  S.  H.  Brown  {Amer- 
ican Journ.  of  OphtJtalm.,  March,  1912)  describes  the  condition  found 
in  the  right  eye  of  a  man  from  whom  the  right  Gasserian  ganglion  had 
been  removed  fourteen  years  before  to  cure  a  tic  douloureux.  lie 
had  been  free  from  tic  doloureux  since  the  operation,  but  had  suffered 
at  times  from  lachrymation,  redness  and  muco-purulent  discharge 
from  the  eye  without  any  pain.  Examination  of  the  right  eye  showed 
slight  entropion  and  trichiasis  of  the  lower  lid,  doubtless  due  to  the 
contraction  of  the  sear  following  the  sloughing  out  of  the  sutures 
inserted  to  keep  the  lids  closed.  The  friction  of  the  lashes  of  this 
incurved  lid  upon  the  cornea  caused  no  discomfort.  There  was  a  slight 
palpebral  and  bulbar  conjunctivitis,  and  a  considerable  pericorneal 
injection,  but  the  most  striking  feature  was  a  large,  superficial, 
slightly-elevated  nebula  which  occupied  the  lower  and  outer  half  of 
the  cornea,  avoiding  the  exact  center.  The  scar  was  rough  on  its 
surface  and  had  the  appearance  of  a  flake  of  some  kind  superimposed 
on  the  cornea.  Vision  was  5/22.5.  The  tension  was  normal.  The 
pupil  was  about  3  mm.  in  diameter  and  very  slightly  active.  It  showed 
a  tendency  to  contract  in  condensed  light,  with  slight  oscillatory  move- 


GANGLION,  LENTICULAR  5343 

ments,  but  woultl  not  dilate  in  the  dark.     This  was  doubtless  due  to 
iritic  adhesious.    No  view  of  the  fundus  could  be  obtained, 

W.  B.  Weidler  {Medical  liccord,  Sept.  14,  1912)  gives  the  history 
of  a  woman  who  hail  the  Gasserian  ganglion  removed,  and  three  days 
after  the  operation  was  unable  to  open  the  right  eye.  This  condition 
gradually  improved,  but  in  about  five  months  an  ulcer  appeared  on  the 
cornea.  The  eye  felt  dry  and  the  patient  said  there  were  no  tears  in 
that  eye  when  she  cried.  A  few  days  later  a  sore  spot  appeared  on 
the  forehead  above  the  right  eye,  which  became  a  neurotrophic  ulcera- 
tion of  the  scalp.  There  was  loss  of  sensation  for  touch  and  pain  over 
the  greater  part  of  the  right  side  of  the  face ;  sensation  for  cold  and 
heat  was  intact.  Later  on,  the  lids  became  swollen  and  the  ptosis  was 
about  as  at  first.  There  was  muco-purulent  discharge,  injection  of 
the  conjunctiva ;  the  ulceration  of  the  cornea  involved  onerhalf  of  its 
diameter,  and  extended  into  the  stroma.  There  were  iritis  and  cyclitis, 
vision  was  reduced  to  counting  fingers  at  one  foot,  and  tension  was 
minus  one.  Seven  months  later  the  acute  inflammatory  symptoms  had 
all  subsided,  the  right  side  of  the  face  was  more  sensitive  to  pain  and 
touch,  the  ptosis  remained,  the  iris  was  atropic,  the  pupil  showed 
remains  of  exudate.  The  injury  to  the  nerves  adjacent  to  the  ganglion 
was  the  result  of  an  accident,  a  hook  becoming  entangled  in  the  sen- 
sory nerves  during  the  operation. 

In  another  case  the  Gasserian  ganglion  was  removed,  and  the  pain 
thus  relieved.  About  seventeen  months  after  the  operation  the  right 
eye  became  painful,  the  lids  swollen,  free  discharge  and  injection  of 
the  bulbar  and  tarsal  conjunctiva.  There  was  central  ulceration  of 
the  cornea  involving  two-thirds  of  it.  Vision  was  reduced  to  counting 
fingers  at  three  feet.  There  was  consideralile  pain  in  the  eye  and 
temple.  Treatment  was  somewhat  similar  to  that  of  the  previous  case, 
and  after  five  months  the  woman  decided  to  have  the  eye  enucleated. 

Macroscopic  section  of  the  eye  showed  the  ulcer  to  have  been  about 
10  mm.  in  diameter,  involving  the  corneal  epithelium,  Bowman 's  mem- 
brane and  the  substantia  propria.  Microscopic  examination  showed 
the  corneal  epithelial  layer  normal  and  intact  around  the  limbus  and 
for  about  one-fourth  of  the  corneal  diameter,  the  remainder  being 
greatly  changed  by  the  ulceration.  In  the  lamina  propria  near  the 
eorneo-scleral  margin,  at  one  side,  were  several  new  blood  vessels,  and 
also  an  invasion  of  leucocytes.  The  iris  tissue  showed  foci  of  round 
cell  infiltrations  and  loss  of  pigmentary  layer  around  the  pupillary 
edge.  The  cellular  infiltration  had  extended  to  the  ciliary  body. 
{Annals  of  Ophihalmology,  Jan.,  1913.) 
Ganglion,  Lenticular.    See  Ganglion,  Ophthalmic. 


5344  GANGLION  MECKELII 

Ganglion  Meckelii.  (L.)  Meckel's  ganglion,  A  ganglion  situated  in 
the  spheiio-iiiaxilhiry  fossa  near  tlie  splieno-i)alatine  foramen.  It 
receives  tlie  two  si)lieno-i)alati)ie  branches  of  the  superior  maxillary 
nerve,  and  sends  branches  to  the  periosteum  of  the  orbit,  the  mucous 
iiu'inbrane  of  the  posterior  ethmoidal  and  sphenoidal  sinuses 
[LusehkaJ.  Its  branches  are  tlie  anterior,  posterior  and  external 
palatine,  the  upper  nasal,  and  the  nasopalatine,  vidian  and  pharyn- 
ii'cal   iKM'ves.     ( Foster.) 

Ganglion  nervi  optici.     Layer  of  gaiij^lion  cells  of  the  rrtina. 

Gangrene  of  the  eyelids.    See  Eyelids,  Gangrene  of  the. 

Ganglion,  Ophthalmic.  Lenticular  ganglion.  Ciliary  ganglion. 
This  important  organ  is  a  small  quadrate  body  about  the  size  of  a 
pin's  head.  It  is  placed  at  the  back  part  of  the  orbit  internal  to  the 
external  rectus  muscle.  It  can  be  found  by  tracing  the  branch  of  the 
third  nerve  to  the  inferior  oblique  backward,  when  the  ganglion  will 
be  seen.  See  Ciliary  ganglion;  also,  for  a  description  of  the  re- 
moval of  this  nervous  center  for  the  relief  of  glaueoma,  see  the  end 
of  the  heading  Glaucoma. 

Gangrene  of  the  lids.    See  Eyelids,  Gangrene  of  the. 

Gansefuss.     (G.)     Infraorbital  plexus. 

Ganzbild.  (G.)  Entire  or  stereoscopic  image — a  term  applied  by 
Ilelmholtz  to  binocular  vision,  as  opposed  to  single  vision  or  to 
di{)lo])ia. 

Gardenia  florida.  (L.)  A  plant  species  found  in  Japan  or  China  and 
cultivated  in  Southern  Asia  for  the  sake  of  its  fragrant  flowers.  The 
fruits  are  used  in  China  as  a  cooling  and  soothing  remedy  in  phthisis, 
fever,  inflamed  eyes,  and  skin  diseases. 

Garengot,  R.  J.  Croissant  de  (1688-1759).  A  celebrated  general  sur- 
geon of  Paris,  who  wrote  a  '^ Surgery"  (1720)  and  a  "Treatise  on 
Instruments"  (1723),  both  of  which  w^ere  much  read  for  many  years. 
He  was  one  of  the  first  to  extract  a  cataract,  having  performed  this 
operation  soon  after  its  invention  by  Daviel.  His  writings,  however, 
l)0ssess  almost  no  o])lit]ialmo]ogic  importance. —  (T.  H.  S.) 

Gargarisme.     (V.)     A  gargle. 

Garlands  of  cells.  An  arrangement  of  cellular  elements,  in  certain 
lumors,  sarcoma,  for  example,  tliat  suggest  the  name. 

Garlic.  Allium  sativum.  According  to  Pliny,  epinyctis,  or  suke,  a  kind 
of  ulcer  of  the  cornea,  was  favora1)ly  affected  hy  garlic  employed  as  a 
poultice.  Garlic  was  also  used  for  excessive  secretion  from  the  eye 
and  for  ecchymosis,  or  "black  eye;"  but,  in  general,  used  as  a  food,  it 
was  thouglit  to  be  detrimental  to  the  vision. —  (T.  II.  S.) 

Gas-burners.     It  is  of  great  [oplitlialmicl  imjiortauce  that  in  the  first 


GAS-EYE  5345 

place  gas-fittings  should  be  adequate  to  supi)ly  the  iiiaxiiuuiii  dcinand 
for  gas;  in  the  seeoiul,  that  tlie  gas  should  emerge  from  each  burner 
under  a  low  i)ressure.  Tliere  should  be  a  governor  for  each  gas- 
burner,  or  for  each  small  group  of  gas-burners;  these  are  now  readily 
procurable  and  when  they  are  used  a  full  tlame  is  obtained  whicli  is 
constantly  and  steadily  kept  up  by  a  comparatively  slow  supply  of 
gas;  the  incandescent  particles  or  heavy  heated  hydrocarbon  vapors 
upon  which  luminosity  depends  are  allowed  to  remain  as  long  as 
possible  in  the  flame  and  the  gas  is  thoroughly  burned ;  and  air  is 
not  swirled  into  the  interior  of  the  tiame  by  the  swift  current  of  gas, 
thus  spoiling  the  luminosity. 

Of  gas-burners  may  be  mentioned  the  bats-wing  burner  with  a  slit 
across  the  head,  the  fish-tail  burner  with  two  holes  converging  towards 
one  another,  the  Argand  burner  with  a  circle  of  holes,  etc.  All  such 
burners  are,  however,  economically  inferior  to  incandescent  burners, 
first  invented  by  Auer  von  Welsbach,  which  are  Bunsen  burners  over 
the  flame  of  which  is  fitted  a  mantle  consisting  of  thoria  along  with  a 
little  ceria,  emitting  a  brilliant  white  light  on  incandescence. — (Stand- 
ard Encyclopedia.) 

Gas-eye.  A  peculiar  disease  said  to  be  jirevalent  among  the  emploj'es 
of  the  gas-pumping  stations  in  the  natural  gas  regions  of  the  United 
States.     The  eyes  are  inflamed,  tender,  and  sensitive  to  light. 

Gas,  Illuminating',  Oculotoxic  symptoms  of.  These  are :  diminution 
of  visual  acuity,  with  contraction  of  the  visual  field;  dilatation  of 
the  retinal  veins  and  contraction  of  the  arteries.  Persistent  bilateral 
hemianopsia,  after  recovery,  has  been  recorded.  There  is  some- 
times paralysis  of  the  various  ocular  muscles,  extrinsic  and  intrinsic, 
accompanied  or  unaccompanied  by  exophthalmia.  When  the  recti 
are  paralysed,  there  is  ahvays  exophthalmia.  See  Legal  relations 
of  ophthalmology,  in  the  middle  of  the  third  article;  as  well  as 
Toxic  amblyopia. — (T.  H.  S.) 

Gas,  Ocular  relations  of.  Apart  from  oculotoxic  symptoms  (see  Gas, 
Illuminating  i  set  up  by  certain  gases — carbon  monoxide,  methane, 
carbon  tlioxide,  formaldehyde,  etc. — and  the  consideration  of  coal 
and  water  gas  as  illuminants.  the  employment  of  air  and  oxygen  in 
ophthalmic  therapy  is  practically  confined  to  such  uses  of  these 
agents  as  are  detailed  on  page  199,  Vol.  I,  of  this  Encyclopedia.  See 
also.  Illumination. 

Gasoline.    See  Petrol. 

Gassendi,  Peter  (151)2-1655).  A  notable  opponent  of  William  Harvey 
and  a  celebrated  physicist.  He  was  one  of  the  first,  but  not  the  very 
first,  to  declare  the  true  location  of  cataract.     Concerning  this  mat- 

Vol.  VII— 32 


5346  GASSERIAN  GANGLION 

ter,  he  says,  in  his  " >)ystcm  of  Physic"  (8,  II,  p.  371)  :  "To  show 
that  the  visual  power  does  not  go  out  from  the  lens  requires  no  other 
proof,  since  that  distinguislied  Parisian  surgeon  has  shown  that  an 
animal  can  see  without  a  lens.  He  has  found,  that  is  to  say,  that  a 
cataract  does  not  consist  of  a  little  membrane  between  the  lens  and 
the  uvea,  Avhich  is  torn  with  the  needle  and  sunken  into  the  deeps  of 
the  eye;  but  that  the  crystalline  body  itself,  which  is  shriveled  up,  is 
torn  from  the  ciliary  processes  and  sunken  into  the  depths."  The 
very  first  to  teach  the  true  doctrine  of  the  nature  and  location  of  cata- 
ract was  Quarre  (1648-1650?)  ;  the  first  to  confirm  that  doctrine  by 
actual  dissection  was  Rolfinck,  in  1656. —  (T.  II.  S.) 

Gasserian  g-anglion.    See  Ganglion,  Gasserian. 

Gastropaca  pini.  The  S3\steniic  iiaiiic  of  a  species  of  caterpillar  Avhose 
liairs  ]iroduce  cruciimus.     See  Conjunctivitis  nodosa. 

Gastrophthalmia.  (L.)  Ophthalmia  8ui)posed  to  be  caused  by  gas- 
tritis. 

Gastroscope.  An  instrument  for  viewing  and  investigating  the  con- 
dition of  the  interior  of  the  stomach.  It  consists  essentially  of  a  tube 
with  an  incandescent  light  and  reflecting  prisms. 

Gastroscopy.    Visual  examination  of  the  interior  of  the  stomach. 

Gataker,  Thomas.  An  English  surgeon,  of  some  imjioi'tance  in  oph- 
tlialmology.  The  place  and  date  (about  1715)  of  his  birth  are  not 
definitely  known.  He  practised  in  London,  was  surgeon  to  St.  George 's 
Hospital  and  to  the  King  of  England.    He  died  in  1769, 

Gataker  wrote,  in  addition  to  works  of  a  general  character,  ''An 
Account  of  the  Structure  of  the  Eye;  with  Occasional  EemarJcs  on 
Some  Disorders  of  that  Organ"  (London,  1761). —  (T.  H.  S.) 

Gateau.     (F.)     In  surgery,  a  roll  of  lint  spread  over  a  wound. 

Gauge,  Strap.  A  measuring  instrument.  See  Eyeglasses  and  spec- 
tacles, Mechanical  adjustment  of. 

Gaule's  pits.    See  Cornea,  Pitting  of  the. 

Gauss,  Theory  of.  Gaussian  toints.  According  to  this  observer  every 
optic  system  has  six  cardinal  points ;  two  principal  points,  two  nodal 
points,  one  anterior  focus  and  one  posterior  focus. 

Gavarrett,  Jules.  A  celebrated  French  physicist  and  ])hysiciaii,  of 
some  importance  in  ophthalmology.  The  date  and  place  of  his  birth 
are  unknown.  He  became  a  physician  at  Paris  in  1843,  and  was 
Inspector  General  for  Medicine,  and  Professor  of  IMedical  Physics  in 
the  same  city.  He  died  Aug.  31,  1890.  Among  his  writings  the  fol- 
lowing are  of  interest  to  ophthalmologists :  1.  Des  Images  par  Reflex- 
ion et  par  Refraction    {Revne   dcs   Cours   Scicntif.,   1866.)      2.  Dc 


GAYET,  CHARLES  ALPHONSE  5347 

rAstiiiiatisiue  (in  collaboration  with  Javal,  Paris,  18G7). —  (T.  II.  S.) 

Gayet,  Charles  Alphonse.  A  celebrated  Lyonese  ophthalmologist.  Born 
in  1832,  he  occupied  the  chair  of  ophthalmology  at  Lyons  from  its 
foundation  in  1872  until  his  death.  He  wrote  no  books,  but  contrib- 
uted many  articles  to  the  Archives  d'Ophtalmologic,  invented  a  cor- 
neal microscope  and  devised  a  number  of  operative  measures  that 
bear  his  name.  He  was  a  member  of  the  Academic  de  Medecine,  Ot'ficier 
de  la  Legion  d'Honneur.  He  died  as  the  result  of  a  carriage  accident, 
in  1904.— (T.  H.  S.) 

Gayet 's  transplantation  of  cilia.  Gayet  suggested  that  a  strip  of  skin 
removed  from  the  eye,  as  in  the  Alt  operation  for  trichiasis  (see  page 
589  of  this  Encyclopedia),  might  be  left  attached  at  the  extremity 
of  the  wound  towards  the  outer  canthus  and  then  transplanted  in 
the  groove  formed  by  splitting  the  lid-margin.  See  Cilia,  Gayet 's 
transplantation  of. 

Gazelle,  The.  The  thing  of  the  gazelle,  enclosed  in  ear  wax  and  swal- 
lowed when  the  moon  is  new,  will,  according  to  Pliny  the  Elder, 
protect  the  person  who  swallowed  it  (and  the  story)  from  all  dis- 
eases of  the  eye.  The  gazelle  was  supposed  to  be  immune  to  ocular 
aflfections.— (T.  H.  S.) 

Geach,  Francis.  A  well-known  English  surgeon  of  some  importance 
in  ophthalmology.  Born  in  1824,  he  became  physician-in-chief  to 
the  Plymouth  Hospital,  and  Fellow  of  the  Royal  Society,  and  died  in 
1798. 

Among  his  writings  the  following  is  of  ophthalmologic  interest: 
''Medical  and  Chirurgical  Observations  on  Inflammations  of  the 
Eyes,"  etc.  (London,  1766-68).— (T.  H.  S.) 

Gebiet.     (Q.)     A  district ;  territory  ;  region. 

Geburtsfehler.     (G.)     A  congenital  defect. 

Geburtsverletzungen.     (G.)     Birth  injuries. 

Gefassast.     (G.)    A  branch  of  a  vessel. 

Gefassbaum.  (G.)  The  aborescent  appearance  of  the  blood-vessels 
when  isolated  in  entirety  from  the  body.  The  image  (shadow)  of 
the  retinal  blood-vessels  of  one's  own  eye,  perceived  when  a  concen- 
trated light  is  directed  obliquely  into  the  eye  and  the  source  of  the 
light  is  moved. 

Gefassbezirk.     (G.)     A  vascular  area. 

Gefassbildung.     (G.)     The  formation  of  vessels. 

Gefasse.     (G.)     Blood-vessels. 

Gefasshaut.     (G.)     Choroid. 

Gefassneubildung.     (G.)     Formation  of  new  vessels. 


5348  GEFASSUNTERBINDUNG 

Gefassunterbindung-.     (G.)     Ligation  of  a  blood-vessel 

Gefassverstopfung-.     (G.j     Obstruction  of  a  vessel. 

Gefensterter  Staar.  (Gj  A  soft  cataract  in  which  the  opacity  is  not 
eoiitimious  or  hoiiiogeneous,  but  iu  which  there  are  patches  or  islets 
of  clear  lens  substance. 

Gefiihl.     (G.)     Sensation;  sense. 

Geg-enfarben.     (G.)     Antagonistic  colors;  contrast-stain. 

Geg-enmittel.     (G.)     Antidote. 

Geg-enseitig-.     (G.)     Reciprocal. 

Gehirn.     (G.)     The  brain;  encephalon. 

Geisoma.     Geison.     The  superciliary  ridge  of  the  frontal  bone. 

Geissler  tube.  Low  vacuum  tube,  employed  in  demonstrating  fluo- 
rescence and  ])liosphorescence  phenomena. 

Geisteskrankheit.     (G.)     Mental  disease. 

Gekreuztes  Doppeltsehen.     (G.)     Crossed  diplopia. 

Gelahmt.     (G.j     Paralj^zed. 

Gelatlg-enous.    Yielding  gelatine. 

Gelatine.  This  Avell-known  agent  is  obtained  from  the  hoofs,  horns, 
bones,  etc.,  of  certain  animals.  It  is  soluble  in  boiling  water,  glycerin 
and  acetic  acid,  but  insoluble  in  alcohol,  ether  or  cold  water.  It  grad- 
ually swells  up  in  the  cold  water,  forming  a  soft,  viscid  mass  that 
absorbs  from  5  to  10  times  its  weight  of  the  fluid. 

Gelatine  is  employed  occasionally  in  the  dispensing  of  ointments, 
and  as  such  is  generally  mixed  with  those  agents  that  are  not  incom- 
patible with  the  water  added  to  soften  it.  Such  a  preparation  is 
Michel's  iehthyol  ointment. 

The  chief  use  to  which  gelatine  is  put  in  the  internal  treatment  of 
ophthalmic  diseases  is  its  exhibition  as  a  blood  coagulant  (see 
Coagulose).  Tubes  of  sterile,  concentrated,  saline  gelatin  solution 
are  prepared  for  injection  into  the  gluteal  muscles  as  a  hemostatic  in 
retinal  and  choroidal  hemorrhages  and  in  ophthalmic  aneurism. 
Each  makes  a  2  per  cent,  solution  with  boiled  water  of  five  ounces, 
constituting  one  injection  at  103°  P.  Sometimes  stronger  solutions 
are  employed  at  a  somewhat  higher  temperature. 

Gelatine  forms  a  good  vehicle  for  those  alkaloids,  such  as  cocain, 
atropia,  homatropin,  hyoscin,  etc.,  that  are  most  commonly  employed 
in  the  treatment  of  eye  diseases  and  for  the  determination  of  the 
refractive  condition.  Made  up  as  small,  round  and  thin  wafers  and 
placed  for  protection  in  glass  bottles,  they  form  a  convenient  and 
accurate  means  of  applying  these  powerful  agents  to  the  eye.  Spread 
out  on  a  piece  of  clean  paper  the  tip  of  a  moistened  camel  hair  brush 
is  applied  to  the  center  of  the  disk.     It  adheres  and  may  then  be 


GELATOSE  SILVER  5349 

placed  u])oii  the  exposed  sclerotic  or  in  the  coiijiuutival  sac  there  to 
undergo  solution  and  absorption. 

Lucien  Howe  has  drawn  attention  to  tlie  fact  that  in  England 
dextrin  is  used  instead  of  gelatine  in  the  manufacture  of  these  ophtiial- 
niic  discs. 

Gelatose  silver.     Sec  Albargin. 

Gelb.     (G.)     YelloAV. 

Gelber  Fleck.     (G.)     Fovea;  yellow  spot. 

Gelbe  Salbe.     (G.)     Pagenstecher's  ointment. 

Gelbes  Jodquecksilber.  (G.)  Yellow  mercury  iodide;  mercurous 
iodide. 

Gelbfarbung.     (G.)     Coloration;  staining. 

Gelbling,  Falscher.  (G.)  The  Cantharellus  aurantiacus,  a  poisonous 
mushroom  whose  ingestion  is  sometimes  a  cause  of  toxic  amblyopia. 

Gelbsehen.     (G.)     Yellow  vision. 

Gelee.     (F.)     Fi-ost;  also,  jelly. 

Gelenk.     (G.)     A  joint. 

Gelenkfiig-ung-.     (G.)     A  joint,  whether  movable  or  not. 

Gelenkrheumatismus.     (G.)     Articular  rheumatism. 

Gelost.     (G.)     Dissolved. 

Gelsemin.  A  yellow-brown  resinoid  from  Gclsfmium  scmpcrvirena, 
which  in  from  i/s  to  2  gr.  doses  is  given  in  chorea,  riieumatism,  etc.  See 
Gelseminin. 

Gelseminin.  {Not  cjclscmin.)  Gelsemina.  CooHo.jN^Oa.  This  alkaloid 
is  ol)tained  from  the  root  of  Gelsemium  nitidum  vel  sempervircus.  It 
occurs  in  minute,  j'ellowish-white  Crystals,  odorless  but  with  a  bitter 
taste ;  very  poisonous ;  slightly  soluble  in  water,  very  soluble  in  ether 
and  alcohol.  The  hydrochloride,  as  white,  granular  crystals,  is  freely 
soluble  in  water. 

The  alkaloid  and  its  salt  act  as  mydriatics  and  are  used  for  dilating 
the  pupil,  in  1  to  500  solutions ;  the  latter  nmy  also  be  had  in  the  form 
of  gelatine  disks,  gr.  1-500. 

Gelsemism.  Poisoning  from  Gelsemium  scmpervirens.  In  light  cases  it 
is  marked  by  vertigo,  ptosis,  and  weakness  of  the  legs;  in  severe  cases 
by  tremor,  anesthesia,  and  dyspnea.    See,  also.  Toxic  amblyopia. 

Gemeiner  Stechapfel.     (G.)     Datura  stramonium. 

Gemma  oculi.     (  L. )     An  old  term  for  the  crystalline  lens. 

Gendron,  Louis  Florentin  Deshais.  A  celebrated  French  ophthalmol- 
ogist. Born  at  Orleans,  the  nephew  of  Claude  Deshais  Gendron.  he 
received  his  medical  degree  at  ]\Iontpelier  and  settled  in  Paris.  Here, 
in  1762,  he  became,  at  the  School  of  Surgery,  Professor  and  Demon- 
strator of  Oplithalmology.    His  celebrated  text-])ook,  Traiti  des  Mala- 


5350  GENEIGT 

dies  dcs  Yeux  (Paris,  1770)  was  for  more  tliaii  30  years  an  authority 
at  home  and  ahroad.  The  dates  of  liis  l)ii'th  and  death  are  not  known. 
—  (T.  II.  S.) 

Geneigt,     (G.)     Bent;  iueliued. 

General  anesthesia  in  ophthalmic  surgery.  See  Vol.  I,  p.  421,  of  this 
J-Jitcijcloptdia. 

General  blood-letting.     See  Phlebotomy. 

General  diseases  and  ophthalmology.  Systemic  conditions  in  their 
KELATiuxs  TO  ucLLAu  .sYMi'TUMs.  Tliis  Very  extcusive  and  important 
subject  has  to  a  large  extent  been  discussed  in  this  Encyclopedia. 
See,  for  examph',  Anemia;  Arteriosclerosis,  p.  612,  \o\.  I :  Diphtheria, 
p.  3998,  Vol.  yi :  Albuminuric  retinitis,  p.  212,  Vol.  1 ;  Bright 's  disease, 
Ocular  symptoms  of,  p.  1296,  Vol.  II ;  Diabetes,  Ocular  relations  of, 
p.  3924,  Vol.  V ;  Exophthalmic  goitre,  i).  4S(J5,  Vol.  VI ;  Brain  tumor, 
p.  1273,  Vol.  II ;  Chlorosis,  Ocular  symptoms  of,  p.  2068,  Xoi.  VIII,  as 
well  as  such  headings  as  Cerebrospinal  meningitis,  p.  1974,  Vol.  Ill ; 
Gout;  Syphilis;  Gonorrhea;  Toxic  amblyopia;  Focal  infections  and 
Disseminated  sclerosis. 

Under  this  heading  the  following  additional  references  (chronolog- 
icall.y  arranged)  are  given  by  observers  especially  competent  to 
speak. 

The  essential  importance  and  relations  of  systemic  to  ocular  dis- 
eases have  been  elsewhere  stated  by  the  Editor  as  follows:  IVIany  eye 
diseases  and  symptoms  are  but  local  expressions  of  general  pathologic 
processes ;  hence  the  need  for  investigating  the  general  condition  of 
the  patient.  Search  for  tubercular,  rheumatic,  syphilitic,  or  neu- 
rologic manifestations  will  be  in  order.  The  vocation,  habits,  and  diet 
should  be  studied.  Often  laboratory  tests,  such  as  examinations  of 
the  blood,  spinal  fluid,  feces,  spermatic  juices  and  urine  will  give 
valuable  data.  The  various  reaction  tests  for  syphilis,  tuberculosis, 
gonorrhea,  malaria,  etc.,  are  often  required.  As  a  rule,  the  reference 
of  the  patient  to  an  internist  fully  alive  to  the  various  needs  of  the 
ophthalmologist  will  l)e  the  most  effective  method  of  dealing  with  these 
matters. 

Treibilcock  {Pract.  Med.  Series,  p.  186,  1910)  writes  upon  certain 
affections  of  the  uveal  tract  in  which  definite  lesions  are  produced,  for 
which  recognized  systemic  diseases  such  as  syphilis,  rheumatism,  gout 
and  some  of  the  anemias  are  responsible.  Included  with  these  are 
nepliritis  and  diabetes,  all  of  which  constitute  a  systemic  dyscrasia. 
He  enters  a  plea  for  the  study  of  the  patient  as  an  individual  and  to 
recognize  and  treat  the  underlying  cause  as  well  as  the  symptoms 
manifest  in  the  eye.     The  importance  of  an  early  diagnosis  of  the 


GENERAL  DISEASES  AND  OPHTHALMOLOGY         5351 

underlying  cause  and  of  the  prompt,  yet  frequently  inconvenient  and 
wearisome  attempt  at  I'limination  of  the  toxins  priiiiai-ily  responsiljle 
for  the  onset  of  the  patliologic  processes,  is  duly  L'nii)hasized.  In  other 
words,  the  treatment  of  the  eye  must  not  consist  in  the  treatment  of 
that  organ  only,  or  in  tlie  therapy  of  the  symptoms  which  it  manifests. 
The  etiology  must  be  arrived  at  by  a  process  of  exclusion.  When 
syphilis,  gonorrhea,  tuberculosis  and  rheumatism  or  any  local  focus  of 
pyemia,  as  disease  in  the  accessory  nasal  sinuses,  or  pyorrliea  alveolaris 
may  be  counted  out,  one  may  direct  one's  attention  to  faulty  metabo- 
lism as  a  cause. 

In  a  number  of  apparently  healthy  eyes,  Chance  {Ophthalmolocjy, 
Vol.  VII,  p.  227,  1912)  has  observed  fine  granules  fioating  in  tlie 
aqueous  humor  or  resting  on  the  lens  capsule.  They  were  not  dis- 
covered until  dilatation  of  the  pupil  threw  them  into  relief  against  the 
fundus  retiex ;  and  the}'  disappeared  in  a  d-Ax  or  two.  All  the  patients 
had  gastro-intestinal  intoxication. 

Butler  {OpJitJtalmoscopc,  ix,  p.  95,  1912)  believes  that  infection 
with  the  diphtheria  bacillus  may  cause  severe  ocular  inflammation, 
which  bears  no  clinical  resemblance  to  the  ordinary  type  of  diph- 
theritic ophthalmia.  He  reports  four  cases  illustrating  this.  In  one 
there  were  general  edema  of  the  lids,  chemosis,  slight  proptosis,  and 
swelling  over  the  lachrymal  gland.  The  swelling  was  incised  without 
showing  pus;  which  appeared  four  days  later,  coming  from  the 
periosteum  of  the  malar  bone.  The  pus  contained  Klebs-Loeffler 
bacilli.  The  second  patient  had  a  whitlow,  and  some  days  later  con- 
junctivitis, without  the  usual  characteristics  of  ocular  diphtheria, 
chemosis,  edema,  and  pustular  eczema  of  the  lids.  Instead  of  staphy- 
lococci, which  were  expected,  Klebs-Loeffler  bacilli  were  found.  In 
the  third  and  fourth  cases  severe  post-operative  infections,  without 
formation  of  false  membrane,  were  due  to  the  same  bacillus. 

The  eye  complications  of  cerebro-spinal  meningitis  observed  by 
Anargyros  {OphtJialmology,  Vol.  viii,  p.  361,  1912)  include  cases  of 
abducens  paralysis  and  inflammations  of  the  conjunctiva  and  cornea. 
Under  the  serum  treatment  these  inflammations  subsided  in  a  few 
days.  Local  instillations  of  the  serum  also  exerted  a  favorable  influ- 
ence, and  Anargyros  regards  the  specific  treatment  as  the  most  im- 
portant. He  thinks  its  early,  local  application  may  prevent  ocular 
complications. 

Anthrax  usually  kills  before  secondary  complications  can  arise. 
Hence  the  eye  is  involved  chiefly  when  the  primary  lesion  is  situated 
on  the  lids.  In  a  few  cases,  however,  secondary  extensions  have  given 
rise  to  panophthalmitis,  gangrene  of  the  lids  and  phlebitis  involving 


5352         GENERAL  DISEASES  AND  OPHTHALMOLOGY 

the  oplitliiiliiiic  veins.  W'rderame  {Klin.  Monatshl.  f.  Augenheilk., 
p.  2.'}2,  Aug.,  li)ll)  reports  a  ease  of  this  kind.  The  vitreous  became 
tilled  with  pus  without  involvement  of  tlie  eornea ;  and  tlie  eyeball 
subsequently  atrophied.  There  was  severe  uveitis,  seeonihiry  uveitis 
and  glaueoma,  witli  perforation  of  the  sclera. 

JSidler-lluguenin  {Archiv  f.  Ophtluilm.,  69,  p.  34:6,  VJ12)  reports 
fourteen  cases  of  metastatic  ophthalmia  after  gonorrhea,  twelve  of 
which  were  undoubtedly  due  to  the  gonococcus.  In  five  of  these 
patients  gonococci  were  found  in  the  blood,  and  in  six  pure  cultures 
were  obtained  from  the  aqueous  humor.  There  were  nine  cases  of 
metastatic  iridocyclitis,  and  three  of  bilateral  metastatic  conjunc- 
tivitis. His  proportion  is  but  twelve  cases  among  65,UUU  patients,  but 
he  believes  the  percentages  would  be  found  much  higher  if  such  cases 
were  carefully  looked  for.  Rollet  and  Aurand  {Revue  Gcncralc 
d'Ophtal.,  31,  p.  97,  1912)  have  experimented  on  the  rabbit  by  inocu- 
lation with  cultures  of  the  gonococcus,  or  with  the  gonotoxin.  The 
organism  inoculated  in  the  anterior  chamber,  iris,  or  vitreous,  pro- 
duced severe  plastic  iritis,  which  ran  its  course  to  recovery  in  from 
three  to  five  weeks.  In  the  choroid  the  resulting  inflammation  was  less 
severe,  and  inoculation  of  the  ciliary  body  proved  negative  in  two 
cases.  Inoculation  of  the  optic  nerve  sheath  caused  optic  neuritis, 
and  subsequent  atrophy.  Introduction  of  the  gonotoxin  into  the 
anterior  chamber  or  vitreous  produced  plastic  iritis;  and  in  the  optic 
nerve  sheath,  an  optic  neuritis  with  subsequent  retinal  degeneration. 
In  the  subconjunctival  and  suprachoroidal  spaces  it  caused  no  dis- 
turbance. They  conclude  that  in  the  rabbit  gonorrheal  infection 
causes  a  poisoning  of  the  retinal  neuro-epithelium. 

The  possible  relationship  between  cataract  and  disturbances  of  inter- 
nal secretion  is  considered  by  Schiotz  {Noisk.  Mag.  for  Laegevid., 
p.  1201,  1913),  who  recalls  that  various  authors  have  reported  the 
occurrence  of  cataract  in  association  with  lowered  activity  of  the 
parathyroid,  pancreatic  and  sexual  glands,  and  that  others  have  noted 
lens  opacities  in  connection  with  hypersecretion  of  those  glands  whose 
activity  is  connuonly  regarded  as  balancing  that  of  the  first  group, 
namely,  the  suprarenals,  the  thyroid  and  the  hypophysis.  He  presents 
some  figures  from  a  pu])lic  clinic  and  a  private  practice  which  seem 
to  show  a  preponderance  of  cataract  in  women  as  compared  with  men. 
Poisoning  with  adrenalin  can  produce  tetany,  and  this  condition  is 
known  as  a  factor  in  tiie  causation  of  cataract.  Special  attention 
should  ])e  paid  to  the  condition  of  the  parathyroid  glands  at  autopsy ; 
and  also  to  the  question  of  the  occurrence  of  cataract  with  jiarathyroid 
insufficiency. 


GENERAL  DISEASES  AND  OPHTHALMOLOGY  G:}:).] 

Kraiik  Alli)()rt  {Opii.  JuconI,  DcciMiiljcr,  1!)12)  ^ivcs  tlu;  liislory  of 
a  boy,  aged  18,  wlio  had  always  had  normal  vision  in  liotli  eyes.  With- 
out accident  or  apparent  cause,  he  noticed  dimness  and  l)lui'rin<,'  of 
vision  of  tlie  right  eye.  He  had  no  pain  hut  felt  indisposed  generally 
and  had  a  temperature  of  102°  V.  and  a  eliill.  'Phere  was  no  rise  of 
temperature,  but  he  looked  yellowish  and  his  tongue  was  thickly 
coated.  Vision  was  2(1/200  and  tension  was  normal.  .Movements  of 
the  eye  were  slightly  j)iiinfiil.  His  nose,  tiu'oat  and  accessory  sinuses 
were  pronounced  normal.  His  fundus  w^as  normal,  lie  had  a  central 
scotoma,  as  shown  in  the  field  of  vision.  A  diagnosis  of  retrobulbar 
neuritis  from  intestinal  toxemia  was  made  and  he  was  given  i)ilocar- 
pine  sweats,  diet,  bowel  fiu.shings,  etc. ;  diagnosis,  catarrhal  jaundice. 

The  patient  rapidly  improved  generally  and  visually,  and  he  left 
the  hospital  in  about  ten  days  quite  well  and  with  a  vision  of  20/30. 

Finally  he  had  vision  of  20/20  and  a  perfect  i)erimeter  chart. 

This  case  shows  the  possibility  of  an  intestinal  toxemia  affecting 
the  optic  nerve  and  the  satisfactory  and  speedy  result  of  prompt  and 
proper  treatment. 

De  Schweinitz  {Section  on  Ophth.,  Seventeenth  Internat.  Cong,  of 
Med.,  London.  Aug.  10,  li)l;|),  speaking  of  Ihe  i)athogenesis  of  chronic 
uveitis,  concludes  that  there  is  absolutely  no  i)roof  that  any  toxic  sub- 
stance elaborated  within  the  tissues  in  the  course  of  a  so-called  gastro- 
intestinal auto-intoxication,  has  of  itself  by  its  toxic  properties,  pro- 
duced a  uveitis. 

While  it  ]nay  be  possible  that  directly  or  indirectly  the  relapses 
and  persistence  of  certain  types  of  uveitis  nuiy  depeiul  upon  the  direct 
or  indirect  effect  of  so-called  gastro-intestinal  intoxications,  exactly 
as  the  contiiniance  of  a  central  amblyojjia  has  been  suppo.sed  to  depend 
upon  the  same  cause,  there  is  no  proof  of  this  connection. 

While  indican  in  the  urine,  especially  in  excessive  amounts,  is  a 
good  index  of  intestiiud  putrefaction,  its  al)sence  does  not  prove  that 
a  gastro-intestinal  intoxication  is  not  present,  and  to  depend  alone 
upon  the  presence  of  tliis  substance  for  information  in  these  respects 
is  a  mistake. 

Inasmuch,  as  intestinal  putrefaction  certainly  depends  upon  tlie 
activity  of  bacteria  upon  the  food-stuffs  in  the  intestines,  tlu-re  seems 
good  reason  to  ])elieve  that  these  bacteria,  or  their  toxic  products,  may 
be  the  cause  of  an  inflammation  of  the  uveal  tract,  exactly  as  bacteria 
from  other  foci  of  sui)puration,  have  a  similar  influence.  In  this 
sense,  therefore,  gastro-intestinal  intoxications  have  a  right  to  be 
included  among  the  etiologie  factors  of  uveitis. 

Inasmuch,    as    acute    articular    rheumatism    (rheumatic    fever)    is 


;354  GENERAL  DISEASES  AND  OPHTHALMOLOGY 

rarely,  ii'  ever,  a  cause  of  iridocyclitis  (uveitis),  and  inasmuch,  as 
various  types  of  myalgia  (inuseular  rlieuuiatism)  and  i)olyarthritis 
are  in  largest  measure  not  strictly  rheumatic  affections,  it  seems  advisa- 
ble to  discontinue  the  term  "rheumatic"  iritis,  or  iridocyclitis,  and 
to  substitute  for  it  some  title  which  does  not  commit  us  to  an  unproven 
etiologic  factor.  Thus  far,  the  one  suggested  by  T.  Harrison  Butler, 
to-wit,  " auto-toxemic  iritis,"  although  not  a  definite  one,  seems  best 
to  fulfil  the  indications. 

Uveitis  (iritis  and  iridoej'clitis)  occurring  in  the  subjects  of  various 
forms  of  polyartliritis,  is  doubtless  due  to  the  same  cause  wliich  creates 
the  joint  affections;  what  the  cause  is  thus  far  has  not  been  discov- 
ered. Similar  ocular  affections  in  the  subjects  of  various  myalgias 
(muscular  rheumatism)  should  probably  be  regarded  as  manifesta- 
tions of  the  same  infection  or  toxemia  which  causes  the  muscle-  and 
fibrous-tissue  pains  and  lesions ;  and,  although  the  so-called  rheumatic 
diathesis  has  been  brought  forward  as  an  etiologic  factor  in  this  dis- 
ease, in  the  absence  of  definite  knowledge  concerning  its  pathogenesis, 
a  more  explicit  statement  as  to  its  causation,  and  therefore  as  to  the 
causation  of  the  iridocyclitis  with  which  it  may  be  associated,  can 
not  be  made. 

Evidence  is  lacking  that  the  relationship  between  gout  and  various 
diseases  of  'the  uveal  tract  (uveitis,  iridocyclitis)  should  be  aban- 
doned, in  that  no  satisfactory  proof  has  been  presented  that  the  same 
cause  which  produces  the  various  manifestations  of  gout,  for  example, 
eczema,  joint  lesions,  etc.,  may  not  also  produce  a  ehemic  inflammation 
of  the  uveal  tract.  It  is  not  unlikely  that  diabetes,  but  much  more 
rarely,  can  be  accused  in  the  same  manner. 

There  is  satisfactory  evidence,  clinical  and  bacteriologic,  that  the 
majority  of  eases  of  uveitis  (iridocyclitis)  are  caused  by  micro-organ- 
isms or  their  toxins.  Potent  in  this  respect  (omitting  those  excluded 
from  this  discussion)  the  gonocoecus  and  the  staphylococcus  are  con- 
spicuous. Other  bacterial  elements  doubtless  may  play  a  similar  role. 
As  Axenfeld  has  pointed  out,  it  is  diiifieult  and  often  impossible  by 
the  ordinary  tests  to  eliminate  the  influence  of  tuberculosis. 

That  the  gonocoecus  is  the  cause  of  many  eases  of  iritis  and  irido- 
cyclitis is  unquestioned,  and  that  it  is  the  cause  of  many  cases  ordinar- 
ily classified  as  rheumatic,  is  undoubtedly  true ;  that  it  may  be  the 
cause  of  chronic  insidious  uveitis,  especially  as  it  occurs  in  women,  has 
not  been  definitely  proved,  but  it  cannot  be  entirely  excluded  from  the 
list  of  those  micro-organisms  which  are  potent  factors  in  this  disease. 

The  primary  source  of  infection  from  which  the  staphylococcus  pro- 
ceeds and  reaches  the  uveal  tract,  there  to  create  an  inllammation,  in 


GENERAL  DISEASES  AND  OPHTHALMOLOGY         5355 

all  probability  most  frequently,  is  ;i  dironie  septic  process  in  the  mouth 
(pyorrhea  alveolaris),  in  the  tonsil,  in  the  naso-pliaryiix,  iu  the  acces- 
sory nasal  sinuses,  in  the  intestines,  in  the  uterine  cavity,  in  the  skin 
(boils,  furuncles,  etc.). 

It  is  probable  tliat  in  most  instances  the  living  bacteria  reach  the 
uveal  tract,  and  by  their  presence  ami  their  elaborated  toxins  bring 
about  the  various  types  of  intlannnation  which  are  classified  under  the 
general  term  uveitis,  tlie  process  being  a  nou-suppurative  one  on 
account  of  the  modification  which  these  bacteria  undergo  in  their 
passage  through  the  blood-stream. 

Although  the  term  infiannuation,  as  ordinarily  defined  and  con- 
ceived, comprehends  a  pathologic  condition  characterized  by  the  pres- 
ence of  bacteria  at  the  site  of  activity,  there  is  much  evidence  to  show 
that  lesions  possessing  all  the  fundamental  characteristics  of  similar 
lesions  which  result  from  the  immediate  action  of  living  bacteria,  can 
be  brought  about  by  bacterial  toxins,  and  that  in  these  lesions  there  is 
nothing  to  suggest  that  in  the  course  of  their  development  bacteria 
were  immediately  present  (Abbott).  Therefore,  while  proof  may  be 
lacking  that  bacterial  toxins  circulating  in  the  blood  are  capable  of 
causing  localized  inflammations  of  the  uvea,  proof  is  equally  lacking 
that  such  is  not  the  case.  Indeed,  we  are  not  justified  in  denying  that 
these  toxins  have  this  power,  unless  we  are  also  willing  to  reject  the 
theory  of  specific  combining  affinities. 

As  it  is  possible  to  speak  intelligently  of  auto-intoxication  only  when 
poisons  are  formed  by  the  tissues  of  the  body  itself,  that  is,  within 
the  metabolism,  and  are  not  introduced  through  specific  bacterial 
infections,  and  as  we  have  no  accurate  knowledge  of  these  toxins,  it 
would  seem  wise  to  discontinue  the  term  "gastro-intestinal  auto-intox- 
ication, ' '  although  freely  admitting  that  gastro-intestinal  intoxications 
of  bacterial  or  parasitic  origin  are  potent  sources  of  infection. 

Although  indican,  when  found  in  excessive  amounts  in  the  urine 
(indicanuria)  is  an  index  of  intestinal  putrefaction,  its  absence  does 
not  prove  that  a  gastro-intestinal  intoxication  is  not  present,  nor  is 
it  proper  to  depend  upon  the  presence  of  this  substance  alone  for 
information  in  these  respects.  If  after  thorough  analysis,  urobilin, 
phenol,  increase  in  the  percentage  of  ammonia  output,  excess  of  fatty 
acids,  and  increase  of  conjugate  sulphates  above  200  mgm.,  etc.,  are 
determined,  intestinal  putrefaction  dependent  upon  the  activity  of 
bacteria  on  the  food-stuffs  in  tiie  intestines  has  been  demonstrated. 
These  analyses  do  not  in  any  way  prove  that  any  toxic  substance 
elaborated  in  the  course  of  a  so-called  gastro-intestinal  auto-intoxica- 
tion, that  is,  a  toxin  formed  witliin  the  metabolism,  can  liy  its  toxic 


5356        SURGERY— RELATIONS  TO  OPHTHALMOLOGY 

l)r()j)ri'1ic.s  pi'oduet'  u  uveitis,  but  tlicy  do  prove;  tlu;  bacterial  activity 
to  whicli  ivt'ereiice  has  been  made,  and  indicate  a  source  from  which 
these  bacteria  or  their  toxic  pi'oducts  may  proceed  and  cause  an  inflam- 
mation of  the  uveal  tract,  exactly  as  bacteria  or  their  toxins  from  other 
foci  have  a  similar  influence.  Jn  this  sense,  therefore,  gastro-intestinal 
intoxications  have  a  definite  right  to  ))e  included  among  the  etiologic 
factors  of  uveitis. 

Chronic  insidious  uveitis,  especially  as  it  occurs  in  women,  who  are 
often  anemic,  is  in  all  probability  most  freciuently  excited  by  bacteria 
or  bacterial  toxins  which  have  come  from  foci  of  chronic  sepsis,  par- 
ticularly in  the  luouth,  the  tonsils,  the  sinuses,  the  pelvis,  and  the 
gastro-intestinal  tract. 

While  indieanuria  certainly  has  not  been  proved  to  have  the  rela- 
tionship to  the  development  of  certain  types  of  chronic  and  relapsing 
uveitis  (iridocyclitis)  that  has  been  given  to  it  by  some  writers,  there 
is  good  reason,  as  Elschnig  insists,  to  study  patients  with  these  dis- 
eases of  the  eye  from  the  metabolic  standpoint.  This  study,  however, 
should  not  be  confined  to  the  ordinary  tests  for  indican  in  the  urine, 
but  should  include  a  thorough  investigation  of  the  patient's  metabo- 
lism. It  is  probable  that  such  studies  may  eventually  lead  to  the 
establishment  of  a  definite  group  of  diseases  of  the  uveal  tract  called 
into  existence  by  infections  of  bacterial  origin  arising  in  the  intestinal 
tract. 

B.  T.  Lang  {Brit.  Med.  Jour.,  Feb.  22,  1913)  points  out  that  in  the 
majority  of  cases  of  scleritis,  keratitis,  iritis,  cyclitis  and  choroiditis, 
the  cause  of  the  affection  is  obscure.  Excluding  physical  damage,  the 
chemical  effects  of  bacteria  or  other  toxins  are  regarded  as  that  cause. 
Septic  foci  occur  in  three  situations:  along  the  respirato-alimentary 
tract;  along  the  genito-urinary  tract;  on  the  skin  or  in  a  sinus  leading 
from  it. 

The  views  of  the  writer  are  liased  upon  an  analysis  of  176  eases. 
The  areas  of  septic  inflammation  which  give  rise  most  often  to  eye 
troubles  are  those  that  are  subjected  to  frequent  mechanical  disturb- 
ances such  as  infections  of  the  gums,  which  are  massaged  at  each  meal, 
or  the  male  urethra,  which  is  continuously  disturbed  during  mictura- 
tion. 

It  is  necessary  in  every  case  to  And  out  and  treat  a  septic  focus  to 
cure  the  patient.  Many  cases  of  iritis  and  the  like  recover  under  the 
influence  of  ordinary  treatment  and  the  action  of  drugs,  but  such  cases 
frefjueiitly  recur  unless  the  septic  focus  is  treated  and  cured. 
General  surgery  in  its  relations  to  ophthalmology.  See  Distant  organs, 
Operations  on,  for  relief  of  eye  symptoms. 


GENERATIVE  ORGANS,  DISEASES  OF  5357 

Generative  organs,  Diseases  of.  Sec,  in  this  connection.  Dysmenor- 
rhea, p.  4106,  Vol.  VI,  also  Climacteric,  p.  22!)1.  Vol.  ill,  of  this 
l-JiK  1/(1  op<  (lid ;  as  well  as  Gonorrhea;  Lactation;  Parturition;  Sup- 
pressio  mensiiim;  Amenorrhea;  Puberty;  Masturbation;  Soft 
chancre;  also  Copiopia;  Gestation;  and  Pregnancy. 

Genievre.     (F.j     (Jin. 

Genoform.  0 — Oxybenzoic-acid-methylene-acetate.  CioHioO^.  This 
proprietary  remedy  is  a  glycolester  resulting  from  the  interaction  of 
acetyl-salieylic  acid  and  formaldehyde,  and  occurs  as  a  white  crystal- 
line powder  with  a  slightly  acid  taste,  solul)le  with  difficulty  in  cold 
water;  readily  soluble  in  hot  water,  alcohol  or  ether.  According  to 
the  proprietors  the  product  passes  the  stomach  unchanged  and  is  split 
in  the  intestines  into  salicylic  acid,  acetic  acid  and  formaldehyde.  It 
exerts  a  decided  analgesic  influence  in  various  rheumatic  and  gouty 
affections.  Its  antiarthritic  properties  are  dependent  upon  the  libera- 
tion of  formaldehyde,  which,  according  to  the  recent  investigations  of 
His  and  Paul,  has  a  tendency  to  form  combinations  with  the  excess 
uric  acid  found  in  the  system  of  the  gouty  patient ;  l)eing  quite  soluble, 
these  urates  are  readily  eliminated  from  the  organism.  The  prepara- 
tion is  apparently  free  from  all  di.sagreeable  after-effects. 

Genoform  is  said  to  have  yielded  excellent  results  in  the  treatment 
of  gout,  rheumatism,  sciatica,  neuralgia  and  the  various  kinds  of  rheu- 
matoid pains,  and  has  been  recommended  as  a  substitute  for  the  salicy- 
lates  (and  similar  compounds)   in  eye  diseases. 

The  dosage  is:  5-7i/o-10  grains,  recommended  every  3  or  4  hours, 
administered  in  powder  or  tablet  form. 

Genou.     (F.)     Knee. 

Genre.     (F.)     Species:  kind. 

Genscul,  Joseph.  Inventor  of  cauterization  of  the  cornea.  Born  at 
Lyons,  Jan.  8,  1797,  he  studied  at  Lyons  and  Paris,  at  the  latter  insti- 
tution receiving  his  degree  in  1824.  Returning  to  Lyons  he  became  a 
famous  surgeon.  According  to  Gurlt  he  was  a  brilliant  operator  and 
inventor,  having  im])roved  the  technique  of  rhinoplasty,  cleft-palate, 
catherization  of  the  nasal  canal,  cauterization  of  varices,  etc.  Two  of 
his  most  important  writings  are  the  following:  1.  Lettre  Chirurgicalc 
sur  quelques  Maladirs  Grarrs  du  Sinus  Ma.rilhircs  et  dc  VOs  Ma.ril- 
lairc  Infericur  (with  folio  atlas;  Lyons,  1833.)  2.  Sur  Ir  Mrraii)s)nc 
de  la  Vmon  (Paris,  1851).— (T.  H.  S.) 

Genth,  Carl.  A  distinguished  Dutch,  or  German,  physician,  Avho.  in 
conjunction  Avith  Pagenstecher,  wrote  the  "'Atlas  dcr  Fathologisclicn 
Anatoniie  des  Augapfels."    The  text  of  this  book  was  translated  into 


5358  GENTIAN 

IOii<j:lisli   ill   ISTT)  ])y  Sir  \Villi;nii  (Jowcrs.     (jlenlli  dird  in  1!J04. —  (T. 
II.  S.) 

Gentian,  (lintiatui  luha.  Ociitiau  juice  was  used  hy  Dioscoridcs  in 
oridar  ])hU'<^iiioii,  wliilc  holli  he  and  Pliny  employed  it  very  frecjuently 
as  an  ingredient  in  oeulai-  ointments. —  (T.  II.  S.) 

Lewin  and  Ouillery  (Dir  Wirkunij  von  (iift<n  aitf  das  Aiifjc,  I,  p. 
.S92)  says  that  ingestion  of  this  bitter  root  has  caused  amaurosis. 

Gentian-violet.  Pakik  violet.  Direct  violet.  Dahlia,  A  green  pow- 
der, soluble  in  water  and  alcohol,  and  used  as  a  dye  and  in  Weigert's 
stain.  This  coal-tar  product  is  said  by  Hock  {Centralbl.  f.  pkt.  Augen- 
heilk.,  p.  105,  1904)  to  have  caused  in  a  workman  a  purulent  con- 
junctivitis and  corneal  ulcer.  They  shortly  afterwards  became 
normal. 

GeogTaphy  of  ocular  affections.  Distribution  of  eye  diseases.  Al- 
though the  importance  of  assigning  or  of  attempting  to  assign  geo- 
graphic, topographic  or  ethnologic  limits  to  certain  eye  diseases,  or  of 
estimating  the  proportion  of  ocular  affections  to  each  country,  is  con- 
siderable, yet  the  difficulties  attendant  upon  such  a  survey  are  often 
insurmountable  because  of  the  paucity  or  unreliability  of  statistics. 
However,  the  work  and  writings  of  such  men  as  Chibret,  Hirschberg, 
Nimier  and  Swan  Burnett  are  of  considerable  help  in  such  a  study. 
Moreover,  Roure  has  given  us  {Encyclopedie  Franqaise  d'Ophtal- 
mologie,  Vol.  IX,  p.  389)  an  excellent  treatise,  the  French  portion  of 
which  has  been  to  some  extent  compiled  from  answers  to  numerous 
qnestionaires  on  the  subject.  To  this  monograph  of  Dr.  Roure  the 
writer  is  indebted  for  much  of  the  following  information.  The  reader 
is  also  referred  to  page  1125,  Vol.  II,  of  this  Encyclopedia,  where  the 
distribution,  as  well  as  the  ethnic  relations  of  hlindness,  is  discussed; 
also  to  the  caption,  Ethnology  of  the  eye,  in  which  the  racial  characters 
of  ophthalmic  diseases  and  anomalies,  including  ocular  anthropology, 
are  treated  at  some  length. 

In  the  following  pages  the  distvihntion  of  particular  diseases, 
together  with  a  consideration  of  the  influences  exerted  upon  each  by 
race,  climate,  topography,  occupation,  etc.,  are  set  forth. 

Statistics  show  that  diseases  of  the  lids  proper  are  rare  in  Russia 
and  do  not  predominate  in  any  particular  country.  Trichiasis  as  a 
result  of  trachoma  is  especially  ])rnnounced  in  Egypt  and  on  the 
Mediterranean  coast. 

Diseases  of  the  cornea  reach  their  maxinium  in  Spain  and  Portugal. 
In  the  three  cities  of  these  countries  fi'om  which  we  have  statistics, 
Madrid,  Barcelona,  and  Lisbon,  more  than  30  per  cent,  of  all  eye 
affections  were  corneal.    In  central  Europe  the  frequency  is  an  average 


GEOGRAPHY  OF  OCULAR  AFFECTIONS  5359 

and  till'  iiiiiiiiniiiii  is  found  in  southeastern  Europe  and  in  Holland, 
that  is,  in  low  and  marshy  regions.  This  condition,  which  at  first 
seems  paradoxical,  is  explained  when  considering  that  in  these  regions 
conjunctivitis  is  very  fre(iuent  and  that  the  predominance  of  this 
disease  lowers  the  percentage  of  all  otiier  eye  affections. 

In  Java,  according  to  Steiner,  corneal  diseases  are,  as  a  whole,  rather 
frequent  (32  per  cent.).  What  makes  the  proportion  so  high  is 
trachoma  complications.  Aside  fi-om  this  it  should  be  noted  that,  on 
the  contrary,  primary  corneal  affections,  such  as  phlyctenular  keratitis 
or  ophthahnic  scrofula,  are  exceedingly  rare.  Steiner  explains  this  by 
the  mode  of  living  of  the  iMalayans.  Unlike  the  poor  population  in 
European  cities,  the  natives  of  Java  live  out-of-doors  or  in  open  or 
poorly-closed  huts.  We  know  that  such  hygienic  conditions  are  most 
favorable  to  the  prevention  of  scrofulous  corneal  affections. 

A  study  of  the  distribution  of  conjunctival  affections  resolves  itself 
in  many  cases  into  a  study  of  the  distribution  of  trachoma,  since  this 
is  the  only  form  of  conjunctivitis  having  an  even  approximately  com- 
plete geography. 

Conjunctival  diseases,  considered  as  a  whole,  appear  to  be  most  fre- 
quent in  Russia,  principally  on  the  border  of  the  Black  and  Caspian 
seas.  They  reach  the  enormous  proportions  of  89.4  per  cent,  at  Sebas- 
topol,  53.3  per  cent,  at  Astrakan,  and  53.2  per  cent,  at  Odessa.  I\Iost 
severely  affected  are  the  Ioav  and  humid  regions,  where  the  poverty  of 
the  inhabitants  precludes  the  taking  of  proper  hygienic  measures.  In 
the  preceding  figures  trachoma  plays  a  prominent  part.  Accord- 
ing to  Steiner  the  conjunctival  diseases  among  the  ^lalayan  popu- 
lation of  Java  totals  42  per  cent.,  of  which  30  per  cent,  is  trachoma. 
From  the  investigations  of  Van  Millingen,  Chibret  and  Hirschberg  it 
appears  that  trachonui  thrives  equally  well  in  arctic,  temperate  and 
tropical  climates.  The  climatic  conditions  of  high  altitude  are  unfa- 
vorable to  trachoma,  especially  if  accompanied  by  low  temperature 
and  moisture,  as  in  Swit^^erland.  If,  on  the  other  hand,  the  climate 
is  warm  and  dry,  as  in  Colorado,  the  altitude  does  not  diminish  the 
frequency  of  this  disease.  Heat  and  sun  aid  and  aggravate  the  devel- 
opment of  trachoma,  and  patients  suffer  more  in  summer  than  in  win- 
ter. Attempts  have  been  made  to  introduce  racial  differences  in 
connection  with  the  etiology'  of  trachoma.  The  white  and  yellow  races 
are  most  affected,  but  the  black  race  is  by  no  means  immune. 

According  to  Swan  Burnett  trachoma  is  a  diathesis  and  race  con- 
stitutes only  a  predisposition.  In  support  of  this  hypothesis  it  can 
be  noted  that  the  Latin  race,  particularly  in  Italy,  is  the  one  most 
affected  in  Europe,  and  that  the  Brazilians,  of  Latin  origin,  are  more 


5360  GEOGRAPHY  OF  OCULAR  AFFECTIONS 

affected  than  other  Americans.  C'hibcrt  believes  the  Celts  to  he  rela- 
tively inimune.  Nevertheless,  pure  Celts  get  the  disease  both  in  Ireland 
and  in  North  America.  Norway  is  free  from  trachoma,  but  racial 
characters  in  no  way  prevent  Norwegians  in  the  Tnited  States  from 
becoming  affected.  The  Jews  are  particularly  exposed  to  this  disease. 
The  gA'psies,  though  unclean,  are  spared,  because  they  do  not  mi.x  with 
the  fixed  inlia])itants  of  any  country.  There  is  but  very  little  trachoma 
among  the  negroes  of  the  Soudan  and  the  United  States  because  they 
live  apart  from  the  white  people ;  yet  trachoma  is  very  frequent  among 
the  negroes  of  Brazil.  Therefore,  the  negro  race  is  by  no  means 
immune. 

Trachoma  is  very  unevenly  distributed  over  the  surface  of  the  globe, 
but  is  found  almost  everywhere.  Russia  is  severely  affected.  Of  1,000 
eye  patients  there  are  96  trachoma  patients  in  Petrograd ;  20  to  40  at 
^loscow;  60  at  Restow;  102  at  Helsingfors;  114  at  Saratow;  116  at 
Lodz;  124  at  AVarsaw;  121  at  Libau;  146  at  Reval :  180  to  350  at 
Dorpat;  200  at  Riga;  150  to  250  at  Odessa;  180  at  Kasan.  In  east 
Germany  we  find  130  at  Posen,  154  at  Koenigsberg.  The  ]\Iediter- 
ranean  coast  is  severely  affected.  In  France  the  inhabitants  of  the 
coasts  are  more  trachomatous  than  those  of  the  interior ;  especially  the 
inland  mountaineers  are  rarely  affected  by  trachoma.  Southern  Italy 
shows  a  high  percentage  of  trachoma.  Of  1,919  eye  diseases  treated 
by  Stilo  d  'Ascola,  from  1898  to  1904,  about  30  per  cent,  were  trachoma- 
tous. In  Greece  the  proportion  is  29.6  per  cent.  Trachoma  is  infre- 
quent in  Switzerland  except  in  Fribourg,  where  it  is  introduced  either 
by  Italian  laborers  or  ]\v  students  coming  from  East  Prussia.  In 
Bavaria  and  Wiirttemberg  this  disease  is  infrequent  and  the  cases 
found  are  isolated  and  appear  to  be  of  exotic  origin.  On  the  other 
hand,  it  is  found  quite  frequently  in  Hohenzollern,  a  country  sur- 
rounded entirely  by  AViirttemberg,  whither  it  was  su]>posedly  brought 
by  soldiers  from  Rhenish  or  East  Prussia.  Trachoma  is  infrequent 
in  Munich,  Nuremberg.  Brandenbourg.  Saxony.  Pommerania,  Hanover 
and  Alecklenbourg.  Africa  is  particularly  affected  by  trachoma.  The 
percentage  is  enormous  both  on  the  coiist.  in  Sahel  and  even  on  the 
high  plateaus  of  Alfa.  The  Arabs  on  the  Saliaran  incline  are  possibly 
still  more  affected,  and  travelers  report  that  nearly  all  aged  people  are 
blind.  In  Egypt  more  than  half  the  native  population  is  contami- 
nated. The  frequency  is  less  in  other  parts  inland,  and  on  the  Atlantic 
and  Pacific  coasts.  All  of  Asia  is  trachomatic.  The  disease  is  common 
in  China  and  Japan.  Hirschberg  gives  the  percentages  20  for  Cal- 
cutta, 10  for  Bombay ;  Harston  reports  70  per  cent,  in  Hongkong,  and 
Steiner  has  observed  30  per  cent,  among  the  ^Malayans  of  Java.     In 


GEOGRAPHY  OF  OCULAR  AFFECTIONS  5361 

Arabia  one-tifth  of  the  natives  are  reported  att'ectcd.  Wliile  infrequent 
in  New  York  and  the  greater  part  of  the  I'liitod  States,  trachoma  is 
eoninion  in  Mexico  and  on  Lai'lata. 

In  Cuba  1  per  cent,  of  the  eye  diseases  is  trachoma.  In  a  review 
of  the  several  epidemics  and  endemic  focci  of  trachoma  in  tlie  ishmd 
of  Cuba  P^ernandez  {Ophthalmology,  p.  173,  Oct.,  11)13)  gives  his 
experience  as  government  expert  during  four  years.  In  the  province 
of  Pinar  del  Rio,  out  of  nearly  2,500  school  children,  he  found  that  230 
had  trachoma,  more  or  less  typical.  In  Havana  he  examined  about 
3,000  children  and  some  adidts  and  found  TOO  cases  of  the  disease. 
At  Matanzas  out  of  750  children  examined.  7')  eases  were  found,  but 
many  more  are  present  in  the  province.  At  Santa  Clara  he  had  sev- 
eral small  focci  to  combat,  and  his  colleague  and  successor,  Penichet, 
found  in  a  small  town  of  less  than  a  thousand  inlia])itants,  over  100 
cases  of  trachoma.  At  Oriente  Province,  very  large  epidemics  liave 
occurred. 

Jolm  Green,  Jr.  {Interstate  Med.  Joudi.,  June,  1013)  states  that  it 
is  impossible,  at  the  present  time,  to  arrive  at  a  complete  knowledge 
of  tlie  pi-evalence  of  trachoma  in  the  United  States,  for  the  reason  that 
as  yet  no  general  surv^ey  of  the  incidence  of  tiiis  disease  has  been  under- 
taken. Even  if  such  a  general  investigation  were  to  be  undertaken, 
it  is  extremely  unlikely  that  it  would  yield  accurate  results.  And  the 
prime  obstacle  in  the  path  of  the  investigator  would  be  the  fact  that, 
witli  rare  exceptions,  boards  of  health,  whether  town,  city  or  state, 
have  failed  to  realize  that  trachoma  is  a  dangerous  contagious  dis- 
ease, and  hence  liave  not  included  it  in  the  list  of  reportable  maladies. 

Schereschewesky  considers  that  the  disease  has  not  yet  become  gen- 
ei-al  ill  the  United  States,  though  it  is  ratiier  frequent  along  the 
Atlantic  seaboard,  owing  to  the  great  immigration ;  it  is  prevalent  to 
a  certain  degree  in  the  West  owing  to  western  iiiigi'atory  movements; 
in  certain  areas  of  southern  Illinois  and  in  the  mountains  of  Ken- 
tucky and  West  Virginia  it  has  been  endemic  foi-  a  number  of  years. 

Brown  states  that  in  New  York  City,  prior  to  1807.  trachoma  con- 
stituted 4  per  cent,  in  over  half  a  million  subjects  with  contagious 
diseases;  three  years  later  (trachoma  having,  in  the  meantime,  been 
classified  as  a  "dangerous  contagious"  disease  by  the  immigration 
authorities,  thus  compelling  the  deportation  of  aliens  so  afflicted)  only 
a  little  over  2  per  cent,  were  seen  in  100,000  eases  of  contagious  dis- 
eases. Although  New  York  City  probably  has  the  greatest  number  of 
eases  of  any  one  focus,  the  disease  is  on  the  decline  when  the  increase 
in  population  is  taken  into  account.    The  Now  York  ^Municipal  Bureau 

Vol.  VII— 33 


5362  GEOGRAPHY  OF  OCULAR  AFFECTIONS 

of  Ik'altli  recorcU'd  soinetliiiig  Jiku  10,435  cases  of  traelioiiui  in  liJU8, 
while  ill  lliU9  tlic  mniiber  reported  was  7,<J!M). 

Infoniiatioii  from  Baltimore,  Cleveland  and  I'liiladelpliia  indieates 
that  the  disease  iu  these  cities  is  on  the  decline.  In  Toledo  and  Akron, 
Ohio,  it  is  on  the  increase.  In  Dayton,  Ohio,  it  is  said  to  be  assuming 
alarming  proportions.    In  Chicago  the  disease  is  stationary. 

It  should  be  noted  that  the  increase  is  especially  noticeable  in  smaller 
towns  and  cities  which  do  not  seem  to  be  able  to  put  in  force  the  pro- 
cedures that  would  insure  prompt  eradication. 

The  disease  is  very  prevalent  in  southern  Illinois  and  in  nortliern 
Arkansas.  In  Missouri  it  is  estimated  that  there  are  not  less  than 
10,000  sutt'erers.  Stucky  found  it  appallingly  i)revalent  in  tlie  moun- 
tain regions  of  eastern  Kentucky  owing  to  the  fact  partly,  that  many 
of  those  who  need  surgical  treatment  and  hospital  care  have  not  the 
tinancial  means  to  o])taiii  thera;  the  country  in  which  they  live  contains 
no  institution  where  they  can  be  cared  for  without  personal  expense, 
and  the  county  treasury  contains  no  funds  to  provide  for  even  the 
hospital  care  elsewhere.  The  United  States  Health  Service  found 
about  12  per  cent,  of  4,000  individuals  selected  at  random  to  be 
afflicted. 

In  Oklahoma.  "White  and  Treibley  found  65  per  cent,  of  the  100,000 
Indian  population  to  be  sufferers  from  trachoma.  These  authors  state 
that  the  disease  is  "very  prevalent  iu  Illinois,  Missouri,  Oklahoma, 
Arkansas  and  Texas."  White  found  that  48  per  cent,  of  the  white 
children  in  the  Pawnee  public  schools  were  afflicted,  and  his  examina- 
tion in  other  white  schools  throughout  the  state  justifies  the  assertion 
that  from  20  to  40  per  cent,  of  all  the  white  school  children  of  Okla- 
homa are  trachomatous. 

Australasia  is  almost  exempt  from  trachoma. 

^Mention  should  also  be  made  of  pure  Eg}ipiian  ophiliahnia,  which, 
in  the  opinion  of  Roure,  should  not  be  mistaken  for  trachoma.  The 
former  disease  is  now  thought  by  some  observers  to  be  a  conjunctivitis 
similar  to  purulent  gonoeoccic  ophthalmia.  Demetriades  thinks  that 
it  is  identical  therewith,  and  is  carried  from  one  person  to  another  by 
flies. 

In  connection  with  trachoma  attention  should  be  called  to  the  black, 
pigmented  spots  appearing  during  this  disease  on  the  tarsal  con- 
junctiva of  the  upper  lid.  Steiner  has  observed  them  in  the  ^Malays  of 
Java  and  in  certain  Chinese. 

Pterygium  is  most  frequent  in  hot  climates.  Its  development  is  due 
to  tlie  combined  actions  of  sunlight  and  of  external  irritating  agencies 
such  as  wind,  dust  and  uncleanliness.     It  is  very  common  in  India, 


GEOGRAPHY  OF  OCULAR  AFFECTIONS  5363 

Constantinople  and  in  Spain.  In  Madeira  its  frequency  is  so  great 
that  it  is  considered  epidemic.  In  France  it  is  principally  found  on 
the  Mediterranean  coast. 

Cases  of  xerosis  are  unusually  numerous  among  the  negroes  of  South 
Carolina,  especially  among  their  children.  The  white  race  in  this 
locality  is  not  affected. 

In  Cuba  are  regular  epidemics  of  catarrhal  conjunctivitis  that  is 
often  contagious.  The  infection  is  spread  by  small  flies  called 
"guasasas."  A  similar  disease  exists  in  Algeria  and  is  caused  by  the 
larvEe  of  Oestrus  ovis.  This  fly  sometimes  deposits  its  eggs  on  people 's 
faces  and  in  their  eyes.  White  worms  are  developed  that  are  the  cause 
of  an  intense  but  not  dangerous  conjunctivitis. 

H.  Campbell  has  observed  numerous  cases  of  leprosy  of  the  con- 
junctiva in  Singapore,  and  the  tubercular  form  of  this  disease  also 
exists  in  Iceland. 

It  is  interesting  to  note  the  exceptional  infrefiucncy  of  vernal  con- 
junctivitis in  Russia.  Krukow  in  ^Moscow  reports  only  3  cases  in 
100,000;  Nentausen  one  in  191,000;  Bellarminow  and  Delganow  none 
in  168,618  cases  of  eye  disease. 

Race  appears  to  have  a  certain  influence  on  the  development  of 
glaucoma.  White  people  are  most  affected,  but  the  disease  is  also 
found  in  .yellow  and  black  races.  In  Havana,  according  to  Lopez, 
glaucoma  is  found  in  the  proportion  of  11  whites  to  6  negroes,  1 
mulatto  and  1  of  the  yellow  race.  The  Jews  are  generally  recognized 
as  highl}^  predisposed.  Among  the  glaucoma  patients  of  de  Wecker's 
clinic  20  per  cent,  were  Jews.  The  Latin  races  come  in  for  a  greater 
proportion  than  Anglo-Saxons.  Thus  glaucoma  is  less  frequent  in 
the  United  States,  where  the  Anglo-Saxon  element  predominates,  than 
in  Havana,  where  the  Spaniards  are  numerous.  There  is  also  less 
glaucoma  in  the  English  colony  of  Singapore  than  in  Java,  although 
the  climate  is  similar.  Climatic  conditions  appear  to  have  no  influence 
on  the  frequency  of  this  affection.  Small  eyes  seem  to  be  most  ex- 
posed. Derby  found  1.24  per  cent,  of  glaucoma  in  America,  -t.To  per 
cent,  in  Asia.  Glaucoma  is  said  to  be  quite  common  in  Africa.  In 
Europe,  Russia  is  most  affected  (from  2  to  10  per  cent.)  ;  Denmark  is 
next  (4.5  per  cent.),  followed  by  Switzerland  (2.6  per  cent.)  and 
Spain  (2.6  per  cent.)  ;  France  is  last.  But  the  question  has  not  been 
fully  investigated  and  the  figures  above  presented  cannot  be  consid- 
ered final. 

The  irregular  geographic  distribution  of  diseases  of  the  lens  (cat- 
.aract)  teaches  us,  to  begin  with,  that  sun  and  heat  have  to  be  counted 
as  uncertain  factors  in  their  causation  until  more  complete  informa- 


5364  GEOGRAPHY  OF  OCULAR  AFFECTIONS 

lion  is  aviiihililf.  'I'lic  iiinxiiimiii  ric(jiiciic_\-  ;iiii()ii<^'  rye  diseases  is  found 
in  Utrecht  (S.;{  per  cent.),  JMadi'id  (11.1  per  cent.),  Amiens  {]'2.')  per 
cent.),  and  liai'celona  (11.1  i)er  cent.),  that  is,  in  i)laces  varying,  l)oth 
in  climate  and  altitmh'.  The  minimum  i)r()])ortion  is  found  in  Petro- 
grad  (;j.()  i)er  cent.),  Pavia  (2.7  per  cent.),  and  Buenos-Aires,  h)cali- 
ties  which  also  dift'er  fi'om  one  another  in  character.  Santos  Fernandez 
justly  remarks  that  on  the  ishind  of  Cuha,  where  the  temperature 
remains  constant  the  year  around,  no  more  nor  less  cataract  is  found 
than  in  otlier  countries,  either  in  Europe  or  America. 

Apart  from  the  rather  freqnent  cases  of  traumatic  cataract  among 
farmers  and  factory-workers,  it  must  be  aihnitted  that  geography  does 
not  give  US  much  information  about  the  etiology  of  this  affection. 

Certain  ])aT'ts  of  France  are  noted  for  traumatic  cataract.  In  Saint- 
Eticume,  a  city  with  vast  metal  industries,  it  often  happens  that  glow- 
ing steel  particles  enter  the  lens.  In  Ardeche  opalescence  of  tile  lens 
is  often  caused  by  stings  of  wasps  that  live  on  chestnut  trees  and  attack 
the  chestnut  harvesters. 

Examination  of  available  statistics  teaches  that  affections  of  the  iris 
and  choroid  are  much  less  frecjuent  in  eastern  and  northern  Europe 
(Russia,  Prussia,  Holland)  than  anywhere  else.  These  diseases  reach 
their  maximum  in  central  Europe  (Bavaria,  Wiirttem])ei-g)  and  are 
found  in  an  average  number  of  cases  (that  may  be  regarded  as  nor- 
mal) in  southern  and  southwestern  Europe  (France,  Spain).  In  Am- 
sterdam and  Glasgow  the  proportion  is  1.7  per  cent. ;  in  Astrakan, 
Petrograd,  Posen,  Odessa  and  Kiew  2  per  cent. ;  in  ^Nlagdebourg  14.0 
per  cent. ;  in  Munich  9.2  per  cent. ;  in  Bordeaux,  Valencia,  Amiens, 
Nantes,  Montpellier  and  Lisbon  from  3  to  6  per  cent. 

The  influence  of  climate  upon  this  grouj)  of  diseases  is  felt  only  in 
connection  with  those  general  diseases  of  which  they  are  symptoms; 
that  is  to  say,  they  are  rarely  primary  diseases,  but  appear  ordinarily 
as  consequences  of  syphilis,  rheumatism  or  infectious  diseases  (influ- 
enza, etc.).  In  Singapore,  for  example,  nearly  all  affections  of  the  iris 
or  the  choroid  are  of  syphilitic  origin. 

Diseases  of  the  sclera  are  most  common  in  southern  Europe.  Statis- 
tics from  Greece,  Spain  and  Portugal  show  the  proportion  to  be  more 
than  1  per  cent.,  while  in  Russia,  outside  of  Petrograd,  the  projiortion 
nowhere  exceeds  0.2  per  cent. 

Anomalies  of  refraction  and  accommodation,  while  frecpient  in  Hol- 
land and  Germany,  are  compai-atively  rare  in  Spain  and  Italy.  In 
addition  we  note  that  ametropia  is  more  frequent  in  the  United  States 
and  Singapore  among  the  Anglo-Saxon-German  population  than  in 
Cuba,  where  Spaniards  are  in  the  majority,  or  in  Java  (yellow  race). 


GEOGRAPHY  OF  OCULAR  AFFECTIONS  5365 

From  llu'se  observations  we  may  conclude  lliat  race  has  a  great  in- 
fluence upon  the  dcveh^piuent  of  these  anomalies. 

It  is  now  generally  conceded  that  cthnograpliic  variations  in  tlie 
form  of  the  skull  correspond  to  sudi  modifications  in  the  visual  appara- 
tus as  shape  of  the  eyeball,  propoi-tion  of  its  diameter  to  the  depth  of 
orbit,  etc.  Anomalies  of  acconnnodation  may  therefore  be  expected 
to  vary  ethnographically.  Among  tlie  Swedes,  who  have  high  orbits 
and  large  orbital  indices,  myopia  is  very  rare.  With  the  yellow  and 
black  races  refraction  is  oftenest  hypermetropic  or  emmetropic, 
altliough  there  are  in  China  many  myopes.  According  to  Callan, 
myopia  is  also  the  exception  in  the  New  York  negro  schools;  tlie 
greater  part  of  the  pupils  being  hypermetropic.  In  the  schools  of 
Titiis,  frequented  by  1,258  Russian,  Armenian  and  Georgian  pupils, 
more  cases  of  myopia  are  found  among  the  Armenians  and  Georgians 
than  among  the  Russians.  With  tlie  ^lalay  population  of  Java  errors 
of  refraction  are  the  exception.  According  to  Steiner  this  depends 
upon  the  open-air  life  of  the  population  and  because  Malay  children 
do  not  go  to  school. 

The  geographical  distribution  of  myopia  is  better  known  than  tiiat 
of  other  refractive  errors,  principally  through  the  studies  of  Boudiu. 
Cherviu  and  Nimier.  In  France  there  are  two  areas  of  maximum 
mj^opia,  one  in  the  southern  and  southwestern  provinces  (714  to  1,477 
for  each  100,000  inhabitants),  the  other  in  the  northern  and  north- 
eastern provinces  (590  to  1,056  per  100,000  inhabitants).  The  least 
affected  regions  in  France  are  Brittany,  the  borders  of  the  Rhine, 
Provence  and  Savoy. 

In  the  rest  of  Europe  we  lind  myopia  most  prevalent  in  the  eastern, 
central  and  w^estern  regions.  In  England  and  Iceland  there  are  but 
few  myopes,  in  Spain  and  Italy  it  is  still  rarer.  In  Russia  myopia  is 
frequent,  reaching  40  per  cent,  in  I*etrograd.  In  Germany  we  find  a.s 
high  as  50  or  60  per  cent.  In  Asia,  China,  Japan  and  Hindoustan  are 
most  affected;  in  Africa,  Egypt,  Al)yssinia,  Tunis  and  ^Morocco.  In 
America  we  find  19  per  cent,  in  New  York,  and  4  per  cent  in  Buenos- 
Aires.  The  Germans  claim  that  myopia  is  in  proportion  to  the  instruc- 
tion of  a  people  and  this  claim  is  not  entirely  witiiout  foundation,  for 
we  find  in  the  grammar  schools  one  per  cent,  of  m^'opes,  in  the  high 
schools  26  per  cent.,  and  59  per  cent,  in  the  colleges.  Sustained  visual 
effort  favors  the  develo})ment  of  myopia.  But  above  all,  the  ethnic 
predisposition  should  be  kept  in  mind.  Pflueger  has  shown  more  cases 
of  myopia  in  the  German  part  of  Switzerland  than  in  the  French  sec- 
tions, wliile  Eperon  and  Sulzer  found,  under  like  school  conditions. 


5366  GEOGRAPHY  OF  OCULAR  AFFECTIONS 

more  casi's  of  myopia  among  the  (Jciniaii  tliiiii  among  the  Latin  race 
l)ii|»ils  in  tlic  schools  of  Lausanne. 

Tlif  inllncni'i'  of  race  on  myoi)iii  becomes  still  more  marked  when 
the  iiereditary  relations  of  this  affection  are  borne  in  mind.  Parent 
found  that  of  330  instances  of  myopia  the  disease  was  hereditary  in 
216  families,  i.  e.,  in  65  per  cent,  of  the  cases.  P^r  the  reasons  before 
mentioned,  astigmatism  largely  depends  upon  the  form  of  the  skull, 
and  therefore  on  race.  In  France,  England  and  Germany  the  vertical 
meridian  has,  as  a  rule,  the  greatest  curvature,  while  in  the  Hebrew 
race  it  is  the  horizontal. 

Regarding  anomalies  of  acconnnochition.  Campbell  Ilighet  states 
that  in  Singai)ore  the  amplitude  dimiiiislies  more  i'ai)idly  than  in 
Europe,  not  only  among  natives,  but  also  among  Europeans  after  pro- 
longed residence  in  the  tropics.  We  have  here  to  do  with  climatic 
intluences.  The  high  temperature  of  these  countries  can  and  does 
actually  produce  an  atony  of  tlie  organism  which,  among  other  symp- 
toms, numifests  itself  ])y  a  lowering  of  the  amplitude  of  accommo- 
dation. 

Heterophoria  and  heterotropia  are  most  frequent  in  Germany. 
When  one  remendiers  the  frecjuency  of  errors  of  refraction  in  that 
country  it  is  not  difficult  to  find  the  reason  for  the  numerous  cases  of 
divergent  and  convergent  stral)ismus  (3  to  6  per  cent.).  In  Russia, 
where  diseases  of  refraction  are  less  frequent,  we  find  also  fewer  cases 
of  strabismus.  In  Petrograd  and  the  surrounding  country  the  pro- 
portion is  highest,  but  reaches  only  2.2  per  cent,  of  the  total  number 
of  eye  diseases.  In  Singapore  errors  of  refraction  and  accommoda- 
tion are  frequent  (48  per  cent.),  although  the  proportion  of  strabis- 
mus is  but  0.6  per  cent.  This  contradiction  is  only  apparent,  since 
the  greater  part  of  the  48  per  cent,  is  associated  with  anomalies  of 
accommodation  probably  due,  as  just  explained,  to  clinuitic  influences. 
But  errors  of  refraction,  not  anomalies  of  accommodation,  is  the 
ordinary  cause  of  strabismus;  therefore  it  is  not  astonishing  to  find 
but  few  cases  of  strabismus  in  Singapore. 

Diseases  affecting  the  eye-ball  and  the  orbit  are  irregularly  dis- 
tributed, but  appear  to  be  less  frequent  in  central  Europe  (0  to  2  per 
cent.)  and  more  frequent  in  Russia  (1  to  4  per  cent.)  than  anywhere 
else.  It  is  possible  to  find  a  plausible  reason  for  this.  It  is  known 
that,  with  the  exception  of  tumors  of  the  globe  and  of  the  orbit,  the 
greater  number  of  affections  of  these  organs  are  panophthalmias, 
which  occur  as  consequences  of  traumatisms  or  septic  ulcers.  For  this 
reason,  in  countries  like  Germany  and  Fi-ance,  where  ojihthalmic  hos- 
pitals  are   close   together,   such   affections   are   taken   care   of  before 


GEOGRAPHY  OF  OCULAR  AFFECTIONS  5;j67 

bulbar  or  orbital  coiiiplicalions  arise,  wbile  in  Kussia,  where  the  uni- 
versities are  far  apart,  the  ophthalmie  surgeon  does  not  generally  see 
sueli  eases  until  they  have  reached  their  last  stages. 

Diseases  of  the  optie  nerve  and  of  the  retina  are  rather  infrefjuent, 
if  we  are  to  trust  available  statistics,  in  Russia.  The  proportion  is 
0.3  per  cent,  in  A.strakan  and  Sebastopol  and  1.1  per  cent,  in  Petro- 
grad.  In  western  Europe  the  frequency  appears  to  be  greater:  9.7 
per  cent,  in  Barcelona,  S.o  per  cent,  in  Valencia,  7.2  per  cent,  in  Paris. 
They  are  as  a  rule  dependent  on  the  general  health  of  the  patient,  and 
it  is  for  this  reason  that  the  geographic  situation  has  a  certain  influ- 
ence. For  example,  in  Germany  we  find  quite  often  a  disease  that  is 
elsewhere  infrequent,  namely,  sub-retinal  cystieercus,  which  is  due  to 
alimentation.  This  affection,  according  to  Mitwalsky,  is  infrequent 
in  Bohemia.  In  Singapore  nearly  all  cases  of  retinitis  are  caused  b}' 
syphilis.  In  addition,  a  considerable  proportion  of  neuritis  and  of 
optic  atrophy  is  attributed  to  malaria.  In  South  Carolina  retinitis 
is  nearly  always  of  syphilitic  origin.  In  the  same  locality  some  cases 
of  albuminuric  retinitis  are  also  on  record,  mostly  among  negroes. 
Wenneman  announces  the  existence  in  the  Congo  of  a  special  form  of 
ophthalmia  said  to  be  very  frequent  both  among  the  natives  and  the 
foreign  population.  It  is  a  diffuse,  unilateral  or  double  chorio-retinitis. 
Its  etiology  is  unknown,  but  it  has  nothing  to  do  with  syphilis  or 
malaria.  Santos  Fernandez  contends  that  in  Havana  toxic  amblj'opia 
is  never  caused  b}'  nicotine,  but  only  ])y  alcohol.  He  states  that  the 
toliaeco  of  Havana  does  not  cause  amblyopia!  It  is  more  probable, 
however,  that  this  immunity  from  tobacco  amblyopia  is  brought  about 
by  the  formation  in  the  system  of  certain  "  stimulines, "  which  accord- 
ing to  ]Metchnikoif  are  capable  of  counteracting  the  effect  of  a  non- 
microbic  poison,  generated  during  several  successive  generations  of 
people  indulging  in  the  poison.  In  Culia  the  white  race  is  the  greatest 
sufferer  from  toxic  amblyopia. 

Rivers  believes  that  the  natives  of  Torres  Strait  and  of  New  Guinea 
have  very  imperfect  chromatic  sense.  In  northern  Queensland  the 
people  have  only  three  words  to  designate  colors.  On  the  island. 
Kiwai,  blue  is  said  to  be  confounded  with  black.  The  negroes  on  the 
strait  of  Torres  do  not  confound  red  and  green,  but  they  are  unable 
to  distinguish  lilue  from  green.  Among  the  Esquimos,  on  the  con- 
trary, the  (?olor  sense  is  highly  developed. 

No  exact  information  is  available  regarding  the  geographic  distribu- 
tion of  diseases  of  the  vitreous  body.  They  are  infrequent  fO.l  to 
3.0  per  cent.),  and,  as  is  well  known,  do  not  constitute  a  morbid  t^ntity 
but,  as  a  rule,  are  merely  a  symptom  of  some  general  disease. 


5;}68  GEOMETRICAL  FORMS 

Diseases  of  the  laelif\  iiial  appacal  us  are  most  i'rei|iieii1  in  central 
lMiro])e,  esprciallv  ill  I"' ranee,  where,  as  a  rule,  the  |»roj)oi"tion  exceeds 
4  pel"  cent.  Ill  none  of  the  l''reiii-h  cities  from  wiiich  we  have  statistics 
is  the  pi'oportioii  less  tlian  :!.7  pel'  cent.  The  inhaliitants  of  soutiiern 
regions  also  seem  to  have  a  pronounceij  tendency  to  lachi'ymal  affec- 
tions. In  oriental  Europe,  in  the  neij^diliorhood  of  Cral  and  in  the 
mountainous  region  of  centi-al  l']ui()pe.  these  affeetions  oeeur  with 
least  fi-e(iuency.  This  fact  appears  to  indicate  that  a  mountain  climate 
favors  the  normal  function  of  the  lachrymal  apparatus. 

Steiner  (of  Java)  calls  attention  to  the  relative  infrequency  of  dis- 
eases of  the  lachrymal  duets  among  the  Malays  in  spite  of  their  flat 
noses.  AVhile  among  us  such  a  nose-form  would  he  indicative  of  a 
congenital  or  an  acquired  pathologic  process,  it  is,  on  the  contrary, 
among  the  ]\Ialayans  a  racial  particularity  which  does  not  imi)air  the 
full  (lev<'loi)nient  of  the  nose  and  the  tear  ducts. —  (Erik  Eenger.) 
Geometrical  forms.     A  term  sometimes  used  to  designate  a  particular 

test-t  >"]){'. 

Geometrical  optics.  That  branch  of  optics  which  concerns  itself  witli 
tlu'  laws  of  the  reflection  and  refraction  of  light.  See  Physiological 
optics. 

Geosccpic  microscope.  An  instiniment  for  investigating  the  minute 
sti-ucture  of  soils. 

Geostatics.     The  statics  of  rigid  bodies. 

Gerade.     ((J.)     Direct,  straight. 

Geradlinig'.     (G.)     Eeetilinear. 

Geradsicht.     ((J.)     Direct  vision. 

Geranium  mexicanum.  (L.)  A  species  of  i)lant  life  fouutl  in  Mexico, 
where  its  root  is  employed  as  an  astringent  in  diarrhea  and  dysentery 
and  in  eye  disease's. 

Gerardus  Cremonensis  (1114-1180  A.  D.j.  An  esteemed  translator  into 
Jjatin  of  Avicenna's  "Cauon."  as  w^ell  as  of  numerous  other  Arabian 
writings;  also  of  the  works  of  Galen  and  Hippocrates.  He  invented 
the  word  orhiid,  whence,  of  course,  has  been  derived  the  English 
"orbit."  It  should  be  recalled,  in  this  connection,  that  Latin  medical 
terms  were  first  employed,  at  least  to  any  great  extent,  in  the  mediaeval 
Latin  versions  of  Arabian  medical  authors  The  Arabs  themselves, 
as  well  as  the  Romans  before  them,  resorted  to  the  ancient  Greek  for 
medical  technicalities.— (T.  H.  S.) 

Gerbsaure.     ((\.)     Tamiic  acid. 

Gerdy,  Pierre  Nicolas.  .\  disl  inLiuished  l-'i'dich  surgeon,  inventor  of 
lachrymal  I'liinotomy  ((].  \.).  I'xtrn  at  liOehes,  France,  May  1,  1797, 
the  son  of  a   peasant,  he  studied  at    Paris  undei"  gn^at  difficulties.     In 


GERLIER'S  DISEASE  5'.m 

1825,  however,  he  was  appointed  liospital  surgeon,  in  1833  professor 
of  external  pathology,  and,  in  1837,  of  cliniL-al  surgery.  lie  died 
JMareh  19,  1856.  He  wrote  on  numerous  sul)jeets:  anatomy,  i)hysiol- 
ogy,  ophthalmology,  philosophy,  painting  and  seulpture.  Ilis  oi)h- 
tlialmologic  writings  are  as  follows:  1.  p]xperienees  sur  la  Vision 
(1840).  2.  Recherehes  sur  1' Unite  de  la  Perception  Visuelle  (184U). 
3.  Historique  sur  les  Travaux  sur  la  Vision  {Bulletin  de  I'Acad.  de 
Med.,  1840).  4.  Remarques  sur  la  Vision  des  Somnambules.  {Ex- 
perience, 1841;  German  trans.,  Quedlinburg,  1842).  5.  Sur  la  For- 
mation d'un  Canal  Artifieiel  dans  les  Cas  d 'Obliteration  du  Canal 
Nasal  {Jour,  dcs  ronnais.  Med.-Chir.,  1848).— (T.  H.  S.) 

Gerlier's  disease.  Vertige  paralysant.  An  aft'ection  noticed  by 
Wilbrand  and  Saenger  {Ncurologie  des  Auges,  Vol.  I)  affecting  some 
])eople  in  the  Swiss  Canton  of  Geneva  who  suffer  from  the  malhy- 
gienic  practice  of  sleeping  in  unventilated  stables.  The  symptoms 
are  recurrent  attacks  of  vertigo,  impaired  vision,  diplopia,  ptosis  and 
oculo-muscular  pareses.  The  attacks  last  ten  minutes;  during  the 
intervals  the  patient  suffers  from  exhaustion  and  a  feeling  of  fullness 
in  the  head.    A  cure  follows  a  change  in  the  method  of  living. 

Germander.  Teucrimn  chamcedris.  The  juice  of  the  leaves  of  this 
plant,  mixed  with  oil,  Avas  used  by  the  ancient  Greeks  and  Romans 
as  a  cure  for  corneal  cicatrices. — (T.  H.  S.) 

Germany,  Law^s  of,  relating  to  ophthalmology.  See  Legal  relations  of 
ophthalmology. 

Gerold,  Jacob  Hugo.  The  surname  is  also  written  "Gerson. "  A  well- 
known  ophthalmologist  of  Aken-on-the-Elbe.  He  was  bom  at  Aken 
Aug.  3,  1814,  and  twenty-one  years  thereafter  received  his  profes- 
sional degree  at  Berlin.  For  fourteen  years  he  practised  in  Agen, 
then  removed  to  Delitsch,  in  order  to  accept  an  appointment  as  County 
Physician.  Three  years  later,  however,  he  returned  to  Aken,  where 
he  continued  to  reside  and  to  practise  until  his  death,  June  29,  1898. 
Among  his  more  important  writings  are  the  following:  1.  De 
Chymificatione  artificio.sa  (Graduation  thesis,  1835).  2.  Uber  Periph- 
akitis  {Casper's  WoclienscJwift,  1845).  3.  Die  Lehre  vom  Schwarzen 
Staar  und  dessen  Heilung  (INIagdeburg,  1846).  4.  Be-  oder  Empfohl- 
ener  Studien-plan  fiir  ]\Iediciner  (^Magdeburg.  1846).  5.  Grundlinien 
zu  einem  Liehtmesser  behufs  der  Nachbehandlung  des  Grauen  Staares, 
u.  s.  w.  (INIagdeburg,  1848).  6.  Die  Nervose  Augenschwache  und  ihre 
Behandlung  (Halle.  1860).  7.  Ophthalmologische  Studien.  Der 
Liehtmesser  fiir  Augenkrankenzimmer,  u.  s.  w.  (Quedlinburg.  1862). 
8.  Ophthalmologisch-klinische  Studien.  Neue  Folge.  Zur  Therapeutis- 
chen  Wfirdigung  Farl)ig('r  Diopter  ((iiessen.  1867).     9.  Die  Ophthal- 


5370  GEROMORPHISM 

mologische   Pliysik   uiul   ihre  Aiiwrnduiif,'  aiif   dw   Praxis    (Vienna, 
ISC!!;   1S701.— (T.  II.  S.) 

Geromorphism.  A  disease  of  the  skin  tluit  occasionally  affects  tlie 
u])i)er  lid,  i)i'odiU'ing  ptosis.  It  is  characterized  by  extreme  relaxation 
iind  tiaccidity  of  the  integument  in  various  parts  of  the  body,  which 
assumes  a  bagginess  that  gives  it,  even  in  young  subjects,  precisely 
the  ai)i)earance  of  the  skin  of  old  subjects. 

Gerontopia.     An  obsolete  term  for  presbyopia. 

Gerontotoxon.  (tEkontoxon  cornE/>:.  Arcus  senilis.  A  fatty  degen- 
eration of  the  periphery  of  the  cornea  which  comes  on  in  old  age, 
affects  both  eyes  simultaneously,  and  is  usually  most  marked  in  the 
upper  and  lower  segments  of  the  cornea.  See,  also,  Vol.  I,  p.  5G0,  of 
this  Encyclopedia. 

Gerontoxon.    S.  c  Gerontotoxon. 

Gerontoxon  lentis.  N'on  Amnion's  name  for  a  "crown-like,"  or  bifur- 
cated, sometimes  stationary,  form  of  partial  senile  cataract.  The 
term  is  sometimes  used  in  the  sense  of  incipient  cataract. 

Gerson,  Georg  Hartog.  A  celebrated  German  surgeon  of  some  impor- 
tance in  ophthalmology.  Born  at  Hamburg,  Germany,  Aug.  25,  1788, 
son  of  the  famous  obstetrician,  Joseph  Gerson,  and  brother  of  two 
physicians,  he  studied  medicine  at  Berlin  and  Gottingen,  at  the  latter 
institution  receiving  the  medical  degree  in  1810.  His  dissertation  on 
this  occasion  w^as  entitled  "De  Forma  Cornea  Oculi  Humani  deque 
Singularis  Visus  Phenomeno, "  one  of  the  earliest  accounts  of  astig- 
matism. (See  Thomas  Young,  in  this  Encyclopedia.)  For  a  time  he 
served  as  surgeon  in  the  Gerinan  army,  and  was  present  at  Waterloo. 
In  1816  he  settled  in  Hamburg,  and  was  soon  a  successful  practitioner. 
He  founded  in  1819  the  "Uamhurg'sches  Magazin  f.  die  AusUindisclie 
Literatur  der  Gesammten  Heilkunde,"  on  which  he  was  a  collaborator 
till  1835,  In  1833  he  was  made  Professor  of  Anatomj^  at  the  newly 
constituted  Anatomico-Surgical  College  in  Hamburg.  After  the  death 
of  his  wife  he  suffered  severely  from  angina  pectoris,  and,  Dec.  3, 
18-13,  died  suddenly  of  this  disease,  immediately  after  he  had  finished 
the  performance  of  an  enterotomy. —  (T.  H.  S.) 

Gerson,  Jacob  Hugo.  A  well-known  ophthalmologist  of  Aken-on-the- 
HIIm-.    See  Gerold. 

Gerstenkorn.     (G.)     Chalazion. 

Gerstenkorngeschwnlst.     ((J.)     lloi-deolum  or  stye;  sometimes,  also,  a 

(•li;il;i/.ion. 
Gescheidt,    Anton.      A    distinguished    Dresden    ophthalmologist.      He 
received  his  medical  degi'ee  at  Leipzig  in  1831,  presenting  as  thesis 
"De  Colol)nniate  Tridis."     His  most  important  writings  are:     1.  Die 


GERSCHMINKTER  STAAR  5371 

Entozoeu  des  Auges.  Eine  Nciturliislorisch-ophthahno-nosologische 
JSkizze  {von  A^nmoii's  Zcitschrift  fur  Oplithalnwlogic,  1833).  2,  Die 
Irideremie,  das  Iridoscliisuia  und  die  Coreetopie,  die  drei  Weseut- 
licheu  Bilduiigsfehler  der  Iris  (von  Graefe  uiid  vou  Walther's  Joui'n., 
1835).  3.  Beitriige  zur  rathologic  und  Therapie  der  Epidemisehen 
Cholera  (Dresden,  1842).— (T.  II.  IS.) 

Gerschminkter  Staar.     (G.)     Blaek  or  pigmented  eataraet. 

Geschnitten.     (G.)     Cut. 

Geschwulst.     (G.)     A  swelling  or  tumor. 

Geschwiir.     (G.)     Abscess;  boil;  sore;  ulcer,. 

Gesetz.     (G.)     Law. 

Gesicht.     (G.)     The  sense  of"  siglit.     The  lace. 

Gesichtlos.     (G.)     Blind. 

Gesichtsachse.     (G.)     Visual  or  optical  axis. 

Gesichtsbetrug.     (G.)     An  optical  illusion. 

Gesichtsempfindungen.     (G.)     Phenomena  of  vision. 

Gesichtsermiidung.     (G.)     Asthenopia. 

Gesichtserscheinung.     (G.)     An  optical  phenomenon. 

Gesichtsfehler.     (G.)     Defect  or  dimness  of  vision. 

Gesichtsfeld.     (G.)     Field  of  vision. 

Gesichtsfeldmesser.     (G.)     Perimeter. 

Gesichtsfeldschema.     (G.)     Perimeter  cliart. 

Gesichtsfeldstorungen.     (G.)     Anomalies  of  llie  visual  field. 

Gesichtshiigel.     iG.)     The  optic  thalanuis. 

Gesichtspriifung.     (G.)     Visual  test. 

Gesichtsschwindel.     (G.)     Ocular  vertigo. 

Gesichtssinn.     (G.)     The  sense  of  sight. 

Gesichtsstorung.     (G.)     Disturbance  of  vision. 

Gesichtstauschung.     (G.)     Optical  illusion. 

Gesichtsverdunkelung.     (G.)     Dimness  of  vision. 

Gesichtsvorstellung.     (G.)     Visual  perception. 

Gesichtswahrnehmung.     (G.)     Visual  perception.. 

Gesichtsweite.     (G.)     The  range  of  vision. 

Gesichtswerkzeug.     (G.)     Visual  apparatus. 

Gesichtswinkel.     (G.)     Facial  (sometimes  visual  or  optical)  angle. 

Gestation.  ^lany  ocular  symptoms  are  attributed  directly  to  this 
process,  but  it  is  questionable  whether  the  majority  have  any  but  an 
indirect  connection  with  the  pregnant  state.  However,  o1)servations 
of  the  fields  of  vision  during  gestation,  made  by  N.  Forti  {Arcliivio  di 
Ottahnologm,  XVII,  8,  abstracted  in  the  Ophthalmic  Revieiv,  p.  240, 
Aug.,  1910),  are  worthy  of  consideration.  Forti  reviews  the  work  of 
Bellinzona  and  Tridondani,  who  had  previously  made  a  series  of  obser- 


r,;572  GESTATION 

vjilioiis  upon  llic  fields  of  vision  in  pregnant  women.  These  investigators 
wci'c  (•ar<'t'iil  to  choose  patients  in  whom  there  was  no  other  disturhing 
cause  which  might  have  injuriously  aU'eeted  the  accuracy  oi"  vision 
and  til  us  have  vitiated  their  statistics.  They  believed  they  were  able 
to  establish  the  following  conclusions:  That  a  bilatei-al  limitation  of 
the  lields  does  occur  in  pregnancy.  That  tiiis  restriction  consists,  not 
in  a  uniform  or  concentric  restriction,  but  in  a  bitemporal  pseudo- 
heminanopsia,  a  limitation  of  the  fiekls  in  the  temjioral  area  of  each. 
That  in  nearly  ever}'  case  the  field  of  tiie  left  eye  was  more  severely 
att'ected  than  that  of  the  right  one.  That  these  alterations  are  more 
evident  in  the  primipara  than  in  those  who  have  borne  several  chil- 
dren, and  that  they  progress  as  pregnancy  proceeds.  That  there  is  no 
tendency  to  dyschromatopsia  or  to  achromatopsia,  the  color  fields  fol- 
lowing their  usual  order  of  white,  blue,  red  and  green.  That  the 
accuracy  of  vision  is  not  in  any  way  interfered  with. 

The  authors  also  believed  that  they  had  been  able  to  establish  a 
relationship  between  the  gravid  state  and  certain  visual  manifestations 
which  are  truly  functional  rather  than  the  effects  of  definite  patho- 
logical alterations,  and  they  support  their  assertions  in  part  by  the 
observations  of  one  of  their  number  who  in  the  course  of  investigations 
regarding  certain  nerve  reactions  in  pregnancy  was  struck  by  the 
analogy  or  resemblance  between  these  reactions  and  those  in  the 
condition  of  hysteria. 

Forti  repeated  the  procedure  and  examined  in  numerous  eases  the 
field  of  vision  in  pregnant  women  whose  condition  was  normal  other- 
wise, and  he  has  arrived  at  the  following  conclusions:  That  there  is 
a  very  sliglit  limitation  to  be  seen  in  the  nasal  half  of  the  field,  and 
a  decidedly  more  definite  restriction  in  the  temporal.  That  as  regards 
right  eye  and  left  there  is  no  dilference ;  they  are  equally  affected. 
That  the  alteration  is  more  marked  in  the  primipara,  but  that  the 
advance  of  pregnancy  makes  no  difference:  certainly  not  for  the  worse. 
Tliat  the  acuteness  of  vision  remains  unaffected,  and  there  is  normal 
amplitude  of  accommodation,  but  when  the  patient  is  compelled  to 
keep  the  eyes  fixed  upon  an  object  for  a  certain  space  of  time  very 
definite  hysterical  symptoms  begin  to  manifest  themselves. 

As  will  thus  l)e  seen,  Forti  is  quite  unable  to  confirm  tlie  statement 
of  Hellinzona  and  Tridondani  that  the  left  eye  is  more  seriously  or 
more  frequently  affected  than  tlic  right;  he  suggests  that  possibly  the 
authors  have  been  misled  by  examining  the  right  eye  first  as  a  routine; 
in  the  ease  of  any  functional  defect  or  lesion  such  as  has  been  sug- 
gested the  eye  examined  after  the  fatigue  of  the  other  would  be  sure 
to  exhibit  the  lesion  si)oken  of.     The  two  authoi-s  do  not  say  whether 


GESTREIFTER  STAAR  oliVi 

they  consisteiilly  cxainiiicd  the  eye  of  one  side  in  parlicMilar  Ix-foi-c 
that  of  the  other,  hut  Foi-ti  tlii'ows  out  the  suj^t^'cstion  for  what  it 
may  be  worth.  The  "fatigue-held"  would  in  that  event  show  itself 
with  more  constaney  in  the  eye  examined  later  than  in  the  other.  He 
confirmed  the  truth  of  this  in  the  eases  he  examined,  for  if  he  took 
the  held  of  the  right  eye  before  that  of  the  left,  it,  the  right,  always 
had  the  better  field,  and  vice  versa. 

There  is  a  fairly  clear  distinction  ])etween  hysterical  restriction  of 
the  fields  and  that  seen  in  tlie  gravid  patient  in  that  in  the  former  the 
limitation  is  (in  the  ordinary  though  not  precisely  in  the  etymological 
sense  of  tiie  word)  concentric,  while  in  the  latter  the  tendency  is 
rather  towards  hemianoi)ic,  or  at  all  events  the  reduction  is  more 
obvious  in  the  two  temporal  fields  than  in  tiie  two  nasal  halves,  but  it 
is  just  possible  that  this  apparent  difference  nmy  be  related  to  the 
usual  custom  of  examining  hrst  the  nasal  field  and  then  the  temporal, 
in  which  case  the  fatigue-symptom  of  additional  limitation  would  of 
course  appear  in  tiie  temporal  half.  This  would  provide  an  additional 
proof  of  the  necessity  of  examining  the  fields  not  in  various  meridians 
but  in  concentric  circles.  By  repeated  trials  Forti  has  thoroughly 
satisfied  himself  of  the  fact  as  stated  in  reg;ard  to  the  reduction  of 
the  field. 

With  the  opinion  of  I>elIinzona  and  Tridondani  that  these  phe- 
nomena are  more  common  in  primipara'  Forti  is  so  far  in  agreement, 
but  he  doubts  if  they  are  correct  in  saying  that  the  symptoms  increase 
as  pregnancy  proceeds;  if  so,  that  is  rather  contrary  to  the  usual 
course  of  "sympathetic"  reactions  in  i)regnancy.  Further,  Bellinzona 
and  Tridondani 's  results  as  regards  the  color  fields  he  does  not  confirm 
at  all;  they  say  that  the  color  fields  are  restricted  iii  a  manner  similar 
to  that  of  the  white  field,  and  that  neitiier  achromatopsia  nor  dyschro- 
matopsia  occurs  among  these  patients.  From  tliis  view  he  dissents 
altogether,  and  finds  that  constantly  the  color  fields  are  irregularly 
altered,  their  boundaries  crossing  one  another,  tiie  limits  for  some 
color  extending  beyond  those  for  white,  and  so  on.  In  short,  iiis 
results  agree  with  the  typical  hj^sterical  indications. 

Among  his  patients  he  did  not  find  any  reduction  of  visual  acute- 
ness  or  any  weakness  of  accommodation,  tiiough  fatigue  on  fixation 
was  well  marked.    See,  also,  Pregnancy. 

Gestreifter  Staar.     (G.)     Striated  cataract. 

Gesund.      (G.)     Sound;  healthy. 

Gesundheitspflege.     (G.)     Hygiene. 

Getafelter  Fundus.     (G.)     Checkerboard  eye-ground. 

Getreide.     (G.)     Grain. 


5:}74 


GEWACHS 


Gewachs.     (0.)     A  <,no\vtli  or  excrescence. 

Gewebe.     ((J.)     Tissue. 

Gewerbserkrankung-en.     (G.)     Occupational  diseases. 

Giaccmi's  method.     A  method  of  staining  tiie  bacillus  of  syphilis. 

Giant  magnet.  This  iin|)ortant  oi)hthalmic  instrument  is  fully  de- 
scribed under  ElectromagTiet,  on  i)age  4252,  Vol.  VI,  of  this  Encyclo- 
pedia. A  few  cuts  of  recent  or  improved  magnets  are  further  pictured 
here. 


Device  lor  Suspending  the  Giant  Magnet.      (S.  J.  Forney.) 

According  to  the  makers,  the  Victor  (domestic)  magnet,  mounted 
on  a  crane  and  weighing  about  si.xty  pounds,  has  a  lifting  power  of 
appi-oximatel\-  four  hundred  pounds  to  the  sipiare  inch.  It  measures 
ten  inches  in  length  from  tlie  tip  to  the  rear  end  and  is  five  and  one- 
half  inches  in  diameter.  The  crane,  although  weighing  with  the 
magnet  considerably  more  than  one  hundred  pounds,  is  mounted  upon 
swivelled,   light    running   castors  and   the   entire   instrument   can    be 


GIANT  MAGNET  5375 

moved  without  any  great  effort.  The  magnet  can  be  raised  and  low- 
ered easily,  quiekly  aiid  safely  I)y  means  of  a  crank  and  gear  arrange- 
ment, as  shown  in  the  illustration.  The  magnet  is  swivelled  so  that  it 
can  be  rotated  in  a  complete  circle  and  can  he  lilted  to  any  angle 
desired.     It  is  so  poised  that  l)ut  little  effort  is  required  in  adjusting 


Haab's  Giant  ^lagiiet.     Improved  English  Model. 

it  to  the  desired  position  and  it  can  be  inunovably  locked  in  any  posi- 
tion. The  chief  advantage  of  this  construction  is  that  the  patient 
may  be  laid  on  a  couch  or  operating  tal)le  and  the  crane  moved  into 
such  a  position  that  the  magnet  is  suspended  directly  over  him,  then 
by  means  of  the  raising  and  lowering  mechanism  the  magnet  may  be 
lowered  to  the  exact  position  desired;  the  accidental  lowering  of  the 
magnet  is  impossible. 


r>:n6 


GIANT  MAGNET 


It  is  best  to  use  a  rlicostat  in  i-oriiicct  ion  with  tin;  magnet  so  tliat 
its  pulling  power  can  he  kept  under  jxM't'eet  control.  This  is  aeeoin- 
])lishe(l  hest  l)y  a  \'ietor  rheostat.  The  foot-eontroHer  is  used  in  pref- 
erence to  th(^  one  operated  hy  hand,  for  the  reason  that  the  use  of  the 
former   alh)ws  tiu;  o])ei'ator  i)erfeet   freedom   in   the   use   of  l)oth   his 


Giant  Magnet  on  a  Oane.     (Victor.) 


iiands.  as  well  as  eiiahlin.u,'  him  to  eoneenti'ate  liis  attention   uiioii   the 
woi-k. 

The  "Little  CJiant"  maj^iirt  has  a  little  over  one-fourth  the  strength 
of  the  lai'^e  Victor  giant  magnet.  It  can  he  raised  and  lowered, 
swivelled  and  tilted.  The  tield  strength  for  a  distance  of  one  inch  from 
the  point  is  quite  effective,  and,  although   it  is  not  to  he  comparecl 


GIANT  BIPOLARS 


G.-^T? 


with  the  larger  magnet,  it  is  ;iii  iiisti-uiiicnt  made  for  use  and  is  in  no 
sense  a  toy. 


Giant  Magnet  Mounted  on  a  liase.      (Victor.) 


Victor  Little  Giant  Magnet. 


Giant  bipolars.     The  largest  of  the  bipolar  eones  of  the  retina. 

Gibbous  iris.  A  name  given  to  a  form  of  postei'ior  synechia  wlien  the 
iris  is  attached  in  certain  places  only  so  that  there  appear  circum- 
scril)ed  and  local  })ulgings. 

Gibril  al-Kahhal.  This  oculist  to  the  Caliph,  Al-Mamun,  flourished  in 
the  9th  century  A.  D.  The  following  story  concerning  Gibril  is  from 
Usaibia,  as  repeated  by  Ilirschberg:  "«Iusuf  b.  Ilirahim  said:  ^lamun 
found  tlie  hand  of  the  oculist  Gibril  especially  light ;  never  had 
anyone  observed  a  gentler  hand  for  the  e^-e.  He  prepared  instru- 
ments for  rul)bing  up  and  rubbing  in  the  coUyria  and  collyrium- 
grinders  and  presented  tliem  to  the  Calipli.  Gibril  was  the  first  wlio 
came  to  him  after  he  had  said  the  early  prayer  and  washed  his  lids 
and  anointed  his  eyes.     This  he  did  again  as  soon  as  ]\lamun  had 

Vol.  VII— 34 


5378  GIBRIL  B.  UBAID-ALLAH 

(iiiislicd  liis  iiii(l(la\'  slcc]).  I^'or  lliis  lie  rccciNcd  lOOO  (li'ai-liiiiH 
iiiontlily.  lijitcf  he  fell  into  disfavor.  1  asked  liiin  on  what  ^I'ound. 
Then  hv  ivlati'd  to  nic  tiiat  tiu*  ciiainhi'i'lain  llusain  had  hccoine  sick 
and  tliat  Jasir,  his  hrotiier,  could  not  visit  him,  because  of  being  occu- 
pied wilh  his  own  duties  about  IManmn's  door.  Directly  Oibril  stepped 
()\il.  Then  Jasir  asked  ine  concerning  the  condition  of  ^lannui ;  1 
answered  that  the  Caliph  slept.  Then  Jasir  seized  upon  the  oppor- 
tunity and  visited  his  Ijrother.  But,  before  his  return,  Mamun  was 
awake,  and  asked  for  the  ground  of  his  absence.  Then  said  Jasir,  'It 
was  told  to  me  that  the  Ruler  of  the  Faithful  was  sleeping.'  'Who 
told  thee  that?'  'Gibi'il.'  Then  ]\Iamun  sent  for  me  and  said:  'O 
Gibril!  Have  I  appointed  thee  to  be  mine  oculist  or  to  be  the  pub- 
lisher of  news  concerning  me?'  Then  I  reminded  him  of  my  services. 
He,  however,  said:  'Verily,  he  has  services.  Therefore  I  shall  con- 
tinue for  him  his  monthly  stipend,  limited  to  150  dirhem.  But  to 
the  court  he  will  no  more  be  admitted.'  "  And  no  more  did  Gibril 
serve  IMainnn  until  his  death. —  (T.  H.  S.) 

Gibril  b.  Ubaid-AUah.  A  little  known  physician  of  Schiraz  and  Bagdad 
(])orn  A.  D.  920,  died  1006),  body  physician  to  the  Sultan,  Professor 
of  Therapeutics  and  Natural  Sciences  in  the  New  Bagdad  Hospital, 
and  author  of  numerous  works  on  general  medicine.  His  only  oph- 
thalmic writing  was  "A  Circular  Letter  concerning  the  Nerves  of 
the  Eye."— (T.  H.  S.) 

Gibson,  John  Mason.  An  American  surgeon,  among  the  earliest  of 
our  ophtlialmolouists.  His  life-dates  are  unknown.  He  became  a 
mem])er  of  tlie  "Faculty"  of  Maryland  in  1825,  and  published,  in 
1832,  a  book  entitled  '^ Condensation  of  Matter  upon  the  Auatmny, 
Surgical  Operations  and  Treatment  of  Diseases  of  the  Eye"  (pub- 
lished by  W.  R.  Lucas,  Baltimore,  1832).  This  was  declared  by  the 
author  himself  to  be  only  a  compilation.  It  was.  how'ever,  written  in 
a  dry  and  o])seure  style,  which  rendered  almost  valueless  its  ill-selected 
and  ill-assorted  matter.  It  was,  however,  the  second  American  work 
on  oplithalninlogy,  and  therefore  deserves  to  be  mentioned. —  (T.  II.  S.) 

Gibson,  William.  An  American  surgeon  of  great  skill.  He  was  not 
only  the  first  in  history  to  tie  the  common  iliac  artery  in  the  living  hu- 
man subject,  but  he  is  also  of  special  interest  in  ophthalmology,  both 
because  of  his  ability  as  an  operator  on  the  eye  and  also  because  of 
the  claim  w'hich  has  frequently  been  made  for  him  that  he  was  the 
first  to  perform  an  operation  for  strabismus.  Born  in  Baltimore  in 
1788,  he  received  the  degree  of  A.  B.  at  Princeton  College  in  ISOG. 
Deciding  to  study  medicine,  he  read  for  a  lime  with  Dr.  John  Owen, 
of  Baltimore,  and  in  1806  altended  eei-tain  lectui'es  at  the  Tnivorsity 


GIBSON,  WILLIAM  5379 

of  Pennsylvania.  For  the  next  three  years  he  studied  in  Edinburgh, 
where  he  received  the  medical  di>gree  in  1809.  Proceeding  to  London, 
he  studied  with  Astley  Cooper,  who  was  vers-  fond  of  him. 

p]ntering  the  English  army  in  1808,  he  participated  in  some  of  the 
hardest  fighting  of  the  Peninsular  War,  being  present,  in  fact,  at  the 
battle  of  Coruna,  where  his  friend,  Sir  John  Moore,  was  killed.  lie 
was  present  at  the  Battle  of  Waterloo,  in  which  he  was  slightly 
wounded.    In  1810  he  sailed  for  America. 

Settling  in  his  old  home,  Baltimore,  he  assisted,  in  1811,  in  founding 
the  Medical  Department  of  the  University  of  Maryland.  He  himself 
was  professor  of  surgery  in  the  new  school,  thougli  only  twenty-three 
years  of  age.  The  following  year  he  tied  the  connnon  iliac  arteiy — 
the  greatest  achievement  of  liis  life.  He  resigned  his  chair  at  the 
Baltimore  School  in  1839,  and  shortly  afterward  removed  to  Philadel- 
phia, where,  after  tlie  retirement  of  Philip  Syng  Physick,  he  was 
appointed  to  the  chair  of  surgery  in  the  University  of  Pennsylvania. 
Here  for  nearly  thirty  years  he  taught  and  practised  with  great  suc- 
cess. In  1855,  being  sixty-seven  years  of  age,  he  retired  from  his 
teaching  position. 

Gibson  is  often  declared  to  have  preceded  even  Dieffenbach  in  the 
performance  of  the  cross-eye  operation.  Thus,  Hubbell,  in  his  Oph- 
thalmologij  in  America,  p.  58,  says:  "He  was  the  first  surgeon  to 
perform  the  operation  for  convergent  strabismus,  which  was  afterward 
made  so  popular  by  Dieffenbach.  Unfortunately,  he  did  not  record 
his  operation  in  time  to  receive  due  credit  for  priority. ' ' 

Still  further,  in  the  same  work,  i.  e.,  at  p.  110,  Hubbell  continues : 

''In  times  past,  as  well  as  today,  there  have  been  many  evidences  of 
great  surgical  originality  and  insight  on  the  part  of  Americans.  In 
some  instances  they  have  been  shown  by  suggestions,  in  others  by  dem- 
onstrating important  procedures  and  devices.  AVlien  Dieffenbach 's 
operation,  for  example,  had  been  made  public,  it  was  found  that  the 
same  operation  had  long  before  been  suggested  and  even  performed 
in  this  country.  The  great  misfortune  was  that  the  genius  of  our 
American  surgeons  had  not  always  been  put  more  fully  into  light  and 
recorded. 

"Dr.  Ingalls'  suggestion  of  the  operation  for  strabismus  was  made 
as  early  as  1812,  as  is  proved  by  the  following: 

"  'Providence,  Feb.  8,  1841. 
To  the  Editors  of  the  Medical  Examiner. 

Gentlemen: — I  have  this  day  received  tlie  following  letter  from 
Samuel  Y.  Atwell,  Esq.,  of  this  city,  in  which  he  gives  the  credit  of 


5380  GIBSON,  WILLIAM 

liaviiiix  lir.st  suggested  the  opci-alion   for  strabismus  to  \)v.   William 
liigalls,  of  Boston. 

iMr.  Atwell  is  an  eminent  member  of  the  legal  profession  in  this 
state,  and  his  statements  are  worthy  of  the  highest  credit. 

I  think  it  due  to  Dr.  Ingalls  that  the  fact  of  his  having  first  sug- 
gested the  operation,  should  be  made  known  to  the  profession. 

I  also  send  you  notes  of  two  cases  of  strabismus  on  which  I  have 
operated  successfully.     Your  obedient  servant, 

Henry  AVhcaton  Rivers,  M.  D.' 

"  'Providence,  Feb.  8,  1841. 
Dear  Sir: — I  observe  from  the  newspapers  that  you  have  operated 
with  great  success  in  several  cases  of  strabismus,  or  squinting.  I  have 
also  noticed  this  operation  spoken  of  as  a  new  discovery  in  the  art  of 
surgery,  and  is  said  to  have  lately  originated  in  Grermany.  Now,  sir, 
I  think  we  should  give  honor  where  honor  is  due.  In  the  years  1812 
and  '13  I  attended  courses  of  surgical  and  anatomic  lectures  delivered 
before  the  Medical  School  of  Brown  University,  by  William  Ingalls, 
J\I.  D.,  of  Boston,  then  the  professor  of  anatomy  and  surgery  in  that 
institution;  I)eing  subject  myself  to  this  infirmity  (strabismus),  Dr. 
Ingalls  took  frequent  opportunities  to  explain  to  me  the  method  of 
its  surgical  cure;  he  did  this  by  dissecting  the  eye  itself,  explaining 
the  power  and  disposition  of  several  muscles  appertaining  to  that 
organ,  and  showed  me  how  by  division  of  one  or  more  of  them,  the 
eye  might  be  brought  to  its  proper  place.  In  my  own  case  I  know  he 
proposed  to  divide  the  rectus  internus.  So  strongly  was  I  impressed 
with  the  practicability  and  success  of  this  operation,  that  I  strongly 
urged  my  father  to  permit  me  to  submit  to  the  operation ;  but  upon 
the  nature  of  the  operation  being  explained  to  liini,  he  declined  the 
permission,  because  he  feared  the  effect  might  be  to  turn  the  eye  the 
other  way. 

I  make  this  statement  in  justice  to  my  friend  and  quondam  master, 
and  to  show  that  we  have  surgeons  in  this  country  as  learned  in  their 
profession  as  some  in  Europe.    Respectfully,  your  obedient  servant. 

Samuel  Y.  Atwell. 

To  Henry  W.  Rivers,  M.  D.,  Providence,  R.  I.' 

"Then  follows  a  report  of  two  cases  successfully  operated  on  by 
Dr.  Rivers  on  Dec.  23,  1840,  and  Jan.  13,  1841,  respectively,  by  divid- 
ing the  rectus  muscle  (externus,  first  ease,  divergent;  internus,  second 
case,  convergent).     {Philadelphia  Medical  Examiner,  IV,  119.) 

"Soon  after  that  William  Gibson,  who  was  then  professor  of  sur- 
gery at  the  University  of  Maryland,  actually  operated  for  this  condi- 


GIBSON,  WILLIAM  5381 

tion.  Dr.  M.  D.  Reese,  in  1842,  in  his  supplement  to  tlie  "Surgical 
Diclionary"  of  ►Samuel  Cooper  (p.  127),  retVrs  to  the  suhjc-ct  in  these 
words : 

"  'It  appears  from  the  "Institutes  of  Surgery"  lliat  i'l'ol'cssor 
Gibson  attempted  the  cure  of  strabismus  by  dividing  the  recti  muscles 
of  the  eye  i)recisely  as  now  practiced,  some  twenty  years  since  in  Bal- 
timore. Soon  after,  he  repeated  it  unsuccessfully,  in  rhiladeli)liia,  in 
several  cases,  and  was  induced  to  abandon  it  by  the  unfavorable  opin- 
ions expressed  on  the  operation  by  Dr.  Pliysick.  He,  however,  incul- 
cated the  propriety  of  the  operation  on  his  class  many  years  since, 
and  Dr.  A.  E.  Ilosack  of  New  York,  tben  one  of  his  pupils,  distinctly 
recollects  Dr.  Gibson's  expressions  of  contidence  that  the  operation 
would  ultimately  succeed. ' 

"Dr.  Gibson  himself  in  the  sixth  edition  of  his  'Insiltutes  of  Sur- 
gery/ published  in  1841,  describes  in  detail  the  operations  whicii  he 
performed  in  1818,  and  also  adds  that  on  the  advice  of  Dr.  Pliysick 
he  was  led  to  abandon  these  experiments." 

Thus  Dr.  Hubbell.  Here  is  the  passage  referred  to  in  Gibson's 
work,  the  ''Institutes  of  Surgery/'  Gth  ed.,  p.  375:  "The  treatment 
of  this  disease  will  depend  very  much  upon  its  cause.  If  it  should 
arise  from  disease  of  tlie  brain,  from  amaurosis,  from  morbid  conili- 
tion  of  the  sixth  or  third  pair  of  nerves,  little  benefit  may  be  expected 
from  general  or  local  means.  But  if  it  proceed,  as  often  happens,  from 
teething,  from  worms,  from  violent  passions  of  the  mind,  disorder  of 
the  digestive  organs,  irritation,  temporary  injuries,  from  partial  ex- 
posure of  one  eye  to  the  light,  from  want  of  power  in  one  set  of  mus- 
cles or  inordinate  strength  in  the  other,  much  may  be  done  towards 
effecting  a  cure,  partly  by  constitutional  remedies,  and  partly  by 
mechanical  contrivances,  or  by  an  operation.  Every  effort  should  be 
made,  then,  to  accomplish  such  a  purpose,  before  resorting  to  the 
latter  measure. 

"In  the  year  1818,  while  practicing  my  profession  extensively  in 
Baltimore,  the  late  Mr.  B.  J.  consulted  me  about  his  daughter,  a  child 
of  eleven  or  twelve  years  of  age,  both  of  whose  eyes  were  directed 
very  much  inwards,  and  were  tliereby  greatly  deformed  ])y  a  sijuint. 
I  advised  a  pair  of  goggles,  so  contrived,  by  having  a  small  opening  in 
the  center  of  each,  as  to  oblige  the  child  to  direct  the  cornea  to  these 
openings,*  and  by  perseverance  for  several  weeks,  succeeded  in  dimin- 
ishing the  deformity,  but  not  in  effecting  a  cure.    In  the  coui'se  of  my 


*  An  invention  of  Ambroise  Pare,  and,  long  before  him,  of  Paulus  of  .lEgina. 
See,  herein,  the  sketches  of  these  two  men,  with   (nnder  Pare)   a  cut  of  the  Pare 

strabismus  mask. 


5382  GIBSON,  WILLIAM 

visits  the  child  rcinarketl,  at  (liU'civiit  times,  that  her  eyes  felt  as  if 
tied  by  a  string.  Struck  with  the  ol)servatioii,  and  conceiving  the 
disease  might  depend  upon  shortening  of  the  internal  rectus  muscle, 
I  determined,  the  first  opportunity,  to  try  the  result  of  division  of 
that  muscle;  and  as  the  friends  of  my  young  patient  were  unwilling 
the  experiment  should  be  first  tried  upon  her,  I  selected  a  hosi)ital 
patient,  and  after  some  difficulty  in  fixing  the  ball,  and  in  cutting  the 
muscle  across,  succeeded  in  restoring  the  eye  partially  to  its  natural 
situation.  Upon  two  other  patients  I  repeated  the  experiment,  with- 
out much  better  success,  but  upon  dividing  the  muscle  in  a  fourth 
patient,  after  my  removal  to  Philadelphia,  the  eye  w'as  so  completely 
turned  to  the  opi)osite  direction  as  to  bury  the  cornea  beneath  the  lids, 
and  create  a  much  greater  deformity  than  had  previously  existed. 
Upon  showing  the  patient  to  Dr.  Physick,  he  advised  the  experiments 
to  be  abandoned,  as  likely  to  be  followed  by  very  unfavorable  results. 
I  mention  these  circumstances,  not  from  a  desire  to  receive  credit  as 
an  inventor,  or  to  detract  from  the  claims  of  the  distinguished  surgeon 
with  whom  the  modern  operation  of  strabismus  originated,  but  merely 
as  a  curious  fact,  calculated  to  show  the  importance  of  not  hastily  lay- 
ing aside  processes  apparently  founded  upon  correct  principles,  simply 
because  we  are  at  first  foiled  in  our  attempts  to  execute  them.  IIow 
much  benefit  would  have  resulted  to  the  community,  if  I  had  followed 
up  my  operations,  until  I  ascertained  the  proper  mode  of  conducting 
them,  or  how  mueii  injury  I  might  have  inflicted  upon  individuals  by 
perseverance  in  the  attempt,  I  shall  not  stop  to  inquire.  It  is  sufiicient 
for  me  to  announce  the  fact, — which  I  have  no  doubt  could  be  easily 
substantiated  by  nuuiy  pupils  w^ho  attended  my  early  lectures,  some 
of  w^hom  have  indeed  already  proffered  their  testimony. — without 
being  over  solicitous,  in  setting  up  a  claim  as  an  inventor,  of  exposing 
my  awkwardness  and  perhaps  want  of  knowledge  of  the  principles 
that  should  have  guided  me  in  following  out  the  practice  I  had 
attempted  to  institute." 

Hirschl)erg,  at  page  forty-two  of  his  " Amcrikas  Augeniirzte  im  19. 
JaJirhimdcrt,"  comments:  "AV.  Gibson  does  not  claim  the  priority. 
And  it  could  not  be  presented  to  him."  The  fact  that  Gibson  does 
not  claim  priority  lias  little  to  do  with  the  real  question,  which  is, 
Was,  or  was  not,  Gibson  the  first  to  perform  the  strabismus  operation? 
As  a  matter  of  fact,  T  l)('li("ve  that  he  was,  but  it  would  be  to  establish 
a  vicious  precedent  1o  allow  a  claim  of  jn-iority  to  be  establislu'd  l)y 
any  one  after  very  many  years  of  silence  on  the  procedure  in  question, 
and  especially  after  the  re-discovery  of  that  procedure  by  another  per- 
son who  carried  it  on  to  a  successful  degree  of  development   (which 


GIBSON,  WILLIAM  538:] 

had  not  been  done  before)  and  llicn  had  iJirsciitcd  it  to  the  worhl. 
(See,  in  this  connection,  Dieffenbach  and  Stromeyer,  both  in  this 
Encyclopedia. ) 

Dr.  Gibson  invented  a  "scissors  for  oi)eration  of  absorption  of 
cataract,"  which  is  tlius  descril)ed :  "So  delicate  as  liardly  to  exceed, 
in  size,  the  iris  knife  of  Sir  William  Adams,  and  at  the  same  time,  so 
strong  and  sharp  as  to  cut,  with  ease,  the  most  solid  and  compact  lens 
and  capsule,  without  injuring,  in  the  slightest  degree,  any  part  of  the 
eye.  These  scissors  are  formed  on  the  principle  of  Mr.  Willaston's 
scissors,  used  for  connnon  purposes — with  the  edge  so  constructed  as 
to  operate  like  a  knife.  On  this  account,  the  instrument  perforates  the 
coats  of  the  eye  with  the  utmost  facility,  and  when  introduced,  the 
blades  can  be  opened  to  a  certain  extent  so  as  to  cut  the  lens  to  pieces 
witliout  bruising  it  or  any  other  part — the  necessary  effect  of  scissors, 
as  they  are  usually  made.  This  instrument  possesses  another  advan- 
tage— the  lens  is  supported  in  its  natural  situation  during  the  opera- 
tion, by  having  one  blade  behind,  and  the  other  before  it,  so  that  it 
may  be  cut  to  pieces,  in  situ,  and  its  remains  afterwards  forced,  by  the 
shut  blades,  into  the  anterior  chamber,  for  dissolution." 

Dr.  Gibson  also  invented  the  so-called  "seton  method"  for  pro- 
ducing the  absorption  of  cataract,  a  procedure  which  he  employed  in 
three  cases.  He  passed  a  common  sewing  needle  through  the  sclera, 
two  lines  from  the  cornea,  then  through  the  opaque  lens,  and  out 
through  the  sclera  of  the  opposite  side.  "The  silk  being  drawn 
through  and  the  ends  cut  off,  a  single  thread  was  thus  left  passing 
through  the  ball  of  the  eye  and  acting  on  the  diseased  lens  in  the  man- 
ner of  a  seton."  In  two  of  the  cases  "no  reaction  or  accident  inter- 
vened, and  at  the  end  of  ten  days,  in  both  cases,  the  diseased  lens 
had  disappeared."  In  a  third  case,  however,  the  operation  "failed  in 
consequence  of  the  iris  being  wounded." 

Gibson  married,  in  early  life,  Sarah  Charlotte  Hollingsworth,  by 
whom  he  had  three  sons  and  two  daughters.  Later,  he  married  a 
second  wife,  by  whom  he  had  three  children. 

The  doctor  "was  five  feet  seven  inches  tall,  broad  and  round- 
shouldered."  He  had  very  bright  eyes,  and  a  genial  and  vivacious 
manner.  His  hobbies  were  to  figlit  tobacco  and  to  keep  an  exhaustive 
diary.  According  to  James  Gregory  Mumford,  he  kept  a  diary  for 
sixty  years,  which  ran  to  150  volumes.  This,  however,  seems  not  to 
have  kept  afloat  upon  the  stream  of  time.  He  was,  for  some  years, 
vice-president  of  an  anti-tobacco  society. 

Dr.    Gibson,   after   his   retirement    from    practice,   became   a    great 


5:^84  GICHT 

travc'h'i'.     Jiiit  at  length,  bowed  down   by  the  weight  of  80  years,  he 
died  at  Savaiiiuili,  (Ja.,  in  the  winter  oi"  18G8. —  (T.  JI.  S.J 

Gicht.     {(l.)     (jout. 

Giemsa's  stain.    See  page  TOG,  \'o].  1  of  this  Encyclopedia. 

Gierl,  Matthias.  A  Avell-known  (jlernian  surgeon  and  ophtliahuologist, 
whose  litc-chites  aie  uni<nown.  lie  received,  however,  his  medical 
degree  at  Landshut  in  1817,  antl  afterwards  practised  at  Augsburg 
and  Lindau.  lie  wrote  "Das  llypojnon  oder  Eiterauge  uud  Seine 
lieluuullung''  (Augsburg,  1825;  Ital.  Trans,  by  Schonberg  at  Naples, 
182G)  and  "  Ueber  die  Kesor])ti()n  (\vr  Cataraetosen  Linse  iu  der  Vor- 
dei-an  Augenkaninier"  {Baycrischc  Annahn,  Bd.  I). —  (T.  H.  S.) 

Gilford's  reflex.  Harold  Gitt'ord  {Klin.  Monatsbl.  /.  AugenJieilk.,  p.  201, 
li)0(i;  observed  an  involuntary  resistance  to  eversion  of  the  upper  lid 
as  an  earlj'  s3'niptoni  of  Graves'  disease.  It  is  })robably  due  to 
irritability  of  JMueller's  muscles.  Dalrymple's  (generally  called 
Stellwag's)  symptom,  viz.:  the  exposure  of  the  sclera  above  the 
cornea  in  ordinary  horizontal  fixation  is  possibly  the  static  form  of 
the  symptom.    See  Exophthalmic  goitre. 

Gift.     (G.)     n.     Poison. 

Giftbohnen.     (G.)     Jequirity. 

Giftkunde.     (G.)     Toxicology. 

Gillet  de  Grandmont,  Pierre  Anatole.  A  celebrated  Parisian  ophthal- 
mologist. Boi'n  at  Paris,  iMareh  28,  1834,  he  received  his  professional 
degree  at  the  university  of  that  city  in  1864.  He  was  ophthalmolo- 
gist to  the  Pklucational  Institute  of  the  Legion  of  Honor,  and  General 
Secretary  of  the  Society  of  Practical  Physicians.  He  died  at  Paris, 
in  July,  1894. 

His  most  important  writings  are  as  follows:  1.  Cure  Radical  des 
Tumeurs  et  Fistules  Lacrymales  (Paris,  1860).  2.  De  I'Examen  Opli- 
thalmoscopique  pour  le  Diagnostic  des  Tumeurs  de  I'Encephale  (Paris, 
1861).  3.  Pilocarpine  dans  les  Affections  Oculaires  (Paris,  1878). 
4.  De  Termination  de  la  Sensibilite  de  la  Retine  aux  Impressions  Lami- 
neuses  Poloriees  (Paris,  1881).  5.  Des  Courants  Electriques  Continus 
Api)liques  an  Voisinage  de  I'Oeil  (Paris,  1883).  6.  Deux  Formes 
Nouvelles  de  Keratite  (Paris,  1888).  7.  Peiioi)toiiietrie  et  Chromo- 
topsie  (Paris.  188S).— (T.  H.  S.) 

Gillot,  Joseph  Francois  de  Paule.  A  wt'lj-known  Freneh  military 
surgeon,  of  sonic  slight  ophthalmologic  importance  because  of  his  "Sur 
les  Aveugles  et  les  Sourds-muets  de  la  Ville  de  IMetz. "  He  was  born 
at  Robecoui-t.  April  1,  1702,  liecame  a  military  surgeon  in  180!).  was 
engagetl    in    militai-y   service   for  several   x'cai's,   received   the   medical 


GILMORE,  ARNOLD  PLUMMER  5385 

degree  in  1817,  and  practised  at  Medonville,  Neufchateau  and  Metz 

sncpossively.  ITo  died  Anjr.  18,  1868.— (T.  II.  S.) 
Gilmore,  Arnold  Plummer.  A  prominent  opiithalinolofjist  of  Cliicago, 
Illinois,  during  the  period  1880  to  lOOf).  He  was  a  native  oi'  Pennsyl- 
vania, born  near  Philadelphia,  Jan.  27,  iSf)!.  He  alteiided  prepara- 
tory seliool  at  an  institution  near  Pitts])urgh  and  went  thenee  to 
Trinity  College,  Hartford,  Conn.  While  in  his  junioi-  year,  during  a 
vacation,  he  was  accidentally  shot  when  liunting  and  lay  for  many 
months  in  slow  recovery.  Dui-ing  that  li-ying  jx'i-iod  lie  decided  to 
adopt  the  profession  he  latei'  followed  and  honored,     lie  matriculated 


A.  P.  Gilmore. 

at  Jefferson  Medical  College,  and  after  graduation  there  practised  for 
a  short  time  in  Philadelphia,  but  feeling  the  need  of  a  wider  knowl- 
edge, went  to  Germany  and  studied  for  two  A'ears.  He  came  to  Chicago 
in  the  early  eighties  and  soon  took  a  prominent  place  in  the  profes- 
sional and  social  life  of  that  city.  A  democrat  in  polities,  he  became 
a  factor  in  that  party's  municipal  activities,  and  in  1889  was  elected  a 
member  of  the  first  Board  of  Trustees  of  the  Sanitary  District  of 
Chicago.  He  rendered  valuable  services  in  his  official  capacity  till  his 
resignation  (in  December,  1895)  from  the  Board,  a  step  necessitated 
by  his  ever-increasing  professional  duties.     He  died  Oct.  10,  1906. 

Dr.  Gilmore  was  of  dignified  and  courtly  presence ;  he  had  a  host  of 
admirers  and  always  exhibited  to  those  who  came  in  contact  with  him 
a  naturally  kind  disposition  and  friendlj'  manner. —  [Ed.] 


5386  GIMBERNATS  COLLYRIUM 

Gimbernat's  collyriiim.     See  X'ol.  J\',  p.  2;{41  of  this  Eiuijclopcdia. 

Gimbernat,  Don  Antonio.  A  celebraled  Spanish  surgeon,  wlio  discov- 
ered the  so-eaHed  "Gimbernat's  ligament"  (which  forms  the  inner 
boundary  of  the  ui)i)er  oi)eniiig  of  tlic  ci'ural  canal),  who  invented  tlie 
treatment  of  aneurysm  by  graduatetl  compression,  and  who  possessed 
a  little  interest  ophthalmologically.  Born  at  Gambrils,  Tarragona, 
Spain,  in  ITS-i,  he  studied  at  Cadiz,  became  professor  of  surgery  at 
Barcelona,  and  finally  removed  to  Madrid.  Here  he  became  body-sur- 
geon to  the  King,  Charles  III.  In  1787  he  founded  the  College  of 
Surgeons  at  San  Carlos,  and  was  for  many  years  its  director.  His 
most  important  writing  is  "Neuvo  Metodo  de  Operar  en  la  Hernia 
Crural"  (Madrid,  1793.  In  this  work  it  was  that  he  first  described 
the  ligament  with  which  his  name  is  still  associated).  According  to 
Hirschberg,  he  read  at  Paris  in  1800  a  paper  on  corneal  ulcers.  These 
affections  he  divided  into  two  kinds :  A  superficial,  which  is  secretory, 
and  a  deep,  which  is  foul.  The  former  he  treated  chiefly  with  an  alum 
wash;  the  latter,  with  a  solution  of  potassium  carbonate.  According 
to  the  same  authority,  Gimbernat,  when  78  years  of  age,  was  suc- 
cessfully operated  on  for  double-sided  cataract  by  Don  Jose  Rives,  of 
the  College  of  San  Carlos ;  but,  the  very  night  that  followed  the  opera- 
tion, the  impatient  patient,  removing  his  ])andages,  put  his  eyes  to 
first  one  test  and  then  another,  with  the  result  that  one  of  the  eyes  was 
l)lindod  completoly  and  the  other  to  a  great  extent. —  (T.  H.  S.) 

Gimelle,  Pierre  Louis.  A  celebrated  f'rench  military  surgeon,  who 
devoted  considerable  attention  to  diseases  of  the  eye.  Born  Nov.  6, 
1790,  at  Saint  Bonnet  Alvert  (Correze),  he  became  a  military  surgeon 
in  1808,  was  engaged  in  military  service  for  several  years,  was  present 
at  the  battle  of  Waterloo,  received  the  Doctor's  degree  at  Paris  in 
1818,  and  died  June  19,  1865.  His  only  ophthalmologic  writing  was 
"Notice  sur  la  Nature  et  la  Traitement  de  I'lritis."— (T.  H.  S.) 

Ginger.  Zingiber  officinale.  According  to  Dioscorides,  ginger  was  used 
in  liis  day  as  a  local  application  for  corneal  cicatrices. —  (T.  H.  S.) 

It  must  be  remembered  that  some  of  the  first  cases  of  methyl  amau- 
rosis in  this  country  arose  from  drinking  the  domestic  "extract"  of 
(Jamaica)  ginger,  the  usual  grain  alcohol  menstruum  of  which  had 
been  adulterated  with  deodorized  wood  alcohol,  the  so-called  Colum- 
bian spirits. 

Gioppi,  Giannantonio.  A  well-known  Italian  ojihthalmologist.  the  date 
of  wliosr  hiitli  is  not  known,  but  who  practised  at  Padua  and  died  in 
January,  1872.  Gioppi 's  writings  are:  1.  Storia  di  un'  Amaurosi 
(Padua,  1858).  2.  Kesoconto  ed  Osservazioni  Pratiche  Kaccolte  nella 
Clinica  Oculistica  dell'   I.   R.  Universita   di   Padova    (Padua,   1858). 


GIORGI,  GIUSEPPE  DE  5387 

3.  Cenni      Nosologi('o-Ti'i'a[)t'ulici      siillc      Coii^iuiitiviti      Coiitaj^iose 
(i'aduii,  1S5G).— (T.  11.  S.) 

Giorgi,  Giuseppe  de.  A  well-know  n  lt;iliaii  surgeon,  avIio  seems  to  have 
devoted  eoiisiderahle  attention  lo  oplitludiuology.  lie  was  professor 
ol:  surgery  at  iniola,  and  died  in  1S37. 

His  only  ophtluUmologie  writing  was  entitled  '".Mem.  sopra  un 
Nuovo  Istroniento  per  Operare  le  Cattaratte  e  i)er  Forniare  la  Papilla 
Artifieiale"    (Iniola,  1S22).— (T.   H.  S.) 

Gipsy  flower.     See  Cynoglossum  officinale. 

Giraldes,  Joachim  Albin  Cardozo  Cazado.  A  eelebi-ated  French  anat- 
omist and  surgeon,  of  Portuguese  descent  and  hirtli,  who  paid  con- 
siderable attention  to  diseases  of  the  eye.  Born  at  Porto,  Portugal,  lie 
received  his  early  education  in  .Madeira,  his  nu'dical  training,  however, 
at  Paris,  where  he  graduated  in  183G.  He  died  at  Paris,  Nov.  27,  1875. 
His  ophthalmologic  writings  are  as  follows:  1.  Etudes  Auato- 
miques,  ou  Recherclies  sur  1 'Organisation  de  I'Oeil,  Consideree  chez 
I'Homme  et  dans  quelques  Animaux  (Graduation  Thesis;  7  Plates). 
2.  Rech.  sur  la  Disposition  Croisee  des  Fibres  de  la  Retine  chez  les 
Cephalopodes  {Bull,  de  la  Soc.  Philos.,  1845).  3.  De  la  Feve  de  Cala- 
bar (Paris,  1863).  4.  Sur  un  Cas  de  Cataracte  Double  chez  une  Jeune 
Fille  de  15  Ans.  (Paris,  1865).— (T.  H.  S.) 

Giraud-Teulon,  Marc  Antoine  Louis  Felix.  A  Parisian  ophthalmolo- 
gist. Born  at  La  Rochelle,  May  30,  1816,  he  received  his  medical 
degree  at  Paris  in  1848.  He  practised  at  Paris,  and  died  at  St.  Ger- 
main-en-Laye,  Aug.  19,  1887.— (T.  H.  S.) 

Girault,  Jean.  A  German  dentist  and  ophthalmologist  of  the  early  IDth 
century.  He  invented  an  instrument  for  the  introduction  of  a  thread 
into  the  lachrymo-nasal  canal  in  the  course  of  the  operation  for  lach- 
rymal fistula.— (T.  H.  S.) 

Girdle-shaped  opacity.     See  Band-shaped  keratitis. 

Girdle,  Visual.  In  some  animals  the  visual  purple  forms  a  deeply  tinted 
stripe  running  horizontally  across  the  retina. 

Girofle.     (F.)     Clove. 

Gitter.     (G.)     Grating;  trellis;  lattice. 

Gittrige  keratitis.     (G.)     Lattice-like  opacity  of  the  cornea. 

Glabella.  (L.)  The  protuberant  (but  occasionally  depressed)  surface 
between  the  two  superciliary  ridges. 

Glace.     (F.)     Ice. 

Gland.  A  name  given  to  numerous  seei'etiv(>  and  excretive  organs  of 
the  body,  whose  chief  function  is  withdrawing  from  the  blood 
material  for  other  purposes,  or  of  excreting  waste  or  injurious 
matter.    A  few  of  the  glands  of  importance  to  ophthalmologists  will 


5388  GLANDERS 

bo  meutioiied  under  Gland,  including  Glands  captions,  but  the 
niiijority  oi"  tlicni  are  described  in  the  sections  devoted  to  the  organs 
{)['  which  they  form  a  part.  In  most  instances  a  reference  to  the 
lieadings  Anatomy  of  the  eye  mikI  Histology  of  the  eye  will  be 
jirolitable. 

Glanders.  Fakcy.  A  disease  of  horses,  communicable  to  man,  and  due 
to  the  Bacillus  ^yiallei.  It  is  marked  by  acute  febrile  symptoms, 
inflanuuation  of  mucous  membranes,  especially  of  the  nose,  with  a 
purulent  discharge  from  the  nose  and  an  eruption  of  isolated  nodules 
on  the  skin  and  mucous  membranes.  These  nodules  coalesce  and 
Ijreak  down,  forming  deep  ulcers,  which  may  end  in  necrosis  of  car- 
tilages and  bones.  In  man  the  disease  usually  runs  an  acute  course, 
ending  in  the  typlu^id  state  and  in  death. —  (Dorland.) 

Rare  cases  of  primary  infection  of  the  lids  with  the  Bacillus  mallei 
have  been  reported  by  Krajewsky,  Scheby-Buch,  and  Neisser.  Dif- 
ferential diagnosis  from  syphilis  or  tubercle  may  be  impossible  with- 
out bacteriological  examination.  Primary  infection  of  the  conjunc- 
tiva has  been  seen.  Lachrymal  fistula  and  abscesses  in  the  orbit  are 
reported.  In  animals  ocular  complications  are,  according  to  Dupuy, 
not  uncommon  (111  times  in  167  horses). 

Filatow  {Klin.  MonatsU.  f.  Augenh.,  p.  100,  Jan.,  1908)  reports  a 
case  of  human  glanders  affecting  the  eye  in  which  the  primary  lesion 
was  an  ulcer  of  the  upper  lid,  which  perforated  the  lid  and  was 
followed  by  panophthalmitis.  When  evisceration  was  done,  ulceration 
of  the  lower  lid  was  noticed.    The  patient  died  of  the  general  infection. 

Glandilemma.     The  capsular  covering  of  a  gland. 

Gland,  Interocular.  In  comparative  anatomy,  the  ectocranial  portion 
of  the  epiphysis  cerebri.  It  is  regarded  as  the  rudiment  of  the  third 
eye. 

Gland  of  Bruch.  Clusters  op  Brucii.  A  number  of  follicles  in  the 
conjunctiva,  mostly  congregated  within  the  folds  of  transmission. 
Sec  Histology  of  the  eye;  also,  Anatomy  of  the  eye. 

Gland  of  Kolliker,     One  of  the  tubular  glands  of  the  olfactory  region. 

Gland,  Pineal.  A  small,  reddish-gray,  vascular  body  situated  behind 
the  third  ventricle,  which  is  embraced  by  its  two  peduncles;  it  is 
also  called  the  conarium,  from  its  conic  shape.  It  rests  upon  the 
pregeminum  and  is  connected  with  the  thai  ami  by  two  peduncles. 
Its  function  is  unknown.  It  is  considered  to  be  the  remains  of  the 
pineal  ey(^  of  lower  vertebrates. 

Glands,  Baumgarten's.  These  are  tubular  glands  of  the  conjunctiva, 
occurring  in  the  nasal  side  of  the  lids. 


GLANDS,  CIACCIO'S  5389 

Glands,  Ciaccio's.  A  name  for  AValdeyer's  or  Krause's  conjunctival 
glands.     Sec  a  footnote  in  I'arsoii's  PatJiol'ifjj/,  Vol.  1,  p.  3. 

Glands,  Ciliary.     See  Ciliary  glands;  as  well  as  Histology  of  the  eye. 

Gland,  Harder 's.    See  p.  2689,  Vol.  IV,  of  this  Encyclopedia. 

Glands,  Henle's.  Conjunctival  depressions  between  the  papilloi  de- 
scribed by  Ilenle  in  18()(). 

Glands,  Krause's.  These  are  conjunctival,  true,  large  acino-tubular 
glands  found  below  the  surface  between  the  nuirj^in  of  the  tarsus  and 
the  fornix,  particularly  on  the  nasal  side.  There  are  from  six  to 
eight  in  the  lower  cul-de-sac  and  about  forty-two  in  the  upper. 

Glands,  Lachrymal.  Laciirymai.  gland.  See  page  350,  Vol.  I,  of  this 
Enri/vlopcdia. 

Glands,  Meibomian.     See  p.  348,  Vol.  I,  of  this  Encyclopedia. 

Glands  of  Moll.  ^Modified  sAveat  glands  of  the  lid  margin.  See 
Anatomy  of  the  eye ;  also,  Histology  of  the  eye. 

Glands  of  Zeiss.  Small  sebaceous  glands  emptying  into  the  follicles  of 
the  cilia.    St'e  Histology  of  the  eye. 

Glands,  Pre-auricular.  Anterior  aikici  lar  glands.  Three  or  four 
small  lymphatic  glands  situated  in  front  of  the  external  ear.  These 
receive  the  lymph  and  excreted  material  from  the  external  ear.  In 
many  infections  of  the  eye — chancre,  chancroid,  vaccinia,  gonorrheal 
ophthalmia,  Parinaud's  conjunctivitis,  tuberculosis  of  the  conjunc- 
tiva, etc. — these  glands  may  become  tender  and  swollen,  but  rarely,  if 
ever,  suppurate,  although  the  induration  may  remain. 

Glands,  Submaxillary.  These  are  spheroidal  salivary  glands  of  about 
half  the  size  of  the  parotid,  situated  one  in  each  submaxillary  triangle, 
covered  by  the  skin,  fascia  and  platysraa  myoides,  and  resting  on  the 
hyoglossus,  mylohyoid,  and  styloglossus  muscles.  Each  gland  is  sep- 
arated from  the  parotid  gland  by  the  stylo-maxillary  ligament,  and  is 
grooved  in  its  posterior  and  upper  portion  by  the  facial  artery.  It 
discharges  into  the  mouth  through  Wharton's  duct. 

In  various  disorders,  Mikulicz's  disease,  epithelioma  of  the  lids, 
vaccinia  of  the  eyelids,  conjunctival  lymphoma,  purulent  conjunctiv- 
itis, for  example,  these  structures  may  become  infected  and  inflamed. 

Glands,  Waldeyer's.  These  acino-tubular  glands  are  found  in  the  con- 
junctiva near  the  upper  border  of  the  tarsus.  See  Histology  of  the 
eye. 

Glandulse  thyroideae  siccae.    Thyroid  extract. 

Glandular  conjunctivitis.  Adknologaditis.  (Obs.")  Terms  originally 
employed  to  designati^  iiiflannnation  of  the  lining  mein])rane  of  the 
Meibomian  ducts  in  the  eyelids;  and  since  erroneously  applied  to  any 
glandular  inflammation  of  the  lids. 


5390        GLANDULOSE  AUGENENTZUNDUNG 

Glandulose  Augenentziindung.     (G.)     ('Iwilaxion.. 

Gland,  Uveal.  A  luinic  ^ivcn  liy  Xicali  to  tin-  secreting  portions  of  the 
ciliary  body,  and  (.'specially  to  that  i)()rtion  excreting  the  atiueous 
lunnor. 

Glan's  prism.     A  partieulai-  form  of  polarising  j)risiii. 

Glanz.     (G.j     Luster ;  shijie. 

Glanzend.     (G.)     Shining,  lustrous. 

Glare.  A  daz/ling,  or  blinding  light;  a  disagreeably  intense  bright- 
ness; as,  the  sun's  glare  on  water.    See  Dazzling. 

Glaring,  Dazzling.  The  intense  light,  as  well  as  its  effects  upon  the 
eye,  of  the  sun,  electric  furnaces,  electric  arc  lights  and  other  power- 
ful artificial  illuminants.  The  ocular  relations  of  these  soiii'ees  of 
light  are  discussed  under  such  captions  as  Eclipse  amblyopia;  Arc 
lights;  Blindness,  Snow;  and  particularly  under  Dazzling,  page  3778, 
Vol.  V,  of  this  Encyclopedia.    See  Eyes  of  soldiers,  sailors,  etc. 

Vogt  {Arcli.  f.  Aug.,  74,  p.  41),  observed  with  others,  that  if  he 
fixed  a  bright  surface,  e.  g.,  the  sky,  white  clouds,  snow,  white  paper 
or  linen,  illuminated  by  the  sun,  with  one  eye,  while  the  other  wa? 
closed,  the  white  surface  after  a  few  seconds  changed  its  hue.  Espe- 
cially in  the  central  portion  of  the  visual  field  pale  pink  alternated 
with  greenish  to  yellowish  tints.  If  now  the  accommodation  is  relaxed 
and  the  eye  stares  at  the  bright  surface,  a  from  relative  to  absolute, 
scotoma  commences  at  the  center  and  expands  towards  the  periphery. 
The  obscured  round  area  of  from  30°  to  40°  is  black-green,  shading 
into  yellow  or  violet  after  longer  fixation.  At  the  moment  at  which 
the  bright  surface  is  again  fixed  the  scotoma  disappears.  Hence  Vogt 
formulates  the  following :  We  are  able  to  voluntarily  arouse  in  our 
visual  apparatus,  exposed  to  a  bright  surface  of  constant  objective 
luminosity,  an  alternation,  which  consists  in  the  voluntary  generation 
and  suppression  of  colored  images  of  glaring  (relative  scotomas), 
and  especially  in  complete  obscurations  of  the  central  visual  field 
(absolute  scotomas).  It  is  independent  upon  convergence,  accommo- 
dation, width  of  pupil,  and  is  most  likely  located  in  the  region  of 
cones.  He  explains  it  by  a  variability  of  the  subjective  luminosity 
dependent  upon  our  will.  It  is  assumed  that  these  changes  are  trans- 
mitted by  the  centrifugal  fibers  of  the  visual  path  and  are  located  in 
the  retina. 

Schan/.,  of  Dresden  {Dent.  Med.  Woch.,  February  20,  1913,  No.  8, 
p.  365),  gives  a  very  good  synopsis  of  the  action  of  the  different  kinds 
of  rays  of  light,  which  excite  the  sensitive  elements  of  the  retina 
directly,  indirectly,  or  not  at  all.    All  three  reach  the  anterior  segment 


GLARING  5391 

of  the  eye  and  act  on  tin-  pafts  wliicli  ai'c  not  |)cniical)k'  by  light,  the 
more  intense,  tlie  more  short-waved  they  are.  The  transparent  parts 
of  the  eye  are  influenced  only  by  the  rays  whieli  are  absorbed  by  these 
parts.  These  are  ehietly  the  short-waved  rays,  which  ])y  being  absorbed 
by  the  cornea  irritate  the  sensitive  nerves  and  in  the  conjunctiva  cause 
the  distressing  symptoms  of  pressure,  burning,  lachryination  and,  by 
longer  action,  catarrh  of  the  conjunctiva,  electric  oplitluUmia,  etc. 

A  large  portion  of  the  short-waved  rays  after  passing  through  the 
cornea  into  the  lens  are  partly  absorbed  by  this,  partly  converted  into 
rays  of  greater  wave  length,  causing  the  fluorescence  of  the  lens.  Their 
augmentation  does  not  seem  irrelevant  for  the  lens.  The  cataract  of 
glass  blowers  and  the  occurrence  of  senile  cataract  in  tropical  India 
at  a  much  earlier  age  may  be  attributed  to  tliese  rays. 

The  fluorescent  light  irritates  the  retina  by  glaring.  A  part  of  it, 
the  lavender  gray,  is  the  fluorescent  light  of  the  retina.  Another  part 
is  not  transformed  and,  on  more  intense  action,  protUu-es  microscopic 
changes  of  the  retina.  Functionally  they  seem  to  diminish  the  dark 
adaptation  of  the  eye.  By  continued  action  they  may  produce  chronic 
electric  ophthalmia  and  disturbances  of  the  color-sense. 

For  protecting  the  eye  euphos  glass  seems  ])est  adapted,  as  it  absorbs 
very  well  the  indirectly-acting  rays  and  very  little  the  visible  rays. 
By  absorbing  the  ra^'s  which  produce  fluorescence  in  the  eye  vision  is 
increased  by  this  glass,  as  found  empirically  by  hunters.  Gray  euphos 
glass  and  Fieuzal  glass  absorb  the  indirect  rays  and  weaken  the  visible 
rays  like  the  smoked  spectacles.  In  the  United  States  various  shades 
of  amber,  as  well  as  Noviol  and  the  Crookes  tints,  are  commonly  pre- 
scribed for  the  same  purpose. 

R.  Cords  {Arch.  f.  Angcnluilk.,  Vol.  75,  p.  224,  1!)14),  after 
considerable  experimentation,  gives  the  following  results :  If  one  eye, 
instead  of  being  covered,  is  darkened  by  a  deeply-tinted  glass,  and  a 
bright  surface  is  fixed,  a  central  zone  of  obscuration  is  evoked,  but 
always  in  the  color  corresponding  to  the  glass. 

If  in  bright  sunlight  one  eye  is  closed,  instead  of  being  covered,  so 
that  the  yellowish-red  of  the  blood,  circulating  in  the  lids,  is  seen,  the 
zone  of  obscuration  has  a  yellowish-red  hue.  This  becomes  grayish- 
black  if  a  screen  which  excludes  all  light  is  placed  before  the  closed  eye. 

If  the  light  proper  of  the  retina  of  the  covered  eye  has  from  previous 
illumination  a  certain  color,  this  appears  in  the  zone  of  obscuration. 
If,  e.  g.,  the  retina  by  wearing  of  a  yellowish-red  glass  is  exhausted 
for  this  color,  the  zone  of  obscuration  in  the  visual  field  of  tlie  other 
eye  appears  bluish-green. 

If  previously  to  the  experiment  a  negative  after-image  is  aroused 


5392  GLASAUGIG 

ill  the  covered  eye,  it  iij)|)e;irs  siiiiiiltaiieoiisl y  with  the  zone  of  obscura- 
tion in  this. 

ZeozoM  is  a  iiioiioxid-dei'ivative  of  the  glycosid  esculin,  wliicli  is 
found  in  tlie  hark  of  the  horse-chestnut,  and  has  been  introduced  by 
Tuna  in  the  form  of  a  paste  for  the  protection  of  tlie  skin  against  the 
undt'sirahle  etiPeets  of  sunlight.  Huhemanu  used  zeozon-water  (a  from 
0.3  to  0.5  per  cent,  solution  of  the  ortho-oxid  derivative  of  Unna's 
preparation  in  liorie  aeid  solution),  as  an  eye  wash  in  40  eases  of 
glaring,  and  reports,  that  all  distressing  symptoms  disappeared  after 
four  instillations  per  day. 

At  the  instance  of  von  Hess,  Pincus  (Archiv.  f.  AugcnheUk.,  Ixxiii, 
p.  291)  investigated  the  properties  of  zeozon  experimentally.  He 
found  by  spectrographic-photographic  methods  tliat  a  thick  layer  of 
zeozon-water  absorbs  the  ultra-violet  rays,  but  not  in  thin  layers.  His 
experiments  on  rabbits  proved  without  exception  that  instillations  of 
zeozon-water  into  the  eye  are  not  capable  of  protecting  it  in  any  way 
against  the  action  of  ultra-violet  rays,  a  result  which,  in  view  of  the 
physical  conditions  regulating  the  absorption  of  rays  of  light  by  fluids 
and  the  physiologic  processes  following  introduction  of  fluids  into  the 
conjunctival  sac,  was  to  be  expected  from  th6  start.  He  therefore 
urgently  warns  against  relying  on  zeozon-water  for  protection  against 
glaring. 

Glasaugig".     (6.)     AVall-eyed;  glassy  appearance  of  the  eye. 

Glasblaserstar.     (G.)     Glass-blower's  cataract. 

Glasdose.     (G.)     Eye  cup. 

Glaserne  Feuchtigkeit  (or  Augenfeuchtigkeit).    (G.)    Vitreous  humor. 

Glashaut.     (G.)     Cornea. 

Glaskassette.     (G.)     Glass  container  for  cotton  wool,  gauze,  etc. 

Glaskorper.     (G.)     Vitreous  body. 

Glaskorperstaar.     (G.)      (Obs.)      Hyaloid  cataract. 

Glaskorperstaub.     (G.)     Dust-like  opacities  in  the  vitreous. 

Glaskorperstrang-e.     (G.)     Vitreous  filaments. 

Glaslamelle.     (G.)     Vitreous  or  glass-like  layer  (of  the  choroid ). 

Glass.  A  substance  resulting  from  the  fusion  of  a  combination  of 
silica  (rarely  l)oric  acid)  with  various  ])ases.  It  is  usually  hard,  ])rit- 
tle,  has  a  conehoi(hil  fracture,  and  is  more  or  less  transparent,  some 
kinds  being  entirely  so,  while  other  substances  to  which  the  name  of 
glass  is  coiiiinoiily  </\\vu  ai'e,  in  consequence  of  the  impurity  of  the 
matei'ial  or  imj)erfection  in  th(>  nuinufacture.  only  slightly  translucent. 
Glass  is  an  inorganic  su))stance,  as  would  naturally  be  inferred  from 
its  being  llie  result  of  fusion,  ])ut  some  organic  substances  are  called 
vitreous.     Some  rocks  have  a  vitreous  structure,  like  that  of  artificial 


GLASS  5393 

glass,  as,  for  instance,  obsidian,  wliidi  is  often  called  volcanic  glass. 
The  slags  produced  in  furnace  operations  are  vitreous  substances,  but 
usually  onl}'  translucent,  and  not  transparent,  because  the  vitritication 
is  incomplete,  and  also  because  they  are  too  deeply  colored  by  metallic 
oxids.  Glass,  as  the  word  is  generally  understood,  is  an  artificial 
product,  and  one  of  the  most  important  of  manufactured,  articles.  Its 
valuable  qualities  are :  the  ease  with  which  it  can  be  made  to  take  any 
desired  shape ;  cheapness,  the  result  of  the  small  cost  of  the  materials 
of  which  it  is  made;  durability,  and  especially  resistance  to  decompo- 
sition by  acids  and  corrosive  substances  generally;  transparency,  a 
quality  of  the  utmost  importance,  as  evidenced  by  its  use  for  windows 
and  in  optical  and  chemical  instruments;  and  the  beautiful  luster  of 
those  kinds  which  are  used  for  ornamental  purposes.  Almost  the  only 
drawback  to  these  good  qualities  of  glass  is  its  brittleness.  The  bases 
used  in  glass-manufacture  are  chiefly  soda,  potash,  lime,  alumina,  and 
oxide  of  lead,  and  the  quality  of  the  article  produced  depends  on  the 
nature  and  amount  of  the  basic  material  united  with  the  silica.  The 
combinations  of  silica  with  a  simple  alkaline  base,  either  potash  or 
soda,  are  soluble  in  water,  and  are  known  as  ivater-glass.  They  are 
useful  substances,  but  very  different  in  their  properties  from  what 
is  ordinarily  known  as  glass. 

In  addition  to  the  alkaline  base  there  must  be  an  alkaline  earth  or 
a  metallic  oxid.  The  cheapest  glass  is  that  used  for  bottles;  in  this 
the  basic  material  is  chiefly  lime,  with  some  potash  or  soda,  and 
alumina.  Glass  for  medicine-bottles  differs  from  ordinary  bottle-glass 
in  containing  more  potash  than  the  latter,  and  also  in  the  greater 
purity  of  the  material  used.  AYindow-glass  usually  contains  both  soda 
and  lime ;  here  absence  of  any  tinge  of  color  is  important,  except  in 
the  most  inferior  qualities.  Potash  and  soda  render  the  glass  more 
fusible ;  alumina  diminishes  its  fusibility ;  lime  makes  it  harder ;  lead 
gives  luster,  fusibility  and  high  refractive  power.  Hence,  in  glass 
which  is  to  be  cut  and  polished,  where  beauty  is  of  prime  importance, 
the  base  is  chiefly  oxid  of  lead,  which  amounts  in  some  cases  to  half 
the  weight  of  the  material  used.  Glass  in  which  lead  is  the  essential 
base  is  called  crystal  or  flint-glass.  The  finer  kinds  of  glass  without 
lead  are  called  crown-glass. 

The  tools  employed  by  the  glass-blower  are  simple,  but  require 
dexterity  for  their  use.  The  process  of  manufacture  depends  on  the 
fact  that,  at  a  very  high  temperature,  glass  is  a  liquid  whicli  can  be 
readily  cast:  at  a  full  red  heat  it  is  soft,  ductile,  and  easily  welded; 
when  cold,  it  is  hard  and  brittle.  Glass  to  be  serviceable  must  be 
annealed  after  the  desired  form  has  been  given  to  it.     This  is  done 

Vol.  VII— 3.5 


53!)4 


GLASS  BALLS 


l)y  Ih'iitinu  it  nearly  to  llic  iiicll  iii^'-poiiit ,  and  then  alhtwinj;  it  to 
cool  vrry  slowly  in  an  aniK-alinj^-cluunhcr.  1>\-  the  ad  ion  of  li\(lro- 
Ihioric  acid,  wliieli  combines  I'cadily  with  tlic  silica  in  <xlf»f^f>,  <'tcliin<r 
can  he  done  on  a  <;lass  sui'i'acc.  When  cold,  <^lass  can  Ijc  jri'oiind 
()!•  cut  iii)on  a  Avlu'ci,  sei-atclicd  hy  a  diainon(l-]K)int  (by  wliich  means 
sheets  of  g:lass  are  i-eadily  divided  or  shaped,  as  they  Avill  hi-eaic 
easily  aloiif;  the  lines  of  such  scratelu's),  cut  and  depolished,  or 
"(irround"  by  a  saiul-])last,  and  brought  to  an  exceedingly  high 
polish. —  (Abridged  from  the  Century  Dictionary.)  See,  also,  Glass, 
Optical. 


(;l;^^s  Ihills  witli  .-nul   witlimit  <  )iifiiiii;is  for  the   Passaj^e  of  Sutures. 


Glass  JJodies  of  Acid-Proof  (ilass. 
'I'o   I  ('  iis(>c|  as  c-asts  for  oiilarjjflng  tlie  orl)ital  cavity. 


Glass  balls.  Apai't  Irom  their  use  in  Mules"  and  similai'  ojierations — 
all  of  which  ace  described  and  depicted  under  Enucleation — acid- 
])r{)of  glass  halls  are  occasionally  used  as  pi'essure-bodies  for  enlarg- 
ing a  eicati-icial  orbit.    See  figures. 


GLASS-BLOWER'S  CATARACT  5395 

They  are  ot-casioiially  provided  with  openings  tlirougli  wliieh  sutures 
may  be  passed  and  the  bails  sewn  into  the  eavity  of  tiie  orbit  or  even 
of  the  denuded  eyeball. 
Glass-blower's  cataract.  About  the  verity  of  this  form  of  traunuitie 
(ghire)  cataract  there  seems  little  or  no  doubt,  although  it  is  probal)ly 
rare.  L.  Stein  {Archiv.  fur  Aiigenhcilk.,  Vol.  84,  p.  53,  1913)  had 
an  excellent  chance,  during  seven  years,  to  examine  the  large  body  of 
workmen  at  the  Kreuznach  glass-works.  He  reports  that  the  majority 
were  of  rather  poor  physique  and  fre(iuently,  as  they  got  older,  suf- 
fered from  asthma  and  lung  tuberculosis.  They  nearly  all  Iiad  em- 
physema of  the  parotid.  To  make  up  for  the  great  loss  of  fluid  by  per- 
spiration most  of  them  drank  enormous  quantities  of  fluid,  chietly  beer 
and  cofl'ee,  up  to  ten  litres  a  day. 

Stein  made  a  point  of  examining  with  the  aid  of  homatropine  every 
case  that  came  befoie  liim.  In  this  way  the  majority  of  his  cataract 
cases  were  discovered  accidentally.  He  gives  a  table  of  55  persons 
examined,  in  28  of  whom  cataract  was  present,  in  some  stage  or  other. 
He  comes  to  the  conclusion  that  the  cataract  usually  begins  at  the 
posterior  i)ole  in  the  left  eye,  the  right  eye  being  affected  later.  The 
posterior  i)olar  opacity  is  either  rosette-shaped,  in  which  case  the  rest 
of  the  lens  may  remain  clear  for  a  long  period,  or  it  is  in  the  shape  of 
a  round  opacity,  in  tlie  middle  of  which  a  more  dense  point  appears; 
in  this  form  it  is  usual  to  find  an  anterior  polar  opacity  developing 
later  together  with  cortit'al  oi)acities.  In  one  case  in  which  the  right 
eye  was  first  affected,  tiie  workman,  conti'ar\-  to  the  usual  practice,  had 
held  the  right  sitle  of  his  face  next  the  oven.  Although  i)osterior  polar 
cataract  is  to  be  regarded  as  the  type  characteristic  of  the  disease, 
there  were  several  patients  in  wliom  the  seat  of  the  opacity  was  in  tlie 
micleus  01'  cortex. 

Stein  liad  ojx-rated  on  six;  the  first  by  discission  with  subsequent 
evacuation  of  the  swollen  lens,  and  the  i-emaiiulei'  by  extraction  six 
W(H'ks  after  a  ])reliminary  iridectomy  with  massage.  There  were  no 
comjjlications,  but  he  found  the  nucleus  nnicli  larger  than  was  to  be 
expected  from  the  age  of  the  patients,  and  advises  a  large  section. 
The  extracted  lenses  were  examined  liy  Hess,  who  failed  to  find  any 
peculiarities. 

In  the  works  at  Krtniznach  an  effort  is  made  to  protect  the  eyes 
of  the  workmen  from  the  ulti'a-violet  rays,  by  means  of  sheets  of  color- 
less glass  which  are  fixed  about  half  a  metre  from  the  ovens,  and  so 
arranged  that  tlie  workmen  look  through  tliem  while  carrying  on  the 
necessary  manipulations  with  the  hands  beneath.  These  have  been  in 
use  for  some  considerable  time.     The  wearing  of  any  form  of  pro- 


5396  GLASSES,  COLORED 

tective  glass  by  the  woi-kincii   is  rendered  impossible  by  th(;  profuse 
sweatinjr.     !^''(\  ;dso,  Cataract  lieadiiigs. 
Glasses,  Colored.     See  j)aj^'e  2:588,  Vol.  IV,  of  this  I'Jn cyclopedia;  also 

Dazzling, 
Glasses,  Convex  and  concave.     Sec  Lenses,  Ophthalmic;  as  well  as  Eye- 
glasses and  spectacles,  History  of,  and  otln  r  Eyeglasses  captions. 
Glasses,  Franklin.     Bifocal  <::lass('s.     See  Franklin  glasses;  as  well  as 

Eyeglasses  and  spectacles,  History  of. 
Glasses,  Hyperbolic.    Those  <iiound  in  the  form  of  an  hyperbola. 
Glasses,  Periscopic.     The  best  example  of  an  eye  glass  or  spectacle  lens 
whose  refracting  surfaces  conform  to  the  surface  of  the  globe  (and  is 
consequently  periscopic)  is  the  toric  lens.    According  to  W.  S.  Dennett, 
a  solid  developed  by  the  revolution  of  a  circle  about  any  axis  other  than 
its  diameter  is  known  as  a  torus.    A  toric  lens  may  be  described  as  one 
which  is  cut  from  a  toric  surface  b}^  a  plane  parallel  to  its  axis  of 
development.     The  optical  centering  of  such  a  lens  requires  that  both 
its  centers,  the  center  of  its  circle  and  the  center  about  which  in  its 
development  the  circle  revolves,  shall  be  on  the  axis  of  the  system. 
Glasses,  Prismatic.     See  Prisms;  Glasses,  Reading;  also  Hand-glass. 
Glasses,  Stenopaic.     Those  consisting  of  a  blackened  disc  of  metal  in 
which  is  placed  a  small,  round  hole  or  a  narrow  slit ;  they  are  used  for 
examining  and  correcting  errors  in  astigmatic  eyes. 
Glass  eyes.     Protheses.     See  Artificial  eye. 

Glass,  Optical.  By  optical  glass  is  meant  a  quality  of  glass  suited  for 
the  production  of  high  grade  prisms,  lenses,  etc.  It  must  be  produced 
in  great  variety  so  that  the  designer  of  optics  may  have  as  wide  a 
choice  as  possible  of  glass  differing  in  dispersion  and  refractive  index. 
It  must  have  in  a  great  degree  such  characteristics  as  freedom  from 
color,  strict,  and  large  bubbles,  and  it  must  be  without  internal  stresses. 
Glass-making  is  largely  dependent  upon  chemistry,  and  peculiar 
kinds  of  glass  are  required  if  we  are  to  obtain  the  best  results  in  spec- 
troscopes, polariscopes,  microscopes,  and  refractometers,  as  well  as 
in  other  instruments  so  useful  and  necessary  to  the  optician,  the  ocu- 
list, the  chemist,  and  to  members  of  other  professions. 

Progress  in  glass-making  and  in  optics  has  been  almost  simultaneous. 
Prior  to  1886  glass-makers  were  offering  a  very  limited  variety  of 
optical  glass  to  the  makers  of  refracting  instruments,  and  the  perfec- 
tion of  such  instruments  was  necessarily  limited  to  the  possibilities 
presented  by  a  few  crown  and  flint  glasses.  Two  lenses  had  been  com- 
bined into  a  doulilet  so  as  to  bring  pairs  of  colors  to  a  common  focus 
on  the  optical  axis  of  the  lens,  thereby  diminishing  chromatic  aberra- 
tion.   Means  to  render  the  image  almost  entirely  free  from  spherical 


GLASS,  OPTICAL  5397 

aberration  had  also  been  devised,  I)iit  no  attempts  liad  been  made  to 
introduce  new  glasses,  eCl'ort  being  exi)ended  only  in  perfecting  tech- 
nical manipulation  and  in  adding  to  tlie  list  of  dense  Hints. 

There  were  a  few  exceptions  to  this  general  condition.  Frauen- 
hofer,  a  German  optician,  succeeded  in  finding  glasses  which  showed  a 
diminution  of  the  secondary  spectrum,  but  the  new  glass  was  not  pro- 
duced on  a  commercial  basis  and  the  formula  was  lost.  In  1825  Fara- 
day was  appointed  by  the  Royal  Society,  together  with  Sir  John 
Herschel  and  Mr.  Dolland,  on  a  committee  to  examine  and  to  improve 
the  manufacture  of  optical  glass.  A  complete  report  was  made  in 
1829,  and,  although  the  glass  resulting  from  a  very  exhaustive  and 
systematic  series  of  experiments  did  not  prove  of  much  practical  use, 
yet  the  work  had  much  directive  influence  on  subsequent  researches. 
Harcourt,  an  English  clergyman,  carried  on  a  numl)er  of  experiments 
and  established  certain  facts  relating  to  the  effect  of  certain  chemical 
elements  upon  the  refraction  of  light;  but  his  meltings  were  so  small 
that  pieces  large  enough  and  sufficiently  perfect  to  permit  complete 
spectrum  analj'sis  could  not  l)e  obtained,  and,  lacking  information 
which  can  be  gained  only  witli  the  spectrometer,  his  subsequent  work 
suffered  for  want  of  guiding  experience. 

Up  to  this  time  silicon,  sodium,  potassium,  calcium,  lead,  and  oxy- 
gen had  been  the  only  elements  used  in  glass-making,  except,  perhaps, 
aluminum  and  tliallium  in  an  experimental  way.  Crown  and  flint 
glasses  were,  however,  being  produced  of  a  far  better  quality  as 
regards  clearness,  homogeneity  and  freedom  from  color;  moreover, 
flint  of  far  greater  refractive  power  and  dispersion  appeared  than  had 
been  offered  up  to  this  time.  But  there  were  only  two  glass  works 
filling  the  popular  demand,  and  the  difficulties  connected  with  taking 
up  work  in  this  field,  the  great  expense  of  the  experimental  work,  and 
the  uncertainty  of  even  limited  success  in  the  near  future  discouraged 
everyone  from  taking  up  the  manufacture  of  new  glass  in  competition 
with  the  existing  makers.  Even  if  successful  the  proportion  of  optical 
glass  to  the  total  amount  of  glass  consumed  was  so  small  that  no  great 
financial  returns  could  be  expected. 

In  the  late  seventies  Professor  Ernest  Abbe,  of  the  University  of 
Jena,  published  a  paper  on  the  microscope  in  which  he  made  an  appeal 
to  scientists  to  take  up  the  improvement  of  optical  glass,  pointing  out 
that  the  microscope,  as  well  as  all  other  optical  instruments,  was  in  a 
state  of  arrested  development  awaiting  such  ])erfection  in  glasses  as 
would  offer  a  great  diversity  in  mean  indi'X  and  mean  dispersion,  and 
render  possible  a  higher  degree  of  achromatism,  thus  diminishing  the 
secondary  spectrum.    He  also  pointed  out  tliat  tlie  optical  glass  supply 


5398  GLASS,  OPTICAL 

might  be  seriously  affected  or  permanently  discontinutd  by  a  single 
accident  owing  lo  production  being  in  the  hands  of  so  few,  and  he 
urged  someone  to  undertake  tiie  manufacture  of  optical  glass. 

His  plea  attracted  Otto  Schott,  and  after  connnunicating  with  Abbe 
the  two  began  an  investigation  of  tlie  prol^lem,  seeking  first  of  all  to 
determine  the  chemical-physical  principles  underlying  the  making  of 
optical  glass.  Schott  carried  out  the  experimental  work,  while  Abbe 
and  Riedel  made  the  spectrometric  measurements  and  conducted  other 
tests.  The  experimental  meltings  did  not  exceed  60  grams,  and  were 
intended  to  determine  just  what  elements  would  enter  into'  the  com- 
position of  glass  and  influence  refractive  power  and  dispersion.  With 
the  knowledge  thus  gained  the  scope  of  the  work  was  enlarged  and 
combinations  of  ingredients  were  systematically  made  on  a  larger 
scale,  the  meltings  weighing  up  to  10  kilos.  It  was  not  until  1886  that 
some  results  were  published,  and  it  was  then  determined  to  undertake 
the  commercial  production  of  optical  glass  as  well  as  to  continue  the 
research  work. 

In  experimenting  with  various  combinations  of  chemical  elements 
the  following  limitations  must  be  ])orne  in  mind :  The  llux  must  not 
act  upon  the  crucible  and  so  absorb  impurities  from  that  material; 
elements  which  evaporate  during  the  process  tend  to  produce  veins  in 
the  glass  and  therefore  must  not  be  used ;  cloudiness,  crystallization 
and  bubbles  must  be  avoided  in  the  processes  of  melting,  cooling,  and 
subsequent  reheating ;  it  must  be  possible  to  bring  the  glass  from  the 
plastic  to  the  solid  state  without  producing  stress;  glass  must  not  be 
^  tarnishable  nor  hygroscopic — that  is,  it  must  not  be  attacked  by  the 
moisture  of  the  air;  it  must  be  colorless  and  strong  enough  to  bear 
manipulation  in  grinding  and  polishing. 

These  various  limitations  cannot  be  made  less  severe,  and  when 
considered  together  present  an  array  of  difficulties  hard  to  overcome. 

Besides  silicic  acid  or  sand,  the  only  glass-nmking  oxides  are  boric 
acid,  phosphoric  acid,  and  perhaps  arsenic  acid.  There  was  a  theory 
tliat  these  three  oxides  give  tarnishal)le  glasses,  but  this  was  investi- 
gated by  combining  phosphoric  and  boric  oxides  with  as  many  metallic 
oxides  as  possible,  the  first  meltings  being  made  in  small  crucibles  and 
later  in  larger  quantities  up  to  25  kilos  in  melting  pots  of  porcelain 
or  fire-clay.  In  addition  to  the  six  elements  so  long  used  in  glass- 
making  28  new  ones  were  introduced  by  degrees  in  quantities  of  at 
least  10  per  cent.  These  were  boron,  pliosphorus.  lithium,  magnesium. 
7,ine,  cadmium,  barium,  strontium,  aluminium,  beryllium,  iron,  man- 
ganes(^  cerium,  didymium,  erbium,  silver,  mercury,  thallium,  bismuth, 


GLASS,  OPTICAL  5399 

aiitiinony,  arsenic,  iiiols  hdimii,  iiiohium,  tunj^sten,  tin,  titaniuiii,  ura- 
nium, and  liuorinc. 

For  tliorouj^lily  mixing'  tlic  contents  of  tlic  criicihlc  a  pon-flain  agi- 
tator was  revolvtHl  rai)i(lly  ami  automatically  raisctl  and  lowcrutl  5  cm. 
or  10  em.  Porcelain  crucibles  were  useil,  but  in  spite  of  active  stirring 
it  was  impossiljle  to  obtain  large  pieces  free  from  vi'ins.  Hoping  for 
better  results,  a  platinum  crucibh^  holding  'A  litres  was  used  with  a 
})latinum  stirrer  weighing  1  i/o  kilos,  but  numerous  l)ubbles  appeared 
at  the  contact  of  the  glass  and  platinum,  and  the  crucible  disintegrated 
so  rapidly  that  it  was  good  for  Imt  four  meltings.  Other  attempts 
were  matle  with  a  very  thick  crucible,  and  the  fact  established  that 
while  platinum  could  be  used  for  melting  boric  glass,  phosphates  dis- 
solved the  metal  and  exuded  it  again  in  gray  masses  during  cooling. 
Special  sorts  of  fire-clay  pots  were  tiually  found  to  be  most  satisfac- 
tory. 

Optical  glass  must  be  free  from  the  stress  acquired  in  solidifying, 
and  this  fact  adds  another  problem  to  glass  manufacture.  After  many 
trials  and  subsequent  testings  with  polarized  light,  a  process  called  fine 
annealing  was  perfected.  Ovens  with  thermo-regulators  whereby  the 
temperature  may  be  kept  at  any  point  between  350°  and  470°  C,  and 
allowed  to  fall  with  any  desired  slowness,  were  used.  It  was  deter- 
mijied  that  the  temperature  of  solidification  is  between  370°  and 
465°  C,  and  by  spreading  this  fall  of  95°  over  an  interval  of  four 
weeks  or  more  perfect  results  were  obtained. 

It  was  soon  seen  that  with  the  introduction  of  new  elements  a  varia- 
tion of  the  hitherto  fixed  relations  between  refraction  and  dispersion 
could  be  attained,  but  on  the  other  hand  very  few  of  the  new  elements 
render  the  dispersion  of  crown  and  flint  more  similar,  whereby  a 
shortening  of  the  secondary'  spectrum  could  be  effected.  Boric  acid 
is  peculiar  in  lengthening  the  red  end  of  the  spectrum  relatively  to 
the  blue,  while  fluorine,  potassium,  and  sodium  have  the  opposite 
effect.  It  is  characteristic  of  the  old  glasses  that  Hint  has  a  higher 
index  and  greatei"  disi)ersion  than  crown,  and  lengthens  the  blue  more 
than  the  red,  hence  it  was  desirable  to  introduce  into  flint  glass  as  high 
a  j)ercentage  as  possible  of  l)oric  acid.  The  problem  of  lengthening 
the  blue  i-elative  to  the  red  in  crown  glasses  is  not  an  easy  one.  Sodium 
has  only  a  slight  influence,  and  when  the  mixture  contains  of  it  more 
than  30  per  cent,  the  glass  is  tarnishable.  Fluorine  would  be  very 
advantageous  in  coml)ination  with  lithium,  barium,  ahniiinium,  phos- 
phoric acid  and  calcium,  but  as  decomposition  of  the  tluorite  takes 
place  during  the  nuiuufacture  and  the  silicic-fluoride  gas  given  off 
attacks   the   crucible    it    cannot   be   used.      In    phosphate   and    borate 


5400  GLASS,  OPTICAL 

glasses  alkalies  must  be  used  very  spai-iii<^ly  or  taruisliiug  is  inevitable. 
By  adding  alumina,  zine  oxide  and  barium  oxide  the  sensitiveness 
could  be  sufficiently  overcome.  A  uundier  of  elements  liad  to  be 
excluded  on  account  of  their  coloring  influence  or  rarity. 

All  this  work,  being  merely  empirical,  was  very  tedious,  but  at  last 
notable  results  were  achieved.  A  scries  of  flint  glasses  containing 
boric  acid  was  established,  by  the  aid  of  which  it  was  possible  to  make 
three-lens  systems  free  from  secondary  spectra,  but  these  glasses  were 
not  so  permanent  as  the  older  ones.  A  valuable  series  of  boro-silicate 
crown  glasses  with  a  lower  refractive  index  and  dispersion  than  the 
ordinary  crown  was  obtained,  and  these  are  now  extensively  used  for 
prisms  and  small  objectives.  The  dense  barium  crown  glasses,  using 
barium  and  boric  acid,  were  perfected,  and  these  glasses  are  used  In 
nearly  all  "anastigmat"  photographic  lenses. 

Up  to  1886  the  net  result  of  all  these  epoch-making  discoveries  was 
nineteen  glasses  of  essentially  new  optical  characteristics,  and  to  these 
more  than  twenty  liave  since  been  added.  The  most  important  result, 
however,  was  the  established  possibility  of  offering  a  wide  range  of 
refractive  index  and  dispersion  to  the  mathematical  optician,  who  is 
now  able  to  regard  these  two  properties  as  more  or  less  independent 
of  each  other. 

The  introduction  of  these  new  glasses  caused  a  revolution  in  the 
scope  and  manufacture  of  optical  instruments.  One  can  well  imagine 
the  expectancy  of  Abbe,  who  now  for  the  first  time  saw  the  cherished 
hopes  of  years  approaching  fulfilment.  First  of  all,  he  applied  these 
new  glasses  to  the  objectives  of  the  microscope,  and  with  their  aid  and 
in  connection  with  other  discoveries  of  a  physical  nature  which  he  had 
made,  he  was  soon  able  to  construct  microscopes  which  resolved  struc- 
tures with  an  exactitude  and  certainty  hitherto  unapproached.  The 
stimulus  given  to  microscopic  research  was  immediate.  New  telescope 
constructions  have  been  found  using  these  glasses,  and  in  the  field  of 
photography  the  application  of  new  optical  glass  has  been  of  great 
significance.  Anomalous  pairs  of  glasses  needed  for  flattening  the 
field  were  available,  and  achromats  could  be  made  in  which  the  positive 
lens  has  a  higher  refractive  index  and  less  dispersion  than  the  negative 
lens.  The  now  well-known  type  of  anastigmat  was  discovered  with  the 
aid  of  the  new  glass. 

IMore  recently,  investigations  have  been  carried  on  in  an  effort  to 
produce  glass  for  spectacles  and  goggles  to  ])revent  cataract  and 
other  diseases  of  the  eye  which  aflFect  glass-makers.  The  ideal  glass 
for  this  and  similar  purposes  should  first  of  all  cut  off  the  heat  rays, 
then  the  ultra-violet  rays,  and,  finally,  transmit  the  highest  possible 


GLASS,  OPTICAL  5401 

percentage  of  the  harmless  luuiiiious  rays.  The  heat  rays  are  from 
the  infra-red  end  of  the  spectrum,  and  the  ultra-violet  has  a  bad 
iuHuence,  as  shown  by  the  intense  fiuorescenee  of  the  crystalline  lens 
when  ultra-violet  light  is  thrown  upon  it.  Luminous  rays  in  excess 
are  harmful.  The  experiments  consistetl  in  adding  elements  to  a 
soda-lime  glass  flux  and  testing  the  resulting  glass  for  heat  rays  by 
a  special  apparatus  in  which  black  mica  was  used  to  cut  off  light  but 
which  allowed  heat  to  pass  through.  xVbsorption  of  ultra-violet  light 
was  measured  by  a  quartz  spectrograph,  luminous  rays  by  Chapman- 
Jones  opacit}^  balance  and  color  by  the  Lovibond  tintometer  (q.  v.). 
While  some  very  excellent  results  have  been  obtained  and  valuable 
information  tabulated,  not  only  as  regards  the  original  problem  but 
regarding  the  reduction  of  glare  from  snow  or  sea,  yet  the  ideal 
result  has  not  yet  been  reached.  Glasses  that  accomplish  one  (in 
some  cases  two)  of  the  desired  ends  have  been  obtained,  but  one 
which  passes  what  is  considered  a  proper  percentage  of  luminous 
raj'S  and  yet  cuts  oft'  a  large  percentage  of  infra-rod  and  ultra-violet 
rays  is  yet  to  be  produced.  See  Eyeglasses  and  spectacles,  History 
of;  also  Glaring;  and  Colored  glasses. 

Glass  is  undoubtedly  a  solid  solution  in  which  silicic  acid  or  other 
acid-forming  oxide  is  the  solvent,  and  the  other  components  the  solutes. 
This  accounts  for  much  of  the  beliavior  of  glass,  as,  for  example,  the 
after-working  observed  in  thermometers  and  the  lack  of  homogeneity 
in  optical  glass  which,  however,  becomes  less  as  the  glass  ages.  Parts 
of  a  solution  adjust  themselves  so  that  the  solution  becomes  uniform 
because  the  different  molecules  find  no  obstacle  to  their  free  move- 
ment. In  glass  this  readjustment  is  rendered  much  more  difiicult. 
hence  the  comparatively  long  time  required  for  the  proper  aging  of 
optical  glass.  Where  aging  does  not  accomplish  perfect  homogeneity 
we  must  resort  to  hand  correction  to  produce  a  surface  as  perfectly 
plane  as  possible. 

Several  characteristics  of  glass  have  received  careful  consideration. 
These  are  density,  tenacity  or  tensile  strength,  resistance  to  crushing, 
elasticity,  hardness,  specific  heat,  conductivity  of  heat,  cubical  expan- 
sion, thermo-endurance,  and  the  chemical  behavior  of  glass  surfaces, 
as  well  as  physical  properties,  such  as  refraction  and  dispersion.  In 
considering  these  characteristics  the  question  naturally  arises  whether 
the  characteristics  of  the  glass  can  be  foretold  from  the  nature  of  the 
oxides  used  in  making  it.  If  this  could  be  done  then  the  properties 
of  the  oxides  in  glass  could  be  determined  from  observations  of  prop- 
erly-selected glasses,  and  when  values  had  been  assigned  to  the  oxides 
the  approximate   character  of  any   glass  containing  them   could  be 


5402  GLASS,  OPTICAL 

(Iflcniiiiicd  ill  advance.  In  (•oiiiiionndinj,'  a  s|)('i-ial  glass  to  meet  a 
given  i-eciiiirenient  this  wonld  he  of  great  help,  hut  in  practice  it  docs 
not  work  out  very  well,  although  computed  results  dill'er  from  those 
oliserved  hy  only  1 '/^  per  cent.,  with  a  ma.ximum  dittcreiice  of  -i  per 
cent.,  where  density  is  under  consideration ;  yet  with  other  character- 
istics the  dift'ereiices  are  great  enough  to  defeat  the  i)lan.  Inforaia- 
tion  lias  been  tabulated  regarding  the  intluence  of  the  various  elements 
ui)on  these  different  characteristics. 

It  is  interesting  to  note  that  the  demand  for  i)urely  optical  glass 
is  not  sutificient  to  make  its  manufacture  a  profitable  industry  apart 
from  other  types  of  glass.  This  is  due  to  the  high  cost  of  the  exi)eri- 
mental  work  and  to  the  fact  that,  as  a  rule,  not  more  than  20  per  cent, 
of  a  large  melting  comes  from  the  annealers  suitable  for  optical  use. 

In  glass-making  every  step  in  the  process  and  each  raw^  material 
are  controlled  with  the  utmost  care.  The  raw  materials  must  be 
analyzed  and  kept  free  from  contamination,  there  must  be  the  most 
rigid  control  of  temperatures,  the  proper  regidation  of  combustion, 
etc.  One  of  the  diiBculties  is  the  production  of  suitable  pots — a  science 
in  itself.  The  aging  of  the  clay  is  a  step  carefully  watched,  and  bac- 
terial action  plays  an  important  role  in  its  ripening.  Various  types 
of  pots,  both  open  and  closed,  are  employed,  and  frequently  a  period 
of  ten  months  passes  from  the  time  the  pot  is  started  until  it  is  ready 
for  use.  It  is  then  gradually  warmed  until  red  hot,  when  it  is  trans- 
ferred to  the  melting  furnace  and  sealed  in.  When  the  temperature 
reaches  the  melting  point  of  the  glass  to  be  made  the  pot  is  glazed 
insidt-  with  pieces  of  glass  from  a  previous  melting,  the  glazing  being 
accomplished  with  an  iron  ladle.  The  mixture  is  then  shoveled  in  in 
layers  until  the  pot  is  full  of  molten  material,  after  which  it  is  kept  at 
a  high  temperature  for  a  considerable  time.  Great  care  is  required  to 
maintain  the  proper  temperature  during  this  refining  process;  and  the 
arrangements,  together  with  the  skill  of  the  operatives,  makes  it  pos- 
sible to  maintain  a  given  temperature  fi'om  10°  up  to  1500°  C. 

Tf  the  temperature  is  too  low  bubbles  are  not  removed,  and  if  too 
high  the  crucilile  itself  is  attacked.  At  the  conclusion  of  this  opera- 
tion the  teiuix'rature  is  allowed  to  fall  slightly  and  the  scum  is  taken 
off  the  pot.  A  red-liot  stirrer  of  fire-clay,  shaped  like  a  hollow  cylinder, 
is  next  introduced  and  allowed  to  remain  for  an  hour  or  more,  to 
allow  air  bubbles  to  rise  to  the  surface.  The  liandle  of  the  stirrer  is 
an  ii-on  tul)e  cooled  by  circulating  water. 

The  glass  is  tested  from  time  to  time  by  blowing  small  flasks,  to 
determine  its  ch^arness.  AVlieii  siiflicieiitly  dear  tlie  stirring  is  con- 
tinued  i'oi-  llircc  or  four  hours,  the  mass  gradually  cooling  mcaiiwliile. 


GLASS,  SOLUBLE  540;{ 

and  when  the  stirrer  can  be  rciiiovcd  only  witli  ^wnt  dil'lk'nlty  it  is 
taken  out.  The  oven  is  next  nnscah'd  and  llic  pot,  wlucli  with  llic 
ghiss  may  weij^h  from  ir)()<)  to  2(t(l()  |)onntls,  is  rt'iiiovcd  on  a  truck  lo 
an  annealing  ovi-n,  oi-  allowed  to  I'ciiiain  in  the  yard  to  cool,  as  the 
case  re(iuires.  The  process  of  shifting  the  pot  is  important  and  nuist 
be  effected  rapidly  to  })revent  too  suddi'n  cooling.  Pots  on  irou  carts 
are  surrounded  with  inllauimable  material  and  the  transfer  is  made 
by  rail. 

In  the  annealing  oven  the  temperature  is  controlled  to  within  5° 
C,  and  the  mass  cooling  down  generally  flies  into  pieces  during  the 
four  or  more  days  it  is  kept  there.  The  pieces  are  carefully  examined, 
faulty  portions  hammered  off  and  rejected.  Every  piece  from  a  given 
melting  is  marked  with  the  same  number,  which  is  the  number  under 
which  the  glass  is  sold.  The  good  glass  is  moulded  into  plates  in  fire- 
brick moulds,  and  in  some  instances  the  fine  annealing  is  done  simul- 
taneously. 

When  the  plates  have  been  formed,  annealed  and  cooled  they  are 
polished  on  two  opposite  sides  or  edges  and  carefully  examined  with 
a  spectrometer  and  with  a  polariscope  to  determine  any  remaining 
defects.  In  this  shape  it  is  received  by  the  manufacturing  optician, 
who  must  saw  from  the  plates  suitable  pieces  for  grinding  and  pol- 
ishing to  produce  the  lenses  his  formula?  recpiire. —  (II.  E.  Howe.) 

Glass,  Soluble.     Potassium  or  sodium  silicate. 

Glassy.  Having  the  appearance  of  glass.  Fixed  and  expressioidess 
(said  of  the  eyes  of  the  dead). 

Glassy  membrane.  Bruch's  membrane.  Lamina  vitrea.  The  homo- 
geneous mend)rane  that  lines  the  choroid.  See  i)age  1317,  Vol.  II  of 
this  Encijclopidia. 

Glastine.     Of  a  bluish  color. 

Glatt.     (0.)     Smooth. 

Glauber's  salt.     See  Sodium  sulphate. 

Glaucoma.  Gouty  eye.  Glaucosis.  In  tlie  discussion  of  this  large 
and  imi)ortant  subject,  it  Avas  considered  wise  to  divide  the  lal)or  among 
several  collaboratoi's.  The  Editor  feels  that  he  has  been  fortunate 
in  having  secured  the  services  of  Drs.  Wm.  Campbell  Posey  and  Burton 
Chance,  of  Philadeli)hia,  to  write  this  major  heading,  the  former  tak- 
ing up  the  operative  treatni<  itf,  the  latter  writing  the  iiitroductori/ 
portion^  including  the  si/mptoniotology,  pathologjf  and  prognosis  of 
the  disease.  For  the  minor  portion — non-operative  treatnunt — tlie 
Editor  is  respon.sible,  as  well  as  t'oi-  bracketed  sections. 

Also,  this  section  should  l)e  I'cad  in  connection  with  Tonometry; 


5404  GLAUCOMA 

Circulation  of  intraocular  fluids ;  Filtration,  Ocular ;  Blood  pressure ; 
Buphthalmus ;  jitid  oilier  rehited  sections. 

P<  jiiiitiuii.  (Jlaucoina  is  ;i  <lise;i.se  chai'ncleri/.cd  li,>-  iiiei-eased  ten- 
sion of  the  glol)e  and  gradual  of  sudden  impainnent  or  loss  of  vision. 
Jt  formerly  indicated,  aeeordinj?  to  Von  Graefe,  ''a  vague  exi)ression- 
less  symptom,  a  sea-green,  a  bottle-green,  or  dirty-green  background 
of  the  eye,  seen  through  a  fixed,  dilated  pupil."  Broadly  speaking, 
the  term  glaucoma  is  applied  to  all  those  conditions  in  which  the 
intraocular  pressure  is  abnormally  increased.  Priestley  Smith  has 
defined  it  tersely  as  "an  excess  of  pressure  within  the  eye,  plus  the 
causes  and  consequences  of  that  excess." 

Histm-y.  The  term  glaucoma  is  of  great  antiquity.  To  the  ancient 
writers  such  a  disease  as  glaucoma  could  not  have  been  known  in  its 
early  stages,  n(>ither  do  they  appear  to  have  recognized  it  as  associ- 
ated with  any  distinct  form  of  disease,  and,  from  the  time  of  Hippoc- 
rates to  the  early  part  of  the  XVIII  century,  the  term  was  applied 
.    to  cataract  as  well  as  to  other  states. 

As  Thos.  H.  Shastid  points  out  regarding  the  origin  of  this  term, 
Hippocrates  employed  not  "glaucoma,"  but  "glaucosis,"  and  that 
but  a  single  time.  The  sense  in  which  he  used  the  term  has  never 
been  exactly  made  out,  but  he  probably  meant  to  cover  the  condition 
Avhich,  today,  we  know  as  "cataract."  By  the  Greco-Roman  writers, 
"glaucoma"  would  seem  to  have  meant  "light  blue."  In  a  pseudo- 
Galenic  manuscript  occurs  this  definition:  "Glaucoma  is  an  altera- 
tion of  the  natural  fluids  (humors)  into  a  clear  blue  with  complete 
blindness."  Still  later,  it  appears  that  in  amaurosis  there  is  no  per- 
ception of  light  and  the  pupil  is  altogether  clear ;  but,  if  the  pupil  is 
bluish,  the  condition  is  termed  "glaucoma."  Neither  condition  is  cur- 
able. If,  however,  the  pupil  that  has  suffered  a  change  of  color,  still 
retains  some  light  perception,  then  the  condition  is  known  as 
hypochyma  (Lat.  suffusio;  since  Constantinus  Africanus,  "cataract"). 
The  next  important  clarification  of  ideas  occurred  when  Rolfinck  (in 
1656),  and,  later,  Bri.sseau  and  IMaitre  Jan  (g.  v.)  pointed  out  and 
demonstrated  the  true  location  and  nature  of  cataract — i.  e.,  that  a 
cataract  is  essentially  a  clouding  of  the  crystalline  lens,  and  not,  as 
had  been  formerly  supposed,  the  flowing  down  of  an  inspissated  humor 
into  a  (purely  imaginary)  cataract  space  between  the  pupil  and  the 
lens.  All  this  time,  however,  the  idea  of  hypertonia  had  never  been 
entertained.  "With  IMiiller  and  von  Graefe  entered  that  conception, 
which,  thenceforward,  has  been  the  essential  idea  of  glaucoma. 

Brisseau  demonstrated  by  his  post-mortem  examinations  that  glau- 
coma is  not  due  to  an  affection  of  th(^  lens:  he  ascribed  it  to  diseasi^  or 


GLAUCOMA  5405 

turbidity  of  the  vitreous  humor.  Tersou,  in  an  account  of  his 
researches  concerning  the  earliest  mention  of  the  liardncss  of  the  eye- 
ball in  glaucoma,  states  that  J.  I'latner,  in  a  work  published  in  1745 
in  which  he  ascribed  certain  cases  of  glaucoma  to  an  aifection  of  the 
crystalline  lens,  gave  evidence  of  his  knowledge  of  the  hardness  of 
the  globe  to  finger  pressure.  More  careful  discrimination  was  shown 
throughout  the  succeeding  years  of  that  century,  so  that  by  1821, 
Demours,  in  an  extended  description,  referred  to  the  increase  of 
tension,  and  associated  glaucoma  with  over-sensitiveness  of  the  nerv- 
ous system,  but  ascribed  the  disease  to  gout  and  rheumatism.  Yet 
it  was  not  until  1830  that  Mackenzie  observed  that  hardness  of  the 
globe  and  an  increase  in  the  contents  of  the  eye  were  accompaniments 
of  the  condition  of  what  was  by  that  time  denominated  glaucoma. 

In  the  succeeding  twenty  years  many  hypotheses  were  advanced  as 
to  the  cause ;  certain  observers  attributed  it  to  disease  of  the  retina 
or  of  the  optic  nerve,  while  others,  among  whom  was  Mackenzie, 
ascribed  it  to  an  affection  of  the  choroid.  Nothing  yet  had  been  devised 
to  relieve  the  symptoms,  and  the  prognosis  remained  unfavorable; 
moreover,  as  it  was  not  until  the  invention  of  the  ophthalmoscope  that 
it  became  possible  to  diagno.se  the  non-inflammatory  types  and  to 
study  the  morbid  changes  which  preceded  the  final  stages,  only  the 
inflammatory  types  were  known  and  studied  prior  to  1850. 

In  1854,  Mackenzie  advised  that  "paracentesis  of  the  cornea,  or  of 
the  sclerotic,  affords  great  relief  of  pain."  Albreclit  von  Graefe's 
observations  on  animals,  and  his  .study  of  cases  of  iris-adhesion  after 
corneal  ulceration  and  of  staphylomata.  in  which,  after  iridectomy 
had  been  performed,  he  noticed  that  the  tension  was  permanently 
lowered,  led  him  to  propose  iridectomy  as  an  effectual  means  for  miti- 
gating the  tension  of  the  globe  and  relieving  the  glaucomatous  condi- 
tion (yet  for  several  years  Desmarres,  in  Paris,  had  practised  para- 
centesis in  the  manner  advised  and  emplyed  by  ^Mackenzie,  although 
in  his  hands  it  had  afforded  only  temporary  relief).  In  1855.  Donders 
observed  the  significance  of  the  adhesion  of  the  iris  to  the  posterior 
surface  of  the  cornea. 

In  1856.  Heinrich  ]\Iiiller  demonstrated  anatomically  the  pressure- 
excavation  of  the  optic  nerve,  and.  a  year  or  so  later.  AVeber  and 
Forster  accurately  diagnosed  it  with  the  aid  of  the  ophthalmoscope. 

So  late  as  the  middle  of  the  nineteenth  century  the  morbid  process 
was  so  completely  mysterious  that  no  chapter  in  ophthalmology  has 
been  so  prolific  of  hypotheses,  nor  so  productive  of  such  serious  and 
laborious  investigation,  as  that  on  glaucoma,  and  all  notwithstanding 
von   Graefe's  beneficent   and   epoch-making  discovery.      Indeed,    for 


5406  GLAUCOMA 

lil'tccii  veil  IS,  liis  very  success  in  llie  relief  of  thousands  of  glaucoma 
l>;iticiits,  led  him  jiihI  the  iorcmost  observers  to  search  for  the  cause 
of  the  product  ion  of  glaucoma  and  the  mystery  of  its  cure;  and  we 
arc  si  ill  tryiii;^'  to  impi'ovc  our  nictliods  of  treatment. 

Dondcrs,  iiotiiif^  tliat  .sim])lc  ^hiucoma  was  unaccompanied  by  in- 
Haminatoi-y  symptoms,  believed  the  increase  of  tension  arose  througli 
irritation  of  the  secretory  nerves  in  the  eye;  others  associated  the 
activity  of  the  secretory  nerves  with  trigeminal  neuralgia;  others  still 
regarded  it  as  the  effect  of  angioneurosis,  which  led  on  to  congestion 
of  the  globe. 

In  the  last  ((uarter  of  the  nineteenth  century  certain  of  the  hypoth- 
eses of  all  time  were  pursued  with  infinite  pains  and  the  atmosphere 
became  clearei-  by  reason  of  moi-e  exact  methods  in  histologic  study, 
especially  the  study  of  eyes  removed  ])ecause  of  secondary  glaucoma. 
Leber  advocated  that  the  cause  lay  in  the  o1)struction  of  the  angle  of 
the  anterior  cluuuber;  his  researches  were  amply  corroborated  by 
Knies  and  Weber,  and  their  conclusions  are  universally  accepted. 
Pi'iestley  Smith,  confiinng  his  studies  to  the  changes  o1)served  in  the 
crystalline  lens  throughout  life,  in  187!)  advanced  the  idea  that  primary 
glaucoma  depended  upon  the  increase  in  the  growth  of  the  lens,  or 
rather  in  a  disproportion  between  the  size  of  the  lens  and  the  size  of 
the  eye. 

In  more  recent  years  the  thesis  of  Thomson  Henderson  has  greatly 
stirred  the  ophthalmic  world.  He  claims  that  sclerosis  of  the  pectinate 
or  cribriform  ligament  is  the  cause  of  the  olistruction  in  the  filtration 
area.  Nevertheless,  the  differences  of  opinion  which  the  investigations 
have  evoked  are  a  measure  of  the  intrinsic  difficulty  connected  with 
the  subject ;  and  the  end  is  not  yet  seen. 

Varieties.  Glauconui  is  spoken  of  as  "primary,"  or  "idiopathic," 
when  it  does  not  appear  to  have  been  caused  by  any  previous  funda- 
mental disease  of  the  eye,  and  "secondary,"  when  it  occurs  as  the 
se(|uel  of  preexisting  diseases,  especially  infiannnation  of  the  uveal 
tract,  in  which  the  increase  of  tension  is  only  a  conse(iuence  of  other 
pathological  conditions. 

The  primnrjf  variety,  to  which  the  term  glaucoma  ought  to  be 
restricted,  is  a  common  disease,  constituting  about  1  i)er  cent,  of  all 
cases  of  eye  disease.  It  is  manifested  either  as  an  acute  congestive 
("inflamiiiatorx")  glaucoma,  or  as  the  subacute,  oi*  clironic.  congestive 
glaucoma;  and  as  the  chronic  non-congestive  ("non-inflammatory") 
glaucoma,  which  is  spoken  of  clinically  as  the  "simple  glaucoma." 

While  it  is  convenient  to  adopt  these  classifications  and  terms,  they 
are  ])urely  artificial,  because  any  stage  may  be  but  the  modification 


GLAUCOMA  5407 

of  one  jiiid  the  saiiic  morbid  pfoccss  ;  iiidrcd,  ;iciltc  •rlaiicoiiia  may  lose 
its  coiij^cstivc  symptoms  so  that  tlit'  coiiditioii  pa.sscs  over  into  the 
c'lironic  variety;  while  simple  glaiieonia  may  at  any  stage  develop 
congestive  symptoms  and  terminate  in  the  mannci-  of  the  acute  ionii. 
IIirs('hl)erg  has  reported  a  case  that  remained  ((uirt  under  his  olisei-- 
vation  for  twenty  years  only  to  have  an  outliurst  of  congestion  de- 
manding enucleation. 

Priestley  Smith,  whose  labors  entitle  him  to  preeminence  among 
the  English-speaking  investigators,  would  have  us  bear  in  mind  how 
closely  the  two  forms  are  related,  and  also  to  observe  that  the  term 
"primary"  really  means  "without  antecedents,"  and  that  pathological 
and  clinical  evidence  seem  to  show  that  acute  and  chronic  glaucoma 
are  essentially  of  a  like  nature,  each  depending  proximately  on  the 
obstiniction  of  the  filtration  angle,  though  the  closure  occui's  (piickly 
in  the  one  case  and  slowly  in  the  other. 

Cliiiicdl  liisfory.  It  is  common  foi-  both  eyes  to  be  subject  to  attacks 
of  glaucoma,  which  connection  depends  not  in  the  way  of  symjiathy. 
but  upon  the  fact  that  the  conditions  which  are  likely  to  lead  to  the 
disease  usually  exist  in  both  eyes.  And  it  is  not  connnon  for  the  two 
eyes  to  be  affected  equally  and  simultaneously;  it  i.s  usual  for  the 
symptoms,  especially  in  the  non-congestive  types,  to  be  manifested 
in  the  fellow  eye  months  or  years  after  the  first  became  affected.  It 
may  be  stated  generally  that  the  more  acute  the  disease  in  the  one 
first  involved,  the  shorter  will  be  the  interval  before  the  other  suffers. 
Increased  hardness  of  fjjrhaU.  There  are  certain  w^ell-defined  symj)- 
toms  connnon  to  all  forms  of  pi-imary  glaucoma,  all  of  which,  how- 
ever, may  not  be  present  in  a  given  case.  The  first,  and  most  important 
symptom  is  a  rise  in  the  intraocular  tension,  or  an  increased  hardness 
of  the  eyeball,  from  which  all  the  other  phenomena  arise.  The  inev- 
itable conse(|uences  of  a  continued  increase  of  tension  are  excavation 
of  the  optic  nerve  and  the  reduction,  with  the  ultimate  annihilation. 
of  the  sight  of  the  affected  eye. 

A  rise  in  the  intraocular  tension  may  be  manifested  in  an  increased 
hardness  of  the  eyel)all.  varying  from  a  degree  of  "doubtfully  in- 
creased tension"  (T  plus  ?),  in  which  the  sclera  presents  more  than 
the  usual  resistance  to  the  palpating  fing(>r.  to  one  of  "extreme 
tension,"  or  "stony  hardness."  in  which  the  finger  cannot  indent 
the  sclera  by  firm  pressure.  There  may  ])e  intermediate  degrees,  from 
but  slight,  though  positive,  increase  ("T  plus  1?"),  to  that  of  con- 
siderate tension  ("T  plus  2").  in  which  the  finger  can  but  sliu'htly 
impress  the  coats.  AVhile  it  is  always  convenient  to  estimate  the 
degree  of  intraocular  tension  by  means  of  the  finger,  the  method  is 


5408  GLAUCOMA 

iicvci'tlu'k'ss  iiU'Xiict,  for  .siiict.'  the  iiil  fodiictioii  of  the  iisr  of  toiioin- 
•  'tcrs,  the  only  accurate  way  to  express  tlie  tension  is  in  tci-m.s  of 
pressiii-e-weii^dit  or  of  pressure-degrees.  (See  Tonometer,  and 
Tonometry. )  With  the  Sehiotz  tonometer  the  normal  tension  varies 
between  J2nini.  to  27niin.  of  niei'eury ;  a  tension  of  more  than  27mni. 
is  certainly  pathologic. 

Cloudiness  of  the  cornea.  When  the  intraocular  pressure  is  in- 
creased and  the  tension  of  the  tunics  suddenly  raised,  a  condition  of 
edema  or  cloudiness  of  the  cornea  is  set  up  from  the  interference  with 
the  flow  of  the  corneal  lymph.  The  corneal  surface  then  resembles  a 
sheet  of  glaas  which  has  been  dulled  by  being  breathed  upon.  (A 
similar  appearance,  however,  may  be  noted  sometimes  in  iritis  and 
irido-choroiditis.)  IMinute  drops  of  fluid  collect  beneath  the  epithe- 
lium and  between  the  fibres  immediately  under  Bowman's  membrane, 
in  closely  aggregated  points,  which  gives  the  cornea  the  well-known 
appearance  of  being  "needle-stuck."  The  cloudiness  of  the  cornea, 
being  more  pronounced  in  the  centre  than  at  the  periphery,  is  (luite 
visible  and  i.s  that  which  gives  rise  to  the  peculiar  obscuration  of  vision 
so  distinct  in  this  form  of  glaucoma.  This  haziness  is  commonly 
marked  in  the  congestive  types,  being  usually  absent,  or  is  present  in 
only  a  slight  degree,  in  the  simple  glaucoma. 

Ciliary  injection.  A  sudden  access  of  pressure  from  an  embarrass- 
ment of  the  flow  through  the  choroidal  veins  invariably  causes  the 
engorgement  of  all  the  external  vessels,  with  more  or  less  edema  of 
the  conjunctiva  and  swelling  of  the  lids;  while  sometimes,  when  the 
engorgement  is  intense,  there  may  be  proptosis.  In  acute  glaucoma 
there  is  usually  a  general  hyperemia  of  the  conjunctiva  and  often 
chemosis.  The  arteries  becoming  hypertrophied,  in  consequence  of 
the  increased  resistance  to  the  entrance  of  blood  into  the  eye,  the  flow 
through  the  anterior  ciliary  veins  is  augmented,  so  that  tortuosity  of 
the  fine  scleral  branches  may  be  pre.sent.  The  arteries  are  to  be 
distinguished  from  the  veins  by  their  greater  tortuosity,  by  their 
very  al)rupt  disappearance  at  the  points  where  the}'-  perforate  the 
sclera,  and,  when  pressed  upon  by  the  finger,  by  the  greater  pressure 
required  to  empty  them,  and,  when  the  finger  is  removed,  by  the 
reestablishmcnt  of  the  current  in  a  direction  from  the  ecjuator  towards 
the  cornea. 

The  edema  of  the  anterior  segment  of  the  globe  may  obscure  the 
characteristic  markings  and  otherwise  efface  the  distinct  patterns  of 
the  iris;  and  at  the  same  time  the  veins  of  the  iris  may  become  so 
greatly  dilated,  distended  and  tortuous  as  to  burst,  so  that  the  surface 
of  the  membrane  becomes  dull  from  the  presence  of  minute  hcmor- 


GLAUCOMA  5409 

rhagic  cft'iisioiis.  The  vitreous  may  hccoine  clomlrd  and  the  li'iis 
cataractous,  and  tlirougii  the  pupillary  space  there  may  be  transmitted 
the  greenish  reflex  from  the  surface  of  the  lens — a  reflex  so  character- 
istic of  glaucoma  from  the  earliest  times  that  it  wa.s  from  this  symptom 
tliat  the  ancients  named  the  disease — fjlaukos,  sea-green. 

Change  in  depth  of  the  anterior  chamhrr.  A  common  symptom  in 
primary  glaucoma  is  the  diininution  in  the  depth  of  tlu^  anterior  cliain- 
ber  brought  about  by  the  pushing  forward  of  the  lens  and  the  per- 


Xormal  Optic  Xervc  Entrance.     (Maitland  Eamsay.) 

ipheral  portion  of  the  iris.  The  depth  varies  in  different  cases  from 
an  almost  imperceptible  degree  to  the  complete  obliteration  of  the 
chamber;  yet  entirely  healthy  eyes  may  have  quite  shallow  chambers. 
It  is  difficult  therefore  to  decide  just  how  much  the  shallowness  of 
the  chamber  has  been  caused  by  the  glaucomatous  process  and  just 
how  much  the  shallowness  is  the  cause  of  the  glaucoma. 

Dilatation  of  the  pupil.  Ordinarily  in  glaucoma  the  size  of  the 
pupil  is  increased  and  its  shape  so  altered  that  it  is  no  longer  round 
but  oval  or  egg-shaped.  The  mobility,  too.  of  the  iris  becomes  slug- 
gish if  not  totally  inactive;  yet,  in  some  instances,  abnormal  pupillary 
symptoms  may  be  entirely  absent. 

Vol.  VII— 36 


5410 


GLAUCOMA 


The  (lil;it;il  ion  of  tlic  pupil  (Impends  upon  paresis  of  tin-  ciliary 
nerves,  toj^etlicr  with  the  loweriiifif  of  IIh'  lilood  sup|)ly  to  the  iris 
thi'oufrh  the  coiistrictiou  of  the  vessels.  This  const  I'ietion  arises  from 
the  compression  of  the  ii'is  base  with  its  acconipanNin^r  pai'alysis  of 
the    iris    muscle.      The    ii-i-eo-ulai'ity    in    the   sha])e    of    the    pupil    may 


( )lilitlialinosfu].ic-  .\i«|.caraiu('  of  ('ujipiiif^'  of  tlic  Optii-  l)i>t.    v-^i'"l''""'  iiaiusay.) 


depend  upon  ineciualities  in  the  pressure  on  the  nerves  and  vessels. 
The  sphincter  pupilla'  may  remain  amenable  to  miotics  for  several 
days. 

Excavation  of  tin  optic  disk.  AVhen  the  excess  of  pressure  has 
contiinied  for  some  time  the  oi)tic  disk  becomes  transfoi'med  into  a 
cup — the  so-called  <i-laucomatous  cup-  owin<,^  to  the  I'ccession  of  the 
hiiiiina  ci'ibrosa,  or  that  part  of  the  sclei-a  which  lies  at  the  point 
of  entrance  of  the  optic  nerve  into  the  eye.     Thi.s  lamina  is  perforated 


GLAUCOMA  5411 

liy  iiuiiicrous  rocaiiiin;!  (|csi^fiii'(|  for  the  passage  ot"  tlic  ImukUcs  of 
the  nerve.  It  is,  tlierefoi-e,  tlie  weakest  spot  in  the  wall  of  tlie  eye 
as  well  as  the  most  iiiipi-essionable,  so  that  hy  the  foree  of  glaueoniatous 
pressure  it  gives  way,  and  tlie  inti-aocular  surface  recedes. 

The  cup  may  vary  in  extent  from  one  displaying  only  a  slight 
concavity  of  a  portion  of  tiie  disk's  surface,  to  one  presenting  the  most 
complete  excavation  of  the  nerve  head,  the  excavation  extending  from 
scleral  border  to  scleral  border.  Over  tiie  abrupt  edge  of  such  a  cup 
the  vessels  are  seen  to  bend  sharply  and  then  di.sappear  under  the 
overhanging  scleral  margin,  and  to  reappear  deeper  but  fainter  at  the 
bottom  of  the  cup,  where  the  dark  spots  of  the  cribriform  layer  shine 
distinctly.  With  the  ophthalmoscope  the  depth  of  the  cup  may  be 
shown  by  the  parallactic  movement  of  the  floor  of  the  cup  when  the 
mirror  is  moved  in  the  vertical  plane,  and  l)y  the  fact  that  a  concave 
lens  is  re(|uirod  to  focus  the  floor.  The  strength  of  the  lens  rtMiuired 
also  gives  the  dej^th  of  the  cup — each  diopter  of  refraction  corre- 
sponding to  0.80  mm.  of  deptli. 

With  the  invention  of  the  ophtlialmoseoi)e  nuicli  was  expected  re- 
garding this  disease,  but  the  expectations  were  not  realized  for  several 
years  after.  Julius  Jacobson  was  the  first  to  use  it  in  the  investigation 
of  glaucoma,  ])ut  his  dissertation,  published  in  1853,  arrived  at  purely 
negative  results.  The  appearance  of  the  nerve-head,  too,  was  not 
easily  understood,  for  Jaeger,  in  describing  the  glaucoma  cup  mistook 
it  for  a  globnlar  swelling  of  the  disk. 

Encircling  the  pallid  and  often  greenish  discolored  papilla  is  a 
yellowish  ring,  the  so-called  "halo'' — which  has  been  produced  through 
atrophy  of  the  choroid  from  the  effects  of  the  increased  pressure  witliin 
the  globe. 

The  mechanism  of  the  production  of  the  cup  is  uncertain  and  is 
still  a  matter  of  dispute.  It  is  likely  that  in  the  early  stiiges  of  the 
disease  congestion  and  edema  of  the  optic  nerve  occur,  if  not  actual 
inflammation.  The  cupping  therefore  does  not  take  place  innnediately, 
neither  during,  nor  even  after  a  first  att^ick  of  acute  glaucoma, 
because  the  process  requires  time  for  its  completion,  and  is  a  conse- 
quence of  atrophy  of  the  nerve  head  ;  for.  without  doubt,  the  excavation 
is  dependent  upon  the  recession  of  the  lamina  cribrosa,  and.  if  the 
changes  of  the  optic  nerve  arise  from  the  excess  of  pressure,  it  is  by 
the  loss  of  ])alance  between  the  intraocidar  pressure  and  the  nutritive 
resistance  of  the  nerve. 

The  glaucomatous  cup  is  to  l)e  distinguished  from  a  large  physiologic 
cup.  and  from  the  excavation  observed  as  a  sequel  to  atrophy  of  the 
optic  nerve.     A  physiologic  cup  or  excavation  occupies  but  a  portion 


5412  GLAUCOMA 

of  llic  siifi'jii'c  (»f  tlic  disk  and  is  of  llic  iioniial  lint,  wliilc  an  alropliic 
I'XcavatioM.  tli()u<,di  it  may  be  coniplctc,  is  usually  shallow  and  is 
found  in  an  avascular,  pearly-white  nerve  head.  A  f^laueomatous 
excavation  i.s,  on  the  contrary,  conijjlctc.  dcei)  and  often  of  a  greenish 
hue.  The  glauconuitous  cup  is  to  he  distinguished  Iroiii  that  of  simple 
atrophy  by  the  dei)th  of  the  excavation  and  the  interruption  of  the 
vessels  at  the  nuirgin  of  the  disk.  Wliilc  these  descriptions  apply  at 
the  same  time  to  marked  or  typical    foi'ins.  it  is  most  difficult  somo- 


(lliiucoiiiatous  Oupping  of  the  Ui>tie    Disc.      (.MaitUuul  liainsay.) 

times  to  decide  in  other  less  well-defined  eases,  for,  when  simple  atrophy 
occurs  in  a  disk  in  which  there  is  already  a  large  physiologic  cup  the 
resulting  condition  may  closely  resemble  a  typical  glaucomatous  cup. 
In  simple  atrophy  of  the  disk,  there  has  been  a  loss  of  nerve-substance 
and  eonseciuent  retraction  of  the  surface  quite  up  to  the  margin  of 
the  papilla,  just  as  in  glaucoma,  yet  the  excavation  remains  shallow 
and  is  never  undermined  as  in  glaucoma,  because  the  lamina  cribrosa 
itself  has  not  been  displaced. 

Changes  in  the  intraocular  vessels.  Tho  central  portion  of  tlie  ves- 
sels, in  the  earlier  stages  of  the  disease  present,  according  to  the  graphic 
description  by  Stellwag  v.  Carion,  (juite  clear  and  well-defined  borders. 


GLAUCOMA 


5413 


The  arteries  are  of  norinal  calibre,  or  soincwliat  narrow;  tlie  veins 
are  broader  in  consequence  of  their  being  flattened  by  tlie  intraocular 
pressure,  and  frequently  surrounded  by  a  net-work  of  small,  anasto- 
mosing branches.  At  a  subsc(|ucnt  period  of  the  disease  all  the  ves- 
sels occupying  the  region  of  the  papilla  become  paler  anil  indistinct  as 
though  veiled  by  a  thin,  grayish  haze,  and  ultinuitcly  almost  wholly 
disappear.  The  retinal  veins  and  arteries  then  ai)p('ar  to  siu'ing 
directly  from  the  margin  of  the  disk.  The  larger  veins  seem  to  end 
in  a  roundish  point,  of  a  much  darker  tint  than  the  rest  of  the  vessels. 
Pulsation  of  the  vessels.  A  striking  characteristic  rarely  seen  on 
the  disk  in  the  healthy  eye,  but  often  in  glaucoma,  is  an  arterial  pul- 
sation. Another  result  of  the  increased  pressure  on  the  retina  is  the 
obstruction  to  the  entrance  of  the  arterial  and  the  exit  of  the  venous 


Field  of  Vision  of  Eight  Eye.  In  a 
case  of  subacute  glaucoma.  Loss  of 
the  nasal  half  and  concentric  restric- 
tion of  the  preserved  field.  (From 
de  Schweinitz,  DL^eases  of  the  Eye.) 


Field  of  Vision  in  Eight  Eye.  In  a 
case  of  chronic  glaucoma,  showing 
concentric  restriction  of  the  field. 
(From  de  Schweinitz,  DL^'jases  of  the 
Eye.) 


streams;  the  arteries  consequently  are  but  incompletely  filled  while 
the  veins  become  congested.  The  veins,  too,  are  rhythmically  com- 
pressed at  each  incoming  wave,  so  that  a  venous  pulsation  also  is 
common,  often  most  marked  in  the  dark  knuckles  as  they  bend  over 
the  margin  of  the  excavation.  These  phenomena  were  discovered  by 
von  Graefe,  who  noticed  the  arterial  pulsation  on  the  papilla  when 
the  eyeball  was  very  hard;  yet  venous  pulsation  is  fre<|uently  seen  in 
eyes  of  normal  tension,  although  not  so  often  as  in  glaucoma.  Donders 
demonstrated  that  the  arterial  pulse  can  be  induced  in  healthy  eyes 
by  a  gradual  increasing  pressure  on  the  glolie,  and  he  noticed  also 
that  at  the  moment  when  the  pulse  appears,  vision  is  temporarily 
abolished.  As  a  consequence  of  the  obstruction  in  the  retinal  cir- 
culation, retinal  ecehymoses  may  be  seen  .scattered  over  the  fundus, 
and  occasionally  aneurysmal  dilatation  of  the  arteries  and  bead-like 
varicosities  of  the  veins  are  seen. 


5414 


GLAUCOMA 


Anesthesia  of  the  cornea.  The  sensitiveness  of  the  cornea  is  com- 
iiioiily  affected  and  aiicsllicsia  m;iy  he  ohscrvcd  (hii'iii^  an  attack  of 
ghmcoma,  and  aj,';iiM  in  the  hiter  dcf^cncrativc  sta<,n's.  vai'yin<j  t'l'oin  a 
slight  (h'lu'eciation  only  to  an  entii-c  h>ss  of  sensation.  SMnictiincs  the 
anesthesia  is  not  uiiil'onn  hut  may  exist  in  s|)ots  or  segments  oi'  tlie 
surface  of  tiie  cornea.  The  anesthesia  is  caused  hy  a  maceration  and 
compression  oi"  the  nerve  fihiments  l)y  the  fluid  which  has  become 
collected  in  tlie  canals  of  Bowman's  memhi-ane. 

Pain.  The  sensitive  ciliary  processi'S  becoming  swollen  and  squeezed 
by  the  sudden  congestion,  the  tunics  too  are  stretched  by  tlie  increa-s- 
ing  pressure.  Mackenzie  and  other  early  classical  writers  observed 
that  the  subjects  of  glaucoma  often  labored  under  symptoms  whicli 
they  ascribed  to  forms  of  irregular  gout,  and  it  was  noted  further 
that  they  not  iiifi'e(|uetitly  suffered  from  .sucli  i)ains  in  tlie  teeth  and 


Annular  Scotoma  in  Chronic  Glaucoma.     Moderate  contraction  of  the  peripheral 
field.      (From  de  Scliweinitz,  Diseases  of  the  Eye.) 

head  as  were  generally  counted  rheumatic.  And,  in  these  later  times, 
although,  in  some  cases  it  may  be  entirely  absent,  pain  is  a  usual 
accompaniment  of  increased  intraocular  pressure.  In  the  violent  con- 
gestive cases  the  agony  is  intense,  with  great  phy.sical  depression  and 
weakness.  The  countenance  is  pallid  and  frequentl}^  there  are  seizures 
of  nausea  and  vomiting.  It  is  in  the  experience  of  all  clinicians  to 
observe  how  profound  a  depression  glaucoma-])ain  can  produce,  and 
to  note  the  e(iual  raj)idity  with  whicli  the  health  reboumls  after 
operation  or  the  excision  of  the  globe. 

In  chronic  cases  the  rise  of  pressure  is  so  grachial  that  the  vessels 
and  nerves  have  time  to  adapt  themselves  to  the  altering  conditions, 
and  accordingly  there  may  be  only  a  general  feeling  of  discomfort, 
with  occasional  darting  neuralgia;  or  the  patient  may  complain  of 
a  heraicrania  or  perhaps  only  a  sense  of  fulness. 

AJt(  ration  in  visnal  arutcniss.  A  characteristic  symptom  in  acute 
glaucoma  is  the  sudden  loss  of  vision  which  in  a  few  hours  mav  be 


GLAUCOMA 


5415 


reduced  to  the  mere  perception  of  light,  wliih"  in  malignant  cases  it 
may  be  rapidly  annihilated.  Generally,  in  each  succeeding  attack  of 
the  subacute  variety  the  vision  fails,  but  is  gra(hially  recovered  as 
the  attack  passes  oft*.  At  each  recurrence  ol"  llie  attacks,  however,  a 
deeper  and  more  permanent  impression  is  h'ft.  In  the  chronic;  cases, 
sometimes,  even  when  the  disk  is  deeply  cupped,  excellent  sharpness 
of  sight  may  be  preserved  for  a  long  time.  It  is  not  safe,  however, 
as  will  be  pointed  out  later,  to  depend  upon  tlu'  degree  of  the  visual 
acuity  as  a  guide  to  the  rate  of  progress  of  chronic  glaucoma. 

Affection  of  the  aecammodation.  One  of  the  earliest  symptoms  of 
the  ordinary  type  of  glaucoma  is  the  diminished  power  of  the  accom- 
modation, as  evidenced  by  the  desire  to  change  tile  reading-glasses  for 
such  as  are  stronger  than  the  degree  of  refraction-error  or  the  age  of 


Field  of  Vision  in  Eifjlit  Eye  in  Case 
of  Chrouie  Glaucoma.  Showing  sec- 
tional defect  (superonasal  tjuadrant). 
(From  (le  Schweinitz,  J)isc(tses  of  the 
Eye.) 


Field  of  Vision  in  Left  Eye  in 
Cluonic  Glaucoma.  Trowel-shaped 
patch  ])reserved  chielly  on  the  tem- 
poral side.  (From  de  Schweinitz,  Dis- 
eases of  the  Eye.) 


the  patient  would  warrant.  So,  too,  as  an  increase  in  tension  tends 
to  render  the  globe  more  spherical,  there  is  manifested  an  alteration 
in  the  refractive  power  of  the  eye,  depending  upon  a  change  in  the 
shape  of  the  cornea.  During  an  attack  of  glaucoma,  the  general  refrac- 
tion is  often  higher  by  one  or  two  diopters  than  it  was  before,  or  than 
it  may  be  found  to  be  after,  the  attack.  The  astigmatism  is  connnonly 
"against  the  rule."  The  displacement  of  the  lens  tends  to  produce 
myopia,  while  tlie  increased  tension  on  the  zonula  tends  to  hyper- 
metropia. 

Alterations  in  the  peripheral  vision.  More  important  than  the 
depreciation  of  the  central  visual  acuity  are  the  alterations  in  the 
peripheral  vi.siou  which  are  so  characteristic  of  glaucoma.  The  center 
of  the  tield  retains  for  a  tinu'  normal  or  nearly  normal  vision,  while 
the  periphery  jirogrcssively  contracts.  The  contraction  of  the  field  of 
vision  is  therefore  an  important  iinli-x  of  the  rate  of  jn-ogress  in  glau- 


5416  GLAUCOMA 

eonia,  aiul  a  careful  map  of  the  field  is  always  necessary  for  a  proper 
uuderstaiRJiiig  of  the  effects  of  the  increase  of  pressure  on  the  retina. 
The  contraction  of  the  color-fields  is  usually  proportionate  to  tliat  of 
the  foriu-iiekl.  Under  the  influence  of  operative  measures  or  miotics 
very  decided  imi:)rovenient  in  the  extent  of  the  visual  field  may  take 
place. 

The  tendency  of  the  visual  field  is  to  contract  progressively  as  the 
disease  advances,  until  finally  all  portions  except  a  small  i^art  upon 
the  temi)oral  side  are  obliterated,  yet  this  portion  also  disappears  in 
the  ultimate  blindness. 

The  contractions  present  certain  typical  forms,  the  most  usual 
variety  being  the  partial  or  complete  loss  of  the  nasal  field,  or  the 
upper  or  lower  (luadrant  of  the  nasal  side.  The  next  common  is  the 
concentric  restriction  of  the  entire  field.  In  the  next,  the  restriction 
is  so  constituted  that  the  remaining  field  assumes  an  oval  or  triangular 
shape.  Then  follow  those  presenting  sectional  defects,  often  in  the 
upper  nasal  area;  the  loss  of  the  entire  field  exeei^t  a  patch  on  the 
temporal  side;  the  formation  of  scotoma,  which  may  be  central,  para- 
central, annular  or  peripheral.  These  isolated  scotomata  may  be  the 
precursors  of  more  extensive  defects  in  the  peripheral  field. 

A  search  for  scotomata  is  imperative ;  these  may  be  found  by  either 
the  ordinary  perimetry  methods,  during  which  care  must  be  taken  to 
investigate  each  meridian  with  suitable  test-objects,  and  under  vary- 
ing degrees  of  illumination,  or,  by  the  methods  of  Bjerrum.  This 
investigator  used  small  test-objects,  and  placed  the  patient  at  a  greater 
distance  from  the  point  of  fixation  than  is  ordinarily  employed.  By 
his  methods  defects  were  found  which  would  otherwise  escape  detec- 
tion. According  to  Bjerrum,  the  earliest  changes  in  the  field  of  vision 
are  not  in  the  periphery  but  in  the  region  of  the  blind  spot ;  a  normal 
blind  spot  therefore  excludes  glaucoma.  He  regards  scotomata  to  be 
the  result  of  the  destruction  of  the  fibres  of  the  papilla  at  the  margin 
or  sides  of  the  excavation.  The}^  are  peculiar  in  that  while  they  may 
spread  towards  the  periphery  in  all  directions,  sometimes  more  in  one 
direction  than  in  another,  except  outwardly,  yet  they  never  pass 
beyond  the  blind  spot.  The  defective  area  wherever  situated,  is  in 
direct  continuity,  therefore,  with  the  blind  spot.  This  phenomenon  is 
known  as  " Bjerrum 's  symptom."  Topographically,  such  scotomata 
are  different  from  those  obtained  in  simple  optic  atroi^hy.  The  line 
of  demarcation  is  well  defined,  and  color-vision  is  usually  retained  in 
the  sentient  area — a  point  to  be  remembered  in  the  study  of  the  con- 
tracted fields  of  chronic  glaucoma  and  those  of  optic  atrophy  due  to 
other  causes.    Bjerrum  found  these  defects  in  the  region  of  tiio  blind 


GLAUCOMA 


5n7 


sj)()t  soiiicf  iiiics  licfoi'c  lie  cniild  dctccl  aii\tliiiiu^  with  llic  oplit  lial- 
nioseopc,  ;iiid  Ik;  believes  tliat  every  ease  of  glaueoina,  if  carerully 
examined  with  small  test-ol).jects,  will  show  such  a  jiai-aeentral  seotoma 
at  some  stage  of  the  disease. 

Roiiiie  found  in  a  num))er  of  cases  an  alteration  in  the  nasal  field 
consisting]:  of  a  sharp,  horizontal  limitation  to  the  defect  in  the  nasal 
field,  which  he  discovered  by  moving  a  small  test-object  radially  5 
degrees  above  and  5  degrees  below  the  horizontal  line,  giving  the  test- 
object  a  circular  movement.  This  defect,  he  believes,  is  caused  by  the 
involvement  of  bundles  of  fibers  which  curve  upwards  and  downwards 
from  the  papilla  ending  in  a  "raphe"  on  the  horizontal  meridian  of 
the  retina.     Sattler,   of  Konig.sberg,   is  of  the  opinion   that   scotoma 


Field  of  Vision  of  Left  Eye  in 
Chronic  Glaucoma.  Bume  case  as  pre- 
vious illustration  six  months  later; 
only  a  small  patch  of  the  preserved 
field  on  the  temjtoral  side.  (From  de 
Schweinitz,  Diseases  of  the  Eye.) 


Chronic  Glaucoma.  Just  beginning 
contraction  of  nasal  field;  scotoma 
extending  from  l)lind  spot  in  a  semi- 
circular manner  upward  and  inward. 
( l''iom  de  Schweinitz,  Diseases  of  the 
Em'-) 


continuous  with  the  blind  spot  (Bjerrum),  and  the  peeidiarity  in  the 
nasal  field  described  by  Ronne,  are  very  important  and  characteristic 
evidences  of  glaucoma.  Cases  may  arise  in  which  the  peripheral  field 
is  not  contracted,  yet  paracentral  scotomata  can  ])e  found. 

Seidel  has  used  Bjerrum's  method  in  the  diagnosis  of  doubtful 
cases;  he  believes  the  test  to  be  more  delicate  than  Hjerrum  thought, 
especially  in  such  cases  as  those  in  which  the  eyeball  and  fundus  are 
apparently  normal,  the  intraocular  pressure,  as  indicated  by  the 
tonometer,  normal,  and  where  the  symptoms  comi)lained  of  are  deemed 
to  be  only  those  of  asthenopia.  In  such  cases,  he  found  paracentral 
scotomata,  and,  he  believes,  these  paracentral  are  developed  from 
lesser  scotomata,  which  at  first  are  scattered  above  and  below  but 
which  later  coalesce  and  unite  to  form  crescentic  or  sickle-shaj^ed 
scotomata.  He  advises  that  in  all  early  cases  search  should  be  made 
for  these  scotomata  as  well  as  to  maji  out  the  area  of  the  blind  spot. 


5418  GLAUCOMA 

and  to  iiolc  liow  they  later  In-coine  iiicliidi-d  with  that  area  assuming 
the  forms  so  well  known. 

Clian^'cs  oceiir  in  tlie  ceiili'al  lij^id,  and  color  senses.  Aceordijig  to 
r>cauvieii.\  and  Dcldiiiic,  the  dirrcrcnt ial  light  sense  is  the  first  to  be 
attaeUed,  and  is  diniinislied  even  hidoi'e  ophthalinoseopie  signs  have 
become  marked.  This  alteration  is  indei)endent  oi'  the  state  of  the 
central  visual  acuity  and  of  the  retraction  of  the  visual  field,  but  is 
due  to  the  condition  of  the  intraocular  pressure.  The  absolute  light 
sense  is  dimiinshed,  on  the  contrary,  only  when  the  glaucoma  has 
advanced  sufficiently  to  produce  changes  in  the  disk,  and  is  therefore 
related  to  the  accoinpanying  optic  atrophy.  It,  too,  is  likewise  inde- 
pendent of  the  central  visual  acuity  as  well  as  of  the  state  of  the  visual 
field.     Tin;  color-sense  is  usually  normal  so  long  as  the  light-sense  is 


Visual  Field  of  Iiight  Eye  in  Chronic  Glaucoma.  Showing  the  mechanism  of 
the  loss  of  the  lower  and  inner  portion  of  the  tield,  j)receded  Ijy  a  scotoma  which 
gradually  extends.  Scotoma  represented  by  parallel  lines;  area  of  dull  vision 
which  subsequently  is  completely  lost,  by  dots.  (From  de  Schweinitz,  Disca.sc-i  of 
the  Eye.) 

unchanged,  but  when  atrophy  sets  in  it  is  not  rare  to  find  the  color- 
sense  affected. 

Cloudiness  of  the  cornea.  "Halo  vision"  may  be  complained  of 
during  the  early,  transient  edema  of  the  cornea.  There  is  dimness  of 
sight  in  the  day  time  and  the  appearance  of  a  ring  or  rainbow-colors 
around  luminous  flames  at  night.  The  flame'  itself  may  be  seen  dis- 
tinctly l)ut  ai'ound  it  is  a  dark  zone  beyond  which  is  a  rainbow  of 
colors.  This  phenomenon  depends  on  the  alteration  in  the  epithelium 
of  the  cornea,  without  doulit  caused  by  the  increased  pressure  from 
the  congestion  of  tiie  uveal  tract.  The  .same  effect  can  be  obtained 
experimi'iitally  ;  and  it  is  well  to  remember  tiuit  the  same  sensiition 
has  been  noticed  during  the  presence  of  thick  nuicous  over  the  corneal 
surface  in  conjunctivitis. 

Suhjrctive  ligJit  sensations.  At  tinu^s  sul),iectivc  sensations  of  light 
are  experienced  by  the  totally  l)lind  glaucomatou.s  patients.  Such 
sensations  dc])cnd   probably  ui)on  the  pulling  or  mechanical  drawing 


GLAUCOMA  5419 

of  the  optic  nerve  upon  the  retina.  And,  occasionally,  even  after 
blindness  has  set  in,  patients  may  be  subject  to  attacks  of  vertigo, 
wliicli  Dor,  of  Lyons,  believes  to  be  dependent  upon  the  etleets  of 
pressure  in  a  sense  organ,  much  as  in  tiie  manner  of  Meniere's  dis- 
ease.    Jn  the  cases  he  reports,  rcliel'  followed  on  excision  of  the  globe. 

CLINICAL   TYPES   OP  GLAUCOMA. 

That  important  form,  aciote  congestive,  or  inflwinmatory  glau- 
coma, may  be  divided  for  convenience  into  two  stages,  the  i)re- 
monitory  and  the  stage  of  glaucomatous  attiick.  The  premonitory 
symptoms  are  characterized  by  a  sudden  diminution  in  the  range  ol' 
accommodation  with  the  desire  for  stronger  ami  stronger  reading 
glasses;  one  or  more  transient  attacks  of  dim  and  rainbow-vi,sion,  aris- 
ing without  warning  in  one  who  has  believed  himself  to  be  entirely 
free  from  all  disorder.  These  early  symptoms  may  follow  an  exhaust- 
ing illness,  a  period  of  emotional  excitement  and  restlessness,  or  de- 
pression or  other  anxiety,  and  sometimes  after  a  too  hearty  meal.  The 
eye  may  be  attacked  more  or  less  suddeidy  and  with  vague  pains  in 
the  forehead  and  temples,  which  the  patient  ascribes  to  neuralgia. 
The  cornea  and  the  aqueous  humor  may  be  more  or  less  turbid  and 
the  pupil  slightly  dilated.  During  the  jiremonitory  attack  the  ten- 
sion of  the  eye,  i.s  increased.  The  symptoms  may  subside  and  the  eye 
return  to  its  natural  state  and  remain  quiet  for  a  week  or  two,  but 
similar  periods  of  discomfort  may  recur  and  recur  during  a  twelve 
month,  if  not  over  a  period  of  years,  when  after  a  sleepless  night,  or 
during  temporary  excitement  or  undue  muscular  strain,  as  after 
excessive  straining  during  constipation,  or  a  liai'd  fit  of  coughing  in 
chronic  bronchitis,  or  during  the  men.strual  molimen — any  intercur- 
rent happening  or  condition  that  influences  the  raising  of  the  arterial 
tension — another  but  more  violent  seizure  occurs,  ushering  in  a  true 
gl  aucomatous-attack. 

The  pain  in  the  side  of  the  face  and  head  increases  hour  by  liour 
so  severely  as  to  excite  nausea  and  vomiting.  There  may  be  flushing 
and  fever,  or  the  patient  may  be  pallid  and  cold  and  profoundiy 
depressed  and  prostrate.  The  vision  is  greatly  impaired.  The  eyelids 
are  swollen,  the  conjunctivas  reddened  and  edematous,  the  cornea 
steamy  and  anesthetic,  the  eye  watery  and  light  intolerable.  The 
pupil  is  more  or  less  dilated  and  immobile,  the  aqueous  turbid  and  the 
iris  discolored.  The  anterior  chaml)er  is  abnormally  shallow.  The 
tension  mounts  higher  and  higher  by  the  finger  test,  or  it  may  register 
from  70  to  80  mm.  of  mercury.  Vision  is  rapidly  lost,  often  only 
light-i)erception   remaining,   but  this,   too,   may   be   abolished.     Some- 


5420 


GLAUCOMA 


times  tilt'  atlack  is  bilateral,  the  sei'Oiid  eye  l)oeomiMg  affected  within 
a  few  hours.  iMore  eoiniiioiilN-  it  is  not  attaeke(]  Tor  weeks  or  months, 
or  even   years. 

In  the  alisence  of  tl'eatliiellt  these  acute  sv  111  J»l  oiiis  last  loi'  sevel'al 
weeks  and  then  subside,  exeept  for  a  sli'i:ht  impaii'ment  in  the  mobility 
of  the  iris,  together  with  a  little  rise  in  the  tension ;  and  there  may  be 
a  partial  return  of  vision,  but  with  a  limitation  of  the  peripheral  field. 


PliysiooHoiiiy  in  Simple  Clironic-  Gluueoma.      (^laitlaud  Eamsay.) 


The  ophthalmoseopic  picture  may  be  but  little  changed  from  the  nor- 
mal, although  during  the  attack  it  is  ditifieult  if  not  impossible  to 
examine  the  fundus.  The  arteries  will  be  seen  to  be  only  slightly 
reduced  in  size  and  pro])ably  pulsating,  the  veins  engorged  and  their 
main  trunks  near  the  disk  collapsing  at  eai-h  arterial  pulse.  Extravasa- 
tions of  blood  are  occasionally  discernible  in  the  retina  or  the  choroid. 
Aft<'r  some  weeks  oi-  months  the  symptoms  reappear,  and,  after  a 
number  of  attacks,  if  the  eye-ground  is  examined  during  a  remission. 


GLAUCOMA  5421 

the  characteristic  cui)piii<i:,  tlic  hah)  and  the  steady  ai'tcrial  pulse  may 
be  revealed. 

If  the  disease  is  not  checked  the  eye  passes  into  a  ^hiucoinatous  state 
wherein  the  pupil  is  dilated  and  fixed,  the  iris  discolored  and  from 
the  lens  the  greenisli  refiex  shines.  The  cornea  is  hazy,  the  anterior 
chamber  sliallow  and  opacities  are  seen  in  the  vitreous.  Giratlually 
the  vision  is  destroyed  and  the  eye  reaches  the  state  of  absolute  glau- 
coma, in  which  tlie  ball  is  stony  hard,  the  iris  degenerated,  the  anterior 
chamber  obliterated  by  the  eataractous  lens  which  has  l)een  pushed 
forward  by  the  excessive  tension.  The  sclera  is  discolored,  the  peri- 
corneal vessels  coarsely  dilated ;  the  cornea  is  oparjue  and  may  become 
ulcerated  even  to  perforation.  Finally  from  changes  in  the  vitreous, 
choroid  and  retina,  the  whole  eyeball  may  become  disorganized  and 
shrunken.  Occasionally  the  globe  ruptures  spontaneously  while  in 
others  excessive  choroidal  hemorrhage  occurs. 

It  is  not  easy  to  conceive  how  the  globe  can  rupture  without  there 
having  been  some  previous  disturbance  of  the  integrity  of  the  coats. 
In  most  cases  there  has  been  ulceration  of  the  cornea,  and  in  some  of 
these  the  ulcerated  cornea  has  later  on  undergone  necrosis  and  rupture 
has  followed,  the  sudden  lowering  of  the  intraocular  tension  being 
succeeded  by  profuse  hemorrhage.  In  a  case  of  my  own  the  cornea 
had  become  firmly  healed,  it  was  believed,  but  a  sudden  congestion  of 
the  eye  led  to  the  rupture  of  the  choroidal  vessels  which  was  followed 
by  elevation  of  the  intraocular  tension  and  rupture. 

Coppez  concluded,  from  a  series  of  histological  studies,  that  such 
ruptures  are  dependent  upon  a  weakened  corneal  membrane  aug- 
mented by  hemorrhagic  extravasation  behind  the  choroid.  Ruptures 
have  occurred  at  the  site  of  the  wound  long  after  the  operation  of 
iridectomy.  The  rupture  may  be  followed  by  hemorrhage  only,  or 
by  the  extrusion  of  the  lens  and  clots,  as  in  my  own  ease,  or,  as  noted 
by  Villard,  by  the  complete  extrusion  of  the  contents  of  the  globe. 

Rarely,  the  onset  of  the  symptoms  may  be  so  sudden  and  their 
course  so  acute  that  within  a  few  hours  their  evolution  may  be  .so 
complete  that  eyesight  is  immediately  destroyed.  This  process  is 
spoken  of  as  glaucoma  fulminans,  in  which  there  is  no  remission. 

Subacute  or  clirouic  conqcstivc  gUiucoma.  The  subacute  form  may 
arise  with  .scareeh'  any  premonitory  symptoms,  or  it  may  be  the  se(|uel 
of  repeated  more  or  less  mild,  acute  attacks.  It  is  characterized  by  its 
intermittency.  The  first  few  attacks  may  amount  to  nothing  more 
than  ol)seured  and  rainl)Ow  vision,  but,  later  on,  the  attacks  recur 
more  frequently,  the  symptoms  increasing  in  severity  and  the  remis- 
sions less  complete.     The  eye  assumes  a  persistently  congested  condi- 


5422  GLAUCOMA 

tioii,  the  conic;!  loses  its  t  rjiiisparciicN'  or  it  iiuiy  lie  j)ositi\cly  s1c;iiiiy  ; 
the  .sclci'a.  hccoiiics  discoloi'cd  and  tlic  ('i)iscl('i'al  vessels  toi'tuous.  The 
a(|ueous  apjX'ars  tiii-l»iil,  tiie  iris  iiioi-c  or  less  ati'opliie,  the  pupil  pai-- 
tially  dilated,  the  dee])er  media  increasingly  opai|Uc,  and,  when  the 
fundus  can  lie  seen,  the  disk  is  found  to  be  cujijx-d  with  i)ulsating 
vessels.  The  tension  is  invariably  eh-vated.  Attacks  of  i)ain  I'ecur 
and  recui-,  \\itli  an  increase  of  all  the  other  symptoms  until  ulti- 
mately after  several  months  or  a  year,  total  l)lin(lness  supervt'ues. 

Chronic  (jlaiKOiiia  (simple  (jlaucoma).  Chronie  glaucoma,  the 
"amaurosis  with  excavation  of  the  optic  nerve"  of  von  Graefe,  begins 
almost  impercei)tibly  in  persons  at  about  fifty  years  of  age.  The  his- 
tory is  usually  obscure;  perhaps  the  first  symi)toms,  of  mere  liaziness 
of  the  sight  with  "rainbows"  or  "showers,"  may  be  dated  back  to  a 
time  of  worry  or  grief,  business  anxiety  or  other  period  of  nervous 
exhaustion  and  depi-ession.  The  progress  is  slow^,  with  scarcely'  any 
exacerbation  or  remission.  And  as  one  cy(?  is  more  commonly  affected 
before  the  otluu'.  the  patient  may  not  complaiji  at  all  until  the  siglit 
of  one  eye  is  found  to  be  practically  destroyed. 

Externally,  little  or  nothing  may  be  noticed;  perhaps  the  anterior 
ciliary  vessels  are  slightly  enlarged,  and  the  cornea  steamy,  or  there 
is  turbidity  of  the  a(iueous  humor  so  tiiat  it  lacks  transparency.  One, 
or  ])oth,  pupils  may  be  partially  dilated,  and,  if  both  eyes  are  affected, 
one  pupil  is  usually  more  affected  than  the  other,  in  which  case  the 
pupil  of  that  one  is  generally  larger  than  its  fellow.  The  depth  of 
the  anterior  chamber  may  not  be  materially  altered. 

The  tension  of  the  eyeball  is  found  to  ho  distinctly  increased.  At 
first  the  excess  may  not  be  discovered  until  after  repeated  examina- 
tions at  different  times  of  the  day.  With  the  tonouK^ter  variations 
may  ])e  o])tained,  though  tlie  range  may  be  but  slight.  Such  variations 
are  doubtless  deixMident  ui)on  tlie  extent  of  the  contact  of  the  iris 
with  the  cril)riform  ligament.  But  when  seen  in  the  later  stages  the 
tension  may  have  progressed  to  such  a  degree  that  the  eye  is  stony 
hard,  when  by  this  time  the  disk  has  Ix'come  deeply-cupped,  and  the 
vessels  displaced. 

Tn  spite  of  these  extensive  changes  then^  may  liavt>  been  entire 
freedom  from  pain  and  other  subjective^  symptoms. 

The  lens  may  take  on  a  gi'ayish  oi-  greenish  siieen.  and  in  cases 
where  the  oplitlialmosco))e  has  not  been  used,  a  diagnosis  of  "cataract" 
has  fre(|uently  been  made,  fi-om  which  the  ])atient  has  been  advised 
to  wait  for  "ri]>ening, "  witli  disastrous  results.  In  the  earlier  stages 
the  central  vision  may  ])e  good,  althougli  the  eye  is  usually  hyper- 
metropic, yet  any  errors  of  refraction   may  be  easily   corrected  and 


GLAUCOMA  r,42:{ 

tlic  vision  l)i-()iii,flit  to  tile  iiofiiKil  stJiiidnrd.  'I'lir  iiuips  of  tlif  lidils  of 
vision,  liowcver,  are  ol"  iinj)oi'taii(*('  in  sliowin^^  iiiarixcd  coiiti-action,  per- 
haps to  such  a  degree  as  to  sliow  only  a  small  area  in  eoiniection  witli 
tile  Mind  spot. 

'i'lic  central  color  perception  does  not  show  any  special  loss,  hut  there 
is  contraction  of  the  peri])heral  color-fields  corresponding  to  that  oT 
the  form-field. 

Causes  of  glaucoma.  Few  subjects  in  ophthalmology  aie  inoie  im- 
portant and  none  more  obscure  than  that  connected  with  tlie  can.ses 
of  primary  glaucoma. 

Predisposing  causes.  The  objective  symptoms  already  described  as 
pertaining  to  glaucoma  are  not,  of  themselves  alone,  suflficient  to  give 
rise  to  glaucoma ;  indeed  the  same  symptoms  may  be  present  in  other 
inflammatory  states.  There  seems  to  be  a  necessary  predisposition 
reciuired  for  its  occurrence.  Persons  of  the  "spare  habit,"  and  the 
"dyspeptic,"  seem  to  be  attacked  more  frequently  than  the  fat,  robust 
and  lymphatic.  Maitland  Ramsay  reminds  us  that  "the  disease  is  not 
to  be  looked  upon  as  a  morbid  entity,  but  as  a  symptom-complex;  and 
its  true  nature  will  be  all  the  better  understood  if  one  thinks  of  its 
acute  manifestations  as  analogous  to  an  attack  of  angina  pectoris.  Its 
occurrences  depend  not  only  upon  the  size  and  immediate  structui-r- 
of  the  eyeball,  but  also  upon  the  age,  race  and  general  health  of  the 
patient."  We  therefore  find  it  associated  with  nervous  affections, 
cardiac  disease  and  circulatory  di.sturhances  or  chronic  intoxications. 

Glaucoma  sometimes  occurs  in  several  members  of  a  family,  appear- 
ing in  two  or  more  succeeding  generations — even  as  many  as  five  gen- 
erations, as  reported  by  Harlan,  and  in  two  or  more  members  of  one 
generation.  It  has  been  o])served  that  when  it  has  occurred  in  several 
generation.s  the  incidence  in  each  succeeding  generation  is  at  an  earlier 
age  than  the  preceding.  It  occurs  hereditarily  in  ])oth  tlie  acute  and 
chronic  forms,  and  it  may  be  transmitted  by  either  sex  or  iidierited  by 
either  sex.  Unless  the  disease  attack.s  the  young  membei-s  in  its 
descent  through  several  generations,  it  is  not  easy  strictly  to  account  for 
the  hereditary  transmission  of  glaucoma.  It  may  be  that  some 
inherent  disproportion  in  size  between  the  corneal  ciliary  region  and 
lens  exi.sts,  or  othei"  anatondc  feature,  as  of  weak  lamiiKe  ci'ibrosa'  with 
steep  physiological  cups. 

Age.  It  rarely  attacks  anyone  l)efoi'e  the  age  of  foi-t \- :  the  lia- 
l)ility  is  extremely  slight  in  childhood  and  youth,  although  unilatei-al 
eases  have  occurred  in  children;  less  than  one  per  cent,  oceui-  earlier 
than  twenty. 

It  continuously  increa.ses  up  to  and  during  the  seventh  decade  so 


5424  GLAUCOMA 

that  Ix'twccii  (jO  and  70  it  is  more  tliaii  twice  as  coiniiion  as  I'rom  40 
to  50.  J'rii'sllcy  Smith  \voukl  have  us  re'iiiciiilxT  that  this  is  tlic  inTiod 
of  eiilargt'iiu'iit  of  the  lens. 

Race.  Whilst  many  cases  occur  in  Jewish  persons,  it  is  uncertain 
that  g:laucoma  manifests  a  particular  predilection  for  that  race.  l>ra- 
zilian  negroes  have  shown  a  higher  percentage  than  was  found  among 
the  whites;  and  many  cases  occur  among  the  Egj'ptians.  It  is  more 
common  in  some  countries  than  in  others;  "Englishmen,"  according 
to  Maitland  Eamsay,  "are  more  commonly  affected  than  Scotchmen. 
This  racial  proclivity  being  in  great  part  dependent  on  heredity  and 
consanguinity."  i\lackenzie  noted  that  dark-eyed  persons  were  more 
prone  to  glaucoma  than  those  the  color  of  whose  iris  is  blue  or  gray. 

Sex.  Females  are  more  susceptible  than  males,  and  this  greater 
predisposition  pertains  to  the  wdiole  of  life.  In  women,  however,  the 
tendency  to  congestive  forms  is  more  marked  than  for  the  non-congest- 
ive. This  extra  susceptibility  of  females  is  in  many  eases  ultimately 
connected  with  the  cessation  of  the  menses. 

Size  of  the  eye.  It  is  a  matter  of  common  observation  that  patients 
wdth  primary  glaucoma  have  small  corneas,  and  as  the  glaucomatous 
eye  is  usually  hyperopic  there  seems  to  be  a  relation  between  the 
smallness  of  the  cornea  and  glaucoma.  Glaucoma  is  not  a  disease  of 
small  eyes,  although  small  eyes  are  especially  susceptible  to  primary 
glaucoma  and  they  appear  to  be  attacked  earlier  in  life  than  others. 
Yet  they  are  not  the  onh^  eyes  which  suffer,  for  the  disease  is  met  in 
eyes  of  average  and  of  more  than  average  size.  The  average  horizon- 
tal diameter  of  the  normal  cornea  is  11.6  mm.,  but  eyes  in  which  the 
meridian  measures  only  10  mm.  seldom  escape  glaucoma.  The  greater 
susceptibility  of  small  eyes  appears  to  depend  on  their  containing 
disproportionately  large  lenses. 

The  thickness  of  the  scleral  tunic  is  affected  by  the  increase  of  the 
contained  pressure  within  the  globe,  according  to  Isehreyt,  who  found 
the  sclera  thin  in  the  anterior  and  equatorial  regions  in  primary 
glaucoma  and  commonly  so  in  absolute  glaucoma.  The  posterior  half 
is  rarely  thinned  except  as  the  result  of  myopia,  altliough  the  thinning 
of  primary  glaucomatous  eyes  resembles  that  which  is  found  in 
hydrophthalmos  rather  than  Avhat  is  noticed  in  myopia  :  and  the  length- 
ening of  tlie  antero-posterior  diameter  of  a  glaucomatous  eye  depends 
upon  the  stretching  of  the  anterior  segment  of  the  globe. 

Myopic  eyes  are  less  frequently  the  subject  of  the  glaucomatous 
process,  and  when  they  are  affected  the  glaucoma  seems  to  run  a  slower 
course,  yet  there  appears  to  ])e  some  antagonism  ])etween  glaucoma 
and   myopia,     !^^yopia    may   dcvdoii   during  tlie   course   of  glaucoma 


GLAUCOMA  5425 

and  when  it  does,  it  has  been  said  to  have  a  beneficial  elfeet  upon  the 
glaucoma. 

Refraction  of  the  eye.  Gilbert  found  among  71  cases  of  glaucoma 
at  the  Munich  clinic,  26  per  cent,  who  were  either  emmetropic  or 
myopic;  in  115  intlannnatory  cases,  77  per  cent,  were  hyperopic,  the 
remainder  being  e(iually  divided  between  the  emmetroi)ic  and  the 
myopic.  It  is  possible,  therefore,  for  the  refraction  of  the  eye  to 
influence  the  form  of  the  disease. 

Exciting  causes.  In  patients  predisposed  to  glaucoma  the  exciting 
causes  of  an  outburst  ma^-  be  apparently  slight.  It  connnonly  arises 
through  some  disturbance  which  causes  congestion  of  the  head  and 
eyes.  As  already  pointed  out,  sleeplessnes.s,  worry,  bronchitis,  influ- 
enza and  neuralgia  of  the  fifth  nerve  may  be  charged  with  producing 
it. 

Cliaiujcs  in  the  general  vascular  system.  Patients  of  the  age  at 
which  primary  glaucoma  is  commonest  frequently  have  degenerated 
vascular  conditions  due  to  some  diathesi.s.  as  that  of  gout  or  syphilis; 
while  others  may  have  marked  arteriosclerosis  with  symptoms  of  renal 
insufficiency.  While  vascular  changes  are  very  frequent  they  are  not 
specific  nor  characteristic  ;  as  most  of  the  individuals  are  beyond  middle 
life  they  usually  represent  only  a  greater  or  less  degree  of  arterio- 
sclerosis. 

Rohmer  has  found  that  arteriosclerosis  may  produce  glaucoma 
through  the  obstruction  of  the  outflow  through  the  veins,  which 
obstruction  affects  the  process  of  osmosis  to  such  an  extent  as  to 
produce  edema  of  the  vitreous.  Sclerosis  can  both  diminish  and  increase 
the  general  blood  pressure ;  its  effect  upon  the  production  of  glau- 
coma is,  however,  less  direct  than  indirect,  that  is  to  say,  it  is  rather 
through  the  influence  exerted  by  the  modified  cardiac  and  renal  func- 
tions, as  well  as  by  the  alterations  in  the  composition  of  the  blood 
effected  through  the  disturbed  innervation  of  the  sympathetic  system. 
Such  a  general  process  cannot  but  be  Avithout  influence  upon  the  vas- 
cular functions  of  the  ocular  tissues,  and  the  study  of  any  case  demands 
that  the  state  of  the  cardio-vaseular  system  must  be  carefully  con- 
sidered. 

Associated  with  these  anatomical  defects  there  is  often  an  abnormally 
high  blood-pressure,  indeed,  if  a  number  of  non-glaucomatous  were 
compared  with  an  equal  number  of  glaucomatous  persons,  of  corres- 
ponding ages,  it  is  extremely  likely  that  the  blood-pressure  in  the  glau- 
comatous would  be  higher,  the  differences  being  undoubtedly  greater 
in  the  congestive  types  than  in  the  simple  non-congestive.  It  is  well 
known  that  the  intraocular  tension,  as  effected  in  laboratory  experi- 

Vol.  VII— 37 


5426  GLAUCOMA 

ninitjitioii.  i-cs|)()ii(ls  to  Hh!  variiitioiis  in  llu;  gi'iieral  blood-pressure; 
it  is  uiH'frtiiiii,  however,  whetlier,  in  a  suhjcet,  exeiteiiieiit  or  emotion 
ean  produee  variations  great  enough  to  eause  an  outburst  of  ghiueouia, 
yet  undoiiblcd  instances  have  occuri-cd  wlicrcin  no  other  factor  could 
be  addiii'cd.  it  must  be  borne  in  miml,  however,  tliat  very  many 
persons  witli  abnormally  high  blood-pressure  are  entirely  free  from 
glaucoma  and  that  many  glaucomatous  persons  Imve  a  low  pressure. 
While  it  does  not  follow  that  a  heightened  i^ressure  in  the  general 
vascular  sj'stem  produces  an  increa.se  in  the  inti-aocular  tension,  the 
degenerate  condition  of  the  vessels  may  h'ad  to  hcnion-liage,  arterial 
and  venous.  Indeed,  as  de  Schweinit/  lias  so  clearly  pointed  out, 
arterial  degeneration  nuiy  be  resjjonsible  in  the  hemoi-rhagic  forms  of 
glaueonui,  and  he  Ixdieves  that  the  liighci-  grades  of  degeneration  may 
render  the  i)rognosi.s  unfavorable  anil  undoubtedly  be  responsible  for 
the  hemorrhage  and  other  complications  arising  after  an  otherwise 
well-performed  iridectomy. 

In  cases  where  the  intraocular  tension  is  so  high  as  I-IO  nun.  ITg.. 
and  more,  such  tension  only  occurs  in  patients  suffering  fi-om  high 
arterial  tension,  and  yet,  a.s  pointed  out  already,  high  arterial  tension 
alone  does  not  cause  glaucoma.  It  is  difficult  to  distinguish  ))etween 
hemorrhage  causing  glaucoma  and  that  resulting  from  it.  It  is  well 
known  that  glaucoma  may  quickly  follow  injuries,  and,  in  a  .sus- 
ceptible person,  after  an  operation  performed  on  the  opposite  eye; 
a  foreign  body  on  the  cornea  may  be  the  apparently  trivial  exciting 
cause,  which  excitement  in  itself  has  so  upset  the  balance  of  control 
in  the  patient's  general  system  as  to  derange  the  circulation  in  the 
eye.  But  it  must  not  be  forgotten  that  this  circulatory  change,  with 
the  consequent  increase  in  tension,  does  not  originate  in  inflammation, 
as  is  shown  by  the  prompt  relief  obtained  by  the  use  of  miotics  in 
contracting  the  pupil.  Conversely,  certain  of  the  general  measures 
such  as  rest,  warmth,  purging,  diet,  depressant  drugs,  resorted  to  for 
the  palliation  of  chronic  glaucoma  miglit  be  considered  as  possessing 
value  because  of  their  influence  on  blood-pressure.  It  is  the  constant 
practice  of  the  writer  of  this  section,  learned  from  Xorris.  Harlan, 
Jackson,  IMcClure  and  others,  in  the  days  when  the  trained  fingers 
applied  to  the  pulse  were  relied  on  as  the  index  of  the  state  of  the 
vascular  system,  to  abstract  blood  from  the  temple,  copiously,  and 
even  to  advise  venesection. 

Overuse  of  eyes.  The  overuse  of  amt>tro])ic  eyes,  esjiecially  luicor- 
rected  hyperopic  astigmia,  or  otherwise  ini])i'operly  corrected  eyi'S, 
by  causing  congestion  in  the  uveal  tissues,  max  biing  on  an  attack. 
This  oliservation  was  made  by  IMackenzie  so  long  ago  as  1854,  when 


GLAUCOMA  5427 

he  mentioned  that  "overuse  of  the  eyes  for  near  objects"  was  one  of 
the  causes  of  ghuu-oinatous  choroiditis.  In  a  primary  attack  tlie  initial 
disturbance  is  vascuhir — a  pure  congestion — yet  tbe  congestion  affects 
onl\-  tile  patency  of  the  filtration  angle  and  does  no  immediate  struc- 
tural damage  to  the  retina.  At  the  time  of  life  at  which  glaucoma 
is  commonest,  the  large  lens,  having  lo.st  its  elasticity,  is  pressed  ui)on 
during  accommodation  by  the  contracted  ciliary  processes  with  the 
result  that  the  tiltration  area  becomes  compressed. 

Improper  use  of  drugs,  mydriatus,  adrenulin,  ete.  It  is  well  known 
tbat  tiie  application  of  mydriatic  solutions,  as  of  atropin  and  cocain. 
may  light  up  a  severe  attack  of  glaucoma  in  an  eye  whicb  ha.s  previously 
shown  no  sigi  s  of  the  disease.  Yet  these  drugs  cannot  of  Ihemselves 
excite  glaucoma  in  eyes  wliich  are  not  already  predisposed  thereto. 
Gunnufsen,  in  studying  the  intraocular  pressure  in  157  cases  of  ser- 
l)ent-ulcer  of  the  cornea,  records  that  in  every  case  which  had  been 
treated  with  atropin  the  tension  was  above  the  normal — 25  nun.  of 
mercury  or  more — and  it  was  only  among  those  thus  treated  that 
dangerously  high  tension  was  foinid.  The  peripheral  folding  and 
thickening  of  the  iris,  together  with  the  narrowing  of  the  perilenticu- 
lar space  which  accompany  dilatation  of  the  pui)il,  may  be  sutficient 
to  block  entireh^  an  already  narrow  filtration  angle.  It  occurs  chiefly 
in  elderly  persons  with  shallow-chambered  eyes,  especially  in  those 
in  whom  there  is  persistently  an  increased  arterial  pressure.  In  this 
connection,  one  must  not  neglect  to  instill  a  miotic,  after  the  employ- 
ment of  a  mydriatic  as  an  aid  in  the  diagnosis  of  obscure  eases  of 
glaucoma,  as  a  preventive  of  continuing  dilatation  of  the  pupil. 

Cases  have  been  reported  in  which  a  striking  increase  of  intraocular 
tension  has  followed  the  use  of  adrenalin,  and  its  use  either  alone  or 
in  conjunction  with  eserin  and  cocaine  may  not  be  without  danger. 
De  Schweinitz  calls  attention  to  the  fact  that  after  sympathectomy 
adrenalin  causes  marked  dilatation  of  the  pupil. 

It  is  known  that  abnormal  chemo-biologic  compounds  may  circidate 
in  the  blood,  consequently  such  compounds  may  of  themselves  bear 
some  part  in  the  vexed  and  vexing  question  of  the  pathogeny  of  glau- 
coma. Kleczkowski  claims  to  have  found  adrenalin  in  the  blood  serum 
in  thirteen  eases  of  glaucoma;  and  in  these  cases  there  was  an  excess- 
ive blood-pressure ;  other  observers,  however,  obtained  negative  results 
in  their  series  of  eases.  Nevertheless,  it  is  not  at  all  improbable  that 
the  instillation  of  therapeutic  solutions  of  adrenalin  into  the  glau- 
comatous eye  tend  to  augment  the  already  elevated  blood  pressure  and 
consequently  a  greater  increase  of  the  intraocular  tension  also. 

Henderson  regards  glaucoma  following  the  use  of  mydriatics  after 


5428  GLAUCOMA 

the  presbyopic  age  has  been  reached,  to  be  an  example  of  the  obstructive 
class  of  secondary  glaucoma,  as  it  is  directly  induced  by  the  diminished 
access  of  tlic  a<iueous  in  the  veins,  and  he  further  states,  that  tiie  shal- 
low anterior  chamber  of  old  age  cannot  be  considered  an  a  predisposing 
factor,  for  if  it  were,  the  danger  of  inducing  glaucoma  would  l)e  equally 
great,  if  not  greater,  in  the  infantile  eye,  with  its  very  shallow  cham- 
ber. 

Injuries.  Occasionally  cases  of  glaucoma  arise  as  a  direct  result  of 
the  effects  of  injuries  to  the  body  or  head,  the  connection  being  mani- 
fested in  subjects  predisposed  to  glaucoma.  Such  persons  may  be 
grouped  with  those  mentioned  elsewhere  in  whom  the  lodgment  of  a 
foreign  body  upon  the  cornea  has  excited  an  outburst  of  glaucoma. 
They  are  those  whose  psychic  natures  are  unstable,  whose  vessels  are 
more  or  less  sclerotic  and  whose  nervous  systems  are  capable  of  being 
profoundly  depressed  by  seemingly  trivial  causes. 

Effects  of  season  and  climate.  It  has  been  stated  that  acute  glau- 
coma appears  to  be  more  fre(|uent  in  winter  than  in  other  seasons  of 
the  year,  yet  it  has  been  the  writer's  experience  to  have  had  each  year 
since  1894,  at  least  one  case  in  niidsuiiinu'r.  It  is  conceival)le  that 
the  frequent  incidence  of  glaucoma  among  Europeans  in  winter,  and 
in  the  natives  of  India  during  the  rainy-season,  is  dependent  upon 
tlie  blood-pressure  changes  influenced  by  climatic  variations.  In 
direct  contrast  to  the  testimony  from  cold  regions  is  the  experience 
of  Lobo,  of  Bogota,  who  states  that  inflammatory  glaucoma  is  very 
common  in  the  hot  Central  American  countries.  He  has  not  found 
that  the  subjects  have  been  more  susceptible  by  reason  of  alcoholism, 
arteriosclerosis,  affections  of  the  heart  or  by  malaria.  Sclerosis  of  the 
crystalline  and  the  onset  of  presbyopia  are  premature  in  hot  coun- 
tries; these  two  factors  he  believes  accelerate  the  development  of  glau- 
coma in  those  whose  occupation  exposes  them  to  great  tropical  heat. 
He  found  glaucoma  in  equal  frequency  in  the  two  sexes  in  early 
life,  but  more  frequently  in  women  at  aliout  fifty  years  of  age. 

The  vascular  and  lymplmtic  circulation  in  the  cijc  in  connection 
with  glauconm.  It  may  be  well  to  consider  certain  aspects  of  the 
circulation  of  the  eye  in  connection  with  glaucoma,  which  are  here 
adapted  from  Fuch's  well-known  description. 

The  uvea  is  very  richly  supplied  with  vessels  derived  fi"om  the  sys- 
tem of  ciliary  vessels  which  has  but  few  anastomoses  with  tiie  con- 
junctival vessels  at  the  margin  of  the  cornea,  and  still  fewer  with  the 
vascular  system  of  the  optic  nerve  and  the  retina  at  the  boi-der  of  the 
scleral  foramen.  But  within  the  uvea  itself  the  anastomoses  are  very 
abundant.     The  arteries  are  connected  bv  two  arches,  one  at  the  root 


GLAUCOMA  5429 

of  tile  iris,  the  other  close  to  the  piipilhiry  inai'^iii.  The  veins  in  the 
choroid  are  arranged  in  whorls  or  vovtiees,  and  the  veins  belonging  to 
any  two  adjoining  whorls  are  connected  by  a  series  of  arched  anas- 
tomoses. Disturbance  of  circulation  in  the  choroid  can  be  compen- 
sated for  much  more  readily  than  in  the  retina,  whose  vessels  possess 
no  anastomotic  connections.  The  voi-tex  veins  carry  otf  almost  all 
the  blood  of  the  uvea  ;  obstruction  of  these  veins,  therefore,  leads  to 
serious  distur])ances  of  cii'culation  and  to  increase  of  tension.  The 
vortex  veins  are  not  numerous  neither  do  they  present  other  con- 
nections, and,  in  the  region  of  the  e(|uator  the  blood  from  the  pos- 
terior half  of  Ihe  uvea  must  enter  from  l)ehind  forward.  Further- 
more, the  very  obli(jue  direction  of  theii'  course  through  compaivitively 
narrow  and  indistensible  canals  in  the  sclera  nmy  lead  to  interference 
with  the  discharge  of  blood  from  the  eye. 

The  richness  of  the  uvea  in  vessels  in  the  anterior  segment  of  the 
eye  is  of  service  in  the  secretion  of  the  a(|ueous,  while  in  the  pos- 
terior segment  it  is  of  service  in  the  nutrition  of  the  retina,  and  in 
the  restoration  of  the  visual  i)urple  ami  other  visual  substances.  The 
arrangement  of  the  choroidal  vessels  favors  these  objects;  the  large 
vessels  are  placed  farthest  from  the  retina,  and  therefore  retain  the 
nutrient  matter,  while  all  the  capillaries,  lying  as  close  to  the  retina 
as  possible,  are  united  to  form  a  single  layer. 

The  retina  is  very  poor  in  vessels,  the  fovea  centralis,  the  spot  that 
is  most  important  for  vision,  being  entirely  destitute.  Neither  have 
the  retinal  vessels  anastomoses  with  each  other,  and  there  are  no 
anastomoses  worth  mentioning  between  the  retiiud  and  ciliary  systems 
of  vessels,  so  that  the  latter,  whose  circulatory  i-elations  are  far  more 
favorable,  cannot  substitute  for  the  former. 

The  amount  of  blood  within  the  eye  is  subject  to  a  variety  of  altera- 
tions not  only  in  those  connected  with  the  blood  vessels  themselves, 
but  also  it  is  affected  by  the  reactions  of  the  iris  and  ciliary  body  as 
well  as  by  the  pressure  exerted  by  the  ocular  muscles  from  without. 

Circulation  of  the  lymph.  The  intraocular  lymph  is  generated 
entirely,  or  almost  entirely,  by  the  ciliary  processes,  the  formation 
of  it  being  favored  by  tlie  rich  vascular  supply  and  the  extensive 
superficial  area  of  the  processes  manifested  by  their  foldings  and 
reduplications.  The  lymph  is  not  secreted  in  the  true  physiological 
sense,  for  there  are  no  glandular  elements  inherent  in  the  ciliary  body ; 
the  lymph  is  poured  out  by  transudation  by  a  process  of  filtration. 

The  lymph  for  the  most  part  passes  forward  from  the  posterior 
chamber  through  the  jjiipil  into  the  anterior  chamber.  The  aqueous 
then  passes  out  of  the  anterior  chamber,  through  the  spaces  of  Fon- 


5430  GLAUCOMA 

t;iii;i  into  tlic  aiitcrioi-  ciliiii-y  veins  by  way  of  Schlemm's  canal,  through 
the  anterior  surlace  of  the  iris  and  tlirouf^ii  tlie  ciliary  body.  None 
can  pass  tlirough  the  cornea  unless  the  endothelium  of  that  membrane 
be  destroyed. 

The  angle  of  the  anterior  chaml)er  provides  easy  filtration,  for  here 
the  blood  vessels  are  merely  endotiielial  tuljes,  the  walls  of  wiiich  are 
kept  open  by  being  adherent  to  the  sclerotic. 

The  outflow  of  fluid  from  the  vitreous  is  slow  under  normal  pressure. 
It  is  probable  that  under  forced  pressure,  experimentally,  the  lymph 
passes  out  by  means  of  the  perivascular  sheaths  of  the  central  retinal 
vessels,  but  during  life  the  fluid  passing  forwards  from  the  vitreous 
largely  aids  in  the  restoration  of  the  anterior  chamber,  in  the  event 
of  a  sudden  loss  of  the  aqueous  by  operation,  accident  or  disease. 

The  perichoroidal  space  drains  into  the  perivascular  lymph  spaces 
around  the  vortex  veins.  This  portion  of  the  h'mph  is  small  in  quantity 
and  is  not  concerned  with  the  maintenance  of  the  intraocular  pressure. 
Pathology  of  glaucomu.  The  pathology  of  glaucoma  is  complex  and 
most  obscure.  The  causative  factors  adduced,  as  heretofore  stated, 
are  innumerable.  Histologically,  quite  definite  changes  have  been 
found  by  several  observers,  each  of  whom  has  ever  been  ready  to  sup- 
port his  hypothesis  as  to  the  causation  of  the  disease,  only  to  be  baffled 
by  the  absence  of  the  vaunted  changes  in  his  next  case.  (For  a 
more  extended  account  the  reader  is  referred  to  Parson's  "Pathology 
of  the  Eye.") 

In  the  acute  congestive  forms  the  uveal  tract  is  congested,  while 
in  the  later  stages  and  in  chronic  glaucoma  there  is  degeneration.  In 
congestive  glaucoma  there  is  marked  venous  stasis,  often  with  hemor- 
rhages, the  tissues  are  swollen  by  exudation  containing  fibrin,  leu- 
cocytes, red  corpuscles,  etc.  In  the  subacute  and  chronic  stages 
degeneration  occurs  in  the  iris  and  ciliary  body  and  in  the  choroid, 
.which  becomes  nnicli  thinner  than  normal.  Changes  are  most  marked 
in  the  vortex  veins.  The  perivascular  lymph-spaces  and  the  sur- 
rounding sclerotic  are  densely  infiltrated,  round  and  oval  cells  pervade 
the  vessel  walls  accompanied  hy  proliferation  of  the  endothelium,  yet 
such  changes  are  frequently  found  in  eyes  wliit-li  are  quite  free  from 
glaucoma. 

In  advanced  cases  of  glaucoma  the  retina  becomes  atrophic. 
In  acute  glaucoma  and  in  chronic  congestive  glaucoma  a  marked 
displacement   of  the   rods  and   cones  has   been   noted,   together   with 
changes  over  the  whole  retina. 

The  effect  of  glaucoma  upon   the  optic    nerve   was  recognized   by 
Ileiiii-ich  IMiiller  as  early  as  ISaG.     The  optic  nerve-entrance  is  the 


Lyiii]ih    Passages   of   the    Kye    (Siheiiiatit*). 

S.  Sehlemm 's  canal,  c.  Anterior  ciliary  \eins.  h.  Hyaloiil  canal.  i>.  I'eri- 
ehoroidal  space,  which  coniinunicates  by  means  of  the  venie  vorticosie,  v,  with 
Tenon's  space,  t.t.  s.  Piipravaf^nnnl  space,  i.  Intervajjinal  sjiace.  ee.  Continua- 
tion of  Tenon's  capsule  uj>on  the  tendon  of  the  ocular  muscles  (lateral  invagina- 
tion).    (Fuchs.) 


GLAUCOMA  5431 

weakest  spot  in  the  oi'iil.ir  \\;ill  so  lliat  iiiciTiiscd  i)i'cssiin'  manifests 
ilseir  aiiatoniically  here  sooner  than  elsewhere.  In  healtli  the  lamina 
eriljrosa  ])as.ses  transversely  across  the  nerve,  l)nt  \t'i'\-  eai'ly  in  }.;lau- 
coma  it  assumes  a  curve  with  the  concavity  forwards.  As  a  result 
of  tiie  i)ressure  the  tihres  in  the  nerve-head  heeome  atropine  and  the 
ganglion  cells  in  the  retina,  fi-om  whicli  the  lihres  spring,  undergo 
degeneration.  In  the  cuppiiiL;:  of  tin-  disk  there  is  accordingly  loss 
of  substance  as  well  as  eetasis.  As  the  ease  advances,  the  ectasis 
increases,  so  that  the  lamina  may  extend  beyond  the  level  of  the 
sclerotic.  The  overhanging  lip  of  the  cup  seen  in  tlic  ophthalmoscopic 
picture  is  really  the  anterior  edge  of  the  scleral  foramen,  for,  in 
advanced  cases,  the  sclera  forms  the  lateral  wall  of  the  cup.  The 
nerve  fibres  lining  the  cup  become  more  and  more  atrophic  as  time 
advances,  as  the  field  of  vision  shows,  the  teinpoi-al  fibres  sulfering 
earliest,  and,  later  on,  total  atrophy  follows.  The  degeneration  in 
the  excised  nerve  can  be  demonstrated  l)y  appropriate  staining 
methods. 

It  is  generally  conceded  that  the  changes  in  the  optic  nerve  are 
brought  about  entirely  by  the  effects  of  prolonged  pressure.  Schnabel, 
however,  advanced  the  view  that  there  iS  also  an  active  neurit ic 
atrophy,  as  shown  by  the  formation  of  new  blood-vessels,  proliferation 
of  the  interstitial  connective  tissue,  etc.  He  considered  that  the  lamina 
cribrosa  is  not  pressed  back  by  the  increased  pressure,  but  is  pulled 
back  by  the  shrinking  connective  tissue  of  the  atrophic  nerve.  From 
the  study  of  a  large  number  of  eyes  he  came  to  the  following  con- 
clusions: Degeneration  occurs  early  in  the  nerve-fibers,  commencing 
in  the  intra-scleral  part,  and  soon  leads  to  the  formation  of  microscopic 
holes  which  rapidly  enlarge,  producing  a  condition  which  he  calls 
cavernous  degeneration.  The  holes  then  coalesce  into  clefts  and  irregu- 
lar spaces,  and  the  lamina  cribrosa  becomes  exposed  upon  the  surface 
anteriorly.  Finally  a  single  large  cavern,  the  glauconuitous  excava- 
tion, results. 

The  amount  of  connective  tissue  on  the  surface  of  the  lamina  cribrosa 
varies,  depending  probably  upon  the  condition  of  the  inherent  normal 
connective  tissue.  In  some  cases  it  may  be  completely  absent,  while 
in  others  the  cup  may  be  tilled  witli  new-formed  connective  tissue;  it 
is  usually  filled  with  vitreous. 

Pressure  within  the  globe  tends  to  cause  stretching  of  the  sclerotic 
and  the  development  of  ectasis.  In  the  eyes  of  the  young  the  sclera 
may  liecome  stretched  e(|ually  in  all  directions,  so  that  total  ectasis 
occurs  (see  Infantile  glaucoma).  In  the  eyes  of  the  adult,  however, 
the  resistance   is  great  euouiih   to   prevent  stretching  in   all   but   the 


5432  GLAUCOMA 

weakest  parts  so  that  the  ectasis  may  be  only  parlial,  wliich  may  be 
confined  to  the  ciliary  region  or  to  tlie  equatorial.  The  ])osterioi'  half 
oi"  the  globe  is  rarely  thinned  except  as  the  result  of  iiiy()j)ia. 

The  eiliaiy  ectasias  form  bluish  bulgings  bexoiid  the  liinbus.  These 
stai)iiylonuita  consist  of  the  stretclied  sclera  and  contain  the  thinued- 
out  ciliary  processes  which  extend  over  the  inner  surface  of  the 
ectatie  area.  Equatorial  staphylomata,  which  are  less  common,  are 
generally  found  slightly  behind  the  e(juator  at  a  weak  point  in  the 
sclerotic  in  the  neighborhood  of  a  vortex  vein.  Tiiey  i)i'esent  a  thin 
niciiibiane,  over  the  inner  surface  of  wiiicli  is  stretched  the  very  much 
degenerated  uvea. 

Pathogenesis.  Von  Graefe,  relying  at  fii'st  iq)oii  -laeger's  mistaken 
idea  in  regard  to  the  appearance  of  the  nerve-head,  assuming  that 
what  is  now  known  to  be  an  excavation  or  cupping  of  the  i)apilla  was 
a  globular  i)rotrusion,  believed  in  the  inflammatory  nature  of  glau- 
coma and  expected  to  find  exudation  and  vascular  dilatation  in  the 
optic  nerve.  And  although  he  very  soon  afterwards  corrected  this 
view,  he  nevertheless  attributed  glaucoma  to  a  serous  choroiditis, 
which  caused  increase  in  volume  of  the  vitreous  and  the  rise  of  intra- 
ocular pressure  with  compression  of  the  retina. 

"The  mystery  which  continued  to  surround  the  causes  of  the  dis- 
ease long  after  its  dependence  on  increased  pressure  had  been  recog- 
nized," writes  Priestley  Smith,  'Svas  due  to  the  lack  of  knowledge  of 
the  processes  by  which  the  supply  of  fluid  to  the  chambers  of  the  eye 
is  maintained  and  regulated."  Through  the  researches  of  Leber,  we 
now  know  that  the  highly  vascular  ciliary  body  is  the  chief  secreting 
organ  of  the  eye,  and  that  the  aqueous  chamber  is  replenished  and 
the  vitreous  and  the  lens  are  nourished  by  a  fluid  which  is  supplied 
through  the  medium  of  the  capillaries  of  the  ciliary  processes,  by  a 
process  of  transudation  from  the  epithelial  surface  of  the  ciliary 
body.  The  freshly  secreted  fluid  stands  in  close  osmotic  relation  with 
that  which  is  contained  within  the  membranes  of  the  vitreous  body. 
The  composition  of  the  aqueous  and  vitreous  fluids  therefore  are  nearly 
but  not  quite  identical,  each  containing  approximately  95  per  cent, 
water,  1  per  cent,  salts  and  extractives  and  a  minute  quantity  of 
albumin.  The  rate  of  its  production  depends  upon  the  difference 
between  the  pres.sure  of  the  blood  and  the  pressure  of  the  fluid  in  the 
aqueous  chamber.  Its  rate  of  formation  is  about  5  c.mm.  a  minute, 
so  that  the  whole  cojitent  of  the  aqueous  chamber  is  changed  in  less 
than  one  hour, 

Tlie  fluid  passes  over  the  lens  and  through  the  pupil  into  the  anterior 
ehamlier,   passing  out  through   the  angle  at   the   junction   of  the   iris 


GLAUCOMA  5433 

aud  cornea,  tlu'iicc  through  the  incshcs  of  the  crihrifonn  or  prctiiiatc 
ligament,  thence  by  liltration  and  difhi.sion  througli  the  canal  of 
Schlemin,  which  is  in  itself  a  mere  jilexus  of  veins.  Some  of  the  tiuid 
is  absorbed  and  eliminated  by  the  iris,  but  the  greater  (piantity  of  it 
passes  into  the  anterior  ciliary  veins,  while  only  a  small  portion  flows 
backward  through  the  vitreous  to  escape  by  way  of  tlu'  lymph  chan- 
nels in  the  optic  nerve. 


i'lciiit   ui    .\uiMi:.l    l',Vfli:ill    t(i   . .,    i        <  ircuinleiii    I    -        ■.    .\''. 

(Muitlaiiil  KaiuMiy.) 

According  to  Schoeuberg,  the  ocular  drainage  in  glaucomatous  eyes 
differs  from  tliat  of  normal  eyes.  The  slower  the  rate  of  drainage 
the  nearer  the  eye  is  to  an  acute  attack  or  to  absolute  glaucoma ;  the 
more  rapid  the  rate  of  drainage  the  nearer  to  a  state  of  compensated 
glaucoma.  A  reduction  of  the  rate  of  ocular  drainage  may  mean  latent 
glaucoma  in  spite  of  an  intraocular  pressure  whicii  is  within  the  nor- 
mal limit,  that  is  to  say,  below  26  mm.  Hg. 

The  sympathetic  nerve  exercises  a  certain  regulating  influence  over 
the  ocular  pressure,  for,  irritation  of  the  cervical  sympatlietic  increases 
the  pressure,  while  section  of  the  nerve  decreases  it.  This  physiologic 
demonstration  led  surgeons  to  practise  sympathectomy  for  the  relief 


5434 


GLAUCOMA 


of  <il;m<'()iii;it(iii.s  ])r('S.sur(',  l)\it  tlie  results  liavo  not  hccii  satisfactory 
Ix'caiisc  the  (liiiiinutioiis  have  been  only  transitor\'. 

Parsons  declares,  however,  tiiat  the  marked  rise  in  the  iulraoeular 
pressure  produced  by  stimulation  of  the  cervical  sympathetic  is  not 
due  to  alteration  in  the  general  blood-pressure.  l)ut  rather  to  the 
contraction  of  the  unstriped  muscle  fibers  in  the  orbit.     The  influence 


The  Angle  of  the  Anterior  Chamber  in  a  Healtliy  Eye,  showing  the  Canal  of 
Schleiiini,  the  liganientuin  iiectinatum,  and  lymphatic  crypts  at  the  periphery  of 
the  iris.     (After  Collins,  in  Posey  and  Wright.) 


of  the  nervous  system  upon  the  maintenance  of  the  pressure  of  the 
fluid  in  the  chamber.s  of  the  eye  is  quite  indireet. 

The  maintenance  of  pressure  is  derived  undoubtedly  from  the  force 
of  the  blood-current,  and  the  pressure  of  it  within  the  chambers  regu- 
lates the  outflow,  while.  Ix'cau.se  the  intraocular  ]>ressure  is  the  same 
in  the  vitreous  and  a(|ueous  chambers,  tlic  c(|uilibrium  preserves  the 
shape  and   tension   of  the  eyeball.      Thus,   again,   to   (luote   Priestley 


GLAUCOMA 


5435 


Smitli,  '■\Vli('ii  I'cgulalion  fails  and  the  pi'cssuri-  in  tlic  cliaMilM-i-s  rises 
above  the  physiological  limits  we  have  tlic  coniplfx  distiirlianee  of 
function  and  structure  called  glaueonia.'' 

It  has  never  been  satisfactorily  determined  wliat  tlic  potent  factoi-s 
are  in  disturbing  the  regulation  of  pressure.  It  is  now  generally  held 
that,  in  the  main,  the  disturbance  is  caused  by  a  retention  of  the  fluids 
through  obstruction  to  their  outflow.  Leber  demonstrated  that  the 
acpieous  escaped  at  the  angle  of  the  anterior  chamber,  and  in   1876, 


Front  of  Evoljall  to  Show  the  Narrow  Circuinlental  Space  in  a  (.ilaut-oinatous  Eye, 
X6.      (Maitland  Ramsay.) 


Knies  and  "Weber  showed  that  the  angle  is  found  to  be  obstructed  in 
eyes  blinded  by  glaucoma  through  the  adhesion  of  the  iris  ba.se  to  the 
periphery  of  the  cornea,  whether  through  iridocyditic  inflannnation 
or  from  pressure  by  a  swollen  ciliary  body.  The  process  therefore 
rests  upon  a  disturbance  of  excretion  rathei-  than  on  an  increase  of 
secretion. 

It  is  of  interest  to  note  that  glaucomatous  eyes  are  hard  not  only 
at  the  time  of  excision  but  renuiin  hard  for  a  long  time  afterward, 
proving  that  the  high  tension  is  dependent  upon  properties  inherent 
in  the  globe  itself  and   not  governed   by  h<'ightened   blood   pressure. 


5436 


GLAUCOMA 


One  of  file  wi'itcf's  cai-licst  tcaclnTs,  who  liad  little  or  no  rcf^ard  for 
llic  pnscrxat  ion  and  liistoloyic  study  of  cxcist'd  ji-lohcs,  iLscd  to 
dcinoiistratc  llic  hardness  hy  drivinj^  tiie  l)all  to  the  floor  and  catching 
it  on  the  rebound!  Major  p]iliot,  however,  in  disputing  the  state- 
ment of  Priestley  Smith,  reports  several  cases  in  which  tension  was 
greatly  diminished,  even  to  well  below  the  normal,  after  excision, 
when  measured  with  the  Sehiotz  tonometer.  l*riestley  Smith  com- 
menting upon  the  results  of  Elliot,  would   qualify  his  statement   l)y 


Normal  Coiiieo-iridic'  Angle,  X30.      (.Maitlaad  Kaiusay.) 

sayino'  that  while  non-glaucomatous  glol)es  soon  begin  to  collapse, 
glaucomatous  eyes  remain  comparatively  full,  showing  no  collap.se 
even  after  several  hours,  becau.se  they  have  parted  with  less  tin  id : 
and  he  recalls  Leber  aiul  Henzen 's  testing  of  excistnl  glaucomatous 
eyes  in  which  it  was  found  that  they  permitted  little  or  no  filtration; 
clear  evidence  of  changes  which  check  the  escape  of  fluid  from  the 
(■hand)ers. 

As  already  mentioned,  the  increase  of  susceptibility  as  the  years 
progress  deixMids  ui)on  the  continuou.s  fjrowth  of  the  ei-ystalliui^  lens. 
While  the  cornea  and  globe  in  ireiiei'al  attain  tlieii'  uiaxiniuni  i:i-owtli 
in  eai-l\'  adult  \-eai's,  the  lens  continues  to  iirow  fi-oiu  youth  to  old  age. 


GLAUCOMA 


5437 


Aceordiiifi:  to  J'cicstlcy  Smitli,  diiriii^^  tlic  I'oily  years  iM'tuccii  25  and 
65  the  lens  adds  oiic-teiitli  to  its  diaiiii'lcr  aiul  one-third  to  its  volume. 
CoiiscHiueiitly  tlie  space  between  the  lens  niarfjin  and  the  surrounding 
structures  is  encroached  ujjon  by  the  growing  lens;  yet  as  the  lens 
grows  larger  tlie  globe  itself  does  not  increase  in  size.  It  is  a  coininon 
experience  to  tind  glaucoma  in  small  eyes.  In  the  hyperopie  eye  the 
ciliary  area  is  usually  small,  and,  tVom  turgescence  of  the  ciliary 
processes  during  the  excessive  strain  attending  accominndation,  the  iris 


To  Sliow  the  llkK-kiiii"-  of  the  Conieo-iridic  Angle  in  Ghiiu-ouia,  XMO. 
(.Maithiiul  Rtinisay.) 


base  is  pressed  upon  and  the  tiltration  angle  is  compressed,  with  the 
result  that  the  outlet  is  blocked.  Contact  of  the  iris  without  com- 
pression does  not  necessarily  shut  oft'  the  aciueous  from  the  ligament 
and  Schlemni's  canal,  but  wiien  the  turgid  processes  are  compressed 
between  the  lens  and  the  iris,  the  fluid  which  they  secrete  into  the 
vitreous  is  unable  to  find  an  exit. 

It  is  ])ossible  that  hypersecretion  is  sometimes  eoneerned  in  the 
onset  of  glaucoma,  or  that  the  character  of  the  fluid  is  changed  so 
that  it  becomes  serous,  as  has  been  noted  in  nuiny  instances  by  the 
presence  of  coagulated  albumin  deposited  on  the  hyaloid  membrane. 


5488 


GLAUCOMA 


Vcl.  tilt'  Jici-illiillljiliori  oi"  lllc  llu'hl  lii'liilid  the  Iciis  scciii.s  to  !)•'  <luc  1o 
the  obstruction  ol'  tliu  eircuiiilciital  .s])a('L'  l)y  tlu;  swollen  ciliary  i)roc- 
esses,  rather  than  to  excessive  secretion. 

The  observations  of  Priestley  Smith  only  support  the  cai'licr  con- 
tention of  Weber  that  primary  glaucoma  depends  on  the  closure  of 
the  filtration  angle,  from  changes  in  the  shape  and  position  of  the 
ciliary  processes  and  of  the  lens,  and  that  in  some  stage  of  the  process 
the  iris  is  brought  into  contact  with  the  cribriform  ligament  and 
becomes  adherent  to  it,  w^hile  the  iris  itself,  in  the  meantime,  is  more 
or  less  compressed  between  the  ligament  and  the  ciliary  body. 


The  Anglo  of  the  Anterior  Chamber  in  a  Case  of  Primary  Glaucoma,  showing 
closnre  of  the  filtration  area  at  the  periphery  of  the  cornea,  by  apposition  with  it 
of  the  root  of  the  iris.     (After  Collins,  in  Posey  and  Wright.) 

As  the  ciliary  processes  are  usually  altered  both  in  size  and  position, 
Hess  observes  that  individual  differences  in  the  form  of  the  ciliary 
l)ody  are  as  important  in  the  consideration  of  tiie  causation  of  glaucoma 
a.s  are  the  variations  in  the  size  of  the  lens,  because  lie  has  demon- 
strated that  during  life  bulbous  outgrowths  may  develop  on  the  ciliaiy 
processes.  The  part  therefore  played  by  tlie  ciliary  l)ody  may  not  be 
inconsiderable,  because  through  the  atrophy  of  it  the  processes,  the 
zonula,  the  lens  and  the  iris  are  gradually  brought  nearer  the  cornea. 
Hess  noted  that  not  infrequently  the  iris  near  its  root  is  twice  as  thick 
in  file  eyes  of  old  people  as  in  those  of  infants. 

It  is  unfoi'tunate  that  we  can  seldom  study  the  early  stages  of  the 
disease  under  the  microscope,  for  the  eyes  are  commonly  .saved  in 
that  stage  l)y  operation.  Tlie  histologic  studies  conseipKMitly  have 
been  of  eyes  that  have  been  long  diseased  and  even  atrophic,  and,  as 


GLAUCOMA 


5439 


tlic  ])n'i);iratioii  of  an  eye  for  iiii('r()S('()i)ic  sliid.x  iiiiisl  necessarily  di.s- 
arraiige  llie  tissues,  the  certainty  of  tlie  eoiiclusions  must  l)e  iiuicii 
aff'eeted.  So,  too,  dift'erent  parts,  when  studied  by  various  authors, 
liave  been  found  to  ))e  prominently  affected;  as,  for  instance,  Brailey 
(h'scrihed  a  chronic  inflammation  of  the  ciliary  processes  with  dis- 
tension of  the  vessels,  wlildi  he  considered  were  the  primary  lesions 


Micio-I'liotOf^iaph  of  tlie  Criliriform  Ligament. 

A  man  a<iOcl  sixty  years.  Eye  fixed  in  formalin.  Van  Gieson's  connective- 
tissue  stain.  There  is  marked  and  complete  sclerosis  of  the  fibres  composing  the 
cribriform  ligament  (C.  L.).  At  C.  L.  the  fibres  lie  on  the  inner  side  cf  the 
scleral  ring  (S.  R.),  and  terminate  (C.  L.)  by  being  incorjjorated  into  the  con- 
nective-tissue stroma  (C.  T.  S.),  here  nmrkedly  sclerosed,  of  the  cinular  fibres 
(C.  F.)  of  the  ciliary  muscle. 

L.  v.,  Longitudinal  fibres  of  the  ciliary  muscle.  D.  P.,  Fibres  of  origin  of  a 
fasciculus  of  the  musculus  dilator  pupillae.  X,  Posterior  extremity  of  Schlenim  's 
canal,  into  which  opens  a  direct  tributary  from  the  ciliary  venous  plexus  which  has 
made  its  way  ahiiig  the  fibres  of  the  cribriform  ligament  internal  to  the  scleral 
ring.     (Thomson  Henderson.) 


in  glaucoma;  Laqueur  and  others  believe  that  the  rigid  sclerotie  coat 
hinders  the  flow  of  the  currents  of  the  lymphatics,  while  Stilling 
believeil  the  hjiidciiing  of  tlie  sclera  in  the  region  of  the  papilla  ol)- 
structed  the  escape  of  the  fluid  from  the  vitreous  and  tlnis  led  to 
glaucoma. 


5440 


GLAUCOMA 


According  to  tlio.se  who  hold  tliiit  tlic  cause  of  ^laucoina  depends 
upon  an  interference  witli  the  escape  of  tiuids  tlirouj^di  tlie  spaces  in 
the  ])osterior  part  of  the  eye  or  throuj;li  both  these  exits,  an  accuniu- 
hilion  of  llie  fluids  is  facilitated  and  tlii'ou^-li  such  ai-cuiiiuhition  the 
intraocular  tension  rises  and  ^laucouui  su])ervenes.  Hence,  u})on  the 
increased  tension  depend  all  the  distui-bance.s  in  the  eye  in  this  disease. 

Other  observers  reject  "retention  theories."  They  hold  that  such 
hypotheses  do  not  explain  the  origin  of  simple  glaneoiiia.  because  in  this 


Cornea 


Sclera 


The  Cribriform  Ligament. 

Tlio  iiiiHM'  lamella  of  the  Cornea  (a  and  b)  are  continuous  with  the  fibres  of 
the  Cribriform  Ligament.  The  outer  fibres,  which  start  from  a,  lie  next  to 
Schlemm's  Canal,  and  terminate  at  n  in  the  scleral  fibres.  The  inner  fibres,  which 
start  from  b,  spread  out  in  a  fan-shaped  nmnner  to  act  as  fibres  of  origin  to  the 
longitudinal  nuiscle  bundles  and  as  check  fibres  to  the  circular  bundles  of  tlie  ciliary 
muscle.  The  pigment  epithelium  (P)  and  ])Osterior  limiting  membrane  (P.L.M.) 
of  the  iris  and  continuous  with  the  respective  pigment  and  hyaline  layers  (H.L. ) 
of  the  ciliary  body.     Descemct's  membrane  (D.M.).     (Thomson  Henderson.) 


form  of  the  affection  there  is  not  usually  a  marked  increase  of  tension. 
Neither  can  it  be  constantly  proved,  they  say,  that  congestive  glaucoma 
arises  through  the  adhesion  of  the  iris  base  with  \ho  blocking  of 
Pontana's  space,  for  they  believe  these  phenomena  may  be  the  result 
of  increased  tension,  and  it  cannot  yet  be  shown  that  they  are  always 
present  in  the  early  stages  of  the  disease. 

Von  Graefe  thought  that  glaucoma  was  a  manifestation  of  choroid- 


GLAUCOMA 


5441 


itis;  Walilfors,  and  othci-  luon-  i-cccnt  ohscrvcr.s,  hold  tliat  llic  pi'iriiary 
lesion  is  an  atrophic  process  in  the  chorio-capillaris,  believing  that 
the  excavation  of  the  nerve  head,  w  ith  the  consequent  defects  in  the 
visual  perception,  are  dependent  ui)()n  iniiritional  changes  in  the  layers 
of  rods  and  cones.  The  increase  of  tension  is  hy  them  explained  on 
the  assumption  that  tlic  slowing  of  tlic  current  of  the  intraocular 
fluids  depends  upon  a  paralysis  of  the  imisculjir  nrtwoi-k  of  the 
choroid,  through  whicli  tlic  retarding  of  tiie  curnnt  permits  the 
deposition  of  formed  elenii'uts  in   the  exit-channels   with   conse(|Uent 


The  Iris  Venous  Eetiirn. 

Tlie  Ciifiiliis  Iridis  Major  (C.I.M.)  is  formed  by  the  Iris  Veins  though  also 
receiving  tributaries  from  Ciliarj'  Veins  (C.V.).  Before  i)iercing  the  Sclera,  it 
gives  off  a  brancli  to  the  posterior  uveal  venous  system  (P.U.V.),  and  then  it 
J  ierces  the  sclera  (A.U.V.)  to  take  part  in  the  anterior  uveal  venous  (see  the 
figure  following).  The  main  trunk  snp])lies  afferent  tributaries  (A)  to  Schlemni's 
canal,  as  well  as  other  branches  which  join  the  sui)erficial  [)lexus  (L)  in  the  limbus. 

On  the  surface  the  trunk  invariably  divides  into  anterior  and  posterior 
branches  (V  and  V').  The  efferent  vessel  (E)  from  Schlemm 's  canal  (S.C.) 
is  closely  associated  with  the  superficial  pericorneal  plexus  (L).  The  cribriform 
ligament-  (C.L.)  and  iris  cry])ts  (K)  lead  the  aqueous  respectively  to  Schlemm 's 
canal  and  the  iris  veins.     (Thomson  Henderson.) 

retention  of  the  fluid;  the  venas  vorticosa?,  meanwhile,  are  compressed 
])}■  the  increased  tension  and  stasis  follows. 

Knies  and  othcr.s  advance  the  hypothesis  that  the  process  is  really 
a  strange  disease  of  the  optic  nerve.  Donders  believed  simple  chronic 
glaucoma  to  be  due  to  innervational  disturl)ances;  and  certain  more 
recent  investigators  incline  to  separate  it  from  glauconui  altogether 
and  place  it  among  the  diseases  of  the  optic  nerve.  Others  still  regard 
it  as  a  neuriti.s  which  blocks  the  lymph  channels  in  the  optic  nerve, 
whereby  drainage  is  prevented  and  the  retention  of  eifete  materials 

Vol.  VII— 38 


5442  GLAUCOMA 

causes  the  iiici'cMsc  ot"  tension  witli  llir  excavation  of  the  nerve  liead. 
By  those  ol)sei'vers  this  I'oiiii  oi"  the  disease  is  spoken  of  as  "posterior 
ghiueoina." 

Zininieriuan  and  others  believe  tliat  tlie  j)i'iiiiary  cause  depend.s  upon 
a  (litferenee  between  the  general  blood-pressure  and  that  of  the  eye. 
But  high  pressure  iu  the  radials  does  not  necessarily  imply  higli 
pressure  in  the  ciliary  capillaries,  and  as  a  matter  of  fact  the  very 
high  blood-pressure  met  with  so  frequently  in  arteriosclerosis  and  in 
interstitial  nephritis  are  not  commonly  associated  witli  an  increase  of 
intraocular  pressure. 

Uribe-Troncoso,  of  Mexico,  found  in  the  a(|ueous  humor  of  glau- 
comatous eyes  an  increase  in  the  normal  amount  of  albumin,  and  he 
adduced  from  his  findings  the  hypothesis  that  the  symptom.s  are  caused 
by  the  presence  of  albumin.  The  albumin  exudes  through  the  dis- 
eased blood  vessels,  and  the  alterations  noted  as  present  in  the  vitreous 
are  not  without  their  influence.  It  is  })rol)able  that  the  process  of 
osmosis  is  materially  affected  by  the  composition  of  the  fluids  and  by 
variations  in  the  degree  of  intraocular  tension,  yet  there  is  no  proof 
that  clironic  glaucoma  originates  in  an  altered  aqueous  fluid.  How- 
ever, as  his  cases  were  of  the  congestive  type  in  which  .serosity  of  the 
aqueous  is  a  natural  result  of  the  high  tension  and  obstructed  circula- 
tion, the  presence  of  albumin  is  to  be  expected  and  his  results  do  not 
shed  much  light  on  the  initial  causes  of  glaucoma.  It  is  none  the  less 
true  that  solid  particles,  as  of  pigment  after  intraocular  hemorrhage 
(Levinsohn),  and  tumor  cells  (Verhoeff),  becoming  caught  in  the 
meshes  of  the  filtration  space,  may  cause  glaucoma. 

Thomson  Henderson,  as  the  result  of  an  examination  of  several  thou- 
sand sections,  came  to  the  conclusion  that  the  old  term  ligamentum 
pectinatum  iridis  is  inappropriate.  Pie  found  that  this  so-called  liga- 
ment is  derived  from  the  innermost  corneal  flliers  which  end.  not  in  the 
iris  root  as  was  formerly  thought,  but  at  the  ligament  of  origin  of  the 
ciliary  muscle,  and  he  suggests,  therefore,  that  a  better  name  would 
be  the  "cribriform  ligament."  Seeking  to  establish  the  circulatory 
nature  of  the  intraocular  pressure  he  conducted  a  most  extensive  study 
of  the  pathogenesis  of  primary  glaucoma,  and,  in  1007.  he  announced 
that  glaucoma  depends  upon  obstruction  and  closure  of  tlie  filtration 
area  as  the  result  of  sclerosis  of  the  fibrous  structures  comprising  the 
cribriform  or  pectinate  ligament,  which  impedes  the  access  of  the 
aqueous  humor  to  Scblemm's  canal. 

The  ligament,  as  Henderson  defines  it,  is  nothing  more  tlian  a  reg)i- 
l;n-  open  network  of  interlacing  fibers  whicli  are  in  direct  contiiuiation 
with   the  cii-i-ulai-  and  longitudinal  linndles  of  the  sclei'a   aronml   tlie 


GLAUCOMA 


5443 


vt' nous  sinus  of  Sclik'nim's  canal.  The  lit^anicnt  is  pulled  taut  and  its 
alveoli  opened  when  the  ciliary  iinisele  contracts.  The  (constant  con- 
ti'action.s  of  the  ciliary  muscle  induces  a  progressive  sclerosis  of  the 
crihrii'orni  ligament  with  the  result  that  the  interspaces  and  alveoli 
ai'e  rrchici'd  in  size  and  the  i-eady  access  of  a<|ueous  to  Schlennn's  canal 
is  thus  seriously  im[)eded  ;  therefore,  the  adult  eye  is  i)rcdisp')sed  to 
glaucoma.  He  maintains  that  it  is  not  the  iris  which  is  j)ushed  forward 
by  the  ciliary  processes;  on  the  contrai-y,  it  is  the  ciliary  processes 
which   are  dragged  forward  by  the   iris.     The  conse(iuences  of  such 


The  Ciliary  Venous  Eetiirn. 

The  Ciliary  Plexus  (C.P.)  is  closely  associated  with  Iris  Veins  (f.V.)  and 
with  the  Muscular  Plexus  (M.P.  and  M.V.)  in  forming  branches  (P.U.V.)  which 
join  the  posterior  uveal  veins  or  venae  vorticosa\  Anteriorly  piercing  the  sclera 
about  the  pericorneal  circumference  are  the  anterior  uveal  veins,  which  derive  their 
blood  directly  from  the  whole  of  the  ciliary  muscle  plexus  (M.P.  and  M.V.). 

The  main  vessels,  as  they  pass  through  the  sclera,  all  communicate  with 
Schlemm  's  canal  either  directly  or  indirectly  and  on  the  surface  break  up  into 
anterior  and  posterior  branches  (V  and  V').  The  former  join  the  superficial 
pericorneal  plexus  (L)  of  the  limbus.  The  ciliary  venous  return  in  its  ])assage 
through  the  sclera  is  thus  closely  linked  with  the  iris  venous  return  (see  pre- 
ceding figure)   to  form  an  anterior  uveal  venous  system.      (Thomson  Henderson.) 


occlusions  are,  first,  a  dimiiuition  and,  later,  a  complete  obstruction  of 
the  outflow.  The  iris  through  the  medium  of  the  crypts  remains  as 
the  only  channel  for  the  passage  of  the  lymph.  He  holds  that  the 
intraocular  pressure  is  vascular  in  origin  and  nature,  and  stands 
and  varies  with  the  intraocular  venous  pressure,  and  is  not  the  product 
of  a  l)alance  between  inflow  and  outflow  of  a(iueous.  As  a  secondary, 
])ut  less  dependable,  cause,  is  a  disturbance  in  the  vascular  mechanism, 
the  excitation  of  which  gives  rise  to  the  attacks  of  increased  tension. 


5444  GLAUCOMA 

lie  declares  tli.it  in  acute  coiigc.stivc  glaucoma  the  vascular  element 
j)re(l()miiiatcs;  in  chronic  non-cougcstive  glaucoma,  it  plays  an  alto- 
gether insubordinate  and  inconspicuous  part.  But  such  an  hypotliesis 
does  not  account  for  the  shallowness  of  the  anterior  chamber  which 
decreases  in  depth,  as  the  disease  progresses,  nor  for  the  progressive 
closure  of  the  filtration  angle.  Henderson  concludes  by  stating  that 
glaucoma  can  be  produced  only  by  the  combination  of  two  factors, 
neither  of  which  alone  can  produce  it — an  increase  of  the  intravenous 
pressure  and  the  sclerosis  of  the  cribriform  ligament  which  raises  a 
mechanical  obstruction  to  the  free  access  of  aqueous  to  Schlemm's 
canal.  A  mechanical  obstruction  such  as  he  defines  cannot  be  other- 
wise in  effect  than  a  retention ;  and,  if  sclerosis  is  the  invariable  proc- 
ess as  age  advances,  how  is  it  that  glaucoma  is  not  found  in  every  aged 
person  ?  So,  too,  only  a  small  proportion  of  the  .senile  with  high  blood- 
pressure  develop  glaucoma,  and  further,  if  the  two  factors  mentioned 
are  essential  for  the  production  of  glaucoma,  how  is  it  that  one  so 
often  sees  glaucoma  in  comparatively  young  persons  ?  As  sclerosis  has 
been  found  in  secondary  as  well  as  in  primary  glaucoma,  it  is  more 
than  probable,  as  Yerhoeff  suggests,  that  the  sclero.sis  of  the  j)ectinate 
ligament  occurs  as  a  consequence  of  iris  adhesion. 

The  contribution  offered  by  a  consideration  of  the  effects  of  palli- 
ative, if  not  curative,  operative  and  medicinal  procedures  is  not  with- 
out value  and  importance. 

The  action  of  miotics  is  accounted  for  upon  the  supposition  that 
by  the  contraction  of  the  pupil  the  iris  is  stretched  in  a  radial  direc- 
tion, and  is  drawn  away  from  the  wall  of  the  eyeball  to  which  it  has 
been  applied,  so  that  the  sinus  of  the  chamber  again  l)ecomes  free — 
and,  according  to  Henderson,  the  iris  crypts  are  opened  out  and  the 
passage  of  tlie  a'lueous  to  the  iris  veins  is  facilitated. 

The  hypothesis  of  Fischer  {Pfliigcr's  ArcJiiv  f.  Physiol,  vol.  127, 
1909)  has  attracted  numerous  adherents.  It  consists  in  the  belief  that 
glaucoma  depends  ii])on  an  edema  of  the  eyeball,  in  which  tlie  hydro- 
j)hilic.  colloids  ot*  the  eye  retain  an  increased  amount  of  watei-.  In  his 
Oi)iMion  the  exciting  causes  of  glaucoma  are  such  as  lead  to  an  al)norraal 
production  or  to  the  increased  accumulation  of  acid  in  the  eye,  and 
further,  that  the  hydrophilism  depends  upon  the  presence  of  the  acid. 
Ku))en  found  that  the  vitreous  was  not  hydrophilic,  neither  did  it 
swell  by  the  action  of  the  acids,  but  the  cornea  and  sclera  became 
enormously  swollen  and  thickened  and  thus  reduced  the  volume  of  the. 
cavity  of  the  eye.  Yet.  in  eases  of  glaucoma  he  did  not  succeed  in 
reducing  the  tension  by  injections  of  sodium  citrate,  introduced  be- 
neath  the   conjunctiva;  nevertheless,   lie  supports   Fischer's  premise. 


GLAUCOMA 


5445 


As  Fischer's  hypothesis  required  a  eonsecutive  phin  oi"  treatment,  his 
method  may,  in  effect,  substantiate  the  claims  of  those  who  regard 
"toxic  acidosis"  to  be  the  cause  of  glaucoma.  Kectal  injections  of 
hypertonic  sodium  chlorid  solutions  are  given,  combined  with  subcon- 
junctival injections  of  solutions  of  sodium  citrate. 


Cornea    =^-f^z;3H=s^ 


'/^^^^s^\\^\'^'' ■''()?  j^S%-^ 


:  Sclera 


E.. 


J lidectoniy  Stump  after  Extraction.     Post-Morteiu  Case;  Date  Uukuown. 

The  Incision  (A.B.C.)  is  not  completely  cicatrized.  There  is  in  this  section 
an  adhesion  of  the  iris  (I),  the  cut  surface  of  which  manifests  no  reparative 
chaiiyt's.  Iris  veins  (V)  in  cross-section;  there  is  a  rent  (H)  in  tlie  posterior 
pigment  layers.  Descemet 's  membrane  (D.M.),  with  its  endothelium  (E),  which 
lias  relined  the  inner  extremity  of  the  incision,  but  stops  short  at  the  raw  iris 
surface.     (Thomson  Henderson.) 

The  reason  why  iridectomy  diminishes  tension  has  not  been  discov- 
ered so  far ;  it  is  quite  as  obscure  as  the  cause  of  the  increase  of  tension. 
It  is,  however,  a  well-established  fact  that  the  tension  of  a  normal  eye 
is  not  diminished  by  an  iridectomy.  Von  Graefe  was  of  the  opinion 
that  the  size  of  the  piece  of  iris  excised  liad  a  direct  i-elation  to  the 
effect  produced,  for  he  believed  that  the  diminution  of  the  intraocular 
pressure  by  iridectomy  was  due  largely  to  the  lessening  of  iris  surface 


5446 


GLAUCOMA 


secretiiit,'  the  iKjucous  humor.  And  Sir  William  P>o\vm;tn,  commenting 
ui)Oii  tills,  stated  his  opinion  to  he  that  the  more  direct  comiininication 
opened  Ix'tween  the  vitreous  and  acpieous  regions  of  tlie  eye  lacilitated 
the  i)lay  of  eiiii-cnt.s  Ix'tween  tlieiii  and  thus  allowed  an  excess  of  fluid 
h«'hind  to  come  forwai'd  to  tlie  corneal  surface  through  which  exos- 
mosis  is  nuich  easier  tlian  through  the  posterior  coats. 


T.M.iithn. 


liidet'toniy   Stump   after   Graefe 's   Extraction.      Case   of   Professor   Fuehs;    Date 

Unknown. 

The  incision  (i)  has  healed  with  the  interposition  of  a  hirjje  intercalary  mass 
between  the  corneal  (C)  ami  the  scleral  (S)  margins  of  the  wound. 

The  iris  stump  is  denuded  altogether  of  the  posterior  pigment  (p).  and 
shows  numerous  rents  and  lacerations  (r). 

The  cut  surface  (c)  shows  no  cicatrization;  at  ./  there  is  an  attachment  of 
iris  to  Descemet 's  membrane  (d). 

The  remnant  of  the  anterior  lens  capsule  (a. I.e.)  is  adherent  to  the  iris 
stump.     (Thomson  Henderson.) 

Henderson  claims  that  the  acpieous  is  absorl)ed  into  the  iris  veins, 
and  he  declares  that  glauconui  follows  from  diminished  access  of  the 
aqueous  to  the  veins,  resulting  in  the  conversion  of  the  intraocular 
circulation  into  a  rigid  s.ystem.  Therefore,  treatment  to  be  effective 
must  facilitate  the  passage  of  the  aqueous  to  the  veins  and  so  restore 
tlie  circulation  to  its  normal  elastic  nature.     He  further  claim.s  that 


GLAUCOMA  5447 

iris  wounds  do  not  c-iuatrizc  and  tiiat  therefore;  tlie  beneficial  results 
of  iridectomy  follow  in  eonsequenec  of  the  raw  edges  of  the  eoloboina 
permittiug  access  of  the  atjueous  to  the  iris  veins.  The  miotic  drugs, 
by  contracting  the  pupil  open  out  tiie  iris  crypts  and  act  in  the  same 
numner.  Yet,  it  i.s  well  known  that  iridectomy  and  miotics  cannot 
influence  the  nornuil  intraocular  pressure  as  such  already  represents 
the  lowest  circulatory  i)ressure  in  the  eye  and  further  contact  between 
acpieous  and  veins  cannot  reduce  it  below  this  level. 

De  Wecker  expressed  the  opinion  that  in  iridectomy  the  section  in 
the  sclera  was  of  greater  importance  than  the  excision  of  the  iris, 
from  his  belief  that  the  scleral  cicatrix  allowed  the  fluid  to  filter 
through  it.  The  operative  procedures  recently  devised  by  Lagrange, 
Ilerliert,  Elliot  and  others  are  designed  to  combine  the  ett'ects  of  a 
filtering  scar  with  those  of  iridectomy.  It  is  still  too  soon  to  maintain 
that  the  sear  remaining  after  these  operations  will  continue  to  act  as 
a  filter.  Probably  the  thin  covering  of  the  sclero-corneal  wound  is 
elastic  and  yields  somewhat  to  an  occasional  rise  of  intraocular 
pressure. 

Alt  appositely  offers  "that  the  excision  of  a  piece  of  iris  of  sufficient 
size  is  the  main  part  of  a  glaucoma  operation.  To  this  may  be  added 
a  certain  amount  of  reopening  of  the  filtration  angle,  if  only  in  parts, 
during  the  execution  of  the  iridectomy ;  perhaps,  by  the  direct  pull 
on  the  iris  by  which  a  part  of  the  peripheral  iris  adhesion  may  be 
loosened.  The  iridectomy,  therefore,  instead  of  opening  up  new  filtra- 
tion ways,  reduces  in  reality  the  secretion  of  fluids  or  alters  their 
composition."  We  are  accordingly  today  not  far  removed  from  the 
position  held  by  von  Graefe  in  1857 !  Yet  it  is  probably  true  that 
operations  on  the  anterior  segment. of  the  globe  really  place  the  ante- 
rior chamber  in  communication  with  the  supra-choroidal  space  and 
thereby  open  up  a  path  for  excretion  from  both  the  anterior  and 
posterior  segments. 

In  conclusion,  it  is  not  improbable,  as  Edward  Jackson  has  said, 
"that  the  formation  of  new  vessels  at  the  site  of  the  operations  has 
much  to  do  with  the  reestablishment  of  the  connections  between  the 
interior  of  the  eye  and  the  canal  of  Schlemm,  by  the  formation  of 
new  venous  channels  of  outflow  which  permit  the  intraocular  pressure 
to  drop  nearer  to  the  venous  pressure  of  the  body. ' ' 

The  subject  remains  in  an  unsettled  state,  and,  as  can  be  seen,  the 
number  of  the  hypotheses  advanced  for  the  explanation  of  the  nature 
and  the  seat  of  glaucoma  is  almost  infinite,  yet  while  the  lines  of 
inquiry  are  clearly  marked  out,  no  single  one  of  them  can  explain 
all  cases.     "The  possible  causes  as  we  have  seen  are  many  and  it  is 


5448 


GLAUCOMA 


liki'ly    that    every    possible    cause    is    soiiietiincs    the    actual    eause. " 
(Priestley  iSiuith.) 

The  hypotheses  cited  above,  however,  J"aii-ly  wcli  outline  the  paths 
pursued  by  the  most  careful  observers.  The  differences  of  opinion 
nhicli  the  investigations  have  evoked  may  be  takeji  as  the  measure 
of  the  intrinsic  difficulty  attending  the  subject.  Only  one  thing  seems 
to  become  more  and  more  certain — that  is,  that  a  pathologic  process 
in  general,  perhaps,  but  surely  in  the  intraocular  blood  vessels,  is 
directly  responsible  for  the  glaucomatous  state  (Alt).  We  are  still 
without  any  definite  key  to  the  explanation  of  the  extraordiiiai\-  proc- 
ess which  gives  rise  to  the  increase  of  intraocular  pressure.  Jt  is  to 
pathological  physiology  that  we  must  turn  for  an  explanation  of  this 
disease. 


Proijer  Method  of  Determining  the  Finger  Tension  of  the  Eyeball. 

Diagnosis  of  glaucoma  in  general.  The  imi^ortauce  of  the  early 
recognition  of  glaucoma  cannot  be  over-estimated.  The  diagnosis  is 
based  upon  the  existence  of  the  cardinal  symptom,  the  increase  of 
tension  as  demonstrated  by  palpation  with  the  linger  or  by  means  of 
the  tonometer.  The  most  usual  premonitory  symptoms  are  the  fre- 
quent desire  to  change  the  reading-glasses,  periodical  ol)scuration  of 
vision,  and  the  appearance  of  halos  about  lights. 

See  Examination  of  the  eye,  p.  4629,  Vol.  VI,  of  this  Encyclopedia. 

Tile  attack  may  be  mistaken  for  cold  in  the  eyes,  for  iritis,  for 
neuralgia  and  reflex  ocular  pains.  The  condition  of  the  pupil,  the 
diminished  depth  of  the  anterior  chaiubcr.  and  tlie  increased  tension 
of  the  globe  are  symptoms  wliicli  should  i)i'('V('nt  so  disastrous  a 
mistake. 

The  diagnosis  of  clironic  ghutcoma  depends  upon  llic  conti'artion  of 
the  field,  the  increase  of  tension  and  the  cui)iiing  of  tlie  disk.  It  is 
sometimes  difficult  to  distinguish  clironic  glaucoma  from  simple  optic 


GLAUCOMA  5449 

atrophy,  especially  when  there  is  not  a  decided  increase  in  the  tension, 
or  otiier  niarkod  syiiiptoin.  In  glaueoiiia  there  may  have  been  a 
history  of  raiiibow-visiuii,  in  optic  atropiiy  the  central  and  color 
visual  defects  are  greater  and  the  peripheral  contractions  are  not  so 
closely  related  to  the  blind-spot.  Of  course  the  intraocular  tension 
is  not  increased  in  the  atrophic  cases,  and  there  is  less  deep  cupi)ing  of 
the  disk. 

The  differential  diagnosis  l)etween  simple  glaucoma  and  the  ambly- 
opia caused  by  simple  atrophy  of  the  optic  nerve  may  be  sometimes 
difficult,  especially  as  there  are  cases  of  glaucoma  in  which  there  is  no 
appreciable  increase  of  the  intraocular  tension,  and  in  which  the 
excavation  of  the  optic  disk  is  only  partial.  The  observation  of  the 
progress  of  the  disease  alone  is  decisive ;  the  diagnosis  of  glaucoma  can 
never  be  made  by  the  oplitlialmoscopic  examination  alone.  "When 
unusually  deep  and  broad  physiological  excavations  are  discovered  in 
persons  of  advancing  j^ears,  with  the  general  characteristics  predis- 
posing to  glaucoma,  the  fields  of  vision  should  be  studied  carefully 
in  spite  of  the  ab.sence  of  any  of  the  classical  symptoms  of  glaucoma. 
It  must  be  borne  in  mind  that  cases  of  undoubted  glaucoma  may 
go  on  for  years  with  the  intraocular  tension  much  of  the  time  not  in 
excess  of  the  normal.  In  such  cases  the  data  o])tained  by  tonometric 
examinations  is  of  the  greatest  importance,  and.  in  the  further  study 
of  any  case  the  state  of  the  patient's  puLse-teusion  should  l)e  measured 
by  the  sphygmomanometer  and  the  information  obtained  duly  con- 
sidered. The  study  of  the  visual  fields  ought  to  be  of  service.  In 
simple  atrophy,  even  in  the  early  stages,  the  color-sense  may  be  con- 
siderably diminished  so  that  the  fields  for  red  and  green  are  markedly 
deficient;  while  in  glaucoma,  the  color  fields  and  the  form  fields  are 
correspondingly  contracted.  The  shape  of  the  fields  and  the  cliaraeter 
of  the  scotomata  are  of  special  interest. 

Seidel's  observations  in  imperfectly-marked  cjiscs.  wlien  studied  by 
Rjerrum's  method  of  perimetry,  led  him  to  conclude  that  an  early 
glaucoma  may  show  merely  a  pallor  of  the  disk  without  excavation, 
and  yet,  cases  of  advanced  glaucoma  may  show  a  pale  disk  without  a 
typical  excavation  extending  to  the  margins;  and,  some  cases  of  so- 
called  primary  atrophy,  with  a  deep  physiological  cup,  ;may  be  indeed 
glaucoma,  especially  if  there  can  be  assigned  no  cau.se  for  atrophy. 

The  condition  of  the  color-sense  will  remain  normal  and  the  light- 
sense  will  be  retained  when  the  integrity  of  the  optic  nerve  has  been 
preserved.  The  study  of  the  light-sense  will  be  of  service.  In  optic 
nerve  atrophy  the  light-sense  from  the  fir.st  may  be  much  reduced, 
although  the  ability  to  distinguish  between  differtMit  degrees  of  inten- 


5450  GLAUCOMA 

sity  may  not  he  iiiucli  affeclcd  until  later,  in  f^laucoina  the  reduction  of 
tlie  lifi;lit-sense  may  be  an  early  symptom:  indeed,  it  may  exist  for 
many  years  before  its  true  natui'c  has  he.  n  un(h"rstoo(l ;  nij^ht-hlindness 
may  he  the  first  symptom  eomi)laincd  of.  This  early  diminution  bears 
no  relation  to  loss  of  central  visual  acuity  nor  to  the  retraction  of  the 
visual  tield.  althouj^h  it  is  dependent  upon  the  state  of  the  ocular  ten- 
sion. The  later  and  al)solute  loss  is  noted  when  positive  changes  in 
the  disk's  surface  have  occurred  and  therefore  marked  contractions  of 
the  field  have  taken  place  owing  to  the  accompanying  optic  atrophy. 

IMost  unfortunate  mistakes  have  occurred  when  glaucoma  has  been 
taken  for  cataract.  The  progressive  failure  of  sight  unaccompanied 
by  pain,  in  an  elderly  person  has  often  been  allowed  to  go  witliout 
attention  with  the  expectation  of  the  "ripening"  of  a  cataract  which 
never  existed.  Here  the  ophthalmoscopic  examination  would  have 
decided  the  case  at  once. 

[As  is  well  known,  it  is  often  difficult  to  decide  whether  one  has  to 
deal  Avith  a  case  likely  to  pass  into  a  glaucomatous  state  that  will  go 
from  bad  to  worse  unless  operated  on.  In  such  cases  the  Editor  has 
been  in  the  habit  of  employing  Edward  Jackson's  test  of  instilling  into 
the  suspected  eye  one  or  two  drops  of  a  mixture  containing  a  2  per  cent, 
solution,  each,  of  euphthalmin  and  cocaine.  When  the  pupil  is  fully 
dilated  if  the  tension  is  palpably  increased  and  the  retinal  arteries 
pulsate  the  verdict  should  be  in  favor  of  operation. 

It  also  throws  some  light  on  the  outcome  of  an  operation  when  the 
action  of  eserine  is  observed ;  should  that  drug  l)ring  about  a  consid- 
erable contraction  of  the  pupil,  followed  ])y  reduction  in  tension  and  the 
relief  of  symptoms,  it  argues  in  favor  of  an  iridectomy  or  other 
operation. 

Sym  (Diseases  and  Injuries  of  the  Eye,  p.  302)  condemns  the  use 
of  homatropin  as  an  aid  to  the  diagnosis  of  doubtful  cases  of  glauconui. 
Dunn  (Lancet,  Aug.  2,  p.  352,  1912)  considers  cocaine  a  much  safer 
mydriatic  for  use  under  such  circumstances.  Stevenson  (Ophthalmo- 
scope, Vol.  II,  p.  73,  1913)  records  the  case  of  a  young  adult  in  whose 
eye  an  attack  of  glaucoma  was  set  up  by  the  use  of  homatropin  to  allay 
the  irritation  which  followed  a  slight  injury.  Elliot  (Ophthahnoscope, 
Vol.  II.  p.  58,  1913)  has  used  homatropin  for  many  years  as  an 
adjuvant  in  the  diagnosis  of  obscure  cases  of  glaucoma  with  hazy 
cornea,  etc.  lie  has  never  seen  the  least  harm  follow,  but  insists  that 
the  i)atient  must  not  be  lost  sight  of  until  after  the  mydriasis  has  been 
turned  into  miosis  by  the  use  of  esei'iu  :  tliis  takes  less  than  half  an 
hour  to  do.] 

Prognosis.     The  prognosis  of  glaucoma  depend.s  upon  the  type  of 


GLAUCOMA  5451 

the  disease  as  well  as  the  stage  tlirough  wliidi  it  is  passing,  yet  all 
forms  end  in  blindness  if  unchecked  hy  treatment,  lor  none  tends  to 
a  spontaneous  cure.  Primary  acute  glaueoma  i.s  remarkably  amenable 
to  treatment  by  iridectomy,  and  it  has  been  said  that  the  moi-e  acute 
the  attack  the  better  the  prognosis.  When  in  uncomplicated  acute 
cases  technically  correct  operative  procedures  can  be  i)ursued,  it  is 
likely  that  the  vision  can  be  largely  rcstoi-ed.  In  cliroiiic  cases  much 
depends  upon  the  state  of  the  eye,  especially  a.s  to  the  changes  api)arent 
in  the  papilla,  and  the  comlition  of  the  iris,  as  well  as  the  state  of  the 
vision,  both  central  and  peripheral.  There  are  some  cases  which  can  be 
treated  suecessfull.v  without  operation,  and  there  are  many  in  which 
certain  auxiliary  measures  are  of  great  value.  In  general,  it  may  be 
taken  as  a  favorable  sign  when  the  ditferential  light-sense  rises  on  the 
instillation  of  miotics;  it  is  positively  hopeful  if  the  light-sense  is 
restored  by  operative  procedures,  Init  the  prognosis  must  be  guarded 
when  the  light-sense  has  not  been  restored  on  the  reduction  of  ten.sion. 

Seidel  found  the  small  isolated  scotomata,  which  he  was  able  to  map 
out  by  Bjerrum's  metliod  as  well  as  the  ordinary  Bjerrum  scotomat<i, 
to  have  entirely  disai)i)eai'ed  after  measures  were  taken  to  reduce  the 
intraocular  tension.  The  ring-scotomata  of  Bjerrum  are,  he  believes, 
in  some  cases  dependent  upon  reduction  of  the  pressure,  but  he  noted 
a  reappearance  on  the  resumption  of  the  tension. 

The  general  condition,  and  especially  the  nervous  system,  should 
be  thoroughly  investigated.  The  course  varies  according  as  the  pre- 
dominating element  in  a  patient's  diathesis  is  either  neuropathic, 
arteriosclerotic,  or  l)oth  nervou.s  and  vaseular.  A  calm,  placid  luiture, 
bearing  the  burdens  of  life  during  advancing  years  with  eciuanimity, 
may  hope  for  a  restoration  of  useful  sight  more  reasonablj'  than  a 
high-strung,  neurotic  individual  with  rapid  and  tense  radials.  In 
cases  where  the  pulsi'  leiision  is  continuously  elevated  both  the  course 
of  the  disease  and  the  proI)able  outcome  of  surgical  interference  are 
less  hopeful  than  in  cases  of  low  tension. 

Iridectoni}'  cannot  be  depended  upon  to  afford  relief  in  chronic 
glaucoma.  It  fails  because  the  obstruction  at  the  filtration  angle  is  due 
to  firm  fibrous  adhesions  of  the  root  of  the  iris  to  the  corneoselera.  and 
the  operation  fails  to  restore  the  permeability  of  these  tissues. 

It  is  the  hope  of  the  advocates  of  the  more  recently  devised  opera- 
tions that  a  greater  amount  of  vision  slmll  lie  retained  by  their  execu- 
tion than  has  always  followed  after  the  ordinary  iridectomy. 

Visual  tests  must  be  made  frequently,  and  the  refraction  measured 
repeatedly.     A  progressive  narrowing  of  the  peripheral  fields,  espe- 


5452  GLAUCOMA 

cially  wlifii  llic  iiKiciiliir  rcj^ioii  is  eiici-oaelicd  iij)()ii.  makes  the  prog- 
Jio.sis  part  iciilarly  ^'looniy. 

SKCOXDARY   GLAUCOMA. 

Till'  turm  "secoiidaiy  glaucoma"  is  applied  to  the  group  of  symp- 
toms associated  with  hardening  of  the  eye-ball,  when  that  hardening 
occurs  as  the  sequel  of  preexisting  ocular  disease.  It  may  appear  as 
a  simple  or  intiammatory  glaucoma,  the  clinical  picture  varying  accord- 
ing to  the  disease  which  it  accompanies,  and  the  anatomic  changes, 
therefore,  vary  greatly  according  to  the  diversity  in  the  nature  of  the 
cases.  And,  just  as  in  the  case  of  primary  glaucoma,  the  secondary 
form  may  arise  in  any  eye  in  which  there  are  no  discoverable  signs  of 
a  i)redisposition  to  the  development  of  glaucoma.  It  is  especially  prone 
to  follow  on  disease  of  the  uveal  tract,  particularly  of  the  anterior 
segment.  Jt  is  therefore  found  in  ectasias  of  the  cornea  with  incar- 
cerations of  the  iris,  after  incarcerations  of  the  iris  in  cicatrices  in 
the  cornea  and  sclera ;  iridocyclitis  with  deposits  in  the  aqueous  and 
on  the  layer  of  Descemet ;  adhesion  of  the  iris  to  the  lens  by  the  entire 
pupillary  circle ;  affections  of  the  crystalline  lens,  as  of  luxation  with 
swelling  of  the  lens,  especially  when  the  lens  has  been  wholly  dislodged 
into  the  anterior  chamber;  sudden  swelling  of  the  lens  after  injury-  or 
operation.  It  arises  ({uite  constantly  in  tlie  course  of  intraocular 
tumors,  as  the  sarcomata  and  gliomata,  and  follows  intraocular  hemor- 
rhage, and  especially  in  cases  of  thrombosis  of  the  central  retinal 
veins.  Shumway  has  reported  a  case  of  glaucoma  arising  in  a  young 
person  with  interstitial  keratitis,  who  had  used  solutions  of  atropin 
for  six  yeai's. 

Tlie  paiJi<)<)(  n(  sis  of  sfcondnrji  glancomn  depends  entirely  upon  the 
o])struction  and  the  retention  of  the  outflow  of  the  intraocular  fluid 
wliicli  arise  in  the  course  of  diseases  of  the  eye  and  as  a  consequence 
of  llic  pi-imary  disease.  Here  the  increase  of  tension  follows,  there- 
fore, as  a  complication  of  an  already  existing  affection,  and  it  entails 
the  same  results  as  augmented  pressure  does  in  the  case  of  primary 
glaucoma.  So,  also,  just  as  in  primary  glaucoma,  does  the  adhesion 
of  the  iris  base  to  the  cornea  bring  about  changes  entirely  comparable 
to  those  seen  in  inflammatory  glaucoma.  In  some  cases  glaucoma  maj' 
be  numifested  only  by  an  increase  of  tension  with  hardening  of  the 
globe  and  the  consequent  excavation  of  the  optic  nerve  head,  together 
with  disturbance  of  siglit  and  contraction  of  tlie  field  of  vision.  Its 
termination  in  l)lindn('ss  and  degeneration  of  the  eycljall  is  the  same 
as  in  priniai'v  glaucoma. 

S('con(hirv  glaucoma  is  met  with  at  all  ages,  although  un(h)nl)ledly 


GLAUCOMA 


5453 


iiiort'  is  i'c(niii-('(l  to  set  it  ii|)  in  youii''^  eyes  lliaii  in  old.  The  vision, 
too,  docs  not  appear  to  Ik'  so  i-apidly  nor  so  permanently  interfered 
with  by  the  increased  tension  in  young  eyes.  Removal  of  the  cause 
too  is  more  certain  to  arrest  the  glaucomatous  process. 


Glauc'oii);i    Secoiiiiary   to   Traumatic   Dislooation   of   the   Leas. 

Posey  aud  Wright.) 


(After  Collins,   in 


It  will  be  well  to  give  a  brief  account  of  the  chief  causes  of  sec- 
ondary glaucoma,  and  to  explain  the  manner  of  the  production  of 
increased  pressure  in  the  several  forms. 

In  the  adiiesion  of  the  iris  to  the  lens  by  the  entire  pupillary  circle, 
or  annular  posterior  synechia,  the  posterior  chamber  is  cut  otV,  and 
the  aqueous  is  unable  to  pass  through  the  pupil  (seclusion  of  the 
pupil),  l)ut  is  held  back  behind  the  iris,  which  becomes  bulged  for- 


5454 


GLAUCOMA 


wjii'd  (ii'is  lioiiihr ) .  The  Iciisidii  consi'iiuciil  ly  I'iscs,  aii<l,  it"  it  is  not 
iTJicvcd.  the  |)cri|)lici>  of  the  ii'is  Ix-conics  0|)i)Osed  to  tile  cornea  and 
iii;i.\-  latci-  liccoiiic  adiu'icnt  to  it.  Jf,  liowevcr.  an  opening  is  made  in 
llic  iiis  in  tlie  early  stage,  the  iris  retreats,  the  angle  is  reopened,  and 
tile  tension  again  becomes  normal.  If  the  tension  has  persisted  for  a 
coiisidcrahlc  ])eriod,  the  ciliary  l)ody  may  be  so  miicli  injured  as  to 


Section  throu<i;h  the  Center  of  tlie  Cololioiii;i  in  an  Eye  which  had  had  an 
Iridectomy  I'ertoniieil  tor  (ilauconin  ot  two  months'  standing;.  (After  Collins, 
in  I'o.'-ey  and  Wright.) 

impair  the  secretory  functions  so  tliat  after  the  operation  the  tension  is 
found  to  be  subnoi'mal.  If  it  has  jicrsisted  still  longer,  lymph  accu- 
mulates in  tile  viti'eous  eliamlici'  and  tlic  se(|U('la'  of  glaucoma  ensue. 
Only  a  wide  and  i)ei'i])hei'al  ii'idcetomy  can  all'oi-d  relief  by  ojtening 
the  occluded  angle. 

rilaucoma   may  ensue  on  the  perforation  of  the  coi'iiea  by  a  wound 
or  as  the  result  of  uh-eration  l'i'(i)ii  the  ineareei-ation  of  the  iris  in  the 


GLAUCOMA  5455 

cicatrix,  becaii.so  of  the  likdiliootl  of  obsti-iictioii  •■iisuing  in  the  liltra- 
tion  angle.  A  small  prolapse  of  the  iris  may  at  first  only  partially 
close  the  angle  which,  later  on,  may  become  permanently  obliterated 
tlu-ough  the  (leveloi)ment  of  a  plastic  iritis.  Central  nlcerations,  also, 
ma\-  lead  to  the  adhesion  of  the  lens  and  ii-is  to  the  cornea,  the  ante- 
rior clunnber  being  abolished  when  the  lens  is  pushed  forvvaril  and  be- 
comes agglutinated  to  the  cornea.  Such  a  condition  may  persi.st,  espe- 
cially when  the  lens  has  been  wounded. 

Increase  of  intraocular  i>ressure  may  develop  in  ectasis  of  the 
cornea  witli  incarceration  of  tiu>  iris,  whereby  the  anterior  chaml)er 
has  become  partially  or  completely  ol)literated.  Such  anterior  .staphy- 
lonui  conunoidy  arises  early  in  life,  while  the  tissues  are  still  plastic 
The  usual  anatomical  features  of  glaucoma  are  therefore  moditietl, 
the  rise  of  tension  tending  to  stretch  the  walls  of  the  globe;  yet  be- 
cause the  ciliary  liody  is  generally  aflfected,  the  production  of  lympli 
may  be  so  much  diminished  that  the  tension  is  not  demonstral)ly  in- 
creased, although  the  disk  is  almost  invariably  found  to  be  deeply 
cupped. 

Affections  of  the  crystalliuc  lens  giving  rise  to  glaucoma.  Ail  foi'ms 
of  displacement  of  the  lens,  be  they  spontaneous,  traumatic  or  con- 
genital, may  give  rise  to  the  development  of  glaucoma.  AVhen  a  small 
or  shruid\en  lens  is  dislocated  into  the  anterior  chamber,  it  may  set  up 
little  or  no  reaction,  and  glaucoma  does  not  occur.  l)ut  if  ii'itis  super- 
venes the  angle  may  become  occluded.  If  tlie  lens  is  large,  glaucoma 
rapidly  follows,  because  through  the  contraction  of  the  splnncter  the 
iris  is  iirmly  a])plie(l  to  the  posterior  surface  of  the  lens,  which  is 
thus  held  firmly  against  the  cornea  so  that  the  passage  of  the  aqueous 
fluid  is  ])revented.  When  the  lens  is  completely  di.slocated  l)ackwards 
the  intraocular  pressure  may  become  increased  by  reason  of  tlie  pas- 
sage of  the  vitreous  fluid  into  the  anterior  chamber  with  the  conse- 
quent ol)struction  of  tlie  angle,  or  from  the  pressure  of  the  vitreous 
on  the  root  of  the  iris.  When,  as  by  a  sudden  blow  upon  the  eye,  the 
normal  lens  is  forced  to  one  side  and  thus  brings  about  the  lateral 
dislocation  of  the  lens,  the  intraocular  tension  nuiy  suddenly  increase 
because  the  unequal  pressure  exerted  by  the  viti-eous  may  lilock  a 
large  part  of  the  filtration  angle. 

The  intumescence  of  a  senile  cataract  may  give  rise  to  the  symptoms 
of  glaucoma,  and  the  sudden  .swelling  of  the  lens  after  injury  or  oper- 
ation not  infrequently  causes  an  increase  of  ten.sion,  especially  in  the 
aged  with  stiffened  sclera,  the  onset  rapidly  following  from  the  press- 
ing of  the  iris  against  the  cornea.  Tn  other  cases  the  filtration  area  is 
blocked  bv  the  swelling  of  jiarticles  of  the  broken  lens  suspended  in  the 


5456 


GLAUCOMA 


juiiicoiis  lliiiil.  It  is  not  ;i1  ;ill  iiiipr()li;il)lc  that  soiiir  cataracts,  both 
t  r-aiiiiiat  ic  and  con^fiiital  in  origin,  contain  .substances  wliicli  are 
iiioi-f  likely  than  othei-s  to  set  ii|>  iri'itation  and  induce  the  increase 
of  tension.  The  syiiiptonis  subside,  liowe\-ei'.  on  the  evacuation  of  the 
lens  fra^'uieuts. 


Glaucoiiia  iSi'LoiKiary  to  Iritis  ami  the  Formation  of  Aiuiular  Posterior 
Synechia.  Fluid  accnnuilatincj  in  tlie  posterior  chamber  has  boweii  the  iris  for- 
ward into  contact  with  the  back  ot  the  cornea.  (After  Collins,  in  Posey  and 
Wright.) 


Intraocuhtr  hnitors.  Tntraoeular  tumoi's,  when  they  have  attained 
any  size,  almost  invariably  g:ive  rise  to  ^huu-onia  if  excision  of  the 
^lobe  is  dela^'cd.  in  the  eai'ly  staples,  the  glaucoma  beinii:  of  the  acute 
type,  t he  syin|)tonis  i'eseinl)le  the  primary  fei'iii.  ami  the  diagnosis  nuiy 
be  most  difficult,  especially  whei'e  thei'e  is  haziness  of  the  media. 


GLAUCOMA  5457 

The  filtration  angle  invariably  becomes  blocked  when  tumors  in- 
volve the  iris,  and  often  the  canal  of  Schlemm  and  the  neighboring 
parts  are  invaded.  Tumors  of  tiie  choroid  may  cause  the  blocking  of 
the  angle  by  the  advance  of  the  iris  consequent  upon  the  detachment 
of  the  retina  and  pressure  upon  the  vitreous.  Glaucoma  may  come  on 
early  while  the  detachment  is  comparatively  small,  especially  when 
the  tumor  lies  near  or  includes  a  vortex  vein.  The  deposition  of  tumor 
particles  and  other  cells  in  the  region  of  the  filtration  area  are  addi- 
tional causative  factors.  Tumors  of  the  ciliary  body  may  not  excite 
to  glaucoma  until  late,  but  when  the  anterior  chamber  is  involved, 
however,  obstruction  of  the  angle  promptly  follows.  Retinal  tumors 
act  quite  the  same  way  as  in  the  case  of  sarcoma  of  the  choroid.  The 
early  symptoms  may  not  be  pronounced,  but  later  when  the  tumor 
occupies  the  vitreous  chamber  the  aqueous  becomes  turbid,  the  lens 
and  the  ii'is  are  forced  forward  to  such  a  degree  that  the  angle  be- 
comes blocked. 

Intraocular  hemorrhage.  Intraocular  hemorrhage,  when  it  is  of 
considerable  amount  following  upon  disturbance  in  the  general  circu- 
lation, as  well  as  from  changes  in  the  ocular  vessels  themselves,  may 
suddenly  raise  the  tension  to  the  highest  degree,  and  the  hardened 
eye  is  painful  in  the  extreme.  The  character  of  the  glaucoma  is  like 
that  of  the  inflammatory  hemorrhagic  type.  It  is  not  uncommon  that 
a  slight  blow  upon  an  old  blind  eye  with  degenerated  vessels  may  be 
followed  by  copious  hemorrhage  which  undoul)tedly  was  arterial  in 
origin.  Hemorrhage  into  the  vitreous  from  the  retinal  vessels  is  prob- 
ably more  frequently  venous,  and  does  not  necessarily  give  rise  to 
glaucoma,  as  the  effusion  is  usually  subchoroidal,  the  choroid  and 
retina  becoming  detached  with  the  forcing  forward  of  .the  vitreous. 
The  eye  is  subjected  to  direct  pressure  at  the  angle  with  the  consequent 
retention  of  the  fluids. 

Detachment  of  the  retina.  Aside  from  that  dependent  upon  the 
presence  of  tumor,  detachment  of  the  retina  occasionally  gives  rise  to 
glaucoma.  It  is  very  rare  for  a  simple  detachment  to  cause  it,  for  the 
tension  in  such  a  case  is,  as  is  well  known,  usually  subnormal.  De- 
tachment, however,  has  been  found  as  an  accompaniment  of  iridocy- 
clitis, in  wliich  case  increased  tension  is  not  unlikely  to  ensue. 

Aniridia.  Congenital  and  traumatic  aniridia  may  give  rise  to  glau- 
coma, althougli  clinically  it  is  difificult  to  imagine  how  the  angle  can 
l)e  lilocked  in  the  congenital  cases,  yet  microscopical  examination  has 
disclosed  that  rudiments  of  the  iris  are  invariably  present,  and  the 
cribriform  ligament  faulty.  Part  of  the  angle  has  usually  been  found 
open,  but  the  stump  of  iris  was  often  adherent  to  the  sclera  at  the 

Vol.  VII— 30 


5458  GLAUCOMA 

I'xtiviiic  limit  of  the  anterior  cliainhcr  Tor  a  coiisidcrahlc  part  of  the 
(•ircimit'ci-i'iicc.  In  snch  eases  liltration  may  be  maintained  for  a  while 
until  some  inlncuircnt  disturbance,  like  a  slight  iritis  or  cyclitis, 
leads  to  the  ol)literation  of  the  angle.  In  traumatie  aniridia  the  lens 
is  likely  to  be  wounded  and  the  ciliary  body  displaced,  whereby  the 
ciliary  processes  come  in  contact  with  the  ligament  and  obstruction 
follows. 

Secondary  to  extraction  of  cataract,  (jlauconia  sometimes  arises,  par- 
ticularly after  needle-operations  subsequent  to  flap-extraction,  without 
the  presence  of,  or  as  the  result  of,  an  intercun-int  iritis.  It  has  been 
attributed  to  the  swelling  of  remnants  of  the  cortt-x  after  extraction  or 
tiiscission,  during  which  the  character  of  the  aqueous  humor  has  become 
altered  and  the  spaces  of  Fontana  became  blocked  by  the  accumulation 
of  cells;  to  displacement  of  the  capsule,  with  traction  and  irritation 
of  the  adherent  ciliary  processes ;  and  by  a  down-growth  of  epithelium 
into  the  anterior  chamber.  After  the  extraction  of  senile  cataract 
plastic  iritis  may  develop  which  binds  the  iris  down  to  the  thickened 
capsule,  fluid  accumulates,  and  the  angle  becomes  blocked.  In  other 
cases  the  iris  and  capsule  may  l)e  found  incarcerated  in  the  cicatrix. 
It  has  been  noted  to  have  occurred  after  extraction,  both  witli  and 
without  iridectomy;  after  extraction  preceded  by  a  preliminary  iridec- 
tomy, and  after  extraction  in  the  ca})sul('.  It  is  now  believed  that  it 
usually  depends  upon  the  incarceratioii  of  the  capsule  or  the  iris,  or 
both,  in  the  wound  of  the  incision,  and  the  increase  of  tension  is  brought 
about  by  either  a  severe  iridocyclitis  or  by  lilocking  of  the  filtration 
angle.  After  the  free  discission  of  capsular  membranes,  glaucoma 
may  arise  from  pressure  of  the  fluid  following  the  laceration  of  the 
vitreous  body,  on  the  root  of  the  iris,  or  from  its  obstructing  the  i)assage 
of  fluid  from  the  posterior  to  the  anterior  cliamljer. 

Aft(  r  iridectomy.  Glaucoma  sometimes  recurs  after  an  iridectomy 
which  has  l)een  performed  for  the  relief  of  glaucoma,  and  glaucoma 
may  ensue  as  the  result  of  complications  arising  out  of  tiie  actual  oper- 
ation. In  such  cases  where  the  lens  has  not  been  wounded  it  may  be 
due  to  various  causes  which  lead  to  the  closure  of  the  filtration  angle, 
the  angle  may  be  blocked  by  a  jiortion  of  the  iris  which  has  been  left 
in  the  coloboma  only  to  become  caught  in  the  scar;  exudative  proc- 
esses may  unite  the  lens  to  the  wound  witli  the  further  entanglement 
of  the  ii'is  and  ciliary  processes.  It  is  a  fact  observed  by  all  that  the 
danger  of  the  development  of  glaucoma  following  iridectomy  for  pur- 
poses other  than  for  the  relief  of  glaucoma  is  itnicli  less  tlinn  in  the 
actual   aflfectinn.     The  eyes  of  such   subjects  are   usn;dl\-   in   a    more 


GLAUCOMA  5459 

healthy  condition  and  the  wonnd  is  likely  to  be  i)lac*ed  somewhat  less 
pci-ipherally  than  in  the  operations  for  essential  glaucoma.  When  it 
does  occur,  however,  tiie  same  factors  as  are  believed  to  give  rise  to 
glaucoma  will  be  found  active. 

In  the  course  of  iridocyclitis.    Tn  certain  cases  of  iridocyclitis  there 
may  be  so  great  an  accumulation  of  morbid  albuminous  fluid  in  the 


Angle   of   the   Anterior   Cliiunber   in   an   Ej'e   whit-h   luul   Glaucoma   Secondary   to 
Serous  Iridocyclitis.     (After  Collins,  in  Posey  and  Wright.) 

anterior  chamber  that  the  filtration  angle  eventually  becomes  blocked 
and  glaucoma  ensues.  There  may  be  not  much  exudation,  but  the 
accumulation  of  fluid  displaces  the  iris  and  lens  backward,  and  an 
additional  factor  is  the  precipitation  in  the  aqueous  and  deposits  of 
flocculent  granules  on  Descemet's  membrane  which  further  clog  the 
filtration  angle.  The  tension  is  usually  increased  thereby,  although 
in  some  cases  it  is  oidy  transitory,  yet  if  it  continues  unrelieved  the 
eye  becomes  blind  and  the  disk  is  found  to  be  excavated  just  as  in 


5460  GLAUCOMA 

otlkT  foi'iiis  of  glaiii'Oiiiii.  In  this  ioi-m  the  retention  is  due  to  the 
abnormal  e()m])ositi()n  of  the  tluid  and  not  to  tlie  narro\vin<^  of  tlie 
outlet;  the  lilt  ration  angle  is  disteiitled  rather  than  compressed,  and 
the  anterioi"  eiiamber  is  deep  instead  of  shallow. 

In  the  higher  degrees  of  eyelitis  liie  secretion  jirocess  is  impaired  or 
suppressed,  and  the  eye  becomes  soft.  The  anterior  chamber  becomes 
completely  abolished  through  degeneration  of  the  lens  and  shrinking 
of  the  vitreous.  Althougli  the  filti-ation  angle  is  annihilated,  in  such 
an  e^'e  high  tension  is  impossible  unless  it  be  accelerated  by  the  rupture 
of  a  blood  vessel. 

Diag)ws'is.  The  diagnosis  of  secondary  glaucoma  is  not  difficult 
wlien  the  history  of  an  antecedent  inflammation  is  clear;  but  it  is  not 
at  all  easy,  however,  in  deep-seated  troubles,  especially  in  the  early 
stages  of  uveal  sarcoma.  The  glaucoma  is  usually  absolute,  and  it  re- 
mains confined  to  tliat  eye  which,  by  being  diseased,  has  caused  the 
increase  of  tension.  Jackson  calls  attention  to  the  existence  of  low 
general  arterial  tension  in  a  case  of  secondary  glaucoma  from  intra- 
ocular tumor,  and  so  impressed  w'as  he  by  this  sign  that  he  offers  this 
as  a  point  to  bear  in  mind  in  the  differential  diagnosis  between  pri- 
mary glaucoma  and  that  secondary  to  the  presence  of  a  tumor. 

Ilnnorrhagic  glaucoma.  Properly  speaking,  this  disease  is  a  form 
of  secondaiy  glaucoma,  ])ut  it  much  resembles  the  congestive  form 
and  is  frequently  indistinguishable  from  it.  There  is  often  a  history 
of  sudden  blindness  coming  on  before  the  attack  of  the  glaucoma.  The 
iris  may  present  the  appearance  of  hemorrhagic  infiltration,  or  there 
may  be  blood  in  the  anterior  chamber.  The  chamber  itself  is  never 
shallowed  in  the  manner  so  characteristic  of  other  forms  of  primary' 
glaucoma.  It  depends  upon  a  grave  disturbance  of  the  circulation  in 
the  retina ;  it  is,  indeed,  simply  a  local  manifestation  of  a  general 
state,  yet  it  is  extremely  difficult  to  decide  whether  the  hemorrhagic 
extravasations  have  been  produced  by  alteration  in  the  tension  of  a 
glaucomatous  eye  or  whether  the  glaucoma  is  secondary  to  the  hemor- 
rhages. The  glaucoma  is  a  late  and  indirect  result,  and  the  subjects 
of  it  have,  commonly,  high  arterial  tension,  as  well  as  marked  vis- 
cosity of  their  blood,  two  factors  affecting  the  hemorrhages. 

Ophthalmoscopically,  there  are  the  common  appearances  of  glau- 
coma together  with  numerous  hemorrhages  from  the  distended  and 
tortuous  veins,  which  are  here  and  there  obscured  by  edema.  Such 
hemorrhages  may  have  occurred  as  the  result  of  thrombosis  and  end- 
arteritis, as  well  as  phlebitis,  of  the  retinal  vessels,  or  through  degen- 
eration of  the  vessel  walls.  .\t  times,  especially  in  the  case  of  venous 
obstruction,   the   transudation    occasioned   by   the   overfulness  of   the 


GLAUCOMA  5461 

vitreous  cliainlicr  iiiay  l)c  so  pi-ol'iisr  as  to  olisciirc  llic  t'liiidiis  ivfiex. 
The  eoniea  tlieii  is  steamy,  the  anterior  chaniljer  obliterated,  the  iris 
diseolored  and  the  i^hihe  intensely  injected  and  very  hard. 

The  individuals  in  \\li()iii  hemorrhagic  glaucoma  occurs  are  almost 
always  far  advanced  in  life  and  subject  to  the  degeneration  of  their 
vessels,  and  they  not  infre(inently  die  of  cerebral  apoplexy. 

Ti'aumatic  (jlinicuiiui.  ( Jlaucoinatous  synii)tonis  occasionally  arise  in 
an  eye  that  has  been  contused  or  otherwise  injured,  although  some- 
times th,e  injury  may  be  ai)parently  ti'itling.  The  symi)toms  may  l)e 
acute  and  set  in  in  a  day  or  two,  or  in  other  eases  they  may  not  be 
present  for  two  or  three  weeks  after  the  injury,  ])eing  preceded  oi" 
not  by  intraocular  hemorrhage,  or  they  are  accompanied  by  a  partial 
or  complete  dislocation  of  the  lens.  Many  theories  have  been  advanced 
to  ex})lain  the  condition,  yet  none  is  satisfactory ;  the  cases  ought 
really  to  be  classed  as  a  type  of  secondary  glaucoma.  It  is  relatively 
rare,  and,  as  might  l)e  expected,  it  is  seen  more  frequently  in  men 
than  in  women.  rndoul)tedly  the  injured  individual  has  been  suscep- 
tibly predisposed  to  glaucoma,  so  that  the  exciting  cause,  as,  for  in- 
stance, so  slight  an  injury  as  that  oc^casioned  l)y  the  lodgment  of  a  for- 
eign body  upon  the  glol)e,  may  l)e  all  that  is  sufficient  to  disturb  the 
nervous  control  and  cause  an  increase  of  tiie  intraocular  contents,  or 
to  change  the  composition  of  the  aqueous  humor.  Other  cases  may 
follow  more  serious  injuries,  as,  for  instance,  contusions  like  a  blow 
from  a  fist,  without  discoverable  lesions  other  than,  perhaps,  a  "l)lack 
eye,"  or  without  presenting  changes  sufficient  to  account  for  the  in- 
crease of  pressure.  And,  finall.v,  cases  in  which  there  are  positive 
injuries  to  the  tissues,  as  of  wounds  to  the  anterior  segment,  to  the 
choroid,  retina  or  nerve. 

Without  doubt  such  happenings  disturl)  the  condition  of  the  angle 
of  the  anterior  chamber,  excite  to  true  infiannnation  and  tend  to  in- 
crease of  albumin  in  the  aqueous. 

Complicated  glaiiroma.  Complicated  glaucoma  is  a  clinical  type 
of  secondary  glaucoma,  of  which  two  forms  usually  have  been  noted : 
cataract  wdth  glaucoma,  and  glaucoma  occurring  in  the  course  of  high 
myopia.  Both  conditions  are  fortunately  rare.  In  the  case  of  cataract, 
onl.v  one  eye  is  affected.  It  is  not  to  be  overlooked  in  any  case  of 
maturing  cataract,  that  the  lens  may  swell  so  much  as  to  press  upon 
the  circund(Mital  space  and  produce  glaucoma,  nnd  in  some  cases  of 
high  myopia  there  ma.v  arise  more  or  less  clioroidal  disturbance,  sutlfi- 
cient,  sometimes,  to  cause  glaucoma,  in  whicli  the  visual  changes,  the 
excavation  of  the  disk,  and  the  restrictions  in  the  field  are  of  the  usual 
character.    The  tension  is.  however,  rarely  very  high,  and  therefore  it 


5462  GLAUCOMA 

is  the  cxcaval  ion  ol"  llic  papilla,  and  sonid  imcs  the  unusual  amount  of 
j)ain  (*()in|)lainc(l  oi"  which  h'ud  one  to  sus])t'et  the  prcsi-nee  of  such  a 
eoniplicatioji.  It  is  not  to  he  expected  tluit  the  excavation  should  he 
so  deep  as  in  other  forms  hecause,  prohably,  of  the  general  weakness 
of  the  posterior  sefj:mcnt  of  the  glolie,  which  allows  distension  of  the 
surrounding  parts  without  exercising  such  forcible  pressure  on  the 
lamina  eribrosa  as  has  been  noted  in  connection  with  the  other  forms 
of  glaucoma. 

INFAXTIT.E    GI.AUCOMA. 

"Buphtiialniic  hycb'oijlithalniia,"  or  bu])hthalmos  (q.  v.),  is  a  form 
of  glaucoma,  present  in  cliildhood,  in  which  the  eye  is  of  an  unusual 
size,  hence  "buphthalmus,"  that  is,  ox-eye.  It  occurs  either  congen- 
itally,  or  it  develops  in  the  first  year  of  infancy.  The  nature  of  the 
disease  has  not  yet  been  fully  cleared  up,  but  the  increase  of  the  intra- 
ocular tension  is  certainly  the  most  important  factor  in  it,  leading  to 
the  enlargement  of  the  eye,  and  to  blindness  through  excavation  of  the 
optic  nerve. 

Historij.  The  history  of  this  interesting  affection  remained  obscure 
from  anti(iuity,  and  the  term  "bnphthalmus"  was  used  by  early 
writers  to  express  several  conditions  in  which  there  was  prominence 
of  the  eyeball.  It  was  not  until  1722  that  Saint  Yves  first  described 
the  true  condition;  in  1867  Mauthner  proclaimed  the  glaucomatous 
nature  of  it,  and  in  1869  Horner  put  forward  the  vieW'  that  buph- 
thalmia  might  be  due  to  some  congenital  abnormality  of  the  angle  of 
the  anterior  chamber. 

Clinically,  the  globe  is  much  enlarg(Hl,  usually  presented  as  an 
elongated  oval.  The  distension  of  the  globe  is  marked  by  more  or  less 
proptosis,  but  the  most  striking  feature  in  buphthalmia  is  the  size  of 
the  cornea,  which  has  given  rise  to  the  term  "megalocornea."  The 
-  cornea  is  hemispherical  or  globular,  the  radii  in  both  meridians  being 
greatly  increased.  The  sclera,  especially  near  the  limbus,  is  bluish, 
in  consequence  of  the  uveal  pigment  appearing  through  it.  The  an- 
terior chamber  is  very  deep.  The  iris  is  usually  flat,  sometimes  in- 
fundibuliform,  and  generally  tremulous  owing  to  the  lack  of  support 
fi-om  the  lens,  but  as  a  rule  it  shows  no  signs  of  inflamnuition.  though 
it  may  be  ati'oj)hic.  It  may  be  rent,  when  tlu*  lacerations  are  to  be 
seen  moi'c  often  at  the  ciliary  attachment.  In  some  cases  the  mem- 
brane is  I'udiiuentary  or  presents  a  colobonia.  The  pupil  is  round, 
usually  slightly  dilated,  but  in  rai'c  instances  it  is  either  nnicli  con- 
tracted or  widelv  dilated.     In  mo.st  cases  it  reacts  badly  to  light,  even 


GLAUCOMA 


5463 


wlicii  the  visual  acuity  is  fairly  well  niaiiitaiiHnl,  probably  because 
of  the  atrophic  condition  of  the  ii'is. 

The  ophtlialuioscoi)ic  examination  in  the  cai-Iy  stages  shows  that 
the  media  are  usually  clear,  and  the  retina  and  choroid  normal ;  the 
course  of  the  disease  progresses  more  slowly  than  is  the  case  in  the 
glaucoma  of  adults,  and  tlie  rctiiui  does  not  suffer  as  early.  The  optic 
disk  is  cupix'd  ;  the  api)earances  of  the  nerve  head  arc  the  same  as  in 


The  Angle  of  the  Anterior  Chamber  in  a  Case  of  Congenital  Glaucoma  or  primary 
buj/hthalmos.     (After  Collins,  in  Posey  and  Wright.) 


adult  glaucoma,  but  tlie  variations  in  size  of  the  vessels  are  not  so 
marked,  and  the  distinctness  of  the  arterial  pulsation  is  less  com- 
monly observed. 

While  the  tension  is  raisetl  it  proba])ly  never  reaches  the  level  met 
with  in  adult  glaucouui,  owing  to  the  lack  of  rigidity  in  the  sclerotic 
in  early  life. 

The  sul)jective  signs  of  diminished  retinal  sensibility-  are  not  want- 


5464  GLAUCOMA 

iii^  ill  tlio  early  stages  of  iiitaiitilt-  glaucoma,  for  the  direct  sight  is 
usually  greatly  reduced,  altiiough  some  cases  have  had  remarkably 
high  visual  acuity.  There  is  generally  contraction  of  the  field  of 
vision,  and  it  is  interesting  to  note  that  this  contraction  is  analogous 
in  kind  witli  that  found  in  ghiucoma  of  the  adult.  Although  con- 
traction usuall}'  manifests  itself  first  in  the  nasal  field,  it  sometimes 
assumes  a  concentric  outline.  Color- vision,  too,  may  be  well  pre- 
served, and  the  condition  of  the  refraction  is  of  interest.  Myopia 
usually  exists,  but  not  to  so  great  a  degree  as  might  be  expected  from 
the  length  of  the  globe.  Seefelder  stated  that  in  his  examination  of 
seven  eyeballs  he  did  not  find  present  the  macular  lesions  of  high 
myopia.  Cases  have  been  cited  in  which  only  a  low  grade  existed  in 
one  eye,  while  the  other  was  emmetropic,  with  quite  high  visual  acuity. 
Schenek  observed  that  in  spite  of  the  large  size  of  the  eye  the  refrac- 
tion, in  his  experience,  is  usually  hyperopie  or  is  the  seat  of  compound 
hyperopic  astigmatism.  Astigmatism  is  common,  and  it  is  usually 
with  the  rule.  In  the  later  stages  of  the  affection  irregular  astig- 
matism is  frequent,  owing,  of  course,  to  the  corneal  changes;  never- 
theless, even  with  proper  correction  the  visual  acuity  is  generally  far 
below  the  normal. 

The  enlargement  is  caused  by  an  increase  of  pressure  within  the 
eye,  and  the  difference  in  external  appearance  between  it  and  the 
glaucoma  of  adults  is  accounted  for,  in  the  main,  by  the  physiological 
properties  of  the  eye  in  childhood.  The  extensibility  of  the  sclera  in 
childhood  renders  it  possible  for  the  heightened  pressure  to  effect  the 
enlargement  of  the  eye  as  a  whole,  whereas  the  rigidity  of  the  sclera 
of  the  eye  of  the  adult  allows  of  expansion,  through  increase  of  pres- 
sure, only  at  the  weakest  spot — the  lamina  cribrosa. 

Etiology.  The  originating  causes  of  infantile  glaucoma  are  quite 
as  obscure  as  are  those  attending  the  glaucoma  of  the  adult.  It  is 
probable  that  it  is  a  manifestation  of  hereditary  syphilis.  Schmidt- 
Rimpler,  disclaiming  a  possible  connection,  admits,  however,  that 
liydi'ophthalmus  does  develop  in  the  parenchymatous  keratitis  of  con- 
genital syphilis,  and  further  notes  that  an  analysis  of  Seefelder 's 
cases  shows  that  a  large  num])er  occurred  in  families  in  which 
numerous  cases  of  fatal  disease  among  children  occurred.  Zentmayer 
expresses  the  thought  that  the  comparative  frequency  of  the  disease 
in  the  negro  might  be  ex]~»laine(l  1)y  the  gn^ater  prevalence  of  syphilis 
in  that  race. 

In  the  histological  studies  syphilis  appears  as  a  true  cause  from 
the  jiredilection  that  disease  has  for  th''  vascular  tissues,  from  the 
])rominence  of  the  endothelial  reactions  and  the  presence  of  mononu- 


GLAUCOMA  5465 

clear  leucocytic  infiltration,  yet  agents  other  than  the  luetic  may  give 
rise  to  similar  effects,  and  the  ('ii(i()i)lil('l)itis  found  in  certain  cases  is 
suggestive  of  toxic  agents  in  tlic  l)h)()(l. 

Distinct  changes  are  noted  in  the  tissues  of  the  globe.  The  cornea 
may  be  clear  or  dull,  opalescent  or  bluish;  a  haze  may  be  the  first 
symptom  to  appear.  The  lens  is  connnoidy  <iuite  clear,  but  after  the 
nutrition  of  the  eye  begins  to  suffer  in  the  later  stages  it  frequently 
becomes  cataractous.  It  is  of  interest  to  note,  in  contradistinction  to 
what  is  the  case  in  adult  glaucoma,  that  the  lens  in  contrast  with  other 
parts  of  the  eye  is  usually  smaller  than  the  normal,  the  mean  diameter 
has  commonly  been  2  to  3  mm.  less,  and  tlu'  antero-posterior  diameter 
also  is  reduced.  The  lens  appears  somewhat  spindle-shaped,  through  the 
stretching  of  the  suspensory  ligament  l)y  the  expansion  of  the  ciliary 
ring.  This  tension  of  the  zonula  may  lead  to  rupture  and  the  conse- 
quent partial  or  complete  dislocation  of  the  lens.  IMore  characteristic 
is  the  displacement  of  the  lens  either  backward  into  the  vitreous  or 
forward  into  the  anterior  chamber. 

Anatomical  changes  ohscrvcd  in  ihe  corma.  The  entire  cornea  is 
displaced  forward,  in  consequence  of  whicli  the  peripheral  circle 
becomes  stretched  and  thinned,  while  the  center  may  be  flattened, 
although  it  is  usually  clear  and  of  the  normal  thickness.  Often,  how- 
ever, the  base  is  vascularized  and  there  may  be  opacities  in  the  cornea. 
Unique  changes  take  place  in  the  cornea  in  this  disease,  and  these 
changes  may  be  the  first  observable  manifestations  of  the  process.  So 
marked  are  they  that  some  believe  that  the  initial  pathologic  changes 
arise  in  the  corneal  membrane  and  that  these  result  in  an  anterior 
uveitis  which  culminates  in  a  secondary  glaucoma.  The  opacities  are 
due  to  one  of  three  causes :  the  increased  intraocular  tension  occa- 
sions stretching  or  excites  to  intercurrent  disease ;  the  increase  of 
tension  may  lead  to  a  diffuse  edema  so  that  keratitis  bullosa  super- 
venes; forcible  stretching  not  infrequently  leads  to  the  rupture  of 
Descemet's  membrane  with  the  formation  of  dark  linear  opacities 
resulting  from  the  repair  of  these  injuries.  In  the  most  severe  cases 
injury  to  the  distended  and  proptosed  globe  may  be  succeeded  by 
ulceration,  with  scarring  as  a  consequence,  or  ulceration  may  be 
caused  by  exposure  of  the  prominent  cornea,  or  from  the  general 
malnutrition  of  the  eye. 

Changes  in  the  sclera.  The  sclera  may  not  show  any  structural 
alteration,  altliough  true  hyperplasia  and  positive  thickening  have 
been  noted.  The  thinning  is  undoul)tt'(lly  due  to  tiu-  general  disten- 
sion, which  distension  is  most  mai'ked  in  llic  region  of  the  limbus; 
true  staphylonuita  are,  however,  rare. 


5466  GLAUCOMA 

l)t  llir  irvi.  There  is  iiotliing  characteristic-  in  the  clianges  which 
have  heeii  noted  in  tiie  iris,  although  tlie  mcMibi-anc  shows  signs  of 
degeneration  and  atrophy,  according  to  and  in  i)ro|)ortion  to  tlie  dura- 
tion of  tile  ilisease.  In  the  later  stages  the  ciliary  body  is  usually 
more  or  less  degenerated  and  the  ciliary  muscle  atrophic,  although 
tlie  ])rocesses  may  be  intact  or  sliow  only  evidence  of  degeneration,  yet 
at  times  there  may  ])e  true  intlaiiiiiiation.  Tlie  choroid,  on  the  con- 
trary, is  usually  markedly  degenerated,  tlie  larger  vessels  of  which 
endure  long  after  the  smaller  ones  have  disapi)eared. 

The  retina  is  normal  in  the  early  stages,  but  later  on  the  layer  of 
the  rods  and  cones  disappears,  and  in  most  cases  the  nerve  fiber  layer 
also  atrophies.  Hemorrhages  from  the  choroidal  and  retinal  vessels 
are  not  uncommon,  and  when  they  take  place  detachment  of  the  retina 
is  usually  produced  by  them.  Nevertheless,  detachment  of  the  retina 
from  other  causes  is  so  common  that  it  may  be  suspected  if  a  sudden 
decrease  of  intraocular  tension  occurs.  The  optic  disk  is  invariably 
found  to  be  cupped,  and,  in  the  later  stages,  extremely  atrophic. 

raihogcnesis.  Buphthalmia  is  without  doubt  the  infantile  form 
of  glaucoma,  the  cause  of  which  arises  in  an  increased  intraocular 
pressure.  Formerly  it  was  believed  that  buphthalmia  depended  upon 
hypersecretion,  but  in  recent  years  it  has  been  conceded  that  it  is  due 
to  the  retention  of  tiuid  in  the  eye.  It  is  singular  that  so  striking  a 
condition  should  give  rise  to  so  few  evidences  of  inflammatory  proc- 
esses; but,  assuredly,  there  are  none  which  can  be  considered  to  be 
at  all  sufficient  to  maintain  hypersecretion.  The  condition  of  the  angle 
of  the  anterior  chamber  precludes  any  other  hypothesis  than  that  it  is 
caused  by  defective  filtration. 

Collins  ascribes  the  origin  of  the  condition  to  an  obstruction  to  tlie 
exit  of  fluid  from  the  eye,  and  the  occurrence  of  increased  tension, 
he  holds  it  to  be  dependent  upon  an  abnormal  persistence  of  the 
prehuman  or  prenatal  state  of  the  ligamentum  pectinatum,  which  lig- 
ament consists  of  an  external  laminated  zone,  with  slit-like  spaces,  and 
an  inner  cavernous  zone,  with  large  irregular  spaces.  The  space  at  the 
angle  of  the  chamber  is  filled  up  with  a  network  of  fibers,  which  in  the 
matured  eye  becomes  part  of  the  anterior  chamber.  The  anterior 
chamber  is  always  deep,  the  pectinate  ligament  is  larger  than  ever 
seen  in  the  healthy  eye.  Parsons  sums  up  by  stating:  "Whatever 
be  the  exact  mechanism,  it  would  seem  to  be  certain  that  there  is  a 
very  definite  obstruction  to  the  filtration  of  lymph  from  the  eye  at 
the  angle  of  the  anterior  chamber,  whether  this  is  due  to  a  congenital 
arrest  of  development  or  to  intra-  or  early  extra-uterine  inflamma- 
tion must  be  left  an  open  question.     Tt  may  be  remarked  that  even 


GLAUCOMA  5467 

an  arrest  of  development  must  have  some  cause,  and  that  this  is  most 
probably  to  be  discovered  in  some  intra-uterine  inflammatory  or  toxic 
condition." 

Magitot  concludes,  after  a  study  of  three  eyes,  two  of  which  were 
from  one  child,  and  from  the  analysis  of  60  published  reports,  that 
there  are  two  classes  of  cases :  the  one,  numerically  very  few,  in  which 
there  is  little  or  no  inflannnatory  lesion.  In  these  cases  there  was 
found  obliterative  endophlebitis  of  the  scleral  vessels  and  of  the  ante- 
rior ciliary  veins,  and  in  cases  where  these  signs  were  not  pronounced 
aplasia  of  the  venous  system  of  the  angle,  together  with  the  absence 
of  Schlemm's  canal.  The  other  more  numerous  classes  were  charac- 
terized by  inflammatory  lesions  more  or  less  variable  and  intense,  ex- 
tending from  afl^eetion  of  the  venous  system  at  the  angle  through  the 
retino-ciliarv^  region  and  of  the  choroid,  to  those  in  which  the  entire 
uveal  tract  and  vorticose  veins  were  affected.  ^Magitot  believes  that 
these  vascular  lesions  are  the  cause  of  the  increased  tension,  and  that 
it  is  unnecessary  to  suppose  that  an  obstruction  to  the  outflow  of  the 
aqueous  humor  exists.  And  he  suggests  that  posterior  glaucoma  might 
readily  exist  from  the  obstruction  of  the  vorticose  veins,  while  anterior 
glaucoma  arises  from  the  obstruction  of  the  anterior  ciliary  veins. 
Keis,  who  made  a  study  of  seven  eyes,  found  nothing  constant.  In 
four  the  angle  of  the  anterior  chamber  was  open,  and  in  two  of  these 
there  was  an  absence  of  Schlemm's  canal.  Stimmel  and  Rotter  state 
the  consensus  of  opinion  to  be  that  the  disease  is  caused  by  an  absence, 
whole  or  in  part,  of  the  canal  of  Schlemm,  which  is  placed  too  far 
l)ack :  in  the  persistence  of  temporary  fetal  connective  tissue  in  the 
angle  of  the  anterior  chamber,  and  in  an  insufficient  separation  of  the 
iris  from  the  cornea. 

In  a  recent  communication  "William  Zentmayer  speaks  of  his  having 
seen  six  cases  of  hydroplithalmus,  four  of  which  occurred  in  colored 
children,  in  two  of  whom  there  were  strong  evidences  of  inherited 
syphilis.  He  gives  the  pathologic  findings  in  two,  and  his  study  of 
them  lends  additional  support  to  the  view  that  the  essential  factor 
in  the  production  of  hydrophthalmus  is  an  absence,  or  an  incomplete 
development,  of  Schlemm's  canal,  and  that  a  probable  contributing 
factor  is  the  presence  of  prenatal  connective  tissue  in  the  angle  of  the 
anterior  chamber. 

Course.  The  disease  probably  always  dates  from  birth,  or  earlier; 
yet,  owing  to  its  insidious  nature,  cases  rarely  come  under  observation 
previous  to  the  full  establishment  of  the  condition.  Some  evidence 
of  the  disease  has  been  found  present  at  birth  in  certain  cases,  or.  as 
in  others,  it  makes  its  appearance  within  the  first  six  months  of  life. 


5468  GLAUCOMA 

KosiMiiaycr  lias  reported  a  ease  assoeiated  witli  plexiforiii  iieiiroina  in 
whicli  liyilro])htlialnius  developed  three  years  after  birtii. 

Tile  progress  of  all  cases  is  slow.  In  some  eases  it  has  come  to  a 
stop  si)ontaneously,  the  inereasc  of  triision  suljsiding  after  a  time, 
although  the  bigness  persisted  hut  did  nut  increase,  and  the  eye  re- 
tained a  moderate  amount  of  sight,  dependent  upon  the  condition  of 
the  nerve,  in  other  cases  it  continued  to  progress  until  it  produced 
blindness,  the  enlargement  keeping  on,  sometimes,  until  quite  extraor- 
dinary dimensions  were  attained,  and  the  eye  became  irritable  and 
painful  and  ruptured  spontaneously,  and  in  the  meantime  complete 
blindness  had  ensued. 

Iit(i(l<  )>(■(.  Huj)htlialinia  is  usually  bilateral,  with  no  predilection 
for  one  side  more  than  the  other;  the  cases  the  writer  of  this  article 
can  recall  have  all  been  unilateral.  Sometimes  there  is  nystagmus, 
and  there  may  be  anomalies  of  .structure,  as  of  coreetopia,  coloboma 
of  iris,  posterior  lenticonus,  plexiform  neuroma,  etc.  A  number  of 
eases  have  presented  malformations  of  the  long  bones  and  of  the  joints. 

Uenditii.  P>upiithalinus  occurs  with  somewhat  greater  frequency 
in  males,  and  the  intlufiiec  of  heredity  is  well  marked;  it  is  essentially 
a  family  disease,  though  direct  inheritance  is  rare.  There  may  be, 
however,  consanguinity  of  the  parents.  Carlotti's  patient  belonged 
to  a  family  of  six  persons,  four  of  whom  suffered  from  hydrophthal- 
mus.  If  buphthalmus  is  not  present  in  other  members  of  the  family 
they  may  perhaps  show  evidences  of  marked  ocular  deformities,  as. 
for  instance,  bilateral  aniridia.  Perhaps  in  a  given  family  all  the 
congenital  ocular  anomalies  ina.v  have  occurred  through  the  effects  of 
some  vicious  infection  or  other  irritation  transmitted  through  the 
maternal  placenta.     Of  Zeiitmayer's  six  cases,  four  were  negroes. 

Ending.  Tn  such  an  article  as  this,  i.  e.,  one  prepared  for  an  ency- 
clopedia, it  is  imi)Ossil)le  to  detail  everj^  contribution  to  the  subject 
of  glaucoma,  indeed,  such  exhaustiveness  should  neither  be  desired  nor 
attempted.  An  effort  has  been  made,  however,  to  present  systemati- 
cally the  facts  which  are  already  accepted  and  established,  and  to 
indicate  the  lines  upon  which  investigators  are  working  toward  the 
further  elucidation  of  those  facts,  as  well  as  to  mention  others  which 
are  i)ointing  to  new  fields  of  research.  :\lucli  of  what  has  here  been 
written  was  long  ago  embodied  in  the  discussion  of  the  disease,  so  that 
the  items  as  they  appear  in  this  article  are  Init  the  commonplaces  in 
the  science  of  ophthalmology,  and  no  acknowledgment  has  been  made 
of  the  original  works  dealing  with  the  subjects.  But  whenever  the 
writer  has  had  occasion  to  note  a  ])articular  fact  of  comparatively 
modern    ascertainment,    or    of    especial    important    knowledge,    the 


GLAUCOMA  5469 

aiitlioi'ity  has  Ix-cn  ^'ivcn.  Extensive  bibliographical  tal)h'S  may  })e 
found  in  Parson's  Patholofjy  of  the  Eye,  and  in  the  Ophthalmic  Year 
Book  may  l)e  found  the  summary  of  all  the  important  contributions, 
as  well  as  quite  complete  title-lists  published  since  1903. —  (B.  C.) 

XOX-OPERATIVE  TREATMENT   OF   GLAlCOilA. 

As  iiii<^lit  have  been  t'xpected  from  the  fact  that  glaucoma  has  been 
called  "gouty  eye,"  the  association  of  so-called  gout  and  rheumatism 
with  (mostly)  primary  glaucoma  is  (Richey)  not  uncommon.  When 
the  surgeon  suspects  or  is  able  to  establish  the  existence  of  such  a 
dyscrasia,  treatment  should  be  given  accordingly.  This  rule  should  be 
borne  in  mind  as  regards  other  systemic  anomalies — all  of  which  should 
receive  attention  where  any  form  of  glaucoma  is  in  question.  See 
General  diseases. 

Trioinu  iit  of  acute  glaucoma.  Although  this  is  almost  always  opera- 
tive, yet  the  Editor  is  in  favor  of  waiting  until  the  iuHammatory  storm 
has  passed  before  resorting  to  operation.  In  the  interim  paracentesis, 
posterior  incision,  massage  with  eserine  oil  or  ointment  and,  above  all, 
the  frequent  use  of  a  5  per  cent,  solution  of  dionin  will  cut  short  the 
attack.  As  a  matter  of  fact  he  generally  uses  the  above  measures  in 
their  reverse  order,  and  agrees  with  the  observation  of  Peter  Callan 
that  the  lymphogogic  effects  of  dionin  should  be  among  the  first 
remedial  measures  applied  in  these  cases.  In  addition  to  local  applica- 
tions a  large  saline  purgative,  restriction  of  diet,  plenty  of  water  inter- 
nally and  complete  rest  should  be  prescribed. 

As  A.  F.  Amadou  points  out,  favorable  results  follow  the  general 
treatment  of  gouty  eye  diseases,  especially  by  colehicin  alone  or  by 
1-64  of  a  grain  of  that  alkaloid,  given  from  4  to  6  times  a  day,  in 
conjunction  with  the  iodides  or  salicylates  in  sufl&cient  quantities  to 
produce  moderately  free  catharsis.  The  alkaloid,  he  adds,  seems  to  be 
far  superior  to  the  tincture  or  wine  of  colchicum,  and  he  has  noticed 
that  the  more  decidedly  the  ease  is  of  gouty  origin  the  more  benefit 
will  be  derived  from  this  treatment. 

Dianoux  prefers  sclerotomy  followed  by  miotics  and  ma.ssage.  He 
begins  massage  twice  daily,  commencing  twelve  hours  after  the  opera- 
tion. The  surgeon  commences  and  the  patient  continues  this  procedure 
for  the  remainder  of  the  latter 's  life.  In  addition,  a  collyrium  contain- 
ing both  eserin  and  pilocarpin,  with  or  without  cocaine  or  adrenalin, 
according  to  cii-cumstances.  is  ordered  twice  daily.  In  simple  chronic 
glaucoma  Dianoux  reconnnends  the  following  routine  examination  of 
patients,  "I  watch  carefully  the  field  of  vision  for  white  and  colors, 
the  light-sense,  the  visual  acuity,  and  the  accommodation :  explain  to 


5470  GLAUCOMA 

till'  piiticiil  flic  iiJiturc  of  llic  disease  and  tlie  results  desired  and  ex- 
peeled  from  treatnuiit,  and  teaeh  hiin  to  inassage  liis  eye  twice  a  day, 
and  at  the  same  time  to  use  the  drops.  The  examination  should  be 
repeated  every  month,  and  if  there  is  no  improvement,  or  the  patient 
is  woi'se,  do  a  sclerotoiiiy,  followed  l)y  the  treatment  already  deseril)ed. 
Intei-nally  small  doses  of  quinine  and  iodide  of  soda,  alternating  with 
small  (loses  of  tincture  of  strophanthus,  may  be  given  with  benefit." 

Schmidt-Kimpler  has  so  far  never  had  occasion  to  perform  resection 
of  the  sympathetic  nerve.  For  alleviating  the  pain  cocaine  with  pilo- 
carpin  is  recommended.  In  some  cases  of  absolute  glaucoma,  in  which 
all  remedies  had  failed,  instillations  of  scopolamin  were  useful. 

Peter  Callan  strongly  advises  the  prescription,  just  referred  to 
(eserin,  sulph.,  gr.  i;  pilocarpin,  mur.,  gr.  ii;  sol.  dionin.  (10  per  cent.), 
fl.  oii),  two  drops  to  be  used  every  hour  until  the  inflammatory  symp- 
toms have  passed  off. 

In  this  connection  he  says:  "I  considci-  this  foi'unila  of  the  greatest 
service  in  acute  and  subacute  inflammatory  glaucoma.  It  is  not  always 
an  easy  matter  to  do  an  iridectomy  in  an  acute  case  of  glaucoma  when 
the  inflammation  is  at  its  height.  By  using  this  mixture  the  surgeon 
may  postpone  the  operation  as  long  as  it  suits  him.  In  fact  many 
cases  quickly  recover  and  I  fail  to  see  the  necessity  for  any  operation. 
It  should  be  used  hourly  until  the  acute  symptoms  have  passed  off 
(which  may  take  24  to  48  hours)  then  every  two  hours.  I  likewise 
use  it  after  simple  glaucoma  operations — beginning,  say,  10  days  after 
the  iridectomy,  using  it  every  night  or  every  other  night  as  the  case 
may  be.  It  has  given  me  excellent  results  and  at  the  same  time  has 
cost  me  some  operations." 

Schmidt-Rimpler  advises  the  use  of  physostigmine  as  a  half  per  cent, 
solution  from  2  to  6  times  daily.  As  long  as  central  vision  does  not 
decline  and  the  visual  fields  show  no  diminution  in  size  this  local  medi- 
cation [or  that  by  pilocarpin  or  arecolin  (q.  v.)]  should  be  continued 
and  no  surgical  procedure  undertaken. 

It  is  not  yet  clear  how  this  reduction  of  tension  is  l)rought  about, 
the  coininoiily  accepted  explanation  being  that  during  the  miosis  the 
stretching-  of  tlie  iris  permits  of  a  readier  cxosmosis  of  tlie  intraocular 
fluids. 

American  patients  seem  very  susccptil)le  to  the  irritation  that  fol- 
lows the  use  of  eserine  and  it  cannot  be  used  in  the  doses  (!/>  to  1  per 
cent.)  generally  prescribed  by  European  writers.  This  difficulty  may 
be  avoided  by  giving  the  di'ug  in  smaller  proportions  as  an  oily  solution 
or  in  the  form  of  ointment.  Anothci-  ])l;iii  is  to  instil  it  in  conjunction 
with  cocaine  or  after  cocaini/.ing  the  eye.     Tliis  proeedure  not  only  ro- 


GLAUCOMA  5471 

lieves  llic  p;iin  Imt  increases  the  miotic  action  of  the  drug.  Cocain. 
hydrocliloi'i.,  gv.  j  ;  cscrin.  salicylatis,  gr.  ss;  aciuic  dcst.,  fi.  3  j. 

The  eye  to  be  kept  closed  for  20  minutes  after  using. 

Eserin  lamellae  with  cocaine  also  act  very  nicely. 

Schmidt-Rimpler  gives  the  following  prescription  for  the  use  of  the 
salicylate:  Eserin,  salicylatis,  0.05;  hydrarg.  bichlor.,  0.002;  sodii 
chlor,  0.01;  aquas  dest.,  10.0. 

A  procedure  followed  l)y  the  relief  of  pain,  and  even  improvement 
in  the  glaucomatous  condition,  is  injecting,  with  an  Anel  or  some 
other  form  of  lachrymtd  syringe,  the  nasal  duct  of  the  affected  eye  with 
a  25  per  cent,  solution  of  antipyrine.  This  may  be  repeated  two  or 
three  times  daily,  if  required ;  after  previous  injection  with  eucapren 
(q.  V.)  or  some  similar  mixture. 

The  non-operative,  like  the  operative,  treatment  of  chroinc  glaucoma 
is  not  as  satisfactory  as  in  the  more  acute  cases.  Indeed  the  diagnosis 
from  pi'imary  progressive  atroi^hy  of  tlie  optic  nerve  is  not  always 
made  with  ease  and  it  is  quite  possible  that  the  treatment  may  be 
unconsciously  applied  to  the  latter  condition  rather  than  to  a  truly 
glaucomatous  affection.  Apart  from  the  (juestionable  employment  of 
iridectomy  or  one  of  its  sul)stitutes  considerable  benefit  is  derived  from 
attention  to  the  general  condition.  Any  lesion  or  morbific  influence 
whatever,  gout,  rheumatism,  disease  of  the  nose,  heart,  intestinal  tract, 
kidneys,  etc.,  should  be  attended  to.  The  most  im])ortant  local  treat- 
ment is  the  use  of  miotics — especially  eserin  and  pilocarpin. 

As  Posey  has  pointed  out,  if  these  remedies  be  properly  and  judic- 
iously applied,  if  need  be  while  life  lasts,  the  disease  may  be  held  in 
check  for  an  indefinite  time  and  no  need  arise  for  the  removal  of  the 
cervical  ganglia,  or  any  othci-  procedur(\  It  is  difficult  to  lay  down 
rules  ai)plical)le  to  every  case,  l)ut  the  method  generally  employed  by  the 
Editor  is  to  prescribe  a  V2  to  1  per  cent,  mixture  of  eserine  in  olive  oil 
or  petrolatum,  one  droj).  or  its  equivalent  of  ointment,  to  be  put  into 
the  eye  every  morning,  afti>r  which  the  eye  should  be  kept  closed  for 
five  minutes.  If  this  is  sufficient  to  keep  the  pupil  well  contracted  a 
second  dose  is  not  used,  during  the  day,  but  in  any  event,  another 
drop  is  instilled  just  before  retiring.  According  to  the  state  of  the 
eyes,  he  employs  in  bis  office,  once,  twdce  or  thrice  a  week,  gentle  finger 
massage  and  with  it  a  1  per  cent,  solution  of  eserine  salicylate.  It  may 
lie  mentioned  in  this  connection  that,  as  Bull  points  out,  both  the  hydro- 
bromide  and  the  salicylate  are  to  lie  preferred  to  the  sulphate  on  ac- 
count of  the  greater  solubility-  of  the  former. 

Schleicli  (abstract  in  Die  Ophthal.  KUuil-,  Oct.  5,  1906\  reports 
the  result  both  of  operative  and  miotic  treatment  of  glaucoma  simplex. 


5472  GLAUCOMA 

in  cases  wliicli  liad  hccii  under  oliservation  more  than  two  years.  In 
tlic  cases  treated  l)y  iridectomy  7.8  per  cent,  became  blind,  either 
immediately  or  within  a  short  time  after  operation;  76.5  per  cent, 
showed  a  more  or  less  jj^radnal  progression  in  the  loss  of  function, 
while  only  15.7  per  cent,  showed  cessation  of  the  process,  i.  e.,  no  in- 
crease in  functional  distur))ance  for  at  least  two  years. 

In  a  smaller  number  of  cases,  forty-six,  treated  by  miotics,  the  results 
were:  proijress  of  the  disease  in  61  per  cent;  retardation  in  81)  per 
cent.  Schleich  believes  the  prognosis  after  operative  treatment  is  more 
unfavorable  in  the  early  stage  of  the  disease  than  later  in  life.  More- 
over, the  use  of  miotics  after  operation  makes  it  difficult  to  determine 
the  value  of  the  operative  procedure.  He  concludes  that  iridectomy 
can  not  be  considered  in  any  sense  a  trustworthy  remedy  for  glaucoma 
simplex,  because  in  "the  majority  of  cases  which  are  followed  long 
enough  it  does  not  give  the  good  results  usually  ascribed  to  it,  and  on 
the  other  hand  in  a  larger  percentage  of  cases  it  produces  immediately 
unfavorable  results,  at  times  rapid  l)lindness.  lie  ])elieves  further  that 
the  value  of  the  faithfully  employed  miotic  treatment  has  not  been 
as  yet  sufficiently  tested,  and  the  bad  results  depend  partly  on  a  lack  of 
thoroughness  in  carrying  out  the  treatment. 

Some  observers  have  noticed  improvement  in  this  form  of  glaucoma 
from  the  use  of  the  ophthalmic  oscillator  or  vibrator  in  any  of  its 
forms.  The  Victor  machine  is  a  valuable  device  for  the  purpose,  but 
any  instrument  that  wdll  produce  rapid  but  gentle  suction  with  an 
alternating  release  ought  to  be  tried  in  these  cases. 

The  treatment  of  seeandarij  glaueoma  is  mostly  operative. 

It  may  also  be  said  of  secondary  glaucoma  that  the  treatment  should 
be  directed  to  the  underlying  cause. 

Very  little  can  he  done  apart  from  surgery  in  hemorrhagie  gl<iu- 
coma.  The  hygienic  aspects  of  the  case  are  important ;  all  causes  of 
worry  and  excitement  should  be  avoided  and  the  patient's  surround- 
ings should  be  as  favorable  to  complete  rest  as  possible.  Salicylate 
of  sodium,  ({uinine  and  ergot  internally  are  said  to  be  useful.  All 
systemic  dyscrasiae  should  be  promptly  treated.  In  addition  to  these 
the  indications  mentioned  under  acute  inflammatory  glaucoma  should 
be  carried  out,  although  it  must  be  acknowledged  that  miotics  produce 
very  little  effect  in  this  discouraging  disease. 

The  treatment  of  huphfhobnos  (q.  v.)  is  almost  exclusively  operative, 
yet  the  continued  employment  of  miotics,  especially  a  combination 
of  pilocarpin  with  cocain  and  dionin  is  of  considerable  value.  The 
Editor   has   suggested   the    following   combination :     Dionin.,    gr.    iv : 


GLAUCOMA  5473 

pilocjirpiii,  liydi'ohi'oiii.,  cocaiii.  liydrohrom.,  fia  gv.  i;  sotlii.  clilor.,  gr. 
ss;  aqiuL'  (k'st.,  fl.  .",i. 

Three  drops  of  this  mixture  is  put  into  the  eye  once  a  day,  and 
when  it  l)eji:ins  to  lose  its  effect  one  or  more  di-ops  at  intervals  of  two 
miinites  may  l)e  instilled  or  tlie  i)ropor1ion  of  dioiiin  increased,  to 
produce  a  decided  edema  of  the  conjunctiva. 

NEW   AND   NOX-Ul'EUATIVE  METHODS  OF  TREATING  THE  VARIOUS  FORMS  OF 

GLAUCOMA. 

Tn  addition  to  the  foregoing,  which  may  he  regarded  as  the  most 
tried  and  trusted  of  the  non-operative  foi-ms  of  treatment,  others  have 
been,  more  or  less  enthusiastically,  advanced  in  recent  years.  For 
example,  Darier  {La  Cliniquc  OphtaJ.,  July  10,  1908)  maintains  that 
in  cases  of  secondary  glaucoma  he  has  seen  a  single  suhconjunctival 
injection  of  a  milligram  of  iodate  of  sodium  result  in  rapid  clearing 
of  the  cornea,  diminution  of  pain  and  lessening  of  intraocular  tension, 
but  it  cannot  ])e  relied  upon  in  essential  glaucoma,  as  it  may  bring 
out  an  acute  attack. 

Stimulated  l)y  Sluder's  report"  of  a  numl)er  of  cases  of  obscure 
headache  relieved  or  cured  by  placing  a  20  per  cent,  solution  of  cocaine 
in  the  nasal  fossa  over  the  region  of  the  spheno-palatine  ganglion, 
Ewing  {Am.  Jour,  of  Ophthalm.,  Dec,  1908)  was  led  to  the  belief 
that  the  same  treatment  might  give  relief  to  the  suffering  of  acute 
glaucoma,  and  soon  had  the  opportunity  of  trying  it.  An  application 
was  made  to  the  region  of  the  nose  on  the  left  side,  adjacent  to  Meckel's 
ganglion,  of  a  50  per  cent,  solution  of  cocain,  and  the  patient's  pain 
in  the  eye  and  temple  ceased  entirely,  and  the  vision  rose  from  20/19 
to  20/15. 

Blessig  {Zrifschr.  f.  Auf/cHlicilk.,  Feb.,  1908,  p.  Ill)  regards  the 
iodin  preparations  as  being  very  useful  in  the  treatment  of  glaucoma, 
especially  of  the  hemorrhagic  form. 

IMoffat  {Borneo.  Eye,  Ear  and  Throat  Jnurn.,  July,  1908)  writes 
concerning  the  value  of  homeopathic  remedies  in  the  treatment  of 
glaucoma  and  the  application  of  the  principle  of  similia  similibus 
euranfur  to  the  therapeutics  of  this  affection.  He  gives  a  list  of  the 
principal  remedies  which  are  indicated  in  the  treatment  of  glaucoma, 
and  includes  among  them  aconite,  bryonia,  conium,  gelsemium,  potas- 
sium iodid.  osmium,  physostygmin,  rhododendron,  etc.  Tn  the  discus- 
sion of  his  paper  Norton  stated  that  he  had  used  gelsemium,  phos- 
phorus, iodid  of  potassium,  bryonia  and  spigelia  with  benefit.  Linnell, 
while  a  firm  believer  in  the  effici(>ncy  of  homeopathic  remedies  in  this 

Vol.  VII— 40 


5474  GLAUCOMA 

(lisciisc,  would  not  rely  iij)oii  lliciii  iiloiic  His  Ix'st  I'csults  were  from 
bi'voiiia,  jrclsciiiiuiM  and  osiiiiuni. 

CillxTt  ((Iracfc's  Ardiir  f.  OphllHil.,  \'ol.  I. XXX.  Part  2.  U)12) 
coiichidcs  fi'oin  cxtoided  clinical  ()l)sri'\-;it  ions  tliat:  1.  I'crifxlic  vcno- 
soction  rcuulation  of  blood  and  intraocular  pressure  is  of  value  in  the 
prodroMud  stage  of  the  disease,  not  to  the  exclusion  of  miotics,  however, 
and  li-eatment  of  tlie  genei-al  condition  accordin<;  to  Eversbuseh's 
rules,  2.  In  evolved  glaucoma,  venesection  should  be  tlie  first  thera- 
pentic  measure,  preceding  a  prospective  operation  for  glaucoma  simplex 
by  six  to  twenty-four  hours,  for  inflammatory  glaucoma  by  twenty-four 
to  forty-eight  bours. 

On  seventy-three  eyes  of  forty-one  i)atients.  Knapp  {Klin.  Moitatsbl. 
f.  Angenheilk.,  June,  p.  691,  1912)  used  the  "pressure  massage"  of 
Domec,  which  consists  of  applying  the  tlunnb  to  the  cornea  thi'ough 
the  closed  lid,  and  making  repeated  pressure  at  a  rate  of  about  100  to 
the  minute.  Tonometer  readings  were  taken  before  and  after,  and 
at  frequent  intervals  during  treatment.  In  a  few  minutes  massage 
of  normal  eyes  produced  a  pronounced  fall  of  tension,  the  average 
being  8.91  ram.  after  1,000  pressures.  The  fall  obtained  in  simple 
glaucoma  always  disappeared  within  fifteen  minutes,  and  in  acute 
glaucoma  a  result  was  seldom  ol)tained.  Oreater  and  more  lasting 
effects  were  obtained  after  operations  in  wliich  a  filtering  cicatrix  had 
been  aimed  at  (iridectomy  and  sclerectomy),  and  massage  is  recom- 
mended as  an  after-treatment  in  such  cases. 

On  the  basis  of  Fischer's  interpretation  of  glaucoma  as  due  to  an 
increase  in  the  normal  affinity  of  the  ocular  colloids  for  water,  Thomas 
{Jour,  of  Oph.  and  Oto-Laryngology,  Vol.  V,  p.  205,  1912)  used  sub- 
conjunctival injections  of  sodium  citrate  to  reduce  tension.  The  em- 
ployment of  this  salt  was  suggested  by  the  antagonism  existing  between 
acids  and  neutral  salts  as  regards  the  imbibition  of  water  by  colloids. 
After  instillation  of  cocain  and  adrenalin  solution  into  the  conjunctival 
sac,  from  5  to  15  drops  of  a  4.05  per  cent,  to  5.41  per  cent,  solution  of 
chemically  pure  crystallized  sodium  citrate  are  injected.  To  the  above 
writer's  nine  successful  cases  of  primary  and  two  of  secondary  glau- 
coma, Sedwick  (Ophthalmic  Record,  Vol.  20,  p.  32S.  1912)  adds  one 
of  acute  glaucoma  in  which  on  f«our  occasions  pain  was  controlled,  and 
tension  fell  in  a  few  hours.  Hut  the  pain  immediately  following  the 
injection  was  severe.  Grandclement  (Cliniqur  Opht(d.,  Vol.  18,  p.  275, 
1912)  reports  the  success  of  the  method  in  a  case  of  glaucoma,  secondary 
to  scleritis  and  in  which  a  number  of  other  measures  had  failed. 
Happe  (Archives  d'Ophtal.,  Vol.  32.  p.  457.  1912),  in  an  experimental 
study  covering  eight  normal   and   nijie  glauconuitons  eyes,  not   only 


GLAUCOMA  5475 

failed  to  confirm  Fisclu-r's  experience,  but  saw  a  distinct  rise  of 
tension  in  several  instances.  Where  lowerinor  of  tension  was  obtained, 
moreover,  it  was  decidedly  inferior  to  that  produced  by  eserin. 

A  special  method  for  combined  use  of  pilocarpin  and  dionin  in 
glaucoma  is  recommended  l)y  Yon  Arlt  (Arrhirrs  (VOphtnl.,  Vol.  '-Vl, 
p.  457,  1912).  During  introduction  of  tlie  drugs  compression  of  the 
lachrymal  canal ieuli  must  be  maintained.  One-thirtieth  grain  of 
powdered  pilocarpin  is  introduced,  and  eight  minutes  later  1/12  grain 
of  powdered  dioinn.  The  j)rocess  is  repeated  every  three  or  four  days, 
and  in  the  meantime  a  2  per  cent,  or  3  per  cent,  solution  of  pilocarpin 
is  instilled  evei"y  three  hours.  The  use  of  the  dionin  is  timed  so  that 
the  maximum  eifect  of  both  drugs  may  coincide. 

Dutoit's  experiments  (Zeitschr.  f.  Anqenheilk.,  Vol.  28,  p.  131,  1912) 
as  to  the  value  of  prolonged  administratioji  of  potassium  iodid  in  cases 
of  arteriosclerosis  with  or  without  glaucoma  were  in  part  favorable, 
but  generally  inconclusive.  Risley's  report  {Animls  of  Ophthul.,  Vol. 
XX,  p.  663,  1912)  of  prompt  relief  of  glaucoma  pain  by  the  high 
frequenc.y  current  Avas  duplicated  in  discussion  by  other  workers.  The 
recommendation  by  Weekers  (Cliniquc  Oplital.,  Vol.  18,  p.  282,  1912) 
of  the  internal  administration  of  chlorid  of  calcium  is  poorly  sup- 
ported. It  is  founded  on  a  demonstration  by  earlier  workers  that  the 
calcium  salts  inhibit  the  processes  of  transudation  and  exudation  else- 
where in  the  body. 

Still  more  recently  a  number  of  investigators  have  reported  upon  the 
non-operative  treatment  of  glaucoma.  Short  abstracts  of  these  papers 
may  be  found  in  the  Ophthalmic  Ycor-Bool\ 

Lawson  (Trans.  Oph.  Sac.  U.  K.,  Vol.  33,  p.  194,  1913)  gives  the 
history  of  a  case  of  bilateral  glaucoma  kept  in  check  for  thirteen  years 
Avithout  surgical  intervention ;  he  does  not  agree  Avith  the  attitude  of 
those  surgeons  who  insist  on  an  operation  so  soon  as  it  is  certain  that 
the  intra-ocular  tension  is  habitually  raised,  and  prefers  to  try  the 
effect  of  palliative  treatment,  provided  that  the  case  can  be  secured 
early  enough.  He  thinks  that  too  much  reliance  has  been  placed  on  the 
use  of  miotics,  and  too  little  on  the  general  management  of  the  patient. 
Eserin  should  be  used  in  the  smallest  doses  that  suffice  to  control  the 
rise  in  tension ;  fresh  solutions  must  always  be  employed :  instillations 
at  night-time  are  an  important  factor  in  obtaining  success. 

Fischer  (Annals  of  Ophihahnolociy.  Vol.  22,  p.  359,  1913)  is  in  favor 
of  rectal  injections  of  alkaline  hypertonic  sodium  chlorid  solution, 
combined  with  a  subconjunctival  injection  of  sodium  citrate  solution. 

Piccaluga  (Annali  rli  Otiahn.,  Vol.  42,  p.  335,  1913)  tested  the  post- 
operative effect  of  massage  in  two  series  of  cases,  one  consisting  of 


5476  GLAUCOMA 

patifrits  on  whom  tlic  L;i<^r;iii^T  si-lci'ci'loin y  foi"  ^'l;nii'oiii;i  li;i<l  Ijccii 
(lone,  and  tlic  other  of  patients  on  whose  eyes  ii-i(h'etoniy  liad  heon 
perfoniu'tl,  eithei"  as  a  trcatinent  for-  <,Haueoina  or  as  preliminary  to 
cataract  extraction.  In  the  ei<:hteen  patients  wlio  had  been  subjected 
to  either  simple  or  coml)ine(l  sclerectomy,  the  effect  of  massage  was 
always  a  considerable  diminution  of  the  tension,  which  in  some  eases 
continued  for  two  days  only,  and  in  otiiers  for  more  prolonged  periods. 
Of  the  sixteen  cases  of  simple  iridectomy,  seven  showed  an  increase  of 
tension  or  an  absence  of  change  following  massage,  while  in  the  re- 
mainder there  was  a  reduction  of  from  2  to  13  mm.  of  Hg.  Further- 
more, the  average  duration  of  the  reduction  after  massage  in  the  second 
series  was  much  less  than  that  in  the  Hrst  series.  In  three  cases  in 
which  sclerectomy  was  done  on  one  eye  and  iridectomy  on  the  other, 
a  marked  diminution  of  tension  was  produced  by  massage  in  the  scler- 
ectomized  eye,  and  none,  or  in  one  case  an  increase  of  tension,  in  the 
iridectomized  eye.  In  another  instance  a  greater  reduction  was  had 
in  the  sclereetomized  than  in  the  iridectomized  eye,  and  in  only  one 
case  was  an  almost  equal  reduction  obtained  in  either  eye  of  a  patient 
on  whom  the  two  respective  operations  had  been  performed. 

Calendoli  (Annali  di  Otfalm.,  Vol.  41,  p.  775,  1913)  studied  thirty 
cases  with  the  ophthalmometer  and  with  the  Schiotz  tonometer,  none 
of  the  patients  having  had  an  operation  on  the  eyeball.  From  the  use 
of  1  per  cent,  solutions  of  eserin  and  pilocarpin  in  nine  cases  of 
glaucoma,  the  action  of  both  drugs  is  stated  to  be  more  marked  the 
higher  the  tension,  at  any  rate  within  certain  limits.  There  may  be 
a  slight  and  transitory  rise  of  tension  during  the  first  few  hours  after 
use  of  the  drugs,  the  reduction  being  always  more  marked  after  such 
an  interval.  When  pilocarpin  is  combined  with  paracentesis,  the 
reduction  of  tension  is  greater.  The  action  of  eserin  is  stated  to  be 
less  constant  than  that  of  pilocarpin.  Hertel  {Jour.  Am.  Med.  Assoc'n, 
Vol.  61,  p.  231,  1913)  has  succeeded  in  causing  a  marked  reduction 
in  the  intra-ocular  pressure  in  animals  by  varying  the  food  and  by 
intravenous  injection  of  various  substances  which  modified  the  molec- 
ular concentration  of  the  blood.  This  remarkable  change  in  the  intra- 
ocular pressure  is  independent  of  the  general  blood-pressure,  and  it 
can  be  due  only  to  changes  in  the  processes  of  osmosis.  The  restvirch 
was  undertaken  to  seek  an  explanation  for  the  remarkable  drop  in 
intra-ocular  pressure  in  the  course  of  diabetic  coma  to  which  Krause 
and  Heine  called  attention  and  suggested  its  differential  importance 
in  coma  of  different  origins.  TJicca  (Archivw  di  Ottalmoloqui,  Vol. 
20,  p.  469,  1913)  investigated  the  action  of  ipotenina.  a  liquid  com- 
posed of  iodid  of  sodium,  nitrate  and  nitrite  of  sodium,  bicarbonate  of 


GLAUCOMA  5477 

sodium,  citral,  and  lubelin.  Toiiometric  measurements  of  rabbits'  eyes, 
before  and  aftt-r  using  the  preparation,  showed  instillation  produeed 
a  tliiuinution  of  intra-oeular  tension,  of  3  or  4  mm.  of  mereury.  llypo- 
dermie  injeetions  redueed  the  tension  (j  to  8  nnu.  The  action  was 
prolonged  for  several  days  after  instillation,  lu'peated  daily  injee- 
tions and  large  dosage  never  gave  rise  to  any  disturbance  or  any  sign 
of  intolerance.  Tristaino  {Archivio  di  Ottalmologia,  Vol.  20,  1913) 
made  tonometric  measurements  on  rabbits  and  on  clinical  cases  of 
glaucoma.  In  the  rabbit  subconjunctival  injections  of  a  lU  per  cent, 
solution  of  chlorid  of  calcium  were  made.  To  four  patients,  two  or 
three  teaspoonfuls  of  a  G  per  cent,  solution  in  water  and  syrup  were 
given  three  times  daily.  In  the  rabbits  subconjunctival  injections 
lowered  the  ocular  tension  from  4  to  8  mm.  of  Ilg.,  according  to  the 
frequency  and  strength  of  the  dose.  In  the  glaucoma  cases  a  marked 
lowering  of  tension  was  obtained,  the  total  reduction  varying  from 
20  to  45  mm.  of  Ilg.  ^larked  relief  from  pain  also  resulted,  together 
with  rapid  absorption  of  hyphema  in  a  case  of  hemorrhage. 

W.  C.  Posey  {Jour.  Am.  Med.  Assoc'n,  July  18,  1914)  has  sup- 
plemented his  earlier  reports  {rule  infra)  by  65  eases  of  glaucoma 
treated  by  non-operative  measures  with  a  further  account  of  18  cases 
now  reported  for  the  first  time.  One  was  observed  for  a  period  of 
18  years,  2  of  10  j'ears,  1  of  8  years,  1  of  7  years,  7  of  6  years,  1  of  5 
3'ears,  2  of  3  years,  2  of  2  years  and  1  of  1  j'ear. 

These  18  cases  presented  but  24  eyes  for  analysis,  some  of  the 
patients  having  already  lost  one  from  glaucoma  before  consultation, 
while  in  others  but  one  eye  was  affected.  Of  these  24  eyes,  13  showed 
but  the  rudiments  of  the  disease  at  the  first  examination,  the  glau- 
comatous process  was  moderately  advanced  in  8,  while  in  3  central 
vision  and  the  visual  field  were  greatly  compromised.  In  the  first 
group  practically  normal  vision  has  been  maintained  while  the  cases 
have  been  under  observation,  for  periods  ranging  from  5  to  18  years, 
an  average  of  7i/o  years.  In  the  second  group  of  8  eyes,  vision  has 
been  maintained  for  periods  ranging  from  2  to  10  years,  an  average 
of  about  4  years,  while  in  the  3  eyes  which  were  in  the  most  advanced 
stage  of  the  disease,  vision  has  been  maintained  for  periods  ranging 
from  1  to  6  years,  an  average  of  3  years.  It  should  be  noted  that  in 
2  out  of  these  3  eyes  the  disease  was  of  a  pronounced  hemorrhagic 
type  and  that  notwithstanding  this,  vision  is  still  maintained  in  1 
after  a  period  of  6  years  and  that  blindness  ensued  in  the  other  after 
the  maintenance  of  6  years  of  fair  vision. 

In  view  of  such  favorable  statistics  from  the  use  of  miotics,  when 
the  risks  and  complications  attending  all  operations  on  the  eye  are 


5478  GLAUCOMA 

considered,  as  well  as  the  possibility  of  error  in  the  dia^iosis  and 
operation  being  performed  on  eyes  with  merely  atrophic  nerves,  is 
operation  ever  justified  when  both  central  and  peripheral  vision  are 
normal,  without  trial  of  what  miotics  can  do? 

"In  11  eyes  in  which  the  disease  was  noted  as  being  moderately 
advanced,  in  the  first  group,  2  maintained  vision  for  8  and  10  years, 
respectively,  and  1  went  blind  in  2  years,  in  the  second  group  vision  has 
been  maintained  for  periods  ranging  from  2  to  10  years,  an  average 
of  about  4  years.  The  best  results  of  all,  relatively  speaking,  were 
attained  in  the  far-advanced  or  desperate  cases,  for  of  the  5  cases  so 
designated,  vision  and  field  were  maintained  without  further  loss  in 
1  ease  for  10  years,  and  in  a  second  wdth  but  slight  loss  during  the 
same  period.  In  the  remaining  3  eyes,  vision  has  been  maintained  for 
periods  ranging  from  1  to  6  years,  and  this  in  spite  of  the  fact  that 
in  2  of  the  latter  the  disease  had  assumed  a  hemorrhagic  type. 

"It  is  in  this  class  of  cases  that  iridectomy  has  been  attended  with 
such  bad  results,  and  w^hile  cyclodialysis  and  the  trephining  operations 
may  be  less  injurious,  I  shall  continue  to  employ  miotics  continuously 
and  energetically  until  convinced  by  the  report  of  a  series  of  suitable 
eases  that  operative  measures  have  proved  their  superiority.  ]\Iy 
observations  have  convinced  me  that  miotics  cannot  be  regarded  in 
any  sense  as  curative,  for  notwithstanding  their  continuous  use,  the 
glaucomatous  process  still  goes  on,  very  slowly,  it  is  true,  but  the  eye 
grows  steadily  harder,  the  excavation  becomes  broader  and  deeper 
and  the  anterior  chamber  shallower.  Again,  I  desire  to  emphasize 
what  I  have  already  said  elsewhere,  namely,  that  miotics  should  be 
relied  on  as  the  sole  means  of  treatment  only  in  those  cases  which  are 
free  from  attacks  of  so-called  glaucomatous  congestion,  the  presence 
of  such  congestive  symptoms  being  in  my  opinion  the  chief  indication 
for  some  form  of  operative  treatment,  be  it  irideetciny,  cyclodialysis 
or  trephining;  and  second,  that  to  gain  the  full  benefit  of  miotics  it  is 
necessary  that  they  should  be  administered  properly.  Beginning  in 
doses  small  enough  to  avoid  creating  spasm  of  the  ciliary  muscle,  and 
rapidly  increasing  the  dose  until  the  ]nii)il  of  the  affected  eye  is  strongly 
contracted,  this  degree  of  contraction  should  be  maintained  as  long 
as  life  lasts  hy  gradually  increasing  the  sti'ength  of  the  solution,  from 
time  to  time,  and  by  instillations  of  the  drug  at  intervals  of  every 
three  or  four  hours. 

"The  miotics  which  are  best  adapted  to  control  intraocular  tension 
are  ])liysos1igmin  (eserin)  salicylate  and  pilocarpin  nitrate.  This  salt 
of  physostigmin  is  more  persistent  in  its  eflPects  and  less  changeable  in 
solution  than  other  salts  of  the  drug  and  is  less  irritating  to  the  con- 


GLAUCOMA  5479 

juMctiva.  I  i)re.scribc  a  solution  ol'  |)ilocarj[)iii  to  be  used  about  every 
four  hours,  luoniing,  noon  and  eveiiin^^,  and  one  of  physosligmiu  of 
twice  tlie  strenj,4li  at  bedtinie,  tliereby  avoitling  in  a  measure  the  blur- 
ring of  vision  which  is  occasioned  by  the  action  of  the  pliysostigmin 
on  the  ciliary  muscle  tluring  the  di\y,  while  the  eye  receives  the  greatest 
effect  of  the  drug  during  the  eight  houi-s  or  more  which  elapse  between 
the  instillations  of  the  (li-()])s  during  tiie  iiight.  In  incipient  cases  of 
the  disease  an  excellent  initial  dose  is  that  of  Y-,  grain  of  pilocarpin  to 
the  ounce  of  water.  The  stivngth  should  be  gradually  increased,  so 
that  at  the  end  of  a  year  1  grain  to  the  ounce  is  employed,  at  the  end 
of  the  second  ye.ir  2  grains,  and  at  the  end  of  third  year  3  grains  to 
the  ounce  solution.  This  strength  will  suffice  to  maintain  the  pupils 
at  the  desired  i)oint  of  almost  pin-point  contraction.  Physostigmin 
should  be  enii)loyed  in  half  the  strength  of  pilocarpin  and  should  be 
increased  in  solutions  of  equal  pro])ortions. 

"Conjunctival  irritation  can  usually  be  avoided  l)y  employing  only 
fresh  and  sterile  solulions  of  the  miotics  and  by  frequent  cleansing  of 
the  conjunctiva  by  borie  acid  solution.  Should  such  irritation  arise, 
local  applications  of  ai-gyi'ol  and  Hushing  of  the  conjunctiva  witli  mild 
lotions,  conjoined  with  the  use  of  ice  compi'esses  and  a  weakened  dose 
of  the  miotic  will  usually  occasion  its  prompt  disappearance. 

"Gentle  massage  of  the  eyeball  is  of  decided  advantage  and  should 
be  practised  several  times  each  day,  for  five  minutes  at  a  time.  In 
addition  to  these  local  measures,  the  patient  should  be  instructed  as  to 
the  numbei-  of  houi's  daily  tile  eyes  should  be  used  in  near  vision.  x\ll 
near  work  should,  of  course,  be  restricted,  and  should  lie  carried  on 
only  under  tlu^  most  favorable  conditions  regarding  illumination, 
posture  of  the  ])atient,  etc. 

"Proper  lenses  should  ])e  adjusted  to  the  eyes  for  both  near  and 
far  use,  and  the  refraction  should  be  frequently  estimated  and  any 
error  corrected,  changes  in  the  refraction  being  rendered  frequent  by 
the  action  of  the  miotic  on  the  ciliary  muscle. 

"A  large  number  of  hours  daily  should  be  spent  in  the  open  air,  and. 
as  the  disease  is  fre(|uently  the  ocular  expression  of  chronic  rheuma- 
tism and  gout,  the  patient  should  be  urged  to  spend  the  greater  i)art  of 
the  year  under  the  most  favoral)le  climatic  conditions  to  comliat  that 
diathesis.  The  skin  should  be  kept  active,  the  gastro-intestinal  ap- 
paratus regidated,  and  any  local  soui'ce  of  inflammation  or  irritation, 
neighboring  on  the  eyes,  such  as  inflammation  in  the  nasal  passages 
or  their  accessory  sinuses,  should  be  allayed.  Particular  care  should 
be  given  to  tlie  peripheral  circulation,  nitroglycerin  and  strophanthus 
being  often  of  value.     Strychnin  should  be  administered,  not  oidy  on 


5480  GLAUCOMA 

account  of"  its  Mction  on  tlic  cii'dihition,  Imt  jilso  hccjmsc  of  its  influence 
on  the  optic  nci'Vc.  On  account  of  their  nntirficuniatic  |)i'()j)('rti('S, 
the  salicylates  are  of  decided  value  and  should  he  aduiinistered  fre- 
(|ucntly  for  continued  periods."  Sec,  also.  Posey's  reniai-ks  on  irulec- 
tuniij  v(  rsKs  iniotics,  under  operative  treatment  of  glaucoma. 

OPERATIVE   TREATMENT   OF   GLAUCOIVLV. 

When  general  treatment  and  local  applications  have  failed  to  relieve 
the  glauconuitous  symptoms  or  to  arrest  tlie  progress  of  the  disease, 
oi'  when  the  surgeon  is  satisfied  that  simple  measures  will  l)e  useles.s, 
immediate   operative   proceedings   should    be    advised. 

Oi)erations  for  the  cure  of  glaucoma  may  be  divided  into  three 
groups:  Those  on  the  anterior  half  of  the  eye;  those  on  the  posterior 
half;  and  those  on  the  sympathetic  system  of  nerves. 

Faruccntesis  of  the  cornea.  Efforts  to  decrease  the  hardness  of  the 
eyeball  by  permitting  some  of  the  contents  to  escape  after  a  simple 
puncture  of  its  envelope  have  been  made  for  a  century  or  more, 
Guerin,  of  Lyons,  according  to  de  Wecker,  having  employed  both 
corneal  and  scleral  i)uncture  for  this  ])urpose  as  early  as  1769.  In 
recent  years,  however,  since  it  has  become  apparent  that  the  effect  of 
the  procedure  is  but  transient,  it  has  l)een  entirely  superseded  by  other 
and  more  complicated  operations,  and  only  resorted  to  when  a  rapid 
and  evanescent  lowering  of  the  tension  is  desired.  The  puncture, 
which  lowers  the  tension  by  permitting  of  the  escape  of  aqueous  con- 
sequent u])on  the  opening  of  the  anterior  chamber,  is  designated  as 
paracentesis  of  the  cornea,  and  is  made  as  follows:  After  thorough 
cocainization  of  the  eye,  or,  if  the  eye  be  very  irritable  and  painful, 
after  etherization  or  general  anesthetization  by  a  more  rapidly  acting 
and  evanescent  general  anesthetic,  a  speculuin  is  introduced,  the  globe 
steadied  with  fixation  forceps,  and  the  cornea  incised  in  its  horizontal 
plane  1  or  2  mm.  from  tiie  liml)us,  by  a  small  keratome.  A  Desmarres 
paracentesis  needle,  which  consists  of  a  small  lance  with  an  abrupt 
thickening  of  the  base  to  prevent  the  needle  from  entering  too  deeply 
into  the  anterior  chamber,  was  formerly  employed,  but  either  this 
instrument  or  a  von  Graefe  cataract  knife  suffices.  The  aqueous 
should  always  be  permitted  to  run  off  slowly,  this  being  accomplished 
by  gently  pressing  the  posterior  flap  of  the  wound,  until  the  greater 
part  of  the  fluid  has  escaped,  and  by  tlie  slow  withdrawal  of  the 
knife. 

After  the  usual  toilet  of  the  eye  and  the  instillation  of  eserin 
fgr.  i  to  f.  ,-)i).  a  baiulage  is  apjilied.  Ordinarily  the  wound  will  close 
in  from  12  to  24  hours.     It  may  then  be  re-oi)ened  by  a  Daviel  spoon 


GLAUCOMA  5481 

if  llic  tension  lias  a^aiii  risen,  indeed  the  ]>araeentesis  may  be  repeated 
a  ninnlxT  of  times  if  tiie  necessity  arise. 

I ndlcdiions.  In  acute  glaiieoma  to  temporarily  lower  tension  t'oi' 
tile  purpose  of  deepening  the  chamher  and  lessening  the  congestion  of 
the  eye  hefoi'c  the  perfornumee  of  iridectomy.  Tn  secondary  glaneoma 
to  relieve  blocking  of  the  filtration  angle  from  lens  matter  or  intiain- 
matory  exudate  or  blood. 

OPERATIONS    WHICH    AIM     TO    EFFECT    A    COMMUNICATION    BETWEEN    THE 
ANTERIOR    CHAMBER    AND    TIIE    SUBCONJUNCTIVAL    SPACES. 

Anterior  schrofoniii.  ("onsidei'ing  that  tlu'  relief  of  tension  follow- 
ing iridectomy  resulted  more  from  the  incision  of  the  sclera  and  the 
opening  of  the  spaces  of  Fontana  than  from  the  excision  of  a  piece 
of  the  iris,  de  Wecker  (Traite  des  Maladies  des  Ycux,  1867)  in  1867 
introduced  an  operation  which  he  termed  anterior  sclerotomy,  where))y 
he  aimed  to  establish  a  cicatrix  in  the  angle  of  the  anterior  chamber 
through  which  the  intraocular  fluids  could  filter  out  of  the  eye.  In 
the  following  year,  Stellwag  von  Carion  practised  this  operation  on 
the  living  subject,  and  two  years  later,  in  1871,  Quaglino  reported  five 
cases  of  glaucoma  which  he  had  successfully  treated  by  sclerotomy. 
During  this  year  de  Wecker  modified  his  original  operation  some- 
what to  avoid  the  prolapse  of  the  iris  which  had  attended  some  of  his 
earlier  incisions.  This  modification  of  the  opcu'ation.  which  has  been 
widely  practised  by  others,  is  performed  as  follows:  After  the  pupil 
has  been  contracted  ad  maximum  with  a  miotic,  and  the  eye  cocainized, 
the  lids  are  separat(>d  with  the  speculum,  and  the  globe  steadied  by 
grasping  the  liull)ar  conjunctiva  a  few  mm.  distant  from  and  below 
the  lower  limbus  of  the  cornea.  A  narrow  von  Graefe  cataract  knife 
is  introduced  1  nun.  from  the  outer  corneal  limbus,  as  i-epresented  at 
a  in  the  figure  and  made  to  emerge  at  h,  at  the  other  side  of  the  anterior 
chamber.  The  incision  is  then  continued  ui)wards  with  slow  sawing 
movements,  the  cutting  edge  of  the  knife  l)eing  directed  somewhat 
anteriority,  until  only  a  bridge  of  tissue,  about  2  mm.  broad  remains  at 
c,  this  being  left  undivided  to  prevent  iris  prolapse.  After  the  aqueous 
has  been  permitted  to  escape  from  the  eye  by  cautiously  tilting  the  edge 
of  the  knife  slightly  forward,  the  knife  is  slowly  withdrawn.  If  the 
pupil  is  round,  eserin  is  instilled  and  a  bandage  applied,  but  if  it  be 
oval  or  irregular,  indicating  a  tendency  of  the  iris  to  prolapse,  the 
membrane  should  lie  gently  stroked  liy  a  spatula  and  attempt  made  to 
restore  the  ])upil  to  its  noi'inal  form,  in  the  I'are  eases  that  actual 
prolapse  of  the  iris  occurs,  the  prolapsed  portion  should  be  excised  at 
once,  and  the  sclerotomy  converted  into  an  iridectomy.     Wiegman  {Kl. 


1482  GLAUCOMA 

Monatshl.  f.  A  iKji  uln  ilk ,  1S!)T,  p.  277)  rccoimru'iKls  making  the  inci- 
sion witli  a  ilouble  kcratomc  which  he  dcsif^ncd  for  the  purpose 

Complications  of  anterior  sclerotomy,  lu  addition  to  prolapse  of 
the  iris  which  lias  just  been  referred  to,  when  the  chamber  is  very 
shallow,  tile  operator  may  fail  to  enter  the  anterior  chamber,  the  knife 
being  insertetl  instead  into  the  deeper  layers  of  the  cornea.  To  avoid 
this  accident  and  also  its  converse  of  making  the  incision  too  far 
posteriorly  and  thereby  wounding  the  lens,  the  best  of  illumination  is 
necessary  and  the  operator  will  do  well  to  resort  to  the  condensation 
of  artificial  light.  In  case  the  operator  gives  a  wrong  direction  to  his 
knife  and  splits  the  cornea  or  makes  what  is  known  as  the  interlamellar 
incision,  the  knife  may  be  withdrawn  and  re-entered  at  a  better  angle. 
Should,  however,  the  chamber  have  been  opened  and  aqueous  per- 
mitted to  escape,  the  knife  should  be  withdrawn  and  the  operation 
postponed  until  the  chamber  has  reformed.  The  same  delay  is  ad- 
vised if  the  operator  realizes  in  time  to  desist,  that  the  counter- 
puncture  has  been  made  too  posteriorly.  (See  p.  509  of  this  Ency- 
clopedia.) 

After  the  toilet  of  the  eye  and  the  instillation  of  a  miotic,  a 
bandage  is  applied,  the  dressing  being  removed  at  the  end  of  24 
hours.  The  lips  of  the  wound  may  be  found  coaptated,  and  healing 
may  be  perfected  so  that  the  thin  cicatrix  is  barely  visible.  Oftener 
perhaps  there  is  a  gaping  of  the  wound  and  the  condition  described 
by  de  Wecker  as  a  filtration-cicatrix  forms.  This  is  less  pronounced 
than  the  cystoid  cicatrix  which  is  observed  after  the  prolonged  and 
imperfect  healing  of  incisions  and  wounds  of  the  eyeball,  and  consists 
of  a  broadening  and  elevation  of  the  sear  with  a  slight  bulging  of  the 
conjunctiva.  De  Wecker  claims  that  such  a  cicatrix  affords  the  maxi- 
mum amount  of  drainage  for  the  intraocular  fluids,  though  he  also 
asserts  that  a  considerable  degree  of  leakage  may  be  attained  through 
even  a  closely  miited  scar. 

Indications.  According  to  de  Wecker,  anterior  sclerotomy  is  particu- 
larly indicated  prior  to  iridectomy  when  the  tension  is  very  high  and 
the  anterior  chamber  shallow.  In  clironic  glaucoma  in  com])ination 
with  miotics,  lie  considered  it  to  be  the  operation  of  choice.  He  also 
recommends  it  in  hydrophthalmus,  in  hemorrhagic  glaucoma  and  in 
cases  of  al)solute  glaucoma  to  lessen  pain.  Finally,  he  commends  its 
performance  in  the  ])rodromal  jieriod  of  inflammatory  glaucoma  when 
miotics  are  williout  effect. 

After  operating  on  a  large  number  of  cases,  Panas  (Maladies  des 
Yeu.r,  p.  r)21)  concluded  tliat  aiitci'ior  sclei-otomy  occupies  the  middle 
place  between  a  large  peripheral  iridectomy  and  repealed  paracentesis 


GLAUCOMA  5483 

of  tlie  cornea.  In  diroiiii'  <rlauc()iiia,  lie  i'oiiiiil  that  it  was  a  useful 
supjjlenient  to  mioties.  In  liydroplitlialinus,  however,  it  was  as  value- 
less as  all  forms  of  operation,  aiul  in  his  opinion  did  not  remove  the 
necessity  of  enucleation  in  absolute  glaucoma.  Although  at  one  time 
extensively  i)ractised,  especially  by  French  surgeons,  sclerotomy  has 
now  but  few  advocates,  as  iridectomy  with  a  scleral  section  has  been 
shown  to  possess  all  the  advantages  of  sclerotomy,  while  affording  at 
the  same  time  a  possi])ility  of  re-esta])lishing  a  communication  between 
the  anterior  chamber  and  the  canal  of  Schlemm. 

Modifications  of  the  operation.  Quaglino's  {Ann.  di  Ottal.,  1871,  I, 
p.  200)  incision  was  much  the  same  as  is  usually  employed  for  iridec- 
tomy and  was  made  with  a  large  triangular  keratome,  the  knife  being 
entered  2  mm.  behind  the  limbus.  During  the  withdrawal  of  the 
keratome,  the  handle  was  tilted  back  to  raise  the  blade,  and  prolapse 
of  tlie  iris  guarded  against  by  permitting  the  aqueous  to  flow  slowly 
otH'.  Despite  this  precaution,  however,  and  the  use  of  eserin,  prolapses 
were  frequent,  necessitating  excision  of  the  prolapsed  portion  of  the 
iris. 

Snellen  (Bericht  dcr  International  Ophthahn.  Kongnss.  Heidelberg, 
1888,  p.  244)  adopted  Quaglino's  method,  as  he  found  it  less  liable  to 
induce  prolapse  of  the  iris.  He  treated  a  series  of  cases  of  bilateral 
glaucoma  by  iridectomy  on  one  eye  and  sclerotomy  on  the  other  and 
found  that  better  vision  was  obtained  by  the  latter.  He,  therefore, 
recommended  sclerotomy,  repeated  if  necessary  as  the  initial  operation, 
resorting  to  iridectomy  only  wdien  the  sclerotomy  failed  to  prevent  a 
rise  of  tension. 

Bader  {Hoijal  Lond.  Bosp.  Reports,  Vol.  VIII,  p.  430)  followed  de 
Wecker's  method  in  its  essential  details,  but  aimed  at  making  the 
corneal  puncture  and  counter-puncture  as  near  as  possible  to,  and  in 
front  of,  the  insertion  of  the  iris.  He  endeavored  to  leave  a  large 
bridge  of  conjunctiva,  stretching  across  the  sclerotic  incision,  and, 
with  this  in  view,  divided  an  extent  of  sclerotic  equal  to  nearly  a  third 
of  the  circumference  of  the  cornea. 

:\rartin  (Annal.  dVcul,  Vol.  XXXI,  1880,  p.  236)  precedes  scler- 
otomy by  paracentesis  with  a  Desmarres  needle  introduced  into  the 
cornea  at  the  vertical  meridian  1  mm.  from  the  limbus.  If  aqueous 
still  remains  after  withdrawal  of  the  needle,  he  permits  it  to  drain  off 
by  the  aid  of  a  lance.  The  wound  is  then  enlarged  witli  one  or  tv>o 
cuts  of  the  iris  scissors. 

Both  Panas  (Soe.  Franc  d'Ophtahn.,  1883)  and  de  Wecker  {Annal 
d'Oculistique,  1885,  p.  10)  advocated  the  operation  of  cicatrisotomie, 
or  outetomie,  when   rise   of  tension   persists  after  iridectonn-.      This 


5484  GLAUCOMA 

consists  ill  iiicisiiiL,''  the  cirjitrix  \\i1li  ;i  luirrow  (ir;irf'r  kiiit'c,  in  oi-dcr 
to  divide  tile  iittncliiiicnts  of  the  iris  in  lln-  ;in<,di'  of  liic  cicalrix,  the 
conjuiu'lival  bridge  licinji-  left  undistiirlicd.  The  writer  lias  found  tins 
l)rot'c'diirt'  of  value  in  the  several  cases  in  w  liich  he  has  resorted  to  it. 

In  cases  of  j^daucoina  simplex  of  a  suspected  malignant  type,  Ptliiger 
{Bericht  der  Oplitluihn.  GclseJ,  1882,  Vol.  16,  p.  152)  incises  the  cornea 
as  if  for  a  broad  iridectomy,  but  withdraws  the  linear  knife  with  which 
the  incision  is  iiijidc  bcfoi'e  the  section  is  coiii|)lctcd.  If  no  decrease  in 
tension  occurs  after  the  esca])c  of  aqueous,  lie  considers  the  operation 
completed.  Should,  however,  the  tension  fall,  the  incision  is  finished 
and  the  iris  excised. 

Irido-sclcrotomij.  As  a  satisfactory  substitute  for  iridectomy,  and 
without  disadvantages  of  prolapse  of  the  iris  and  the  formation  of  a 
cystoid  cicatrix,  Panas  {Arch.  d'Ophtalm.,  Vol.  IV,  1884,  p.  481) 
devised  this  operation,  which  consists  essentially  of  combining  a  de 
Wecker's  sclerotomy  with  iridotomy  for  the  relief  of  high  tension 
in  eyes  with  extremely  shallow  or  obliterated  anterior  chambers,  such 
as  occurs  in  pupillary  occlusion  when  the  posterior  chamber  is  enlarged 
as  a  consequence  of  over-accumulation  of  aqueous.  The  incision  is 
made  with  a  Grraefe  knife  below  and  to  the  outer  side,  equidistant  from 
the  horizontal  meridian  and  the  lower  limbus.  As  soon  as  the  point 
of  the  knife  enters  the  anterior  chamber,  it  is  plunged  through  the  iris 
8  to  10  mm.  back  of  this  membrane  and  then  made  to  perforate  the 
iris  a  second  time  at  the  counter-puncture,  which  is  situated  at  a  point 
corresponding  to  the  incision.  The  limbal  tissues  are  next  incised,  as 
in  an  ordinary  sclei'otomy,  to  an  extent  of  2  to  8  mm.  Finally,  the 
cutting  edge  of  the  knife  is  turned  somewhat  anteriorly  and  as  the 
instrument  is  slowly  withdrawn,  the  remaining  bridge  of  iris  ti.ssue  is 
completely  divided,  a  retraction  of  the  central  jiortion  of  the  iris 
indicating  that  this  has  been  accomplished. 

Iiidicatw)is.  Panas  claimed  that  this  operation  was  applicable  to 
cases  in  which  the  inci-eased  tension  was  dep(>ndent  ujjou  an  excessive 
accumulation  of  the  aqu(»ous  humor,  esjiccially  when  the  anterior  cham- 
ber was  very  shallow.  It  entailed  but  little  risk  of  injury  to  the  li'us. 
He  thought  it  ])articularly  ada])ted  to  all  cases  of  adherence  of  the 
iris  with  abolition  of  the  anterior  chamber,  as.  for  (»xam]de,  in  corneal 
staphylonui.     It  may  also  be  perfoi'ined  as  a  i)reliminarv  to  iridectomy. 

Scleriritoniy.  A  quite  similar  oi)eration  has  also  been  described  by 
Knies.  The  steps  of  his  method  are  as  follows  :  Aftci-  the  pupil  has  been 
well  contracted  with  eserin,  a  very  ])eri|)heral  incision  is  made,  j^refer- 
abl\-  above,  either  with  a  von  (Iraefe  oi-  a   i>eer's  knife.      The  incision 


GLAUCOMA  5485 

engages  tlic  iris  jiiid  a  sort  oC  irido-dialysis  results  from  tlic  division 
of  the  root  of  the  iris  from  the  sidera. 

De  Wecker  regarded  this  operation  with  disfaxor  on  account  of 
the  very  evident  dang^^r  of  injury  to  tlie  h-ns.  A  somewhat  siniiUir 
procedure  to  irido-sch-rotomy  was  also  introduced  hy  Xicati  {Rev. 
giniralc  d'Ophtalm.,  18!)4,  p.  8,  ref.  Jahrcsbrr.  f.  Ophtahn.,  1894,  p. 
401)  in  1894.  This  operation,  wliich  was  termed  scleriritomy,  was 
particuhirly  advocated  in  staphylomata,  tliough  found  hy  its  inventor 
to  he  of  service  in  ordinary  glaucoma. 

The  essential  difference  in  the  incision  i)lanned  l)y  Nicati  is  that 
the  iris  is  incised  from  hefore  backwards  instead  of  from  behind  for- 
wards, as  in  the  Knies  {Brricht  d<v  OpJithalm.  Gcsscl,  189.'},  p.  118) 
and  Panas  procedures.  The  incision  is  made  precisely  as  in  an  ordinary 
sclerotomy,  but  in  withdrawing  the  knife,  it  is  given  a  rapid  quarter 
turn,  so  that  its  plane  is  l)rouglit  at  a  right  angle  to  that  of  the  iris 
with  the  edge  backw^ard.  After  the  aqueous  has  escaped,  the  knife 
is  rapidly  withdrawn,  incising  the  root  of  the  iris.  The  lips  of  the 
wound  are  now  made  to  gape  so  that  the  blood  may  be  permitted  to 
escape  from  the  antei'ior  cham])er. 

Combined  sclcroto»uj  of  elc  Wecker.  In  1894  de  Wecker  [Anned. 
(VOcul.,  1894,  C.  XII,  p.  261)  introduced  another  operation,  which  has 
for  its  object  the  production  of  artificial  dialysis.  After  the  pupil  has 
been  contracted  with  eserin  and  the  eye  cocainized,  de  Wecker  intro- 
duced the  6  nun.  broad,  stop-knife  which  he  especially  designed  for 
the  purpose,  1  mm.  l)ehind  the  upper  limbus,  and  the  incision  was 
made  as  for  ordinary  iridectomy.  After  the  aqueous  has  flowed  off 
slowly  to  prevent  iris  prolapse,  a  very  delicate  iris  forceps  with  prongs 
well  rounded  off  at  the  extremity  are  introduced  into  the  anterior 
chamber  and  a  fold  of  iris  seized  2  mm.  from  the  limbus.  The  iris  is 
then  gently  drawn  toward  the  center  of  the  cornea  and  traction  made 
until  its  periphery  is  detached  from  its  root  to  the  extent  of  6  or  8 
mm.  A  profuse  hemorrhage  usually  follows,  filling  the  anterior  cham- 
ber. The  forceps  are  then  opened  to  prevent  the  iris  being  drawn  back 
again  to  the  peripliery  and  held  for  a  few  minutes  in  the  incision  to 
facilitate  the  escape  of  blood  and  prevent  the  severed  iris  from  pro- 
lapsing. 

Incision  of  the  iris  anfjle.  This  operation,  devised  by  de  Vincentiis 
(Annali  di  Ottalm.,  1898,  XXII,  p.  540)  in  1895  and  termed  1)y  him 
incisione  dell'angolo  irideo,  aims,  as  its  name  indicates,  in  the  incision 
of  the  tissues  within  the  iris  angle.  For  this  purpose  de  Vincentiis 
employed  an  instrument  with  a  needle-like  shaft,  at  the  extremity  of 
which  is  attaclied  a  small,  siekle-sliaped.  curved  blade  with  the  cutting 


5486  GLAUCOMA 

siii-fcicc  on  tlif  coiiNTx  side,  tlic  shaft  liciiij;  devised  to  completely  close 
tlie  incision  made  by  tile  cutting  portion  so  as  to  prevent  the  escape 
of  a(}ueous.  After  cserinization  and  cocainization,  the  puncture  is 
made  ol)li(|uely  tliroufjli  tiic  sclera  1.5  mm.  from  the  limbus  on  a  level 
witii  file  horizontal  diameter  of  the  coi-iiea  and  made  to  enter  the 
antei'ior  clnunber.  (When  opcra1in<r  on  the  left  eye,  the  entrance 
puncture  is  made  down  and  out ;  on  the  right  eye,  the  operator  stand- 
ing behind  the  patient's  lieacl  and  operating  witli  the  right  hand,  up 
and  out.)  The  point  of  the  knife  is  then  passed  across  tlie  chamber 
and,  by  giving  the  handle  a  slight  rotary  motion,  incisions  are  made  of 
1  or  more  mm.  in  deptli  into  tlie  tiss\ies  of  the  anterior  chamber.  As 
the  instrument  is  withdrawn,  the  convex  cutting  edge  is  made  to 
sweep  around  the  periphery  of  the  chamber,  incising  the  angle  from 
the  point  of  first  incision  almost  to  the  entrance  puncture.  Eserin 
should  be  instilled  for  some  days  after  the  optn-ation. 

Tailor  {Anudli  di  Ottalni.,  1891,  XX,  p.  117),  de  Vincentiis'  assist- 
ant, gives  the  following  indications  for  this  procedure — prodromal, 
acute  and  chronic  irritative  glaucoma;  hcMiiorrhagic  glaucoma;  chronic 
glaucoma  simplex;  secondary  glaucoma  in  so-called  iritis  serosa  (cycli- 
tis)   and  anterior  sclerotico-choroiditis. 

Czermak  {Augcnartzliche  Operatiancn,  Vol.  IT,  p.  234),  however, 
thinks  that  an  exact  performance  of  this  operation  would  only  be 
possible  in  eyes  with  free  anterior  chambers,  in  which  high  tension 
is  not  the  result  of  attachments  of  the  iris  root,  but  due  to  other  causes, 
as,  for  instance,  a  blocking  of  the  meshes  of  the  pectinate  ligament. 
Where  the  iris  root  is  adherent,  he  claims  the  operation  could  easily 
result  in  extensive  irido-dialysis. 

From  an  anatomical  examination  made  on  16  dead  infants'  eyes, 
upon  which  they  had  performed  the  de  Vincentiis  operation  and  de 
Wecker's  sclerotomy,  Valude  and  Duclos  (Ann.  (VOcul.,  1898,  XTX. 
p.  98  and  241)  conclude  that  the  same  result  is  obtained  from  either 
operation  and  that  either  may  l)e  termed  an  incision  of  the  iris  angle. 
Clinical  experience  proved  the  procedure  of  value  in  their  hands  in 
prndi-omal  and  in  some  cases  of  chronic  glaucoma,  and  they  deemed 
it  worthy  of  trial  in  hydrophthalmus. 

OPERATIONS    WHICH    AIM    Td    KI'I'ICCT   A    COMMUNICATION    BETWEEN 
THE    ANTERIOR   CHAMBER   AND   VITREOUS. 

Sclcro-cydo-iruHc  puncture.  Chibret  {XII  Intern.  Congress,  Sect. 
XI,  OpJithal.,  1898.  p.  29)  effected  a  communication  between  the 
posterior  and  anterior  chaiiibeis  by  making  a  Hat  puncture  by  means 
of  a  double-edged  knife  3  to  4  nun.  from  the  limbus,  through  the  sclera 


GLAUCOMA  5487 

into  the  aufjle  of  tlic  aiitcrioi-  cliainhcr.  Tlic  knife  is  gnii<^G(l  towards 
the  anterior  surface  of  the  iris,  tiie  thickest  portion  of  which  is  speared 
and  the  iris  piiUed  towards  the  pupillary  center,  thereby  loosening  the 
attachment  of  the  iris  I'oot  to  the  posterior  corneal  surface ;  stronger 
tugging  sometimes  causes  iridodialysis.  This  i)rocedure  is  repeated 
in  5  to  6  meridians.  Severe  hemorrhage  into  the  anterior  chamber 
usually  follows.  Tension  is  markedly  decreased  in  from  20  to  40  hours, 
and  vision  continues  to  improve  for  8  days  after  the  operation.  The 
operation  is  repeated  if  the  first  procedure  is  unsucei^ssful ;  in  very 
rare  cases  is  a  third  operation  necessary. 

The  Stcrns-Scmmcreole  sclcrotcmiia  antero-postcrior.  This  operation 
is  done  after  an  ineffectual  iridectomy,  and  consists  in  the  introduction 
of  a  Graefe  knife  (2  mm.  within  the  lim])us)  into  the  anterior  chamber 
in  the  region  of  the  coloboma.  The  knife  is  then  passed  posteriorly 
into  the  vitreous.  The  procedure  resembles  Antonelli's  (Ecvue  genfrale 
d'Ophtalm.,  189(),  ]>.  885)  peripheral  iritomy  (iritomie  peripherique), 
and  should  perhaps  only  be  attempted  in  blind  eyes,  because  of  the 
liability  of  producing  a  traumatic  cataract.  Antonelli  employed  a 
doul)le-edged  lance,  which  he  introduced  in  the  sclero-corneal  region 
nearly  perpendicular  to  the  surface  of  the  globe. 

The  point  of  the  knife  is  thrust  into  the  chamber,  into  the  tissue  of 
tile  iris,  and  its  base  incised  by  sweeping  the  knife  arovnid  the  periph- 
ery of  the  chamber  to  the  extent  of  5  to  6  mm. 

A  similar  section  of  the  iris  root  by  means  of  a  lance  knife  intro- 
duced y)erpendi('ularly  into  the  vitreous  tlirough  the  cornea,  scleral 
]iml)us,  sclera  and  ii'is-zonula  was  attempted  by  Schnabel  (1868-9)  in 
a  small  numlier  of  eyes  with  absolute  glaucoma,  as  well  as  in  glaucoma 
after  perforating  serpent  ulcer,  but  because  of  the  uncertainty  of 
results  he  soon  abandoned  the  operation. 

Hern's  operation.  Hern  (IX  Internat.  Congress  of  Ophthdhnol- 
ogy,  Utrecht,  Aug.,  181)9)  aimed  at  re-establishing  the  connection 
between  the  anterior  chanilier  and  the  vitreous  hy  means  of  what  he 
termed  a  corneo-ii-ido-vitreous  puncture.  This  wns  accomplished  as 
follows:  After  iridectomy,  he  introduc(Ml  a  donble-edged  (iraefe 
cataract  knife,  alwut  one-lliird  to  one-<|uarter  the  size  of  the  ordinary 
instrument,  through  the  cornea  about  a  line  interval  to  the  sclero- 
corneal  junction,  tlirough  the  cololioma,  into  the  circumlental  space. 
Care  should  be  exercised  that  the  needle  enters  the  cornea  with  its 
long  diameter  parallel  to  the  antero-posterior  axis  of  the  globe,  and 
with  its  cutting  edg(>  lateral,  so  that  wIkmi  the  vitreous  chamber  has 
been  entered  a  lateral  movement  of  the  handle  increases  the  extent  to 


5488  GLAUCOMA 

wliicli   ihc   lilt  r;iti()ii   aii<,'lc   is  opnicd    up  jiud   tlic  coiiiicctioii   Itctwccn 
llif  t'liamlHTs  established. 

hidf  (fo)))!/.  In  1856  Albivcht  von  (jraefe  {Arcliiv  f.  Oplilluilm., 
III.  2,  is.')?,  p.  456)  discovered  that  irideetomy  is  capable  of  curing 
glaucoma.  This  must  undoubtedly  be  regarded  as  the  greatest  contri- 
bution which  has  been  made  to  ophthalmic  science,  for,  while  other 
measures  and  operative  procedures  have  been  introduced  to  combat 
this  disease,  the  experience  of  more  than  half  a  century  has  served 
to  convince  the  ophthalmic  world  that  this  operation  is  the  most  potent 
procedure  of  all.  The  distinguished  discoverer  of  the  operation  was 
led  to  the  supposition  that  iridectomy,  by  reducing  the  intraocular 
tension,  might  be  beneficial  in  glaucoma  as  a  result  of  the  observation 
that  partial  staphyloma  of  the  cornea  sometimes  flattens  after  iridec- 
tomy is  performed.  As  will  appear  later,  the  full  reason  of  the  effi- 
cacy of  iridectomy  in  glaucoma  is  still  in  doubt ;  the  fact,  however,  of 
the  cure  of  glaucoma,  especially  in  its  acute  form,  b}'  iridectomy  is 
established,  and  von  Graefe  must,  therefore,  be  regarded  as  one  of  the 
greatest  benefactors  of  the  human  race. 

Before  resorting  to  iridectomy  in  glaucoma  of  an  inflammatory 
type,  and  particularly  if  the  tension  is  very  high,  it  is  usually  desirable 
to  reduce  the  tension  somewhat  by  other  means  before  entering  the 
very  narrow  anterior  chamber  with  a  knife  and  excising  a  portion 
of  the  iris.  This  may  be  accomplished  in  a  variety  of  ways.  Undoubt- 
edly the  surest  and  quickest  of  these  is  posterior  sclerotomy,  and 
a  number  of  operators,  among  whom  may  be  mentioned  Priestley 
Smith  and  Arnold  Knapp,  make  puncture  of  the  sclera  a  uniform 
procedure  before  iridectomy,  the  incision  being  practised,  24  to  48 
hours  in  advance  of  the  iridectomy. 

iliotics,  too,  are  of  great  value,  often  reducing  the  glaucomatous 
process  in  a  few  hours  sufficiently  to  permit  of  operation.  They 
should  be  invariably  instilled  into  both  eyes,  as  their  use  in  the  un- 
affected eye  may  prevent  a  ])ost-o])('rative  acute  attack  of  glaucoma, 
which  has  been  observed  not  infrequently  within  a  few  hours  after 
operation  on  the  affected  eye.  One  or  two  drojis  of  solution  of  eserine 
(gr.  i  to  f.  .-)  i)  oi"  of  ])ilocarpine  (gr.  ii  to  f.  ,")  i)  may  be  employed 
and  should  l)e  instilled  into  the  eyes  every  hour,  until  the  pupils 
become  small  and  the  inflammatoi-y  signs  less.  It  nnist  be  cautioned, 
however,  tliat  even  tliougli  this  plan  of  treatment  causes  the  glaucoma- 
tous symptoms  to  disajijx'ar,  it  is  unwise  to  postpone  operation  in  the 
inflammatory  types  of  glaufoina  and  to  I'ely  upon  the  contiiuious  use 
of  miotics,  foi-,  while  in  a  few  cases  api>arently  fav(U-able  results  have 
l)een  obtained  by  tliis  iiicaiis.  in  the  majority  tlie  ghiucomatous  process 


GLAUCOMA 


5489 


Instruments  for  Iridectomy,     a,  von  Graefe  cataract  knife,     b,  Angular  lance 
knife,     c,  d,  e,  Iris  forceps,     f,  Tyrrell's  blunt  iris  hook,     g,  Curved  scissors  for 
excising  the  iris,     h,  de  Wecker's  scissors  (pince-ciseaux).     i,  Combined  spatula 
and  blunt-pointed  probe. 
Vol.  VII — 11 


5490 


GLAUCOMA 


will  develop  insidiously  in  si)itc'  of  the  druf;,  and  the  afllicsions  bet  ween 
the  root  of  the  iris  and  the  eornea  will  become  closer,  and  the  excava- 
tion in  the  head  of  the  nerve  deeper  until  vision  is  hopch-ssly  com- 
promised. Cocaine  (3  to  5  gr.  to  f.  .'>  i)  may  be  used  in  conjunction 
with  the  miotics,  increasing  their  action  on  the  pupil  and  relieving 
pain  (Wood's  System  of  OphtlKihnic  Th/  rap(  utics,  p.  810).  The  ben- 
efits to  be  derived  from  llie  lymphagogic  effects  of  dionin  have  been 


Iridectomy  for  Glaucoma.     Beginning  of  the  Incision. 

The  lancet  is  applied  slantingly  against  the  sclera  at  a  distance  of  at  least 
1  mm. 


highly  lauded  by  Peter  Callan  and  Casey  AVood  and  this  drug  should 
be  frequently  instilled  in  from  5  to  10  per  cent,  doses.  ^Massage  of  the 
eyeball  is  also  of  advantage,  and  hot  compresses  should  be  applied 
almost  continually.  In  addition  to  these  local  measures,  the  patient 
sliould  be  placed  in  bed,  the  temple  leeched,  and  morphin  and  chloral 
administered  internally  to  relieve  pain  and  secure  sleep.  Priestley 
Smith  advises  a  dose  of  sulphonal  or  of  chloral  hydrate  an  hour 
before  the  operation,  so  as  to  produce  some  degree  of  drowsiness,  the 


GLAUCOMA 


5491 


patient  tlicii  taking  ctlicr  oi'  cliloroi'onn  more  quietly,  and  the  ten- 
dency to  voMiitinjJC  or  exeiteinent  aftei'wards  beinjif  often  avoided.  Full 
doses  of  salicylate  of  soda  should  also  Ije  administered  to  control  the 
inflammatory  process  and  relieve  pain.  The  bowels  should  he  freely 
opened. 

Ancsllnsid.  in  iridcclunti/.     While  local  anesthesia  has  the  advantage 
of  enahlini,'  the  operator  to  gain  the  co-operation  of  the  patient  dur- 


Method  of  holding  the  bent  keiatonie  for  incision  of  the  upper  corneal  margin. 
(Czermak.) 

ing-  the  performance  of  the  operation,  and  by  its  use  the  vomiting, 
which  is  often  so  troublesome  after  ether,  is  avoided,  it  is  frequently 
difficult  to  produce  perfect  anesthesia  by  cocaine  on  account  of  the 
imperfect  absorption  of  the  drug  by  reason  of  the  high  tension.  Gen- 
eral anesthesia,  therefore,  should  be  employed  unless  contra-indicated 
by  some  grave  systemic  condition,  in  all  cases  where  the  glaucoma 
is  of  a  congestive  type,  for  this  procedure,  simple  as  it  appears,  is 
one  of  the  most  ditificult  which  the  surgeon  is  called  upon  to  perform 


5492  GLAUCOMA 

jiiid  (Icmaiids  lliat  tin-  eye  Ix'  absolutely  <|ui('t  until  the  excision  of 
the  iris  is  completed.  Where  serious  renal  or  cartiiac  disease  is 
present,  it  is  usually  advisable  to  delay  the  iridectomy  for  a  time,  and 
to  reduce  tension  and  lessen  the  inflammatory  syinptoms  by  an  imme- 
diate posterior  sclerotomy. 

General  narcosis  should  always  be  employed  in  children  and  in 
nervous  and  ignorant  subjects.  Cocaine,  2  per  cent.,  may  be  used  in 
combination  with  adrenaline  chlorid,  1/3,000,  but  a  miotic  should  be 
administered  at  the  same  time  in  cases  where  the  inflammatory  symp- 
toms are  not  pronounced,  or  where  a  general  anesthetic  is  contra- 
indicated. 

For  the  successful  performance  of  iridectomy  in  glaucoma,  certain 
points  are  essential.  1.  The  incision  must  lie  well  within  the  sclera. 
2.  The  coloboma  must  be  of  good  width ;  and  3.  Some  of  the  root  of 
the  iris  must  be  excised.  It  is  also  necessary  to  study  the  iris  care- 
fully before  operation,  in  order  that  a  section  may  be  chosen  for  ex- 
cision which  is  not  too  highly  atrophic. 

Instruments  required.  Speculum,  fixation  forceps  (2  pairs),  kera- 
tome  or  von  Graefe  knife,  iris  forceps,  iris  scissors  and  repositor.  If 
the  anterior  chamber  is  very  shallow,  a  linear  knife  with  a  very  nar- 
row blade  is  to  be  preferred  to  a  keratome,  as  the  operator  can  much 
more  readily  avoid  injury  of  the  iris  and  lens  by  his  ability  to  change 
the  direction  of  the  knife  and  modify  the  position  of  the  wound, 
than  is  the  ease  with  the  keratome.  The  keratome  has  the  advantage, 
however,  of  making  a  more  regular  wound,  so  that  its  edges  come  into 
better  apposition,  and  by  filling  the  wound  until  the  section  is  com- 
pleted, the  aqueous  is  retained  as  long  as  possible,  avoiding  unneces- 
sary prolapse  of  the  iris. 

If  the  keratome  be  employed,  botli  eyes  may  be  operated  upon  from 
behind,  but  if  the  Graefe  knife  is  used  and  tlie  operator  is  not  ambi- 
dextrous, the  left  eye  should  be  operated  ui)on  while  tlie  operator 
sits  or  stands  upon  the  left  side  of  the  patient. 

First  step.  The  incision.  After  the  introduction  of  a  speculum, 
the  eye  is  grasped  witli  the  fixation  forceps  near  the  limbus  at  a  point 
opposite  the  site  of  incision.  If  the  incision  is  made  with  a  keratome, 
the  blade,  wliich  should  be  quite  broad,  should  be  applied  somewhat 
perpendicularly  to  the  sclera  1.5  mm.  posterior  to  the  sclero-corneal 
junction  (see  the  fig.),  and  cautiously  and  steadily  pushed  forwards 
until  the  tip  of  the  knife  is  seen  in  the  angle  of  the  elianiber.  The 
handle  of  the  instrument  should  be  held  between  the  thuml)  and  index 
and  middle  fingers  like  a  pen  (see  fig.),  the  operator  steadying  his 
hand  by  resting  the  two  smaller  fingers  on  the  ]vUient's  forehead,  and 


GLAUCOMA  5493 

the  forward  movcmi'iit  imparted  to  tlic  blade  by  a  simple  straighten- 
ing of  the  fingers.     (See  fig.) 

After  the  tip  of  the  keratoma  is  seen  in  the  angle  of  the  anterior 
chamber,  the  handle  of  the  knife  should  be  gently  depressed,  bringing 


Making    the    Sclero-iriJectomy.     The    lance-head    has    entered    the    anterior 
chamber.      (After  Beard.) 

the  blade  parallel  with  the  plane  of  the  iris.  The  blade  is  then  ad- 
vanced, care  being  exercised  to  maintain  the  point  in  the  plane  of  the 
iris,  avoiding  injury  both  to  the  iris  and  the  cornea.  As  soon  as  an 
incision  of  9  to  10  mm.  in  length  is  obtained,  the  handle  should  be 
slightly  depressed  and  the  instrument  withdrawn  slowly  from  the  eye, 
giving  the  a(|ueous  time  to  flow  off'  gently.     If  a  wider  wound  is  de- 


5494 


GLAUCOMA 


sired,  tliis  may  he  accoiiiplislicd  hy  pressing,'  llic  cdjrc  of  the  blade 
ajraiiist  the  inner  or  outer  aiij^le  of  tiie  wound  as  tlu*  knife  is  slowly 
witlidrawn  from  tlie  eye.  This  maneuvre  should  oidy  be  resorted  to 
when  absolutcl\'  necessary,  as  it  is  liable  to  make  the  incision  irref^ular 
and  thereby  interfere  soinewliat  with  the  pronipl  and  jx-i'fcct  healing 
of  the  wound. 

Sudden  escape  of  aqueous  should  always  be  guarded  against  on 
account  of  the  danger  of  rapid  forward  prolapse  of  the  lens,  which 
may  be  followed  by  rupture  of  the  zonula  and  luxation  of  the  lens, 
rupture  of  the  hyaloid  membrane  and  prolapse  of  the  vitreous.  In 
eyes  with  very  high  tension,  intraocular  hemorrhages  may  also  result. 

If,  instead  of  a  keratorae,  a  Graefe  knife  is  employed,  and  this — as 
has  been  said — is  advised  when  the  chaml)er  is  extremely  shallow,  the 


Iridectomy  in  Glaucoma,  aa,  Ex- 
ternal orifice  of  the  wound  situated 
in  the  sclera;  ii,  Internal  orifice  situ- 
ated at  the  sclero-corneal  junction. 
(Fuchs.) 


Diagram  showing  the  point  of  the 
knife  thrust  just  through  at  the 
limbus. 


incision  is  made  somewhat  similar  to  that  for  the  removal  of  cataract, 
with  the  important  ditferenee,  however,  that  it  must  be  somewhat 
shorter  and  must  be  entirely  in  the  sclera.  (See  tig.)  When  ambi- 
dextrous, stationed  behind  the  patient  wlieii  operating  on  both  eyes,  or, 
if  not,  on  his  left  side  when  operating  upon  the  left  eye,  the  surgeon 
steadies  the  eye  by  grasping  the  bulbar  conjunctiva  with  tixation 
forceps  3  or  4  mm.  from  the  lower  limbus  of  the  cornea  and  intro- 
duces a  narrow  Graefe  knife  into  the  sclera  about  1.5  nun.  back  of  the 
corneal  limbus,  and  from  2.5  to  :i  mm.  above  the  transverse  diameter. 
(See  fig.)  As  soon  as  the  point  of  the  knife  is  seen  in  the  angle  of  the 
cham])er.  the  handle  is  somewhat  deiiressed  and  the  lilade  is  pushed 
slowly  forwards  in  a  plane  jiai-allcl  with  the  transverse  diameter  of 
the  cornea,  the  greatest  care  being  exercised  to  avoid  wounding  the 
iris  and  to  make  the  counter-puncture  at  the  same  point  in  tiie  sclera 
as  the  initial  pnnctui-e.  if  the  cliam])er  is  exceedingly  shallow,  it  will 
be  necessarv  to  avoid  bringing  the  knife  across  the  ci'utral  zone  of  the 


GLAUCOMA 


5495 


iris,  oil  Mccouiit  of  tlic  greater  proiiiiiieiice  of  the  lens  and  iris  in  that 
portion  tliaii  at  the  jx-ripliery  of  the  cliainlx'r,  and  to  carry  the  point  of 
the  knife  instead  around  the  edj^e  of  the  ehaiuber,  making  it  describe 
a  segment  of  a  circle  between  tlie  puncture  and  counter-puncture. 
(See  fig.)  Sliould  tlie  operator  fail  to  pierce  the  cornea  liefore  the 
anterior  chamber  has  been  entered,  a  so-called  intra-lamellar  incision 
will  result.  If  this  accident  occurs,  tlic  knife  should  be  withdrawn 
and  another  incision  should  Ix'  made  at  tlie  site  of  the  first,  but  with 
better  direction. 


Method  of  Holding  the  Straight  Graefe  for  Upward  Incision.      (Czerniak.) 


As  soon  as  the  counter-puncture  has  been  accomplished,  the  knife 
is  pushed  steadily  upwards,  keeping  the  wound  entirely  in  the  sclerotic, 
as  in  the  operation  of  anterior  sclerotomy,  and  is  finally  made  to  emerge 
about  2  mm.  behind  the  limbus.  The  greatest  care  must  be  exercised 
not  to  permit  the  point  of  the  knife  to  sink  too  deep  into  the  angle  of 
the  chamber,  but  to  keep  the  point  of  counter-puncture  on  exactly  the 
same  plane  as  the  puncture,  else  a  slanting  incision  will  result  with 
probable  injury  to  the  ciliary  body.  The  conjunctival  flap  should  now 
be  reflected  forwards  over  the  cornea  to  permit  of  the  ready  excision 


i496  GLAUCOMA 

of  the  iris,   being  easily  replaced   in   its  original  position   l)efore  tlie 
toilet  of  the  eye  has  been  eonipletcMJ. 

Second  step.  Seizure,  icitlidraival  and  excision  of  iris.  If  the 
operation  is  being  performed  under  local  anesthesia,  a  drop  of  cocaine 
should  now  be  applied  directly  to  the  iris,  to  render  it  still  more  insen- 
sitive. The  operator  then  takes  a  delicate  pair  of  iris  forceps  in  his 
left  hand  and  a  pair  of  iris  scissors  in  his  right,  relinquishing  his  hold 
on  the  fixation  forceps  to  an  assistant  who  is  requested  to  keep  the  eye 
rotated  somewhat  downward.  (See  fig.)  The  iris  forceps  should  be 
held  like  a  pen,  between  tlie  tluimb  and  index  and  middle  fingers,  the 
little  and  ring  fingers  resting  on  the  supraorbital  ridge,  the  move- 
ments of  the  forceps  being  executed  by  extension  and  flexion  of  the 
fingers.  (See  fig.)  The  de  Wecker  scissors  are  usually  preferred  to 
the  small  scissors  curved  on  the  flat,  which  were  previously  employed. 
They,  too,  like  the  iris  forceps,  should  be  grasped  like  a  pen,  by  the 


'"^mrn^ 


Diagram  Showing  the  Point  of  the  Knife  Directed   Toward  a  Point  in  the 
Cornea  about  1  mm.  Within  the  Limbus,  so  as  to  Begin  the  Counter  Punc-ture. 

ball  of  the  thumb  and  index  finger  resting  on  the  blades  of  the  handle. 
With  the  blades  of  the  forceps  closed,  the  operator  cautiously  intro- 
duces the  little  instrument  into  one  angle  of  the  wound,  and  gently 
opening  the  forceps,  grasps  a  small  fold  of  iris  near  the  pupillary 
margin.  This  portion  of  iris  is  drawn  outwards  into  the  angle  of  the 
wound,  and  at  the  moment  of  strongest  traction  the  iris  should  be 
incised  as  near  the  base  as  possible  by  the  scissors,  the  blades  of  which 
should  be  held  parallel  with  the  wound.  (See  accompanying  figs.) 
The  iris  is  then  torn  from  its  base  by  deflecting  the  forceps-  to  the 
opposite  angle  of  the  wound,  and  a  final  snip  given  the  portion  which 
has  been  dragged  out  of  the  eye.  By  introducing  the  forceps  in  the 
angle  of  the  wound  instead  of  through  the  middle  of  the  incision,  a 
procedure  which  was  first  practiced  by  Bowman,  it  is  possible  to  make 
the  base  of  the  colobonui  broader  than  the  extent  of  the  incision,  while 
the  peripheral  incision  of  the  iris,  and  the  tearing  it  from  its  attach- 
ment, insures  the  excision  of  its  root,  without  which  an  iridectomy  for 
glaucoma  may  be  considered  a  failure.  I\Iany  operators,  however, 
favor  snipping  the  iris  with  one  clip  of  the  scissors,  believing  the 
method  which  has  just  been  described  possesses  no  advantage  over  the 


GLAUCOMA 


5497 


single  cut  incision,  wliilc  it  prolongs  tlie  procedure  and  is  more  painful. 
Third  step.  The  toilet  of  the  U'OuncJ.  After  the  excision  of  the 
iris  is  coinpleted,  a  delicate  iris  repositor  should  be  inserted  a  short 
distance  into  the  angle  of  the  wound  and  incarceration  of  the  iris  pre- 
vented by  gently  stroking  the  pillars  of  tlic  coloboma  in  the  direction 
of  the  c]iani])er.     The  repositor  should  then  be  made  to  traverse  the 


Steps  of  the  Operation. 


The  blades  of 
the  iris  forceps 
hehl  dose  to  the 
pupillary  margin 
have  just  been 
opened. 


The  blades 
have  been  closed 
and  have  seized  a 
fold  of  the  iris. 


The  portion  of  the  iris,  which  has  been 
drawn  forward,  is  cut  off  by  the  scissors 
brought  from  below. 


entire  length  of  the  wound,  to  remove  blood  clots  and  to  smooth  out 
the  edges  of  the  flaps.  If  there  be  much  blood  in  the  anterior  chamber 
it  may  usually  be  removed  l)y  gently  depressing  the  posterior  lip  of  the 
wound  with  the  repositor  and  by  stroking  the  cornea  in  the  direction 
of  the  wound.  If  the  hemorrhage  continues,  it  may  be  necessary  to 
apply  a  pressure  bandage  without  waiting  for  its  control.  If  consider- 
al)le    incarceration    still    persists    after    the    manipulation    witii    the 


5498  GLAUCOMA 

rcposiloi-,  I'lii'thcr  excision  of  tlic  ifis  iiiiist  be  resorted  to,  but  great 
care  should  be  exereised  in  inlrodueiug  the  foreeps  a  seeoud  time  to 
avoid  injuring  the  lens  capsule.  Tlie  iris  may  be  judged  to  be  in 
proper  position  and  the  toilet  of  the  eye  completed  when  the  lips  of 
the  wound  are  in  perfect  apposition  and  the  two  i)illars  of  the  colo])oma 
are  of  the  same  height  and  situated  in  tlie  curve  of  the  former  pupillary 
margin.  The  speculum  is  now  withdrawn,  and  after  eserine  has  been 
instilled  into  botli  eyes,  a  compression  bandage  is  applied. 

Accidents  complicating  iridectomy  in  glaucoma.  If  the  incision  has 
been  too  short  and  the  opening  into  the  chamber  too  small  to  permit 
of  the  ready  opening  of  the  blades  of  the  forceps,  the  wound  should  be 
enlarged  ])y  one  short  cut  of  a  small  pair  of  delicate  curved  scissors 
(Stevens'  strabotomy  scissors),  which  should  be  introduced  into  the 
outer  angle  of  the  wound. 

Transfixion  of  the  iris  may  occur  either  immediately  after  the  cham- 
ber has  been  entered,  in  which  event  the  knife  should  be  slightly 
withdrawn  and  then  pushed  forward  more  anteriorly,  or  it  may  happen 
when  the  knife  is  more  deeply  engaged  in  the  wound  and  its  with- 
drawal necessitates  loss  of  aqueous.  If  this  latter  occurs,  the  knife 
should  be  entirely  withdrawn  and  the  operation  postponed  until  the 
chamber  has  reformed,  the  continuance  of  the  incision  being  attended 
with  too  great  danger  of  irido-dialysis  and  injury  to  the  lens  capsule. 

Separation  of  the  iris  at  its  ciliary  attachment  to  a  greater  or  less 
extent,  and  even  complete  detachment,  may  occur  if  the  patient  make 
a  sudden  movement  of  the  eye  and  the  operator  is  not  quick  to  release 
the  iris  from  the  forceps.  Severe  hemorrhage  usually  follows,  wliich 
obscures  the  field  of  operation  and  prevents  the  proper  toilet  of  the 
wound.  As  a  rule,  however,  the  blood  is  rapidly  absorbed  and  only  in 
rare  eases  is  the  blood  clot  converted  into  a  dense  cicatrix  which 
occludes  the  pupil  and  contracts  the  coloboma. 

It  sometimes  happens  that  the  sphincter  is  not  included  in  the  ex- 
cised portion.  In  this  event  a  blunt  hook  should  be  inserted  parallel 
with  the  anterior  surface  of  the  iris,  and  the  narrow  bridge  of  tissue 
broken  through  by  traction  with  the  hook,  or  divided  with  scissors 
after  it  has  been  brought  out  of  the  eye. 

If  the  aqueous  is  evacuated  too  suddenly,  the  abrupt  lowering  of 
the  intraocular  pressure  may  occasion  (rlioroidal  hemorrhage,  rupture 
of  the  zonule  and  hyaloid,  presentation  of  vitreous  and  subluxation  of 
the  lens.  When,  however,  none  of  these  disastrous  consequences  fol- 
low, and  tlie  iris  alone  is  prolapsed  into  the  wound,  rather  than  ex- 
cising the  protruding  membrane  at  once,  Czermak  advises  replacing  it 
before  proceeding,  in  order  to  correctly  gauge  the  amount  of  iris  to 


GLAUCOMA  5499 

be  excised  and  to  i^ropci'ly  fashion  tlic  coloboma.  He  recommends  ex- 
cision without  previous  replacement,  however,  wlien  the  conjunctiva  is 
so  inflamed  as  to  entail  danger  of  infection ;  when  the  tension  is  high  ; 
when  the  lens  is  dislocated  or  abnormally  small,  as  in  hydrophthalmus, 
or  when  the  vitreous  is  presenting;  and  in  nei-vous  pei-sons  and  chil- 
di'en  who  are  under  local  anesthesia  only. 

Spontaneous  rupture  of  the  lens  capsule  may  occur  as  a  consequence 
of  increased  vitreous  tension,  immediately  after  completing  the  scleral 
incision  or  later  with  spontaneous  discharge  of  the  lens  nucleus.  ]\Iore 
frequently  the  injury  to  the  capsule  is  occasioned  by  the  knife  or  by 
the  forceps,  but,  even  in  the  latter  event,  traumatic  cataract  of  greater 
or  lesser  extent  follows,  which  interferes  with  vision  or  is  attended 
with  even  more  serious  consequences. 

Luxation  of  the  lens  may  follow  rupture  of  the  zonule  either  from 
too  abrupt  discharge  of  the  aqueous,  as  has  already  been  mentioned,  or 
it  may  result  from  pressure  by  the  instrument  or  from  faulty  manipu- 
lation. The  edge  of  the  lens  is  at  once  forced  into  the  angle  of  the 
wound  or  into  the  coloboma  if  the  iris  has  already  been  excised.  In- 
crease of  tension  follows  and  malignant  glaucoma  may  result. 

For  the  relief  of  this  condition  de  Wecker  {Chir.  Ocul.,  p.  155)  ad- 
vised a  sclerotomy  opposite  to  the  coloboma,  the  lens  being  replaced 
by  pressure  on  the  upper  lid  while  the  knife  is  still  in  the  wound. 
Weber 's  procedure  {Arch.  f.  Ophthahn.,  XXIII,  Part  1,  p.  86)  for  the 
same  purpose  is  more  complicated.  This  operator  counselled  making 
a  puncture  8  to  10  mm.  from  the  external  limbus  in  the  horizontal 
meridian  of  the  eye  with  a  double-grooved,  so-called  broad  needle,  the 
needle  being  rotated  on  its  axis  one-fourth  to  make  the  wound  gape. 
The  lens  is  then  replaced  by  gradual  increase  of  pressure  on  the  upper 
lid  or  by  a  cataract  spoon  applied  to  the  cornea  perpendicular  to  the 
surface  of  the  coloboma,  the  usual  site  of  the  luxated  lens.  A  high 
degree  of  pressure  should  l)e  maintained  for  a  minute  or  more  to 
permit  of  the  re-accumulation  of  the  aqueous.  A  slight  pressure 
bandage  is  applied  and  the  patient  placed  in  the  supine  position 
for  24  hours. 

Weber  insists  that  the  operation  should  be  undertaken  from  10  to 
20  days  after  the  luxation,  the  cicatrix  being  then  sufficiently  strong 
to  withstand  the  pressure.  If  postponed  until  later,  adhesions  are  apt 
to  form  betw^een  the  lens  and  the  iris  and  cicatrix  which  complicate 
the  procedure,  and  in  addition  the  eye  is  subjected  to  the  danger  of 
continued  high  tension. 

If  vitreous  presents  following  rupture  of  the  zonule  before  the  ex- 
cision of  the  iris  and  results  in  a  sudden  deepening  of  the  chamber, 


5500  GLAUCOMA 

as  it  ('S('a|)t'S  from  the  wound.  Ilic  iiltcndant  pi-olajjst-  of  iris  sliould  be 
imiiicdiatt'ly  t'Xcisi'd,  the  iris  hciii'^  dcawii  out  of  the  wound  by  means 
of  a  blunt  hook.  Both  speculum  and  fi.xation  fore('])s  should  be  dis- 
pensed witli,  the  lids  being  fixed  by  an  assistant.  If  the  prolapse 
occurs  after  tlie  iris  has  l)een  excised,  the  oi)cration  should  be  discon- 
tinued and,  if  considerable  vitreous  presents,  it  should  be  snipped  off 
with  scissors. 

After  very  bungling  operations  the  lens  may  prolapse  into  the 
wound  and  may  subsequently  become  incarcerated,  hernia  lentis 
(phakocele),  and  extraction  may  have  to  be  resorted  to. 

Slow  closing  of  the  wound  after  iridectomy  for  glaucoma  is  always 
a  serious  complication,  the  attending  reactive  inflammation  usually 
al)olishing  all  the  advantages  which  the  operator  had  hoped  for,  the 
coloboma  being  choked  with  inflammatory  material,  the  pillars  of  the 
coloboma  incarcerated,  and  the  eye  slowly  passing  into  a  state  of 
iridocyclitis  or  absolute  glaucoma. 

After-treatment  of  iridectomy  for  glaucoma.  While  some  operators 
prefer  a  binocular  bandage,  a  compress  bandage  upon  the  operated 
eye  alone  suffices,  unless  the  patient  is  intractable  and  persists  in 
rolling  the  unbandaged  eye  about  and  repeatedly  opening  and  shutting 
it,  thereby  disturbing  the  operated  eye.  Under  these  circumstances 
both  eyes  should  be  closed.  The  patient  should  be  confined  to  bed, 
but  not  necessarily  in  the  supine  position.  If  no  incarceration  of  the 
iris  is  feared,  the  bandages  should  not  be  removed  for  48  hours,  when 
the  lips  of  the  wound  will  generally  be  found  to  be  united  and  the 
anterior  chamber  reformed.  The  sclera  adjacent  to  the  wound  is 
usually  somewhat  injected  and  the  cornea  may  exhibit  a  delicately 
striated  opacity.  If  at  the  first  dressing  the  chamber  is  found  re- 
formed, the  patient  may  be  permitted  to  sit  up  by  the  side  of  the  bed, 
and,  if  the  process  of  healing  continues  favorably,  he  may  be  permitted 
to  walk  about  at  the  end  of  another  48  hours.  The  bandage  should  be 
maintained  for  ten  days,  unless  it  gives  rise  to  conjunctival  irritation, 
when  it  may  be  removed  earlier,  the  eye  being  protected  from  the 
light  by  dark  glasses. 

It  is  usually  the  custom  to  instill  miotics  into  the  operated  eye,  as 
well  as  its  fellow^  at  the  time  of  the  operation,  and  to  continue  the  in- 
stillation at  each  dressing.  Czermak,  however,  advises  against  this,  as 
he  argues  that  the  miotic,  by  reducing  the  tension,  may  obscure  an 
unsuccessful  result  from  the  operation,  and  may  permit  the  eye  to 
l)ass  into  a  condition  of  unsusi)ccte.d  chronic  glaucoma,  which  would 
have  asserted  itself  earlier  if  no  miotics  had  been  employed,  and 
might  have  been  relieved  liy  a  second  operation. 


GLAUCOMA  5501 

Complications  di(ri)if/  the  Jwaling  process  in  iridectotny.  Delayed 
union  of  the  woniul  may  be  caused  ])y  overlapping  of  the  edges  or  by 
hemorrhages  from  the  blood  vessels  of  the  iris  or  choroid.  A  con- 
tinued compress  bandage  will  usually  overcome  the  latter  difficulty 
unless  it  be  caused  by  choroidal  hemorrhage,  in  which  event  the  eye 
is  generally  lost  from  irido-cyclitis. 

When  the  incision  has  been  made  with  a  Graefe  knife  and  a  long 
conjunctival  flap  olitained,  the  edge  of  the  wound  may  be  kept  sepa- 
rated by  the  fold  of  conjunctiva.  Smoothing  out  of  the  flap  and  the 
application  of  the  bandage  will  overcome  this  complication. 

Incarceration  in  the  wound  of  portions  of  the  iris  or  prolapse  of 
the  lens  or  of  the  vitreous  may  interfere  with  the  proper  closing  of 
the  wound  and  may  give  rise  to  broadened,  often  imperfectly  formed, 
fistulous  cystoid  cicatrices,  ectasia  of  the  broadened  cicatrix,  or  of 
the  prolapsed  iris  with  their  sequelae. 

Tension  may  still  remain  high  after  iridectomy,  and  the  anterior 
chamber  be  obliterated  owing  to  a  luxation  of  the  lens  or  choroidal 
hemorrhage. 

An  expulsive  hemorrhage  of  the  choroid  may  follow  the  sudden 
decrease  in  tension  and  the  eye  be  lost  by  atrophy.  In  other  cases  a 
gradual  increase  in  tension  supervenes  without  inflammatory  symp- 
toms and  the  eye  passes  into  chronic  glaucoma.  In  such  cases  iridec- 
tomy must  be  repeated,  followed  by  a  sclerotomy  or  cyclodialysis,  if 
necessary. 

If  the  secondary  rise  in  tension  depends  upon  one  of  the  margins 
of  the  coloboma  becoming  incarcerated  in  the  lips  of  the  wound,  the 
liberation  of  the  attached  iris  should  be  essayed  by  inserting  a  Graefe 
knife  at  one  angle  of  the  scar,  carrying  it  through  the  anterior  chamber 
until  it  reaches  the  other  side  of  the  site  of  adhesion  and  then  bring- 
ing it  out  as  far  in  the  periphery  as  possible.  The  incision  should  then 
be  completed  with  sawing  movements.  If  the  iris  has  not  been  sepa- 
rated from  the  cicatrix  by  this  incision,  it  should  be  dragged  out 
of  the  wound  by  iris  forceps  and  as  large  a  piece  as  possible  excised. 

Iritis  and  irido-cyclitis  may  follow  iridectomy.  The  inflammation 
is  usually  of  but  a  mild  grade ;  in  other  cases,  however,  due  to  infec- 
tion of  the  uvea  at  the  time  of  operation  or  to  a  traumatic  exacerbation 
of  a  previously  existing  insidious  inflammation,  the  inflammation  may 
assume  a  grave  type  and  occlusion  of  the  pupil  and  coloboma  may 
follow,  destroying  the  effect  of  the  operation. 

Panophthalmitis  is  very  rare,  and,  when  it  occurs,  takes  the  same 
course  as  that  observed  after  cataract  operation. 

Theories  to  account  for  the  efficacy  of  iridectomy.     The  manner  in 


5502  GLAUCOMA 

wliicli  ii'i(lcctoiii,\-  reduces  iuti'aoeular  tension  in  glaucoma  is  still  un- 
solved. (Jraet'e  himself  attributed  it  to  the  reduction  of  the  supposed 
secreting  surface  of  the  iris,  hut  this  theory'  has  been  disproved  by 
the  observations  of  a  numl)er  of  investigators  wlio  have  shown  that 
the  iris  has  but  little  to  do  with  the  secretion  of  the  intram-ular  tkiid, 
the  ciliary  body  being  practically  the  sole  source.  In  recent  years 
careful  microscopical  study  of  glaucomatous  eyes  upon  which  iridec- 
tomy had  been  successfully  performed  for  the  relief  of  tension,  but 
which  were  later  enucleated  on  account  of  some  intercurrent  affection, 
has  shown  that  in  these  eyes  either  the  obstructed  passage  for  the 
exit  of  fluid  at  the  angle  of  the  anterior  chamber  was  found  opened 
up,  or  a  new  channel  of  exit  had  been  established  by  the  formation  of 
what  is  termed  a  cystoid  cicatrix. 

After  a  lengthy  presentation  of  the  many  theories  which  have  been 
advanced  sinee  Graefes  epoch-making  discovery,  Czermak  (Die 
Augetiaerztlichen  Operationen)  finally  summarizes  the  situation  as 
follows:  "Typical  iridectomy  with  corneoscleral  incision  abolislies 
glaucoma  by  separating  the  iris  from  the  trabecule  in  the  region  of 
the  wound  and  establishing  at  this  point  a  permanent  opening  in  the 
iris.  The  essential  feature  of  the  coloboma  is  its  peripheral  position. 
Iridectomy  may  also  be  efficacious  by  causing  a  detachment  of  the 
adjacent  iris  tissue.  When  this  occurs  and  there  is  incarceration  of 
the  base  of  the  iris  and  non-separation  of  the  iris  in  the  region  of  the 
wound,  vicarious  drainage  is  assured  and  a  favorable  result  attained. 
Typical  sclerotomy  with  clean,  scleral  incision,  abolishes  glaucoma  by 
reopening  the  natural  outlet  of  the  intraocular  tiuid,  in  consequence 
of  incision  of  the  adherent  iris  and  of  its  ligament."  Czermak  re- 
gards an  iridectomy  with  a  clean  scleral  incision  as  being  nothing 
more  than  a  sclerotomy  with  excision  of  the  centrally  situated  portion 
of  the  iris.  Irido-sclerotomy,  the  incisione  dell'angolo  irideo  and 
sclerotomy  act  identically.  Czermak  thinks  it  is  almost  impossible 
to  establish  by  operative  means  an  entirely  new  channel  of  exit  in  cases 
where  the  natural  channels  have  been  permanently  closed. 

Prognosis  after  iridect&my.  In  view  of  these  facts,  it  is  evident 
that  the  prognosis  for  the  restoration  of  vision  after  iridectomy  de- 
pends upon  the  variety  of  glaucoma  and  the  duration  of  the  disease. 
In  the  acute  and  subacute  inflanniiatory  types,  it  may  be  said  to  exer- 
cise a  curative  action,  and  this  is  true  in  proportion  to  the  time  that 
the  operation  is  performed  after  the  appearance  of  the  attack.  If  per- 
formed early,  when  the  blocking  of  the  ehamber  is  due  to  vascular  con- 
gestion and  not  to  permanent  causes,  the  filtration  angle  may  be 
permanently  opened,  and  the  disease  actually  cured.     In  acute  fulmi- 


GLAUCOMA  5503 

nating  glaucoma  the  results  of  operation  in  recent  eases  are  especially 
favoral)le,  and  if  iridectomy  is  performed  soon  after  the  outbreak  of 
the  inflammatory  attack,  a  degree  of  siglit  is  secured  which  is  some- 
what, but  not  much,  smaller  than  it  was  before  the  attack,  and  the 
good  results  are  permanent.  The  operation  must  be  performed  early, 
however,  for  if  it  is  delayed  and  tiiere  has  been  no  perception  of 
light  for  two  or  three  days,  the  chances  of  restoration  of  vision  are 
very  small.  Full  vision  nuiy,  however,  be  regained  after  even  some 
hours  of  absolute  loss  of  light  perception.  In  a  certain  small  propor- 
tion of  cases  (malignant  glaucoma)  iridectomy,  even  if  repeated  or 
associated  with  sclerotomy,  Avill  not  control  the  process,  and  blindness 
will  ensue.  As  has  been  nu'iitioned,  operations  done  in  the  prodromal 
stage  give  particularly  favorable  results,  so  that  this  may  be  regarded 
as  the  time  of  election  for  iridectomy  in  inflammatory  glaucoma. 

The  prognosis  for  conservation  of  vision  after  iridectomy  in  sub- 
acute glaucoma  is  also  favorable,  and  the  operation  should  always  be 
resorted  to,  though  the  emergency  for  an  immediate  operation  is  not 
so  great,  since  miotics  may  hold  the  disease  in  abeyance  for  a  time. 
It  must  be  cautioned,  however,  that  the  continued  use  of  these  drugs 
in  any  form  of  inflammatory  glaucoma  is  to  be  deprecated,  as  any 
pennanent  effect  upon  tlie  progress  of  the  disease  can  be  secured  by 
operation  alone. 

Wygodski's  {Klin.  Mouaishlattcr  f.  Augcnh.,  1902,  XLI,  II,  p.  177) 
table  of  results  after  iridectomy  for  acute  glaucoma  show  that  the 
prognosis  was  favorable  in  80  per  cent,  of  the  cases.  Of  237  cases  of 
glaucoma  of  all  types  iridectomized  by  Grosz,  success  was  obtained  in 
96  per  cent,  operated  in  the  prodromal  stage  and  in  87  per  cent,  oper- 
ated in  the  active  stage. 

Iridectomy  of  most  value  in  the  acute  forms  of  glaucoma.  While 
advocated  l)y  many  surgi^ons,  experience  has  shown  that  iridectomy 
is  not  as  efficacious  in  the  relief  of  tension  in  chronic  non-inflammatory 
glaucoma  as  in  the  more  acute  varieties.  This  is  doubtless  due  to 
the  completeness  of  the  adhesions  in  the  angle  of  the  chamber,  which 
form  as  a  consequence  of  the  long-continued  increased  pressure  within 
the  eye,  rendering  the  removal  of  the  root  of  the  iris  and  the  opening 
of  the  spaces  of  Fontana,  by  operation,  impossible.  Be  this  as  it  may, 
many  operators  have  abandoned  iridectomy  in  chronic  glaucoma  and 
have  sought  to  cure  this  type  of  the  disease  by  other  surgical  proce- 
dures, the  majority  of  wliieli  have  for  their  aim  the  creation  of  a  means 
of  filtration  for  the  intraocular  fluids  out  of  the  eye,  by  the  produc- 
tion of  more  or  less  patidous  cicatrices.  Several  years  ago.  removal 
of  the  cervical  symi)at]u'tic  ganglion  was  favored  by  a  few  operators 


5504  GLAUCOMA 

as  a  means  of  reducing  tension  in  chronic  j;]aiicoiii}i.  but  the  operation 
was  never  widely  practised  and  is  now  practi(;ally  never  j)erforrned. 

Miotics  versus  operative  measures  in  chronic  rjlaueonui.  Of  late 
years  there  has  been  an  increasing  number  of  ophthalmologists  who 
have  expressed  the  conviction  that  the  operative  form  of  treatment  is 
not  the  only  means  of  combating  the  increased  tension  of  chronic 
glaucoma,  and  the  eontinnous  use  of  miotics  has  been  widely  extolled 
in  the  management  of  this  non-inflammatory  form  of  glaucoma.  The 
writer  {Journal  of  the  A.  M.  A.,  1!)()7,  XLVIII,  p.  676;  Ophthnlmoloejy, 
April,  1907;  Journal  of  the  A.  M.  A.,  Oct.  24,  1908,  Vol.  LI.  pp. 
1389-1394)  has  long  been  an  advocate  of  this  form  of  treatment,  and 
in  several  communications  has  emphasized  the  beneficial  effect  which 
may  be  deriv(Ml  fi-om  these  drugs.  In  a  late  j)aper  he  aiuilyzed  the 
liistories  of  65  cases  of  a  i)ure  type  of  simple  chronic  glaucoma,  of 
which  number  all  but  7  luid  used  a  miotic  continuously  for  over  a 
period  of  two  years,  and  12  for  more  than  10  years.  As  most  inves- 
tigators of  simple  clironic  glaucoma  urge  the  necessity  of  early  opera- 
tion in  this  type  of  the  disease,  as  well  as  in  tlie  inflannuatory,  and  as 
it  is  generally  recognized  that  the  treatment  and  the  prognosis  of 
chronic  glaucoma  are  much  influenced  by  the  stage  in  wliich  the  dis- 
ease comes  under  observation,  the  cases  were  divided  into  three  classes, 
according  to  their  degree  of  development:  (1)  Beginning  eases.  (2) 
^Moderately  advanced  cases.  (3)  Ver\^  advanced  or  desperate  cases. 
Of  the  110  glaucomatous  eyes  which  could  be  studied  for  statistical 
purposes,  it  was  found  that  vision  had  improved  or  held  its  own  dur- 
ing the  entire  time  the  ease  Avas  under  observation  in  80  per  cent., 
that  there  had  been  a  slow  deterioration  of  vision,  both  central  and 
peripheral,  in  11.8  per  cent.,  while  in  8  per  cent,  the  miotics  seemed  to 
exert  no  influence,  the  eyes  going  blind  and  passing  into  absolute 
glaucoma. 

[V.  Ilippel  {Klin.  Manatshl.  f.  Augenheilk.,  July,  1907;  review  by 
Blair  in  the  Oph.  Rcviciv,  p.  21,  Jan.,  1908)  upholds  the  generally 
accepted  opinion  that  iridectomy  is  not  only  justifiable,  but  that 
the  ophthalmic  surgeon  is  bound  to  recommend  it,  and  to  give  his 
patients  the  benefit  of  the  only  treatment  which,  in  his  opinion,  is 
calculated  to  restrain  the  progress  of*  the  disease.  Ophthalmic  sur- 
geons, however,  do  not  all  agree  on  this  point.  De  AVecker  obtained 
the  opinions  of  120  experienced  operators,  and  found  that  nine-tenths 
favored,  while  one-tenth  opposed,  the  operation;  but  Pechin,  after  a 
similar  investigation,  came  to  the  opposite  conclusion,  namely,  that 
the  majority  of  operators  considered  it  of  little  or  no  use.  Roth 
Schleich  and  he  believe  that  tlu^  only  treatment  of  any  avail  is  the 


GLAUCOMA  5505 

regular  use  of  miotics.  Schleich  mentions  that  all  statistics  of  oper- 
ative treatment  in  simple  glaucoma  become  more  and  more  unfavor- 
able in  proportion  to  the  length  of  time  during  which  the  cases  are 
under  observation. 

The  evidence  v.  Ilippel  brings  forward  is  altogether  in  favor  of 
iridectomy,  and  he  considers  that  it  distinctly  retards  the  progress  of 
the  disease.  In  his  clinic  41  per  cent,  of  the  cases  operated  upon 
showed  no  aggravation  of  symptoms  after  two  years ;  20  per  cent, 
showed  none  after  five  years ;  14  per  cent,  after  ten  years ;  and  9  per 
cent,  after  fourteen  years. 

Yon  Hippel  points  out  that  these  favorable  cases  were  not  all  oper- 
ated on  in  the  early  stages  of  glaucoma,  but  that  many  had  markedly 
contracted  fields  and  pronounced  cupping  of  the  disc.  He  also  states 
that  in  no  case  was  the  acuity  of  vision  diminished  by  the  operation. 
He  condemns  the  use  of  miotics  before  operation  if  it  leads  to  any 
delay,  but  thinks  the  iridectomy  should  be  done  as  soon  as  the  disease 
is  diagnosed.  ^liotics,  on  the  other  hand,  should  be  used  regularly  and 
continuously  after  operation.  Sclerotomy  also,  the  writer  maintains, 
ought  never  to  be  employed  as  a  substitute  for  iridectom}^  but  should 
be  reserved  for  a  secondary  operation  in  case  the  tension  rises  after 
iridectomy.  Even  in  advanced  cases  of  simple  glaucoma  he  considers 
that  iridectomy  should  be  performed,  and  that  even  then  it  tends  to 
defer  the  advent  of  blindness. 

A  report  on  the  value  of  iridectomy,  based  upon  an  analysis  of  1,200 
operations,  is  furnished  by  Hallauer  {Ai^cltivcs  of  Ophthalm.,  July,  p. 
436,  1908),  who  takes  up  the  results  of  this  operation,  in  so  far  as  it 
applies  to  the  cure  of  glaucoma.  He  says  that  in  acute  glaucoma, 
iridectomy  was  followed  l)y  diminished  vision  in  2.6  per  cent,  of  the 
cases.  In  35  per  cent,  there  were  relapses,  which  in  most  cases  could 
be  controlled  by  miotics.  Sixty-nine  per  cent,  were  improved.  Vision 
remained  the  same  in  12  per  cent.,  and  was  diminished  in  18  per  cent. 
In  chronic  inflammatory  glaucoma,  operation  was  followed  by  recur- 
rences in  19  per  cent.,  of  which  12.5  per  cent,  were  controlled  by 
miotics.  There  was  improvement  of  vision  in  35  per  cent.,  diminution 
in  39  per  cent.,  and  no  change  in  26  per  cent.  In  glaucoma  simplex, 
tension  was  reduced  to  normal  in  80.5  per  cent.  Recurrences  occurred 
in  31  per  cent.  A  second  iridectomy  was  necessary  in  6  per  cent. 
Three  per  cent,  ran  a  malignant  course  after  the  operation.  When  a 
glaucoma  iridectomy  in  one  eye  is  followed  by  a  malignant  course  of 
the  glaucoma,  iridectomy  should  not  be  performed  on  the  second  eye. 
Of  seven  cases  of  absolute  glaucoma  operated  on  on  account  of  pain, 
five  improved.  In  hydroplithalmus  two  operations  resulted  in  a  dimi- 
voi.  VII— 4:; 


5506  GLAUCOMA 

nution  of  tension,  with  preservation  of  vision.  In  one  case  a  second 
iridectomy  was  necessary.  In  hemorrhagic  ghiuconia,  iridectomy  is 
contraindicated.  In  two  cases  in  which  it  was  done  as  a  last  resort 
in  place  of  enucleation,  pain  was  relieved,  but  there  was  diminution  of 
vision. 

Macnal)  reports  a  case  of  glaucoma  which  he  iiad  the  opportunity 
of  observing  long  years  after  iridectomies  had  been  performed  for 
its  relief,  in  one  eye  39  years  and  in  the  other  eye  3-4  years  prior  to 
his  investigation.  lie  found  the  vision  apparently  the  same  as  it  was 
immediately  after  the  operation,  and  that,  too,  in  spite  of  the  tension 
being  fairl^^  high  in  one  of  the  two  eyes. 

]\Iinor  operated  on  a  patient  aged  57,  who  had  been  blind  for  nearly 
a  month  as  the  result  of  glaucoma.  The  double  iridectomies  restored 
vision,  M'hich  at  its  best  rose  to  20/30  and  20/40,  respectively. 

Wolffliu  leaves  the  sphincter  pupilhB  intact  in  doing  iridectomy  for 
glaucoma,  believing  that  the  subsequent  use  of  miotics  will  be  more 
effective,  and  the  edges  of  the  coloboma  Avill  be  less  apt  to  prolapse 
into  the  wound  during  the  healing  process.  He  reports  three  success- 
ful operations  for  chronic  glaucoma.  The  same  operation  has  been 
proposed  by  Ptliiger  and  Snellen.  DijDlopia  was  not  complained  of  by 
the  patients.     Ed.] 

Treatment  of  hemorrhagic  glaucoma.  Owing  to  the  sublying  arte- 
rial sclerosis  which  is  presen,t  in  cases  of  hemorrliagic  glaucoma  and 
the  danger  of  hemorrhage  following  the  diminution  of  intraocular 
tension,  iridectomy  is  seldom  practised  in  this  variety  of  glaucoma, 
less  radical  surgical  measures,  conjoined  with  the  use  of  miotics,  and 
remedies  directed  to  the  sublying  physical  condition,  being  preferred. 
Thus  Bull  recommends  a  careful  corneal  paracentesis,  after  complete 
cocainization,  the  aqueous  being  permitted  to  flow  out  only  drop  by 
drop  from  the  anterior  chaml)er.  The  temple  is  then  leeched,  after 
which  a  solution  of  eserine  sulphate,  one  grain,  and  pilocarpine  hydro- 
chlorate,  four  grains,  to  the  ounce,  is  instilled  every  hour  until  the 
eye  softens.  Hot  compresses  are  then  applied  until  all  pain  has  dis- 
appeared. Twenty  drops  of  the  fluid  extract  of  jaborandi  are  pre- 
scribed three  times  daily  to  lower  ii it la vascular  tension.  Repetition 
of  the  paracentesis  may  be  necessary.  A  careful  regimen  of  the  life 
of  the  patient  must  be  enjoined. 

On  the  other  hand,  Weekers  {Ophthalmic  Year  Book,  1909,  p.  211) 
does  not  believe  that  iridectomy  is  always  contraindicated  in  hemor- 
rhagic glaucoma.  He  thinks  that  there  are  two  distinct  classes  of 
this  type  of  tlie  disease,  one  with  nuirked  degeneration  of  the  intra- 
ocular vessels,  rcadil.N-  I'upturcd  by  the  sudden  release  of  the  intraocular 


GLAUCOMA  5507 

tension  following  an  ii-idcctomy,  and  aiiotlici-  class  of  cases  in  wliich 
the  vascular  cliaiiges  are  jiot  so  marked,  in  this  latter  chiss  iridectomy 
relieves  the  action  of  iiyperteiision  in  the  blood  vessels  and  permits  the 
repair  of  existing  vascular  lesions. 

Treatment  of  huphthalnius.  The  treatment  of  this  condition  is  very 
unsatisfactory.  Miotics  are  of  but  litth'  avail  and  no  form  of  surgical 
intervention  lias  been  tlevised  which  can  cure,  or  even  cheek,  the 
process.  Iridectomy  is  not  followed  by  good  results,  nor  have  its 
substitutes  proven  of  service  in  tliis  destructive  form  of  glaucoma. 
The  best  results  seem  to  be  attained  by  repeated  posterior  sclerotomies. 

Treatment  of  secondary  glaneonui.  If  the  rise  of  tension  be  but 
temporary,  as  in  traumatic  cataract  or  serous  iritis,  paracentesis  of 
the  cornea  will  suffice  to  relieve  the  glaucoma.  If,  on  the  other  hand, 
the  glaucoma  is  due  to  definite  anatomical  conditions  which  occasion 
a  blocking  of  the  angle  of  the  chamber,  more  radical  measures  are 
necessary,  and  different  procedures  will  have  to  be  resorted  to,  to 
relieve  the  various  sublying  causes  which  have  been  mentioned  else- 
where. 

If  this  form  of  glauconui  is  consequent  upon  the  ])locking  of  the 
angle  of  the  chaml)er  from  anterior  synechia,  the  operation  of  synechi- 
otomy  {vide  intra)  is  advised.  When  the  rise  of  tension  has  been 
caused  by  seclusion  of  the  pupil,  iridectomy  is  indicated,  the  glaucoma 
being  rc^lieved  by  the  re-establislnnent  of  a  nornud  circulation  between 
the  posterior  and  anterior  chambers.  The  removal  of  the  iris  is  very 
difficult,  however,  in  cases  of  total  posterior  synechia,  and  is  often 
unsuccessful.  If  iris  bombe  is  present,  Fuchs'  operation  of  transfixio 
iridis  is  the  operation  of  choice. 

In  secondary  glaucoma  after  wounds  and  operations  due  to  pro- 
lapse of  lens  capsule,  or  hyaloid  membrane  of  vitreous,  l)etween  the  lips 
of  the  corneal  wound,  tension  may  usually  be  relieved  by  carefully 
dividing  the  prolapse  witli  a  sharp  knife-needle. 

When  the  glaucoma  has  been  occasioned  by  a  dislocation  of  the 
lens  into  the  anterior  chamber,  this  structure  should  be  cautiously 
removed  by  an  incision  with  a  Graefe  knife,  after  the  pupil  has  been 
contracted  as  much  as  possi1)le  with  eserine.  Some  loss  of  vitreous 
usually  follows  this  procedure. 

If  the  increase  in  tension  has  been  set  up  by  a  lens  tluit  has  been 
luxated  into  the  vitreous,  the  removal  is  attended  with  still  greater 
danger  of  loss  of  vitreous,  and  is  best  accomplished  by  first  l)ringing 
the  lens  into  a  normal  position  by  a  needle  passed  posteriorly  through 
the  sclera  and  then  removing  it  by  means  of  a  scoop. 

Modifications  of  the  procedure  of  iridectomy.     Although  favoring 


5508  GLAUCOMA 

llic  linear  knife,  Schcrk  {Klin.  Moimtsbl.  f.  Aiigenlieilk,  1873,  p.  101) 
tliouf,'lit  the  laiieet  more  practical  in  certain  cases.  To  combine  tiie 
advantages  of  hotli  these  instruments,  lie  (h-vised  a  bayonet-sliaped 
knife  witli  a  blade  15  mm.  lontj;  inserted  at  a  litth'  more  than  a  right 
angle  into  a  20  mm.  long  shank,  whi(;li  is  fixed  again  at  a  little  more 
than  a  right  angle  into  an  ordinary  knife  liandle. 

Czermak  is  a  warm  advocate  of  a  metliod  practised  by  Dehenne 
{Arch.  cVOphtal.,  1888,  p.  120),  esjx'cially  in  primary  glaucoma  witli 
a  shallow  or  obliterated  anterior  chamber  and  in  iris  bombe.  Tliis 
operator  punctured  the  outer  inferior  quadrant  of  the  globe  1.5  mm. 
from  the  limlius  with  a  ver^^  fine  linear  knife.  The  sclera  is  perforated 
until  the  point  of  the  knife  appears  in  the  angle  of  the  chamber.  The 
scleral  incision  is  then  enlarged  parallel  to  the  limbus  4  to  5  mm.  by 
slow  sawing  movements  of  the  knife.  No  counter-puncture  is  made. 
During  this  maneuvre  the  aqueous  escapes  drop  by  drop  and  tension 
is  reduced  very  gradually.  The  iris  is  then  withdrawn  and  excised, 
Czermak  makes  his  incision  in  the  upper,  outer  quadrant  and  usually 
fixes  the  eyeball  with  two  pairs  of  forceps. 

Streatfeild  {Cangres  de  Londres,  1873,  compt.  rend.,  p.  154-159) 
also  avoided  counter-puncture  and  made  much  the  same  incision  as 
Dehenne,  employing  the  point  of  a  broad  cataract  knife  for  the 
purpose. 

Deschamp's  method  {Anal.  dVcid.,  1902,  CXXVII,  p.  101)  of 
making  an  incision  through  the  limbus  and  adherent  iris,  thus  re- 
opening the  posterior  chamber,  seizing  the  posterior  surface  of  the 
iris  and  then  withdrawing  and  excising  that  membrane,  also  resembles 
Dehenne 's. 

Gayet  {Bidletin.  ct  Mem.  Soc.  Franc.  d'Opht(dm.,  1884,  p.  41)  has 
devised  an  operation  which  has  ])een  somewhat  modified  by  Dufour 
{Annales  d'Oculist.,  Jan.,  1901),  which  is  appliealile  to  cases  in  which 
the  anterior  chamber  is  so  shallow  that  it  is  impossible  to  open  it 
without  wounding  the  iris  if  the  ordinary  plan  of  incision  is  followed. 
In  this  procedure  the  surgeon  grasps  the  conjunctiva  with  ]Monoyer's 
fixation  forceps,  api)lying  one  point  above  and  the  other  below  the 
cornea.  The  incision  is  then  made  at  the  scleral-corneal  junction  witli 
an  ordinary  Desmarres  scarificator  througli  the  cornea  from  without 
inwards,  the  membrane  being  divided  layer  by  layer  hy  gentle  sawing 
movements,  care  being  exercised  to  keep  the  knife  constantly  in  contact 
with  the  tissues  to  prevent  the  incision  from  becoming  jagged.  As 
soon  as  a  drop  af  aqueous  presents,  the  scarificator  is  dispensed  witli 
and  llie  incision  is  finished  willi  small,  l)luiit-])ointed  scissors,  or,  as 
recomineiKJed    1)\-    Dufour.   willi   snudl,   bent   knives    (iridesis   knives). 


GLAUCOMA  5509 

Till'  cxt'isioii  of  the  iris  now  follows  in  the  usual  manner.  General 
anesthesia  is  desirable.  Gayet  deemed  his  procedure  particularly 
adapted  to  cases  of  acute  glaucoma  with  opaque  cornea.  The  compli- 
cations consist  in  hemorrhage  into  the  anterior  chamber  and  injury  of 
the  iris  by  the  scariticator,  but  the  blood  is  rapidly  absorbed,  and  if 
the  iris  is  injured,  it  can  readily  be  excised. 

Dianoux  {Bull,  et  Mem.  de  la  Soc.  Fran(;.  d'OphtcUm.,  1884,  p.  44) 
substituted  a  Beer's  knife  for  the  scarificator  and  a  Weber  probe- 
pointed  lachrymal  knife  for  the  scissors.  Beard  {Ophthalmic  Sur- 
giry,  p.  44(j)  suggests  that  a  little  instrument,  one  less  likely  to  wound 
the  iris,  would  be  a  small  model  of  the  Desmarres  keratoma. 

When  the  anterior  chamber  is  very  shallow,  Czermak  cuts  the  con- 
junctiva close  to  the  limbus  with  fine-pointed  scissors,  and  dissects 
back  a  flap  embracing  nearly  one-half  of  the  corneal  circumference 
and  a])out  4  to  5  mm.  high  at  the  center.  After  checking  any  slight 
heniori'liage  with  adrenaline  and  ice  cold  sponges,  he  makes  an  incision 
with  a  well-curved  scalpel,  through  the  sclera,  1  mm.  from  the  edge 
of  the  clear  cornea,  cutting  carefully,  layer  by  layer,  until  the  anterior 
chamber  is  opened.  If  the  iris  ])rolai)ses,  it  is  replaced,  and  the  well- 
rounded  point  of  a  fine  Louis'  scissors  is  introduced,  and  the  incision 
broadened  to  one  or  both  sides.  The  original  incision  needs  to  be 
only  large  enough  to  admit  the  scissors'  point,  and  should  be  slightly 
oblique  instead  of  vertical,  tlie  liack  of  the  knife  being  inclined  almost 
toward  the  equator  of  tlie  ball.  In  this  way  the  inner  wound  is  almost 
exactly  opposite  the  boundary  of  Descemet's  membrane,  and  a  colo- 
boma  4  to  8  mm.  wide  can  be  secured.  After  introducing  the  iris 
forceps,  they  are  opened  wide  so  as  to  secure  a  ])road  fold  of  iris,  the 
iris  is  grasped  in  the  center  and  drawn  gently  toward  the  pupil,  the 
forceps  being  pushed  forward.  This  loosens  the  ligament,  and  the  iris 
is  then  drawn  outward  and  excised. 

In  cases  in  whieh  the  iris  is  adherent  to  the  cornea,  and  is  more 
or  less  atrophic,  Czermak  combines  Heine's  cyclodialysis  with  the 
iridectomy.  Following  Heine's  method,  he  frees  the  attachment  of 
the  ciliary  body  and  the  adhesion  of  the  iris  with  a  delicate  spatula, 
and  then  perfoi-ms  tlie  iridectomy.  He  has  done  the  combined  opera- 
tion in  a  number  of  cases,  but  is  unable  to  make  a  definite  report  upon 
its  results.  In  order  to  avoid  seizing  the  ciliary  body  with  the  forceps, 
if  it  prolapses  into  the  wound,  lu'  lias  liad  constructed  a  forceps  witli 
protecting  jilates.  Tsually  at  the  conclusion  of  the  operation  he  passes 
a  silk  suture  through  the  edges  of  the  conjunctival  wound,  and  if  the 
ciliary  body  prolapses  he  makes  a  superficial  scleral  puncture. 

In  cases  of  acute  glaucoma  with  abolition  of  the  anterior  chamber 


5510  GLAUCOMA 

;in(l  tile  iris  i-cduccd  to  a  narrow  I'iiu  oi-  wholly  lost  to  sight  heneath 
the  conico-sc  Ida!  margin,  liurnctt  {Am.  Journ.  Ophthalm.,  April, 
1!)02,  J).  114)  inoditic'd  the  incision  after  the  method  originally  intro- 
duced by  Streati'eild  in  his  operation  for  cataract,  as  follows:  An 
opening  is  made  into  the  anti'i'ior  chand)er  from  without,  by  successive 
strokes  with  the  point  of  a  Graefe  knife,  following  the  curves  of  the 
corneal  base  as  far  behind  the  (dear  cornea  as  desirable  for  the  most 
])eriph('ral  position  of  tlie  wound,  the  essential  idea  being  to  cut  the 
layers  at  the  sclero-corneal  junction  as  evenly  as  possible  throughout 
the  whole  extent  of  the  incision.  The  bottom  of  the  wound  thus  care- 
fully made,  finally  gives  w^ay  at  some  point,  and  through  this  opening 
there  is  a  gush  of  aqueous  and  usually  a  i)rolapsed  iris.  A  triangular 
'  knife  with  a  bulbous  point  is  then  introduced  into  the  w^ound  and  the 
section  of  the  already  thinned  tissue  completed  by  the  sharp  sides  of 
the  knife.  The  iris  now  usually  occupies  the  opening  and  is  seized 
with  the  forceps  and  cut  in  the  usual  way. 

A.  A.  Bradburne  has  adopted  the  plan  (when  operating  for  ({uiet, 
simi)le  glaucoma)  of  removing  only  the  base  of  the  iris,  taking  partic- 
ular care  to  leave  intact  the  periphery.  To  do  this  well  he  finds  it  ad- 
visable, after  the  usual  incision  has  been  made  with  a  keratome,  to 
grasp  the  center  of  the  iris  and  to  make  gentle  traction  to  the  center 
of  the  pupil  so  as  to  first  dislocate  the  root.  It  is  then  withdrawn  and 
cut  off  in  the  usual  manner. 

The  advantages  of  this  modification  are,  (1)  it  produces  little  dis- 
figurement, (2)  it  causes  very  little  shock,  (3)  it  does  not  destroy  the 
optical  properties  of  the  iris  as  regards  its  light-protecting  or  visual 
properties,  (4)  it  does  not  allow^  the  iris  to  fall  back  into  the  anterior 
chamber  as  the  more  drastic  operation  does,  (5)  it  lessens  the  need  for 
so  large  an  incision  and  therefore  lessens  the  liability  to  prolapse  of 
the  lens,  corneal  astigmatism  and,  finally,  does  not  prevent  other  opera- 
tions being  performed  if  necessary  later  on.  Personally,  he  has  never 
found  occasion  to  do  anything  further  in  any  case  in  which  he  has  em- 
ployed it. 

Sclcro-iridectomy.  Terson,  Sr.  {Memoires  du  Cong.  d'Opht.  dc 
Paris,  Jan.  26,  1885;  SocieU  de  Med.  de  Taulame,  Jan.  11,  1889) 
aimed  at  insuring  the  beneficial  action  of  both  operations  h\  com- 
bining iridectomy  wdth  sclerotomy — sclero-iridectomy.  A  sclerotomy 
is  first  performed  after  the  method  of  de  Wecker,  the  puncture,  how- 
ever, being  made  much  higher,  in  line  with  a  point  2  to  3  mm.  from 
the  upper  end  of  the  perpendicular  corneal  margin,  the  counter- 
puncture  as  a  consequence  occurring  only  slightly  above  the  nasal 
extremity  of  the  horizontal  meridian.     The  incision  is  continued  with 


GLAUCOMA  5511 

sawing  movements  and  the  wound  of  entrance  is  made  much  longer 
tlian  that  of  the  eounter-ijuneture  by  raising  the  handle  of  tlie  knife. 
To  previ'iit  the  partially  divided  conjunctiva  over  the  wound  of  en- 
trance from  interfering  willi  the  excision  of  the  iris,  tiie  knife  is  thrust 
forward  a  st'cond  time  after  withdrawal  and  a  ])ortion  of  the  conjunc- 
tival hi'idge  (livith'd.  The  Hap  tlius  formed  is  reflected  over  the  cornea, 
and  the  iris  tiieii  drawn  out  and  excised  as  peripherally  as  possible. 
A  I'esultant  narrow  coh)boma  is  thus  secured  above. 

This  operation  reseudjles  somewiuit  the  sclero-dilatatorectomy  of 
Logetschnikow  {Bericht  iiber  die  23  Versammlung  der  Ophthal.  Ge- 
sellscJi.,  Heidelberg,  1893,  p.  21),  in  which  the  operator  aims  to  per- 
form irich'ctomy  with  preservation  of  the  pupillary  margin  in  combi- 
nation with  doubh;  sclerotomy.  If  the  iris  is  merely  incised,  the 
operation  should  be  designated  sclero-dilatatorotomy. 

Filtering  cicatrix.  As  lias  already  ))een  stated,  de  Wecker  long  ago 
suspected  that  it  was  not  the  removal  of  tlie  iris  which  diminished  the 
intraocular  tension  in  glaucoma,  ])ut  rather  the  formation  of  the 
"filtering  cicatrix."  In  recent  years  this  theory  has  gained  many 
adherents,  and  ophthalmological  journals  have  contained  a  remarkable 
number  of  diverse  methods  to  obtain  filtration  areas.  While  there 
are  still  those  who  believe  that  a  soundly-healed  cicatrix  possesses 
filtration  properties,  the  majority  of  observers,  perhaps,  have  now 
arrived  at  the  conclusion  that  such  is  not  the  case,  and  consider  that  a 
firndy-iiealed  cicatrix  in  the  sclera  is  no  more  permeable  than  normal 
tissue.  The  newer  procedures,  therefore,  aim  at  the  removal  of  some 
of  the  sclera,  in  the  hope  that  the  remaining  parts,  even  after  healing, 
will  be  permanently  less  resistant,  and  will  thus  allow  the  intraocular 
fluids  to  pass  more  rapidly  from  the  eye. 

[B.  James  and  S.  Ilosford  {Tram.  Oph.  Soc.  U.  K.,  July,  1912) 
report  a  description  by  j\lr.  James  in  1909  of  a  method  of  operating 
upon  all  cases  of  glaucoma  by  cutting  through  the  sclera  from  without, 
after  having  turned  down  a  preliminary  conjunctival  flap  to  cover 
over  the  linear  wound.  kSIucc  then  the  operation  has  been  somewhat 
elaborated  by  turning  out  a  piece  of  sclera  by  the  following  method : 
The  conjunctiva  liaving  ])een  made  anesthetic,  and  a  few  drops  of 
adrenaline  solution  instilled,  a  large  conjunctival  flap  was  turned 
downwards  to  the  corneal  margin.  All  further  bleeding  was  now 
stopped  by  adrenaline.  An  incision  was  next  made  at  the  limbus.  con- 
centric witli  the  corneal  margin,  by  cutting  with  the  edge  of  the  Graefe 
knife  near  its  tip,  so  that  the  lips  of  the  wound  were  perpendicular. 
The  i)aring  was  proceeded  with  until  a  fair  depth  of  wound  had  been 
obtained.    A  snmll  puncture  was  then  made,  and  the  aqueous  allowed 


5512  GLAUCOMA 

to  evacuate  itself  very  slowly.  A  blunt-pointed  Stilling  knife  was 
now  inserted  into  this  opening,  and  the  wound  enlarged  throughout 
its  extent.  A  moderately  large  iridectomy  was  then  made  in  the  usual 
way.  The  operator  then  proceeded  to  turn  out  a  piece  of  sclera  from 
the  upper  lip  or  the  angles  of  the  wound,  endeavoring  to  ensure  that 
some  of  the  lining  membrane  was  attached  to  its  under  surface.  This 
was  laid  flat  on  the  surface  of  the  adjoining  sclera,  and  held  in  posi- 
tion by  the  conjunctival  flap  being  stroked  over  its  surface.  The 
special  points  in  the  operation  w^ere :  (1)  The  fact  that  the  edges  of 
the  scleral  incision  were  perpendicular,  not  slanting  as  made  by  the 
Graefe  or  the  keratome.  (2)  It  would  be  noticed  that  the  iris  fell  back- 
wards much  more  readily  than  in  an  ordinary  iridectomy,  and  did  not 
require  the  introduction  of  another  instrument  into  the  eyeball  to 
replace  it.  (3)  The  scleral  flap  could  be  cut  by  one  of  two  methods. 
In  some  of  the  cases  this  was  done  by  means  of  a  punch.  This,  how- 
ever, was  somewhat  uncertain,  and  occasionally  punched  a  piece  of 
sclera  clean  out,  which  was  not  desirable.  (4)  Another  method  was 
to  turn  outwards  by  means  of  scissors  or  knife  a  strip  from  one  or 
both  angles  of  the  wound.  If  this  plan  were  adopted  it  was  better 
to  outline  a  strip  by  marking  out  its  limits  almost  through  the  whole 
thickness  of  the  sclera  "prior  to  opening  the  anterior  chamber,  as  the 
relaxed  state  of  the  tissues  when  the  aqueous  had  escaped  rendered 
the  proceeding  more  difficult.  Hosford  carried  the  method  out  in  all 
his  cases  of  glaucoma  except  one,  and  that  he  did  on  the  periphery  of 
the  iris.  Whatever  method  was  employed  there  was  a  predilection  on 
the  part  of  the  sclera  to  close  up.  Ten  out  of  38  cases  so  treated  closed 
up.  Of  the  38,  28  leaked  by  first  intention  and  8  of  the  remaining  10 
leaked  secondarily.    The  operation  was  simple.    Ed.] 

One  of  the  chief  opponents  of  the  theory  of  filtering  cicatrices  is 
Henderson  {The  Ophthalmoscope,  Dec,  1907,  p.  701),  who  contends 
tliat  the  success  of  the  operative  procedure  in  glaucoma  does  not  result 
from  the  particular  method  of  incision  adopted,  but  depends,  as  has 
been  well  shown  clinically  since  Graefe 's  time,  on  the  iridectomy  and 
on  the  state  of  the  iris.  He  bases  this  statement  upon  anatomical  in- 
vestigations, which  demonstrate,  in  his  opinion,  that  while  corneal 
incisions  heal  and  cicatrize,  the  cut  iris  surface  forming  the  base  and 
pillars  of  the  coloboma  never  does,  but  always  remains  as  when  first 
severed,  thus  acting  as  a  drainage  area,  the  efficacy  of  wliich  depends 
on  the  condition  of  the  iris  at  the  time  of  operation.  Thomson  and 
Grimsdale  {The  Ophthalmoscope,  Nov.,  1908,  p.  875)  give  an  impar- 
tial review  of  the  (luestion  of  the  so-called  filtering  cicatrix.  Quite 
recently,  also,  Ballantyne  {The  Ophthaimoscope,  July  1,  1910,  p.  507) 


GLAUCOMA 


5513 


lias  eontributod  an  cxtronu'ly  valuable  paper  upon  the  same  subject, 
and  lias  (^ivcn  a  most  lucid  rrvicw  of  all  the  newer  operations  for 
glaucoma. 

The  Lagrange  irido-sdcrotaniij  oix  ration.  Of  all  the  opera- 
tions designed  to  establish  a  filtering  cicatrix,  that  devised 
by  Lagrange  {h'lvuc  gene  rah  d'OpJithal.,  11)06,  p.  358;  Arch. 
d'Ophtahn.,  1906,  XXVI,  p.  481)  and  designated  by  him  as  irido- 
sclerotomy,  or  iridectomy  comliined  with  sclerotomy,  has  probably  met 


Illustrating  Ditt'eieiit  Steps  in  the  Lagrange  Operation. 

with  the  greatest  favor.  To  obtain  this  permanent  filtration  cicatrix, 
after  eserinization,  an  oblique  incision  is  made  through  the  sclera  by 
means  of  a  narrow  Graefe  knife  and  a  large  conjunctival  flap  secured. 
This  is  obtained  by  making  a  peripheral  section  of  the  sclero-corneal 
margin  with  the  knife,  and,  as  soon  as  the  edge  of  the  knife  reaches 
the  upper  limit  of  the  anterior  chamber,  it  is  turned  backward  and 
brought  out  through  the  sclera  obliquely  (see  fig.).  The  conjunctival 
flap  is  then  turned  back  over  the  cornea,  and  the  fragment  of  sclera 
that  was  left  attached  to  the  cornea  is  removed  by  means  of  a  fine  pair 


5514  GLAUCOMA 

of  delicate  curved  scissors  (see  fig.),  following  whicli  an  iridectomy  is 
performed.  The  conjunctival  Hap  is  now  replaced  and  a  bandage 
aijplied.  This  operation  opens  a  large  filtration  passage  for  the  intra- 
ocular fluids  and  the  prompt  healing  of  the  wound  with  its  mucous 
covering  prevents  prolapse  of  the  iris. 

Although  Lagrange  advocated  iridectomy  in  all  cases  in  his  first 
communication,  he  no  longer  judges  the  procedure  to  be  necessary  in 
all  instances,  reserving  it  for  cases  in  which  for  any  reason,  such  as 
hypertension,  prolapse  is  to  be  feared.  Under  no  circumstances  must 
the  iris  be  left  between  the  lips  of  the  wound. 

While  Lagrange  holds  that  it  is  necessary  to  open  the  anterior  cham- 
ber, Bettremieux  {Bull,  de  la  Soc.  Belg.  d'Ophtal.,  No.  23,  p.  36,  1908; 
The  Ophthalmoscope,  Oct.,  1908,  p.  818)  thinks  that  a  removal  of  but 
a  portion  of  the  thickness  of  the  sclera  suffices.  His  procedure  is  as 
follows:  After  raising  a  flap  of  conjunctiva  from  the  neighborhood 
of  the  limbus  above  the  cornea,  a  medium-sized  needle,  curved  and 
flattened  towards  its  point  and  flrmly  grasped  in  a  needle-holder,  is 
thrust  superficially  into  the  sclera  tangentially  to  the  upper  edge  of 
the  cornea,  so  as  to  become  fixed  in  the  capsule  of  the  eyeball.  A  small 
shaving  of  the  sclera,  about  i/^  mm.  thick,  II/2  to  2  mm.  broad  and  from 
2  to  3  mm.  long,  is  then  excised  by  means  of  a  narrow  Graefe  knife. 
The  scleral  slip  is  then  freed  from  the  conjunctiva  at  each  end  and 
the  mucous  membrane  brought  together  over  the  wound  by  fine  cat- 
gut sutures. 

Terson  believes  that  a  filtering  cicatrix  is  not  necessary  or  desirable 
to  cure  an  ordinary  glaucoma,  but  approves  of  the  procedure  of  La- 
grange when  a  peripheral  iridectomy  has  produced  only  a  temporary 
effect. 

Weeks  has  done  the  Lagrange  operation  for  glaucoma  many  times. 
It  has  given  him  very  good  results,  superior,  he  thinks,  to  the  results 
ol)tained  by  the  classical  ojieration,  in  that  there  is  filtration  through 
the  new-formed  tissue  at  the  site  of  the  wound  for  a  longer  period  of 
time.  He  does  not  think  that  permanent  filtration  is  established  in 
many  cases,  if  in  any.  He  makes  the  incision  a  little  shorter  than 
recommended  by  Lagrange. 

Ballantyne  (The  Ophthalmoscope,  July  1,  1910)  has  summarized 
Lagrange's  conclusions  as  follows:  "The  results  of  sclerectomy  vary 
according  to  the  degree  of  hypertension  of  the  eye  operated  on.  Three 
varieties  of  cicatrix  are  distinguishable  according  to  the  amount  of 
sclera  excised:  (1)  That  in  which  tiiere  is  mere  tliiiuiing  of  the  sclera 
owing  to  the  excised  portion  not  reaching  the  posterior  surface  of  the 
cornea   (conjunctiva  smoothly  covers  tlie  cicatrix).      (2)   Tliat  repre- 


GLAUCOMA 


5515 


sentod  by  a  .subeoiijuiictival  fistulette,  clue  to  excision  of  the  whole 
thickness  of  the  sclera,  in  an  eye  with  moderate  tension  (the  conjunc- 
tiva lies  smoothly  over  the  cicatrix).  ;i  The  fistulous  cicatrix  with 
an  ampulliform  elevation  of  the  overlying  conjunctiva,  resulting  from 
excision  of  the  whole  thickness  of  the  sclera  in  an  eye  the  seat  of  high 
tension.  In  cases  of  liigh  tension,  even  a  simple  sclerotomy  will  allow 
ample  filtration,  owing  to  the  gaping  of  the  wound,  while  in  cases 
without  elevation  of  the  tension,  sclerotomy  will  be  quite  ineffectual. 
Lagrange  therefore  proposes  the  following  rules  of  procedure:  (a)  If 
tension    is   normal    to    +1,    do   sclerectoiny   witliout    iridectomy,   the 


Limbal  Puncture.     (D.  Priestley  Smith.) 

amount  of  sclera  excised  l)eing  inversely  in  proportion  to  the  degree  of 
hypertension,  (b)  If  tension  is  -f  1  to  +  3,  do  sclerotomy-iridectomy, 
the  iridectomy  being  added  to  avoid  entanglement  of  the  iris.  La- 
grange does  not  reconnnend  his  operation  for  acute  glaucoma.  It  is 
especially  adapted  for  cases  of  chronic  simple  glaucoma." 

Some  operators  have  combined  sclerotomy  with  an  irido-dialysis. 
Thus  Knies  {Bcricht  der  Ophtlialm.  Gesscl.  1893,  p.  118)  expressed 
his  opinion  that  the  value  of  iridectomy  was  chiefly  in  the  fact  that 
removal  prevented  prolapse  and  adhesion.  He,  therefore,  in  dealing 
with  glaucoma,  cuts  through  the  attached  base  of  the  iris  with  the 
knife  at  the  time  of  the  section  of  the  globe,  making  an  operative  partial 
irido-dialysis.    He  calls  the  method  "  irido-sclerotomy. " 

[Limhal  puncture.  David  Priestley  Smith  (Ophthal.  Ecvicw.,  p.  33, 
Feb.,  1915)  described  a  method  of  puncturing  the  eye  deeply  at  the 


5516 


GLAUCOMA 


margin  of  the  cornea  for  the  relief  of  tension.  It  was  done  many  years 
ago  by  Soloinoii,  Hancock,  Pritcliard,  and  others,  but  never  in  the  way 
described.  Tlie  autlior  has  done  it  three  times  for  buphthahnos  and 
17  times  for  glaucoma  in  adults. 


Linibal  Puncture.      (D.  Priestley  Smith.) 


Liinbal  Puncture.      (D.  Priestley  Smith.) 


For  buphthalmos.  The  puncture  consists  of  a  radial  slit  through 
the  limbus,  angle  of  anterior  chamber  and  periphery  of  iris,  into  the 
vitreous.  Three  instruments  are  needed — speculum,  fixation  forceps, 
and  Graefe  knife. 

To  perform  the  operation :    Anesthetize  the  child,  cut  the  lashes,  and 


GLAUCOMA  5517 

insert  the  speculum.  Standing  at  the  side  to  be  operated  on,  take  the 
forceps  in  the  hand  nearest  the  patient's  feet,  and  the  Graefe  in  the 
other.  Seize  the  ocular  conjunctiva  3  or  4  mm.  above  the  corneal 
margin,  and  draw  it  down  over  the  cornea  until  the  limbus  is  peeled 
of  its  own  conjunctiva  and  covered  only  l)y  that  stretched  down  from 
above.     (See  figs.)     This  traction  also  turns  the  eye  down. 

Now  puncture  the  eye  at  the  limbus  thus:  Hold  the  Graefe  knife 
with  its  back  towards  the  visual  axis  and  the  blade  aiming  for  the 
center  of  the  globe,  i.  e.,  perpendicular  to  the  surface  of  the  globe  at 
the  limbus  (see  fig.)  and  pierce  the  globe  to  a  depth  of  about  5  mm. 
Withdraw  the  knife  and  release  the  conjunctiva,  which  then  goes  back 
into  place  and  covers  the  wound  in  the  limbus. 


Limbal  Puncture.      (D.  Priestley  Smith.) 

The  above  description  needs  amplifying:  A  very  big  cornea  more 
than  fills  the  lid-aperture,  so  that  to  get  hold  of  the  conjunctiva  above, 
one  has  to  introduce  the  forceps  under  the  upper  lid,  for  which  pur- 
pose rather  narrow  forceps  are  best.  When  the  conjunctiva  is  pulled 
down 'over  the  cornea  it  takes  the  form  of  a  flattened  tent.  The  line 
of  reflection  of  the  under  layer  of  this  "tent"  from  the  globe  can  be 
seen  as  a  ridge  or  step  in  the  overlying  layer;  and  to  make  it  show 
well  the  conjunctiva  must  be  closely  applied  to  the  globe  as  shown  in 
the  figure,  not  pulled  away  as  in  another  figure.  The  position  of  the 
limbus  has  to  be  judged ;  through  the  thin  conjunctiva  of  a  buphthal- 
raos  it  shows  as  a  difference  in  color  from  the  sclera,  though  not  so 
clearly  as  shown  in  the  first  illustration  herewith.  The  surgeon  stands 
at  the  side  of  the  head,  facing  scjuare  across  the  patient,  so  that  by 
bending  down  nearly  to  the  level  of  the  eye  when  about  to  puncture  he 
can  make  sure  that  the  knife  is  perpendicular  to  the  surface  and 
therefore  pointing  to  the  center  of  the  globe.    A  high  table  makes  this 


5518  GLAUCOMA 

easier.  While  hcudin^f  down  llius  he  can,  by  slightly  raising  the 
forc'('i)s  from  tlie  surface  of  tlie  cornea  and  looking  into  the  sulcus  of 
reliocted  conjunctiva,  make  sure  also  that  he  does  not  button-hole  it 
with  the  point  of  the  knife.  The  knife  should  enter  the  eye  until  the 
parallel  part  of  the  blade  is  in  the  M'all. 

For  glaucoma  in  adults.  The  procedure  in  adults  dill'ers  in  one  vital 
point  from  that  in  buphthalmos,  namely,  the  direction  of  the  knife 
necessary  to  avoid  the  lens.  The  back  of  the  knife  must  be  parallel  to 
the  visual  axis,  as  shown.  As  in  a  few  persons  over  50  the  lens  reaches 
a  diameter  of  10  mm.  Imt  not  more,  the  rule  should  be  that  if  the  clear 
cornea  is  less  than  11  mm.  across  in  the  meridian  in  whicli  the  puncture 


Limbal  Puncture.      (D.  Priestley  Smith.) 

is  to  be  made  (usually  the  vertical),  the  knife  must  be  entered  out- 
side the  limbus — always  being  kept  parallel  to  the  visual  axis. 

Except  in  eases  where  the  peripher}-  of  the  iris  is  adherent  to  the 
back  of  the  cornea  the  knife  thus  directed  can  always  open  the  anterior 
chamber  without  touching  tlie  lens,  for  the  chamber  is  always  wider 
than  the  lens. 

In  many  cases  there  is  a  trickle  of  lilood  down  the  anterior  surface 
of  the  iris  showing  tliat  the  anterior  chamber  has  been  opened. 

Smith  believes  fi'om  such  a  limited  experience  one  can  form  only  a 
very  uncertain  opinion;  (1)  that  it  may  prove  suitable  for  buphthal- 
mos, (2)  that  if  there  are  cases  in  adults  in  which  it  is  desirable  to 
make  a  radial  slit  through  the  structures,  forming  the  tiltration-angle 
it  can  be  done  with  impunity. — Ed.] 

Ciliarotomy.  Within  tlie  past  few  years,  Aliadie  {Archiv.  d'opht- 
alm.,  May,  1910,  p.  262)  under  the  supi)Osition  that  irritation  of  the 
rich  circular  nervous  plexus  which  covers  the  ciliary  zone  immedi- 
ately behind  the  insertion  of  tlu^  iris,  may  induce  glaucoma,  has  under- 
taken to  relieve  the  condition  by  division  of  the  ciliary  zone,  or,  as 


GLAUCOMA  5519 

he  terms  it,  by  "ciliarotomy. "     The  technique  of  the  operation  is  as 
follows : 

A  fohl  of  the  bulbar  eoujuuetiva  is  raised  by  means  of  forceps 
towards  the  supero-external  quarter  of  the  cornea.  The  conjunctiva, 
raised  with  fine  dull-pointed  scissors,  is  divided  in  the  direction  of  the 
corresponding  meridian  of  the  eye  for  about  I14  centimeters.  The 
conjunctiva  being  thus  cleft,  one  takes  the  superior  flap  and  with 
ordinary  strabismus  scissors  detaches  it  from  the  sclera  wiiile  raising 
it  up,  taking  care,  in  order  to  disengage  it  well,  to  liberate  its  attach- 
ment to  the  selero-corneal  limbus  by  small  cuts  of  the  scissors.  The 
inferior  Hap  is  treated  in  a  similar  way.  By  these  means  a  large 
triangular  surface  of  the  sclera  is  bared,  the  base  of  which  is  formed 


Linibal  Puncture.      (D.  Priestley  Smith.) 

l)y  the  cornea  and  the  apex  by  the  terminal  point  of  the  conjunctival 
ojieiiing  made  in  the  first  instance.  A  couple  of  sutures  are  now  passed 
through  the  two  conjunctival  flaps,  whereby  they  may  be  brought 
together  in  order  to  cover  the  wound  which  is  about  to  be  made  in 
the  ciliary  region. 

The  sutures  once  in  place,  both  are  pulled  outward  in  such  a  way 
as  to  expose  the  field  of  operation.  Then,  seizing  with  fixation  forceps 
the  conjunctiva  and  the  episcleral  tissue  at  the  level  of  the  inferior 
conjunctival  flap,  so  as  to  keep  the  eye  perfectly  steady,  the  point  of 
Richter's  triangular  knife  is  inserted  just  at  the  junction  of  sclerotic 
and  cornea,  immediately  behind  the  insertion  of  the  iris.  It  is  gently 
plunged,  so  to  speak,  into  the  globe,  its  point  being  directed  towards 
the  centre  of  the  eye,  while  the  blade  makes  the  incision.  In  con- 
sequence of  its  triangular  form,  its  propulsion  towards  the  centre 
of  tlie  eye  causes  its  cutting  edge  to  divide  the  ciliary  zone.  By  slight 
sawing  movements  of  the  blade,  this  section  is  enlarged  in  such  a  way 


5520  GLAUCOMA 

that  it  attains  a  length  of  from  7  iimi.  to  H  miii. — that  is  to  say — 
about  the  extent  of  the  ciliary  nervous  plexus.  The  knife  is  then  with- 
drawn. Contrary  to  what  might  be  expected,  only  one  or  two  drops  of 
vitreous  issue  from  the  incision,  which  is  only  a  mere  slit. 

Then,  by  tying  the  two  sutures  previously  placed  in  the  con- 
junctival flaps,  the  conjunctiva  is  brought  together,  thereby  covering 
the  scleral  surface  and  the  incision  that  has  just  been  made. 

Abadie  asserts  that  his  procedure  is  especially  adapted  to  cases 
of  glaucoma  which  persist  despite  iridectomy.  The  results  have  been 
uncomplicated,  without  luxation  of  the  lens,  or  intraocular  hemorrhage. 

Incarceratimi  methods. — While  the  operators  who  designed  the  pro- 
cedures which  have  just  been  described  aimed  at  establishing  a  per- 
meable cicatrix  by  a  filtration  scar  which  was  free  from  iris  tissue, 
others  have  attempted  to  accomplish  the  same  result  by  producing 
incarceration  of  the  iris.  As  aptly  summarized  by  Ballantyne  {The 
Ophthalmoscope,  July  1st,  1910,  p.  510)  : 

"The  authors  of  the  incarceration  operations  base  their  proposals 
on  the  following  three  facts:  (1)  That  in  such  an  operation  as  extrac- 
tion of  cataract  the  entanglement  of  iris  in  the  wound  frequently  leads 
to  the  formation  of  a  cj'stoid,  or,  at  least,  a  fistulous,  scar,  and  that 
the  eye  in  consequence  remains  permanently  soft,  with  evidence  of 
leakage  of  aqueous  fluid  into  the  subconjunctival  tissue;  (2)  that  in 
iridectomies  done  for  acute  glaucoma  the  best  and  most  permanent 
results  are  found  in  cases  where  the  iris  has  become  entangled  between 
the  lips  of  the  wound;  and  (3)  that  the  risk  of  infection  of  a  pro- 
lapsed or  incarcerated  iris  is  greatly  less  in  the  cases  where  the  latter 
is  covered  with  conjunctiva.  If  the  beneficial  effect  of  iridectomy  in 
many  cases  is  due,  not  to  the  iridectomy,  ])ut  to  an  accidental  inclusion 
of  iris,  why  not,  they  ask,  set  out  to  produce  such  an  inclusion  in  a 
regulated  and  delibei-ate  manner,  adding  the  conjunctival  covering  to 
avoid  risk  of  infection?" 

Two  chief  advocates  of  the  incarceration  method  are  Herbert  and 
Ilolth.  In  a  recent  conununication  Herbert  (Trans.  Ophtliahn.  Soc. 
V.  K.,  1903,  p.  324)  gave  the  details  of  a  variety  of  methods  which 
he  liad  employed  to  obtain  a  permea])le  scar  by  producing  a  large 
I)rolapse  of  the  iris  ])y  a  free  sclerotomy.  Finding  that  X\\e  iris  dainmcd 
up  tile  fluids,  he  was  led  to  excise  a  small  portion  of  this  membrane, 
thereby  establishing  a  fistula.  In  other  cases  a  large  conjunctival  flap 
was  made  above  the  section  and  a  fold  of  conjunctiva  tucked  between 
the  lips  of  the  scleral  wound.  As  soon  as  the  anterior  chamber 
reformed,  the  fold  of  conjunctiva  was  distended  by  the  aqueous  and 
a  bulging  prominence  formed  above  the  wound.      In   favoi'able  cases 


GLAUCOMA  5521 

this  wound  (lid  not  licjil  lii'inly  and  ;i  sul)coii.juiictiv;d  fistula  formed 
wliicli  permitted  the  free  escape  of  aqueous.  Another  procedure 
consisted  in  fastening  the  fold  of  conjunctiva  to  the  wound  by  tying 
the  two  threads  of  a  suture  into  a  knot,  and  then  passing  it  through 
the  middle  of  the  conjunctival  flap;  the  needle  is  then  passed  into 
the  anterior  chamber  and  the  suture  brougiit  out  through  the  upper 
limbus  of  the  cornea,  the  two  ends  of  the  thread  being  tied  on  the  sur- 
face.    The  thread  is  removed  after  24  hours. 


Herbert's  Glaucoma  Knife  for  the  ^Vcllyc  Isolatiun  Operation. 

W<clgc-isol(itio)i  operation. — IlerV'rt  has  devised  another  opera- 
tion {The  OpJitludmosvope,  June,  1907,  p.  292),  which  has  been  termed 
the  w'edge  isolation  operation.  By  this  procedure  Herbert  claims  *o 
avoid  what  he  considers  the  faults  of  the  Lagrange  operation,  i.  e., 
too  long  an  incision,  the  excision  of  too  large  a  portion  of  iris,  and 
the  lack  of  means  of  regulating  the  size  and  depth  of  the  portion  of 
excised  sclera.  He  reports  that  38  such  wedge-isolation  operations 
have  been  performed  with  uniform  and  trustworthy  results  in  the 
production  of  a  filtering  scar.  It  is  claimed  that  the  smallness  of 
the  incision  makes  the  operation  a  safe  one,  while  if  the  procedure 
fail,  subsequent  operations  of  a  different  nature  are  not  interfered 
with.    The  writer  describes  the  operation  as  follows : 


Herbert's   Trowel  Shanked   Glaucoma   Knife  for  Lateral  Incision   in   the   Wedge- 
Isolation  Operation. 

The  knife  used  (see  figure)  is  an  old  and  worn  Graefe,  ground 
down  to  a  breadth  of  a])out  -4/5  mm.  It  must  taper  gradually  to  the 
point.  One  blade  which  served  us  very  well  tapered  from  point  to 
heel.  It  measured  al)Out  l^/i  nnn.  in  width  at  the  heel  and  was  2G 
mm.  long.  The  eye  is  fixed  with  foreei)s  at  the  inner  side.  After 
the  counterpuneture  has  been  made,  there  is  little  or  no  trouble  in 
the  matter  of  fixation  during  the  slow  section,  because  witli  so  snudl 
an  incision  the  knife  lying  in  the  wound  suffices  almost  to  prevent 
upward  rotation  of  the  globe.  The  conjunctival  puncture  is  made  liA 
mm.  or  2  mm..  a})ove  the  projected  line  of  incision,  the  loose  con- 
junctiva lieing  then   puslied   down   in   a   fold   with  the   point   of  the 

Vol.  VII — 43 


5522 


GLAUCOMA 


knife.  In  making  the  sclero-corneal  puncture  quite  close  to  the  cornea, 
the  direction  of  the  blade  is  nearly  transverse.  It  must  point  but 
little  downwards,  since  otherwise  a  fair  share  of  the  section  is  not 
accomplished  in  the  puncture.  Our  very  small  primary  incision  is 
largely  accomplished  in  the  acts  of  puncture  and  counter-puncture, 
and  if  too  much  tissue  is  left  to  be  cut  in  the  counter-puncture,  the 
latter  can  not  be  made  without  the  use  of  an  objectionable  degree 
of  force.  The  cutting  edge  of  the  knife  is  directed  either  exactly 
upwards  or  slightly  backwards,  although  this  latter  inclination  makes 
the  counter-puncture  a  little  less  easy.    The  course  of  the  blade  within 


The  Wedge-Isolation  Operation. 
B  and  C  Show  the  Directions  of  the  Incisions  Correctly,  but  the  Position  of  A 
should  probably  be  more  to  the  right,  in  order  to  make  the  diagrams  applicable 
to  the  middle  of  the  transverse  wound.     Possibly  there  the  apex  of  the  wedge 
reaches  the  posterior  surface  of  the  cornea. 

the  anterior  chamber  need  not  extend  to  more  than  3  mm.  or  4  mm. 
The  point  is  then  brought  a  little  forward  to  engage  in  the  posterior 
surface  of  the  cornea.  It  should  reach  the  scleral  surface  quite  close 
to  the  corneal  boundary.  As  it  slowly  emerges,  some  aqueous  usually 
leaks  out  beside  it,  raising  the  neighboring  conjunctiva  before  the 
latter  is  fully  pierced.  As  soon  as  the  point  is  well  through,  the 
blade  is  turned  to  direct  the  cutting  edge  downward,  and  the  puncture 
and  counter-puncture  are  enlarged  thus. 

This  downward  enlargement  is  commonly  sufficient  when  almost 
the  whole  width  of  the  blade  can  be  seen  through  the  cornea,  the 
knife  being  momentarily  twisted  to  show  this.  It  is  needed  to  allow 
the  blade  to  be  twisted  freely  and  placed  correctly  for  the  for- 
ward cut  (b).  But  before  this  secondary  forward  cut  is  made,  the 
primary  incision  may  be  further  enlarged  upwards  and  somewhat 
backwards,  taking  care  to  leave  a  bridge  of  superficial  sclerotic  still 
undivided.     (See  the  figure.) 

The  blade  is  then  twisted,  and  the  secondary  incision  (b)  forward 
and  upward,  exactly  perpendicular  to  the  surface,  is  made  with  slow, 
gentle,  to-and-fro  movements.     The  knife-edge  should  aim  to  reach 


GLAUCOMA  5523 

the  surface  almost  exactly  at  tlie  corneal  margin,  about  the  middle 
of  the  small  incision.  AVith  ordinary  care,  gentleness  and  delibera- 
tion, there  is  no  difficulty  in  completing  this  forward  sclero-corneal 
cut  without  dividing  the  overlying  conjunctiva,  even  though  the  latter 
be  not  elevated  at  all  by  aqueous.  Tlie  primary  upward  incision 
is  then  completed  subconjunctivally  to  isolate  the  wedge.  The  latter 
should  be  quite  narrow.  Its  vertical  measurement  should  be  i/^ — 2/3 
mm.  In  completing  the  section,  therefore,  Ihe  knife-edge  has  usually 
to  be  turned  more  or  less  forward,  as  in  the  figure.  It  is  obvious  that 
precision  and  care  are  needed  in  locating  and  directing  these  cuts  cor- 
rectly, especially  the  forward  cut  (b),  since  quite  small  variations 
ma}'  influence  the  depth  of  the  wedge  very  considerably.     (See  figure.) 


The  Two  T^pjier  Lines  in  Fig.  D  Represent  the  Conjunctival  Incisions  nearly 
Completing  a  Conjunctival  flap. 

It  is  easy,  by  twisting  the  blade  a  little  when  making  the  counter- 
puncture,  to  produce  a  free  escape  of  aqueous  beneath  the  conjunctiva, 
thus  insuring  it  against  the  possibility  of  accidental  section.  But,  if 
this  be  done,  one  can  not  see  well  enough  through  the  distended 
mucous  membrane  for  the  exact  outlining  of  the  sclero-corneal  strip 
of  tissue. 

It  still  remains  to  cut  a  conjunctival  flap,  for  a  sufficient  opening 
is  required  for  the  performance  of  an  iridectomy,  and  it  appears 
advisable  to  arrange  for  elastic  shrinkage  and  subsequent  distension 
and  elevation  of  the  conjunctiva  over  the  wound.  It  is  preferable 
to  leave  a  small  bridge  of  conjunctiva  undivided  above,  to  exclude  the 
possibility  of  the  flap  l)ecoming  b(>nt  downwards  over  the  cornea,  as 
happened  in  one  "jagged  incision''  operation  upon  an  acutel}'  glau- 
comatous eye,  where  the  conjunctiva  was  somewhat  swollen. 

The  iridectomy  is,  where  possible,  merely  a  small  peripheral  but- 
tonhole, made  solely  for  the  purpose  of  preventing  adhesion  or 
incarceration  of  iris  in  the  wound.  For  the  proper  performance  of 
this  minute  iridectomy,  and  to  aid  in  the  subse(|uent  retraction  of  the 
iris,  the  pupil  should  be  always  contracted,  if  possible,  by  eserine 
beforehand. 

It  may  be  broadly  stated  that  the  scheme  and  purpose  of  this 
operation  are  much  the  same  as  in  Lagrange's  sclerotomy.     In  the 


5524  GLAUCOMA 

latter  operation,  l)y  excision  willi  scis.soi-s,  a  <,'roove  is  left  in  the 
sclerotic  of  somewhat  uncertain  depth.  In  the  plan  conunoniy  fol- 
lowed, the  sclero-eorncal  gap  remains  covered  in  hy  tlie  detached  strip 
of  tissue,  and,  being  cut  from  within,  sliould  hear  a  more  definite  and 
constant  relation  (as  yet  nndertermined)  to  the  deep  surface  of  the 
cornea.  The  dependence'  upon  absorption  of  tissue — a  process  of 
nature — in  the  final  adjustment  of  the  i-csult  apj)ears  sound.  At  least, 
it  was  thus  that  we  came  to  explain  the  consistent  results  obtained 
formerly  as  regards  tension,  in  our  operations  by  subconjunctival 
prolapse  of  iris. 

We  commonly  bandage  the  eye  for  a  day  only,  and  afterwards 
protect  it  with  a  shield.  If  there  is  any  tendency  to  the  formation  of 
synechiae,  as  there  fre(|uently  is  after  operation  foi-  ai'utc  or  suti-acutc 
glaucoma,  atropin  is  used  freely.     The  tension  of  the  eye  should  be 


Vacher's  Punch-forceps  Modified  by  Holth  for  Sclerectomy. 

watched  for  some  time.  In  one  or  two  highly  congested  eyes  massage 
was  needed  the  day  after  operation  to  reduce  a  return  of  tension, 
evidently  due  to  glueing  together  of  the  wound  surfaces  by  lymph  and 
blood-clot.  In  a  number  of  eyes  the  tension  remained  very  low, 
— 2  or  — 3,  for  a  variable  period  after  operation.  The  longest  period 
yet  observed  of  this  low  tension  was  one  of  from  tliree  to  four  weeks. 
Holth's  formation  of  a  cystoid  cicatrix.  To  lessen  the  dangers  of 
infection  and  sympathetic  disturbance,  following  the  purposive  for- 
mation of  a  cystoid  cicatrix,  Ilolth  {Ann.  d'  Oculist.,  I\Iay,  1907,  p. 
345)  devised  an  operation  which  he  designated  iridencleisis  anti- 
glaucomatosa,  and  by  means  of  which  he  aimed  at  producing  sub- 
conjunctival incarceration  of  iris  tissue  combined  with  extra- 
sphincteric  iridectomy.  The  incision  is  usually  made  above  with  a 
keratome,  about  10  mm.  Ix'hind  the  corneal  limbus,  beneath  the  con- 
junctiva, the  knife  l)eing  l)rought  out  at  the  corneal  scleral  margin.  The 
anterior  chamber  is  now  opened  and  a  convex  fold  of  iris  brougiit  into 
the  wound,  establishing  a  fistulous  opening  between  the  anterior  cham- 
ber and  the  exterior  which  is  covered  by  a  broad  fold  of  conjunctiva. 
(See    figure.)      The    anterior   chamber    may    remain    unrestored    for 


GLAUCOMA 


5525 


st'Vi'ral  months  at'tci'  this  procedure,  but  tension  keeps  normal.  Schiotz 
advocates  tliis  pfoccdiirc,  l)ut  makes  a  normal  iridectomy  witli  a  large 
coiijuiietival  thip,  obtaining  ineareeration  of  a  small  i)ortion  of  the 
iris.  He  was  able  to  secure  a  filtering  scar  in  only  about  28  per  cent, 
of  the  cases,  although  Iloltli  claimed  that  he  secured  this  type  of  scar 
in  75  to  85  per  cent.  Vollert  {Ophthalmic  Year  Book,  1908,  p.  li)2) 
thinks  Ilolth's  is  the  best  operation  for  tiie  relief  of  glaucoma.  To 
avoid  the  danger  of  infection  through  the  cystoid  scar,  he  reconnnends, 
however,  the  transplantation  of  a  flap  of  conjunctiva  after  Kuhnt's 
method. 

[Iridotasis. — Borthen  {Archives  of  Ophthalmology,  July,  1911), 
claims  that  his  experience  with  the  Ilolth  operation  and  a  tongue- 
shaped  iris  flap  has  been  favorable.     Of  twenty-six  cases,  nine  were 


Holth's  Elbowed  Fixation  Forceps. 
It  is  a  useful  instrument  for  fixation  of  the  lower  part  of  the  linibus  when  the 
eye  must  be  turueil   downwanls  far  enough  to  make  the  subconjunctival  incision 
above  witli  the  keiatome. 

cured,  nine  unimjjroved,  and  eight  could  not  be  followed  up.  lie 
has  always  doubted  the  advisability  of  incising  the  iris  and  making 
a  flap  for  incarceration,  believing  this  part  of  the  operation  to  be 
ininecessary,  and  is  convinced  that  the  same  eff^ect  could  be  produced 
by  inclusion  of  a  fold  of  the  iris,  allowing  its  posterior  surface  to 
coalesce  with  the  subconjunctival  tissues,  assuring  a  position  of  the 
sphincter  external  to  the  section,  and  with  this  free  drainage.  The 
writer  states  that  he  has  operated  in  the  manner  described  on  fifty 
cases  and  has  not  seen  a  single  instance  of  simple  or  absolute  glaucoma 
in  which  it  failed.  He  proposes  the  term  iridotasis  for  the  operation. 
A  comparison  of  this  series  with  the  twenty-six  operated  on  according 
to  Holth  has  convinced  him  that  his  simj)litied  procedure  is  the  bet- 
ter, and  that  the  incision  of  the  iris,  which  was  supposed  to  be  of 
such  importance  for  the  formation  of  a  permanent  fistula,  has,  on  the 
contrar}^  the  eflFect  of  diminishing  the  prospects  of  pernmnently  redu- 
cing tension.  Furthermore,  he  says,  it  is  worth  noting  that  iridotasis 
may  be  ineffectual  where  the  iris  is  atrophic,  even  if  subconjunctival 
edema  appears  after  the  prolapse.  In  conclusion  he  lays  stress  on  the 
importance   of  operating  under  atropin   mydriasis  so   that   complete 


5526  GLAUCOMA 

paralysis  of  the  iris  may  prevent  spontaneous  reposition,  and  on  the 
advisability  of  avoiding  for<'il)l('  1  Taction  on  tlie  iris  after  it  has  l)een 
bi'ought  out  through  tlie  scleral  section  in  very  old  patients  with  a 
rigid  iris. — Ed.] 

Maher  (OpJilhaJmie  licvuw,  July,  1900,  p.  185),  while  advocating 
iricU'ctomy  in  the  early  stage  of  chronic  glaucoma,  believes  this  opera- 
tion to  be  useless  in  cases  of  long  standing,  where  it  is  no  longer 


^==^===y 


Jloltli's   JJoiihle   Blunt  Hook   for   Turning  Back   the  Conjunctiva  after  Sub- 
conjunctival Incision  with  a  Keratoma. 

possible  to  reopen  tlie  filtration  angle  by  this  method.  He  believes 
that  an  operation  should  then  be  preferred  which  establishes  a  cystoid 
cicatrix,  and  has  introduced  a  method  which  he  claims  has  given  him 
excellent  results  during  recent  years.  His  metliod  of  procedure  is  as 
follows : 

"Having  made  the  usual  scleral  section  with  a  broad  keratome,  I 
drag  on  the  iris  with  one  or,  preferably,  two  iris  forceps — one  in  each 


Diagram  of  Sclerectomy  (by  Holth's  method)  of  the  Anterior  Lip  with  a  Punch- 
forceps  after  Incision  with  a  Narrow  von  Graefe  Knife. 

hand — detaching  its  base  at  tlie  part  corresponding  to  the  scleral 
section.  The  loop  of  iris  thus  formed  is  left  well  prolapsed  for  a  week, 
when  it  is  snipped  off  with  an  iris  scissors  level  with  the  sclerotic  at 
each  angle  of  the  wound.  Sonu'tiines  I  vary  the  procedure  by  cutting 
the  iris  at  the  time  of  the  ojieration  at  one  angle  of  the  wound,  and 
then,  by  dragging  on  it  with  the  iris  forceps,  tear  it  away  from  its 
attachment  corresponding  to  tlie  section,  in  the  hope,  if  possible,  of 


GLAUCOMA  5527 

re-estal)lishinfi:  tlic  pommunicatioii  between  the  anterior  chamber  and 
tlie  canal  of  Schlemin.  Instead  of  now  completing  the  iridectomy,  I 
leave  prolapsed,  at  the  other  angle  of  the  wound,  a  large  portion  of  the 
tag  or  iris  tlius  formed,  and  at  the  end  of  a  week,  snip  it  off  hivel 
with  the  sclerotic.  ]iy  this  means  1  generally  obtain  small  flat  cystoid 
cicatrices.  The  same  result  may  often  be  obtained,  but  with  less  cer- 
tainty, by  performing  an  iridectomy  in  the  usual  way,  but  cutting  the 
iris  so  that  it  is  left  slightly  entangled  at  one,  or  both,  angles  of  the 
section." 

lie  admits  tliat  eyes  with  cystoid  cicatrices  run  a  risk  of  infection 
and  that  the  entanglement  of  iris  no  doubt  increases  the  liability  to 


Elliot's   Operation.      First   Stage   of   Operation.      Showing   the   Site   of   the   Tri- 
angular Flap  When  Made  Above  the  Cornea. 

sympathetic  ophthalmia.     These  sequelae,  however,  he  has  but  rarely 
met  with. 

T/ic  lise  of  the  scleral  trephine  in  glaucoma. — Fergus  (The  Ophthal- 
moscope, Feb.,  1910,  p.  74)  modified  the  Lagrange  operation  by  remov- 
ing the  piece  of  sclera  with  a  trephine  instead  of  with  scissors  and 
forceps,  combining,  as  it  were,  trephining  with  cyclodialysis.  The 
technique  consists  in  dissecting  a  conjunctival  flap  up  towards  the 
cornea  and  laying  it  over  the  corneal  surface,  when  a  small  disc  of 
sclera  is  removed  by  a'Bowman's  trephine  one  or  two  millimeters  from 
the  apparent  corneal  margin.  A  repositor  is  then  passed  between  the 
sclera  and  the  ciliary  body  and  iris  into  the  anterior  chamber,  keeping 
it  in  close  contact  with  the  sclera  and  cornea.  The  conjunctiva  is 
then  stretched  in  position. 


5528 


GLAUCOMA 


/'Jlliot's  operation  for  (jUmcoma. —  lOlliot  {TIk  OphtJudmoficopc,  Dec. 
Isl,  !!)()!))  has  adoptetl  iniicli  llic  satiic  procedure  and  has  operated  on  a 
large  series  of  cases  witliout  septic  ac^cident,  indicating  to  him  that 
tliere  is  litth'  risk  in  dissecting  up  the  large  conjunctival  flap.  He 
cautions  against  the  danger  of  making  the  trephine  hole  too  far  out 
and  thus  tapping  the  supra-choroidal  space  instead  of  the  anterior 
chamber.  If  this  happens,  the  anterior  chamber  does  not  empty,  the 
tension  is  not  well  lowered,  and,  if  any  effort  is  made  to  excise  the 
bulging  uveal  coat,  vitreous  loss  will  occur.  (See  figures.)  Iridectomy 
is  resorted  to  if  there  be  a  tendency  to  incarceration. 

To  quote  the  author's  own  description  {The  Ophthalmoscopf ,  July 
1st.   1!)10,  p.  488)  : 


Elliot's  Uperation. 
Second  stage  of  operation,      (a)   Eaw  surfaee  left  by  raising  the  conjunctival 
flap,     (b)   Trephine  hole,     (e)   Flap  of  conjunctiva  turned  down  over  the  cornea. 


"The  operation  may  be  perfoi'iiicd  under  the  local  influence  of 
cocaine  and  adrenalin,  dropped  into  the  sac.  If  there  is  much  pain  or 
congestion,  or  if  the  patient  is  unruly,  a  hypodermic  injection  of 
mori)hin  may  be  given  twenty  minutes  before  the  operation.  In 
recent  cases  we  have  been  using  subconjunctival  injections  of  cocaine 
and  adrenalin  with  excellent  results.  The  patient  looks  down,  and  a 
large  triangular  flap  of  conjunctiva  is  dissected  up  from  above  the 
cornea,  the  attached  base  of  the  triangle  lying  at  the  sclero-corneal 
margin.  Experience  has  shown  the  importance  of  dissecting  this  flap 
right  up  to  the  liml)al  attachment  of  the  conjunctiva.  The  flap  is 
turned  down  on  the  cornea.  The  si)ot  selected  for  the  trephining 
should  be  as  close  to  the  limbus  as  jKwsible,  and  should  l)e  prepared 
by  using  the  scissor  points  freely,  either  cutting  or  scraping  or  both, 


GLAUCOMA  5529 

rig^ht  clown  to  the  scleral  coat.  It  is  inii)ortant  that  no  conjunctival 
tissue  be  left,  as  otherwise  it  will  catch  in  the  trephine  and  tend  to 
draw  the  tlap  into  the  latter  as  it  is  working.  I  never  pull  on  the 
flap,  but  simply  steady  the  glol)e  by  pressing  on  the  cornea  through 
tile  down-turned  flap ;  I  find  this  quite  sufficient  to  effect  the  purpose 
of  keeping  the  eye  at  rest  in  the  proper  position.  The  trephine  is 
used  with  quick  light  movements,  and  care  is  taken  that  its  first  appli- 
cation suffices  to  bite  into  the  sclera,  before  it  is  raised  to  see  the 
progress  nuide.  Once  a  clean  ring  is  thus  started,  it  is  very  easy  to 
replace  the  trephine  in  it.  At  first  the  operator  feels  the  need  of 
frequently  removing  the  trephine  to  watch  progress,  but  he  soon  learns 
to  know  by  the  feel  when  he  i.s  tlirough.  As  soon  as  the  anterior 
chamber  is  tapped,  aqueous  fluid  wells  up  alongside  the  trephine ; 
even  apart  from  this,  there  is  a  curious  sucking  sensation  which 
tells  one  the  trepliine  is  through.  Moreover,  the  patient  often  helps 
by  a  slight  movement  due  to  the  pain  (seldom  severe)  which  attends 
the  completion  of  the  section.  The  conjunctival  flap  is  replaced  in  situ 
to  see  whether  the  iris  is  in  position  or  not.  If  it  is,  and  if  there  is 
no  bulging  of  its  base  into  the  wound,  the  eye  is  at  once  closed.  It 
sometimes  happens  that  the  iris  Inilges  into  the  section  the  moment  the 
disc  is  cut  tlirough;  if  so,  it  is  snipped  with  scissors  to  let  the  aqueous 
fluid  escape,  and  it  then  often  goes  back  of  itself.  If  it  does  not, 
then  an  iridectomy  is  jierformed.  As  a  rule,  a  very  small  and  per- 
ipheral section  of  the  membrane  suffices ;  more  rarely  it  is  necessary  to 
make  the  iridectomy  complete.  We  instil  eserine  drops  into  the  eye 
after  operation,  if  for  any  reason  we  fear  a  prolapse  may  take  place. 
As  a  rule,  no  drops  whatever  are  used  immediately  after  the  opera- 
tion. We  have  used  a  Bowman's  trephine  throughout  in  Madras, 
and  are  still  wavering  between  one  of  2  mm.  diameter  and  one  of 
2.5  mm." 

Elliot  also  emphasizes  the  following:  "(1)  It  is  possible  by  using 
the  points  of  the  scissors,  and  dissecting  concentrically  with  the  cornea, 
to  get  very  close  to  the  limbus.  In  doing  so,  one  must  keep  the  points 
directed  towards  the  plane  of  the  posterior  pole  of  the  lens;  one 
must  not  dissect  tangentially  to  the  eye.  If  one  does  the  latter,  one 
will  qui(tkly  button-hole  one's  flap;  if  tlu>  former,  one  undermiiu's  llie 
limbus  and  makes  a  deep  groove  overhung  by  the  latter.  It  is  the 
making  of  tills  overhung  groove  which  determines  that  one  enters  the 
chamber  with  the  trephine  with  certainty. 

(2)  If  the  trephine  used  is  a  sharp  one,  one  can  quickly,  easily  and 
certainly  cut  out  a  clean  disc  every  time,  with  the  reservation  that 
in  a  large  number  of  cases  the  disc  remains  attached  at  one  small 


5530 


GLAUCOMA 


point,  whore  tlio  iiiunit  tissue  acts  like  a  hinge ;  one  clean  snip  of  the 
scissors  severs  this,  leaving  a  clean  cut  circular  hole  witii  no  ragged 
edges  whatever.  I  have  recently  made  a  point  of  pressing  a  little  more 
on  the  corneal  than  on  the  scleral  edge  of  the  disc  I  am  trephining,  so 
as  to  make  sure  of  entering  the  chamber  as  far  forward  as  possible. 


.I;iHH.o 


The  Elliot  Trephine. 


(3)  If  a  clean  disc  is  thus  cut  out,  without  undue  pressure  of 
the  trephine,  one  comparatively  seldom  requires  to  interfere  much 
with  the  iris. ' ' 

[The  trephine  preferred  by  Elliot  is  figured  in  the  text.  Since 
trephining  operations  came  into  vogue  many  modifications  in  shape  and 
manner  of  employment  have  been  described  and  pictured  in  the  litera- 
ture of  this  subject.  The  advantages  claimed  by  Elliot  for  his  instru- 
ment are,  chiefly,  the  conical  shape  of  the  handle,  which  prevents 
slipping  of  the  fingers  during  manipulations,  easy  adjustment  of  the 


<mQ 


The  Gradle  Trephine,  Driven  by  the  Flexible  Attachment. 

knife  and  an  uninterrupted  view  of  the  operative  wound  during  the 
procedure. — Ed.  ] 

[As  already  stated,  Elliot  makes  the  base  of  his  triangular  flap  at 
the  sclero-corneal  margin,  but  Fox  {Op]ithahnoIo(/i/,  Oct.,  1912)  has 
reversed  this  practice,  and,  as  in  the  Van  Lint  sliding  flap  opera- 
tion for  cataract,  he  seizes  witli  the  forceps  the  conjunctiva  on  the 
inner  side  of  tlie  right  cornea  about  4  mm.  below  its  summit  and  dis- 
sects it  around  the  upper  corneal  margin  to  the  outer  side,  then  with 


GLAUCOMA 


5531 


scissors  he  detaclies  tlie  conjunctiva  for  12  or  14  mm.  upwards.  A 
suture  is  next  inserted  in  t\w  loosened  conjunctiva  at  the  lowest  point 
of  the  inner  side.  From  this  point  he  makes  a  perpendicular  incision 
for  14  mm.  through  the  conjunctiva,  W'hieh  is  continued  diagonally 
upwards  and  outwards  to  a  similar  distance.     (See  the  figures.) 


Fox's    Modification    of   the   Conjunctival   Flap    in    Trephining   the   Sclera   for 

Glaucoma. 

When  operating  on  the  left  eye  Fox  begins  the  dissection  of  the  flap 
on  the  outer  side  of  the  cornea  and  makes  similar  perpendicular  and 
diagonal  incisions  upwards  and  inwards.  When  completed  the  flap 
is  drawn  over  to  its  attached  side  on  the  eyeball,  leaving  a  space  for 
the  trephining  along  the  upper  selero-corneal  margin.  After  the 
trephining  the  conjunctival  flap  is  replaced  and  by  means  of  the 


Scleral  Trephining  for  Glaucoma.     Conjunctival  Flap  in  Position.     (Fox.) 

suture  already  inserted  it  is  drawn  downwards  to  cover  the  hole  in 
the  sclera  and  the  upper  part  of  the  cornea. 

From  time  to  time  Fox  has  modified  the  treatment  of  the  con- 
junctival flap,  at  one  time  stitching  it  down  on  one  side  and  removing 
the  thread  at  the  end  of  twenty-four  hours;  at  another  simply  loosen- 
ing the  conjunctiva  over  the  corneo-scleral  opening  and  allowing 
it  to  heal — but  the  above-described  method  has  given  the  most  satisfac- 
tion. 


5532 


GLAUCOMA 


Tlu'  same  oixTiitor  lias  also  iiiodilicd  and  advised  the  use  of  the  von 
TlipprI  trcpliiiic  i'oi'  lliis  opci-atioii.     (Sec-  llic  illustration.) 

1).  rricstlcy  Siiiitli  ( Oph llnil .  l!(vi<u',  p.  7:},  ^lareli,  V.)V.))  has 
descrilx'd  a  inodilication  of  llic  Mlliol  (if  Lagrange  operation  as  fol- 
lows: It  is  little  more  than  a  coiuhinatioii  of  several  well-known  pro- 
cedures, the  objects  being  iridectomy  and  fistulization  of  the  anterior 
chambci-.  It  consists  of  Elliot's  conjunctivo-corneal  tlap,  and,  instead 
of  a  trei)hine  hole,  a  keratome  incision  notched  on  its  anterior  lip. 
(See  the  figures.)  It  is  suggested  as  suitable  for  cases  in  which  scleral 
l)uiicture  is  desirable,  namely,  cases  of  high  tension  and  shallow 
cluunber. 


Von   TIi]ipol  Tieiiliine,  Adapted  to  (ilaucoma  Operations.      (Fox.) 

After  cocainizing  in  chronic  cases,  or  under  a  general  anesthetic  in 
acute,  the  speculum  is  inserted,  and  the  eye  turned  down  liy  an  assist- 
ant. For  this  j)urpose  a  bent  forceps  is  used,  so  that  the  handle  shall 
be  out  of 'the  operator's  w^ay.  (See  tigure  1  of  accompanying  plate.) 
The  operator  stands  l)ehind  the  patient's  head. 

The  conjunctiva  is  picked  up  6  or  7  nun.  from  the  cornea  and  incised 
with  scissors  along  a  curved  line  running  almost  concentric  with  the 
corneal  margin,  so  as  to  leave  some  conjunctiva  uncut  between  the 
ends  of  the  incision  and  the  cornea.  Elliot  has  found  that  if  the  ends 
reach  the  cornea  the  aqueous  nuiy  l)i'  pent  in  under  the  flap  by  the 
watertight  healing  of  the  cut  edge  with  the  episcleral  tissue.  The  flap 
is  dissected  up  with  scissors  until,  in  the  middle,  the  corneal  margin 
is  reached.  It  now  ceases  to  peel  easily,  and  the  cornea  must  be  split. 
For  this  purpose  the  author  made  a  dissector  out  of  a  broad,  round- 
ended  spatula,  one  edge  of  wliich  he  shari)en('d  to  half-way  round  the 
end  but  no  further.  (See  figure  2  of  i)late.)  If  the  end  is  sharp  all 
the  way  round  it  is  more  likely  to  liuttonholc  llie  llap.  While  using 
this  instrument  the  flap  is  kept  turned  down  by  means  of  small,  firm, 
mounted  swabs.    If  bleeding  is  troublesome  a  drop  of  epinine  or  adren- 


GLAUCOMA 


5533 


"^■•"'^^'^M'-'  ^  J^^^^^^^'^TT-yl^i.^ 


~'^'-^:ii\'^ 


A 


■«Sa 


m. 


// 


/  t 


/ 


/^ 


/ 


4 

7 


it' 


David  Priestley  Smith's  Glaucoma  Operation. 


5534  GLAUCOMA 

aline  on  tlic  swab  is  useful,  as  it  is  essential  to  see  into  the  angle 
of  reflected  conjunctiva  all  the  time.  The  dissection  is  carried  on 
until  the  area  of  cornea  exposed  forms  a  slate-grey  ellipse  about  2 
mm.  wide  in  the  middle.     (See  figures  3  and  4  of  plate.) 

The  flap  is  now  replaced  for  a  few  seconds,  while  the  vitreous  is 
tapped.  This  is  done  with  a  Graefe  knife  6  mm.  behind  the  cornea  and 
just  above  the  upper  margin  of  the  external  rectus,  the  conjunctiva 
first  having  been  picked  up  in  forceps  and  slid  forward  so  that  when 
released  it  shall  cover  the  opening  in  the  sclera.  The  knife  is  directed 
towards  the  centre  of  the  globe  with  its  back  to  the  cornea. 

The  flap  is  now  picked  up  by  forceps  again  and  the  point  of  a  broad 
keratome  entered  immediately  (less  than  1  mm.)  outside  the  margin  of 
the  cornea,  the  flap  laid  ])ack  on  to  the  keratome,  and  the  latter  pushed 
into  the  anterior  chamber  until  the  incision  is  about  5  mm.  long. 
(See  figures  5  and  6  of  plate.)  The  keratome  is  now  withdrawn.  It 
has  been  suggested,  and  it  doubtless  would  be  better,  that  the  operator 
should  take  the  fixation  forceps  while  making  the  incision,  and  the 
assistant  hold  up  the  flap. 

A  small  triangular  piece  is  now  snipped  out  of  the  corneal  lip  of 
the  incision  by  two  scissor-cuts  converging  to  meet  just  short  of  the 
line  of  reflection.  The  aperture  thus  made  should  be  about  equilateral. 
Figure  7  of  the  plate  was  meant  to  represent  the  second  scissor-cut 
being  made,  but  by  mistake  it  was  drawn  reversed  as  to  right  and 
left ;  the  first  cut  should  be  the  left,  so  that  when  the  second  is  being 
made  the  "chip"  may  be  steadied  by  iris  forceps  held  in  the  left 
hand.    Figure  8  shows  the  shape  of  gap  aimed  at. 

The  iridectomy  is  performed  in  the  ordinary  way.  The  operator 
tries  to  leave  the  sphincter. 

The  flap  is  now  replaced,  the  eye  released  from  the  fixation  forceps 
and  the  speculum  removed.  Xo  suture  is  needed  if  the  flap  is  above 
the  cornea ;  if  below  it  is  necessary.  No  drops  are  put  in  unless  the 
pupil  was  previously  contracted  by  eserine  or  pilocarpine,  in  which 
case  a  drop  of  atropin  is  used.  The  eye  is  closed,  a  pad  and  shield 
applied  and  five  grains  of  antipyrine  given  within  the  next  half-hour. 
Figure  9  shows  the  ideal  appearance  on  completion  of  the  operation. 

Late  infection  after  trephining  operations. — In  doing  an  Elliot's 
trephining,  the  ordinary  precautions  seem  to  be  sufficient  to  guard 
against  infection  at  the  time  of  the  operation ;  not  so,  however,  against 
a  secondary  infection.  H.  Gifford  (Ophth.  Becorel,  January,  1914) 
points  out  that  at  the  Heidelberg  Congress  in  1912,  AVagenmann,  in 
a  discussion  on  trephining,  mentioned  a  case  in  which,  some  time  after 
a  successful   trephining,    a   late   infection   of   the    anterior   chamber 


GLAUCOMA  5535 

occurred.  The  final  outcome  is  not  given.  This  remained  an  isolated 
case  till  June  of  that  year  (1912),  since  when,  twelve  additional  cases 
of  late  infection,  after  Elliot's  operation,  have  been  reported.  Of 
these,  the  cases  of  Stock,  Story,  ]\Iorax,  Wicherkiewicz  and  Bronner 
were  mentioned  at  the  London  International  Congress,  in  the  discus- 
sion of  the  papers  of  Lagrange  and  Elliot.  Stock's  two  cases  occurred 
some  time  after  trepliinings  at  which  the  Hap  was  buttonholed.  One 
of  these  led  to  panophthalmitis,  the  other  to  purulent  iritis  with  much 
reduction  of  sight.  In  Story's  case,  the  infection  set  in  several  weeks 
after  the  operation  and  led  to  phthisis  bulbi.  Bronner  observed  severe 
plastic  iritis  in  two  cases,  several  weeks  after  the  operation ;  while  in 
a  third  his  patient  developed  panophthalmitis. 

The  other  cases  were  the  following :  Isakowitz,  severe  purulent  iritis 
six  weeks  after  trephining;  operation  smooth,  no  reaction;  no  con- 
junctivitis nor  other  complication  to  account  for  infection.  At  time 
of  writing  the  report,  it  looked  as  if  the  patient  would  not  recover 
any  sight. 

Schur's  patient  did  well  for  five  weeks  after  the  trephining.  She 
then  struck  the  eye  against  a  chair  and  promptly  developed  a  purulent 
iritis,  and  the  eye  was  enucleated.  The  microscopic  examination 
showed  a  line  of  infection  beginning  in  a  small  epithelial  defect  a  lit- 
tle below  the  trephine  hole.  The  latter  was  found  to  be  placed  too  far 
back,  so  that  the  line  of  infection  which  led  to  it,  from  the  epithelial 
defect,  proceeded  into  both  the  anterior  chamber  and,  through  the 
ciliary  body,  into  the  vitreous. 

In  Harm's  case,  the  eye  was  perfectly  quiet  and  satisfactory'  for 
about  six  weeks,  when  it  began  to  have  spells  of  irritation  with  pho- 
topho])ia  and  lachrymation,  without  any  well-defined  cause.  Five 
months  later,  without  any  special  cause,  a  violent  infection  started  up 
with  exudate  and  pus  in  the  anterior  chamber;  much  congestion;  espe- 
cially in  the  neighborhood  of  the  filtration-blel)  which,  when  fluorescein 
was  used,  showed  a  large  epithelial  defect.  After  cauterization  of  the 
bleb  and  paracentesis,  the  condition  improved  somewhat,  but  a  slow 
iridocyclitis  set  in  which  promised,  at  last  account,  to  blind  the  eye. 
An  interesting  feature  of  this  case  is  the  fact  that  the  other  eye  was 
operated  about  the  same  time,  but  as  the  flap  was  perforated,  the 
conjunctiva  was  loosened  along  the  limbus  and  drawn  down  over  the 
cornea.  For  some  time  after  the  operation,  the  filtration-bleb  was  as 
prominent  in  this  eye  as  in  the  other,  then  it  flattened  down  and  dis- 
appeared. This  eye  showed  none  of  the  spells  of  irritation  which 
bothered  the  other  eye,  in  which  the  bleb  persisted;  and  Harms  con- 


5536  GLAUCOMA 

eluded  tliiit  llic  (lclcniiiiiiii<^  I'actoi'  in  lliis  ini'cctidii  was  the  irritation 
of  the  l)li'l)  by  the  iiiovenu'iits  of  tiit*  lids  and  tlic  cyi'-ljall. 

Kulint  trephined  both  eyes  of  his  patient.  In  the  right  tlie  liltration- 
bleh  gradually  flattened  down  completely,  whih'  in  the  left  the  bleb 
reniaini'd.  Al)oiit  three  and  a  half  months  later  he  developed  a 
conjunctival  catarrh  of  both  eyes ;  under  the  influence  of  which  tiie 
conjunctiva  of  the  bleb  in  the  left  eye  became  markedly  loosened  up. 
About  two  weeks  later  the  eye  suddenly  l)ecame  blind  and  was  found 
to  have  purulent  iridocyclitis,  with  the  conjunctiva  over  the  trephine 
hole  grayish-yellow,  thick  and  eroded.  Under  vigorous  treatment  with 
mercury,  pilocarpine  and  Roemer's  pneumococcus-sennn,  the  inflam- 
mation gradually  sul)sided  and  the  vision  rose  to  nearly  what  it  had 
been  before  the  infection.  Then,  the  filtration-bleb  gradually  disap- 
peared and  the  tension,  which  had  been  normal,  rose  to  .'50  mm.  and 
the  field  began  to  contract. 

Beside  these  infections  after  trephining  Axenfeld  and  Pagenstecher 
report  similar  experiences  with  the  iridosclerectomy  of  Lagrange. 
Axenfeld 's  patient  maintained  a  hypotension  with  well-marked  filtra- 
tion-bleb for  about  nine  months  after  a  Lagrange  operation.  Then, 
without  apparent  cause,  the  eye  got  red  and  the  bleb  showed  a  yellow- 
ish-gray infiltrate  with  a  minute  fistula  at  its  summit.  Then  a  severe 
purulent  iritis  developed,  which  gradually  yielded  to  treatment ;  but 
with  the  cure  of  the  iritis,  the  bleb  disappeared  and  the  tension  rose 
above  the  normal. 

Pagenstecher  mentioned  his  case  at  the  discussion  in  London.  The 
patient  did  well  for  a  month  after  a  faultless  Lagrange.  Then 
purulent  iritis  appeared,  but  it  yielded  to  treatment. 

Gififord's  own  experience  with  infection  after  trephining,  in  tlic 
thirty  cases  (up  to  1914)  in  which  he  had  done  the  operation,  is  con- 
fined to  the  following  cases:  H.  0.,  aged  48,  came  to  him  in  1913  with 
the  right  eye  blind  from  an  injury  received  some  years  before.  The 
left  eye  had  vision  reduced  to  fingers  at  three  to  four  feet  as  the 
result  of  irido-cyclitis,  with  occlusion  of  the  pupil :  tension  40  mm. 
Tile  right  eye  was  eviscerated  and  the  left  eye  trephined,  with  an 
iridectomy.  In  doing  the  oi)eratinn  lie  took  extra  pains  to  carry  the 
flap  as  far  over  tlie  cornea  as  possible,  but  did  not  si)lit  the  cornea  in 
the  manner  recommended  by  Elliot.  No  reaction  followed;  the  tension 
was  reduced  to  well  witliin  the  noniial  limits,  and  the  patient  went 
home  a  week  later.  The  only  thing  unusual  about  the  appearance  of 
the  eye  a  week  after  the  ojieration,  was  that  the  membrane  covering 
the  hole  was  ininsually  thin,  i)r()tni(ling  like  a  part  of  a  thin  bubble. 
He  returned  two  weeks  after  the  operation  stating  that  for  a  couple 


GLAUCOMA  5537 

of  days  the  eye  had  been  discharging  freely  and  liad  f^ivcii  him  much 
pain.  The  writer  found  a  marked  catarrhal  conjunctivitis  with  much 
congestion  of  the  globe.  There  was  also  a  slight  amount  of  pus  in  the 
anterior  chamber,  and  with  oblique  illumination,  a  line  of  purulent 
exudate  could  be  traced  from  the  trephine  hole  past  the  coloboma, 
behind  the  iris  and  out  through  tiie  pupil  into  the  anterior  chamber. 
The  membrane  of  the  ball  was  congested  and  thickened,  but  not 
eroded,  so  far  as  it  was  possible  to  determine.  On  paracentesis, 
mercury  and  salicylates,  the  eye  improved  somewhat ;  the  formation 
of  pus  stopped,  and  the  intlannnation  decreased,  l)ut  the  eye  remained 
decidedly  inflamed,  and  the  prospect  for  useful  vision  seemed  very 
poor.  Gifford  was  not  sure  whether  the  inflammation  of  the  con- 
junctiva in  this  case,  was  primary,  or  whether  it  followed  the  intra- 
ocular infection.    It  yielded  promptly  to  the  use  of  zinc. 

These  cases  make  it  perfectly  clear  that  the  fistulizing  operations, 
that  is,  the  Lagrange,  the  Elliot  and  all  their  various  modiflcations 
which  depend  for  their  efficacy  on  the  production  of  a  subconjunctival 
fistula,  carry  with  them  the  danger  of  late  infection.  ^Moreover,  the 
more  successful  the  oi)eration  from  the  staiidpoint  of  pressure-reduc- 
tion, the  greater  the  danger.  The  case  of  Kuhnt  illustrates  this  most 
effectually.  Both  eyes  were  trephined.  In  the  left,  the  conjunctival 
bleb  persisted  and  the  tension  remained  low;  while  in  the  right,  the 
bleb  gradually  disappeared  and  the  tension  rose  to  over  30  mm.  But 
when,  later  on,  both  eyes  developed  a  catarrhal  conjunctivitis,  only 
the  one  with  the  bleb  become  infected.  Axenfeld  says  that  the  cases 
which,  after  trephining,  show  a  clear,  glassy  bleb  always  give  him 
a  feeling  of  anxiety.  Stock,  whose  infections  followed  operations 
with  buttoidioled  flaps,  advises  that  when  the  flap  is  perforated  it 
is  better  to  interrupt  the  operation  and  make  a  fresh  start.  Bronner, 
whose  experience  has  been  especially  bad  (3  cases  of  infection), 
declares  that,  for  himself,  he  would  prefer  the  safer,  if  somewhat  less 
effective,  iridectomy.  Opposed  to  these  unfortunate  results  is  the 
very  significant  fact  that  neither  Lagrange  nor  Eliot  has  seen  a  case 
of  late  infection ;  and  while  the  latter  admits  that  the  nature  of  much 
of  his  clinical  material  makes  it  easily  possible  that  he  might  have  had 
one  without  its  being  reported,  yet  Gifford  thinks  there  is  a  very 
decided  prol)ability  that  his  techni(iue  is  in  large  measure  responsible 
for  his  freedom  from  infections;  and  the  same  applies  with  greater 
force  to  the  results  of  Lagrange.  The  latter  advises  to  cut  the  flap 
thick,  while  Elliot  burrows  in  between  the  layers  of  the  cornea,  in 
such  a  way,  as  to  make  the  central  portion  of  his  flap  extra  thick. 
Whether  time  will  prove  it  to  be  possible  to  make  the  flap  so  thick  as  to 

Vol.  VII— 44 


5538  GLAUCOMA 

entirely  prevent  late  infections,  witliout  interfering?  with  the  efficacy 
of  the  fistula,  remains  to  be  seen.  Axciifeld  raises  this  point,  and 
Kuhnt  insists  strongly  that  to  get  a  good  fistula  we  must  have  a  thin 
flap.  He  suggests  that  it  may  be  possible,  by  touching  the  bleb  with 
tincture  of  opium  or  something  of  tlio  sort,  to  increase  its  resistance  to 
infection.  The  results  of  Lagrange  and  Kuhnt,  however,  indicate  that 
a  sufficiently  thick  flap  to  insure  against  infections,  is  not  inconsistent 
with  good  pressure-regulation.  As  a  matter  of  prudence,  however, 
we  might  in  the  future,  warn  patients  with  conjunctival  blebs,  to  pay 
special  attention  to  the  hygiene  of  the  conjunctival  sac  and  to  the 
condition  of  the  lachrymal  passages.  Patients  living  far  from  any 
.  oculist  should  keep  a  zinc  collyrium  on  hand  to  combat  the  first 
symptoms  of  catarrhal  conjunctivitis;  and  the  importance  of  report- 
ing to  the  oculist  at  regular  intervals  for  inspection  of  the  bleb  with 
the  aid  of  fluorescein,  should  be  urged. 

Of  course,  the  fact  that  late  infection  sometimes  occurs  after  fistuliz- 
ing  operations,  is  no  more  a  w^arrant  for  discarding  them  than  a  similar 
late  infection  which  sometimes  occurs  after  a  cataract  expression,  is  for 
a  return  to  the  practice  of  couching,  since  many  cases  of  glaucoma 
can  be  cured  by  these  operations  which  are  otherwise  incurable;  but 
it  certainly  raises  the  question,  whether  their  use  is  justifiable  in 
all  forms  of  glaucoma,  especially  in  acute  glaucoma,  where  a  single 
iridectomy  usually  gives  such  good  results;  and  if  the  event  proves 
that  such  late  infections  are  at  all  common,  even  with  the  most  ap- 
proved methods  of  forming  the  flap,  it  may  be  doubtful  whether  they 
should  be  resorted  to  until  an  iridectomy  has  first  been  tried.  With 
the  exception  of  the  single  infection  reported,  Gifford's  experience 
with  trephining  has  been  most  satisfactory,  althougli  he  does  not  con- 
sider it  as  easy  an  operation  as  an  iridectomy,  in  chronic  glaucoma. 
There  can  be  no  doubt,  however,  that  there  is  less  chance  of  doing 
harm  with  it  than  there  is  with  an  iridectomy,  where  the  tension  is 
at  all  high. 

A  report  of  Meller's  {Zritschr.  f.  AugrnhcUk.,  Nov.,  1918)  shows 
that  out  of  389  sclerectomies  according  to  Lagrange,  1.3  per  cent,  of 
the  eyes  were  lovst  by  late  infection,  while  with  178  Elliot  operations, 
late  infection  apparently  was  not  observed. 

In  the  discussion  of  ]\Ieller's  paper,  Elschnig  reported  an  additional 
case  of  late  infection  after  trephining,  and  predicted  that  in  a  few  years 
fistulizing  operations  would  be  given  up  in  favor  of  iridectomy  and 
cyclodialysis.  Gifford  also  noted  the  cases  reported  liy  Fehr.  in  which 
a  case  of  infection  from  latent  dacryocystitis  occurred  ten  days  after 
trephining.     In  an  address  delivered  at  the  recent  Clinical  Congress 


GLAUCOMA  5539 

in  Chicago,  Gifford  predicted  that  it  wouhl  not  be  long  before  cases 
of  sympathetic  ophthalmia  would  be  reported  after  trephining,  and 
Casey  Wood  sends  word  that  .Spalding,  of  Portland,  had  already 
written  him  of  having  seen  such  a  case,  together  with  one  other  of  late 
uveitis  after  trephining, 

[Elliot  {Ophthalmoscupc,  Vol.  II,  p.  523,  1913)  contends  that  the 
operation  of  sclero-corneal  trephining  is  at  once  the  easiest,  the  safest 
and  the  most  certain  method  of  effecting  a  decompression  of  a  high- 
tension  eye.  In  his  oxj)erience  sclero-corneal  trephining  is  the  opera- 
tion of  choice,  not  only  for  cases  of  chronic  glaucoma,  but  also  for 
those  of  the  acute  condition  and  for  the  exacerbations  of  chronic  con- 
gestive glaucoma.  As  to  technic,  he  considers  that  the  circular  trephine 
wound  is  in  every  way  justified  by  an  appeal  to  scientific  principles. 
The  flap  should  be  large,  the  cornea  should  l)e  split  for  1  mm.  beyond 
the  limbus,  tlie  hinge  left  at  the  completion  of  trephining  should  be 
on  the  scleral  side  of  the  wound,  the  corneal  edge  being  cut  clean 
through.  The  trephine  should  be  planted  as  far  forward  on  the  cornea 
as  possible,  and  a  small  peripheral  iridectomy  should  invariably  be 
performed  in  order  to  minimize  the  risk  of  iris  prolapse.  In  doing  this 
the  disk  and  the  protruding  iris  should  be  seized  in  one  grip  of  the 
forceps  and  should  l)e  removed  together  with  a  single  snip  of  the 
scissors ;  iris  complications  will  ])e  thereby  avoided.  He  holds  that  the 
encleisis  of  uveal  tissue  in  the  trephine  wound,  whether  primary  or 
secondary,  is  a  misfortune  which  we  should  spare  no  pains  to  avoid. 
The  quiet  iritis  which  follows  sclerectomy  of  all  kinds  can  be  rendered 
harmless  by  the  free  use  of  atropin.  He  also  believes  that  {Brit.  Med. 
Jour.,  Nov.,  p.  1160,  1913)  some  of  the  causes  of  failure  after  trephin- 
ing are  dislocation  of  the  lens  or  vitreous  body  towards  the  trephine 
hole ;  prolapse  of  uveal  tissue  into  the  trephine  hole,  and  ])locking  of 
the  trephine  hole  by  a  proliferation  of  connective  tissue,  either  from 
the  episcleral  tissue  on  the  surface,  or  from  the  uveal  tissue  in  the 
depth  of  the  wound.  He  shows  that  the  area  of  split  cornea  partici- 
pates in  the  filtration.  He  is  opposed  to  the  sliding  Map  as  unsound 
in  principle ;  and  he  contends  that  the  dissection  of  the  flap  he  has 
advocated  is  witliin  the  powers  of  any  ophthalmic  surgeon  of  moderate 
skill  and  experience. 

Elliot  (Ophtk-almoscopc,  Vol.  II,  p.  523,  1913)  further  points  out 
that  there  are  two  distinct  conditions  under  which  a  shallow  anterior 
chamber  persists  after  operation,  namely,  (1)  eases  in  which  the 
diaphragm  of  the  eye  has  been  displaced  forward  before  operation,  due 
to  long-continued  overstretching  of  the  zonule,  and  (2)  those  in  which 
a  tiny  fistulette  is  formed  at  some  part  of  the  periphery  of  the  flap, 


5540  GLAUCOMA 

owing  to  a  want  of  healing  there ;  in  such  the  anterior  chamber  cannot 
refill,  as  it  is  continually  drained  of  fluid.  In  the  former  class  the 
condition  is  practically  incapable  of  much  alteration,  while  in  the 
latter  tlic  simple  expedient  of  touching  the  neighborhood  of  the  fistula 
with  silver  nitrate  solution  on  a  swab  serves  to  close  the  channel  and 
fill  the  chamber. 

Wallis  (Ophthalmoscope,  Vol.  II,  p.  588,  1913)  gives  his  experi- 
ence of  one  hundred  and  thii'ty-seven  cases  of  Elliot's  operation  per- 
formed in  ^loorfields  Hospital  l)y  various  members  of  the  staff.  He 
says  that  this  procedure  has  almost  entirely  superceded  Herbert's 
sclerotomy  in  chronic  glauconui ;  the  conclusion  has  been  gradually 
established  that  the  tension,  after  the  latter  operation,  did  not  remain 
permanently  normal  in  the  majority  of  cases.  Iridectomy  has  been 
but  rarely  performed  for  other  than  acute  cases;  the  Elliot  operation 
has  been  used  in  not  a  few  acute  cases  with  satisfactory  results.  He 
considers  the  operation  excellent  but  difficult,  and  details  the  technic, 
in  most  of  which  he  follows  Elliot's  teaching,  except  that,  while 
actually  trephining  he  holds  the  flap  forward  so  as  to  leave  the  anterior 
chamber  open  to  view  all  the  time.  In  the  presence  of  an  old  iridec- 
tomy he  thinks  the  coloboma  area  should  ))e  avoided  for  the  trepliine; 
and  an  iridectomy  (preferably  peripheral  and  triangular)  should  be 
made  as  a  routine  step  in  the  operation.  The  introduction  of  a 
spatula  to  clear  the  trephine  hole  is  unsatisfactory  and  dangerous; 
the  flap  should  alwaj^s  be  sutured.  He  finds  that  the  anterior  chamber 
is  slowly  restored  in  most  cases  in  which  it  was  shallow  before  the 
operation,  and  vice  versa,  and  he  suggests  a  preliminary  sclerotomy 
before  trephining  when  the  anterior  chamber  is  very  shallow.  The 
instillation  of  0.25  per  cent,  atropin  solution  the  morning  after  the 
operation  is  advocated.  If  a  case  of  trephining  presents  a  normal 
tension  after  a  month,  and  particularly  if  massage  does  not  reduce  it, 
he  thinks  commencing  failure  is  to  be  suspected. 

Vogt  [Klin.  M.  f.  Aiigcnh.,  April,  p.  504,  1913)  trephines  for  all 
conditions  of  glaucoma ;  he  has  been  impressed  with  the  risks  which 
he  considers  inseparable  from  a  hand-driven  trephine.  These  risks 
are  enhanced  if  the  chamber  is  shallow,  or  if,  owing  to  a  preliminary 
sclerotomy,  the  tension  of  the  eye  has  been  lowered;  he  has  therefore 
had  an  electro-motor  trephine  made  and  fitted  with  a  fixed  stop,  which 
only  partly  encircles  the  blade  and  so  gives  the  surgeon  a  full  view 
of  the  field  of  operation.  With  this  instrument  he  finds  that  the 
operation  is  made  nuich  easier  and  safer,  and  that  a  cleaner  trephine 
hole  is  cut ;  he  lays  stress  on  the  fact  that  the  rapid  rotation  of  such 
a  trephine  obviates  all  necessity  for  pressure  in  the  axis  of  the  instj-u- 


GLAUCOMA  5541 

nu'iit.  He  uses  sul)-eonjuiictival  injections  of  adrenalin  and  eoeaiu 
three  minutes  before  operation,  and  thinks  this  greatly  superior  to  the 
instillation  of  these  drugs  in  the  ordinary  way. 

Axenfeld's  {Klin.  M.  f.  Auyenh.,  June,  p.  816,  11)13)  experience  of 
trephining  has  been  less  favorable  than  that  of  many  other  surgeons, 
as  he  finds  that  in  one-half  of  his  eases  the  trephine  opening,  after  a 
variable  period,  quickly  has  become  closed  by  such  thick  tissue  as  to 
stop  free  filtration.  He  does  not  limit  successes  to  those  with  perma- 
nently filtering  cicatrices  with  fornmtion  of  edematous  areas,  but 
thinks  that  many  cases  with  closure  without  apparent  filtration  are 
favorably  influenced.  He  suggests  the  possible  occurrence  of  a  sub- 
conjunctival microscopic  filtration ;  also  tlmt  a  deeper  drainage  to 
Schlennn's  canal  may  be  oi)ened  up;  and  again  that  the  iridectomy 
may  play  a  part  in  the  result.  He  finds  "iritic  irritations"  rarer 
after  Lagrange's  than  after  Elliot's  operation.  When  the  anterior 
chandjer  is  very  shallow  it  is  easier  to  perform  an  iridectomy  in  the 
course  of  a  trephine  operation  than  in  the  classical  way  with  a  kera- 
tome  or  knife;  but  he  waits  to  know  whether  the  final  results  are  as 
good  in  the  former  cases  as  in  the  latter.  He  thinks  that  the  upward 
movement  of  the  pupil  is  the  most  valuable  sign  that  the  trephine  is 
through  into  the  chamber;  the  trephining  should  be  gently  continued 
a  little  beyond  this  point.  He  is  much  concerned  over  the  later  infec- 
tions; thin  blebs  with  a  good  result  fill  him  with  anxiety.  Glaucoma 
should  be  healed  without  the  fornmtion  of  a  fistula,  if  possible.  He 
considers  iridectomy,  sclerotomy  and  cyclodialysis  less  hazardous 
methods  than  trephining. 

Roemer's  (Trans.  37th  Ophth.  Congress,  Tleidclherg,  p.  377,  1913) 
operation  consists  of  a  trephining  with  von  llippel's  instrument  (3  to 
4  mm.)  beneath  the  inferior  rectus,  whieh  is  divided  for  the  purpose; 
the  anterior  chamber  is  previously  tapped,  the  muscle  is  reunited  and 
the  wound  closed.  He  has  operated  on  twelve  cases,  and  was  able 
to  follow  up  eight ;  two  failed,  two  were  partial  successes,  and  four 
were  successes ;  in  no  ease  was  the  visual  acuity  or  the  field  of  vision 
improved;  in  five  the  vision  was  worse  after  operation;  in  every  case 
prognosis  had  been  bad  before  operation. 

Dupuys-Dutemps  {Ann.  d'Ocul,  Vol.  149,  p.  409,  1913)  considers 
that  trephining  entails  little  surgical  risk,  even  in  acute  glaucoma ; 
he  has  modified  Elliot's  technie  by  detaching  the  conjunctiva  from 
its  corneal  attachment  for  about  one-fourth  of  the  circumference  and 
using  this  as  a  sliding  flap  to  cover  a  2  mm.  trephine  hole  made  just 
behind  the  limbus. 

Morax  {Soc.  Opht.  dc  Paris,  :\larch.  1913;  Ann.  d'Ortd.,  Vol.  149. 


5542  GLAUCOMA 

p.  28!),  li)13)  had  not  met  willi  tlie  difficulties  which  induced  Dupuys- 
Dutenips  to  make  tlic  above  modification,  and  feared  that  tiie  sliding 
Hap  might  leave  the  trephine  iiole  uncovered.  He  found  Elliot's 
trepliining  a  simpler  operation  than  a  Lagrange,  but  considered  that 
the  verdict  between  the  two  procedures  must  lie  with  time. 

Kuhnt  (Zeit.  f.  Augenli.,  Vol.  xxx,  p.  399,  1913)  found  a  difficulty 
in  knowing  when  the  trephine  was  through;  he  felt  himself  between 
tlic  dangers  of  insufficiently  dividing  the  sclera,  and  of  damaging  the 
ciliaiy  body;  he  therefore  devised  a  trephine  the  tubular  blade  of 
whieii  carries  a  solid  style,  the  end  of  which  can  be  adjusted  to  any 
desired  depth  from  the  cutting  edge.  He  places  this  guard  at  a  dis- 
tance corresponding  with  the  thickness  of  the  sclera  and  is  then  able 
to  use  the  instrument  with  confidence;  the  stylet  can  easily  be  removed 
for  sterilization. 

T.  Harrison  Butler  (Ophthalmoscope,  p.  370,  August,  1915)  has 
published  under  the  caption,  "The  Tragedy  of  Sclerostomy,"  an 
account  of  eight  cases  of  late  infection  after  various  operations — 
Lagrange,  trephining,  punching  and  wedge-isolation.  He  divides  these 
calamitous  sequela?  into  three  classes:  (1)  acute  cases,  ending  in  acute 
uveitis  and  panophthalmitis  necessitating  removal  of  the  eye;  (2) 
cases  of  severe  iridocyclitis,  which  destroy  the  sight;  (3)  cases  of  mild 
iritis,  and  local  inflannnation  around  the  aperture,  which  recover. 

After  describing  the  eight  cases  he  remarks  that  they  show  every 
kind  of  sear  to  have  been  affected.  ' '  In  one  case  there  was  apparently 
firm  cicatrization  with  no  filtration ;  others  had  ectatic  scars.  In  two 
a  small  l)utton-liole  was  made  at  the  operation.  Some  operators  make 
light  of  button-holes ;  in  fact,  some,  I  believe,  turn  back  no  flaps,  and 
so  leave  an  open  hole  in  every  case.  ]\Iy  experience  tends  to  show  that 
a  button-hole  constitutes  an  additional  danger.  I  have  always  tried 
to  obtain  a  thick  flap  of  conjunctiva  and  have  generally  succeeded  in 
doing  so.  A  thin  covering  to  the  aperture  is  obviously  unsafe.  It 
may  be  suggested  that  my  cases  were  mostly  treated  with  the  punch, 
and  that  my  conclusions  can  not  be  applied  to  the  trephine  operation, 
I  can  only  state  that  the  scars  obtained  by  the  punch  method  are  in 
appearance,  both  to  the  naked  eye  and  under  the  microscope,  almost 
exactly  similar  to  those  yielded  by  the  trephine. 

"I  conclude  that  late  infection  is  a  peril  which,  like  the  sword  of 
Damocles,  hangs  over  every  eye  which  possesses  a  filtering  cicatrix  of 
any  type,  however  obtained." — Ed.l 

[The  Editor  believes  that  notwithstanding  the  pronounced  draw- 
backs urged  against  the  two  popular  forms  of  sclerectomy — 
Elliot's  and  the  Lagrange  operation — the  advantages  they  offer  over 


GLAUCOMA  5543 

the  classic  operations  formerly  in  vogue  (iridectomy  in  particular) 
are  so  many  and  so  valuable  that  a  general  return  to  tlie  older  pro- 
cedures, especially  in  the  chronic  forms  of  glaucoma,  is  highly  improb- 
able. The  individual  operator  will  have  to  decide  whether  he  can  more 
easily  employ  the  method  of  the  French  or  the  British  surgeon;  in 
other  words,  whether  he  can,  to  the  best  advantage  of  his  patient,  fol- 
low the  technic  of  the  Lagrange  or  the  Elliot  procedure. — Ed.] 

VerJweff's  sclerostomc.  Verhoeff  (The  Ophthalmoscope,  March, 
1910,  p.  188)  has  devised  a  new  instrument,  the  sclerostome  (see  fig- 
ure), for  producing  a  subconjunctival  fistula,  hoping  to  obviate  by 
its  use  the  trauma  to  the  tissues  which  he  has  observed  after  the 
Lagrange  operation.  His  exi)erience  with  the  operation  thus  far  has 
been  limited  to  blind,  painful  glaucomatous  eyes,  but  the  results 
suffice  to  show  tliat  the  opening  made  by  the  instrument  remained 
patent  and  was  effective  in  lowering  the  tension. 

Trans fixio  iridis  of  Fuchs.  In  secondary  glaucoma  with  protrusion 
of  the  iris  due  to  annular  postei'ior  synechia,  when  iridectomy  is 
contra-indicated  on  account  of  the  friability  of  the  tissue  of  the  iris 
antl  the  danger  of  hemorrhage  and  recurring  iritis,  Fuchs  {Bei-icht 
der  Ophthahn.  Gessel.,  1896,  p.  179)  recommends  the  following  pro- 
cedure : 

"After  local  anesthesia  and  the  introduction  of  a  speculum,  a 
medium  sized  Graefe  knife  is  introduced  1  to  2  mm.  within  the 
temporal  limbus  in  the  horizontal  meridian  of  the  cornea.  The  blade 
is  inserted  parallel  with  the  surface  of  the  iris  and  is  then  passed 
through  the  anterior  chamber  and  counter-puncture  made  at  a  sym- 
metrically opposite  point.  The  iris  being  driven  forward  is  pierced 
by  the  knife  as  it  traverses  the  chamber  and  holes  made  in  it  both 
temporally  and  nasally.  These  holes  remain  open  and  the  communi- 
cation between  the  chambers  being  restored,  the  intraocular  pressure 
becomes  normal  and  the  iris  returns  to  its  normal  position.  After  the 
eye  has  become  quiet,  it  is  usually  advisable  to  follow  with  an  iri- 
dectomy, which  can  now  be  performed  without  difficulty  on  account  of 
the  lessened  tension." 

OPERATIONS  FOR   GF^AUCOMA  WHICH  HAVE  FOR  THEIR  OB,JECT  THE  INDUC- 
TION OF  DRAINAGE  THROUGH  THE  CHOROID  AND  PERICHOROIDAL  SPACES. 

Hancock  {R.  L.  Hosp.  Rep.,  Vol.  Ill)  being  of  the  opinion  that  the 

ciliary  muscle  in  glaucoma  is  either  in  a  state  of  spasm  or  atrophy,  as  a 
consequence  of  which  the  loss  in  elasticity  impeded  the  circulation 
through  the  vessels  of  the  choroid  and  thus  favored  increase  of  tension, 
sought  to  remove  the  obstacle  to  the  vascular  flow  by  dividing  the  ciliary 
muscle.    AVith  this  end  in  view,  he  introduced  a  Beers'  knife  through 


5544  GLAUCOMA 

the  st'lero-coriioal  junction  at  the  lower  outer  margin  of  the  cornea, 
the  point  of  the  knife  being  directed  oljliquely  backwards  and  down- 
wards unlil  the  libres  of  the  sclerotic  were  divided  for  more  than  an 
eiglith  of  an  inch.  Ball  {Ophthalmic  Year  Book,  1908,  p.  193)  had 
good  results  from  this  procedure  for  the  relief  of  pain  in  absolute 
glaucoma. 

Walker's  operation.  Hancock's  operation  was  modified  by  Walker 
by  what  was  termed  hyposcleral  cyclotomy.  In  this  procedure  a  very 
narrow  knife  is  passed  through  the  clear  cornea,  close  to  the  margin, 
with  the  edge  turned  away  from  the  center.  It  is  then  thrust  forward 
through  the  base  of  the  iris,  care  being  taken  to  avoid  injury  of  the 
lens.  The  knife  is  then  slowly  withdrawn,  incising  the  sclera,  which 
imparts  to  the  hand  the  sensation  of  cutting  through  gristle.  This 
operation  ditt'ers  from  Hancock's  sclerocyclotomy  in  that  Hancock's  is 
through  the  sclera,  which  is  cut  for  about  Vs  of  an  inch  in  the  danger 
zone,  whereas,  in  hyposcleral  cyclotomy  the  knife  passes  through 
cornea  and  iris,  and  the  ciliary  body  is  divided  as  it  lies  against  the 
sclerotic. 

Sclero-choriotomy.  An  operation  somewhat  similar  to  the  fore- 
going is  practised  by  Querenghi  {Annal.  d'Ocidist.,  June,  1900,  p. 
441)  under  the  name  of  sclero-choriotomy,  the  object  being  to  incise 
the  eye  in  such  a  way  that  the  ciliary  muscle  will  be  divided  at  its 
attachment  to  the  sclera,  thereby  opening  up  a  passage  between  the 
supra-choroidal  space  and  the  anterior  chamber.  Querenghi  considered 
that  glaucoma  depends  upon  the  lack  of  communication  between  these 
two  spaces.  The  operation  is  performed  by  thrusting  a  needle  with  a 
lance-shaped  point,  or  a  narrow  Graefe  knife,  through  the  sclera  2  mm. 
from  the  limbus  into  the  posterior  chamber.  The  handle  of  the  knife 
is  now  depressed  and  the  blade  pushed  forward  so  that  it  glides  along 
the  outer  wall  of  the  chamber,  the  cutting  edge  being  turned  toward 
the  ciliary  body.  After  the  knife  has  been  advanced  into  the  chamber 
to  the  extent  of  5  or  6  mm.,  the  choroid  is  incised  from  within  out- 
wards, down  to  the  sclerotic,  by  short  sawing  movements,  care  being 
taken  not  to  enlarge  the  site  of  puncture,  to  avoid  prolapse  of  the  iris. 

Cyclodialysis.  Heine's  operation  (Deittsch.  Med.  Woch.,  1905,  N. 
21 ;  Bcricht  der.  Ophth.  GesclL,  1905;  Milnch.  Med.  Woch.,  1906,  N.  2) 
of  cyclodialysis,  which  bears  some  relationship  to  the  foregoing,  inas- 
much as  it  is  based  upon  the  desirability  of  establishing  a  communica- 
tion between  the  anterior  chamber  and  the  supra-choroidal  space,  was 
suggested  to  its  originator  by  Fuchs'  observation  on  detachment  of 
the  choroid  in  eyes  after  iridectomy  or  cataract  extraction,  and  the 
hypothesis  of  Axenfeld  that  such  detachment  may  have  an  important 


GLAUCOMA 


5545 


A 


2  o^ 

^  o  o 


50   (-h     p 
5' 

p  5" 


p.  fi 


9b 


o   »" 

o 


5546 


GLAUCOMA 


bearing  on  the  method  of  cure  after  successful  operations  for  glau- 
coma. 

After  local  anesthesia  and  th(>  introduction  of  a  six'cvduni,  the 
patient  is  told  to  look  upward,  and  the  ^\o]h'  being  fixed  willi  forceps, 
an  incision  is  made  through  the  conjuiietiva  with  scissors,  al)Out  5  mm. 
from  the  limbus,  in  its  lower  and  outer  portion.  The  tiaps  of  the  con- 
junctival wound  are  somewhat  undermined  and  the  sclera  exposed  by 
causing  the  wound  to  gap  by  traction  with  two  double  tenacula  lield 
by  an  assistant.     An  incision  2  nun.  long  is  now  made  througli  the 


(Jyclodialysis  iii  the  Lett  Lye.  The  eyeiids  iu  this  operation  are  lieid  apart  by 
a  spring-speculum.  After  the  eonjunctiva  has  been  incised  and  the  sclera  exposed 
to  view,  a  short  incision  is  made  with  the  lancet  (keratome)  parallel  to  the  limbus 
and  at  a  distance  of  about  5  mm.  to  the  outer  and  lower  side  of  it.  The  lancet  is 
made  to  cut  with  its  side  and  not  with  its  point.     (After  Meller. ) 

sclera  with  a  lancet  or  with  the  lateral  edge  of  a  small  keratome  held 
vertically  at  a  distance  of  5  mm.  from  the  limbus  and  parallel  to  it 
(see  fig.).  The  incision  should  be  made  with  caution,  to  avoid  injury 
to  the  sublying  ciliary  body,  the  tissues  of  the  sclera  being  divided 
layer  by  layer  until  the  black  of  the  uvea  appears  in  the  wound.  A 
small  spatula  is  now  introduced  into  the  wound  and  pushed  slowly 
forwards  between  the  sclera  and  ciliary  body,  with  its  plane  parallel 
to  both,  until  the  tip  appears  in  the  angle  of  the  chamber.  (See  tig.) 
As  soon  as  this  is  accomplished,  the  handle  of  the  instrument  is  de- 
flected to  the  right  and  left,  thereby  widening  the  incision  in  the  angle 
of  the  chamber  and  detaching  the  ciliary  muscle  from  the  sclera  to  as 


GLAUCOMA  5547 

great  au  extent  as  ])ossible,  care  being  exercised  to  avoid  injury  of 
the  lens  or  iris  witli  the  point  of  tlie  spatula.  (See  fig.)  The  spatula 
is  now  withdrawn,  the  conjunctiva  sutured  and  the  eye  bandaged. 

Care  must  be  exercised  in  making  the  incision  to  avoid  injuring 
the  anterior  ciliary  veins,  not  oidy  on  account  of  obscuring  the  field  of 
operation,  but  also  to  obviate  blood  entering  the  chamber  after  the 
introduction  of  the  spatula.  Adrenaline  will  usually  control  any 
bleeding  from  snmll  scleral  vessels,  though  it  may  be  necessary  to 
resort  to  the  thermocautery  to  stop  severe  hemorrhage  from  a  ciliary 
vein. 

The  comi)lications  during  the  operation  consist  in  too  deep  an  in- 
cision, causing  prolapse  of  vitreous.  This  is  prevented  by  keeping  the 
incision  the  same  depth  in  the  entire  length  of  the  wound  and  discon- 
tinuing it  the  moment  the  uvea  appears.  Instead  of  entering  the 
chamber,  the  spatula  may  be  pushed  forward  into  the  cornea,  detaching 
Deseemet's  membrane  from  the  substantia  propria.  This  accident 
should  be  recognized  by  a  sensation  of  resistance,  when  the  instrument 
must  be  withdrawn  and  further  attempts  made  to  enter  the  chamber 
by  gently  raising  the  handle  of  the  spatula. 

The  tension  as  a  rule  after  this  operation  does  not  fall  for  some 
hours  afterward,  and  does  not  attain  its  lowest  degree  until  one  to 
three  days  later.  Meller  {Ophthalmic  Operations,  p.  203)  has  found 
that  three  kinds  of  cases  are  distinguished  according  to  the  condition 
of  the  eye  after  the  operation:  those  in  which  (1)  the  tension  is  re- 
duced permanently;  (2)  the  diminution  is  only  temporary;  (3)  ten- 
sion is  wholly  unafifected.  In  the  first  class  (about  30  per  cent.)  ten- 
sion sinks  gradually  during  the  first  three  days;  indeed  it  may  be 
even  subnormal.  The  previously  hazy  cornea  becomes  clear,  the  ante- 
rior chamber  deeper,  though  still  shallower  than  normal,  the  pupil 
a  little  less  dilated  than  before.  The  eye  may  remain  in  this  condition 
permanently.  In  al)out  40  per  cent,  the  diminution  of  the  tension  is 
only  temporary  and  an  increase  returns  within  a  few  weeks;  in  about 
35  per  cent,  the  operation  has  no  effect  at  all  on  the  glaucoma.  This 
is  especially  the  case  in  glaucoma  absolutum. 

Wernicke,  drawing  his  deductions  from  76  operations  performed 
upon  61  patients  in  Uhthoff's  clinic,  believes  that  on  account  of  the 
dangers  of  iridectomy,  i.  e.,  intraocular  hemorrhage  from  the  sudden 
reduction  in  intraocular  tension,  injury  to  the  lens,  and  the  non-closure 
of  the  wound,  cyclodialysis  is  to  be  preferred  to  the  classic  operation 
in  many  cases,  and  is  equally  valuable  in  others.  In  the  eases  above 
referred  to,  the  operation  improved  the  condition  as  long  as  the  eases 
were  under  observation  (20  after  a  period  of  2  years)  in  57  per  cent., 


5548 


GLAUCOMA 


while  llicrc  was  t('iiii)<)rar\-  impi-oviMiiciit  in  25  per  cent.  Only  IJ  per 
cent,  showed  no  iini)rovenient. 

Ai'iiokl  Kna])p  rei)orte(l  a  series  of  18  eases  upon  which  he  had  per- 
formed this  opei'ation,  and  while  he  did  not  think  it  could  in  any  way 
replace  iridectomy,  he  eoneluded  that  cyclodialysis  is  of  value  in  cer- 
tain limited  conditions,  lie  found  it  indicated  in  the  advanced  cases 
of  chronic  glaucoma,  especially  those  in  which  iridectomy  had  not 
succeeded  in  reducing  tension. 

It  seems  to  he  the  conviction  of  many  conservative  operators  who 
have  employed  this  procedure  in  a  sufficient  numher  of  cases  to  war- 
rant reliable  deductions,  that,  while  it  may  for  a  time  lower  tension. 


Cyclodialysis.     The  spatula,  held  parallel  with  the  surface  of  the  sclera  and  the 
ciliary  body,  and  appears  in  the  angle  of  the  chamber.     (After  Meller.) 

this  effect  is  not  permanent,  and  the  procedure,  in  their  opinion,  has 
not  proven  itself  to  he  of  equal  value  with  iridectomy  or  with  any 
other  of  its  recent  modifications. 

[Meisner  and  Sattler  {Archiv  f.  Augenh.,  LXXI,  p.  341,  li)13)  fur- 
nish the  results  of  a  series  of  fifty-four  cyclodialysis  operations,  done 
in  the  years  1910  and  1911  at  the  Konigsberg  clinic.  These  authors 
regard  the  operation  as  easier  of  execution  than  iridectomy,  especially 
when  the  anterior  chamber  is  shallow.  Although  the  ciliary  body  was 
detached  by  means  of  a  flat  si)atula  for  about  a  third  of  its  circum- 
ference, in  only  one  instance  was  the  shape  of  the  pupil  altered.  In 
fifteen  cases  tlie  operation  was  comi)lieated  by  hemorrhage  into  the 
anterior  cliaml)er,  usually  from  ruptured  anterior  ciliary  vessels.  In 
eight  cases  the  hemorrhage  was  absoi-bed   within   fourteen  days,  and 


GLAUCOMA  5549 

the  results  wrrv  good.  lUit  the  operation  was  unsuccessful  in  the 
other  seven  cases,  in  which  al)sorption  was  slower.  Accidental  per- 
foration of  the  uvea  did  not  generally  appear  to  spoil  the  result.  ]\Iost 
of  the  patients  were  free  from  pain  after  the  first  few  hours  following 
the  operation.  Partial  atrophy  of  the  iris  was  seen  in  one  case  about 
a  year  after  operation.  Post-operative  inflammation  occurred  in  an 
old  trachomatous  eye,  and  again  in  a  case  of  glaucoma  following  cat- 
aract extraction. 

As  completely  successful  the  autliors  reckon  only  those  cases  in 
which,  after  at  least  three  to  six  months'  observation,  the  tension 
stayed  iioi'inal  and  no  deterioration  occurred  in  vision  or  the  visual 
field.  These  conditions  were  fulfilled  by  fifteen  cases,  of  which  five 
were  observed  for  at  least  six  months  and  seven  for  not  less  than  a 
year.  Two  out  of  three  of  tlie  conditions  were  satisfied  by  five  fur- 
ther cases.  Relapses  occurred  in  ten  cases,  which  had  for  a  time  ap- 
peared successful.  As  regards  the  relative  efficiency  of  the  operation 
in  chronic  and  acute  glaucoma,  joint  consideration  of  the  completely 
and  incompletely  satisfactory  results  suggests  that  the  prospects  are 
most  favorable  in  glaucoma  simplex.  A  comparative  study  of  results 
of  iridectomy  and  of  cyclodialysis  done  (a)  each  in  one  eye  of  the 
same  patient,  or  (b)  in  the  order  named  on  one  arid  the  same  eye,  does 
not  argue  in  favor  of  either  mode  of  treatment. — Ed.] 

Fostrrior  sclcrotoniij.  Although  de  Wecker  is  authority  for  the 
statement  that  Gueriu  practised  puncture  of  the  sclera  and  cornea 
for  the  relief  of  increased  pressure  within  the  eye  as  early  as  1769, 
William  IMackenzie,  of  Glasgow,  in  1830,  was  probably  the  first  British 
surgeon  who  tapped  the  posterior  segment  of  the  eyeball  on  account 
of  increased  hardness.  This  distinguished  investigator  advised  scleral 
puncture  for  hydrophthalmus  and  glaucoma,  and  in  some  cases  ob- 
tained, to  use  his  own  words,  "a  transient  amelioration  of  vision  as 
well  as  relief  from  pain,"  the  incision  being  made  with  a  lance  knife 
at  the  site  of  the  old  operation  for  depression  of  cataract.  The  instru- 
ment was  then  thrust  backwards  towards  the  center  of  the  vitreous  and 
rotated  somewhat  about  its  axis  and  allowed  to  remain  in  position 
from  one  to  two  minutes  until  sufficient  of  the  ocular  fluids  had  escaped. 

Although  practised  to  some  extent  by  Middlemore  in  1835,  the 
operation  fell  into  disuse  for  the  relief  of  the  diseases  to  which  ]\[ac- 
kenzie  had  applied  it  until  1872.  wlien  de  Luca  (Ann.  di.  Ottalm., 
1872,  II,  p.  155:  Ann.  di  Ottalm.,  1876,  IV,  p.  217),  without  appar- 
ently being  cognizant  of  ^Mackenzie's  work,  recommended  it  in  glau- 
coma, not  only  for  the  relief  of  pain  in  blind  eyes,  but  also  in  those 
which  still  possessed  useful  vision.     Since  that  time  the  procedure  has 


5550  GLAUCOMA 

been  frequently  practised  witli  various  modifications  and  is  now  a 
well  recognized  means  of  temporarily  reducing  tension  in  any  form 
of  glaucoma. 

Technique.  After  cocainization,  tlie  lids  are  separated  by  an 
assistant,  the  j)atient  is  instructed  to  look  upwards  and  inwards,  and 
the  globe  is  grasped  near  the  limbus  with  fixation  forcei)s.  A  Graefe 
knife  is  then  inserted  midway  between  the  tendons  of  the  external 
and  inferior  rectus  muscles  at  a  point  at  least  15  mm.  behind  the 
limbus,  which  seems  to  be  free  from  conjunctival  or  episcleral  vessels. 
The  point  of  the  knife  is  inserted  perpendicular  to  the  center  of  the 
globe  and  is  permitted  to  enter  the  eye  to  a  depth  of  5  or  6  nun.  If  the 
effect  of  a  simple  paracentesis  is  alone  desired,  the  knife  is  withdrawn 
and  the  wound  permitted  to  close. 


Cyclodialysis.  Figure  showing  the  position  of  the  spatula  during  the  per- 
formance of  the  lateral  movement  intended  to  detach  the  ciliary  body.  (After 
Meller.) 

Usually,  however,  it  is  found  desirable  to  augment  the  effect  of  the 
operation  by  still  further  incising  the  sclera.  This  is  accomplished 
with  gentle  sawing  movements  of  the  knife  with  its  edge  directed 
forwards  until  a  meridional  incision  is  made,  i.  e.,  one  running  from 
behind  forward,  some  5  or  6  mm.  in  length.  Care  should  be  taken  to 
avoid  injury  to  the  lens  or  ciliary  body.  "When  the  incision  has 
attained  the  desired  length,  the  knife  is  turned  slightly  about  its  axis 
and  the  subretinal  fluid,  with  usually  a  bead  of  vitreous,  escapes  under 
the  conjunctiva,  immediately  made  evident  by  a  ballooning  out  of  the 
conjunctiva.  The  knife  is  then  withdrawn  and  a  bandage  applied.  A 
free  escape  of  fluid  is  met  with,  both  in  acute  inflanunatory  and  in 
chronic  non-inflammatory  cases.  If  yellow  fluid  presents,  it  indicates 
ill  all  probability  an  earlier  hemorrhage  into  the  vitreous.  External 
bleeding  from  the  wound  is  usuallv  but  slight  and  can  be  disregarded. 


GLAUCOMA  5551 

Perfect  asepsis  will  prevent  the  septic  infiltration  of  the  vitreous  which 
has  followed  the  puneture  in  a  few  instances. 

Motais  (Annal.  d'Ocul.,  1887,  XCVII,  p.  251)  has  shown  that,  unless 
the  capsule  of  Tenon  is  opened  by  the  knife,  but  a  small  quantity  of 
fluid  escapes.  He  insists,  therefore,  that  the  incision  must  lie  behind 
the  insertion  of  the  rectus  muscles,  and  inserts  the  knife  rather  in 
front  of  the  equator  well  away  from  the  venae  vorticosa?,  midway  be- 
tween the  superior  and  external  recti.  A  simple  rotation  of  the  knife 
around  its  axis  before  withdrawal  will  make  an  L-  or  T-shaped  in- 
cision, resembling  that  of  a  leech  bite,  and  will  insure  a  leakage  of 
the  wound  for  some  days  afterwards;  the  tension  will  be  kept  down 
for  at  least  two  or  three  days.  Motais  follows  the  operation  by  mas- 
sage of  the  eye  for  five  minutes  at  a  time  every  2  or  S  hours  for  a 
fortnight  or  more  after  the  puncture,  as  he  claims  by  this  means  to 
retard  the  cicatrization  of  the  wound  and  preserve  its  filtration  with- 
out harm  to  the  patient.  If  a  second  puncture  is  deemed  desirable, 
he  avoids  the  site  of  the  previous  incision. 

Motais  has  found  posterior  sclerotomy  of  advantage  in  the  follow- 
ing conditions :  Absolute  glaucoma,  to  relieve  pain  and  obviate  enucle- 
ation; in  acute  glaucoma,  where  iridectomy  and  anterior  sclerotomy 
have  not  assisted  the  process  (in  one  of  his  cases  he  preserved  vision 
for  nearly  two  years  by  this  method)  ;  preparatory  to  iridectomy.  He 
claims  to  be  the  first  to  call  attention  to  the  value  of  posterior  scler- 
otomy, (1)  in  prodromal  glaucoma,  in  which  he  thinks  no  other  form 
of  operation  can  take  its  place,  (2)  in  chronic  secondary  glaucoma, 
(3)  in  acute  secondary  glaucoma.  He  thinks  the  action  of  the  scler- 
otomy remarkable  in  this  latter  class  of  cases  on  account  of  its  rapidity 
and  efficacy. 

Tobler  (Arch.  f.  Augenh.,  1899,  XXXVIII,  I,  p.  93),  of  Basel,  has 
shown  experimentally  that  the  risk  of  hemorrhage  is  much  greater 
if  the  incision  is  made  in  the  e(iuatorial  plane  instead  of  in  a  meridional 
one,  for  not.  only  is  the  direction  of  most  of  the  scleral  fibers  in  the 
latter  plane,  and  hence  such  sections  gape  the  least,  but  with  the  in- 
cision in  this  direction  only  a  few  choroidal  vessels  are  encountered 
and  there  is  less  danger  of  hemorrhage.  IMeller  has  demonstrated  that 
the  wound  after  posterior  sclerotomy  becomes  solidly  cicatrized  in  a 
few  months. 

T-shaped  sclerotomy.  When  a  filtering  cicatrix  is  desired,  for  ex- 
ample, after  iridectomy  and  anterior  sclerotomy  have  proved  of  no 
avail,  as  in  absolute  and  hemorrhagic  glaucoma,  Parinaud  (Arch. 
d'Ophtalm.,  1885,  V,  p.  180)  also  recommended  the  rotation  of  the 
knife  in  the  wound,  thereby  making  a  T-shaped  incision.     Claiming 


i552  GLAUCOMA 

that  this  form  of  incision  was  necessary  for  the  persistence  of  filtra- 
tion, he  asserted  that  his  best  results  were  obtained  in  cases  where 
there  was  but  little  escape  of  fluid  directly  after  the  puncture,  and 
the  tension  did  not  begin  to  diminish  until  a  day  or  so  after  the  oper- 
ation. He,  too,  thouglit  massage  useful  and  insisted  on  its  continu- 
ance for  a  long  time  after  tlie  procedure. 

Small  equatorial  sclerotanuj.  ]\Iasselon  {Annal.  d'Oculist.,  1888, 
p.  226;  Anml.  cVOcidut.,  1886,  p.  231)  formerly  favored  a  long 
meridional  incision  of  the  sclera  alone,  in  order  to  avoid  injury  to 
the  deeper  portion  of  the  vitreous,  and  made  a  flat  puncture  and 
counter-puncture;  later,  however,  he  performed  a  very  small  equa- 
torial incision. 

Simi  {Bollettino  d'Oculist.,  1887,  IX,  p.  17)  favored  4  mm.  equa- 
torial incisions  through  the  sclera,  without,  however,  injuring  the 
choroid,  as  a  precursor  of  iridectomy  in  cases  of  inflammatory  glau- 
coma with  obliteration  of  the  anterior  chamber. 

In  1886,  Galezowski  {Bulletin  Mem.  franc.  d'Ophthalm.,  1886,  p. 
256)  performed  what  he  termed  sclero-choriotomy  (q.  v.),  though  in 
reality  the  procedure  was  a  post-sclerotomy  for  the  relief  of  glaucoma 
simplex,  hydrophthalmus  and  profuse  vitreous  hemorrhages.  A  Graefe 
knife  was  introduced  between  the  superior  and  external  rectus  muscles 
posteriorly  into  the  sclera,  choroid  and  retina,  the  incision  being  pro- 
longed anteriorly  to  the  ciliary  region.  Two  years  later  he  devised 
a  peculiarly  shaped  knife  by  means  of  whicli  two  incisions  were  made 
through  the  sclera  only  as  far  posteriorly  as  possible.  This  procedure 
was  especially  applicable  to  cases  of  glaucoma  simplex. 

In  1894  Priestley  Smith  (Trans  of  8th  Intcrnat.  Ophth.  Cong., 
Edinburgh,  Aug.,  1894,  p.  33)  advocated  puncture  of  the  sclera  as 
an  adjunct  to  iridectomy  in  tlie  treatment  of  glaucoma,  and  has 
since  then  written  that  a  continued  experience  still  eonfirins  the  value 
and  safety  of  his  procedure. 

[Sclerotwnia  cruciata  multiplex.  When  Wicherkiewicz  (Ophthal- 
mology, July,  1913)  devised  a  new  operation  for  certain  forms  of 
glaucoma,  he  was  guided  by  the  tliought  that  whether  the  anterior 
outlets  were  free  or  irrevocably  closed,  they  were  not.  in  this  partic- 
ular procedure,  the  object  of  his  operative  aims.  His  metliod  was 
intended  for  those  forms  of  glaucoma  in  which  iridectomy  and  ante- 
rior sclerotomy  fail,  viz.,  glaucoma  simplex  and  those  cases  in  which 
former  operations  had  no  lasting  results.  These  are  certain  forms  of 
inflammatory  glaucoma  in  whicli  the  inflannnatory  symptoms  are 
favorably  influenced  hy  iridectomy,  but  in  which  vision  gradually 
deteriorates,  then  secondary  glaucoma,  in  whicli  the  anterior  outlets 


GLAUCOMA  5553 

cannot  be  approached,  sets  in.  Jn  other  words,  that  part  of  the  eye 
which,  so  far,  has  not  received  sufficient  attention,  viz.,  the  sclera, 
ought  to  be  made  the  object  of  treatment. 

Frequently  the  sclera,  especially  of  older  persons,  feels  very  rigid 
to  the  touch,  and  examinations  of  enucleated  eyes  confirms  this  by  the 
increased  thickness  of  the  sclera.  If  the  sclera  becomes  rigid,  it  loses 
its  elasticity  and  forms  a  resistance  in  increased  intraocular  tension, 
which  even  in  physiological  fluctuations  must  act  on  the  vascular, 
and  even  more  on  the  nervous,  parts  of  the  visual  organ.  Then  an- 
other element  may  play  a  role.  The  rigid  sclera  may  occasionally,  as 
will  be  set  forth  below,  close  the  communication  between  the  supra- 
choroidal  and  Tenon's  spaces,  which  perhaps  participates  in  the 
excretion.  The  vessels  penetrating  the  sclera,  especially  the  vorticose 
veins,  are  surrounded  by  lymphatic  sheaths,  which  connect  both  spaces. 
By  accumulation  of  connective  tissue,  in  rigidity  of  the  sclera,  these 
communications  are  constricted  or  closed,  which  may  decidedly  con- 
tribute to  the  increase  of  intraocular  tension.  If  this  be  the  case, 
multiple  incisions  of  the  rigid  sclera  to  its  deepest  layers  must  make  it 
more  expansi])le,  lower  the  pressure  exerted  by  it  and  prevent  a  stasis 
of  lymph  in  the  supra-choroidal  space. 

After  instillation  of  eocain,  a  subconjunctival  injection  of  a  1  per 
cent,  solution  of  eocain  with  adrenalin  is  made  into  the  upper,  tem- 
poral region  of  the  eyeball.  While  an  assistant  rotates  the  eyeball 
far  downwards  with  a  sharp  hook,  inserted  above  the  cornea,  the  oper- 
ator makes  a  long  meridional  incision  through  the  conjunctiva.  The 
subconjunctival  tissue  is  lifted  with  two  pairs  of  forceps  and  incised 
successively  to  the  sclera,  the  bleeding  being  controlled  by  instillations 
of  adrenalin.  After  the  sclera  is  largely  exposed,  make  with  von 
Graefe  knife  from  4  to  6  meridional  incisions,  10  to  12  mm.  long,  into 
the  sclera  and  as  many  cross  sections,  as  far  back  as  possilile.  If  the 
sclera  is  very  thick  some  of  the  incisions  are  deepened,  but  only  from 
2  to  3  mm.  long,  as  deep  as  the  choroid.  After  irrigations  with  salt 
or  boric  acid  solutions,  and,  finally,  electragol,  the  wound  in  the  con- 
junctiva and  Tenon's  capsule  is  closed  with  a  few  firm  sutures  and  a 
bandage  applied  for  from  one  to  two  days.  The  patient  is  not  con- 
fined to  bed.  After  from  four  to  five  days  the  sutures  are  removed. 
Generally  the  intraocular  tension  is  considerably  diminished  imme- 
diately after  the  operation,  lint  more  so  if  the  eye  is  massaged,  which 
always  ought  to  be  done  before  applying  the  dressing. — Ed.] 

The  sclera  teas  first  trephined  for  gleiucoma  by  Argyll  Robertson 
(Boyal  Loud:  Hospital  Beporfs,  Vol.  YIIT,  p.  404),  but  with  only  par- 
tial success,  and  the  procedure  was  abandoned.     IMore  recently,  how- 

Vol.  VII— 45 


5554  GLAUCOMA 

ever,  Frohlich  (Klin..  Monatshl.  f.  Augenheilk.,  1904,  p.  411)  recora- 
nu'iids  the  removal  of  a  pii'cc  of  tlu-  sclera  in  preference  to  enucle- 
ation, or  one  of  its  substitutes,  in  blind  glaucomatous  eyes.  He  per- 
forms the  operation  as  follows:  Incisions  in  the  conjunctiva  10  to  12 
mm.  long  are  made  parallel  to  the  lower  edge  of  the  external  rectus 
to  the  outer  edge  of  the  inferior  rectus,  and  the  flap  of  conjunctiva 
between  these  incisions  is  turned  back.  Von  Hippel's  trephine  with 
the  5  mm.  crown  is  api)lied  to  the  sclera  back  of  the  ciliary  body,  and 
so  adjusted  that  a  disc  will  be  cut  from  the  sclera  without  injuring 
the  choroid.  Otherwise  intraocular  hemorrhage  would  occur  and  ren- 
der the  operation  unsuccessful.  The  vitreous  breaks  through  the 
retina  and  choroid,  lowering  the  tension,  the  conjunctival  flap  is 
sutured  in  place  and  the  tension  remains  subnormal.  In  four  cases 
reported,  one  irritative,  one  hemorrhagic,  and  two  secondary  glaucoma, 
the  results  were  favorable.    In  a  fifth  case  the  operation  was  a  failure. 

Again  this  operation  was  practically  abandoned  until  Elliot  and 
Fergus  modified  and  improved  the  technic,  and  so  made  a  successful 
procedure  of  it. 

Indications  for  posterior  sclerotomy  in  glaxico^na.  As  has  just  been 
shown,  posterior  sclerotomy  is  admirabl}^  adapted  to  effect  a  normal 
or  almost  normal  depth  of  the  anterior  chamber  in  all  forms  of  glau- 
coma, and  may  safely  precede  iridectomy  when  this  procedure  is  ren- 
dered ineffective  by  the  presence  of  a  very  shallow  chamber.  It  may 
also  be  employed  to  temporarily  reduce  tension  in  inflammatory  glau- 
coma when,  for  any  reason,  such,  for  example,  as  septic  conditions  of 
the  eye,  or  from  the  immediate  risk  of  an  anesthetic,  iridectomy  must 
be  postponed.  The  puncture  holds  the  glaucoma  in  abeyance  until  the 
septic  condition  has  been  removed,  or  until  the  decrease  in  the  in- 
flammatory symptoms  with  which  it  is  followed  does  away  with  the 
necessity  of  a  general  anesthetic  and  permits  of  the  use  of  cocaine. 
In  hydrophthalmus  it  is  the  writer's  operation  of  choice.  It  is  also 
often  of  service  in  absolute  glaucoma  with  pain,  when  other  operations 
have  been  of  but  little  avail  and  the  patient  refuses  enucleation.  While 
advised  and  practised  by  some  in  eases  of  non-congestive  glaucoma 
when  the  vision  has  been  almost  entirely  lost,  the  writer  believes 
sclerotomy  is  contra-indicated  on  account  of  the  danger  of  annihilat- 
ing the  little  vision  that  remains,  as  a  consequence  of  the  intraocular 
hemorrhage  which  may  follow  the  procedure.  The  persistent  use  of 
miotics  even  in  these  desperate  cases  affords  the  best  means  of  con- 
serving vision. 

[One  of  the  most  valuable  resumes  of  operative  experience  by  men 
competent  to  operate  and  observe  results  is  that  furnished  by  Morax 


GLAUCOMA  5555 

and  Fourriere  {Annales  d'Oculistiquc,  Vol.  CLI,  May,  1914)  ou  the 
surgical  treatment  of  pnmarij  chronic  glancmnn.  An  excellent  ab- 
stract of  the  voluminous  original  is  given  in  the  Oph.  Review  by 
W.  C.  Souter,  and  is  partially  incorporated  herewith. 

Since  1906  there  have  been  37  men  and  40  women,  as  against  the 
9  men  and  47  women  of  the  acute  series;  and  the  ages  varied  from 
30  to  75,  with  5  cases  between  30  and  40  and  most  between  50  and  70. 
Usually  both  eyes  were  affected,  64  out  of  77,  even  when  watched  for 
only  a  few  years. 

The  anesthetic  was  general — chloroform — only  14  times,  and  local — 
novocain  1  in  20  followed  by  cocaine  1  in  30  as  drops,  supplemented 
by  subconjunctival  injection,  far  back  and  above,  of  2  or  3  drops  of 
sterile  cocaine — adrenalin  if  much  redness — 86  times,  the  authors 
much  preferring  local  anesthesia.  The  operation  was  iridectomy'  in  23 
eyes  and  sclerecto-iridectomy  in  83  eyes.  In  the  first  years  they  stuck 
closely  to  Lagrange,  using  a  Graefe  knife,  curved  scissors  and  Vacher's 
punch.  Since  ^lay,  1912,  they  followed  Fergus  and  Elliot,  using  a 
Graefe  knife  to  dissect  into  the  cornea,  and  a  2  mm.  Bowman's  tre- 
phine, in  most  cases  as  far  forward  as  possible.  The  iridectomy  always 
followed  the  sclerectomy,  and  usually  by  the  snip-drag-snip  method, 
only  in  some  cases  was  it  peripheral  with  retention  of  the  iris  sphincter. 
As  Elliot  advises,  any  marked  dragging  on  the  iris  was  avoided.  Com- 
plementary sclerectomy  or  sclerecto-iridectomy  was  done  in  a  small 
number  of  cases  that  previously  had  had  iridectomy  or  sclerecto- 
iridectomy,  the  site  chosen  being  usually  between  "9  and  11"  o'clock  or 
between  ' '  1  and  3. ' '  The  trephine  was  placed  over  the  edge  of  the  old 
iris  coloboma.  As  many  as  three  successive  scleral  trephine  operations 
had  been  done  on  one  eye.  Sclerotomy  posterior  was  done  in  cases 
witli  tension  at  60-90  mm.  of  Ilg.,  a  fine  Graefe  knife  being  passed  in 
radially  about  1  cm.  from  corneal  edge,  and  the  operation  gone  on 
with  after  a  few  moments. 

Of  operative  complications,  the  immediate  ones  were,  escape  of 
vitreous,  expulsion  of  lens  plus  some  vitreous,  and  expulsive  hemor- 
rhage, each  in  Lagrange  cases.  The  post-operative  ones  being  the 
early,  viz.,  inversion  of  the  flap  after  trephining,  hyphema  lasting  20 
days,  hyphema  appearing  on  the  seventeenth  day,  and  post-operative 
pains,  rare  in  Lagrange  cases,  1  in  15,  more  frequent  in  trephine 
cases.  10  in  24;  and  the  later,  of  three  sorts,  (a)  late  infection  of  fis- 
tulous passage,  one  pneumococcus  infection  7  months  after  a  Lagrange, 
and  one  20  months  after  trephining;  (b)  late  vitreous  hemorrhages — 2 
cases,  and  (c)  opacification  of  center  of  cornea.  The  anterior  chamber 
reformed   rather  more   slowly  after  trephining  than   after   the   La- 


5556  GLAUCOMA 

grange-Holth  operation,  and  tlic  aiifliors  nolcd  in  some  cases  that  the 
slowness  of  its  reforming  was  a  good  sign  from  the  point  of  view  of 
the  formation  of  a  cystoid  cicatrix  and  of  the  favorable  compensatory 
action  of  this  scar  on  the  tension. 

Of  operative  results — (a)  The  tension  and  the  filtering  cicatrix 
after  the  sclerectomy-iridectomy,  viz.,  (1)  the  state  of  the  tension 
after  the  different  interventions  in  chronic  glaucoma.  Simple  iridec- 
tomy cases  are  few  since  tonometer  became  so  general,  23  cases  in  all, 
majority  showing  a  more  or  less  marked  return  to  hypertension.  Of 
5  cases  tested  by  tonometer,  3  had  tension  greater  than  normal,  while 
the  other  2  had  cystoid  scars  from  iris  inclusion  and  tension  not  greater 
than  normal.  Sclerectomy-iridectomy  of  Lagrange-IIolth,  24  cases, 
and  of  Fergus  and  Elliot,  21  cases,  fully  examined.  Of  the  24,  22 
gave  tension  within  normal,  some  well  below,  e.  g.,  7,  10,  13  mm.  Hg. 
Of  the  21  cases,  in  17  tension  has  kept  normal,  e.  g.,  14 — 25  mm.,  while 
in  4  cases  increased  tension  recurred ;  in  one  of  the  cases  the  edematous- 
flap  could  be  felt  through  the  lid,  reminding  one  of  a  chalazion,  and 
for  many  months  with  a  tension  of  44  mm.  the  vision  held  its  own ;  (2) 
the  evolution  of  the  filtering  scars  after  sclerecto-irideetomy ;  Lagrange- 
Holth,  in  30  operations  20  have  a  marked  filtering  scar  still  after 
periods  varying  from  15  and  29  days  to  2  years  and  6i  i'  years,  while 
in  10  filtration  had  ceased  by  1  and  2  months  up  to  2i/j  and  3  j-ears 
after  operation.  Fergus-Elliot  cases,  21  eyes  have  16  fltering  scars 
after  12  and  22  days  up  to  15  and  16  months;  (3)  filtration  may  soon 
disappear  in  some  cases,  and  in  others  last  long,  but  it  is  apparently 
the  case  that  as  good  functional  results  can  be  got  even  with  flat, 
non-cystoid  scars,  while  an  eye  with  a  cystoid  scar  may  develop  in- 
creased tension;  (b)  the  functional  results  of  sclerecto-irideetomy:  it 
is  very  difficult  to  follow  up  cases,  and  many  of  the  cases  were  operated 
in  extremis,  so  to  say.  Of  the  eyes  operated  on  by  the  Lagrange-Holth 
method  and  watched  for  a  year  or  more  there  are  14.  All  may  be  con- 
sidered satisfactory,  some  are  slightly  worse,  some  slightly  better,  and 
none  have  gone  to  the  bad.  Of  the  eyes  trephined  and  watched  for  a 
year  or  more  there  are  only  6.  One  of  these  is  a  rebellious  case  call- 
ing for  further  treatment,  while  the  5  have  given  excellent  results, 
but  the  authors  say  that  the  antiglauconiatous  action  of  trephining  is 
not  greater  than  that  of  the  Lagrange-IIoltli  operation. 

Cases  with  narrowed  or  even  eccentric  fields  are  not  unsuitable  for 
operation.  Sclerecto-irideetomy  is  a  delicate  intervention,  it  can  give 
rise  to  quite  serious  operative  complications.  Tlie  resiilting  subconjunc- 
tival fistula  can,  exceptionally  no  doubt,  furnish  tlie  point  of  entry 
of  an  exogenous  infection.    Nevertheless  in  the  presence  of  an  affection 


GLAUCOMA  5557 

as  serious  as  chronic  glaucoma  we  may  be  thankful  for  having  in 
selerecto-iridectomy  the  means  of  arresting  for  a  longer  or  shorter  in- 
terval the  serious  disturliances  resulting  from  increased  tension. — Ed.] 

PERMANENT    FOREIGN-BODY    DRAINS. 

Seton  or  thread  operations.  In  recent  years  several  operators  have 
devised  measures  by  which  subconjunctival  drainage  of  the  anterior 
chamber  has  been  established  and  maintained  by  a  silk  thread.  Stephen 
Mayou  (The  Ophthalmoscope,  May,  1912)  designed  his  operation  to 
correct  the  fault  common  to  most  operations  depending  upon  a  filtra- 
tion cicatrix,  that  of  the  wound  healing  firmly,  stopping  filtration 
through  the  cicatrix  with  resulting  rise  of  tension. 

The  method  of  procedure  is  as  follows:  After  the  instillation  of 
adrenalin,  cocain  and  eserin,  a  very  large  and  thick  conjunctival  flap 
is  turned  forwards  over  the  cornea  and  carefully  dissected  up  to  the 
liiubus.  An  incision  about  3  mm.  long  is  made  from  the  outside  into 
the  anterior  chamber,  by  gradually  cutting  thfough  the  fibers  of  the 
sclerotic  with  the  knife  point,  starting  2  mm.  behind  the  limbus.  A 
piece  of  black  silk  tliread,  5  mm.  long,  having  a  knot  at  one  end,  is 
carefully  sterilized  and  with  a  pair  of  forceps  is  laid  across  the  in- 
cision in  the  sclera.  With  a  narrow  iris  spatula,  having  a  rounded 
notch  in  the  end,  the  silk  is  tucked  into  the  incision.  As  the  silk  is 
pushed  forward  into  the  anterior  chamber,  the  knot  sticks  in  the  lips 
of  the  wound,  w'hilst  the  free  end  passes  forward  into  the  angle  of  the 
anterior  chamber.  The  conjunctival  flap  is  then  replaced  in  position, 
a  stitch  being  inserted  if  necessary.  The  whole  operation  can  be  per- 
formed without  emptying  the  anterior  chamber,  and  is  quite  easy  to 
execute. 

The  wound  in  the  conjunctiva,  after  forty-eight  hours,  is  usually 
firmly  healed  and  tlie  subconjunctival  tissue  is  fiUed  with  fluid.  At 
first  this  usually  extends  beyond  the  area  of  the  conjunctival  flap, 
but  after  a  time  it  becomes  more  localized.  The  tension  of  the  eye  is 
usually  subnormal  from  four  days  to  a  week,  after  which  time  it 
regains  its  normal  tension.  In  none  of  the  cases  was  there  any  iritis  or 
undue  reaction;  the  only  contretemps  was  in  one  case,  where  there 
was  a  small  prolapse  of  tlie  iris  at  the  time  of  operation.  This  was 
probably  due  to  the  fact  that  eserin  had  not  been  previously  instilled, 
and  that  the  incision  was  made  rather  larger  than  usual. 

At  the  same  time  Arthur  Zorab  {The  Ophthalmoscope,  IMay,  1912) 
described  an  almost  identical  opei-ation,  which  he  has  called  aquco- 
plasty:  The  eye  is  cocainized  and  cleansed  in  the  usual  way,  eserin 
being  used  to  contract  the  pupil.     A  large  flap  of  conjunctiva  is  then 


5558 


GLAUCOMA 


raised  ott'  tlic  globe,  a  erescentie  attacliiiiciit  at  1in'  liinluis  Ix-ing  left. 
For  ehoiee,  the  tlap  should  l)e  taken  from  the  upper  i)art,  wliieh  is 
generally  covered  by  the  lid.  The  wliolc  tliickness  of  the  conjunctiva 
is  taken,  and  as  the  limbus  is  neared,  the  conjunctiva  here  being  thin, 
great  care  is  taken  not  to  make  a  "l)uttonhole. "  The  flap  is  then  re- 
flected onto  the  cornea,  and  the  globe  being  steadied  by  fixation  for- 
ceps at  the  opposite  side,  an  incision  is  made  with  a  keratoma  into  the 
anterior  chamber. 

The  incision  is  about  3  mm.  long,  and  begins  about  2  mm.  from  the 
corneal  margin.  A  small  piece  of  sterile  silk,  not  more  than  half  an 
inch  long,  is  doubled  on  itself  and  tli<'  Ix'iid  placed  against  the  lips  of 


'"Mn^^^"  ^ 


The  Sclerocorneal  Seton  in  the  Treatment  of  Glaucoma.      (Casey   WootL) 
Introduction  of  the  knife  as  for  an  anterior  sclerotomy. 

the  wound  in  the  sclera,  the  rest  of  the  silk  lying  on  the  exposed  sclera. 
As  soon  as  the  bend  can  be  seen  in  the  chamber  the  flap  of  conjunc- 
tiva is  replaced,  thus  covering  the  distal  portions  of  the  silk.  Great 
care  is  taken  at  this  stage  to  see  that  the  ends  of  the  silk  are  well  away 
from  the  margin  of  the  conjunctival  flap,  it  sometimes  being  necessary 
to  cut  ofif  a  small  piece  from  each  end.  The  flap  is  then  stitched  in  a 
couple  of  places  and  the  operation  is  complete. 

The  eye  is  bandaged  for  a  couple  of  days,  })ut  the  patient  is  up  and 
about  on  the  day  after  the  operation.  There  is  very  free  drainage 
for  the  first  few  days,  the  chamber  being  a])olished,  and  the  conjunc- 
tiva rendered  very  edematous  by  the  aciueous.  Within  a  week  the 
chamber  is  re-established,  and  the  conjunctival  condition  improves 
rapidly. 

Casey  Wood   {Ophthnlmic  Becord,  p.  235,  May,  1915),  stimulated 


GLAUCOMA 


5559 


])}'  the  preceding  efforts  to  establish  a  permanent  seton-drain  from 
tile  anterior  chamber,  as  well  as  by  the  experience  of  Rollet  {Revue 
Gencrale  d'Oplitalm.,  p.  481,  Nov.,  1906)  and  Vail  {Ophthalmic 
Record,  April,  1915),  experimented  with  various  forms  of  the  intra- 
ocular seton  in  the  hope  of  securing,  if  possible,  by  a  method  simpler, 
easier  and  safer  than  any  of  the  foregoing,  such  capillary  drainage  of 
the  anterior  chamber  as  will  insure  a  uniform  and  permanent  outlet 
for  the  pent-up  intraocular  fluids — tluit  chief  desideratum  in  the  treat- 
ment of  chronic  glaucoma. 


The  Sclerocorneal  Seton  in  the  Treatment  of  Glaucoma.     (Casey  Wood.) 
Threading  the  knife  with  a  double-needled  suture. 

After  some  preliminary,  lower-animal  experimentation,  the  opera- 
tion M'as  made  on  human  subjects — seven  cases  in  all  to  date.  In  six 
of  tliese  the  eyes  were  practically  blind,  and  would,  in  the  ordinary 
course  of  events,  be  considered  proper  subjects  for  enucleation. 

The  procedure  adopted  may  be  described  as  follows:  The  eye  is 
carefully  rendered  as  aseptic  as  possible  and  the  pupil  is  contracted 
by  eserin.  A  narrow  Graefe  knife,  with  a  hole  near  its  point,  is  intro- 
duced and  passed  in  precisely  the  same  fashion  as  in  the  preliminary 
steps  of  an  anterior  sclerotomy.  The  puncture  and  counter-puncture 
are  made  entirely  in  the  sclera,  ])ut  as  near  the  clear  corneal  margin  as 
possible,  so  that  at  least  one-half  the  operative  wound  communicates 


5560  GLAUCOMA 

witli  the  anterior  diambor.  When  the  point  of  the  instrument  emerges 
from  the  globe  at  tiie  counter-puneture  one  needle  of  a  double-armed, 
white  "00,"  braided,  silk  suture,  about  eight  inches  long,  is  passed 
through  the  lioJe  in  the  knife-point.  After  a  number  of  trials  it  was 
found  that  a  half-curved  needle  is  better  adapted  to  the  purpose  than 
a  straight  one.  It  should  be  just  large  enough  to  pass  easily  through 
the  eye  of  the  knife,  and  should  not  be  more  than  two-thirds  of  an  inch 
long.  Thus  armed,  the  knife  is  withdrawn,  so  that  about  the  same 
lengths  of  double  suture  protrude  from  puncture  and  counter-puncture. 
The  knife  is  now  freed  from  the  sutures  with  scissors,  and  the  first 
needles  are,  with  a  needle-holder,  separately  passed  (by  way  of  the 
counter-puncture  wound)  in  different  directions  and  for  the  length 
of  the  needle,  beneath  the  ocular  conjunctiva.  The  loose  ends  of 
suture  corresponding  to  the  puncture  opening  are  then  threaded  and 
the  same  maneuvre  is  practised  on  that  side.  The  so-called  split-  or 
patent-eye  needle  is  most  useful  here,  since  a  wet,  sterilized  suture 


Knife  Used  in  Selerocoineal  Seton  Operation. 

can  be  immediately  threaded  upon  it ;  otherwise,  valual)le  time  is  sure 
to  be  lost  in  vain  attempts  to  pass  damp  thread  through  the  eye  of  the 
ordinary  needle. 

It  matters  not  what  form  of  anesthesia  be  used.  It  is  well  to  em- 
ploy a  mixture  of  cocain  and  adrenalin  locally  to  stanch  the  bleeding 
from  the  scleral  wounds. 

The  accompanying  drawings  Avill  serve  further  to  explain  the  steps 
of  the  operation. 

No  claims  are  made  as  to  the  efficiency  of  this  form  of  sclerocorneal 
seton ;  that,  of  course,  M'ill  be  decided  by  the  lapse  of  time  and  future 
experience. 

The  writer  believes  that  if  the  aseptic  threads  do  not  set  up  any  more 
irritation  and  are  not  more  dangerous  than  the  double  suture  of  the 
Zorab-Mayou  procedure  there  may  be  a  chance,  through  lining  of  the 
seton-canal  with  epithelium,  of  eventually  withdrawing  the  threads  of 
the  seton  in  this  operation  without  endangering  the  patency  of  the 
filtration  openings.    But,  of  course,  all  this  remains  to  be  seen. 

Wire  drain.  Arthur  Prince  introduces  {Trans.  Oph.  Sec,  III.  State 
Med.  Soc,  INIay,  1915)  the  terminals  of  a  gold  horseshoe-shaped  wire 
into  the  scleral  opening  made  either  in  the  Elliot  (trephine)  or  La- 


GLAUCOMA 


5561 


grange  (sclerectomy)  operation,  for  the  purpose  of  insuring  a  per- 
manent drain.  The  curved  wire  is  kept  in  i)laee  ehieHy  l)y  the  over- 
lying conjunctival  flap.  Prince  is  so  far  well  satisfied  with  the  results 
of  the  operation.  The  presence  of  the  wire  is  not  productive  of  irri- 
tation.— Ed.] 

[A  number  of  well-known  surgeons  have  recently  given  their  reasons 
for  choosing  some  particular  operative  measure  in  certain  forms  of 
glaucoma.  Of  especial  value  are  the  oliservations  of  Priestley  Smith 
(OpJtth.  Rev.,  Vol.  XXXII,  p.  73,  1913),  who  divides  modern  opera- 


The  Sclerocorneal  Seton  in  the  Treatment  of  Glaucoma.     (Casey  Wood.) 
"Withdrawal  of  the  knife  so  that  the  cut  ends  of  the  suture  may  be  armed  with 
two  additional  needles. 


tions  for  glaucoma  roughly  into  three  classes,  according  as  they  act 
(1)  by  entangling  iris  or  other  tissue  in  the  wound;  (2)  by  compli- 
cating the  form  of  the  wound  so  as  to  prevent  its  closing  easily,  and 
(3)  by  excising  a  piece  of  tissue  with  scissors,  punch  or  trephine. 
He  is  opposed  to  iridencleisis,  in  spite  of  the  favorable  results  which 
sometimes  have  attended  it ;  nor  is  he  favorable  to  anterior  sclerotomy 
or  to  the  insertion  of  threads.  He  considers  that  the  wedge  opera- 
tion of  Herbert  deserves  more  attention  than  it  has  received,  proba])ly 
because  of  the  difficulty  of  understanding  it.  Lagrange's  sclerecto- 
iridectomy  has  paved  the  way  for  the  introduction  of  other  methods, 
notably  Holth's  procedure.  He  has  addressed  a  number  of  inquiries 
to  British  surgeons  with  a  view  to  elicit  information  as  to  the  opera- 


5562 


GLAUCOMA 


tion  they  are  employing,  and  lie  finds  that  iridectomy,  though  prac- 
tised in  a  number  of  ways,  is  still  the  most  popular  operation  for 
acute  glaucoma,  and  trephining  for  chronic  glaucoma. 

The  advantages  of  the  trephining  are  summarized  as  (1)  ease  and 
safety  of  execution;  (2)  absence  of  post-operative  astigmatism,  and 
(3)  thorough  and  permanent  reduction  of  tension;  while  the  disad- 
vantages mentioned  are  (1)  risk  of  losing  the  disk  in  the  chamber; 
(2)  frecjuent  occurrence  of  synechias,  and  (3)  persistence  of  subnormal 
tension;  he  is  in  favor  of  the  free  use  of  atropin  after  operation.  In 
congenital  glaucoma,  the  answers  he  received  were  very  various,  and 


The  Selerocorneal  Seton  in  the  Treatment  of  Glaucoma.     (Casey  Wood.) 
Three  of  the  sutures  in  place  beneath  the  conjunctiva. 

many  of  them  discouraging;  on  the  other  liand,  some  of  his  cor- 
respondents have  spoken  favorably  of  the  treatment  of  this  condition 
by  iridectomy,  by  repeated  anterior  sclerotomy,  by  the  trap-door 
operation,  and  by  trephining. 

He  considers  that  the  operative  treatment  of  glaucoma  has  under- 
gone more  improvement  during  the  last  five  years  than  during  the 
previous  fifty.  The  improvement  relates  chiefly  to  the  treatment  of 
chronic  glaucoma.  It  has  come  through  recognition  of  the  fact  that 
chronic  glaucoma  can  be  arrested  only  by  establishing  a  subconjunc- 
tival fistula  or  filtering  cicatrix  in  connection  with  the  aqueous  cham- 
ber.    Experience  will  doubtless  bring  further  change  of  practice,  but 


GLAUCOMA  5563 

it  is  unlikely  that  any  one  method  will  ultimately  exclude  all  others. 
On  the  contrary,  it  is  likely  tliat  better  knowledge  of  causation  will 
lead  to  a  discriminating  choice  of  ditt'erent  methods  for  different  forms 
and  stages  of  glaucoma.  The  time-honored  iridectomy,  though  now 
to  some  extent  re])la('ed  by  other  methods,  especially  by  trephining, 
is  far  from  being  obsolete.  ]\Iodified  in  various  ways,  it  still  stands 
first  in  favor  for  acute  glaucoma.  In  chronic  glaucoma  a  permanent 
lowering  of  tension  can  sometimes  be  effected  without  excising  any 
portion  of  the  iris,  but  the  attempt  involves  unnecessary  risk.  For  every 
form  of  glaucoma  the  most  trustworthy  operation  will  probably  always 
include  the  making  of  an  aperture  in  the  iris  corresponding  in  position 
with  the  incision  in  the  tunics. 

Lagrange  {Ann.  d'OcuL,  Vol.  149,  p.  213,  1913)  thus  formulates 
his  conclusions:  (1)  Iridectomy  suffices  for  the  cure  of  cases  of 
acute  glaucoma,  but  time  alone  will  show  whether  it  is  better  to  add  a 
sclerectomy  in  these  eases;  (2)  chronic  glaucoma  is  rarely  treated 
successfully  by  medical  means,  and  demands  the  establishment  of  a 
fistula,  and  not  of  a  filtering  cicatrix;  (3)  the  establishment  of  filtra- 
tion is  sometimes  effected  by  iridectomy  alone,  but  not  satisfactorily 
so;  (4)  anterior  sclerectomy  enables  us  in  all  cases  to  establish  sub- 
conjunctival filtration,  and  beyond  this  surgical  science  can  not  at 
present  go;  (5)  anterior  sclerectomy,  either  without  an  iridectomy,  or 
with  only  a  small  peripheral  one,  is  as  efficacious  as  that  with  a  com- 
plete iridectomy,  and  has  the  great  advantage  of  permitting  the 
patient  to  obtain  full  benefit  from  the  use  of  miotics;  this  is  proof 
that  the  excision  of  a  piece  of  iris  is  not  necessary  for  the  cure  of 
glaucoma;  iridectomy  is  useful  in  that  it  serves  to  avoid  the  danger 
of  an  iris  prolapse;  this  is,  however,  the  limit  of  its  usefulness;  (6) 
the  essence  of  sclerectomy  is  the  establishment  of  a  channel  whereby 
the  aqueous  can  pass  from  the  anterior  chamber  into  the  subconjunc- 
tival spaces;  this  is  effected  by  the  removal  of  a  piece  of  sclera,  and 
is  the  principle  underlying  the  Lagrange  method  of  operating;  (7) 
the  establishment  of  filtration  in  this  way  is  the  key  to  the  successful 
treatment  of  glaucoma,  by  surgical  intervention,  and  explains  the 
improvement  in  the  results  of  modern  methods  as  compared  with  those 
in  vogue  before;  (8)  Lagrange's  method  can  be  put  into  execution  in 
many  different  ways,  according  to  the  skill  and  ingenuity  of  the  indi- 
vidual operator.  Of  all  the  devices  for  the  purpose  he  considers  the 
trephine  the  least  to  be  recommended,  since  it  cuts  out  a  circular  piece 
of  tissue;  he  also  thinks  it  a  dangerous  instrument,  so  far  as  the 
ciliary  body  is  concerned.  He  considers  that  the  piece  of  sclera 
removed  should  be  3  to  4  mm.  long  by  1  mm.  broad,  and  that  it  should 


i564  GLAUCOMA 

be  taken  I'roiii  the  iici^lilioi'liood  of  1  lie  cjiiiiil  of  Sclilcmm ;  he  is  oppose'd 
to  Elliot's  tecliiiic  of  splitting  the  eoruea,  and  warns  surgeons  against 
interfering  with  tliis  membrane  in  their  selereetomies. 

Stephenson  {Med.  Press  <nid  Circ,  July  IG,  1913)  states  that  it  is 
the  view  of  those  well  qualified  to  judge  that  selero-eorneal  trephining 
embodies  better  than  any  known  proeedure  those  points  now  generally 
believed  to  be  essential  for  the  cure  of  glaucoma,  and  that  it  bids  fair 
to  displace  the  other  modern  substitutes  for  iridectomy,  but  that  like 
other  operations  it  has  its  failures.  He  classifies  the  causes  of  these 
under  the  headings  (1)  septic,  (2)  hemorrhagic,  and  (3)  mechanical, 
lie  founds  his  remarks  primarily  on  a  full  and  careful  examination 
of  four  eyeballs  removed  after  failures  following  this  operation.  Ln 
all  but  one  of  the  eyes  the  trephine  track  was  occluded  by  vascular 
fibronuclcar  tissue,  through  which  were  disseminated  particles  of  iris 
pigment.  In  tlie  remaining  specimen  the  trephine  track  w^as  patent, 
and  there  its  closure  was  rendered  impossible  owing  to  the  interposi- 
tion of  the  ciliary  body  and  lens.  The  anatomical  features  of  the 
split  cornea  were  also  studied,  and  the  flap  was  found  to  include  some 
of  the  more  superficial  fibers  of  the  substantia  propria  of  the  cornea, 
often  a  good  deal  altered  in  appearance.  I\Iost  of  the  complications 
met  with  were  due  to  the  incarceration  of  uveal  tissue,  lens  or  capsule 
in  the  wound,  the  trephine  track  being  obliterated  by  pigmented  con- 
nective tissue. 

Von  Mende  {Klin.  M.  f.  Augcnh.,  pp.  56  and  354,  Jan.  1913)  says 
that  while  all  recognize  the  simplicity  of  Elliot's  operation  and  the 
immediate  relief  which  it  gives  to  tension,  yet  certain  complications 
have  been  met  with.  He  advocates  a  small  basal  iridectomy  and  the 
instillation  of  atropin ;  he,  too,  uses  a  sliding  flap ;  he  scrapes  the 
epithelium  from  the  cornea  around  the  trephine  hole  in  order  to  make 
the  flap  adhere. 

Beard  {Ann.  of  Oplith.,  Vol.  XXII,  p.  363,  1913)  is  opposed  to  the 
making  of  large  openings  in  the  tunics  of  the  eye.  He  prefers  Elliot's 
operation  to  any  other  and  has  invented  a  trephine  of  his  own  for  the 
purpose;  he  does  not  think  well  of  cyclodialysis,  nor  would  he  use 
posterior  sclerotomy  except  for  blind  eyes  with  very  high  tension. 

Reber's  {Ophthalmoscope,  Vol.  XII,  p.  188,  1913)  choice  lies 
between  iridectomy  and  one  of  the  filtration  operations.  He  finds 
Elliot's  operation  easy,  less  risky  than  the  Lagrange  operation  or  than 
iridectomy,  and  reasonably  promising  of  improvement  or  cure.  He 
has  trephined  twenty-six  cases,  all  under  local  anesthesia,  and  is  in 
favor  of  a  mechanically-driven  trephine ;  he  uses  a  dental  engine  for 
the  purpose.     Intra-ocular  hemorrhage  will  iii(>vitably  occur  in  a  cer- 


GLAUCOMA  5565 

tain  percentage  of  cases,  but  is  a  negligil)le  factor  in  trephining,  so 
far  as  the  integrity  of  the  eye  goes.  The  risks  under  a  general  anes- 
thetic are  less  than  in  iridectomy. 

Verhoeff  {Ophthalmoscope,  Vol.  XI,  p.  220,  1013)  continues  to  use 
his  sclerectome  (q.  v.),  which  does  not  seem  to  have  found  much  favor; 
he  finds  it  necessary  to  have  two  instruments  and  to  use  each  for  not 
more  than  three  consecutive  cases;  he  is  in  favor  of  using  a  thin  con- 
junctival flap,  as  he  believes  that  the  inclusion  of  episcleral  tissue  in 
the  flap  greatly  increases  the  tendency  of  the  scleral  opening  to.  close ; 
he  believes  that  the  fluid,  which  escapes  under  the  conjunctival  flap, 
difi'uses  tlirough  the  conjunctiva  and  is  not  removed  by  the  lymphatic 
eliannels.  Both  these  latter  opinions  are  controverted  by  many  other 
surgeons. 

Schieck  {Zcitsch.  f.  Angenh.,  Vol.  XXIX,  p.  196,  1913)  has  been 
lately  performing  Elliot's  operation,  but  in  view  of  the  short  duration 
of  his  cases  reserves  opinion  as  to  the  ultimate  result.  He  finds  the 
operation  a  simple  one.  To  avoid  iris  prolapse  he  makes  a  radial 
incision  into  the  bead  of  iris  projecting  through  the  trephine  hole,  and 
is  satisfied  with  the  result.  In  one  case  in  which  he  did  not  incise  the 
iris,  as  it  did  not  present  in  the  wound  at  the  time  of  operation,  there 
was  a  return  of  tension,  due  to  this  membrane  filling  up  the  wound ; 
eserin  permanently  relieved  the  condition.  In  another  case  in  which 
the  iris  w^as  adherent  far  forward,  the  trephine  entered  the  vitreous 
chamber,  but  the  case  did  well.  He  would  reserve  trephining  for  cases 
in  which  sclerotomy  was  formerly  held  to  be  indicated,  and  in  others 
he  would  perform  an  iridectomy. 

Grosz  {Amer.  Jour.  Ophth.,  Vol.  XXX,  p.  365,  1913)  performs 
Lagrange's  operation  for  cases  of  simple  glaucoma.  He  trephines  in 
chronic  inflammatory  glaucoma,  does  an  iridectomy  for  all  acute  cases, 
and  simple  sclerotomy  for  juvenile  glaucoma ;  he  enucleates  eyes  which 
have  passed  into  the  degenerative  stage.  He  still  keeps  an  open  mind 
as  to  what  will  be  the  operation  of  the  future. 

Meller  {Zeit.  f.  Augcnh.,  Vol.  XXX,  p.  447,  1913)  reports  on  389 
Lagrange  and  178  Elliot  operations.  Of  the  former  12  per  cent,  were 
for  acute  glaucoma,  61.5  per  cent,  for  chronic  inflammatory  glaucoma, 
9  per  cent,  for  the  simple  variety,  the  rest  miscellaneous.  In  4  per 
cent,  no  iridectomy  was  done ;  the  period  of  observation  extends  to  five 
years.  There  was  a  good  result  in  70  per  cent,  and  bad  in  10  per 
cent. ;  opacity  of  the  lens  followed  in  4  per  cent. ;  the  formation  of 
posterior  synechiiP  was  very  common :  in  3.4  per  cent,  the  eye  had  to  ho 
enucleated,  in  2.3  per  cent,  there  was  severe  iridocyclitis,  and  in  1.3 
per  cent,  there  was  late  infection  -.  two  eyes  were  lost  from  expulsive 


5566  GLAUCOMA 

hemorrhage;  there  was  recurrence  of  trouble  in  11.3  per  cent.  With 
regard  to  the  Elliot  operation,  IMeller  finds  that  while  it  is  less  dan- 
gerous than  the  Lagrange,  it  offers  the  same  chances  for  the  establish- 
ment of  filtration ;  it  was  followed  by  a  bad  result  in  only  2.4  per  cent. ; 
the  performance  of  an  iridectomy  is  necessary  in  order  to  avoid  recur- 
rence of  high  tension ;  he  thinks  that  trephining  is  to  be  preferred  to 
sclerectomy ;  it  is  not  possible  to  claim  that  trephining  takes  the  place 
of  von  Graefe's  iridectomy;  on  the  other  hand,  in  difficult  and  dan- 
gerous cases  it  may  be  availal)le  in  place  of  that  operation. — Ed.] 

Excision  of  the  superior  cervical  ganglio)i.  In  the  symposium  on  the 
relation  of  tlu»  cervical  sympathetic  to  the  eye,  which  was  held  in  the 
►Section  on  Ophthalmology  of  the  American  Medical  Association  in 
New  Orleans  in  May,  1903,  de  Schweinitz,  in  a  paper  on  the  Physiology 
of  the  Sympathetic  in  Relation  to  tfie  Eye,  said:  "As  long  ago  as  the 
time  of  Pourfour  de  Petit,  that  is,  in  1727,  it  was  observed  tliat  after 
section  of  the  sympathetic,  the  eye  was  softer,  and  this  fact  was  after- 
wards vei-ified  by  Claude  Bernard  and  other  experimenters,  and  very 
early  it  was  suggested  that  a  primary  disease  of  the  sympathetic 
ganglia  of  the  neck  might  be  the  basal  cause  of  glaucoma." 

The  various  theories  which  had  been  advanced  by  diiferent  ol)servers 
to  explain  the  influence  of  the  sympathetic  on  intraocular  tension  were 
then  discussed  at  length  and  the  conclusions  from  the  evidence  which 
had  been  collected  summarized  as  follows:  "Electrical  stiniulation 
of  the  cervical  sympathetic  produces  at  first  an  increase  and  later  a 
decrease  of  intraocular  tension,  the  increase  being  probably  due  to 
an  effect  on  the  muscles  of  the  eye.  Slow-acting,  mechanically-pro- 
duced irritation  of  the  sympathetic  causes  a  rise  of  tension,  which, 
according  to  Lodato,  is  independent  of  dilatation  or  constriction  of  the 
blood  vessels,  and  also  independent  of  the  state  of  the  pupil.  Section 
of  the  sympathetic,  or  extirpation  of  the  sympathetic  ganglion,  is  fol- 
lowed by  a  fall  of  intraocular  tension,  which  depends  on  vascular  and, 
perhaps,  muscular  changes.  The  lowering  of  tension  is  more  decided 
after  excision  of  the  ganglion  than  after  section  of  tlie  symi)athetic 
cord,  but  in  either  case  the  effect  is  a  temporary  one,  and  may  last  no 
more  than  a  few  days,  and  sometimes  disappears  within  a  few  hours." 

According  to  Grimsdale  and  Brewerton  (Ophthalmic  Operations,  p. 
312),  Wegner  noticed  changes  of  the  intraocular  pressure  in  animals 
when  the  cut  end  of  the  cer\'ical  sympathetic  was  stimulated,  a  fact 
noted  in  the  12th  volume  of  Graefe's  Archives.  It  was  not.  however, 
until  1897  that  any  form  of  operation  was  proposed  on  the  vaso-motor 
nerves  of  the  eye  to  influence  glaucoma,  when  Abadie  (Arrh.  d'Oph- 
talm.,  Vol.  XIX).  who  ascribed  the  increased  tension  of  glaucoma  to 
a  vascular  disturbance,  proposed  to  relieve  the  condition  by  the  re- 


GLAUCOMA  5567 

moval  of  the  cervical  sympathetic.  Before  he  had  an  opportunity, 
Jonneseo  {Ccutralbl.  f.  Chirurgic,  1899)  published  a  paper  in  whicli 
he  reported  the  results  of  a  series  of  operations  whieh  had  been  per- 
formed in  pursuance  of  Abadie's  suggestions.  Both  of  these  investi- 
gators, however,  held  different  theories  as  to  the  cause  of  glaucoma, 
Abadie  attributing  it  directly  to  an  increase  of  exudation  l)rouglit 
about  by  an  active  dilatation  of  the  blood  vessels,  particularly  the  ar- 
teries, while  Jonneseo  asserted  that  the  small  arteries  are  contracted, 
and  that  the  resulting  increase  of  intra-vascular  pressure  occasions 
an  increased  transudation  and  probably  an  increase  in  the  amount  of 
aqueous  humor.  The  dilatation  of  the  blood  vessels  was  thought  by 
Abadie  to  be  due  to  the  activity  of  the  vaso-motor  centers,  and  he 
asserted  that,  when  the  chain  is  cut,  the  stimuli  cease,  and  the  blood 
vessels  resume  their  normal  caliber. 

Jonneseo  removes  the  superior  cervical  ganglion  by  an  incision  along 
the  anterior  border  of  the  sterno-mastoid  muscle,  about  3  inches  long, 
having  its  center  oi)posite  the  angle  of  the  jaw.  The  various  layers 
of  the  cervical  fascia  are  then  carefully  divided  until  the  border  of 
the  muscle  is  exposed.  The  sheath  of  the  carotid  artery  is  then  laid 
bare  and  the  dissection  continued  between  the  artery  and  vein  until 
the  ganglion  is  exposed  behind  the  former. 

To  avoid  the  risk  of  opening  the  sheath,  Burghard  {British  Med. 
Jour.,  Oct.,  1900)  deflects  it  inwards  with  a  blunt  hook,  when  tlie  sym- 
pathetic ganglion  is  found  just  posteriorly.  The  ganglion  is  readily 
freed  from  its  surroundings  by  careful  dissection,  and  is  excised  by  a 
few  clips  of  the  scissors,  the  ascending  branches  being  divided  close 
above  the  top,  and  the  descending  cord  about  half  an  inch  below  the 
ganglion.  The  wound  is  then  sutured.  Some  operators  advise  ex- 
posing the  ganglion  by  way  of  the  posterior  portion  of  the  sterno-cleido- 
mastoid  muscle,  but,  as  this  exposes  the  spinal  accessory  nerve  to  the 
risk  of  injury,  the  anterior  route  is  to  be  preferred. 

In  the  symposium  referred  to  above,  Wilder  spoke  of  the  influence 
of  resection  of  the  cervical  sympathetic  ganglion  in  glaucoma  and  epit- 
omized the  records  of  68  operations  done  on  54  cases  in  the  following 
table : 

No.  ef  Temporarily  Sta-  Un- 

Form  of  glaucoma.           cases.           Improved.       improved,  tionary.  improved. 

Simple   chronic    38  15  5  3  15 

Chronic   inflammatory    ...    16  4  3  3  6 

Subacute    4  3  1 

Acute    3  1  1  1 

Absolute   4  1  ..  ..  3 

Hemorrhagic    2  2 

Buphthalmus    1  .  .  1 

68  2G  10  7  26 


5568  GLAUCOMA 

The  i-csults  ('xliil)it('(l  in  tliis  sci-ics  of  cases,  at  first  glance,  do  not 
seem  as  favorable  as  those  pi'cseiitcd  ))y  Roliiiier  {AtDtal.  d'Oculvit, 
July,  1902,  Part  1),  who  drew  conclusions  from  a  study  of  74  cases 
collected  by  Richat,  to  which  lie  added  20  of  his  own.  On  these  94 
cases,  114  operations  were  done.  Tlie  following  table  gives  a  summary 
of  the  results  of  their  analysis  of  these  cases : 

No.  of 
cases  ojier- 

Fonii  of  <il;nit()iii;i.              ated  on.              liiijnoved.            Negative.  Worse. 

Simi)le  cliroiiic    43  36  5                           2 

Chronii'   iufianiiiiatory    ....      34  23  10                           1 

Subacute    14  6  6                        2 

Acute    9  4  5 

Absolute     3  1  2 

Hemoirliafiic     5  5 

Hydroiihthahiius     6  4  1                          1 

114  79  29  6 

As  a  consequence  of  the  statistics  which  he  had  gathered.  Wilder 
thought  that  while  positive  conclusions  are  yet  to  be  reached  and  will 
not  be  attained  until  more  carefully  selected  cases  can  be  studied  for 
longer  periods  of  time,  he  could  assent  to  the  statement  of  Axenfeld 
that  "there  is  obtained  by  this  operation  in  a  certain  proportion  of 
cases  of  simple  glaucoma,  a  definite  and  important  result,  and  in  some 
instances  there  has  been  a  decided  improvement,  even  where  a  previous 
iridectomy  has  failed." 

Wilder  considered  the  operation  in  itself,  while  a  major  one,  is  not 
to  be  regarded  as  one  of  unusual  danger,  and  with  modern  technique 
should  show  a  very  trifling  mortality.  His  conclusions  were  as  follows : 
"The  statistics  up  to  date  seem  to  indicate  that  the  simple  chronic 
form  is  the  one  most  suited  for  it,  next  to  the  hemorrhagic  form,  if 
that  can  be  determined.  As  a  guide  for  my  own  practise,  I  should  feel 
very  much  like  following  Abadie  when  he  says:  'In  acute  forms  of 
glaucoma  and  in  subacute  with  intermissions,  practise  first  iridectomy, 
and  if  it  fails,  do  sympathectomy.  In  simple  glaucoma,  use  miotics 
twice  a  day ;  if  they  suffice,  continue  them.  If,  in  spite  of  their  sys- 
tematic employment,  the  vision  fails,  do  sympathectomy.'  " 

During  the  past  few  years  the  operation  has  been  rarely  practised, 
for,  though  sometimes  successful  in  reducing  tension,  disastrous  results 
have  also  occurred,  and  several  have  died  from  the  operation.  In 
others  symptoms  of  tachycardia  and  exophthalmus  have  developed.  Its 
most  favorable  results  are  no  better  than  can  be  attained  by  other 
and  less  dangerous  operations  on  the  globe  itself,  or  from  the  con- 
tinuous use  of  miotics. 

Elschnig's  experience  (Klin.  Monatshl.  f.  AugcnhcUk.,  :\Iay,  1912) 


GLAUCOMA  5569 

with  S3'mpathectomy  has  led  him  to  discard  the  operation.  He  reports 
having  done  it  in  six  cases,  two  of  secondary  glaucoma,  one  of  sec- 
ondary hydrophtiialniiis,  two  cases  repeatedly  operated  upon  by  cyclo- 
dialysis and  iridectomy,  and  a  case  not  previously  operated  upon.  In 
every  case  the  tension  became  lower,  but  only  for  a  time.  On  the  other 
hand,  the  operation  was  followed  by  a  disfiguring  ptosis  with  eleva- 
tion of  the  lower  lid,  while  in  two  instances  there  was  violent  and  long- 
continued  headache,  and  in  one  tinnitus  aurium.  Jess  reports  a  case 
in  which  a  paresis  of  the  left  sympathetic  had  existed  since  childhood, 
probably  due  to  thyroid  enlargement.  Nevertheless  absolute  glaucoma 
developed  in  the  left  eye,  which  should  have  been  protected  against 
glaucoma  if  the  theories  on  which  sympathectomy  is  based  are  correct. 

Removal  of  tJie  ciliary  gancjli&n.  Believing  that  the  ciliary  ganglion 
controls  the  vascularization  of  the  anterior  segment  of  the  eye,  and  the 
superior  cervical  ganglion  that  of  the  posterior  segment,  Rohmer 
(Amial.  d'Oculist,  July,  1902,  Part  I)  devised  an  operation  for  the 
removal  of  the  ciliary  ganglia  of  the  orbit  and  practised  it  on  seven 
cases  of  absolute  glaucoma.  His  procedure  was  as  follows:  After  a 
resection  of  the  outer  wall  of  the  orbit,  as  recommended  by  Kronlein, 
the  tissues  of  the  orl)it  are  exposed  as  directed  by  this  operator,  by 
dividing  the  iieriosteum  and  orbital  fascia  until  the  external  rectus 
muscle  is  laid  bare.  This  is  divided  and  efforts  made  to  remove  the 
ciliary  ganglion,  which  consists  of  a  nerve  mass  not  more  than  2  mm. 
in  its  largest  diameter,  and  lies  about  15  mm.  behind  the  posterior  pole 
of  the  eye,  and  about  9  mm.  in  front  of  the  optic  foramen,  between  the 
external  rectus  muscle  and  the  optic  nerve,  by  means  of  a  special  for- 
ceps. These  are  a  modification  of  the  common  forci-pressure  for- 
ceps, one  blade  being  grooved  on  its  outer  surface  longitudinally,  to 
permit  of  its  being  guided  along  the  optic  nerve  on  its  outer  side. 
Half  a  dozen  ])ites  of  the  orbital  tissue  are  made  with  these  forceps,  a 
careful  exaniiiiation  being  made  of  the  avulsed  fat  and  tissue  after  each 
attempt,  to  discern  the  bruised  and  mangled  ganglion.  Even  if  the 
ganglion  is  not  found,  a  pallor  of  the  conjunctiva  and  a  fall  in  tension 
indicates  .its  removal,  and  tlie  surgeon  may  proceed  to  the  closure  of 
the  wound,  which  is  accomi)lished  as  directed  by  Kronlein.  Although 
Rohmer  claims  that  the  pain  in  the  seven  cases  operated  by  him  was 
ultimately  alleviated,  even  though  tension  was  never  reduced  to  normal 
in  any,  the  operation  has  not  been  practised  by  others ;  indeed,  Parsons 
believes  that  the  results  of  Rohmer 's  work  afford  little  support  to  the 
view  that  the  increased  intraocular  tension  of  glaucoma  is  in  any  way 
associated  with  the  ciliary  ganglion. 

Terrien  and  Poirson  have  reported  seven  cases  of  absolute  glaucoma 

Vol.  VII— 46 


5570  GLAUCOMA,  ABSOLUTE 

successfully  operated  by  this  method,  but  other  operators  seem  to  have 
found  the  procedure  too  drastic  for  cases  of  even  absolute  glaucomft, 
and  it  has  not  yet  found  a  place  in  ophthalmic  surgery. 

Avtilsio7i  of  the  infratrochlcar  nerve.  In  1883  Jiadal  {Ayuiaks 
d'Oculist.,  p.  84)  recommended  stretching  of  the  infratrochlcar  branch 
of  the  nasal  nerve  to  relieve  the  pain  of  glaucoma.  It  was  noted  that 
hypotonus  frequently  followed  several  weeks  after  tliis  procedure, 
but  the  degree  of  the  hypotonus  was  less  than  after  iridectomy  or 
sclerotomy,  and  was  probably  occasioned  by  the  simultaneous  avulsion 
of  the  sympathetic  root  of  the  ciliary  ganglion.  Abadie  and  Idovian 
{Arch.  d'Opldahn.,  II,  p.  225)  operated  on  several  cases  after  this 
method,  and  Angelucci  on  thirteen.  In  all  cases,  a  temporary  decrease 
in  pain  and  hyperemia  and  intraocular  tension  followed,  but  the 
symptoms  reappeared  after  several  days.  The  procedure  has  been  espe- 
cially recommended  in  glaucomatous  myopic  eyes  in  which  dislocation 
of  the  lens  was  to  be  feared  at  the  time  of  operation,  also  in  hemorrhagic 
glaucoma,  and  finally  Villemonte  {Rec.  d'Ophtalm.,  1906,  p.  513) 
thinks  it  of  service  in  glaucoma  simplex  and  secondary  glaucoma. 
—  (W.  C.  P.) 

Glaucoma,  Absolute.     See  page  40,  Vol.  I,  of  this  Encyclopedia. 

Glaucoma,  Anterior.  This  term  is  applied  to  the  disease  when  the  chief 
alterations  appear  in  the  anterior  ocular  segment,  such  as  adhesions 
of  the  iris  to  the  cornea,  closure  of  Schlemm's  canal,  etc. 

Glaucoma  apoplecticum.  (G.)  This  form  of  the  disease  is  associated 
with  multiple  hemorrhages  in  the  retina  and  choroid;  frequently  also 
into  the  iris  and  vitreous.  It  is  to  be  differentiated  from  hemorrhagic 
glaucoma. 

Glaucoma  assoluto.     (It.)     Absolute  glaucoma. 

Glaucoma,  Compensated.  Elschnig  has  proposed  this  term  as  a  sub- 
stitute for  glaucoma  simplex;  also  "uncompensated"  for  "inflamma- 
tory" glaucoma. 

Glaucoma,  Cong-enital.  Sometimes  regarded  as  synonymous  with  in- 
fantile glaucoma  or  buphthalmia.  See  page  1339,  Vol.  II  of  this 
Encyclopedia. 

Glaucoma  deg^enerativum.  (G.)  Advanced  form  of  the  disease  in 
which  sclerosis  of  the  whole  eyeball  sets  in,  local  staphylomata 
appear  and  these  lesions  are  followed  by  enlargement  of  the  globe. 

Glaucoma  diabeticum.  (L.)  Glaucoma  that  occurs  in  diabetic  sub- 
jects. 

Glaucoma  evolutum.     The  second  stage  of  glaucoma. 

Glaucoma  fulminans.  This  term  is  given  to  those  rare  cases  of  acute 
inflammatory   glaucoma  in   which   blindness   follows  quickly   in   the 


GLAUCOMA,  HEMORRHAGIC  5571 

wake  of  the  first  attack  of  the  disease.  Prodromal  symptoms  are 
often  absent.  Tlicrc;  is  rapid  rise  in  intraocular  tension  with  max- 
imal dilation  of  tlie  pupil  and  intense  pain.  Vision  may  be  lost 
within  a  few  hours.  Ophthalmoscopic  examination  shows  diffuse  hazi- 
ness of  the  aqueous  and  vitreous  humors,  with  engorgement  of  the 
retinal  veins  and  narrowing  of  the  arteries.  In  a  brief  period,  often 
within  a  week,  the  optic-nerve  head  shows  an  excavation,  Sulzer  and 
von  Graefe  observed  cases  in  which  the  nerve-head  was  red  and 
swollen.  The  disease  occurs  in  persons  over  50  years  of  age.  The  prog- 
nosis is  serious.  An  iridectomy,  if  made  promptly,  may  save  useful 
vision.— (J.  M.  B.) 

Glaucoma,  Hemorrhagic.  Sec  Glaucoma.  In  addition  to  the  matter 
therein,  attention  may  be  called  to  the  paper  of  Stiihli  {Archives  of 
Ophthal.,  May,  1913)  in  which  he  declares  that  the  changes  found  in 
the  vessels  of  cases  clinically  recognised  as  hemorrhagic  glaucoma  are 
so  characteristic  as  to  warrant  a  separate  classification  of  this  disease 
from  ordinary  glaucoma.  ^Microscopic  examination  of  three  typical 
cases,  in  which  the  eyes  had  to  be  removed  on  account  of  the  increased 
intra-ocular  pressure,  showed  changes  found  in  the  central  artery  as 
well  as  in  the  central  vein.  In  two  cases  the  endarteritic  thickening 
is  due  to  the  swelling  and  hydropic  condition  of  the  intima  cells.  This 
edema  cannot  be  without  importance.  It  seems  likely  that  acute,  espe- 
cially transitory  conditions  of  occlusion  of  a  vessel  may  be  brought 
about  by  such  changes.  The  central  vein  shows  marked  sclerosis.  A 
curious  change  is  presented  by  the  vein  in  one  case,  namely,  a  division 
of  the  lumen  into  three  parts  with  cessation  of  two.  This  is  probably 
a  congenital  condition,  which  was  of  importance  as  soon  as  the  circu- 
lation became  disturbed.  In  all  the  vessels  the  endothelial  layer  is 
intact.  This  explains  the  absence  of  thromboses.  The  retinal  vessels 
show  in  all  cases  more  or  less  sclerosis.  Vascular  changes  are  also 
found  in  the  choroid,  iris,  and  ciliary  body.  There  are  no  ruptures 
of  the  vessel  wall. 

Glaucoma  hemostaticum.  A  name  proposed  by  Lange  (Klin.  Monatshl. 
f.  Augothcilk,  Nov.,  1912)  for  that  form  of  the  disea.se  in  which 
lymph  and  blood  stasis  is  prominent.    See  Glaucoma,  Malignant. 

Glaucoma,  Hereditary.  F.  P.  Calhoun  (Journ.  A.  M.  A.,  July  4,  1914) 
has  investigatt'd  Jicreditary  glaucmna  simplex  and  believes  that,  as 
Lawford  points  out,  in  that  disease  "anticipation"  is  a  prominent 
feature ;  in  other  words  hereditary  glaucoma  practically  always 
develops  in  adults,  or  at  an  age  far  remote  from  the  usual  periods 
and  whenever  a  case  of  glaucoma  simplex  is  recognized  in  one  under 
the  age  of  30,  suspicion  as  to  its  possible  hereditary  character  should 


5572  GLAUCOMA  IMMINENS 

be  aroused.  The  sinallness  of  the  cornea  and  frh)l)c'  plays  an  impor- 
tant part  m  the  pathogenesis  of  tiie  disease ;  it,  however,  is  not  the 
sole  cause,  for  two  families  of  myopes  have  been  reported.  Unfor- 
tunately few  corneas  have  been  measured.  General  diseases,  other 
than  gout  and  rheumatism  mentioned  ])y  the  older  writer.s,  have 
small  part  in  the  causation  of  this  disease.  Transmission  by  the  two 
sexes  is,  roughly,  equal  in  both.  The  male  sex,  however,  shows  a 
greater  liability  to  inheritance.  See  Heredity  in  relation  to  the 
eye. 

Glaucoma  imminens.  (G.)  Glaucoma  thi-eatened  but  not  yet  fully 
developed. 

Glaucoma,  Infantile.     Juvenu.e  glaucoma.     See  Buphthalmia. 

Glaucoma,  Malignant.  A  name  given  to  that  form  of  the  disease  that  is 
unimproved  or  made  worse  by  operation  or  other  treatment.  C.  F. 
Heerfordt  (Graefe's  Arcliiv  filr  Ophthalmologie,  Vol.  89,  p.  62,  1914) 
points  out  that  the  most  noteworthy  of  the  peculiarities  of  malignant 
glaucoma,  first  described  in  1869  by  Graefe,  is  that  the  anterior 
chamber,  instead  of  being  re-established  within  a  few  hours  after 
operation,  is  either  not  re-established  at  all  or  only  in  a  slight  degree. 
To  this  a  second  and  highly  characteristic  peculiarity  should  be  added ; 
that  is,  the  development,  with  gradually  tirmer  closing  of  the  oper- 
ative wound,  of  a  rise  of  tension,  which,  as  a  rule,  decidedly  exceeds 
the  increase  of  tension  which  was  present  before  the  operation.  Gil- 
bert has  stated  that  the  method  of  operation  cannot  be  the  cause  of 
this  change  for  the  worse,  since  it  occurs  not  only  after  iridectomy, 
but  also  after  any  of  the  modern  operations,  based  as  they  are  upon 
most  varied  principles. 

Referring  to  his  ow^n  recent  work  on  the  valvular  blocking  of  the 
vortex  veins  as  a  cause  of  glaucoma  (hemostatic  glaucoma),  Heerfordt 
argues  that  the  mode  of  origin  of  malignant  glaucoma  is  to  be  explained 
as  follows:"  (1)  There  is  very  close  agreement  between  the  clinical 
symptoms  and  anatomic  changes  of  malignant  and  hemostatic  glau- 
coma, since  the  only  variation,  that  is,  the  complete  obliteration  of  the 
anterior  chamber  which  arises  in  malignant  glaucoma,  is  accounted 
for  by  the  fact  that  the  hemostatic  glaucomatous  displacement  forward 
of  the  iris,  ciliary  body  and  lens  must  necessarily  be  especially  pro- 
nounced if  hemostatic  glaucoma  occurs  in  an  eye  whose  anterior 
chamber  is  opened.  (2)  In  eyes  with  chronic  glaucoma,  at  the 
moment  when  a  surgical  opening  is  made,  there  exists  a  decided 
tendency  to  the  occurrence  of  "valvular  blocking,"  which  (according 
to  Heerfordt 's  earlier  work)  is  practically  certain  to  produce  hemo- 
static glaucoma.      (3)    Conse(|uently  uudigiiant  glaucoma  is  probably 


GLAUCOMA,  MALIGNANT  5573 

oecasioiu'il  by  the  saiiu'  valvular  blocking  of  tiie  vortex  veins  which 
produces  hemostatic  glauconui.  Malignant  glaucoma  is  thus  conceived 
as  an  "exoperative  hemostatic  glau(;oma"  (glaucoma  hemostaticuni 
exoperativum).  Either  a  valvular  blocking  may  have  existed  prior 
to  the  operation,  on  the  basis  of  a  congenital  overlapping  of  the  sinus 
or  of  the  venous  channel,  or  a  valvular  block  not  previously  existent 
may  arise  during  or  immediately  after  performance  of  the  operation. 

In  the  belief  that  the  most  malignant  cases  generally  depend  upon 
the  occurrence  of  a  venous  stasis  which  did  not  previously  exist, 
Heerfordt  maintains  that  to  avoid  such  an  accident  the  essential  con- 
dition is  to  keep  the  tension  of  the  eye  normal  for  a  suitable  length 
of  time  before  operation.  He  i)laces  the  lengtii  of  this  period  at 
seventy-two  hours,  it  is  preferable  that  the  pre-operative  reduction 
in  tension  should  be  constant  and  complete.  As  means  for  lowering 
the  tension  he  uses:  (1)  instillation  of  a  2  per  cent,  pilocarpin  solution 
in  the  conjunctiva;  (2)  the  introduction  of  solid  i)hysostigmin  sal- 
icylate into  the  conjunctiva,  in  tlie  l)ulk  of  a  small  pin  head,  lYo  hours 
before  operation;  (3)  venest'ction,  according  to  tlie  method  of  Evers- 
busch  and  Gilbert;  and  (4)  subconjunctival  puncture  of  the  anterior 
chamber  with  partial  evacuation  of  tlie  aqueous  humor. 

Nine  illustrative  cases  are  described  in  which  Elliot's  trephine  opera- 
tion was  done  and  one  or  more  of  the  prophylactic  measures  just 
referred  to  were  employed.  (Heerfordt  regards  Elliot's  "quiet 
iritis"  as  merelj^  the  expression  of  a  venous  stasis  set  in  action  by 
the  operation.)  None  of  these  operations  was  followed  in  any  marked 
degree  by  the  "malignant"  symptom  comi)lex,  and  none  of  the  oper- 
ated e^'es  showed  the  least  subseciuent  loss  of  function.  All  of  them 
belonged  to  the  type  of  eyes  with  chronic  irlaucoma,  whose  tension 
is  influenced  sluggishly,  incompletely  and  only  for  a  short  time  by 
pilocarpin.  In  the  majority  of  the  cases  the  glaucoma  was  advanced 
and  had  existed  for  a  long  time,  and  in  most  of  the  cases  the  tension 
w^as  quite  high.  The  prophylactic  measures  referred  to  are  to  be 
employed  therapeutically  in  cases  which  show  any  post-operative  ten- 
dency to  a  malignant  character.     {Ophthal.  Literature,  1915.) 

G.  F.  Alexander  (Ophtlwl.  Rev.,  July,  1914)  describes  the  case  of  a 
woman,  46  years  of  age.  who  came  to  him  after  having  had  the  left  eye 
removed  following  unsuccessful  operation  for  glauconui.  "When  first 
seen  by  Alexander  the  right  eye  had  a  tension  of  -1-2.  and  the  pupil 
w^as  contracted  by  eserine.  He  performed  iridectomy  and  the  next  day 
there  was  obliteration  of  the  anterior  chamber  and  tension  of  +3. 
On  the  day  following,  as  there  was  no  improvement,  repression  of 
the  lens  was  performed.     A   i>uncture  through  the  sclera  was  made 


5574 


GLAUCOMA,  MYOPIA  IN 


near  the  equator  between  the  inferior  and  external  recti  muscles,  and 
pressure  was  niad(^  on  tlie  center  of  the  cornea  with  a  curette,  so  as 
to  push  the  lens  directly  backwards.  This  was  accompanied  by  con- 
siderable loss  of  vitreous,  and  after  seven  minutes  the  lens  remained 
back  in  position  and  the  tension  was  subnormal.  A  few  minutes  after 
the  performance  of  the  sclerotomy  blood  appeared  in  the  anterior 
chamber.  The  subsequent  course  of  this  ease  had  been  so  far,  i.  e., 
four  months  after  operation,  entirely  satisfactory.  The  tension 
remained  below  normal  and  there  had  Ix'en  no  pain. 
Glaucoma,  Myopia  in.  As  Burton  Chance  (see  Glaucoma)  says,  myopic 
eyes  are  not  often  the  subject  of  glaucoma.  When  they  are  affected 
the  glaucomatous  process  generally  runs  a  slow  course.  In  other 
words,  there  appears  to  be  some  antagonism  between  glaucoma  and 
myopia.  Myopia  may  develop  during  the  course  of  glaucoma  and  when 
it  does,  it  has  been  said  to  have  a  beneficial  etfect  upon  the  glaucoma. 
J.  B.  Story  {Ophthalmic  Eevieiv,  p.  225,  Aug.,  1911)  records  two 
cases  of  myopia  of  medium  amount  in  which  treatment,  both  medical 
and  operative,  was  not  very  satisfactory  so  far  as  central  vision  was 
concerned.  The  perimeter  charts  are  depicted  in  the  text,  and  show 
the  results  of  operation  especially. 

J^////it  £ye 


280        2  0        2^0 

Myopia  in  Glaucoiiia.     (ytory.)     First  Case. 
Chart  of  central  fields.     Test  object  L'nini.  siiuare,  white.     Ri^jht  eye  before 
iridectomy. 


flO  90  IQO 


280         ^^5  260      "° 

^ilyopia  ill  (ilaucuiiui.     (Story.)     First  Case. 

Chart   of   central    fields.      Test   object   •Jiiini.   sfjuare,   white.      Left  eye   before 
iridectomy. 

Ze/i  £ye 

60  ^0  100 


280  270  260 

Myopia  in  Glaucoma.     (Story.)     First  Case. 

Chart   of   central   fields.      Test  object   2mm.   square,   white.      Left  eye   three 
weeks  after  operation. 


J^i^ht.  £ye 


280         270         260 

Myopia  in  Glaucoma.      (Story.)     First  Case. 

Chart   of   central    fields.      Test   object    2mm.    square,   white.      Right    eye   ten 
months  after  operation. 

flO        90  100 


280 ^75         260 
Myopia  in  Glaucoma.     (iStory.)     First  Case. 

Chart  of  central  fields.     Test  object  2mm.  square,  white.     Left  eye  ten  months 
after  operation. 


t,n  90  inn 


280        270         2^° 

Myo])ia  in  Glaucoma.      (Story.)     Stn-oiul  Case. 

Chart  of  central   fields.     Test  object   2mni.   sciiiare,   grey.     Right  eye  before 
iridectomy. 


/tU///if.  -^yo 


280         ;7Q         260 

Myopia  in  Glaucoma.     (Story.)     Second  Case. 

Chart  of  central  fields.     Test  object  2mm.  square,  grey.     Right  eye  three  and 
one-half  years  later. 


5578  GLAUCOMA  NEGLECTUM 

Glaucoma  neglectum.  (G.)  A  case  in  which  there  has  been  neglect  on 
the  part  of  the  patient  to  apply  for  relief,  or  on  the  side  of  the  sur- 
geon to  give  it. 

Glaucoma  prodromale.     (G.)     The  same  as  Glaucoma  imminens. 

Glaucoma,  Posterior.  This  term  indicates  that  the  chief  lesions  in  the 
disease  ati'eet  the  posterior  segment  of  the  eye ;  for  example,  in  the 
nerve-head  and  its  vicinity. 

Glaucoma  simplex.     (G.)     See  Glaucoma. 

Glaucomatic.  Glaucomatose.  Glaucomatous.  Pertaining  to  or  of 
the  nature  of  glaucoma. 

Glaucomatous  cavernae.  Fleischer  {Ophthalmology,  July,  1913)  found 
these  cavernie  almost  regularly  in  secondary  and  primary  glaucoma, 
if  the  excavation  was  not  too  far  advanced.  While  Schnabel  consid- 
ered cavernae  as  a  primary  affection  of  the  optic  nerve,  specific  for 
glaucoma  but  independent  of  the  increased  ocular  pressure,  the  writer's 
findings  were  such  that  the  cause  for  the  formation  of  cavernae  must 
be  attributed  to  an  accumulation  of  fluid,  a  lymph  stasis,  due  to  dis- 
turbances of  circulation  from  the  abnormal  conditions  of  tension. 
Fleischer,  therefore,  considers  the  cavernge  to  be  a  secondary  process. 

Glaucomatous  crisis.  The  acute  stage  explosion  or  attack.  Same  as 
glaucoma  cvolutum   (Graefe). 

Glaucomatous  vertigo.  A  term  employed  by  Dor  {La  Clinique  OphtJial., 
June,  1913)  which  he  says  is  so  common  that  a  history  of  it  can  be 
obtained  in  25  per  cent,  of  glaucomatous  patients,  but  which  has  as 
yet  escaped  the  attention  of  ophthalmic  surgeons.  It  occurs  even  in 
those  who  are  totally  blind ;  the  patients  do  not  connect  the  symptom 
with  their  eye  condition  and  hence  do  not  mention  it  to  the  surgeon. 
He  thinks  that  it  is  caused  by  the  increase  in  the  ocular  tonus,  and 
that  it  has  an  analogy  with  Meniere's  disease,  which  it  resembles  in 
many  ways  clinically.  He  does  not  call  all  cases  of  vertigo  in  the 
glaucomatous  by  the  appellation  ' '  glaucomatous  vertigo, ' '  but  restricts 
the  term  to  those  which  evidently  stand  to  the  glaucoma  in  the  rela- 
tionship of  effect  to  cause.  The  point  of  greatest  interest  in  this  con- 
nection is  that  the  relief  of  the  glaucomatous  condition  is  at  once  fol- 
lowed by  the  cessation  of  the  attacks  of  vertigo.  Dor's  patients  have 
very  warmly  appreciated  the  benefits  thus  conferred  on  them. 

Glaucoma  Woulhousi.     (Obsolete.)     A  cataract. 

Glaucosis.     The  blindness  resulting  from  glaucoma. 

Glaucous.  Of  a  sea-green  or  grayish-green  color;  covered  with  a 
bloom,  like  the  leaf  of  the  cabbage. 

Glede  kite.  In  ancient  Greco-Roman  times  the  liver  of  the  glede  kite 
was  often  employed  as  a  poultice  in  various  diseases  of  the  eye. — 
(T.  H.  S.) 


GLEDITSCHINE  ^  5579 

Gleditschine.  An  alkaloid  derived  from  several  species  of  Gleditschia; 
e.  y.,  Goodman  is  said  to  have  discovered  it  in  the  leaves  of  Gleditschia 
triacanthos.  It  has  both  anesthetic  and  mydriatic  properties.  It  was 
at  first  called  stcnocarpinc.  Its  lack  of  the  properties  ascribed  to  it 
was  soon  discoveretl,  and  the  substance  sold  as  gleditschine  was  sus- 
pected to  be  merely  a  mixture  of  cocaiue  and  atropine. 
Gleich.     (G.)     Equal. 

Gleichfarbig.     (G.)     Of  the  same  color,  or  of  unifonn  color. 
Gleichgewicht.     (G.)     Equipoise;  equilibrium;  the  condition  in  which 

contending  forces  are  equal. 
Gleichwinkelige  Diplopie.  (G.)  Homonymous  diplopia. 
Gleize.  A  distinguished  surgeon  and  o])hthalmologist  of  the  later  18th 
century,  whose  Christian  name  and  life  dates  cannot  now  be  ascer- 
tained. He  was  born  at  Montpellier,  became  master  of  surgery,  oph- 
thalmologist to  the  Royal  Coll(>ge  of  Surgery  at  Orleans,  and  oculist 
to  the  Duke  of  Orleans  and  Count  of  Artois.  He  was  a  great  braggart, 
making  use  of  the  public  journals  for  the  purpose  of  exploiting  his 
achievements. 

He  wrote:  1.  Xouvelles  Observations  sur  les  Pratique  .Maladies  de 
rOeil  et  leur  Traitement.  (Paris,  1786;  Orleans,  1811.)  2.  Regle- 
ment  de  Vie,  ou  comment  Doivent  se  Gouveruer  ceux  qui  sont  Affliges 
de  Faiblesse  de  Yue.  (Orleans,  1787.)  3.  ]\Iemoire  sur  TOphthal- 
mostate  de  M.  Demours.  {Jour,  de  Med.,  Chirurg.  et  Pharm.,  1788.) 
4.  ]\Iemoire  sur  les  Avantages  du  Seciton  a  la  Nuque  dans  les  Ophthal- 
mies  Humides  ou  luveterees.  {Op.  cit.,  1789.)  5.  Des  Staphylomes. 
{Op.  cit.,  1789.)— (T.  H.  S.) 
Glene.     (Obs.)     The  interior  of  the  eye;  also,  the  shallow  articular 

cavitj'  in  a  boue. 
Glenitis.     (L.)     An  old  term  for  phakitis,  or  ''inflammation"  of  the 

lens. 
Glied.     (G.)     A  member;  a  limb;  a  joint. 
Glimmer brillen.     (G.)     Mica  spectacles. 

Glioma.  Glioma  in  general.  A  form  of  round-celled  sarcoma  consist- 
ing of  a  tumor  of  neuroglia  cells  occurring  in  the  brain,  spinal  cord 
and  in  certain  nerves  or  their  nervous  expansions. 

Besides  the  interest  of  the  ophthalmologist  in  this  neoplasm,  as  it 
aifects  the  optic  nerve  and  retina,  gliomatous  tumors  of  the  central 
nervous  system  may  indirectly  affect  the  eye. 
Glioma  endophytmn.  A  term  given  to  the  tumor  when  it  springs  from 
the  retina  and  extends  forward  into  the  vitreous  towards  the  anterior 
portion  of  the  eyeball. 


5580  GLIOMA  EXOPHYTUM 

Glioma  exophytum.     That  lorin  of  the  neoplasm  that  arising  from  the 

retina  ^n-ows  backwards  into  the  sub-retinal  space. 
Glioma  of  the  optic  nerve.  True,  that  is  primary,  intradural  gliomata 
of  the  optic  nerve  are  exceedingly  rare.  Finlay  records  three  of  them 
in  a  total  of  117  neoplasms  of  the  optic  nerve.  liyers,  who  lias  tabu- 
lated 102  histories  of  primary  intradural  tumors,  has  recorded  six 
examples  of  glioma.  Fouclier  {Ophthalmic  Record,  January,  1910) 
had  an  opportunity  of  treating  and  studying  histologically  one  of 
these  rare  and  interesting  neoplasms.  The  subject  was  a  boy,  aged 
2  years  and  3  months. 

When  first  seen  the  right  eyeball  had  become  quite  prominent, 
the  pupil  was  dilated  and  through  tlie  transparent  media  one  could 
see  the  optic  papilla  presenting  the  appearance  of  an  optic  neuritis; 
swollen  disk;  tortuous,  congested  vessels  on  tlie  background,  disap- 
pearing in  places  to  reappear  a  little  further  on ;  hemorrhages  scat- 
tered here  and  there  about  the  arteries  and  veins.  The  intra-ocular 
tension  of  the  globe,  as  immobile  as  if  it  were  affected  by  a  complete 
ophthalmoplegia  externa,  was  very  high.  Although  the  child  was 
too  young  to  make  the  usual  tests,  vision  appeared  to  be  completely 
abolished;  the  sudden  approach  of  an  object  to  the  right  eye,  while 
the  left  was  covered,  had  no  effect  upon  the  child.  The  patient  now 
began  to  suffer  severe  (glaucomatous)  pains. 

After  a  careful  review  of  the  case  the  writer  concluded  that  he  had 
to  deal  with  a  tumor  of  the  optic  nerve  proper. 

He  adds  that  to  facilitate  the  complete  enucleation  of  the  globe 
and  tumor  from  the  orbit  he  found  it  necessary  to  transfix  the  cornea 
with  needle  and  suture;  probably  the  needle  lacerated  the  lens  and 
this  accounts  for  the  alterations  subsequently  found  in  these  struc- 
tures. 

No  doubt  the  exophthalmos  was  not  only  due  to  the  growth  of  the 
orbital  tumor  but  also,  in  a  large  measure,  to  the  congestion  of  the 
orbital  circulation,  as  we  know  that  even  small,  extra-ocular  growths 
may  cause  a  decided  protrusion  of  the  globe,  or  a  decided  proptosis 
may  follow  simple  enlargement  of  the  intra-orbital  optic  tissue. 

The  exophthalmos  occurred  straight  forward  and  the  globe  was 
immovable,  thus  proving  that  the  tumor  more  or  less  perfectly  sur- 
rounded the  eyeball,  pushing  it  almost  uniformly  forward  and  pre- 
venting its  excursions  in  any  direction. 

A  second  examination,  made  two  weeks  after  the  first,  showed  a 
decided  change  in  the  intra-ocular  picture;  the  papillitis  now  gave 
evidence  of  subsiding  and  atrophic  signs  appeared.  The  increased 
tension  was  still  (juite  apparent,  the  disease  being  evidently  that  of  a 


GLIOMA  OF  THE  OPTIC  NERVE  5581 

well-iuarkt'd  glaucoma — witli  a  steamy  conica,  widely-dilated  pupil, 
pericorneal  injection,  enlarged  scleral  veins  and  a  slight  haze  of  the 
media. 

The  mother  related  the  following  history:  The  exophthalmos 
showed  itself  about  five  months  previously  and  was  shortly  followed 
by  apparent  discoinfort  about  the  eye,  which  deepened  during  the 
next  few  weeks  into  severe  pain.  AVith  the  exception  of  an  instru- 
mental delivery  there  was  no  history  of  traumatism  and  there  had 
been  no  examples  of  tumor  in  the  family  for  at  least  four  generations, 
when  a  paternal  ancestor  had  had  cancer. 

On  considering  the  possibilities  of  the  case  Foucher  thought  at  first 
that  he  would  remove  the  growth  witliout  sacrificing  the  eyeball,  either 
by  the  method  of  Lagrange  or  that  of  Krijnlein,  but,  afterw^ards,  con- 
cluded it  would  hardh"  be  worth  the  while,  in  view^  of  the  defective 
vision,  the  mutilation  necessary  and  the  doubt  about  the  exact  char- 
acter of  the  growth.  Consequently  he  did  a  simple  enucleation,  and 
completely  removed  the  tumor  with  all  its  orbital  attachments.  The 
patient's  recovery  w^as  perfect  and  six  months  after  the  operation  the 
family  physician  wrote  that  there  was  no  sign  of  recurrence. 

The  histologic  examination  was  made  by  E.  P.  Carlton,  who  pro- 
nounced the  growth  to  be  an  intradural  glioma  of  the  optic  nerve. 
He  was  led  to  this  conclusion  on  finding:  1.  That  there  had  been 
parenchymatous  degeneration  of  the  nerve  elements.  2.  That  no 
edema  was  noted  to  explain  the  enlargement  of  the  nerve,  which  was 
about  twice  the  normal  diameter.  3.  That  there  had  been  an  enormous 
proliferation  of  the  interstitial  tissues,  aifecting  chiefly  the  neuroglia ; 
to  a  much  less  degree,  thickening  of  the  septa.  4.  That  there  was  optic 
neuritis  as  show^n  by  the  large  ninnbers  of  small  round  cells  anci  fibro- 
blasts. 5.  That  there  w^as  chronic  perineuritis  involving  the  pia  and 
arachnoid  as  evidenced  by  an  obliteration  of  the  intervaginal  space 
through  enormous  proliferation  of  the  endothelium  and  by  infiltra- 
tion with  fibroblasts  and  round  cells.  6.  That  there  was  a  true  papil- 
litis due  to  proliferation  and  infiltration. 

It  was  noted,  also,  in  the  eyeball  proper:  1.  That  the  wound  in  the 
cornea  occurred  at  the  time  of  enucleation,  or  shortly  before,  as  there 
was  no  evidence  of  inflammatory  reaction  or  repair.  2.  That  there  had 
been  a  pyramidal  cataract  with  adhesions  at  the  site  of  the  corneal 
wound,  followed  later  by  loss  of  degenerated  lens  fibers  through  this 
Avound.  3.  That  there  had  been  an  iritis  Avith  posterior  synechia. 
4.  That  thoi-e  was  evidence  of  glaucoma.  5.  That  the  retina  had  been 
involved  secondarily  through  the  optic  nerve.  6.  That  in  neither  optic 
nerve   nor  tumor  was  there  anywhere   noted   infiltration   with   poly- 


5582  GLIOMA  OF  THE  RETINA 

morplionuclear  leucocytes  nor  was  there  any  other  sign  of  an  infec- 
tion, 7.  That  the  changes  in  the  posterior  half  of  the  bulb  were  sec- 
ondary to  trouble  in  the  nerve,  while  tiie  changes  in  the  anterior  half 
were  secondary  to  the  injury  of  the  cornea  and  lens. 

Another  of  these  rare  neoplasms — a  ganglionic  glioneuroma — is 
described  by  G.  C  Ruhland  {Jour.  Amer.  Med.  Ass'n,  February  1, 
1913).  This  growtli  belongs  to  the  rarer  forms  of  nerve  tissue  tumors, 
and  is  found  most  commonly  in  the  central  nervous  system  and  cord. 

The  patient,  a  girl,  first  began  to  show  evidences  of  eye  trouble  at 
the  age  of  six.  At  the  age  of  eight  she;  contracted  scarlet  fever  with 
rapidly-developing  exophthalmos  and  complete  blindness  of  the  eye. 
An  enucleation  was  done  and  an  oblong  tumor,  3  cm.  in  length,  and 
1.5  cm.  in  widtli,  was  found  occupying  the  optic  nerve.  Microscopic 
examination  showed  neurogliar  tissue  forced  apart  by  hemorrhage 
and  edema,  witli  t.ypical  ganglionic  cells  and  nerve  fibers.  The  eyeball 
was  not  involved.  The  tumor  was  undoubtedly  congenital  in  origin 
and  represents  misplaced  nerve  tissue.  Its  growth  was  slow  until  the 
febrile  condition  of  the  scarlet  fever  with  its  accompanying  hyperemia 
stimulated  the  tumor  into  an  active  growth.  It  was  histologically  a 
benign  growth  and  there  had  been  no  return  during  a  period  of  one 
and  one-half  years. 
Glioma  of  the  retina.  Neuroepithelioma  retin.e  (Flexner).  Gli- 
oma RETiNxic.  Retinal,  gliomatosis.  Sarcoma  of  the  retina. 
Fungus  hematodes  retin.^.  This  new  growth  of  the  retina  is  of 
epithelial  origin. 

"Wintersteiner,  after  an  exhaustive  microscopic  study  of  these  tumors, 
concluded  that  they  arise  from  the  neuroepithelial  layer  of  the  retina, 
and  should  be  named  neuroepitheliomata.  According  to  their  location 
and  the  direction  of  growth,  the  following  varieties  are  distinguished. 
They  exist  only  in  the  early  stages:  1.  Several  nodes  the  size  of  a  pin- 
head  appear  in  the  retina ;  they  grow  only  slightly  toward  the  vitreous, 
but  spread  in  the  subretinal  space.  By  confluence  they  form  a  tube- 
rous deposit  on  the  outer  surface  of  the  detached  retina :  neuroepi- 
thelioma exophytum  or  tuberosum.  2.  The  detached  retina  is  thick- 
ened in  its  entire  extent  or  in  spots ;  the  deposits  remain  comparatively 
thin  and  level ;  later  by  proliferation  the  surface  becomes  uneven  and 
protuberant :  neuroepithelioma  dififusum  or  planum.  3.  The  new 
growth  increases  only  in  the  direction  of  the  vitreous;  the  retina 
remains  attached  to  the  choroid ;  the  mass  spreads  upon  the  inner 
surface  of  the  retina,  to  which  it  is  united  not  closely,  but  by  proc- 
esses; the  vitreous  surface  of  the  growth  is  finely  lobulated,  cauli- 
flower-like, or  nodular:    neuroepithelioma  endophytum. 


GLIOMA  OF  THE  RETINA  5583 

Unlike  intra-ocniar  sarcoma,  neuroepithelioma  is  never  pigmented. 
The  tumor  grows  from  the  two  granular  layers  of  the  retina,  but 
chiefly  from  the  inner  one.  The  ma.ss  is  composed  of  small  cells  in  a 
soft  basement-substance.  The  cells  consist  of  nuclei  surrounded  by 
protoplasm  in  which  minute  processes  are  often  found.  Some  are 
glia-cells,  others  are  ganglion-cells.  The  cells  are  especially  numerous 
along  the  larger  vessels,  and  this  arrangement  gives  rise  to  a  tubular 
appearance.  Many  specimens  present  long  cylindric  cells  from  the 
neuroepithelium  of  the  retina.  Tliese  form  groups  inclosing  a  free 
cavity,  into  which  the  extremities  of  the  cells  project.  The  retina 
becomes  irregularly  thickened,  folded,  and  detached.  Small  free 
nodules  involve  both  the  choroid  and  the  vitreous  humor.  Degenera- 
tion of  the  intercellular  substance  occurs  very  early. 

The  cause  of  neuroepithelioma  of  the  retina  is  unknown.  It  is  a 
disease  of  childhood,  no  true  case  having  been  found  after  the  six- 
teenth year.  Cases  heretofore  reported  of  greater  age  have  been 
found  to  be  either  sarcomas  of  the  choroid  or  pseudo-neuroepitheli- 
omata.  Of  467  true  cases,  31-4  occurred  during  the  first  three  years, 
62  in  the  fourth,  and  29  in  the  fifth  year.  The  disease  surely  is  eon- 
genital  in  10  per  cent,  of  the  cases,  and  possibly  in  the  majority.  Sox 
is  without  influence  in  this  disease.  In  25  per  cent,  of  the  cases  both 
eyes  are  affected.  The  second  eye  becomes  involved  independently, 
there  being  no  extension  of  the  disease  via  the  chiasma.  The  disease 
often  appears  in  several  children  of  the  same  family.  Lerche  saw 
four  cases  among  seven  brothers  and  sisters  and  Wilson  met  wuth  a 
family  of  eight,  all  of  whom  had  neuroepithelioma  of  the  retina. 

Usually  the  first  symptom  is  a  peculiar  reflex  from  the  interior  of 
the  eye,  which,  from  its  resemblance  to  a  cat's  eye  shining  in  the 
dark,  was  named  by  Beer  and  the  older  authors  "amaurotic  cat's 
eye."  The  parents  may  note  that  the  child  does  not  see  with  the 
affected  eye.  In  this,  the  first  stage,  there  is  no  pain  or  redness,  the 
media  are  clear,  the  pupil  is  somewhat  dilated,  and  the  child's  health 
is  unaffected.  Ophthalmoscopic  examination  shows  a  whiti.sh,  yellow- 
ish, or  reddish-yellow  mass  in  the  fundus.  The  growth  is  covered 
with  a  plexiform  network  of  vessels  and  has  a  smooth  or  nodulated 
surface.  In  this  stage  the  growth  increases  slowly,  and  months  may 
pass  before  the  mass  fills  the  globe,  thus  completing  the  second  stage. 

In  the  third  stage  there  is  increased  tension.  The  child  becomes 
fretful,  emaciated,  and  cachectic.  The  neoplasm  enmeshes  all  the 
tissues  of  the  globe,  and  finally  breaks  out  at  the  corneo-scleral  junc- 
tion in  front  or  at  tlie  optic-nerve  entrance  behind.  Once  out  of  the 
globe  it  grows  rapidly,  forming  a  large,  ulcerated  mass,  which  bleeds 


5584  GLIOMA  OF  THE  RETINA 

at  the  slightest  touch.  This  condition  was  named  by  the  older  authors 
"fungus  hematodes  oculi."  Now  the  organs  are  involved  by  con- 
tiguity or  l)y  metastasis.  The  optic  nerve  furnishes  a  road  by  which 
the  growth  rapidly  travels  brainward.  Metastases  may  take  place  in 
the  brain,  cranial  bones,  Ij'mphatic  glands,  parotid  gland,  spinal  cord, 
liver,  lungs,  ovaries,  kidneys,  submaxillary  gland,  or  spleen.  The 
patient  dies  of  exliaustion. 

If  the  ophthalmoscope  shows  a  whitish  tumor,  with  retinal  vessels 
coursing  over  it,  and  the  tension  is  increased,  the  case  probably  is 
one  of  neuroepithelioma.  An  error  in  diagnosis  is  possible  in  two 
directions :  a  tumor  may  be  present  and  be  overlooked,  or  a  diagnosis 
of  neuroepithelioma  may  be  made,  the  eyeball  may  be  removed,  and 
the  microscopic  examination  show  incorrectness  of  the  diagnosis. 
Ilirschberg's  dictum  that  a  diagnosis  between  true  and  false  retinal 
tumors  is  always  possible,  has  ])een  found  erroneous.  The  most  careful 
diagnosticians  have  often  been  in  error.  Of  twenty-four  eyes  removed 
at  Moorfields  Hospital  between  1888  and  1893  for  "glioma,"  seven 
were  "pseudo"  growths.  Retinal  detachment  and  suppurative  proc- 
esses in  the  vitreous  humor  cause  frequent  mistakes.  The  history  of 
the  case  is  always  important.  The  parents  should  be  questioned  as 
to  trauma,  meningitis,  typhoid  fever,  influenza,  and  other  infectious 
diseases,  since  these  are  followed  by  diseases  of  the  vitreous  humor. 
If  the  tension  is  greatly  increased,  the  ca.se  is  probably  one  of  neuro- 
epithelioma ;  if  the  tension  is  decidedly  reduced,  it  is  not  neuroepi- 
thelioma. Between  these  extremes  are  cases  in  which  tension  is  normal 
or  changes  from  time  to  time.  The  presence  or  absence  of  blood- 
vessels on  the  growth  is  important ;  if  present,  the  case  is  probably 
neuroepithelioma ;  if  absent,  the  tumor  is  usually  due  to  an  exudative 
choroiditis.  Unfortunately,  however,  there  are  neuroepitheliomata 
which  are  not  vascular;  and,  on  the  other  hand,  exudation  into  the 
vitreous  humor  sometimes  becomes  vascularized.  The  "amaurotic 
eye"  reflex  is  valueless  in  differential  diagnosis.  The  conditions  often 
mistaken  for  neuroepithelioma,  according  to  Wintersteiner  are: 
1.  Simple  detachment  of  the  retina.  This  is  comparatively  rare  in  child- 
hood. Although  a  tumor  shows  a  more  yellowish  or  reddish  color  than 
a  detachment,  which  is  of  a  bluish  tint  as  a  rule,  yet  it  must  be  remem- 
bered that,  with  a  small  tumor  and  a  large  detachment  of  the  retina, 
the  folds  of  the  latter  can  completely  conceal  a  neoplasm ;  and 
although  the  newly  formed  vessels  of  a  tumor  generally  present  a 
course  and  ramifications  different  from  those  of  the  retinal  vessels, 
yet,  on  the  other  hand,  there  are  cases  whicli  show  almost  no  ves.sels. 
Although,  as  a  rule,  a  retina  which  is  lifted  up  by  serous  effusion 


GLIOMA  OF  THE  RETINA  5585 

vibrates  and  floats  when  the  eye  is  moved,  while  a  retina  detached  by 
a  tumor  remains  at  rest,  yet  exceptions  occur.  The  statement  that  in 
sim])le  retinal  detachment  the  tension  is  reduced  and  in  intra-ocular 
tumor  it  is  increased  must  be  accepted  with  allowances,  for  in  the  first 
stage  of  neuroepithelioma  tension  is  normal,  and,  on  the  other  hand, 
in  serous  detachment  it  is  often  increased. 

2.  Leucosarcoma  of  the  choroid.  This  is  a  comparatively  rare  dis- 
ease in  childhood.  Of  259  sarcomas  of  the  uveal  tract,  Fuchs  found  6 
leucosarcomas  in  children  under  twelve  years  of  age.  In  these  cases 
the  symptoms  of  intra-ocular  tumor  are  added  to  those  of  retinal 
detachment.  The  diagnosis  is  particularly  difficult  if  the  media  are 
opaque  or  if  the  choroidal  tumor  perforates  the  globe  posteriorly 
without  causing  retinal  detachment. 

3.  Tubercles  in  the  choroid.  Here  the  historj'  of  the  case  is  impor- 
tant. iMiliary  tubercles  of  the  choroid  are  usually  found  near  the 
optic-nerve  entrance  in  the  macular  region.  They  appear  as  whitish- 
yellow  masses  or  nodules  in  the  stroma  of  the  choroid,  varying  in  size 
from  one-eighth  the  diameter  of  the  optic  disc  to  the  size  of  the  disc 
itself.  By  confluence  they  sometimes  form  large  masses.  A  rare 
condition  is  solitary  tubercle,  which  appears  as  a  nodule  and  resem- 
bles a  beginning  neuroepithelioma.  Diagnosis  is  particularly  difficult 
in  cases  where  the  vitreous  chamber  is  filled  with  granulation  tissue, 
and  in  consequence  of  secondaiy  glaucoma  scleral  ectasia  appears. 

The  diagnostic  difficulties  are  shown  by  two  cases  reported  by  Jung. 

In  the  first  neuroepithelioma  was  diagnosticated  and  tuberculosis 
was  found;  the  second  was  regarded  as  tubercular  and  a  tumor  was 
found. 

4.  Chronic  inflammatory  processes  in  the  choroid  and  ciliary  body. 
These  are  the  conditions  most  often  causing  error.  Tliey  show  retinal 
detachment  and  the  presence  of  a  fibrinous  vitreous  exudate,  which 
later  becomes  organized.  The  chief  points  in  differential  diagnosis  are 
these:  (a)  In  exudative  choroiditis  the  color  of  the  vitreous  mass  is 
a  metallic,  brass-like  j'ellow,  while  in  the  retinal  neoplasm  whitish, 
yellowish,  reddish,  and  green  tints  are  seen ;  yet  even  here  the  metallic 
lustre  may  be  observed,  (b)  IMany  oliservers  state  that  the  exudate 
is  non-vascular,  while  a  retinal  tumor  possesses  vessels.  Others  equally 
competent  report  cases  of  true  neoplasm  in  which  vessels  were  never 
visible  to  ophthalmoscopic  examination ;  and.  on  the  other  hand,  an 
exudate  into  the  vitreous  often  undergoes  organization,  (c)  The  sur- 
face of  a  tumor  is  knobbed ;  that  of  an  exudate  is  smooth  or  ragged. 
A  tumor  growing  into  the  vitreous  may  have  a  smooth  surface  if  it 
presses  against  the  lens,  while  an  exudate  may  become  shrunken  and 

Vol.  VII— 47  ^ 


5586  GLIOMA  OF  THE  RETINA 

conglobate.  In  such  eases  it  may  be  impossibb;  to  make  a  diagnosis 
mieroseopically  even  after  enucleation.  A  tumor  witli  a  smooth  sur- 
face may  be  a  neuroepithelioma  growing  chiefly  into  the  retina,  (d) 
Early  in  neuroepithelioma  of  the  retina  the  tension  is  normal ;  later 
it  is  increased.  In  vitreous  exudation  it  is  usually  diminished.  Yet 
there  are  exceptions.  The  author  has  seen  one  case  of  pseudo-glioma 
with  increased  tension,  (e)  Posterior  synechia;  and  other  evidences 
of  iridal  inflammation  are  not  reliable,  since  tliey  may  be  present  or 
absent  in  each  condition. 

5.  Acute  suppurative  hyalitis  producing  a  yellow  mass  behind  the 
lens,  inflammatory  symptoms,  and  increased  tension  can  be  mistaken 
for  a  neoplasm.  The  rapid  course  of  the  disease,  the  presence  of 
hypopyon,  scleral  perforation,  and  the  discharge  of  pus  will  serve  to 
clear  the  diagnosis. 

6.  Cysticercus  in  the  vitreous  can  scarcely  be  a  cause  of  mistaken 
diagnosis  in  this  country,  since  it  is  an  extremely  rare  disease  in 
America,  although  common  in  Germany.  It  appears  as  a  bluish-white 
mass  in  the  vitreous,  without  vessels,  with  normal  tension  and  blind- 
ness. 

7.  Congenital  abnormalities.  In  some  instances  eyes  have  been 
enucleated  for  neoplasm  and  examination  showed  persistent  vascu- 
larity of  the  lens-capsule,  and  a  hyaloid  artery  with  posterior  polar 
cataract. 

8.  Retinitis  circinata,  when  occurring  in  children,  may  be  mis- 
taken for  neuroepithelioma  of  the  retina. 

9.  Detachment  of  the  retina  with  dropsical  degeneration  of  the 
visual  cells  (rods  and  cones),  according  to  de  Schweinitz  and  Shum- 
way,  may  exactly  resemble  neuroepithelioma. 

This  is  always  a  serious  disease,  but  the  prognosis  depends  upon 
the  stage  of  the  condition.  Without  treatment  neuroepithelioma  of 
the  retina  always  causes  death.  Early  operations  are  followed  by  13 
per  cent,  of  recoveries.  If  the  growth  has  penetrated  the  eyeball,  and 
particularly  if  perforation  occurs  posteriorly,  death  is  almost  sure; 
but  operation  will  probably  prolong  life.  Operation  for  recurrence  is 
useless.  It  is  said  that  if  the  disease  does  not  return  within  four 
years  the  patient  will  be  exempt. 

The  treatment  of  neuroepithelioma  retina  should  be  early  and 
heroic.  Any  suspicious  growth  within  the  eye  of  a,  child  calls  for 
immediate  enucleation  and  removal  of  the  orbital  part  of  the  optic 
nerve  as  far  back  as  possible.  The  eye  should  then  be  submitted  to  a 
competent  pathologist  for  microscopic  diagnosis.  If  found  to  be  true 
neuroepithelioma  retinse,  the  orbital  contents  should  be  removed.   This 


GLIOMA  OF  THE  RETINA  5587 

leaves  a  great  dcfoiniily,  l)iit  iiiereases  the  clianee  of  saving  lilV.  In 
cases  where  the  neoplasm  has  already  pierced  the  globe  exenteration 
of  the  orbit  should  be  done  iiiiinediately,  uidess  the  disease  lias  pro- 
gressed so  far  that  the  patient  cannot  recover  from  the  depression  of 
the  anesthetic  and  operation.  If  the  neoplasm  lias  invaded  the  cavi- 
ties adjacent  to  the  orl)it,  operation  is  contra-indieated.  in  a  case  with 
involvement  of  both  eyes  the  same  principles  of  treatment  should 
apply.— (J.  M.  B;) 

Cures  after  ablation  of  glioma  of  the  retina  are  rare  enough  to 
warrant  the  publication  of  those  cases  which  come  under  observation. 
For  this  reason  de  Speville  {La  Clinique  Ophtal.,  March  25,  1906) 
reports  a  case.  The  patient,  a  robust  child  of  3  years,  had  never  been 
sick;  five  other  children  in  the  family  all  healthy.  The  father  is 
gouty  and  sutfers  from  migraine  and  gastric  crises;  motliei-  has  always 
had  good  health.  The  parents  had  observed  that  for  two  months  the 
left  eye  had  a  peculiar  aspect  when  turned  towai'd  the  right.  The 
eye  externally  presented  nothing  abnornud  ;  cen1i-al  vision  was  excel- 
lent. When  the  eye  was  directed  towards  the  right  the  pui)illary 
I'ellex  very  clearly  gave  the  so-called  ''amaurotic  cat's  eye."  The 
ophthalmoscope  demonstrated  in  the  internal  poi'tien  a  whitish-yellow 
tumor  about  the  size  of  a  pea  pushing  into  the  vitreous  humor.  The 
neoplasm  was  hidden  by  the  iris  when  looking  at  the  macula,  which 
latter  region  was  noi'mal,  as  also  were  the  upper  external  portions  of 
the  fundus.  In  the  inferior  equatorial  regions  were  several  small 
limited  tumors  presenting  the  aspect  of  white  cotton.  ^Microscopic 
examination  of  the  enucleated  tumor  proved  it  to  be  a  typical 
e.\oi)hytic  glioma.  The  child  was,  eight  years  afterwards,  perfectly 
healthy. 

Further  evidence  on  the  important  sub.ject  of  prognosis  is  furnished 
by  De  Kleijn  (v.  Graefe's  Archiv  fur  Ophthalm..  Yol.  80,  No.  2,  p. 
371,  1912).  Of  eighteen  cases  of  glioma  retime  operated  on  in  Ftrecht 
eight  recovered.  The  condition  of  the  optic  nerve  was  not  known  in 
one  of  these,  in  four  it  was  free,  in  two  aflt'ected  peripherally.  ;ind  in 
the  remaining  one  it  was  completely  involved  as  far  as  the  section. 

In  this  case,  which  occun-ed  in  a  child  of  eight  months,  the  histo- 
logical structure  of  the  tumor  was  typically  gliomatous  so  that  the 
diagnosis  was  beyond  doubt.  Three  months  afterwai-ds  the  other 
eye  was  found  to  be  afifected  and.  under  the  circumstances,  enuclea- 
tion was  postponed  until  it  should  become  painful.  The  child  was 
not  l)rought  back  lint  was  found  four  years  subse(|uently  in  an  asylum, 
1)lind  but  in  good  health.  The  remaining  eye  was  atrophic  and  abso- 
lutelv  blind:  ;i  veai'  later  it  was  removed  as  a  precautionary  measure. 


5588  GLIOMA,  PSEUDO- 

Microscopical  cxaiiiiiialioii  showed  the  characteristic  features  of 
atropliy  of  the  hiilh.  The  sdcia  contained  a  partly  bony,  partly 
calcareous  mass  in  vvhicli  luTe  and  there  portions  of  necrotic  tissue 
showing  traces  of  a  small-celled  structure  occurred.  The  retina  could 
not  be  seen  and  the  optic  nerve  was  completely  atrophied. 

Although  microscopically  it  was  not  possible  to  demonstrate  glioma 
tissue  in  the  second  eye  the  author  considers  the  diagnosis  of  glioma 
well  justified  and  attributes  the  outcome  of  the  case  to  some  unknown 
factor  which,  in  the  contest  between  the  tumor  and  its  host,  turned 
the  scale  in  favor  of  the  latter.  (H.  M.  Traquair,  in  Oph.  Rev.,  p. 
78,  ]!)];{.)     See,  also,  Tumors  of  the  eye. 

Glioma,  Pseudo-.  Cryptoglioma.  C'erlain  forms  of  exudative  uveitis, 
siimdating  the  appearance  of  retinal  glioma.  See  page  'Aolo,  Vol.  V,  of 
this  Encyclopedia. 

Glioma  retinae  luxurians.  A  term  applied  by  Schobl  {System  ejf  Dis- 
coses  of  the  Eye,  Vol.  Ill,  p.  554)  to  a  rare  group  of  gliomata  in 
which,  for  a  long  period,  regressive  metamorphoses  are  not  observed, 
or  concern  only  very  small  portions  of  the  growth.  In  such  tumors 
all  the  cells  remain  fresh  and  alive  and  can  be  stained  with  hema- 
toxylin. Their  blood-vessels  show  hardly  any  signs  of  degeneration. 
The  tumors  usually  preserve  much  longer  that  ramification  of  the 
blood  vessels  characteristic  of  young  gliomata.  There  are  no  large 
hemorrhages.  These  tumors  grow  relatively  quickly,  and  in  sections 
appear  uniform  from  their  original  site  to  the  edge  of  the  exophthal- 
mic mass. 

Glioma  teleangeiectaticum.  A  form  of  glioma  in  which  the  blood- 
vessels are  luimerous  and  dilated. 

Gliomatosis.     (L.)     The  formation  of  a  glioma. 

Gliosis.  FiBRoiTs  degeneration.  The  condition  of  Ix'iiig  affected  or 
attacked  by  a  fibromatous  tumor  or  process ;  or  ])y  changes  occurring 
in  the  neuroglia.  Parsons  (Pattiology  of  tJie  Eye,  p.  576)  says  of 
gliosis  retincB  that  it  has  been  seen  not  only  in  inflammatory  condi- 
tions but  even  more  in  chronic  venous  congestion  from  heart  failure, 
etc.  It  is  also  noticed  in  senile  degeneration,  wounds,  etc.  In  most 
cases  the  retina  is  much  atrophied ;  and  there  is  no  proof  that  more 
neuroglia  is  present  than  could  be  accounted  for  by  the  persistence 
of  the  normal  tissue,  which  shows  little  tendency  to  become  absorbed. 
The  condition  corresponds  with  that  whicli  is  usually  termed 
fibrous  degeneration  in  England.  TIk^  view  that  the  tissue  whicli 
persists,  and  also  the  new-formed  tissue,  when  any  is  present,  is  neu- 
roglia depends  chiefly  on  staining  reactions,  particularly  a  yellow 
coloration  with  van  Gieson.     These  reactions  are  open  to  doubt  a.s 


GLITTERANCE  5589 

final  criteria  of  the  tissue  genesis,  and  the  doubt  is  emphasised  in  this 
case  by  the  fact  that  tlie  normal  neuroglia  of  the  retina  does  not  stain 
specifically  with  many  of  the  specific  stains  for  the  neuroglia  of  the 
central  nervous  system.  There  is  an  al)Uii(hince  of  evidence  that  the 
greater  part  of  the  new-formed  fihi-ous  tissue  which  is  found  in 
inflamed  or  degenerated  retime  is  of  mesoblastic  origin,  and  is  there- 
fore derived  from  the  walls  of  the  blood  vessels  or  from  the  choroid. 
There  is  no  evidence  that  the  cells  of  the  vitreous  can  proliferate  and 
produce  fibrous  tissue. 

In  the  condition  known  as  gliosis  the  glia-cells  are  said  to  be 
increased  and  the  fibres  thickened.  The  nuclei  are  increased  in  the 
nerve-fibre  layer,  and  nuclei  appear  in  the  reticular  layers,  in  which 
they  are  absent  or  scanty  under  normal  conditions,  Muller's  fibres 
are  said  to  be  thickened  and  the  glia  network  is  coarser  and  more 
■  obvious,  especially  in  the  inner  reticular  layer.  This  thickening  is 
to  a  large  extent  relative  rather  than  absolute,  owing  to  the  degenera- 
tion of  the  true  nervous  tissues.  The  increase  in  nuclei  is  partly  rela- 
tive, many  being  remnants  of  the  nuclear  layers,  but  undoubtedly  in 
part  absolute,  being  due  to  infiltrating  cells  and  others  of  connecting- 
tissue  origin. 

Neurological  fibres  are  described  as  streaming  out  into  the  vitreous, 
as  in  retinitis  proliferans,  and  into  the  choroid,  as  in  choroido-reti- 
nitis.  In  the  latter  case  it  is  far  more  probable  that  the  fibres  are 
choroidal  in  origin,  while  in  the  former  they  are  mostly  derived  from 
the  retinal  vessel  walls. 

Glitterance.  A  term  of  doubtful  origin,  used  to  indicate  a  neoplasm 
of  the  retina. 

Globe.    A  name  for  the  eyeball ;  the  globe  of  the  eye. 

Globe  de  I'oeil.     (P.)     Eyeball. 

Globe  d'une  bande.     (F.)     A  rolled-up  bandage. 

Globe  lens.  A  lens  consisting  of  two  achromatic  and  identical  con- 
vergent meniscus  lenses,  so  arranged  that  the  outer  surfaces  form  a 
sphere. 

Glebe  cculaire.     (F.)     Eyeball. 

Globe  of  the  eye.    The  eyeball. 

Globe-tube.  A  disused  term,  applied  to  a  lens  system  having  an  aper- 
ture of  nearly  ninety  degrees. 

Globoid.    C.i.oBosE.     Gi/)Bri.OTD.     Approximately  globular. 

Globule  de  I'oeil.    (F.)    Eyeball. 

Globules,  MorgagTii's.  Morgagni's  spheres.  Small  hyaline  bodies  found 
between  the  crystalline  lens  and  its  capsule  before  and  after  death. 


5500  GLOBULET 

especially  in  cases  of  catai'jid.     'I'licy  nw  due  to  coaf^ulatioii  of  the 
alhuiiiiiious  fluid  contained  in  the  lens. 
Globulet.     A  minute  globulose  particle. 
Glomus.     (L.)     A  name  given  by  Wenzels  to  the  portion  of  the  choroid 

plexus  of  the  lateral  ventricle  that  covers  the  optic  thalamus. 
Glossina  morsitans.     The  (Afi-ican)  tsetse  tly. 

Glosso-labio-pharyngeal  paralysis.  Bulbar  paralysis,  in  rare  cases 
the  i)rogress  of  tlie  disease  upwards  affects  one  or  more  oculo-muscu- 
lar  centres,  above  all  the  rectus  externus  and  the  levator  ])alpebra' 
su])erioris.  See  Bulbar  paralysis  and  Neurology  of  the  eye. 
Gloster.  The  central  figure  of  the  suh-plot  in  Shakespeare's  "King 
Lear."  After  his  betrayal  by  his  bastard  son,  Edmund,  his  eyes  were 
torn  from  tlieir  sockets  by  file  detestable  Cornwall.  The  pas.sage  in 
which  this  unspeakal)le  outrage  occurs,  is  to  be  found  in  Act  111. 
Scene  VII,  and  runs  as  follows: 

Enter  Gloster,  hron<jlit  iit  hij  lieu  or  three. 

lUgan.     Ingrateful  fox !   't  is  he. 

Cornwall.     P>ind  fast  his  corky  arms. 

Gloster.     What   ineans  your   graces? — Good   my   friends,   consider. 
You  are  my  guests ;  do  me  no  foul  play,  friends. 

(JornwaU.     Bind  him,  I  say. 

Begun.  Hard,    hard. — 0    filthy    traitor! 

Gloster.     Unmerciful  lady  as  you  are,  I'm  none. 

Cornwall.     To  this  chair  bind  hiuL^^'illain,  thou  shalt  find — 

[Regan  plucks  his  beard. 

Gloster.     By  the  kind  gods,   't  is  most  ignobly  done.     To  pluck  me 
by  the  beard. 

Regan.    So  white,  and  such  a  traitor! 

Gloster.  Naughty  lady, 

These  hairs  which  thou  dost  ravish  from  my  chin 
Will  quicken  and  accuse  thee.    I  am  your  host ; 
With  robbers'  hands  my  hospitable  favors 
You  should  not  ruffle  thus.    What  will  you  do? 

Cornwall.    Come,  sir,  what  letters  had  you  late  from  France? 

Regan.     Be  simple-answer 'd,  for  we  know  the  trutli. 

Cornwall.     And  what  confederacy  have  you  with  the  traitors  late 
footed  in  the  kingdom? 

Regan.    To  whose  hands  have. you  sent  the  lunatic  king?    Speak. 

Gloster.  I  have  a  letter  guessingly  set  down. 
Which  came  from  one  that's  of  a  neutral  heart, 
And  not  from  one  oppos'd. 

Cornwall.  Cuninng. 


GLOSTER  5591 

Regan.  And  false, 

Cornwall.     Wlu'i-c  hast  tliou  sent  the  king? 

(ilostcr.  To  Dover. 

liajan.     Wherefore  to  Dover.' — Wast  tliou  not  charg'd  at  peril — 

Cornwall.    Wherefore  to  Dover? — Let  him  first  answer  that. 

Glostcr.    I  am  tied  to  the  stake,  and  1  nnist  stand  the  conrse. 

Regan.     Wherefore  to  Dover? 

Gloster.    Because  I  would  not  see  thy  cruel  nails 
Pluck  out  his  poor  old  eyes,  nor  thy  fierce  sister 
In  his  anointed  tiesh  stick  bearish  fangs. 
The  sea,  with  such  a  storm  as  his  bare  head 
In  liell-black  night  endur'd,  would  have  Inioy'd  up, 
And  (|uen(;ird  the  steih'd  fires; 
Yet,  poor  old  heart,  he  holp  the  heavens  to  rain. 
If  wolves  hatl  at  tliy  gate  howl'd  that  stern  time, 
Thou  siiouldst  have  said,  'Good  porter,  turn  the  key, 
All  ci'uels  else  subscribe.'    But  I  shall  see 
The  winged  vengeance  overtake  such  children. 

Cornwall.      See't    shalt    thou    never. — Fellows,    hold    the    chair. — 
Upon  these  eyes  of  thine  I'll  set  my  foot. 

Gloster.    He  that  will  think  to  live  till  he  be  old, 
Give  me  some  help  ! — O  cruel !     0  you  gods ! 

Regan.     One  side  will  mock  another;  the  other  too. 

Cornwall.     Tf  you  see  vengeance — 

1  Servant.  Hold  youi-  hand,  my  lord! 

I  have  serv  \l  you  ever  since  I  was  a  child ; 
But  better  service  have  I  never  done  you 
Than  now  to  bid  you  hold. 

Regan.  How  now,  you  dog ! 

1  Servant.    If  you  did  wear  a  beard  upon  your  chin, 
I'd  shake  it  on  this  quarrel.     What  do  you  mean? 

Cornwall.     ]\Iy  villain!  [They  draw  and  fight. 

1  Servant.    Nay,  then,  come  on,  and  take  the  chance  of  anger. 

Regan.    Give  me  thy  sword. — A  peasant  stand  up  thus! 

[Takes  a  sword,  and  runs  at  him  behind 

1  Servant.     0,  I  am  slain! — My  lord,  you  have  one  eye  left 
To  see  some  mischief  on  him. — 0!  [Diis. 

Cornwall.    Lest  it  see  more,  prevent  it. — Out,  vile  jelly ! 
AVhere  is  thy  lustre  now? 

Gloster.     All  dark  and  comfortless. — Where's  my  son  Edmund? — 
Edmund,  enkindle  all  the  sparks  of  nature, 
To  quit  this  horrid  act. 


5592  GLOTTISCOPE 

Regan.  Out,  treacherous  villain ! 

Thou  call'st  on  him  that  hates  tliee;  it  was  he 
That  made  the  overture  of  thy  treasons  to  us, 
"Who  is  too  good  to  pity  thee. 

Closter.    0  my  follies!  then  Edgar  was  abus'd. — 
Kind  gods,  forgive  me  that,  and  prosper  him ! 

Regan.    Go  thrust  him  out  at  gates,  and  let  him  smell 
His  way  to  Dover, —  [Exit  one  with  Gloster.]     How  is't,  my  lord? 
How  look  you  ? 

Cornwall.    I  have  receiv'd  a  hurt;  follow  me,  lady. — 
Turn  out  tliat  eyeless  villain ;  throw  this  slave 
Upon  the  dunghill. — Regan,  I  bleed  apace; 
Untimely  comes  this  hurt.    Give  me  your  arm. —  (T.  H.  S.) 

Glottiscope.  A  mirror  devised  for  introduction  into  the  mouth  for 
examining  the  glottis  and  adjacent  parts. 

Glotzaugig.  (G.)  Exophthalmic;  affected  with  exophthalmia ;  goggle- 
eyed. 

Glotzenauge.     (G.)     Abnormal  protrusion  of  the  eyeball. 

Glotzenaugenkropf.     (G.)     Exophthalmic  goitre. 

Glucose.  Grape-sugar.  Dextrose.  This  form  of  maize  (corn)  sugar 
is  found  in  honey,  grapes,  and  other  fruits.  It  is  a  colorless,  crystal- 
line compound,  soluble  in  water,  capable  of  turning  a  ray  of  polarized 
light  to  the  right;  hence  its  name,  dextrose.  It  is  a  constituent, 
especially  in  patliological  states,  of  the  urine  and  the  blood.  See 
Diabetes,  Ocular  relations  of;  also  Glycosuria. 

Glycamyl.     See  Glycerite  of  starch. 

Glycere.     (F.)     A  medicine  having  glycerine  as  the  excipient. 

Glycerin.  Glycerol.  C3H5(0H)3.  Trihydric  alcohol.  This  agent 
is  a  colorless,  viscid,  sweet,  soluble  liquid  found  in  fats  and  fixed  oils 
(4-7  per  cent.)  in  combination  with  the  fatty  acids,  as  compound 
ethers.  It  is  mostly  obtained  as  a  by-product  in  the  manufacture  of 
soap.  Glycerine  is  verj^  hygroscopic  and  mixes  in  all  proportions  with 
water  and  alcohol. 

Glycerine  is  used  as  a  solvent  of  or  in  chemical  combination  with 
other  agents  to  form  compounds  known  as  (glycerita,  glyeerina) 
glycerols,  glycerides,  glyeerites  or  glycerins  (B.  P.),  quite  a  number 
of  which  are  used  in  ocular  diseases.  In  addition  to  this  employment 
of  the  remedy  it  is  sometimes  added  to  ointments,  or  even  directly 
applied,  in  full  strength  or  diluted  with  half  its  bulk  of  water,  to  the 
conjunctiva  where  it  acts  as  a  mild  stimulant,  antiseptic  ( ?)  and  pro- 
tective.    After  pencilings   with   blue   stone,  lapis   divinus   or   silver 


GLYCERIN  OF  ALUM  559:3 

nitrate  it  may  be  applied  witli  a  hiiisli  to  limit  tlie  caustic  action  of  the 
drug.  It  is  an  adiuirahle  exeipieiit  for  eoi)per  sulj)liate  in  traelioiiia 
and  may  be  used  in  saturated  solution  or  diluted  with  water  to  tlie 
extent  desired.  It  also  dissolves  iodine,  phenol  and  other  ocular  rem- 
edies, making  with  them  solutions  that  are  readily  applicable  to  the 
eye  structures. 

Harman  {Frac.  Med.  Scries,  p.  254,  1909)  has  found  a  glycerin 
formula  which  reduces  the  pain  caused  by  nitrate  of  silver,  lie  adds 
15  per  cent,  of  pure  glycerin  to  a  0.5,  1  or  2  per  cent,  solution  of 
silver  nitrate  in  distilled  water.  This  raises  the  specific  gravity  ol' 
the  nitrate  and  increases  its  penetrative  action  on  account  of  the 
hygroscopic  powers  of  glycerin,  lie  has  used  this  preparation  on 
a  large  number  of  patients,  and  finds  it  distinctly  less  painful  than 
the  ordinary  solution  of  nitrate  of  silver,  and  rather  more  etfective. 
The  salt  does  not  lose  in  caustic  action,  since  a  fine  pellicle  of 
destroyed  epithelium  can  be  seen,  but  the  pain  is  reduced  by  the 
action  being  sjiread  over  a  loiigei-  jx-riod.  See  Glycerites;  also, 
Glycerita. 

Glycerin  of  alum.     See  Glycerite  of  alum. 

Glycerin  of  borax.     See  Glycerite  of  borax. 

Glycerin  of  starch.     See  Glycerite  of  starch. 

Glycerin  of  tannin.     Sec  Glycerite  of  tannin  or  tannic  acid. 

Glycerita.     See  Glycerites;  also  Glycerine. 

Glycerite  of  alum,  ({lycerin  op  alum.  This  is  a  convenient  prepara- 
tion containing  about  one  part  of  alum  dissolved  in  eight  parts  of 
glycerin.     Its  ocular  uses  are  the  same  as  alum. 

Glycerite  of  borax.  Gtlycerin  of  borax.  This  preparation  contains 
one  pai't  of  borax  to  six  of  glycerin.  Diluted  with  a  varying  quantity 
of  water  this  mixture,  that  always  has  a  little  free  l:»orie  acid,  is  used 
by  some  ophthalmologists  as  a  collyrium. 

Glycerite  of  hydrastis.  This  is  an  official  mixture  intended  to  fui-nish 
a  fluid  preparation  of  hydrastis,  miscible  with  water  in  all  propor- 
tions. Each  cc.  represents  1  grm.,  or  463  grains,  of  hydrastis  to  the 
fluid  ounce. 

Glycerite  of  starch.  Glycamyl.  Plasma.  Glycerin  op  starch.  A 
homogeneous,  neutral,  jelly-like  mass  containing  10  per  cent,  each  of 
starch  and  glycerine  with  80  per  cent,  of  water.  It  is  an  emollient 
application  useful  in  burns  of  the  face  and  eyelids,  may  be  used  to 
remove  iodine  stains  and  has  been  employed  as  a  medium  for  other 
applications  to  the  external  eye. 

Glycerite  of  tannin  or  tannic  acid.  Glycerin  op  tannin.  This  com- 
pound contains  20  per  cent,  of  tannin  and  80  per  cent,  of  glycerin  and 


5594  GLYCERITE  OR  GLYCJIRIDE  OF  BORIC  ACID 

forms  a  l)i'()\viiisli  solution  tliat  can  he.  conveniently  applied  as  an 
asti'iii<;t'iit  in  tliosi;  ocular  conditions  (traciioina,  follicular  conjunc- 
tivitis)  in  wliicli  tannic  acid  is  useful. 

Glycerite  or  giyceride  of  boric  acid.     Sec  Boroglycerin. 

Glycerites.  Glycekita.  The  glycerites  are  solutions  of  medicinal  sub- 
stances in  glycerin.  Although  all  are  intended  to  be  used  internally, 
except  that  called  boroglycerin,  yet  all  are  adapted  for  external  appli- 
cation. Glycerite  of  yolk  of  egg  (no  longer  oflftcial),  which  should  be 
freshly  made  when  wanted,  is  frequently  used  for  making  emulsions 
of  cod-liver  oil  and  as  a  vehicle  for  other  substances,  e.  g.,  it  may  be 
employed  as  a  menstruum  in  eye  lotions. 

Glycerol.     See  Glycerine. 

Glyceryl  borate.     Sec  Boroglycerin. 

Glycocromyda.  (L.)  A  sweetish  onion,  growing  to  the  weight  of  a 
])Ountl  on  the  (Greek)  island  of  Tenos.  Eaten  moderately,  it  is  .said 
to  be  wholesome,  but  if  immoderately  used,  to  weaken  the  sight. 

Glycogen.  Animal  starch.  This  is  a  white,  amorphous,  odorless,  taste- 
less powder,  insoluble  in  alcohol  but  forming  an  opalescent  solution 
with  water.  It  occurs  normally  in  the  liver  and  blood,  being  elabo- 
rated by  the  former.  It  is  transformed  by  diastasic  ferments  into  glu- 
cose. It  is  found,  pathologically,  in  various  parts  of  the  eye,  especially 
in  spring  catarrh,  some  corneal  degenerations,  in  some  forms  of  iritis 
and  usually  in  association  with  hyaline  deposits.  Parsons  {Pathology 
of  the  Eijc,  p.  516)  describes  it  as  ai)pearing  in  the  form  of  globules 
and  sickle-shaped  deposits  in  hardened  specimens.  It  is  best  seen  in 
fresh  preparations,  but  also  after  hardening  in  absolute  alcohol.  It  is 
soluble  in  saliva;  it  stains  brown  with  Lugol's  iodine  solution,  and  is 
then  soluble  in  water  and  more  so  in  glycerine.  It  often  stains  by 
Weigert's  method;  this  also  attacks  the  pigment.  It  does  not  stain 
with  iodine  and  sulphuric  acid,  methyl  violet  or  acid  fuchsin ;  it  stains 
with  carbol  fuchsin.  Best  gives  the  following  directions  for  staining : 
(1)  Stain  with  strong  solution  of  iodine  in  potassium  iodide  and  50  per 
cent,  alcohol;  wash  out  in  iodized  absolute  alcohol;  origanum  oil  bal- 
sam; (2)  stain  15  to  30  minutes  in  carbol  fuchsin,  wash  rapidly  in 
%  per  cent,  hydrochloric  acid  alcohol,  decolorize  quickly  in  absolute 
alcohol.  The  sections  may  be  prin'iously  counter-stained  with  hema- 
toxylin. 

Glycosuria.  The  secretion  of  an  abnormal  quantity  of  glucose  with 
the  urine  ;  cliief  sign  of  diabetes  mellitus. 

Glycosuric  cataract.  Diabetic  cataract.  See  Diabetes;  as  well  as 
Cataract,  Diabetic. 


GLYCOSURIC  RETINITIS  5595 

Glycosuric  retinitis.  Dijihclic  retinitis.  See  page  '.V.)24,  Vol.  V,  of  lliis 
/'Jtni/(l(>/)( (lid,  as  well  as  Retinitis,  Diabetic. 

Glycothymcline.  A  propiictaiy  article  emi)loyetl  in  eatarrlial  condi- 
tions of  mucous  ineiiibraiies.  It  is  occasionally  used  in  ocular  therai)y 
and  is  said  to  contain  potassium  carbonate,  sodium  benzoate,  sodium 
borate,  smaller  portions  of  sodium  salicylate,  thymol,  menthol,  glycerin 
and  alcohol,  colored  with  cochineal. 

R.  L.  Randolph  usually  treats  cases  of  dacryocystitis  by  irrigation 
and  the  solution  which  he  has  found  most  useful  is  glycothymoline 
(Kress)  commencing  with  equal  parts  of  water  and  glycotliymoline 
and  finally  irrigating  regularly  with  the  undiluted  preparation. 

H.  ]\IcI.  Morton  finds  the  following  collyrium  Avhen  used  in  an  eye- 
cup  of  especial  advantage  in  many  forms  of  simple  conjuncttivitis: 
Acid  boric,  gr.  300;  sodii  borat.,  gr.  200;  hydrarg.  chlor.  corros.,  gr. 
1-12;  glycothymol.,  fi.  oi;  aquce  dest.  ad.,  fl.  .^xii. 

Glycozone.  A  proprietary  liquid  agent  said  by  the  maker,  Marchand, 
to  be  a  stable  chemical  compound  resulting  from  the  action  of  ozone 
on  pure  glycerin.  It  has  a  pleasant,  sweetish-acid  taste  and  may  be 
used  for  much  the  same  purposes  that  the  ofificial  hydrogen  dioxide 
water  is  employed. 

Gnat.  CuLEx  giganteus.  Mosquito.  The  damage  done  to  the  eye  by 
the  stings  of  this  and  similar  insects  is  generally  confined  to  edema 
and  localized  inflanuuation  of  the  lid  skin,  or  conjunctiva,  although 
it  sometimes  ends  in  sui)i)uration  of  the  part  affected.  The  treatment 
consists  chiefly  in  the  early  external  use  of  iced  fomentations  with 
lead  water;  or  of  iced  water  to  which  a  few  drops  of  liq.  anunoniae 
have   been   added. 

Goat.  The  products  of  the  goat  were  highly  esteemed  in  Greek  and 
Greco-Roman  antiquity.  The  dung  of  the  animal,  wrapped  in  wax, 
was  swallowed  during  the  new  moon  for  excessive  discharge  from  the 
eyes  (lippitudo) .  Goat's  milk  was  thought  to  possess  an  all-round 
value  as  a  sharpener  of  the  vision,  while  a  poultice  of  goat's  cheese 
mixed  with  honey  was  applied  for  ocular  ulcers.  Almost  all  the  prod- 
ucts of  the  goat,  moreover,  were  supposed  to  be  sovereign  remedies 
for  nyctalopia  (q.  v.)  :  the  flesh,  the  blood,  the  milk,  the  dung.  This 
curious  supposition  was  based  on  still  another:  that,  namely,  the 
vision  of  the  goat  is  fully  as  sharp  by  night  as  it  is  in  daytime. — 
(T.  H.  S.) 

Goat's  horn.     Ree  Tragacanth. 

Gober,  Prince  Ali.  A  (heat  ^Mogul.  who  was  blinded  by  his  vizier, 
Gholara  Kadir.     See  Shah  Allum. 


5596  GOBLET-CELL 

Goblet-cell.  This  is  ;i  foi'iii  of  t'])itliciial  cell  filled  with  mucin  and 
bulged  out  in  the  shape  mentioned.  They  are  found  in  the  mucous 
membranes  of  the  body ;  in  the  eye  they  resemble  somewhat  the  goblet- 
cells  of  the  intestine.  They  are  everywhere  found  as  a  normal  struc- 
ture in  the  conjunctival  epithelium — especially  of  the  ocular  con- 
junctiva and  of  the  fornix.  Parsons  {Pathology,  p.  31)  says  of  the 
ocular  goblet-cells  that  in  the  fresh  state  they  are  large  round  or 
oval  cells,  strongly  refractile  and  jnuch  like  fat  cells.  They  are  found 
at  various  depths,  the  deeper  ones  being  smaller  and  round,  the  super- 
ficial ones  oval  and  larger  than  the  epithelial  cells  (25/x  by  16/jt)  and 
l)ossessing  a  definite  opening  or  stoma  on  the  surface.  They  have  a 
double-contoured  membrane  or  theca,  and  a  pointed  process  below, 
which  often  reaches  down  to  the  basement  membrane.  The  main 
contents  of  the  cell  consist  of  mucin,  which  forms  homogeneous  or 
finely  grainilar  droplets  when  fresh,  and  larger  granules  or  networks 
when  hardened.  This  secretion  pushes  aside  the  cytoplasm,  which  is 
almost  invisible,  and  the  flattened  nucleus  forms  a  crescent  at  the  base. 
The  latter  may  be  apparently  absent  in  thin  sections  owing  to  the 
size  of  the  cells.  Only  the  superficial  cells  have  a  stoma,  and  the  mucin 
is  often  seen  i)rotruding  from  it.  The  stomata  are  well  displayed  in 
surface  prepai-ations  when  the  outlines  of  the  neighboring  cells  are 
marked  by  silver  staining.  The  secretion  stains  xevy  variously.  It 
is  more  or  less  extracted  during  the  process  of  hardening,  unless 
fixed  by  acetic  acid,  and  even  then  stains  variously,  owing  probably  to 
the  presence  of  intermediate  products  (mucinogen).  The  fresh  mucin 
usually  stains  with  hematoxylin  and  ba.sic  aniline  dyes,  best  with 
thionin.  The  superficial  cells  give  the  best  thionin  reaction,  owing  to 
the  greater  quantity  of  the  final  product  (mucin)  present. 

Ley  dig  (1857)  first  discovered  such  cells  in  the  epidermis  of  the 
fish,  and  called  them  "mucous  cells"  (Schleimzellen).  They  were 
called  "goblet-cells"  (Becherzellen)  by  Schulze  (1863),  as  it  was 
doubtful  if  they  all  contained  mucin.  Stieda  (1867)  fii-st  found  them 
in  the  conjunctiva,  and  called  them  "unicellular  mucous  glands." 

Waldeyer  (1874)  ac^opted  this  idea,  pointing  out  the  tendency  of 
the  cylinder  cells  to  become  metamorphosed  into  goblet-cells.  Now 
these  cells  are  found  in  far  greater  numbers  in  conditions  of  chronic 
inflammation,  so  that  Sattler  (1877)  looked  u|)on  them  as  pathological. 
They  are  also  more  numerous  in  tumors  (papillomata,  etc.).  Since, 
however,  they  occur  in  the  fetus  and  new-born,  and  were  found  by 
Green  in  thirty  consecutive  uoniial  conjunctiva^  they  may  be  regarded 
as  normal,  though  subject  to  great  and  even  enormous  increase  under 
pathological  conditions.     Stieda,  in  1890,  altered  his  previous  opinion 


GODMAN,  JOHN  D.  5597 

that  tliry  wi-re  secretory  cells,  and  regai-dcd  tliciii  as  degenerated  cells. 
It  seems  probable,  ijidced,  that  the  cells  aiv  destroyed  after  tiiey  have 
expelled  their  contents,  secretory  activity  ending  in  destruction;  and 
in  this  respect  they  may  be  compared  with  the  cells  of  the  active  mam- 
mary gland.  Though  reseiid)ling  the  goblet-cells  of  the  intestine,  they 
are  not  identical  with  them.  The  latter  an;  formed  only  upon  the 
surface,  and  regenerate  after  expelling  their  contents.  The  former 
are  much  more  nearly  allied  to  the  epiblastic  cells  described  by  L.^ydig 
in  fishes  and  the  larva-  of  ami)hibia  (Pfitzner).  They  are  apparently 
formed  only  from  the  cylindi'ical  cells,  i.  e.,  mostly  from  the  deepest 
layer,  remain  closed  as  they  pass  toward  the  surface,  still  retaining  a 
filamentary  connection  with  the  basement  mend)i-ane,  and  finally  open 
ui)on  the  surface,  expelling  their  contents,  thereby  being  destroyed. 
Their  function  can  hardly  l)e  considered  doubtful.  They  are  true 
unicellular  mucous  glands  moistening  and  protecting  the  conjunctiva 
and  cornea,  so  that  even  extiri)ation  of  the  lachrymal  gland  is  innocu- 
ous; whilst,  on  the  othei-  hand.  X(U'osis  of  the  conjunctiva,  involving 
their  destruction,  leads  to  desiccation  in  spite  of  a  copious  flow  of 
tears. 
Godman,  John  D.  A  l)rilliant  American  surgeon,  -who  first  reported  a 
case  of  so-called  "inverted  vision."  Bom  at  Annapolis,  ]\Id.,  Dec. 
30,  1794,  he  lost  his  mother  when  he  was  only  two  years  old,  and  his 
father  in  less  than  thi'(n'  years  later.  The  story  of  the  orphan's 
uphill  efforts  for  an  echication  is  truly  pitiful.  Sufiftce  it,  however,  in 
these  pages,  to  give  the  barest  outline  of  this  remarkable  physician's 
very  brief  life.  In  1815  he  began  to  live  and  study  with  a  Doctor 
Luckey,  of  Elizaliethtown,  Pa.,  but,  five  months  later,  removed  to 
Baltimore,  where  he  lived  and  studied  with  Dr.  Davidge,  of  the  Uni- 
versity of  Maryland.  In  1818,  at  this  institution,  he  received  his 
nu'dical  degree.  Tie  practised  for  a  time  in  New  Holland,  but  soon 
removed  to  Philadelphia.  In  1821,  on  the  invitation  of  Dr.  Daniel 
Drake,  he  removed  to  Cincinnati  in  order  to  accept  the  chair  of  sur- 
gery in  the  ^Medical  College  of  Ohio.  After  a  single  lecture  there 
occurred  a  quarrel  in  the  faculty,  and  he  resigned.  He  established 
then  The  Western  Quarterly  Reporter,  which  lived  for  a  year  and  a 
half. 

In  1822  he  returned  to  Philadelphia,  and.  taking  rooms,  began  to 
deliver  a  course  of  private  lectures  on  anatomy.  In  a  very  short  time 
his  reputation  was  established.  He  also  wrote  a  number  of  brilliant 
books  and  articles  on  subjects  connected  with  natural  history,  of  which 
the  most  important  is  Amcncdn  Natural  Histarij  (.3  vols..  1826).    He 


5508 


GODMAN,  JOHN  D. 


was  OIK"  of  the  editors  of  Thr  Aii)(  rican  Journal  of  the  Medical  Sci- 
ences from  1824  until  his  death. 

Godinan's  most  important  oi)lithalmolo<i:i('  ai'tiele  is  entitled  "Note 
of  an  Interesting  Fact  Connected  with  the  Physiology  of  Vision," 
from  which  I  copy  the  following  passage,  from  iru))lieirs  "Ophthal- 
mology in  America"  (p.  123)  :  "The  following  instance  communi- 
cated to  me  by  Reuben  Peale,  Es(j.,  the  uncle  of  the  young  man,  is  the 
only  one  with  M'hicli  we  are  at  pi'esent  ae((uainted,  where  the  inversion 
of  objects  on  the  retina  was  productive  of  inaccuracy  of  judgment  as  to 


John  D.  Godmaii. 


position,  notwithstanding  all  the  other  senses  were  in  their  ordinary 
conditioji,  and  the  individual  had  arrived  at  the  age  of  7  years. 

"When  his  father,  who  was  a  distinguished  artist,  began  to  give 
him  lessons  in  drawing,  he  was  very  much  surprised  to  find  that  what- 
ever object  he  attempted  to  delineate,  he  uniformly  inverted.  If 
ordered  to  make  a  drawing  of  a  candle  and  candlestick  set  before 
him,  he  invariably  drew  it  with  the  base  represented  in  the  air  and 
the  flame  downwards.  If  it  was  a  chair  or  a  table  he  was  set  to  copy, 
the  same  result  was  the  consequence;  the  feet  were  represented  in 
the  air,  and  the  upper  part  of  the  object,  whatever  it  might  be,  was 
turned  to  the  ground.     His  father,  perplexed  at  what  he  considered 


GOEBEL'S  DISCISSION  FORK  5500 

the  perverseness  of  the  boy,  threatened,  iuid  fvcii  did  pimisli  him  for 
his  supposed  folly.  When  questioned  on  the  suliject  the  youth  stated 
that  he  drew  the  objects  exaetly  as  he  saw  them,  ami  as  his  drawinf,rs 
were  in  other  respects  quite  accurate,  there  was  no  reason  to  doubt  his 
statement.  Whenevei-  an  object  was  inverted  previous  to  his  di-awing 
it,  the  drawing  was  made  to  represent  it  in  its  proper  position,  show- 
ing that  the  seiisalioiis  he  received  from  the  eye  were  exaetly  corre- 
spondent with  the  inverted  pictures  formed  on  the  retina.  This  con- 
dition of  his  vision  was  observed  to  continue  for  more  than  a  year, 
when  his  case  gradually  ceased  to  attract  attention,  which  was  when 
he  was  about  8  years  old.  Since  that  time  he  has  imperceptibly 
acquired  the  habit  of  seeing  things  in  their  actual  position." 

Godman  married,  in  October,  1821,  a  daughter  of  Peale,  the  jirtist. 
Tie  died  in  ISIU),  wlien  only  36  years  of  age.— (T.  11.  S.) 

Goebel's  discission  fork.  In  opei-ations  for  secondary  cataract  three 
errors  must  be  avoided  as  much  as  possible,  viz.,  larger  openings  of 
the  anterior  chaml)ei',  escai)e  of  aqueous,  traction  on  the  ciliary  body, 
deep  penetration  into,  and  injury  of,  the  vitreous,  in  order  to  attain 
this  better  than  with  the  instruments  so  far  in  use  Goebel  {Prac.  Med. 
iScrics,  p.  2'.]6,  1910)  has  devised  a  discission  fork,  wliich  after  being 
introduced  behind  the  cataractous  membrane,  establishes  a  tirm  layer 
of  resistance.  The  prongs  of  the  instrument  consist  of  two  parallel 
discission  needles  from  1  to  2  mm.  distant  from  one  another,  forming 
with  the  handle  an  angle  of  from  110  to  ItiO  degrees.  It  is  inserted 
subconjunctivally  from  the  nasal  limbus  and  at  the  margin  of  the  iris, 
or  eventually  through  the  iris  into  the  secondary  cataract,  advanced 
under  this  more  or  less  over  the  opposite  margin  of  the  iris,  and  lifted 
forwards  toward  Knapp's  needle-knife,  which,  also  subconjunctivally, 
has  been  introduced  from  the  temporal  limbus.  AVith  slow  and  saw- 
ing movements  the  membrane  is  cut  between  the  prongs.  If  necessary, 
a  vertical  incision  may  be  added.  The  writer  does  not  doubt  that  the 
thickest  iritic  membranes  can  thus  be  easily  and  safely  severed  with- 
out exerting  any  dangerous  traction  on  the  ciliaiy  body. 

Goethe,  Johann  Wolfgang.  The  life  of  this  versatile  writer  is  of  in- 
terest to  oplithalmologists  on  account  of  his  original  theories  of  color- 
vision,  which  appeared  in  his  "Zur  Farhenlchrc,"  published  in  1810 
(referred  to  on  page  2-120,  Vol.  IV,  of  this  Encychpedia) .  He  was 
born  in  1749  in  Frankfort-on-the-]\Iain,  Gennany.  Ills  father  was  a 
doctor  of  laws  and  obtained  the  title  of  imperial  councilor.  He  was 
quick  to  learn  and  had  the  advantage  of  careful  instruction  from  his 
father  and  from  tutors.  The  French  theatre  which  opened  in  the 
cit}^  attracted  the  boy,  and  thus  he  became  familiar  with  Racine  and 


5600  GOETHE,  JOHANN  WOLFGANG 

till'  iiioi-r  rrcciit  (Iraiiiiitists.  Latin,  Greek,  Italian,  English,  even 
Hebrew,  were  stiRJieil,  and  he  j)lanned  a  kind  of  i)rose  fiction  main- 
tained by  several  correspondents  in  various  languages.  At  the  age  of 
16  he  was  admitted  as  a  student  in  the  University  of  Leipzig.  Three 
years  later  he  was  seriously  ill,  and  during  this  period  under  the  guid- 
ance of  his  doctor  lie  made  a  study  of  alchemy  which  was  of  service 
to  him  later  on  when  he  wrote  Faust.  After  obtaining  his  doctor's 
degree,  at  the  University  of  Strasburg  in  1771,  he  returned  to  his 
native  city  and  was  admitted  an  advocate,  but  had  no  heart  in  his 
profession.  Ilis  creative  geuius  was  aroused  and  when  he  read  Shake- 
speare he  felt  himself  moved  to  something  like  rivalry.  During  the 
next  five  years  works  of  the  most  varied  description  were  written. 
Some  of  his  most  exquisite  lyrics  belong  to  1775.  A  new-  period  of 
activity  began  with  Goethe's  entrance  to  Weimar.  In  1776  he  was 
made  a  member  of  the  privy-council  {Geheimcr  Lcgationsrath),  and  he 
set  himself  strenuously  to  serve  the  state.  He  acquitted  himself  of 
every  duty  with  masterly  intelligence  and  a  rare  thoroughness.  In 
1782  he  received  a  patent  of  nobility,  and  during  the  next  ten  j^ears 
his  mind  seemed  to  turn  away  from  vague  aspirings  and  sentimental 
moods  to  the  definite  and  the  real.  He  became  deeply  interested  in 
the  natural  sciences — geology  and  mineralogy,  botany,  comparative 
anatomy.  ]\Iany  literary  works  were  begun  in  this  period  but  not 
many  completed.  He  visited  Italy  at  this  time,  re-entering  Weimar 
in  1788,  and  bringing  back  to  his  home  a  beautiful  girl  of  humble 
rank,  Christiane  Vulpius.  His  son  August  was  born  the  following 
year.  Although  from  the  first  he  regarded  Christiane  as  his  wife,  the 
marriage  ceremony  was  not  celebrated  until  1806.  Christiane  had 
good  cjualities  and  was  dear  to  Goethe,  but  his  choice  was  in  many 
respects  unsuitable.  Science  continued  to  interest  Goethe  profoundly. 
His  remarkable  essay  on  the  Metamorphosis  of  Plants  appeared  in 
1790,  and  while  in  Venice  in  INIay,  he  suddenly  struck  out  his  much 
discussed  theory  of  the  vertebral  structure  of  the  skull.  In  1791 
Goethe  was  intrusted  with  the  control  of  the  court  theatre  at  Weimar, 
and  it  was  his  aim  and  earnest  effort  to  make  the  stage  a  means  of 
true  artistic  culture.  About  this  time  appeared  his  Venetian  Epi- 
grams, GrosskopUta,  Die  Aufgrvcgten,  Burger-general  (acted  in  1793), 
and  Reynard  the  Fox.  In  1792  Goethe  accompanied  the  duke  on  the 
disastrous  campaign  against  the  French ;  he  heard  the  cannonade  at 
Valmy,  went  under  fire  in  order  to  study  his  ovn\  sensations,  and  was 
present  at  the  siege  of  ^lainz.  He  has  recorded  his  experiences  and 
observations  in  an  admirable  narrative.  It  is  possilile  that  at  this 
time  Goethe  might  have  grown  discouraged  and  bitter  were  it  not  for 


GOGGLE-EYED  5601 

the  friendship  formed  with  Schiller  in  17!)4.  This  friendship  and  its 
fruits  fill  the  memorahle  years  from  that  date  to  1805,  the  year  of 
Schiller's  death.  Together  they  worked  in  the  "II ore n,"  a  review 
designed  to  elevate  the  literary  standard  in  (jlermany.  Together  in 
the  Xenien  (1796)  they  discharged  their  epigrams  against  their  foes, 
the  literary  Philistines.  Schiller's  sympathy  encouraged  Goethe  to 
set  to  work  once  more  on  Wilhelm  Meistcrs  Lchrjaiirc,  a  novel  which 
more  than  any  other  work  of  Goethe  may  be  said  to  exhibit  his  criti- 
cism on  life.  In  1810  he  published  his  two  volumes  on  light  and  color, 
Ziir  Farhenlchre,  already  referred  to,  and  these  were  speedily  fol- 
lowed by  the  first  part  of  his  autobiography,  Dichtung  mid  Wahrhcit, 
the  continuation  of  which  occupied  him  from  time  to  time  during  sev- 
eral subsequent  years.  A  grief,  real  and  deep,  came  to  Goethe  in  his 
sixty-seventh  year,  in  the  death  of  his  wife.  In  his  later  years  Goethe 
still  continued  active.  From  time  to  time  during  more  than  half  his 
life  he  had  worked  at  the  second  part  of  Faust;  it  occupied  him  much 
during  the  closing  years,  and  was  completed  in  1831.  Goethe  died  in 
1832  after  a  short  illness,  and  his  body  lies  near  that  of  Schiller  in 
the  ducal  vault  at  Weimar.  Goethe  was  a  man  of  noble  bodily  pres- 
ence, both  in  youth  and  age.  His  influence  has  affected  every  civilized 
people.  His  teaching  has  been  styled  the  creed  of  culture;  it  is  rather 
the  creed  of  self-development  with  a  view  to  usefulness. —  (C.  P.  S.) 

Gog-gle-eyed.  Having  prominent,  staring,  or  rolling  eyes;  also  em- 
ployed by  the  vulgar  as  a  synonym  of  exophthalmus  and  of  strabis- 
mus. 

Goggles.  A  pair  of  plain  or  colored  glasses  worn  like  spectacles,  fixed 
in  short  tubes  of  ware  gauze  spreading  at  the  base  over  the  eyes,  for 
their  protection  from  cold,  dust,  sparks,  etc.,  or  from  too  great 
intensity  of  light,  or  so  contrived  with  holes  or  slits  as  to  direct  the 
eyes  straight  forward,  in  order  to  cure  squinting.  Also  contrived  for 
horses  that  are  apt  to  take  fright.  See  Eye-shades;  also,  Eye  pro- 
tectors. 

Goitre,  Exophthalmic.  See  Basedow's  disease ;  as  well  as  Exophthalmic 
goitre. 

Goitre  exophthalmique  variqueux.  (F.)  Exophthalmic  goitre  with 
immerous  varicose  veins  crossing  the  surface  of  the  tumor. 

Gold  and  sodium  chloride.  Chloride  op  gold.  See  Auri  et  sodii 
chloridum. 

Gold  carbolate.  This  agent,  of  slight  ophthalmic  interest,  has  been 
recommended  l\y  Galezowski  in  one  per  cent,  solution  as  a  cautery 
for  corneal  ulcers  in  place  of  lactic  acid. 

Gold  chloride.      Airic  chloride.      Gold  trichixjride.      Au  Cl;j+nC14- 

Vol.  VH — 18 


5602  GOLDEN  SEAL 

IIILO.    This  salt  appears  as  yellow  crystals,  soluble  in  water  and  alco- 
liol.  and  eontains  about  40  per  eent.  of  pure  g^old. 

The  great  expense  and  untried  cliaraeters  of  j,'ohl  salts  make  it  un- 
likely that  any  of  them  will  ever  be  used  lo  any  f^reat  extent  in  oph- 
thalmie  j)raetiee.  However,  a  report  of  \'erhoeft'  (Journal  American 
Midival  Association,  1!)()6)  is  wortii  a  short  notice.  Hy  dissolving  1 
gnu.  (gr.  15)  of  chloride  of  gold  in  50  cc.  (f.  oz.  1  2-3)  of  water,  and 
adding  enough  5  per  cent,  aqueous  caustic  soda  solution  to  make  the 
reaction  faintly  alkaline,  a  liuid  is  obtained  of  very  powerful  bacter- 
cidal  action;  it  is  used  as  a  colly rium  with  50  cc.  (f.  oz.  12-3)  of 
Jiornuil  saline  solution  and  100  cc.  (f.  oz.  3  1-3)  of  a  1  per  cent,  solu- 
tion of  boric  acid.  This  gold  solution  possesses  great  antiseptic  and 
antifermentative  power,  and  is  said  to  possess  the  great  additional 
advantage  of  being  without  irritant  action  on  the  conjunctiva.  Again, 
no  constitutional  disturbance  occurs  as  the  result  of  introducing  the 
proper  quantity  of  the  salt  into  the  conjunctival  sac.  See.  also,  Auri 
et  sodii  chloridum. 

Golden  seal.     See  Hydrastis. 

Goldhand.  See  Abu  Ruh.  Muh.  bin  Mansur  bin  Abi  Abdallah  bin 
Mansur  alyamani. 

Gold  trichloride.     See  Gold  chloride. 

Golf-ball.  Golf-ball  accidents  op  the  eye.  Direct  injury  to  the  eye 
from  the  impact  of  the  ball  is  not  uncommon  and  the  lesions  resulting 
from  this  form  of  trauma  do  not  much  differ  from  those  seen  in 
injuries  from  similar  blunt  objects.  On  the  other  hand,  certain  so- 
called  "fluid-core"  or  "water-core"  balls,  containing  heavy,  corrosive 
liquids,  occasionally  explode  and  burn  the  external  e.ye. 

An  early  example  of  this  accident  is  reported  by  II.  ]\Iaxwell  Lang- 
don  [Annals  of  Opkthalm.,  p.  171,  Jan.,  1913)  :  It  seems  that  while 
opening  an  English  "Zodiac"  golf  ball,  it  suddenly  exploded, 
the  contents  of  the  core  being  thrown  in  the  patient's  eyes.  The  right 
eye  showed  decided  chemosis  of  the  conjunctiva,  and  a  general  rough- 
ening of  the  corneal  epithelium.  The  left  eye  had  lost  the  epithelium 
from  the  lower  third  of  the  cornea,  the  remaining  portion  was  rough, 
taking  fluorescein  stain,  and  the  conjunctiva  was  so  cheraosed  that  the 
lids  could  not  close.  The  cornea  was  quite  hidden  until  the  conjunctiva 
was  pushed  aside  with  a  spatula. 

He  was  j)lace(l  in  ])ed,  and  ice  compress(>s  and  atropin  were  used; 
in  twenty-four  hours  the  chemosis  was  much  less,  and,  on  account  of 
the  condition  of  the  cornew  and  the  large  nuisses  of  subconjunctival 
exudate,  heat  was  used  instead  of  ice.  The  condition  gradually  im- 
proved, and  in  two  weeks  he  was  discharged,  with  a  vision  of  o/S  and 


GOLF-BALL  ryGO'S 

5/6  in  0.  D.  and  ().  S.,  respectively.  The  last  len  days  lie  was  on 
dionin,  which  hastened  the  absorption  of  the  suhconjunclival  exudate 
very  decidedly. 

He  has  two  small  scars  near  the  lowei-  iiiar^dn  of  the  left  cornea, 
and  a  small  traumatic  i)tery^ium  to  the  nasal  side  of  tin-  left  cornea. 

The  core  of  the  English  Zotliac  golf-hall  is  a  small  i-uhher  l)ag  lilled 
with  a  grayish  paste,  which  is  strongly  alkaline  in  reaction. 

J.  T.  Carpenter  and  B.  F.  Baer,  Jr.  {Annals  of  Ophtli.,  p.  169,  Jan., 
1913)  exhibited  a  patient,  who,  on  August  4,  1912,  received  a  severe 
burn  of  the  left  eye  following  an  explosion  of  a  "Zodiac"  golf-ball, 
the  core  of  which  consists  of  a  i)utty-like  matci'ial  possessing  strong 
caustic  properties. 

The  patient  was  first  seen  by  Carpenter  two  hours  after  the  acci- 
dent, and  presented  the  following  condition:  The  left  eyelids  were 
swollen  and  reddened,  the  entire  bulbar  and  palpebral  conjunctiva 
transformed  into  gray,  sloughing  tissue,  the  cornea,  except  the  upper 
fifth,  opaque  and  milky,  chemosis  so  gr(>at  that  the  lids  failed  to  cover 
the  protruding  conjunctiva.  The  vision  was  reduced  to  counting 
fingers.  Treatment  consisted  of  atropin,  dionin,  holocain,  ice,  and 
hiter  hot  compresses.  At  the  end  of  two  weeks  there  developed  a 
severe  iridocyelitis,  with  hypopyon  and  necrosis  of  the  lower  corneal 
quadrant. 

Following  the  recession  of  the  iridocyclitis  a  third  stage  of  the 
process  began — gradual  failure  of  nutrition  in  the  anterior  ocular 
segment — the  cornea  being  covered  with  superficial  blebs,  the  episcleral 
tissues  pale  and  cicatriztnl,  and  the  corneal  parenchyma  so  densely 
opaque  that  vision  was  oidy  about  1/60.  At  this  time,  six  weeks  after 
the  injury,  subconjunctival  salt  injections  were  begun,  a  large  quantity 
of  normal  salt  solution  being  injected  on  every  third  day.  The  effect 
was  so  remarkable  that  but  four  injections  were  reciuired.  The  eye 
which  had  shown  no  tendency  to  react  to  any  treatment  i)romptly 
responded  to  the  salt  injections,  and  remained  ((uiet,  the  cornea  so 
clear  that  vision  with  a  plus  1.75  sphere  is  6/6,  the  pupil  widely 
dilated,  and  there  is  a  complete  absence  of  subjective  symptoms. 

W.  O.  Nance  {Jour.  Opiith.  and  Oto-Lanjn.,  November,  1912)  de- 
scribes a  severe  burn  of  the  eye  from  an  exploding  fluitl-core  ball. 
The  patient  suffered  intense  pain  in  the  eye  and  the  skin  surrounding 
the  eye  was  burned  in  one  direction  for  a  distance  of  two  inches. 
Examination  demonstrated  a  deep  opacity  of  the  cornea  in  almost  its 
entire  area.  In  addition  there  was  a  cicatrized  conjunctival  area 
extending  from  the  limbus  for  a  distance  of  almost  an  inch  to  the 
inferior   nasal   aspect,   at  least  one-quarter  of  an   inch   wide.     The 


5604  GOLFE 

remaining  bulbar  conjunctiva  was  swollen  and  red.  Vision  was 
reduced  to  mere  perception  of  light.  Tension  was  minus.  Enuclea- 
tion of  the  eye  was  advised. 

The  Editor  (Ophthal.  Record,  Oct.,  1912)  has  published  a  case  of 
burn  of  the  eyeball  from  the  explosion  of  a  w'ater-core  ball.  Both 
the  ocular  and  palpebral  conjunctivas  were  swollen  and  hyperemia ; 
in  two  situations  there  were  subjunctival  hemorrhages.  There  was 
marked  ciliary  and  scleral  congestion.  About  two-thirds  of  the 
cornea  was  covered  by  a  thin,  whitish  eschar.  The  vision  was  restored 
to  6/12  minus. 

Lowell  {Jour.  Am.  Med.  Assocn.,  V.  61,  p.  3202,  1913)  observed 
six  cases,  of  which  three  lost  the  use  of  one  eye.  There  appear  to  be  at 
least  two  different  kinds  of  caustic  put  in  the  cores  of  these  balls. 
Lowell  had  one  mass  analyzed  by  R.  L.  Emerson.  It  was  found  to 
contain  a  mixture  of  barium  sulphate,  soap  and  a  free  alkali.  Balls 
of  another  make  have  been  found  to  contain  zinc  ehlorid  in  the  solu- 
tion. In  view  of  the  danger  to  the  eyes  of  curious  persons,  mostly 
children,  from  such  balls,  a  bill  has  been  introduced  into  the  legislature 
of  Massachusetts  to  prohibit  the  sale.  The  United  States  Golf  Asso- 
ciation has  also  issued  a  warning  against  the  dangerous  practice  of 
cutting  ojien  golf  balls.  See.  also,  Injuries  of  the  eye;  as  well  as 
Conservation  of  vision;  and  Blindness,  Prevention  of. 

Golfe.      (F. )     A  deep  hollow;  a  sinus. 

Golgi's  method.     A  method  of  staining  nerve-cells. 

Gomenol.  Oil  of  niaouli.  This  essential  oil  has  been  recommended  as 
an  application  to  the  lids  in  trachoma  by  Dufaure  (La  Cliniquc 
Ophtal.,  Vol.  XVII,  p.  472,  1911).  It  is  derived  from  Mdohuca 
veridiflora,  a  Myrtacea  found  in  New  Caledonia,  near  Gomen.  Dufaure 
advises  this  mixture:  gomenol,  1.00;  carbonate  of  guiacol,  0.30;  cam- 
phor, 0.20 ;  olive  oil,  washed  and  sterilized,  30.00. 

As  the  changes  which  probably  take  place  in  this  mixture  give  rise 
in  time  to  pain-producing  products,  he  finally  decided  on  the  follow- 
ing :  gomenol,  1.00 ;  oil  of  lemon,  0.25 ;  olive  oil,  washed  and  sterilized, 
30.00. 

The  oil  of  lemon  is  vaso-constrictive  and  highly  bactericidal.  AVith 
this  mixture  he  has  had  comparatively  great  success,  and  he  claims 
that  with  the  help  of  a  collyrium  of  zinc  sulphate,  it  will  bring  about 
a  condition  that  resembles  a  cure,  if,  indeed,  it  does  not  effect  a  cure, 
in  a  greater  percentage  of  cases  than  by  any  other  known  remedy. 
Its  virtue  lies,  furthermore,  in  the  fact  that  it  does  not  cause  atrophy 
of  the  conjunctiva.  Nor  is  its  use  limited  to  cases  of  trachoma  :  it  acts 
as  an  excellent  prophylactic  in  contagious  eye  diseases,  no  matter  what 


GOMME  5605 

their  etiology.  In  one  case  of  complete  xerosis  of  hotli  eyes  repeated 
instillations  of  gomeuol  afforded  tlie  previuiisly  blind  patient  sufficient 
sight  to  return  to  iiis  home  unaided. 

Dufaure  warns  against  the  use  of  his  remedy  in  parenchymatous 
keratitis  tluring  the  intlauuiiatory  stages,  and  also  during  acute 
pannus. 

Gonime.     (F.)     Gum. 

Gomme  de  la  ccnjonctive.  (F.)  Gummatous  conjunctivitis;  gumma 
of  the  conjunctiva. 

Gommite.  (F.)  A  mucilaginous  gum;  a  term  for  all  gunnny  sub- 
stances. 

Gondole.     (F.)     Eye-cu[)  for  eye  douclies. 

Gondret,  Louis  Frangois.  A  French  ophthalmologic  charlatan,  iiorn 
at  Auteuil,  near  Paris,  July  12,  1776,  he  received  his  medical  degree  at 
Paris  in  1803.  He  was  physician  at  the  Third  Dispensary  of  the 
Philanthropic  Society,  Physician  to  the  Court  of  First  Instance,  etc. 
lie  advertised  extensively  a  derivative  salve  of  his  pretended  inven- 
tion, called  by  various  names,  such  as  "ponimade  ou  graisse  annuonia- 
cale,"  "caustique  amnioniacal,"  and  "liparole  ainmoniacal."  This 
he  pretended  would  (among  other  wonderful  effects)  cure  cataract 
without  operation.     He  died  in  September,  1855. 

Gondret  wa-ote :  1.  Observations  d'Amaurose  (Paris,  1821).  2.  Ob- 
servations sur  les  Maladies  des  Yeux  (Paris,  1823).  3.  Des  Effets  de 
la  Derivation  et  2°  Appendice  a  mes  Observations  sur  les  Affections 
Cerebro-Oculaires  (1832;  2  ed.,  1833).  -4.  Du  Traitement  de  la  Cata- 
racte  sans  Operation  (1839).— (T.  H.  S.) 

Gonelli,  Giovanni.  Also  called  Gambasius  and  Gambasio.  A  blind 
Italian  sculptor,  of  considerable  merit.  He  was  born  in  Tuscany  in 
1610,  and  died  in  1664.  He  lost  his  sight  at  the  age  of  twenty,  and, 
ten  years  later,  was  suddenly  seized  with  a  desire  to  become  a  sculptor. 
Besides  ideal  images,  he  carved  a  number  of  portraits,  tiie  most  remark- 
able of  which  is  that  of  Pope  Urban  VIII.— (T.  H.  S.) 

Gonflement.     (F.)     Swelling;  tumefaction. 

Goniometer.  Angulometer.  An  apparatus  for  measuring  solid  an- 
gles; especially  one  for  measuring  the  angles  formed  by  the  faces  of 
prisms  and  of  crystals. 

Goniometric.     Relating  to  the  measurement  of  angles, 

Goniometric  function.  The  value  of  an  angle  of  a  prism  or  crystal 
expressed  by  a  line  of  suitable  length  relative  to  an  assumed  radius, 
such  as  the  sine,  tangent,  etc. ;  a  trigoniometric  function. 

Goniometry.     The  art  of  measuring  solid  angles. 


5606  GONOBLENNORRHEA 

Gonoblennorrhea.  The  puiulcut  discharge  (Irom  the  eyes)  due  to 
infection  from  the  gonococcus. 

Ilerreschwand,  of  Innsbruck  (Graefe's  Archiv.  filr  Oplithal.,  Vol. 
82,  Part  2)  linds  that  airol  (l)isinuthoxyioditlegalhite  containing  24.8 
l)er  cent,  iodin)  added  to  the  culture  medium  in  1/10,000  concentra- 
lion,  conipk'tely  checked  the  develoi)ment  of  the  gonococci.  In  con- 
trast to  the  silver  salts,  the  antisejjtic  action  of  the  drug  is  enhanced 
by  sodium  chloi'id  and  albuminous  bodies.  Under  these  conditions 
a  coneentration  of  1/1,000  suffices  to  kill  the  gonococci  wilhin  half 
an  hour. 

The  germicidal  action  is  attri])utal)lc  in  part  to  the  desiccating 
action  of  the  bismuth  and  to  the  astringent  action  of  the  gallic  acid, 
but  above  all  to  the  liberation  of  free  iodin. 

While  the  silver  salts  impair  phagocytosis,  aii-ol  bi'ings  about  in- 
creased  i)hagocytic  activity. 

Gcnococcus.  (G.)  The  specific  organism  of  gonorrhea.  See  Bacteri- 
olog-y  of  the  eye. 

Gonococcus  conjunctivitis.  Oimithalmia  nkoxatorum.  Adult  gonor- 
rheal opiiTHALMLv.    See  Gonorrhea,  Ocular  relations  of. 

Gonocoque.     (F.)     Gonococcus. 

Gonorrhea,  Ocular  relations  of.  The  chief  local  manifestations  of  this 
disease  have  already  been  described  under  Bacteriology  of  the  eye; 
Blencrrhea  neonatorum;  Blindness,  Prevention  of;  Conservation  of 
vision;  as  well  as  under  such  headings  as  Conjunctivitis,  Purulent, 
and  Iritis,  Gonorrheal,  in  Avliich  the  local  infection  is  discussed,  but, 
as  yet,  little  has  been  said  of  the  general  disease  or  of  the  systemic  rela- 
tions of  the  ophthalmic  lesion.s  set  up  l)y  it.  It  is  proposed  here  to 
discuss  this  last  subject  in  particular. 

Diagnosis  of  systemic  gonorrhea.  .  Ajjart  from  a  inicroscopical  and 
cultural  examination  of  such  discharges  and  of  such  tissues  as  are 
available  for  the  purpose,  the  Bordet-Gengou  or  "complement-fixa- 
tion" test  seems  most  valuable.  J.  J.  Ower  (Canadian  Med.  Journ., 
p.  1074,  1914)  describes  this  reaction  as  depending  on  the  following 
factors:  (1)  Complement,  a  substance  present  in  all  blood  sera  and 
destroyed  by  heat  at  56°  C. ;  (2)  Amboceptor,  a  substance  present  in 
the  blood  serum  of  an  animal  which  has  been  immunized  against  (3) 
some  foreign  protein,  in  this  case  red  blood  cells  of  an  aninuil  of  a 
different  species.  If  two  sera  containing  certain  definite  proportions 
of  these  two  sulistanees  are  placed  together  in  the  presence  of  the  red 
l)lood  cells  of  an  animal  of  one  species  which  have  been  used  to 
immunize  another  animal  of  a  different  species  in  the  preparation  of 
the  aiid)()ceptoi',  the  result  will  be  a  destruction  of  these  red  cells — 


GONORRHEA,  OCULAR  RELATIONS  OF  5607 

hemolysis.     It  is  upon  this  hemolysis  that  tlie  complement  fixation 
test  depends. 

It  is  known,  howevei-,  that  under  certain  condilious  the  presence 
of  two  other  substances  will  inhibit  this  hemolysis.  Tiiese  are  (4) 
"antigen"  and  (5)  antibody.  Antibodies  comprise  certain  substances 
formed  in  the  blood  serum  of  individuals  sutlering  from  a  given  dis- 
ease, and  are  produced  as  the  result  of  the  specific  infecting  agent. 
The  antigens  for  these  antibodies  are,  strictly  speaking,  all  substances 
(of  proteid  nature)  which  when  introduced  into  an  animal  excite  the 
production  of  antibodies.  By  confusion  of  ideas  the  name  today  is 
also  applied  to  substances  which  have  some  of  the  chenncal  charac- 
teristics of  the  organism  or  agent  causing  any  i)articular  disease. 
Thus  we  speak  of  heart  or  liver  extract  as  a  syphilitic  antigen;  it 
having  been  found  that  these  can  replace  the  syphilitic  viiMis  in  the 
Wassermann  reaction. 

If  antigen  and  blood  sei-um  containing  its  specific  antibody  are 
added  to  complement,  and  these  addetl  to  amboceptor  and  red  blood 
cells,  then  the  antibody  and  antigen  combine  with  complement  in  such 
a  way  as  to  destroy  its  power  to  unite  with  amboceptor  to  cause  hemol- 
3'sis.  This  union  of  the  antigen  and  antibody  with  complement  with 
the  resulting  inhibition  of  its  power  to  destroy  red  blood  cells  is  called 
fixation  or  deviation  of  complement,  and  when  present  in  a  test  in 
which  a  suspected  serum  is  used  instead  of  a  known  antibody,  consti- 
tutes a  positive  reaction. 

This  is  a  somewhat  brief  explanation  of  the  conditions  required  for 
this  phenomenon.  Each  step  recjuires  scrupulously  careful  prepara- 
tion. It  has  been  found  by  experiment  that  fresh  guinea-pig  serum 
best  fulfills  the  requirements  of  a  complement.  Blood  serum  of  a 
rabbit  which  has  been  immunized  against  sheep  red  l)lood  cells  by 
repeated  intravenous  injections  of  snmll  quantities  of  fresh  sheep 
red  blood  cells  constitutes  or,  more  accurately,  contains  one  of  the  best 
ambocei)tors.  Sheep  red  blood  cells  must  of  course  lie  used  in  the 
complement  fixation  test  with  a  sheep  blood  amboceptor  because  the 
action  of  the  latter  is  specific.  Antigen  varies  with  the  disease  in 
question,  but  is  usually  an  extract  of  the  organism  which  causes  the 
disease.  The  antibody  is  of  course  the  unknown,  and  a  positive  com- 
plement fixation  test  proves  its  presence  in  the  serum  of  the  suspected 
individual  aiul  therefore  the  presence  of  the  suspected  disease  in  the 
individual. 

In  sunnning  up  the  results  of  our  experience  it  nuiy  be  said  that  the 
claims  of  recent  investigators  on  liehalf  of  the  test  seem  to  be  justified. 
The  test  is  specific  and  a  positive  reaction  with  a  propei-  te(hni(|ue 


5608  GONORRHEA,  OCULAR  RELATIONS  OF 

indicates  the  presence  of  a  gonorrheal  lesion.  On  the  other  hand, 
negative  results  are  not  so  valuable,  as  many  sera  from  cases  which 
are  undoubtedly  gonorrheal  give  negative  complement  fixation  tests, 
as,  for  example,  in  acute  urethritis,  where  the  reaction  is  practically 
always  negative. 

An  analysis  of  the  cases  seems  to  show  that  the  best  results  are 
obtained  where  the  lesions  occupy  sites  where  there  is  possibly  a  lack 
of  free  drainage.  This  is  borne  out  by  the  high  percentage  of  posi- 
tive results  in  arthritis,  salpingitis  and  prostato-vesiculitis.  These  are 
the  very  cases  in  which  diagnosis  is  often  extremely  difficult  and  it 
is  just  in  these  cases  that  the  test  is  of  most  value  in  indicating  the 
line  of  treatment  to  be  followed.  As  a  positive  reaction  undoubtedly 
means  the  presence  of  an  active  focus  of  gonococci,  its  presence  in  a 
clinically  cured  case  of  gonorrhea  W'Ould  necessitate  further  careful 
examination  of  the  case. 

E.  E.  Irons  {A7inals  of  OphtJialm.,  p.  771,  Oct.,  1913)  states  that 
in  addition  to  the  complement-tixation  test  we  have,  as  in  tuberculous 
infections,  a  general  reaction  which  can  be  elicited  by  the  introduction 
of  comparatively  large  doses  of  toxic  material  from  gonococcal  cul- 
tures. These  give  rise  to  malaise,  headache  and  a  certain  local  reaction 
at  the  site  of  the  injection,  together  with  a  focal  reaction  in  the 
affected  part.  Such  reactions  are  not  constant  in  gonococcus  infec- 
tions, but  occur  with  sufficient  frequency  to  be  of  some  value  in  diag- 
nosis. Then  there  is  the  local  subcutaneous  reaction  which  may  be 
obtained  by  a  smaller  dose  subcutaneously.  A  small  dose  in  a  normal 
individual  will  produce  little  or  no  reaction ;  in  an  infected  individual 
a  more  extensive  reaction.  This  line  of  diagnostic  work  has  been 
followed  out  pretty  carefully  in  the  German  clinics  in  the  pelvic  affec- 
tions of  women  and  has  been  found  to  be  of  considerable  value,  as 
confirmed  by  operation. 

Then  there  is  the  cutaneous  reaction  which  can  be  demonstrated  as 
in  tuberculosis  after  the  method  of  von  Pirquet.  Wliile  there  are 
certain  disadvantages  which  rather  decrease  the  value  of  this  method 
as  a  single  diagnostic  agent,  still  there  are  certain  advantages  in  the 
study  of  the  patient  by  the  cutaneous  reaction  in  the  use  of  glycerin 
cultures  of  the  gonococcus,  and  by  repeated  tests  we  can  determine 
that  the  immunity  curve  is  not  constant  but  goes  up  and  down,  and 
that  the  exacerbations  of  joint  lesions  and  the  temperature  are  coinci- 
dent or  follow  shortly  after  a  period  of  low  cutaneous  reactivity. 

Another  method  by  which  we  can  identify  rather  obscure  cases  of 
gonococcal  infection  is  the  cultural  method  of  the  various  secretions, 
particularly  those  of  the  prostate.     Although  it  is  rather  not  the  rule 


GONORRHEA,  OCULAR  RELATIONS  OF  5609 

in  urethral  infections,  the  prostate  may  remain  infected  for  a  h>iig 
time,  and  certain  metastatic  manifestations  in  the  joints  are  merely 
expressions  of  metastasis  of  the  organisms  passed  into  the  blootl  stream 
and  lodged  in  certain  vulnerable  spots.  So  that  in  cases  in  whidi  tlie 
etiologic  factor  is  not  evident  we  may  ai)])ly  these  four  tests  and  in  a 
certain  proportion  obtain  positive  results  in  cases  due  to  gonococcal 
infection. 

W.  G.  M.  Byers  {Studies  from  the  Royal  Victoria  Hospital,  Mont- 
real, Vol.  II,  No.  2,  1908)  concludes  Xhut  systemic  gonorrhea  most  com- 
monly occurs  in  males,  but  nothing  deiiuite  is  known  as  to  the  factors 
which  underlie  the  undoubted  predisposition  of  certain  individuals 
to  this  form  of  the  disease.  Pathological  evidence  seems  to  sliow  tliat 
the  gonococci  themselves  and  not  their  free  toxines,  or  the  secondary 
or  mixed  infections,  are  responsible  for  the  local  manifestations. 
Metastatic  inflammations  of  the  eye,  of  gonorrheal  origin,  are  marked, 
in  general,  by  uncertainty  and  irregularity  as  regards  tlieir  time  of 
occurrence,  the  severity  of  their  symptoms  and  theii-  coui-se  and 
behavior;  by  their  close  association  with  metastases  of  like  origin  in 
other  parts;  and  by  a  nuirked  tendency  to  relapse  and  to  recur.  Ocu- 
lar intiammations  are  often  the  first  manifestation  of  systemic  gonor- 
rhea, and  there  is  reason  to  believe  they  are  sometimes  the  sole  ex- 
pression of  this  condition. 

Metastatic  gonorrheal  conjunctivitis  is  a  well-established  clinical 
entity.  It  occurs  at  any  time  during  systemic  gonorrhea,  and  usually 
involves  both  eyes  simultaneously.  In  30  per  cent,  of  the  cases  the 
inflammation  is  complicated  by  affections  of  other  coats  of  the  eye. 

The  I'eratitis  whicli  occurs  in  association  with  systemic  gonorrhea 
is  of  a  multiple  and  superficial  cliaracter  and  connnonly  symmetrieal, 
and  central  in  situation. 

Cases  of  gonorrheal  sclero-conjunctivitis  ought  to  l)e  differentiated 
from  metastatic  conjunctivitis  and  classed  by  themselves. 

In  every  case  of  gonorrheal  iritis  the  pathological  process  is  not  lim- 
ited to  the  iris.  It  is  prol)ably  advisable  to  discard  the  term  iritis  for 
that  of  irido-cyclitis. 

Metastatic  gonorrheal  affections  of  the  uveal  tra^t  sliow  a  tendency 
to  be  bilateral  in  the  first,  as  compared  with  second  and  later  attacks, 
and  to  relapse  and  to  recur  with  fresh  gonorrheas.  They  precede, 
follow  or  accompany  other  manifestations,  or  form  the  sole  expression 
of  the  systemic  infection  ;  but  they  are  marked  by  no  sjiecial  features 
except  that  swellings  of  any  kind  in  the  iris  tissue  are  never  observed. 
Gelatinous  exudations  are  more  indicative  of  the  severity  than  of  the 
origin  of  the  inflammation. 


5610  GONORRHEA,  OCULAR  RELATIONS  OF 

The  metastatic  gonorrheal  mflammations  of  the  optic  iicrvc  and 
retina  conimonly  take  the  form  of  a  diffuse  iieufo-rctinitis,  associated 
at  times  witli  eoiisiderable  retinal  edema.  Pathological  evidence  favors 
the  blood  vessels  rather  than  the  lymph  spaces  as  the  principal  route 
for  infection. 

The  cases  of  dacrijo -adenitis,  wliich  have  been  attributed  to  systemic 
gonorrheal  infection,  conform  to  what  is  known  of  inflammation  of  the 
lachrymal  gland  in  general,  viz.,  that  wliile  eases  caused  by  direct 
extension  are  generally  unilateral  and  go  on  to  suppuration,  those 
produced  by  metastasis  are  usually  bilateral  and  end  in  resolution. 

Herrfordt  (Graefe's  Archiv.  f.  Ophthalm.,  72,  2,  190!))  observed 
23  cases  of  "endogenous"  conjunctivitis  in  2,310  patients  affected  by 
gonorrhea — just  one  per  cent.  The  proportion  was  smaller  in  women 
than  men,  and  relatively  larger  in  cases  of  recurrent  or  chronic  gonor- 
rhea. It  was  associated  relatively  often  with  arthritis.  Gonococci 
were  only  very  exceptionally  found  in  the  conjunctival  secretion. 
Compared  with  the  ordinary  or  "exogenous"  form  these  cases  run  a 
mild  course  and  are  easy  to  cure  though  apt  to  relapse  so  long  as  the 
gonorrhea  lasts.  The  inflammation  affects  the  bulbar  more  than  the 
palpebral  conjunctiva,  is  usually  bilateral  and  may  be  either  diffuse 
with  much  superficial  injection  or  localized  with  deeper  episcleral  in- 
jection. It  is  very  apt  to  take  the  form  of  a  phlyctenular  conjunctivi- 
tis and  in  these  cases  the  cornea  may  become  affected  as  in  phlyctenular 
keratitis. 

The  treatment  recommended  for  cases  without  secretion  is  daily 
massage  with  yellow  ointment,  for  cases  with  secretion  copper  sulphate 
solution  Vi  per  cent.  As  the  cases  are  rare,  their  cause  may  easily  be 
overlooked  and  the  important  thing  is  to  remember  that  an  uncured 
gonorrhea  is  liable  to  produce  this  among  other  ill  effects. 

There  are,  according  to  McKee,  of  IMontreal,  at  least  three  theories 
of  the  origin  of  metastatic  gonorrheal  conjunctivitis,  viz.:  that  it  is 
due  to  gonotoxiii,  to  the  toxin  to  wliicli  tlie  organism  gives  rise  and  not 
to  the  organism  itself;  that  the  original  infection  is  a  mixed  one  and 
that  the  conjunctivitis  is  caused  by  one  of  the  organisms  other  than 
the  gonococcus;  and  that  it  is  a  true  metastatic  infection,  the  gono- 
coccus  being  carried  by  blood-vessels  or  otherwise  from  urethra  to 
conjunctiva.  McKee  believes  that  he  has  Ihmmi  able  to  settle  the  matter 
and  prove  the  metastatic  theory  to  be  true  by  (iiuling  the  organism  in 
the  conjunctival  secretion.  The  case  which  afforded  him  his  material 
was  in  most  respects  a  typical  one — the  recent  gonorrhea,  the  sudden 
onset  ill  botli  eyes  at  once. of  a  muco-purulcnt  ro-njuuctivitis,  the  ab- 
sence of  any  serious  involvement  of  the  cornea,  the  marked  tendency 


GONORRHEA,  OCULAR  RELATIONS  OF  5611 

to  recurrence,  the  simultaneous  development  of  joint  involvement — all 
were  recorded  in  this  instance.  The  chief  point  lies  in  the  suceess — 
all  the  more  noteworthy  because  numerous  good  ol)servers  have  failed 
— of  the  endeavor  to  determine  the  presenee  of  gonococci  in  the  con- 
junctival secretion.  This  was  attended  with  great  difficulty  and  ncees- 
sitated  enormous  patience  on  tiie  part  of  the  observer.  For  example, 
at  the  first  visit  of  the  patient,  McKee  made  and  exhaustively  exam- 
ined eighteen  slides  unsuccessfully  before  lie  found  one  in  which  there 
were  at  one  part  a  very  few  organisms  resembling  gonococci  lying  in 
leucocytes.  Growth  on  hemoglobin  agar  (after  failure  with  other 
media)  showed  a  development  after  some  time  which  consisted  almost 
entirely  of  xerosis  bacillus,  but  in  it  were  a  few  small  areas  of  different 
aspect  from  which  the  desired  organism  was  obtained  and  gradually 
isolated  in  pure  culture.  This  was  by  several  tests  distinguished  fi-um 
micrococcus  catarriialis  (nose),  from  meningococcus,  a  urethral  micro- 
coccus, and  saprophytic  Gram-negative  diplococcus.  The  observer 
failed  to  discover  anj^  organisms  in  a  morsel  of  tissue  cut  from  the 
conjunctiva  during  the  stage  of  inflammation. —  {Ophthulmolog ij ,  July, 
19Ui).) 

Sidler-Hugenin  {Archives  of  Ophthalm.,  July,  1912)  reviews  twelve 
cases  of  metastatic  ocular  disease.  Of  these,  five  had  a  severe,  and 
four  a  mild  unilateral  metastatic  irido-cyelitis,  and  three  a  bilateral 
metastatic  conjunctivitis.  In  five  cases  gonococci  were  demonstrated 
in  the  blood,  whereas,  from  the  anterior  chamber  of  six  patients  with 
irido-cyclitis,  gonococci  were  cultivated  only  once.  In  this  particular 
case  the  disease  was  of  exceptional  severity. 

In  order  to  cultivate  gonococci  from  the  blood  or  anterior  chamber, 
the  author  advises  examination  during  the  time  of  highest  temperature, 
as  it  appears  likely  that  in  tlie  afebrile  period,  or  when  there  is  very 
little  increased  temperature,  the  gonococci  do  not  circulate  in  the  blood. 
He  recommends  the  use  of  as  large  a  quantity  of  material  as  possible. 

In  an  addendum  he  gives  two  cases,  one  of  his  own  and  one  of 
Haab's,  in  both  of  which  a  metastatic  abscess  formed  in  the  lid,  and 
though  this  burst  and  flooded  the  conjunctival  sac  ^\nth  gonococci,  no 
general  conjunctivitis  followed.  This  the  autlior  suggests  may  have 
been  due  to  the  prophylactic  use  of  silver  nitrate,  but  it  seems  not 
unlikely  that  these  particular  organisms  may  have  undergone  a  con- 
sideral)le  alteration  in  their  virulence. 

In  classifying  a  corneal  involvement  as  endogenous  keratitis  gouor- 
rlioica  the  following  requirements  must,  according  to  F.  Pincus  {Arch. 
f.  OphthaL,  ^larch,  1914)  l)e  present:  First,  the  presence  of  gonococci 
in  the  urethral  or  vaginal  discharge  at  the  time  of  onset  of  the  kerati- 
tis.    Second,   the  keratitis  must   not   be  the  only  manifestation  of  a 


5612  GONORRHEA,  OCULAR  RELATIONS  OF 

systemic  infection,  hut  citluT  preceding  or  following  the  keratitis  there 
must  be  some  other  form  of  gonorrheal  metastasis.  Third,  the  con- 
junctival secretion,  if  present,  must  be  negative  as  to  gonococci. 
Fourtli,  we  must  exclude  the  presence  of  a  scrofulosis,  occurring  witli 
a  gonorrhea,  which  might  be  the  cause  of  the  keratitis.  The  author 
does  not  believe  that  a  well-defined  clinical  picture  can  be  described. 

Finally,  it  must  not  be  forgotten  that  if  a  ijrimary  uretliral  or  vagi- 
nal gonorrheal  infection  may  poison  the  whole  system,  including  the 
eye,  infection  of  the  whole  organism  from  toxins  of  ocular  origin 
may  (tliougii  rarely)  also  occur.  Sydney  Stepiiensou  {Ophthal.  Rec- 
ord, Sept.,  1906)  believes  it  to  be  more  common  than  is  generally  sup- 
posed. He  reports  a  curious  example  of  general  sepsis  following 
probable  gonorrheal  ophthalmia.  It  was  a  case  of  antepartum  oph- 
thalmia in  which  the  gonococci  could  not  be  found.  Both  cornese  per- 
forated. One  month  after  birth  the  child  developed  multiple  abscesses, 
one  on  the  foot,  the  arm  and  the  hand.  They  were  opened  l)ut  no 
gonococci  found.  At  no  time  did  the  temperature  go  above  normal. 
The  child  recovered. 

Treatment  of  endogenous  ocular  gonorrhea.  The  conduct  of  sys- 
temic gonorrhea,  including  the  primary  infection,  really  belongs  to  the 
domain  of  the  general  practitioner,  yet  the  ophthalmologist  should 
keep  himself  informed  as  to  the  best  means  of  combating  the  disease. 
Perhaps  the  most  effective  treatment  of  the  general  toxemia  is  ser&pa- 
thy  (q.  v.).  For  example,  Harrison  Butler  {Ophthalmoscope,  Dec, 
1911)  reports  three  cases  of  gonorrheal  iritis  which  were  treated  witli 
antigonococcal  serum.  All  cases  had  resisted  the  ordinary  forms  of 
treatment,  such  as  atropin,  hot  fomentations,  sodium  salieylate,  etc., 
and  showed  marked  improvement  after  injection  of  the  serum. 

In  one  case,  two  injections  (2  cc.  each)  of  the  Parke-Davis  anti- 
gonococcal serum  were  followed  by  rapid,  complete  recovery. 

In  a  second  case,  the  first  two  injections  had  a  pronounced  effect 
upon  the  disease,  but  it  did  not  appear  to  be  lasting,  for  the  left  eye 
relapsed  slightly  and  the  right  became  inflamed.  The  last  injection 
acted  like  a  charm,  the  right  pupil,  which  before  would  not  dilate, 
within  twenty-four  hours  of  the  injection  became  fully  dilated  and  the 
iritis  rapidly  lost  its  acute  character.  The  second  injection  caused 
slight  symptoms  of  serum  disease,  urticaria  and  some  irritation  of  the 
skin. 

In  the  third  case,  one  injection  was  followed  by  a  disappearance 
of  symptoms.  Antigonococcal  serum  being  made  from  ram's  blood 
seems  to  be  more  likely  to  cause  serum  disease  tlian  the  ordinary  horse 
serum,  and  it  is  better  to  give  both  injections  within  a  short  inti-rval 
and  not  to  repeat  the  dose  more  than  once. 


GONORRHOISCHE  BINDEHAUTENTZUNDUNG  5613 

Arnold  Knapp  {Arch,  of  Oplithai,  Marcli,  p.  235,  1908)  reports  the 
results  of  treatnicnt  of  a  single  case  of  gonorrheal  iritis  with  Torrey's 
seruin.  The  patient  eontraeted  tlie  disease  two  and  one-iialf  years 
before,  and  had  suffered  from  inllaiiniiatiou  of  tlie  ankle,  knee,  hip, 
and  pericardium,  lie  iuul  three  attacks  of  iritis;  and  in  tlie  last  two 
— one  in  each  eye — received  injections  of  Torrey's  antigonococcic 
serum.  The  tirst  injections  aggravated  tlie  ocular  symptoms,  and  one 
of  them  was  followed  by  fever,  but  afterwards  the  eyes  cleared  up 
very  raj)idly.    Ten  injections  were  given  in  each  attack. 

Reber  and  Lawrence  (Ophthalmic  Record,  March,  1915)  report 
three  cases  of  iritis  as  a  manifestation  of  an  old,  latent  gonococcemia. 
In  each  instance  the  etiologic  diagnosis  was  not  entirely  rested  upon 
the  clinical  findings,  which  may  often  be  misleading,  but  was  firmly 
establislied  on  a  scientific  basis  by  the  use  of  the  complement-fixation 
test  for  Neisser's  organi.sm.  The  subsequent  treatment  with  bacterins 
and  serums  was  followed  by  results  prompt  and  gratifying. 

Gonorrhoische  Bindehautentziindung-.    (G.)    Gonorrheal  conjunctivitis. 

Gonzales  y  Morillas,  Don  Jose  Maria.  A  pathologist  and  ophthalmol- 
ogist of  Havana,  whose  life  dates  are  unknown.  He  wrote:  "Mono- 
grafm  OftaJmoIogica  6  Dcscripcion  dc  Todas  lus  Enfcrmedades  que 
Piicden  Padeccr  los  Organos  dc  la  Vision  y  Partes  Anexas  (2  vols., 
Habana,  1848-50).— (T.  H.  S.) 

Gocdland,  William.  An  English  surgeon  of  the  early  19th  century, 
who  ])ractised  at  Bolsaver,  Derbyshire,  and  Bury,  Lancashire.  He 
wrote  "Observations  an  Purulent  Ophthalmia"   (1810). —  (T.  H.  S.) 

Goose,  The.  The  gall  and  the  fat  of  the  goose  were  both  employed  as 
medicaments  in  ancient  Greco-Roman  ophthalmology.  Thus,  accord- 
ing to  Pliny,  the  gall  was  good  for  contusions.  The  fat  was  used  for 
a  menstruum,  in  the  manufacture  of  eye  salves,  and  was  also  thought 
to  possess  considerable  value  as  an  ocular  anesthetic.  An  especial  rep- 
utation as  an  ocular  "pain-killer"  was  had  for  many  centuries  by  the 
salve  called  "commagenum."  To  produce  this  valuable  article,  the 
grease  of  the  goose  Avas  mixed  with  cinnamon,  cassia,  white  pepper  and 
Valeriana  scabiosaefolia  in  a  vessel  cooled  with  snow. —  (T.  H.  S.) 

Gordon,  Bernard  de.  A  French  physician  of  Scotch  descent,  wlio 
received  his  medical  education  at  the  school  of  Salerno,  Italy.  The 
dates  of  his  birth  and  death  are  not  known.  He  taught,  however,  at 
Montpelier,  from  1285  to  1307.  He  wrote  in  1302  (1303  ?-5?)  a  work 
entitled  "Lilium  Medicime"  (Lily  of  Medicine).  This  is  a  kind  of 
medical  encyclopedia,  including  as  it  does  the  entire  pathology  of  the 
human  system.  In  1377  it  was  translated  into  French  under  the  title, 
"La  Pratique   de   Tres  Excellent   Doctcur  et  Maistrc   en   Medicine, 


5614  GORGE 

Jl(  riuird  de  Gordon,  qui  VAppcUc  Flcur  de  Lye  en  Medicine."  The 
ocular  jiortion  of  the  " Lilium"  includes  no  surgery  at  all.  When- 
ever a  surf^ical  matter  requires  mentioning,  Bernardus  simply  refers 
lis  to  a  " '  chiriirgus  literatus  et  expertus. "  However,  the  ocular  por- 
tion of  the  ^'Lilimn"  is  quite  an  interesting  affair.  First,  it  treats  of 
ocular  anatomy  and  physiology,  then,  in  successive  chapters,  the  dis- 
eases of  the  conjunctiva,  the  cornea,  the  uvea,  those  of  the  eye  through- 
out its  entirety,  and,  finally,  those  of  the  lids. 

What  he  says,  in  chapter  I,  about  the  nature  of  vision  possesses  an 
especial  historical  value.  "The  animal  spirit  called  the  visual, 
descends  by  the  optic  nerves  to  the  eye,  where  it  spreads  to  the  crys- 
talline humor,  and  then  to  the  interior  surface  of  the  eye ;  it  receives 
there  the  image  of  the  object,  which  has  been  brought  [i.  e.,  from 
without]  to  the  crystalline,  in  which  situation  is  produced  the  first 
modification  of  colors  (mutatio  colorum) ;  then  it  carries  the  repre- 
sentation of  the  object  (simulacrum)  as  far  as  to  the  common  sense 
[intelligence]." 

Bernard  is  said  to  have  been  the  first  medical  writer  to  mention  the 
use  of  spectacles.  Of  course,  the  word  "medical,"  in  this  connection, 
should  l)e  well  emphasized.  (Roger  Bacon  it  was  who,  in  his  "Opus 
Ma  jus," — almost  fifty  years  earlier  than  Gordon's  ""Lilium'' — first 
records — so  far  at  least  as  history  shows — the  value  of  convex  lenses 
for  those  who  are  old-  or  weak-of-sight.)  Gordon,  moreover,  adds 
that  he  knows  of  a  collyrium  which  renders  spectacles  unnecessary. 
His  words  on  this  head  are  indeed  of  so  great  historical  importance 
that  I  append  them  here  as  they  stand  in  the  original  Latin:  "Hoc 
collyrium  est  taiitas  virtutis  quod  decrepitum  faeeret  legere  litteras 
minutas  sine  ocularibus. "  So  the  printed  editions  run.  True  and 
Pansier,  however,  inform  us  that,  in  the  manuscripts,  the  expression 
employed  by  Bernardus  was  not  "oculare,"  but  "oculus  verrelinus" 
or  "oculus  berillinus" — i.  e.,  "eye  of  glass,"  or  "eye  of  beryl." — 
(T.  H.  S.) 

Gorge.      (F.)     Throat ;  neck;  gullet. 

Gorgcn.  The  early  Greek,  in  his  ritual,  had  a  hideous  nuisk — the 
Gorgoneion.  This  he  employed  to  scare  away  evil  things,  both 
enemies  and  ghosts.  Concerning  this  (mask)  head,  in  the  course  of 
time,  there  grew  up  a  considerable  mythology.  Poets  said  that  the 
Gorgoneion  was  the  head  of  a  certain  unspeakable  monster,  a  Gorgon. 
Homer  declares,  for  example,  that  the  Gorgon's  head  is  one  of  the 
terrors  of  Hades,  also  that  it  forms  the  center,  or  boss,  of  the  shield 
of  Jove.  Hesiod  has  three  Gorgons:  Stheno  {Valeria,  the  mighty), 
Euryale  (Lativolva,  the  wide-wandering)  and  Medusa  {Ouhcrna,  the 


GORRE 


5615 


ruler).  Tlioy  are  daugliters  of  the  sea-god  Pliorcys  by  liis  sister 
Ceto,  and  sisters  of  the  Graiie  ((i.  v.).  They  have  snakes  for  girdles 
and  hair,  and  the  glanee  of  an  eye  of  any  one  of  tliem  turns  the 
beholder  iumu'diately  to  stone.  See  Basilisk,  Cockatrice,  and  Vathek. 
Perseus,  on  aeeount  of  a  j)ronHse  rashly  given  to  Polydectes,  made 
an  expedition  against  ^ledusa,  the  only  one  of  the  Gorgons  who  was 
mortal.  First,  he  stole  the  eye  and  tooth  of  the  Graia;  (or  Phorcydes) 
and  tliese  he  would  not  I'eturn  until  these  sisters  of  the  Gorgons  had 
informed  him  how  to  procure  of  certain  nymplis  the  winged  shoes, 
the  magic  wallet  and  tlie  helmet  of  Pluto,  which  nmde  the  wearer 
invisible.  Having  actiuired  and  donned  these  ai'ticles,  he  took  the 
sword  (Ilarpa)  which  Hermes  had  given  him,  and  flew  to  the  place 
where  the  Gorgons  lay  asleep.  To  keep  from  being  turned  to  stone, 
he  looked  at  the  head  of  ]\Iedusa  as  this  was  retiected  in  his  shield, 
and  so,  guided  by  Athene,  he  smote  the  horrible  head  from  its  owner's 
shoulders.— (T.  H.'  S.) 

Gorre.     (F.)     An  old  name  for  syphilis. 

Gcssypium  acidi  borici.  Borated  cotton.  A  preparation  of  the  Loudon 
Throat  Hospital  containing  50  per  cent,  of  boric  acid. 

Gotta  serena.     (It.)     "Drop  serene."     Amaurosis. 

Gouetre.     (F.)     Goitre. 

Gouge  pour  corps  etrangers.  (F.)  Spud  for  the  removal  of  foreign 
bodies. 

Gouges,  Ophthalmic.  These  instruments  are  employed  for  the  removal 
of  bone  and  for  enlarging  openings  and  cavities  in  bony  tissue.    They 


Gouges  and  Raspatories  for  RemoviiiLt  Bone  and  in  Making  Lachrymal  Sac 

Openings. 


5616 


GOUGH,  JOHN 


are  made  of  many  shapes  and  sizes,  albeit  more  delicate  and  smaller 
than  the  majority  of  corresponding  instruments  used  in  general 
surgery.     See  the  figures. 


Gouges  and  Raspatories  for  Removing  Bone  and  in   flaking  Lachrymal  Sac 

Openings. 

Gough,  John.  A  celebrated  blind  instructor  of  sighted  pupils.  He  was 
born  at  Kendal,  AVestmoreland,  England,  and  at  the  age  of  two  was 
completely  blinded  by  smallpox.  When  six  years  old  he  was  sent  to 
the  School  of  the  Society  of  Friends,  where  he  seems  to  have  advanced 
more  rapidly  than  any  of  his  sighted  companions.  He  afterwards 
studied  mathematics  under  a  private  instructor,  a  Mr.  John  Slee. 

He  then  became  an  instructor  of  sighted  pupils,  and,  in  this 
capacity,  is  said  to  have  been  ' '  the  greatest  known  example. ' '  Among 
the  celebrated  scholars  who  once  were  under  his  tutelage,  were  Dalton, 
Whewell,  Gaskin,  King  and  Daws. 

Gough  wrote  numerous  articles  on  the  following  subjects:  botany, 
mechanics,  statics,  hydrostatics,  pneumatics,  acoustics,  electricity, 
magnetism,  zoology,  music  and  scotography.  These  appeared,  for  the 
most  part,  in  Nicholson^s  Journal  and  the  Memoirs  of  the  Literary 
and  Philosophical  Society  of  Manchester. 

Gough  died  in  1825,  aged  68,  and  was  buried  in  Kendal  church- 
yard.—(T.  H.  S.) 

Gouging.     The  violent  removal  (enucleation)  of  an  eye, 

Goulard's  extract.    See  Lead  water. 

Goulard,  Thomas.  A  well-knoAvn  French  physician,  surgeon  and  oph- 
tlialinologist,  introducer  of  "Goulard's  Extract,"  an  aqueous  solution 
of  the  subacetate  of  lead,  and  of  "Goulard's  Cerate,"  an  ointment 
^'ontaining  this  extract.  He  was  born  at  Saint-Nicholas-de-la-Grave, 
near  IMontauban,  France,  about  1724,  and,  at  an  early  age,  was 
appointed  demonstrator  royal  of  anatomy  and  surgery,  as  well  as 
surgeon-major,  at  the  IMilitary  Hospital  in  IMontpellier.     In  1740  he 


GOUT  5617 

became  a  Fellow  of  the  Academy  of  Surgery.  He  seems  to  have 
been  a  man  of  strongly  qiiackish  tendencies.  Ilis  subacetate  solution, 
to  which  he  gave  the  name  of  "A(iua  Vegeto-.Mineralis, "  he  com- 
mended as  a  well-nigh  infallible  cure  for  almost  every  disease  in  the 
nosology,  especially  for  those  of  the  eye  and  the  urethra. 

Ilis  principal  writings  are  as  follows:  1.  ^lemoire  sur  les  .Maladies 
de  rUretere  et  sur  un  Remede  Specifique  pour  les  Guerir.  (Mont- 
pellier,  17-16.)  2.  Lettre  de  M.  Goulard,  a  M.  de  la  .Martiniere  sur 
les  Bougies  pour  les  Carnosites.  (Montpcllier,  1751.)  3.  De  la  Com- 
position des  Bougies.  (Montpellier,  1751.)  4.  Traite  des  Maladies 
de  rUretere,  avec  le  Composition  des  DitTerentes  Especes  de  Bougies 
propres  a  les  Guerir  Radicalement.  (Montpellier,  1752.)  5. 
Remarques  et  Observations  Pratique  sur  les  Maladies  Veneriennes,  etc. 
(Montpellier  and  Pezenas,  1760.)  6.  Traite  sur  les  Etfets  des  Prepara- 
tions de  Plomb,  et  Principalement  de  I'Extrait  de  Saturne,  Employe 
sous  Differentes  Formes,  et  pour  Differentes  Maladies  Chirurgucales. 
(Montpellier,  1760;  Eng.  Trans.,  London,  1769  and  1775.)  7.  Oeuvres 
de  Chirurgie.     (2  vols.,  Paris,  1768  and  1767;  Liege,  1779.) 

Goulard  also  invented  a  number  of  surgical  instruments.     In  1772 
he  became  blind,  and,  in  1784,  he  died. —  (T.  H.  S.) 
Gout.     (F.)     Taste. 

Gout,  Ocular  relations  of.  Gouty  eye.  It  is  the  belief  of  Parsons 
{Pathology  of  the  Eye,  p.  1310)  that  the  role  of  gouty  affections  in  eye 
diseases  is  either  difficult  or  impossible  to  determine.  That  the 
diathesis  is  the  cause  of  some  of  these  conditions  can  scarcely  be 
doubted,  but  it  is  still  more  probable  that  many  are  due  to  intercurrent 
disease  and  are  modified  by  the  constitutional  disorder.  In  the 
present  unsatisfactory  state  of  knowledge  as  to  the  pathology  of  gout 
the  ocular  conditions  which  arise  can  only  be  enumerated.  Amongst 
them  are  [in  particular,  glaucoma  and  episcleritis  periodica  fugax] 
eczema,  tophi,  hyperemia,  and  edema  of  the  lids,  conjunctivitis,  scle- 
ritis,  sclerosing  keratitis,  band-shaped  opacity,  iritis,  cyclitis,  and 
choroiditis,  punctate  opacities  in  the  lens,  recurrent  vitreous  hemor- 
rhages, with  detachment  of  retina,  or  retinitis  proliferans,  retinal 
hemorrhages,  retinitis  punctata  albescens,  papillitis  and  retrobulbar 
optic  neuritis. 

Each  of  these  ocular  affections  will  be  found  fully  described  under 
appropriate  headings. 

Bull  (Ophth.  Year-Book,  p.  66,  1909)  says  the  deep  lesions  of  the 
eye  associated  with  gout  seem  to  be  increasing  in  frequency,  and  are 
very  destructive  of  vision.  They  are  seen  in  patients  past  middle 
age,  markedly  gouty,  who  lead  a  sedentary  life.     Advanced  cardio- 

Vol.  VII — iO 


5618  GOUTTE 

vascular  changes  are  always  present.  The  ocular  inflammation  he 
has  not  seen  simultaneous  with  an  arthritic  attack,  but  always 
associated  with  an  intestinal  attack;  and  the  urine  always  showed 
excess  of  uric  acid  and  indican.  Intraocular  hemorrhages  occur  early 
in  the  disease,  but  are  less  fre(iuent  later.  The  treatment  must 
modify  habits  of  life,  diet  and  exercise.  A  moderate  use  of  alcohol, 
well-diluted,  is  less  dangerous  tlian  the  use  of  tobacco.  In  giving 
vaso-dilators.  Bull  regards  the  sensations  of  the  patient  as  an  impor- 
tant guide.  Somewhat  related  to  the  condition  Bull  describes  are 
the  ocular  lesions  of  alimentary  constitutional  origin,  reported  by 
Ileilbron.  He  has  met  two  cases  of  severe  irido-cyclitis  preceded  by 
vomiting,  chill,  fever,  and  in  one  case  palpitation  of  the  heart  and 
unconsciousness.    See,  also,  Glaucoma;  and  General  diseases. 

Goutte.     (F.)     Drop  (of  a  liquid)  ;  also,  the  gout. 

Goutte  serene.     (F.)     Drop  serene.     Amaurosis. 

Gouttiere.     (F.)     Gutter;  groove. 

Gouttiere  lacryinale.     (F.)     Lachrymal  groove. 

Gower,  Sir  John.  A  famous  English  poet,  who  was  blind  in  the  latter 
portion  of  his  life.  He  was  born  in  1325,  and  was  therefore  a  con- 
temporary of  Chaucer.  He  was  a  man  of  great  learning,  and  was 
patronized  by  both  Richard  II  and  Henry  IV.  He  wrote  in  Latin, 
French  and  English.  His  best  known  works  are,  in  French,  "Specu- 
lum Meditantis;"  in  Latin,  "Vox  Clamantis;"  and,  in  English,  "Con- 
fessio  Amantis."  In  1397  he  married  Agnes  Groundolf.  Very 
shortly  afterward,  he  became  blind.  His  declining  years  were  spent 
in  the  Priory  of  St.  Saviour's,  Southwark.  There  he  died  in  1408; 
there,  too,  he  was  buried;  and  there  now  stands  his  monument. — 
(T.  H.  S.) 

Gowers'  pupil.  This  sign  is  occasionally  seen  in  tabes  dorsalis.  It 
consists  of  intermittent  and  abrupt  oscillations  of  the  iris  under  the 
influence  of  light,  and  is  found  mostly  before  the  total  loss  of  the 
light  reflex. 

Grab  backs.     See  end  of  heading  Eyeglasses  and  spectacles,  History  of. 

Grab  fronts.  Lenses  attachable,  usually  ])y  hooks,  to  the  anterior  surface 
of  permanently  worn  glasses  for  the  purpose  of  increasing  temporarily 
their  refractive  effect. 

Gracillimus  oculi.  (L.)  Gracillimus  orbits.  Comes  obliqui  supebi- 
ORis.  An  anomalous  accessory  superior  oblique  muscle  of  the  eye, 
resulting  from  the  separation  of  the  muscle  into  two  parts. 

Gradatim.     (L.)     By  degrees ;  step  by  step. 

Gradation  of  tone.  The  gradual  merging  of  one  tint  or  color  into 
another. 


GRADENIGO,  COUNT  PIETRO  DE  5619 

Gradenigo,  Count  Pietro  de.  A  famous  Italian  ophthalmologist.  He 
was  born  at  Venice  in  1831,  and  in  his  native  city  received  his  pre- 
liminary education.  When  seventeen  years  of  age  he  served  with 
distinction  as  a  volunteer  in  the  uprising  against  Austria.  He  studied 
medicine  at  Padua,  receiving  his  medical  degree  from  that  institution 
in  1855.  He  was  soon  appointed  assistant  in  the  Ophthalmic  Clinic 
in  the  same  city,  and,  in  1858,  surgeon  to  the  Venice  Hospital.  The 
latter  position  he  resigned  in  1868,  and  in  1873  was  appointed  to  the 
full  professorship  in  ophthalmology  in  the  University  of  Padua.  He 
died  Dec.  1,  1904. 

Gradenigo  is  said  to  have  introduced  the  ophthalmoscope  into 
Italy.  He  certainly  invented  a  special  form  of  the  clinical  thermom- 
eter and  of  the  stethoscope,  both  of  which  have  been  found  very 
useful.  He  wrote  a  large  number  of  articles  on  ophthalmologic  sub- 
jects; chiefly  ocular  antisepsis,  corneal  opacities,  the  extraction  of 
cataract,  and  digital  massage  in  various  diseases  of  the  eye.  His 
numerous  contributions  were  published  in  volume  form  in  1904  by 
two  of  his  pupils.  Ovio  and  Bonamico. —  (T.  H.  S.) 
Gradenigo 's  syndrome.     Paralysis  of  the  abducens  during  the  course 

of  an  acute  or  chronic  otitis.  See  Ear  and  eye,  Relations  of  the. 
Gradle,  Henry.  A  celebrated  ophthalmologist  of  Chicago,  author  of 
the  iirst  work  in  English  on  the  ''Germ  Theory."  He  was  born  at 
Frankfort-on-the-^Iain,  Germany,  August  17,  1855.  His  medical 
degree  was  received  at  the  Chicago  Medical  College  in  1874.  After 
an  interneship  at  Mercy  Hospital,  Chicago,  he  studied  in  Vienna, 
Heidelberg,  Leipsic,  Paris  and  London.  He  was  professor  of  Physi- 
ology in  the  Chicago  :\Iedical  College  from  1881  till  1895;  and  Pro- 
fessor of  Ophthalmology  and  Oto-Laryngology  in  the  same  institution 
from  1895  to  1906.  He  was  a  member  of  the  Chicago  Medical  Society, 
the  Chicago  Ophthalmological  Society  (of  which  he  was  once  Presi- 
dent), the  American  .Medical  Association,  and  the  Ileidelberger  Oph- 
thalmologische  Gesellschaft.  He  wrote,  as  stated,  the  first  work  in 
English  on  the  ''Gem}  Theory,"  and  also  a  "Textbook  on  the  Nose, 
Pharynx  and  Ear."  He  also  contributed  numerous  articles  to  Ameri- 
can and  German  periodicals.  •  As  an  operator,  he  was  unexcelled. 

Dr.  Gradle  was  a  man  of  unique  personality.  "The  Little  Giant," 
Dr.  G.  Frank  Lydston  called  him.  He  was  five  feet  one  inch  high, 
stockily  built,  and  with  a  very  large  head.  In  early  life  his  hair  was 
black,  curly,  and  abundant,  but,  as  his  years  advanced,  he  became 
almost  totally  bald.  His  reddish  mustache  was  never  tamed,  but 
wandered  at  will.  He  was  wont  to  declare  it  "a  virgin."  His  eyes 
were  brown  and  usually  very  serious,  though  any  incident  that 
appealed  to  him  aroused  in  them  a  merry  twinkle. 


5620 


GRADLE,  HENRY 


He  was  a  iiiau  of  rugged  eonstitulioii,  and  daily  for  over  thirty 
years  walked  to  and  from  his  office — nearly  two  miles.  Yielding  to 
physical  weakness  was  a  fault  he  could  never  condone  in  others,  as 
he  himself  was  never  known  to  complain. 


Henry  Ciiadle. 

His  manner  with  patients  was  brusque,  and  he  did  not  attempt  to 
ingratiate  himself.  But  his  worth  soon  revealed  itself  to  them,  and 
seldom  if  ever  did  his  patients  seek  other  sources  of  aid.  He  was  a 
counsellor,  and  they  came  to  him  with  their  woes  as  well  as  with 
their  ocular   pathology. 

His  recreations  were  very  few  and  simple.  Chief  of  all  was  scien- 
tific reading,  and  this  he  indulged  in  nicrhtly  from  9:30  to  12, 
propped  up  in  bed  and  smoking  a  cigar.  Not  alone  ophthalmolog\% 
but  general  medicine,  bacteriology,  neurology  and  especially  physi- 
ologj-^  and  physiologic  optics  were  among  his  favorite  subjects.  Helm- 
holtz  was  his  divinity,  and  he  discovered  passages  in  the  great  man's 


GRADUATED  TENOTOMY  5621 

writings  that  li;ul  been  entirely  overlooked  by  eveji  trained  physicists. 
His  other  recreations  were :  horseback-riding,  sea-bathing,  croquet 
and  walking.     Oiu-e  a  week  he  ])owled  with  a  few  old  friends. 

Jle  died  at  Santa  liarbara,  California,  April  4,  1911,  of  carcinoma 
of  the  bladder,  aged  55.  His  large  collection  of  medical  books  was 
left  to  tile  John  Crerar  Library,  at  Chicago.  He  also  left  to  the 
Crerar  l^ibrary  a  fund,  the  yearly  increment  of  which  is  devoted  to 
tile  purchase  of  journals  relating  to  the  eye,  ear,  nose  and  throat. — 
(T.  H.  S.) 

Graduated  tenotomy.  This  operation  (see,  also,  Muscles,  Ocular)  has 
been  practised  for  many  years,  but  the  question  of  its  value  still 
remains  a  subject  of  dispute.  The  toi)Ographic  relations  existing 
between  the  muscles  of  the  eyeball  and  the  eyeball  itself;  the  small 
result  sometimes  obtained  from  a  complete  division  of  a  tendon;  and 
the  slight,  at  times  negative,  etfect  upon  muscular  anomalies  even 
when  the  graduated  operation  has  been  repeatedly  performed,  all  are 
calculated  to  inspire  distrust  in  its  efficacy. 

In  those  exceptional  cases  where  attention  to  the  error  of  refrac- 
tion, to  the  development  of  the  ducting  power  of,  the  muscles,  and 
to  the  health  of  the  patient  fails  to  remove  undoubted  reflex  symp- 
toms, it  will  usually  be  found  that  there  exists  a  latent  phoria  which 
finally,  under  prismatic  correction  of  the  manifest  degree,  becomes 
total  and  suited  to  a  thorough  surgical  procedure. 

For  this  operation  special  instruments,  more  delicate  in  construc- 
tion than  those  used  for  complete  tenotomy,  have  been  devised  by 
Stevens.  A  small  fold  of  conjunctiva,  directly  over  the  insertion  of 
the  tendon,  is  seized  and  snipped  transversely  so  as  to  make  a  minute 
opening.  Into  this  opening  the  forceps  are  introduced  and  a  small 
fold  of  the  tendon,  immediately  behind  its  insertion  into  the  sclera, 
is  grasped  and  snipped.  One  blade  of  the  scissors  is  introduced  into 
the  opening  thus  made,  and  is  slipped  beneath  the  tendon,  which  is 
then  snipped  in  the  direction  of  one  of  its  borders,  to  such  an  extent 
as  may  be  deemed  necessary.  The  scissors  are  then  turned  in  the 
direction  of  the  opposite  border,  and  an  equal  extent  of  the  tendon 
divided.  The  effect  of  the  operation  is  then  determined,  and,  if  insuf- 
ficient, more  of  the  tendon  is  divided.  This  procedure  is  repeated 
until  orthoporia  is  produced. —  (J.  ^I.  B.) 

Giaduating  diaphragm.  Iris  diaphr.^gm.  A  diaphragm  so  arranged 
that  it  is  capable  of  concentric  enlargement  and  reduction  of  the 
aperture. 

Graduction.     Angular  subdivision  into  degrees,  etc. 

Graefe,  Albrecht  von.  One  of  the  greatest  ophthalmologi-sts  of  all  time, 
inventor  of  iridectomy  for  glaucoma  and  of  the  linear  operation  for 


5622  GRAEFE,  ALBRECHT  VON 

the  extraction  of  cataract.  lioni  at  Berlin,  Germany,  ]\Iay  22,  1828, 
the  son  of  Carl  Ferdinand  von  Graefe,  he  received  his  early  educa- 
tion at  the  French  Gymnasium  in  Berlin.  lie  then  entered  upon  the 
study  of  medicine  in  the  Berlin  University.  All  who  knew  him  in  his 
student  days  declared  him  to  be  a  man  of  incomparable  brilliancy. 
Aug.  21,  1847,  he  received  his  degree,  presenting  as  dissertation 
"De  Bromo  ejusque  Praeparatis."    In  1848  he  went  to  Prague,  where 


Albret'ht  von  Graefe. 

he  came  under  the  influence  of  Ferdinand  Arlt,  then  in  the  zenith 
of  ophthalmologic  glory.  To  Arlt  the  thanks  of  the  world  are  due 
for  directing  young  von  Graefe  into  ophthalmology  as  an  exclusive 
life  career.  After  parting  with  Arlt,  von  Graefe  spent  two  years  in 
Paris  under  Sichel  and  Desmarres.  Then,  for  a  time,  he  studied  with 
Jaeger,  Father  and  Son,  in  Vienna,  and  in  London  with  the  great 
Critchett  and  the  still  greater  Bowman.  In  London  a  beautiful 
friendship  sprang  up  between  Bowman,  Bonders  (of  Utrecht)  and 
the  young  von  Graefe — a  friendship  on  which  was  based  an  abundant 
three-cornered  correspondence  that  endured  till  the  death  of  the 
lamented  von  Graefe  at  the  early  age  of  42.  See  Bowman  and 
Bonders. 


GRAEFE,  ALBRECHT  VON  5623 

In  1850  von  Graefe  returned  to  Berlin,  being  now  an  epitome  of 
all  the  ophthalmology,  theoretical  and  practical,  that  existed  in  his 
day.  He  began  at  once  to  practise,  and  was  at  once  successful.  In 
1852  he  became  privat-docent  in  ophtlialraology,  presenting  as  his 
thesis  "Ueber  die  Wirkung  der  Augeninuskeln."  He  was  one  of  the 
first  to  employ  the  oplithalmoscope  after  its  invention  by  von  Helm- 
holtz  in  1851,  He  it  was  who  revived  and  improved  the  strabismus 
operation,  which  liad  fallen  into  disuse.  In  1854  he  founded  the 
"Archiv  fiir  Ophtlialmologie,''  which  marked  an  epoch  in  the  devel- 
opment of  ophthalmology.  His  investigations  into  the  nature  and 
extent  of  the  visual  field  were  followed  by  rich  results.  He  was  the 
first  to  show  that  "optic  nerve  paralysis"  was,  in  fact,  a  result  of 
inflammation  of  the  optic  nerve.  He  discovered  the  relation  which 
exists  between  cerebral  tumor  and  the  so-called  "choked  disc."  He 
was  the  first  to  recognize,  ophthalmoscopically,  the  conditions  result- 
ing from  embolism  of  the  arteria  centralis  retince.  His  discoveries  in 
connection  with  glaucoma  were  numerous  and  immensely  important. 
In  particular,  the  operation  of  iridectomy  *  as  a  means  of  treating 
glaucoma,  has  rendered  him  immortal.  The  modified  linear  extrac- 
tion of  cataract  (1866)  was  also  his  invention. f  For  the  performance 
of  this  operation  von  Graefe  invented  a  straight  and  narrow  knife, 
2  to  3  mm.  in  width,  which  is  still  almost  universally  employed  in  cat- 
aract extraction,  and  still  is  known  as  the  von  Graefe,  or,  incorrectly, 
the  Graefe,  knife.  The  linear  operation,  however,  is  now  very  seldom 
employed.  Its  purpose  was  to  obviate  suppuration — a  consummation 
still  to  be  devoutly  wished,  but  now  secured  (since  the  time  of  Lister) 
by  means  of  strict  asepsis. 

Von  Graefe 's  most  important  writings  are  as  follows :  ' '  Beitrage 
zur  Physiologic  und  Pathologie  der  Schief en  Augenmuskeln  " ;  "  Ueber 
Doppelsehen  naeh  Schieloperationen  und  Incongrueuz  der  Xetz- 
hiiute";  "Ueber  die  Diphtherische  Conjunctivitis  und  die  Anwendung 
des  Causticum  bei  Acuten  Entzlindungen " ;  "  Ueber  das  Gesichtsfeld 
bei  Amblyopic";  "Ueber  die  Iridectomie  bei  Iritis";  "Ueber  den 
Werth  Eiuseitiger  Cataraetextraction " ;  "Ueber  Lineare  Extraction"; 


*  He  (lid  not,  however,  invent  the  proeedure  itself.  The  honor  of  so  doings  be 
longs  to  Beer,  who,  in  1795,  both  invented  and  employed  this  operation  as  a 
means  of  forming  an  artificial  pupil,  the  C'heselden  operation  (1728)  having  been 
a  mere  iridotomy.  Von  Graefe,  however,  was  the  first  to  employ  an  iridectomy  as 
a  means  of  treating  glaucoma. 

i  He  was  not  the  first  to  perform  a  combined  cataract  extraction — that  is  to 
say,  to  employ  a  preliminary  iridectomy.  The  honor  of  having  so  done  belongs 
to  von  Mooren  of  Diisseldorf  (1864),  but  von  Graefe  was  the  first  to  do  the  com- 
bined linear  operation. 


5624  GRAEFE,  ALFRED  CARL 

"Schielen  und  Schieloperation";  "Ueber  Morbus  Basedowii";  "Die 
Iridectomie  bei  Glaucom";  "Ueber  Enibolie  der  Arteria  Centralis  Ret- 
inae"; "Neuritis  Optica  naeli  Cerebralkrankheiten";  "Ueber  Glaucom 
und  Iridectomie";  "Ueber  Calabar-Bohne " ;  "Ueber  Muskuliire 
Asthenopie";  "Ueber  die  Modifieirte  Linearextraction";  "Beitriige 
zur  Pathologic  und  Therapie  des  Glaucoms";  "Ueber  die  Operation 
des  Dynamischen  Auswartssehielens,  Besonders  in  Riicksicht  auf  Pro- 
gressive Myopie." 

Like  his  celebrated  cousin,  Alfred,  Albrecht  von  Graefe  was  always 
of  feeble  health.  This  valetudinarianism  was  very  much  increased  by 
his  enormous  activities — activities  which,  no  doubt,  were  always  some- 
what over-stimulated  by  the  presence  at  his  clinics  of  great  throngs 
of  students  and  practitioners  from  every  portion  of  the  civilized 
world. 

Von  Graefe  was  a  very  charitable  and  kindly  man.  All  his  patients, 
rich  and  poor,  high  and  low,  were  alike  welcome.  There  was  never 
the  slightest  discrimination.  All  were  met  with  gentleness  and  cour- 
tesy. 

Already  in  1858  von  Graefe  was  very  much  troubled  by  recurrent 
hemoptysis  and  pleurisy.  He  continued  to  work,  however,  until  he 
died — July  20,  1870,  At  the  time  of  his  death  he  was  still  a  young 
man,  being  only  42  years  of  age.  No  doubt  his  demise  was  hastened 
by  his  long-continued  overwork.  After  all,  however,  the  value  of  a 
life  cannot  be  measured  in  mere  years ;  and,  measured  in  kindliness 
and  courtesy,  in  stingless  charity  and  unhesitating  sacrifice  of  self, 
Albrecht  von  Graefe 's  mundane  existence  had  been  of  almost  infinite 
duration.— (T.  H.  S.) 
Graefe,  Alfred  Carl.  Cousin  of  the  more  distinguished  ophthalmol- 
ogist, Albrecht  von  Graefe,  and  nephew  of  that  distinguished  inventor 
in  the  field  of  general  plastic  surgery,  Carl  Ferdinand  von  Graefe.  Born 
Nov,  23,  1830,  in  the  castle  of  his  grandfather,  ]\Iartinskirchen,  near 
Miihlberg  a,  d.  Elbe,  he  studied  from  1850  to  1854  at  the  universities 
of  Halle,  Heidelberg,  Wiirzburg  and  Leipsiz.  His  medical  degree  was 
received  at  Halle  in  1854,  presenting  as  dissertation  "De  Canaliculo- 
rum  Lachrymalium  Natura."  From  1855-58  he  served  as  assistant 
to  his  cousin,  the  world-renowned  Albrecht  von  Graefe.  The  cousins 
were  nearly  of  the  same  age  (Alfred  being  the  younger  by  only  two 
years)  and,  until  the  death  of  Albrecht  at  the  early  age  of  42,  were 
fast  friends. 

In  1858  Alfred  became  privat-docent  in  ophthalmology  at  Halle, 
and  in  the  same  year  founded  the  "Klinik  fiir  Augenkranke" — at 
first  a  private,  but  later  a  public,  institution.    The  attendance  at  this 


GRAEFE,  ALFRED  CARL  5625 

hospital  was  enormous,  as  was  i)roi)i'i-ly  tlic  case  when  the  founder  and 
surgeon-in-chief  of  the  institution  held  a  record  of  400  cataract  extrac- 
tions without  the  loss  of  one  single  eye.* 

In  1864  Graefe  became  extraordinurius,  and,  in  1873,  ordinarius. 

To  Graefe  the  honor  belongs  of  introducing  into  opiithalmology 
Lister's  ideas  of  sterilization.  These  ideas,  of  course,  required  a  great 
deal  of  modification,  before  they  became  of  much  use  in  our  special 
field,  and  most  of  these  modifications  we  owe  to  Graefe.  Suppuration 
after  cataract  operations  at  once  became  a  thing  of  the  past,  or  at 
least  of  very  rare  occurrence. 

Graefe  was  also  the  first  to  observe  a  cysticercus  in,  and  to  remove 
one  from,  the  interior  of  the  eye.  This  was  very  soon  after  the  inven- 
tion of  the  ophthalmoscope  by  Helmholtz  (1851)  and,  in  a  very  few 
years  thereafter,  Graefe  had  constructed  a  highly  successful  "special 
localizing  ophthalmoscope,"  the  object  of  which  was  to  aid  in  the 
removal  of  cysticerci. 

Perhaps  his  most  important  writing  was:  "KUnische  Analyse  der 
Motilitatsstorungen  des  Augcs"  (Berlin,  1858),  which  still  remains 
a  very  useful  work.  From  1874  to  '80  he  published,  together  with 
Saemisch,  the  world-renowned  "  Graefe-Saemisch  Haiulhucli  der 
Gesamti  n  Aiigcnlieilkiinde.''  To  this  monumental  affair  he  contrib- 
uted the  article  on  "The  Disturbances  of  Motility-  of  the  E^'e." 

He  was  a  very  prolific  writer.  Among  his  numerous  contributions, 
not  already  mentioned,  the  following  are  most  important:  "  re])er 
Cysticercus-Extraetion  aus  den  tiefsteu  Theilen  des  Auges,  mit  Con- 
struction eines  Localizations-Ophthalmoskops";  "Ueber  Ischaeraia 
Retina"";  "Ueber  das  Binocularsehen  bei  Schielenden";  "Ueber 
Wundbehandlung  bei  Augenoperationen";  "Ueber  Extraction  Un- 
reifer  Staare";  "Ueber  Enucleatio  Bulbi";  "Ueber  Caustische  und 
Antiseptische  Beliandlung  der  Conjiinctival-Entziindungen,  mit  Be- 
sonderer  Beriicksichtigung  der  Blennorrhoea  Neonatorum." 

As  a  man,  Alfred  Graefe  was  upright,  honest,  amiable.  High  and 
low,  young  and  old,  alike  revered  and  honored  liim.  He  was  no  mere 
dry-bones  of  a  scientist,  but  was  ever  a  charming  companion,  a  loyal 
and  serviceable  friend.    He  wrote  a  good  deal  of  poetry,  and  had  he 


*  Graefe  seems  to  have  been  a  careful  refractionist,  as  well  as  a  brilliant 
operator.  Thus,  The  Ophthalmoscope.  July,  1908,  p.  560:  "Describing  the  life 
of  that  eminent  Scot,  Sir  Donald  N.  Wallace,  the  'World'  makes  a  singular  state- 
ment about  the  state  of  ophthalmic  knowledge  in  this  country  some  40  years  ago. 
Whih^  a  student  in  Ediniiurgh  in  the  early  (50  "s  Sir  Donald  found  that  he  was 
unable  to  read  for  more  than  a  few  minutes  at  a  time.  lie  accordingly  con- 
sulted 'the  best  men'  in  England,  but  it  was  not  until  he  saw  Graefe  in  Berlin 
that  the  cause  of  his  distress  in  the  shape  of  astigmatism  was  diagnosed  and 
remedied. ' ' 


5626  GRAEFE,  CARL  FERDINAND  VON 

not  chosen  to  become  an  ophthalmologist,  he  might  very  well  have 
been  a  poet  of  the  first  rank. 

There  was  really  a  good  deal  of  boyish  fun  in  iiim.  Thus  one  writer 
relates :  ' '  Having  removed  two  cysticerci  in  one  sitting  from  one  and 
the  same  eye  (July  12,  1892)  he,  in  a  jovial  manner,  announced  to 
his  friends  and  acquaintances,  elegantly  printed  on  a  gold-bordered 
card :    '  The  happy  delivery  of  two  lively  cysticerci. '  ' ' 

He  was  always  a  frail,  sickly  man,  and  was  accustomed  to  declare 
that,  but  for  the  constant  attention,  often  the  actual  nursing,  of  his 
wife,  he  would  never  have  accomplished  anything  worth  mentioning. 

Because  of  ill  health,  he  retired  in  1892  from  active  practice  and 
the  direction  of  the  "Klinik,"  and  returned  to  beautiful  Weimar. 
Here,  for  a  number  of  years,  he  continued  to  write.  He  died  at 
Weimar,  April  12,  1899. 

In  his  honor  was  founded  the  well-known  "Graefe  INIedal,"  a  mark 
of  distinction  conferred  "every  tenth  year  on  that  person  of  whatever 
nationality  who  has  done  most  to  advance  ophthalmology'. ' '  Two 
copies  of  the  medal  have  been  conferred :  the  first  on  H.  von  Helm- 
holtz,  the  second  on  Th.  Leber.— (T.  H.  S.) 
Graefe,  Carl  Ferdinand  von.  A  famous  general  surgeon  of  the  early 
19th  century,  the  father  of  Albrecht  von  Graefe  and  himself  a  well- 
known  ophthalmologist.  Born  at  Warsaw,  March  8,  1787,  the  son  of 
an  agent  of  Count  Moszynski,  he  pursued  the  study  of  medicine  at 
Dresden,  Halle,  and  Leipsic.  At  the  last  named  institution  he  received 
his  degree  in  1807.  In  1808  he  became  Court  Councillor  and  Body- 
Physician  to  the  reigning  duke  of  Anhalt-Bernburg- Alexius  in  Ballen- 
stedt.  Here  he  erected  a  hospital,  and  was  otherwise  very  active.  In 
1810  he  was  called  to  Berlin  as  professor-in-ordinary  and  director  of 
the  Clinico-Chirurgico-Ophthalmic  Institute.  His  long,  numerous  and 
very  important  services  to  the  army  we  cannot  here  enumerate.  In 
1826  he  was  ennobled  by  Czar  Nicholas  of  Russia,  and  the  honor  was 
recognized  by  his  own  king.  In  1830  he  was  called  to  London  to  treat 
Prince  George  of  Cumberland  for  an  ocular  affection.  Having  gone 
to  Hanover  for  the  purpose  of  performing  an  ophthalmic  operation 
on  the  Crown  Prince,  he  died  there  July  4,  1840. 

As  an  operator  on  the  eye,  C.  F.  von  Graefe  was  absolutely  unex- 
celled. He  was  also  a  brilliant  lecturer  on  ophthalmology,  and  a 
writer  of  no  mean  merit.  His  investigations  into  the  cause,  nature, 
and  cure  of  Egyptian  ophthalmia,  are  of  very  great  value  today,  and 
are  often  referred  to  by  ophthalmic  writers  when  treating  of  this 
disease. 

In  the  general  field  his  light  burned  still  more  brightly.     He  was 


GRAEFE,  EDWARD  ADOLF  5627 

the  first  ill  all  (jerniany  to  perform  a  staphylorrhaphy.  He  invented  a 
combination  of  the  Indian  and  tiie  Italian  methods  of  rhinoplasty — a 
procedure  which  still  is  known  under  the  name  of  "The  German 
Method."  He  was  the  first  in  Germany  to  tie  the  innominate  artery. 
He  invented  the  "compressorium"  for  the  meningeal  arteries,  the 
ligature-stafi',  an  operating-table,  the  eoreoncion,  and  numerous  other 
instruments  and  paraphernalia. 

His  most  important  writings  are:  1.  Angiektasie,  ein  Beitrag  zur 
Rationellen  Cur  uiid  Erkenntniss  der  Gefiissausdehnungen"  (Leip- 
sic,  1808).  2.  "Xormen  fiir  die  Ablosung  Griisserer  Gliedinassen  nach 
Erfahrungsgrundsiitzen  Entworfen"  (Berlin,  1812,  with  7  plates). 
3.  "Rhinoplastik,  oder  die  Kunst,  den  Verlust  der  Nase  Organiseh  zu 
Ersetzen"  (Berlin,  1818,  with  G  plates).  4.  Die  Gaumennaht,  ein 
Neuentdecktes  Mittel"  {Jour,  fiir  CJiir.  u.  Augcnh.,  1820).  5.  "Die 
Epidemisch-Gontagiose  Augen  bleiinorrlioe  Aegypteiis  in  den  Euro- 
piiischeii  Befreiungsheeren"  (Berlin,  182.'3). —  (T.  II.  S.) 

Graefe,  Edward  Adolf.  Younger  brother  of  Carl  Ferdinand  von 
Graefe.  Born  Ma}'  10,  1794,  at  Pulsnitz,  in  the  Kingdom  of  Saxony, 
he  studied  medicine  at  Halle  and  Berlin,  receiving  his  degree  at  the 
latter  institution  in  1817.  In  1820  he  settled  in  Spremberg,  but  five 
years  later  removed  to  Berlin.  He  was  rather  a  voluminous  contrib- 
utor to  the  literature  of  general  medicine,  and  composed  a  num])er  of 
papers  on  ophtlialmologic  subjects.  Of  these  the  most  important  is 
"Erfahrungeii  iiber  den  Lichtstrahlen  Brechende  Verinogen  der 
Durchsichtigeii  Gebilde  in  ]\Ieiischliehen  Auge"  (1820).  He  died  at 
Unruhstadt  in  the  Province  of  Poseu,  June  16,  1859. —  (T.  II.  S.) 

Graefe's  collyrium.  The  celebrated  coUyrium  adstringcns  lutcum.  It 
is  made  as  follows:  camphor,  10  grains;  alcohol,  1  ounce;  chlorid  of 
ammonium,  15  grains;  sulphate  of  zinc,  30  grains;  croci  pulv.  his- 
panici,  2  grains;  distilled  water,  5  ounces.  One  drop  of  this,  after 
filtration,  is  used  morning  and  evening. 

Graefe's  sickel  needle.  This  is  one  of  the  best  known  (and  one  of  the 
oldest)  knife-needles  for  the  discission  of  cataract. 


Graefe's  Siekle-Xeedle. 

Graefe's  sign  of  exophthalmic  goitre.  AVhen  the  upper  lid  only  im- 
])ei"feetly  follows  the  downward  movement  of  the  eyeball. 

Graefe's  spots.  Certain  spots  near  the  supraorbital  foramen,  or  over 
the  vertebrae,  which,  when  pressed  upon,  cause  a  sudden  relaxation 
of  the  orbicularis  in  cases  of  blepharo-facial  spasm. 


5628  GRAEFE'S  TEST 

Graefe's  test.  This  is  one  of  tlic  iiiuiicfous  prism  tests  i'or  feigned 
blindness,    See  Blindness,  Simulated. 

Grafting.  Grafts  in  oi'iiTiiALMic  .suuciKitv.  'I'iie  insertion  of  a  small 
portion  of  skin,  mucous  membrane,  etc.,  into  or  upon  a  raw  surface 
or  tissue  deficient  in  the  desired  structure,  or  so  placed  for  protect- 
ing or  increasing  the  bulk  or  area  of  the  parts.  The  various  methods 
ai-e  described  under  Blepharoplasty,  ]).  1040,  \^ol.  11,  of  this 
Encyclopedia. 

In  addition  to  the  matter  under  that  heading,  the  lip-membrane 
graft  for  the  relief  of  entropion  of  Gitford,  first  described  by  him 
{Am.  Journal  Ophthalm.,  Jan.,  1892)  and  afterwards  employed  by 
W.  0.  Maher  (Ophthalmoscope,  April,  1914),  is  worthy  of  mention. 
Giff'ord  recently  {Ophthalmoscope,  p.  698,  Dec,  1914)  draws  attention 
to  the  fact  that  before  1892,  Noisewski  had  advocated  the  grafting  of 
lip  membrane  into  the  under  side  of  the  lid,  but  this  was  for  the  cure 
of  inveterate  trachoma,  not  for  entropion.  The  trachomatous  parts 
of  the  tarsus  are  scraped  or  cut  away  and  membrane  put  in  its  place. 
Giff'ord  has  tried  it  in  a  few  cases,  and  can  testify  to  its  eifectiveness, 
when  extirpation  of  the  tarsus  is  not  desirable. 

The  technique  consists  in  making  an  incision  through  the  tarsus 
from  the  inner  surface,  about  3  mm.  from  tlie  free  margin.  This 
cut  is  made  to  gape  by  inserting  three  sutures  as  follows:  the  needle 
is  passed  through  the  outer  edge  of  the  free  margin  of  the  lid,  taking 
a  bite  rather  more  than  1/1 6th  inch  wide,  then  it  is  passed  through 
a  small  fold  of  the  lid-skin  about  .'V16ths  inch  farther  away  from 
the  lid-edge.  Before  the  threads  are  tied,  a  bit  of  wet  cotton  is  rolled 
into  a  hard  cylinder  about  3  cm.  long  and  5  mm.  in  diameter.  This 
is  slipped  between  the  loose  loops  of  thread  and  the  outer  surface  of 
the  lid  so  that  when  the  threads  are  tied  they  press  the  cylinder 
against  the  lid  and  evert  its  margin.  Into  the  tarsal  cut  thus  made 
to  gape,  one  can  introduce  either  a  Thiersch  flap  or  a  strip  of  lip- 
membrane,  and  if  a  little  hemorrhage  is  started  by  scratching  the 
sides  of  the  cut  here  and  there  (to  get  fresh  fibrinogen),  and  the 
graft  is  carefully  pressed  into  the  gap  with  a  moist  instrument,  it 
heals,  almost  invariably,  without  any  retaining  sutures.  See,  also, 
Cornea,  Transplantation  of  the. 

Graham,  James.  A  well  known  London  ])liysician,  M'ho  seems  to  have 
devoted  considerable  attention  to  the  eye.  His  only  ophtlialmologic 
writing  is  "Thoughts  on  the  Present  State  of  the  Practice  in  Disor- 
ders of  the  Eye  and  Ear,  etc."  (London,  1775).  The  date  of  his  birth 
is  not  known,  but  he  died  in  1830  at  a  very  advanced  age. —  (T.  H.  S.) 


GRAI^  5629 

Graise.  Literally,  "tlie  old  women."  Also  called  Phorcydes.  They 
lirst  appear  in  llcsiod  {Theug.)  and  are  by  hini  declared  to  be  daugh- 
ters of  the  sea-god,  Tliorcys,  by  his  sister,  Ceto,  and  sisters  of  the 
three  Gorgons.  They  are  beautiful,  well-dressed,  and  white  of  hair 
from  birth.  In  ^schylns  {from.  Vine.)  they  are  described  as  mon- 
sters, swan-shaped,  and  possessing  in  common  but  one  eye  and  one 
tooth,  which  neither  the  sun  nor  the  moon  had  ever  shone  upon,  and 
which  they  borrowed  from  one  another  as  occasion  demanded.  Some 
of  the  poets  make  them  guardians  of  tlie  Gorgons.  Their  names  are: 
Pephredo,  Enyo,  and  Dino. 

The  Graiie  have  been  thought  to  symbolize  the  clouds,  the  transfer- 
able eye  and  tooth  representing  the  flash  of  the  lightning  and  its 
rapid  interchange  from  one  cloud  to  another. 

For  the  connection  of  the  Phorcydes,  or  Graia',  witli  tlie  Perseus 
myth,  see  Gorgon. —  (T.  II.  S.) 

Graisse.     (F.)     Fat ;  oil ;  adipose  tissue;  ointment. 

Graisseux,     (F.)     Fatty. 

Gramia.     (L.)     Lippitudo. 

Gramme.      (L.)     A  line;  of  the  old  authors,  the  mai'gin  of  the  cornea. 

Grain's  fluid.  Gram  stain.  Gram's  method.  A  test  for  amyloid  liver, 
and  a  mordant  in  staining  for  tubercle-bacilli,  consisting  of  iodin  1 
part,  potassium  iodid  2,  Avater  300.  The  preparation  is  taken  from  the 
color-bath,  washed  and  plunged  into  this  solution  until  it  takes  a 
blackish  tinge,  then  washed  in  alcohol  until  deeolorization  is  complete. 
This  process  is  called  Gram's  method.     (Gouhl.) 

The  terms  Gram-positive  and  Grmn-negative  are  employed  to  indi- 
cate tlie  showing  or  otherwise  of  the  microbes  submitted  to  the  test. 

Granatapfel.     (G.)     Pomegranate. 

Granatum.     See  Pomegranate. 

Grand  canthus.     (F.)     Inner  canthus;  internal  canthus. 

Grand  cercle  de  I'iris.     (F.)     Annulus  iridis  ciliaris. 

Grand  mal.     (F.)     A  tei'm  for  fully-developed  epilepsy ;  major  epilepsy. 

Grando.     fO])s.)     A  small  tumor  of  the  eyelid;  a  chalazion. 

Grand  sympathique.     (F.)     The  sympathetic  nerve. 

Granny  knot.  A  double  knot  in  which  one  end  of  the  cord  in  the  second 
knot  is  passed  over  or  under  the  other  in  the  same  relative  position 
as  in  the  first  knot. 

Granular  conjunctivitis.  Grani'lar  lids.  "Granulated"  lids.  An 
acute  conjunctivitis  characterized  by  hyperemia,  serous  infiltration, 
swelling  of  the  papillary  portion,  increased  secretion,  and  the  develop- 
ment of  round,  grayish-red.  j)7'oniin(Mit  structures,  especiallv  in  the 
region  of  the  retrotarsal  fold  and  neigliboring  pari   of  the  palpebral 


5630  GRANULAR  LIDS,  SIMPLE 

conjunctiva.  These  undergo  definite  changes  and,  in  time,  frequently 
lead  to  secoiulary  changes  in  the  cornea  and  deeper  parts  of  the  lids. 
The  disease  is  usually  trachoma  {q.  v.). 

Granular  lids,  Simple.     See  Conjunctivitis,  Follicular. 

Granuloma.  Simple  granuujma.  (jIkaxlloma  simplex.  A  terra  used 
by  \'irchow  to  include  such  neoplasms  as  do  not  advance  beyond  the 
stage  of  granulation  tissue.  According  to  Parsons  {Pathology  of  the 
Eye,  p.  119)  simple  granulation-tis.sue  tumors  occur  frequently  as  the 
result  of  irritation,  ulceration,  or  injury.  They  are  particularly  com- 
mon in  chalazia  which  have  broken  through  the  conjunctiva  or  have 
been  incompletely  dealt  with,  and  in  tenotomy  wounds.  They  may  be 
sessile  or  definitely  polypoid. 

Microscopically  they  are  typical  granulation  tissue  with  its  great 
variety  of  cells,  amongst  which  all  kinds  of  leucocytes,  endothelial  cells, 
giant-cells,  and  young  connective-tissue  cells  are  found.  They  are 
richly  pervaded  by  very  thin-walled  new  vessels,  and  hemorrliages  are 
common.  It  may  not  be  easy  to  distinguish  them  from  inflamed  capil- 
lary nevi.  They  are  usually  uncovered  by  epithelium,  but  layers  of 
rapidl.y  growing  epithelium  often  partially  cover  the  peripheral  parts, 
and  islets  of  epithelium  are  often  enclosed,  especially  near  the  sur- 
face. 

They  often  bleed,  being  a  cause  of  "bloody  tears,"  and  they  also 
drop  off  as  the  result  of  the  movements  of  the  lids. 

Simple  granulomata  may  reach  a  large  size  and  project  between 
the  lids,  which  partially  strangle  the  pedicle.  The  head  is  then  edema- 
tous, and  the  microscopical  characters  are  not  unlike  those  of  myxom- 
atous tissue.  ]\Ioreover,  the  epithelium  covering  the  .surface  dips  into 
every  crevice  of  the  granulation  tissue,  so  that  the  appearance  of 
epithelioma  may  be  simulated. 

Granulation  tissue  often  accumulates  around  embedded  foreign 
bodies.  One  such  case  is  reported  by  Uhthoff' ;  the  patient  was  a  stone- 
mason, and  had  a  small  growth  on  the  conjunctiva  which  was  taken 
for  a  melanotic  sarcoma.  Examination  showed  it  to  consist  of  granu- 
lation tissue  with  giant-cells,  developed  around  quartz  particles  which 
gave  an  iron  reaction. 

Granuloma  g'ig'anto-cellulare  (of  de  Vincentiis).  This  is  a  synonym  of 
chalazion  or  Meibomian  cyst. 

Granuloma  iridis.  (L.)  The  name  first  given  by  von  Graefe  to  a 
small,  non-malignant  tumor  of  the  iris,  composed  of  a  highly  vascu- 
lar, small-celled,  fibrillar  (sarcoma-like)  tissue.  According  to  de 
Wecker,  this  disease  may  be  subdivided  into  simple,  spontaneous, 
telangeiectatic,  and  traumatic  forms. 


GRANULOMA  OF  THE  CONJUNCTIVA  5631 

Probably    the    great    majority    are    tubercular    in    character — as 
demonstrated  by  Ilaab.    See  Iris,  Tubercle  of  the;  as  well  as  Tuber- 
culosis of  the  eye. 
Granuloma  of  the  conjunctiva.     This  is  a  neoplastic  growth  resembling 
a  polypus.    Granulomata  differ,  however,  from  polypi  in  this  respect : 
they    are   not    covered    by   conjunctiva,    but    are   naked    granulation 
masses.     They  arise  from  surfaces  made  raw  either  by  ulceration  or 
by  operation.     They  are  often  found  after  an  operation  for  strabis- 
mus, enucleation,  or  chalazion.     They  cause  bloody  tears  and  many 
of  the  miraculous  instances  of  bloody  lachrymation  can  be  thus  ex- 
plained.    They  are  soft,  irregular  on  the  surface,  but  often  become 
smooth  from  friction.     They  may  expand  so  as  to  cover  one-half  the 
inner  surface   of  the   upper  lid.      They   should   be   removed   by   the 
scissors.    The  base  should  be  cauterized.     If  this  be  thoroughly  done, 
they  do  not  return. —  (J.  M.  B.) 
Granuloma  of  the  cornea.     A  very  rare  and  exceedingly  vascular  tumor 
described  by  a  few  of  the  older  writers  as  growing  from  the  limbus, 
and  considered  as.  jjorhaps,  similar  to  a  leueosareoma.     (Foster.) 
Granuloma  of  the  eyelid.     See  Eyelids,  Granuloma  of  the. 
Granuloma  of  the  retina.    Under  this  title  Thomas  and  Coats  {Trans. 
Ophth.  Soc.  i'nitcd  Kingdom,  xxxi,  p.  149,  1912)  report  a  mass  found 
in  the  retina  beside  the  optic  disk  and  showing  the  structure  of  a 
granuloma  and  other  evidences  of  inflammation.    The  lesion  was  noted 
immediately  after  an  attack  of  influenza,  when  a  bright  scarlet,  flat 
area,  surrounded  by  swollen  nerve  fibres,  was  observed  with  the  oph- 
thalmoscope.    The  patient  was  a  lad  of  18.     Later  the  retina  became 
detached,  and  the  eye  blind  and  painful,  requiring  enucleation. 
Grape-sugar.     See  Glucose. 

Grapheus,  Benevenutus,  of  Jerusalem  (also  called,  Benvengut,  Bene- 
ventus,  Yengut,  Grassus,  Grassi,  Grasso,  and  Ben  Vengut  de  Salerno). 
The  most  famous  ophthalmologist  of  the  Latin  (European,  or  Chris- 
tian) Middle  Ages,  and  the  author  of  the  first  monograph  on  diseases 
of  the  eye  printed  by  means  of  movable  types.  The  time  and  place 
of  his  birth  and  death  are  all  unknown;  Hsesar  believes  he  was  born 
in  Jerusalem.  It  is  likely  that  he  flourished  in  the  14th  century,  but 
Hirschberg  refers  him  to  the  middle  of  the  12th.  He  was  probably  a 
Jew ;  he  certainly  studied  at  Salerno,  and  quite  as  certainly  practised 
in  Italy  and  the  South  of  France.  He  wrote  a  book  on  diseases  of 
the  eye,  called  "Practica  OcuJorum,"  which,  for  centuries,  was  the 
standard  work  of  its  kind  throughout  Christian  Europe.  Numerous 
manuscripts  of  this  treatise  are  still  extant,  written  in  various  early 


5632  GRAPHOLOGY 

Western  European  languages,  as  well  as  in   Latin,  and,  as  early  as 
1474,  it  received  the  honors  of  print. 

Despite  its  great  and  long-standing  populai'ity,  however,  the  book 
possesses  but  little  original  value.  It  seems  to  have  owed  its  remark- 
able acee])tance  to  the  fact  tiiat  it  comprised  not  only  the  oculistie 
science  of  the  ancients,  but  also  that  of  the  Aral)ians.  We  should 
recall,  in  this  connection,  the  author's  Oriental  origin,  together  with 
the  fact  that  tiie  other  physicians  of  Western  Europe  at  that  time 
were,  for  the  most  part,  acquainted  with  the  writings  of  the  ancients 
only.— (T.  II.  S.) 

Graphology.  Tlie  science  of  diagnosticating  diseases,  such  as  aphasia, 
locomotor  ataxia,  etc.,  by  the  person's  handwriting. 

Graphoscope.  An  instrument  invented  by  Giraud-Teuloii,  a  convex 
lens  of  2  dioptres  refractive  power,  50  ctm.  focal  length,  and  10  or 
12  ctm.  aperture,  mounted  in  a  plane  parallel  to  the .  plane  of  the 
surface,  which  occupies  the  focal  point.  It  was  recommended  for  the 
treatment  of  asthenopia  due  to  esorphoria  and  of  progressive  myopia. 
This  term  is  also  used  to  designate  an  instrument  for  magnifying 
photographs,  etc.,  with  the  aid  of  a  single  lens. 

Gras.  (F.)  Fat;  fatty;  of  plant-organs,  succulent;  thick;  also,  a 
fatty  or  plump  structure  or  sul)stance. 

Grasmeyer,  Paul  Friedrich  Herman.  The  first  one  in  history  to  employ 
a  mydriatic  in  connection  with  diseases  of  the  eye.  Born  at  Hamburg, 
Germany,  he  received  his  medical  degree  at  Gottingen,  where  he  set- 
tled for  practice.  While  there  he  wrote  "Diss,  de  Conceptione  et 
Foecundatione  Humana"  (Gottingen,  1789),  "Abhandlung  von  Eiter 
und  den  Mitteln,  ihn  von  Allen  ihm  Aehnlichen  Feuchtigkeiten  zu 
Unterscheiden"  (Gottingen,  1790). 

Later  he  removed  to  his  native  Hamburg,  and  there  he  first  made 
use  of  belladonna  in  the  practice  of  ophthalmology.  In  the  presence 
of  Reimarus,  in  1796,  he  extracted  a  cataract  via  a  pupil  which  had 
been  dilated  for  that  purpose  by  means  of  belladonna. —  (T.  H.  S.) 

Grass.  GR.VMiNACEyE.  Grass  as  an  ophthalmic  remedy  is  recommended 
by  ])oth  Pliny  and  Dioscorides.  First,  the  grass  was  boiled;  then  to 
the  decoction  were  added  wine,  honey,  frankincense,  pepper  and 
myrrh.  Finally,  the  whole  was  boiled  again  in  a  copper  kettle.  The 
resulting  mixture  was  said  to  be  especially  good  for  epiphora. —  (T. 
H.  S.) 

Grasso.     See  Grapheus. 

Gratama's  test.  This  is  a  test  for  simulated  blindness  api^lied  by  means 
of  an  instrument  made  of  two  parallel  tubes.  Baudry  (Sj/stem  of 
Diseases  of  the  Eye,  p.  885)  describes  these  as  being  provided  at  both 


GRATING  5633 

ends  with  sliding  plates,  that  cut  off  a  part  of  the  width  of  the  tubes, 
and  in  which  there  are  rectangular  apertures.  Beyond  the  intersec- 
tion of  the  two  visual  lines  a  printed  scale  is  placed  in  front  of  one 
of  the  tubes  and  a  white  card  in  front  of  the  other.  The  transposition 
of  the  images  being  obtained  by  the  intercrossing  of  the  visual  lines, 
the  malingerer  reads  with  the  eye  that  is  declared  to  be  amblyopic 
what  he  thinks  he  is  reading  with  the  sound  eye.  To  this  apparatus 
have  been  added  two  three-degree  prisms,  placed  base  inward  inside 
the  tubes  near  their  ocular  ends  in  such  a  way  that  the  superimposed 
letters  form  words.  This  test  presupposes,  it  is  unnecessary  to  say, 
that  the  person  examined  enjoys  binocular  vision. 

Gratingf.  In  optics,  a  glass  minutely  ruled  with  fine  parallel  lines,  the 
whole  acting  to  produce  dispersion  of  chromatic  rays. 

Gratiolet's  bundle.     Optic  radiations  running  into  the  occipital  cortex. 

Grattag-e.     Tliis  method  of  removing  the  granulations  from  the  lids, 


Weeks'  Grattage  Knife. 

especially  in  trachoma  is  closely  allied  to  Brossage.  The  operation 
may  be  performed  with  a  pair  of  fixation  forceps,  a  three-bladed 
scarifier,  a  tooth-brush,  and  a  solution   (1  to  500)   of  bichlorid  of 


Trachoma  Rake  for  Grattage. 

mercury.  The  everted  lid  being  held  by  forceps,  the  surgeon  thor- 
oughly scarifies  the  conjunctiva  and  scru])s  the  incised  surface  with 
a  stiff  brush  soaked  in  the  bichlorid  solution.  Cold  applications  are 
to  be  used  for  a  few  days.  A  probe  is  used  daily  to  prevent  the 
formation  of  adhesions  between  the  palpebral  and  ocular  parts  of 
the  conjunctiva. —  (J,.  M.  B.) 

Other  methods  include  the  use  of  pummice  stone  employed  since 
the  days  of  Galen  (q.  v.).  sand  j^ajier  (Coover\  rough  dry  gauze 
(Webster  Fox)  and  similar  agents  thoroughly  rubbed  on  the  exuber- 
ant granulations  in  such  a  way  as  to  crush  and  remove  them  from 
their  beds  in  the  conjunctiva  without  serious  damage  to  that  mucous 
membrane.    See  Trachoma. 

Vol.  VII— 50 


5634  GRAUER  STAAR 

Grauer  Staar.     (G.)     Senile  or  gray  cataract. 

Graue  Salbe.     Gray  ointment.    See  Mercurial  ointment. 

Gravelle.     (F.)     An  old  term  for  chalazion. 

Graves'  disease.  See  Basedow's  disease;  as  well  as  Exophthalmic? 
goitre. 

Graves,  Robert  James.  A  famous  physician  of  Ireland,  by  some  con- 
sidered as  the  discoverer  of  the  so-called  Graves'  disease,  or  exophthal- 
mic goitre.  Born  at  Dublin  in  1797,  he  studied  at  Dublin,  London, 
Berlin,  Gottingen,  Hamburg,  and  Copenhagen.  In  1821  he  began  to 
practise  in  Dublin.  A  short  time  afterward,  he  founded  the  Park 
Street  School,  in  which  he  taught  medical  jurisprudence,  anatomy 
and  internal  medicine.  He  was  a  skilful  diagnostician,  and  a  teacher 
of  unquestioned  genius. 

He  was  physician  to  the  ^Meath  Hospital,  the  County  of  Dublin 
Infirmary  and  the  Hospital  for  Incurables.  In  1827  he  became  Pro- 
fessor of  the  Institutes  of  Medicine  at  King's  and  Queen's  College  of 
Physicians.  He  was  also  a  Fellow  and  Censor  of  the  College  of  Phy- 
sicians. 

For  ten  years  he  was  one  of  the  editors  of  the  Dublin  Journal  of 
Medical  and  Chemical  Science,  and  he  contributed  numerous  articles 
to  this  and  to  various  other  periodicals.  Among  his  best  known  books 
are:  1.  Clinical  Reports  of  the  Medical  Cases  in  the  Meath  Hospital 
and  County  of  Duhlin  Infirmary  during  the  Session  of  1826-27  (in  col- 
laboration with  Stokes;  Dublin,  1827).  2.  A  Selection  of  Cases  from 
the  Medical  Records  of  the  Meath  Hospital  (in  collaboration  with 
Stokes;  Dublin,  1827).  3.  Lecture  on  the  Functions  of  the  Lymphatic 
System  (Dublin,  1828).  4.  Clinical  Lectures  Delivered  during  the 
Sessions  of  1834-5  and  1836-7  (Philadelphia,  1838).  5.  A  System  of 
Clinical  Medicine  (Dublin,  1843 ;  various  editions  in  other  years  and 
countries).  6.  Clinical  Lectures  on  the  Practice  of  Medicine  (Dublin, 
1844).  His  chief  performance  was  the  discovery  of  the  symptom- 
complex  which  is  sometimes  called  Graves'  disease,  sometimes  Base- 
dow's disease,  and,  perhaps  most  frequently  of  all,  exophthalmic 
goitre.  For  a  discussion  of  the  question  of  priority  in  connection  with 
this  matter,  see  Basedow. 

Graves  died  March  20,  1853,  aged  56.  Twenty-five  years  after- 
ward, a  statue  was  erected  to  his  honor  in  Dublin. —  (T.  H.  S.) 

Gravidanza.     (It.)     Pregnancy. 

Graviditat.     (G.)     Pregnancy. 

Gravimeter.     An  instrument  for  the  measurement  of  specific  density. 

Gravimetric.  Pertaining  to  measurement  by  weight;  opposed  to 
volumetric. 


GRAY  DEGENERATION  5635 

Gray  degeneration.  A  term  commonly  applied  to  the  ophthalmoscopic 
appearances  of  certain  forms  of  optic  atrophy,  especially  in  tabes 
dorsalis. 

Gray,  Henry.  One  of  the  greatest  anatomists  of  all  time,  of  consider- 
able importance  in  ophthalmology  both  because  of  the  ocular  portion 
of  his  "Anatomy,  Descriptive  and  Surgical"  (familiar  to  students 
and  physicians  alike),  and  also  because  of  his  '"On  the  Anatomy  and 
Physiology  of  the  Nerves  of  the  Hum^n  Eye,"  which  brought  him,  in 
1839,  the  triennial  prize  of  the  Royal  College  of  Surgeons.  lie  was 
Professor  of  Anatomy  at  St.  George 's  Hospital  and  Assistant  Surgeon 
at  the  same  institution.  This  remarkable  man  died  at  the  early  age 
of  36,  in  June,  1861.— (T.  H.  S.) 

Gray  oil.  Oleum  cinereum,  A  semifluid,  fatty,  mercurial  liquid  intro- 
duced into  medicine  by  Lang,  of  Vienna,  in  1886.  It  is  used  in  the 
treatment  of  syphilis  by  injections.  It  is  prepared  as  follows:  A 
given  quantity  of  lanolin — 1  or  2  drams — is  rubbed  up  with  sufficient 
chloroform  to  emulsify  it.  This  mixture  is  to  be  thoroughly  triturated, 
during  which  operation  the  chloroform  will  evaporate.  While  the 
mixture  is  still  in  a  fluid  state,  metallic  mercury  to  the  amount  of 
double  the  quantity  of  the  lanolin  is  to  be  added,  the  trituration  being 
meanwhile  continued.  As  a  result,  a  pomade  of  mercury  is  left,  which 
represents  two  parts  of  mercury  and  one  part  of  lanolin.  This  is 
called  strong  gray  lanolin  ointment.  From  this  salve-basis  a  50  per 
cent,  oleum  cinereum,  or  gray  oil,  may  be  obtained  by  mixing  three 
parts  with  one  part  of  olive  oil.  A  mild  gray  lanolin  ointment  may  be 
made  in  the  same  manner  as  the  strong,  by  taking  equal  parts  of 
lanolin  and  mercury  and  thoroughly  mixing  them.  From  this  salve- 
basis  a  30  per  cent,  gray  oil  may  be  made  by  mixing  six  parts  with 
four  parts  of  fresh  almond-oil  or  olive-oil.     (Gould.) 

Gray  ointment.     See  Mercurial  ointment. 

Gray  powder.  ]\Iercury  with  chalk.  Hydrargyrum  cum  creta. 
Chalk  ^hxture.  Contains  mercury  38,  clarified  honey  10,  prepared 
chalk  57,  water  q.  s.  Dose,  gr.  ss-x;  generally  prescribed  in  children's 
diseases. 

Greater  canthus.     Inner  canthus. 

Green,  Admiralty.  Sec  Eyes  of  soldiers,  sailors,  etc.,  Examination  of 
the. 

Green  blindness.    Achloropsia. 

Green  cancer.     A  common  name  for  chloroma  (q.  v.). 

Green  cataract.     (Obs.)     Glaucomatous  cataract. 

Green  soap.     See  Soft  soap. 


5636        GREEN  SPOT  ABOUT  THE  MACULA 

Green  spot  about  the  macula.  Tliis  nwiculai'  plicnoinciioii  is  analogous 
to  the  brown  or  black  spot  seen  in  a  certain  percentage  of  myopic  indi- 
viduals. 

Stargardt  (Zeitschr.,  f.  Augenhcilk.,  p.  ."527,  April,  1!)12)  and  Har- 
rison Butler  have  both  described  this  rare  affection,  which  Butler 
considered  as  a  formation  of  a  hole  and  changed  coloring  matter  of 
the  blood.  Stargardt 's  i)atient  was  a  woman,  aged  28,  with  myopia 
of  17  D.,  annular  broad  staphyloma  and  diffuse  atrophy  of  the  fundus, 
which  contained  very  little  pigment,  except  at  the  macula.  In  the 
center  of  the  macula  was  an  irregular  quadrangular  patch,  l^o  disc 
diameters  across,  of  emerald-green  color.  It  was  sharply-defined, 
chiefly  by  a  seam  of  fine,  black  pigment,  corresponding  in  intensity  and 
lustre  to  the  tapetum  of  animals.  It  was  neither  depressed  nor  ele- 
vated, was  traversed  by  two  small  retinal  vessels,  and  the  choroid 
under  it  was  preserved,  since  choroidal  vessels  could  be  seen  passing 
under  it  and  emerging  from  it  at  the  other  side.  There  were  no 
hemorrhages.  A  macular  hole  could  be  excluded,  on  account  of  the 
preserved  retinal  vessels,  but  from  the  central  scotoma  a  destruction 
of  the  cones  and  rods  could  be  inferred. 

Stargardt  considers  the  affection  analogous  to  the  central  black 
spot  in  myopia  described  by  Fuchs,  and  as  found  anatomically  by 
Lehmus,  produced  by  a  proliferation  of  pigment  epithelium,  due  to 
a  progressive  nutritive  disturbance.  The  green  color  results  from  a 
proliferation  of  the  pigment  epithelium  which  at  the  same  time  loses 
the  greatest  portion  of  its  pigment.  The  proliferated  cell  mass  acts 
in  the  same  fashion  as  the  tapetum  cellulosum  of  carnivorous  animals 
which,  as  an  opaque  medium,  converts  the  black  color  into  blue-green, 
probably  as  an  interference  phenomenon.  The  blood,  circulating  in 
the  choroid,  gives  an  admixture  of  yellowish-red  to  the  bluish  tint 
and  tliu.s  produces  the  green  color.    See  Black  spot  about  the  macula. 

Greene,  Duff  Warren.  A  well-know^n  ophthalmologist  of  Dayton,  Oiiio. 
He  was  born  at  Fairfield,  Greene  County,  Ohio,  ]\Iay  17,  1851,  the  son 
of  Dr.  John  W.  Greene,  a  general  practitioner  of  that  place.  He 
attended  the  Ohio  Wesleyan  University,  at  Delaware,  Ohio,  for  two 
or  three  years,  but  did  not  graduate.  His  medical  degree  was  received 
at  the  Ohio  Medical  College,  Cincinnati,  in  1876. 

For  a  time  he  practised  general  medicine  at  Fairfield  in  partnership 
with  his  fatlier.  Then.  ])ursuing  the  study  of  oplithalmology  for 
several  months  in  New  York  City,  he  removed  from  Fairfield  to  Day- 
ton, where  he  practised  as  an  ophthalmologist  until  the  very  day, 
almost  hour,  of  his  d(>ath — more  than  thirty-one  years. 

In  1888  he  studied  ophthalmology  in  A'ieinia   for  six  months.     In 


GREENE,  DUFF  WARREN 


5637 


]!)09  he  went  to  Juluiulur,  India,  where  lie  made  a  speeial  study  of 
the  iiitraeapsidar  inetliod  of  eataraet  extraetion  as  i)raetised  by  Colonel 
Smith.  In  1!)12  lie  proeeeded  again  to  Kurope,  where  he  studied  the 
eye  in  various  liospitals  in  all  tlie  medieal  eenters. 

In  1884  he  was  api)ointed  oeulist  and  aurist  to  the  National  Mili- 
tary Home,  Oliio — a  j)osilion  wiiich  he  held  twenty-nine  years,  until 
his  death.  He  belonged  to  numerous  medieal  societies,  general  and 
speeial,  and  in  1912  was  nuide  a  mend)er  of  tlie  Oxford  Ophthalmo- 


Duff  Warren  Greene. 

logical  Congress.  For  the  last  ten  years  of  his  life  lie  was  associated 
in  practice  with  Dr.  Horace  Bonner. 

Dr.  Greene  was  a  voluminous  and  excellent  contributor  to  ophthal- 
mic literature.  Aside  from  numerous  journal  articles,  he  wrote  most 
valuable  chapters  on  the  intracapsular  operation  for  cataract,  in  Vol. 
II  of  Casey  A.  Wood's  System  of  Ophthahniv  Operations,  and  in  tliis 
Encyclopeclia. 

Dr.  Greene  was  a  man  of  great  enthusiasm  and  almost  limitless 
capacity  for  work.  Nevertheless,  he  was  not  what  is  termed  a  slave  to 
his  profession.  He  went  on  long  vacations,  in  summer,  in  the  northern 
portion   of  the   I'liited   States  and   in    Canada,   hunting  and   fishing. 


5638  GREEN,  JOHN 

Numerous  trophies  of  his  outdoor  skill  adorned  his  home.     He  was, 
for  a  time,  a  member  of  the  Ohio  State  Fish  and  Game  Commission, 

lie  was  a  member  of  Mystic  Lodge,  A,  F.  and  A.  :\I. ;  Unity  Clmpter, 
R.  A.  M. ;  the  Reed  Commandery  of  th(^  Knights  Templars;  and  of  the 
Antioeh  Temple  of  Shriners.  He  was  long  a  member  of  Grace  M,  E. 
Church,  and,  shortly  before  his  death,  was  elected  a  member  of  the 
official  board. 

In  1877  Dr.  Greene  married  Miss  Belle  Norton,  of  Delaware,  Ohio. 
Of  the  union  were  born  two  children,  both  of  whom  died  in  infancy. 
The  Doctor  died  Aug.  16,  1918. 

The  manner  of  Dr.  Greene's  death  was  touching  in  the  extreme. 
For  a  long  time  he  had  felt  distress  about  the  heart,  but,  in  his  strong- 
willed  way,  had  bravely  continued  at  work.  The  very  forenoon  of 
the  day  on  which  he  died,  he  went  to  his  office,  and,  attending  there  to 
certain  minor  matters,  proceeded  to  St.  JNlary's  Hospital,  and  there 
performed  an  important  surgical  operation.  Later  in  the  day,  accom- 
panied by  his  wife,  he  was  proceeding  in  his  automobile  to  one  of  tlie 
railway  stations  to  meet  a  number  of  friends.  But  the  hand  of  Des- 
tiny was  on  Dr.  Greene.  Just  before  they  reached  the  station  he 
besought  his  wife  to  halt  the  automobile,  so  great  had  become  the  pain 
in  the  region  of  his  heart.  She  did  as  he  requested,  and  the  Doctor, 
pillowing  his  head  on  his  wife's  shoulder,  passed  silently  aw^ay. — 
(T.  H,  S.) 
Green,  John.  A  well-known  ophthalmologist  of  St,  Louis,  ]\Io.,  inven- 
tor of  Green's  operation  for  entropium.  Green's  extirpation  of  the 
lachrymal  sac.  Green's  styles.  Green's  tendon-tucker.  Green's  test- 
types,  etc.  He  was  born  at  Worcester,  Mass.,  April  2,  1835,  the 
nephew,  grandson,  and  great-grandson  of  doctors,  all  of  whom  bore 
the  name  of  John  Green  and  all  of  whom  resided  at  Worcester,  Mass. 
The  subject  of  this  sketch  entered  Harvard  College  in  1851,  received 
the  degree  of  A.  B.  in  1855,  that  of  S.  B.  in  1856,  A.  M.  in  1859,  and 
M.  D.  in  1866.     From  1858- '60  he  studied  medicine  in  Europe. 

In  1857  he  accompanied  Prof.  Jeffries  Wyman  on  a  scientific  expe- 
dition to  Surinam.  Four  years  later  he  began  to  practise  medicine 
in  Boston.  In  1862  he  served  on  the  Western  U.  S.  Sanitary  Com- 
missions, and  was  for  a  time  acting  assistant  surgeon  in  the  armies  of 
the  Tennessee. 

He  was  a  delegate  to  the  American  Medical  Association  in  1864, 
1865,  1873  and  1877. 

In  1865  he  went  again  to  Europe  for  further  study  in  ophthalmol- 
ogy, and  on  returning  to  America,  removed  to  St.  Louis.  There  he  at 
once  became  a  successful  and  influential  opiithalmologist. 


GREEN,  JOHN 


5639 


Dr.  Green  was  made  a  member  of  the  American  Ophthalmological 
Society  in  1866,  and  was  one  of  the  charter  members  of  the  American 
Otological  Society.  lie  was  a  member  of  the  International  Ophtlial- 
mological  Congress  in  1872,  a  delegate  to  the  International  ^Medical 
Congress  in  1876  and  secretary  in  that  congress  to  the  section  on 
ophthalmology. 


John  Green. 


He  was  appointed  full  professor  of  ophthalmology  and  otology  in 
the  St.  Louis  College  of  Physicians  and  Surgeons  in  1866,  lecturer  on 
ophthalmology  in  the  St.  Louis  Medical  College  in  1871,  surgeon  to 
the  St.  Louis  Eye  and  Ear  Infirmary  in  1872,  consulting  ophthalmic 
surgeon  to  the  St.  Louis  City  Hospital  in  1872,  and  ophthalmic  sur- 
geon to  St.  Luke's  Hospital  in  1874. 

He  married  Harriet  Louisa,  daughter  of  George  W.  Jones,  of  Tem- 
pleton,  Mass.  ]\Iiss  Elizabeth  Green  and  Dr.  John  Green,  Jr.,  of  St. 
Louis,  are  their  children. 


5640  GREEN,  JOHN 

Dr.  Green  died  at  his  home  in  St.  Louis,  Dee.  7,  1913,  and,  with 
his  passing,  there  was  removed  the  last  of  that  great  early  western 
trio — Holmes,  of  Chicago;  Williams,  of  Cincinnati;  and  Green,  of 
St.  Louis. 

Dr.  Green  was  low  in  stature,  of  full  habit,  short-bearded,  rapid 
and  curt  in  his  speech,  supersensitive,  irascible,  yet,  withal,  extremely 
kindhearted.  He  was  somewhat  feared  by  many  of  his  students,  but 
was  also  greatly  respected  and  liked  by  all  of  them.  Indeed,  he 
received  from  them  the  crowning  mark  of  affection — a  nickname — 
"Johnny." 

I  cannot  close  this  sketch  without  the  quotation  of  two  or  three  anec- 
dotes about  this  most  remarkable  and  highly  individual  man.  The 
first  of  the  stories  is  by  Dr.  Washington  E.  Fischel : 

''We  will  admit  that  Dr.  Green  was  severe,  yes,  a  trying  taskmaster 
with  those  who  thought  they  were  entitled  to  preferential  consideration 
and  forbearance.  He  was  often  wearied  by  unnecessary  questions 
and  irrelevant  statements  when  in  the  midst  of  a  tremendously  busy 
day's  work.  It  was  then  that  he  would  burst  out  in  exclamations  that 
would  strike  hard  and  cut  deep  into  the  vanity  or  self-conscious  pride 
of  the  offending,  or — better  said — the  off'ensive  questioner.  On  one 
occasion  the  wife  of  a  prominent  townsman  was  particularly  insistent 
in  plying  absurd  questions  and  volunteering  her  diagnosis  of  her  eye 
condition.  Dr.  Green  at  first  politely  requesting  her  not  to  disturb 
or  distract  him  by  needless  questioning  and  personal  experiences, 
finally  told  her — still  politely,  the  story  goes — that  he  much  preferred 
to  have  nothing  more  to  do  with  her.  The  woman,  nothing  daunted 
by  his  refusal  to  continue  his  professional  services,  proved  not  averse 
to  go  on  with  her  dissertation  on  her  case.  That  proved  too  strong  a 
temptation  for  an  honest  expression  of  his  conviction.  Looking  up 
from  his  record  of  another  case  to  which  he  had  in  the  meantime 
directed  his  attention,  he  burst  out  with  the  exclamation:  'Madam, 
go  home  and  tell  your  husband  he  has  a  fool  for  a  wife. '  Who  but  Dr. 
Green  could  have  dispatched  such  a  message  to  a  husband  by  such  a 
messenger?  I  relate  this  story  as  illustrative  of  the  courage  of  our 
friend.  Perhaps  undiplomatic ;  but  the  applied  epithet  was  correct, 
as  on  a  subsequent  occasion  the  husband,  in  a  small  gathering  of 
friends,  admitted  the  fitness  of  Dr.  Green's  allegation." 

The  second  of  the  anecdotes  is  also  by  Dr.  Fischel :  "I  recall  with  a 
feeling  of  great  affection  for  Dr.  Green  an  act  of  sympathetic  consid- 
eration, of  the  big,  warm-heartedness  and  helpfulness  of  the  man. 
Some  years  ago  Dr.  Green  appeared  at  my  house  at  two  o'clock  in  the 
morning.    It  was  a  bitter  cold  night.    Apologizing  for  awakening  me, 


GREEN,  JOHN  5641 

he  asked  whether  I  would  see  one  of  his  poor  patients  with  him,  whom 
he  feared  was  seriously  ill.  1  accompanied  him  to  a  boarding  liouse, 
where  in  a  very  small  rear  room,  overheated  and  practically  impossi- 
ble of  ventilation,  I  found  an  old  woman  in  an  attack  of  pneumonia. 
There  was  no  one  on  hand  to  care  for  her.  This  is  what  happened. 
Dr.  Green  called  the  landlady,  and  finding  out  that  a  large  front  room 
was  unoccupied,  immediately  engaged  it,  and  the  patient  was  forth- 
with carried  into  comfortable  lodgings.  He  promised  the  attendance 
of  a  trained  nurse  later  in  the  morning,  and  in  the  meantime  assumed 
the  responsibility  of  carrying  out  my  instructions.  There  was  no 
chance  for  me;  the  poor  woman  had  in  the  first  instance  put  herself 
in  his  care,  and  it  was  his  privilege  as  well  as  his  duty  to  tide  her  over 
that  night.  No  reasoning  to  the  contrary  would  prevail.  It  was  truly 
a  benediction  to  witness  his  tenderness  and ,  kindness ;  how  he  gladly 
deprived  himself  of  a  well-earned  sleep  to  minister  to  this  suflTering 
fellow  creature  without  a  thought  of  self.  It  was  ever  so.  lie  was 
always  pedantically  conscientious  in  his  professional  attention  to  those 
who  came  to  him  without  means,  without  prestige — just  to  him — 
knowing  that  they  would  receive  at  least  as  skilled  and  kindly  atten- 
tion as  the  more  fortunate  of  human  kind. ' ' 

The  third  of  the  stories  is  by  E.  A.  Engler,  LL.  D. :  "When  Dr. 
Green  was  approaching  the  age  of  sixty  years,  that  is  to  say,  when  I 
was  some  twenty  years  or  so  younger  than  I  am  now,  he  called  on 
me  one  afternoon  in  my  ofifice,  as  he  was  in  the  habit  of  doing  from 
time  to  time  when  he  wished  to  get  away  from  his  grind,  and  his  occu- 
pation permitted,  and  said  to  me  quite  familiarly,  'John'  (and  he 
called  me  'John'  because  that  was  not  my  name),  'I  have  come  to 
make  a  confession  to  you  and  to  ask  your  help.'  I  replied,  'Well,  Dr. 
Green,  both  phases  of  that  statement  interest  me  very  much.' 

"  'You  know,'  said  he,  'when  I  was  a  youngster  I  went  to  Harvard 
College  for  an  education.  Now  you  may  not  have  discovered  it,  but 
it  is  a  fact,  tliat  the  teaching  in  Harvard  College,  and  especially  the 
teaching  in  mathematics,  has  improved  since  I  was  a  college  student.' 

"To  this  I  replied,  'I  hope,  Doctor,  that  what  you  say  is  true, 
because  I  myself  am  engaged,  and  have  been  all  my  life  engaged,  in 
attempting  to  improve  the  teaching  of  mathematics.' 

' '  He  continued,  "  We  had  a  prescribed  course  of  study  in  those  days, 
and,  therefore,  I  had  to  study  mathematics.  I  suppose  I  had  about 
as  much  brains  as  the  rest  of  the  fellows :  at  all  events,  I  did  not  con- 
sider that  I  was  a  fool ;  but  they  had  a  habit  of  turning  loose  on  us  the 
young  fellows  who  had  .just  graduated  from  the  college  the  year  before 
and  thev  were  to  teach  us  mathematics.    As  vou  know,  I  have  the  kind 


5642  GREEN,  JOHN 

of  mind  that  is  not  satisfied  by  a  statement  which  I  do  not  understand. 
A  lesson  would  be  assigned  to  us  from  a  text-book  and  we  would  be 
expected  to  come  to  the  next  exercise  with  that  lesson  learned.  1  used 
to  try  for  a  while  to  learn  the  lessons,  but  had  difficulties.  Then  I 
would  come  to  the  instructor  for  help ;  I  was  invariably  told  to  go  and 
read  the  book.  I  had  tried  to  read  the  book  and  could  not  understand 
it,  and  it  was  clear  to  me  that  the  teacher  did  not  understand  it 
because  he  was  unable  to  help  me.  Finally  I  concluded  there  was  no 
use  in  my  attempting  to  learn  mathematics.  Not  getting  any  good 
out  of  it,  I  became  disgusted  with  the  whole  field  of  mathematics  and 
so  would  do  only  the  work  required  so  as  to  pass.  The  way  I  did  this 
was  not  to  w^ork  at  all  during  the  ordinary  term,  but  a  week  or  two 
before  the  examination  I  hired  a  coach.  He  was  a  shrewd  man,  who 
knew  what  questions  would  be  asked  at  the  examination,  and  was 
skillful  enough  to  fill  me  up  with  the  correct  answers ;  and  in  that  way 
I  scraped  through.  So  I  got  through  Harvard  and  received  my 
bachelor's  degree.  I  thanked  my  stars  I  did  not  have  to  bother  with 
that  matter  any  more ;  that  was  behind  me. 

"  'You  know  I  profess  to  be  an  oculist,  and  have  been  doing  some- 
thing in  that  line  for  a  number  of  years;  and  now  I  am  confronted 
with  a  curious  situation.  I  find,  especially  of  late,  that  not  only  are 
nearly  all  the  advances  that  are  made  in  my  science  expressed  in  the 
publications  in  mathematical  formulae,  which  I  cannot  read,  but  even 
the  text  is  so  stated  that  it  means  very  little  to  me,  and  I  really  don 't 
know  what  I  am  to  do.  There  is  another  phase  of  it.  I  have  got  a 
number  of  things  in  my  head  which  I  would  like  to  express  to  other 
people  and  I  find  that  I  cannot  do  it  because  the  expression  of  them 
requires  a  knowledge  of  technical  mathematical  language.' 

"I  listened  with  great  interest  to  this  story  and  I  said,  'Well, 
Doctor,  what  do  you  want  me  to  do  ? ' 

"He  said,  'I  want  you  to  tell  me  how  I  can  learn  mathematics.' 

"I  replied,  'Doctor  Green,  I  can  tell  you  very  simply  how  you  can 
learn  mathematics.' 

* '  I  told  him  that  at  the  University  of  Berlin,  while  I  was  there,  one 
of  the  most  distinguished  mathematicians  in  the  world  began  a  series 
of  lectures  by  this  statement  (in  German,  of  course ;  I  will  translate 
it),  'Mathematics  is  the  science  of  things  that  are  self-evident.' 

"So  I  said,  'That  being  the  correct  definition,  and  I  thoroughly 
agree  with  it,  you  can  learn  mathematics  very  easily;  but  I  know  no 
high  road  to  that  accomplishment.  The  only  way  is  to  begin  at  the 
bottom,  if  necessary  go  through  the  drudgery,  and  you  will  learn  it 
in  spite  of  yourself.' 


GREEN,  JOHN  5643 

"  'Well,'  he  said,  'that  is  what  I  want  to  do;  but  1  want  you  to  tell 
me  how  to  do  it. ' 

"  'Very  well,'  I  replied;  'if  you  are  iu  earnest  I  am  ready  to  help 
you. ' 

"I  went  to  a  book  ease  and  got  out  a  rather  comprehensive  treatise 
on  Algebra  written  by  an  Englishman,  far  too  heavy  for  the  ordinary 
student. 

"I  said,  'Here  is  a  book.    Read  it.' 

"He  said,  'I  will  put  on  tliis  iill  the  time  I  can  spare.  I  have  even- 
ings and  Sundays.' 

"I  said,  'Read  this  book.  I  think  you  will  not  read  more  than  a 
page  and  a  half  before  you  find  sometiiing  tliat  will  bother  you.  Make 
a  note  of  the  difficulty.  Proceed  in  this  manner  till  you  feel  that  you 
have  got  as  far  as  you  can  go  without  iielp,  and  then  come  to  me. ' 

"He  started  in.  I  would  see  him  some  weeks  once,  some  twice,  and 
each  time  he  would  have  a  lot  of  (|ucstions  to  ask  me.  I  helped  him 
over  the  difficulties.  He  went  at  it  with  an  avidity  and  earnestness 
that  1  have  never  seen  eijuallcd  by  any  student  who  has  come  under 
my  instruction. 

"After  having  gone  through  the  subject  of  Algebra  he  did  a  similar 
thing  with  Trigonometry,  Analytic  Geometry,  and  the  Calculus,  and 
he  got  such  a  hold  on  these  sulijects  that  he  could  not  only  read  intelli- 
gently the  writings  in  his  own  line  by  others,  but  began  writing  him- 
self and  introduced  mathematical  formulas  and  technical  mathematical 
language  to  such  a  degree  that  it  attracted  the  attention  of  oculists  all 
over  the  world, 

"By  that  work,  which  he  continued  directly  with  me  for  four  or 
five  years,  and  which  he  kept  up  on  his  own  account  till  the  time  of 
his  death,  he  got  into  the  habit  of  looking  at  things  from  the  mathema- 
tician's point  of  view,  so  tliat  he  used,  in  talking  with  me  at  least, 
mathematical  phrases  and  terms  which  expressed  his  ideas  so  accu- 
rately that  it  would  be  scarcely  possible  to  improve  on  his  diction. 

"This  incident  has  always  seemed  to  me  a  most  remarkable  thing, 
and  it  has  impressed  me  particularly  because  of  Dr.  Green's  age  when 
he  began  this  study,  and  his  persistence  in  carrying  it  forward  to  a 
useful  end.    I  shall  make  no  further  comment  upon  it." 

BIBLIOGRAPHY  OF  THE  WRITINGS  OF  JOHN  GREEN,  M.  D. 

City  Hospitals. — Boston,  Little,  Brown  &  Co.,  1861. 

Case  of  fracture  of  the  thigh  treated  by  immovable  apparatus  of  gyp- 
sum.— Boston  M.  and  S.  Journal,  1863-1,  Ixix. 

On  amputation  of  the  thigh. — 34  p.  Boston  M.  and  S.  Journal,  1863-4, 
Ixix. 


5644  GREEN,  JOHN 

Mechanical  ulcer  of  the  stuini). — Boston  M.  and  S.  Journal,  1863-4, 
Ixix. 

Toetslyiieii  tot  bepaliug  \aii  astigiiiatisin. — \'er.sl.  Xederl.  (Jastli.  v. 
Ooogl.,  Xo.  7,  s.  155.    Nedrl.  Arch.  v.  Gen.  en  Xaturk,  II. 

On  a  new  .system  for  the  detection  and  measurement  of  astigmatism, 
witli  an  analysis  of  sixty-four  cases  of  refractive  anomalies  observed 
by  tlie  aid  of  the  method. — Trans.  Amer.  Ophth.  Soc'y.  4th  and 
5th  meeting,  1867-8.    N.  Y.,  1869. 

On  the  modern  treatment  of  lachr^^mal  obstruction  by  dilatation  of  the 
natural  passages. — 16  p.    St.  Louis  M.  and  S.  Journal,  1868,  n.  s.  vi. 

On  the  use  of  styles  of  lead  in  the  treatment  of  disease  of  the  lachry- 
mal sac. — Trans.  Amer.  Ophth.  Soc'y.  4th  and  5th  meetings,  1867-8. 
N.  Y.,  1869. 

Remarks  on  the  use  of  leaden  styles  in  the  treatment  of  lachrymal 
obstructions  with  description  of  a  new  plan  for  facilitating  their 
introduction. — Trans.  Amer.  Ophth.  Soc'y.  6th  meeting,  1869. 
N.  Y.,  1869. 

On  a  series  of  test-letters  for  determining  the  acuteness  of  vision. — 
Trans,  of  the  Amer.  Ophth.  Soc'y.  4th  and  5th  meetings,  1867-8. 
N.  Y.,  1869. 

On  a  color  test  for  astigmatism. — Trans,  of  the  Amer.  Ophth.  Soc'y. 
4th  and  5th  meetings,  1867-8.    N.  Y.,  1869. 

An  optical  demonstration  of  the  characteristic  phenomena  of  astig- 
matic vision. — Trans,  of  the  Medical  Assn.  of  the  State  of  Missouri, 
St.  Louis,  1870. 

On  the  treatment  of  lachrymal  obstruction  by  dilatation  of  the  natural 
passages. — Ihid. 

Case  of  aspergillus  in  the  external  auditory  meatus. — Trans,  of  the 
Amer.  Otological  Soc'y.    3rd  meeting,  1870.    N.  Y.,  1870. 

Remarks  on  cataract  extraction ;  suggestions  for  securing  greater  pre- 
cision in  reporting  operations  and  results;  form  of  corneal  section. 
—Trans,  of  the  Amer.  Ophth.  Soc'y.  9th  meeting,  1873.  N.  Y., 
1873. 

On  a  color-test  for  ametropia,  based  upon  the  chromatic  aberration  of 
the  eye. — Trans.  Amer.  Ophth.  Soc'y.  10th  meeting,  1874.  N.  Y., 
1874. 

Iridotomy  by  de  Wecker's  method. — Trans,  of  the  Amer.  Ophth. 
Soc'y.    11th  meeting,  N.  Y.,  1876,  p.  352. 

Notes  on  the  examination  of  the  eyes  of  a  criminal  executed  by  hang- 
ing.— Ihid.,  p.  354. 

Improvements  in  instruments  and  appliances  for  diagnosis. — Ibid., 
467. 


GREEN,  JOHN  5645 

Castor  oil  as  a  nieiistruuiii  for  dissolving  atropia  for  application  to  the 

eye. — Ibid.,  p.  355. 
Remarks  on  association  of  myopia  and  astipjmatism. — Ihid,  p.  318. 
Test-diagrams  for  the  detection  and  measurement   of  astigmatism. — 

Trans.  Amer.  Ophth.  Soc'ij.    N.  Y.,  1878,  ii.  pt.  4,  467-473. 
Stereoscopic  diap^rams  for  testing  l)ino('nlar  vision. — IhuL,  474. 
A  new  modification  of  Loring's  ophthalmoscope. — Ibid.,  476-482. 
Improved  series  and  arrangements  of  the  glasses  of  the  trial  case  for 

measuring  refraction. — Ibid.,  483-488. 
A  practical  treatise  on  diseases  of  the  eye,  by  Robert  Brudenell  Carter- 

ed.,  with  additions  and  test-types  by  John  Green,  M.  D. — Phil,,  Lea., 

1876. 
Trichiasis  and  distichiasis. — St.  Louis  Courier  of  Medicine,  1879.    i,  p. 

339-343;  p.  593-596  (Two  articles.) 
Cross-eye ;  its  origin,  prevention  and  treatment. — St.  Louis  M.  and  S. 

Jouriwl,  1880,  xxxix,  157-163. 
A  case  of  detached  retina  treated  by  hypodermic  injections  of  muriate 

of  pilocarpin. — Trans.  Amer.   Ophth.  Soc'y.     16th  meeting,  1880. 

N.  Y.,  1880. 
Exhibition   of  a  combination   set   of  trial   glasses,   and   a  new   trial 

frame. — Trans.  Amer.  OpJdh.  Soc'y.     16th  meeting,  1880.     N.  Y., 

1880. 
An  improvement  in  concave  spectacle  lenses  of  high  power. — Ibid. 
An  acute  glaucomatous  invasion,  following  closely  upon  a  single  appli- 
cation of  a  very  weak  preparation  of  duboisia. — Ibid. 
A  modified  operation  for  discission  in  soft  cataract. — Ibid. 
Case  of  nucleus  like  bodies  in  the  lenses  of  a  child  escaping  after  dis- 
cission.— Ibid. 
An  operation  for  entropion. — Ibid. 
On    some    therapeutical    application.s    of    pilocarpin. — Trans.    Amrr. 

Ophth.  Soc'y.    N.  Y.,  1881.    iii,  302-305. 
An  operation  for  closed  pupil  with  anterior  synechia,  using  the  pinee- 

ciseaux  of  de  ^\e(iker.— Trans.  Amer.  Ophth.  Soc'y.  X.  Y.,  1881.  iii, 

214. 
Das  Schielen. — Read  before :  Verein  Deutscher  Aerzte,  St.  Louis,  Sept. 

28,  1882. 
A  case  of  ruptured  zonula ;  lens  continuing  transparent  after  three 

years;  mydriasis  and  loss  of  acconnnodation ;  increase  of  refraction 

under  influence  of  myotics. — Amer.  Jour.  Ophth..  St.  Louis,  1884. 

i,  43-47. 
An  operation  for  the  removal  of  the  eyeball,  together  with  the  entire 

conjunctival  sac  and  lid  margins. — Amer.  Jour.  Ophth.,  St.  Louis, 

1884.    i,  65-68. 


5646  GREEN,  JOHN 

Notes  on  some  of  the  physiological  effects  and  practical  applications  of 

cocaine   hydrochlorate. — Amcr.  Jour.   Ophth.,   St.  Louis,   1884.     i, 

231-7. 
On    accommodation    and    refraction. — Reference    Handbook    of    the 

Medical  Sciences,  ed.  by  Albert  H.  Buck.     N.  Y.,  Wood,  1885-93. 

i,  50. 
On  asthenopia. — Ibid.,  i,  391. 
On  astigmatism. — Ibid.,  i,  400. 
On  diplopia. — Ibid.,  ii,  475. 
On  hemeralopia  and  nyctalopia. — Ibid.,  iii,  605. 
On  hypermetropia. — Ibid.,  iii,  775. 
On  ophtlialmoscope,  ophthalmoscopy. — Ibid.,  v,  298. 
On  optometry. — Ibid.,  v,  349. 
On  presbyopia. — Ibid.,  vi,  22. 
On  spectacles. — Ibid.,  vi,  502. 

Die  operation  des  entropium. — Historische  Studie.     St.  Louis,  1886. 
On  the  operative  treatment  of  entropium. — Amer.  Jour.  Ophth.,  St. 

Louis,  1884.    i,  193-200. 
On  operation  for  the  partial  or  total  removal  of  the  e^^eball. — Amer. 

Jour.  Ophth.,  St.  Louis,  1885.    ii,  51-61. 
On  spectacle  lenses  of  a  sjonmetrical  curvature. — Amer.  Jour.  Ophth., 

St.  Louis,  1886.    iii,  53-59. 
On  the  operative  treatment  of  entropium. — Amcr.  Jour.  Ophth.,  St. 

Louis,  1886.    iii,  363-388. 
On  a  transient  myopia  occurring  in  connection  with  iritis. — Trans. 

Amer.  Ophth.  Soc'y,  Boston,  1887.    iv,  599. 
Test-letters  for  measuring  the  acuteness  of  vision,  based  upon  the 

test-letters  of  Professor  H.  Snellen,  and  the  test-letters  in  geomet- 
rical progression  of  Dr.  John  Green.     By  John  Green  and  A.  E. 

Ewing. — St.  Louis,  1886. 
On  certain  stereoscopical  illusions  evoked  by  prismatic  and  cylindrical 

spectacle-glasses. — Trans.    Amcr.    Ophth.    Soc'y,    Hartford,    1889. 

449-456. 
Notes  on  21  cases  of  cataract  occurring  in  a  single  family. — Trans. 

Amer.  Ophth.  Soc'y,  Hartford,  1890.    v,  pt.  iii,  724-727. 
An  elementary  discussion  on  some  cases  of  centrical  refraction  through 

tipped    spectacle   lenses.      Trans.   Amer.    Ophth.    Soc'y,   Hartford 

1890.    V,  pt.  iii,  690-717. 
Note  on  the  variations  in  the  power  and  in  the  astigmatism  of  thin 

spherical,  toric  and  cylindrical  lenses  in  i)rineipal  cases  of  oblique 

centrical  refraction. — Trans.  Amcr.  Ophth.  Soc'y,  1895.    Hartford, 

1896.    vii,  329-341. 


GREEN,  JOSEPH  HENRY  5647 

and  A.  E.  Ewing.     Hypopyon  keratitis;  break  in  Descemet's 

membrane  preceding  corneal  perforation. — Trans.  Atner.  Ophth. 
Soc'y,  1896.     Hartford,  1897.     vii,  716-23,  3  pi. 

In  memoriam.  Dr.  Henry  Hillard  AVilliams  (1821-1895). — Trans. 
Amcr.  Ophth.  Soc'ij,  1896.    Hartford,  1897.    vii,  479-496. 

and  A.  E.  Ewing.     Hypopyon  keratitis;  break  in  Descemet's 

membrane  preceding  eorneal  perforation ;  passage  of  hydrogen 
peroxide  and  fluorescein  through  the  corneal  ulcer  into  the  anterior 
chamher.— Trans.  Amcr.  Ophth.  Soc'y,  Hartford,  1897-8.  viii,  374- 
385.    3  pi. 

and  A.  E.  Ewing.    A  case  of  melano-sarcoma  of  the  conjunctiva 


and  cornea  of  long  duration. — Trans.  Amer.  Ophth.  Soc'y,  Hart- 
ford, 1898.    viii,  468-471.    2  pi. 
Address  at  the  50th  anniversary  of  the  founding  of  the  Academy  of 

Science. — Trans,  of  the  Acad,  of  Science,    v,  16,  p.  xlv,  1906. 
Biography  of  the  older  Agassiz,  Jean  Louis  Rodolphe  Agassiz. — Trans. 

of  the  Acad,  of  Science,    v,  17,  p.  xxxiii,  1907. 
Biography    of    Dr.    Gustav   Baumgarten. — Traits,    of    the    Acad,    of 

Science,    v,  19,  p.  xli,  1910. 
Periscopic  spectacles. — Am.  Jour.  Ophth.,  St.  Louis,  1908.    xxv,  321- 

324. 
Coquille  protective  spectacles. — Am.  Jour.   Ophth.,  St.  Louis,  1909. 

xxvi,  321-327,  p.  1  pi. 
Coquille  protective  spectacles.     Relation  of  the  thickness  of  a  coquille 

of  zero  power  to  the  principal  focal  lengths  and  to  the  power  of  its 

surfaces. — Amcr.   Jour.   Ophth.,   St.   Louis,   1910.     xxvii,   231-3. — 

(T.  H.  S.) 
Green,  Joseph  Henry.  A  celebrated  English  surgeon,  anatomist,  phys- 
iologist and  ophthalmologist.  Born  in  1791,  at  London,  he  studied 
at  Berlin  and  also  at  St.  Thomas's  Hospital,  London,  where,  in  1813, 
he  was  made  prosector.  In  1815  he  became  an  M.  R.  C.  S.,  and,  three 
years  later,  instructor  in  anatomy  and  physiology  at  St.  Thomas's. 
He  was  a  very  successful  operator,  especially  for  stone,  having  per- 
formed, before  1827,  40  lithotomies,  with  only  one  death.  In  1828 
ho  published  his  ^'Manual  of  Modem  Surgery,"  and  two  years  later 
was  appointed  Professor  of  Surgery  at  the  newly  founded  King's 
College,  a  position  which,  however,  together  with  his  private  practice, 
he  gave  up  in  1837.  He  was  also  for  a  few  years  a  professor  of 
anatomy  at  the  Academy  of  Fine  Arts.  Green's  "Lectures  on  Diseases 
of  the  Eye"  reached  its  ninth  edition  in  1836,  and  was  highly  esteemed 
both  by  students  and  practitioners.    In  1849  he  was  President  of  the 


5648  GREEN  VISION 

College  of  Surgeons,  and  again  in  1858.     He  died  Dec.  13,  1863,  at 
liis  country  seat,  The  Mount  Hadley,  near  Barnet. —  (T.  H.  S.) 
Green  vision.      Ciiloropsia.     Up  to  the  present  time  only  a  few  cases 
of  green  vision  have  been  observed  and  described.     After  the  extrac- 
tion of  a  lens  for  the  relief  of  myopia,  a  tliirty-two  year  old  artisan 
who  was  suffering  from  ta])etic  optic  nerve  atrophy  saw  everything 
an  emerald-green ;  after  severe  exhaustion  there  would  appear  to  him 
red  points  on  a  green  field.     Green  vision  developed  in  a  physician 
after  having  slept  for  a  few  hours  in  the  full  sunshine.     Alter  de- 
scribes a  case  of  green  vision   (which  he  calls  monochromatopia  for 
green)    in  a  color-blind  paralytic.     In  a  tabetic,  the  field  of  vision 
appeared  in  green  and  violet  spots,  and  the  same  condition  was  present 
with  the  eyes  closed.    One  case  of  green  vi.sion  was  observed  as  an  aura 
in  an  abortive  epileptic  attack,  in  a  twelve  year  old  girl. —  (C.  P.  S.) 
See  p.  2202,  Vol.  Ill,  of  this  Encyclopedia. 
Green,  Visual.    A  greenish  pigment  found  in  the  rods  of  the  retina:  of 
frogs  and  some  reptiles.     It  resembles  visual  purple  in  the  higher 
animals,  and  is  similar  in  its  properties. 
Greffe  epidermique.  (F.)  Epidermal  graft. 
Greffotome.    A  knife  used  in  cutting  surgical  grafts. 
Greisenstaar.  (G.)  Senile  cataract. 

Gregorian  telescope.     The  first  reflecting  telescope  made. 
Greisenbogen.  (G.)  Arcus  senilis. 
Grele.  (F.)  Chalazion. 
Grenzwinkel  (G.)  Critical  angle. 

Griffin,  Ovidus  Arthur.  A  well-known  ophthalmologist  of  Ann  Arbor, 
Mich.  He  was  l)orn  Dec.  10,  1872,  at  Fayette,  Ohio,  received  the 
degree  of  B.  S.  at  the  State  Normal  School,  Fayette,  and  his  medical 
degree  at  the  University  of  Michigan,  June,  1899.  He  studied  the 
eye,  ear,  nose  and  throat  at  New  York,  Philadeli^liia,  Vienna  and 
Berlin. 

For  three  years  he  was  Dr.  Fleniming  Carrow's  first  assistant  and 
demonstrator  of  ophthalmic  and  aural  surgery  and  clinical  ophthal- 
mology and  otology  in  the  department  of  medicine  and  surgery  in  the 
University  of  ^Michigan.  Until  his  death  he  continued  to  practise  in 
Ann  Arbor. 

He  was  a  member  of  the  Ann  Arbor  ]\Iedical  Club,  the  Washtenaw 
Medical  x\ssoeiation,  the  American  Medical  Association,  and  the  Amer- 
ican Academy  of  Ophthalmology  and  Olo-Laryngology. 


GRIL  DE  LA  COUCHE  OPTIQUE 


5649 


Among  his  more  important  writings  are:  1.  Disorders  from  Eye- 
Strain.  (Read  before  the  Michigan  State  Medical  Society,  at  Petos- 
key,  June,  1905.)  2.  Complete  Removal  of  the  Faneial  Tonsils. 
(Read  before  the  American  Academy  of  Ophthalmology  and  Oto- 
Laryngology,  1906.)  3.  Ocular  Symptoms  of  Nasal  Origin.  (Read 
before  the  Michigan  State  Medical  Society,  1907.)  4.  Diseases  of  the 
Eye  and  Ear.     (A  Student's  .Manual:     Lea  Bros.,  1905.) 

He  invented  a  number  of  useful  instruments,  among  them  the  well 
known  Grififin  tonsil  scissors.  He  also  designed  a  model  operating 
chair. 

Dr.  Griffin  M^as  a  stout,  siiiootli-faced  man;  good  natured,  but  very 
serious;  and  with  a  way  about  liim  that  always  inspired  confidence. 


Ovidus  Arthur  Griffin. 

He  was  a  man  of  the  cleanest  possible  kind  of  life.  He  was  a  member 
of  the  First  Methodist  Church,  and  an  active  worker  in  that  institu- 
tion. He  was  a  great  lover  of  his  profession  and  his  home.  He  was 
a  good  story-teller,  and  an  excellent  listener.  An  ecstatic  lover  of 
the  beautiful,  his  favorite  pastime  was  the  collection  of  reproductions 
in  period  furniture,  of  which  he  had  many  beautiful  and  valuable 
pieces  in  his  house. 

He  married,  June  20,  1901,  Miss  Jessie  Almira  Curtis.     There  were 
no  children. 

He  died  at  Ann  Arbor,  Mich.,  Oct.  27,  1911,  of  spinal  meningitis, 
contracted  from  a  patient  with  a  "walking"  form  of  the  disease.     He 
was  ill  but  a  few  days.— (T.  II.  S.) 
Gril  de  la  couche  optique.     (F.)     Substantia  reticularis;  optic  fibre 
crossing.  ,  , 

Vol.  VII— 51 


5650  GRILL-LIKE  KERATITIS 

Grill-like  keratitis.    See  Cornea,  Lattice-shaped  opacity  of  the. 

Grimaldi,  Francesco  Maria.  A  famous  Italian  pliysicist,  who  diseovered 
the  ditl'raction  and  the  interference  of  light.  Born  in  Bologna,  Italy, 
in  1618,  he  became  an  instructor  in  mathematics  at  the  Bolognese 
Jesuit  College,  and  died  in  1663.  His  only  work  on  optics  was  entitled, 
'^ Physic o-Mathe sis  de  Lumine,  Coloribus  et  Iride  Aliisque  Annexis 
Libri  II,"  which  did  not  appear  until  1665,  that  is  to  say,  two  years 
after  his  death.  In  this  small  volume  we  find,  inter  alia,  an  account 
of  its  author's  great  discoveries.  First,  he  took  up  the  diffraction  of 
light.  The  experiment  showing  this  phenomenon  was  performed  as 
follows:  In  a  room  that  was  otherwise  dark,  a  single  cone  of  light 
was  permitted  to  enter,  and  was  caught  upon  a  white  ground,  or 
screen.  Then  a  staff  was  held  between  the  screen  and  the  place  of 
entrance  of  the  light,  and  the  shadow  of  the  staff  on  the  screen  was 
examined  closely.  Grimaldi  then  observed :  1.  That  the  full  shadow 
was  larger  than,  by  the  ordinary  calculation,  it  should  have  been. 

2.  On  either  side  of  the  shadow  was  a  zone  of  color,  w^hich,  in  the 
direction  of  the  shadow,  was  blue,  and,  in  the  opposite  direction,  red. 

3.  The  light-intensity  and  the  color-intensity  of  both  these  color  zones 
diminished  from  the  shadow  outwards.  4.  If  the  light  that  entered 
the  room  was  very  bright  sunlight,  then  certain  zones  of  color  appeared 
in  the  shadow  itself. 

These  "influences"  of  the  shadow  on  the  illuminated  portion  of  the 
screen,  and  vice  versa,  were  called  by  Grimaldi  himself  "the  diffrac- 
tion of  light,"  so  that  the  discoverer  of  the  phenomenon  is  also  the 
inventor  of  the  term.  Grimaldi  also  correctly  explained  these  influ- 
ences of  illuminated  part  on  shadow  and  vice  versa,  as  due  to  a  bending 
of  some  of  the  rays  of  light,  either  inward  or  outward,  as  it  passed  by 
the  border,  or  edge,  of  the  shadow-casting  body. 

Next,  Grimaldi,  in  his  little  book,  took  up  the  interference  of  light. 
This  phenomenon  he  discovered  in  the  course  of  an  experiment  by 
which  he  endeavored  to  show  that  diffraction  is  something  altogether 
different  and  apart  from  both  reflection  and  refraction.  Laying  aside 
the  staff  he  had  employed  in  the  original  experiment,  he  placed  in  the 
path  of  the  light  an  opaque  plate  in  which  there  was  a  small  opening. 
Once  again  catching  the  light  upon  a  w^hite  ground,  or  screen,  he  found 
the  illuminated  circle  larger  than,  according  to  the  size  of  aperture, 
might  have  been  pre-estimated. 

He  next  proceeded  to  make  in  the  shutter  of  the  darkened  room  a 
second  aperture  for  light,  and  then,  on  a  single  screen,  caught  the 
two  light-discs  from  the  two  apertures  at  such  a  distance  that  the 
light-discs  partly  overlapped  each  other.     Then  Grimaldi   observed. 


GRIMAUD,  AIME  5651 

around  each  disc  of  light,  a  /one  or  ring  of  darkness,  which,  after  the 
manner  of  the  discs  tlicinsclves,  iiiterseetcHl  each  otlier.  He  also 
observed  tluit  the  area  wliicli  lay  witliiii  both  tlie  rings  was  very  inucli 
brighter  than  that  wliich  lay  inside  either  one  of  the  rings  alone. 
Furtlierinore,  the  bortk'r  of  each  dise  was  dark  in  the  illuminated 
area  of  the  other  circle.  Grimaldi's  conclusion  was:  "An  illumiiuited 
body  can  become  darker,  when  to  the  lii^ht  which  it  receives  is  added 
other  light." 

As  will  readily  be  perceived,  Grimaldi  did  not  eliminate  from  his 
experiment  the  influence  of  difi'raction.  He  took,  however,  the  very 
first  step  toward  a  knowledge  of  the  iutei-ference  of  light,  wdiile  fui'- 
ther  steps  remained  to  be  taken  by  Young,  and  especially  by  Fresnel. 
(See  Young,  Thomas,  and  Fresnel,  Jean  Augiistin,  in  this  Encyclo- 
pedia.)—{'\\  11.  S.) 

Grimaud,  Aime.  A  celebrated  Paris  pli3^sician,  who  paid  considerable 
attention  to  diseases  of  the  eye.  Born  at  Angers,  France,  in  1789,  he 
received  his  medical  degree  in  1818,  became  physician  to  the  Bureau 
of  Charity,  and  lectured  for  many  years  on  internal  medicine.  He 
died  Jan.  10,  1866. 

Grimaud 's  only  ophthalmologic  writing  was  ''  Traitf  dc  la  Cataractc: 
3Ioycns  Xouvcau  de  la  (incrir  sans  Operation  ChivHrgiculc"  (Paris, 
1842).— (T.  H.  S.) 

Grimm,  Johann  Frledrich  Karl.  A  well-known  German  botanist  and 
I)hysician,  who  devoted  considerable  attention  to  diseases  of  the  eye. 
Born  at  Eisenach  in  1737,  he  received  his  medical  degree  at  Gottin- 
gen  in  1758,  and  settled  as  general  practitioner  in  Eisenach.  lie  made 
an  excellent  translation  of  the  Hippocratic  Collection  (First  ed.,  Glo- 
gau,  1781-92 ;  2d  ed.,  Glogau,  1837-39) .  His  only  ophthalmologic 
writing  was  his  graduation  dissertation,  entitled  "De  Visu"  (1758). — 
(T.  H.  S.) 

Grippe,  La.    Also  called  the  grip.    See  Influenza. 

Groenouw's  disease  of  the  cornea.    See  Cornea,  Nodular  opacity  of  the. 

Groove,  Corneal.  The  depression  that  runs  around  tiie  globe  at  the 
sclero-corneal  junction. 

Groove,  Lachrymal.  A  gutter  in  front  of  the  opening  of  the  antrum, 
on  the  iiuier  surface  of  the  superior  maxillary  ])oiu\ 

Groove,  Optic.  The  groove  on  the  superior  surface  of  the  sphenoid 
bone  terminating  on  either  side  in  the  optic  foramen. 

Grooves,  Lachrymal.  Rarely,  the  canaliculi  are  (congenitally)  replaced 
by  grooves  or  gutters  such  as  is  found  normally  in  some  birds.  See, 
for  example,  Depene  (Kli)i.  Monatshl.  f.  Angenheilk.,  p.  396,  Sept., 
1911)  and  Comparative  ophthalmology. 


5652  GROPING-TEST 

Groping-test.  In  ophthalmology,  a  test  for  false  orientation  in  paraly- 
sis of  the  ocular  muscles.  The  affected  eye  does  not  locate  objects  in 
their  true  place,  and  if  asked  to  point  quickly  at  an  object  the  patient 's 
finjrer  will  be  carried  to  one  side  of  it. —  (Gould.) 

Gros  mal.  (F.)  The  well-marked  form  of  epilepsy;  major  epilepsy. 

Gros  nez.    See  Eyelids,  Goundon  of  the. 

Gross  anatomy.  Macroscopic  anatomy.  Anatomy  considered  without 
rcfcicticc  to  histology  or  the  details  of  minute  structure.  See  Anat- 
omy of  the  eye. 

Gross  appearances.  Macroscopic  appearances,  without  attention  to 
minute  details. 

Grossaugig.  (G.)  Large-eyed. 

Grosse.  (G.)  Magnitude. 

Grosser  Augenbrauenmuskel,  (G.)  The  epicranius  or  occipitofrontalis 
muscle. 

Grossissement.     (F.)     Magnification. 

Gross,  Samuel  David.  A  famous  general  surgeon  of  Philadelphia,  who 
was  also  widely  known  as  an  operator  on  the  eye.  He  was  born  near 
Easton,  Penna.,  July  8,  1805,  the  son  of  Philip  and  Juliana  Brown 
Gross.  After  a  classical  education,  he  studied  with  Dr.  Joseph  K. 
Swift,  of  Easton,  and  also  with  Prof.  George  ^IcClellan,  of  Philadel- 
phia. Entering  Jefferson  Medical  College  in  1826,  he  there  received 
his  medical  degree  two  years  later,  his  graduation  thesis  ])eing  entitled 
"The  Nature  and  Treatment  of  Cataract."  He  settled  at  once  in 
Philadelphia,  but  soon  removed  to  Easton,  then  to  Cincinnati,  Ohio, 
w^here,  in  1833,  he  became  Demonstrator  of  Anatomy  in  the  Ohio 
Medical  College.  Two  years  later  he  was  made  Professor  of  Path- 
ological Anatomy  in  the  Medical  Department  of  the  Cincinnati  Col- 
lege. Four  years  later  he  removed  to  Louisville,  where  he  was  pro- 
fessor of  surgery  in  the  University  of  Louisville  for  ten  years.  In 
1850  he  removed  to  New  York  City,  where  he  succeeded  Dr.  ]Mott  in 
the  chair  of  Pathological  Anatomy.  The  following  year  he  returned 
to  his  former  position  at  Louisville.  In  1856,  however,  he  returned 
to  Philadelphia,  in  order  to  accept  the  chair  of  surgery  in  the  Jeffer- 
son ]\ledical  College — a  position  whicli  lie  held  till  about  two  years 
before  his  death. 

Dr.  Gross  was  a  very  prolific;,  as  well  as  a  clear  and  cogent,  writer. 
His  most  important  work,  no  doul)t,  Avas  the  well  known  System  of 
Surgery,  which  passed  through  many  editions.  He  wrote,  however,  a 
number  of  other  important  volumes.  He  was  also  one  of  the  founders 
and  chief  editors  of  the  North  Ameriean  Medieo-Chinirgieal  Review. 
After  the   reception   of   numerous   honors,    among   them   D.  C.  L., 


GROUND  GLASS 


5653 


Oxford,    and    LL.  D.,    Cambridge',    Dr.    Gross   died    iu   ^lay,   1884. — 

(T.  H.  S.) 
Ground  glass.    Glass,  one  or  both  surfaces  of  wliicli  have  been  ground 

with  emery  or  some  similar  agent. 
Groundsel.     Senecio  vulgaris.     In  the  days  of  Pliny  and  Dioscorides, 

cross-wort,  or  groundsel,  was  employed,  mixed  with  saffron  and  cold 

water,  as  a  poultice  for  epiphora. —  (T.  H.  S.) 
Ground-substance   (of  the  cornea).     Substantia  propria;  the  corneal 

substance  proper. 
Growing-cell.     Growing-slide.    A   plain    glass   box   adapted   for   the 

ju-eservation   of  living  micro-organisms. 
Growth.    A  term  generally  sjmonymous  with  tumor. 
Grube.  (G.)  Fossa;  fovea;  groove. 
Grumeau.  (F.)  Clot. 
Grumous  cataract.    Cataracta  cruenta.     An  obsolete  name  for  an 

opacity   due   to   hemorrhage   into  the   cornea,   anterior   chamber   or 

vitreous. 
Griinblindheit.   (G.)   Green  blindness. 
Grundfarben.   (G.)   Primary  colors. 
Grundlinie.  (G.)  Base  line. 
Griiner  Staar.   (G.)   Green  cataract. 
Griinsehen.   (G.)   Green  vision. 
Grlinspan.    (G.)   Verdigris. 
Grut,  Edmund  Hansen.     A  famous  European  ophthalmologist.     Born 


E<liininil  (iottt'rii'il   liaiisoii  l!nit. 

at  Copenhagen,  Denmark,  Jan.  15,  1S31,  he  studied  medicine  in  that 
city,  and,  later,  ophthalmology  in  Paris  and  Berlin.     He  received  his 


5654  GUACHAMACINE 

degree  in  1857,  presenting  as  dissertation  a  treatise  on  the  ophthal- 
moscope. From  1859-61  he  was  first  assistant  at  the  Surgical  Uni- 
versity-Clinic of  the  Frederick  Hospital,  Copenhagen,  and  in  1863 
began  to  give  instruction  in  diseases  of  the  eye  as  privatdo(.'ent.  From 
1882-1890  he  was  full  professor  of  ophthalmology  at  the  Copenhagen 
University.  He  w^as  a  man  of  very  great  influence  over  the  younger 
generation  of  Danish  ophthalmologists.  In  1889  he  delivered  the 
Bowman  lecture  before  the  Ophthalmological  Society  of  the  United 
Kingdom,  of  which  he  M'as  an  honorary  member.  He  contributed 
numerous  articles,  chiefly  on  oplitlialmologic  sul)jects,  to  the  Danish 
journal,  "Hospitals  Tidende/'  and  died  in  August,  or  September, 
]907.— (T.  H.  S.) 

Guachamacine.  An  alkaloid,  probably  identical  with  curarin,  obtained 
by  J.  Schiffer  from  guachamaca.  It  is  soluble  in  water,  less  soluble  in 
absolute  alcohol  and  insoluble  in  ether  and  in  chloroform. 

Guaco.  (Sp.)  In  Central  and  Soutli  America  and  the  West  Indies,  a 
name  for  various  species  of  AristuJochui  and  Mikania  having  supposed 
alexipharmac  properties.  Guaco  is  employed  as  a  preventive  of,  and 
remedy  for,  the  bites  of  poisonous  serpents,  as  a  febrifuge  and  anthel- 
minthic,  in  chronic  rheumatism,  and  externally  in  purulent  and 
blennorrhagic  ophthalmia,  chronic  ulcers,  etc. 

Guaiacolben^yl  ester.    See  Bremscain. 

Guaicol.      GUAIACOL.      MoNOMETHYLCATECIIOL.      ]\lETiri'L  ESTER  OF  PROTO- 

CATECHiN.  This  agent  is  made  from  beechwood  creosote  by  frac- 
tional distillation;  is  a  faintly-yellow,  limpid,  oily  liquid  with  an  aro- 
matic odor.     It  is  insoluble  in  water. 

Another  preparation  is  in  crystalline  form,  soluble  in  oils  and 
slightly  soluble  in  water;  it  is  used  in  the  same  dose  and  for  the  same 
purpose  as  the  preceding. 

Tersan  {Pract.  Med.  Series,  p.  238,  1907)  claims  that  the  antiseptic, 
alterative,  anesthetic,  analgesic  action  of  guaiacol  is  of  service  in  dis- 
eases of  the  eye.  As  an  application  to  the  skin  a  10  per  cent,  solution 
in  oil  or  glycerin,  either  alone  or  in  combination,  in  oily  solution,  with 
camphor  or  menthol,  will  be  found  useful  in  herpes  zoster,  furun- 
culosis,  phlegmonous  dacryocystitis,  etc.  As  a  conjunctival  applica- 
tion he  employs  a  mixture  of  copper  sulphate  and  guaiacol,  each  one 
part  to  20  parts  of  glycerin.  In  burns  he  uses  a  solution  of  atropin 
(the  alkaloid)  in  sterile,  chemically  pure  oil  to  which  may  be  added 
guaiacol,  menthol  and  camphor  1/20.  Internally  and  intramuscularly 
it  is  of  use  in  scrofulous  tuberculous  and  syphilitic  eye  affections. 

H.  L.  Gowens  (Jour.  Ophth.,  Otol.  and  Lari/ng.,  March,  1915) 
agrees  with  Darier  that  the  drug  in  the  form  of  a  2  per  cent,  ointment 


GUANIDIN  5655 

and  in  1  per  cent,  to  2  per  cent,  watery  solution  is  of  especial  value 
in  the  various  forms  of  ocular  tuberculosis.  Guaiacol  cacodylate  in  2 
per  cent,  solution  in  sterile  water  is  recommended  as  a  subconjunctival 
injection  in  tuberculous  affections  of  the  anterior  segment  of  the  globe. 
By  mixing  the  injection  with  a  few  drops  of  alypin  it  does  not  produce 
any  inconvenience. 

Guanidin.  Carbomidine.  This  agent  is  said  by  Lewin  and  Guillery  to 
act  as  a  mydriatic  eitlier  when  applied  locally  or  when  given  in  full 
doses  to  the  lower  animals. 

Guarana.  A  dried  paste  prepared  from  the  seeds  of  Paullinia  cupana 
vet  sorhilis,  found  in  Brazil.  It  contains  an  alkaloid,  guaranin, 
CglljoN^Oo.  ir.O,  identical  with  caffein.  It  is  employed  chiefly  in 
migraine  and  other  headaches.  The  commercial  preparations  are  not 
always  trustworthy.  Dose  of  the  fld.  ext.,  mv-xxx ;  of  guaranin  gr. 
j-iij  :  of  the  solid  ext.  gr.  iij-x  ;  of  the  tincture  (1  in  4)  ."ss-j. 

Guards,  Eye-glass.  Sec  Eyeglasses  and  spectacles,  History  of;  also 
Eyeglasses  and  spectacles.  Mechanical  adjustment  of. 

Gudden's  commissure.  A  mass  of  fibers  forming  the  upper  (dorsal) 
part  of  the  optic  tracts.  They  are  demonstrated  in  man  with  diffi- 
culty unless  there  is  degeneration  of  the  optic  fibers  proper. 

Guenz,  Justus  Gottfried.  A  German  anatomist,  physician  and  surgeon, 
who  devoted  considerable  attention  to  ophthalmology.  Born  at  Konig- 
stein,  Germany,  ]March  1,  171-i,  he  received  his  early  education  from 
his  father,  a  highly  educated  minister,  and  his  medical  training  at 
Leipsic,  where  he  graduated  in  1738.  After  a  number  of  Wander- 
jahre,  he  settled  at  Leipsic,  and  became  in  1747  professor  of  physiol- 
ogy, and,  a  little  later,  of  anatomy  and  surgery.  He  was  a  celebrated 
lithotomist,  and  wrote  a  number  of  articles  on  cataract  and  glaucoma. 
In  1751  he  was  appointed  body-physician  to  the  Elector  of  Saxony. 
Shortly  afterward  (in  1751)  he  died. —  (T.  H.  S.) 

Guepin,  Ange.  A  distinguished  ophthalmologist  of  Nantes.  He  was 
born  at  Pontivy,  France,  Aug.  30,  1805,  and  received  his  medical 
degree  in  1828.  Having  settled  at  Nantes,  he  there  became  professor 
of  economic  and  industrial  chemistry.  In  1835  he  became  an  oph- 
thalmologist exclusively — so  far  at  least  as  medicine  is  concerned,  for 
he  held  a  number  of  political  offices.  He  was  one  of  the  founders  of 
the  Revue  Philosophique  et  Religieuse.     He  died  May  21,  1873. 

His  medical  works  are  as  follows:  1.  Lettres  a  Ribes.  de  :Montpel- 
lier,  sur  Divers  Sujets  de  Med.,  de  Chir.,  et  d 'Hygiene.  (Nantes  and 
Paris,  1836.)  2.  Etudes  d 'Oculistique.  (Paris,  1844.)  3.  Nouvelles 
Etudes  Theoriques  et  Cliniques  sur  les  :Maladies  des  Yeux :  I'Oeil  et 


5656  GUEPRATTE,  ALPHONSE  PIERRE  PROSPER 

la  Vision,     (Paris,  1857.)     4.  Des  Kaux  .Mineralisees.     (Paris,  1857.) 
—  (T.  II.  S.) 

Guepratte,  Alphonse  Pierre  Prosper.  A  French  naval  physician,  who 
seems  to  have  devoted  some  attention  to  the  eye.  Born  at  lirest,  July 
20,  1808,  he  received  his  medical  degree  in  1842  at  Montpellier.  After 
about  five  years  of  practice  in  this  city,  he  died  Sept.  17,  1847,  aged 
only  39  j^ears. 

His  only  ophthalmologic  writing  was  "Hemeralopie  des  Pays 
Chauds,  Observations  Recueillies  a.  Bord  de  la  Fregate  Armide, ' '  etc, 
{Gaz.  Med.  de  Mont  pettier,  1847).— (T.  H.  S.) 

Guerin,  Jules  Rene.  A  celebrated  French  physician,  pathologist,  and 
surgeon,  who  paid  considerable  attention  to  ophthalmology.  Born  at 
Boussu,  Belgium,  a\Iarch  11,  1801,  he  obtained  his  medical  degree  at 
Paris  in  1826.  Two  years  later  he  was  editor  and  proprietor  of  the 
Gazette  de  Sante.  In  1838  he  founded  the  Orthopedic  Institute  at 
Passy,  where  lie  himself  performed  a  large  number  of  orthopedic 
operations.  In  1839  he  was  appointed  Orthopedic  Surgeon  at  the 
Children's  Hospital.  He  died  Jan.  25,  1886,  aged  85.  His  only  oph- 
thalmologic writing  was  Mem.  sur  I'Etiologie  Generale  du  Strabisme 
(2ded.,  1843).— (T.  H.  S.) 

Guerin,  Pierre.  A  French  surgeon  and  ophthalmologist.  Born  at 
Lyons,  France,  May  26,  1740,  he  became  a  Fellow  of  the  Royal  College 
of  Surgeons  at  Lyons,  surgeon-in-chief  of  the  Lyon  Hotel  Dieu,  etc. 
He  died  at  Bordeaux,  Feb.  13,  1827. 

Guerin 's  only  ophthalmologic  writing  was  Trcdle  des  Maladies  des 
Yenx  (Paris,  1770).— (T.  II.  S.) 

Guiding  sensation.    See  Fusion  field. 

Guide.   See  Guy  de  Chauliac. 

Guide  de  CauUace.    See  Guy  de  Chauliac. 

Guillemeau,  Jacques  (1560-1613).  A  graduate  of  Paris,  and  one  of 
the  brightest  pupils  of  Riolan,  Courtin  and  Paris,  he  became  physician- 
in-ordinary  to  the  King  of  France  and  a  surgeon  of  world-renowned 
ability.  He  was  not  very  great  as  an  ophthalmologist,  but  his  book, 
Des  Maladies  de  I'Oeil  qui  sont  en  N ombre  de  Cent  Treize  aux  quelles 
il  est  Subject  (Paris,  1585),  on  account  of  the  excellence  of  its  matter 
and  the  clearness  of  its  literary  style,  was  very  popular  in  Germany 
and  England,  as  well  as  in  France,  for  many  years.  In  England, 
indeed,  it  was  well  enough  thought  of  to  form  the  sum  and  substance 
of  Banister's  One  Hundred  and  Thirteen  Diseases  of  the  Eyes  and 
Eyelids — which,  by  the  way,  seems  to  have  been  the  earliest  general 
work  on  eye  diseases  in  the  English  language. 

Guillemeau 's  work  is  based  almost  entirely  on  the  Arabians  and  the 


GUILLIE,  SEBASTIAN  5657 

Greeks,  but  it  contains  a  few,  if  uniini)ortant,  original  operations — 
ainoiig  tliciii  one  for  lid-coloboma. —  (T.  II.  S.) 

Guillie,  Sebastian.  A  well-known  ophthalmologist  of  Paris.  lie  was 
born  at  liordeaux,  Aug.  24,  1780,  and  received  his  professional  degree 
at  Paris  in  1807.  For  a  short  time  he  was  a  field  physician  in  the 
army.  Then  he  became  superintendent  of  the  Institution  for  the  Blind. 
Almost  immediately  afterwards  he  was  arrested  and  imprisoned  by 
mistake,  and  so  remained  in  durance  for  a  year.  He  seems  to  have 
been  a  man  of  quackish  tendencies,  for  he  advertised  and  sold  at  a 
high  price  a  "Drogue  Antiglaireuse, "  whereby  he  achieved  a  for- 
tune. 

His  writings  are  as  follows:  1.  Traite  de  I'Origine  des  Glaires 
(devoted  to  the  exploitation  of  his  nostrum,  and  vigorously  pushed  to 
its  31st  edition).  2.  Kapport  Fait  a  S.  E.  le  Ministre  .  .  .  sur 
I'Etat  de  I'lnstitution  Koyale  des  Jeunes  Aveugles,  pendant  les  Exer- 
cices  de  181G  et  1817  (Paris,  1818).  3.  Nouvelles  Recherches  sur  la 
Cataracte  et  la  Goutte-Sereine  (Paris,  1818).  4.  Essai  sur  I'lnstruc- 
tion  des  Aveugles,  etc.  (Paris,  1817;  3d  ed.,  1820).  5.  Rapport  Fait 
a  j\lM.  les  Membres  et  les  Souscrii^teurs  de  la  Clinique  Oculaire  de 
Paris  pendant  1820,  21  (Paris,  1821).  G.  Bibliotheque  Ophthalmolo- 
gique,  ou  Recueil  d 'Observations  sur  les  Maladies  des  Yeux  Faites  a 
la  Clinique  de  I'lnstitution  Royale  des  Jeunes  Aveugles;  avee  des 
Notes  de  Dupuytren  (Paris,  1820,  21).  Guillie  died  in  November, 
18C5.— (T.  11.  S.) 

Guipsin.  An  internal  remedy  usually  given  for  the  purpose  of  reducing 
vascular  tension,  and  indirectly  intended  to  relieve  the  intraocular 
pressure  in  glaucoma.  See,  for  example,  M.  A,  Terson  {Bull,  d-c  la 
Soc.  d'O phial,  dc  Paris,  Jan.,  1912). 

Gujasanol.  Diethylglycocollguaiacol  hydrochloride.  This  salt  oc- 
curs as  colorless  crystals  with  a  faint  odor  of  guaiacol.  It  is  very 
soluble  in  water;  slightly  in  alcohol. 

It  is  a  mild  antiseptic  and  used  as  such  in  simple  acute  and  chronic 
conjunctivitis,  in  from  5  to  20  per  cent,  solutions  three  or  four  times 
daily.    See  Guaicol. 

Gullstrand's  ophthalmoscope.  See  page  4758,  Vol.  VI,  of  this  Encyclo- 
pedia; also  Ophthalmoscope. 

Gum.  Various  sorts  of  gum,  called  generically  sarcocoUa,  were  em- 
ployed by  the  ancient  Greco-Roman  physicians  as  a  menstruum  for 
various  oi)hthalinie  medicaments. —  (T.  II.  S.) 

Gum  arabic.   See  Acacia. 

Gumma.  Gumma  of  the  ocular  apparatus.  This  neoplasm  is  essen- 
tially a  soft,  elastic  tumor  resulting  from  secondary  changes,  often 


5658  GUMMA 

caseation,  of  tertiary  syphilitic  inflammatory  deposits.  These 
growtlis  may  occur  in  any  portion  of  the  ocular  a[)paratus,  exti-a-  or 
intracranial.  Although  this  suhject  Avill  also  be  considered  under 
various  captions,  for  example,  Sjrphilis;  Eyelids,  Gumma  of  the,  and 
under  the  general  heading  Tumors  of  the  eye,  yet  it  is  considered 
proper  to  make  here  a  few  observations  of  tiie  lesion  as  it  most  com- 
monly affects  the  eyeball  and  its  appendages. 

Gumma  of  the  lids  is  not  rare ;  see  Eyelids,  Gumma  of  the. 

Gummatous  tarsitis  is  not  uncommon;  indeed  Parsons  {i'atltologij 
of  the  Eye,  I,  p.  6)  speaks  of  the  tarsus  as  particularly  liable  to  syphi- 
litic inflammation.  It  is  then  much  enlarged,  so  that  the  lid  cannot 
be  everted,  and  is  of  cartilaginous  hardness.  When  cut  into  it  does  not 
bleed.  Both  lids  of  the  same  eye  may  be  affected.  It  is  a  tertiary 
affection,  which  runs  a  prolonged  course  of  several  months.  Cases 
examined  histologically  have  shown  hyaline  degeneration  of  the  fibrous 
tissue  with  few  nucleated  cells.  Near  the  surface  the  tissue  was 
infiltrated  with  round-cells  and  partially  replaced  by  granulation 
tissue,  with  new-formed  connective  tissue.  In  one  case  there  were 
calcareous  deposits.  The  vessels,  especially  the  small  arteries,  showed 
hyaline  degeneration,  atrophy  of  the  media,  slight  thickening  of  the 
adventitia,  and  enormous  proliferation  of  the  intima,  amounting  often 
to  endarteritis  obliterans.  The  veins  suffered  least.  In  one  case,  of 
seven  years'  duration,  the  conjunctival  epithelium  resembled  epider- 
mis; in  another,  of  eight  years'  duration,  the  conjunctiva  bulbi  was 
xerotic. 

For  an  account  of  gumma  of  the  conjunctiva,  see  p.  3025,  A"ol.  IV,  of 
this  Encyclopedia. 

Gumma  of  the  sclera.  In  this  region  primary  gumma  is  an  exces- 
sively rare  neoplastic  growth,  although  Andrews  {System  of  Diseases 
of  the  Eye,  III,  253)  has  reported  a  case. 

Gumma  of  the  cornea  is  also  a  most  unusual  tumor,  although  a  few 
cases  liave  been  recorded. 

Gumma  of  the  iris.  Gummatous  iritis  is,  perhaps,  the  commonest 
form  of  ocular  gumma.  It  appears  in  the  later  secondary  stage  of 
syphilis,  and  presents  clinical  signs  peculiar  to  itself.  In  rare  instances 
it  is  found  in  infants  with  hereditary  syphilis.  The  iris  shows  one  or 
more  yellowish-brown  or  reddish-brown  nodules,  varying  in  size  from 
a  pin's  head  to  a  pea.  They  are  found  in  the  ciliary  or  pupillary 
border  or  midway  between  the  two,  and  are  often  crossed  by  vessels. 
Although  found  in  the  secondary  stage  of  sypliilis,  the  name  gummata 
has  been  applied  to  them.  Unlike  true  gummata  they  do  not  break 
down  or  suppurate.     They  soon  disappear  under  treatment  without 


GUMMA  5659 

leaving  scars  in  the  iris-tissue.  Some  authors  ai)i)ly  tlie  term  iritis 
papulosa  to  this  condition,  and  reserve  the  name  gummatous  iritis  to 
those  rare  cases  of  true  gummata  which  appear  later  in  the  history  of 
syphilis. 

Rollet  (Archives  d'Ophtalmologie,  May,  1908)  met  with  twelve  cases 
of  syphilitic  iritis  and  classifies  them  in  tlie  following  manner:  (1) 
Circumscribed  notlule;  (2)  gunniiatous  pseudo-hypopyon;  (8)  diffuse 
syphilitic  infiltration.  (1)  Of  the  circumscribed  nodule  he  has  seen 
eight  instances ;  the  nodule  was  usually  solitary  and  about  the  size  of 
a  pin's  head.  The  ages  of  the  patients  varied  from  14i/>  to  50  years, 
ant!  the  interval  since  the  appearance  of  tlie  primary  lesion  from  5  to 
14  months. 

Gumma  of  the  ciliary  body  is  a  rare  condition,  appearing  in  from 
one  to  three  and  one-half  years  after  tlie  initial  lesion  of  syphilis.  The 
gummatous  tumor  is  preceded  by  an  attack  of  iritis.  The  vision  is 
rapitUy  reduced,  the  eye  showing  great  conjunctival  and  ciliary  injec- 
tion. The  cornea  becomes  hazy,  the  anterior  chamber  deep,  and 
hypopyon  is  present.  A  yellowish-red  tumor  is  seen  projecting  from 
the  angle  of  the  anterior  chamber,  and  at  a  spot  corresponding  to  its 
site  there  is  a  bulging  of  the  ciliary  region.  This  is  of  a  purple  color. 
Tension  becomes  increased ;  there  is  great  pain  and  considerable  con- 
stitutional disturbance,  as  shown  by  the  presence  of  anorexia,  furred 
tongue,  insomnia,  and  elevation  of  temperature.  Other  nodules  appear, 
and  these  develop  into  ciliary  staiiliylomata,  presenting  a  bluish-black 
color,  owing  to  the  pigment  showing  through  the  thin  sclera.  Under 
proper  treatment,  which  has  l)een  instituted  and  continued  for  several 
weeks,  the  eye  becomes  clear,  the  hypopyon  disappears,  and  the  tension 
gradually  diminishes.  Vision  improves,  but  generally  is  not  restored. 
The  staphyloma  may  diminish  in  size,  but  some  bulging  always  remains. 
If  the  treatment  is  not  efficacious,  the  eye  becomes  perforated,  or 
atrophy  of  the  globe  may  occur  without  perforation. 

The  diagnosis  must  rest  upon  the  history  and  clinical  signs  as  given 
above. 

Prognosis  should  always  be  guardcnl  in  these  cases.  If  the  patient 
retains  the  globe  intact  and  possesses  vision  equal  to  the  counting  of 
fingers  at  a  few  feet,  he  should  be  congratulated.  Stieren,  however, 
has  recorded  a  case  of  gumma  of  the  ciliary  body,  with  vision  reduced 
to  perception  of  light,  which  recovered  vision  (6/8)  under  enormous 
doses  nOO  to  200  grains,  three  times  a  day)  of  potassium  iodid. 

Anti-syphilitic  remedies  should  in  treatment  be  pushed  vigorously. 
Locally  atropin  or  scopolamin  drops  must  be  used,  and  the  usual  reme- 
dies are  to  be  prescribed  for  the  relief  of  pain. —  (J.  ^I.  B.) 


5660  GUMMA 

All  account  of  a  guiiiina  of  tlie  ciliurij  bodij  diid  oplic  nerve  is  given 
by  Matsiikawa  {Klin.  Monats.  f.  liugenheilk.,  Vol.  51,  p.  665).  A  man, 
aged  32,  had  a  hard  chancre  and  inguinal  buboes  iu  April,  I'Jll.  Eight 
months  later  he  had  iritis  and,  after  three  months,  exhibited  papulous 
syphilitic  iritis,  which  rai)idly  subsided  after  an  intravenous  injection 
of  0.6  salvarsan,  followed  by  mercury  and  iodine  for  a  month.  Ou 
admission  the  Wassermann  reaction  was  positive.  Six  months  later  he 
returned  with  a  gumma  of  the  ciliary  body  in  the  form  of  a  bluish-red 
tumor  at  the  inferior  temporal  limbus;  an  irregular  pupil  closed  by 
grayish-white  exudations,  iris  adherent  to  the  lens ;  V  =  0.  On  account 
of  very  severe  pain  the  eye  was  enucleated. 

The  histologic  examination  revealed  a  gumma  of  the  ciliary  body 
and  optic  nerve.  No  spirochtetes  were  found.  Matsukawa  considers 
this  as  a  neuro-relapse  and  a  luetic  manifestation  after  salvarsan, 
although  this  condition  generally  occurs  from  four  to  five  months  after 
•  the  primary  sore,  not  one  and  one-half  years,  as  in  this  case,  and  is 
not  due  to  an  intoxication  by  salvarsan. 

Gumma  of  the  choroid.  Parsons  {Pathologij  of  the  Eye,  II,  p.  462) 
says  that  true  guinmata  of  the  choroid,  characterized  by  necrosis,  are 
of  extreme  rarity;  indeed,  only  gummatous  infiltration  has  hitherto 
been  observed.  The  changes  occur  in  the  tertiary  stage  as  well  as 
earlier,  but  necrosis  is  absent,  v.  Ilippel's  case  was  essentially  one 
of  gumma  of  the  ciliary  body,  with  diffuse  extension  into  the  choroid 
and  other  parts  of  the  eye.  There  is  dense  infiltration  with  small 
round  cells,  with  some  endothelial  proliferation.  The  granulomatous 
nature  is  emphasized  by  the  rich  development  of  new  vessels,  mostly 
mere  endothelial  tubules.  The  distinctive  feature  is  the  fatty  degen- 
eration of  the  tissues,  going  on  to  total  necrosis.  Schobl  has  also 
described  thickening  of  the  choroid  with  nodular  infiltration,  the 
largest  nodules  being  in  a  state  of  necrosis.  Endarteritis  was  noted, 
and  this  may  account  for  the  extensive  degeneration. 

Gummatous  new  formations  of  the  optic  disc  are  extremely  rare. 
Mylius  {Klin.  MonatsU.  f.  Augcnhcilk.,  ]\Iay,  1913)  could  find  in  liter- 
ature only  three  cases.  He  reports  the  following :  A  woman,  aged  25, 
came  on  November  1,  1011,  complaining  of  impairment  of  vision  of 
left  eye  for  a  w^-ek,  which  was  reduced  to  counting  fingers  at  1/2  m. 
The  ophthalmoscope  revealed  floating  opacities  of  the  vitreous.  The 
optic  disc  was  not  visible,  being  completely  covered  by  a  dense,  bluish- 
white  mass,  pervaded  by  a  few.  partly  ectatic,  blood  vessels.  The 
mass  measured  vertically,  a])0ut  two  disc  diameters;  horizontally, 
three.  The  surrounding  parts  of  the  retina  were  slightly  opaque.  The 
tumor  i)rotruded   6  D.     The  outer  borders  of  the  visual  field  were 


GUMMATOUS  CONJUNCTIVITIS  5661 

normal  for  largjor  objects;  there  was  no  absolute  central  scotoma. 
Wassermann  was  positive.  Under  mercurial  inunctions  the  affection 
healed  within  si.K  weeks;  V.  5/5,  fundus  perfectly  normal.  The 
benign  course  indicated  an  affection  of  the  surface  of  the  disc  without 
involving  the  optic  nerve,  api)arently  a  perivasculitis  with  excessive 
formation  of  granulation  tissue  around  the  vessels  of  the  hilus. 

Gumma  of  the  orbital  periosteum  is  rarer  than  tlie  same  disease  in 
the  })eriosteal  covering  of  the  other,  cranial  bones.  The  condition  is 
a  rarefying  osteitis :  i.  e.,  the  subperiosteal  bone-cells  undergo  soften- 
ing and  become  in  structure  similar  to  the  gummatous  tissue.  The 
symptoms  are  those  of  ordinary  periostitis  with  certain  exaggerations. 
Nocturnal  pain  and  neuralgia  are  prominent  symptoms.  The  swelling 
is  more  circumscribed  than  in  periostitis  and  simulates  more  a  true 
tumor,  exophthalmos  being  frequently  produced  if  the  gumma  is  in 
the  deeper  parts  of  the  orbit.  Orl)ital  gummata  cause  great  immo- 
bility of  the  eyeball,  marked  fixity  of  the  eyeball  being  characteristic 
of  this  form  of  intlammation.  They  are  amenable  to  specific  treatment, 
but  when  they  disappear  great  holes  and  depressions  are  left  in  the 
bones.— (J.  ]\f.  B.) 

Gummatous  conjunctivitis.  (Obs.)  A  localized  conjunctivitis  of  plastic 
type,  occasioned  l)y  the  development  of  a  gummy  tumor  in  the  con- 
junctiva or  subconjunctival  tissue.  These  gummy  deposits  usually 
occur  in  the  course  of  the  external  rectus  muscle  or  between  the 
latter  and  the  superior  rectus.     See  Gumma. 

Gummatous  iridochoroiditis.  A  very  rare  disease,  running  a  course 
similar  to  iritis  gummatosa,  but  often  involving  the  ciliary  body, 
choroid,  and  sclera,  and  leading  to  perforation  of  the  latter  before 
resolution.    See  Iritis,  Syphilitic;  as  Avell  as  Gumma. 

Gum  of  the  eye,  A  vulgar  name  for  mucus  secreted  by  the  Meibomian 
glands  and  mixed  with  particles  of  dust,  drying  on  the  eyelids. 

Gum-resin  myrrh.    See  Myrrh. 

Gum  tragacanth.    See  Tragacanth. 

Gunn's  dots.  These  are  fully  described  on  p.  3560,  Vol.  V.  of  this 
Encyclopedia. 

Gunn,  Robert  Marcus.  A  celebrated  English  ophthalmologist,  discoverer 
of  "(hinn's  dots,''  or,  as  he  himself  preferred  to  call  them,  "Crick 
dots."  Born  at  Dunnet,  Sutherlandshire,  of  Scandinavian  stock,  in 
1850,  he  received  his  early  education  at  the  Thos.  Fraser  School  in  Gols- 
pie. Proceeding  to  the  I'niversity  of  Edinburgh,  he  there  received  the 
degree  of  M.  A.  in  1871  and  the  ]\[.  B.  and  CM.  in  1873.  Then 
for  a  number  of  months  he  studied  at  Vienna  with  Jaeger. 

Returning  to  Loudon,  he  became  at  the  Royal  London  Ophthalmic 


5662 


GUNN,  ROBERT  MARCUS 


Hospital  ("]\Ioorfields")  Junior  House  Surgeon  in  August,  1876,  and 
Senior  House  Surgeon  in  the  December  following.  In  1882  he  became 
an  F.  R.  C.  S.  (England),  and  in  1883  Assistant  Surgeon,  in  1888 
Surgeon,  to  the  Royal  London  Ophthalmic  Hospital.  Among  his 
other  hospital  appointments  were:  Ophthalmic  Surgeon  to  the  Na- 
tional Hospital  for  the  Paralysed  and  Epileptic,  Ophthalmic  Surgeon 
to  the  Hospital  for  Sick  Children,  and  Assistant  Ophthalmic  Surgeon 
to  the  University  College  Hospital.  From  1896  to  1899  he  was  Vice- 
President,  and  from  1907  to  1909  President,  of  the  Ophthalmological 
Society  of  the  United  Kingdom. 


Eobert  Marcus  Giinu. 

In  1898  he  was  Vice-Chairman  of  the  Section  of  Ophthalmology  of 
the  British  Medical  Association,  and,  in  1906,  at  Toronto,  Chairman 
of  the  same  assemblage.  He  delivered  a  number  of  addresses  on  oph- 
thalmologic subjects  before  various  foreign  ophthalmologic  bodies, 
perhaps  the  most  important  being  "On  Certain  Affections  of  the 
Optic  Nerve"  before  the  American  Academy  of  Ophthalmology  and 
Oto-Laryngology. 

His  original  work  in  the  field  of  human  ophthalmology  was  almost 
wholly  on  the  subject  of  the  optic  nerve,  the  retina,  and  the  cornea ; 
the  anatomy,  physiology,  and  diseases  of  these  structures.  His 
researches  in  comparative  ophthalmology,  especially  comparative  anat- 
omy and  histology,  are  ver.y  extensive  and  important. 

Dr.  Gunn  died  Nov.  29,  1909,  leaving  a  wife  and  two  daughters. 

He  will  long  be  remembered  not  only  by  his  friends,  but  by  all  who 
ever  met  him.  Strongly  marked  in  character,  he  could  not  be  forgot- 
ten. Positive,  aggressive,  sometimes  actually  intolerant,  rather 
inclined  to  enthusiasm  when  absolutely  certain  of  his  views,  coolly 
skeptical  on  other  occasions,  sensitive  to  injustice,  decidedly  ready  to 


GUNNING,  WILLEM  MARIUS  5663 

forgive,  and  (rarest  of  all  the  virtues)  as  ready  to  be  forgiven.  He 
was  fond  of  outdoor  recreation,  shooting,  hunting  and  tlie  like,  and, 
to  the  end  of  his  days,  was  an  ardent  student  in  the  open  air  of  botany, 
zoology,  geology  and  mineralogy. 

He  wrote  no  books,  but  pul)lished  a  number  of  articles,  the  chief  of 
which  are:  1.  Peculiar  Appearance  of  the  Ketina.  ("Crick-dots," 
or  "Gunn's  dots,"  li.  L.  0.  H.  Reports,  III.)  2.  Amblyopia  from 
Bisulphide  of  Carbon.  {T.  0.  S.,  Vol.  VI.)  3.  Uniocular  Nystagmus. 
(/6w/.,  Vol.  VII.)  4.  Toxic  Amblyopia.  {Ibid.,  Vol.  \1L)  5.  Growth 
of  New  Lens-Fibres.  {Ibid.,  VIII  and  XV.)  6.  Peculiar  Foveal  Ke- 
flex in  I\Iyoi)ie  Amblyojua.  (/6/rf.,  Vol.  VIII.)  7.  Congenital  Malfor- 
mations of  Eye.  {Ophthul.  Review,  Vol.  VIII,  2  Lectures,  1889.) 
8.  On  Sympathetic  Inflammation  of  the  Eyeball.  {R.  L.  0.  H.  Re- 
ports,, Vol.  XL  pp.  78-102,  and  27:3-326.)  9.  Note  on  Certain  Retinal 
Reflexes  Visible  with  the  Ophthalmoscope.  {Ibid.,  Vol.  XII,  'S-iS.) 
10.  Light-Percipient  Organs  and  Light  and  Color-Perception.  {Ibid., 
Vol.  XII,  p.  101.)  11.  Ophthalmoscopic  Evidence  of  Increased  Ar- 
terial Tension,  and  of  General  Arterial  Disease.  {T.  0.  S.,  Vols.  XII, 
XVIII,  and  XXIV.)  12.  Pemphigus  of  Conjunctiva.  {Ibid.,  Vols. 
XIII  and  XV.)  13.  Hemorrhage  into  Optic  Nerve  Sheath.  {Ibid., 
Vol.  XIV.)  14.  Acute  Bullous  Eruption  of  Skin  and  Conjunctiva. 
{Ibid.,  Vol.  XVI.)  15.  Retinitis  Circinata.  {Ibid.,  Vol.  XVIII.) 
16.  Bowman  Lecture — Visual  Sensations.  {Ibid.,  Vol.  XX.)  17. 
Keratitis  Nodosa,  Family  Case.  {Ibid.,  Vols.  XXII  and  XXIX.) 
18.  Family  Optic  Atrophy.  {Ibid.,  Vol.  XXVII.)  19.  Presidential 
Address.  {Ibid.,  Vol.  XXVIII.)  20.  Hemorrhagic  Disease  of  Retina, 
with  Obliteration  of  Veins.  {Helmholtz  Festschrift,  Plate  II,  1891.) 
—  (T.  H.  S.) 

Gunning,  Willem  Marius.  A  Dutch  ophthalmologist  of  considerable 
local  reputation.  Born  at  Hoorn,  Holland,  July  15,  1834,  he  received 
his  medical  degree  at  Utrecht,  Sept.  11,  1857.  For  a  time  he  was 
assistant  physician  at  "Buiten-Gasthuis,"  but  always,  owing  to  the 
influence  of  Donders,  under  whom  he  had  studied  in  the  University, 
he  desired  to  be  an  ophthalmologist.  In  accordance  with  this  desire, 
he  began  about  1863  to  devote  himself  to  ophthalmology  exclusively. 
In  1877  he  was  appointed  full  professor  of  ophthalmology  at  the 
Amsterdam  University.  He  wrote  a  few  articles  and  reports,  but  no 
books.    He  died  in  May.  1912.— (T.  H.  S.) 

Gunpowder  burn  of  the  eye.  This  is  one  of  the  commonest  of  injuries, 
but  owing  to  the  crusade  in  this  country  against  the  reckless  use  of 
fireworks  and  firearms,  especially  during  Fourth-of-July  celebrations, 
they  are  not  as  frequent  as  formerly.    See  page  3232,  Vol.  V,  of  this 


5664  GUN  SEARCHER 

Encyclopedui.    The  treatment  and  additional  information  regarding 
gunpowder  injuries  will  be  found  under  Injuries  of  the  eye. 

1\.  II.  Elliot  {OpJithalmoIogij,  July,  1911;  rr])()rts  tliat  during  the 
closing  months  of  each  year  a  number  of  gunpowder  wounds  of  the 
eyes  are  seen  in  India,  due  to  the  fact  that  at  that  time  there  are  feasts 
at  which  explosives  are  used.  The  mo.st  common  form  of  explosive 
is  prepared  by  making  a  mixture  of  sulphide  of  arsenic  and  chlorate 
of  potash.  After  this  has  been  gently  rubbed  together  by  digital 
pressure  it  is  mixed  with  gravel,  carefully  wrapped  in  paper  and 
cloth  and  is  exploded  by  concussion.  After  the  mixture  with  gravel 
the  danger  of  explosion  is  greatest  and  the  eyes  suffer  most  frequently. 
The  mixture  slowly  dissolves  in  the  tissues  where  it  is  lodged  and 
produces  a  chemical  irritation,  followed  by  chronic  irido-cyclitis,  not 
infrecjuently  culminating  in  loss  of  vision  and  even  of  the  eye.  It  is 
very  difficult  to  remove  the  granules  and  little  can  be  done  except  the 
use  of  atropin  and  treatment  along  general  lines. 
Gun-searcher.    An  optical  appliance  for  use  in  examining  the  bore  of 

a  gun. 
Gunshot  injuries  of  the  ocular  apparatus.  This  is  an  interesting  and 
important  subject  which  is  treated  under  Injuries  of  the  eye,  as  well 
as  under  Military  surgery  of  the  eye.  Here  attention  may  be  drawn 
to  some  of  the  references  furnished  by  a  recent  issue  of  the  Ophthalmic 
Ycar-Book. 

Oguchi  {Beitrdge  zur  Augenhcilk.,  Vol.  83,  p.  75,  1913)  gives  a 
resume  of  no  fewer  than  3,093  cases  of  injuries  of  the  eyes  observed 
i)i  the  Busso-Japanese  tear.  Statistics  concerning  ocular  injuries  in 
late  wars  show^  that  the  number  as  well  as  the  percentage  of  such  were 
far  higher  during  this  war  than  in  preceding  ones.  ]Most  were  caused 
by  rifle  shot;  they  occurred  decidedly  oftener  in  open  battles  than 
during  attacks  upon  fortresses.  Shot  wounds  affected  both  eyes  with 
equal  frequency,  but  stab  wounds  involved  the  left  eye  in  80  per  cent, 
of  the  entire  number;  515  enucleations  and  94  exenterations  were 
practised  in  all. 

Shot  injuries  involved  the  globe,  as  a  rule,  by  contusions;  the 
reporter  divides  them  into  (1)  direct  crushing  of  the  globe  and  the 
wall  of  the  orbit;  (2)  indirect  effects  through  the  bony  orbital  wall 
with  decided  changes  in  the  anterior  segment  of  the  globe;  (3)  grazing 
shots,  especially  of  the  lids;  (4)  distant  effects  in  injury  of  other  parts 
of  the  skull,  and  (5)  double  perforations. 

The  cornea  was  affected  in  the  most  varied  manner;  besides  per- 
forations, permanent  opacities  of  the  membrane  were  observed.  In- 
juries of  the  sclera,  iris  and  ciliary  body  were  relatively  frequent, 


GUNSHOT  INJURIES  OF  THE  OCULAR  APPARATUS   5665 

both  as  woiiiuls  and  also  as  contusions.  Sympathetic  opiithahuia  was 
very  frequent.  Choi-oidal  iui)tures  were  mostly  due  to  shot  in.juries. 
This  was  unifoi'inly  the  case  in  retinal  disturbances  (contusion  and 
amotio).  The  reporter  mentions  esi)ecially  the  so-called  retinitis 
traumatica,  and  opacity  oi"  the  retina  lasting  for  months.  The  optic 
nerve  was  wounded  in  a  pi-etty  large  number  of  instances,  without 
exception  by  shot.  Injuries  of  the  lens  occurred  particularly  in  attacks 
upon  fortresses,  especially  through  explosions.  Contusion  cataract 
from  shot  injury  was  rare.  Injuries  of  the  orbit,  in  50  per  cent,  due 
to  rifle  shots,  were  generally  accompanied  by  severe  injuries  of  the 
brain,  and  were  o])served  particularly  in  open  battles.  Disturbances 
of  motility  resulted  from  adhesions  of  the  posterior  segment  to  the 
surrounding  parts,  and  from  symblepharon.  They  were  also  due  to 
lesions  of  the  muscles  or  paralysis  of  the  motor  nerves. 

In  two  cases  of  huUrt  iiijiiriff;  of  the  orbit  seen  by  Lange  (Klin. 
Monatshl.  f.  AugenJuilk.,  p.  553,  Nov.,  1912)  no  permanent  injury  was 
done  to  the  eyeballs  or  orbital  structures. 

In  de  Lapersonne's  and  Velter's  { Archives  d'Ophtahn.,  Vol.  33,  p. 
193,  1913)  case  a  boy  of  14  was  shot  by  a  small  caliber  revolver  bullet 
through  the  orbit  directly  from  before  backwards.  The  left  eyeball 
was  ruptured,  the  anterior  portion  protruding  l)etween  the  lids.  There 
was  also  a  voluminous  hematoma  of  the  left  orbit.  The  right  eye  was 
normal.  The  X-rays  showed  llie  ])ul]ct  in  tlie  left  occipital  lobe  close 
to  the  median  line,  at  a  short  distance  from  the  posterior  and  superior 
wall  of  the  cranium.  The  nervous  system  presented  no  focal  symp- 
toms. The  general  condition  was  very  grave :  marked  torpor,  slow 
pulse  (65)  but  no  rise  in  temperature.  The  following  days  the  gen- 
eral condition  became  still  graver;  almost  complete  coma  supervened 
with  abolition  of  all  the  reflexes.  The  right  papilla  was  markedly 
hyperemic.  The  fourth  day  lumbar  puncture  withdrew  25  cc.  of 
bloody  fluid.  A  second  puncture  two  days  later  giving  only  a  clear 
yellow  liquid,  was  followed  by  progressive  and  definite  amelioration. 
Nine  days  later  the  left  eye  was  removed.  The  operation  resulted  in 
such  marked  improvement  that  the  patient  was  out  of  bed  in  three 
days. 

Examination  made  16  days  after  the  accident  showed,  firet,  very 
marked  intellectual  stupor  with  complete  disorientation  as  to  time  and 
space ;  second,  a  considerable  amnesia  concerning  all  facts  anterior  to 
the  accident,  all  the  circumstances  of  the  accident  and  even  in  regard 
to  recent  events ;  third,  complex  aphasic  disturbances.  There  was  not 
a  trace  of  verbal  deafness  but  a  certain  degree  of  verbal  blindness  and 
especially   of  physical    blindness   for   words.     There   was   no   motor 

Vol.  VII— 52 


5666  GUNSHOT  INJURIES  OF  THE  OCULAR  APPARATUS 

aphasia  but  an  aphasia  from  amnesia — a  condition  belonging  to  the 
group  which  has  been  described  under  the  term  visual  verbal  amnesia 
and  more  definitely  optic  aphasia;  in  which  the  motor  image  of  the 
word  is  no  longer  evoked  by  the  sight  of  the  object,  but  where  the 
evocation  is  possible  if  other  sensory  impressions  (hearing)  come  to 
the  aid  of  the  visual  impression.  With  the  exception  of  these  symp- 
toms, the  nervous  system  presented  nothing  abnormal.  Rapid  improve- 
ment took  place ;  two  and  one-half  months  after  the  accident  both  the 
mental  confusion  and  disorientation  had  disappeared ;  the  amnesia  of 
evocation  still  persisted,  and  there  remained  traces  of  literal  blindness 
but  for  certain  characters  only. 

The  right  eye,  whose  visual  acuity  was  normal,  showed  a  qumlrant 
hemianopsia  localized  in  the  superior  segment  of  the  temporal  visual 
field ;  there  was  also  a  slight  contraction  of  the  remaining  field.  Wer- 
nicke's  hemianopic  reaction  could  not  be  obtained. 

The  quadrant  hemianopsia  noted  has  been  rarely  recorded  in 
traumatism  of  the  cranium  by  firearms,  for  the  reason  perhaps  that 
examination  of  the  visual  field  is  only  possible  in  the  fortunate 
cases  in  which  recovery  takes  place.  The  psychic  and  aphasic  dis- 
turbances present  in  this  case  have  been  frequently  noted  by 
various  authors  in  more  or  less  extensive  alterations  of  the  occipital 
lobe,  especially  in  the  region  of  the  cuneus  (hemorrhage,  softening, 
tumors).  Dide  has  proposed  the  term  "occipital  syndrome."  This 
syndrome  is  very  rare  in  traumatism  by  firearms.  When  it  occurs  in 
connection  with  hemianopsia,  it  may  be  taken  to  indicate  a  lesion  of 
the  posterior  pole  of  the  encephalon,  but  exact  localization  is  very 
difficult.  In  the  case  reported,  to  judge  from  the  radiograms,  the 
track  of  the  ball  seems  to  have  been  quite  high,  above  the  isthmus  of 
the  encephalon,  perhaps  even  above  the  optic  thalamus,  and  to  have 
affected  the  optic  tracts  only  at  the  posterior  and  superior  part  of  the 
left  occipital  lobe. 

The  writers  raise  the  question  whether  in  cases  of  traumatism  of 
the  orbit  involving  the  globe  by  firearms,  surgical  intervention  should 
be  immediate  or  delayed.  They  incline  to  the  view  that  delay  is 
preferable,  although  opinions  differ.  They  also  discuss  the  point 
whether  in  the  presence  of  grave  general  symptoms  and  particularly 
signs  of  intracranial  hemorrliage  which  determine  dangerous  hyper- 
tension, lumbar  puncture  or  trephining  is  to  be  practised.  Here 
again  they  incline  to  the  performance  of  the  former  unless  an  exten- 
sive wound  or  compression  of  bone  call  for  immediate  trephining. 

In  Hesse's  (Klin.  M.  f.  Augenh.,  p.  29,  July,  1913)  case  the  patient 
was  wounded  by  a  small  shot  which  entered  the  neck  on  the  left  side 


GUNZ,  JUSTUS  GOTTFRIED  5G67 

about  tile  .junction  of  the  upper  and  middle  third  of  the  sterno-cleido- 
mastoid  near  its  posterior  edge.  A  hemorrhagic  exudate  larger  than 
a  fist  appeared.  At  the  time  of  the  traumatism  a  sliarp  sensation  of 
light  was  experienced,  apparently  before  tiie  left  eye,  accompanied 
by  temporary  blindness  of  both  eyes,  but  this  quickly  disappeared. 
Subsequently  more  exact  observation  by  the  patient  himself  showed 
that  he  was  unable  to  distinguish  objects  to  the  riglit  and  down- 
wards. The  scotoma  was  very  large  in  the  beginning  but  had  markedly 
improved  in  a  few  weeks.  Besides  severe  headache  upon  the  left  side 
of  the  vertex  and  occipit-al  region  all  other  complaints  were  absent. 

Examination  four  weeks  later  showed  that  the  central  visual  acuity 
equalled  1.0.  The  visual  fields  of  both  eyes  presented  an  almost  per- 
fectly symmetrical  absolute  sectorf&rm  scotoma  extending  from  the 
fixation  point  about  .30  degrees  downward  and  outward  toward  tlie 
periphery;  this  was  followed  by  a  relative  scotoma  extending  to  tiic 
outer  limits  of  the  fields  with  diminished  sensibility  for  white,  but 
nowhere  permitting  a  certain  appreciation  of  colors. 

Giinz,  Justus  Gottfried.  A  well-known  German  surgeon,  obstetrician, 
medico-historian  and  ophthalmologist.  Born  at  Konigstein,  Germany, 
March  1,  1714,  he  received  his  training  in  the  liberal  arts  at  the  gym- 
nasium in  Gorlitz,  and  his  medical  education  at  the  University  of 
Leipsig  from  1732-38.  In  1747  he  was  ap])ointed  to  the  chair  of 
physiology  in  his  alma  mater,  and,  a  little  later,  to  those  of  anatomy 
and  surgery  in  the  same  institution.  In  1751  lie  became  official  phy- 
sician to  the  Elector  of  Saxony,  but  very  soon  afterward  died. 

According  to  Ilirschberg,  his  ophthalmologic  writings  are  as  fol- 
lows: 1.  Diss,  de  Staphylomate,  etc.  (Leipsig,  1748.)  2.  De  Suf- 
fusionis  Natura  et  Curatione.  (Liepsig,  1748.)  The  first  of  tiiese 
works,  according  to  the  same  authority,  is  of  very  little  value,  while 
the  second  possesses  a  high  degree  of  merit  because  of  its  clear  and 
exact  description  of  the  cataract  operation. —  (T.  II.  S.) 

Giirtelformige  Hornhautentziindung.   (G.)   Band-shaped  keratitis. 

Giirtelschicht  des  Thalamus.  (G.)  Stratum  zonale  of  the  optic  thalamus. 

Guthrie,  Fred  Ashford.  A  locally  well-known  ophthalmologist  of  La 
Salle,  Illinois.  Born  at  Aledo,  111.,  Feb.  21,  1872,  son  of  Noah  II.  and 
Delilah  Guthrie,  he  received  his  general  education  at  the  University 
of  Illinois  and  his  medical  training  at  the  Rush  ^Medical  College,  at 
which  institution  he  received  the  degree  in  1896.  Forming  a  part- 
nership with  Dr.  J.  ]\I.  Wallace  at  Aledo.  he  practised  for  a  time  as 
general  practitioner,  but,  afterwards  studying  ophthalmology  and  oto- 
laryngology, he  removed  to  La  Salle,  111.,  where  he  practised  as  spe- 
cialist in  those  branches  until  his  death. 


5668 


GUTTA 


He  iiian-icd  in  1896  ]\Iiss  Anna  Laurena  Oliver.  To  this  union  were 
born  two  children,  John  Oliver  and  Laurena  Grace. 

Dr.  Guthrie  died  in  the  Presbyterian  Hospital,  Chicago,  Feb.  28, 
1915.  He  was  a  vefy  pleasant  and  agreeable  young  man,  of  medium 
height,  stout,  smooth-faced,  of  fair,  rosy  complexion,  and  with  bright 
blue  eyes,  and  a  brisk,  gay,  hapi)y  manner,  which  endeared  him  to  all, 
patients  and  profession  alike.— (T.  H.  S.) 


Fred  Ashford  Guthrie. 

Gutta.  (L.)  Drop.  Effusion  of  a  liciuid  drop  by  drop.  The  bathing  of 
a  part  by  dropping  water  on  it. 

Gutta  opaca.  (L.)  A  name  given  by  the  ancients  to  cataract,  as  they 
supposed  it  an  opaque  drop  in  front  of  the  lens.  See  Guy  de  Chauliac. 

Gutta  Serena.  A  name  given  by  the  ancients — probably  original  with 
the  Arabians — to  amaurosis,  supposing  it  to  depend  on  a  clear  drop 
fallen  from  the  brain  into  the  eye;  the  ''drop  serene"  of  Milton. 
See  Guy  de  Chauliac. 

Guttate  iritis.    See  Iritis,  Guttate. 

Guttatim.   (L.)  By  drops. 

Gutter  lens.  A  very  rare  congenital  anomaly  of  the  crystalline  de- 
scribed by  Otto  Becker  in  18813. 

Guy  de  Chauliac  (also  called  Guido).  The  greatest  surgeon  of  the 
^Middle  Ages.     He  was  born  about  1300  at  the  village  of  Chauliac.  or 


GUY  DE  CHAULIAC  5669 

Cauliaco,  on  the  borders  of  Auvergne,  France.  Educated  at  Mont- 
pellier,  liologna,  and  Paris,  he  settled  in  Lyons,  wliere  lie  practised 
for  a  long  time,  and  finally  became  i)hysiciau-iu-ordiuary  to  three 
successive  popes — Clement  VI,  Innocent  VI,  and  Urbau  V  at  Aviguou. 
He  died  in  1638. 

Guido's  greatest  work  is  his  "Chiruryke  Tractatus  Septem,  cum 
Antidotario"  or  '' Collcctorium  Artis  Chirurgicalis  Mediciiut,"  better 
known,  however,  as  ''Chirnrgia  Magna,''  because  of  another  and 
smaller  work  by  the  same  writer,  entitled  ''Chirurgia  I'arva."  The 
"Chirurgia  Magna,"  a  marvel  of  learning  and  of  literary  style,  was 
facile  princcps  of  all  the  works  on  surgery  throughout  Western  Europe 
for  many  centuries. 

De  Chauliac's  writings  on  ophthalmology,  so  far  as  extant,  are  com- 
prised in  the  second  ])art  of  the  seventh  division  of  his  "Chirurgia 
Magna."  Opinions  differ  greatly  as  to  the  value  of  these  31  folio 
pages.  Pansier  declares  them  to  be  an  "uninteresting  compilation"; 
Ilirsc'hberg,  on  the  contrary,  says  regarding  them:  "I  find  this 
treatise  better  than  almost  any  other  which  the  European  Middle  Ages 
have  bequeathed  to  us  in  our  special  branch ;  at  all  events,  it  was,  in 
its  day,  more  practical  and  instructive."  The  truth,  in  this  instance, 
is  probably  with  Pansier,  for  little  that  is  really  original  appears  in 
the  book.  The  following  passage,  however,  on  cataract  and  "gutta 
Serena,"  is  memorable,  as  exhibiting,  in  a  style  at  once  terse  and  clear, 
the  medieval  views  on  cataract  and  amaurosis:  "Cataract  is  a  cuticu- 
lar  blemish  in  the  eye,  in  front  of  the  pupil,  which  disturbs  the  sight. 
It  consists  of  a  foreign  humor,  which  gradually  descends  into  the  eye, 
and  hardens  in  consequence  of  the  eye 's  coldness.  ^Yhether  this  humor 
collects  between  the  cornea  and  the  iris  (as  Jesus  proves)  or  between 
the  aqueous  humor  and  the  crystalline  lens  (as  Galen  pretends  in  the 
tenth  book  'On  the  Use  of  the  Parts')  does  not  interest  me  just  now. 
The  first  stage  is  called  '  Illusion  of  the  Sight ; '  the  second,  '  The  Fall- 
ing of  the  Water,'  or,  sometimes,  'Gutta;'  the  third,  or  last,  stage, 
'Cataract,'  because  it  obstructs  the  visual  power,  as  the  sluice  of  the 
mill,  and  as  the  waterfall  from  the  sky  obstructs  the  sun. ' ' 

Besides  the  general  surgeries — magna  and  parva — Guido  also  wrote 
a  purely  ophthalmologic  monograph,  no  longer  extant,  entitled  "'Man- 
ner of  Life  for  Cataract-Patients."  Concerning  the  origin  of  this 
book  there  runs  a  story.  John,  King  of  Bohemia,  finding  that  he  was 
going  blind,  sent  to  France  for  an  oculist.  The  unfortunate  eye-doc- 
tor arrived,  but,  proving  unable  to  cure  the  irritable  monarch,  he  was 
sewn  up  in  a  sack  and  cast  into  a  river.  An  Ai-abian  oculist  was  next 
sent  for.     He  also  was  unsuccessful,  and  would,  no  doubt,  have  suf- 


5670  GYMNASTICS,  OCULAR 

fered  a  like  fate  with  that  of  his  Fraiikisli  confrere,  but  for  the  fact 
tliat  he  had  been  clever  enough  to  arrange  in  advance  for  a  "safe 
conduct."  Then  the  king  betook  himself  to  iMontpellier,  there  to 
consult  I  lie  great  de  Chauliac.  Ouido,  however,  would  not  undertake 
the  case.  Instead,  he  wrote  for  his  royal  patient  the  little  book  in 
question — "Manner  of  Life  for  Cataract-Fatients."  The  king,  how- 
ever, does  not  seem  to  have  been  greatly  cheered  by  the  volume  which 
his  calamity  had  called  forth,  and,  be(;oming  shortly  afterward  stone 
blind,  he  purposely  sought  and  soon  found  "the  greater  darkness  still" 
in  the  battle  of  Crecy.— (T.  H.  S.) 
Gymnastics,  Ocular.  Regular  muscular  exercise  of  the  eye  to  over- 
come muscular  insufficiency.  This  important  subject  will  be  consid- 
ered under  Muscles,  Ocular.  Here  the  Editor  gives  the  following 
method  of  using  prisms  for  the  home  exercise  of  the  convergence  and 
accommodation  which  he  has  for  many  years  been  prescribing: 

1.  There  are  necessary  a  small  candle  or  gas  flame,  placed  twenty 
feet  distant  on  a  level  with  the  eyes,  in  a  fairly  dark  room,  and  the 
squared  prisms  ordered  from  the  optician.  Assume  that  they  are 
10°,  5°  and  3°. 

2.  Sit  squarely,  facing  the  light,  with  both  eyes  open  and  (when 
these  are  ordered)  wearing  the  glasses  that  are  used  for  seeing  in  the 
distance. 

3.  Hold  the  10°  prism  in  the  right  hand  with  the  inner  surface  touch- 
ing the  eye  lashes  (or  glasses  if  these  are  worn)  and  the  thin  edge 
touching  the  nose;  rotate  the  prism  slightly  until  two  lights  appear 
and  are  seen  on  the  same  level.  Then  attempt  to  fuse  the  two  lights 
into  one  image  as  follows :  Hold  the  left  forefinger  on  a  level  between 
the  eyes  and  the  light,  about  ten  inches  in  front  of  the  nose,  and  while 
looking  intently  at  the  finger-tip  slowly  bring  it  nearer  until  within 
four  or  five  inches  of  the  nose.  Then  look  up  at  the  light,  which 
should  appear  single;  if  not,  go  through  the  same  movements  again 
until  able  to  see  one  light  without  the  aid  of  the  finger.  When  the 
two  lights  are  in  this  way  seen  as  one  the  prism  should  be  held  before 
the  eye  until  ten  is  slowly  counted.  Then  remove  it  for  the  same 
period. 

4.  These  movements  are  to  be  repeated  for  two  minutes  over  each 
eye  three  times  a  day  until  one  light  is  easily  seen  the  moment  the 
prism  is  held  before  either  eye.  Continue  the  exercises  with  this  prism 
for  3  days.  Then  use  for  three  days  more  the  next  strongest,  which 
is  13°,  obtained  by  placing  the  thickest  edges  of  10°  and  3°  together. 
Put  a  small  rubber  band  around  them,  to  hold  them  in  place,  and  pro- 


GYMNOPHTHALMUS  5671 

ceed  as  with  the  single  one.     Next,  use  the  lO'^  and  5^  for  three  days 
and  finally  all  three  together  for  tiiree  days. 

Caution. — Do  not  use  the  prisms  more  tliaii  four  minutes  at  a  sit- 
ting nor  if  their  use  causes  pain  or  discomfort.  Be  sure  that  the  two 
lights  are  on  the  same  level  before  trying  to  fuse  them.  The  main 
purpose  of  these  maneuvers  is  not  merely  to  overcome  the  highest 
prism  or  prisms  possilile,  but  to  exercise  the  eye  muscles  with  a  prism 
whose  double  images  can  be  readily  overcome.  During  tiiis  period  of 
exercise  the  patient  should  consult  the  oculist  as  often  as  directed  that 
he  may  supervise  the  treatment  of  the  case. 

Gymnophthalmus.  (L.)  Having  the  eye  uncovered;  without  true  eye- 
lids, especially  in  reptiles.  The  Gymnophthnlnuita  of  Forbes  are 
MediiscF,  in  which  the  eye-specks  at  the  margin  of  the  disc  are  unpro- 
tected. 

Gynocardia  odorata.  An  East  Indian  i)lant  the  seeds  of  which  yield 
chaulmoogra   oil. 

Gjrpseous  cataract.  An  over-mature,  degenerated  capsular  or  capsulo- 
lenticular  cataract ;  so  called  from  its  white  appearance. 

Gyral.   Gyrant.   Whirling;  rotating. 

Gyrate  atrophy  (of  choroid  and  retina).  See  p.  2139,  Vol.  TIT,  of  this 
E»r]l(Jopedia'. 

Gyrational.    Characterized  by  gyration,  or  a  motion  of  revolution. 

Gyroidal.     Spiral  or  gyratory. 

Gyrus,  Angular.  Angular  convolution.  This  cerebral  area  has  im- 
portant optic  relations.  It  is  situated  at  the  posterior  portion  of  the 
inferior  parietal  lobule,  and  hooks  about  the  superior  temporal  fissure. 
Its  posterior  half  really  forms  part  of  the  occipital  lobe. 


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